Many persons have heard a lot about the word “schizophrenia”, and many believe that the term means “split” or “dual personality”, this, however, is not the case. Another common misconception is that schizophrenia is caused by factors such as family dysfunction or drug and alcohol abuse. The accompanying display lists these and other myths about the disease.
Dispelling common myths about Schizophrenia
- Schizophrenia does not mean split personality as in Dr. Jekyll and Mr. Hyde. There are psychiatric disorders of multiple personalities, but they are very different from schizophrenia. The word “schizophrenia” does mean splitting of the mind, but this name was chosen to reflect the effects of schizophrenia on thoughts and language, not personality.
- Schizophrenia individuals are not unusually prone to violence. While schizophrenia persons do commit crimes and some are very dangerous, the majority of schizophrenia individuals are not violent. Although schizophrenic persons are rarely dangerous to others, their risk of suicide is very high, approaching 10%.
- Schizophrenia is not caused by family dysfunction. Psychological factors influence the way individuals and families cope with schizophrenia, but families do not cause schizophrenia any more than they cause multiple sclerosis or cancer. While the biological factors leading to schizophrenia remain unknown, schizophrenia is clearly a disease of the brain, not a primary psychological disorder.
THE EXPERIENCE OF SCHIZOPHRENIA
A nursing perspective on disordered thought requires consideration of the subjective human experience of the disease. Because rational cognitive ability is so important for functioning, there are human responses that pervade every aspect of a persons living when one is unable to think. Several nursing diagnoses apply when caring for such a person. These will be discussed as the reader examines the presenting symptoms and current definitions of schizophrenia.
1. Disorder Thoughts
Disturbed or disordered thoughts are a major characteristic of schizophrenia. When schizophrenic individuals talk, they demonstrate a flow of thought that ca be described as “loose”, that is, the topics and ideas follow one another with far less other than one expects in everyday speech. Often one idea or thought is followed by a seemingly unrelated one: either topic might make good conversational sense, but when put together, the ideas do not quite seem to mesh. The confusion is not in speech alone, but in the thinking process itself.
Schizophrenia often evolves slowly over years. In the early stages of schizophrenia, formal thought disorder may be very subtle and hard to recognize.
2. Delusions
Many schizophrenic persons express delusions, false beliefs that misrepresent either perceptions or experiences. Delusions are major defining characteristic of psychosis. Delusions are commonly characterized as grandiose, persecutory, or referential. Grandiose delusions involve perceptions of importance; delusional persons often believe themselves to have special powers and may claim to be religious Messiahs. Persons with persecutory delusions are paranoid, they believe that others intend to do them harm. Persons with referential delusions believe that common events refer specifically to them. In the following passage, written about himself in the third persons, a young schizophrenic man describes grandiose delusions and multiple ideas.
3. Hallucinations
Hallucinations are another major part of the psychotic experience and are also very common in schizophrenia. Hallucinations are sensory experiences not perceptible to other non psychotic individuals. While hallucinations can involve virtually any sensory modality, they are most commonly auditory. Psychotic individuals typically describe “hearing voice” and these voice are perceived as quite distinct from the individuals own thoughts. The voices generally have specific content, and this is most frequently of a threatening or negative nature.
SYMPTOMS
Flattened affect: describes the loss of expressiveness that most schizophrenic persons develop during their illness. While schizophrenic individuals may sometimes smile or seem to develop some human warmth, the overall impression of schizophrenia is that of extreme emotional distance and lack of human response.
- Alogia: refers to tendency of schizophrenic individuals to speak very little and even when speaking openly, to use brief and often seemingly empty phrases.
- Avolition: is the tendency for those with schizophrenia to lack motivation for work or other goal directed activities.
- Anhedonia: is the seeming inability to find enjoyment in activities that would be pleasurable to unaffected individuals. While by no means unique to schizophrenia most schizophrenic individuals do display a significant degree of loss of pleasure in daily activities.
ETIOLOGY
Psychoanalytic Theory
While Freud did not believe that psychotherapy could cure psychosis, he did not offer a range of potential psychoanalytic explanations for the symptoms of schizophrenia. Spurred by some apparent therapeutic successes, some of his followers eventually proposed psychoanalytical theories of the etiology of schizophrenia. These included a view that childhood temper tantrums and other unneutralized aggressions might ultimately lead to psychosis. At about the some time, a psychoanalytic theory emerged that portrayed schizophrenia arising out of inadequate maternal nurturance in early infancy.
Genetics
The inheritance of schizophrenia, however, is very complex and still incompletely understood.
