CHAPTER II

REVIEW OF RELATED LITERATURE

Definition

Local

1. Cacanindin, E. Psychiatric Nursing: Student Guide 1st Edition. Educational Publishing

House, Manila. 2002

Schizoprenia is a deteriorated, hopeless condition with poor prognosis. It is

characterized by thought, mood, behavioral disturbance as well as ineffective

communication that consist of delusions, ambivalence, inappropriateness, withdrawal and

regression.

Statistics

1. Philippine Star (2009). Understanding schizophrenia. Retrieved from [Link] dated

June 26, 2008

Schizophrenia is a serious disorder of the mind and brain that occurs in all

societies regardless of class, color, religion or culture. It is found in over one percent of

the population over the age of 18 or as many as 51 million people worldwide. It appears

between the ages of 15 and 25 with men getting the disease earlier than women according

to [Link], a non-profit online community that provides information, support,

and education to people with schizophrenia. It is one of the Top 10 causes of

disabilities in developed countries, according to the World Health Organization. In

the Philippines, a disability survey made by the National Statistics Office revealed that
 mental illness (which includes schizophrenia) is the third most common form

of disability with a prevalence rate of 88 cases per 100,000 population.

Foreign

History

1. Shives, L.R., Basic Concepts of Psychiatric –Mental Health Nursing Seventh Edition.

Lippincott Williams & Wilkins. 2008

Schizophrenia’s written descriptions have been traced back to Egypt during the

year 200BC. At that time, mental and physical illness were regarded as symptoms of the

heart and the uterus and thought to originate from blood vessels, fecal matter, poison or

demons. Greek physicians blamed delusions and paranoia on an imbalance of bodily

humors. Hippocrates believed that insanity was caused by a morbid state of the liver.

The understanding between the relationship between nerves and organs increased during

18th century and it was finally decided that disorders of the central nervous system were

the cause of insanity.

The term schizophrenia was first described as a specific mental illness in 1887 by

a psychiatrist Emil Kraeplin. Eugen Bleuler coined the term in 1911. He was also the

first individual to describe the positive and negative symptoms of schizophrenia.

1. Boyd, M.A., Psychiatric Nursing: Contemporary Practice Fourth Edition. Lippincott

Williams & Wilkins. 2008

Since the 1970s, purely psychological theories have been replaced by a

neurobiologic model that says that patient with schizophrenia have a biologic

predisposition or vulnerability that is exacerbated by environmental stressors. These

inherent vulnerabilities include cognitive, psychophysiologic, social competence, and

coping deficits that alter the individuals ability, both coginitively and emotionally, to

manage life events and interpersonal situations.

Schizophrenia is considered the most common and disabling of the psychotic

disorders. It stems from a physiologic malfunctioning of the brain. This disorder affects

all races, and is more prevalent in men than in women. No cultural group is immune, and

persons with intelligence quotients of the genius level are not spared. It occurs twice as

often in people who are unmarried or widowed. People with schizophrenia are more

likely to be members of lower socioeconomic groups.

1. Boyd, M.A., Psychiatric Nursing: Contemporary Practice Fourth Edition. Lippincott

Williams & Wilkins. 2008

Schizophrenia occurs in all cultures and countries. It occurs in about 1.3% of the

population or more than 3 million people in the United states. People with schizophrenia

tend to cluster in the lowest social classes in the industrialized countries and urban

communities. The symptoms of illness are so pervasive that it is difficult for these

individuals to maintain any type of gain for employment. Homelessness is a problem for

severely mentally ill. People with schizophrenia, may make up 11% to 14% of the

homeless population, compared with 1% to 1.3% of the general population.

Risk factors

1. Boyd, M.A., Psychiatric Nursing: Contemporary Practice Fourth Edition. Lippincott

Williams & Wilkins. 2008

Risk factors for schizophrenia includes stresses in the perinatal period (starvation,

poor nutrition, infections, obstetrical complications and genetic and family

susceptibility). Studies suggest that the incidence may be higher among individuals born

in urban settings than those born in rural ones and may be somewhat lower in later born

birth (Harrison et al. 2003).

