S-Z

S-Z

Schizophrenia

Schizophrenia is characterized by disturbances (for at least 6 months) in thought content and form, perception, affect, sense of self, volition, interpersonal relationships, and psychomotor behavior. (See Phases of schizophrenia, page 142.)

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), recognizes paranoid, disorganized, catatonic, undifferentiated, and residual schizophrenia. Onset of symptoms usually occurs during adolescence or early adulthood. The disorder produces varying degrees of impairment. Up to one-third of patients with schizophrenia have just one psychotic episode and no more. Some patients have no disability between periods of exacerbation; others need continuous institutional care. The prognosis worsens with each episode.

CAUSES AND INCIDENCE

Schizophrenia affects 1% to 2% of people in the United States and is equally prevalent in both sexes. It’s thought to result from a combination of genetic, biological, cultural, and psychological factors. Some evidence supports a genetic predisposition. Close relatives of people with schizophrenia have a greater likelihood of developing schizophrenia; the closer the degree of biological relatedness, the higher the risk.

The most widely accepted biochemical theory holds that schizophrenia results from excessive activity at dopaminergic synapses. Other neurotransmitter alterations such as serotonin increases may also contribute to schizophrenic symptoms. In addition, patients with schizophrenia have structural abnormalities of the frontal and temporolimbic systems. Computed tomography scans and magnetic resonance imaging studies show various structural brain abnormalities, including frontal lobe atrophy and increased lateral and third ventricles. Positron emission tomography scans substantiate frontal lobe hypometabolism.

Numerous psychological and sociocultural causes, such as disturbed family and interpersonal patterns, also have been proposed. Schizophrenia is more common in urban areas and among lower socioeconomic groups, possibly due to downward social drift, lack of upward socioeconomic mobility, and high stress levels that may stem from poverty, social failure, illness, and inadequate social resources. Higher incidence is also linked to low birth weight and congenital deafness.

PHASES OF SCHIZOPHRENIA

Schizophrenia usually occurs in three phases: prodromal, active, and residual.

Prodromal phase

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), characterizes the prodromal phase as clear deterioration in functioning before the active phase of the disturbance that isn’t due to a disturbance in mood or to a psychoactive substance use disorder and that involves at least two of the following signs and symptoms:

▪ marked social isolation or withdrawal

▪ marked impairment in role functioning as wage-earner, student, or homemaker

▪ markedly peculiar behavior

▪ marked impairment in personal hygiene and grooming

▪ blunted or inappropriate affect

▪ digressive, vague, overelaborate, or circumstantial speech; poverty of speech; or poverty of content of speech

▪ odd beliefs or magical thinking influencing behavior and inconsistent with cultural norms

▪ unusual perceptual experiences

▪ marked lack of initiative, interests, or energy.

Family members or friends may report personality changes. Typically insidious, this phase may extend over several months or years.

Active phase

During the active phase, the patient exhibits frankly psychotic symptoms. Psychiatric evaluation may reveal delusions, hallucinations, loosening of associations, incoherence, and catatonic behavior. The patient’s psychosocial history may also disclose a particular stressor before the onset of this phase.

Residual phase

According to the DSM-IV-TR, the residual phase follows the active phase and occurs when at least two of the symptoms noted in the prodromal phase persist. These symptoms don’t result from a disturbance in mood or from a psychoactive substance use disorder.

The residual phase resembles the prodromal phase, except that disturbances in affect and role functioning usually are more severe. Delusions and hallucinations may persist.

SIGNS AND SYMPTOMS

Schizophrenia is associated with many abnormal behaviors; therefore, signs and symptoms vary widely, depending on the type and phase (prodromal, active, or residual) of the illness.

Watch for these signs and symptoms:

• ambivalence—coexisting strong positive and negative feelings, leading to emotional conflict

• apathy and other affective abnormalities

• clang associations—words that rhyme or sound alike used in an illogical, nonsensical manner—for instance, “It’s the rain, train, pain”

• concrete associations—inability to form or understand abstract thoughts

• delusions—false ideas or beliefs accepted as real by the patient; delusions of grandeur, persecution, and reference (distorted belief regarding the relation between events and one’s self—for example, a belief that television programs address the patient on a personal level); feelings of being controlled, somatic illness, and depersonalization

• echolalia—automatic and meaningless repetition of another’s words or phrases

• echopraxia—involuntary repetition of movements observed in others

• flight of ideas—rapid succession of incomplete and loosely connected ideas

• hallucinations—false sensory perceptions with no basis in reality; usually visual or auditory, but may also be olfactory (smell), gustatory (taste), or tactile (touch)

• loose associations—rapid shifts among unrelated ideas

• magical thinking—belief that thoughts or wishes can control others or events

• neologisms—bizarre words that have meaning only for the patient

• poor interpersonal relationships

• regression—return to an earlier developmental stage

• thought blocking—sudden interruption in the patient’s train of thought

• withdrawal—disinterest in objects, people, or surroundings

• word salad—illogical word groupings, such as “She had a star, barn, plant.”

