Care of the Patient with Schizophrenia

Mary is a patient assigned to you today. You are told that Mary has schizophrenia and is hearing voices today. The nurse asks that you spend extra time with Mary because she has been wandering the halls into other patient rooms. You tentatively approach Mary and introduce yourself. You notice that Mary has on dirty, wrinkled clothes and has not eaten her breakfast yet. She is talking to the wall like there is someone there. She even reaches over and appears to touch someone. Although you talk to her, Mary does not look at or respond to you. The nurse also asks that you monitor her output and get her to bathe today. You wonder what you are going to do with Mary.

John is a 46-year-old male with a long history of psychosis. He is currently a resident at the facility where you work. The patient has refused to eat and take his medication for the last week. The patient states, “The spies have contaminated the food and medication.” The patient goes on to say, “God spoke to me and told me not to eat or take my medication because it is poison.” You notice that John does not show emotion when he speaks, and his eyes mostly look at the floor. He has a strong body odor, and his clothes are very dirty. He is very distracted, frequently stops talking, and looks toward the end of the room with a frightened look on his face. What will you do with John?

Schizophrenia is a devastating disease that affects how the patient thinks, acts, and feels. People with schizophrenia often have trouble telling the difference between what is real and what is imaginary. It is not a split personality or multiple personalities. Patients with this diagnosis have a brain disorder that causes them to experience and react to the world differently. People with schizophrenia are often stigmatized as being violent or crazy. However, some statistics show that those diagnosed with schizophrenia are no more violent than the average population (Halter, 2022).

Schizophrenia Definition

Schizophrenia is more common in males than in females and affects about 1% of the American population (National Alliance on Mental Illness [NAMI], 2015). The average onset of the disease for men is in their early 20’s and for women in their late 20’s or early 30’s. Although uncommon in children, the disease can be seen in approximately one in every 40,000 children (Halter, 2022).

German psychiatrist Emil Kraepelin was the first to recognize this illness in 1887 (Burton, 2020). He recognized this form of psychosis as being different from psychosis that appears in mood disorders. He called the disease “dementia praecox” and believed that it only occurred in young people (Burton, 2020). However, documentation of an illness with symptoms much like schizophrenia has been discovered in Egypt dating back to 1550 BC. Interestingly, archeologists have found Stone Age skulls with holes drilled into them, perhaps to let the evil spirits out. Kraepelin’s classification of schizophrenia and other diseases has been the basis for the classifications of mental disorders we use today for the International Classification of Diseases, Tenth Revision (ICD-10), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Additionally, Eugen Bleuler was the first to call the disease schizophrenia (Halter, 2022). Bleuler believed, contrary to Kraepelin’s belief, that the disease led to mental deterioration and that schizophrenia led to heightened experiences and memories (Burton, 2020). He was also the first to view schizophrenia as a group of disorders, with the most noticeable symptoms being what he called a ‘loosening’ of thoughts and feelings (Burton, 2020). Bleuler’s fundamental signs of schizophrenia are still used today and are called the four A’s (Halter, 2022):

1. Affect- Normal feelings or emotions that can be seen on a person’s face. In Schizophrenia, there are no visible feelings. The patient is said to have a flat or blunt affect.
2. Associative looseness – This is a disorganized thought pattern. Disorganized thought patterns can be seen as mixed-up or illogical words and the inability to think logically.
3. Autism – This refers to the person being in their own world. It is evidenced by delusions, hallucinations, or making up words that only have meaning to the patient.
4. Ambivalence – Two emotions, attitudes, or ideas are present that conflict with each other. The patient may state they want the hallucinations to stop but refuse to take medications due to paranoia.

The causes of schizophrenia are unclear. Researchers believe that the disease can be inherited and may be triggered by the environment, viral infections, stress, or a combination of these that affect how the brain works (Halter, 2022), particularly how the brain uses chemicals or neurotransmitters. Scientists believe there is an imbalance in the brain of the chemicals serotonin and dopamine, also called neurotransmitters (Halter, 2022). These neurotransmitters cause nerve cells to send messages through the brain that tell the person how to feel, act, or respond to stimuli. Normally, a person can respond to words, music, or thoughts rationally because of these neurotransmitters. However, someone with schizophrenia may misinterpret stimuli such as music or words and react differently because they understand it differently. The misinterpretation of the environment or thoughts may lead to a response of hallucinations, delusions, or paranoia. Understanding these responses, why they may occur, and how to care for the patient is important.

Schizophrenia has a predictable pattern or phases. Symptoms are further classified into positive, negative, cognitive, and affective. Positive symptoms may or may not be present, such as hallucinations or delusions. Negative symptoms are behaviors that should be present but are not, such as motivation or thought processes. Cognitive symptoms are unusual thinking patterns. Affective symptoms describe emotions and expressions (Halter, 2022). According to the DSM-5, the patient must have at least two symptoms for one month in a six-month time period (Nussbaum, 2013).

