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Schizophrenia Pathology and Etiology

 Mental illness is
defined as suffering from the impaired ability to think, feel, make sound
judgements, or adapt. It is experiencing difficulty with or inability to cope
with reality and form strong personal relationships (Williams and Hopper, 2015,
p. 1342). The diagnosis of schizophrenia is a form of mental illness. It is now
being viewed as a group of disorders, rather than a single illness. According
to Williams and Hopper (2015), the term schizophrenia means “split-mind” and
was coined by Swiss psychiatrist Eugene Bleuler in 1911 (p.1368). Schizophrenia
is a serious brain disorder of thought and association. Patients are unable to
distinguish between what is reality and what is a hallucination or delusion. This,
paired with poor self-esteem, leads patients to have reduced socialization. Patients
with schizophrenia cannot focus on one topic for any period of time. This
disorder often begins during adolescence or early adulthood with a subtle onset
(Williams and Hopper, 2015, p.1368).

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Williams and Hopper (2015) found that there are four phases
of schizophrenia (p.1368). The first phase is the schizoid personality phase.
Patients are calm, aloof, and indifferent. They lack close relationships and
may be categorized as loners.  Not all
patients in this phase will progress into schizophrenia. The second phase is
known as the prodromal phase. Although sufferers will continue to be socially reserved,
they will start to show eccentric behavior. Patients often neglect their personal
hygiene in this phase. Communication, formation of ideas, and perception are also
disrupted. Phase three is the schizophrenia phase. This is the active phase, in
which patients experience psychotic symptoms that include hallucinations,
delusions, and impairment in self-care, socialization, and work. The last phase
is the residual phase. In this phase, patients will have a flat affect and
neglect their activities of daily living (Williams and Hopper, 2015, p1368).

Although schizophrenia is an idiopathic disorder, it is thought
to be a combination of neurobiological and environmental influences.  According to Williams and Hopper (2015), “patients
with a diagnosis of schizophrenia typically have elevated dopamine levels or a
brain that overreacts to the amount of dopamine present” (p.1369). An
underactivity in the excitatory neurotransmitter glutamate has also been linked
to schizophrenia. Other neurobiological factors showing a link to schizophrenia
are significant loss of gray matter in the brain and diminished prefrontal
cortex functioning. Environmental factors that have been found in the diagnosis
of schizophrenia are infections, substance abuse, and central nervous system
damage during childbirth (Williams and Hopper, 2015, p.1396).

Signs and Symptoms

There are both positive and negative symptoms of
schizophrenia. Positive symptoms are characterized by the presence of reality distortions.
An example of a reality distortion is the occurrence of delusions. In the book
Understanding Medical Surgical Nursing, Williams and Hopper describe delusions
as “fixed, false beliefs that cannot be changed by logic or factual proof”
(2015, p.1368). The patient can feel delusions of persecution or guilt, and believe
these delusions to be true. Williams and Hopper describe hallucinations,
another positive symptom, as “false sensory perceptions” that most often affect
hearing and vision, although any of the five senses can be affected. Patients
will see and hear people and things that no one else can see or hear. These
hallucinations are very real to the patient. Patients with schizophrenia may
experience misperceptions of reality (Williams and Hopper, 2015, p. 1368).

Negative symptoms of schizophrenia mean the patient has a deficiency
of normal, daily functioning. Patients may lack the initiative to complete
daily tasks, isolate themselves, display a flat affect, or even be unable to
speak. Patients are most incapacitated by these symptoms because they are
unable to continue living normally. Negative symptoms react best to atypical antipsychotic
medications (Williams and Hopper, 2015, p.1368).


A diagnosis of schizophrenia is made by collecting and
analyzing the patient’s health history and through a thorough psychiatric
evaluation (Williams and Hopper, 2015, p.1371). During this evaluation, a psychiatrist
will use the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5), which groups illnesses into
categories of clinical disorders, to diagnose (Williams and Hopper, 2015,
p.1343). A positron emission tomography scan, or PET scan, can be used for
diagnosis. A PET scan of the brain measures blood flow and metabolic processes.
In the case of schizophrenia, a PET scan will detect physiological changes in psychosis
(Van Leeuwen and Bladh, 2015, p.1258-1259). A fluorodeoxyglucose-positron
emission tomography scan, or FDG-PET scan, aid in the evaluation, staging, and
monitoring of metabolically active malignant lacerations in the brain, which
also will detect physiological changes in psychosis (Val Leeuwen and Bladh,
2015, p. 1262-1263).

