Schizophrenia Spectrum & Delusional Disorder

Schizophrenia Spectrum Disorders

• Characterized by psychosis, which involves altered cognition, perception, and an impaired ability to determine reality.
• Disorders with "Schizo" in the name require some form of psychosis.
• Differences between disorders often depend on how long the symptoms persist.

Delusional Disorder

• Characterized by delusions (false beliefs) lasting one month or longer.
• Includes grandiose delusions (belief of being powerful), nihilistic delusions (major catastrophe will occur)
• Control delusions (another controls thoughts), erotomanic delusions (another desires them)
• Persecutory delusions (being singled out for harm), somatic delusions (body changing unusually)
• Referential delusions (events are related to them)

Hallucinations and Delusions

• Hallucinations are sensory experiences (five senses)
• Delusions are thoughts and beliefs.
• In delusional disorder, these are not impairing enough to cause any functional deficits, and those affected do not seem bizarre or act strangely

Brief Psychotic Disorder

• Characterized by a sudden onset of one or more of the following: delusions, hallucinations, disorganized speech, or catatonic behavior (decreased motor activity).
• Symptoms last longer than a day but less than a month, with an expectation of return to normal functioning.

Schizophreniform Disorder

• Identical symptoms to schizophrenia but lasting less than 6 months.
• Impaired social or occupational functioning may not be apparent.
• Patients may return to normal functioning or develop persistent/recurrent symptoms.

Schizoaffective Disorder

• Is a mix of schizophrenia and bipolar disorders.
• Diagnosed with major depressive, manic, or mixed episodes concurrent with symptoms that are considered criteria for schizophrenia.
• Schizophrenia symptoms are not caused by substance use or a general medical condition

Substance-Induced Psychotic Disorder and other Medical Conditions

• Illicit drugs, medications, or toxins can induce delusions and/or hallucinations
• Can be caused by a general medical condition such as delirium, neurological disease, hepatic, or renal disease.
• Substance use and medical conditions should be ruled out before diagnosing schizophrenia spectrum disorder.

Schizophrenia (General)

• Typically develops gradually and insidiously between 15 and 25 years of age.
• Cases of child onset (before 15 years) and late onset (after 40 years) exist.
• Requires at least one psychotic symptom: hallucinations, delusions, or disorganized speech/thought
• Symptoms must be severe enough to disrupt normal activities like school, work, family, social interactions, and self-care
• Basic needs are often neglected, leading to disruption of socialization and relationships
• Significantly impacts daily functioning

Comorbidities Associated with Schizophrenia

• Substance use disorder is common
• Anxiety, depression, and suicide risk are elevated
• Physical illness is frequently present
• Polydipsia (compulsive drinking of fluids) affects 20% of patients

Risk Factors Contributing to Schizophrenia

• 80% of the risk is genetic, primarily related to dopamine disorder
• Largely related to dopamine levels via serotonin, glutamate, and GABA
• Brain structure abnormalities like gray matter, lower blood flow, and glucose processing in temporal and frontal lobes may all be factors in etiology
• Prenatal stressors and environmental factors (stressors, trauma, abuse, toxins)

Phases of Schizophrenia

• Prodromal - before acute symptoms, there may be mild changes in thinking, anxiety, obsessive thoughts, and compulsive behaviors; typically appears 1-12 months before the first full episode.
• Acute - symptoms vary, from few and mild to many and disabling -- this may impact ADLs.
• Stabilization - symptoms are stabilizing and diminishing, generally within 4 months timeframe
• Maintenance or Residual - condition has stabilized, positive symptoms are significantly diminished or absent, and negative/cognitive symptoms continue to be a concern.

Assessments

• Positive symptoms are the presence of symptoms that should NOT be present -- presence of hallucinations, delusions, paranoia, or disorganized/bizarre thoughts, behavior, or speech
• Negative symptoms are the absence of qualities that SHOULD be present -- includes anhedonia, social discomfort, lack of goal-directed behavior/withdrawal, or catatonia.
• Cognitive symptoms subtly or obviously impair memory, attention, and thinking.
• Affective symptoms involve emotions and their expression (flat affect).

Positive Symptoms/Alterations

• Positive symptoms precipitate admission or treatment -- reality testing is often impaired
• Delusions involve false beliefs despite a lack of evidence.
• Speech may be affected including associative looseness, a jumble of meaningless words (word salad), clang association (choosing rhyming words), neologisms (making up new words), and echolalia (pathological repetition of another's words)
• Patterns include circumstantiality (including many details) and tangentiality (changing topics)
• Generalized slowing of thinking (cognitive retardation), pressured speech (intense speech), and flight of ideas (rapidly jumping between ideas)
• Symbolic speech involves words used on symbolism, such as a patient saying "demons are sticking needles in me."
• Magical thinking is believing reality can be changed with thoughts or actions, while paranoia involves irrational fears, such as being suspicious without reason.

