The alternate reality of schizophrenia

The alternate reality of schizophrenia MICHAEL TRINSEY SCHIZOPHRENIA IS A GROUP of chronic, disabling psychiatric disorders characterized by disturbed thinking and disorganized speech. Patients with schizophrenia may have difficulty distinguishing fantasy from reality. The American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders, 4th edition, defines five subtypes of schizophrenia: catatonic, disorganized, paranoid, undifferentiated, and residual (see The schizophrenia subtypes). Some symptoms are common to all five subtypes; others are unique to a particular type. In the United States, about 1% of people develop schizophrenia at some point in their lifetime. More than 2 million Americans (1 in 100 people) have it in any given year. Men and women are affected equally. The most common age of onset is late adolescence. Symptoms usually emerge in men in their late teens or early 20s. Women are usually affected in their mid-20s or early 30s. Childhood schizophrenia is rare. Schizophrenia affects brain functioning and behaviors. Symptom severity depends on when the disease was diagnosed and how well the patient follows his treatment plan. Most patients with schizophrenia have to stay on medication for life. An estimated 50% of people with schizophrenia are substance abusers, which can lead to nonadherence to the medication plan, repeated relapses, frequent hospitalizations, declining function, and loss of social support. Schizophrenia is diagnosed based on a medical history, family history, and diagnostic findings, which are used to rule out other causes, like a brain tumor or toxic reaction. In this article, we ll look at the causes of schizophrenia, symptoms, how the disease progresses, available treatment options, and what you can do to help your patients with the disease. What causes schizophrenia? The precise cause of schizophrenia is unknown, but it most likely results from the interplay of genetic, biochemical, developmental, and physical factors. As-yet undiscovered genetic factors are thought to predispose a person to schizophrenia. Children with a parent who has the disease have a 10% greater chance of being diagnosed with it as well. If an identical twin has the illness, the other has a 40% to 65% greater risk. Recent evidence points to chromosomes 6 and 13 as playing a role in the development of schizophrenia. Patients with schizophrenia may have an imbalance of the neurotransmitters dopamine, serotonin, norepinephrine, glutamate, and gamma-aminobutyric acid (GABA). The neurotransmitter levels may be decreased or increased, resulting in symptoms. Too much dopamine, for 14

example, translates to a lack of motivation and disturbances in reality perception. Too little GABA can cause an exaggerated response to stimuli that leads to paranoia. Developmental factors may play a role as well. Neurobiologists have suspected that schizophrenia might result from faulty connections formed by neurons during fetal development. These errors are dormant until puberty, when normally occurring brain changes may interact adversely with the faulty connections. Certain physical conditions may also be possible causes of schizophrenia. These include: maternal influenza during the second trimester of pregnancy birth trauma head injury epilepsy (especially of the temporal lobe) Huntington s disease cerebral tumor stroke systemic lupus erythematosus. Symptom categories and disease progression Symptoms of schizophrenia are divided into three categories: positive, negative, and disorganized. Positive symptoms primarily include hallucinations which are the most common feature of schizophrenia and delusions. Hallucinations involve seeing, hearing, smelling, tasting, or feeling touched by things that aren t there. A common hallucination is hearing voices. Delusions are strongly held beliefs that can t be changed by reason or logic. A delusional patient may be certain that he s a famous person or that someone is reading his thoughts. Negative symptoms include apathy, lack of motivation, blunted affect, brief and meaningless speech, social withdrawal, and the inability to experience pleasure. Disorganized symptoms reflect the patient s abnormal thinking and inability to communicate. They include thought disorders like confused thinking and speech and bizarre behavior like childlike laughing, inappropriate hygiene or conduct, and agitation. You may notice certain characteristic symptoms when you evaluate a patient who s been diagnosed with schizophrenia or who s suspected of having it. See Recognizing schizophrenia for more details. A patient with schizophrenia usually progresses through three distinct phases of the disease: prodromal, active, and residual. The prodromal phase may last a year or so. During this phase, the patient shows a clear decline from his pre- May/June l LPN2007 15

