?This essay focuses on the diagnosis of schizophrenia, a major mental illness with much stigma and misinformation associated with it. World Health Organisation (WHO, 2012) epidemiological evidence suggests that schizophrenia is a mental illness affecting 24 million people worldwide. This essay will define schizophrenia and its characteristic signs and symptoms in relation to cognition, mood, behaviour and psychosocial functioning. The criteria enabling a diagnosis of schizophrenia are explored, as well as contemporary nursing care and pharmacological treatments.
The positive and negative signs and symptoms of schizophrenia will be discussed and the treatment and care requirements outlined by the NSW Mental Health Act (2007) are also investigated, while prevalent Australian societal attitudes and how this may affect sufferers is also outlined.
According to Varcarolis, Carson and Shoemaker schizophrenia is not a single disease, however, a set of symptoms that involves neuro-anatomical and neuro-biochemical abnormalities in the midst of strong genetic links.
Schizophrenia is an overwhelming brain disease which facilitates the affects of; personality, social behaviour, emotions, thinking, language and the ability to identify authenticity accurately (Varcarolis et al 2006).
For sufferers, the combination of disturbances are as unique as the number of individuals burdened with the illness emphasising the need for treatment that is correspondingly individualised, emphasising the need for treatment that is correspondingly individualised (Schizophrenia Fellowship of NSW ).
Schizophrenia is considered one of the most debilitating and misconstrued of all recognised mental illnesses (Bardwell & Taylor 2009, p. 250). The illness occurs indiscriminate of ethnicity, culture, gender, status or intellect (SFNSW, n. d. ), although SFNSW (n. d. ) observe, the disorder is slightly more common in males. Typically presenting between fifteen and thirty years of age, according to the Schizophrenia Research Institute (SRI) (2010), sufferers commonly endure its symptoms for more than two years before medical intervention (SRI 2010).
Schizophrenia Research Institute ( SFNSW) state that roughly ten percent of sufferers will commit suicide, while Van Os & Kapur (2009, p. 635) contend, the life expectancy for schizophrenia sufferers is between fifteen and twenty years less than the population average. Despite the advances in medical knowledge, practice and technology in this time, the specific cause of schizophrenia is yet to be determined (Bardwell & Taylor 2009, p. 250). Theories explaining its development are numerous, however, they remain unable to adequately provide conclusive reasoning for its development, or the complexities post manifestation.
Biological theories contend the existence of neurological abnormalities are a significant factor for developing schizophrenia (Bardwell & Taylor 2009, p. 250), whereby, influences possibly caused by developmental disturbances such as illness in early life (Bardwell & Taylor 2009, p. 251), resulting in ‘structural and functional’ irregularities of the brain, are hypothesised. While the actual causes proposed by subscribers to this theory remain unconfirmed, modern diagnostic imaging confirms the existence of significant structural irregularities of the brains of sufferers, according to Townsend (2011, p.
108). Another philosophy attempting to explain the aetiology of schizophrenia is the theory of genetic predisposition. Bardwell & Taylor (2009, p. 251) suggest, research indicates individuals are more likely to develop this illness, the closer they are biologically related to a sufferer. Another system of belief known as the stress-diathesis model, incorporates both biological and biochemical theories and considers the notion that stress, an intrinsic dynamic of life, is a key contributor to schizophrenia development (Bardwell & Taylor 2009, p.
252). Research indicates that schizophrenia can be divided into positive and negative symptoms; people diagnosed with schizophrenia have numerous disturbing and disabling symptoms that effect cognition, mood, behaviour and psychosocial functioning (Brissos et al. 2011). Varcarolis et al. 2006 describe positive symptoms of schizophrenia as ‘florid psychotic symptoms’ ‘as they capture attention’. Cognitive deficits lay primarily within the domains of memory and language affecting mood and behaviour (Elder et al. 2009).
Positive symptoms of schizophrenia include delusions, hallucinations and sever thought process disturbances and have an acute onset (Elder et al. 2009). Varcarolis, Carson and Shoemaker (2006) state that a patient experiencing a delusion is convinced that what they perceive is real and consequently the patients thinking often reflects feelings of great fear, isolation and trust issues. Additionally Elder et al. (2009) state that cognitive deficits are considered psychotic symptoms and that behaviours, perceptions and beliefs shown in a person having an exacerbation of schizophrenia are not consistent with normal human experience.
Negative symptoms involve a decrease in, or loss of normal functions including loss of motivation, an inability to feel emotionally as well as a reduction in the quantity and quality of speech (SFNSW n. d. ). Elder et al. (2009) state that negative symptoms to be; anhedonia (loss of the experience of pleasure), alogia (poverty of speech), blunted or flat affect and anergia (loss of energy). According to Varcarolis et al. (2006) psychosocial functioning impedes by interfering with relationships either intimate or to initiate and maintain, to hold a job and make decisions.
