Sally is a young girl suffering from schizophrenia. Schizophrenia is a psychotic disorder, or a group of disorders represented by a severe impairment of individual thought process, and behavior (TheFreeDictionary, 2012). According to Meyer, Chapman, and Weaver (2009) “it may be more accurate to refer to schizophrenia as a family of disorders rather than a singular disorder.” (p. 90). Untreated patients suffering from schizophrenia are normally unable to filter various sensory stimuli, and exhibit enhanced perception of color, sound, and other environmental factors. In most cases, a patient suffering from schizophrenia will gradually withdraw from personal interactions, and loose the ability to care for his or her individual basic needs (TheFreeDictionary, 2012). Schizophrenia is considered to be one of the top ten illnesses resulting in long-term disability, and accounts estimate that approximately 1% of the world population is affected by the illness (TheFreeDictionary, 2012).
The following analysis is designed to provide and analysis of the patient’s history, and events that resulted in her hospitalization. The analysis will provide the specifics of the patient’s biological, behavioral, cognitive, and emotional components that factor into her illness.
Schizophrenia includes three different subtype, and two over subtypes. The main subtypes include the classifications of paranoid, disorganized, and catatonic, and each of these subtypes displays unique characteristics or symptoms (Hansell, & Damour, 2008). Patients suffering from paranoid schizophrenia will usually display symptoms of hallucinations or delusions. Patients suffering from disorganized schizophrenia are subject to an inappropriate effect, and disorganized speech patterns. Patients suffering from catatonic schizophrenia display symptoms of strange or bizarre sensory motor function (Hansell, & Damour, 2008). Individuals who display symptoms of schizophrenia but lack any symptoms of the three primary classifications are likely to be diagnosed into one of two alternate classifications: residual or undifferentiated schizophrenia (Hansell, & Damour, 2008). Symptoms of schizophrenia are classified into two primary categories. These two categories relate to positive and negative symptoms. Patients displaying positive symptoms exhibit pathological excesses including hallucinations, irrational thinking, and irrational behaviors, whereas patients displaying negative symptoms will exhibit pathological deficits including withdrawal and isolation from social interactions, and poverty of speech capabilities ((Hansell, & Damour, 2008).
Schizophrenia is a complex illness that affects both men and women on an equal level. The illness usually starts around the age of ten, or in young adulthood. However, cases of childhood-onset schizophrenia indicates that the illness can start as young as five years of age. This is a more rare case of schizophrenia that can difficult to diagnose in relation to other childhood developmental problems (PubMedHealth, 2012). While researchers have yet to discover the cause of schizophrenia, many suspect genetics to be a major contributor (PubMedHealth, 20120).
The patient’s case study indicates that she has a history of eccentricity. Medical notations indicate that the patent's mother was an avid smoker, consuming approximately two packs of cigarets daily before and during pregnancy. Further notations include that the patient’s mother suffered from a very severe case of the flue during her fifth month of pregnancy. As a child, the patient showed signs of slower developmental skills, and was diagnosed as suffering from hyperactivity in early childhood. Records indicate that the patient experienced a turbulent home life because of ongoing conflicts between her parents that resulted in separation, and reconciliation. Because of her apparent developmental disabilities, her parents devoted time to the patient however, the patient did receive criticism from her father for her behavioral dysfunctions.
As the patient matured, she displayed signs of being socially awkward and isolated from her peers, and in early adulthood started to display worsening symptoms like talking to herself, and displaying unusual behavior like stating at the floor for long periods. Her first documented schizophrenia episode requiring hospitalization occurred shortly after the additional symptoms started to be displayed. During her examination, the patient displayed signs of unresponsiveness, and waxy flexibility that allowed her limbs to be easily positioned (Meyer, Chapman, & Weaver, 2009). After the initial hospitalization, the patient was returned home to facilitate a quicker recovery. that was short lived because the patient failed to follow the prescribed treatment regimen which, resulted in a secondary episode shortly after her return to college. Further home-based treatments proved unsuccessful as the patient slowly declined, resulting in unresponsiveness, and displaying hebephrenic symptoms like unprovoked giggling, and rocking movements (Meyer, Chapman, & Weaver, 2009).
The patient’s second hospitalization and treatments started to show positive results, and she was taken back to her home environment. She was able to obtain a part-time position at work, and maintain daily household chores. However, the patient failed to follow the prescribed treatment regimen. Following the death of her father, and additional stressors resulting from her mother’s added dependency, the patient suffered from a third regression of the illness. Her third hospitalization resulted from local law officials discovering her walking in a local pond while incoherently mumbling to herself.
