Schizophrenia and Bipolar Disorder

Schizophrenia and Bipolar Disorder

• Schizophrenia's name comes from the Greek words "skhizo" (split) and "phren" (mind).
• Schizophrenia is likely caused by a mix of genetic predisposition, biochemical dysfunction, physiological factors, and psychosocial stress.
• Schizophrenia needs comprehensive treatment with a multidisciplinary approach.
• Schizophrenia, compared to other mental illnesses, tends to cause more lengthy hospital stays, family chaos, high costs, and fear.
• Schizophrenia causes disturbances in thought processes, perception, and affect.
• Schizophrenia leads to severe decline in social and job-related functioning.
• Schizophrenia has a lifetime prevalence of 1% in the United States.

Nursing Process: Positive Symptoms of Schizophrenia

• Positive symptoms involve content of thought and include delusions, which are fixed, false personal beliefs such as persecutory, grandiose, somatic, erotomanic, and jealous types.
• Positive symptoms involve the form of thought, including associative looseness (loose association) which is a shift of ideas from one unrelated topic to another.
• Neologisms are made-up words that have meaning only to the person who invents them.
• Concrete thinking is interpreting things literally.
• Clang associations involve choosing words based on their sound, often rhyming.
• Word salad is grouping words together randomly.
• Circumstantiality involves a delay in reaching the point of a communication because of unnecessary and tedious details.
• Tangentiality involves an inability to reach the point of communication because many new topics are introduced.
• Mutism is an inability or refusal to speak.
• Perseveration is persistently repeating the same word or idea in response to different questions.
• Positive symptoms involve perception; how stimuli are interpreted through the senses.
• Hallucinations are false sensory perceptions without real external stimuli and include auditory, visual, tactile, gustatory, and olfactory types.
• Illusions are misperceptions of real external stimuli.
• Echopraxia is repeating movements that are observed.

Nursing Process: Negative Symptoms of Schizophrenia

• Negative symptoms involve affect; the feeling state or emotional tone.
• Inappropriate affect means emotions are incongruent with the circumstances.
• Bland affect means a weak emotional tone.
• Flat affect appears to lack emotional tone.
• Apathy is a lack of interest in the environment.
• Avolition is being unable to start goal-directed activities.
• Emotional ambivalence is having opposite emotions toward the same thing.
• Deterioration in appearance means impaired personal grooming and self-care activities.
• Negative symptoms include impaired interpersonal functioning and relationship to the external world.
• Impaired social interaction involves clinging and intruding on others' personal space, as well as culturally or socially unacceptable behavior.
• Social isolation focuses inward on the self, excluding the external environment.
• Lack of insight is a negative symptom.
• Anergia is a deficiency of energy.
• Anhedonia is an inability to experience pleasure.
• Another negative symptom is a lack of abstract thinking ability.
• Waxy flexibility is passively yielding all movable parts of the body to any effort made at placing them in certain positions.
• Posturing is voluntarily assuming inappropriate or bizarre postures.
• Pacing and rocking refer to pacing back and forth and rocking the body.
• Regression is retreating to an earlier level of development.
• Eye movement abnormalities are associated features.

Treatment Modalities

• Psychopharmacology involves using antipsychotics to decrease agitation and psychotic symptoms related to schizophrenia.
• Typical antipsychotics act as Dopaminergic blockers with different affinities for cholinergic, α-adrenergic, and histaminic receptors.
• Atypical antipsychotics are weak dopamine antagonists, potent 5-HT2A antagonists, and also antagonize cholinergic, histaminic, and adrenergic receptors.

First-Generation Antipsychotics

• First-generation antipsychotics are dopamine (D2) receptor antagonists.
• They target the positive symptoms of schizophrenia.
• An advantage is that they are less expensive than second-generation antipsychotics.
• Disadvantages include extrapyramidal side effects (EPS), anticholinergic (ACh) side effects, tardive dyskinesia, weight gain, sexual dysfunction, and endocrine disturbances.

Second-Generation Antipsychotics

• Second-generation antipsychotics are Serotonin (5-HT2A receptor) and dopamine (D₂ receptor) antagonists, like clozapine.
• These treat both positive and negative symptoms.
• Minimal to no EPS or tardive dyskinesia is observed.
• A disadvantage is the tendency to cause significant weight gain and risk of metabolic syndrome.

Monitoring

• Baseline and repeat EKG is necessary.
• Baseline and repeat A1C, lipid panel is necessary.
• Weight should be monitored.
• A weekly CBC is necessary for clozapine usage only.

Antipsychotics: Side Effects

• Common side effects include anticholinergic effects, nausea, gastrointestinal upset, skin rash, sedation, orthostatic hypotension, photosensitivity, hormonal effects, electrocardiogram changes, and hypersalivation.
• Other side effects include weight gain, hyperglycemia/diabetes, and increased risk of mortality in elderly clients with dementia.
• Antipsychotics can cause reduction in seizure threshold, agranulocytosis, extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome.

Antipsychotics: Extrapyramidal Symptoms

• Extrapyramidal symptoms include Pseudoparkinsonism, Akathisia, and Dystonia.
• Antiparkinsonian agents may be prescribed to counteract EPS.

Potentially Dangerous Responses to Antipsychotics

• Dangerous responses include ACh toxicity, neuroleptic malignant syndrome (NMS), agranulocytosis, prolongation of the QT interval, and liver impairment.

Bipolar Disorder

• Mood is a pervasive and sustained emotion that greatly influences a person's view of the world.
• Examples of mood include depression, joy, elation, anger, and anxiety.
• Affect is the emotional reaction to an experience.
• Mania is a mood alteration with elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking/speaking.
• Mania can be biological/organic, psychological, or a response to substance use/medical conditions.
• Bipolar disorder features mood swings from deep depression to extreme euphoria (mania), with normal periods in between.
• Delusions or hallucinations may or may not appear.
• Symptom onset can follow a seasonal pattern.
• Hypomania is a milder form of mania.

Types of Bipolar Disorders

• Bipolar 1 disorder involves experiencing a full syndrome of manic or mixed symptoms.
• These clients may also experience episodes of depression.
• Bipolar 2 disorder is characterized by bouts of major depression with episodic occurrence of hypomania.
• These clients have never met the criteria for a full manic episode.
• Acute mania involves marked impairment in functioning and often requires hospitalization.
• The symptoms include elation and euphoria or a continuous "high".
• Other symptoms are flight of ideas, accelerated and pressured speech, hallucinations, delusions, excessive motor activity, social/sexual disinhibition, and little need for sleep.

Treatment Strategies

• Psychopharmacology for bipolar disorder includes:
• Lithium
• Divalproex
• Carbamazepine
• Lamotrigine
• Atypical antipsychotics
• Attention deficit/hyperactivity disorder (ADHD) is a common comorbid condition.
• ADHD agents may worsen mania and should be given only after bipolar symptoms are controlled.

Client/Family Education: Lithium

• Take the medication at the same time each day regularly.
• Maintain consistent dietary sodium intake.
• Drink six to eight glasses of water daily.
• Notify the physician with vomiting or diarrhea.
• Have serum lithium levels checked every 1 to 2 months, or as advised by the physician.
• Notify the physician if any of the following symptoms occur: persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, or mental confusion.

Client/Family Education: Anticonvulsants

• Refrain from stopping the drug abruptly.
• Immediately report symptoms like skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, or yellow skin/eyes to the physician.
• Avoid alcohol and over-the-counter medications unless approved by the physician.