Negative Symptoms and Progression of Schizophrenia (Nursing)

00:00 Now, let's think about the negative symptoms. These negative symptoms are a little bit more difficult to identify as being symptoms in schizophrenia. They have a very slow insidious onset and usually they are indicative of some chronic deterioration of this person. So for example, a negative symptom is apathy, when a person losses all interest and care about the things around them. Also anhedonia. When they can't find pleasure in things they used to find pleasure in taking the dog for a walk, having a really nice morning cup of coffee, suddenly nothing gives them pleasure anymore. They also might have alogy, which is poverty of speech. When you think of poverty of speech, it means minimalist. They don't want to use a lot of words, they will answer you with yes or with no and they won't give you a full answer. Also, avolition when they are not able to do any of the activities that they normally would do. Even if they want to start something, they can't start it because their energy level is so low and they just have no desire to be part of it. So, as we're thinking about these negative symptoms, also think about what other kinds of mental illnesses you might see some of these kinds of negative symptoms. Of course, in other places we're not calling them negative symptoms. In schizophrenia, they are 100% the negative symptoms of schizophrenia. So, we can look at the affect, the way the person is expressing their emotions. And, they might have an inappropriate affect. So, you want to have an affect that is congruous with your mood. You want to show people that you are happy and the way you do it is you smile, you tell people that you're happy, so your mood and your affect is congruous. But if you have incongruity, you might be like this and say "I'm so happy." Or you might be like this "Oh gosh, I'm so sad." Real incongruity of your emotions. You also might have this really flat or blunted affect. So, that's that blank stare. Someone comes over and says "Oh, I just had a baby" and your response is (nothing). That is a totally flat affect. Very very few facial expressions. Actually the muscles in the face seem to sort of like go flat and lax. Isolation. Now, isolation is one of those negative symptoms that at least if it's your family member or friend, you really want to be aware of when a person starts self-isolating, when they start withdrawing from the social environments that they once were a vibrant part of. And then, an affect that is really not logically connected to the situation, a bizarre affect, so that when they are in an environment that is really sad they might be laughing. Now, one of the things that I want to say about this is there is another syndrome and it's called bulbar affect dysregulation and that is not schizophrenia but it is when a person who is in a sad situation may turn into someone who giggles and laughs uncontrollably because they don't have control over that emotional response or they might start crying. So pseudobulbar affect is something to think about that you're not looking at schizophrenia, but pseudobulbar affect. And there are medications that people can take that help them with that, which is totally different from schizophrenia. So, before we go on to the progression of schizophrenia and the functional decline that we see, I hope that you're beginning to understand that because there are certain symptoms that are associated with schizophrenia, it doesn't mean that that means the person has schizophrenia. If you think of the symptoms, many of the symptoms of schizophrenia like you think of the symptoms of a common cold. So you have a little malaise, you might have a low grade fever, you're nose might be running, you might have a cough. Well, does that mean that you have a cold? Or does it mean that you have hay fever? Does it mean that maybe you are exposed to COVID? Does it mean that you have the flu? Does it mean that maybe you have the beginnings of the measles which often comes on as sort of flu-like symptoms? We don't know. And so when a person has some of these symptoms, we're not going to jump to the conclusion that that person probably has schizophrenia. What we're going to start doing is monitoring, assessing, being focused on what the person's need is and being able to come up with some nursing diagnoses that are going to keep that person safe and allow them to continuing functioning. So while we're thinking about the cognitive symptoms of schizophrenia, let's go back to Pat. You remember Pat? He came in to the emergency room with the parents, there were some auditory hallucinations going on and Pat was saying that he thought the grodimeres were coming for him, they were going to kill him. So, let's stop and think for a minute. What kind of symptoms is Pat showing there? Mom and dad said Pat was isolating himself. So, isolation is one of those negative symptoms. Correct? Withdrawing. Pat's not taking such good care, not washing. That's another negative symptom, a withdrawal and self-care deficit. But what else are we seeing? We're seeing that auditory hallucinations, we're seeing the neologisms, and so those are symptoms that we would be thinking that are the positive symptoms of schizophrenia. The idea of the lifelong little eccentricities, I don't think that that comes into play at this point.

07:01 It might be a footnote, but these are parents who are very concerned about Pat and it's important that we don't have judgment in what we're hearing, that someone might have missed some important heralding of medical disease or a psychiatric disease. Let us think about schizophrenia as a brain disease, and we can't see inside of the brain just like we can't see inside of the pancreas. And somebody might be more thirsty over the last week than they had been in their past, we're not going to say "Oh my God I missed the first signs the person may be having a problem with their pancreas and beginning having a need for insulin." I'm not looking at it as diabetes. We can't be looking at everything to try and put a label. Instead, we take it in as another factor.