Schizophrenia Spectrum Disorders PDF

S c h i z o p h re n i a S p e ct r u m D i s o rd e rs Edward A. Herzog @ V i s it the Evo lve we b s ite fo r a p retest on...

S c h i z o p h re n i a S p e ct r u m D i s o rd e rs Edward A. Herzog @ V i s it the Evo lve we b s ite fo r a p retest on t h e c o ntent in t h i s c h a pte r: htt p ://evo lve. e l s e v i e r. c o m/V a rc a ro l i s 1. Identify the schizophrenia spectrum disorders. 5. Develop teaching plans for patients taking first-generation 2. Discuss at least three of the neurobiological findings that and second-generation antipsychotic drugs. indicate that schizophrenia is a brain disorder. 6. Create a nursing care plan incorporating evidence­ 3. Differentiate among the positive and negative symptoms of based interventions for symptoms of psychosis, schizophrenia in terms of treatment and effect on quality of including hallucinations, delusions, paranoia, cognitive life. disorganization, anosognosia, and impaired self-care. 4. Discuss how to deal with common reactions the nurse may 7. Demonstrate or role-play interventions for a patient who is experience while working with a patient with schizophrenia. hallucinating, delusional, and exhibiting disorganized thinking. O UT LINE Delusional Disorder, 1 92 Diagnosis, 2 0 1 Brief Psychotic Disorder, 1 92 Outcomes Identification, 2 0 1 Schizophreniform Disorder, 1 92 Phase I: Acute, 201 Schizoaffective Disorder, 1 92 Phase II: Stabilization, 202 Substance Induced Psychotic Disorder Phase III: Maintenance, 202 and Psychotic Disorder Due to Another Planning, 202 Medical Condition, 1 92 Phase I: Acute, 202 Schizophrenia, 1 92 Phase II: Stabilization and Phase III: Maintenance, 202 Clinical Picture, 1 92 Implementation, 202 Epidemiology, 193 Phase I: Acute, 202 Comorbidity, 193 Settings, 202 Risk Factors, 1 94 Interventions, 202 Biological Factors, 1 94 Working with an Aggressive Patient, 203 Genetic, 1 94 Phase II: Stabilization and Phase III: Maintenance, 203 Neurobiological, 1 94 Teamwork and Safety, 207 Brain Structure Abnormalities, 1 94 Activities and Groups, 208 Psychological and Environmental Factors, 1 94 Counseling and Communication Techniques, 208 Prenatal Stressors, 1 96 Intervening with Hallucinations, 208 Psychological Stressors, 1 96 Intervening with Delusions, 208 Environmental Stressors, 1 96 Intervening with Associative Looseness, 208 Prognostic Considerations, 1 96 Health Teaching and Health Promotion, 208 Phases of Schizophrenia, 1 96 Psychobiological Interventions, 21 0 Application of the Nursing Process, 1 96 Injectable Antipsychotics, 21 1 Assessment, 1 96 First-Generation Antipsychotics, 2 1 1 Prodromal Phase, 1 96 Other Side Effects of FGAs, 2 1 4 General Assessment, 197 Second-Generation Antipsychotics, 2 1 4 Positive Symptoms, 1 97 Side Effects of Second-Generation Antipsychotics, 214 Negative Symptoms, 1 99 Dangerous Antipsychotic Side Effects, 2 1 6 Cognitive Symptoms, 200 Advanced Practice Interventions, 21 7 Affective Symptoms, 200 Evaluation, 2 1 7 Self-Assessment, 200 Quality Improvement, 2 1 8 191 1 92 U N IT 4 Psyc h o b i o l o g i ca l D i s o rd e rs acute dystonia delusions neologism affect depersonalization neuroleptic malignant syndrome affective symptoms derealization paranoia akathisia echolalia positive symptoms anosognosia echopraxia prodromal phase anticholinergic toxicity executive functioning pseudoparkinsonism antipsychotic medication extrapyramidal side effects psychosis associative looseness hallucinations reality testing dang association illusions recovery model cognitive symptoms long-acting injectable tardive dyskinesia command hallucination metabolic syndrome word salad concrete thinking negative symptoms Schizophrenia spectrum disorders are disorders that share features SCHIZOAFFECTIVE DISORDER with schizophrenia. These disorders are characterized by psycho­ sis, which refers to altered cognition, altered perception, and/or This disorder is characterized by an uninterrupted period of ill­ an impaired ability to determine what is or is not real. This chapter ness during which there is a major depressive, manic, or mixed begins with an overview of schizophrenia spectrum disorders and episode, concurrent with symptoms that meet the criteria for then focuses on schizophrenia and associated nursing care. schizophrenia. The symptoms must not be caused by any sub­ stance use or abuse or general medical condition. It is about one-third as common as schizophrenia with a lifetime preva­ DELUSIONAL DISORDER lence of 0.3%. Delusional disorder is characterized by delusions that have lasted 1 month or longer. The delusions tend to have a general theme that includes grandiose, persecutory, somatic, and refer­ SUBSTANCE INDUCED PSYCHOTIC DISORDER ential delusions. These delusions are usually not severe enough AND PSYCHOTIC DISORDER DUE TO ANOTHER to impair occupational or daily functioning. Individuals with M EDICAL CONDITION this personality disorder do not tend to behave strangely or bizarrely. The lifetime prevalence of delusional disorder is fairly Substances such as drugs, alcohol, medications, or toxin expo­ low at around 0.2% sure can induce delusions and/or hallucinations. Hallucinations or delusions can also be caused by a general medical condition such as delirium, neurological problems, alterations, hepatic or BRIEF PSYCHOTIC DISORDER renal diseases, and many more. Substance use and medical con­ Brief psychotic disorder is characterized by the sudden onset of at ditions should always be ruled out before a primary diagnosis of least one of the following: delusions, hallucinations, disorganized schizophrenia or other psychotic disorder is made. speech, and disorganized or catatonic (severely decreased motor activity) behavior. The symptoms must last longer than 1 day, but SCHIZOPHRENIA no longer than 1 month with the expectation of a return to nor­ mal functioning. Brief psychotic disorder accounts for about 9% CLINICAL PICTURE of all first-time psychoses and is twice as common in females. In about 75% of those with schizophrenia the disorder devel­ ops gradually, usually presenting between 1 5 and 25 years of age SCHIZOPHRENIFORM DISORDER (Dean et al., 2016). However, there are also child-onset (before 1 5 The essential features of this disorder are exactly like those of years) and late-onset (after 4 0 years) forms as well. People who schizophrenia, except that symptoms last a much shorter period later develop schizophrenia often experience a prodromal phase of time (less than 6 months). Also, impaired social or occupa­ during which some milder symptoms of the disorder develop, tional functioning during some part of the illness is not apparent often months or years before the disorder becomes fully apparent (although it might occur). It is difficult to know the prognosis of (Miller, 20 1 6). During the prodromal phase the person may do a schizophreniform disorder because some individuals return less well in school than his or her peers, be less socially engaged to their previous level of functioning, while others have a more or adept, and demonstrate memory impairment, suspiciousness, difficulties in moving forward. and/or disorganization or oddities in speech or thought.  CHAPT E R 1 2 S c h i zo p h re n i a S p ect r u m D i s o rd e rs 1 93 All people diagnosed with schizophrenia have at least one M u ltiple episodes, currently i n acute episode: M u ltiple episodes may psychotic symptom such as hallucinations, delusions, and/ be determ ined after a m i n i m u m of two episodes ( i. e. , after a first episode, a or disorganized speech or thought. The symptoms are severe rem ission and a m i n i m u m of one re lapse). enough to disrupt normal activities such as school, work, fam­ M u ltiple episodes, c u rrently i n partia l rem ission ily and social interaction, and self-care; in children and young M u ltiple episodes, c u rrently i n fu l l rem ission adults they often delay or halt achievement of age-appropriate Conti nuous: Symptoms fulfi l l i n g the diag nostic symptom criteria of the d is­ milestones. Basic needs such as hygiene, nutrition, and health­ order a re rema i n i n g for the majority of the i l l ness course with subthreshold care are often neglected, and socialization and relationships are symptom periods being very brief relative to the overa l l course. often disrupted. The full criteria for schizophrenia are listed in U nspecified the DSM-5 box. Specify if: With catatonia Specify current severity: Severity is rated by a qua ntitative assessment of the primary sym ptoms of psychosis, including delusions, h a l l ucinations, disorganized D S M -5 CRITERIA FOR S C H I ZO P H R E N IA speech, abnormal psychomotor behavior, and negative sym ptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on A. Two or more of the fo l lowing, each present for a sign ificant portion of time a 5-point sca l e ranging from 0 (not present) to 4 (present and severe). d u ring a 1 -m onth period (or less if successfu l ly treated). At l east one of From American Psyc h i atric Associatio n. (2 0 1 3 ). Diagnostic and sta tisti­ these must be ( 1 1. 