Chapter 16 mental health Schizophrenia
severe
Although the symptoms of schizophrenia are always __________________the long-term course does not always involve progressive deterioration. The clinical course varies among clients.
Schizophrenia
CAUSES DISTORTED and bizarre thoughts, perceptions, emotions, movements, and behavior. It cannot be defined as a single illness; rather, schizophrenia is thought of as a syndrome or as a disease process with many different varieties and symptoms, much like the varieties of cancer. For decades, the public vastly misunderstood schizophrenia, fearing it as dangerous and uncontrollable and causing wild disturbances and violent outbursts. Many people believed that those with schizophrenia needed to be locked away from society and institutionalized. Only recently has the mental health industry come to learn and educate the community at large that schizophrenia has many different symptoms and presentations and is an illness that medication can control. Thanks to the increased effectiveness of newer atypical antipsychotic drugs and advances in community-based treatment, many clients with schizophrenia live successfully in the community. Clients whose illness is medically supervised and whose treatment is maintained often continue to live and sometimes work in the community with family and outside support. Schizophrenia is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The prevalence of schizophrenia is estimated at about 1% of the total population. In the United States, this translates to nearly 3 million people who are, have been, or will be affected by the disease. The incidence and the lifetime prevalence are roughly the same throughout the world (Sadock et al., 2015). p. 266 p. 267 The symptoms of schizophrenia are divided into two major categories: positive or hard symptoms/signs, which include delusions, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms/signs, which include flat affect, lack of volition, and social withdrawal or discomfort. Box 16.1 describes these symptoms more fully. Medication may control the positive symptoms, but frequently the negative symptoms persist after positive symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to recovery and improved functioning in the client's daily life. Schizoaffective disorder is diagnosed when the client is severely ill and has a mixture of psychotic and mood symptoms. The signs and symptoms include those of both schizophrenia and a mood disorder such as depression or bipolar disorder. The symptoms may occur simultaneously or may alternate between psychotic and mood disorder symptoms. Some studies report that long-term outcomes for the bipolar type of schizoaffective disorder are similar to those for bipolar disorder, while outcomes for the depressed type of schizoaffective disorder are similar to those for schizophrenia. Treatment for schizoaffective disorder targets both psychotic and mood symptoms. Often, second-generation antipsychotics are the best
immediate course
In the years immediately after the onset of psychotic symptoms, two typical clinical patterns emerge. In one pattern, the client experiences ongoing psychosis and never fully recovers, although symptoms may shift in severity over time. In another pattern, the client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recovery from the psychosis.
Onset
Onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, loss of interest in school or work, and neglected hygiene. The diagnosis of schizophrenia is usually made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disordered thinking (psychosis). Regardless of when and how the illness begins and the type of schizophrenia, consequences for most clients and their families are substantial and enduring. When and how the illness develops seems to affect the outcome. Age at onset appears to be an important factor in how well the client fares: Those who develop the illness earlier show worse outcomes than those who develop it later. Younger clients display a poorer premorbid adjustment, more prominent negative signs, and greater cognitive impairment than do older clients. Those who experience a gradual onset of the disease (about 50%) tend to have a poorer immediate and long-term course than those who experience an acute and sudden onset. Approximately one third to one half of clients with schizophrenia relapse within 1 year of an acute episode. Higher relapse rates are associated with nonadherence to medication, persistent substance use, caregiver criticism, and negative attitude toward treatment (Moritz et al., 2014).
positive and negative symptoms of schizophrenia
POSITIVE OR HARD SYMPTOMS Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation Associative looseness: Fragmented or poorly related thoughts and ideas Delusions: Fixed false beliefs that have no basis in reality Echopraxia: Imitation of the movements and gestures of another person whom the client is observing Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from one topic to another Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality Ideas of reference: False impressions that external events have special meaning for the person Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic Bizarre behavior: Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior Negative or Soft Symptoms Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of content) Anhedonia: Feeling no joy or pleasure from life or any activities or relationships Apathy: Feelings of indifference toward people, activities, and events Asociality: social withdrawal, few or no relationships, lack of closeness Blunted affect: Restricted range of emotional feeling, tone, or mood Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance Flat affect: Absence of any facial expression that would indicate emotions or mood Avolition or lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks Inattention: Inability to concentrate or focus on a topic or activity, regardless of its importance
related disorders.
Schizoaffective disorder was described earlier in this chapter. Other disorders are related to, but distinguished from, schizophrenia in terms of presenting symptoms and the duration or magnitude of impairment. Black and Andreasen (2014) identify p. 268 p. 269 Schizophreniform disorder: The client exhibits an acute, reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. If symptoms persist over 6 months, the diagnosis is changed to schizophrenia. Social or occupational functioning may or may not be impaired. Catatonia: Catatonia is characterized by marked psychomotor disturbance, either excessive motor activity or virtual immobility and motionlessness. Motor immobility may include catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and not influenced by external stimuli. Other behaviors include extreme negativism, mutism, peculiar movements, echolalia, or echopraxia. Catatonia can occur with schizophrenia, mood disorders, or other psychotic disorders. Delusional disorder: The client has one or more nonbizarre delusions—that is, the focus of the delusion is believable. The delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre. Brief psychotic disorder: The client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month. The episode may or may not have an identifiable stressor or may follow childbirth. Shared psychotic disorder (folie deux): Two people share a similar delusion. The person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions, most commonly siblings, parent and child, or husband and wife. The more submissive or suggestible person may rapidly improve if separated from the dominant person. Schizotypal personality disorder involves odd, eccentric behaviors, including transient psychotic symptoms. Approximately 20% of persons with this personality disorder will eventually be diagnosed with schizophrenia. Schizotypal personality disorder is discussed in Chapter 18.
long term course
The intensity of psychosis tends to diminish with age. Many clients with long-term impairment regain some degree of social and occupational functioning. Over time, the disease becomes less disruptive to the person's life and easier to manage, but rarely can the client overcome the effects of many years of dysfunction. In later life, these clients may live independently or in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment. However, many clients with schizophrenia have difficulty functioning in the community, and few lead fully independent lives. This is primarily due to persistent negative symptoms, impaired cognition, or treatment-refractory positive symptoms (Hafner, 2015). Antipsychotic medications play a crucial role in the course of the disease and individual outcomes. They do not cure the disorder; however, they are crucial to its successful management. The more effective the client's response and adherence to his or her medication regimen, the better the client's outcome. Longer periods of untreated psychosis lead to poorer long-term outcomes (Penttilä et al., 2014). Therefore, early detection and aggressive treatment of the first psychotic episode with medication and psychosocial interventions are essential to promote improved outcomes such as lower relapse rates and improved insight, quality of life, and social functioning (Allott et al., 2014)
DSM 5 criteria for schizophrenia
Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): Delusions Hallucinations Disorganized speech (e.g., frequent derailment or incoherence) Grossly disorganized or catatonic behavior Negative symptoms (i.e., diminished emotional or avolition) For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve the expected level of interpersonal, academic, or occupational functioning). Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). Reprinted with permission from the American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. (Copyright 2013). American Psychiatric Association.
