Schizophrenia Spectrum and other Psychotic Disorders

Schizophrenia Spectrum and other Psychotic Disorders 150 150 Tony Guo

Schizophrenia Spectrum and other Psychotic Disorders

  • The word schizophrenia is derived from the Greek words skhizo (split) and phren (mind).
  • The diagnosis of schizophrenia is commonly misinterpreted as a split personality.
  • Schizophrenia is probably caused by a combination of factors, including:
    • Genetic predisposition
    • Biochemical dysfunction 
    • Physiological factors
    • Psychosocial stress
  • Schizophrenia requires treatment that is comprehensive and presented in a multidisciplinary effort.
  • Of all mental illnesses, schizophrenia probably causes more:
    • Lengthy hospitalizations
    • Chaos in family life
    • Exorbitant costs to people and governments  
    • Fears

 

Nature of the Disorder

  • Schizophrenia causes disturbances in:
    • Thought processes
    • Perception 
    • Affect
  • With schizophrenia, there is a severe deterioration of social and occupational functioning.
  • In the United States, the lifetime prevalence of schizophrenia is about 1%.
  • Premorbid behavior of the patient with schizophrenia can be viewed in four phases.

Phase 1

  • Premorbid phase
    • Shy and withdrawn
    • Poor peer relationships
    • Doing poorly in school
    • Antisocial behavior

Phase 2 

  • Prodromal phase
    • Lasts from a few weeks to a few years
    • Deterioration in role functioning and social withdrawal
    • Substantial functional impairment
    • Depressed mood, poor concentration, fatigue
    • Sudden onset of obsessive-compulsive behavior

Phase 3

  • Acute schizophrenic episode
    • In the active phase of the disorder, psychotic symptoms are prominent.
    • Delusions
    • Hallucinations
    • Impairment in work, social relations, and self-care

Phase 4

  • Residual phase
    • Symptoms similar to those of the prodromal phase.
    • Flat affect and impairment in role functioning are prominent.

 

Prognosis

Factors associated with a positive prognosis

  • Good premorbid functioning
    • Later age at onset
    • Female gender
    • Abrupt onset precipitated by a stressful event
    • Associated mood disturbance
    • Brief duration of active-phase symptoms
    • Minimal residual symptoms
    • Absence of structural brain abnormalities
    • Normal neurological functioning
    • No family history of schizophrenia

 

Predisposing factors

  • Biological factors
    • Genetics
      • A growing body of knowledge indicates that genetics plays an important role in the development of schizophrenia.
    • Biochemical factors
      • One theory suggests that schizophrenia may be caused by an excess of dopamine activity in the brain.
      • Abnormalities in other neurotransmitters have also been suggested
  • Physiological factors
    • Viral infection
    • Anatomical abnormalities 
    • Electrophysiology
    • Epilepsy
    • Huntington’s disease
    • Birth trauma
    • Head injury in adulthood
    • Alcohol abuse
    • Cerebral tumor
    • Cerebrovascular accident
    • Systemic lupus erythematosus
  • Psychological factors
    • These theories no longer hold credibility. Researchers now focus their studies of schizophrenia as a brain disorder. 
    • Psychosocial theories probably developed early on out of a lack of information related to a biological connection.
  • Environmental Influence 
    • Sociocultural factors: Poverty has been linked with the development of schizophrenia.
    • Downward drift hypothesis: Poor social conditions seen as consequence of, rather than a cause of, schizophrenia
    • Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse.
    • Studies of genetic vulnerability for schizophrenia have linked certain genes to increased risk for psychosis and particularly for adolescents who use cannabinoids.
  • Theoretical integration
    • Schizophrenia is most likely a biologically based disease, the onset of which is influenced by factors in the internal or external environment.

 

Types of Schizophrenia and Other psychotic Disorders

  1. Delusional disorder: The existence of prominent, nonbizarre delusions
  • Erotomanic type
  • Grandiose type
  • Jealous type
  • Persecutory type
  • Somatic type
  • Mixed type
  1. Brief psychotic disorder
  • Sudden onset of symptoms
  • May or may not be preceded by a severe 
  • psychosocial stressor
  • Lasts less than 1 month
  • Return to full premorbid level of functioning
  1. Substance- and medication-induced psychotic disorder
  • The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal
  1. Psychotic disorder due to another medical condition
  • Prominent hallucinations and delusions are directly attributable to a general medical condition.
  1. Catatonic disorder due to another medical condition
  • This diagnosis is made when the catatonic symptoms are directly attributable to the physiological consequences of a general medical condition.
  1. Schizophreniform disorder
  • Same symptoms as schizophrenia with the exception that the duration of the disorder has been at least 1 month but less than 6 months
  1. Schizoaffective disorder
  • Schizophrenic symptoms accompanied by a strong element of symptomatology associated with mood disorders of either mania or depression

 

