Management Of Schizophrenia

This disorder is characterized by disturbances (for at least 6 months) in thought content and form, perception, affect, sense of self, volition, interpersonal relationships, and psychomotor behavior.
Treatment
With schizophrenia, treatment focuses on meeting the physical and psychosocial needs of the patient, based on his previous level of adjustment and his response to various interventions. 

Treatment may combine drug therapy, long-term psychotherapy for the patient and his family, psychosocial rehabilitation, vocational counseling, and the use of community resources.

Antipsychotics
The primary treatment for more than 30 years, antipsychotics (also called neuroleptic drugs) appear to work by blocking postsynaptic dopamine receptors. These drugs reduce the incidence of psychotic symptoms, such as hallucinations and delusions, and relieve anxiety and agitation.
Other psychiatric drugs, such as antidepressants and anxiolytics, may control associated signs and symptoms.
Certain antipsychotics are associated with numerous adverse reactions, some of which are irreversible. Most experts agree that patients who are withdrawn, isolated, or apathetic show little improvement after antipsychotic treatment.
Some antipsychotics are depot formulations that are implanted I.M. once or twice a week to once a month; this method allows gradual release of the drug.
Clozapine, which differs chemically from other antipsychotics, may be prescribed for severely ill patients who fail to respond to standard treatment. It effectively controls a wider range of psychotic signs and symptoms without the usual adverse effects. However, clozapine can cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, seizures, and agranulocytosis.
A potentially fatal blood disorder, agranulocytosis is characterized by a low white blood cell count and pronounced neutropenia. Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If caught in the early stages, this disorder is reversible.

Psychotherapy
Clinicians disagree about the effectiveness of psychotherapy in treating schizophrenia. Some consider it a useful adjunct to drug therapy.
Others suggest that psychosocial rehabilitation, education, and social skills training are more effective for chronic schizophrenia. Beside improving understanding of the disorder, these methods teach the patient and his family coping strategies, effective communication techniques, and social skills.
Because schizophrenia typically disrupts the family, family therapy may be helpful to reduce guilt and disappointment as well as improve acceptance of the patient and his bizarre behavior.

Special considerations

• Assess the patient’s ability to carry out activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn’t eating.
• If the patient thinks that his food is poisoned, let him fix his own food when possible or offer foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.
• Maintain a safe environment, minimizing stimuli. Administer prescribed medications to decrease symptoms and anxiety. Assess the patient’s capacity for self-harm as well as harm to others. Use physical restraints according to your facility’s policy to ensure the patient’s safety and that of others.
• Adopt an accepting and consistent approach with the patient. Short, repeated contacts are best until trust has been established.
• Avoid promoting dependence. Reward positive behavior to help the patient improve his level of functioning.
• Engage the patient in reality-oriented activities that involve human contact, such as inpatient social skills training groups, outpatient day care, and sheltered workshops.
• Provide reality-based explanations for distorted body images or hypo-chondriacal complaints. Explain to the patient that his private language, autistic inventions, or neologisms aren’t understood. Set limits on inappropriate behavior.
• If the patient is hallucinating, explore the content of the hallucinations. If he hears voices, find out whether he believes that he must do what they command. Explore the emotions connected with the hallucinations, but don’t argue about them. If possible, change the subject.
• Teach the patient techniques that interrupt the hallucinations (listening to an audiocassette player, singing out loud, or reading out loud).
• Don’t tease or joke with a schizophrenic patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who is told “That procedure will be done on the floor” may become frightened, thinking he’ll need to lie down on the floor.
• If the patient expresses suicidal thoughts, institute suicide precautions. Document his behavior and your actions.
• If the patient expresses homicidal thoughts (for example, “I have to kill my mother”), institute homicidal precautions. Notify appropriate facility personnel and the potential victim. Document the patient’s comments and the names of those who were notified.
• Don’t touch the patient without telling him first exactly what you’re going to do—for example, “I’m going to put this cuff on your arm so I can take your blood pressure.”
• If necessary, postpone procedures that require physical contact with facility personnel until the patient is less suspicious or agitated.
• Mobilize community resources to provide a support system for the patient. Ongoing support is essential to his mastery of social skills.
• Encourage compliance with the drug regimen to prevent a relapse. Also, monitor the patient carefully for adverse reactions to drug therapy, including drug-induced parkinsonism, acute dystonia, akathesia, tardive dys-kinesia, and malignant neuroleptic syndrome. Document all such reactions.
• Help the patient explore possible connections between anxiety and stress and the exacerbation of symptoms.

For catatonic schizophrenia:

• Assess the patient for physical illness. Remember that the mute patient won’t complain of pain or physical symptoms; if he’s in a bizarre posture, he’s at risk for pressure ulcers or decreased circulation to a body area.
• Meet the patient’s physical needs for adequate food, fluid, exercise, and elimination; provide urinary catheterization and enemas as needed.
• Provide range-of-motion exercises for the patient, or help him walk every 2 hours.
• Prevent physical exhaustion and injury during periods of hyperactivity.
• Tell the patient directly, specifically, and concisely which procedures need to be done. For example, you might say to the patient, “It’s time to go for a walk. Let’s go.” Don’t offer the negativistic patient a choice.
• Spend some time with the patient even if he’s mute and unresponsive. The patient is acutely aware of his environment even though he seems not to be. Your presence can be reassuring and supportive.
• Verbalize for the patient the message that his nonverbal behavior seems to convey; encourage him to do so as well.
• Offer reality orientation. You might say, “The leaves on the trees are turning colors and the air is cooler. It’s fall!” Emphasize reality in all contacts to reduce distorted perceptions.
• Stay alert for violent outbursts; if they occur, get help promptly to ensure the patient’s safety and your own.

For paranoid schizophrenia:

• When the patient is newly admitted, minimize his contact with the facility staff.
• Don’t crowd the patient physically or psychologically; he may strike out to protect himself.
• Be flexible; allow the patient some control. Approach him in a calm and unhurried manner. Let him talk about anything he wishes initially, but keep the conversation light and social, and avoid entering into power struggles.
• Respond to the patient’s condescending attitudes (arrogance, put-downs, sarcasm, or open hostility) with neutral remarks.
• Don’t let the patient put you on the defensive, and don’t take his remarks personally. If he tells you to leave him alone, do leave, but return soon. Brief contacts with the patient may be most useful at first.
• Don’t make attempts to combat the patient’s delusions with logic. Instead, respond to feelings, themes, or underlying needs—for example, “It seems you feel you’ve been treated unfairly” (persecution).
• Be honest and dependable. Don’t threaten the patient or make promises that you can’t fulfill.
• If the patient is taking clozapine, stress the importance of returning weekly to the facility or an outpatient setting to have his blood monitored.
• Teach the patient the importance of complying with the drug regimen. Tell him to report any adverse reactions instead of discontinuing the drug. If he takes a slow-release formulation, make sure that he understands when to return for his next dose.
• Involve the patient’s family in his treatment. Teach them how to recognize an impending relapse, and suggest ways to manage symptoms, such as tension, nervousness, insomnia, decreased ability to concentrate, and apathy.