Schizophrenia is a discussion that attracts attention to annual conference The American Psychiatric Association/APA in Miami, Florida, United States, May 1995 ago. Because of in United States the rates of schizophrenia patients was quite high (lifetime prevalence rates) reached 1/100 citizens. As comparison, in Indonesia if to PJPT I the rates 1/1000 citizens if the projection to PJPT II, 3/1000 citizens even can higher again.
Based on data in United States:
- Annually there are 300.000 schizophrenia patients having acute episode;
- Prevalence of schizophrenia is higher than Alzheimer disease, multiple sclerosis, diabetic patient who uses insulin and muscular dystrophy);
- 20% - 50% schizophrenia patients try to commit suicide and 10% of them succeed (death because of suicide);
B. Causing Factors of Schizophrenia
Until now has not found definite etiology why someone who suffers schizophrenia, although others don’t. In fact from the previous researches conducted has not found single factor. Causing factors of schizophrenia based on recent researches such as:
- Genetic factor
- Auto antibody
How far the role of genetic to schizophrenia? From the research gained description as follows:
1. A study to a family said that parents 5.6%, brother or sister 10.1%; children 12.8%; and citizen entirely 0.9%.
2. A study to twin people said identical twin 59.20%; while fraternal twin 15.2%.
Other researches said that disorder to fetus brain also has role for the emerging of schizophrenia someday. This disorder emerged, such as malnutrition, infection, trauma, toxin and hormonal disorder.
Recent research said that although there is abnormal genetic schizophrenia will not emerge unless along with other factors named epigenetic factor. The conclusion is schizophrenia emerges if occur interaction between abnormal genetic with:
- Virus or other infection during pregnancy which can disturb the development of fetus brain
- Based on autoimmune which probably caused by infection during pregnancy
- Pregnancy complication
- Quite serious malnutrition, particularly to trimester pregnancy
Furthermore, pointed that people who have epigenetic factor, if having psychosocial stressor in life, thus the risk is higher to suffer schizophrenia than people who have not previous epigenetic factor.
C. General Causing of Mental Disorder
Human reacts entirely, wholly, or can be said also somato-psycho-social. In searching the causing of mental disorder, thus these three elements should be pay attention. Mental disorder is a pathologic dominant symptom from physic elements. This case is not means that other element is not disturbed. Once again, who sick and suffer is human wholly and not only his or her body, mental but also environment.
The cases that can influence human behavior are inherit and constitution, age and sex, physical condition, psychological condition, family, custom, culture and belief, job, married and pregnancy, losing and death of someone who loved, aggression, hostility feeling, relationship between human etc. Table below is raw estimation the sum of patients some mental disorder type in one year in Indonesia with citizens 130 millions people.
Table 4.1. Sum of Mental Disorder Client in Indonesia
Syndrome of acute organic brain
Syndrome of yearly organic brain
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Although, general symptoms or prominent symptoms are in the mental components, however the main causes probably in the body (somatogenetic), in social environment (sociogenic) or dipsike (psychogenic). Usually there is no single cause, but there are some causes directly from some components that influence each other or coincidence occur at the same time, then emerge physic or mental disorder. For instance someone who depression, because lack of eating and sleep his or her immune become decreases thus having throat inflammation or someone with mania got accident.
Vise versa someone with physic illness for instance inflammation that weaken, thus psychological immune also decrease thus he or she having depression. It is been known also, that illness to brain often causing mental disorder. Another example is a child who has brain disorder (because in birth, inflammation etc) then become hyperkinetic and hard to care. He or she influences environment, particularly parents and other families in the same home. They react one another and they influence each other.
The causing source of mental disorder influenced by factors to three components that persistently influence each other, those are:
1. Somatic factors (somatogenetic) or Organ biological
a. Neuron anatomy
b. Neuron physiology
c. Neuron chemical
d. Maturation level and organic development
e. Pre and peri-natal factors
2. Psychological factors (psychogenic) or psychoeducative
a. Interaction of mother-child: normal (confidence and safety feeling) or abnormal based on the lack, distortion and break condition (unconfident and doubt feeling)
b. Father’s role
c. Competition between brother or sister
e. Relationship in family, job, playing and public.
f. Loss that cause worried, depression, shame or guilty feeling
g. Self concept; self identity understanding against indefinite role
h. Skills, talent and creativeness
i. Adaptation pattern and defense as reaction toward danger.
j. Emotional development level
3. Social culture factors (sociogenic)
- Family stability
- The pattern of caring child
- Economy level
- Housing: cities against villages
- Minority group problem which covers prejudice and health facilities, education and welfare which are not appropriate
Detailed knowledge of the cause or causes of schizophrenia is lacking. Genetic factors are important in some (perhaps all) cases, but it is not yet clear which genes are deviant, how they contribute to pathophysiology, or whether the same or different genes are invilved in all cases that have a genetic etiology.