Nursing process: Positive Symptoms

  • Content of thought
    • Delusions: Fixed, false personal beliefs
      • Persecutory
      • Grandiose
      • Somatic 
      • Erotomanic
      • Jealous
  • Form of thought
    • Associative looseness (also called loose association): Shift of ideas from one unrelated topic to another
    • Neologisms: Made-up words that have meaning only to the person who invents them
    • Concrete thinking: Literal interpretations of
      the environment
    • Clang associations: Choice of words is governed by sound (often rhyming)
    • Word salad: Group of words put together in a random fashion
    • Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details
    • Tangentiality: Inability to get to the point of communication due to the introduction of many new topics
    • Mutism: Inability or refusal to speak
    • Perseveration: Persistent repetition of the same word or idea in response to different questions
  • Perception: interpretation of stimuli through the senses
    • Hallucinations: False sensory perceptions not associated with real external stimuli
      • Auditory
      • Visual
      • Tactile
      • Gustatory
      • Olfactory
    • Illusions: Misperceptions of real external stimuli
    • Echopraxia: Repeating movements that are observed

 

Nursing process: Negative Symptoms

  • Affect: The feeling state or emotional tone
    • Inappropriate affect: Emotions are incongruent with the circumstances
    • Bland: Weak emotional tone
    • Flat: Appears to be void of emotional tone
    • Apathy: Disinterest in the environment
  • Avolition: Impairment in the ability to initiate goal-directed activity
    • Emotional ambivalence: Coexistence of opposite emotions toward same object, person, or situation
    • Deterioration in appearance: Impaired personal  grooming and self-care activities
  • Impaired interpersonal functioning and relationship to the external world
    • Impaired social interaction: Clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable
    • Social isolation: A focus inward on the self to the exclusion of the external environment
  • Lack of insight
    • Anergia: deficiency of energy
    • Anhedonia: Inability to experience pleasure
  • Lack of abstract thinking ability
  • Associated features
    • Waxy flexibility: Passive yielding of all movable parts of the body to any effort made at placing them in certain positions
    • Posturing: Voluntary assumption of inappropriate or bizarre postures
  • Pacing and rocking: Pacing back and forth and rocking the body
  • Regression: Retreat to an earlier level of development
  • Eye movement abnormalities

 

Diagnosis/Outcome Identification

  • Disturbed Sensory Perception (auditory and visual) 
  • Disturbed Thought Processes 
  • Social Isolation
  • Risk for Violence: Self-directed or Other-directed
  • Impaired Verbal Communication
  • Self-Care Deficit
  • Disabled Family Coping
  • Ineffective Health Maintenance
  • Impaired Home-Maintenance

 

Outcome: The Patient

  • Demonstrates an ability to relate to others satisfactorily 
  • Recognizes distortions of reality
  • Has not harmed self or others
  • Perceives self realistically
  • Demonstrates ability to perceive the environment correctly
  • Maintains anxiety at a manageable level
  • Relinquishes need for delusions and hallucinations
  • Demonstrates ability to trust others
  • Uses appropriate verbal communication in interactions with others
  • Performs self-care activities independently

 

Planning/Implementation

  1. Disturbed Sensory Perception: Auditory/Visual: Impaired communication (inappropriate responses), disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, tilts head to side as if to be listening
  • Observe the client for signs of hallucinations.
  • Help client understand connections between anxiety and hallucinations.
  • Distract the client from hallucinations.
  1. Disturbed Thought Processes: Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others; inaccurate interpretation of the environment
  • Do not argue or deny the belief.
  • Reinforce and focus on reality.
  1. Risk for Violence: Risk factors: Aggressive body language (e.g., clenching fists and jaw, pacing, threatening stance); verbal aggression; catatonic excitement; command hallucinations; rage reactions; history of violence; overt aggressive acts; goal-directed destruction of objects in the environment; self-destructive behavior; active, aggressive suicidal acts
  • Observe client’s behavior.
  • Maintain calm attitude.
  • Have sufficient staff on hand.
  1. Impaired Verbal Communication: Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization
  • Facilitate trust and understanding.
  • Orient the client to reality.

 

Client/Family Education

  • Nature of illness
    • What to expect as illness progresses
    • Symptoms associated with illness
    • Ways for family to respond to behaviors associated with illness
  • Management of the illness
    • Connection of exacerbation of symptoms to times of stress
    • Appropriate medication management
    • Side effects of medications
    • Importance of not stopping medications
    • When to contact healthcare provider
    • Relaxation techniques
    • Social skills training
    • Daily living skills training
  • Support services
    • Financial assistance
    • Legal assistance
    • Caregiver support groups
    • Respite care
    • Home healthcare

 

Evaluation

  • Has client established trust with at least one staff member?
  • Is anxiety level maintained at a manageable level?
  • Is delusional thinking still prevalent?
  • Is client able to interrupt escalating anxiety with adaptive coping mechanisms?
  • Is client easily agitated?
  • Is client able to interact with others appropriately?

 

Treatment Modalities

  • Psychological treatments
    • Individual psychotherapy: Long-term therapeutic approach; difficult because of client’s impairment in interpersonal functioning
    • Group therapy: Some success if occurring over the long-term course of the illness; less successful in acute, short-term treatment
    • Behavior therapy: Chief drawback has been inability to generalize to community setting after client has been discharged from treatment.
  • Social treatments
    • Social skills training: Use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship development
    • Family therapy: Aimed at helping family members cope with long-term effects of the illness
  • Program of Assertive Community Treatment 
    • A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness

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