Schizophrenia is characterized by disturbances (for at least 6 months) in thought content and form, perception, affect, sense of self, volition, interpersonal relationships, and psychomotor behavior. (See Phases of schizophrenia, page 440.) The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), recognizes paranoid, disorganized, catatonic, undifferentiated, and residual schizophrenia. Onset of symptoms usually occurs during adolescence or early adulthood. The disorder produces varying degrees of impairment. Up to one-third of patients with schizophrenia have just one psychotic episode and no more. Some patients have no disability between periods of exacerbation; others need continuous institutional care. The prognosis worsens with each episode.
Schizophrenia affects 1% to 2% of the population in the United States and is equally prevalent in both sexes. It may result from a combination of genetic, biological, cultural, and psychological factors. Some evidence supports a genetic predisposition. Close relatives of people with schizophrenia have a greater likelihood of developing schizophrenia; the closer the degree of biological relatedness, the higher the risk.
The most widely accepted biochemical theory holds that schizophrenia results from excessive activity at dopaminergic synapses. Other neurotransmitter alterations, such as serotonin increases, may also contribute to schizophrenic symptoms. In addition, patients with schizophrenia have structural abnormalities of the frontal and temporolimbic systems. Computed tomography scans and magnetic resonance imaging studies show various structural brain abnormalities, including frontal lobe atrophy and increased lateral and third ventricles. Positron emission tomography scans substantiate frontal lobe hypometabolism.
Numerous psychological and sociocultural causes, such as disturbed family and interpersonal patterns, also have been proposed. Schizophrenia is more common in lower socioeconomic groups, possibly due to downward social drift, lack of upward socioeconomic mobility, and high stress levels that may stem from poverty, social failure, illness, and inadequate social resources. Higher incidence is also linked to low birth weight and congenital deafness.
Schizophrenia is associated with many abnormal behaviors; therefore, signs and symptoms vary widely, depending on the type and phase (prodromal, active, or residual) of the illness.
Watch for these signs and symptoms:
❑ ambivalence — coexisting strong positive and negative feelings, leading to emotional conflict
❑ apathy and other affective abnormalities
❑ clang associations — words that rhyme or sound alike used in an illogical, nonsensical manner — for instance, “It’s the rain, train, pain”
❑ concrete associations — inability to form or understand abstract thoughts
❑ delusions — false ideas or beliefs accepted as real by the patient; delusions of grandeur, persecution, and reference (distorted belief regarding the relation between events and one’s self — for example, a belief that television programs address the patient on a personal level); feelings of being controlled, somatic illness, and depersonalization
❑ echolalia — automatic and meaningless repetition of another’s words or phrases
❑ echopraxia — involuntary repetition of movements observed in others
❑ flight of ideas — rapid succession of incomplete and loosely connected ideas
❑ hallucinations — false sensory perceptions with no basis in reality; usually visual or auditory, but may also be olfactory (smell), gustatory (taste), or tactile (touch)
❑ illusions — false sensory perceptions with some basis in reality; for example, a car backfiring mistaken for a gunshot
❑ loose associations — rapid shifts among unrelated ideas
❑ magical thinking — belief that thoughts or wishes can control others or events
❑ neologisms — bizarre words that have meaning only for the patient
❑ poor interpersonal relationships
❑ regression — return to an earlier developmental stage
❑ thought blocking — sudden interruption in the patient’s train of thought
❑ withdrawal — disinterest in objects, people, or surroundings
❑ word salad — illogical word groupings, such as “She had a star, barn, plant.”
After a complete physical and psychiatric examinations rule out an organic cause of symptoms such as an amphetamine-induced psychosis, a diagnosis of schizophrenia may be considered. A diagnosis is made if the patient’s symptoms match those in the DSM-IV-TR. (See Diagnosing schizophrenia, page 442.)
In schizophrenia, treatment focuses on meeting the physical and psychosocial needs of the patient, based on his previous level of adjustment and his response to medical and nursing interventions. Treatment may combine drug therapy, long-term psychotherapy for the patient and his family, psychosocial rehabilitation, vocational counseling, and the use of community resources.
The primary treatment for more than 30 years, antipsychotic drugs (also called neuroleptic drugs) appear to work by blocking postsynaptic dopamine receptors. These drugs reduce the incidence of positive psychotic symptoms, such as hallucinations and delusions, and relieve anxiety and agitation. Newer antipsychotics are effective in relieving positive and negative symptoms of schizophrenia. Other psychiatric drugs, such as antidepressants and anxiolytics, may control associated signs and symptoms.
Certain antipsychotic drugs are associated with numerous adverse reactions, some of which are irreversible. (See Reviewing adverse effects of antipsychotic drugs, page 443.) The newer antipsychotic drugs appear to be effective in treating the negative symptoms of schizophrenia (withdrawal, apathy, or blunted affect). Antipsychotic drugs are broken down into two major classes: dopamine receptor antagonists (haloperidol and thorazine) and dopamine-serotonin antagonists, also called atypical antipsychotics (risperidone and clozapine). The long-acting medications haloperidol and fluphenazine may be given I.M. every 3 to 4 weeks to improve compliance.
Clozapine may be prescribed for severely ill patients who fail to respond to standard treatment. This agent effectively controls more psychotic signs and symptoms without the usual adverse effects. However, clozapine can cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, and seizures. Agranulocytosis, a potentially fatal blood disorder characterized by a low white blood cell count and pronounced neutropenia, may also occur; therefore, patients on clozapine must be monitored closely with frequent complete blood counts. Risperidone and olanzapine, like clozapine, have reduced the incidence of adverse effects, including extrapyramidal symptoms and anticholinergic adverse effects.
Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If caught in the early stages, this disorder is reversible.
