Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. Etiology

Although its specific cause is unknown, schizophrenia has a biologic basis, as evidenced by alterations in brain structure (eg, enlarged cerebral ventricles, decreased size of the anterior hippocampus and other brain regions) and by changes in neurotransmitters, especially altered activity of dopamine and glutamate. Some experts suggest that schizophrenia occurs in people with neurodevelopmental vulnerabilities and that the onset, remission, and recurrence of symptoms are the result of interactions between these enduring vulnerabilities and environmental stressors.

Neurodevelopmental vulnerability: Vulnerability may result from genetic predisposition; intrauterine, birth, or postnatal complications; or viral CNS infections. Maternal exposure to famine and influenza during the 2nd trimester of pregnancy, birth weight < 2500 g, Rh incompatibility during a 2nd pregnancy, and hypoxia increase risk.

Although most people with schizophrenia do not have a family history, genetic factors have been implicated. People who have a 1st-degree relative with schizophrenia have about a 10% risk of developing the disorder, compared with a 1% risk among the general population. Monozygotic twins have a concordance of about 50%. Sensitive neurologic and neuropsychiatric tests suggest that aberrant smooth-pursuit eye tracking, impaired cognition and attention, and deficient sensory gating occur more commonly among patients with schizophrenia than among the general

population. These markers (endophenotypes) also occur among 1st-degree relatives of people with schizophrenia and may represent the inherited component of vulnerability.

Environmental stressors: Stressors can trigger the emergence or recurrence of symptoms in vulnerable people. Stressors may be primarily biochemical (eg, substance abuse, especially marijuana) or social (eg, becoming unemployed or impoverished, leaving home for college, breaking off a romantic relationship, joining the Armed Forces); however, these stressors are not causative. There is no evidence that schizophrenia is caused by poor parenting.

Protective factors that may mitigate the effect of stress on symptom formation or exacerbation include good social support, coping skills, and antipsychotics

The symptoms of schizophrenia are categorized into two major categories: Positive symptoms In schizophrenia, positive symptoms reflect an excess or distortion of normal functions. These active, abnormal symptoms may include:

Delusions. These beliefs are not based in reality and usually involve misinterpretation of perception or experience. They are the most common of schizophrenic symptoms. Hallucinations. These usually involve seeing or hearing things that don't exist, although hallucinations can be in any of the senses. Hearing voices is the most common hallucination among people with schizophrenia. Thought disorder. Difficulty speaking and organizing thoughts may result in stopping speech midsentence or putting together meaningless words, sometimes known as "word salad."

Disorganized behavior. This may show in a number of ways, ranging from childlike silliness to unpredictable agitation. Negative symptoms Negative symptoms refer to a diminishment or absence of characteristics of normal function. They may appear months or years before positive symptoms. They include:

Loss of interest in everyday activities Appearing to lack emotion Reduced ability to plan or carry out activities Neglect of personal hygiene Social withdrawal Loss of motivation

TYPES OF SCHIZOPHRENIA:

Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive behavior. Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social withdrawal, flat affect and looseness of associations.

The most common early warning signs of schizophrenia include:

Social withdrawal Hostility or suspiciousness Personal hygiene deterioration Flat, expressionless gaze

Depression Oversleeping or insomnia Odd or irrational statements Forgetful; unable to concentrate

Inability to cry or express joy Inappropriate laughter or crying

Extreme reaction to criticism Strange use of words or way of speaking

UNUSUAL SPEECH PATTERNS OF CLIENTS WITH SCHIZOPHRENIA Neologism Clang association Verbigeration Echolalia Stilted language Perseveration Word salad

A client with schizophrenia usually experience delusions (fixed, false beliefs with no basis in reality. Types of delusions: Persecutory/Paranoid delusions Grandiose delusions Religious delusions Somatic delusions Referential delusions Management and Treatment

Selected antipsychotic medications for treating schizophrenia Typical Antipsychotics Chlorpromazine (thorazine) Fluphenazine (prolixin) Haloperidol (haldol) Molindone (moban) Thioridazine (mellaril) Thiotixene (navane) Trifluperazine (stelazine) Atypical Antipsychotics Clozapine (clozaril) Olanzapine (zyprexa) Quetiapine (seroquel) Risperidone (risperdal) Sertindole (serlect) Ziprasidone (geodon) Dopamine-system stabilizers Aripiprazole (abilify)

TREATMENTS AND MEDICATIONS: Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments. Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will minimize symptoms and maximize quality of life.

