immobility may be manifested by catalepsy
(waxy flexibility) or stupor. Excessive motor
activity is apparently purposeless and is not
influenced by external stimuli. Other features
include extreme negativism, mutism, pecu-
liarities of voluntary movement, echolalia,
and echopraxia.- Schizophrenia, undifferentiated type:char-
acterized by mixed schizophrenic symptoms
(of other types) along with disturbances of
thought, affect, and behavior - Schizophrenia, residual type:characterized
by at least one previous, though not a cur-
rent, episode; social withdrawal; flat affect;
and looseness of associations.
CLINICAL COURSE
Although the symptoms of schizophrenia are always
severe, the long-term course does not always involve
progressive deterioration. The clinical course varies
among clients.
Onset
Onset may be abrupt or insidious, but most clients
slowly and gradually develop signs and symptoms
such as social withdrawal, unusual behavior, loss of
interest in school or work, and neglected hygiene.
The diagnosis of schizophrenia usually is made when
the person begins to display more actively positive
symptoms of delusions, hallucinations, and disordered
thinking (psychosis). Regardless of when and how
the illness begins and the type of schizophrenia, con-
sequences for most clients and their families are
substantial and enduring.
When and how the illness develops seems to af-
fect the outcome. Age of onset appears to be an im-
portant factor in how well the client fares. Those who
develop the illness earlier show worse outcomes than
those who develop it later. Younger clients display a
poorer premorbid adjustment, more prominent neg-
ative signs, and greater cognitive impairment than
do older clients. Those who experience a gradual
onset of the disease (about 50%) tend to have both a
poorer immediate and long-term course than those
who experience an acute and sudden onset (Buchanan
& Carpenter, 2000). Approximately 30% of clients
with schizophrenia relapse within 1 year of an acute
episode; this figure doubles by the end of the second
year (Marland & Cash, 2001).Immediate Course
In the years immediately after the onset of psychotic
symptoms, two typical clinical patterns emerge. In
one pattern, the client experiences on-going psy-
chosis and never fully recovers, although symptoms
may shift in severity over time. In the other pattern,
the client experiences episodes of psychotic symp-
toms that alternate with episodes of relatively com-
plete recovery from the psychosis.298 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
Ricky was staying with his father for a few weeks on a
visit. During the first week, things had gone pretty well,
but Ricky forgot to take his medication for a few days.
His father knew Ricky wasn’t sleeping well at night, and
he could hear Ricky talking to himself in the next room.
One day while his father was at work, Ricky began to
hear some voices outside the apartment. The voices
grew louder, saying “You’re no good; you can’t do any-
thing right. You can’t take care of yourself or protect your
dad. We’re going to get you both.” Ricky grew more
frightened and went to the closet where his dad kept his
tools. He grabbed a hammer and ran outside. When his
father came home from work early, Ricky wasn’t in the
apartment though his coat and wallet were still there.
Ricky’s father called a neighbor, and they drove around
the apartment complex looking for Ricky. They finally
found Ricky crouched behind some bushes. Although it
was 45°F (7°C), he was wearing only a T-shirt and shortsCLINICALVIGNETTE: SCHIZOPHRENIA
and no shoes. Ricky’s neighbor called emergency ser-
vices. Meanwhile Ricky’s father tried to coax Ricky into
the car, but Ricky wouldn’t come. The voices had grown
louder, and Ricky was convinced that the devil had kid-
napped his father and was coming for him too. He saw
someone else in the car with his dad. The voices said
they would crash the car if he got in. They were laughing
at him! He couldn’t get into the car; it was only a trap. His
dad had tried his best, but he was trapped, too. The
voices told Ricky to use the hammer and to destroy the
car to kill the devil. He began to swing the hammer into
the windshield, but someone held him back.
The emergency services staff arrived and spoke
quietly and firmly as they removed the hammer from
Ricky’s hands. They told Ricky they were taking him to
the hospital where he and his father would be safe. They
gently put him on a stretcher with restraints, and his fa-
ther rode in the emergency van with him to the hospital.