Jon Haws 2011
The word schizophrenia in itself means split mind and comes from a combination of two Greek words, schizo (split) and phrene (mind). This term was developed by Eugen Bleuler, a Swiss psychiatrist in 1911. Although psychiatrists had been visiting with, classifying, and attempting to treat patients with various signs and symptoms for many years, Bleuler was one of the first to subdivide schizophrenia into categories based on the patients presenting symptoms. Over the years schizophrenia has been further studied and subdivided into categories yet this highly complex disorder still holds much to be uncovered in the years to come.
There is a great deal of ambiguity concerning the precipitating factors of schizophrenia yet several hypotheses exist. These hypotheses can be further subdivided into biological and psychological and/or environmental contributing factors. Despite the complexity behind identifying a specific cause for schizophrenia it is acknowledged that schizophrenia is the result of “multiple inherited gene abnormalities combined with nongentic factors” (Walker and Tessner, 2008).
Biological and Family Characteristics
Certain biological factors also appear to lead to the development of schizophrenia including genetics, neurobiological factors, and structural abnormalities of the brain. Varcarolis and Halter (2010) explain that schizophrenia tends to develop at an increased rate in patients that are relatives of individuals diagnosed with schizophrenia, in fact individuals with a first degree relative diagnosed with schizophrenia are ten time more likely to develop the disorder in comparison with the general population. In twin studies it has been found that in identical twins there is a 50% concordance rate compared to just 15% in fraternal twins (Tandon et al., 2008). Given this information it becomes clear the importance of including family members in counseling sessions, not only to allow them the chance to understand how they might be able to aid their suffering family member, but so that they can understand and recognize the symptoms. According to Varcarolis and Halter (2010) “family education and family therapy improve the quality of life for the patient . . . and reduce the relapse rate for many patients”, for this reason it should be initiated early in the treatment plan.
Neurobiological theories are related primarily to imbalances between medications and neurotransmitters. It was found that antipsychotics that block dopamine receptor were able to reduce schizophrenic symptoms in patients, conversely, it was found that drugs which increase dopamine activity also gave rise to schizophrenic symptoms. Serotonin blockers have been found to reduce the signs of schizophrenia indicating a possible connection of serotonin in the development of schizophrenia. Glutamate, a neurotransmitter is also considered to play a role in the development of schizophrenia.
Structural Abnormalities of the Brain
With the advent of advanced imaging technology further insight into the cerebral structures of schizophrenic patients is now possible. It has been found that common structural abnormalities of the brain exist within some schizophrenic patients. These abnormalities include ventricular enlargement, reduced volumes, increased sulci size, and increased cerebrospinal fluid volumes.
There are four fundamental signs of schizophrenia as defined by Bleuler, they are referred to as the four A’s and include affect, associative looseness, autism, and ambivalence (Varcarolis & Halter, 2010). To expound, schizophrenia can cause flat, blunted behavior, disorganized thinking, illogical speech, thinking that is not bound to reality, hallucinations, and simultaneously holding two opposite emotions. Schizophrenia can be subdivided into three phases; the acute phase, the stabilization phase, and the maintenance phase. Generally patients progress through each of the three phases in order although individual patients will not experience the same symptoms given that patients can suffer from positive or negative symptoms. Positive symptoms include the presence of a behavior that is not normally present like paranoia. Negative symptoms are absent symptoms that are normally present and lacking at the time including lack of emotion. Symptoms can also be cognitive, thinking process, or affective, emotions. Positive expressions can include alterations in speech demonstrated as made up words (neologisms), repeating the words that people say (echolalia), or jumbling words (word salad). Positive symptoms may also present as alterations in perception including false perceptions of the environment, hallucinations, and hearing voices. Behaviors may also change and many patients exhibit catatonia or changes in motion or impaired impulse control. Common negative symptoms are a flat or blunted mood and can affects one’s ability to function at a normal level in society by causing a lack of energy possibly to the point of impeding the patient’s ability to provide proper hygiene and self care.
Schizophrenia is managed with antipsychotic medications. There are two groups of antipsychotic medications; conventional and atypical. Conventional antipsychotics are dopamine antagonists meaning that they block the dopamine receptors. Atypical antipsychotics are serotonin-dopamine antagonists meaning that they block serotonin and dopamine receptors. It generally takes about two to six weeks for antipsychotics to take effect and it has been shown that the vast majority of patients will respond to therapy. Prior to the use of antipsychotics schizophrenic patients were merely sedated and contained within mental institutions.
Atypical antipsychotics are the first line defense against schizophrenia as they have the ability to treat both the positive and negative symptoms and because they cause fewer extrapyramidal symptoms. Commonly used atypical antipsychotics include risperidone (Risperdal), quentiapine (seroquel), ziprasidone (Geodon), and apripiprazole (Abilify). Conventional antipsychotics are used less common because their likelihood to cause extrapyramidal symptoms, seizures, photosensitivity, and tardive dyskinesia. Drugs are chosen primarily based upon their side effects and if they are present in a given patient. It is important for nurses and physicians to consider all pharmacological therapy a patient is receiving especially if the patient is receiving other psychotropic drugs simultaneously. In a study done in Taiwan researchers found that a vast majority (79.2%) of schizophrenics were also taking benzodiazepines in conjunction with their antipsychotics, in these patients it was found that they suffered a much higher risk of neurocognitive side effects than other patients taking benzodiazepines (Wu et al, 2011). Below is a brief chart of some of the primary side effects associated with commonly given atypical antipsychotics.
