SCHIZOPHRENIC DISORDERS

above: MRI imaging showing differences in brain ventricle size in twins - one schizophrenic, one not. (image courtesy NIH - Dr. Daniel Weinberger, Clinical Brain Disorders Branch)

Schizophrenia is a Functional Psychosis with age of Onset in Adolescence or Young Adulthood. It is a severe Psychosis and often become a Chronic Disorder. 15% of admissions to psychiatric hospital and 45% of long stay patients have Schizophrenia.

ETIOLOGY:

The cause of Schizophrenia is not known. There seems to be a strong GENETIC link, where the individual Inherits a TENDENCY to the illness. That is the individual Inherits the GENE [predisposing Factor] and STRESS [ Precipitating Factor] triggers the illness.

1. Monozygotic Twins : 60%
2. Dizygotic Twins : 18%
3. One Parent Schizophrenic : 12%
4. Both Parent Schizophrenic : 40%
5. General Population : 0.8%

Another theory on the etiology of Schizophrenia suggest that a BIO-CHEMICAL IMBALANCE causes the disorder. Certain drugs such a LSD [Lysergic Acid Diethylamide] produce effects similar to Schizophrenia. Individuals who take Amphetamines may develop Amphetamine Psychosis which is very difficult to separate from a Schizophrenic Psychosis.

These drugs have a similar structure to DOPAMINE [A Neurotransmitter in the nervous system]. Neuroleptics which reduce the symptoms of Schizophrenia block Dopamine Receptors whereas the above drugs have the opposite effect.

PATHOGENIC FAMILIES are also put forward as a cause. In this model children of schizophrenic parents are subjected to confusing and contradictory signal from the parent [DOUBLE BIND. The VERBAL signal (I love you) may be accompanied by a NON-VERBAL signal [Keep away, I hate you.]

PRESENTATION:

Schizophrenia may be either REACTIVE, [where an individual responds to a Crisis with a Schizophrenic Reaction}. or a PROCESS, [where the illness is a development of the individual's Personality]. The prognosis of REACTIVE Schizophrenia is very good.

In Process Schizophrenia the disorder is Development of the individual's PRE MORBID SCHIZOID PERSONALITY. Before the disorder develops the individual would have been quiet. withdrawn and isolated with a lack of drive.

Signs and Symptoms of Schizophrenia include DISORDERS OF:

1. THOUGHT
2. PERCEPTION
3. AFFECT
4. VOLITION (DRNE)
5. BEHAVIOUR

THOUGHT:

DELUSIONS may be PRIMARY and arise without any obvious reason or SECONDARY and build up into a SYSTEM with a whole collection of Delusions which explain and support each other.

THOUGHT BLOCK is common together with CONCRETE thinking and IDEAS of REFERENCE. The patient may experience ideas of P ASSMTY where their thoughts are controlled from outside and they are Forced to do things even to the extent of committing Suicide.

PERCEPTION:

The commonest disorder of Perception is the HALLUCINATION which may be:

a. AUDITORY [Commonest]

b. VISUAL

c. TACTILE

d. GUSTATORY

e. OLFACTORY.

AFFECT:

The dominant effect on Mood is a BLUNTING of AFFECT which may lead to APATHY and a. general loss of interest in what is happening in the worlds around them. They may also have an INCONGRUITY of AFFECT where their Emotional response in inappropriate.

The Blunting of Affect and Apathy lead to the biggest problem in the rehabilitation of patients with Schizophrenia which is the LACK OF VOLITION.

VOLITION:

The lack of Volition leads the patient to withdraw into an inner world of Fantasy and a disinterest in the real world. They have no motivation to try to return to a "Normal" state. When any stress occurs they retreat back into fantasy. This is a major problem in Rehabilitation as they are usually quite happy to stay in hospital where they are protected and don't have to worry about things such as work, clothing and food.

BEHAVIOUR:

Abnormal body movements may consist of :

a. Abnormal Facial Movements (Grimaces)

b. Strange movements of the Limbs

c. Strange Postures which are held for a long time(Waxy Flexibility) and Echopraxia.

d. Strange GAIT the way in which they walk.

TYPES OF SCHIZOPHRENIA:

1- SIMPLE

2- HEBEPHRENIC

3- CATATONIC

4- PARANOID

5- RESIDUAL

1. SIMPLE

Age of Onset during Adolescence. The onset in Insidious and slowly progresses with deterioration of the Personality. Hallucinations and Delusions may not be present with the Main Symptom being LACK of VOLITION. Many of these individuals end up as tramps or prostitutes who are "protected" by a "pimp". The Prognosis is very poor.

2. HEBEPHRENIC

Onset is in late Adolescence. Hallucinations and Delusions are present and are often very strange [Bizarre]. Behavior is very odd with them often laughing and making strange faces at mirrors and windows.

