Understanding Schizophrenia: Causes, Symptoms, and Prognosis

1. Chapter 15 Schizophrenia Spectrum and Other Psychotic Disorders

2. Introduction • The word schizophrenia is derived from the Greek words skhizo (split) and phren (mind).

3. Introduction (cont’d) • Schizophrenia is probably caused by a combination of factors, including • Genetic predisposition • Biochemical dysfunction • Physiological factors • Psychosocial stress

4. Introduction (cont’d) • Schizophrenia requires treatment that is comprehensive and presented in a multidisciplinary effort.

5. Introduction (cont’d) • Of all mental illnesses, schizophrenia probably causes more • Lengthy hospitalizations • Chaos in family life • Exorbitant costs to people and governments • Fears

6. Nature of the Disorder • Schizophrenia causes disturbances in • Thought processes • Perception • Affect

7. Nature of the Disorder (cont’d) • With schizophrenia, there is a severe deterioration of social and occupational functioning. • In the United States, the lifetime prevalence of schizophrenia is about 1 percent.

8. Nature of the Disorder (cont’d) • Premorbid behavior of the patient with schizophrenia can be viewed in four phases.

9. Phase I Premorbid phase • Social maladjustment • Antagonistic thoughts and behavior • Shy and withdrawn • Poor peer relationships • Doing poorly in school • Antisocial behavior

10. Phase II Prodromal phase • Lasts from a few weeks to a few years • Deterioration in role functioning and social withdrawal • Substantial functional impairment • Sleep disturbance, anxiety, irritability • Depressed mood, poor concentration, fatigue • Perceptual abnormalities, ideas of reference, and suspiciousness herald onset of psychosis

11. Phase III Schizophrenia • In the active phase of the disorder, psychotic symptoms are prominent • Delusions • Hallucinations • Impairment in work, social relations, and self-care

12. Phase IV Residual phase • Symptoms similar to those of the prodromal phase • Flat affect and impairment in role functioning are prominent

13. Prognosis • A return to full premorbid functioning is not common • Factors associated with a positive prognosis include • Good premorbid functioning • Later age at onset • Female gender • Abrupt onset precipitated by a stressful event • Associated mood disturbance • Brief duration of active-phase symptoms

14. Prognosis (cont’d) • Factors associated with a positive prognosis (cont’d) • Minimal residual symptoms • Absence of structural brain abnormalities • Normal neurological functioning • Family history of mood disorder • No family history of schizophrenia

15. Predisposing Factors Biological influences • Genetics • A growing body of knowledge indicates that genetics plays an important role in the development of schizophrenia

16. Predisposing Factors (cont’d) Biological influences (cont’d) • Biochemical influences • One theory suggests that schizophrenia may be caused by an excess of dopamine activity in the brain • Abnormalities in other neurotransmitters have also been suggested

17. Predisposing Factors (cont’d) Biological influences (cont’d) • Physiological influences • Factors that have been implicated include • Viral infection • Anatomical abnormalities • Histological changes in brain

18. Predisposing Factors (cont’d) • Physiological influences (cont’d) • Various physical conditions • Epilepsy • Huntington’s disease • Birth trauma • Head injury in adulthood • Alcohol abuse • Cerebral tumor • Cerebrovascular accident • Systemic lupus erythematosus • Myxedema • Parkinsonism • Wilson’s disease

19. Predisposing Factors (cont’d) Psychological influences • These theories no longer hold credibility. Researchers now focus their studies of schizophrenia as a brain disorder. • Psychosocial theories probably developed early on out of a lack of information related to a biological connection.

20. Predisposing Factors (cont’d) Environmental influences • Sociocultural factors: Poverty has been linked with the development of schizophrenia. • Downward drift hypothesis:Poor social conditions seen as consequence of, rather than a cause of, schizophrenia.

21. Predisposing Factors (cont’d) Environmental influences (cont’d) • Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse.

22. Predisposing Factors (cont’d) Theoretical integration • Schizophrenia is most likely a biologically based disease, the onset of which is influenced by factors in the internal or external environment.

23. Types of Schizophrenia and Other Psychotic Disorders • Delusional Disorder • The existence of prominent, non-bizarre delusions • Erotomanic type • Grandiose type • Jealous type • Persecutory type • Somatic type • Mixed type

24. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Brief Psychotic Disorder • Sudden onset of symptoms • May or may not be preceded by a severe psychosocial stressor • Lasts less than 1 month • Return to full premorbid level of functioning

25. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Substance-Induced Psychotic Disorder • The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal

26. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Psychotic Disorder Associated with Another Medical Condition • Prominent hallucinations and delusions are directly attributable to a general medical condition

27. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • The Catatonic Features Specifier • Catatonic features may be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder • Symptoms of catatonic disorder include • Stupor and muscle rigidity or excessive, purposeless motor activity • Waxy flexibility, negativism, echolalia, echopraxia

28. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Catatonic Disorder Associated with Another Medical Condition • This diagnosis is made when the catatonic symptoms are directly attributable to the physiological consequences of a general medical condition

29. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Schizophreniform Disorder • Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months

30. Types of Schizophrenia and Other Psychotic Disorders (cont’d) • Schizoaffective Disorder • Schizophrenic symptoms accompanied by a strong element of symptomatology associated with the mood disorders, either mania or depression

31. Types of Schizophrenia and Other Psychotic Disorders (cont’d) 1. A client is admitted with a diagnosis of brief psychotic disorder, with catatonic features. Which symptoms are associated with the catatonic specifier? a) Strong ego boundaries and abstract thinking b) Ataxia and akinesia c) Stupor, muscle rigidity, and negativism d) Substance abuse and cachexia

32. Types of Schizophrenia and Other Psychotic Disorders (cont’d) Correct answer: C Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors.

33. Nursing Process: Assessment Positive symptoms • Content of thought • Delusions: false personal beliefs • Religiosity: excessive demonstration of obsession with religious ideas and behavior • Paranoia: extreme suspiciousness of others • Magical thinking: ideas that one’s thoughts or behaviors have control over specific situations

34. Assessment: Positive Symptoms (cont’d) • Form of thought • Associative looseness (also called loose association): shift of ideas from one unrelated topic to another • Neologisms: made-up words that have meaning only to the person who invents them • Concrete thinking: literal interpretations of the environment • Clang associations: choice of words is governed by sound (often rhyming)

35. Assessment: Positive Symptoms (cont’d) • Form of thought (cont’d) • Word salad: group of words put together in a random fashion • Circumstantiality: delay in reaching the point of a communication because of unnecessary and tedious details • Tangentiality: inability to get to the point of communication due to introduction of many new topics • Mutism: inability or refusal to speak

36. Assessment: Positive Symptoms (cont’d) • Form of thought (cont’d) • Perseveration: persistent repetition of the same word or idea in response to different questions

37. Assessment: Positive Symptoms (cont’d) 2. The client hears the word “match.” The client replies, “A match. I like matches. They are the light of the world. God will light the world. Let your light so shine.” Which communication pattern does the nurse identify? a) Word salad b) Clang association c) Loose association d) Ideas of reference

38. Assessment: Positive Symptoms (cont’d) Correct answer: C Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question represents this communication pattern.

39. Assessment: Positive Symptoms (cont’d) • Perception: interpretation of stimuli through the senses • Hallucinations: false sensory perceptions not associated with real external stimuli • Auditory • Visual • Tactile • Gustatory • Olfactory • Illusions: misperceptions of real external stimuli

40. Assessment: Positive Symptoms (cont’d) • Sense of self: The uniqueness and individuality a person feels • Echolalia: repeating words that are heard • Echopraxia: repeating movements that are observed • Identification and imitation: taking on the form of behavior one observes in another • Depersonalization: feelings of unreality

41. Assessment: Positive Symptoms (cont’d) 3. A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech? a) Identify with the person speaking b) Imitate the nurse’s movements c) Alleviate alogia d) Alleviate avolition

42. Assessment: Positive Symptoms (cont’d) Correct answer: A Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.

43. Assessment: Negative Symptoms • Affect: the feeling state or emotional tone • Inappropriate affect: emotions are incongruent with the circumstances • Bland: weak emotional tone • Flat: appears to be void of emotional tone • Apathy: disinterest in the environment

44. Assessment: Negative Symptoms (cont’d) • Volition:impairment in the ability to initiate goal-directed activity • Emotional ambivalence: coexistence of opposite emotions toward same object, person, or situation • Deterioration in appearance: impaired personal grooming and self-care activities

45. Assessment: Negative Symptoms (cont’d) • Impaired interpersonal functioning and relationship to the external world • Impaired social interaction: clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable • Social isolation: a focus inward on the self to the exclusion of the external environment

46. Assessment: Negative Symptoms (cont’d) • Psychomotor behavior • Anergia: deficiency of energy • Waxy flexibility: passive yielding of all movable parts of the body to any effort made at placing them in certain positions • Posturing: voluntary assumption of inappropriate or bizarre postures • Pacing and rocking: pacing back and forth and rocking the body

47. Assessment: Negative Symptoms (cont’d) • Associated features • Anhedonia: inability to experience pleasure • Regression: retreat to an earlier level of development

48. Nursing Process: Diagnosis/Outcome Identification • Disturbed Sensory Perception (auditory and visual) related to panic anxiety, extreme loneliness, and withdrawal into self • Disturbed Thought Processes related to inability to trust, panic anxiety, or possible hereditary or biochemical factors

49. Nursing Diagnosis (cont’d) • Social Isolation related to inability to trust, panic anxiety, weak ego development, delusional thinking, regression

50. Nursing Diagnosis (cont’d) • Risk for Violence: Self-directed or Other-directed related to • Extreme suspiciousness • Panic anxiety • Catatonic excitement • Rage reactions • Command hallucinations