Other early influences, variously marked by gestational and birth complications and winter birth excess, must be involved in the causal pathways for schizophrenia, but the pathophysilogical mechanisms underlying the involvement of those factors are not yet know. Various versions of viral and immun theories of causation are plausible, but no virus or immune mechanis has yet been established as an etiological factors in schizophrenia.
For about a decade a cntral question underlying the investigation of etiology of schizophrenia has been whether schzophrenia ia a neurodevelopmental or neuropathological disorder. Is the causes of schizophrenia to be found in failure of the brain to develop nomally, or is it to be found in a disease process that alters a normally developed brain? Both causes, of course, may be true,for the schizophrenia syndrome probably represent more than one etiological and disease proses, and a developmental abnormality may increase the risk for subsequent disease pathogeneity. However, although there are sporadic reports of a disease process and subsequent neuropathological response, the preponderance of evidence is consistent with the hypothesis that schizophrenia is a neurodevelopmental disorder. The consistency with which the know data point to early deviations in the development of the central nervous system (CNS) has been useful in focusing theory and investigative work.
Increasing information on the neurobiology of brain development has led to considerable new knowledge of the mechanism of pathogenic influences. It is now clear taht subtle deviations in brain development could create dysfunctions associated with specific behaviors. Postmortem findings of abnomalities in pyramidal cell density and aligment, although not always replicated, support the proposition that the developmental process of cell migration underlying the establishment of normal brain cytoarchitecture may go awryin schizophrenia. Alternatively, it is known that the braiin has extensive redundancy during the developing years, and that the fine-tuning necessary for efficient funtioning involves eliminating certain nerve cells and many of the synapses connecting cells. Inadequate pruning of nerve cells and synapses or errors in selection for pruning could, in theory, underlie dysfunctions that later lead to schizophrenia symptoms.Principal hypothese regarding causesation include the altered expression of genes, neoroimmunovirology factors, and hypoxic damage during gestation and birth.
As indicated by the assessment, a person with schizophrenia may have a variety of symptoms. Although there may be many clients on a unit with schizophrenia, each may present with different personal needs and defensive behaviors. Each client requires a nursing care plan that reflects individual needs and strategies appropriate to the client’s behaviors and level of functioning. Some nursing diagnoses that are appropriate to nurses’ work with schizophrenic clients are discussed.
During the course of schizophrenia, a client is likely to experience positive (hallucinations, delusions) and negative (withdrawal, poor social functioning) symptoms. During this time, impairment in thought processes may be evident in the client’s ability to reason, problem-solve, make decisions, and concentrate. These distortions alter the client’s ability to perceive reality accurately (hallucinations or delusions) and usually impair the client’s judgment. A nursing diagnosis of altered thought process is appropriate. Altered thought process may be related to alteration in biochemical compounds, panic, levels of anxiety, emotional trauma, and so forth.
With alteration in thought process come changes in language and speech. Therefore, impaired verbal communication may be a problem to varying degrees. When looseness of communicate needs or feelings. The nurse interacts in a variety of ways to try to understand and help reduce the client’s anxiety. Use of neologisms, echolalia, clang associations, and word salad contribute to the client’s impaired verbal communication.
When a person is unable to interpret the world accurately his or her ability to cope with environment is also impaired. Therefore, ineffective individual coping is most always present. A person’s ineffective individual coping may be evidenced by inappropriate use of defenses mechanisms and inability to meet role expectations. Symptoms may include withdrawal or excitability, disorganized or regressive behaviors, paranoid or disorganized thinking, and inability to meet basic needs.
A person who is extremely paranoid may have special problems. For example, if the person is refusing to eat because he or she thinks the food is poisoned then altered nutrition: less than body requirements is used.
