23.C.docx

**Overview**: Schizophrenia is a serious neurobiological disorder marked by psychotic symptoms, difficulties in social interactions, and unusual behaviors. It commonly presents during early adulthood but can start in childhood, adolescence, or later in life. The most chronic and disabling aspects of...

**Overview**: Schizophrenia is a serious neurobiological disorder marked by psychotic symptoms, difficulties in social interactions, and unusual behaviors. It commonly presents during early adulthood but can start in childhood, adolescence, or later in life. The most chronic and disabling aspects of the disorder are associated with significant functional deficits affecting communication, cognition, attention, memory, emotional regulation, and social interactions. Schizophrenia can lead to a reduced life expectancy due to comorbid conditions and high suicide rates. Stigma related to the disorder is a major challenge for those affected. **Pathophysiology**: Schizophrenia involves complex pathologic mechanisms including structural brain alterations, neurotransmitter abnormalities, and immune function impairments. Structural abnormalities often seen include reduced gray matter volume in areas such as the prefrontal cortex, temporal lobes, hippocampus, and thalamus; enlarged ventricles; and decreased blood flow to these brain regions and alterations in glucose metabolism. These changes can become more noticeable with episodes of psychotic symptoms. **Neurotransmitter Abnormalities** Schizophrenia is associated with abnormalities in neurotransmitter function. Key systems involved include: - **Dopaminergic System**: Antipsychotic medications target D2 (dopamine) receptors. - **GABA and Acetylcholine Systems**: Disturbances, including reduced nicotinic acetylcholine receptors in the hippocampus, contribute to symptoms. - **Glutamate System**: Dysregulation of NMDA glutamate receptors and low glutamate levels in the cerebrospinal fluid (CSF) affect dopamine and prefrontal processing. **Immunologic and Inflammatory Pathways** Inflammatory and immune pathways play a role in schizophrenia: - **Microglia**: Activated microglia produce cytokines that can disrupt NMDA receptor activity and dopamine regulation. - **Cytokines**: Elevated levels are observed, especially during acute psychosis or relapse. **Etiology** The causes of schizophrenia are not fully understood but involve: - **Genetic Factors**: A polygenic predisposition is evident. Having a parent with schizophrenia increases risk. - **Paternal Age**: Older paternal age is associated with higher risk due to mutations in sperm. - **Maternal Age**: Advanced maternal age may also be a risk factor. - **Environmental Factors**: Events such as prenatal health issues and exposure to infections like Toxoplasma gondii (from cat feces) are implicated. - Epigenetic factors: birth complications, in utero infections, and substance use, are also significant. SAFETY ALERT! Individuals with schizophrenia are at high risk for suicide and should be closely monitored. Risk factors include greater awareness of the illness, younger age, recent loss, limited support, recent discharge, and treatment failure. Risk Factors: early life adversity, such as poverty, violence, and trauma. Children and adolescents with developmental alterations may be at higher risk for the disorder. Stress during early childhood or adolescence can also increase risk. Psychosocial risk factors are increased in instances where disparities in healthcare exist, such as with recent immigrant populations. Children and adolescents who display certain alterations in emotional, cognitive, language, and motor development are at an increased risk for developing schizophrenia Prevention: Early screening and detection of cognitive, developmental, and behavioral changes associated with schizophrenia can lead to better outcomes, especially with coordinated care and cognitive-behavioral therapy (CBT). Secondary prevention, such as starting antipsychotic treatment with prodromal symptoms, raises ethical concerns because these patients may or may not go on to develop the disorder. Health promotion for patients includes emphasizing recovery and rehabilitation, focusing on symptom management, adherence to treatment, reducing stress, and preventing relapse. The goal is prevention of relapse to acute phase of the illness. Rehabilitation involves achieving a level of wellness that allows the individual to engage in goal-directed activities such as maintaining a job and self-care. **Clinical Manifestations** The symptoms of schizophrenia can vary and may include periods of exacerbation and remission. Understanding these symptoms is crucial for addressing the needs of individuals with the disorder. Many patients may struggle with activities of daily living (ADLs) and independent functioning, and may benefit from in-home services, day treatment programs, group homes, or psychiatric rehabilitation. **Symptom Types** Schizophrenia symptoms are categorized into positive, negative, and cognitive types, with affective symptoms also commonly present. The presence of these manifestations does not necessarily indicate that an individual has schizophrenia. **Positive Symptoms** - **Hallucinations**: Abnormal perceptual experiences without external stimuli, often auditory. - **Delusions**: False