Mood and anxiety symptoms are particularly concerned with depression and apprehension, both common and debilitating aspects of schizophrenia (SFNSW n. d. ). Diagnosis Diagnosis begins with a detailed assessment which includes physical examination, past and present medical history, as well as detailing physical functions such as elimination, exercise, sleep and nutritional status (Bardwell & Taylor 2009, p. 187). The key assessment document applied, is the mental status examination (MSE), an assessment tool that investigates the individuals ‘neurological and psychological’ capacity according to Bardwell & Taylor (2009, p.
184). The MSE allows the assessor to capture the intricacies of elements such as the individuals’ appearance, behaviour, speech, mood and effect, form of thought and content, perception, sensorium, cognitive factors and insight (Bardwell & Taylor 2009, p. 185-187). Videbeck (2011, p. 253) state that a diagnosis must be made by a psychiatrist and when the patient meets the criteria for major affective or mood disorders. The author proposes the assessment of “affect” requires sensitivity of differences in eye contact, acceptable emotional expressions and body language.
Diagnosis of schizophrenia is universally guided by criteria listed in ‘The Diagnostic and Statistical Manual of Mental Disorders’ (DSM) (American Psychiatric Association 2000, cited in Bardwell & Taylor 2009, p. 252), a text produced by the American Psychiatric Association (APA), which allows consistency and accuracy when assessing individuals. According to the APA (2000) for a diagnosis of schizophrenia, an individual must have experienced for at least a month, two common symptoms of schizophrenia, such as delusions, hallucinations, disorganised speech patterns, behavioural disturbance or negative symptoms.
APA (2000) specifies only one of these criteria are necessary if delusions or hallucinations are considered particularly extraordinary. There must also be a recognisable deficiency to perform in employment, ‘relationships and self-care’ (APA 2000). If a result is considered significant, pathology and diagnostic testing are employed to rule out organic causes, however, once diagnosed, the individual is further categorised into one of the subtypes of schizophrenia dependent on specific characteristics of their presentation.
Townsend (2011, p. 105) explain the subtypes, such as paranoid schizophrenia, distinguished by the presence of severe ‘suspiciousness’ and delusions that maintain persecutory or grandiose qualities. Disorganized schizophrenia comprises of ‘regressive’ or ‘primitive’ behaviour, an absence of inhibitions, as well as inappropriate and incoherent communication (Townsend 2011, p. 105). Catatonic schizophrenia is characterised by ‘stupor’ and ‘psychomotor retardation’, according to Townsend (2011, p. 105), while Bardwell & Taylor (2009, p.
253) suggest, this state has an excitation phase involving impulsiveness and improper behaviour that does not match the environment. Undifferentiated schizophrenia, describe Townsend (2011, p. 105), contains disorganised behaviour as well as symptoms of psychosis, however, symptoms present do not adequately fit other subtypes (Bardwell & Taylor 2009, p. 253). Residual schizophrenia is diagnosed when schizophrenic behaviours are present, however they are less extreme than other subtypes, while psychotic symptoms are not necessarily present. Contemporary nursing care and pharmacological treatment
Contemporary nursing care and treatment of schizophrenia sufferers is guided by the New South Wales Mental Health Act (MHA) (2007), with principles listed such as providing the best care possible in an environment that facilitates maximum treatment effectiveness, care must contribute to enabling the individual’s ability to function in the community, maintain an occupation and cope with life (MHA 2007, p. 38). Care must also and be minimally intrusive to the individual’s autonomy, while they must be fully informed of their rights, responsibilities and treatments available (MHA 2007, p. 38).
The nursing care of mental health patients is to establish a therapeutic relationship and that ninety percent of all mental health care is delivered in primary care (Currid et al 2011). With mental health being a national priority and it is reasonable to suggest that registered nurses will care for a patient with schizophrenia in a primary health setting (Elder et al. 2009). The Australian Government has implemented a National Mental Health Plan to encourage a holistic approach and encourages the development of evidence based interventions that spans from prevention, recovery and relapse in a primary health care setting (NMHP, 2008).
XXXX Based on these principles, care is multidimensional and focusses on stabilising and recovery of the individual, incorporating methods such as cognitive behavioural therapy, which Bardwell & Taylor (2009, p. 256) point out, is potentially beneficial in creating positive outcomes that negate debilitating symptoms such as hallucinations and delusions, while limiting other potential triggers such as stress and stigma. Bardwell & Taylor (2009, p. 257) suggest supportive psychotherapy is imperative to recovery and continued ability to function with normality in society.
Family education, support and assistance are also crucial, facilitating understanding and fostering a positive environment that is safe and responsive to the sufferers needs. SRI (2010) further suggest ‘supported employment programs, case management, social support and housing programs’, all contribute to effective rehabilitation and re-integration into society for sufferers. Frangou (2008, p. 407) contend, the primary treatment for schizophrenia is the administration of antipsychotic medications which are divided into two categories, according to editor Barker (2009, p. 218), namely, typical and atypical antipsychotics.
