Cognition in Schizophrenia

Exemplar Learning Outcomes

  • Analyze schizophrenia as it relates to cognition
  • Describe the pathophysiology of schizophrenia
  • Describe the etiology of schizophrenia
  • Compare the risk factors and prevention of schizophrenia
  • Identify the clinical manifestations of schizophrenia
  • Summarize diagnostic tests and therapies used by interprofessional teams in the collaborative care of an individual with schizophrenia
  • Differentiate care of patients with schizophrenia across the lifespan
  • Apply the nursing process in providing culturally competent care to an individual with schizophrenia

Overview

  • Schizophrenia: Profound neurobiological disorder characterized by:

    • Psychotic symptoms
    • Diminished capacity to relate to others
    • Odd or bizarre behaviors

  • Impact on Functioning:

    • Chronic and disabling aspects linked to functional deficits
    • Affects: communication, cognition, attention, memory, emotional regulation, initiative, social interactions

  • Onset: Typically emerges in early adulthood but can occur at different life stages

  • Stigma: One of the greatest challenges associated with the disorder

Pathophysiology

  • Structural Anatomic Alterations

    • Decreased gray matter in:
    • Prefrontal cortex
    • Temporal lobes
    • Hippocampus
    • Thalamus
    • Enlarged ventricles and sulci
    • Changes in cerebral blood flow and glucose metabolism

  • Neurotransmitter Abnormalities:

    • Dopamine system
    • GABA and acetylcholine systems
    • Nicotine acetylcholine receptors

  • Immunologic and Inflammatory Pathways

Etiology

  • Genetic Factors:
    • Biological parent with schizophrenia increases risk by 30%
    • Greater risk for children born to older fathers (age 60+) and advanced maternal age

Risk Factors

  • Early Life Adversities:
    • Exposure to poverty, violence, trauma
  • Developmental Factors:
    • Alterations in emotional, cognitive, language, and motor development increase risk
    • Stress during developmental periods can elevate risk

Prevention

  • Early Screening: Cognitive, developmental, and behavioral alterations associated with schizophrenia
  • Care Coordination: Non-pharmacologic interventions (Cognitive Behavioral Therapy) improve outcomes
    • Consider risks of early antipsychotic use
    • Emphasize potential for recovery and rehabilitation

Cognitive Symptoms

  • Detailed Challenges:
    • Concrete thinking
    • Limited insight
    • Executive functioning problems
    • Attention, vigilance, and concentration issues

Clinical Manifestations

  • Positive Symptoms: Symptoms not present in healthy individuals

    • Hallucinations: Most common is auditory
    • Delusions: False beliefs
    • Types include: delusions of reference, nihilistic delusions, religious delusions, grandiose delusions, persecutory delusions
    • Features of thought broadcasting, control, withdrawal, insertion

  • Motor Symptoms:

    • Motor retardation, posturing, catatonia, mutism, echopraxia, echolalia
    • May include combativeness, impulsivity

  • Negative Symptoms:

    • Diminished or absent affects and behaviors
    • Symptoms include: flat affect, thought blocking, alogia, anhedonia, avolition
    • Persist throughout all phases

Comorbid Disorders

  • Common Issues:
    • Self-care deficits, sedentary lifestyle, social isolation
    • Poor healthcare access, dietary habits, smoking
    • Increased risk for: cardiovascular disease, diabetes, COPD, infections
    • Substance abuse in nearly 50% of patients; also high comorbidity with depression (40-60%)

Collaboration Challenges

  • Management: Characterized by complicating factors
    • Clinical manifestations, healthcare system issues, restrictive policies, cultural biases

Diagnostic Tests

  • Evaluation: Combination of psychiatric evaluation, history, and examination
  • Laboratory Tests/Imaging: Used to rule out other conditions
  • Criteria: Significant impairment in functioning for ≥6 months

Pharmacologic Therapy

  • First-line Treatment: Aimed to reduce psychotic symptoms to enable daily functioning

  • Challenges:

    • High relapse rates upon discontinuation (50-80%)
    • Adherence issues due to denial and adverse effects of medications

  • Medication Types:

    • First Generation: Typical antipsychotics targeting positive symptoms
    • Risks include anticholinergic effects, sexual side effects, extrapyramidal symptoms
    • Second Generation: Atypical antipsychotics covering both positive and negative symptoms
    • Third Generation: Dopamine system stabilizers for comprehensive symptom management

Nonpharmacologic Therapy

  • Family Interventions and Psychoeducation: Can significantly lower relapse rates
  • Social Skills Training: Skills taught to enhance daily functioning
  • Cognitive-Behavioral Therapy: Learning about emotions and skills
  • Vocational Training and Case Management: Community service models for enhanced support

Lifespan Considerations

  • Early-Onset Schizophrenia (EOS):

    • Symptoms manifest before age 18; rare before puberty

  • Late-Onset: Symptoms occur post-40; higher incidence in women

    • Respond well to lower doses of antipsychotics

  • Very-Late-Onset: Symptoms post-age 60 managed similarly, with psychosocial interventions emphasized.