Schizophrenia and Related Disorders

Schizophrenia Overview

• Schizophrenia is a serious mental disorder where individuals interpret reality abnormally.
• It requires lifelong treatment and is likely caused by a combination of genetic predisposition, biochemical dysfunction, physiological factors, and psychosocial stress.
• The word schizophrenia is derived from the Greek words "skhizo" (split) and "phren" (mind).

Schizophrenia Spectrum Disorders

• Categories include schizophrenia, schizoaffective disorder, delusional disorder, schizotypal disorder, brief psychotic disorder, schizophreniform disorder, and substance-medication-induced psychotic disorder.

Delusional Disorder

• Characterized by the presence of prominent, non-bizarre delusions.
• Types of delusions include erotomanic, grandiose, jealous, persecutory, somatic, and mixed.

Brief Psychotic Disorder

• Features a sudden onset of symptoms that may or may not be preceded by severe psychosocial stressors.
• The duration is less than 1 month.

Substance-Induced Psychotic Disorder

• Marked by prominent hallucinations and delusions directly attributed to substance intoxication or withdrawal.

Psychotic Disorder

• Psychotic disorder is associated with another medical condition includes hallucinations and delusions directly related to a general medical condition.

Schizoaffective Disorder

• Includes schizophrenic symptoms along with a strong presence of mood symptoms like mania or depression.
• Monitor potassium levels.

Catatonic Disorder

• Catatonic disorder is due to another medical condition arising from metabolic disorders or neurological conditions. Metabolic examples include hepatic encephalopathy, diabetic ketoacidosis, hypo- and hyperthyroidism, hypo- and hyperadrenalism, hypercalcemia, and vitamin B12 deficiency. Neurological examples include epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis.

Schizophreniform Disorder

• Exhibits similar symptoms to schizophrenia
• The duration of the disorder lasts for at least 1 month but less than 6 months.

Diagnostic Criteria

• Requires two or more specific symptoms present for a significant portion of time during a 1-month period.
• Includes delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms.
• Significant functional decline in major areas like work, interpersonal relations, or self-care is also a criterion.
• Continuous signs of the disturbance must persist for at least 6 months.
• Schizoaffective and depressive/bipolar disorders with psychotic features must be ruled out.
• Symptoms are not attributable to substance use or another medical condition.
• Requires prominent delusions or hallucinations for at least 1 month if there's a history of autism spectrum or childhood-onset communication disorder.

Influences

• Biological and Physiological: Factors include viral infections and anatomical abnormalities.
• Psychological: Researchers focus on schizophrenia as a brain disorder.
• Environmental: Sociocultural factors, like poverty, are linked to development, and stressful life events can exacerbate symptoms.
• Genetic vulnerability: Studies link certain genes to psychosis, especially in adolescents using cannabinoids.
• Schizophrenia is most likely a biologically based disease influenced by internal and external environmental factors.

Schizophrenia Treatment

• There is likely no single cure.
• Treatment involves a comprehensive, multidisciplinary effort including pharmacotherapy, psychosocial care, cognitive remediation therapy, rehabilitation/recovery, and family therapy.
• A comprehensive, patient-centered approach offers hope for recovery and improved quality of life.
• Schizophrenia can result in lengthy hospitalizations, chaos in family life, excessive costs, fears, and presents a major risk for suicide.

Phases of Schizophrenia

• Prodromal phase: Lasts weeks to years, involving deterioration in functioning, sleep disturbance, and depressed mood.
• Acute episodes: Schizophrenia is a chronic illness, acute episodes are characterized by more pronounced symptoms like delusions and hallucinations. These symptoms can impair work, social relations, and self-care

Recovery

• Ultimate goal is achieved through therapeutic regimens, healthy lifestyle maintenance, stress management, and meaningful relationships.
• Family support and involvement are essential.
• Education is a key part of remission, patients and their families must anticipate relapse and how to cope with it

Relapses

• Can occur during treatment and recovery
• Failure to take medication consistently is a major reason
• Other factors include: impairment in cognition/coping skills, limited resources/income, stigmatization, social isolation

Prognosis

• Positive factors include: later age at onset, abrupt onset precipitated by a stressful event, associated mood disturbance, brief duration of active-phase symptoms, absence of brain abnormalities, normal neurological functioning, a family history of mood disorders, and no family history of schizophrenia.

Positive Symptoms

• Involve excessive or distorted thoughts and perceptions like hallucinations (usually visual or auditory).
• Hallucinations can involve one or more senses. Command hallucinations are a specific type.
• Delusions are erroneous, fixed, false beliefs, there are types like grandiose, nihilistic, persecutory, and somatic.

