Schizophrenia

99 Schizophrenia

Overview/pathophysiology

Schizophrenia is a neurobiologic disorder of the brain categorized as a thought disorder with disturbances in thinking, feeling, perceiving, and relating to others and the environment. Schizophrenia is a mixture of both positive and negative symptoms that are present for a significant part of a 1-mo period but with continuous signs of disturbance persisting for at least 6 mo. Positive symptoms are those that exist but should not be present including delusions, hallucinations, thought disorder, disorganized speech, and disorganized or catatonic behavior. Negative symptoms refer to behaviors that should be present but are not, including restriction or flattening in the range and intensity of emotion, reduced fluency and productivity of thought and speech, withdrawal and inability to initiate and persist in goal-directed activity, and inability to experience pleasure. Schizophrenia is considered the most disabling of the major mental disorders, with an estimated 2 million Americans afflicted. Risk factors include being unmarried and younger than 45 years for both men and women, having been the product of a difficult birth during the winter, and living in an industrialized urban area as a member of the lower socioeconomic class. Theories of causation include genetics, infectious autoimmune factors, neuroanatomic changes, the dopamine hypothesis, and psychologic factors. There are several subtypes of schizophrenia, including paranoid, disorganized, catatonic, undifferentiated, and residual.

Health care setting

Most patients with schizophrenia receive treatment across a variety of settings, including inpatient and partial hospitalization, day treatment, psychiatric home care, and crisis stabilization. Community services include assertive community treatment, outpatient therapy, case management, and psychosocial rehabilitation.

Assessment

Schizophrenia affects all aspects of a person’s being. How the individual looks, feels, thinks, interacts with others, and moves in the world are all drastically affected by this disorder. A thorough assessment focuses not only on the bizarre behaviors characteristic of the disease but on the whole person—his or her physical, emotional, social, and spiritual dimensions.

Biologic:

A thorough history and physical are essential to rule out medical illness or substance abuse that could cause the psychiatric symptoms. It is essential to screen for comorbid treatable medical illnesses. People with schizophrenia have a higher mortality rate from physical illness and often have smoking-related illnesses such as emphysema and other pulmonary and cardiac disorders. The patient may appear awkward and uncoordinated, with poor motor skills and abnormalities in eye tracking. It is important before any medications are begun to have a baseline regarding abnormal movements. Use of a standardized assessment of abnormal movement disorders such as the Abnormal Involuntary Movement Scale (AIMS) or the Simpson-Angus Rating Scale is recommended.

Psychologic:

Many patients report prodromal symptoms of tension and nervousness, lack of interest in eating, difficulty concentrating, disturbed sleep, decreased enjoyment and loss of interest, restlessness, forgetfulness, depression, social withdrawal from friends, feeling that others are laughing at them, feeling bad for no reason, thinking about religion more, hearing voices or seeing things, and feeling too excited. Most of these symptoms are negative ones.

Appearance:

Patient may appear in bizarre and eccentric dress, be disheveled, and have poor hygiene.

Objective behaviors:

Patient may display stereotypy (idiosyncratic, repetitive, purposeless movements), echopraxia (involuntary imitation of another’s movements), and waxy flexibility (posture held in odd or unusual fixed position for extended periods). Patients may display altered mood states ranging from heightened emotional activity to severely limited emotional responses. Affect, the outward expression of mood, may be described as flat, blunted, or full range, or it may be described as inappropriate. Other common emotional symptoms include affective lability, ambivalence, and apathy.

Delusions:

Delusions are beliefs that are held despite clear contradictory evidence. Sometimes they are nonbizarre and plausible; at other times the delusions expressed are bizarre, implausible, and not derived from ordinary life experiences. Delusions of persecution are the most common type. Delusions of grandeur are also commonly expressed. Ideas of reference are delusional ideas in which these patients believe actions of others are directed toward them. Two other forms of delusional thinking include thought broadcasting—the belief that one’s thoughts can be heard by others—and thought insertion—the belief that thoughts of others can be inserted into one’s mind. It is important to assess content of the delusion; the degree of conviction with which the delusion is held; how extensively other aspects of the patient’s life are incorporated into the delusion; the degree of internal consistency, organization, and logic evidenced in the delusion; and the impact exerted on the patient’s life by this delusion.

Hallucinations:

A hallucination is an alteration in sensory stimulation. Although hallucinations can be experienced in all sensory modalities, auditory hallucinations are the most frequent in schizophrenia. Patients may not spontaneously share their hallucinations, and in order to assess for them, nurses may need to rely on observations of the patient’s behavior, including pauses in a conversation during which the patient seems to be preoccupied or appears to be listening to someone other than the interviewer, looking toward the perceived source of a voice, or responding to the voices in some manner.

Disorganized communication:

Both speech content and patterns are important to assess. Abrupt shifts in conversational focus are typical of disorganized communication and are referred to as loose association. The most severe shifts may occur after only one or two words, referred to as word salad—a jumble of unrelated words; a less severe shift may occur after one or two phrases, referred to as flight of ideas; the least severe shift in the focus occurs when a new topic is repeatedly suggested and pursued from the current topic, referred to as tangentiality. In addition to these abrupt shifts from one topic to another, the person with schizophrenia experiences thought blocking in which thoughts and psychic activity unexpectedly cease. Language may be difficult to understand and may begin to serve as a tool of self-expression rather than a tool of communication. Sometimes the person creates completely new words, referred to as neologisms.

Cognitive impairments:

Although cognitive impairments vary widely from patient to patient, several problems are consistent across most patients; these include hypervigilance (increased and sustained attention on external stimuli over an extended time), a diminished ability to distinguish relevant from irrelevant stimuli, familiar cues going unrecognized or being improperly interpreted, and diminished information processing leading to inappropriate or illogical conclusions from available observations and information.

• Memory and orientation: Individuals with schizophrenia display impairments in memory and abstract thinking. Although orientation to time, place, and person remains relatively intact unless the person is preoccupied with delusions and hallucinations, all aspects of memory are affected in schizophrenia. Patients experience diminished ability to recall within seconds newly learned information. Short- and long-term memory are affected.

• Insight and judgment: Insight and judgment depend on cognitive functions that are frequently impaired in people with schizophrenia.

Social issues:

As the disorder progresses, individuals become increasingly socially isolated. People with schizophrenia have difficulty connecting with others on a one-to-one basis. Emotional blunting, inability to form emotional attachments, problems with face and affect recognition, inability to recall past interactions, problems making decisions and using appropriate judgment in difficult situations, and poverty of speech and language all serve to separate and isolate the individual.

Spiritual issues:

Persons with schizophrenia may experience delusions and hallucinations with religious content, and some health care providers tend to dismiss all religious verbalizations as psychotic expressions. However, the contrary is true. Religion and spirituality can be a source of comfort to patients dealing with a terrible disease. It is important to assess religious commitment, religious practices, and spiritual issues such as the meaning of the illness to the individual, the role of God, and sources of hope and support.

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Jul 18, 2016 | Posted by admin in NURSING | Comments Off

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