Karen Magorrian, RN, RMN.
Day Hospital Manager, Barnes Hospital, South West London, and St George’s Mental Health NHS Trust, London. She was formerly Senior Clinical Nurse, Hounslow and Spelthorne Community and Mental Health NHS Trust, The West Middlesex Hospital, Hounslow, Middlesex
Schizophrenia is a major mental illness characterised by psychotic symptoms in which the person can lose touch with reality and may not appreciate that he or she is ill and in need of treatment. It is an illness in which the person suffers from disorders of thought, emotion, behaviour and perceptions, giving rise to difficulties in everyday functioning (Howe, 1995).
Research into schizophrenia began with the work of the psychiatrist Dr Emil Kraeplin, who in 1896 defined the condition he called Dementia Praecox, a term applied to patients suffering with the symptoms of what we now know as schizophrenia. Kraeplin’s work formed the basis of all future research and led to the work of Dr Eugen Bleuler who in 1911 coined the term schizophrenia (Tsuang and Farone, 1997).
Incidence of schizophrenia
About one in 100 people may be diagnosed with schizophrenia at some stage in their lives, with the peak age of incidence between 16 and 25. Schizophrenia affects men and women equally, although men tend to develop it younger and be more seriously affected in the long run (NSF, 1996).
Theories about causation
Schizophrenia is a biologically based mental illness. Current theories about causation include neuro-anatomical and neuro-chemical abnormalities that may be induced either genetically or environmentally, for example by a virus or birth defects (Varcarolis, 2000).
Although the condition is not caused by psychological events, stressful life events can trigger an exacerbation of the patient’s illness (Varcarolis, 2000).
Signs and symptoms of schizophrenia are various and were first described by Schneider in 1959 as ‘first-rank’ symptoms, later to be defined by Strauss in 1974 as positive and negative symptoms (Kavanagh 1992) (Box 1).
Positive symptoms are so called because they add something new to the person’s experience, albeit abnormal, bizarre and unwelcome symptoms. Positive symptoms tend to be more common during acute episodes of the illness (Howe, 1995).
The most common of the positive symptoms are hallucinations, which are most frequently auditory; the person hears voices which can often be threatening and compelling. Delusions are false beliefs with no basis in reality, which are not amenable to reasoning. They can be persecutory, grandiose, somatic or religious in nature. Schizophrenia can also cause the person to have loosening of association, concrete thinking (is unable to think in abstract terms and is very literal in approach) and have impaired verbal communication. Positive symptoms are more obvious to the observer as they tend to cause the person to act in a bizarre fashion (Howe, 1995).
Negative symptoms can be defined as those that take something away from the person’s original personality, tending to reduce or even obliterate normal mental or behavioural processes. These symptoms tend to be present in chronic illness, although they can appear in an acute phase (Howe, 1995).
Negative symptoms are those which feature a reduction in mental or behavioural processes leading to lack of motivation, emotional blunting or flattening, poverty of speech, social withdrawal and poor self-care.
Positive symptoms are often described as the more distressing symptoms but are in turn normally more responsive to treatment. Negative symptoms tend to increase with the duration of the illness and when they are a marked and prominent feature of the illness prognosis is poorer (Howe, 1995).
Factors that affect prognosis are listed in Box 2. A positive prognosis indicates that a favourable outcome/recovery from the schizophrenic episode is expected. A negative prognosis indicates an unfavourable outcome/poor recovery.
Antipsychotic medication is used to control the acute symptoms being experienced by the patient. These fall into two groups: typical and atypical antipsychotics (Box 3). Typical antipsychotics target the more flagrant (positive) symptoms such as hallucinations. They work by reducing the disturbing quality of the symptoms and accompanying disruptive behaviour.
Atypical antipsychotics, introduced in the early 1990s, are now the first choice of treatment. They not only target the acute and disturbing symptoms but also the negative symptoms - which allows for improvement in quality of life. They also generally have fewer side-effects.
