Schizophrenia and Psychosis Overview

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Introduction to Mental Health

Learning Objectives

  • Integrate therapeutic use of self: Includes therapeutic relationships, therapeutic communication, and interpersonal processes with diverse individuals, families, and communities.

  • Explore through reflection and self-assessment: Assess one's own beliefs and values in providing nursing care across the continuum of mental health from wellness to illness.

  • Describe roles of the professional nurse: Focuses on caring for clients and families experiencing psychiatric/mental disorders/problems.

  • Explain various aspects of psychiatric/mental health disorders: Covers etiology, risk factors, neurobiology, signs and symptoms, complications, psychopharmacology, nursing interventions, and treatment modalities.

  • Utilize evidence-based practice: Employ clinical judgment and the nursing process as frameworks for providing holistic care.

  • Examine legal, economic, sociocultural, and ethical issues: Review their impacts on the psychiatric/mental health delivery system and continuum of care.

Schizophrenia Spectrum Disorders and Psychosis

Overview

  • Definition: A range of disorders characterized by psychotic symptoms.
      - Includes:
         - Schizophrenia
         - Schizoaffective disorder
         - Schizophreniform disorder
         - Brief psychotic disorder
         - Delusional disorder
         - Shared psychotic disorder
         - Substance-induced psychotic disorder
         - Late-onset schizophrenia

  • Cure: There is currently no cure available.

  • Treatment Focus: Management of symptoms and improvement of daily functioning (NIMH, 2020).

  • Nursing Responsibilities:
      - Act as a liaison for clients, interprofessional team members, and community organizations.
      - Initiate referrals to primary care or specialized mental health services.

Understanding Psychosis

Characteristics

  • Disconnection with Reality: Caused by disturbances in a client’s thoughts and perceptions.
      - Symptoms include:
        - Hallucinations
        - Troubling thoughts or beliefs
        - Emotional changes
        - Withdrawal
        - Lack of self-care (Pen Medicine, 2020).

Diagnosis

  • Criteria:
      - Elimination of other medically related causes.
      - Gradual onset observed.
      - Consideration of family history.

  • Treatment Options: Antipsychotic medications, psychotherapy, cognitive behavioral therapy, support, and education for both the client and their family.

DSM-5-TR Criteria for Schizophrenia

Diagnostic Information

  • Age of Onset: Typically diagnosed between 16 and 30 years old.

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

  • Criteria for Diagnosis:
      - Two or more symptoms must be present for at least 1 month, with signs of continuous disturbance for at least 6 months.
        - Symptoms include:
          - Delusions
          - Hallucinations
          - Disorganized speech
          - Grossly disorganized or catatonic behavior
          - Negative symptoms
      - Presence of impairment in one major area of functioning, such as self-care, work, or interpersonal relationships for an extended period.

Common Facts about Schizophrenia

  • Productive Lives with Treatment: Individuals can lead productive lives when treatment and support are available.

  • Stigma Impact: Stigmatization leads to limited healthcare access, underdiagnosis, and undertreatment (Living with Schizophrenia, 2022).

  • Risk of Victimization: Individuals diagnosed with schizophrenia are 14 times more likely to be victims of crime or violence than the general population.

  • Co-occurring Disorders: Approximately one-half of individuals with a diagnosis of schizophrenia also have a co-occurring mental health disorder.

Risk Factors and Etiology

Genetics

  • Inheritance: No single gene identified; involves multiple genes that contribute to inherited vulnerability (NAMI, 2021).

Physiological Factors

  • Neurodevelopment: Associated with prenatal hypoxia and infections.

  • Biochemical Factors: Chronic exposure to cortisol has been cited.

Environmental Factors

  • Cannabis Use: Identified as a significant risk factor for schizophrenia onset.

Clinical Presentation of Schizophrenia

Symptom Classifications

  • Positive Symptoms:
      - Hallucinations
      - Delusions
      - Disorganized speech (APA, 2022).