Current View
If psychological factors are not fundamental causes and genetic factors only play a partial role, what does cause schizophrenia? By the end of the nineteenth century some leading psychiatric felt strongly that schizophrenia was due to “organic causes”, that is, was something physically and structurally wrong with the brains of schizophrenic individuals. The trouble with this theory was that no one could find any structural abnormalities in the brains examined at autopsy. Dr. Alzheimer was able to show only mild generalized cell loss and scarring in schizophrenia, findings too nonspecific to offer clues to causation.
Dopamine Hypothesis
This hypothesis states that the functional abnormalities in schizophrenia are due to excessive activity of brain dopamine. Dopamine is normally produced in the brain, and it serves as a signaling molecule or neurotransmitter. Dopamine seems to have its most important effects in the basal ganglia of the brain; reduction of dopamine in these structures leads to Parkinson’s disease. First, drugs effective in the control of positive symptoms of schizophrenia all seem to have significant dopamine receptor blocking activity; that is, these drugs seem to work because they reduce the effect of an individuals own dopamine on his or her brain. Secondly, drugs like amphetamines, which have ability to cause strikingly schizophrenic-like psychoses, act by increasing brain dopamine concentrations. Finally, all of the neuropathological findings from multiple autopsies of persons dying with schizophrenia. The most reproducible is an increase in dopamine receptors in the brain’s basal ganglia. If receptors are increased in number, then any given amount of brain dopamine can exert a stronger biological effect.
TREATMENT
· Psychosocial Treatment
· Clinical and Family Support Services
· Rehabilitation
· Humanitarian Aid/Public Safety
· Pharmacological and Physical Treatments
NURSING THEORY
The Modeling and Role-Modeling Theory (Ericson, Tomlin, and Swain, 1983; Frisch and Bowman, 2002) assist by providing the nurse with the five aims of intervention that can become the foundation for all work the schizophrenic client:
1. Build trust
2. Promote positive orientation
3. Promote perceived control
4. Promote strengths
5. Set mutual goals that are health directed
NURSING PROCESS
ASSESSMENT
An important consideration in assessing a client with schizophrenia is the degree to which symptoms of the disease are currently affecting the client’s functioning. The display on the following page lists important parameters of assessment. The nurse will be need to obtain information from the client and, often, from other sources. For example, a schizophrenic individuals may not be able to communicate regarding negative symptoms, such as lack of motivation or poverty of speech and will not be able to tell the nurse if current behavior is a change from previous functioning. Such information is appropriately obtained from family members or others who may relate observations over period of time.
In assessment nurse is not looking for evidence that symptoms of schizophrenia exist; she is also looking for clues as to the immediate concerns of and the kind of assistance desired by the client or family members.
DIAGNOSIS
Nursing diagnoses made during the acute episode may be:
- Disturbed thought processes related to inability to think rationally, complete a sentence, or communicate coherently
- Disturbed thought processes related to persecutory delusions
- Disturbed sensory perceptions related to auditory hallucinations
- Self-care deficit (specify) related to inability to maintain personal hygiene
- Disturbed sleep pattern related to fear of falling asleep
In contrast, in a rehabilitative phase of treatment, the nursing diagnoses may be:
- Ineffective role performance related to change in self-perception of role
- Social isolation, related to absence of or inability to engage in satisfying personal relationships
- Ineffective therapeutic regimen management related to knowledge deficit and complexity of therapeutic regimen
For each diagnosis, the nurse must establish appropriate and expected outcomes and goals. Again, the expected outcomes will be different depending on whether the client is being treated in an acute or rehabilitative phase.
- Acute phase: In the acute phase, the immediate goal of treatment is to bring symptoms under control. For example, for the diagnoses of disturbed thought processes, a stated outcome might be “within 3 days of initiating treatment, the client will be able to answer simple direct questions”. For the diagnoses of disturbed sensory perception, related to hallucinations, the outcome might be “within 3 days of initiating medication, the client will experience a decline in number of hallucinations”. For the diagnoses of disturbed sleep pattern, the stated outcome might be “within 3 days of hospital admission, the client will sleep through the night”.
- Rehabilitative phase: Clearly, the nurse providing care in the rehabilitative phase will establish goals aimed at helping the client and his family to make the best adjustment possible to a chronic illness and will take any measures possible to maintain the clients independence to whatever degree possible. Outcomes should be identified for every nursing diagnosis.
Planning/Intervention:
Acute phase
In the acute phase of schizophrenia, the assessment, plan, and outcomes are all based on alleviating acute symptoms. Thus, much of the nursing care will be collaborative and involve use of medications to bring symptoms under control. Independent nursing care will be done through interventions that establish a safe and trusting environment and provide an acutely ill client a space for sleep without interference from others.
Rehabilitative phase
In the rehabilitative phase, the interventions must be planned by the nurse and client together, not by the nurse alone. The most successful interventions will be creative, as the nurse and client attempt to identify the reasons that impede successful meeting of client goals and to come up with plans that work for the client.
