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Pathology

Schizophrenia is a thought disorder characterized by deterioration in mental functioning, disturbances in sensory perception and changes emotion. The condition is irreversible although improvement may be achieved through drug therapy. The characterization and nomenclature of the disorders are quite arbitrary and are influenced social culture factors and schools of psychiatric thought. It is categorized as a psychobiologic disorder because of recent findings in brain and neurotransmitter chemistry. Dopamine excess is believed to be a major cuase of the symptoms. Imbalances of nor epinephrine, serotonin, and GABA also play a role. The disease is known to have genetic component. One theory suggests that it is the result of a viral infection experienced by an individuals mother during pregnancy. The neurotransmitter imbalances are primarily manifested by disturbed thinking which may include suspiciousness, persecutiuon, being controlled, and paranoia. Symptoms are classified as positive symptoms or negative symptoms. Positive symptoms include delusions, hallucinations and fluent but disorganized speech. Negative symptoms are characterized by defects, which include impoverished speech, inability to enjoy relationships, or inability to express emotions. Positive symptoms are more easily mangaed than negative symtoms. Classic symptoms are inexplicable sensory experiences such as hearing voices, or seeing apparitions that are not there. Schizophrenic disoders are subdivided on the basis of certain prominent phenomena that are frequently present. Disorganized Schizophrenia is characterized by marked incoherence and an incongruous or silly effect. Catatonis Schizophrenia is distinguished by a marked psychomotor disturbance of either exictement or rigidity. There may be a rapid alteration between excitement and stupor. Paranoid Schizophrenia includes marked persecutory or grandiose delusions often accompanied by hallucinations of similar content and with less marked disorganization of speech and behavior. Undifferentiated Schizophrenia denotes a category in which symptoms are not specific enough to warrant inclusion of the illness in the other subtypes. Resdual Schizphrenia is a classification that includes persons who have clearly had an episodewarrantign a diagnosis of schizophrenia but who at present have no overt psychotic symptoms, though they show milder signs such as social withdrawl, flat effect, and eccentric behaviors.

DIAGNOSIS
It is currently belived that the schizophrenic disorders are of multifunctional cause, with genetic, environmental, and neurotransmitter pathophysiologic components. At present, there is no laboratory method for confirming the diagnosis of schizophrenia. There my or may not be a history of a major disruption in the persons life before gross psychotic deterioration is evident. Essentials of diagnosis include: social withdrawal, usually slowly

and progressive often with deterioration in personal care; loss of ego boundaries, with inability ot percieve oneself as a separate entity; loose though associations, often with slowed thinking or over inclusive rapid thinking from topic to topic; autistic absorption in inner thoughts and frequent preoccupations; auditory hallucinations, often of a derogatory nature; delusion, often of a grandiose or persecutory nature; and symptoms lasting six months or more. Aditionallt other symptoms may accompany the above such as : rapidly alternating mood shifts irrespective of circumstances; hypersensitivity to environmental stimuli, with a feeling of enhanced awaremness; variability or changeable behacvior incongruent with the external enviornment; concrete thinking with inability to abstract; impaired concentration worsened by delusions and hallucinations; depersonalization whre one behaves like a detached observer of their own actions. A diagnosis of schizophrenia should be reconsidered in any person who has received that diagnosis inn the past especially when the clinical course has been atypical. Many of these patients have been found to actually have atypical episodic affective disorders that have reponde well to lithium. Manic episodes oftern mimic schizophrenia. Many have been diagnosed as schizophrenic in error. Psychotic depressions, psychotic organic mental states,and any illness with psychotic ideation tend to be confused with schizophrenia, partly because of the misuse of the term. Medical disodres such as thyroid dysfunction, adrenal and pituitary disorders, reaxctions to toxic materials, and almost all organic mental states must be ruled out. Toxic drug states arising from prescription, over the counter or illegal drugs may mimic all fo the psychotic disorders. The chronic use of amphetamines, cocaine or other stimulants often produce a psychosis that is almost identical to acute paranoid schizophrenia. Neoplasms, viral and bacterial encephalopathies, central nervous system hemmorage, metabolic disorders such as diabetic ketoacidosis, sedative withdrawl, and hepatic and renal malfunction may produce similar symptoms.

TREATMENT
Patients with scizophrenia are referred to the care of a psychiatrist. A full mediacl evsaluation and CT or MRI should be considered in first episodes and any other psychotic episodes of unknown cause. Hospitalization is often necessary, particularly when the patients behavior shows extreme disorganization. Antipsychotic drugs are the mainstay of treatment. Proper treatment therefore involves the proper administration of medication and monitoring for effectiveness or adverse affects. Typical antipsychotics for the treatment of schizophrenia are neuroleptics that block dopamine receptors. These include Haloperidol (Haldol), Fluphenazine (Proloxin), Risperdine (Risperdal), Clozapine (Clozaril) and Olanzapine (Zyprexa). These neuroleptics can be very effective in the treatment of schizphrenic receptors with the relapse rate being reduced by 50% with proper therapy. Antidepressant drugs may be

used in conjunstion with the neuroleptics is significant depression is present. In a large majority of patinets, alleviation of positive symtoms such as hallucinations or delusions is achieved through medication. Negative symptoms such as diminished emotions and sociability are more difficult to treat but are responsive to antipsychotic preparations. Noncompliance with drug therapy remains the leading cause for the return of symptoms and need for hospitalization. Depot injections (IM) may be given as they are in oil suspension and are gradually absorbed over 2 - 4 weeks. Environmental consideratios are also bery important in the treatment of these disorders. The most theraputic environment is one that reduces stimuli. There is an inverse relationship between the stability of the living situation and the amounts of required antipsychotic drugs. Board and care homes stafed by personnel experienced in caring for psychiatric patients can be of great help. Vocational rehabilitation and work agenicies provide assessment, training, and job opportunities at a level with pateints clinical condition as well. The need for psychotherapy varies depending on the patients status and history. In aperson with a single pyschotic episode and previously somewhat normal history, psychotherapy may help the patient reintegrate the experience and become more selfobservant who can recognize early signs of stress and made modifcations to possibly avoid repeating the outcome. Research suggests that cognitive behavioral therapy, in conjunction with medication, may have benefitsin the treatment of the symptoms of schizophrenia. Behavioral therapies are most frequently used in a therapeutic setting such as a day treatment center but they may also be used in family settings. For instance, portable music players with earphones may be used to divert the patints attention from auditory hallucinations.

NURSING INTERVENTIONS
Since noncompliance with the prescribed medication regime is the leading cause of reoccurance, nursing interventions include the proper administration of medications and monitoring for effectieness and adverse effects. Mental status assessments should be done periodically to monitor for changes. Assessment includes recognizing positive and negative symptoms and ensuring they are not a danger to themselves or others. Proper intervention to protect themselves and or others may include medication changes or separating the patient from others. The nurse al;so assists with the physical staus of the client. Personal hygiene is often neglected. The nurse will assist in this area as well as effort to insure that the nutritional needs of the patient are met as anorexia is often accompanies this condition. Supportive measures must also be implemented. The nurse must make the patient feel comfortable and secure. A calm approach and demeanor is necessary to provide this environement. Sensory stimuli should be kept to a minimum as this arouses symptoms. The nurse may be involved in education of family into the pathology as wellas

managemnet of a loved one with this condition as well.