The schizophrenia subtypes Catatonic. In this rare form of schizophrenia, the patient tends to remain in a fixed stupor or position for long periods. Symptoms include remaining mute, exhibiting bizarre mannerisms and postures, rapid swings between stupor and excitement, a diminished sensitivity to painful stimuli, repeating words or phrases spoken by others (echolalia), and imitating others movements (echopraxia). Disorganized. The patient with disorganized schizophrenia has thought disorders and exhibits bizarre behavior. Symptoms include confused thinking and speech, ranging from disorganized speech to incoherent rambling; jumping from one idea to another; childlike silliness; laughing or giggling; agitation; inappropriate appearance, hygiene, or conduct; and an inability to make sense of everyday sights, sounds, and feelings. Paranoid. A defining characteristic of paranoid schizophrenia is the presence of hallucinations or delusional thoughts. Patients with paranoid schizophrenia often feel as if they re being followed or persecuted or someone is reading their thoughts. They lack the disorganized behavior and thought disorders that characterize some of the other subtypes. Symptoms include hallucinations and delusions about a consistent theme, suspiciousness, and paranoia. Undifferentiated. This type of schizophrenia is diagnosed when a patient has symptoms of schizophrenia, but the symptoms are not specific enough to meet the criteria for the four other subtypes. Residual. This subtype is diagnosed when a patient s symptoms lessen in severity. vious level of functioning. The active phase is commonly triggered by a stressful event, and the patient has acute psychotic symptoms. His functional deficits worsen, and the prognosis worsens with each acute episode. The residual phase is usually characterized by stabilization of the disease but rarely marked by full remission. Symptoms resemble those of the prodromal phase, with the persistence of some psychotic symptoms like hallucinations. Next, let s take a closer look at treatment options for schizophrenia. Recognizing schizophrenia During the assessment interview, you may note characteristic signs and symptoms in a patient with schizophrenia. Remember that specific findings vary with the schizophrenia subtype catatonic, disorganized, paranoid, undifferentiated, residual and other factors. Speech abnormalities The patient s speech may include: clang associations words that rhyme or sound alike, used in an illogical, nonsensical manner (for example, It s the rain, train, pain ) echolalia meaningless repetition of words or phrases loose association and flight of ideas rapid succession of incomplete ideas that aren t connected by logic or rationality word salad illogical word groupings (for example, She had a star, barn, plant ) neologisms bizarre words that have meaning only for the patient. Thought distortions Stay alert for evidence of: overly concrete thinking inability to form or understand abstract thoughts delusions false ideas or beliefs accepted as real by the patient hallucinations false sensory perceptions with no basis in reality thought blocking sudden interruption in the train of thought magical thinking a belief that thoughts or wishes can control other people or events. Social interactions Note whether the patient exhibits: poor interpersonal relationships withdrawal and apathy lack of interest in objects, people, or surroundings. Other findings In some patients with schizophrenia, you also may assess: regression return to an earlier developmental stage ambivalence coexisting strong positive and negative feelings, leading to emotional conflict echopraxia involuntary repetition of movements observed in others. Treatment is available Treatment goals in schizophrenia include reducing the severity of psychotic symptoms, preventing recurrences of acute episodes and associated functional decline, meeting the patient s physical and psychosocial needs, and helping the patient function at the highest level possible. Several drugs are commonly used in the treatment of schizophrenia. Antipsychotics are the mainstay of treatment for symptoms of schizophrenia. When the level of the neurotransmitter dopamine is too high, the patient can develop hallucinations or a lack of motivation. Antipsychotics work by decreasing the amount of dopamine. Three categories of antipsychotics are available: conventional antipsychotics, atypical antipsychotics, and clozapine (Clozaril). Conventional antipsychotics include chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine (Trilafon), fluphenazine (Prolixin), and thioridazine (Mellaril). These antipsychotic medications have many adverse effects that can negatively impact adherence to treatment (see Adverse effects of antipsychotic drugs). To fur- 16