121. or (3): cal manual of mental disorders (5th ed. ). Wa s h i ngton, D C : Author. 1. D e l usions. 2. H a l l ucinations. 3. D isorgan ized speech (e.g., frequ ent dera i l m e nt or incoherence). 4. G rossly disorganized o r catatonic behavior. EPIDEM IOLOGY 5. N egative sym ptoms ( i.e., d i m i n ished emoti onal expression or avo l ition). The prevalence of childhood-onset schizophrenia is about 1 in B. For a sign ificant portion of the time since the onset of the distu rbance, 40,000 children. It affects individuals of all races and cultures l evel of functi oning in one o r more major a reas, such a s work, i nterper­ equally. It is diagnosed more frequently in males ( 1.4: 1 ) and sonal re lations, or se lf-care, is markedly below the l eve l achieved before among individuals growing up in urban areas (Haddad et al., the onset (or when the onset is in c h i l dhood o r a d o l escence, there is fa i l ­ ure to achieve expected l eve l o f i nterpersona l , academic, or occupationa l 2 0 1 5 ). Onset in males is usually between the ages of 1 5 and 25 functioning). years and is associated with poorer functioning and more struc­ C. Continuous signs of the d isturbance persist for at least 6 months. This tural abnormality in the brain. The onset tends to be somewhat 6-month period must include at least 1 month of sym ptoms (or less if suc­ later in women (ages 25 to 35 years), who tend to have a better cessfu lly treated) that meet Criterion A (i.e., active-phase symptoms) and may prognosis and experience less structural changes in the brain. include periods of prodromal or residual symptoms. D u ring these prodromal or residual periods, the signs of the d isturbance may be manifested by only negative symptoms or by two or more sym ptoms listed in Criterion A present COM ORBIDITY in an attenuated form (e.g., odd beliefs. unusual perceptua l experiences). Substance use disorders, particularly alcohol and marijuana, D. Schizoaffective d i sorder and d epressive or bipolar disorder with psychotic occur in nearly half of affected individuals. Substance use is asso­ features have been ruled out because either ( 1 ) no major depressive or ciated with higher rates of treatment nonadherence, relapse, manic episodes have occu rred concu rrently with the active-phase symp­ toms, or (2) if mood episodes have occu rred d u ring active-phase symp­ incarceration, homelessness, violence, suicide, and a poorer prog­ toms, they have been present for a minority of the tota l d u ration of the nosis (Marquez-Arrico et al., 20 1 5). About 60% of individuals with active a n d resi d u a l periods of the i l l ness. schizophrenia use nicotine, possibly due to genetically mediated E. The d i sturbance is not attri buta ble to the physiological effects of a sub­ causes or as a form of coping with cognitive impairment or anx­ sta nce (e.g., a drug of abuse, a med ication) or another medical condition. iety (Akbarian & Kundakovic, 20 1 5). Smoking doubles the risk of F. If there is a h i story of a utism spectrum d isorder or a commun ication cancer and contributes to cardiovascular and respiratory disorders. d i sorder of chi ldhood onset, the additional d iagnosis of schizophrenia is Anxiety, depression, and suicide co-occur frequently in made only if prominent del usions or h a l l ucinations. i n addition to the othe r schizophrenia. At least 20% of people with schizophrenia req u i red sym ptoms of schizophren ia, a re a lso present f o r at least 1 month attempt suicide while 5% to 10% die by suicide, a rate five times (or less if successfu l ly treated). that of the general population. Suicide attempts are more com­ Specify if: The fo l l owing course specifiers a re only to be used after a 1 -yea r mon within 3 years of diagnosis and especially upon discharge d u ration of the disorder and if they a re not in contra d iction to the diagnostic course criteri a. after the first episode of the schizophrenia but can occur at any Fi rst episode, currently i n acute episode: Fi rst man ifestation o f the point in the illness (American Psychiatric Association, 2 0 1 3 ). d isorder meeting the defining diag nostic symptom a n d time criteria. An acute Physical illnesses are more common among people with episode is a time period in which the symptom criteria a re fulfi l led. schizophrenia than in the general population. The risk of pre­ Fi rst episode, currently i n partia l rem ission: Partial remission is mature death due to medical illness is 3.5 times greater than that a period of time d u ring which a n i m provement after a previous episode is in the general population, and on average, patients with schizo­ m a i nta ined and i n which the defining criteria of the disorder a re only parti a l ly phrenia die more than 20 years prematurely (Rao et al., 2 0 1 5 ). fulfi l l e d. Individuals with psychotic disorders may be at greater risk of Fi rst episode, currently in f u l l rem ission: Full remission is a period of poor health maintenance behaviors, poor nutrition, substance time after a previous episode d u ring which no d isorder-spec ific sym ptoms a re use, medication effects, poverty, limited access to healthcare, present. and reduced ability to recognize or respond to signs of illness. 1 94 U N IT 4 Psyc h o b i o l o g i ca l D i s o rd e rs They may also receive poorer quality health care due to poverty, reduce dopamine activity do not alleviate all the symptoms of stigma, impaired ability to express their needs, or stereotyping schizophrenia, it seems likely that other neurotransmitters or (e.g., emergency room staff assuming that chest pain is imagi­ other factors are involved as well. nary or not serious). Other neurochemical hypotheses. Second-generation (atypi­ Polydipsia is compulsive drinking of excess fluids. It occurs cal) antipsychotics block serotonin (5-hydroxytryptamine 2A, in up to 20% of individuals with schizophrenia and causes hypo­ or 5-HT2A) and dopamine, which suggests that serotonin may natremia (also known as water intoxication) in 2% to 5%. Symp­ play a role in schizophrenia as well. toms include confusion, delirium, hallucinations, worsening of Phencyclidine (PCP) induces a state that resembles schizo­ existing psychotic symptoms, and ultimately coma. Contributing phrenia. This observation led to interest in the N-methyl-o-as­ factors include antipsychotic medication (causes dry mouth), partate (NMDA) receptor complex and the possible role of compulsive behavior (present in some with schizophrenia), and glutamate in the pathophysiology of schizophrenia. Glutamate, neuroendocrine abnormalities (Goldman, 2009). One should dopamine, and serotonin act synergistically in neurotransmis­ consider the possibility of hyponatremia when there is a sudden sion and thus glutamate may also play a role in causing psychosis increase in psychotic symptoms, particularly if delirium (e.g., dis­ (Andreou et al., 2 0 1 5 ). Neurotransmission by another calming orientation, restlessness, fluctuating vital signs) is also present. neurotransmitter, gamma-aminobutyric acid (GABA), is also impaired in schizophrenia (Frankie et al., 2 0 1 5). Acetylcholine, active in the muscarinic system, may play a role in psychosis. RIS K FACTORS What has traditionally been called schizophrenia is now believed B ra i n Stru cture A b n o rma l ities to be a group of disorders with common overlapping etiologies. It is possible that structural abnormalities cause disruption in People with schizophrenia demonstrate differences in brain communication within the brain. Structural differences may chemistry, structure, and neurotransmission. This variation in be due to errors in neurodevelopment or errors in the normal etiologies makes it difficult to identify reliable neurostructural pruning of neuronal tissue that happens in late adolescence and or neurochemical variations that could be used to identify indi­ early adulthood. Inflammation or neurotoxic effects from fac­ viduals at high risk