Schizophrenia

Schizophrenia:

Mental disorder in which there exists disturbances in thought content and form, perception, affect, language, social activity, sense of self, volition, interpersonal relationships, and psychomotor behavior.  

Schizophrenia pathophysiology:

Results from excessive activity at dopaminergic synapses, leading to active psychotic signs and symptoms; a decrease in prefrontal activity of dopaminergic pathways leads to negative cognitive symptoms.  

Suspected causes of schizophrenia:

Excessive activity at dopaminergic synapses, norepinephrine, serotonin, glutamate neurotransmission, gamma-aminobutyric acid transmission, structural abnormalities of the brain, genetics, culture. 

Risk factors of schizophrenia:

Biological relative with schizophrenia, maternal malnourishment or viral illness during pregnancy.  

Incidence of schizophrenia:

Onset is typically late teens to mid-30s, with major deterioration occurring within the first 5-10 years of the disorder, males have a higher onset and more severe symptoms, suicide risk averages 5%. 

Complications related to schizophrenia:

Suicide, self-inflicted trauma, comorbid substance abuse problems, and tardive dyskinesia (due to medications). 

Positive S/S (abnormally present):

Delusions (bizarre or nonbizarre), hallucinations, disjointed disconnected speech patterns, and disorganized behavior (aggression, agitation, etc.). 

Negative S/S (absence or diminution of normal processes):

Flat affect, ambivalence, difficulty with emotional expression, anhedonia, alogia, apathy. 

Cognitive impairment/mood S/S:

Memory and attention deficits, diminished executive functioning, depression, anxiety, and mood or behavior that is difficulty to understand such as being catatonic.  

History and Physical assessment findings:

Possible long-standing mental illness with repeated episodes of psychosis, decreased academic or social functioning, odd beliefs or delusions, disturbed sleep-wake cycle, social awkwardness, right-left confusion, long pauses before answering questions, and inability to identify objects by touch or numbers traced on the skin.  

DSM-5 Criteria:

identifying two or more of the following signs and symptoms for a significant portion of time during a 1-month period (or only one symptom if delusions are bizarre, hallucinations consist of a voice issuing a running commentary, or hallucinations consist of two or more voices conversing with each other): Delusions, prominent hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative S/S. In addition, one or more major areas of functioning are below previous level. 

Diagnostic test results:

Labs (to rule out other disorders), CT or MRI of the brain, electroencephalography, neuropsychiatric testing, and mental status examination with DSM-5. 

Treatment options:

Psychotherapy, social skills training, family therapy, vocational rehabilitation, CBT, metacognitive training for psychosis, milieu therapy, cognitive remediation, assertive community treatment, inpatient hospitalization for exacerbations, increased physical activity, regular sleep routine, pharmacology, and electroconvulsive therapy.  

Pharmacological options:

Antipsychotics, atypical antipsychotics are first-line agents, IM long-acting antipsychotics (if poor adherence to PO), anticonvulsants for high seizure risk, and benztropine mesylate or lorazepam for parkinsonism associated w/ antipsychotic use. 

Nursing interventions:

Assess ability to perform ADLs, promote independence, maintain a safe environment, minimize stimuli, implement the least-restrictive environment for the pt, approach calmly from the front, reward positive behavior, provide reality-based explanations, set boundaries on inappropriate behavior, build trust. 

Patient Education:

Disorder, drugs, S/S of impending relapse and ways to manage S/S, medication adherence, limit-setting and behavioral measures, appropriate coping strategies, distraction techniques and reality-based diversional activities, safety plan, when to seek help for suicidal ideation, importance of appointment adherence.