Over the past several decades, the World Health Organization has consistently cited that schizophrenia affects 1% of individuals around the world (Jablensky, Sartorius, Ernberg, Anker, Korten at al, 1992) and ranks among the top 10 causes of disability in developed countries (Murray & Lopez, 1996). Schizophrenia is associated with a financial burden of over $62 billion in the United States (Wu, Birnbaum, Shi, Ball & Kessler, 2005) and nearly $7 billion in Canada (Goeree, Farahati, Burke, Blackhouse, O’Reilly et al, 2005). McGrath, Saha, Chant and Welham (2008, June 14) now suggest that the incidence and costs may well be higher than these seminal estimates and that individuals with schizophrenia have a two- to threefold increased risk of dying. Given the current trend towards admitting patients with psychiatric illnesses such as schizophrenia into flex beds in health care settings, nurses can expect to meet individuals struggling with this devastating illness in all areas of their practice. Nurses who know what to do and say can save lives.

What Is Schizophrenia?

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), schizophrenia is a persistent, often chronic and usually serious mental disorder affecting a variety of aspects of behaviour, thinking, and emotion. Patients with hallucinations or delusions may be described as psychotic. Thinking may be disconnected and illogical. Peculiar behaviours may be associated with social withdrawal and disinterest (American Psychological Association APA, 2000). Causes of the disorder are not clear; however an imbalance of serotonin, norepinephrine, an abnormally large number of dopamine receptors, and a faulty neurotransmission process may play a role (Schizophrenia.com, n.d.). Symptoms often present between the ages of 18 and 25 and early intervention when the first psychotic symptoms are expressed is encouraged (Dyer & McGuinness, 2008).

Distinguishing between positive or hard, and negative or soft symptoms is of particular importance with schizophrenia. In this context, “positive” does not mean “good.” Rather, positive symptoms are psychotic and demonstrate how individuals have lost touch with reality. Positive symptoms are those that exist but should not exist such as hallucinations, delusions and disorganized thinking and behaviour.

Delusions fall into several categories. Individuals with a persecutory delusion may believe they are being tormented, followed, tricked, or spied on. Individuals with a grandiose delusion may believe they have special powers. Individuals with a reference delusion may believe that passages in books, newspapers, television shows, song lyrics, or other environmental cues are directed to them. In delusions of thought withdrawal or thought insertion, individuals believe others are reading their mind, their thoughts are being transmitted to others, or outside forces are imposing thoughts or impulses on them. With positive symptoms, understanding that individuals are deeply convinced the delusions are real is essential (Austin & Boyd, 2008; Mohr, 2003; Varcarolis, Carson, & Shoemaker, 2006).

In contrast, negative symptoms are those characteristics that should be there but are lacking. For example, negative symptoms include: apathy (lack of interest in people, things and activities), lack of motivation, blunted affect, poverty of speech (brief terse replies to questions that lack content), anhedonia and asociality (avoidance of relationships). A blunted affect does not reflect an inability to feel emotion. Withdrawing from others is a coping mechanism for those with schizophrenia – not a rejection of those who initiate contact.

What Can Nurses Do?

QUESTION WHETHER A DIAGNOSIS OF SCHIZOPHRENIA BEEN DESIGNATED. Is the presentation of psychotic behaviour associated with a diagnosis of schizophrenia? Or might drugs, alcohol, brain injury or even dehydration be causing the unusual behaviour?

IDENTIFY PRESCRIBED ANTIPSYCHOTIC MEDICATIONS. Individuals diagnosed with schizophrenia can be expected to have antipsychotic medications prescribed for life. Since the side effects can be devastating, patients often stop taking them. However, without antipsychotic medications, the positive and negative symptoms of schizophrenia will return and seriously impair functioning.

Antipsychotic medications are either ‘typical’ (Chlorpromazine/ Thorazine or Haloperidol/Haldol); or ‘atypical’ (Clozapine/ Clozaril, Risperidone/Risperdal, Olanzapine/Zyprexa or Quetiapine/Seroquel). While traditional typical antipsychotics reduce positive symptoms, they can also induce extrapyramidal (EPS), tardive dyskinesia and over sedation (Varcarolis, Carson & Shoemaker, 2006). The newer atypical antipsychotics, which reduce both positive and negative symptoms, can cause significant weight gain, metabolic abnormalities, movement disorders and over sedation (Cullen, Kumra, Regan, Westerman, & Schulz, 2008). While non compliance is understandable, it is vital for nurses to know what antipsychotic medications have been prescribed for individuals with schizophrenia and whether the individual is currently taking them.

ENSURE MEDICATION IS INGESTED. Hallucination and delusion content often includes the belief that anti-psychotic medication is “poison,” and in response to this belief, individuals frequently “cheek” or pretend to swallow pills. Given this inalterable aversion to swallowing pills, long acting medications offering relief from psychosis are often administered IM each month.

What Can Nurses Say?

ARE YOU HEARING VOICES RIGHT NOW? With schizophrenia, it is important to emphasize that nurses are required to know the content of any hallucination or delusion. Posing a clear direct question such as “Are you hearing voices right now?” during each interaction is expected. A hallucination could involve a deep loud commanding male voice incessantly admonishing an individual that he/she is “worthless and must die.” Observe for cues such as eyes darting to one side, muttering to self or looking to a vacant area.