for developing schizophrenia. tors such as oxidative stress, infection, or autoimmune dysfunc­ The diathesis-stress model is probably the best explanation tion may also alter the brain's structure (Sekar et al., 2 0 1 6). for the existence of this disorder (Berry & Cirulli, 2 0 1 6). Schizo­ Using brain imaging techniques-computed tomography phrenia occurs when multiple inherited gene abnormalities (CT), magnetic resonance imaging (MRI), functional MRI combine with nongenetic factors. These factors include viral (fMRI), and positron emission tomography (PET)-researchers infections, birth injuries, environmental stressors, prenatal mal­ (Dean et al., 2 0 1 6) demonstrated structural brain abnormalities nutrition, and abnormal neural pruning that alters brain devel­ including: opment or function and/or injure the brain directly. Reduced volume in the right anterior insula (may contribute to negative symptoms) B i o l o g i c a l Facto rs Reduced volume and changes in the shape of the hippo cam­ G e n et i c pus Schizophrenia-spectrum disorders are inherited. About 80% Accelerated age-related decline in cortical thickness of the risk of schizophrenia comes from genetic and epigene­ Gray matter deficits in the dorsolateral prefrontal cortex area, tic factors (factors such as toxins or psychological trauma that thalamus, and anterior cingulate cortex, as well as in the fron­ affect the expression of genes). Over 1 00 loci in the human totemporal, thalamocortical, and subcortical-limbic circuits genome are associated with an increased risk of schizophrenia Reduced connectivity among various brain regions (Castellani et al., 2 0 1 5). Concordance rates (i.e., the percentage Neuronal overgrowth in some areas, possibly due to inflam­ of a shared disorder in twins) are about 50% for identical twins mation or inadequate neural pruning and about 1 5% for fraternal twins. Evidence suggests that mul­ Widespread white matter abnormalities (e.g., in the corpus tiple genes on different chromosomes interact with one another callosum) in complex ways to create vulnerability for schizophrenia. PET scans also show a lowered rate of blood flow and glucose metabolism in the prefrontal cortex. This executive functioning N e u ro b i o l o g i c a l part of the brain governs planning, abstract thinking, social adjust­ Dopamine theory. The first antipsychotic drugs, known as ment, and decision making. Fig. 3.5 in Chapter 3 shows a PET first-generation (typical) antipsychotics, (e.g., haloperidol scan demonstrating reduced brain activity in the frontal lobe of a and chlorpromazine), block the activity of dopamine-2 patient with schizophrenia. Such structural and functional changes (D2) receptors in the brain and reduce symptoms such as may worsen as the disorder continues. Postmortem studies show a hallucinations and delusions. Symptom reduction suggested reduced volume of gray matter, especially in the temporal and fron­ that dopamine plays a significant role in psychosis. tal lobes. People with the most tissue loss had the worst symptoms. Amphetamines and cocaine can induce psychosis in peo­ ple without schizophrenia and can also bring on the disorder. Psyc h o l o g i c a l a n d Enviro n m e nta l Fa ctors Almost any drug of abuse, particularly marijuana, can increase A number of biological, chemical, and environmental stressors the risk of schizophrenia in biologically vulnerable individu­ are believed to combine with genetic vulnerabilities to produce als (Morgan et al., 2 0 1 6). However, because medications that schizophrenia.  CHAPT E R 1 2 S c h i zo p h re n i a S p ect r u m D i s o rd e rs 1 95 Neurobiology of Schizophrenia and the Effects of Anti psychotics The anti psychotics affect a n u m ber of neu rotransmitters including dopam i n e , norad renaline/norepinephrine, seroton i n , and GABA. An excess of seroton i n may contribute to both the positive and negative symptoms of schizoph ren ia. GABA reg u l ates dopam i n e activity and i n some people with schizop h renia, there is a loss of GABAerg ic n e u rons i n the h i ppocam pus, potentially causing hyperactivity of dopam i n e. S i nce dopam ine is the most studied and most promi nent o f the neu rotransmitters (01 , 02, 03, 04, and 05) i n schizop h renia, the role of dopamine is p rese nted here. Frontal cortex Mesocortical pathways Tuberoinfu n d i b u lar Dopam ine Pathways I n Sch izophrenia Meso l l m blc pathway: reward motivation, emotions and positive symptoms of schizop h renia. Mesocortical pathways: relevant to cogn itive fu nction and executive function and negative symptoms of schizoph re nia. N i g rostriata l : normally responsible for pu rposeful movement. Tubero i nfu n d i bular: normally responsible for reg u l ation of prolacti n. Fi rst-generation anti psychotic ( FGA) d rugs are potent antagonists/blockers o f 02. Second-generation anti psychotics (SGA) have less affin ity for 02 receptors, and tend to bind with 03 and 04 receptors. S i nce the expression of 03 and 04 is l i m ited to the n e u rons of the l i mbic system and cerebral cortex, the action of these drugs are limited to areas i nvolved i n the pathology of schizop h renia. Second-generation drugs also i n h ibit the seroto n i n (5HT) receptors. S i nce serotonin i n h ibits the release of dopamine, the dopam i n e rgic transmission is affected. The pote ntial serious effects of the SGA's (metabolic effects: weight gain, diabetes, and dysli pidem ia) come from the blockade of norad renaline/norepinephrine (alpha- 1 ) , histamine, and acetylchol ine. Dopamine Pathways and Anti psychotic Responses Dopamine Pathway Abnormal ity in Schizophren ia Responses to Anti psychotic Drugs Mesol i m b i c pathway connects the Hyperactive i n schizophrenia FGA - 02 blockage results i n red uction i n positive VTA to the n ucleus accu m bens Associated with positive symptoms Associated with reward, motivatio n , and symptoms (halluci nations, SGA - 03 and 04 antagonism resu lts i n red uction of emotion delusions, disorganized positive symptoms thoug ht) Mesocortical pathway made u p of Hypofunction i n schizophrenia FGA - 02 blockage may result i n a worsen i n g of dopami nerg ic neurons that project resu lts i n cogn itive impairment these symptoms from the ventral tegmental area to and negative symptoms SGA - S i nce there are more seroto n i n (5 HT) the prefrontal cortex (apathy, anhedonia, lack of receptors than 02 receptors in this area, blockage of Relevant to cog n ition, executive motivation) 5HT is more profou nd. Blockage of 5HT may help function , emoti ons, and affect improve negative symptoms Tuberoi nfu ndibular pathway consists U n affected FGA (to a less degree SGA) - Blockade of 02 of dopaminergic projections from the receptors increases prolactin levels resulting in hypothalamus to the pituitary gland hyperprolactinemia and lactation I n h i bits prolacti n release N i g rostriatal pathway-su bstantial U n affected FGA (to a lesse r degree SGA) - Long-term blockade n i g ra to basal ganglia of 02 receptors can cause u p regu lation (increase Responsible for pu rposeful movement response to a sti m u l us) to those receptors, which may lead to extrapyramidal side effects e. g. , tardive dyskinesia (TO) 1 96 U N IT 4 Psyc h o b i o l o g i ca l D i s o rd e rs Pren ata l Stresso rs schizophrenia. Symptoms appear a month to more than a Infection during pregnancy increases the risk of mental illness in year before the first full-blown episode of the illness. During the child. Prenatal infections in the mother also increase the risk this phase speech and thought may be odd or eccentric. Anx­ of infection in the child after birth, and those infections in the chil­ iety, obsessive thoughts, and compulsive behaviors may be dren also can make them more vulnerable to mental illness (Blom­ present. Deterioration in concentration, school or job perfor­ strom et al., 20 1 6). Other factors associated with an increased risk mance, and social functioning are accompanied by distressing of schizophrenia include a father older than 35 at the child's con­ thoughts, suspiciousness, memory impairment, and signifi­ ception and a child's being born during late winter or early spring. cant disorganization in speech or behavior. The person may feel that he or she is "not right" or that "something strange'' is Psyc h o l o g i c a l Stresso rs happening. Stress increases cortisol levels, impeding hypothalamic develop­ Acute- Later symptoms vary, from few and mild to many ment and causing other changes that may precipitate