Scizophrenia pathophysiology, sign and symptoms and nursing interventions PDF

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Schizophrenia and Schizophrenia Spectrum Disorders PSYCHOSIS: ● Loss of contact with reality ● Disorganization of the personality ● Deterioration of social functioning Psychotic Disorders ● Defined by abnormalities in 1 of the following 5 domains ○ Delusions ○ Hallucinations ○ Disorganized speech/thinking ○ Grossly disorganized or abnormal motor behavior, including catatonia - Catatonia is marked by a significant decrease in someone's reactivity to their environment. This can involve stupor, mutism, negativism or motor rigidity, and even purposeless excitement. ○

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Negative symptoms (blunting of affect, poverty of speech and thought, apathy, anhedonia, reduced social drive, loss of motivation, lack of social interest, and inattention to social or cognitive input)

DX of Schizophrenia * one symptom must be delusions, auditory or visual hallucinations, or disorganized speech/thinking; two symptoms x 6months The more disorganized the speech, the more bizarre the speech

Delusions ● Fixed false beliefs ○ Persecutory ■ Someone or something is after them ■ Believe someone out to get them, to harm them, poison them ■ Ex. Pt won’t eat food on the trays, won’t drink from the same water pitcher, want a sealed one ○ Referential (ideas of reference) ■ Belief that events or circumstances that have no connection to the person are related directly to them ■ May believe a song in radio was written just for them, the news reporter is talking to me, they feel like everything is about and r/t them ○

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Grandiose ■ Being of power or having a relationship with someone in power ■ Believe they are powerful, they are messiah, have special relationship w/ someone w/ power, they may say they know the president, they think they are God Somatic – false beliefs about their body ■ Believe their body is changing in unusual rates ■ Ex. Rotting heart, horrible body odor, tumors or organs not working, broken bones ■

They may be driven to bathe excessively or withdraw to manage their body's offensive odor.

Hallucinations ● Perception like experiences that occur without an external stimulus

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Vivid, clear with the full-force and impact of normal perceptions, the person perceives them as real Can occur with any sensory modality ○ Auditory – hearing voices or sounds, range from God/demonic figure is talking to them, can be familiar or unfamiliar, can be single or multiple voices, can be pleasant or unpleasant, can be a command hallucination (harm someone for example) ○ Visual – seeing things or objects, real to the pt., not a blurry figure ○ Olfactory – they are smelling things not there, but they are there for them. ○ Tactile – feelings of movement or sensation in the body that are not present (Ex. bugs on skin or hair) ○ Gustatory – taste. Usually an intolerable taste (like chemical or rotting taste)

Disorganized Thinking ● Illogical thinking and poor concentration /Thought disorder ● Thinking is evaluated by speech observation and evaluation ● Inferred from person’s speech ○ Loose associations/derailment - lack of logic between words, thoughts, and ideas ○ Tangential speech - all over the place, never get back to the point of the topic. *Can create a barrier in nursing care: inability to collect a clear history. If unable to get Hx from pt. get it from family. ○ Word salad - extreme form, basically jumble of word meaningless to the listener. ● There is no effective communication Grossly Disorganized or Abnormal Behavior ● Catatonia: ○ A pronounced increase or decrease in the rate and amount of movement ○ Bizarre posture ○ Most extreme form patient moves little or not at all ○ They are in a fixed position/statue form/fixed in place. ● The excitement form of Catatonia ○ motor activity is purposeless ○ accompanied by echolalia (repeating other’s words) ○ echopraxia (mimicking other’s movement) Schizophrenia (min 2 symptoms) ● Syndrome of variable but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior ● Estimated to account for approximately 2.5 percent of all health care costs ● Not a homogeneous disorder with a single cause Epidemiology of Schizophrenia ● Lifetime prevalence of schizophrenia is 1% worldwide (2.5 million Americans) ● No difference related to:

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○ Race ○ Social status ○ Culture Only about ½ of all patients with schizophrenia obtain treatment Equally prevalent in men and women Peak age of onset 18-25 years in men, 25-35 years for women At this age big life events like going to college – could be a stressor High mortality rate 80% of patients have comorbid medical illnesses Substance abuse is a common co-morbidity and associated with poorer function Patients with schizophrenia account for 15-45% of the homeless population in US Occupy 50% of all psychiatric inpatient beds *** most at risk 19-year-old male ***