Released in the middle of the nineteenth century (Van Os & Kapur 2009, p. 639), Pridmore (2010, p. 3) explains, the ‘typical’ subgroup includes the original antipsychotics such as chlorpromazine, haloperidol, fluphenazine and thiothixene. Also known as first generation antipsychotics (Van Os & Kapur 2009, p. 639), their action blocks dopamine receptors which can effectively control psychotic symptoms (Pridmore 2010, p. 3) with positive symptoms dramatically reduced for sixty to seventy percent of sufferers (Frangou 2008, p. 407), however, side effects are common observe Van Os & Kapur (2009, p.
639). The side effects can be severe, debilitating, and potentially damaging, creating a major impediment to medication compliance. These include side dysfunctions such as involuntary muscle spasms, akathisia presenting with mental and motor restlessness as well as amenorrhoea and infertility due to dopamine obstruction, and a build-up of prolactin (Pridmore 2010, p. 4). Weight gain is also a common side effect of first generation antipsychotics, according to Pridmore (2010, p. 5). Atypical antipsychotics, also known as second generation antipsychotics (Van Os & Kapur 2009, p.
639), include clozapine, resperidone, paliperidone, olanzapine, quetiapine, amisulpride and aripiprazole (Pridmore 2010, pp. 8-9). These second generation medications, observe Keen & Barker (2009, p. 220), are comparably effective in decreasing the positive symptoms as their predecessors, if not marginally better. Contributing less of the debilitating side effects as first generation antipsychotics, their real strength lies in decreased side effect intensity (Keen & Barker 2009, p. 220). While Agid, Kapur & Remington (2008, cited in Van Os & Kapur 2009, p.
639) state, atypicals remain ineffective in reducing the negative symptoms of schizophrenia, Burton (2006, cited in Pridmore 2010, p. 6) contend there is evidence of improvement in the domains of mood, cognition and quality of life. Scherk & Falkai (2006, cited in Pridmore 2010, p. 6), also contend there is evidence the structural brain changes evident in schizophrenia show improvement, with volume increases in thalmic and cortical grey matter. Pridmore (2010, p. 6) observes, weight gain is still an issue with typical and atypical antipsychotics, while clozapine, considered as a last resort medication (Keen & Barker 2009, p.
220) when all others are ineffective or inadequate, requires close metabolic monitoring due to the serious side effect of agranulocytosis. For this particular drug, blood testing and metabolic monitoring, strictly accompanies its prescription according to Keen & Barker (2009, p. 220). Regardless of the chosen drug, the goal of pharmacological therapies in the treatment of schizophrenia, suggest editors Elder, Evans & Nizette (2009, p. 259), is to reduce the debilitating symptoms allowing the individual the opportunity to enjoy a normal life with the secondary aim of preventing relapse. Societal attitudes and stigma
Schizophrenia has been misunderstood for as long as it has existed, its sufferers throughout history mistreated, neglected and shunned, with sufferers and their families commonly keeping the fact a secret from significant others, friends and workmates (SRI 2010). The stigma for sufferers and their families is caused by a society consistently exposed to erroneous, ill informed, sensationalisms devoid of factual evidence, painting sufferers as ‘violent, comical or incompetent’ (SANE Australia n. d. ), while media misrepresentation of this debilitating disorder is a powerful negative influence on societal beliefs (SANE Australia n.
d. ). Viewed as a character defect with connotations of being crazy, emotionally demanding, devious and potentially dangerous (Horsfall, Cleary & Hunt 2010, p. 451), all schizophrenia sufferers are tarred with the same brush. The negative stigma places additional burdens on the already suffering individual and their families (SANE Australia n. d. ), devaluing sufferers and inducing feelings that they are less than human. Ironically, as opposed to popular belief, sufferers of schizophrenia are more likely to be the victims of violence than be the perpetrators of it, however, they are more likely to harm themselves (SFNSW n.
d. ). Making matters worse, government funding for research and public awareness programs, fail to match the population affected (SRI 2010). Wong (et al. 2009, p. 108) suggests this type of treatment by society in general, is a ‘barrier to help seeking’ behaviour impacting effective treatment, further complicating the situation, while SANE Australia (n. d. ) contends, this will also contribute to social withdrawal, induce feelings of low self-esteem and possibly lead to drug and alcohol abuse. Van Brakel (2006, cited in Wong et al. 2009, p.
108) submit, stigma increases stress, facilitates illness, relationships suffer, while social interaction becomes unbearable and employment and education opportunities are diminished. What is needed is understanding and acceptance from a society that predominantly holds false views in regards to this highly debilitating mental health disorder. Van Os & Kapur (2009, p. 639) affirm this view with a hope for the future suggesting, ideally, society should treat sufferers with ‘respect, hope and dignity’, rather than ‘stigma, pessimism and exclusion’. Summary
This paper described the intricacies of schizophrenia, a major mental illness. Characteristic signs and symptoms related to cognition, mood, behaviour and psychosocial functioning have been investigated, while the criteria for diagnoses of schizophrenia as well as contemporary nursing care and pharmacological treatments have also been explored. The treatment and care requirements outlined by the NSW Mental Health Act (2007) have been highlighted, while the prevalent Australian societal attitudes and how this may affect sufferers have also been examined.
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