the illness and disabling. Symptoms such as hallucinations, delusions, in vulnerable individuals. Schizophrenia often manifests at times apathy, social withdrawal, diminished affect, anhedonia, of developmental and family stress such as beginning college or disorganized behavior, impaired judgment, and cognitive moving away from one's family. Social, psychological, and phys­ regression result in functional impairment. As symptoms ical stressors may play a significant role in both the severity and worsen the person has difficulty coping, and symptoms once course of the disorder and the person's quality of life. concealed become apparent to others. Increased support or Other risk factors include childhood sexual abuse, expo­ hospitalization may be required. sure to social adversity (e.g., chronic poverty), migration to or Stabilization- Symptoms are stabilizing and diminishing, and growing up in a foreign culture, and exposure to psychological there is movement toward a previous level of functioning (base­ trauma or social defeat (Evans et al., 2 0 1 5 ). These factors may line). Care in an outpatient mental health center or partial hospi­ cause structural changes in the brain via epigenetic changes to talization program (which includes many of the services offered the genome. Even psychological trauma in a parent or grand­ in inpatient mental health units, but without an overnight stay parent may cause epigenetic changes that increase vulnerability, in the hospital) may be needed. The person may receive care and this increased risk can be passed on to one's descendants. in a residential crisis center (similar to a mental health unit but based in the community and less restrictive in nature) or a Enviro n m e nta l Stressors staff-supervised residential group home or apartment. Environmental factors such as toxins, including the solvent Maintenance or Residual- The condition has stabilized and tetrachloroethylene (used in dry cleaning, to line water pipes, a new baseline is established. Positive symptoms (which will and sometimes found in drinking water), are also believed to be described later) are usually absent or significantly dimin­ contribute to the development of schizophrenia in vulnera­ ished, but negative and cognitive symptoms continue to be a ble people (Aschengrau et al., 2 0 1 2 ). Living in urban areas or concern. Ideally, recovery with few or no residual symptoms high-crime environments is also believed to increase the risk of will occur, and the patient is again able to live independently schizophrenia (Haddad et al., 2 0 1 5 ). or with family. A pattern of recurrent exacerbations (worsening of symptoms) Pro g n ost i c C o n s i d e rations separated by periods of reduced or dormant symptoms is com­ For most individuals symptoms improve with medications mon. Some people have several episodes and none thereafter. For and psychosocial interventions. As a result, many people with most patients, however, schizophrenia is a chronic disorder that, schizophrenia experience a good quality of life and success like diabetes or heart disease, is managed with ongoing treatment. within their families, occupations, and other roles. In many cases, schizophrenia does not respond fully to treat­ APPLICATION OF THE NURSING PROCESS ments, leaving mild to severe residual symptoms and varying degrees of dysfunction or disability. A minority of individuals ASSES S M ENT requires repeated or lengthy inpatient care or institutionaliza­ tion. Factors associated with a less positive prognosis include a Assessment involves interviewing the patient and observing slow onset (e.g., more than 2 to 3 years), younger age at onset, behavior and other manifestations of the disorder. Information longer duration between first symptoms and first treatment, from others who know the patient is also important as patients longer periods of untreated illness, and more negative symp­ may conceal or minimize symptoms. Assessment should include toms. Reducing the frequency, intensity, and duration of relapse a mental status examination along with review of spiritual, (when previously controlled symptoms return) is believed to cultural, biological, psychological, social, and environmental improve the long-term prognosis. elements that might be affecting the presentation. Trust, a ther­ apeutic nurse-patient relationship, sound therapeutic commu­ Phases of S c h izo p h re n i a nication skills, and an understanding of the disorder and what Schizophrenia usually progresses through predictable phases, patients may be experiencing all strengthen the assessment. although the presenting symptoms during a given phase and the length of the phase can vary widely. These phases are: Prodromal Phase Prodromal- Mild changes in thinking, reality testing, Early assessment plays a key role in improving the prognosis and mood, insufficient to meet the diagnostic criteria for for individuals with schizophrenia. Intervening at this early  CHAPT E R 1 2 S c h i zo p h re n i a S p ect r u m D i s o rd e rs 1 97 stage to reduce risk factors such as high levels of stress and sub­ Genera l Assessment stance abuse, coupled with enhancing social and coping skills, Not all people with schizophrenia have the same symptoms, and can reduce the risk of developing schizophrenia in biologically some of the symptoms of schizophrenia are also found in other vulnerable people. Box 12. 1 identifies other schizophrenia pre­ disorders. Fig. 12. 1 describes the four main symptom categories vention strategies during this phase. in schizophrenia: 1. Positive symptoms: The presence of something that should not be present. Positive symptoms include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech. 2. Negative symptoms: The absence of something that should M a l n utrit i o n , i nfecti o n , a n d tobacco use d u ri n g p r e g n a n cy, a n d m a ri j u a n a be present. Negative symptoms include the inability to enjoy a n d d r u g use i n b i o l o g i ca l ly v u l n e ra b l e p e o p l e i n c rease the risk of d e v e l ­ activities, social discomfort, or lack of goal-directed behavior. o p i n g schizoph re n i a. P r i m a ry p reve ntion a i m s at avo i d i n g these fa ctors. 3. Cognitive symptoms: Subtle or obvious impairment in H owever, not a l l risk factors c a n be avo i d e d. Avo i d i n g tri g g e rs , such as memory, attention, thinking (e.g., disorganized or irrational environmental stressors, and interventions to promote res i l i e ncy a n d c o p i n g i n c h i l d re n a n d fa m i l ies, a re h e l pfu l. Two a d d i t i o n a l o p t i o n s a re thoughts), judgment, or problem solving. ( 1 ) e a r l y treatment with a n t ip sychotic m e d ications a n d ( 2 ) s u p p l e m e nta l 4. Affective symptoms: Symptoms involving emotions and essentia l fatty a c i d s. their expression. Assessment t o o l s h e l p to identify prodro m a l (ea rly) sym ptoms s u c h as eccentric or magica l thinking, cogn itive disorgan ization, or quasi-h a l l ucina­ Positive Symptoms tions. Once at-risk sym ptoms a re identified, antipsychotic med ications may The positive symptoms usually appear early. Their dramatic reduce the d eve lopment or severity of schizophre n ia. Controversial ly, only one­ nature captures our attention and is often what precipitates third of those deemed at risk for schizophrenia actua l ly d eve lop the disorder. treatment. These symptoms are what most individuals associate Prophylactic a nti psychotic use can unnecessa rily expose people to sign ificant with mental illness, making schizophrenia the classic "crazy" side effect risks. disorder. Positive symptoms include: M o re promising is the use of omega-3 a nd omega-6 polyu nsatu rated fatty Alterations in Reality Testing. We all experience thoughts acids found in fish o i l s and oily fish such as tuna, sa lmon, and sard i nes. These fats a re a bnorm a l l y low i n the bra i n s of people with schizophrenia. They that are irrational or distorted, yet we can usually catch and reduce infl a m mation and free radicals i n the bra i n and contribute to ACH and correct the error by using reality testing. Reality testing is the seroto n i n sta b i l ity. Pre l i m i n a ry evid ence suggests that fatty acid supplements automatic and unconscious process by which we determine reduce rates of conversion from "at risk" to actua lly having schizophrenia from what is and is not real. You might think you hear a voice but 27% to 5 %. you see that no one is present. You conclude you are mistaken­ it wasn't real. With impaired reality testing the person believes Ko h l er, C. , B o rg m a n n-Winter, K. E. , H u rford, I , N e u stadter, E , Yi, J. , & C a l k i n s , M. E. ( 2 0 1 4). Is preve ntion a rea l i stic goa l for s c h i z o p h re n i a ? that hallucinations or delusions are real. Current Psychiatry Reports, 6 , 439. Delusions are false beliefs held despite a lack evidence to support them. The most common delusions involve persecutory, grandiose, Positive Symptoms Negative Symptoms Halluci nations Blunted affect Delusions Poverty of thought (alogia) Disorgan ized speech Loss of motivation (avol ition) (associative looseness) Inabil ity to expe rience pleasure Bizarre behavior or joy (anhedonia) Cognitive Symptoms I nattention, easily distracted Affective Symptoms Impaired memory Poor problem-solving skills Dysphoria Poor decision-making ski lls Suicidal ity I l logical thinking Hopelessness Impaired j udgment All dimensions alter the individual's Abil ity to work I nterpersonal relationsh ips Self-care abil ities Social functioning Qual ity of l ife F I G. 1 2. 