Schizophrenia Spectrum Disorders and Psychosis

• Range of disorders with psychotic symptoms

• Schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, delusional disorder, shared psychotic disorder, substance-induced psychotic disorder, late-onset schizophrenia

• No cure- Schizophrenia Spectrum Disorders 
and Psychosis

• Treatment focuses on managing symptoms and maintaining or improving daily functioning

• Nursing responsibilities- Schizophrenia Spectrum Disorders 
and Psychosis

• Liaison for clients, other interprofessional team members, and community organizations

• Initiate referrals to primary care or specialized mental health services

• Psychosis

• Hallmark characteristic of a psychotic-related disorder

  • Disconnection with reality caused by disturbances in a client’s thoughts and perceptions

  • Hallucinations

  • Troubling thoughts or beliefs

  • Emotional Changes

  • Withdrawal

  • Lack of self-care 

• Diagnosis- psychosis 

• Eliminate other medically related causes

• Gradual onset

• Family history

• Treatment- psychosis 

• Antipsychotic medications, psychotherapy, cognitive behavioral therapy, support, and education for both the client and family

• Criteria of Schizophrenia

• Schizophrenia is typically diagnosed when a client is between 16 and 30 years old.

• Prevalent and appears earlier in clients assigned male at birth than in clients assigned female at birth.

• Two or more symptoms must be present for a period of 1 month or longer with signs of continuous disturbance for at least 6 months.

• Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms, catatonic behavior, negative symptoms

• Impairment in one area of major functioning, such as self-care, work, and/or interpersonal relationships, for an extended period.

• Common Facts About Schizophrenia

• Productive lives when treatment and support are available.

• Stigma leads to limited health care access, underdiagnosis, and undertreatment

• One-half of persons who have a diagnosis of schizophrenia have a 
co-occurring mental health disorder.

• 14 times more likely to be victims of crime or violence than the greater population.

• genetic risk factors for schizophrenia

•  Not one gene but that several different genes

• - Inherited vulnerability(NAMI, 2021, p. 2).

• - People with a family member who has this condition have a higher likelihood of developing it  themselves

Physiological risk of schizophrenia

• - Neurodevelopment

• - Associated with hypoxia

• - Infections

Biochemical risks for schizophrenia

• Chronic exposure to cortisol

Environmental risks for schizophrenia

• Cannabis use

• Clinical Presentation- schizophrenia

• Positive and negative symptoms are two broad types of symptoms seen in many psychiatric disorders, including schizophrenia. 

• In the context of schizophrenia, a positive symptom is present when an individual shows behaviors, experiences, or emotions that are not usually present. 

• In the context of schizophrenia,  a negative symptom is present when an individual shows behaviors, experiences, or emotions that are usually present but are diminished in their severity. Positive symptoms are more likely to affect language and reasoning than negative symptoms.

• Positive symptoms of schizophrenia

• Hallucinations 

• Delusions 

• Disorganized speech and thoughts 

• Negative symptoms of schizophrenia 

• Anhedonia 

• Avolition 

• Blunted affect 

• Cognitive symptoms of schizophrenia 

• Memory issues 

• Inability to process social cues 

• Impaired sensory perception 

• The Nurse’s Role- schizophrenia

• Creating and maintaining a safe therapeutic relationship

• Ensuring a safe, calm, therapeutic environment

• Advocating and supporting early detection of psychosis

• Ensuring assessment, including mental status examination is complete and thorough

• Providing interventions that focus on stabilizing

• Providing support to the client toward recovery, self-management, and engagement

• Phases of Therapeutic Relationship

• Orientation

• Identification

• Exploitation

• Resolution

• Orientation Phase

• Client does not recognize the need for assistance and blocks alliance

• Family or Friends are unable or unwilling due to client history of symptoms

• Manifestations of psychosis & cognitive deficit of client

• Health team’s feelings or bias

• During the orientation phase, the nurse working with a client experiencing schizophrenia builds a therapeutic alliance with the client. It is important for family members to be involved from early in the illness, as they are often vital resources for the person with schizophrenia. The nurse develops a therapeutic relationship with the client and family members, incorporating them as partners in treatment planning.

• Identification Phase

• Poor insight

• Challenges with communication and daily functioning

• Monitor positive and negative manifestations

• Assist in understanding

• Prioritize safety

• The identification phase of schizophrenia can be challenging for both clients and caregivers for various reasons.

• The lack of awareness of what is really happening makes it harder to seek treatment and less likely the client is willing to self-report symptoms.

• Monitoring treatment progress using the mental status exam is important to determine treatment effectiveness and allow the nurse to manage priorities as needed.

