Schizophrenia

Schizophrenia Overview

  • Schizophrenia characterized by:

    • Distorted and bizarre thoughts

    • Perceptions

    • Emotions

    • Movements

    • Behavior

Categories of Symptoms (Box 16.1)

  • Positive (hard) symptoms:

    • Examples include:

    • Delusions: Strongly held false beliefs despite contradictory evidence.

    • Hallucinations: Sensory experiences without external stimuli.

  • Negative (soft) symptoms:

    • Examples include:

    • Flat affect: Lack of emotional expression.

    • Lack of volition: Decreased motivation or volition to perform tasks.

    • Inattention: Difficulty sustaining focus or attention.

Epidemiology

  • Diagnosis: Typically occurs in late adolescence or early adulthood.

    • Peak incidence of onset:

    • Men: Ages 15 to 25

    • Women: Ages 25 to 35

  • Prevalence: Estimated at about 1% of the total population.

  • Impact: In the United States, approximately 3 million people are affected, have been, or will be by the disease.

  • Schizoaffective disorder:

    • Clients are severely ill, displaying a mix of psychotic and mood symptoms.

Clinical Course

  • Onset:

    • Can be abrupt or insidious; however, most individuals exhibit a slow, gradual development of signs and symptoms.

  • Diagnosis: Often made when more positive symptoms of psychosis are present.

Immediate-Term Course

  • Two distinct patterns:

    • Ongoing psychosis with no full recovery.

    • Episodes of psychotic symptoms alternating with episodes of relative recovery.

Long-Term Course

  • Intensity of psychosis tends to diminish with age.

    • Disease becomes less disruptive over time; many clients may achieve independent living later in life.

    • Significant difficulties with community functioning persist for many.

Etiology of Schizophrenia

  • Biologic theories:

    • Genetic factors: Risk is polygenic, meaning multiple genes contribute to the risk of developing schizophrenia.

    • Neuroanatomic and neurochemical factors:

    • Observed less brain tissue and cerebrospinal fluid.

    • Excess of dopamine along with serotonin modulating dopamine levels.

    • Immunovirologic factors:

    • Considerations include viral exposure and cytokine involvement.

    • Research focuses on infections during pregnancy as potential origins, particularly post-influenza epidemics and respiratory illnesses.

Cultural Considerations

  • Cultural differences influence delusional beliefs; for example:

    • Ideas deemed delusional in one culture may be accepted in another.

    • Auditory or visual hallucinations can be normalized as part of religious experiences in some cultures.

  • Cultural concepts of distress:

    • These include idioms and expressions of distress and are not pathologic.

    • Ethnic differences affect responses to psychotropic medications.

Psychopharmacology Treatment

  • Conventional antipsychotics:

    • Mechanism: Dopamine antagonists.

    • Target: Positive symptoms only; no impact on negative symptoms.

  • Atypical antipsychotics:

    • Mechanism: Both dopamine and serotonin antagonists.

    • Benefit: Diminish positive symptoms and lessen negative symptoms.

Maintenance Therapy

  • Six antipsychotics available as long-acting (depot) injections:

    • Fluphenazine: in decanoate and enanthate preparations.

    • Haloperidol: available in decanoate form.

    • Risperidone, Paliperidone, Olanzapine, and Aripiprazole.

  • Transition to depot injections may require several weeks of stable oral therapy.

Side Effects of Psychopharmacology

Neurologic Side Effects (Common):

  • Extrapyramidal side effects include:

    • Acute dystonic reactions

    • Akathisia

    • Parkinsonism

    • Tardive dyskinesia

    • Seizures

    • Neuroleptic malignant syndrome

Nonneurologic Side Effects (Table 16.2):

  • Common nonneurologic side effects include:

    • Weight gain

    • Sedation

    • Photosensitivity

    • Anticholinergic symptoms:

    • Dry mouth

    • Blurred vision

    • Constipation

    • Urinary retention

    • Orthostatic hypotension

Psychosocial Treatment

  • Approaches include:

    • Individual and group therapy

    • Medication management and community support

    • Social skills training

    • Cognitive adaptation training

    • Cognitive enhancement therapy (CET)

    • Family education and therapy

Clinical Assessment in Schizophrenia

Assessment Components

  • History:

    • Age at onset of illness

    • Previous suicide attempts

    • Current support systems

    • Perception of the situation.

  • General appearance and behavior:

    • Can appear odd; may exhibit psychomotor retardation, word salad, echolalia, and latency of response.

  • Mood and affect:

    • Usually flat and blunted; anhedonia is common.

  • Thought process and content:

    • Signs of thought blocking, broadcasting thoughts, withdrawal, or insertion.

    • Presence of delusions (refer to Box 16.4).

  • Sensorium and intellectual processes:

    • Hallucinations that may encompass auditory, visual, olfactory, tactile, gustatory, cenesthetic, and kinesthetic experiences; depersonalization may be noted.

Additional Assessment Insights

  • Judgment and insight:

    • Typically impaired in schizophrenia.

  • Self-concept:

    • Often involves loss of ego boundaries.

  • Roles and relationships:

    • Usually marked by social isolation and frustrations in fulfilling family/community roles.

  • Physiological and self-care considerations:

    • Often see inattention to hygiene and grooming; failure to recognize physical sensations; polydipsia.