Chapter12/Exam2

Overview of Schizophrenia Spectrum Disorders

• Schizophrenia spectrum disorders are a group of conditions that share common features with schizophrenia.

• These disorders are primarily characterized by psychosis, which involves:

  • Altered cognition.

  • Altered perception.

  • An impaired ability to determine what is or is not real (impaired reality testing).

Specific Schizophrenia Spectrum Disorders

• Delusional Disorder

  • Characterized by false thoughts or beliefs that have lasted for at least $1$ month or longer.

  • These delusions are not severe enough to significantly impair the individual's daily functioning.

  • Common themes of delusions include:

    • Grandiose themes.

    • Persecutory themes.

    • Somatic themes.

    • Referential themes.

• Brief Psychotic Disorder

  • Characterized by the sudden onset of at least one of the following symptoms:

    • Delusions.

    • Hallucinations.

    • Disorganized speech.

    • Disorganized or catatonic behavior.

  • Duration requirements: The symptoms must last longer than $1$ day but no longer than $1$ month.

  • The expectation for this disorder is a return to the individual's normal level of functioning.

• Schizophreniform Disorder

  • The symptoms of this disorder are exactly like those of Schizophrenia, but with a different duration.

  • Duration: Symptoms have lasted less than $6$ months.

  • Impairment: Notable social or occupational functioning impairment may not yet be apparent.

  • Prognosis: The individual may or may not return to their previous level of functioning.

• Schizoaffective Disorder

  • This condition involves a major depressive, manic, or mixed episode occurring concurrently with symptoms that meet the criteria for schizophrenia.

  • It is explicitly not caused by any substance use or a general medical condition.

• Substance-Induced Psychotic Disorder & Psychotic Disorder Due to Another Medical Condition

  • Psychosis (delusions or hallucinations) specifically resulting from:

    • Illicit drugs, alcohol, medications, or toxins.

    • Delirium, neurological disease, hepatic or renal disease, and many more medical contexts.

Schizophrenia: Epidemiology and DSM-V Criteria

• General Characteristics

  • Schizophrenia affects approximately $1\%$ of the general population.

  • It is characterized by psychosis, including altered cognition, perception, and reality testing.

  • Age of onset: In $75\%$ of cases, it develops gradually, presenting between $15$ to $25$ years of age.

  • Child-onset schizophrenia and late-onset schizophrenia are considered more rare.

• DSM-V Diagnostic Criteria Highlights

  • At least two or more of the following must be present for a significant portion of time during a period of $1$ month:

    • Delusions.

    • Hallucinations.

    • Disorganized speech.

    • Gross disorganization or catatonia.

    • Negative symptoms (such as diminished emotional expression or avolition).

  • There must be functional impairment of some kind.

  • Continuous signs of the disturbance must persist for at least $6$ months.

  • Other causes, such as substances or other disorders, must be ruled out.

• Epidemiology and Demographics

  • Childhood-onset schizophrenia occurs in approximately $1$ in $40,000$ children.

  • There are no observed differences in prevalence related to race or culture.

  • The disorder is more frequently diagnosed:

    • Among males.

    • In urban areas.

Comorbidity and Risk Factors

• Comorbid Conditions

  • Substance abuse disorders, notably high rates of nicotine dependence.

  • Anxiety, depression, and suicide.

  • Physical illnesses.

  • Polydipsia (excessive thirst).

• Risk Factors

  • Biological Factors

    • Genetics.

    • Neurobiological factors involving neurotransmitters: Glutamate, dopamine, serotonin, and acetylcholine.

    • Brain structure abnormalities.

  • Environmental Factors

    • Prenatal stressors.

  • Prognostic variables.

Phases of Schizophrenia

• Prodromal Phase

  • The beginning stage characterized by onset and mild changes in behavior or thinking.

• Acute Phase

  • Characterized by the exacerbation of symptoms.

• Stabilization Phase

  • Symptoms begin to diminish, and the patient moves toward their previous level of functioning.

• Maintenance or Residual Phase

  • A new baseline of functioning is established.

Clinical Assessment: Symptoms of Schizophrenia

• Positive Symptoms

  • These include alterations in reality testing and the presence of behaviors that should not be there.

  • Delusions: False, fixed beliefs.

