Management of Schizophrenia and Criteria of Diagnosis

What is Schizophrenia,Schizophrenia and Its Statistics,Criteria for Diagnosis,Qualitative and Quantitative Research,Management of Hallucination and Nursing Care,Psycho-social Rehabilitation.

What is Schizophrenia

    Schizophrenia, the most serious and persistent of the brain
diseases in psychiatry, strikes at least one in every hundred people. About
1.3% of the population worldwide develops the disease regardless of race,
ethnic group, gender, or country of origin. 

    Between two and three million
people in the United States suffer from schizophrenia and the accompanying
stigma. In three out of four cases the illness begins between the ages of 17
and 25, robbing its victims of their most productive young adult years. 

    The average
lifespan of a person with schizophrenia is 20% shorter than that of the general
population.

Schizophrenia and Its Statistics 

    Schizophrenia is a chronic illness that is five times more common
than multiple sclerosis, six times more common than insulin dependent diabetes,
60 times more common than muscular dystrophy, and 80 times more common than
Huntington’s disease. 

    To date schizophrenia is unpreventable, its exact cause
is unknown, and it is not reliably curable. The word schizophrenia is a
combination of two Greek words, schizein meaning to split and phren meaning
mind. The word refers to a split from reality, not split personality.

Criteria for Diagnosis

    The criteria for diagnosis in the American Psychiatric
Association’s (2000) Diagnostic and Statistical Manual (4th edition text
revision) requires that at least two of the following be present for a
significant portion of time during a 1-month period: delusions; hallucinations
disorganized speech; grossly disorganized or catatonic behavior; and, negative
symptoms which refer to cognitive deficits such as alogia, poverty of speech,
avolition, and flattening of affect. 

    For a significant portion of the time
since the onset of the disturbance, one or more major areas of functioning,
such as work, interpersonal relations, or self-care, is markedly below the level
achieved prior to the onset. Continuous signs of the disturbance must persist
for at least 6 months.

    Approximately 400,000 acute episodes occur annually in the US and
three million occur worldwide. Schizophrenia is ranked fourth of the top ten of
all diseases worldwide in terms of burden of illness. The top three are
unipolar disorder, alcohol use, and bipolar disorder. 

    Schizophrenia ranks
second in women age 14-44 years of all disease’s worldwide in terms of burden
of illness. It is projected that by 2020 neurobiological illnesses will account
for almost 15% of all illnesses worldwide.

    Schizophrenia accounts for 40% of all long-term care days. $104
billion, 3% of the total United States health care expenditure, is spent
annually on schizophrenia related costs not including loss of productivity. 

    Twenty-five percent of all United States hospital beds are occupied with
someone diagnosed with schizophrenia. Twenty to fifty percent of patients with
schizophrenia attempt suicide, while 10% succeed.

    Recent research aided by new technological advances has redefined
schizophrenia as a major neurobiological disease, a concept in psychiatry that
now replaces outdated psychological theories of causation. There is now
indisputable evidence of anatomical, neurophysiological, biochemical, and
electrical abnormalities, including loss of gray matter in the frontal and
prefrontal lobes and enlarged ventricles. 

    Further biological evidence for the
brain disease model of schizophrenia has come out of studies of genetics, epidemiology,
neuroimmunology, and neuroradiography. Understanding of this disease is rapidly
increasing with recently developed advanced brain imaging technologies.

    A CINAHL search of nursing research in schizophrenia since 1998
returned 117 citations. The majority of these were descriptive reports of
program development and/or nursing interventions. Ongoing nursing research has
been focused on 14 major categories. These categories are: 

(1) symptom
management and relapse prevention

(2) caregiver and family burden

(3)
treatment adherence and medication side effects

(4) management of
hallucinations and delusions

(5) wellness, lifestyle, and medical comorbidity

(6) psychoeducation

(7) psychosocial rehabilitation

(8) outcome measures and
assessment tools

(9) inpatient treatment; (10) empathy and hope

(11) suicide
and depression 

(12) children and adolescents

(13) psychotherapies

(14)
women’s issues. All 117 citations will be described

Qualitative and Quantitative Research

    Qualitative and quantitative research related to symptom management
and relapse prevention is ongoing at the University of Washington in Seattle
(Kennedy, Schepp , & O’Connor, 2000). 

    Additional relapse prevention
research is being conducted in the Netherlands by van Meijel , van der Gaag ,
Kahn, and Grypdonck (2002a, 2002b, 2003a, 2003b) and in South Africa by Mwaba
and Molamu ( 1998).

    A large corpus of literature is evolving in the area of family and
caregiver burden. Tool development for sibling burden is being conducted at the
University of Iowa by Friedrich, Lively, Rubenstein, and Buckwalter (1999,
2002), and Friedrich, Lively, and Buckwalter (1999). 

    Researchers in Great
Britain (Gall, Elliot, Atkinson, & Johansen, 2001, 2003) have developed a
training program to support caregivers of relatives with schizophrenia. Also in
Great Britain, Macinnes (1998) reported on differences between health
professionals in assessment of caregiver burden. Saunders (1999, 2003; Saunders
& Byrne, 2002) at the University of Texas has ongoing studies on overall
family functioning. 