Clinicians disagree about the effectiveness of psychotherapy in treating schizophrenia. Some consider it a useful adjunct to drug therapy. Others suggest that psychosocial rehabilitation, education, and social skills training are more effective for chronic schizophrenia. In addition to improving understanding of the disorder, these methods teach the patient and his family coping strategies, effective communication techniques, and social skills.
Because schizophrenia typically disrupts the family, family therapy may be helpful to reduce guilt and disappointment as well as improve acceptance of the patient and his bizarre behavior.
❑ Assess the patient’s ability to carry out activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn’t eating. If he thinks that his food is poisoned, let him fix his own food when possible or offer foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.
❑ Maintain a safe environment, minimizing stimuli. Administer prescribed medications to decrease symptoms and anxiety. Use physical restraints according to your hospital’s policy to ensure the patient’s safety and that of others.
❑ Adopt an accepting and consistent approach with the patient. Short, repeated contacts are best until trust has been established.
❑ Avoid promoting dependence. Reward positive behavior to help the patient improve his level of functioning.
❑ Engage the patient in reality-oriented activities that involve human contact, such as inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Explain to the patient that his private language, autistic inventions, or neologisms aren’t understood. Set limits on inappropriate behavior.
❑ If the patient is hallucinating, explore the content of the hallucinations. If he hears voices, find out if he believes that he must do what they command. Explore the emotions connected with the hallucinations, but don’t argue about them. If possible, change the subject.
❑ Assist the patient to recognize the nonreality of his hallucinatory experience.
❑ Teach the patient techniques that interrupt the hallucinations (listening to an audiocassette player, singing out loud, or reading out loud).
❑ Don’t tease or joke with a patient with schizophrenia. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who’s told, “That procedure will be done on the floor,” may become frightened, thinking he’ll need to lie down on the floor.
❑ If the patient expresses suicidal thoughts, institute suicide precautions. Document his behavior and your actions.
❑ If he’s expressing homicidal thoughts (for example, “I have to kill my mother”), institute homicidal precautions. Notify the physician and the potential victim. Document the patient’s comments and the names of those who were notified.
❑ Don’t touch the patient without telling him first exactly what you’re going to do — for example, “I’m going to put this cuff on your arm so I can take your blood pressure.”
❑ If necessary, postpone procedures that require physical contact with hospital personnel until the patient is less suspicious or agitated.
❑ Remember, institutionalization may produce symptoms and disabilities that aren’t part of the patient’s illness, so evaluate symptoms carefully.
❑ Mobilize community resources to provide a support system for the patient. Ongoing support is essential to his mastery of social skills.
❑ Encourage compliance with the medication regimen to prevent a relapse. Also, monitor the patient carefully for adverse reactions to drug therapy, including acute dystonia, drug-induced parkinsonism, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Document and report such reactions promptly.
❑ Help the patient explore possible connections between anxiety and stress and the exacerbation of symptoms.
For catatonic schizophrenia:
❑ Assess for physical illness. Remember that the mute patient won’t complain of pain or physical symptoms; if he’s in a bizarre posture, he’s at risk for pressure ulcers or decreased circulation to a body area.
❑ Meet the patient’s physical needs for adequate food, fluid, exercise, and elimination; follow orders with respect to nutrition, urinary catheterization, and enema.
❑ Provide range-of-motion exercises for the patient or help him ambulate every 2 hours.
❑ Prevent physical exhaustion and injury during periods of hyperactivity.
❑ Tell the patient directly, specifically, and concisely which procedures need to be done. For example, you might say to the patient, “It’s time to go for a walk. Let’s go.” Don’t offer the negativistic patient a choice.
❑ Spend some time with the patient even if he’s mute and unresponsive. He’s acutely aware of his environment even though he seems not to be. Your presence can be reassuring and supportive.
❑ Verbalize for the patient the message that his nonverbal behavior seems to convey; encourage him to do so as well.
❑ Offer reality orientation. You might say, “The leaves on the trees are turning colors and the air is cooler. It’s fall!” Emphasize reality in all contacts to reduce distorted perceptions.
❑ Stay alert for violent outbursts; if they occur, get help promptly to ensure the patient’s safety and your own.
For paranoid schizophrenia:
❑ When the patient is newly admitted, minimize his contact with the hospital staff.
❑ Don’t crowd the patient physically or psychologically; he may strike out to protect himself.
❑ Be flexible; allow the patient some control. Approach him in a calm and unhurried manner. Let him talk about anything he wishes initially, but keep the conversation light and social. Avoid entering into power struggles.
❑ Respond to the patient’s condescending attitudes (arrogance, put-downs, sarcasm, or open hostility) with neutral remarks.
❑ Don’t let the patient put you on the defensive, and don’t take his remarks personally. If he tells you to leave him alone, do leave but return soon. Brief contacts with the patient may be most useful at first.
❑ Don’t make attempts to combat the patient’s delusions with logic. Instead, respond to feelings, themes, or underlying needs — for example, “It seems you feel you’ve been treated unfairly.”
❑ Be honest and dependable. Don’t threaten the patient or make promises that you can’t fulfill.
❑ If the patient is taking clozapine, stress the importance of returning weekly or biweekly to the hospital or an outpatient setting to have his blood monitored.
❑ Teach the patient the importance of complying with the medication regimen. Tell him to report any adverse reactions instead of discontinuing the drug. If he takes a slow-release formulation, make sure that he understands when to return to the physician for his next dose.
❑ Involve the patient’s family in his treatment. Teach them how to recognize an impending relapse, and suggest ways to manage symptoms, such as tension, nervousness, insomnia, decreased ability to concentrate, and apathy.
Review other book chapters online related to Childhood-Onset Schizophrenia:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X 
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