Schizophrenia has existed for thousands of years but did not receive its present name until 1908. Eugen Bleuler (1857–1939), a Swiss psychiatrist, invented the word as a replacement for an older term he considered misleading. Because the word schizophrenia means “split mind,” some people confuse it with dissociative identity disorder (formerly called multiple personality disorder). It is important to note that people with schizophrenia do not have separate internal personalities. People with schizophrenia vary from one another in their symptom patterns and their ability to function in society. Some have periods of surprising productivity, such as John Nash (1928–), a mathematician who was hospitalized for schizophrenia in 1959 but slowly recovered during the 1980s and was awarded the Nobel Prize in economics in 1994. (A film about Nash, A Beautiful Mind, was released in 2001.)
Other patients are never able to function well and require ongoing help from family members, psychiatrists, and social workers. A common misunderstanding of people with schizophrenia is that they are violent. Some schizophrenics do commit bizarre or violent crimes, often under the influence of alcohol or drugs of abuse. Most people with the disorder, however, are more afraid of other people than are violent or aggressive toward them.
The role of drug and alcohol abuse in Schizophrenia is complicated. On the one hand, the disorder itself is not caused by alcoholism or drug abuse. On the other, schizophrenics are more likely than others to abuse drugs and alcohol, often as a way of coping with their symptoms. One problem with drug and alcohol abuse is that it makes schizophrenia harder to treat. Drugs like phencyclidine or PCP (“angel dust”), marijuana, or cocaine can make the symptoms of schizophrenia worse; they also make patients less likely to follow their treatment plan. The drug that is most commonly abused by schizophrenics, however, is nicotine. Between 75 and 90 percent of people with schizophrenia are heavy smokers, compared with 25 to 30 percent in the general population.
Schizophrenia is thought to affect about 1 percent of the population around the world over the age of eighteen. In the United States, about 2 million people have been diagnosed with schizophrenia. As far as is known, schizophrenia affects all races and ethnic groups equally. It is considered one of the most disabling disorders in all countries, being ranked just behind spinal cord injuries and dementia in the severity of its impact on people’s lives.
Risk factors for the disorder include:
• Age. Schizophrenia is largely a disorder beginning in adolescents and young adults. It is rare in children, although cases have been reported in children as young as five. It is also rare for schizophrenia to develop in adults over forty-five.
• Gender. Males are more likely to develop schizophrenia in their late teens and early twenties and to have more severe symptoms. Females are more likely to develop symptoms in their late twenties or early thirties.
• People with a family history of schizophrenia. A child of a schizophrenic parent has a 10 percent chance of developing the disorder.
• People exposed to viruses or malnutrition prior to birth, or whose mothers had a difficult childbirth.
• People who experimented with recreational drugs during their early teens.
• People whose fathers were over forty at the time of their birth.
• People who live in large cities.
Nursing Care Plan Signs and SymptomsThe causes of Schizophrenia are not fully understood. There is general agreement that genetic factors are involved because the disorder is known to run in families. However, no specific gene has been identified as the cause of schizophrenia. In 2007 and 2008, researchers uncovered evidence that rare genetic mutations, rather than common genes, may be responsible for the disorder—and that some of these mutations may be unique to isolated individuals rather than distributed throughout the population.
Other theories about the causes of schizophrenia include the notion that the brains of people with schizophrenia are different in structure from those of people without the disorder, or that they have abnormally high levels of a neurotransmitter (brain chemical) called dopamine. One theory that has been completely discarded in recent years is that schizophrenia is caused by bad parenting.
Doctors classify the symptoms of Schizophrenia into three groups:
positive, negative, and cognitive. Positive symptoms refer to behaviors that indicate a loss of contact with reality:
• Hallucinations: seeing or hearing things that are not really there. People with schizophrenia commonly have auditory (hearingrelated) hallucinations, often voices telling them to do something, including harming other people.
• Delusions. Delusions are false ideas that a person continues to hold even after they are shown to be false.
• Disorganized speech. This may include making up words that have no meaning or stringing words together in nonsensical ways.
• Movement disorders. The patient may be clumsy and uncoordinated, or may sit motionless for hours—a condition called catatonia.