INTERJECT DOUBT. After asking if hallucinations and delusions are present, avoid reacting as if these are real, do not argue back to the voices and set time limits for talking about them. Acknowledge the individuals experience while at the same time offering your own perceptions. For example: “I do not hear these voices, but I understand how scary this must be for you.” Focus on feelings. Present diversions based on reality either through conversations or working together on a simple project. Suggest: “Try not to listen to the voices right now; we’ll walk down the hall and look at the decorations.” Suggest listening to music with earphones. If an individual seems anxious, the symptoms may be increasing.

HAVE YOU BEEN FEELING SUICIDAL? Approximately  10 percent of individuals with schizophrenia (especially younger adult males) commit suicide (National Institute of Mental Health NIMH, 2006; Public Health Agency of Canada PHAC, 2002), so assessing suicide risk is critical. Pose three direct questions. First, have you considered taking your own life? Second, how do you plan to commit suicide? Third, what stops you?

HAVE YOU TAKEN ANY DRUGS OR ALCOHOL TODAY? IN THE LAST WEEK? IN THE PAST? Quantifying specific amounts of substance, such as the number of beers, marijuana cigarettes or grams of cocaine is important. The lifetime incidence of substance abuse occurring in schizophrenia is 60% (American Psychological Association APA, 2000). Substance abuse is associated with negative outcomes such as incarceration, homelessness and violence. Referral to a dual diagnosis treatment program may be needed to address both a schizophrenic illness and substance abuse problems.

Summary

Communicating with individuals who express delusions they believe are real is not easy. And nor is reaching out to engage individuals who present with severely blunted affect. But, those who live with schizophrenia need nurses to understand their illness and help by monitoring medication compliance and asking questions about hallucinations, suicide and substance abuse.

References

American Psychological Association APA. (2000). Diagnostic and Statistical Manual of Mental Disorders 4th ed. Text Revision (DSM-IV-TR) Washington, DC: Author.

Austin, W., & Boyd, M.A. (2008). Interventions in psychiatric and mental health nursing practice. Psychiatric nursing for Canadian practice. Philadelphia: Lippincott Williams & Wilkins.

Cullen, K., Kumra,S., Regan,J., Westerman, M. & Schulz, C.(2008). Atypical antipsychotics for treatment of schizophrenia spectrum disorders [Online Version]. Psychiatric Times, 25(3). Retrieved August 6, 2008 from http://www.psychiatrictimes.com/display/article/10168/1147536?pageNumber=2

Dyer, J.G. & McGuinness, T.M. (2008). Update on early intervention in schizophrenia. Journal of Psychosocial Nursing and Mental Health Services, 46(6), 19-22.

Goeree, R., Farahati, F., Burke, N., Blackhouse, G., O’Reilly, D., Pyne, J., & Tarride, J. (2005). The economic burden of schizophrenia in Canada in 2004. Current Medical Research and Opinion, 21 (12), 2017-2028.

Jablensky, A., Sartorius, N., Ernberg, G., Anker, M., Korten, A., Cooper, J.E., Day, R. &, Bertelsen, A. (1992). Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine Monograph Supplement, 20, 1-97.

McGrath, J., Saha, S., Chant, D., & Welham, J. (2008, June 14). Schizophrenia: A Concise Overview of Incidence, Prevalence, and Mortality. Epidemiology Reviews, 0 (mxn001v2-mxn001) [Epub ahead of print online version].

Mohr, W. (2003). Johnson’s psychiatric-mental health nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins.

Murray, C. & Lopez, A. (1996) The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. In Murray CJL and Lopez AD (Eds.). The global burden of disease (Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Cambridge (MA)) (Global Burden of Disease and Injury Series, Vol. 1).

National Institute of Mental Health NIMH. (2006) Schizophrenia. Bethesda, MD: U.S. Department of Health and Human Services. National Institutes of Health. NIH Publication No. 06-3517. Retrieved August 6, 2008 from http://www.nimh.nih.gov/health/publications/schizophrenia/summary.shtml

Public Health Agency of Canada PHAC. (2002). A report on mental illness in Canada. Chapter Three: Schizophrenia. Ottawa, ON. Publication prepared for Health Canada. ISBN: H39-643/2002E Cat No: 0-662-32817-5 Retrieved August 6, 2008 from http://www.phac-aspc.gc.ca/publicat/miic-mmac/chap_3-eng.php

Schizophrenia.com (n.d.). Schizophrenia facts and statistics [Fact Sheet]. Retrieved August 6, 2008 from Schizophrenia.com website http://www.schizophrenia.com/

Varcarolis, E., Carson, V. B., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing: A clinical approach (5th ed.). St. Louis, MO: Saunders Elsevier.

Wu, E., Birnbaum, H., Shi, L., Ball, D., Kessler, R. Moulis, M. & Aggarwal, J. (2005). The economic burden of schizophrenia in the United States in 2002. Journal of Clinical Psychiatry, 66(9), 1122-9