Understanding and Caring for People with Schizophrenia

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The following course content

Introduction   

Schizophrenia is a chronic mental disorder that causes changes in an individual’s thinking, behavior, and how they process information due to experiencing delusions, hallucinations, and disorganized speech. People with schizophrenia make up approximately 1% of the world’s population (20 million) (1). Schizophrenia causes a tremendous burden on the health, social, and economic status not only for patients but for their families, caregivers, and society. 

Treating a patient experiencing schizophrenic symptoms is an extraordinarily complex task, and in some cases, it can take years before the patient responds to the therapy. Schizophrenia is more prevalent in men than in women, and both experience different types and symptoms, but the effects are equal. People with schizophrenia are two to three times more likely to die earlier than the general population because they will not seek medical treatment for preventable physical diseases such as cardiovascular diseases, infections, or metabolic diseases (1). People with schizophrenia require lifelong treatment, and the care they receive is essential to their recovery.  

Case Studies

Case Study #1

Stephanie is a 56-year-old mother of four and recently widowed. She started experiencing psychotic symptoms in her early 20s and has lived with them for over 30 years. Stephanie first started experiencing delusions and hallucinatory voices after her second child’s birth and the death of her parents, who died in a car crash. Her mother suffered from major depression after years of drug abuse and her father suffered from PTSD. Stephanie has been treated as an inpatient in treatment facilities for her psychiatric symptoms as well as outpatient facilities.  

She is experiencing a relapse of her psychiatric symptoms because of her husband of 32 year’s recent passing. Stephanie described her husband as a loving, kind, gentle spirit that would do anything for anyone in need, however, her symptoms resurfaced in the form of hallucinatory voices of him calling her an abusive mother and promiscuous. The voices tell her to harm her children in various ways and seek a relationship with married men. Stephanie is a devout Catholic and is very disturbed by the commands of the voices.  

Over time, Stephanie was able to gain control of the hallucinatory voices with medication and her family’s help. Although the voices have fluctuated and stayed with her, she has worked hard at keeping them under control. Her husband‘s death has caused her to have an increase in positive symptoms as well as negative symptoms. Stephanie’s family has decided to have her committed against her will because of recent suicidal ideations. The medications that she is taking have not had the desired effect on her positive symptoms but have also increased her negative symptoms. Her psychotic symptoms have gained dominance over her abilities as a mother, wife, and individual.  

Case Study #2 

Larry is a young man that was diagnosed with learning disabilities at age 6. He was sent to a special school for people with learning disabilities and was told he was quite different from the rest of his family. Larry’s uncle was diagnosed with manic depressive disorder, and his mother has always been very demanding and controlling of everyone in the household.  

As Larry transitioned into his teen years, he started experimenting with marijuana, opiates, alcohol, and other mind-altering drugs. He participated in a work program for adults with learning disabilities that helps them transition into every day, sustainable living. From there, he moved into a shared home that housed other adults with learning disabilities and began to experience florid psychotic symptoms. Larry began to believe that everyone there was trying to poison him because they thought he was a murderer. His family tried to help him, but his mental experiences became more frequent and to the point of him needing full inpatient admission.  

While in the hospital, he was sitting up all night because he believed he had to protect everyone from the outside world. Larry’s paranoia was heightened when he learned that the facility he was in was over 100 miles away from his family. When his family came to visit, he would appear frightened and informed them that his roommates were stealing from him and physically abusing him; they removed him from the facility. Larry’s family had his services transferred to their general practitioner, who then referred him to a primary care mental health service.  

Despite all efforts, Larry has not responded to any type of therapy, and spends his days drinking alcohol and watching television. He refuses to take any medication because of his suspicions and continues to stay up all night trying to protect his family from gangsters. Larry feels as though there is no help for him and his mental health. 

Throughout the course, please refer to the case studies above to answer the exercise questions.  

Definition 

Although Emil Kraepelin, from the late 19th century, was the first individual to distinguish schizophrenia from other forms of psychosis in 1887, the oldest available description of an illness closely resembling schizophrenia was found in Ebers papyrus dating back to Egypt in 1550 BCE. There have been some archaeological findings from the Stone Age with skulls with burr holes drilled into them presumably to release evil spirits; those findings have led to the speculation that schizophrenia is as old as humankind (10). 