3. CATATONIC

Onset is in late Adolescence to the early Twenties. It is not very common and early and effective treatment means that the acute signs and symptoms are rarely seen. The main symptom is disturbed Behavior. The patient may go into a Catatonic STUPOR where full consciousness is retained. and Catatonic EXCITEMENT. Negativism, Echolalia and Echopraxia are common.

4. PARANOID

Onset is late from Thirty to Fifty years. The main symptoms are PERSECURITY Delusions with Auditory Hallucinations. Ideas of Reference are very common and may lead to aggression.

5. RESIDUAL

A chronic stage in the development of Schizophrenia. Characterized by long term Negative symptoms such as Blunting of Affect. Passivity, Poverty of Ideas.

PHYSICAL TREATMENT

CHEMOTHERAPY

These drugs were introduced in the 1950s and had a profound effect on the treatment of Schizophrenia. They are not just Tranquilizers but reduce the Psychotic symptoms Le.: Delusions and Hallucinations. The development of long acting DEPOT IN.JECTIONS has meant that many patients can now be discharged from hospital while COMPLIANCE with chemotherapy is possible through Outpatient or Community Psychiatric Nurse Visits.

ANTI PSYCHOTICS (Neuroleptics) :

a. Phenothiazines (Chlorpromazine, Triflouperazine)

b. Haloperidol (Haldol, Serenace)

DEPOT Injection :

a. Fluphenazine Decanoate (Modecate)

b. Flupenthixol Decanoate (Depixol)

ELECTRO-CONVULSIVE THERAPY:

Is rarely used in the treatment of Schizophrenia. It may be used where there is severe Mood Disturbance. or where a patient is in a Catatonic Stupor.

NURSING CARE:

• Individuals with Schizophrenia become Withdrawn. Isolated and Institutionalized. Nurses. therefore need to break down this isolation by providing Caring, Human Contact and maintaining . Communication even when the patient rejects this relationship.
• Passivity and Institutionalization are major reasons for patients witI1 Schizophrenia becoming Chronic and Long Stay patients in hospital. They must be involved in Decision Making about their care and treatment, and involved in social events.
• In the clinical area you will be involved with the patients in group social activities in Occupational Therapy. Sports.
• Gardening and Parties. You cannot involve patients in these activities unless you involve yourselves. Remember that when you take a group of patients to the park this is Not a day-out for you, but part of the patient's therapy.
• These patients are often Rejected b)' their Families, which increases their Isolation. Contact with the family must be encouraged especially when discharge is near. In any countries Half-way Houses and Hostels help with an effective rehabilitation. Long Term Follow Up through Day Hospitals, Out Patients and/or Community Psychiatric Nurses is very important to prevent relapses.

KEY POINTS:

I) Schizophrenia is a Functional Psychosis with Onset in Adolescence or Young Adulthood. It is a severe Psychosis and often becomes a Chronic Disorder.

2) The cause of Schizophrenia is not known The individual Inherits the GENE {Predisposing Factor/ and STRESS (Precipitating Factor/ triggers the illness.

3/) Another theory on the etiology of Schizophrenia suggest that a BIO-CHEMICAL IMBALANCE causes the disorder. DOPAMINE. A Neurotransmitter in the nervous system. may be involved in the etiology of Schizophrenia.

4) PATHOGENIC FAMILIES are put forward as a cause. Children of Schizophrenic parents are subjected to confusing and contradictory signal from the parents, DOUBLE BIND.

5) Schizophrenia may be either REACTIVE or PROCESS. The prognosis of REA CTIVE Schizophrenia is very good.

6) Signs and Symptoms of Schizophrenia include Disorder of Thought. Perception. Affect. Volition. and Behavior.

7) Types of Schizophrenia may include Simple. Hebephrenic. Catatonic. and Paranoid.

8) Ami Psychotic medicines are not just Tranquillizers but reduce the Psychotic symptoms of Delusions and Hallucinations. The development of long acting Depot Injections has meant that many patients can now be discharged from hospital

9) Electro-Convulsive Therapy is rarely used in the treatment of Schizophrenia. It may be used where there is severe Mood Disturbance, or where a patient is in a Catatonic Stupor.

10) Individuals with Schizophrenia become Withdrawn, Isolated and Institutionalized. Nurses need to break down this isolation by providing Caring, Human Contact and maintaining Communication.

11) Patients with Schizophrenia must be involved in Decision Making about their care and treatment. and involved in social events.

12/ Patients are involved in group social activities UI Occupation Therapy, Sports. Gardening and Parties.

13) Patients are often Rejected by the Families, which increases their Isolation. Contact with the family must be encouraged.

14) In many countries Half-way Houses and Hostels help with effective rehabilitation. Long Term Follow Up through Day Hospitals. Out Patients and/or Community Psychiatric Nurses is 'very' Important to prevent relapses.