  • Negative Symptoms:
      - Alogia (lack of speech)
      - Anergia (lack of energy)
      - Anhedonia (inability to experience pleasure)

  • Cognitive Symptoms:
      - Poor concentration
      - Slow thinking
      - Poor memory

The Nurse’s Role

Responsibilities

  • Therapeutic Relationship: Create and maintain a safe therapeutic relationship.

  • Therapeutic Environment: Ensure a safe, calm, therapeutic environment.

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

  • Thorough Assessment: Ensure completion of assessments, including a mental status examination.

  • Stabilizing Interventions: Provide interventions focusing on stabilizing the client

  • Support for Recovery: Offer support to the client towards recovery, self-management, and engagement (Young, 2018; Hartley et al., 2020; Calabrese et al., 2022).

Phases of Therapeutic Relationship

  • Orientation Phase:
      - Client may not recognize the need for assistance and can block therapeutic alliance (Hartley et al., 2020).
      - Challenges include client's symptoms and health care team biases.

  • Identification Phase:
      - Issues include poor insight and difficulties in communication and daily functioning.
      - Focus is on assisting the client in understanding their condition and ensuring safety.

  • Exploitation Phase:
      - Explore various interventions and recognize triggers.
      - Encourage expression of difficulties and seeking assistance when necessary.

  • Resolution Phase:
      - Focus on rehabilitation and recovery, facilitating the client's ability to function independently.

Treatments and Therapies

  • Recovery-oriented approach: Focus on overall rehabilitation and has key components like:
      - Use of antipsychotic medications
      - Cognitive Behavioral Therapy
      - Family education and support
      - Assertive community treatment (Chow, 2021).

Nursing Interventions

Management of Environment

  • Therapeutic Milieu: Establishing and maintaining a calm environment with reduced stimulation.

  • Safety Monitoring: Regular checks on the client to ensure safety and collecting vital data, including vital signs and mental status assessments (Calabrese et al., 2022).

Client Education

  • Family Education: Educate clients and families about the disorder, including the distinction between positive and negative symptoms, and understand treatment options, including medications.

  • Engagement: Encourage clients to participate in social and support groups.

  • Communication: Maintain open communication with the healthcare team to ensure coordinated care.

  • Medication Administration: Administer medications and evaluate the client’s response to interventions.

Client Teaching

Discharge Instructions

  • Medication Management: Highlight importance of following prescribed medications.

  • Lifestyle Recommendations: Provide guidance on diet and exercise regimens.

  • Recognizing Signs of Relapse: Teach clients to recognize signs of relapse to seek timely help.

  • Referrals: Provide referrals for continued support (University of Michigan, 2020).

Serious Mental Illness

Definition

  • Characterized by functional impairment that interferes or limits major life activities, including:
      - Schizophrenia spectrum
      - Bipolar disorder
      - Severe depression

  • Notable severity often correlates with the earlier onset of symptoms (American Psychiatric Association, 2022).

Social Problems Linked to Mental Illness

  • Stigmatization: Leads to increased isolation and loneliness.

  • Victimization: Individuals with mental illness are at risk of victimization (WHO, 2018).

Economic Challenges

  • Unemployment Issues: High levels of unemployment in those with serious mental illness (NAMI, 2021).

  • Homelessness Risk: Many experience homelessness due to losses in economic stability.

  • Caregiver Burden: Family members can face significant burdens when caring for loved ones with serious mental illness.

Treatment Issues

Common Challenges

  • Nonadherence to Treatment: Many individuals struggle with adherence to treatment plans (NAMI, 2021).

  • Inadequate Treatment Options: Access to effective treatment can often be insufficient.

  • Anosognosia: A condition where the patient is unaware of their illness, complicating adherence.

Appendix

Positive, Negative, and Cognitive Symptoms

  • Positive Symptoms: Visibly active brain activity reflecting outbursts or energy.

  • Negative Symptoms: Associated with lack of energy or depressive appearance.

  • Cognitive Symptoms: Indicate impaired functioning, represented by disrupted mechanisms in mental processing.

Image Descriptions

  • Positive Brain: Depicted with lightning bolts and an upward-trending graph.

  • Negative Brain: Shown with clouds and a downward-trending graph.

  • Cognitive Brain: Visualized with gears that are broken and a dotted graph.