1 F o u r m a i n symptom g ro u ps of s c h i z o p h re n i a. 1 98 U N IT 4 Psyc h o b i o l o g i ca l D i s o rd e rs or religious ideas. Table 1 2. 1 provides definitions and examples of Neologisms are words that have meaning for the patient but types of delusions. Delusions can reflect underlying issues or needs a different or nonexistent meaning to others. A person may use (e.g., a person with poor self-esteem may believe he is Beethoven or a known word differently than others understand it or can cre­ God, possibly driven by a need to feel more beloved or powerful). ate a completely new word that others do not understand (e.g., Just because someone has a mental illness does not mean that "His mannerologies are poor"). every story that sounds improbable is delusional. One patient Echolalia is the pathological repeating of another's words, repeatedly told the staff that the Mafia was out to kill him. The occurring perhaps because the patient's thought processes are staff later learned that he had been selling drugs and had not paid so impaired that he is unable to generate speech of his own. his drug sources, and that drug dealers were trying to harm him. Nurse: Mary, come get your medication. Alterations in Speech. A striking positive symptom of Mary: Come get your medication. schizophrenia spectrum disorders is the use of unusual Other pathological speech patterns are: speech patterns. One of the most common, associative Circumstantiality: Including unnecessary and often tedious looseness, or looseness of association, results from haphazard details in conversation but eventually reaching the point. and illogical thinking where concentration is poor and Tangentiality: Wandering off topic or going off on tangents individuals loosely associate their thoughts. For example: "I and never reaching the point. need to get a Band-Aid. My friend was talking about AIDS. Cognitive retardation: Generalized slowing of thinking, Friends talk about French fries but how can you trust the which is represented by delays in responding to questions or French?" A word salad, the most extreme form of associative difficulty finishing thoughts. looseness, is a jumble of words that is meaningless to the Pressured speech: Urgent or intense speech; resists allowing listener (e.g., "throat hoarse strength of policy highlighters comments from others. on a boat reigning supreme"). Flight of ideas: Moving rapidly from one thought to the next, Clang association i s choosing words based o n their sound often making it difficult for others to follow the conversation. rather than their meaning and often involves words that rhyme Symbolic speech: Using symbols instead of direct commu­ or have a similar beginning sound ("On the track... have a Big nication. For example, a patient reports "demons are sticking Mac" or "Click, clack, clutch, close"). needles in me" when what he means is that he is experienc­ ing a sharp pain (symbolized by "needles"). Thought blocking: A reduction or stoppage of thought. Interruption of thought by hallucinations can cause this. Delusion Defi n ition Exam le Thought insertion: The uncomfortable belief that someone Persecutory Bel ieving that one is being Shannon believes that her food else has inserted thoughts into the brain. singled out for harm, or is poisoned; therefore, she Thought deletion: A belief that thoughts have been taken or prevented from making eats only prepackaged food. are missing. progress, by others John believes co-workers p l ot Other positive symptoms manifested in disorders of thought to prevent hi s promotion. include: Referentia l A b e l i e f that events or Barbara believes that the birds Magical thinking: Believing that thoughts or actions affect circumstances that have sing songs to cheer her up. others. This is common and usually nonpathological in chil­ no connection to you a re Andrea believes songs on the somehow related to you rad io a re chosen to send her a dren (e.g., wearing pajamas inside out to make it snow, or message. because I was mad at him, he fell down). Grandiose Bel ieving that one is a very Brianna believes she is a fa mous Paranoia: An irrational fear, ranging from mild (wary, guarded) powerfu l or im porta nt playwright. to profound (believing irrationally that another person intends person to kill you). Fear may result in defensive actions, harming Erotomanic Bel ieving that another Although he barely knows her, another person before that person can harm the patient. person desires you Patty insists that Eric wou l d Alterations in perception. Alterations in perception involve romantica l l y ma rry her if only his cu rrent errors in how one interprets perceptions or perceives reality. wife would stop interfering. The most common perceptual errors are hallucinations. N i h l istic The convicti on that a Larry g ives away a l l h is belong- Hallucinations occur when a person perceives a sensory major catastrophe will ings since they won't be of any experience for which no external stimulus exists (e.g., hearing a occu r u s e w h e n t h e comet h its. Somatic Believing that the body is Chris says her heart is dead an d voice when no one is speaking). Types of hallucination include: changing in unusual ways rotting away. Auditory: Hearing voices or sounds Control Bel ieving that another per- Brian covered h is apartment Visual: Seeing people or things son, group of individuals, wa l l s with a l u m i n u m foi l to Olfactory: Smelling odors or externa l force contro ls block a l iens' efforts to control Gustatory: Experiencing tastes thoug hts, fee l i ngs, h is thoughts. Tactile: Feeling bodily sensations (e.g., feeling an insect impu lses, or behavior crawling on one's skin) A fa lse b e l ief held rega rd l ess of evidence to t h e contra ry. N ote that Auditory hallucinations, the most common form in schizo­ u n u s u a l b e l i efs that stem from o n e ' s c u l t u re o r s u bc u ltu re a re not phrenia, are experienced by more than 60% of people with c o n s i d e red d e l u s i o n s. schizophrenia (Waters, 2014). They may be vague sounds or  CH APTE R 1 2 S c h i z o p h re n i a S p e ct r u m D i s o r d e rs 1 99 indistinct or clear "voices:' Hallucinations seem to come from Alterations in Beha vior. Alterations in behavior involve outside the person's head. Auditory processing areas of the brain changes in the speed of movement and behaviors that are are activated during these hallucinations just as they are when a illogical or inappropriate including: genuine sound is heard. Catatonia: A pronounced increase or decrease in the rate and John Nash, the world-renowned mathematician with schizo­ amount of movement. Excessive motor activity is purpose­ phrenia portrayed in the film A Beautiful Mind (200 1 ) , describes less and accompanied by echolalia (repeating others' words) his hallucinations: and echopraxia (mimicking others' movements). The most common form of catatonia is when the person moves little or I thought of the voices as... something a little different from aliens. I thought of them more like angels... It's really my not at all. Muscular rigidity, or catalepsy, may be so severe that the limbs remain in whatever position they are placed. subconscious talking; it was really that, I know that now. Freezing in place may result in problems such as exhaustion, Internal voices may be single or multiple, distinct or indistinct, pneumonia, blood clotting, malnutrition, or dehydration. and can be attributed