1. Boyd, M.A., Psychiatric Nursing: Contemporary Practice Fourth Edition. Lippincott

Williams & Wilkins. 2008

Positive symptoms can be thought of as symptoms that exist but should not, and

negative symptoms as ones that should be there but are not

Neurocognitive impairment exists in schizophrenia and may be independent of

positive and negative symptoms. Neurocognition includes memory, vigilance or

sustained attention, verbal fluency or the ability to generate new words, and executive

functioning, which includes volition, planning, purposive action, and self-monitoring

behavior. This impairment is independent of the positive symptoms. That is, cognitive

dysfunction can exist even if the positive symptoms are in remission.

Disorganized thinking include echolalia, circumstantiality, loose associations,

tangentiality, flight of ideas, word salad, neologisms, paranoia, referential thinking,

autistic thinking, concrete thinking, verbigeration, metonymic speech, clang association,

stilted language and pressured speech.

Disorganized behavior includes aggression, agitation, catatonic excitement,

exhopraxia, refressed behavior, stereotypy, hypervigilance and waxy flexibility.

Lippincott Williams & Wilkins. 2008

Symptoms of schizophrenia may appear suddenly or develop gradually over time.

Clinical symptoms fall into three broad categories: positive symptoms, negative

symptoms and disorganized symptoms.

Positive symptoms include excess or distortion of normal functions, delusions,

conceptual disorganization, hallucinations, excitement or agitation, hostility or aggressive

behavior, suspiciousness, pressurized speech, bizarre dress or behavior, and possible

suicidal tendency.

Negative symptoms include diminution or loss of normal functions, anergia or

lack of energy, anhedonia or loss of pleasure or interest, emotional withdrawal, poor eye

contact, blunted affect, avolition (passive, apathetic, or social withdrawal), difficulty in

abstract thinking, alogia or lack of spontaneity and flow of conversation, and

dysfunctional relationship with others.

Disorganized symptoms include cognitive defects or confusions, incoherent

speech, disorganized speech, repetitive rhythmic gestures such as walking in circles or

pacing, and attention deficits.

Diagnosis

1. Boyd, M.A., Psychiatric Nursing: Contemporary Practice Fourth Edition. Lippincott

Williams & Wilkins. 2008

and Statistical Manual of Mental Disorders, 4th edition, text revision states that

schizophrenia is a mixture of positive and negative symptoms that present for a

significant portion of a 1-month period but with continuous signs of disturbance

persisting for at least 6 months.

The DSM – IV – TR criteria for diagnosing schizophrenia include necessary

symptomatology, duration of symptoms, evaluation of functional impairment, and

elimination, and elimination of alternate hypotheses that might account for the symptoms

(APA, 2000).

Several schizophrenia subtypes are currently recognized: paranoid, disorganized,

catatonic, undifferentiated, and residual. There is a growing belief that this subtyping is

not useful for predicting the course and response to treatment.

The diagnostic characteristics of schizophrenia subtypes include paranoid type

wherein an individual is preoccupied with delusions or auditory hallucinations,

disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect is

not prominent. Disorganized type wherein an individual manifests disorganized speech,

disorganized behavior, and flat or inappropriate affect. Catatonic type wherein the

individual manifests at least two of the following characteristics: motor immobility or

stupor, excessive purposeless motor activity, extreme negativism, posturing, stereotyped

movements, prominent mannerisms, or prominent grimacing and echolalia or echopraxia.

Undifferentiated type only has the characteristic symptoms present but does not meet the

criteria for the other subtypes. Residual type is when the individual manifests absence of

prominent delusions, hallucinations, disorganized speech, and grossly disorganized or

present in attenuated form such as odd beliefs or unusual perceptual experiences.