Comorbidities ● Substance related disorders: nearly 50% ○ Nicotine dependence: 70-90% (CVD & Respiratory disease) ● Anxiety, depression, and suicide ● Physical health or illness ○ Death: 25 years prematurely ○ HTN, obesity, CVD, DM, COPD, & trauma ● Polydipsia: 20% **boards question ** ○ Excessive thirst from meds (anti-cholinergic) ○ Can lead to hyponatremia from water intoxication -> will worsen psychosis – Nursing intervention: monitor I&O ● Metabolic Syndrome Suicide Risk - hand and hand with schizophrenia ● Close to 10% of individuals with schizophrenia die from suicide ● 20% attempt suicide on 1 or more occasions ● Many have significant suicidal ideation ● May be related to command hallucinations ● Suicide risk remains high over the entire course of the illness ● Young males with co-morbid substance abuse are at particular risk ● Suicide risk heightened with unemployment, feelings of hopelessness, depression, period after psychosis and hospitalization (because they have the energy to do it!) Genetic Factors Prevalence in Specific Populations ● General Population: 1% ● Non-twin sib of schizophrenic: 8% ● Child with one parent with schizophrenia: 12% ● Dizygotic twin of schizophrenic: 12% ● Child of 2 parents with schizophrenia: 40% ● Monozygotic twin of schizophrenic parents: 47%

Schizophrenia and Genes (NOT TESTED) ● C4 is a gene with known roles in immunity - C4 is an immune system “complement” factor—a small secreted protein that assists immune cells in the targeting and removal of pathogens ●

People with schizophrenia are more likely to have overactive forms of the protein C4-A ○ C4-A increase leads to inappropriate/overactive pruning - gets rid of things we don't need in the cell ○ Increases variable risk by about 25% ○ Normally, pruning gets rid of excess connections we no longer need, streamlining our brain for optimal performance, but too much pruning can impair mental function

Etiology of Schizophrenia ● Biological factors ○ Genetics ● Neurobiological ○ Dopamine theory: Increase or dysregulation ○ Other neurochemical hypotheses: ■ 5-HT2A (Serotonin) dysregulation - 5-hydroxytryptamine or serotonin ■ Glutamate dysfunction (decrease) ■ Ach (dysregulation) ● Brain structure abnormalities ● Psychological and environmental factors ○ Prenatal stressors: poor nutrition, hypoxia, infection, trauma, loss ■ Decrease in child Vitamin D (occurs mostly late winter and early spring – exposure to sun is the shortest), infection during pregnancy, if father is over age of 35 ○ Psychological stressors: increased cortisol ■ Childhood sexual abuse, social adversity, migration, traumatic event (trauma in family can cause in way the brain in made up (by genes modification)) ■ Environmental stressors: toxins Anatomical Abnormalities ● Ventricular enlargement (fluid spaces) ● Sulci Enlargement (fissures on the surface of the brain) ● Cerebellar atrophy (reduced volume) ● Reduced cortical, frontal lobe, & hippocampal volumes; less grey matter ● Reduced connectivity in various brain regions Course of the Disorder ● Prodromal: onset (forewarning) 1 month to over a year before 1st psychotic break ○ Phobia or obsessions ○ Feeling strange - “Something feels wrong” ○ Low concentration, memory impairment

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Mild changes in mood or thinking Person may be anxious or withdrawn May be a little paranoid Symptoms fluctuate – go up and down for up to a year. If they seek treatment for these symptoms – might receive anti-psychotics, but usually not diagnosed at this stage because symptoms not specific yet and might go non-diagnosed Chronic: exacerbations alternating ○ periods of reduced/dormant symptoms Responses to treatment ○ If dx early enough antipsychotic meds may be ordered and possibly reduce the development or severity of schizophrenia ○ Omega fatty acids may also be used to reduce inflammation and increase free radicals in the brain which will promote ACH and Serotonin stability. ○ Better prognosis: abrupt onset, good premorbid social & occupational functioning ○ Poorer prognosis: insidious onset, younger person, increased time between symptoms and treatment

Phases of Schizophrenia ● Phase 1 - Acute ○ Onset of exacerbation of symptoms ○ From mild to severe ○ Symptoms from few to many and are very disabling ■ Delusions ■ Hallucinations ■ Apathy (lack of interest, enthusiasm, or concern) ■ Social withdraw ■ Diminished affect ■ Impaired judgement ■ Cognitive regression ○ Person needs to be hospitalized – which might be difficult (pt. refusing) ● Phase 2 - Stabilization ○ Symptoms diminishing ○ Movement toward previous level of functioning ○ May be seeking help at rehab or other places ○ Does not cure it, it is a chronic disorder ● Phase 3 - Maintenance ○ At or near baseline functioning ○ Negative or cognitive symptoms are still of concern ○ Can return home but needs to be in continued care ○ Might still have an exacerbation of the illness

