Schizophrenia and Bipolar Disorder Overview

• Schizophrenia and bipolar disorder overview by Annie Smith, RN-BC, MSN.

Objectives

• Identify symptoms of schizophrenia and other psychotic disorders for patient assessment and treatment.
• Formulate nursing diagnoses and outcomes for patients with schizophrenia and other psychotic disorders.
• Recognize bipolar disorder symptomatology for client assessment and treatment.
• Create nursing diagnoses and goals for clients experiencing manic episodes.
• Describe symptoms of borderline and antisocial personality disorders for patient assessment.
• Develop nursing diagnoses and goals for patients with personality disorders, including appropriate interventions.

Introduction

• Schizophrenia is derived from the Greek words "skhizo" (split) and "phren" (mind).
• Schizophrenia causes are likely a combination of genetic predisposition, biochemical dysfunction, physiologic factors, and psychosocial stress.
• Treatment requires comprehensive, multidisciplinary efforts.
• Schizophrenia results in lengthy hospitalizations, chaos in family life, exorbitant costs and increased fears.

Nature of Schizophrenia

• Schizophrenia causes disturbances in thought processes, perception, and affect.
• Schizophrenia leads to deterioration in social and occupational functioning.
• The lifetime prevalence of schizophrenia in the United States is about 1%.

Nursing Process: Positive Symptoms

• Positive symptoms include content and form of thought and perception.
• Delusions are fixed, false personal beliefs, including persecutory, grandiose, somatic, erotomanic, and jealous types.
• Associative looseness (loose association) is the shift of ideas from one unrelated topic to another.
• Neologisms are made-up words that have meaning only to the person inventing them.
• Concrete thinking refers to literal interpretations of the environment.
• Clang associations involve the choice of words 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 and tedious details.
• Tangentiality means the inability to get to the point of communication due to the introduction of new topics.
• Mutism involves the inability or refusal to speak.
• Perseveration is the persistent repetition of the same word or idea in response to different questions.
• Hallucinations are false sensory perceptions not associated with real external stimuli, including auditory, visual, tactile, gustatory, and olfactory types.
• Illusions are misperceptions of real external stimuli.
• Echopraxia involves repeating movements that are observed.

Nursing Process: Negative Symptoms

• Affect is the feeling state or emotional tone.
• Inappropriate affect: Emotions are incongruent with the circumstances.
• Bland affect: Weak emotional tone.
• Flat affect: Appears to be void of emotional tone.
• Apathy: Disinterest in the environment.
• Avolition: Impairment in the ability to initiate goal-directed activity.
• Emotional ambivalence: Coexistence of opposite emotions toward the same object, person, or situation.
• Deterioration in appearance: Impaired personal grooming and self-care activities.
• Impaired interpersonal functioning and relationship to the external world.
• Impaired social interaction: Clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable
• Social isolation: A focus inward on the self to the exclusion of the external environment.
• Lack of insight.
• Anergia: Deficiency of energy.
• Anhedonia: Inability to experience pleasure.
• Lack of abstract thinking ability.

Associated features

• Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at placing them in certain positions.
• Posturing: Voluntary assumption of inappropriate or bizarre postures.
• Pacing and rocking: Pacing back and forth and rocking the body.
• Regression: Retreat to an earlier level of development.
• Eye movement abnormalities.

Treatment Modalities

• Psychopharmacology involves the use of antipsychotics.
• Antipsychotics decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders.
• Typical Antipsychotics: These are Dopaminergic blockers with various affinity for cholinergic, α-adrenergic, and histaminic receptors
• Atypical Antipsychotics: These have weak dopamine antagonist with potent 5HT2A antagonists; also exhibit antagonism for cholinergic, histaminic, and adrenergic receptors.

First-Generation Antipsychotics

• Dopamine antagonists (D₂ receptor antagonists).
• Target positive symptoms of schizophrenia.
• 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

• Serotonin (5-HT2A receptor) and dopamine (D₂ receptor) antagonists, e.g., clozapine .
• Treat both positive and negative symptoms.
• Minimal to no EPS or tardive dyskinesia.
• Disadvantage: Tendency to cause significant weight gain; risk of metabolic syndrome.

Monitoring

• Monitor baseline and repeat EKG.
• Monitor baseline and repeat A1C, lipid panel.
• Monitor weight.
• Weekly CBC required for clozapine (Clozaril) only.

Antipsychotics: Side Effects

• Side effects include anticholinergic effects, nausea/gastrointestinal upset, skin rash, sedation, orthostatic hypotension, photosensitivity, hormonal effects, electrocardiogram changes, hypersalivation, weight gain, and hyperglycemia/diabetes.
• Increased risk of mortality in elderly clients with dementia
• Reduction in seizure threshold.
• Agranulocytosis.
• Extrapyramidal symptoms.
• Tardive dyskinesia.
• Neuroleptic malignant syndrome.

Antipsychotics: Extrapyramidal Symptoms

• Pseudoparkinsonism.
• Akathisia.
• Dystonia.
• Parkinsonian agents may be prescribed to counteract EPS.

Potentially Dangerous Responses to Antipsychotics

• ACh toxicity.
• Neuroleptic malignant syndrome (NMS).
• Agranulocytosis.
• Prolongation of the QT interval.
• Liver impairment.

Bipolar Disorder

• Mood: defined as a pervasive and sustained emotion that affects perception of the world.
• Affect: The emotional reaction associated with an experience.
• Examples of mood include depression, joy, elation, anger, and anxiety.
• Mania is an alteration in mood with elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking/speaking.
• Mania can occur from biological, psychological disorders, substance use, or medical conditions.
• 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 Involves clients experiencing, or has experienced, a full syndrome of manic or mixed symptoms
• May also have had episodes of depression.
• Bipolar 2 disorder is characterized by bouts of major depression with episodic occurrence of hypomania.
• Individuals has never met criteria for full manic episode.

Nursing Process/Assessment

• Acute mania involves impairment in functioning and hospitalization is usually required
• Symptoms include elation and euphoria (“high”), flight of ideas, accelerated/pressured speech, hallucinations, delusions, excessive motor activity, social/sexual disinhibition, and little need for sleep.

Treatment Strategies

• Psychopharmacology includes lithium, divalproex, carbamazepine, lamotrigine, and atypical antipsychotics.
• Attention deficit/hyperactivity disorder (ADHD) is the most common comorbid condition and ADHD agents may exacerbate mania

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 occur.
• Have serum lithium level checked every 1 to 2 months, or as advised by physician.
• Further, notify physician if persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive output of urine, increasing tremors, and/or mental confusion occur.

Client/Family Education: Anticonvulsants

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