Today, we still have facilities for mental illness patients, and not much has changed in the prevalence and disability of schizophrenia (10). In the past, this disorder was determined to be a psychotic reaction due to rejection, an ambivalent mother, or evil spirits that have invaded the individual’s body (10). 20th century Swiss psychiatrist, Paul Eugene Bleuler, coined the term schizophrenia from the Greek word schizo (split) and phren (mind). He intended the term to mean losing thoughts and feelings, but the public took it to mean split personality (10).  Contrary to most beliefs, schizophrenia is not a split or multiple personality disorder (10).  

Schizophrenia is a chronic severe mental disorder that affects how a person thinks, expresses emotions, perceives reality, and relates to others (2). People with this disorder often have problems blending in with society whether at work, school, or in their relationships. They feel frightened, withdrawn, and can appear to have lost touch with reality. Schizophrenia involves psychosis which is a type of mental illness in which a person cannot tell what is real from what is imagined (2). People with schizophrenia lose touch with reality, and the world appears like a jumble of emotions, thoughts, images, and sounds. Men often experience initial symptoms in their late teens or early 20s, while women tend to show the first signs of the illness in their 20s and early 30s. Early more subtle signs that may be present include troubled relationships, reduced motivation, and poor school performance (2).  

The severity of schizophrenia varies from person to person. Individuals may have one episode while others have multiple lifetime episodes but tend to lead a normal life in between. Schizophrenia symptoms can get worse or improve in cycles, and this is known as relapse and remissions.  

Symptoms 

Schizophrenia is characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behaviors, decreased participation in daily activities. Although the exact signs and symptoms can vary with everyone, most symptoms in people with schizophrenia can be categorized into subsections including behavioral, cognitive, mood, psychological, speech, and miscellaneous (3). 

Behavioral

These symptoms include disorganized behavior, aggression, compulsive behavior, repetitive movements, agitation, social isolation, lack of restraint, hostility, and excitability (3). 

Cognitive

These symptoms include thought disorder, delusions, amnesia, mental confusion, false belief of superiority, disorientation, slow in performing activities, belief that their thoughts are someone else’s thoughts, belief that every day events have special meanings behind them (3). 

Mood

Their symptoms include anger, anxiety, apathy, feeling detached from self, elevated mood or inappropriate emotional response, lack of interest or pleasure in any activities, and general discontent (3). 

Psychological

These symptoms include hallucinations, paranoia, hearing voices, depression, fear, persecutory delusions, or religious delusions (3). 

Speech

These symptoms are categorized by circumstantial speech, incoherent speech, rapid and frenzied speech, or speech disorder (3). 

Miscellaneous

These symptoms can include fatigue, impaired motor function, lack of emotional response, or memory loss (3). 

Following, the DSM–5 categorizes the symptoms of people with schizophrenia as positive or negative. 

Positive Symptoms

When dealing with mental health symptoms, the word positive does not mean something good. It refers to increased thoughts or actions that are not based (4). Positive symptoms in people with schizophrenia are related to over-stimulation of interval timing, an understanding that their time perception may be associated with psychosis (5). Positive symptoms can include the following: 

Delusions

Mixed strange false beliefs that are not based, and the person refuses to give up those beliefs when shown true facts (4). 

Hallucinations

Involve various sensations that are not real. The most common hallucination that people experience is hearing auditory voices. Those voices will sometimes comment on the person’s behavior, say things that insult them, or give commands. Some people with schizophrenia may experience visual hallucinations, but it is less common. Additionally, they may also experience smelling strange orders, verbalize having a funny taste in their mouth, or a feeling of sensation on their skin, although nothing is visibly touching them (4). 

Catatonia

This a condition in which the person may stop speaking and their body may be fixed in a single position for an exceptionally long time (4). 

Disorganized

This symptom showcases that a person cannot think clearly or respond as expected. Usually, this is due to the person using nonsense words, shifting quickly from one thought to another without any logical connection, moving slowly, unable to make decisions, writing excessively but without any meaning, forgetting, losing things frequently, repeated movements or gestures, having problems making sense of everyday sounds, feelings, or sight (4). 

When a patient is experiencing positive symptoms, they have trouble understanding information or making decisions, focusing, paying attention, using their information immediately after learning, or recognizing that they have any of these problems. 

