Comprehensive Study Notes on Psychiatric Nursing: Schizophrenia and Somatic Therapies

Major Classifications of Mental Illnesses

There are two major classifications for mental illnesses: neurosis and psychosis. Neurosis is defined as a mild-to-moderate illness with an organic or known etiology. Patients with neurosis typically exhibit good insight, awareness, and understanding of their condition, as well as maintaining proper orientation. Psychosis, conversely, is a severe illness with an idiopathic or unknown etiology. Clinical manifestations of psychosis include poor insight, delusions, and hallucinations. While neurosis involves voluntary admission and intact autonomy, psychosis involves altered sensory perception, altered thought processes, and often requires involuntary admission. Legal priority for decision-making typically follows the order of spouse, adult children, parents, and then siblings. Suicidal ideation or attempts in psychotic patients are linked to diminished autonomy and must be carefully monitored.

Suicide and Crisis Management

Suicide is defined as the intentional killing of oneself and is frequently viewed as a "crisis" or a "cry for help." In many board examinations, specific data regarding suicide are highlighted. The primary neurotransmitter associated with suicide is serotonin; a deficiency in serotonin levels is typical in these cases. Statistics on suicide include specific frequency and timing patterns. The highest frequency of attempts occurs during the dry season. The day of the week with the highest incidence is Monday, typically characterized as a high-energy day. Regarding the time of day, the most common period for suicidal acts is between midnight and the dawn hours, specifically from $12:00\text{ midnight}$ to $4:00\text{ am}$.

Schizophrenia: Definitions, Statistics, and Legal Framework

Schizophrenia was originally termed "dementia praecox." Its etymology is derived from the Greek words "schizo," meaning split, and "phrenia," meaning mind. This condition is categorized by the World Health Organization (WHO) and clinical manuals into several types. Paranoid schizophrenia involves "disturbia" or the presence of an invisible threat. Catatonic schizophrenia is marked by abnormal movement and posture, including "waxy flexibility" (wax posture) and pacing. Disorganized schizophrenia is characterized by weird or bizarre behaviors. Undifferentiated schizophrenia is a combination of at least two types and is currently cited by the WHO as the most common type.

Statistical data provided by the WHO for general populations include: $1\%$ of clients in a general population (amounting to approximately $120\text{ million}$ people currently) have schizophrenia; $5\%$ of clients suffer for a lifetime; there is a $50\%$ recovery rate; $33\%$ of clients experience severe side effects; $10\%$ of clients are homeless; and a significant percentage commit suicide. In the Philippines, Republic Act (RA) $11036$, known as the National Mental Health Act, establishes that mental health is a fundamental right. The modern WHO definition describes schizophrenia as a severe mental condition affecting thoughts, emotions, cognition, memory, behavior, and personality. It is considered a fatal condition due to suicide and often results in disability (Person With Disability or PWD status).

Risk Factors and Pathophysiology of Schizophrenia

The causes of schizophrenia are considered multifactorial. Genetics and heredity play a significant role, as evidenced by twin studies: identical (monozygotic) twins have a $50\%$ risk if one twin is affected, while fraternal (dizygotic) twins have a $25\%$ risk. Neuroanatomical studies using MRI have shown instances of microcephaly (a smaller brain), involving the frontal lobe (affecting thoughts and cognition) and the temporal lobe (affecting emotions and behavior). Neurochemical factors involve imbalanced neurotransmitters; specifically, an excess of dopamine is easier to treat, while imbalances in serotonin (responsible for energy and mood) are also implicated. Psychological factors include stress and crises, while social factors include poverty and the "hygiene hypothesis."

DSM-5 Diagnostic Criteria and Nursing Diagnoses

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the criteria for a schizophrenia diagnosis include the presence of at least two symptoms (marked as $2_1$ or $3_2$) persistent for at least one month. One of these symptoms must come from the first three: delusions, hallucinations, or disorganized speech. Other symptoms include disorganized behavior and negative symptoms. The psychosis must result in a disability or negative effect on functioning, and this disability must persist for at least $6\text{ months}$ for it to be considered chronic. Furthermore, the psychosis must be unrelated to substance abuse or another medical condition. The North American Nursing Diagnosis Association International (NANDA-I) lists diagnostic priorities such as Disturbed thought processes, Altered sensory perception, and Risk for self-inflicted harm.

Positive Symptoms: Delusions, Hallucinations, and Management

Psychotic symptoms are classified as positive or negative. Positive symptoms are energy-active, hard, and evident, primarily driven by dopamine. Delusions are false, fixed beliefs that cannot be changed through logical persuasion. Types include: grandiose (exaggerated status), religious (e.g., claiming to be the second coming of Christ), persecutory (invisible threat or paranoia), referential (feeling like the center of everything), erotomania (unfounded belief in sexual attraction from another), nihilistic (denying the existence of things), control (believing in superpowers), and folie à deux (a shared delusion with another person). Hallucinations represent altered sensory perception without an external stimulus. These include: auditory (hearing voices, the most common), visual (seeing things, such as dead people), olfactory (smelling fragrances or smoke, often occurring as an "aura" before an underlying event), tactile (haptic sensations like spiders or ants crawling), and gustatory (tastes without an ingredient, the least common). Management for both delusions and hallucinations involves presenting reality by voicing doubt (e.g., "I find that difficult to believe"), acknowledging the patient’s emotions, and offering self.

