schizophrenia /skit′səfrē″nē·ə, skiz′ə-/ [Gk, schizein, to split, phren, mind] , any one of a large group of psychotic disorders characterized by gross distortion of reality, disturbances of language and cognitive function, withdrawal from social interaction, disorganization and fragmentation of thought, altered perception, and emotional reaction. The term schizophrenia denotes one of the fundamental characteristics of the patients, the splitting off of a part of the psyche. The part that splits off then dominates the psychic life of the patient, even though it may express behavior that is contrary to the original personality of the patient. Apathy and confusion; delusions and hallucinations; rambling or stylized patterns of speech, such as evasiveness, incoherence, and echolalia; withdrawn, regressive, and bizarre behavior; and emotional lability often occur. Most patients have both positive and negative psychotic symptoms. Positive symptoms include hallucinations; negative symptoms include anergia, flatness, and anhedonia. The condition may be mild or require prolonged hospitalization. No single cause of the disorder is known; genetic, biochemical, psychological, interpersonal, and sociocultural factors are usually involved. Although slowly progressive deterioration of the personality may occur, dementia is not an inevitable consequence of the disorder. There may be recovery in some cases, and there may be relapse marked by intermittent episodes that begin after prolonged remission. Formerly called dementia praecox. ▪ OBSERVATIONS: Characteristics vary in type and severity, and onset may be sudden or insidious. Symptomatic periods may be episodic or continuous. Typical characteristics are divided into prodromal (pre/early), positive (excess/distortion of normal function), and negative (reduction /loss of normal function) symptoms. Prodromal symptoms include withdrawal, social isolation, reduced interest or initiative, elaborate speech, magical thinking, unusual perceptual experiences, and strange behaviors. Positive symptoms include psychosis as evidenced by distortions of thought content (delusions) and/or perceptual distortion (hallucinations) and disorganization evidenced by disorganized speech and behavior. Negative symptoms include restricted emotional expression (flattened affect), poverty of speech (alogia), apathy, decreased ability to experience pleasure (anhedonia), difficulty naming or describing emotions (alexithymia), and a lack of interest in social relationships. These symptoms often resemble depression. The various manifestations greatly impair the ability to function and interfere with work, relationships, and self-care, ultimately leading to social isolation. Deterioration in function is marked in the first 5 years, with a plateau effect later in the disease process. Suicide is the major cause of premature death in schizophrenics. Comorbid substance abuse is a significant problem for about 50% of individuals with schizophrenia and signals the likelihood of a poor outcome. Diagnosis is made primarily through careful clinical history and evaluation. Diagnostic criteria include two or more of the following: delusions, hallucinations, disorganized speech or behavior, catatonia, and negative symptoms for at least a month with evidence of prodromal manifestations or social, occupational, or self-care impairments for at least 6 months. A neurological exam may exhibit soft signs, such as astereognosis, agraphesthesia, dysdiadochokinesia, muscle twitching, increased eye blinks, impaired fine motor movements, or abnormal smooth pursuit eye movements. CT scan or MRI may reveal structural brain abnormalities; medial and superior lobe abnormalities may be seen with positive manifestations; and frontal, cortical, and ventricular system abnormalities may be seen with negative manifestations. ▪ INTERVENTIONS: Hospital milieu is helpful for early disease stages to introduce and regulate antipsychotic medications. Crisis care is indicated for high-risk periods for harm (suicide and/or violence). Antipsychotics are used for control of delusions/hallucinations, and sedatives are administered for agitation. Medication compliance is a long-term focus of treatment. Antiparkinsonian agents are used to treat tardive dyskinesia, which may result from use of traditional neuroleptic drugs. Prevention efforts are focused on long-term antipsychotic drug prophylaxis for individuals who have had one schizophrenia episode. ▪ PATIENT CARE CONSIDERATIONS: Significant social support is needed for most schizophrenic patients and their families. Support includes supportive psychotherapy, psychosocial skill training, vocational rehabilitation, occupational therapy for activities of daily living, and community support services to promote self-care. Specialized programs and structured, supervised living environments are needed for dual diagnosis patients (schizophrenia and substance abuse). Families may benefit from family therapy and respite care. Individual and family education are needed about the disease process, including psychosis identification, symptoms of relapse, and medication effects and side effects. The importance of long-term medication compliance is stressed. Instruction is needed in coping strategies to increase daily functioning. Information and referral to community support systems can aid individual and family coping (e.g., National Alliance for the Mentally Ill).