Alterations in Perception

• Common errors are hallucinations (most common) including auditory (voices), visual (seeing things), olfactory (smelling odors), gustatory (experiencing tastes) and tactile (feeling sensations)
• Command hallucinations are MOST SEVERE and include voices commanding actions
• Illusions include misinterpretations of a stimuli

Alterations in Behavior

• Involve changes in the speed of movement and illogical/inappropriate behaviors
• Catatonia can include a pronounced increase or decrease in movement, while motor retardation or agitation may also be evident
• Individuals may display echopraxia (mimicking movements) or negativism (resisting requests)
• Impaired impulse control can lead to risk-taking behaviors

Negative Symptoms of Schizophrenia

• Are a serious problem and difficult to treat
• Anhedonia includes a reduced ability to experience pleasure, while avolition is reduced motivation
• Asociality means decreased desire for social interaction, while affective blunting means reduced expression
• Apathy is decreased interest, and alogia is "poverty of speech"

Description of Affect

• Affect is a common way to explain an external expression of a person's emotional state
• Flat affect is immobile or blank, while blunted affect is reduced.
• Constricted affect is reduced in range or intensity, inappropriate affect is incongruent, and bizarre affect is odd/illogical.

Cognitive Symptoms

• Concrete thinking involves taking things literally
• Memory is typically short-term
• Impaired information processing includes the inability to filter out background noise, which can manifest in overstimulation
• Impaired executive functioning causes difficulty with reasoning and setting priorities
• Anosognosia includes the inability to realize the person is ill.

Assessment Guidelines (Schizophrenia and Other Disorders)

• Complete a medical workup to check the physical symptoms before assuming the disorder
• Assess for indications of medical problems or substance use disorder
• Complete a MSE (mental status exam) looking for what the voices are saying.

Interventions for Schizophrenia

• Therapeutic communication
• Interventions for hallucinations include recognizing the hallucination
• Interventions for delusions include trying to see world through person's eyes, then acknowledging them
• Teamwork and safety- promote trust and repeat reality as needed.

Anorexia Nervosa

• Intense fear of weight gain or being fat, with a misperception that individuals refuse to eat despite being hungry
• May have significant differences with sensory perceptions of taste, appetite, and satiety
• May engage in compensatory behaviors

Thoughts and Behaviors Associated with Anorexia

• Verbalizing terror of gaining weight, preoccupation with thoughts of food, viewing self as fat, peculiar handling of food
• May include rigorous exercise regimen and disturbed cognition -- may judge self-worth by their weight

Risk Factors

• Heavy social media use that associates value with a body size
• Low distress tolerance and deficits in behavioral control in response to stress. Common among athletes

Symptoms and Assessments for Anorexia Nervosa

• Low weight and amenorrhea is common
• May present with yellow skin and jaundice or cold extremities and edema
• Can have psychological symptoms of depression, social withdrawal, obsessive thoughts abou foods

Ego-syntonic Disorder

• Affected individual value their disorder and believe the benefits outweigh the risks -- often aligned with a need for control through food restriction

Self-Assessment

• The nurse may underestimate the severity of the obsessive component to the disorder and need to that behavior is to avoid feelings

Implementations/Treatments

• Initial focus is medical stabilization including comprehensive assessment (vitals, labs)
• Structured meal times-close observations before, during and after meals with adherence to selected menu items
• Refeeding syndrome- rapidly introducing nutrition can cause a serious-life threatening condition where there is an abnormality of fluid balance and electrolytes

Treatment

• Patients should feel accepted and safe- should include eating behaviors, underlying feelings of anxiety, dysphoria
• Assistance with meal planning, shopping for food and navigation of various social or familial situations where food is involved

Comorbidities/Treatments

• Comorbidities include bipolar, anxiety, and depressive disorders
• May also present with obsessive-compulsive disorder or post-traumatic stress disorder (PTSD)
• Treatment Modalities include integrative medicine along with therapy and nutritional counseling

Bulimia Nervosa

• Engaging in repeated episodes of binge eating, followed by compensatory behaviors
• Binge eating is eating between 1500-5000 calories within a 2 hour period.
• A person may maintain a 'normal weight'

Risk Factors

• Self-evaluation based on weight and shape
• Environmental factors of socialization

Bulimia Nervosa Assessment

• Dental erosion and cavities from purging and vomiting = (Acids)
• Clinical signs or calluses on knuckles
• depressive symptoms are sometimes present

Nursing Implementations

• Normalize eating habits, treat underlying causes
• CBT is best for patients with this disorder

Substance Use Disorders

• Chronic, relapsing that leads to dependence

4 Key Terms

• Brain disease that rewires the production of dopamine
• Intoxication -- in the process of using leading to behavioral and physical changes
• Tolerance -- needing a HIGHER dose to have the same affect

Categories

• DSM lists 10 categories for substances
• One example is alcohol or caffeine
• other process addictions include gambling or sex

Alcohol Use Disorder

• a sedative with initial euphoria after.