The symptoms in each phase can vary in length and acuity (American Psychiatric Association [APA], 2006). The phases are as follows (Halter, 2022; Holland, 2019):

• The prodromal phase usually occurs in teens and features social deficits such as decreases in school performance. There may be changes in the thought process, such as bizarre ideas. The patient may exhibit social isolation when they were once very outgoing. The signs can be very subtle in this stage.
• The acute phase is the onset of the disease. Symptoms are present and active. The symptoms may include hallucinations, delusions, withdrawal, or any other symptoms associated with the disorder. The patient is usually hospitalized and treated.
• The stabilization phase is the patient’s return to a more normal function. Symptoms begin to subside when treated and become manageable. The patient may be placed in a day program or a residential facility.
• The maintenance phase is the return to a baseline function. Note that patients may never return to pre-schizophrenic diagnosis function. They can function on their own with minimal help. They are, however, on lifelong medication treatments.

The patient with schizophrenia suffers from impairments in thinking or cognitive functions. Along with hallucinations, delusions, and paranoia, it is important to remember that this patient may not be able to respond or communicate appropriately. Speech may not be understandable, and they may not interact normally.

Understanding and patience are the most important characteristics of caring for this person. Hallucinations, delusions, and paranoia are scary for them. Good communication is very important. Do not pretend to see or hear the person’s hallucinations. Likewise, do not agree with the delusions or the paranoia. Finally, do not try to convince the patient that what they are experiencing is not real. To them, it is real. Speak slowly and calmly. Be careful about touching the person; this may upset them more (Halter, 2022; Sorrentino & Remmert, 2014). Stating, “I know that the voices are real to you; I do not hear them,” allows the caregiver to be honest and may help the patient accept that the voices are not real; this allows the patient to gain control over the hallucination (Townsend, 2015; Halter, 2022).

Communicating with the patient may be difficult because they can mix up words or develop their own language. Remember, the patient thinks you can understand them. Orienting the patient to reality by using their name and validating any part of the conversation you understand is important. Try to decode the conversation by anticipating their needs. Clarifying what the patient is trying to tell you by stating, “I am not sure what you mean,” or “I am not sure what you are trying to tell me. Can you try to explain it to me again, please?” (Halter, 2022). Notice that the responsibility for understanding the patient is placed on the caregiver; this helps the patient understand how they are being perceived and alleviates any anxiety or blame for the patient. The patient may also exhibit concrete thinking or literal thinking. Avoid using abstract phrases or clichés such as “the early bird gets the worm;” the patient can misinterpret this (Townsend, 2015).

Asking if the patient is hearing voices can be an early intervention. If the patient is experiencing hallucinations, report your observations to the nurse. Also, observe for any trigger in the environment that can be removed. The patient may be laughing to themselves, talking to themselves, shifting eyes around the room, or staring at a particular area (Townsend, 2015). Participating in activities can help decrease social withdrawal and inappropriate behaviors and increase motivation (Halter, 2022). Remember that the activity has to be within the patient’s functioning level. Some activities to consider are drawing, reading, listening to music, or walking. These are activities in the “here and now” (Halter, 2022). Keeping the patient focused on reality-based activities is important in helping them cope with these symptoms.

Likewise, when a patient experiences delusions, it is important to focus on reality. It is okay to ask about the delusion to obtain assessment information for the nurse; however, do not argue or deny the belief (Mason et al., 2014). The patient may be using delusions as an attempt to understand their environment (Halter, 2022). If the patient is suspicious, attempt to promote trust by using the same staff and being honest with the patient. Activities should be more one-to-one for a suspicious patient.

Furthermore, the patient may believe their food is poisoned or controlled (Townsend, 2015). Offer food they can open themselves with supervision or allow them to choose between actions so they feel some control over their environment. The patient may also become agitated or anxious. Offer empathy, such as “You seem anxious. How can I help you?” This offers validation of the patient’s feelings and reinforces trust (Townsend, 2015).

Another important aspect of care is the nonverbal communication of the caregiver. Nonverbal communication involves tone of voice, stance, eye contact, facial expressions, and movements. When interacting with the patient, be sure to face the person, maintain eye contact, stand near the person (but not too close), and try to position yourself at the patient’s level; facial expressions should show your interest or concern, and you should speak slowly and calmly (Townsend, 2015). It is also important to remember that patients with schizophrenia can have difficulty with memory. Repeating steps or phrases several times may be required (Halter, 2022). Also, this patient can react quickly to increased stimuli. It may be necessary to keep sessions or groups shorter. Interactions and communication should help the patient to feel more comfortable and reduce symptoms.

If the patient becomes agitated, the caregiver should take measures to protect themselves. When interacting with the patient, ensure the door is closer to you. You should have a clear escape route if needed. Call for help if needed. Never try to handle the situation yourself. Always be aware of your surroundings and understand how to recognize agitation or anxiety in the patient.