Some of the side-effects of antipsychotics include extrapyramidal symptoms such as parkinsonian symptoms, tremor and dystonic features, which can be disturbing and lead to the patient stopping medication. Side-effects can be treated with antimuscarinic drugs such as procyclidine.
Adherence to treatment regimen
Adherence to medication is often linked to the person’s level of insight into his or her illness. Adherence may be enhanced if the person has a supportive family/environment. It is also helpful if the person has been educated about what to expect from the medication, including side-effects, and knows that medication can be changed to reduce undesirable side-effects. It is also helpful if the person is aware that he or she needs to take the medication regularly to keep symptoms at bay.
Alongside medication is the need for social interventions, including education and support for patients and carers, social skills training and the care provided by day hospitals/centres.
Cognitive behavioural therapy can help patients gain a degree of control over their symptoms by helping them understand the links between their thought processes and subsequent behaviour and then to move on to look at ways of changing/managing the thoughts and behaviours (Birchwood and Jackson, 2001).
Family interventions can also help in reducing levels of stress and in the management of contributing factors to patient relapse (Birchwood and Jackson, 2001). Barrowclough et al (1987) demonstrated that giving carers information about schizophrenia is helpful in its management. Support and information needs to be ongoing, both in everyday situations and also at times of crisis.
Carers and families have always played an important role in the management of people with schizophrenia. With the increasing emphasis on maintaining patients in the community, this role is assuming increasing significance. This means that carers’ needs and concerns require a higher level of attention. These needs include:
- A need for information/education on schizophrenia and its management
- A need for regular contact with clinical teams that offers both support and advice about the patient and is responsive to carers’ concerns
- A need for support for carers’ own feelings such as emotional burden, guilt and frustration. This may be through support groups or individually
- A need for a service that works in partnership with the carers and patients, thereby optimising the patient’s care and allowing patients to continue living in the community.
- National Schizophrenia Fellowship, 28 Castle Street, Kingston upon Thames, Surrey KT1 1SS. Tel:020-85473937.
- Carers’ National Association, 20-25 Glasshouse Yard, London EC1A 4JT. Tel:020-74908818.
Atkinson, J.M., Coia, D.A. (1995)Families Coping with Schizophrenia: A practitioner’s guide to family groups. Chichester: J. Wiley and Sons.
Frangou, S., Murray, R.M. (2000)Schizophrenia. London: Martin Dunitz.
Lintner, B. (1996)Living with Schizophrenia: A positive guide for sufferers and carers. London: Vermilion.
During an acute phase of a schizophrenic episode the nurse’s role is primarily one of assessment of the presenting symptoms and the level of risk these may pose to the patient and other people.
It is important during this acute phase to introduce medication to maintain a safe environment for the person and to begin to build up a rapport and a sense of trust with the person (Varcarolis, 2000). This trusting relationship is a basis for ongoing work.
One very important aspect of ongoing nursing care for patients with schizophrenia is education. The nurse can help the patient and his or her carers gain an understanding of the illness and how it affects him or her.
Helping patients and their carers develop a routine, working towards the patient taking part in purposeful activities, be it work, training or attendance at a day centre can help maintain patient well-being (Howe, 1995).
Barrowclough, C., Tarrier, N., Watts, et al. (1987) Assessing the functional value of relatives’ knowledge about schizophrenia: a preliminary report. British Journal of Psychiatry 151: 1-8.
Birchwood, M., Jackson, C. (2001) Schizophrenia. London: Psychology Press.
Howe, G. (1995) Working with Schizophrenia: A needs-based approach. London: Jessica Kingsley.
Kavanagh, D.J. (1992) Schizophrenia: An overview and practical handbook. London: Chapman and Hall.
National Schizophrenia Fellowship. (1996) Notes for Relatives (3rd edn). London: NSF.
Tsuang, M.T., Farone, S.V. (1997) Schizophrenia: The facts. Oxford: Oxford University Press.
Varcarolis, E.M. (2000) Psychiatric Nursing Clinical Guide: Assessment tools and diagnosis. London: W.B. Saunders.