Evaluation Evaluation of nursing care is always based or not the identified outcomes are written in behavioral and measurable terms, the nurse can readily evaluate if the outcome has been met.
ASSESSMENT PARAMETERS FOR SCHIZOPHRENIC CLIENTS
Observe for:
1. Presence of delusions
- Does the client have ideas or beliefs that others say are untrue?
- Does the client have the belief that neutral cues in the environment refer to him?
- Does the client believe he has special talents and extraordinary powers?
- Does the client see, hear, or smell things others do not?
- Can the client communicate logically and rationally?
5. Negative symptoms of schizophrenia, include:
- Flat affect (dampening of emotions)
- Poverty of speech
- Lack of motivation
- Symptoms of depressions
Caring For Schizophrenic Clients: Acute Phase
- The symptoms of disordered thoughts, hallucinations, and loss of function are often frightening to the client. Nursing actions to promote a calm, peaceful, trusting, atmosphere are essential in alleviating fear and establishing a nurse-client relationship.
- The nurse should express reality regarding client reports of hallucination and delusions but should not enter into arguments regarding whether or not the delusions are true or the hallucinations are real.
- The nurse should work collaboratively with the treatment team to initiate a plan to control the acute symptoms and move the client into rehabilitative care.
Caring For Schizophrenic Clients: Rehabilitative Phase
The clinical picture of the client with acute presentation of schizophrenia includes both the positive and negative symptoms of the disease:
· Delusions, hallucinations, and disorganized speech
· Flat affect, avolition, alogia, anhedonia
· Decrease level of functioning
Common Nursing Diagnoses
1. Altered thought processes: delusions
2. Altered sensory perceptions: hallucinations
3. Self care deficit
4. Impaired social interaction
Nursing Diagnosis I : Altered thought processes: Delusions
Outcomes:
1. Verbalize decrease distress related to delusions or cognitive distortions
2. Be oriented to person, time, and place
3. Be able to participate in therapeutic activities
NOC: Reality Orientation
Interventions (NIC: Delusions management)
- Assess and document mental status
- Provide reality orientation –express doubt, do not enter into the delusions
- Be attentive to themes that may express the client’s underlying concerns and feelings
- Redirect toward therapeutic, reality-oriented activities
Rationale
- Provide education/support for taking antipsychotic medications · Provides baseline data and allows care to be individualized
- Helps to correct distortions and misperceptions of the environment
- Themes may indicate fears or concerns
- Brings the client into reality, provides distractions from delusions, and provides means to cope
- Client needs to be accepting of the role medications have in controlling symptoms
Nursing Diagnosis 2: Altered Sensory Perceptions: Hallucinations
Outcomes: client will verbalized one method of coping with hallucinations
NOC: Self Restraint Of Disruption Of Perception
Interventions (NIC: Hallucination Management)
- Assess and document the type of hallucination
- Be attentive to themes that may express the client’s underlying concerns and feelings
- Teach how to cope with distressing hallucinations: humming, using radio, telling the voices to “go away”
- Provide education and support to taking antipsychotic medications
- Provides baselines information and documents the kind of hallucination
- Themes may express fears, distortions, or possible danger to self/other
- Distraction techniques can be used for symptom relief
- Assist the client to understand the role of medication in controlling symptoms
Nursing Diagnosis 3: Self-Care Deficit
Outcomes: client will manage day-to-day activities, beginning with appropriate dressing, grooming, and nutrition
NOC: Ability To Perform Activities Of Daily Living Without Assistance
Interventions (NIC: Self-Care Assistance)
- Assess the client’s current strength and weak nesses in this area
- Ensure easy access to clothing and grooming materials
- Provide a schedule of daily activities that includes time for dressing, bathing, meals, and exercise/activity
- Document current and expected behaviors
- Clients with thought disorders can easily be overwhelmed if preparatory activities are too complicated
- Client with disordered thoughts respond well to having their time structured and are unable to structure their time themselves
Nursing Diagnosis 4: Impaired Social Interaction
Outcomes:
1. Client will exhibit less discomfort in social situations
2. Client will pick up on social cues when interacting with others
NOC: Social Involvement; Social Interaction
Interventions (NIC: Self-Awareness/Behavior Management Related to Social )
- Assess patters of social activity, including areas of strengths and weaknesses
- Identify client goals for interaction
- Support and reinforce efforts at social interaction
- Provide supportive group to enhance and to practice social skills
- Teach essential components of social interactions: making eye contact, how to productive patterns of speech, how to relate a message, and how to enter into a conversation · Care can be individualized based on the client’s specific patterns
- Set mutual goals for interaction
- Client will need encouragement; reinforcement of new behaviors is important when the client is trying to master new patterns
- Gives the client a safe place to try out new skills and new interactive patterns
- Address gaps in knowledge about social skills