Any changes that are observed should be reported to the nurse. Report any abnormal behaviors, emotions, hallucinations, delusions, or disorganized thoughts. Also, note if there are issues with the patient’s safety, such as wandering or hearing voices telling them to hurt others or themselves. Report any triggers that seem to be causing the behavior or emotion. Some other observations to report are (Acello & Hegner, 2015):

• Is there another person involved, real or in a hallucination?
• What is the environment like? Lighting? Stimuli? What time of day is it?
• What is the behavior?
• Is there a pattern to the behavior? Same time of day? Same stimuli?
• What happens right before the behavior starts?

Additionally, it is important to report the following:

• Is the patient bathing and dressing themselves? Do they need help?
• Is the patient eating? Does the patient feed themselves or need help?
• Are bowel patterns regular?
• Does the patient sleep or nap?
• Does the patient participate in activities?
• How does the patient get along with others?

A lack of understanding of schizophrenia leads to poor care and mismanagement of patient symptoms. The caregiver should recognize symptoms of schizophrenia, including hallucinations, delusions, paranoia, or disorganized thoughts. Knowing what to expect from the patient and what triggers the symptoms is also important to care for the patient. The caregiver should recognize if the patient is agitated, anxious, or stressed. Further, knowing what can be done to help alleviate the patient’s discomfort is important. Offering involvement in activities is one way to help the patient. The family should also be involved when appropriate. The caregiver should help the family understand the disease and what strategies can be used to help the patient.

Working with this group of patients can be scary and uncomfortable for the healthcare worker. The patient may be slow to respond to treatment or care, making the caregiver feel helpless or angry (Caruso et al., 2013). Statements may be made such as “He will never get better.” or “Why bother? She doesn’t know what is happening anyway.” These feelings and statements are nontherapeutic and interfere with the patient’s care. It is important for the caregiver to recognize when they feel frustrated and talk to another staff member. Examining these feelings and developing other methods to cope and to help the patient may be necessary. Remember, the patient also feels helpless and may even be angry at their circumstance or may not recognize that they are ill (Halter, 2022).

The caregiver should attempt to recognize their own feelings. Studies have shown that when caregivers feel helpless or stressed when caring for patients, they can develop physical and psychological problems themselves (Tan et al., 2012). Furthermore, caregivers may get frustrated by the situation and quit their jobs. Additional training on how to cope and work with patients diagnosed with mental illness has been shown to be effective (Caruso et al., 2013). Some strategies to overcome feelings of helplessness and frustration when working with a patient who has schizophrenia are as follows (Halter, 2022):

• Use empathy. Empathy conveys trust and support. This also helps establish a therapeutic relationship.
• Realistic expectations. Realizing what the patient can and cannot do may help decrease the frustrations of caring for the patient.
• Understand the disease. Learning about how schizophrenia progresses, as well as what symptoms are involved, will help to decrease helplessness in staff.
• Learn how to respond to the patient. Patients who suffer from hallucinations, delusions, or other symptoms of schizophrenia may need to be approached and addressed differently. Learning how to respond can decrease stress and anxiety.

Recognizing feelings about taking care of a patient with schizophrenia can be an important step in helping the patient as well as the caregiver. Likewise, education on how to work with the patient in various stages of the disease can decrease feelings of helplessness.

Mary is diagnosed with schizophrenia and has been assigned to you for her care. First, Mary is hallucinating. You observe that Mary talks to the hallucination like a child. She is sitting down in the chair and does not appear agitated. You are sure she is safe and not becoming anxious. You want to notify the nurse and then try to distract Mary from her hallucination. You approach Mary so she can see you and crouch down to her eye level. Speaking slowly and calmly in an empathetic tone, you ask her if she would like to eat the new breakfast you brought for her. Once she has eaten and you have noted how much she has eaten, you ask her if she would like to wash up. You help her wash and get dressed. Mary begins to talk again to the person she believes is across from her. You suggest Mary go into the living room area where a drawing group has started. You know that getting Mary into the group to draw will distract her and help keep her in reality. At the end of your shift, you report what worked to help Mary and what stimuli in the area seemed to trigger her hallucination. You also report how well she ate, that she had regular bowels, and that she participated in the group.

John is suffering from auditory and visual hallucinations. It is important to tell the nurse what you have observed and any triggers that may have occurred prior to this episode. Also, ask the following questions: Did something happen? Did he have a visitor? What is in the environment? Did he sleep last night? You can try to distract John with an activity as long as you and he remain safe. You will want to stay on the same side of the room as where the door is so that your escape, if necessary, is not blocked. You will also want to report his eating habits over the last few days, as well as his appearance. Try to get him to wash himself and change without agitating him. You may need the help of the nurse to do so.

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