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E91 : Mental Health : Symptoms of Schizophrenia

Question: 

Demonstrates understanding of psychopathology of schizophrenia and its impact on the person and significant others.

Demonstrates understanding of person-centred care as a strategy that contributes to autonomy and recovery, including the role of the nurse.

Answer: 

Part A: Schizophrenia

Introduction

Schizophrenia is a mental disorder that has affected people of all ages throughout history. Individuals with the disease have difficulties caring for themselves or holding a job, so they rely on relatives and friends for help (Lynall et al., 2010). Treatment helps reduce schizophrenia symptoms, but most individuals with the disorder cope with the signs in their entire lives. Luckily, studies show that psychotic individuals can live rewarding as well as meaningful lives. Scientists are also developing more effective medications plus utilising modern scientific tools to comprehend the causes of schizophrenia (Pharoh et al., 2010). Therefore, with years to come, such an effort will help prevent as well as better treat the condition.

Causes of schizophrenia

Schizophrenia is caused by the action of genetic plus environmental factors which include genetic inheritance, imbalance of dopamine in the brain, family relationships and environmental factors like stress.

Signs and symptoms of schizophrenia

There are three categories of signs and symptoms of schizophrenia:

1. Cognitive symptoms.

Cognitive symptoms of schizophrenia are difficult to recognise. They are detected when other examinations tests have been completed. The cognitive symptoms include; poor executive functioning or the ability to comprehend information as well as utilise it in the decision-making process; difficulties with working memory that is being unable to use information after learning (Lichtenstein et al., 2009). These and other symptoms make it hard for the victims to lead a healthy life hence causing them great emotional distress.

Positive symptoms.

These are psychosis behaviours not visible in healthy people (Grandón, Jenaro & Lemos, 2008). Individuals with positive symptoms continually lose touch with reality as the symptoms come and go. Some of these symptoms include:

Hallucinations; According to Grandón, Jenaro and Lemos (2008) hallucinations are things that a psychotic person hears, sees, smells, and feels that no other individual can experience them. Voices are a common type of


hallucination psychotic individual’s might experience. The victims hear the voices for a lengthy period before relatives and friends notice the condition.

Delusion; these are unreal beliefs that are not part of a person’s culture and are static. Individuals with schizophrenia may experience delusions that are unrealistic like believing that a person can control their behaviour using magnetic waves (Boyle, 2014). They may also think that other peoples are planning to harm them by either poisoning, cheating, harassing or spying on them.

Thought disorders; they are unusual ways of thinking. Thought disorders happen when an individual has difficulties in organising thoughts or trying to connect them in a logic manner (Brown  et al., 2010). At times, psychotic persons talk in a way that is difficult for others to comprehend or make pointless words.

Movement disorder; they appear as restless body movements. A person with this type of condition can repeat some motion from time to time. In other instance, a person with a movement disorder may neither move nor respond to others (Hor & Taylor, 2010).

Negative symptoms

They involve disruptions to either normal emotions or behaviour. Negative symptoms are hard to identify as part of schizophrenia can be mistaken for depression. Some of the noticeable symptoms include flat feet or talking in a monotonous/dull voice; speaking little, being unable to begin/sustain planned activities, and lack of pleasure (McAuliffe, O'connor& Meagher, 2014). To counteract such challenges, individuals with schizophrenia need help with activities of daily living. 

Interventions for schizophrenia

1. Effective communication

Nurses can help schizophrenic persons with stressors, provide learning as well as form a healing relationship. Other than providing effective communications plans to persons with schizophrenia, they can also offer advice (Evans, Nizette &O’Brien, 2017). Effective communication is achieved through respecting patient’s privacy, listening effectively to what the patients are saying and keeping brief conversations. In addition, nurses give one message at a go without offering too many choices and lastly, they do not dismiss patients irrespective of what they are saying.

2. Psychopharmacological interventions

Antipsychotic medication administration aims to control the positive signs of schizophrenia especially bizarre behaviour, delusion thinking, agitations, hallucinations as well as feelings of paranoia. The drugs are less effective especially when controlling the negative signs of schizophrenia such as loss of energy, emotional blunting and social withdrawal. Besides, atypical antipsychotics are effective against negative symptoms in which they are for recovery-oriented treatment (Evans, Nizette &O’Brien, 2017). Nurse’s, help monitor the efficacy as well as adverse effects of drugs, respond with necessary treatment and ensure that the medical staff is advised on the impact of a medicine on individuals. They also provide information to a person plus offer a personal medical support.