    Hope in relationship to family caregivers is documented in
Bland and Darlington (2002). Wuerker (2000) has ongoing family research at the
University of California at Los Angeles. 

    Canadian researchers at the University
of British Columbia are studying the family illness experience ( Teschinsky ,
2000) while the Ryerson Polytechnic University in Toronto is focusing on
parents of individuals experiencing a first episode of schizophrenia. Milliken
(2001), Milliken and Northcott (2003), and Milliken and Rodney (2003) are
studying the burden of families caring for adult children with schizophrenia at
the University of Victoria in British Columbia. 

    German researchers at the
University of Leipzig are also looking at subjective burden of parents of
patients with schizophrenia ( Jungbauer , Wittmund , Dietrich, &Angermeyer
, 2003) as are Korean researchers, YM Lim and Ahn (2003) and Jung (2000). 

    Researchers at KhonKaen University in Thailand are studying psychologycal
morbidity of rural families as well as religious practices used as
interventions (Rungreangkulkij, Chafetz , Chesla, &Gilliss , 2002;
Rungreangkulkij &Chesla, 2001). The effects of support groups on caregivers
in

    China is reported by K. Chou, Liu, and Chu (2003). Attitudes and
beliefs in families is researched in South Africa ( Mbanaga et al., 2002). The
reliability and validity of the concept as expressed in families and nurses in

    Hong Kong is articulated by Arthur (2002). Another growing body of
research is in the area of adherence with the treatment regimen. Australian
researchers Pinikahana , Happell , Taylor, and Biscuit (2002) provided a
comprehensive review of the complex issues involved with compliance. 

    In Great
Britain, Gray, Wykes, and Gournay (2002) are ad-dressing compliance with
antipsychotic medications while NR Harris, Lovell, and Day are studying
consent. L Jennings and colleagues (2002) are evaluating effects of knowledge
of illness, insight, and attitudes toward taking medications. 

    In Atlanta,
Jarboe and Schwarz (1999) and Jarboe (2002) are also researching compliance
with antipsychotics, Kozuki and Froelicher (2003) reported on lack of awareness
as a factor in nonadherence. The evidence base for compliance is being studied
in Scotland by Marland (1999) and by Marland and Sharkey (1999). 

    Marland and
Cash (2001) are also studying why patients decide not to take prescribed
medications. In Israel, Navon and Ozer (2003) are exploring the patient’s
reasoning regarding compliance. Managing medication side effects to effect
compliance is ongoing in Berkshire, England (Sin & Gamble, 2003). 

    Scandinavian researchers are studying the morality of using depot neuroleptics
( Svedberg , Hallstrom, &Lutzen , 2000). The role of the community mental
health nurse in doing more than just giving injections is reported by
Muir-Cochrane in 1998.

Management of Hallucination and Nursing Care

    The management of hallucinations has been of concern to nurses
throughout the history of psychiatric nursing. Ongoing research at the
University of California at San Francisco involves randomized controlled trials
of a specific psychoeducational intervention ( Buccheri et al., 2004; Trygstad
et al., 2002). 

    Similar research is ongoing in Great Britain (Wykes, Parr, &
Landau, 1999). Also, in Britain and Holland, Baguley and Davies (1999a,1999b)
are studying the complications added to managing hallucinations and delusions
when the patient is abusing substances. Sayer, Ritter, and Gournay (2000) are
researching patient beliefs about their voices and the effects on coping.

    Wellness, medical comorbidity, and lifestyle in relationship to management
of schizophrenia is also a prominent focus of current research. The effects of
antipsychotic medication on quality of life, including weight management and
metabolism, is intensely researched by the ProMedica Research group in Georgia
(Littrell, Hilligoss, Kirshner, Petty, & Johnson, 2003; Littrell &
Littrell, 1999). 

    Health promotion is being addressed by Beebe (2003) while
Chafetz and Ricard (1999) are addressing biopsychosocial approaches. Health
outcomes related to satisfaction with social functioning and general health are
reported by Badger and colleagues in 2003. The association of cigarette smoking
to schizophrenia is reviewed by McCloughen (2003) and by Forchuk and colleagues
(2002). 

    A 22-year follow up study on smoking, body mass index, and risk of
heart disease following the first episode of schizophrenia is reported by Luty
, Kelly, and McCreadie (2002). Risk of HIV infection in the schizophrenic
population is being studied by Gray, Brewin, Noak , and colleagues (2002). The
primary care needs of people with schizophrenia is reported by J. Rodgers,
Black,

    Stobbart, and Foster (2003). Psychoeducation was intensely studied
in the 1980s and 1990s, primarily by the allied health disciplines. Current
nursing research is being conducted in Hong Kong (Chien, WT, & Norman,
2003; Chien, WT, & Lee, 2002; Chien, WT, Kam, & Lee, 2001) and in
Australia (Fung & Fry, 1999).