Negative Symptoms

• Interfere with day-to-day functioning.
• Include ambivalence (opposing feelings), alogia (reduced speech), anhedonia (inability to enjoy activities), and inappropriate affect (emotions incongruent with circumstances).
• Can manifest as bland or flat affect, apathy, and lack of interpersonal skills/interest/insight.

Neurocognitive Impairment

• Involves memory, vigilance, and executive function.
• May be independent of positive and negative symptoms.

Disorganized Symptoms

• Make it difficult for the person to understand and respond to ordinary sights and sounds
• Echolalia: Repetition of another's words.
• Circumstantiality: Extremely detailed and lengthy discourse.
• Loose associations: Sudden shifts in thoughts without apparent relationship.
• Tangentiality: Changing the conversation to an entirely different and logical topic.
• Flight of ideas: Rapidly changing topics of conversation.
• Word salad: Stringing together unconnected words.
• Neologisms: Made-up words with no common meaning.
• Paranoia: Unrealistic suspiciousness.
• Perseveration: Persistent repetition of the same word or idea.
• Referential thinking: Belief that neutral stimuli have special meaning.
• Autistic thinking: Restricts thinking to the literal.
• Concrete thinking: Lack of abstraction.
• Verbigeration: Purposeless repetition of words.
• Metonymic speech: Use of words with similar meanings interchangeably.
• Clang association: Repetition of words with similar sounds.
• Stilted language: Overly artificial formal language.
• Pressured speech: Speaking as if words are being forced out.
• Magical thinking: Belief that one's thoughts have control over situations.
• Disorganized behavior includes aggression, agitation, catatonia, catatonic excitement, echopraxia, regressed behavior, stereotypy, hypervigilance and waxy flexibility.

Goals for the client

• Demonstrate ability to relate properly with others
• Recognize distortions of reality
• Not harm self or others
• Perceive self accurately
• Perceive environment accurately
• Maintain anxiety at a manageable level
• Relinquish the need for delusions and hallucinations
• Demonstrate ability to trust others
• Use appropriate verbal communication in interactions
• Perform self-care activities independently

Nursing Process

• Focus on disturbed thought processes, risk for violence, and impaired verbal communication.
• Treatment includes Assertive Community Treatment (ACT).

Treatment Modalities

• Program of Assertive Community Treatment (ACT): Evidence -Based program of case management using team approach for psychiatric treatment, rehabilitation and support for those with mental illness. Recovery After Initial Schizophrenia Episode (RAISE): Using a team approach for the individuals psychiatric treatment.
• Psychopharmacological treatment: uses antipsychotics to decrease agitation and psychotic symptoms.

Antipsychotics

• Side effects include anticholinergic effects, nausea, skin rash, sedation, orthostatic hypotension, photosensitivity, hormonal effects, electrocardiogram changes, hypersalivation, weight gain, hyperglycemia/diabetes, increased mortality risk in elderly with dementia, and reduction in seizure threshold, agranulocytosis, extrapyramidal symptoms, tardive dyskinesia, and neuroleptic malignant syndrome.
• Antiparkinsonian agents may be prescribed to counteract EPS

Extrapyramidal Symptoms (EPS)

• Consists of pseudoparkinsonism, akinesia, akathisia, dystonia, and oculogyric crisis.

Recognizing Neuroleptic Malignant Syndrome

• Onset: 2 weeks after initiation of antipsychotic treatment/ a change in dosage.
• Risk factors include male gender, preexisting medical/neurologic disorders, depot injection administration, and high ambient temperature.
• Immiment indicators Include metal status changes, muscle rigidity, hyperthermia, tachycardia, hypertension/hypotension, tachypnea/hypoxia, diaphoresis/sialorrhea, tremor, incontinence, elevated creatinine phosphokinase/myoglobinuria, leukocytosis, and metabolic acidosis.

Schizoaffective Disorder

• Marked by intense symptom exacerbation alternating with periods of adequate psychosocial functioning.
• Presents with psychosis at times, mood disturbance at others.
• Long-term outcome is better than schizophrenia but worse than mood disorder.
• Patients are at risk for suicide, as risk factors like risky substance abuse/cigarette usage, previous suicide attempts and lack of social activity increase likelihood.
• Risk reduction achieved by encouraging social networks and self-protection against environmental stressors.

Delusional Disorder

• Characterized by stable and well-systematized delusions without other psychiatric disorders.
• Onset can be acute or gradual
• Characterized by normal behavior
• Personality doesn't change dramatically during the disorder instead they become more envolved with their delusional concerns and ideations.

Other Psychotic Disorders

• Schizophreniform disorder Essential features of Schizophrenia but with shorter duration
• Brief psychotic disorder duration of symptoms are less then 1 month but more then 1 day and there is a risk of increase suicidal ideations