Undifferentiated Schizophrenia

By MICHAEL BENGSTON, M.D.

The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes. The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome. How Is It Diagnosed? Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it depends on establishing the slowly progressive development of the characteristic negative symptoms of schizophrenia without any history of hallucinations, delusions, or other manifestations of an earlier psychotic episode, and with significant changes in personal behaviour, manifest as a marked loss of interest, idleness, and social withdrawal.

When a person is exhibiting symptoms which meet many of the symptoms of schizophrenia, but does not fully or clearly fit one of the other types of schizophrenia (paranoid, catatonic, disorganized or residual), then s/he is given a diagnosis of undifferentiated schizophrenia.

Symptoms and Diagnosis

The person with this type of schizophrenia must have at least two or more of the following symptoms: Delusions Firmly held beliefs which are not based in reality, and are maintained despite evidence which disproves the belief or even when practically no one else ascribes to the same belief Hallucinations Seeing or hearing or otherwise sensing things which arent really there Disorganized speech Person cant stay on one topic, gives irrelevant responses, or his/her words make no sense at all Extremely disorganized or catatonic behavior Extremely unkempt appearance, bizarre dress, unresponsive to his/her surroundings, rigid posture, or exhibits bizarre or overly excited movements Negative symptoms

Examples of negative symptoms as lack of emotional expression or response, or significantly impaired thinking, or is unable to initiate or carry out basic tasks) Also, these symptoms must be present for at least one month, unless the person was treated successfully before the end of a one month period. According to the DSM-IV, the person needs to meet only one (rather than two) of the above criterion when:
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Delusions are bizarre. Bizarre delusions would involve a belief which is completely implausible, such as believing that an alien surgically removed the persons heart and put another one inside the persons body in its place. The patient is hearing at least two voices talking to each other, or is hearing a voice which is giving an ongoing commentary on the persons activities or thoughts.

Additional Diagnostic Criteria

In order to meet the diagnosis of schizophrenia, regardless of the type, these other criteria must also be met:
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A marked decline in functioning, after the onset of symptoms, in at least one of the primary aspects of the persons life (e.g., work, school, relationships, self-care). Signs of the disorder are present continuously for a period of at least 6 months. For at least one month of that time period (less if they subside due to effective treatment), the active-phase symptoms (e.g. delusions,hallucinations, extremely disorganized behavior, etc.) must be present. Schizoaffective disorder (a disorder similar to schizophrenia but with prominent mood episodes) or other mood disorder have been ruled out. In the other types of schizophrenia, at least one of the above symptoms is very prominent. But in undifferentiated schizophrenia, none are prominent. However, as with all the types, it is possible that at a different point in time the individual will meet the criteria for one of the other types.

INTRODUCTION: Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The symptoms of schizophrenia are categorized into two major categories, the positive or hard symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication treatment can control the positive symptoms but frequently the negative symptoms persist after positive symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to recovery and improved the functioning of clients daily life. TYPES OF SCHIZOPHRENIA: The diagnosis is made according to the clients predominant symptoms:

Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive behavior. Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social

   

withdrawal, flat affect and looseness of associations. ANATOMY AND PHYSIOLOGY: Structure and function of the nervous system I. Structures A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements. 1. The CNS is composed of the brain and spinal cord. 2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. 3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia. B. The brain is covered by three membranes. 1. The dura matter is a fibrous, connective tissue structure containing several blood vessels. 2. The arachnoid membrane is a delicate serous membrane. 3. The pia matter is a vascular membrane. C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral. D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter. It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid membrane. II. Function

A. CNS 1. Brain a The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and right) and four lobes, each with specific functions. i The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses. ii The temporal lobe is the center for taste, hearing and smell, and in the brains dominant hemisphere, the center for interpreting spoken language.

iii The parietal lobe coordinates and interprets sensory information from the opposite side of the body. iv The occipital lobe interprets visual stimuli.

b The thalamus further organizes cerebral function by transmitting impulses to and from the cerebrum. It also is responsible for primitive emotional responses, such as fear, and for distinguishing between pleasant and unpleasant stimuli. c Lying beneath the thalamus, the hypothalamus is an automatic center that regulates blood pressure, temperature, libido, appetite, breathing, sleeping patterns, and peripheral nerve discharges associated with certain behavior and emotional expression. It also helps control pituitary secretion and stress reactions. d The cerebellum or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.