COMPLICATIONS

• Inability to maintain employment or attend school

• Financial difficulties and poverty

• Homelessness

• Suicide or self-destructive behavior

• Victim of crime

• Legal problems from committing violent crime

• Health problems secondary to adverse reactions from drug treatment

DIAGNOSTIC CRITERIA

After a complete physical and psychiatric examination rules out an organic cause of symptoms such as an amphetamine-induced psychosis, a diagnosis of schizophrenia may be considered. A diagnosis is made if the patient’s symptoms match those in the DSM-IV-TR. (See Diagnosing schizophrenia, page 144.)

TREATMENT

Treatment focuses on meeting the physical and psychosocial needs of the patient, based on his previous level of adjustment and his response to medical and nursing interventions. Treatment may combine:

• drug therapy

• long-term psychotherapy for the patient and his family

• psychosocial rehabilitation

• vocational counseling.

Clinicians disagree about the effectiveness of psychotherapy in
treating the patient with schizophrenia. Some consider it a useful adjunct to drug therapy. Others suggest that psychosocial rehabilitation, education, and social skills training are more effective for chronic schizophrenia. In addition to improving understanding of the disorder, these methods teach the patient and his family coping strategies, effective communication techniques, and social skills.

DIAGNOSING SCHIZOPHRENIA

The following criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, are used to diagnose a person with schizophrenia.

Characteristic symptoms

A person with schizophrenia has two or more of the following symptoms (each present for a significant time during a 1-month period—or less if successfully treated):

▪ delusions

▪ hallucinations

▪ disorganized speech

▪ grossly disorganized or catatonic behavior

▪ negative symptoms (affective flattening, alagia, anhedonia, attention impairment, apathy, and avolition).

The diagnosis requires only one of these characteristic symptoms if the person’s delusions are bizarre, or if hallucinations consist of a voice issuing a running commentary on the person’s behavior or thoughts or two or more voices conversing.

Social and occupational dysfunction

For a significant period since the onset of the disturbance, one or more major areas of functioning (such as work, interpersonal relations, or selfcare) are markedly below the level achieved before the onset.

When the disturbance begins in childhood or adolescence, the dysfunction takes the form of failure to achieve the expected level of interpersonal, academic, or occupational development.

Duration

Continuous signs of the disturbance persist for at least 6 months. The 6-month period must include at least 1 month of symptoms (or less if signs and symptoms have been successfully treated) that match the characteristic symptoms and may include periods of prodromal or residual symptoms.

During the prodromal or residual period, signs of the disturbance may be manifested by only negative symptoms or by two or more characteristic symptoms in a less severe form.

Schizoaffective and mood disorder exclusion

Schizoaffective disorder and mood disorder with psychotic features have been ruled out for these reasons: Either no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms, or, if mood disorder episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

Substance and general medical condition exclusion

The disturbance isn’t due to the direct physiologic effects of a substance or a general medical condition.

Relationship to a pervasive developmental disorder

If the person has a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is appropriate only if prominent delusions or hallucinations are also present for at least 1 month (or less if successfully treated).

Because schizophrenia typically disrupts the family, family therapy may be helpful to reduce guilt and disappointment as well as improve acceptance of the patient and his bizarre behavior.

Drugs

• Antipsychotic drugs—as the primary treatment for more than 30 years, antipsychotic drugs (also called neuroleptic drugs) appear to work by blocking postsynaptic dopamine receptors. These drugs reduce the incidence of positive psychotic symptoms, such as hallucinations and delusions, and relieve anxiety and agitation. Newer antipsychotics are effective in relieving positive and negative symptoms of schizophrenia. Certain antipsychotic drugs are associated with numerous adverse reactions, some of which are irreversible. (See Reviewing adverse effects of antipsychotic drugs, page 146.)