Negative Symptoms

When dealing with mental health symptoms, the word negative does not mean bad. Negative just means that there is an absence of normal behaviors in people with schizophrenia. The person experiencing negative symptoms will have a lack of emotion or a limited range of emotions, less energy, loss of pleasure or interest in life, poor hygiene and grooming habits, less speaking, and an obvious withdrawal from family friends and social activities (4). 

Causes and Risk Factors of Schizophrenia  

Although the actual cause of schizophrenia remains unclear, physicians know that the etiology of the disorder is multifactorial and has genetic and environmental factors. The most significant risk factor for people with schizophrenia is having a first degree relative with schizophrenia. Various studies have concluded that the interaction of genetic risk (parent with the disorder) with environmental risk (a mother experiencing depression along with another mental disorder) significantly increases the likelihood by least 9 times that the individual will have schizophrenia (5).  

Maternal depression during pregnancy significantly increases the risk of schizophrenia in offspring if one of the parents has a psychotic disorder (5). It is believed that the genetic risk of schizophrenia presents itself in two ways. The first is the polygenetic interaction of multiple common variants of thousands of genes and the second is rare but included highly penetrant genetic events such as deletions or duplications of several variations (5). Researchers believe that hormones and physical changes in the body can be a factor leading to schizophrenia because the symptoms of the disorder usually begin in young adults during a time of major change; puberty going into adulthood, for example (10). 

Traditionally the pathophysiology of schizophrenia has been associated with abnormalities in dopamine (DA) transmissions, which in turn, have been linked to the speed of the internal clock. Several studies have demonstrated dopamine receptors agonist accelerate the internal clock while antagonist decelerates it (6). Schizophrenia currently is thought to be a very subtle neurodevelopmental disorder of brain connectivity. It is likely an abnormal developmental trajectory of synapse and circuit formation that ultimately leads to brain miswiring and clinical symptoms (5).  

The over-stimulation of time has been thought to be caused by accelerated time processing which may be linked to the hypervigilance state that has been implicated in positive symptoms of schizophrenia. Hypervigilance is a mental state in which intention to external stimuli is exaggerated. The environmental causes of schizophrenia include infection, depression/stress, exposure to toxins and viruses while the individual is still in the womb, increased activation of the immune system, the use of mind-altering drugs, especially during the teen and young adult years (6).  

DSM-5 Criteria for Diagnosis of Schizophrenia 

Before a diagnosis can be made, the physician must perform a full medical examination to rule out other neurological or medical illnesses that may have symptoms like schizophrenia. It is also important to rule out substance abuse prior to making a diagnosis (8).  

The criteria in the DSM-5 specifies that a patient is always required to have at least two characteristic symptoms. The patient must have at least two symptoms that cause a continuous disturbance (attenuated symptoms, residual symptoms) for at least six months, and those symptoms are delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (7). The patient must be experiencing active symptoms during the six months, and the symptoms should negatively affect them socially or occupationally, and the symptoms cannot be the result of a different condition (7). The patient is also required to have at least one of the following positive symptoms: delusions, hallucinations, or disorganized speech (7).  

It must be ruled out that the patient may have a bipolar or depressive disorder with psychotic features or schizoaffective disorder before an official diagnosis of schizophrenia can be determined (9). Other symptoms that are taken into consideration include inappropriate affect, dysphoric mood, cognitive and memory deficit, anxiety and phobia, disturbed sleep pattern, behavior deficit such as hostility or aggression, suicidal ideations, depersonalization, and derealization (9).

Stages of Schizophrenia 

For most people with schizophrenia, the disorder usually occurs in episodes, where the individual cycles through all three stages in order. It is exceedingly difficult for a person suffering from schizophrenia to break the cycles without any treatment or help from a physician. The stages of schizophrenia are identified as the prodromal phase (beginning), acute phase (active), and recovery phase (residual) (11). It is unclear of how and why each individual moves through the stages at the pace that they do. Some of the factors such as a combination of chemical or structural changes in the individual‘s brain may influence how quickly a person progresses from one phase to another. We will look at each phase in depth. 