“Voices” that tell the person to harm others or himself or herself can result in bodily harm or even death to the client or others. High risk for violence directed at others or self-directed would take priority (refer to section on paranoia).
During the excited phase of catatonia, a client may be highly agitated and can exhaust himself or herself to a dangerous level if rest and high-calorie fluid replacement are not immediately provided. Extreme hyperactivity can lead to cardiac or respiratory collapse and indicates a nursing diagnosis of activity intolerance.
During extreme withdrawal, attention to physical care is vital. Some useful nursing diagnoses might be (1) constipation/incontinence, (2) impaired physical mobility, or (3) self-care deficit: feeding, bathing, dressing/grooming, and toileting.
When the disease becomes chronic, it is not uncommon to note multiple admissions to a unit. Problems with compliance with medications is thought to be a major factor. Families with schizophrenic members may have their own confused patterns of communication and insufficient knowledge of the client’s problems or may feel powerless in coping with the client at home. Ineffective family coping: compromised or disabling may be an important area for intervention by members of the health care team, especially in relation to discharge planning.
Most people with schizophrenia suffer from a low self-concept. There is often confusion of sexual identity, as well as unrealistic and confuses the person’s perception of body image. Disturbance in self-esteem is usually present.
PlanningPlanning involves more than the identification of measurable and attainable goals. Identification of personal reactions and feelings regarding the client is necessary if the interventions in the nursing care plan are to be carried out effectively. Therefore, planning involves (1) content level-planning goals and (2) process level-nurses’ reactions and feelings.
Content Level – Planning Goals
It is important that goals be both meaningful and attainable by nursing action. The goals are usually directed toward the “related to” component of the nursing diagnosis. Therefore, altered thought process related to isolation and altered thought process related to unclear communications would have different short term and long term goals. The goals listed subsequently are offered as examples and guidelines for nursing actions.
Altered thought process related to panic levels of anxiety, as evidenced by hallucinations or delusions (positive symptoms).
Long and Short Term Goals
- By (date), client will go from panic to severe levels of anxiety with the aid of medication and nursing intervention.
- Client will meet with nurse once a day for 15 minutes in an activity in which the client feels comfortable.
- By (date), client will state that “the voices” or “the thoughts” are less frequent with the aid of medication and nursing intervention.
- By (date), client will engage in one unit activity per day that provides reality testing.
- By (date), client will identify personal interventions that lower hallucinations.
- By (date), client will talk about concrete happenings without talking about delusions or hallucinations for short periods.
- By (date), client will make needs and wants clearer with the aid of medication and nursing interventions.
Ineffective individual coping related to lack of motivation to respond, as evidenced by alteration in social participation (negative symptoms).
Long and Short Term Goals
- By (date), client will meet with nurse for 10 minutes two times a day in a activity in which the client feels safe
- By (date), client will meet with the nurse and one other client in a simple activity
- Client will sate that he or she feels more comfortable with nurse by (date)
- Client will sate that he or she feels more comfortable with one other client or staff member by (date)
- Client will attend one simple group activity each day by (date).
High risk for violence directed at others related to misperceived messages from others, as evidenced by persecutory delusions and hallucinations.
Long and Short Term Goals
- By (date), client will state that the voices are less angry, with the aid of medication.
- By (date), client will identify helping behaviors of nurses and staff.
- Client will join the nurse for one activity per day in which he states that he feels safe.
- By (date), client will state that he feels safe on the unit with the staff.
Activity intolerance related to extreme physical activity, as evidenced by constant physical agitation and increased respiration and pulse
Long and Short Term Goals
- Client will decrease high levels of agitation within 20 minutes after intramuscular medication is administered.
- Client will take 8 ounces of a high-calorie fluid every 30 minutes.
- Client will have five-minute rest periods every 30 minutes.
Process Level – Nurses’ Reactions and Feelings
Working with individuals diagnosed as schizophrenic is bound to bring up strong emotional reactions from health care worker. The psychotic client is intensely anxious, lonely, dependent, and distrustful. The intensity of these emotions can stir up intense, uncomfortable, and frightening emotions in all health care workers. The identification of transference and countertransference phenomena is an important part of the work of the therapeutic process.