Negative symptoms refer to losses or deficiencies in relating to others or in general functioning:
• Lack of emotion in the voice or facial expressions
• Social isolation
• Neglecting personal cleanliness and grooming
• Inability to take pleasure in things that most people enjoy
• Problems in starting and organizing tasks or activities
• Refusing to speak even when spoken to Cognitive symptoms refer to problems with thinking, memory, and the ability to pay attention. These are the symptoms that interfere most severely with the patient’s education and employment in adult life.
Nursing Care Plan DiagnosisThere is no laboratory or imaging test that can be used to diagnose Schizophrenia, although in some cases the doctor may order blood or urine tests to rule out medical disorders or imaging studies of the head to rule out brain tumors or head injuries. The diagnosis is made on the basis of an interview with the doctor followed by a series of questionnaires and a detailed family history. During the interview, the doctor will listen to the patient’s tone of voice and observe his or her appearance and behavior as well as the content of the answers to questions. In some cases the doctor will need to talk to members of the patient’s family or close friends in order to collect information about the patient’s previous ability to function; when the symptoms began; and whether there is a family history of mental illness.
To be diagnosed with schizophrenia, the patient must meet the following criteria:
• The presence of at least two of the following: delusions, hallucinations, disorganized speech, catatonic behavior, or any negative symptoms.
• Significant inability to function at home, in school or at work, or in carrying out daily tasks.
• The symptoms have lasted for at least six months.
• Other mental health disorders have been ruled out.
Nursing Care Plan TreatmentThe treatment of Schizophrenia is a lifelong process; there is no cure for the disorder. Some patients occasionally require hospitalization if they appear to be dangerous to themselves or others. Most, however, can be treated as outpatients. One of the chief difficulties with therapy for schizophrenia, however, is that most patients do not think that they are ill or that they need treatment. Doctors describe this characteristic as a lack of insight into the illness.
The mainstay of treatment for schizophrenia is medications, known as anti-psychotics. These are divided into two categories: older drugs that have been used since the 1950s and newer drugs introduced in 1989. The older drugs include medications like Haldol and Thorazine, which often had severe side effects and were also not effective in treating such symptoms as the lack of motivation or feeling. The newer drugs, which are sometimes called atypical anti-psychotics, include medications like Risperdal and Zyprexa. They also have side effects. Whichever medication is prescribed, however, it is critical for patients with schizophrenia to take their medications correctly and regularly. Failure to take the medications is the most common reason for relapses.
In addition to medications, patients with schizophrenia need psychotherapy and other forms of help:
• Individual therapy. This form of treatment is recommended to help schizophrenics understand their disorder, realize the importance of taking their medications, and learn to handle everyday life problems.
• Family therapy. Some doctors recommend family therapy as a way to help family members cope more effectively with the stresses produced by caring for someone with schizophrenia.
• Rehabilitation. Rehabilitation includes training in job-related as well as social skills so that patients are better equipped to live independently.
• Treatment for co-occurring substance abuse. Between 30 and 70 percent of patients with schizophrenia are also diagnosed with alcoholism or substance abuse disorders. Patients usually do better in programs that combine drug treatment with treatment for schizophrenia than in programs that treat the disorders separately.
• Self-help groups. Patients with schizophrenia benefit from the opportunities to learn and practice social skills in these groups as well as find support for the problems they face.
Nursing Care Plan PrognosisThe newer anti-psychotic medications have helped many patients with schizophrenia who did not respond to the older drugs. However, there are still some who do not respond to medications at all or choose to stop taking them after a year or so because of the side effects. Despite ongoing research, schizophrenia remains a difficult disease to treat, and the prognosis for recovery is still poor. A few patients do recover completely, but most have periodic relapses and need group homes or long-term structured programs in order to function in the community. In addition to problems with drug abuse and dependence, patients with schizophrenia also have a very high rate of suicide—10 percent. Patients who have a family history of schizophrenia, whose symptoms began in their teens, and who have negative symptoms have the poorest prognosis. Patients who were older when their symptoms started, got treatment quickly, and had a high level of functioning before they were diagnosed have the most hopeful prognosis for recovery.
There is not enough known about the causes of schizophrenia for any preventive strategies to be effective.
Most researchers in the field of mental health do not expect schizophrenia to become either more or less common than it is at present. They are focusing on behavioral treatments for schizophrenia as well as newer medications with fewer side effects. One new drug currently in clinical trials is administered as a nasal spray rather than an injection; another is a drug that needs to be given only twice a month rather than every day, which would make it easier for patients to stick with medication therapy. Another critical area of research is the genetic factors involved in the disorder.