The diagnostic criteria for schizophrenia include two or more of the following

characteristic symptoms present for a significant portion of time during a 1-month period:

delusions, hallucinations, disorganized speech, grossly disorganized or catatonic

behavior, negative symptoms. One or more major areas of social or occupational

functioning (such as work, interpersonal relations, self-care) markedly below previously

achieved level. Continuous signs persisting for at least 6 months. Absence or

insignificant duration of major depressive, manic, or mixed episodes occurring

concurrently with active symptoms. Not a direct physiologic effect of a substance or

medical condition. Prominent delusions or hallucinations present when a prior history of

autistic disorder or another pervasive developmental disorder exists.

Target symptoms and associated findings for individuals with

schizophrenia include inappropriate affect, loss of interest or pleasure, dysphoric mood

(anger, anxiety, or depression) disturbed sleep patterns, lack of interest in eating or

refusal of food, difficulty concentrating, some cognitive dysfunction such as confusion,

disorientation, memory impairement, lack of insight, depersonalization, derealization,

somatic concerns, motor abnormalities.

Associated physical examination findings include physically awkward, poor

coordination or mirroring, motor abnormalities, cigarette-related pathologies, such as

emphysema and other pulmonary and cardiac problems.

Associated laboratory findings include enlarged ventricular system and prominent

sulci in the brain cortex, decreased temporal and hippocampal size, increased size of
 basal ganglia, decreased cerebral size, slowed reaction times, and abnormalities in eye

tracking.

Treatment

1. Antai-Otong, D., Psychiatric Nursing: Biological & Behavioral Concepts Second

Edition. Cengage Learning Asia Pte. Ltd. 2008

Treatment may involve use of pharmacologic agents as well as psychosocial

rehabilitation and therapy. Psychopharmacological interventions include traditional or

typical and atypical antipsychotic medication. All of these medications affect the

anatomic and functional systems of the brains. Hence, they assist with ending or

minimizing the presence of hallucinations, delusions, and illusions that interfere with a

person’s ability to recover and function appropriately on a daily basis. Traditional

medications were developed during the 1950’s. Among these medications were

haloperidol, chlorpromazine, and thiothixene. These medications are associated with

higher adverse symptoms such as tardive dyskinesia and extrapyramidal side effects.

However in the 1990’s additional medications have been developed, including

risperidone(risperdal), olanzapine(zyprexa), quetiapine(seroquel), ziprasidone(geodon),

aripiprazole(abilify).

In addition to pharmacologic interventions, psychotherapeutics are necessary

components of holistic treatment planning. The efficacy of psycho education and

psychotherapy that focus on schizophrenia, family involvement, coping skills, and

psychosocial rehabilitation are well documented.

Prognosis
Nursing Management

1. Boyd, M.A., Psychiatric Nursing: Contemporary Practice Fourth Edition. Lippincott

Williams & Wilkins. 2008

Nursing management of the patient with schizophrenia lasts many years.

Different phases of the illness require various nursing interventions. In the clinical area,

effective nursing management requires an integration of the assessment data from all

domains into meaningful interventions. Nursing interventions should cover all aspects of

functioning including biologic, psychological, social and family functioning.

2. Videbeck, S.L. Psychiatric-Mental Health Nursing Fourth Edition. Lippincott Williams

& Wilkins. 2008

Promoting the safety of client and others, safety for both the client and the nurse

is the priority when providing care for the client with schizophrenia. The nurse must

approach in nonthreatening manner and giving the client ample personal space usually

enhances his or her sense of security. Establishing trust between the client and nurse also

helps to allay the fears of a frightened client. Provide explanations that are clear, direct

and easy to understand. Body language should include eye contact but not staring, a

relaxed body posture, and facial expressions that convey genuine interest and concern.

Communicating with clients should include the use of therapeutic communication, where

the nurse tries to understand and make sense on what the client is saying. Active listening

is an important skill for the nurse trying to communicate with a client whose
verbalizations are disorganized or nonsensical. The nurse must let the client know when

his or her meaning is not clear.

The nurse must avoid openly confronting the delusion or arguing with the client

about it. The nurse must avoid reinforcing the delusional belief by “playing along” with

what the client says. It is the nurse’s responsibility to present and maintain reality by

making simple statements.

