Schizophrenia Spectrum and Delusional Disorder

Schizophrenia Spectrum Disorders

• Psychosis involves altered cognition and perception, impairing the ability to distinguish reality
• "Schizo" disorders require the presence of psychosis
• The duration of symptoms differentiates schizophrenia spectrum disorders

Delusional Disorder

• Characterized by delusions lasting at least 1 month
• Grandiose delusions involve the belief of being powerful and important
• Nihilistic delusions involve the conviction that a major catastrophe will take place
• Control delusions involve the belief that another person controls thoughts/feelings
• Erotomanic delusions involve the belief that another person desires the individual romantically
• Persecutory delusions involve the belief of being singled out for harm or prevented from making progress
• Somatic delusions involve the belief that the body is changing when it is not
• Referential delusions involve the belief that unrelated events or circumstances are somehow related to the individual
• Hallucinations are sensory experiences involving the five senses
• Delusions are thoughts and beliefs
• Individuals don't act bizarrely or impair functioning with delusional disorder

Brief Psychotic Disorder

• Sudden onset of one or more of: delusions, hallucinations, disorganized speech, catatonic behavior
• Symptoms last longer than a day but less than a month, with expected return to normal functioning

Schizophreniform Disorder

• Presents identical symptoms to schizophrenia, however, has lasted less than 6 months
• Social or occupational functioning impairment may not be apparent
• Individuals may return to normal functioning

Schizoaffective Disorder

• Involves a mixture of major depressive, manic, or mixed episodes concurrent with schizophrenia symptoms
• Schizophrenia symptoms cannot be due to substance use or a general medical condition
• It's crucial to rule out physical symptoms before diagnosing a psychiatric disorder

Substance-Induced Psychotic Disorder and Psychotic Disorder

• Illicit drugs, medications, or toxins can induce delusions and/or hallucinations
• Psychotic conditions, like delirium or neurological/hepatic/renal diseases can be caused by general medical conditions
• Substance use and medical conditions should be ruled out before diagnosing schizophrenia spectrum disorder

Schizophrenia (General)

• Onset usually occurs between 15 and 25 years of age, developing gradually and insidiously
• Child onset (before 15 years) and late onset (after 40 years) are possible
• Requires at least one psychotic symptom, such as hallucinations, delusions, or disorganized speech/thought
• Symptoms must be severe enough to disrupt normal activities including self-care
• Basic needs like hygiene, nutrition, and healthcare are neglected, leading to disrupted relationships and socializing
• Significantly impacts daily functioning

Comorbidities

• Common co-occurring conditions include; substance use disorder, anxiety, depression, suicide, physical illness
• Polydipsia: compulsive drinking of fluids occurs in 20% of schizophrenia patients

Risk Factors

• 80% of the risk for schizophrenia is primarily genetic, involving dopamine disorder
• Neurotransmission: largely related to dopamine levels, through serotonin, glutamate, GABA
• Brain structure abnormalities: gray matter, lower blood flow, glucose processing in the temporal and frontal lobes
• Prenatal stressors
• Environmental factors like: stressors, trauma, abuse, toxins, ACEs, stress and abuse

Phases of Schizophrenia

• Prodromal: mild changes in thinking, anxiety, obsessive thoughts, and compulsive behaviors with a feeling that "something is not right" occurring 1-12 months before a full schizophrenia episode
• Acute: Symptoms vary and can impact ADL's
• Stabilization: Symptoms stabilize and improves, and lasts for 4 months while movement goes back to previous level of functioning
• Maintenance: stabilized condition with a new baseline involving community level care

Assessments

• Positive symptoms: presence of symptoms that should NOT be present like hallucinations, delusions, paranoia etc
• Negative symptoms: absence of qualities that should be present; Anhedonia, social discomfort, or withdrawal
• Cognitive symptoms encompass subtle or obvious impairments in memory, attention, thinking, impaired judgment etc
• Affective symptoms involve; emotions and their expression, flat affect, affective symptoms