3. Cognitive behaviour therapy, CBT

CBT is all about individuals influencing symptoms. The process involves unlearning damaging means of the past as well as replacing them with effective plans for the future. In addition, CBT focuses on a person’s strengths thus improving self-esteem and goals achievement. Cognitive behaviour therapy is useful especially when identifying stressors in a person’s life, ways of avoiding too much stress as well as remedies to specific stressful experiences or situations.

Developmental phases.

Acute phase

The characteristic psychotic signs of the acute phase of schizophrenia subside with treatment. Positive symptoms like delusions and hallucinations are the focus of clinical interventions and respond to antipsychotic medications (Evans, Nizette &O’Brien, 2017). The negative symptoms are the critical determinants for disability and the chronicity of a person’s condition. Early manifestations of acute phase of schizophrenia include poor/ worsening school performance, decreased self-care, poor social relations as well as failure to attain expected developmental milestones. The DSM-5 shows that there is a lifetime of widespread schizophrenia of about 0.3 and 0.7%. This figure varies in different areas regarding race, ethnicity, and the origin of immigrants plus their children. In Australia, the lifetime prevalence of schizophrenia in 2010 was 0.75% while in New Zealand 2008 was 0.1% in 2008. Schizophrenia is prevalent among those socially disadvantaged.  

2. Prodromal phase

Prodrome is early/premonitory sign of a disorder (Evans, Nizette &O’Brien, 2017). The first markers of schizophrenia commence in adolescence. Prodromal phase is recognised when schizophrenia becomes severe to be diagnosed; that it is when prodromal features become recognised and significant as precursors. Negative symptoms of schizophrenia are common in this phase.

Theories for development of schizophrenia

1. Biological theories

The commonly discussed biological causative factors include the brain anatomy, genetics as well as brain biochemistry.

Neuroanatomical disorder; schizophrenia is a neuropsychological condition which shows the origin of the psychological disturbance. According to research, brain changes happen due to illnesses which occur shortly after the first episode of psychosis (Evans, Nizette &O’Brien, 2017). However, modern imaging techniques can be used to show lower brain volume as well as cerebrospinal volumes.

Genetic predisposition; individuals genetic make is vulnerable to the development of schizophrenia to some extent. A person at risk of developing schizophrenia is one that shares most genes with an individual having the disorder. This shows that a person with a relative who has schizophrenia is at more risk of having the condition than any other person. However, the prevalence of such condition is about 1%.

2. Aetiological theories

This theory is divided into nature vs nurture, and the diathesis-stress model. The latter argues that a person was born being schizophrenic or was destined to develop the disorder due to upbringing or environment. As per the nurture, parents are to blame particularly the mother for treatment of their child which gave rise to symptoms of psychosis. The diathesis-stress model also notes that individuals are exposed to stressful events in their lives thus precipitating symptoms of schizophrenia (Evans, Nizette &O’Brien, 2017). The model also shows that some people are more vulnerable to mental disorders than others due to genetics, environmental factors, biochemistry, aberrations in the brain and much more.

Impacts/Complications of Schizophrenia on the Person and Significant Others.

1. Mortality

Although schizophrenia is not a fatal disease, its mortality is double that of the general population (Yanos et al., 2008). Poor conditions lead to a high occurrence of communicable diseases thus causing death. The same can pose a significant challenge whenever the large population of the victims spend most of their time in crowded- asylum like zones. Recent studies of individuals living with schizophrenia show accidents like suicide as the leading causes of death in developed and developing nations.  Suicide has emerged to be a subject of great concern, as lifetime risks of suicide with a mental disorder has been shown to be above 10%; about eleven times that of the general population (Yanos et al., 2008).

2. Social stigma

These are discrediting attributes connected to negative traits as well as belief towards a sect likely to impact an individual’s identity (Chadwick, 2014). Some of the negative implications that erupt due to stigmatisation include limited access to social services, barriers to employment/housing and increased institutionalisation or oppression. Stigma operates both in larger communities as well as within mental health units. It represents a significant challenge concerning the integration of individuals with schizophrenia as well as other psychiatric disorders within the society (Chadwick, 2014). Stigma also acts as a barrier to treatment as mental health experts plus psychological health services holds a negative attitude towards mentally ill persons; hence; fostering dependency, segregation as well as low self-esteem.

