schizophrenia

Schizophrenia Spectrum Disorders and Psychosis

Learning Objectives

  • Therapeutic Use of Self: Integrate therapeutic relationships, therapeutic communication, and interpersonal processes with diverse individuals, families, and communities.

  • Self-Assessment: Explore self-reflection on personal beliefs and values in nursing care from wellness to illness.

  • Nursing Roles: Describe the roles of nurses in caring for clients and families experiencing psychiatric/mental disorders.

  • Understanding Schizophrenia: Explain the etiology, risk factors, neurobiology, signs, symptoms, complications, psychopharmacology, nursing interventions, and treatment modalities for individuals experiencing psychiatric disorders.

  • Evidence-Based Practice: Utilize frameworks such as evidence-based practice, clinical judgment, and the nursing process to provide holistic care for mental health issues.

  • Ethical Issues: Examine the legal, economic, sociocultural, and ethical issues affecting the psychiatric/mental health delivery system.

Schizophrenia Spectrum Disorders and Psychosis

  • Definition: A range of disorders characterized by psychotic symptoms, including:

    • Schizophrenia

    • Schizoaffective disorder

    • Schizophreniform disorder

    • Brief psychotic disorder

    • Delusional disorder

    • Shared psychotic disorder

    • Substance-induced psychotic disorder

    • Late-onset schizophrenia

  • Cure Status: There is no cure for these disorders.

  • Focus of Treatment: Treatment is primarily aimed at managing symptoms and maintaining or improving daily functioning (National Institute of Mental Health [NIMH], 2020, p. 3).

  • Nursing Responsibilities:

    • Act as a liaison between clients, interprofessional team members, and community organizations.

    • Initiate referrals to primary care or specialized mental health services.

Psychosis

  • Definition: Hallmark characteristic of psychotic-related disorders marked by a disconnection from reality.

  • Causes of Disconnection: Disturbances in a client’s thoughts and perceptions lead to:

    • Hallucinations

    • Troubling thoughts or beliefs

    • Emotional changes

    • Withdrawal from social activities

    • Lack of self-care (Pen Medicine, 2020, p. 2).

  • Diagnosis:

    • Important to eliminate other medically related causes.

    • A gradual onset of symptoms is typical.

    • Family history may indicate risk.

  • Treatment Options:

    • Antipsychotic medications.

    • Psychotherapy.

    • Cognitive behavioral therapy (CBT).

    • Support and education for both the client and their family.

DSM-5-TR Criteria of Schizophrenia

  • Typical Diagnosis Age: Most diagnoses occur between ages 16 and 30 years.

  • Gender Prevalence: More prevalent in clients assigned male at birth compared to those assigned female at birth (Hope Way, 2021).

  • Criteria:

    • Two or more symptoms must be present for at least 1 month, with signs of continuous disturbances for a minimum of 6 months.

    • Symptoms include:

    • Delusions

    • Hallucinations

    • Disorganized speech

    • Grossly disorganized or catatonic behavior

    • Negative symptoms

    • Must show impairment in major areas of functioning such as self-care, work, and interpersonal relationships for an extended period.

Common Facts About Schizophrenia

  • Life Outcomes: Individuals can live productive lives with appropriate treatment and support.

  • Stigma Effects: Stigma in society can significantly limit access to healthcare, leading to underdiagnosis and undertreatment (Living with Schizophrenia, 2022c, p. 2).

  • Victimization: People with schizophrenia are 14 times more likely to be victims of crime or violence compared to the general population.

  • Co-occurring Disorders: About 50% of individuals with schizophrenia also experience a co-occurring mental health disorder.

Risk Factors and Etiology

  • Genetics: No single gene but a collection of genetic factors contribute to inherited vulnerabilities (NAMI, 2021, p. 2).

  • Physiological Factors:

    • Neurodevelopmental issues possibly linked to hypoxia and infections.

    • Biochemical imbalances (e.g., chronic cortisol exposure).

