Schizophrenia its Criteria of Diagnosis and Management

Afza.Malik GDA

Management of Schizophrenia and Criteria of Diagnosis

Schizophrenia its Criteria of Diagnosis and Management

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.

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