Introduction
Schizophrenia is one of the most common of the serious mental disorder. The disorder usually begins before age 25 years, persists throughout life and affects persons of all social classes. It involves changes in perception, emotion, cognition, thinking and behavior. Schizophrenia have been described into five subtypes based predominantly on clinical presentation: Paranoid, disorganized, catatonic, undifferentiated, and residual.1
According to the survey National Mental Health Survey 2016 conducted on 12 states including Assam (is the state with only 5.8% mental disorders) revealed that prevalence rate of schizophrenia is 0.4%.2
The word “Paranoid Schizophrenia’ means “delusional”. Paranoid schizophrenia is at present the most common form of schizophrenia. It is characterized by delusion of persecution, delusion of reference, delusion of jealousy, delusion of grandiosity & hallucinatory voices like auditory hallucinations. Other features are include disturbance in affect like-blunt affect, volition, speech and motor behavior.
Etiology
Many authorities suggest that multiple factors must cause schizophrenia explains the disorder.
Neurostructural theories
Research suggests that the prefrontal cortex and limbic cortex may never fully develop in the brains of persons with schizophrenia. Computed tomography and magnetic resonance imaging studies of brain structure show:
Genetic theories
The disease is more common among people born of consanguineous marriages. Studies show that relatives of schizophrenics have a much higher probability of developing the disease than the general population.
Perinatal risk factors
Multiple non-genetic factors influence the development of schizophrenia like maternal influenza, birth during late winter or early spring, complications of pregnancy particularly during labor and delivery.
Developmental theories
According to Freud, there is regression to the oral stage of psychosexual development, with the use of defense mechanisms of denial, projection and reaction formation.
Family theories
Family relationship act as major influence in the development of illness like mother- child relationship, dysfunctional family system & double blind communication.
Vulnerability-stress model
According to this model, people with a predisposition to schizophrenia may avoid serious mental disorders if they are protected from the stresses of life. Individual with a similar vulnerability may succumb to schizophrenia if exposed to stressors.
Social factors
Studies have shown that schizophrenia is more prevent in areas of high social mobility and disorganization, especially among members of very low social classes.3
Diagnosis
A mental status examination, psychiatric history and careful clinical observation form the basis for diagnosing schizophrenia. Diagnostic criteria for schizophrenia are-
Delusions of persecution, reference, exalted birth, special mission, bodily change, or jealousy.
Hallucinatory voices that threaten the patient or give commands, or auditory hallucinations without verbal form, such as whistling, humming, or laughing.
Hallucinations of smell or taste, or of sexual or other bodily sensations; visual hallucinations may occur but are rarely predominant.4
Investigations
No diagnostic test definitely confirms schizophrenia, tests may be ordered to rule out disorders that cause psychosis, including vitamin deficiencies, uremia, thyrotoxicosis and electrolyte imbalances.
CT scan and MRI show enlarged ventricles, enlargement of the sulci on the cerebral surface and atrophy of the cerebellum.3
Treatment modalities
Pharmacotherapy- An acute episode of schizophrenia typically responds to treatment with antipsychotics agents, which are most effective in its treatment. Conventional and atypical antipsychotics are used in treatment of schizophrenia.
Electroconvulsive Therapy.
Psychological therapies-Group therapy, Behavior therapy, Cognitive therapy, Family therapy, Social skill training.
Psychosocial rehabilitation.5
Nursing Management: A Case Study
A case study of a 31 years old female with Paranoid Schizophrenia is discussed with consent from her elder sister. Miss X, 31 years old female admitted in psychiatry ward GMCH on 04/04/2022 with the complain of Burning cloths, Cutting mosquito net & bed sheet, muttering to self, wandering behavior & throwing household things from last 2 months, Decrease sleep, suspiciousness towards family members & not taking medication from last 1 month. She has past history of similar psychiatric episode in the year of 2015, 2017 & 2019. She has no past medical and surgical history except some cold and fever. In family history, her grandmother also had history of similar symptoms and she found as Paranoid schizophrenia. On arrival vital signs are stable. Mental status examination was done and finding shows that blunt affect, thought insertion, delusion of persecution, auditory hallucination, disoriented to time, place & person, poor judgment with grade I insight. MRI revealed enlarged ventricle, enlargement of the sulci on the cerebral surface and atrophy of the cerebellum. Nursing care is discussed elaborately using nursing process approach.
Nursing diagnosis
Disturbed thought process related to inability to trust, suspiciousness as evidence by delusional thinking.
Expected outcome
The patient will able to maintain a good relationship with family members while having control over thoughts.
Intervention
Content of delusional thinking was assessed.
Intensity, frequency & duration of delusional thought was assessed.
The context and environmental triggers for the delusional experience was assessed.
Avoid laughing, whispering or talking quietly where the patient can see but cannot hear what is being said.
Educate the patient and family about the patient’s symptoms, the importance of medication compliance, and follow up-visits.
Nursing diagnosis
Disturbed sensory perception (auditory/visual hallucination) related to panic anxiety, possible hereditary or biochemical factors evidenced by inappropriate responses, disordered thought sequencing, poor concentration, disorientation, withdrawn behavior.
Intervention
Assess the type of hallucinations and characteristics of hallucinations.
Observe the patient for hallucinating behavior like talking to self, stopping in mid-sentence.
Determine precipitating factors may exacerbate the patient’s hallucinatory experience.
Interrupt hallucination by calling patient by name or other distraction or move the patient to another area. Be alert to cues that the patient is hallucinating.
Help the patient learn that he can dismiss hallucinations by humming or whistling or saying ‘go away’ or ‘be quiet’.
Nursing diagnosis
Potential for violence, self directed or at others, related to command hallucinations evidenced by physical violence, destruction of objects in the environment or self-destructive behavior.
Intervention
Maintain low level stimulation (low lighting, low noise, few people etc) in the patient’s environment.
Remove all dangerous objects from the patient’s environment.
Provide a structured environment with scheduled routine activities of daily living.
Do not use physical restraints or techniques without sufficient reason. Apply mechanical restraints safely. Check extremities for color temperature, and pulse distal to the restraints for every 15 minutes.
Administer tranquillizers as prescribed.
Nursing diagnosis
Impaired health maintenance related to inability to trust, extreme suspiciousness evidenced by poor diet intake, inadequate food and fluid intake, difficulty in falling asleep.
Intervention
Assess for malnutrition & dehydration.
Monitor food and fluid intake.
Suspicious patient’s sleep may be distributed by nightmares or severe anxiety so that he cannot fall asleep, provide less stimulating environment (dim light, comfortable bed, less noise etc.)
Administer sedatives if needed.
Prevent day time naps by involving actively in physical exercises or day time treatment program.
Conclusion
Schizophrenia is characterized by disturbances in thought and verbal behavior, perception, affect, motor behavior and relationship to the external world. The incidence of schizophrenia is believed to be about 0.5 per 1000. The onset of schizophrenia occurs usually later in women and often runs a relatively more benign course, as compared to men.
Article DOI