• Exploitation Phase

• Explore interventions

  • - Medications

  • - Cognitive therapies

• Recognize triggers

• Express difficulties and seek assistance when needed

• The exploitation phase helps clients to move from being controlled by the illness to taking control of their illness. In contrast to the acute phase of care, in which the focus was on emergency stabilization, safety and symptom reduction, in the exploitation phase the focus turns toward maximizing quality of life measures.

• Resolution Phase

• Rehabilitation and recovery

• Able to function without live in support or supervision

• Continue therapeutic relationship with client to improve daily functioning

• The resolution phase of schizophrenia assumes that all the requirements of rehabilitation and recovery have been met and that the client is now able to live on their own with a solid approach to managing, treating and living with the disorder.

• We should still be encouraging clients to seek support if negative or detrimental thoughts come into play, but they should also be learning how to recognize these triggers and eventually learn to control them without help.

• Treatments and therapies- schizophrenia 

• Recovery-oriented approach

• Medications : DO NOT CURE SCHIZOPHRENIA.  Medications help control symptoms

  • Antipsychotics

  • Antidepressants

  • Mood stabilizers

• Cognitive behavioral therapy

  • Help people learn how to deal with symptoms and work through social issues

  • Help people change their thinking pattern to deal with stressors

• Family education and support

  • How to interact

  • How to recognize warning signs to prevent relapse

• Assertive community treatment: assists individuals who have repeated hospitalizations or who are without housing

• Interventions - schizophrenia

• Establishing and maintaining a therapeutic milieu

  • Calm environment with reduced stimulation

  • Physical examination and recognize that safety is a priority

• Frequently checking on client to ensure safety

  • May need one to one observation for clients at risk of self harm or harm to others. 

  • Remove all items that could result in harm

• Monitoring client

  • Data collection, vital signs, neurological vitals, mental status assessment, suicidality, evidence of manifestation of psychosis

• Encouraging client to use symptom management strategies

  • Goal is to improve their quality of life

• Providing education to client and family regarding the disorder, positive and negative symptoms of psychosis, medications, treatment

• Encouraging clients to engage in social and support groups and activities

• Communicating with the health care team

• Administering medication

  • Medication helps reduce symptoms such as hallucinations and delusions while psychosocial interventions address the symptoms and behaviors caused by the disease. 

• Evaluating the client’s response to interventions

  • Medications

  • Therapies - These include occupational therapy, social skills training, cognitive behavioral therapy, family-focused therapy and supported employment programs.

• Client teaching- schizophrenia 

• Discharge instructions 

  • Include the client and their family

• Medications

• Diet

• Exercise regimens

• Signs of relapse

• Referrals for continued support

  • Follow-up with primary care and mental health providers

• Serious Mental Illness

• Functional impairment

  • A serious mental illness (SMI) is one that “resulted in functional impairment which substantially interferes with or limits one or more major life activities.”

• Variety of disorders

  • Schizophrenia spectrum

  • Bipolar disorder

  • Severe depression

• Younger the onset of manifestations, more severe later in life (American Psychiatric Association, 2022)

• These illnesses are considered serious because they can cause significant problems in functioning and quality of life. In fact, people with these conditions often have very poor outcomes compared to the general population.

• Social Problems- schizophrenia

• jail/prison

• Stigma 

• Isolation and loneliness 

• Victimizaton 

• Social problems

  • Individuals with schizophrenia can face a number of challenges in daily life and relationships. The World Health Organization suggests that social and economic issues, coupled with increased risk of physical health issues, can reduce the lifespan by 10 to 25 years of those with severe mental illnesses.

  • These include:

    • Reduced ability to perform everyday tasks. This includes personal care, communication skills and understanding information.

    • Difficulty forming relationships with others. This includes friendships, dating partners and family members.

    • Loss of motivation to engage in activities that once brought pleasure or meaning to life. These may include work or school as well as hobbies or other interests that once made life enjoyable for people with schizophrenia.

    • Increased risk of developing physical health problems such as diabetes, cardiovascular disease, cancer and obesity due to poor nutrition and lack of exercise caused by their condition.

• Economic Challenges- schizophrenia

• Unemployment 

• Homelessness

• Caregiver burden

• Treatment issues- schizophrenia

• Nonadherence

  • Hesitant to seek help due to shame or embarrassment

• Treatment inadequacies

  • Failure to receive adequate information about available treatments 

  • Do not understand treatments

• Anosognosia: failure to recognize or acknowledge their health or neurological deficit(s)

  • Unaware of the need for treatment; think they are “not sick enough” to seek help

• Some patients who receive adequate treatment still fail to respond fully or become resistant to it over time. Treatment resistance may be due to several factors including lack of compliance (failure to take medications as prescribed), poor communication between patient and provider, insufficient dosage or duration of medication, poor therapy skills by therapist (e.g., failure to properly establish rapport with patient), stressors in patient's life that interfere with treatment progress (e.g., death of loved one), or environmental factors such as homelessness that interfere.