3. Social disability.

As per the World Health Organisation, impairment is either abnormality or loss of physiological, psychological as well as the anatomical purpose; whereas disability is being unable to execute an activity in a way that is considered normal (Lichtenstein et al., 2009). In a mental condition like schizophrenia, disability might complicate social functioning in different spectra such as self-care, functioning in a broader social context plus concerning household members/families, and occupational performance. Data from North America and Europe studies show continuous disability of about 35% of males with schizophrenia contrary to the 23% of females.  Nations such as India, Latin America, and part of Africa have witnessed lower figures (Lichtenstein et al., 2009).

4. Social costs

Estimates of economic costs of mental disorders particularly schizophrenia can be found only for the industrialised nations. There exists a broad distinction between direct costs and indirect costs. The former ranges between 1.5% and 2.7% of the total healthcare expenditure in western nations accounting for 6% and 13% of the GNP; accounting for £396 million in Britain and $18billion in America (Boyle, 2014). Such costs are unevenly distributed among subgroups with varying severity of the condition. As per the US analysis, the economic impact of schizophrenia is close as per the per capita approximations to that of severe illnesses like hypertension. On the other hand, high indirect costs show that projections for possible gains by lowering morbidity plus mortality via treatment are more for mental disorders than for chronic diseases like hypertension.

5. Implication on caregivers

Studies show that the ratio of psychotic individuals living with carers ranges between 35% in the USA to a higher than 84% in China. The impacts of schizophrenia on carers include the economic burden linked to the need to support the patient, emotional reactions to the individual’s conditions and disruption of household routine (Golembiewski, 2015).  Variability of these impacts, along with financial problem and cross-cultural difference lead to family burden ranging between 28% and 79%. A Malaysian survey shows that subjective emotional weight accounts for 41% of families where hostility, violence, as well as disruption of family activities are the primary sources or stress (Golembiewski, 2015).

Part B; Person-centered care in Schizophrenia

Person-centred care, PCC is a strategy that serves the goals as well as the needs of a patient. It guides physicists in the sense that clinical examinations plus interventions are as a result of the goals and the needs of clients and not those of others (Ahmad et al., 2014). Therefore, PCC promotes the principle of anatomy or self-determination which is the right to have control and authority over own life. Autonomy is key to the formation as well as the exercise of intrinsic /extrinsic motivation which goes beyond self-control. Hence, it’s an inherent need of every person to exercise self-determination as well as have the capacity to decide if to proceed to a particular course of action or not (Lynall et al., 2010). Self-determination leads to empowerment based on the ability to influence owns purpose to affect or respond. Patient restraint via autonomy precedes within an equitable relationship between a physicist and a patient, where such connection is anchored on the alliance between agents than on lay associations.  However, there exists a conflict regarding the worth of a given approach; where in one instance, it has had favourable ramifications for the patients while in others, and it has been linked with low patient gratification.  Moreover, there exists a division between reality and the rhetoric of patient autonomy. For example, the client self-determination Act of 1994 in the USA requires physicist receiving Medicare or Medicaid payments to make patients cautious of the admission of the rights under state policies to refute to consent to treatment (Ruddick, 2010).

The preoccupation of health care providers with autonomy known within the professional dominance aspect over patients; as well as the need to re-conceptualise the relationship between the patients and the professionals that may be seen as lively partners than just passive beneficiaries of care (Gask & Coventry, 2012). The development of patient autonomy calls for acknowledgement where an imbalanced link happens between the patient as well as a nurse, and the rhetoric of autonomy and collaboration holds such variance. As a result of precarious situations, patients could not exercise independence. For example, the aspect of case management system is a healthcare workers plan which started to control demand growth for society psychiatric services and not as a result of improving person’s value of life. Therefore, it’s a system management care that is different from the aspect of the patient’s participation in their care.

Limits to autonomy is also eminent. While enhancing this approach, physicists assume patient’s need that they are at will to opt for focused behaviour as per the desires of doctors and other healthcare professionals. The decision of the patients not to take part in this behaviour can be seen as opposed to the will of the nurse wanting to promote wellbeing. As an example, they may opt to be reliant on others in a self-ruled manner. A person’s right to autonomy is conditional on its aspects as well as attitudes not destabilization the wellbeing of themselves plus that of others (Pharoah et al., 2010). The promotion of patient’s autonomy is hard to attain as a balance must exist between intervention and development of the concept. Such stability is hard to maintain with psychotic individuals due to the unforeseen way of their condition. Autonomy calls for a person to be in a position to think plus act rationally, but schizophrenia can compromise such (Videbeck, 2013). Regardless of the severity of a state, individuals are entitled to autonomy as it’s an essential facet of quality of life.