to specific sources (e.g., God, a family mem­ Waxy flexibility: Maintaining a given posture inappropri­ ber) or unrecognized. They may be supportive and pleasant or ately, usually seen in catatonia. For example, when the nurse derogatory and frightening. They can be subtle and unobtrusive raises the arm, the patient continues to hold this position in or intrusive and highly distressing. Hallucinations commenting a statue-like manner. on the person's behavior or conversing with the person are com­ Motor retardation: A pronounced slowing of movement. mon. Indications that a person is hallucinating include tracking Motor agitation: Excited behavior such as running or pac­ motions (turning one's head in the direction of the perceived ing rapidly, often in response to internal or external stimuli. sound), lips moving silently, talking as if to another when no one The agitation can put the patient at risk (e.g., exhaustion, is present, and otherwise unexplained changes in affect (e.g., sud­ running into traffic) or others at risk (being knocked down). denly laughing without apparent reason). Stereotyped behaviors: Repetitive behaviors that do not A person who hears voices struggles to understand the expe­ serve a logical purpose. rience, sometimes developing related delusions to explain the Echopraxia: The mimicking of movements of another. voices (e.g., believing the voices are from God or due to a device Negativism: A tendency to resist or oppose the requests or implanted by the CIA). Patients may attempt to cope by drown­ wishes of others. ing out auditory hallucinations with loud music or by compet­ Impaired impulse control: A reduced ability to resist one's ing with them by talking loudly, humming, or singing. Such impulses. Examples include interrupting in the group setting auditory competition may, in fact, reduce hallucinations and or throwing unwanted food on the floor. It can increase the serve as a recommended intervention. risk of assault. A command hallucination is a particularly disturbing Gesturing or posturing: Assuming unusual and illogical symptom that directs the person to take an action. This type expressions (often grimaces) or positions. of hallucination must be monitored carefully because they may Boundary impairment: An impaired ability to sense where be dangerous, for example, telling a patient to "jump out the one's body or influence ends and another's begins. For exam­ window" or "hit that nurse:' Command hallucinations are often ple, a patient might stand too close to others or might drink frightening and may be a warning flag for a psychiatric emer­ another's beverage, believing that because it is near, it is theirs. gency. It is essential to assess what the patient hears, the ability to recognize the hallucination as "not real," and the patient's abil­ N e g ative Symptoms ity to resist any commands. Positive symptoms are so attention-getting, they make treatment Visual hallucinations are the second most common form seem more urgent than negative symptoms. Yet negative symp­ in schizophrenia. They may involve distortion of visual stimuli toms are serious problems for people with schizophrenia because or can be formed and realistic images. Seeing individuals and they are the absence of essential human qualities. Treating nega­ animals are most common. tive symptoms is more difficult than treating positive symptoms. Olfactory, tactile, or gustatory hallucinations are unusual Negative symptoms include the following six symptoms that in mental illness. When present, other causes should be all start with the letter A: investigated. Anhedonia (an = without + hedonia = pleasure): A reduced Other alterations in perception are: ability or inability to experience pleasure in everyday life. Illusions: Misperceptions or misinterpretations of a real Avolition (a = without + volition = making a decision) : Loss of experience. For example, a man sees a coat on a shadowy motivation; difficulty beginning and sustaining goal-directed coat rack and believes it is a bear. activities; reduction in motivation or goal-directed behavior. Depersonalization: A feeling of being unreal or having lost Asociality: Decreased desire for, or comfort during, social identity. Body parts do not belong or the body has drastically interaction. changed (e.g., a patient may see the fingers as being smaller Affective blunting: Reduced or constricted affect. or not theirs). Apathy: A decreased interest in, or attention to, activities or Derealization: A feeling that the environment has changed beliefs that would otherwise be interesting or important. (e.g., everything seems bigger or smaller or familiar sur­ Alogia: Reduction in speech, sometimes called poverty of roundings seem somehow strange and unfamiliar). speech. 200 U N IT 4 Psyc h o b i o l o g i ca l D i s o rd e rs These symptoms can contribute to poor social functioning in logical order or groups, anticipation and planning, and inhib­ and social withdrawal. They can impede a person's ability to ini­ iting undesirable impulses or actions. Impaired executive func­ tiate and maintain conversations and relationships or succeed in tioning interferes with problem solving and can contribute to school or work. Apathy and avolition result in deficits in basic inappropriateness in social situations. activities such as maintaining adequate hygiene, grooming, and other activities of daily living Affe ctive Sym ptoms Affect, an additional ''!\' word, is the external expression Affective symptoms are those that involve the experience and of a person's internal emotional state. In schizophrenia, affect expression of emotions. They are common and increase patients' may be diminished or not coincide with inner emotions. suffering. Mood may be unstable, erratic, labile (changing rap­ Some antipsychotics can also cause diminished affect. Affect idly and easily), or incongruent (not what would be expected for in schizophrenia can usually be categorized in one of four the circumstances). ways: A serious affective change often seen in schizophrenia Flat: Immobile or blank facial expression is depression. Depression may occur as part of a shared Blunted: Reduced or minimal emotional response inflammatory reaction affecting the brain or may simply be Constricted: Reduced in range or intensity (e.g., shows sad­ a reaction to the stress and despair that can come from living ness or anger but no other moods) with a chronic illness. Assessment for depression is crucial Inappropriate: Incongruent with the actual emotional state because it may indicate an impending relapse, further impair or situation (e.g., laughing in response to a tragedy) functioning, and increase risk of substance use disorders. Bizarre: Odd, illogical, inappropriate, or unfounded; Most importantly, depression puts people at increased sui­ includes grimacing cide risk. C o g n itive Symptoms Se lf-Assessment Cognitive symptoms represent the third symptom group and People with schizophrenia often experience anosognosia are evident in most patients with schizophrenia. These impair­ (uh-no-sog-NOH-zee-uh), an inability to realize they are ill ments can lead to poor judgment and leave the patient less able caused by the illness itself. Anosognosia may result in the to cope, learn, manage health, or succeed in school or work. patient resisting or stopping treatment, making care challeng­ Cognitive symptoms include the following. ing and frustrating to staff. The inability to recognize the illness Concrete thinking is an impaired ability to think abstractly, along with paranoia creates a situation in which requesting or resulting in interpreting or perceiving things in a literal manner. even accepting help is impossible. For example, a nurse might ask what brought the patient to the hos­ Working with individuals who have schizophrenia can bring pital, and the patient answers "a cab" rather than explaining a sui­ about anxiety or fear. Discussing your feelings with staff, fac­ cide attempt. Interpreting proverbs can be used to assess abstract ulty, and peers may help. Examining whether one's expectations thought. An abstract interpretation of "The grass is always greener of patients are realistic, learning more about the nature of the on the other side of the fence" is that it always seems we would be illness, and seeking new more effective ways of helping patients happier given other circumstances. A concrete interpretation could can help staff overcome feelings of helplessness and reduce be "That side gets more sun, so it's greener there:' Concreteness