If personal countertransferential reactions are ignored by the nurse, feelings of helplessness follow increased feelings of helplessness escalate anxiety. Without the support, opportunity, and willingness to explore these reactions with more experienced nursing staff, defensive behaviors emerge. Defensive behaviors in the nurse, such as denial, withdrawal, and avoidance, thwart the client’s progress and undermine the nurse’s self-esteem. These behaviors are associated with staff burnout. Statements such as “These clients are hopeless”, “You can’t understand these people.” and “You waste your time with them” are examples of unexamined or unrecognized emotional reactions to client’s behaviors or feelings.
For new nurses introduced into the psychiatric setting, especially for student nurses, the availability of supportive supervision is a must if learning is to take place. The student’s part in the supervisory process is a willingness to discuss and identify personal feelings as well as to identify problem behaviors. This can be and often is done in group supervision. Experienced psychiatric nurses call this process peer group supervision.
Individual supervision provides the greatest opportunity for a better understanding of the interpersonal issues involved in establishing a working relationship with the client. Individual supervision can increase the learner’s understanding of the client and the client’s situation, competence with therapeutic skills, and self-confidence. Unfortunately, many schools of nursing do not have the time or faculty to provide this learning opportunity for students. Some psychiatric settings encourage the practice of supervision and provide time and personnel for psychiatric nurses and other staff.
Kahn (1984) identifies three strong tree strong transferences on the part of schizophrenic clients that can trigger equally strong counterstransference reactions among mental health care workers. These three transferences are (1) the dependent transference, (2) the angry transference and (3) the eroticized transference. These issues are best dealt with during supervision. During this time, the transference phenomena are identified, personal reactions of the nurse are explored, and appropriate intervention strategies are suggested and evaluated.
For example, in dealing with dependency issues, decisions need to be made about when to gratify modest dependency needs without hindering the development of the client’s autonomy. What feelings does the nurse experience in relationship to the client’s exhaustive dependency needs? Which responses are rational and which irrational? Do the irrational feelings toward the client block effective therapeutic work?
During supervision of the angry transference feelings, the nurse learn to inhibit the urge to act on angry personal responses, to provide alternative experiences for the client to deal with anger, and to understand the function the anger serves for the client (e.g., maintaining distance).
Eroticized transference may be anxiety producing to both the client and the nurse. Supervision may explore with the nurse-clinician ways for setting clear limits while maintaining effective contact with the client (Kahn 1984).
Menninger (1984) discusses the extreme frustration that staff have with the slow progress of schizophrenic clients. This sense of frustration and feelings of helplessness can lead to burnout. Periodic reassessment of treatment goals and scaling down of expectations can benefit both staff and client.These are some but by ni means all of the kinds of issues that may surface in dealing with a schizophrenic client. Clinical practice with adequate supervision increases the nurse’s skills, lowers personal anxiety, increases confidence, and can improve the quality of interpersonal relationships with clients as well as relationships with others.
The detrimental effect of stress on a schizophrenic person’s environment has been long observed by clinicians. Environmental stress can result in an exacerbation of schizophrenic symptoms. Much of the work with schizophrenic clients involves decreasing waxing levels of environmental stress, thereby lowering the client’s level of anxiety and improving the client’s perceptions and adaptive responses lowered anxiety levels can decrease the intensity of schizophrenic symptoms and make the client more amenable to engagement in activities and relationships with health professionals, improved family interactions, and involvement in nonthreatening activities. Lowered anxiety levels make it possible for all people, including people with schizophrenia, to define problems and focus on issues.For planning interventions, it is important not to overlook the adaptive skills of a psychotic client. Attention should bi given to the client’s assets and healthy functioning as well as to areas of deficiencies.
Therapeutic strategies for working with schizophrenic clients often involve interventions that address specific behaviors. Psychotherapeutic interventions are aimed at lowering the client’s anxiety, decreasing defensive patterns, encouraging participation in the environment and raising the client’s level of self- esteem. Refer strategies for paranoid, withdrawn, excitable, and regressed behaviors.
All nurses should be familiar with the principles of dealing with phenomena that are certain to arise with most schizophrenic clients. These are the phenomena of (1) hallucination, (2) delusion, and (3) looseness of association.
HALLUCINATION. Understanding the process of hallucinations offers useful guidelines for working with clients who are actively hallucinating. The hallucinatory process starts out in a painfully lonely and isolated person under stress. Hallucinations are a means to allay the terrorizing feelings of alienation and the resulting panic levels of anxiety.