  • Concrete Thinking: The inability to think abstractly.

  • Alterations in Speech:

    • Associative Looseness: Fragmented or poorly connected thoughts.

    • Word Salad: The most extreme form of associative looseness; a jumble of words meaningless to a listener.

    • Clang Association: Choosing words based on their sound (e.g., rhyming) rather than meaning.

    • Neologisms: Creating words that have meaning only for the patient.

    • Echolalia: Pathological repetition of another person's words.

  • Other Abnormal Speech Patterns:

    • Circumstantiality.

    • Tangentiality.

    • Cognitive retardation.

    • Pressured speech.

    • Flight of ideas.

    • Symbolic speech.

  • Disorders or Distortions of Thought:

    • Thought blocking.

    • Thought insertion.

    • Thought deletion.

    • Magical thinking.

    • Paranoia.

• Alterations in Perception

  • Hallucinations: Can be auditory, visual, olfactory, gustatory, or tactile.

  • Command Hallucinations: Voices that direct the person to take specific actions.

  • Illusions: Misinterpretations of real external stimuli.

  • Depersonalization: A feeling of being unreal or having lost personal identity.

  • Derealization: A feeling that the environment has changed or is unreal.

• Alterations in Behavior

  • Catatonia.

  • Motor retardation or motor agitation.

  • Stereotyped behaviors.

  • Waxy Flexibility: Maintaining a given posture inappropriately.

  • Echopraxia: Mimicking the movements of another.

  • Negativism: Doing the opposite of what is requested.

  • Impaired impulse control.

  • Gesturing or posturing.

  • Boundary impairment.

• Negative Symptoms

  • The absence of essential human qualities:

    • Anhedonia: Inability to experience pleasure.

    • Avolition: Loss of motivation.

    • Asociality: Lack of interest in social interactions.

    • Affective Blunting: Reduced intensity of emotional expression.

    • Apathy: Decreased interest in or attention to activities.

    • Alogia: Poverty of speech.

  • Affect: The outward expression of a person's internal emotional state. Descriptions include:

    • Flat: No emotional expression.

    • Blunted: Minimal emotional expression.

    • Constricted: Limited range of emotions.

    • Inappropriate: Emotional expression does not match the situation (e.g., laughing at a tragedy).

    • Bizarre.

• Cognitive Symptoms

  • Concrete thinking.

  • Impaired memory.

  • Impaired information processing.

  • Impaired executive functioning.

  • Anosognosia: The inability to realize one is ill, caused by the illness itself.

• Affective Symptoms

  • Assessment for depression is crucial because it:

    • May herald an impending relapse.

    • Increases substance abuse.

    • Increases suicide risk.

    • Further impairs functioning.

Nursing Process and Assessment Guidelines

• Self-Assessment for Nurses

  • Recognize the impact of Anosognosia: This may result in resistance to treatment. When combined with paranoia, accepting help may become nearly impossible for the patient.

  • Nurses should monitor their own feelings of anxiety, fear, frustration, and manage their clinical expectations.

• Assessment Guidelines

  • Identify any medical problems or medical problems that mimic psychosis.

  • Evaluate for drug or alcohol use disorders.

  • Perform a mental status examination, including a cognitive assessment (e.g., reality testing).

  • Assess for hallucinations, delusions, and suicide risk.

  • Assess the ability to ensure personal safety and health.

  • Assess prescribed medications and the symptoms' impact on functioning.

  • Assess the family's knowledge of the disorder.

• Nursing Diagnoses

  • Hallucinations / Delusions.

  • Risk for violence.

  • Distorted thinking / Impaired abstract thinking.

  • Impaired communication.

  • Anosognosia.

  • Negative self-image.

  • Risk for loneliness.

  • Powerlessness.

  • Risk for suicide.

  • Impaired health maintenance.

Outcomes and Planning by Phase

• Phase I: Acute

  • Focus: Patient safety and medical stabilization.

  • Implementation: Psychiatric, medical, and neurological evaluation; psychopharmacological treatment; support/psychoeducation; supervision; monitoring fluid intake; managing aggression.

• Phase II: Stabilization

  • Focus: Helping the patient understand the illness and treatment, stabilizing medications, and controlling or coping with symptoms.