e The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord. 2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control. B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord. C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions. 1. The sympathetic nervous system serves as an emergency preparedness system, the flight-for-fight response. Sympathetic impulses increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic stimuli are mediated by norepinephrine. 2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic impulses are mediated by acetylcholine. III. Differences in nervous system response. The nervous system is one of the first systems to form in utero, but one of the last systems to develop during childhood. A. Accuracy and completeness of the neurologic assessment is limited by the childs development. B. The childs brain constantly undergoes organization in function and myelinization. Therefore, the full impact of insult may not be immediately apparent and may take years to manifest. C. The peripheral nerves are not fully myelinated at birth. As myelinization progresses, so does the childs fine motor control and coordination. D. Early signs of increased intracranial pressure (ICP) may not be apparent in infants because open sutures and fontanelles compensate to a limited extent. E. The development of handedness before 1 year of age may signify a neurologic lesion.

F. Several primitive reflexes are present at birth, disappearing by 1 year of age. Absence, persistence, or asymmetry of reflexes may indicate pathology. G. The spinal cord ends at 13 in the neonate, instead of L1-L2 where it terminates in the adult. This affects the site of lumbar puncture. H. Children have 65 to 140 ml of CSF compared to 90 to 150 ml in the adult. PATHOPHYISOLOGY DIAGNOSTIC TEST: 1. Clinical diagnosis is developed on historical information and thorough mental status examination. 2. No laboratory findings have been identified that are diagnostic of schizophrenia. 3. Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC, urinalysis, liver function tests, thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an inherited disease, wilsons disease, in which the body retains excessive amounts of copper), PET scan, CT scan, and MRI. Rating scale assessment:

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Scale for the assessment of negative symptoms. Scale for the assessment of positive symptoms. Brief psychiatric rating scale TREATMENTS AND MEDICATIONS: Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early diagnosis and, appropriate pharmacological and psycho-social treatments. Hospitalization may be required to stabilize ill persons during an acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment plan that will minimize symptoms and maximize quality of life. A comprehensive treatment program can include:  Antipsychotic medication  Education & support, for both ill individuals and families  Social skills training  Rehabilitation to improve activities of daily living  Vocational and recreational support  Cognitive therapy Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode has passed, most people with schizophrenia will need to take medicine indefinitely. This is because vulnerability to psychosis doesnt go away, even though some or all of the symptoms do. In North America, atypical or second generation antipsychotic medications are the most widely used. However, there are many first-generation antipsychotic medications available that may still be prescribed. A doctor will prescribe the medication that is the most effective for the ill individual Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they can help ill individuals effectively manage their disorder. Talking with your treatment team will ensure you are aware of all available programs and medications. In addition, persons living with schizophrenia may have access to or qualify for income support programs/initiatives, supportive housing, and/or skills development programs, designed to promote integration and recovery. NURSING INTERVENTIONS: Strengthening differentiation  Provide patient with honest and consistent feedback in a non threatening manner.  Avoid challenging the content of patients behavior  Focus interactions on patients behavior.  Administer drugs as prescribed while monitoring and documenting patients response to drug regimen.

  

Use simple and clear language when speaking with the patient. Explain all procedures, test and activities to patient before starting them Promoting socialization

 

     

Encourage patient to talk about feelings in the context of a trusting, supportive relationship. Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions. Use supportive, emphatic approach to focus on patients feelings about troubling events or conflicts. Provide opportunities for socialization and encourage participation in group activities.

Be aware of personal space and use touch judiciously. Help patient to identify behaviors that alienate significant others and family members. Ensuring safety:  Monitor patient for behaviors that indicate increased anxiety and agitation.

     

Collaborate patient to identify anxious behaviors as well as causes. Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers. Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury. Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action. Frequently monitor the patient within guidelines of facilitys policy on restrictive devices and assess the patients level of agitation. When patients level of agitation begins to decrease and self control regained, establish a behavioral agreement that identifies specific behaviors that indicate self control against are escalation agitation.