Schizophrenia: Understanding Symptoms and Diagnosis

Schizophrenia Overview

• Schizophrenia involves distorted and bizarre thoughts, perceptions, emotions, movements, and behavior.
• Historically, schizophrenia was greatly misunderstood.
• Perspectives on schizophrenia have evolved recently, with the advent of medications to manage symptoms.

Symptom Categories

• Symptoms are categorized as positive (hard) or negative (soft).
• Positive symptoms involve additions to normal behavior or thinking.
• Positive symptoms include delusions and hallucinations.
• Negative symptoms involve a reduction in certain functions.
• Negative symptoms are harder to treat.
• Examples of negative symptoms: flat affect, lack of volition, and inattention.

Positive Symptoms Explained

• Ambivalence: Holding contradictory feelings about a person, event, or situation.
• Associative looseness: Fragmented and poorly related thoughts and ideas.
• Bizarre behavior: Outlandish appearance, repetitive movements, or unusual social/sexual behavior.
• Delusions: Fixed false beliefs with no basis in reality.
• Echopraxia: Imitating movements and gestures of another person being observed.
• Flight of ideas: Rapidly jumping from one topic to another in continuous speech.
• Hallucinations: False sensory perceptions that aren't based in reality.
• Ideas of reference: False impressions that external events have special meaning.
• Perseveration: Persistent adherence to an idea, repeating words/phrases, and resisting topic changes.

Negative Symptoms Explained

• Alogia: Speaking little with minimal substance of meaning, and poverty of content.
• Anhedonia: Lack of joy or pleasure.
• Apathy: Indifference towards people, activities, and events.
• Asociality: Social withdrawal with lack of relationships.
• Avolition: Absence of will, ambition, or drive.
• Blunted affect: Restricted range of emotional feeling, tone, or mood.
• Catatonia: Psychologically induced immobility marked by periods of agitation/excitement.
• Flat affect: Absence of facial expressions indicating emotions.
• Inattention: Inability to concentrate, irrespective of importance.

Onset and Prevalence

• Diagnosed in late adolescence or early adulthood.
• Schizophrenia is rare in childhood.
• Onset peaks in men between 15 and 25 years.
• Onset peaks in women between 25 and 35 years.
• Estimated prevalence is about 1% of the total population.
• Schizoaffective disorder: client is severely ill, mixed with psychotic and mood symptoms.

Clinical Course

• Onset can be abrupt or insidious.
• Most commonly, slow and gradual development of signs and symptoms.
• These symptoms can be social withdrawal, loss of interest, or neglected hygiene.
• Diagnosis often happens with actively positive symptoms of psychosis, such as hallucinations and delusions.
• Earlier age of onset is correlated with a worse prognosis.

Immediate and Long-Term Course

• Immediate-term course can involve ongoing psychosis without full recovery.
• It also can involve episodes of psychotic symptoms alternating with relative recovery.
• In the long-term, intensity of psychosis tends to diminish with age.
• The disease becomes less disruptive.
• Clients may live independently later in life.
• Many have difficulty in the community due to persistent negative symptoms.

Related Disorders

• Schizophreniform: Symptoms of psychosis last <6 months.
• Catatonia: Can be either excessive or no movement at all.
• Delusional disorder has one or more non-bizarre delusions.
• Brief psychotic disorder: has at least 1 psychotic symptom lasting 1 day-1 month.
• Shared psychotic disorder (folie a deux) involves two people who share a similar delusion.
• Schizotypal personality disorder characterized by odd, eccentric behavior in a personality disorder.

Etiology of Schizophrenia

• Schizophrenia is considered multifactorial (genetics and environment).

Biologic Theories: Genetic Factors

• Studies on twins indicate identical twins had a 50% risk.
• compared with 15% of fraternal twins.
• Children with 1 biologic parent who has schizophrenia has a 15% risk.
• Children with both biologic parents who have schizophrenia have a 35% risk.

Neuroanatomic and Neurochemical Factors

• Anatomy shows less brain tissue and cerebrospinal fluid.
• Chemically, there is excess dopamine and an alteration of serotonin modulation of dopamine.

Immunovirologic Factors

• Elevated Cytokines are a factor.
• Infections in women who were pregnant are related.
• Waves of schizophrenia in England occurred a generation following an influenza epidemic.

Cultural Considerations

• Ideas considered delusional in one culture are possibly accepted by other cultures.
• Auditory or visual hallucinations, such as seeing the Virgin Mary or hearing God's voice, might be normal in certain cultures.
• Assessment of affect requires sensitivity to cultural differences in eye contact, body language, and emotional expression.

Psychopharmacology Treatment

• Conventional antipsychotics are potent dopamine antagonists that target positive signs.
• Conventional antipsychotics have no observable effect on negative signs.
• Atypical antipsychotics involve weaker dopamine antagonists and serotonin antagonists.
• Atypical antipsychotics diminish positive symptoms and lessen negative signs.
• Third generation medications are dopamine output stabilizers.