Psycho-social Rehabilitation

    The topic of psychosocial rehabilitation, overall quality of life,
and community-based care is appearing in the general nursing literature as well
as in specific psychiatric nursing journals. AntaiOtong (2003) provided a
comprehensive review of psychiatric rehabilitation while CC Williams and
Collins (2002) are looking at the social construct of disability. 

    Social
function and quality of life for persons with schizophrenia is described. by J
McDonald and Badger (2002) and by Walton (2000). A comparison between
psychiatric nurses, psychiatrists, and the public regarding beliefs about
interventions is presented by Caldwell and Jorm (2000). 

    The cognitive aspects
of activities of daily living are a focus at the University of Kansas ( Rempfer
, Hamera , Brown, & Cromwell, 2003). Functioning in the community is being
studied in the United States by Hampton and Chafeftz (2002), B Johnson and
Montgomery (1999), and Beebe (2001, 2002). 

    Australian researchers are studying
grounded research in the willingness to access community mental health services (McCann, TV, & Clark, 2003) while Pinikahana , Happell , Hope, and
Biscuit (2002) are looking at overall quality of life. 

    In Sweden the focus is
the effect of living in a homelike setting ( Pejlert , Asplund , & Norberg,
1999). In Taiwan work is ongoing in the area of social skills training (Chien,
HC, et al., 2003). 

    In Hong Kong, Chan, S., Mackenzie, and Jacobs (2000),
Tin-Fu, Chan, and Jacobs (2000), and Chan, S., Mac-Kenzie, A., Tin-Fu, and
Leung (2000 ) are studying cost effectiveness of case management versus routine
community care, as are Lin, Yin, Kuo , and colleagues in Taiwin . Japanese
researchers are studying client empowerment by public health nurses (Kayama,
Zerwekh , Thornton, &Murashima , 2001) . 

    Anger management is also being
studied in Hong Kong (Chan, H., Lu, Tseng, & Chou, 2003). Needs assessment
and quality of life in Scandinavia is described in a 5-year follow-up study by
Foldemo and Bogren (2002).

    An increasing number of studies are focusing on tool development
for various measures. In 1999 nursing students developed a tool for assessing
safety (Blanchard et al., 1999). 

    In Manchester, England, Lockwood and Marshall
(1999) have been studying the importance of standardized and reliable
assessment tools in schizophrenia research. Sherrell, Buckwalter, Bode, and
Strozdas (1999) are evaluating cognitive abilities screening tools in the assessment
of elderly schizophrenics. Beebe (2003b) is emphasizing the importance of the
vulnerability model to guide research in schizophrenia. 

    Menzies and Farrell
(2002) remind psychiatric nurses of the importance of the traditional Abnormal
Involuntary Movement Scale in evaluating patients for side effects related to
antipsychotic medications. McCay and Seeman (1998) developed a scale to measure
the impact of schizophrenia on self-concept.

    The use of critical pathways to guide inpatient care at the Chinese
University in Hong Kong is emphasized by SW Chan and Wong in 1999 and also in
London by A Jones (2000, 2001). 

    Ar the University of Hawaii, Anders, Kawano,
Mori, Kokusha , and Tokunaga ( 2001) are studying inpatient treatment in Japan,
Thailand (Anders, Thapinta , Wiwatkunupakan , Kitsumban , &Vadtanapong ,
2003) and the US (Different, 2000). 

    From the patient perspective, Finnish
researchers Koivisto, Janhonen , and Vaisanen (2003) are studying the patient’s
experience of psychosis using phenomenological methodology. In India, Mahato
(2000) studied the relationship between the length of hospitalization and the
ability to resume self-care.

    Depression and suicide are being studied in Australia by Pinikahana
, Happell , and Biscuit (2003) and in Italy by Pompili , Mancinelli , Girardi,
and Tatarelli (2003). In the United States, Menzies (2000) at the University of
Virginia is studying the neglected aspect of postpsychotic depression. 

    The
concept of hope is being studied by Kirkpatrick, Landeen , Woodside, and Byrne (2001),
TV McCann (2002), and Salerno (2002).

    The use of psychotherapeutic techniques include cognitive
behavioral therapy (Siddle &Kingdon , 2000), transactional analysis (Paley
& Shapiro, 2001), sense of coherence (Bengtsson-Tops & Hansson, 2001),
general psychosocial interventions (McCann, E. , 2001), insight (Baier et al.,
2000; Baier & Murray, 1999), the nurse patient relationship ( Forchuk ,
Westwell , et al., 2000), and Newman’s theory (Yamashita, 1999).

    Women’s issues (Clarke, Chernomas , & Chisholm, 2001) and
sexuality (McCann, E., 2000) are beginning to appear in the literature; however
there was only one study documented related to children and adolescents with
schizophrenia (lambert, lt, 2001).

    In the past 5 years, the quality and quantity of nursing research
in schizophrenia has expanded around the globe. psychiatric nurse researchers
are contributing significantly to the improvement of care for individuals with
schizophrenia and their families. the corpus of research is maturing with the
appearance of randomized controlled trials involving nursing interventions. 

    Research that has been presented in poster format at major research conferences
but has yet to be published in refereed journals is demonstrating increased
sophistication in methodology in each of the 14 major areas.