Levels of Symptoms

• mild 2-3
• Moderate: 4-5
• Severe: 5 or more

Cultural Considerations

• adolescents heavily influenced by their peers

Types of Drinking

• Binge Drinking: too much alcohol quickly
• Heavy Drinking - too much too often

Alcohol Intoxication

• In most states concentration of .08 is what a DUI Is

Screening Tools

• Audit used for a variety of alcohol use disorders. 10 questions to assess use

Nursing Intervention Implementations

• Promote safety and sleep first

Treatment Modalities

• Disulfiram (can cause unpleasant side effects) while naltrexone blocks euphoric effects

Treatment

• Motivational Interviewing -- help pt explore the reasons for change

Care Continuum for Substance Use Disorders

• Detox -- ensure they are medically stable
• Rehabilitation address behavior

Chapter 24: Personality Disorders

• Cluster A is Eccentric
• Cluster B is Erratic
• Cluster C is Anxious

Borderline Disorder (Cluster B): Intense fear of abandonment and root cause

• Very unstable and severe impairments in functioning Emotional lability, feelings are always changing

Borderline Interventions

• safety is key for these type of patients.
• DBT psychotherapy

Antisocial Personality Disorder

• Characteristics are completely disrespectful
• Antagonistic behaviors are being deceitful and manipulative
• Shallow, unexpressive

Antisocial Assessment

Patients don't tend to answer honestly

Implementation

Boundaries, consistency, keep it the same

• Offer them choices -- increase autonomy
• Call for help if needed

Child, Adolescent, and Neurodevelopmental Disorders

• 20% of children have neurological issues and cause impairment

Cognitive Function

Assessment Interventions: Testing and observing Behavior Implementations: Play therapy and Bibliotherapy

Neurological Development Disorders

• Communication is key Language Disorder: difficulty attaining what they want to say Speech: confuse words easily Motor: impairments or below childs average age.

Treatment For disorders

• • IEP in school
• -Monitor processes
• • Teach parents consistency

Attention Deficit Hyperactive Disorder

• Inappropriate degrees of hyperactivity.

Interventions

• -Focus on the negative coping skills
• -Safety is major to assess
• -Meds can be taken .

Impulse Control Disorders

Impulsive disorders come from

• Aggression

• Lack of relationships

• -ODD: behavior in children

• -Intermittent disorder

• -Pyromania

• • Kleptomania recurrent behavior of stilling things that are worthless

Oppositional Defiant Disorder

AHA hallmark is impulse control

• DSM5: pattern of angry/ irritable mood touchy Can lead to harm High ACE scores

Persistent disorders continue into adulthood.

Persistent, negative behavioral pattern

• Stealing
• Bullying
• Getting into fights

Intermittent Explosive Disorder

Pattern of outburst and intense aggressiveness out proportion

• PostOutburst
• Ranges of emotions are always changing, its why it's important to use nursing intervention De-escalation
• • Pymania
• • Impulse related disorders.

Nursing Process

• Teamwork
• Safety

Pharmacology

• therapy PTM

Neurocognitive Disorders

Delirium is a medical emergency

• increased morbidity and mortality

Underlying causes can be treated with,

Interventions, supportive treat, assess , educate

• Dementia in broad category of decline in function overtime Can lead to changes of behavior or loss of function Hyperorality -- putting everything in the mouth. Sundowning--mood behavior decreases through the day Modalities: Meds or something for that is done for symptom management

Chapter 27: Anger, Aggression and Violence

Anger - an emotional response Aggression- resulting attack

• The nurse can be a frequent target, Increase demands, irritability and redness Implementation, set expectations, state behaviors

The plan is to be there!

• Try to listen and what they want to say and their feelings
• Ask what they intend to do, if someone mentions harm.
• Offer choices, but you need to be safe.

Know layout Six Basic considerations for safety

• Stay level minded

• Stay calm Cool and collected

• No judgement stay humble

• Safety is always first

Dying Death

• Cares more about their life

Advance in tech that is blurring lines

• Transplant Models
• hospice and begins after their death

Always do the plan with family.

Kubler-Ross -- dealing with shock Always honor the dignity

• Know your patient
• Do not overwork