beliefs such as beliefs of reference, nihilistic, religious, grandiose, or persecutory delusions. Examples include thought broadcasting or withdrawal. - **Motor Symptoms**: Includes motor retardation, posturing, catatonia (such as mutism, echopraxia, echolalia, waxy flexibility, and automatic obedience), and other psychomotor abnormalities. - **Disorganized Thinking**: Disruption in speech and thought processes, including loose associations, tangentiality, incoherence, circumstantiality, and pressured speech. **Negative Symptoms** - **Flat or blunted affect**: Reduced emotional expression. - **Thought blocking**: Sudden interruption in speech. - **Alogia**: Poverty of thought and speech. - **Anhedonia**: Inability to experience pleasure. - **Avolition**: Lack of motivation or initiative. - **Social withdrawal**: Avoidance of social interactions. **Cognitive Symptoms** - **Memory deficits**: Issues with verbal processing and visual memory. - **Attention and vigilance**: Difficulty concentrating and filtering extraneous information. - **Facial recognition**: Problems with recognizing faces. - **Nonverbal processing**: Difficulty interpreting nonverbal cues. - **Executive functioning**: Issues with planning, organization, and impulse control. - **Concrete thinking**: Focus on literal facts and details. **Affective Symptoms** - **Depression and mania**: Increased risk of suicide, especially with other risk factors. - **Schizoaffective disorder**: Diagnosis when mood disorder is present alongside schizophrenia. **Phases of the Illness** - **Premorbid**: Emotional, cognitive, and motor delays during childhood. - **Prodromal Phase**: Symptoms like sleep disturbance, poor concentration, and social withdrawal before full psychosis. - **Acute Phase**: Onset of intense psychotic symptoms; may require hospitalization. - **Residual Phase**: Post-acute phase involving stabilization and maintenance, with possible persistent cognitive and negative symptoms. **Comorbid Disorders** - **Cardiovascular disease, diabetes, COPD, and infectious diseases**: Increased risk. - **Substance abuse**: Common substances include alcohol, cannabis, and opioids. - **Depression and anxiety disorders**: Higher prevalence compared to the general population. - **Posttraumatic stress disorder**: Seen in some patients. **Collaboration** The management of schizophrenia is complex, involving clinical manifestations such as avolition and disordered thought processes, as well as limited access to quality mental health care. Cultural biases and provider judgments can also complicate diagnosis and treatment. **Diagnostic Tests** Diagnosis of schizophrenia involves a psychiatric evaluation, including a history, examination, and potentially the use of screening tools. The patient must meet DSM-5 criteria, showing significant impairment in one or more areas for 6 or more months. Other mental disorders and substance use must be ruled out. **Pharmacologic Therapy** - **Antipsychotics** are the primary treatment. Their goal is to reduce positive symptoms like hallucinations and delusions. They do not cure schizophrenia but can help patients manage symptoms and maintain social relationships. - **Adherence** to medication is crucial, as discontinuation significantly increases the risk of relapse. Challenges to adherence include denial, self-care deficits, and side effects. - **Life-threatening risks** associated with antipsychotics include an increased risk of suicide and severe health issues, particularly in older adults with dementia. Atypical antipsychotics have a black box warning against use in dementia-related psychosis. **Types of Antipsychotics** 1. **Typical Antipsychotics**: - **Mechanism**: Block postsynaptic D2 receptors. - **Adverse Effects**: Include anticholinergic effects (dry mouth, constipation), sexual dysfunction, endocrine effects, and extrapyramidal symptoms (EPS) such as akathisia, dystonia, secondary parkinsonism, tardive dyskinesia (TD), and neuroleptic malignant syndrome (NMS). Management may involve antiparkinsonian medications or discontinuation and supportive care for severe cases. 2. **Atypical Antipsychotics**: - **Mechanism**: Block D2 receptors and serotonin receptors. - **Advantages**: Lower incidence of EPS and TD. - **Adverse Effects**: Can include metabolic syndrome, cardiovascular issues, type 2 diabetes, and other severe health problems. 3. **Dopamine-System Stabilizers (DSSs)**: - **Mechanism**: Target both dopamine and serotonin receptors. - **Advantages**: Generally well tolerated with fewer side effects and can address affective symptoms like anxiety and depression. They are often used as adjunct therapy. **Adjunctive Medications** Patients may also receive antianxiety agents, antidepressants, and mood stabilizers as needed. **Adherence Technology** Aripiprazole (Abilify MyCite) features an ingestible sensor that helps track medication adherence through a smartphone app. ### Nonpharmacologic Therapy The recovery and rehabilitation model emphasizes individualized care for people with schizophrenia, integrating a variety of resources to support personal goals and strengths. Nurses will collaborate with psychiatrists, social workers, occupational therapists, psychologists, psychiatric rehabilitation specialists, and mental health workers. ### Family Intervention and Psychoeducation