Alterations in Perception

• Positive symptoms usually lead to treatment/admission and involve reality testing, and delusions
• Reality testing: the way we determine reality
• Delusions: false beliefs with lack of evidence that should not be argued with
• Alterations in speech involve unusual patterns
• Associative looseness: illogical thinking where concentration is poor or thoughts are only loosely connected
• Word salad: jumble of meaningless words
• Clang association: words based on sounds instead of meaning
• Neologisms: words with unique meaning to the patient
• Echolalia: pathological repetition of another's words

Pathological Speech Patterns

Circumstantiality: including unnecessary and tedious details in conversation eventually reaching the point

• Tangentiality: wandering off topic never reaching the point
• Cognitive retardation: slowing of thinking with delays
• Pressured speech: urgent and intense speech not allowing comments to be made
• Flight of ideas: switching topics fast that is difficult to follow
• Symbolic speech: implies not meaning via using symbolism and association

Hallucinations vs Illusions

• The most common error in perception is auditory and visual hallucinations, and, can be, olfactory, and tactile sensations
• Command hallucinations are dangerous, while the most often experienced one is auditory
• Illusions: misinterpretations of a real experience like seeing a coat but thinking it’s a person
• Depersonalization is the feeling of being unreal, while derealization is the feeling that the environment has changed
• Catatonia involves; alterations in behavior or being illogical with inappropriate actions

Negative Symptoms

• Anhedonia: inability to experience pleasure, and social withdrawal with an increased risk of depression
• Avolition: diminished motivation or goal-directed behaviors
• Asociality: decreased social interaction desire
• Affective blunting: constricted affect
• Apathy: is having decreased outside interests
• Alogia: poverty of speech
• Impaired impulse control can lead to emotionally triggering actions

Affect

• Affect shows a person’s emotional state
• Flat, blunted, constricted, inappropriate and bizarre

Thinking & Cognitive Symptoms

• Concrete thinking means processing what has been said, and may be unintended for real world context versus the situation
• Cognitive symptoms and assessments involve: memory, impaired information processing, impaired executive functioning, and anosognosia

Assessment

• Medical workups, medical orders, physical symptoms
• Assess for indications of medical problems that might mimic psychosis
• Complete a mental status exam (MSE), and review safety
• Hallucinations: what voices are saying
• Delusions: real belief
• Assess suicide risk
• Assess ADLs, medications regimen, family's understanding/response

Interventions for Symptoms

• Therapeutic communication, hallucination interventions, reorientation
• Recognize if a patient is having delusion, and, engage to acknowledge the experience
• Teamwork and safety, activities and groups, health teaching and promotion and provide trust
• Goal: help patient identify reality and safety

Anorexia Nervosa

• Involves the intense fear of gaining weight, or "being too fat"
• There is a perception that individuals with anorexia refuse to eat, even if they are hungry
• Sensory function decreases, perpetuating the disorder: restriction, taste, full and appetite decreases
• Engage behaviors, with an extreme preoccupation with food and distorted self-image
• Purging: misuse of laxatives and stimulants
• Terror from viewing self as fat even if emaciated can lead to disturbed judgement of worth and the world

Factors

• Heavy social media usage increases body sizing, deficits in behavioral control
• Athletes can have the disorder (dancers)
• LGBTQ: emotional identification, regulation, and processing issues

Assessment

• Low weight, amenorrhea: complete loss of menstruation, cold extremities, muscle weakening
• Medical: yellow skin, jaundice Psychological: thoughts of food, withdrawals

Disorders

• Ego-Syntonic: disorder can have benefits that outweigh the risks and restriction of food intake
• Anxious is common, and perfectionism temperaments are aligned with control through food restriction
• Underestimation of the severity of disorders
• The patient should be be comfortable

Evaluation

• Problems include: perception, eating habits, dieting/purging, how weight is controlled, assigned value
• Evaluation of: interpersonal social functioning, mental status, and physical parameters and factors
• Treatment: structured meals, constant observations post-meal, monitoring movement, and exercise

Interventions

• Eating behavior should be accepted, and there should be a safe space
• Refeeding syndrome is a life threatening condition because of the quick introduction of nutrition that results into fluid and electrolyte abnormal imbalances
• Planning of meals for navigation of social structures with food