countertransference. reduces one's ability to understand and respond to concepts requir­ ing abstract reasoning such as love or humor. Concreteness, especially when combined with an impaired ability to recognize variations in affect or tone of voice, can also Schizophrenia and Other Psychotic Disorders make it difficult to recognize social cues such as sarcasm. For 1. Ensure that the patient has had a medical workup. Concu rrent medical example, a patient who had forgotten his wallet asked a store disorders a re common and patients may have experienced recent trauma clerk if he could pay later for a bag of chips. When the clerk or i l l ness that has affected their menta l status. sarcastically replied, "Oh sure, we let our customers pay when­ 2. Assess for ind ications of med ica l problems that m ight m i m ic psychosis ever they want;' the patient took this literally. The patient was (e.g., d ig ita l is or a ntich o l i n e rgic toxic ity, bra i n tra u m a , drug intoxication, distressed when police arrested him for theft despite his protests delirium, fever). that he had permission not to pay. 3. Assess for substance or a lcohol-use di sorders. Impaired memory impacts short-term memory and the ability 4. Complete a menta l status exa m i nation ( M S E ) including insight rea l ity to learn. Repetition and verbal or visual cues may help the patient testing, judgment cogn itive a b i l ities (memory, concentration, a bstract to learn and recall needed information (e.g., a picture of a tooth­ reasoning), knowledge of the i l l ness, re lationships and support systems, brush on the patient's wall as a reminder to brush his or her teeth). other coping resources, and strengths an d need. Impaired information processing can lead to problems 5. Assess for h a l l ucinations: Do not imply that the perceptions are rea l (e.g., ask: "What do you such as delayed responses, misperceptions, or difficulty under­ hear?" not "What a re the voices saying?"). standing others. Patients may lose the ability to screen out insig­ Assess when the h a l l ucinations began, their content h ow the patient nificant stimuli such as background sounds or obj ects in one's experiences them (e.g., supportive o r distressing, i n the background peripheral vision. This can lead to overstimulation. or i ntrusive), what makes them worse or better, how the patient is Impaired executive functioning includes difficulty with responding, an d what the patient does to cope. reasoning, setting priorities, comparing options, placing things  CHAPT E R 1 2 S c h i zo p h re n i a S p ect r u m D i s o rd e rs 201 DIAGNOSIS Patients with schizophrenia have multiple distressing and often Schizophrenia and Other Psychotic Disorders disabling symptoms. They require a multifaceted approach to Questi ons should include: "Are you hearing a voice that is te l l ing you care and treatment of both the patient and the family. Table 1 2.2 to do something?" "Do you believe what you hear is real?" Any "yes" lists signs and symptoms and potential nursing diagnoses for a suggests a n increased risk that the patient will act o n the commands person with schizophrenia. and, if they i nvolve dangerous behavior, create a risk to self o r others. 7. Assess for delusions: If present, a re they fi rmly held? I s the patient a b l e to rea l ity test (d eter­ OUTCOM ES IDENTIFICATION m i n e what is rea l)? Nursing Outcomes Classification (NOC; Moorhead et al., 2 0 1 3 ) Does the patient believe that there is danger ( e. g. , is paranoia pres­ ent)? Does the patient believe that acting agai nst a person or organi­ i s one useful guide for developing outcomes. Outcomes should zation w i l l provide protection or vengeance? A "yes" to either of these focus on illness knowledge, management, coping, and quality q u esti ons poses a n increased risk of danger to others. of life. Outcomes should be consistent with the recovery model 8. Assess for suicide risk ( refer to Chapter 25). (refer to Chapter 32), which stresses hope, living a full and pro­ 9. Assess for a b i l ity to ensure personal safety and hea lth: ductive life, and eventual recovery rather than focusing on con­ M a i nta i n adeq uate food a nd fl uid intake? (e.g., patients may make trolling symptoms and adapting to disability. Desired outcomes poor n utriti onal choices o r experi ence a risk of choking due to medica­ vary with the phase of the illness. tion side effects impairing swa l l owing) Ach i eve adeq uate sleep and rest? Phase 1: Ac ute Complete hygiene and self-care? For the acute phase of schizophrenia, the overall goal is patient M ove a bout safe ly? ( e. g. , fa l l risk, d i stracti b i l ity that leads to walking safety and stabilization. If the patient is a risk to self or others, i nto traffic) Control impu lses and m a ke sound safe decisions? D ress safely for weather conditions? (e.g., hypothermia and hyperther­ mia-patients with schizophrenia are at risk of heat-related emergencies) Meet hea lth needs? ( e. g. , recog nize onset or worsening of medical Signs a n d Symptoms N u rsing Diagnoses i l l nesses, adhere to treatment for concu rrent med ica l conditions) 1 0. Assess prescribed med icati ons, whether and how they a re taken, effec­ Positive Symptoms tiveness, side effects, and what factors ( e. g. , costs, mistrust of staff, Hears voices that others do not (auditory Disturbed sensory percep­ stigma) a re affecti ng adherence. hallucinations) tion. auditory/visual 1 1. Determ ine the impact of symptoms and side effects on functioning (e.g., Hears voices te l l i n g h i m or her to h u rt self o r Risk for self-directed/oth- hygiene, caring for hea lth needs, social ization). others (command hallucinations) er-directed violence 1 2. Assess the fam i ly's knowledge of and response to the patient's i l lness and De l usions Disturbed belief system symptoms. Are fam i ly mem bers overprotective? H osti le? Anxious? Are they Altered thought processes* familiar with and using fa mily support groups and respite resources? Shows loose association of ideas (associative Impaired verbal commu- looseness) nication Conversation is dera i l e d by unnecessary an d Altered thought processes* ted ious deta i l s (circumstantiality) Stigma of Schizophrenia in Chinese Families Neg ative Symptoms Uncommun icative, withd rawn Social isolation M rs. Chou, a young Chinese-American woman, learned that her mother died Expresses fee l i n gs of rejection or a loneness Impaired verbal commu- from pneumonia. M rs. Chou commented that her mother would not have become ( l ies i n bed all day, positions back to door) nication ill if she had been a better daughter and that she brought evi l u pon her fami ly. Impaired social interaction After the funeral M rs. Chou beca m e i ncreasingly l ethargic, sta ring into space Risk for loneliness and m u m b l i n g to herself. When M r. Chou asked to whom she was ta lking, she Ta l ks a bout self as "bad" or " n o good" Chronic low self-esteem answered, "My m other. " M r. Chou knew someth ing was wrong with h i s wife Feels g u i lty because of "bad thoughts"; Risk for self-directed but was rel uctant to seek h e l p. In his cu lture there is strong stigma agai nst extremely sensitive to rea l o r perceived s l i g hts violence menta l i l l ness, and it is often perceived a s a punishment. Shows lack of energy (anergia) Ineffective coping When M rs. Chou quit eating and taking care of herself, M r. Chou took her to an Shows lack of m otivation (avolition}, unable to Self-care deficit (bathing/ herbal ist. The herbal ist convinced M r. Chou to take her to a hospita l. During her in itiate tasks (soc i al contact, g rooming, and hygiene, dressing/ admission, the unkempt, dehydrated, and pale M rs. Chou sat motionless and mute. other aspects of daily l iving) grooming) M r. Chou apologized for burden ing others with her care and asked that her treatment be kept secret. Staff helped M r. Chou recognize that M rs. Chou had Other a physical i l lness of her brain that affected her thinking and behavior, and that Fa m i l ies and sign ificant others become confused Compromised family treatment was compara b l e to treatment for heart d isease or dia betes. They also or overwhe l m ed, lack knowledge a bout coping stressed that seeking help for bra i n i l lness is accepted in the American cu lture. disorder o r treatment, feel powerless i n coping Caregiver role strain M r. Chou calmed down as he rea l ized he did not need to feel shame and that with patient Deficient knowledge others would h e l p. As