Family interventions, including psychoeducation and counseling, can help reduce relapse rates and improve family dynamics. Extended interventions combined with pharmacologic treatments yield the best outcomes. ### Social Skills Training Social skills training helps individuals with schizophrenia improve their ability to interact with others. One effective method is Social Cognition and Interaction Training (SCIT), which involves learning about emotions, understanding situations, and practicing skills over six months. ### Cognitive-Behavioral Therapy (CBT) CBT helps patients cope with symptoms through techniques like distraction, positive self-talk, and behavioral processes. Although its overall efficacy is debated, CBT can aid in symptom management and coping strategy development. ### Cognitive Remediation Cognitive remediation addresses cognitive deficits in schizophrenia through compensatory and drill-and-practice techniques. Strategies may include using computer programs and modifying the environment to support cognitive functions. ### Vocational Training Vocational training aims to enhance employability and functional capacity. Supported employment programs assist individuals in finding and maintaining jobs. ### Community Service Models 1. **Crisis Intervention**: Provides short-term, intensive care to address symptoms or behaviors impacting safety. Services may include medication adjustments, monitoring, or inpatient care. 2. **Case Management**: Coordinates care through a case manager who assesses needs, develops plans, and ensures quality care. 3. **Assertive Community Treatment (ACT)**: Offers comprehensive, collaborative care with frequent team interactions, available 24/7. ### Electroconvulsive Therapy (ECT) ECT may be used in treatment-resistant schizophrenia or emergency situations involving severe symptoms like depression, paranoia, or catatonia. It is most effective when combined with medication. ### Repetitive Transcranial Magnetic Stimulation (rTMS) rTMS uses an electromagnet to deliver pulses to the brain and is FDA-approved for depression. It may reduce auditory hallucinations in schizophrenia, though evidence is still emerging. ### Complementary Health Approaches Nutritional interventions and mind--body practices have not proven effective as primary treatments for schizophrenia. Omega-3 fatty acids show some promise in certain stages of the disease, but more research is needed. ### Lifespan Considerations Schizophrenia typically emerges in early adulthood. Early-Onset Schizophrenia (EOS) appears before age 18, and Late-Onset Schizophrenia (LOS) occurs after age 40. EOS may present with symptoms similar to developmental disorders, and its management involves similar treatments to those used in adults, with attention to developmental considerations and potential side effects. ### Late-Onset Schizophrenia (LOS) and Very-Late-Onset Schizophrenia (VLOS) **LOS:** - Onset after age 40; more common in women. - Predominant symptoms include paranoia, elaborate delusions, and hallucinations. - Cognitive and negative symptoms are less severe compared to earlier onset. - Patients often respond to lower doses of antipsychotic medication. **VLOS:** - Onset after age 60. - Lower genetic load, higher premorbid function. - Believed to be neurodegenerative with possible sociocultural factors. - Management includes lower-dose antipsychotics and psychosocial interventions. ### Nursing Process **Assessment:** - **Observation:** Look for deteriorating appearance, neglect of hygiene, weight loss, unusual gestures, pacing, incoherence, and smoking. - **Health History:** Includes age, family history, perinatal health, developmental delays, trauma, substance abuse, and history of mental illness. - **Physical Examination:** Evaluate overall condition, watch for metabolic or cardiovascular issues, drug/alcohol abuse, and side effects from medications. - **Mental Status Examination:** Monitor symptoms and consider cultural and religious background. **Diagnosis:** - Common needs include managing risks such as suicide and injury, addressing self-care deficits, improving communication, and enhancing coping skills. **Planning:** - Goals focus on symptom reduction, improving quality of life, and achieving life goals. - **Symptom Reduction:** Reduce hallucinations, disordered thoughts, and negative symptoms; ensure medication adherence. - **Quality of Life:** Improve self-care, sleep, avoidance of risky behaviors, and social interaction. **Implementation:** - **Prevent Injury:** Ensure a safe environment, manage medications, and monitor for suicidal behavior. - **Provide Symptomatic Treatment:** Orient patients, avoid overstimulation, and check adherence to treatment. - **Educate:** Inform about symptoms, treatments, medication side effects, and coping strategies; encourage healthier behaviors and social interactions. - **Advocate:** Ensure interventions are in the patient's best interest, and assist with advance directives. **Evaluation:** - Monitor symptoms, self-care, medication adherence, and overall safety. - Evaluate improvements in sleep, substance use, coping skills, social interactions, and emergency planning. **Patient Teaching:** - Guide families in effective communication techniques, such as using "I" language, active listening, and making specific, emotion-linked requests.