Treatment of Schizophrenia ● PREP - Prevention and recovery in early psychosis ● Hospitalization and partial hospitalization day programs ● Intensive outpatient program (about 8 hours) ● Medication ● ECT ● Social skills training ● Family oriented therapy ● Case management – could be a nurse ● PACT - Program of assertive community ● CBT ● Art therapy ● Cognitive rehabilitation Indications for Hospitalization ● Acute psychosis ● Suicidal ideation ● Homicidal ideation ● Threatening behavior ● Grossly disorganized or inappropriate behavior ● Severe agitation ● Inability to care for self ● Treatment of acute psychosis focuses on safety and alleviating the most severe symptoms ● May use IM antipsychotics combined with benzodiazepine most commonly Lorazepam (Ativan) Assessment of a patient with schizophrenia ● During the pre-psychotic phase ● General assessment ● Positive symptoms ○ Presence of something that should not be present ○ Ex. hallucinations ● Negative symptoms ○ Absence of what should be present ● Cognitive symptoms – Confusion, poor motor coordination, loss of short-term or long-term memory, identity confusion, impaired judgment. ●

Affective symptoms - prolonged sadness, irritability or anxiety, lethargy and lack of energy, lack of interest in normal activities, major changes in eating and sleeping habits, difficulty concentrating, feelings of guilt, aches and pains that have no physical explanation.

Negative Symptoms Negative symptoms refer to an absence or lack of normal mental function involving thinking, behavior, and perception.

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Associated with schizophrenia Diminished emotional expression * Avolition ○ Reduced desire motivation or persistence Alogia ○ Reduction/poverty of speech Anhedonia ○ Finds no pleasure in everyday activities Asociality ○ Decreased desire for or comfort during social interactions Diminished self-care ○ * particularly prominent in schizophrenia Affect is flat ○ No or nearly no emotional expression ○ May not react at all to circumstances that usually evoke strong emotions in others Affect is blunted ○ A reduction in an individual’s emotional response ○ Emotional response is a lot weaker than one would expect in similar circumstances ○ Not as severe as flat affect ○ Flat affect, look – no expression at all Inappropriate – Ex. someone in their family just died, instead of being sad, they will do the opposite like smiling Bizarre

Positive Symptoms Positive symptoms - highly exaggerated ideas, perceptions, or actions that show the person can’t tell what’s real from what isn’t. The word "positive" means the presence (rather than absence) of symptoms. ● ● ● ●

Alterations in thinking Delusions - false, fixed beliefs Concrete thinking - inability to think abstractly (outside the box) Alterations in speech − Associative looseness ○ Clang associations - choosing words based on sounds rather than their meaning: “On the track, big mac, click-clack” ○ Word salad - most severe form of associative looseness; jumble of words ○ Neologisms - words that have meaning to the patient but a different or nonexistent to others Ex. “His manoregism is poor”

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Echolalia – pathological repeating of another’s words; thought process so impaired unable to generate speech of his/her own Other disorders of thought or speech ○ Religiosity excessive religious observance/religiously preoccupied ○ Magical thinking: believing that thoughts or actions affects others. ○ Paranoia: an irrational fear ranging from mild to severe ○ Circumstantiality: including unnecessary and often tedious details in conversation but eventually getting to the point ○ Tangentiality: wandering off topic, never getting to the point ○ Cognitive retardation: generalized slowing of thinking, delays in responsiveness ○ Alterations in perception ■ Depersonalization-feeling of being unreal, lost identity, feel they are not a real person ■ Derealization A feeling that the environment has changed, surroundings are strange and unfamiliar ■ Hallucinations ● Auditory ● Command ● Visual

Disordered Thought/Speech ● Other disorders of thought or speech (cont.) ○ Alogia, or poverty of speech ○ Flight of ideas: over productive speech characterized by rapid shifting from one topic to another and fragmented ideas ○ Thought blocking: sudden stopping in the train of thought or during a sentence ○ Thought insertion: the thought that someone has inserted thoughts into your brain ○ Thought deletion: a belief that your thoughts have been taken Behavioral Changes/Alterations ● Catatonia ● Waxy flexibility ○ maintaining a given posture usually seen in Catatonia ● Motor retardation ○ a pronounced slowing of movement ● Motor agitation ○ Excited behavior such as running or pacing rapidly ● Stereotyped behaviors ○ repetitive behavior that doesn't make logical sense (swimming in circles on the floor, rocking) ● Echopraxia ○ the mimicking of movements of others ● Negativism:

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○ tendency to do the opposite of one is requesting Impaired impulse control ○ interrupting the group setting ○ Have to be redirected Gesturing or posturing ○ assuming illogical expressions Boundary impairment ○ an impaired ability to sense where one's body influences starts and ends