Maintenance Therapy

• There are six antipsychotics available for long-acting (depot) injections.
• Fluphenazine is available in decanoate and enanthate preparations
• Haloperidol is available in decanoate.
• Other medicaitons available include: Risperidone, Paliperidone, Olanzapine, and Aripiprazole.
• Effects from the medication last for 1 to 3 months, which eliminates the need for daily oral medications.

Neurologic Side Effects of Psychopharmacology

• Extrapyramidal side effects include: acute dystonic reactions, akathisia, and parkinsonism.
• Tardive dyskinesia needs monitoring with AIMS every 3-6 months.
• Any increases should be reported.
• Other neurologic side effects include neuroleptic malignant syndrome.
• Risk of seizure is 1%, where clozapine has a 5% risk.
• Agranulocytosis is common, but mostly with clozapine.

Nonneurologic Side Effects of Psychopharmacology

• Weight gain and sedation.
• Photosensitivity.
• Anticholinergic symptoms might occur.
• Dry mouth.
• Blurred vision.
• Possible constipation and urinary retention.
• Orthostatic hypotension.

Psychosocial Treatment

• Individual and group therapy provides opportunity for relationships.
• Individual and group therapy supports medication management.
• Social skills training.
• Cognitive adaptation training utilizes environmental supports such as signs and calendars.
• Cognitive enhancement therapy (CET).
• Family education and therapy diminishes negative symptoms.

Assessment: History

• Patient's history prior to the crisis.
• Age at onset of symptoms.
• Previous suicide attempts.
• Current support systems.
• Perception of the situation.

General Apperance/Motor Behavior

• Includes appearance: which can be normal, disheveled, unkempt, strange or inappropriate clothing.
• Behavior - waxy flexibility, catatonia, echopraxia.
• Speech can include echolalia; latency of response (30-45 seconds).

Unusual Speech Patterns

• Clang associations: Speech pattern is based on phonetics instead of semantics.
• Neologisms: Made-up words only understood by the speaker.
• Verbigeration: Senseless repetition of words or sentences.
• Echolalia: Repetition of another person's words or phrases.
• Stilted language: Use of overly formal or flowery speech.
• Perseveration: Repetition of a particular response regardless of stimulus.
• Word salad: Randomly spoken words and phrases that demonstrate highly disorganized thinking.

Assessment: Mood and Affect

• Flat and blunted; anhedonia; all powerful.

Assessment: Thought Process & Content

• Thought blocking, broadcasting, withdrawal, or insertion.
• Circumstantial and tangential thinking.
• Alogia.

Assessment: Delusions

• Delusions are fixed, false beliefs.
• External contradictory information or facts cannot alter these beliefs.
• Categories include: Persecutory/paranoid, grandiose, religious, somatic, sexual, nihilistic, or referential.

Assessment: Sensorium and Hallucinations

• Hallucinations are false sensory perceptions that exist in reality.
• Auditory hallucinations are the most common, and include command hallucinations.
• Visual hallucinations - second most common.
• Other forms: olfactory, tactile, gustatory, and cenesthetic.
• Tactile hallucinations are rare in schizophrenia.
• Illusions are a distorted or misinterpretation of actual stimuli.

Assessment: Intellectual Processes and Self-Concept

• Intellectual deficits include disoriented and depersonalization plus difficulty in abstract thinking.
• Loss of ego boundaries.
• Public undressing, talking to oneself in 3rd person, and clinging to objects in environment
• Socially inappropriate behavior, social isolation, or frustration in fulfilling family and community roles can occur.
• Physiological and self-care considerations.
• Self-care deficit.
• Failing to recognize hunger or thirst and sleep problems are all important.

Actions: Promoting Safety

• Approach patient in non-threatening manner and give personal space.
• Agitated patients: administer medications or provide quiet environment or seclusion if necessary.

Actions: Therapeutic Communication

• Communication can be difficult because of hallucinations.
• Reality orientation involves calling them by their name, and spending time engaging with the patient.
• Clarify any statements that are vague.

Actions: Managing Delusional Thoughts

• Do not confront/argue/agree with delusions.
• Establish and maintain reality for the client.
• Use distracting techniques to change the subject.
• Teach the client positive self-talk and thinking to ignore delusional beliefs.

Actions: Managing Hallucinations

• Elicit description of hallucination.
• Acknowledge the client's feelings and present reality.
• Increase prevention by having frequent contact and offering reality-based activities to distract.
• Talk back to voices by talking on a cell phone and telling them to shut up.

Actions: Socially Inappropriate Behavior

• Redirect clients away from situations or others.
• Protect the client's right to privacy and dignity.
• Utilize distraction techniques such as going for a walk or listening to music.
• Engage client in behaviors that are appropriate.

Other Actions: Client Education

• Provide client and family with information about the disorder and treatment.
• Educate on signs and symptoms of relapse.
• Educate on self-care, nutrition, and social skills.
• Explain medication management.
• Evaluate the effectiveness of interventions and outcomes.

Test your knowledge of schizophrenia, including historical understanding, symptom differentiation (positive vs. negative), and diagnostic considerations. Questions cover onset age, related conditions, and prevalence, focusing on key aspects of this complex disorder.