Prodromal Phase (Beginning) 

The prodromal phase of schizophrenia is known as the beginning phase prior to psychosis. During this phase, the individual begins to have changes in their thought process, including bizarre feelings or ideas, social isolation, and impaired functioning. Friends and family may notice a change in the individual because they may want to be alone most of the time, focus on certain topics like religion, the government, or public figures more than normal.  

This phase can usually last from weeks to years, but some people with schizophrenia never get past this point (11). Studies have shown that individuals with disorganized symptoms were more likely to have negative symptoms and the prodromal phase, and individuals with paranoid symptoms were more likely to have positive symptoms in this stage (11). Unfortunately, this phase can go undetected until more severe symptoms develop into the acute phase. Symptoms in may include increased anxiety, difficulty concentrating or paying attention, lack of motivation, isolation from family, social life, and friends, sleep disturbance, increased irritability, forgetting or neglecting personal hygiene, and major changes in normal routines (12, 13). 

Acute Phase (Active) 

The acute phase of schizophrenia is the most disturbing phase because of the active introduction of psychosis. Family and friends may become scared and alarmed because of the individual‘s obvious signs of disturbing hallucinations, delusions, disorganized speech, and thoughts. The acute phase can come on suddenly without a prodromal phase sometimes but is rare (12). Research has shown that negative symptoms and cognitive defects in this phase are core features of schizophrenia that account for much of the long-term mobility at poor functional outcomes (10, 12, 13). Symptoms in this phase may include paranoid delusions, confused or disorganized thoughts, disorganized speech, lack of eye contact, flat affect, hallucination, or seeing things that no one else sees, and useless or excessive movement (12, 13). 

Recovery Phase (Residual) 

The recovery phrase is not a recognized diagnosis by the DSM–5, but this term is still used to describe the period in which the individual with schizophrenia has fewer obvious symptoms, but still some that are present. The clinician will often use this phase to describe the symptoms and the progression of schizophrenia (12).  

During this phase of the illness, the individual may experience some elements of the acute phase, and sometimes relapse between the acute and residual phases.  

Symptoms during the recovery phase may include lack of motivation, low energy, social withdrawal, eccentric behavior, illogical thinking, conceptual disorganization, lack of emotion, and aggressive vocalization (13). 

Current Treatment

Therapy for people with schizophrenia has evolved over the last century. Prior therapies included lobotomies, Metrazol therapy, insulin coma therapy, isolation and asylums, bloodletting and purging, trephination, and electroconvulsive therapy (ECT).  

Currently, treatment includes a strict pharmacological regimen, psychosocial therapy (family therapy, individual psychotherapy, cognitive remediation, rehabilitation), ECT, coordinated specialty care (CSC) and hospitalization. 

Pharmacological

Antipsychotic drugs have been the mainstay of psych schizophrenia treatment since the introduction of chlorpromazine. Antipsychotics do not cure schizophrenia, but they help relieve the most problematic symptoms, including hallucinations, delusions, and disorganized thoughts. Antipsychotics work by affecting the neurotransmitters in the brain specifically serotonin and dopamine. 

Psychosocial Therapy

Although medication helps to relieve symptoms of schizophrenia, psychosocial treatments help with the behavioral, psychological, social, and occupational problems that go along with the illness. There are various therapies under psychosocial therapy that are available to help the individual and family members identify early warning signs of relapse and manage a relapse prevention plan (4). 

Family-Based Therapy

Family therapy is based on the system theory, which underlies multifamily treatment approaches that include coping recommendations, problem–solving, crisis intervention, reduction of pathogenic interactions, and psychoeducation. This form of therapy helps the patient and family members identify early warning signs that may show that the individual is at a high–stress level (13). 

Personal Therapy 

Personal therapy combines with aspects of social skills training (SST) as well as some other common elements of cognitive behavior therapy. The social skills training is based on a behavioral model that targets the improvement of the person’s ability to function skillfully in social situations and interactions in improving both positive and negative symptoms. This therapy is focused on the area of recovery, and it is a long-term endeavor that has shown to decrease the probability of relapse because of the basis of supportive psychotherapy (13). 

Cognitive Remediation Therapy (CRT)

CRT is a computer-based intervention that was originally designed to improve deficits in cognitive abilities in people suffering from traumatic brain injury but has now been a part of treatment for schizophrenia. CRT is used in combination with SST, groups, coaching, and problem solving to help improve the individual‘s social cognition attention span and speed of processing for the individual with Schizophrenia (13). 