Cognitive Symptoms ● Difficulty with ○ Attention ○ Memory: impaired short term (i.e. reminder to brush teeth, shower, may have to redirect) ○ Information processing – May have to repeat information ○ Cognitive flexibility: refers to the brain’s ability to transition from thinking about one concept to another. ○ Executive functions: difficulty with reasoning-impedes on problem solving – May have to help them get the resources they need at discharge (group therapy, transportation…) Affective Symptoms ● Assessment for depression is crucial ○ May result in impending relapse, along with decreased ability to concentrate ○ Increases substance abuse ○ Increases suicide risk ○ Further impairs functioning Assessment Guidelines ● Any medical problems ● Abuse of or dependence on alcohol or drugs ● Risk to self or others ● Command hallucinations ● Delusions ● Suicide risk ● Ability to ensure self-safety, able to communicate that they won’t hurt themselves ● Medications – when was the last time taken, do they know who’s their mental health provider and healthcare provider. ● Mental status examination ● Patient’s insight into illness – do they know they have a mental health disorder – Might ask: “Have you been hospitalized before?” ● Family’s knowledge of patient’s illness and symptoms Case Study:

 You believe that the young man you are admitting to your unit is suffering from command hallucinations.  What would be some questions to ask him? Questions to ask include: • Do you recognize the voices? • Do you believe the voices are real? • Do you plan to follow the command? What are the voices telling you to do? Violence/Impulsive Behaviors ● Increased potential for violence in untreated schizophrenia ● Assess for history of violent behavior ● Dangerous behaviors while hospitalized ● Command hallucinations Mental Status Exam ● Appearance: ranges from disheveled, screaming, agitated to obsessively groomed, completely silent and immobile ● Affect: reduced emotional responsiveness or overly active, inappropriate, flat ● Mood: depressed, anxious, anhedonic ● Perceptual disturbances: hallucinations ● Thought disorders ● Impulsiveness, violence, suicide and homicide ● Orientation usually oriented to time place and person ● Memory: usually intact ● Cognitive impairment: subtle cognitive dysfunction in attention, executive functioning, working memory, episodic memory ● Judgment and insight: poor insight Thoughts/Disorders Found in Schizophrenia ● Thoughts & Thought Content ○ Delusions ○ Religiosity ○ Paranoia ○ Magical thinking ● Form of Thought ○ Looseness of associations ○ Neologisms ○ Concrete thinking ○ Clang associations ○ Word salad ○ Circumstantiality ○ Tangentiality ○ Mutism ○ Perseveration – repetition of a word, a phrase or a gesture

Potential Nursing Diagnoses ● Positive symptoms ○ Disturbed sensory perception ○ Disturbed thought process ○ Risk for self-directed or other-directed violence ○ Impaired verbal communication ● Negative symptoms ○ Social isolation ○ Chronic low self-esteem ○ Self-care deficit Differential Diagnosis ● Temporal lobe Epilepsy, Parkinsonism ● Tumor, Stroke, brain trauma, TBI ● Infectious encephalitis, neuro-syphilis and AIDS ● Autoimmune e.g. Systemic Lupus ● Alzheimer’s, Huntington’s ● Drug Induced: stimulants: amphetamines, cocaine ○ Hallucinogens ○ Withdrawal from ETOH (can see things, have things crawling on them, might have seizures..), barbiturates and anticholinergics Substances Associated with Psychosis ● Alcohol ● Cannabis ● Hallucinogens ● Phencyclidine (PCP) ● Inhalants ● Sedatives ● Hypnotics ● Anxiolytics ● Cocaine ● Methamphetamine ● Ketamine (Special K) – course tranquilizer ● MDMA – ecstasy ● Designer drugs Outcomes Identification ● Phase I – Acute o Patient safety and medical stabilization ● Phase II – Stabilization o Help patient understand illness and treatment o Stabilize medications

o Control or cope with symptoms Phase III – Maintenance o Maintain achievement o Prevent relapse o Achieve independence, satisfactory quality of life Case Study:  After an acute admission, discharge is being planned for this patient.  What are some things that need to be considered?

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Some things to be considered are external factors, such as the patient's living arrangement, economic resources, social supports, and family relationships, and important internal factors, such as resilience and range of coping skills. Another important factor is connecting the patient and family with (not simply refer them to) community resources that provide therapeutic programming and social, financial, and other needed support. Interventions ● Acute Phase ○ Psychiatric, medical, and neurological evaluation ○ Psychopharmacological treatment ○ Support, psychoeducation, and guidance ○ Supervision and limit setting in the milieu ○ Monitor fluid intake (r/t polydipsia) Nursing Interventions ○ Provide a safe environment ○ Intervene at ...