Interventions

• Anxiety and depressive disorders
• Disorders may result in OC (obsessive compulsions), PTSD, substance usage, and trauma
• Integrative medicine: bright light therapy, acupuncture etc

Therapies

• Individual, family, and cognitive behavioral therapies
• The patient may need peer or medical counseling

Bulimia Nervosa

• Bulimia involves binge eating with a large amount of calories in just 2 hours
• After binge eat comes compensatory behavior like purging through stimulants and medication misuse

Factors

• Attachment challenges such as self eval and neurotransmitter imbalances
• Environmental: thin body image, bullying.
• Assesment include: systems review of fluids and laboratory studies
• Clincal signs: damages to teeth or knuckles, depressive systems Planning implementation like destructive cycles, normalizin eating habits
• Therapy for underlying causes include most helpful CBT and maybe SSRI

Substance-Related and Addictive Disorders

• Addictive behavior may occur because of genetics and environment stimuli
• DSM: tolerance for lack of control by the individual
• The key takeaway is that with addiction, a deficiency or neurobiological factors in the brain occur that need to be treated

Addiction Factors

• Genetic
• Substances: pills, opioids
• DSM: caffeine, cannabis, inhalants, opioids
• Stimili

Addiction and Symptoms

• Medical: increased energy and cardiovascular risk
• Reversal: addiction has relapses and cycles and can lead to death
• The substances can lead to changes that can then lead to abuse
• Interventions: maintain safety, promote coping abilities, explore feelings

Modalities of Treatment

• Recovery: public support and therapy

Personality Disorders

• The three clusters are: Schizoid, Erratic, and Avoidant

Personality Disorders

• Borderline: erratic, impulsive, image issues and mood swings and instability
• Risk: suicide
• Borderline personality disorders: cognitive psychotherapy
• Antisocial: Discomforts and disregard for others
• Conduct disorder
• Lack of ability to conform behavior. This starts being assessed at a young age

Nursing Process: BPD and APD

• Assess high rewards and disregarding of consequences to the patient when conducting an assessment
• Safety is important
• Therapeutic communication
• Psychotherapy such as cognitive or dialectival are potential Treatment for neurodevelopmental disorders:
• Treat childhood disorders, like ADHD
• Family intervention

Childhood Behavior

• Mental: safe and supportive
• Appropriate actions should be taken
• Treatment: behavioral to family

Behavioral Treatment

• Emotional: low stimuli and a calm attitude.
• Communications: speech, language barriers, etc. And will give a plan for the patient by giving intervention
• Neurotic and stereotyped disorders result from these kinds of mental issues

Management Treatment

• Focus on behavior, rewarding good behavior and a social environment to the patient

Impulse Control Disorders

• Includes ODD, pyromania, kleptomania
• ODD is a form of acting aggressive with vindictive behavior
• ODD: lacks impulse control, which becomes the focus
• ODD: Hallmark is a disregard to other people

Treatment

• Cognitive training, skill training and family interaction

Delirium and Management

• Neurocognitive disorders like dementia: caused by long term issues with a loss of memory
• Characterized by: safety issues of agitation, and confusion
• Management: provide comfort and avoid harm

Behavioral Treatment

• Cognitive training, skill training and family interaction

General Medical Safety Interventions

• Make sure to establish a rapport with the patient and acknowledge their feelings. Provide safety by doing so
• Make sure to assess the patients' need for help and evaluate the risks before anything goes sideways
• Have a team with you to help you out
• A calm approach helps

Assessment and Considerations

• Always start out low and progress slowly
• Avoid any long-term use without checking risks or assessing and reassessing needs
• Agressions and any kind and all violence: A general violence is an emotional fear that turns in a very dangerous thing

Prevention for the Nurse as the Provider

• Assess for the appropriate and safe means for the individuals
• Maintain professionalism
• Apply and provide patient safety
• Understand and communicate to the individual
• Provide them the with choices
• Have your group members informed of what can go on

Ethics

• Ensure the basic human rights and medical treatment is available.
• Try to understand what is the best course of action for the situation
• Provide all options that are available to the patients

Dying:

• Ensure and provide a person to help at the time and place of death