Therapeutic Measures
for Schizophrenia


Schizophrenic patients will be prescribed medications such
as typical and atypical antipsychotics. These medications block dopamine
receptors in the brain (Williams and Hopper, 215, p. 1369). Atypical
antipsychotics have less adverse side effects than typical antipsychotics
(Vallerand, Sanoski, and Deglin, 2015, p. 54-55). Typical antipsychotic
medications effect the motor function tract of the brain which can cause
parkinsonism. Patients may be prescribed anticholinergic medications such as benztropine
and trihexyphenidyl to fight this (Williams and Hopper, 2015, p. 1369). Clozapine,
haloperidol, and phenothiazines are examples of typical antipsychotics
(Vallerand, Sanoski, and Deglin, 2015, p.54).  Clozapine attaches to dopamine receptors in
the central nervous system and blocks anti-cholinergic and alpha-adrenergic activity
to reduce schizophrenic and suicidal behavior (Vallerand, Sanoski, and Deglin,
2015, p.328). Haloperidol and phenothiazines modify the influence of dopamine
in the central nervous system, as well as block anti-cholinergic and
alpha-adrenergic activity to lessen symptoms of psychosis (Vallerand, Sanoski,
and Deglin, 2015, p. 303, 629).


Patients can attend psychotherapy to learn coping mechanisms
and social skills. Psychotherapy can also include the patient’s family, or
other patients with schizophrenia or like-mental illnesses. Therapy permits
patients to express their thoughts and feelings to clear their minds and feel a
sense of support. A peaceful and relaxing milieu for therapy can decrease the
patient’s feelings of anxiety. Group, individual, and family therapy will support
the patient’s social functioning in the community (Williams and Hopper, 2015,

Ms. B


            Ms. B is a 38-year-old patient
who stated she has been diagnosed with schizophrenia, depression, anxiety, borderline
personality disorder, and obsessive-compulsive disorder. She also stated that
she was a drug and alcohol abuser in the past. Upon assessment, her clothes
were clean, intact, and appropriate for the climate. Her hair was clean and
braided. While talking to me, Ms. B sat slouched down in her chair with one leg
propped up on another. She was fidgety and could not sit still. Ms. B
cooperated well with myself and other health care personnel. This patient was
alert and oriented to person, place, and time. Although she struggles from
flight of ideas, Ms. B could recall events from two weeks ago up to greater
than five years ago. The speed of the conversation did not stay at a consistent
rate. The patient used the appropriate volume when speaking. I did not observe
any stuttering, word repetition, or neologisms. Her facial expressions were
congruent with her mood. The patient’s mood did not fluctuate. Ms. B
demonstrated the ability to make sound decisions for herself by stating “when I
get out of here I want to get a job and an apartment to make a better life for
my daughter”. No evidence of hallucinations occurring during my time spent with
this patient. She was not able to recognize or have insight to the source of
her illness due to the deficiency of her prefrontal cortex functioning as a
result of her mental illness, schizophrenia (Williams and Hopper, 2015,

Functioning and Contributing Causes

Ms. B discussed with me her feelings of sadness, but also of
hopefulness. She explained to me she was sad because she had to be away from
her daughter. Ms. B has a nine-year-old daughter. Her daughter is currently
living with her parents. Ms. B is also hopeful to leave Laurelwood and start
over with a job and a new apartment to live in with her daughter. This patient
has many life stressors. These life stressors include being able to maintain a
job, providing for her daughter, moving out of her parents’ house, and the
constant wondering of when symptoms of her condition will arise again. She is
also a single mom. This has been a life stressor and contributing factor since
her daughter was born. Ms. B stated she used to be addicted to alcohol and
would use drugs occasionally. It is believed that patients with schizophrenia
turn to alcohol as a way of self-medication. I believe Ms. B was
self-medicating before she was diagnosed with schizophrenia.  Group therapy sessions taught Ms. B many
coping mechanisms to practice when she is out and on her own. Some coping
mechanisms she learned were journaling, exercising, counting to 100, and deep
breathing exercises. During our conversation, Ms. B continued to say, “thank
God”. This is a possible indicator of religious affiliation with the Christian church.
Ms. B may also turn to God and the church for guidance and support.

Discharge Planning

This patient will not need any specific dietary
modifications. She will need to be set up with a therapist she can go to close
to where she lives. Ms. B may want to consider both individual and group
therapy to avoid social isolation. She needs to appoint someone, like her
parents, to hold her accountable to keeping any therapy and doctors’
appointments she makes. Ms. B needs to set reminders to pick up her
prescriptions and take them as directed.


I enjoyed speaking with Ms. B. She was polite and pleasant
to talk to. I had to listen actively and ask questions to piece together her
story in order to understand it, due to her flight of ideas. This was an
eye-opening experience because some of these patients were within normal parameters
in appearance, which made it seem like they did not have a mental illness. It
made me think of how many people I pass on the street every day that look mentally
healthy, but could have a debilitating mental illness. It was heartbreaking to
think of the emotions these patients go through daily. After this clinical, I would
consider going into the mental health profession. There are many patients that
need medical help as well as someone to just listen to them. This experience
had a positive impact on my career even if I do not go into the mental health
field. It gave me the experience to care for patients in any setting that may
be suffering from a mental illness. 

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