Components of the Schizophrenic Episodes
The primary component of the patient’s episodes appear to be related to stress as the primary factor. However, biological factors resulting from her mother’s illness and smoking during pregnancy, and a genetic predisposition related to her grandfather's eccentricity are viable underlying factors resulting in the patient’s illness. In addition to the primary stressor, and the underlying genetic and biological factors, it is possible that the emotions of the patient also contributed to her condition. Further documentation indicates that interfamilial expressed emotion, and communication deviance are probably contributors that appear to be operative in the patient’s case (Meyer, Chapman, & Weaver, 2009). The first of these factors, expressed emotion would be explained by the turbulent relationship, combined with her mother’s over protective nature conflicting with her father’s over critical reactions to the patient’s behavioral issues (Meyer, Chapman, & Weaver, 2009). The second of these factors, communication deviance resulted from the patient’s inability to focus and maintain normal dialog with others (Meyer, Chapman, & Weaver, 2009).
Cognitive factors are a viable consideration for this patient’s case. Meyer, Chapman, and Weaver (2009) suggest that prodomal pruning theory may be one example of a cognitive factor. Prodomal pruning theory suggests that the human brain deletes unnecessary synapses to allow the brain to function properly during the change from adolescence to adulthood (Meyer, Chapman, & Weaver, 2009). Behavior is another factor relating to the patient’s repeated hospitalization. The patient displayed behavior deficiencies in regard to compliance to prescribed treatment regimens, and involvement in situations that could produce high level stressors in her life.
Because illnesses like schizophrenia relate to various and different factors, each person effected by the illness will show differences in ability to function in a normal environment. The various classifications of schizophrenia, ability to receive treatments, and the consideration of various influences and base-line factors help researchers determine what classification a patient falls into. In this particular case, the patient displays symptoms of catatonic schizophrenia. She is able to function in environments that do not produce high levels of demand or stress on the individual. However, the underlying assumptions would indicate that the combination of outlined biological, emotional, cognitive, and behavioral were in-place, and waiting for the appropriate stressor to trigger her symptoms.
b.Emotional Factors - Interfamilial Expressed, Emotion, Communication Deviance
d.Behavioral Factors - Lack of Treatment, High Stress Activities
Steve is a 23 year old accountant and comes to the clinic because he feels strange about feeling unmotivated. He said even eating feels like a chore. He confirmed not taking a bath for three days straight because the water feels like needles on his skin. At work, he verbalizes that someone is whispering at him and this causes him to lose his concentration. He is convinced his co-workers envy him so much that they are planning to take him down.
Despite it being one of the most common psychiatric disorders, schizophrenia is usually misunderstood. Here is how it is described and defined:
- Schizophreniarefers to a group of severe, disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, possible delusions and hallucinations, and emotional, behavioral, or intellectual disturbance.
- These disturbances last for at least for six (6) months. The level of functioning in work, interpersonal relationship, and self-care are markedly below the level since the onset of symptoms.
- Have difficulty distinguishing reality from fantasy. Their speech and behavior may frighten or mystify those around them.
Schizophrenia occurs in all societies without regard to class, color, and culture.
- It affects 1.1% of the population above age 18, which is estimated to be 51 million people worldwide.
- In the United States alone, 2 million Americans each year are affected, with 7.2 in 1000 persons developing it during their lifetime.
- Affects both men (late teens or early 20s) and women (mid-20s to early 30s) equally
- Prevalence is higher than diabetes mellitus, Alzheimer’s disease, and multiple sclerosis.
Like many diseases, schizophrenia is linked to various factors.
- Precise cause is unknown.
- There is currently no way to predict who will develop the disease.
- Genetic factors. It is believed that multiple genes (strongest evidence points to chromosomes 13 and 6) are involved in predisposition to schizophrenia. Other factors like prenatal infections, perinatal complications, and environmental stressors are also being studied. The manner of transmission of genetic predisposition is not clearly understood.
- Biochemical factors. Involves dopamine (focus of most studies), serotonin, norepinephrine, and epinephrine. Excessive dopamine activity is linked to hallucinations, agitation, and delusion. High norepinephrineis linked to positive symptoms of schizophrenia.
- Other factors include structural brain abnormalities (e.g. enlarged ventricles), developmental (e.g. faulty neuronal connections), and other possible causes (e.g. maternal influenza during second trimester of pregnancy, epilepsy of the temporal lobe, head injury, etc.)
Signs and Symptoms
Behaviors and functional deficiencies seen in schizophrenia vary widely among patients.
- Signs and symptoms are divided into three clusters: positive, negative, and cognitive symptoms.
- Positive symptoms are associated with temporal lobe abnormalities.
- Negative symptoms are associated with frontal cortex and ventricular abnormalities.
- Deviant symptoms. These are symptoms that are present but should be absent. They indicate that patient has lost touch with reality.
- Primarily include delusions and hallucinations.
- Hallucinations are the most common feature of schizophrenia. These involve hearing, seeing, smelling, tasting, and feeling touched by things in the absence of stimuli. An example is hearing voices that command the patient to do certain things, usually abusive and self-destructive.
- Delusions are fixed false beliefs. They cannot be changed by logic or persuasion. An example is a patient believing that people can read his mind. Several categories of delusions include:
- Persecutory delusions. Patient thinks he is being tormented, followed, tricked, or spied on.
- Reference delusions. Patient thinks that passages in books, music, TV shows, and other sources are directed at him.