A comprehensive treatment program can include:

Antipsychotic medication Education & support, for both ill individuals and families Social skills training Rehabilitation to improve activities of daily living

Vocational and recreational support Cognitive therapy NURSING INTERVENTIONS: Strengthening differentiation

Use simple and clear language when speaking with the patient. Explain all procedures, test and activities to patient before starting them Promoting socialization

Provide patient with honest and consistent feedback in a non threatening manner. Avoid challenging the content of patients behavior Focus interactions on patients behavior. Administer drugs as prescribed while monitoring and documenting patients response to drug regimen.

Encourage patient to talk about feelings in the context of a trusting, supportive relationship. Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions. Use supportive, emphatic approach to focus on patients feelings about troubling events or conflicts. Provide opportunities for socialization and encourage participation in group activities.

Be aware of personal space and use touch judiciously. Help patient to identify behaviors that alienate significant others and family members. Ensuring safety: Monitor patient for behaviors that indicate increased anxiety and agitation. Collaborate patient to identify anxious behaviors as well as causes. Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers. Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury. Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action. Frequently monitor the patient within guidelines of facilitys policy on restrictive devices and assess the patients level of agitation. When patients level of agitation begins to decrease and self control regained, establish a behavioral agreement that identifies specific behaviors that indicate self control against are escalation agitation.

Treatments
During an episode of schizophrenia, you may need to stay in the hospital for safety reasons, and to provide for basic needs such as food, rest, and hygiene. Antipsychotic or neuroleptic medications change the balance of chemicals in the brain and can help control the symptoms of the illness. These medications are effective, but they can have side effects. However, many of these side effects can be addressed, and should not prevent people from seeking treatment for this serious condition.

Common side effects from antipsychotics may include:

Sleepiness (sedation) Weight gain

Other side effects include:

Feelings of restlessness or "jitters" Problems of movement and gait Muscle contractions

Long-term risks include a movement disorder called tardive dyskinesia, in which people move without meaning to. Newer drugs known as atypical antipsychotics appear to have fewer side effects. They also appear to help people who have not improved with the older medications. Treatment with medications is usually needed to prevent symptoms from coming back. Supportive and problem-focused forms of therapy may be helpful for many people. Behavioral techniques, such as social skills training, can be used during therapy, or at home to improve function socially and at work. Family treatments that combine support and education about schizophrenia (psychoeducation) appear to help families cope and reduce the odds of symptoms returning. Programs that emphasize outreach and community support services can help people who lack family and social support.

Drugs
Medications are the mainstay of treatment for schizophrenia. Drug therapy for the disorder, however, is complicated by several factors: the unpredictability of a given patient's response to specific medications, the number of potentially troublesome side effects, the high rate of substance abuse among patients with schizophrenia, and the possibility of drug interactions between antipsychotic medications and antidepressants or other medications that may be prescribed for the patient. NEUROLEPTICS.The first antipsychotic medications for schizophrenia were introduced in the 1950s, and known as dopamine antagonists, or DAs. They are sometimes called neuroleptics, and include haloperidol(Haldol), chlorpromazine(Thorazine), perphenazine(Trilafon), and fluphenazine(Prolixin). About 40% of patients, however, fail to respond to treatment with these medications. Neuroleptics can control most of the positive symptoms of schizophrenia as well as reduce the frequency and severity of relapses but they have little effect on negative symptoms. In addition, these medications have problematic side effects, ranging from dry mouth, blurry vision, and restlessness (akathisia) to such long-term side effects as tardive dyskinesia(TD). TD is a disorder characterized by involuntary movements of the mouth, lips, arms, or legs; it affects about 15%20% of patients who have been receiving neuroleptic medications over a period of

years. Discomfort related to these side effects is one reason why 40% of patients treated with the older antipsychotics do not adhere to their medication regimens. ATYPICAL ANTIPSYCHOTICS.The atypical antipsychotics are newer medications introduced in the 1990s. They are sometimes called serotonin dopamine antagonists, or SDAs. These medications include clozapine(Clozaril), risperidone(Risperdal), quetiapine(Seroquel), ziprasidone(Geodon), and olanzapine(Zyprexa). These newer drugs are more effective in treating the negative symptoms of schizophrenia and have fewer side effects than the older antipsychotics. Clozapine has been reported to be effective in patients who do not respond to neuroleptics, and to reduce the risk of suicide attempts. The atypical antipsychotics, however, do have weight gain as a side effect; and patients taking clozapine must have their blood monitored periodically for signs of agranulocytosis, or a drop in the number of white blood cells. These drugs are now considered first-line treatments for patients having their first psychotic episode.

Complications

People with schizophrenia have a high risk of developing a substance abuse problem. Use of alcohol or other drugs increases the risk of relapse. Physical illness is common among people with schizophrenia due to side effects from medication and living conditions. These may not be detected because of poor access to medical care and difficulties talking to health care providers. Not taking medication will often cause symptoms to return.