Common Side Effects
|Aripiprazole (Abilify)||Agitation, akathisia, anxiety, constipation, headache, insomnia, lightheadedness, N/V|
|Quetiapine (Seroquel)||Dizziness, dry mouth, headache, somnolence, abdominal pain, constipation, dyspepsia, vomiting, fever|
|Risperidone (Risperdal)||Somnolence, insomnia, agitation, anxiety, rhinitis, headache|
|Ziprasidone (Geodon)||Somnolence, respiratory disorders, nausea, constipation, EPS, rash|
There are many possible nursing diagnoses that would apply to the schizophrenic patient due to the vast amount of presenting symptoms and possible medication side effects. Possible nursing diagnosis include; disturbed thought process, nonadherence to medication regimen and others, the focus here is on possible needs the patient might have concerning safety and well being. Below are two nursing diagnosis that would be appropriate for the schizophrenic patient.
Self care deficit related to extrapyramidal symptoms, motor retardation, catatonia
A primary outcome criterion for this patient would be to demonstrate improved ability to care for self as evidenced by the inability to provide self cares. This would require significant and intense interventions in order to aid the patient in developing the ability to care for self. The two primary interventions that would most aid the this patient would be set a specific schedule built around the times when the patient has fewest EPS and cognitive impairments are lowest. Medication side effects may be lower at given times and the patient will be able to determine a schedule of functional times thus being able to determine when they are most coherent and capable. Another important intervention would be to offer praise as the patient is able to slowly provide self care thus providing the patient with positive reinforcement and confidence in small accomplishments.
Risk for falls related to medication side effects and extrapyramidal symptoms
Injury and falls is a primary concern for any patient, but is of even greater concern for the mental health patient. The primary outcome criteria for this patient would be that the patient will not experience a fall while on the unit. In order to achieve this outcome the two interventions that should be implemented would be to place a fall risk bracelet on the client so that all staff is continually aware of the risk factor for this client and remain more vigilant of their condition. Secondly this patient should be properly oriented to the unit, their bedroom, the public areas and all other areas upon arriving to the floor to insure that they are familiar with all areas thus decreasing their risk for falling due to being unfamiliar and potential wandering leading to falls.
Patients with schizophrenia will require lifelong health care and vigilance from health care professional in order to manage and control symptoms. Teaching needs to be directed not only at the patient but the family should be included in all teaching and educational materials as well. Patients and families should be taught about the disease, the signs and symptoms, coping, and relapse prevention. In order to fully help the patient, a productive teaching plan would focus on secondary prevention and include teaching regarding medications their side effects, dosage, and method of action. Due to the uncomfortable side effects of antipsychotic medications many patients discontinue their use. In one study published in The American Journal of Psychiatry it was found that “Even brief periods of partial nonadherence lead to greater risk of relapse than what is commonly assumed” (Subotnik et al, 2011). Subotnik and his research associates found that patients in the early stages of schizophrenia who fail to take their prescribed risperidone have an increased risk of experiencing a return of positive symptoms. With this information in mind it becomes clear the importance of a well designed medication teaching plan. The plan would begin with instructing them about the signs and symptoms of schizophrenia to enable them to recognize the symptoms as they present. They should then be taught specifically regarding the medication that they are prescribed, for example if the patient is prescribed that they might expect to feel a strong desire to sleep upon taking the medication but that they also might experience insomnia. They should be taught that they may experience periods of anxiety and agitation. It is important that they understand the adverse effects in order to recognize them for what they are rather then to confuse them with possible worsening of their disease process. The patient should also be taught to call if they experience any severe adverse effects and to discuss them with their doctor as many schizophrenic patients are given the opportunity to try several antipsychotic drugs in an effort to minimize adverse effects. They should also know that the medication will take some time to take effects. Family members should be taught about the prescription and be encouraged to aid the patient in compliance with medication regimens. The patient should be instructed to never stop taking the medication even when the symptoms subside as these medications do not cure the disease. With this knowledge and assistance available the schizophrenic patient has a much improved chance of a more normal life free of symptoms. The nurse should always follow up with the patient regarding their medication and compliance with prescriptions and keep open channels of communication to allow the patient to express concerns.
Schizophrenia is a highly complex disorder requiring further research and understanding. Despite its complexity there are medications and therapies that have proven successful in aiding the patient to experience a far more normal life without becoming a slave to the disease. Nurses should educate themselves on the signs, symptoms, and side effects of the medications in order share their knowledge with patients and aid them in the healing process. When providing care for the schizophrenic client it is vital to maintain continual milieu therapy in order to allow the client the ability to always feel safe regardless of what phase they might be experiencing.
German, B., Luque, R., Villagran, J. (2003) Schizophrenia: A conceptual history. International Journal of Psychology and Psychological Therapy, 3(2), 111-140. Wu, C., Lin, Y., &
Liu, S. (2011). Benzodiazepine use among patients with schizophrenia in taiwan: a nationwide population-based survey. Psychiatric Services, 62(8), 908-914.
Subotnik, K., Nuechterlein, K., Ventura, J., Gitlin, M., Marder, S., Mintz, J., & … Singh, I. (2011). Risperidone nonadherence and return of positive symptoms in the early course of schizophrenia. American Journal of Psychiatry, 168(3), 286-292.
Tandon, R., Keshavan, M.S., & Nasrallah, H.A. (2008). Schizophrenia, “just the facts”: What we know in 2008, (part 2) epidemiology and etiology. Schizophrenia Research, 102(1-3), 1-18.
Varcarolis, E., Halter, M., (2010). Foundations of psychiatric mental health nursing: A clinical approach 6th edition. Elsevier, St. Louis
Walker, E., & Tessner, K. (2008). Schizophrenia. Perspectives on Psychological Science (Wiley-Blackwell), 3(1), 30-37.