Rehabilitation

This form of therapy focuses on the job training and social skills to help the individual function in the community and be able to live an independent life (4). 

Electroconvulsive Therapy (ECT)

ECT has been around since 1930 and has been utilized for various stages of schizophrenia. A course of ECT involves two to three treatments per week for several weeks while the patient goes under general anesthesia, the doctors send a small shot to the brain, which causes a controlled seizure. Currently, ECT treatment is utilized for medication–resistant schizophrenia and causes improvement in symptoms and in cognition (21). 

Coordinated Specialty Care (CSC) 

CSC uses a team approach to treating schizophrenia when the first symptoms appear. There is a combination of medicine and therapy with social services employment and educational intervention. The family is utilized as much as possible and early treatment is the key to helping the patient lead a normal life (4). 

Hospitalization

This option is for patients who have severe problems, might want to harm themselves, or are unable to care for themselves at home. Usually, people with schizophrenia who must be hospitalized are treated as inpatient because it is a better and safer option for them until they can be placed in the outpatient clinic setting (4). 

Role of the Nurse in Understanding and Caring for Patients with Schizophrenia 

Although most nurses in a regular clinical setting typically care for patients with medical conditions, it isn’t unusual for them to see patients with mental health conditions as well. Nurses who are charged with the task of providing compassionate care to people with schizophrenia must understand several factors about the disorder in order to achieve positive outcomes, including the disease process, necessary supportive communication skills, and patient safety protocols.  

Although there are various mental health specialties in nursing, all nurses can be empowered to provide care to patients with mental health disorders such as schizophrenia.  A nurse can do this by gaining the individual’s trust and building their confidence by actively listening to them and reading their non-verbal cues such as body language. By doing so, it allows the medical staff to direct the appropriate treatment plan and encourages the patient to participate (15). 

A nurse’s ability to identify and understand the symptoms schizophrenia can be an extremely useful skill to possess, and may improve the effectiveness of further assessments, medication administration, education, and counseling for the patient. By understanding the effects of both positive and negative schizophrenia symptoms and the impact it poses on the patient’s life, it can help the nurse further assist the patient in making informed decisions regarding their treatment plan (15). Simply put, along with the patient’s family and physician, the nurse should serve as an advocate for the patient. 

Healthcare and Economic Impact 

Because people with schizophrenia tend to cycle through the three phases (prodromal, acute, and recovery) they are often left with psychiatric deficits, which can lead to unemployment, homelessness, incarceration.  

Schizophrenia is now one of the top 15 leading causes of disability worldwide, and individuals with the disorder have an extremely high risk of premature death at a younger age than the general population (16). In the U.S., the estimated average of potential early mortality is 28.5 years. There is an estimated 4.9% of people with schizophrenia committing suicide, and the rate is far greater than the general population, with the highest risk being in the early stages of the illness (2). 

People with schizophrenia have comorbid medical conditions such as liver disease, diabetes, and heart disease. This is usually one of the main contributing factors of early mortality. There is a dispropotionately high financial cost associated with schizophrenia when compared to other chronic mental and physical conditions (2).  

If schizophrenia is left untreated, it can result in severe problems that affect every area of life. For example, the amount of health care services needed to treat the disorder can be an economic burden on the patient and their families (16). 

While schizophrenia affects only 1% of the population, it accounts for 2.5% of total health care expenditures in the United States. The estimated cost of all mental illness care was $103.7 billion, with schizophrenia alone accounting for $22.7 billion (16).  

Conclusion  

Schizophrenia is a complex multi–factor disorder that is difficult to control. From the current knowledge that we have, it does not seem very probable that all symptoms of the disease can be treated under one modality. In over a century, significant progress has been made in the treatment of schizophrenia from lobotomy operations to psychosocial therapy. Although despite our best efforts, there is a high rate of relapse in people with schizophrenia.  

As healthcare workers, we must continue to integrate medical and psychological approaches of treatment for our patients. By showing our compassion and understanding of their struggles, we must empower them to want to live positively and that their symptoms are under control if they continue their treatment plan. Our biggest asset as healthcare professionals is to be an advocate and a coach for these patients.

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