The Role of the Nurses in Providing Person-Centered Care for patients with schizophrenia

PCC is more than how a nurse treats a patient. It is about how healthcare services, as well as government, create/support policies to put patients at the centre of care. Therefore, the nurses should:

1. Provide person-centred care

Nurses should provide safe and high-quality care to their patients. This involves the need to know the preferences of care for their patients and honouring them in the entire treatment. When healthcare is client-centred, nurses explain treatment options and respect their client’s decision (Ahmad et al., 2014). They acknowledge the patients for who they are and not discriminate based on background, preferences or beliefs.

2. Actively participate in care for the patients

Nurses should provide their patients with all the necessary information to make informed decisions. Opportunity to ask questions and converse with carers/relatives/friends before making decisions is also vital. In cases where many treatments are required at the same time, being actively involved in providing care can help nurses and the healthcare team to plan and prioritise their patient’s treatment (Boyle, 2014). This helps everyone know what is happening.

3. Respect in a healthcare environment

According to Boyle (2014), nurses should provide treatment with respect and dignity by respecting the privacy of their patients and as well as the confidentiality of their health records. They should provide care without discrimination of their patient’s beliefs such as cultural background.

4. Provide excellent communication to the patients.

Standard healthcare should be open and active two-way communication between a nurse and the patient. The patients should understand what their nurses say, and in case they converse in a foreign language, a professional interpreter is necessary (Golembiewski, 2015). Nurses need to provide and explain information regarding their patients care and condition among them treatment options, potential side effects in case of any, and costs.

Ultimately, nurses should provide an environment where their patients feel safe by providing treatment that is private like having separate treatment rooms.  

How person-centred care, PCC helps recover from schizophrenia

PCC helps detect the early signs of potential relapse and put measures to prevent the condition if possible. Prevention is through the establishment of therapeutic relationships as well as ongoing education along with the identification of early signs of relapse. Next, improving access as well as reducing delays in initial treatments along with educating the family about schizophrenia can help prevent the condition (Evans, Nizette &O’Brien, 2017). Other PCC measures that can be taken include promoting wellness among family members and carers are, supporting people during their recovery and developing a plan for maintaining mental health.

References:

Ahmad, N., Ellins, J., Krelle, H., & Lawrie, M. (2014). Person-centred care: from ideas to action. Health Foundation.

Boyle, M. (2014). Schizophrenia: A scientific delusion? Routledge.

Brown, S., Kim, M., Mitchell, C., & Inskip, H. (2010). Twenty-five year mortality of a community cohort with schizophrenia. The British journal of psychiatry, 196(2), 116-121.

Chadwick, P. (2014). Mindfulness for psychosis. The British Journal of Psychiatry, 204(5), 333-334.

Evans, K., Nizette, D., & O’Brien, A (2017). Psychiatric & Mental Health Nursing-E-Book. 4th edition.

Gask, L., & Coventry, P. (2012). Person-centred mental health care: the challenge of implementation. Epidemiology and psychiatric sciences, 21(2), 139-144.

Grandón, P., Jenaro, C., & Lemos, S. (2008). Primary caregivers of schizophrenia outpatients: Burden and predictor variables. Psychiatry research, 158(3), 335-343.

Golembiewski, J. A. (2015). Mental health facility design: The case for person-centred care.

Hor, K., & Taylor, M. (2010). Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of psychopharmacology, 24(4_suppl), 81-90.

Lichtenstein, P., Yip, B. H., Björk, C., Pawitan, Y., Cannon, T. D., Sullivan, P. F., & Hultman, C. M. (2009). Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. The Lancet, 373(9659), 234-239.

Lynall, M. E., Bassett, D. S., Kerwin, R., McKenna, P. J., Kitzbichler, M., Muller, U., & Bullmore, E. (2010). Functional connectivity and brain networks in schizophrenia. Journal of Neuroscience, 30(28), 9477-9487.

McAuliffe, R., O'connor, L., & Meagher, D. (2014). Parents' experience of living with and caring for an adult son or daughter with schizophrenia at home in Ireland: a qualitative study. Journal of psychiatric and mental health nursing, 21(2), 145-153.

Pharoah, F., Mari, J., Rathbone, J., & Wong, W. (2010). Family intervention for schizophrenia. The Cochrane database of systematic reviews, (12), CD000088.

Ruddick, F. (2010). Person-centred mental health care: myth or reality? Mental Health Practice, 13(9).

Videbeck, S., & Videbeck, S. (2013). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.

Yanos, P. T., Roe, D., Markus, K., & Lysaker, P. H. (2008). Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services, 59(12), 1437-1442.

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