Schizophrenia and Bipolar Disorder

Schizophrenia and Bipolar Disorder

• Schizophrenia's name comes from the Greek words "skhizo" (split) and "phren" (mind).
• The treatment for schizophrenia requires a comprehensive, multidisciplinary approach.
• Schizophrenia can cause lengthy hospitalizations, chaos in family life, exorbitant costs, and fears.
• Schizophrenia causes disturbances in thought processes, perception, and affect.
• Schizophrenia is associated with a severe deterioration of social and occupational abilities.
• The lifetime prevalence of schizophrenia in the United States is approximately 1%.
• Schizophrenia is likely caused by a combination of factors including genetic predisposition, biochemical dysfunction, physiological factors, and psychosocial stress.

Nursing Process: Positive Symptoms

• Positive symptoms involve content of thought, such as delusions.
• Persecutory delusions involve the belief of being persecuted.
• Grandiose delusions involve feelings of exaggerated importance, power, knowledge, or identity.
• Somatic delusions involve false beliefs about one's body or health.
• Erotomanic delusions involve the belief that someone is in love with the individual.
• Jealous delusions involve the belief that one's partner is unfaithful.
• Positive symptoms also involve the form of thought, such as associative looseness where ideas shift from one unrelated topic to another.
• Neologisms are made-up words that have meaning only to the person inventing them.
• Concrete thinking denotes a literal interpretation of the environment.
• Clang associations involve the choice of words being governed by sound, often rhyming.
• Word salad is a group of words put together randomly.
• Circumstantiality is a delay in reaching the point of communication due to unnecessary details.
• Tangentiality is the inability to reach the point of communication due to new topics being introduced.
• Mutism is an inability or refusal to speak.
• Perseveration is the persistent repetition of a word or idea in response to different questions.
• Positive symptoms also involve perception, with stimuli interpreted through the senses.
• Hallucinations are false sensory perceptions that are not associated with real external stimuli.
• Hallucinations can be auditory, visual, tactile, gustatory, or olfactory.
• Illusions are misperceptions of real external stimuli.
• Echopraxia is the repetition of movements that are observed.

Nursing Process: Negative Symptoms

• Negative symptoms include affect, which is the feeling state or emotional tone.
• Inappropriate affect shows emotions that are incongruent with the circumstances.
• Bland affect has a weak emotional tone.
• Flat affect is when someone appears to be void of emotional tone.
• Apathy shows disinterest in the environment.
• Avolition is impairment in the ability to initiate goal-directed activity.
• Emotional ambivalence involves the coexistence of opposite emotions toward the same object, person, or situation.
• Deterioration in appearance involves impaired personal grooming and self-care activities.
• Impaired interpersonal functioning includes impaired social interaction and social isolation.
• Anergia is a deficiency of energy.
• Anhedonia is the inability to experience pleasure.
• Lack of abstract thinking ability.
• Associated features include waxy flexibility where someone passively yields all movable parts of the body to any effort made to place them in certain positions
• Posturing involves voluntary assumption of inappropriate or bizarre postures.
• Regression is retreat to an earlier stage of development.
• Eye movement abnormalities can be another associated feature.

Treatment Modalities: Psychopharmacology

• Antipsychotics are used to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders.
• Typical antipsychotics are dopaminergic blockers with varying affinity for cholinergic, α-adrenergic, and histaminic receptors.
• Atypical antipsychotics are weak dopamine antagonists and potent 5HT2A antagonists; they also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors.

First-Generation Antipsychotics

• First-generation antipsychotics are dopamine antagonists (D₂ receptor antagonists).
• First-generation antipsychotics target the positive symptoms of schizophrenia.
• An advantage of first generation antipsychotics include being less expensive than second generation.
• Disadvantages of first generation antipsychotics 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 (e.g., clozapine).
• Second-generation antipsychotics treat both positive and negative symptoms.
• Second-generation antipsychotics have minimal to no EPS or tardive dyskinesia.
• Disadvantages of second generation antipsychotics include a tendency to cause significant weight gain and risk of metabolic syndrome.

Monitoring

• Monitoring for antipsychotics includes:
  • Baseline and repeat EKG
  • Baseline and repeat A1C, lipid panel
  • Weight
  • Weekly CBC (clozapine only)

Antipsychotics: Side Effects

• Side effects of include anticholinergic effects, nausea, skin rash, sedation, orthostatic hypotension, photosensitivity, hormonal effects, electrocardiogram changes, and hypersalivation.
• More side effects of antipsychotics are weight gain, hyperglycemia/diabetes, increased risk of mortality in elderly clients with dementia, and reduction in seizure threshold.
• Additional possible side effects: agranulocytosis, extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome.

Antipsychotics: Extrapyramidal Symptoms

• Extrapyramidal symptoms include:
  • Pseudoparkinsonism
  • Akathisia
  • 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 defined as a pervasive and sustained emotion that may have a major influence on a person’s perception of the world.
• Examples of mood include depression, joy, elation, anger, and anxiety.
• Affect is described as the emotional reaction associated with an experience.
• Mania is an alteration in mood expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.
• Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.
• Bipolar disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy.
• Delusions or hallucinations may or may not be part of the clinical picture.
• Onset of symptoms may reflect a seasonal pattern.
• A somewhat milder form of mania is called hypomania.

Types of Bipolar Disorders

• Bipolar 1 disorder is when a client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms, as well as possible episodes of depression.
• Bipolar 2 disorder is characterized by bouts of major depression with episodic occurrence of hypomania and has never met criteria for a full manic episode.

Nursing Process/Assessment: Acute Mania Symptoms

• Acute mania involves marked impairment in functioning and usually requires hospitalization.
• Symptoms of acute mania are elation and euphoria as continuous “high,” flight of ideas, accelerated, pressured speech, hallucinations and delusions, excessive motor activity, social and sexual disinhibition, and little need for sleep.

Treatment Strategies

• Psychopharmacology includes lithium, divalproex, carbamazepine, lamotrigine, and atypical antipsychotics.
• Attention deficit/hyperactivity disorder (ADHD) is a common comorbid condition.
• ADHD agents may exacerbate mania, so they should only be administered after bipolar symptoms have been controlled.

Client/Family Education: Lithium

• Take the medication regularly.
• Do not skimp on dietary sodium.
• Drink six to eight glasses of water each day.
• Notify physician if vomiting or diarrhea occurs.
• Have serum lithium level checked every 1 to 2 months, or as advised by physician.
• Notify physician if persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine, increasing tremors, or mental confusion occur.

Client/Family Education: Anticonvulsants

• Refrain from discontinuing the drug abruptly.
• Report symptoms such as skin rash, unusual bleeding, spontaneous bruising, sore throat, fever, malaise, dark urine, or yellow skin or eyes.
• Avoid alcohol and over-the-counter medications without approval from a physician.