Adverse effects of antipsychotic drugs Patients with schizophrenia must take antipsychotic drugs for a long time usually for life. Unfortunately, some of these drugs may cause unpleasant adverse effects. Sedative effects Dystonia refers to prolonged, repetitive muscle contractions that may cause twisting or jerking movements, especially of the neck, mouth, and tongue. It s most common in young males, usually appearing within the first few days of drug treatment. Anticholinergic effects Drug-induced parkinsonism results in bradykinesia (abnormally slow movements), muscle rigidity, shuffling gait, stooped posture, flat facial affect, tremors, and drooling. It may emerge 1 week to several months after drug treatment begins. Extrapyramidal effects Akathisia causes restlessness, pacing, and an inability to rest or sit still. Intermediate-potency conventional antipsychotics (like perphenazine) have a moderate incidence of extrapyramidal effects. Low-potency agents (like chlorpromazine) are highly sedative and anticholinergic but cause few extrapyramidal effects. Orthostatic hypotension Low-potency antipsychotics may cause orthostatic hypotension (low blood pressure when standing). Tardive dyskinesia With prolonged use, antipsychotics may cause tardive dyskinesia a disorder characterized by repetitive, involuntary, purposeless movements. Signs and symptoms include grimacing, rapid eye blinking, tongue protrusion and smacking, lip puckering or pursing, and rapid movements of the hands, arms, legs, and trunk. Symptoms may persist long after the patient stops taking the antipsychotic drug. With careful management, though, some symptoms eventually lessen or even disappear. Neuroleptic malignant syndrome In up to 1% of patients, antipsychotic drugs cause neuroleptic malignant syndrome. This life-threatening condition leads to fever, extremely rigid muscles, and altered consciousness. It may occur hours after drug therapy starts or the dosage is increased. ther complicate matters, conventional antipsychotics have many extrapyramidal adverse effects (tremors, slurred speech, involuntary muscle contractions). Those can be treated with anti-parkinson s agents like amantadine (Symmetrel) and trihexyphenidyl (Artane) or benztropine (Cogentin). Atypical antipsychotics, like olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal), are more selective in their effect on dopamine, have fewer adverse effects, and are considered safer to use. They re not, however, free from adverse effects. Clozapine was the first atypical antipsychotic, introduced in 1990. It controls a wider range of signs and symptoms and causes few or no adverse effects. It s effective in 25% to 50% of patients who don t respond to conventional antipsychotics. It may, however, cause agranulocytosis, a fatal blood disorder. Additional drug therapies for schizophrenia include antidepressants and anxiolytics to control associated signs and symptoms; mood-stabilizing agents, like lithium, carbamazepine (Tegretol), and valproic acid (Depakote) to manage mood swings; and benzodiazepines (lorazepam [Ativan]) for patients who are substance abusers. Along with drug therapy, schizophrenia can be treated with psychosocial treatment, compliance promotion programs, vocational counseling, supportive psychotherapy, and community resources. How you can help No matter which type of schizophrenia your patient has, you can use these interventions to help him cope with his illness. Ensure safety. Maintain a safe environment with minimal stimulation. If the patient expresses homicidal or suicidal thoughts, institute the proper precautions. Establish trust and rapport. Do this by using an accepting, consistent approach and speaking in clear, unambiguous language. Don t touch the patient without first telling him exactly what you re going to do. Be sure to convey a sense of hope for possible improvement. Maximize the level of functioning. Assess the patient s ability to carry out activities of daily living and avoid promoting dependence. Reward positive behavior and work with him to increase his sense of personal responsibility in improving his level of functioning. Promote social skills. Encourage the patient to engage in meaningful interpersonal relationships. Support him in learning social skills. Provide reality-based activities and explanations. Make sure the activities involve human contact. Clearly explain any distorted body images or hypochondriacal complaints. Deal with the patient s hallucinations. Tell him you don t hear the voices, but you know they re real to him. Avoid arguing about the hallucinations and change the subject if possible. Promote adherence to and monitor drug therapy. Encourage the patient to adhere to his medication regimen and regularly assess him for adverse drug effects. Instruct the patient taking a slow-release drug formulation when to return for his next dose and urge him to keep the appointment. 18

Encourage family involvement. Teach family members how to recognize an impending relapse. Suggest ways they can help manage the symptoms. Help establish new LPN/LVN Infusion Therapy Guidelines! Participate in our LPN/LVN National Practice Survey on Infusion Therapy Visit www.napnes.org click on Infusion Therapy Survey or call 703-933-1003 A positive outlook The outcome for patients with schizophrenia has improved with better and safer treatments. About one-third of patients achieve a significant and lasting improvement; another third improve somewhat but have intermittent relapses. With an accurate diagnosis, patients with schizophrenia can receive the help they need to effectively treat this serious illness. LPN Selected references American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th edition, text revision. Washington, D.C., American Psychiatric Association, 2000. Murphy K. The separate reality of bipolar disorder and schizophrenia. Nursing Made Incredibly Easy! 3(3):6-18, May/June 2005. National Institute of Mental Health. Schizophrenia. January 2007. http://www.nimh.nih.gov/publicat/schizoph.cfm. Accessed January 26, 2007. Straight A s in Psychiatric & Mental Health Nursing. Philadelphia, Pa., Lippincott Williams & Wilkins, 2006. May/June l LPN2007 19