• The newer antipsychotic drugs appear to be effective in treating the negative symptoms of schizophrenia (withdrawal, apathy, or blunted affect). However, these drugs have problematic adverse effects. Antipsychotic drugs are broken down into two major classes: dopamine-receptor antagonists (haloperidol and thorazine) and dopamine-serotonin antagonists, also called atypical antipsychotics (risperidone [Risperdal] and clozapine [Clozaril]). The long-acting drugs haloperidol (Haldol) and fluphenazine (Prolixin) may be given I.M. every 3 to 4 weeks to improve compliance.

– Clozapine may be prescribed for severely ill patients who fail to respond to standard treatment. This drug effectively controls more psychotic signs and symptoms without the usual adverse effects. However, clozapine can cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, and seizures. Risperidone and olanzapine (Zyprexa), like clozapine, have reduced the incidence of adverse effects, including extrapyramidal symptoms and anticholinergic adverse effects.

REVIEWING ADVERSE EFFECTS OF ANTIPSYCHOTIC DRUGS

The newer atypical drugs, such as risperidone, olanzapine, quetiapine, sertindole, and ziprasidone, produce fewer extrapyramidal symptoms than the first, older class of antipsychotics. Risperidone is associated with increases in serum prolactin. Olanzapine, in moderate doses, induces little extrapyramidal symptoms, but has been associated with weight gain and blood glucose abnormalities. Quetiapine can cause weight gain, hypotension, and sedation.

Older classes of antipsychotic drugs (sometimes known as neuroleptic drugs) can cause sedative, anticholinergic, or extrapyramidal effects; orthostatic hypotension; and, rarely, neuroleptic malignant syndrome.

Sedative, anticholinergic, and extrapyramidal effects

High-potency drugs (such as haloperidol) are minimally sedative and anticholinergic but cause a high incidence of extrapyramidal adverse effects. Intermediate-potency drugs (such as molindone) are associated with a moderate incidence of adverse effects, whereas low-potency drugs (such as chlorpromazine) are highly sedative and anticholinergic but produce few extrapyramidal adverse effects.

The most common extrapyramidal effects are dystonia, parkinsonism, and akathisia. Dystonia usually occurs in young male patients within the first few days of treatment. Characterized by severe tonic contractions of the muscles in the neck, mouth, and tongue, dystonia may be misdiagnosed as a psychotic symptom. Diphenhydramine or benztropine administered I.M. or I.V. provides rapid relief from this symptom.

Drug-induced parkinsonism results in bradykinesia, muscle rigidity, shuffling or propulsive gait, stooped posture, flat facial affect, tremors, and drooling. Parkinsonism may occur from 1 week to several months after the initiation of drug treatment. Drugs prescribed to reverse or prevent this syndrome include benztropine, trihexyphenidyl, and amantadine.

Tardive dyskinesia can occur after only 6 months of continuous therapy and is usually irreversible. No effective treatment is available for this disorder, which is characterized by various involuntary movements of the mouth and jaw; flapping or writhing; purposeless, rapid, and jerky movements of the arms and legs; and dystonic posture of the neck and trunk.

Signs and symptoms of akathisia include restlessness, pacing, and an inability to rest or sit still. Akathisia may be misinterpreted as agitation or a worsening of psychotic behavior. Propranolol relieves this adverse effect.

Orthostatic hypotension

Low-potency neuroleptics can cause orthostatic hypotension because they block alpha-adrenergic receptors. If hypotension is severe, the patient is placed in the supine position and given I.V. fluids for hypovolemia. If further treatment is needed, an alpha-adrenergic agonist, such as norepinephrine or metaraminol, may be ordered to relieve hypotension. Mixed alpha- and beta-adrenergic drugs (such as epinephrine) or beta-adrenergic drugs (such as isoproterenol) shouldn’t be given because they can further reduce blood pressure.

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome is a life-threatening syndrome that occurs in up to 1% of patients taking antipsychotic drugs. Signs and symptoms include fever, muscle rigidity, and altered level of consciousness occurring hours to months after initiating drug therapy or increasing the dose. Treatment is symptomatic, largely consisting of dantrolene and other measures to counter muscle rigidity associated with hyperthermia. You’ll need to monitor vital signs and mental status continuously.

ALERT

More than 50% of patients taking atypical antipsychotics will have significant weight gain and should be monitored for the development of
metabolic syndrome and type 2 diabetes.

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