- Delusions of thought withdrawal/thought insertion. Patient believes others can read his mind, his thoughts are being transmitted to others, or outside forces are imposing their thoughts or impulses on him.
- Deficit symptoms. These symptoms reflect the absence of normal characteristics.
- Apathy is lack of interest in people, things, and activities.
- Anhedonia is diminished capacity to feel pleasure.
- Blunted affect is characterized by patient’s face appearing immobile and inexpressive; this is the flattening of emotions and becomes more pronounced as the disease progresses.
- Poverty of speech is a speech that is brief and lacks content.
- Reflect the patient’s abnormal thinking, poor decision-making skills, poor problem-solving skills, and ability to communicate and his strange behavior.
- Thought disorder is characterized by confused thinking and speech (e.g., incoherent ramblings, loose association, word salad, wandering).
- Bizarre behavior include childlike silliness, laughing or giggling, agitation, inappropriate appearance, hygiene, and conduct.
Phases of Schizophrenia
Schizophrenia usually progresses through three distinct phases:
- Occurs before hospitalization or within the year.
- Characterized by clear decline from his previous level of functioning.
- May withdraw from friends and families and hobbies and interests, exhibit peculiar behavior, and deterioration in work and school performance.
- Commonly triggered by a stressful event
- Characterized by presence of acute psychotic symptoms (e.g. hallucinations, delusions, incoherence, and catatonic behaviors).
- Prognosis worsens with each acute episode.
- This is at this point in which illness pattern is established, disability level may be stabilized, and late improvements may occur.
Types of Schizophrenia
Schizophrenia is classified into five subtypes:
- Characterized by persecutory or grandiose delusional thought content and delusional jealousy.
- Stressmay worsen patient symptoms.
- Experience frequent auditory hallucinations but lack symptoms of other subtypes like incoherence, loose associations, and affect problems.
- Tend to be less severely disabled than other schizophrenics and are more responsive to treatments.
- Marked by incoherent, disorganized speech and behaviors, and blunted or inappropriate affect.
- Usually includes extreme social impairment.
- Starts early and insidiously, with no significant remissions.
“Knowing that you’re crazy doesn’t make the crazy things stop happening.”
–Mark Vonnegut, The Eden Express: A Memoir of Insanity
- A rare disease form characterized by fixed stupor or positions for long periods and periodically yielding to brief spurts of extreme excitement.
- Increased potential for destructive, violent behaviors when agitated.
- They remain mute and have refusal to move about or tend to personal needs.
- Presence of schizophrenic symptoms such as delusions and hallucinations in patients who does not fall to the category of the other subtypes.
- Muted form of the disease that stops short of recovery.
- No prominent psychotic symptoms.
- Has history of acute schizophrenic episodes and persistence of negative symptoms.
The basis for diagnosing schizophrenia is formed by mental status examination, psychiatry history, and careful clinical observation.
- Diagnostic test results. No definitive diagnostic tool for schizophrenia but certain tests like CT scan and MRI may be ordered to rule out disorders than can cause psychosis (e.g. vitamin deficiencies and enlarged ventricles).
- Ventricular-brain ratio may find elevated VBR in schizophrenic patients. Brain scans reveal functional cerebral asymmetries in a reverse pattern.
Here’s how schizophrenia is medically managed:
- Drug Therapy. Schizophrenia is mainly treated by antipsychotics (neuroleptic) drugs.
- These prevent relapse of acute symptoms.
- Psychotic symptoms must be present 12 to 24 months before patients receive their first medical treatment.
- Examples of these drugs include the typical or conventional typical antipsychotic chlorpromazine (Thorazine) and the atypical
- Electroconvulsive Therapy. Rarely used but is for patients with acute schizophrenia and those who can’t tolerate or don’t respond to medication. It is effective in reducing depressive and catatonic symptoms of schizophrenia.
- Other treatments include compliance promotion programs, psychosocial treatment and rehabilitation, vocational counseling, supportive psychotherapy, and appropriate use of community resources.
Here are the nursing responsibilities for taking care of patients with schizophrenia:
- Recognize schizophrenia. Note characteristic signs and symptoms of schizophrenia (e.g., speech abnormalities, thought distortions, poor social interactions).
- Establish trust and rapport. Don’t tease or joke with patients. Expect that patient is going to put you through rigorous testing periods. Introduce yourself and explain your purpose.
- Maximize level of functioning. Assess patient’s ability to carry out activities of daily living (ADLs).
- Assess positive symptoms. Assess for command hallucinations; explore answers. Assess if the client has fragmented, poorly organized, well-organized, systematized, or extensive system of beliefs that are not supported by reality. Assess for pervasive suspiciousness about everyone and their actions (e.g., vigilant, blames others for consequences of own behavior, argumentative, threatening).
- Assess negative symptoms. Assess for the negative symptoms of schizophrenia (as mentioned above).
- Assess medical history. Assess if the client is on medications, what these are, and adherence to therapy.
- Assess support system. Determine whether the family is well informed about the disease. Does the family understand the need for medication adherence?