As antipsychotic medications begin to have a therapeutic effect, it will be possible

for the nurse to discuss the delusional ideas with the client and identify ways in which the

delusions interfere with the client’s daily life. The nurse can help the client minimize

effects of delusional thinking. Distraction techniques, such as listening to music,

watching television, writing, or talking to friends, are useful. Direct action, such as

engaging in positive self-talk and positive thinking and ignoring the delusional thoughts,

may be beneficial as well.

Intervening when the client experiences hallucinations requires the nurse to focus

on what is real and to help shift the client’s response toward reality. Protecting the client

is a primary nursing responsibility and includes protecting the client from retaliation by

others who experience the client’s intrusions and socially unacceptable behavior.

Redirecting the client away from situations or others can interrupt the undesirable

behavior and keep the client from further intrusive behaviors. The nurse must also try to

protect the client’s right to privacy and dignity.

Because of apathy or lack of energy over the course of the illness, poor personal

hygiene can be a problem for clients who are experiencing psychotic symptoms as well as

for all clients with schizophrenia. When the client is psychotic, he or she may pay little
 attention to hygiene or may be unable to sustain the attention or concentration required to

complete grooming tasks. The nurse may need to direct the client through the necessary

steps for bathing, shampooing, dressing, and so forth. The nurse gives directions in short,

clear statements to enhance the client’s ability to complete the tasks.

Client’s may be isolated from others for a variety of reasons. The bizarre

behavior or statements of the client who is delusional or hallucinating may frighten or

embarrass family or community members. Clients who are suspicious or mistrustful may

avoid contact with others. Clients may lack the social or conversation skills they need to

make and maintain relationships with others. A stigma remains attached to mental

illness, particularly for clients for whom medication fails to relieve the positive signs of

the illness. The nurse can help the client develop social skills through education, role

modeling, and practice.

Maintaining the medication regimen is vital to a successful outcome for clients

with schizophrenia. Failing to take medications as prescribed is one of the most frequent

reasons for recurrence of psychotic symptoms and hospital admission. The nurse must

determine the barriers to compliance for each client. The nurse can teach the client about

schizophrenia, the nature of the chronic illness, and the importance of medications in

managing symptoms and preventing recurrence.

Pathology

1. Porth C.M (2005). Pathophysiology Concepts Altered Health Stages. Lippincott

William and Wilkins 2005 page 1176.

The pathogenesis of schizophrenia is unknown but some studies suggests that the

anatomical alterations are not the result of progressive brain deterioration due to repeated
 psychotic episodes or ti effects of psyhotropic drugs, but rather are caused by

abnormalities in neurodevelopment in intrauterine and early postnatal life. The lateral and

third ventricles are enlarged, the thalamus and hippocampus are somewhat smaller, and

the left heisphere is both smaller and smoother than that of person without illness. These

changes are accompanied by a change in brain volume.

2. Mcglashan T.H and Hoffman R.E (2001). Neural Networks Model of Schizophrenia. The

Neuroscientist, Vol. 7, No. 5, pp. 441-454

There is considerable neurobiological evidence suggesting that schizophrenia is

associated with reduced corticocortical connectivity. The authors describe two neural

network computer simulations that explore functional consequences of these

abnormalities. The first utilized an "attractor" neural network capable of content-

addressable memory. Application of a pruning rule that eliminated weaker connections

over longer distances produced functional fragmentation and the emergence of localized,

"parasitic" attractors that intruded into network dynamics. A second neural network

simulation examined effects of corticocortical pruning in a speech perception network.

Excessive pruning caused the network to produce percepts spontaneously, that is, in the

absence of inputs, thereby simulating hallucinations. The "hallucinating" network also

demonstrated subtle impairments in narrative speech perception. A parallel study of

human patients found similar impairments when comparing hallucinating patients with

nonhallucinating patients. In addition, the authors have used transcranial magnetic

stimulation (TMS) to directly probe speech perception neurocircuitry in patients with

that "suppressive" low-frequency TMS reduces auditory hallucinations. Neural network

simulations provide empirically testable concepts linking phenomenological, cognitive,

and neurobiological findings in schizophrenia.