  • Implementation: Medication administration/adherence; building relationships with care providers; community-based therapy; teamwork and safety; groups.

• Phase III: Maintenance

  • Focus: Maintaining achievements, preventing relapse, and achieving independence with a satisfactory quality of life.

  • Implementation: Counseling and communication techniques for hallucinations and delusions; health teaching and promotion.

Pharmacotherapy: Antipsychotic Medications

• First-Generation Antipsychotics (FGAs)

  • Mechanism: Dopamine antagonists ($D_2$ receptor antagonists).

  • Target: Positive symptoms of schizophrenia.

  • Advantage: Less expensive than second-generation drugs.

  • Examples: Haloperidol, fluphenazine decanoate.

  • Disadvantages:

    • Extrapyramidal side effects (EPS).

    • Anticholinergic (ACh) side effects.

    • Tardive dyskinesia.

    • Weight gain, sexual dysfunction, and endocrine disturbances.

• Second-Generation Antipsychotics (SGAs)

  • Mechanism: Serotonin ($5-HT_{2A}$ receptor) and dopamine ($D_2$ receptor) antagonists.

  • Target: Both positive and negative symptoms.

  • Example: Clozapine (Clozaril), olanzapine pamoate, paliperidone palmitate.

  • Advantage: Minimal to no EPS or tardive dyskinesia.

  • Disadvantage: Tendency to cause significant weight gain and risk of metabolic syndrome.

• Third-Generation Antipsychotics

  • Mechanism: Dopamine system stabilizers; often considered a subset of SGAs.

  • Target: May improve positive and negative symptoms and cognitive function.

  • Examples: Aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar).

  • Advantage: Little risk of EPS or tardive dyskinesia.

Serious and Dangerous Responses to Antipsychotics

• Anticholinergic Toxicity

  • Signs: Reduced or absent peristalsis (leading to bowel obstruction); urinary retention; mydriasis; hyperpyrexia without diaphoresis (hot dry skin); delirium with tachycardia; unstable vital signs; agitation; hallucinations; seizure; repetitive motor movements.

• Neuroleptic Malignant Syndrome (NMS)

  • Signs: Severe muscle rigidity, dysphasia; flexor-extensor posturing; reduced or absent speech and movement; decreased responsiveness.

  • Vital signs: Hyperpyrexia (temperature over $103^{\circ}F$); autonomic dysfunction (hypertension, tachycardia, diaphoresis, incontinence).

  • Mental status: Delirium, stupor, coma.

• Severe Neutropenia

  • Reduced neutrophil counts leading to increased frequency and severity of infections.

  • Evaluation needed for symptoms like sore throat, fever, malaise, or body aches.

• Cardiac and Organ Impairment

  • Prolongation of the QT interval: Delays ventricular repolarization; can result in tachycardia, fainting, seizures, or sudden death.

  • Liver impairment: Usually occurs in the first weeks. Signs include jaundice, abdominal pain, ascites, lower extremity edema, dark urine, and pale/tar-colored stool.

• Metabolic Syndrome

  • Components: Weight gain (specifically abdominal), dyslipidemia, increased blood glucose, and insulin resistance.

  • Risks: Increases risk of diabetes, certain cancers, hypertension, and cardiovascular disease.

• Extrapyramidal Side Effects (EPSs)

  • Acute Dystonia: Sudden, sustained contraction.

  • Akathisia: Motor restlessness; inability to stay still.

  • Pseudoparkinsonism: Temporary symptoms resembling Parkinson’s disease.

  • Tardive Dyskinesia: Involuntary rhythmic movements.

Psychological Therapies and Modalities

• Individual and group therapy.

• Psychoeducation.

• Medication prescription and monitoring.

• Basic health assessment.

• Cognitive remediation or enhancement.

• Family therapy.

• Support groups.

Questions & Discussion

• Question 1: Loose associations in a person with schizophrenia indicate:

  • A. paranoia

  • B. mood instability

  • C. depersonalization

  • D. poorly organized thinking

  • Answer: D. poorly organized thinking.

• Question 2: Which assessment finding represents a negative symptom of schizophrenia?

  • A. Apathy

  • B. Delusion

  • C. Motor tic

  • D. Hallucination

  • Answer: A. Apathy.