Voices are the most are the most common hallucinatory experience reported by schizophrenic clients. It is important initially to understand what the voices are saying or telling the person to do. The presence of suicidal or homicidal messages indicates priority measures for all members of the health care team.
Peplau believes that an important perspective for nurses to have when working with a client who is hallucinating is to view hallucinations as evidence that loneliness might be a problem. Though hallucinations significant human contact is being sought (Smoyak 1994). The nurse might ask, “What is going on right now?” and follow up with dialogue that “keeps clear that what the person is experiencing can be differentiated from what others see and hear” (Smoyak 1994).
When the client is asked to give up something important, no matter how maladaptive, something more adaptive and useful should be available to take its place, namely, receptive and interested people in the client’s environment. Establishing a relationship that minimizes anxiety and is built on honesty, consistency of care, and genuine concern for the client is an important first step. Moller (1989) has outlined 12 steps nurses can take when working with a hallucinating client. These are part of a process that progresses over time and is shared with the hallucinating individual. Moller cautions that nurse may become frustrated at times, and is to be expected.
DELUSIONS. Delusions are a result of misperception of cognitive stimuli. It is useful if the nurse attempts to see the world as it appears through the eyes of client. In that way, the nurse can better understand the client’s delusional experience. For example
CLIENT:You people all alike …. All in on the CIA plot to destroy me.
NURSE :I do not want to hurt you, Tom. Thinking that people are out to destroy you must be very frightening.
First, the nurse clarifies the reality of his or her intent. Second, the nurse empathizes with the client’s apparent experience, the feelings of fear. The nurse does not get drawn into the conversation regarding the content of the delusion (CIA and plot to destroy) but looks for the feelings the person may be experiencing. Talking about the client’s feeling experience can be useful for the client; talking about delusional material is not.
It is not useful to argue with the client regarding the content of the delusion. Doing so can intensify the client’s retention of irrational beliefs. Although the nurse does not argue with the client’s delusions, clarifying misinterpretations of the environment is useful. For example :
CLIENT : I see the doctor is here, and he is out to get me and destroy me.
NURSE : It is true the doctor wants to see you, but he wants to talk to you about your treatment. Would you feel more comfortable talking to him in the day room?
Interacting with the client on concrete realities in the environment can be useful in minimizing the client’s time spent with delusional ruminations. Specific manual tasks within the scope of the client’s abilities can often be useful as distractions from delusional thinking. The more time the client spends with reality-based activities or people, the more opportunity the client has to learn to be more comfortable with reality.
LOOSENESS OF ASSOCIATION. Looseness of association often mirrors the client’s autistic thoughts. The client’s autistic and disorganized ramblings may leave the nurse confused and frustrated. Increase in the client’s autistic speech patterns can indicate increased anxiety on the part of the client and reflect his or her difficulty responding to internal and external stimuli.
Decoding is a term used for interpreting the meaning of autistic communications. Decoding is not always possible, but when it is possible, it can help in understanding the client’s experience and needs.
The following guidelines may be useful for spending time with a client whose speech is confused and disorganized :
- Do not pretend you understand the client’s communications when you are confused by the client’s words or meanings.
- Tell the client you are having difficulty understanding his or her communications.
- place the difficulty in understanding on yourself, not the client. For example, say “ I am having trouble following what you are saying,” not “ You are not making any sense.”
- Look for recurring topics and themes in the client’s communications. For example, “You’ve mentioned trouble with your brother several times. I guess your relationship with your brother is on your mind.”
- When understanding the client’s autistic communications is not possible, just listening to and being accepting of the client can be meaningful.
- Emphasize what is going on in the client’s immediate environment (here-and-now) and involve the client in simple reality-based activities. These measures can help the client better focus his or her thoughts.
- tell the client what you do understand and reinforce clear communication and accurate expression of needs, feelings, and thought.
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- Kaplan, Sadock, B. 1995. Comprehensive Text Book of Psychiatry. 6th ed,vol 1. Maryland: William & Wilkins.
- Kozier, Barbara. 1979. Fundamental of Nursing. California: Wesley Publishing Company.
- M Varcarolis, Elizabeth. 1994. Foundations of Psychiatric: Mental Health Nursing. Philadelphia: W.B Sounders Company
- Yosep, Iyus. 2009. Keperawatan Jiwa Edisi Revisi. Bandung: Refika Aditama.