M rs. Chou improved, she and M r. Chou came to attri­ bute the i l l ness to grief, reducing their g u i lt. They met with a C hi n ese healer * N on-NANDA d i a g n os i s who assisted them to i nteg rate their beliefs with the beliefs a nd resources of H e r d m a n , T. H. , & Ka m its u r u , S. ( E d s. ) (20 1 4). NANDA In terna tional their adopted cu lture. nursing diagnoses: Definitions and classification, 20 7 5-20 7 7. Oxfo rd, U K : W i l ey-B la c kwe l l. 202 U N IT 4 Psyc h o b i o l o g i ca l D i s o rd e rs initial outcome criteria address such safety issues (e.g., patient refrains from self-injury, hyponatremia is prevented). Another A. Know the early warn ing signs of re lapse: sleep di sturbances, tro u b l i n g example of a desired outcome is a patient who consistently thoughts, d ifficu lty t h i n k i n g o r remembering, being unsure of w h a t is rea l , labels hallucinations as "not real-a symptom of an illness:' hearing voices, an d becoming m o re uncomforta ble a round others. B. Let your treatm ent tea m know right away if you begin to have sym ptoms Phase I I : Sta b i l ization of relapse. Make a l ist of whom to ca l l , what to do, an d where to go for Outcome criteria during phase II focus on patient understand­ h e l p. Keep it with you. ing of the illness and treatment, achieving an optimal medica­ C. Find people you can trust who wi l l h e l p you and l isten to them if they te l l tion and psychosocial treatment regimen, and controlling and/ y o u that your i l lness seems t o be becoming worse. or coping with symptoms and side effects. The outcomes target D. Remember that rela pse is part of the i l l ness. It is not a sign of fa i l u re, and the negative and cognitive symptoms as these tend to respond it does not mean that yo ur i l l ness won't get better. less well to initial treatment than do positive symptoms and may E. D eve lop a re la pse prevention pl an : not using drugs or alcohol, ta king med­ reduce treatment success. ications, managing stress through stress avoidance and re laxation tech­ niques, seeking support when u pset or i n crisis, avoid confl ict with others, Phase I l l : M a i ntenance do not become isolated, and get enough sleep. F. Partici pate in fa m i ly, g roup, and individ u a l thera py as needed or suggested Outcome criteria for phase I I I focus o n maintaining and by staff. increasing symptom control and insight. Measures during the G. Learn new ways to act and new coping skills to help handle fami ly, work, and maintenance phase include adhering to treatment, preventing other stress. Get information from your nurse, case manager, doctor, support relapse, maintaining and increasing independence, and achiev­ groups, community menta l hea lth groups, or a hospita l. Everyone needs a ing a satisfactory quality of life. place to ta lk about fears and losses and to learn new ways of coping. H. Have a written plan of how to cope with especia l ly stressfu l times: go for a wa lk, pet the dog, di stract yourself with a book, o r ta l k with a friend. One PLANNING resource is the We l l ness Recovery Action Plan at http://menta lhea lthre­ Again, the planning of appropriate interventions is guided by the covery.com/getting-sta rted-with-wra p/. I. Adhere to treatm ent. We know that individ u a l s who stay on their medica­ phase of the illness and the strengths and needs of the patient. tion and fo l l ow othe r treatments that work for them a re more l i kely to get Cultural considerations, available resources, and patient prefer­ better an d stay better. Patients an d fa m i l ies should remember that: ences influence planning. 1. Stopping med ication o r keeping side effects a secret can make it harder for you to have the l ife you want. Phase 1: Ac ute 2. Engaging i n struggles over adherence does not h e l p but tying adher­ Hospitalization is indicated if the patient is considered a danger ence to the patient's own goals does. " Staying in treatment w i l l h e l p to self or others (e.g., refuses to eat or is too disorganized to you k e e p y o u r job an d stay out o f t h e hospita l. " function safely in the community). It may also be needed to clar­ 3. Share concerns a bout tro u b l i n g s i d e effects o r treatment such as sex­ ify and confirm the diagnosis. Planning focuses on selecting the ual problems, weight gain, or "fee l i n g fun ny" with your n u rse, case best strategies to ensure patient safety and control symptoms. manager, docto r, or social worker. M ost side effects can be managed. J. Avo id alcohol an d/or drugs; they can act on the bra i n i n ways that cause a Phase II: Sta b i l ization and Phase I l l : M a i nten a n c e re lapse. Learn othe r ways to feel better or deal with stress. Planning during the stabilization and maintenance phases focuses on providing patient and family education, support, and skills training. Planning incorporates interpersonal, functional, Hospitalization provides external structure and support (e.g., coping, health care, shelter, educational and vocational strengths others guiding the patient's activities). As previously discussed, and needs, and addresses how and where these needs can best anosognosia is a symptom of schizophrenia that may impair a be met within the community. person's ability to recognize that he or she is ill. In this case, Relapse prevention efforts (Box 1 2.2) are vital. Each relapse court-ordered hospitalization might be required. of psychosis may increase residual dysfunction and deteriora­ While a minority of patients require extended inpatient care tion and can contribute to despair, hopelessness, and suicide (more than 1 month), the length ofhospitalization or other inten­ risk. Recognition of the early warning signs of relapse-such sive treatment during the acute phase is typically short (days to as reduced sleep, social withdrawal, and worsening concentra­ weeks), ending when acute symptoms have been stabilized. How­ tion-followed by close monitoring and intensification of treat­ ever, this does not necessarily take into account the extended ment is essential to minimize the duration of psychotic episodes time needed for full recovery from serious mental illness, making and resulting disruption to the patient's life. continued engagement and care in the community all the more important after discharge. Community-based services provide IM PLEM ENTATION such care during the stabilization and maintenance phases. Phase 1 : Ac ute I nterve nti o n s S ett i n g s Structure within the therapeutic milieu provides a feeling of safety In general, during the acute phase of schizophrenia, 24-hour and security for patients who have been experiencing severe support is required to prevent harm to self or others. anxiety. Patients are monitored for suicide risk and intervene  CHAPT E R 1 2 S c h i zo p h re n i a S p ect r u m D i s o rd e rs 203 promptly to address risk factors such as despair or hopelessness All care is geared toward the patient's strengths, culture, per­ and provide for the patient's safety (see Chapter 25). sonal preferences, and needs. Communication, continuity in Virtually all people with psychotic disorders will be given care, and trusting relationships with care providers are essential pharmacological treatments to manage positive and negative for optimum recovery and relapse prevention. symptoms. Medication response is monitored and side effects Postdischarge care typically includes group and individ­ will be addressed. For example, fluid intake and weight can ual psychotherapy and psychoeducation (e.g., social or coping be assessed to identify polydipsia. Registered nurses provide skills), medication and case management, and structured activ­ support, psychoeducation, and guidance regarding the nature ities such as day programs and recreational activities. Commu­ of the illness and its treatment. Psychoeducation promotes nity mental health centers usually provide medication services, patient-centered care by helping the patient to recognize and day treatment, case management, and 24/7 crisis and psychi­ self-manage symptoms such as anxiety, impaired concentration, atric emergency services. Community mental healthcare can social withdrawal, impaired rest or nutrition, impaired cogni­ also provide housing support, allied physical health services, tion, and hallucinations and delusions employment programs. Peer-led services are available in most communities. These services include drop-in centers, some­ Work i n g with an Agg ressive Pat i e nt times called clubh