  • Environmental Factors:

    • Cannabis use is a noted risk factor contributing to the onset of symptoms.

Clinical Presentation

  • Positive Symptoms: Include:

    • Hallucinations

    • Delusions

    • Disorganized speech (American Psychiatric Association [APA], 2022).

  • Negative Symptoms: Characterized by:

    • Alogia (poverty of speech)

    • Anergia (lack of energy)

    • Anhedonia (inability to feel pleasure)

  • Cognitive Symptoms: Include difficulties such as:

    • Poor concentration

    • Slow thinking

    • Poor memory.

The Nurse’s Role

  • Therapeutic Relationship: Establish and maintain a safe and therapeutic relationship with clients.

  • Environment: Create a calm and therapeutic environment.

  • Early Detection: Advocate for and support early detection of psychosis.

  • Assessment: Ensure comprehensive assessments, including mental status examinations, are performed thoroughly.

  • Interventions: Focus on stabilizing conditions and support recovery, self-management, and engagement (Young, 2018, p. 4; Hartley et al., 2020, pp. 3, 11; Calabrese et al., 2022, pp. 8-9).

Phases of Therapeutic Relationship

  • Orientation Phase:

    • Client may not recognize the need for help, creating barriers to alliance (Hartley et al., 2020, p. 4).

    • Challenges include client cognitive deficits and healthcare team biases.

  • Identification Phase:

    • Clients may have poor insight and communication challenges.

    • It is crucial to monitor positive and negative manifestations and assist clients in understanding their conditions.

    • Safety is prioritized during this phase.

  • Exploitation Phase:

    • Explore various interventions, including medications and cognitive therapies.

    • Recognize triggers and assist clients in expressing difficulties (Pinho et al., 2017, p. 2).

  • Resolution Phase:

    • Focus on rehabilitation and recovery enabling independent functioning without supervision (Pinho et al., 2017, p. 2).

    • Maintain therapeutic relationships to further enhance daily functioning.

Treatments and Therapies

  • Recovery-Oriented Approach:

    • Use of medications, specifically antipsychotics.

    • Incorporating cognitive behavioral therapy (CBT).

    • Providing family education and support.

    • Implementing assertive community treatment (Chow, 2021, p. 2).

Interventions

  1. Establishing a Therapeutic Milieu:

    • Create a calm environment with reduced stimulation.

    • Regularly check on clients for safety.

    • Monitor vital signs, neurological status, mental status assessment, suicidality, and manifestation of psychosis.

    • Encourage clients to apply symptom management strategies (Calabrese et al., 2022, p. 5).

  2. Client and Family Education:

    • Provide education on schizophrenia, including positive and negative symptoms, medications, and treatment options.

    • Encourage social engagement and participation in support groups.

    • Maintain communication with the healthcare team.

    • Administer medications and evaluate responses to interventions (Pinho et al., 2017, p. 3).

Client Teaching

  • Discharge Instructions:

    • Information about medications, diet, exercise regimens, signs of relapse, and referrals for ongoing support (University of Michigan, 2020, p. 1).

Serious Mental Illness

  • Definition: Conditions leading to functional impairment that disrupt or limit major life activities, including a variety of disorders such as schizophrenia spectrum disorders, bipolar disorder, and severe depression.

  • Age of Onset: A younger age at onset of symptoms often correlates with more severe outcomes later in life (American Psychiatric Association, 2022).

Social Problems Associated with Mental Illness

  • Consequences: Issues include incarceration (jail/prison), stigma, social isolation, loneliness, and victimization (WHO, 2018, p. 7).

Economic Challenges

  • Impact on Individual: High rates of unemployment (NAMI, 2021, p. 1), homelessness, and caregiver burden affect families and communities.

Treatment Issues

  • Barriers: Challenges include nonadherence to treatment (NAMI, 2021, p. 1), treatment inadequacies, and anosognosia (lack of awareness of the condition).