Negative Symptoms and Disorganized Patterns

Negative symptoms are energy-passive or "soft" symptoms primarily driven by serotonin and resemble depression-like manifestations. These terms often begin with the prefix "a-": Anhedonia (loss of pleasure), Apathy (lack of concern), Alogia (poverty of speech), Avolition (lack of motivation), and Affective flattening (lack of emotion). Ambivalence is noted as a soft symptom. Disorganized speech consists of abnormal or bizarre patterns of talking that lead to communication failure. Examples include: Perseveration (repeating something over and over), Palilalia (repeating the last part of one's own word or phrase), Echolalia (repeating what others say), Verbigeration or "word salad" (random illogical words, e.g., "blue Kia pineapple USA Coco"), Clang association (random rhyming), and Neologisms (words only the patient understands). Management includes making detailed observations to increase self-awareness and setting age-appropriate limits. Disorganized behavior includes abnormal actions such as psychomotor agitation (active) or psychomotor retardation (passive), which includes mutism, waxy flexibility, and cataplexy (sudden paralysis). Agitation may include echopraxia (mimicking movements) and pacing.

Psychopharmacological Management

The general management of schizophrenia includes short-term goals of decreasing psychosis through psychopharmacology and long-term goals of returning the client to their premorbid status. Medications, including neuroleptics or major tranquilizers, can be administered orally (tablets, capsules, or caplets) or parenterally (IM or IV for agitated persons). The downtime for these meds is usually $3$ to $6\text{ weeks}$. There are three classes: First Generation Antipsychotics (FGAs or Typical), such as Chlorpromazine (Thorazine) used for hiccups and marked by dopamine antagonism; Second Generation Antipsychotics (SGAs or Atypical), which are balanced dopamine and serotonin antagonists (e.g., those ending in -pine or -peridone); and Third Generation Antipsychotics (TGAs or Novel), such as Aripiprazole (Abilify), which are also balanced antagonists but carry different risks like tardive dyskinesia.

Side Effects of Antipsychotic Medications: Sexual and Anticholinergic

Side effects are categorized by the mnemonic EPOR (Excitement, Plateau, Orgasm, Resolution). Sexual dysfunction can occur at any phase. In men, dopamine causes decreased libido and erectile dysfunction (which may require a penile pump). In women, side effects include dryness, dyspareunia, and vaginismus (managed with KY jelly or relaxants). Anticholinergic effects result from the stimulation of muscarinic receptors due to dopamine changes. The systemic effects are remembered by the mnemonic BUCOPANDAN: Blurred vision, Urinary retention, Constipation (give milk), Orthostatic hypotension, Photosensitivity, Amnesia, Nausea, Dry mouth (Xerostomia), Ataxia (uncoordinated body movement), and Nighttime discomfort (Insomnia).

Extrapyramidal Side Effects (EPS) and Pharmacological Interventions

Extrapyramidal side effects (EPS) are Parkinson-like symptoms caused by dopamine deficiency. The earliest onset is $2\text{ weeks}$ after the initial dose, and the latest is $6\text{ months}$. The mnemonic APAT describes the progression: Acute dystonia (muscle rigidity, oculogyric crisis, opisthotonus, torticollis/wryneck), Pseudoparkinsonism (bradykinesia, cogwheel rigidity, robot movement, shuffling gait), Akathisia (restlessness, inability to sit or stand still, rocking chair movement), and Tardive dyskinesia (the last to appear at $6\text{ months}$, involving involuntary facial movements, lip smacking, and tongue protrusion, and it is irreversible). The drug of choice for Akathisia is Propranolol, though it is contraindicated for asthma. General management for EPS includes continuing the medication, reporting to the physician, and anticipating antidotes. The primary antiparkinsonian antidotes are Cogentin (Benztropine) and Benadryl (Diphenhydramine) at doses up to $100\text{ mg}$, requiring a doctor's order.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT), or shock therapy, is a form of somatic therapy that promotes chemical balance through electrical charges administered to the head via electrodes. There are two types: unilateral (using $2\text{ electrodes}$ on the frontal and temporal areas, which yields fewer side effects) and bilateral (using $4\text{ electrodes}$, which is more effective). The most common side effect is a seizure (generalized rigidity, jerking, tonic-clonic movements, and unconsciousness). Indications for ECT include severe schizophrenia, depression, mania, or suicidal tendencies when other treatments fail (last resort). Contraindications include epilepsy, MI, CHF, CAD, stroke (CVA), fractures, and preeclampsia (though it is generally stable for pregnancy in the third trimester). The mnemonic MO4Sg suggests a schedule of $4$ to $7$ sessions normally.

Preparation involves the physician explaining the procedure and obtaining consent. The patient must abstain from chemicals that affect the brain (smoking, drinking) for $3\text{ days}$ prior. NPO (nothing by mouth) is required after midnight for a morning schedule. During the procedure, lights are dimmed (central lights off, corner lights on), curtains are drawn, and the patient is positioned supine with the bed lowered and side rails raised. Administered medications include Atropine (to reduce saliva), Brevital (to decrease pain sensation), and Succinylcholine (IV muscle relaxant). The procedure lasts only a few seconds. Post-procedure, the primary priority is checking the airway and vital signs. If the respiratory rate (RR) is $28/\text{min}$ and the patient is unarousable, it indicates respiratory depression and must be reported to the MD. Amnesia is managed by frequent reorientation to people, place, and time. The total number of sessions ranges from $6$ to $12$, scheduled every $2$ to $3\text{ days}$.