Advanced Mental Health

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Advanced Mental Health ± Psychiatric Nursing

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Feb. 5

University of St. La Salle

Graduate School

The Client with

SchizophreniaAnd Other Psychotic Disorders

In Partial Fulfillment

of the Requirements in


Submitted to:

Ms. Jocelyn May Flor A. Cadena RN, RT, MN

Professor

Submitted by:

Angeline C. Lopez, RN

February 5, 2011




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Feb. 5

Table of Contents

Overview of Schizophrenia and Other Psychotic Disorders ................................................... 4

What is schizophrenia? ............................................................................................................ 4

Schizophrenia: The Course of Illness ....................................................................................... 5

Differential Diagnosis for Medical and Psychiatric Altered Sensory Brain

Disorders«««««««««««..........................................................................................6

What are the major types of Adult

Schizophrenia?............................................................................................................................ 7

Epidemiology and Prevalence of Schizophrenia ......................................................................8

Causative Factors: Theories and Perspectives.......................................................................10

Systems Involvement and Behavior .......................................................................................13

Psychosis and Issues of

Care«««««««««««««««««««««««««««««...««««««13

Overview of Other Brain Disorders«««««««««««««««««««««««««««««««««««««« 15

Summary««««««««««««««««««««««««««««..«««««.16

Bibliography««««««««««««««««««««««««««««««««. 16




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KEY TERMS

Alogia: Inability to speak owing to a mental condition or symptom of dementia.

Altered Sensory Perception: Refers to the physical and psychological changes that affect brain

functioning, behavior patterns, and the five senses.

Anhedonia: Refers to an inability to experience pleasure in activities and life.

Avolition: A marked decrease in motivation and inattention.

Autism: Denotes the presence of abnormal and impaired development in social and

communication skills and severely restricted activity and interests.

Delusion: A fixed false belief unchanged by logic.

Hallucinations: Refer to a false sensory perception occurring in the absence of an external

stimulus.

Illusions: Misinterpretations of actual occurring events.

Negative symptoms: Denote schizophrenic symptoms associated with structural brain

abnormalities. Most negative symptoms include blunted affect, inability to experience pleasure,apathy, a lack of feeling, and impaired attention.

Positive symptoms: Refer to schizophrenic symptoms with good premorbid functioning, acute

onset, and positive response to typical and atypical antipsychotics. Common positive symptoms

include hallucinations, delusions, disorganized thinking, and speech, and gross behavioral

disturbances. These symptoms are linked with dysregulation of biochemical processes.

Psychosis: A person¶s symptom state that refers to the presence of reality misinterpretations,

disorganized thinking, and lack of awareness regarding true and false reality.




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OVERVIEW OF SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

I. What is Schizophrenia?

Schizophrenia is a chronic, severe, and disabling mental disorder characterized by

deficits in thought processes, perceptions, and emotional responsiveness (Regier DA,

1993).

It causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior.

An incredibly complex disorder that has increasingly been recognized as a collection of

different disorders, Schizophrenia symptoms are typically described as ³positive´ or

³negative´.

A. Positive symptoms are those that are found among people with Schizophrenia, but not present among those who do not have the disorder. These may include:

> Hallucinations e.g. hearing imaginary voices, seeing people who aren¶t

there

> Delusions e.g. false beliefs of being under surveillance

> Disorganized speech

>Bizarre or

Disorganized behavior

People with schizophrenia may hear voices other people don¶t hear, or believe other people are reading their minds, controlling their thoughts, or plotting to harm them

(NIMH, 2009).

B. Negative symptoms are those found among people who do not have the disorder but

that are missing or lacking among individuals with schizophrenia. These may include

avolition (a lack of desire or motivation to accomplish goals), lack of desire to form

social relationships, and blunted affect and emotion. These symptoms make holding a

job, forming relationships, and other day-to-day functions especially difficult for

people with schizophrenia (Videbeck, 2005).

Most of schizophrenia patients cope with symptoms all throughout their lives. However

treatments may help relieve these disabling symptoms so that many people affected with

schizophrenia can lead meaningful and rewarding lives in their communities (NIMH,

2009).




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II. SCHIZOPHRENIA: The Course of Illness

There are two phases for the development of schizophrenia: prodromal and active. The

prodromal phase of schizophrenia may occur acutely or has a slower onset. Symptoms within

this phase include drastic alterations in the normal behavior patterns, unusual preoccupation

regarding other persons, social isolation, and problems in school or work areas (APA, 2000). Theacute phase has active overt symptoms. These include the manifestation of positive and

negative symptoms (APA, 2000).

ACUTE (ACTIVE) PHASE PRODROMAL AND RESIDUAL PHASES

DefinitionActive Phase: presence of psychotic symptoms

± at least one from the list of positivesymptoms (DSM ± IV Option A1)

Symptoms

Positive symptoms

y Delusion

y Hallucination

y Disorganized Speech

y Bizarre or disorganized behavior

Negative symptoms

y Flat affect

y Avolition

y Anhedonia

y Attention impairment

Impairment in Functioning (one or more major areas)

y Work

y Interpersonal relations

y Self-care

y Failure to achieve expected levels of interpersonal, academic, or

occupational development.

Minimum DurationOne month

DefinitionProdromal Phase: clear deterioration in

functioning occurring prior to active phaseinvolving minimum of two symptoms listed

below.

Symptoms

y Marked social isolation and withdrawal

y Marked impairment in role functioningas wage earner, student, or homemaker

y Markedly peculiar behavior

y Marked disturbance in speech

CircumstantialPoverty of speech and content

VagueOverelaborate

y Odd beliefs

y Unusual perceptual experiences

y Marked lack of initiative, interests,energy

Minimum DurationContinuous signs persisting a minimum of 6

monthsMust include active-phase period lasting 1

week to 1 month




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DIFFERENTIAL DIAGNOSIS FOR MEDICAL AND PSYCHIATRIC ALTERED SENSORY

B RAIN DISORDERS

Differential diagnosis between medical conditions and psychiatric altered sensory perception

disorders is accomplished after an in-depth physical and psychological examination of a person.

Complete blood work and scans need to be included in order to assess the person¶s condition. It

is important to use criteria listed in the Diagnostic and Statistical Manual Disorders (4th

edition,

Revision) (DSM-IV-TR) (American Psychiatric Association [APA], 2000) as another resource

regarding differential diagnosis.

MEDICAL, NEUROLOGICAL, AND PSYCHIATRIC DISEASES THAT MAY

MIMIC SYMPTOMS OF SCHIZOPHRENIA

MEDICAL AND NEUROLOGICAL DISEASES

PSYCHIATRIC DISEASES

y Temporal lobe epilepsy, parkinsonism

y Tumor, stroke, brain trauma

y Endocrine/metabolic disorders

Porphyria

Cushing¶s DiseaseThyroid Disorder

y Vitamin deficiency (e.g. B12)

y Infectious (e.g. herpes encephalitis,neurosyphilis, AIDS)

y Autoimmune (e.g. systemic lupuserythematosus)

y Toxic (e.g. heavy metal poisoning ± mercury, arsenic)

y Alzheimer¶s, Huntington¶s, Wilson¶sDisease

y Drug induced stimulants ± amphetamine,cocaine

Hallucinogens ± phencyclidine

Withdrawal from alcohol, barbiturates, and anticholinergics

MOOD DISORDERS

y Major depression with psychoticfeatures

y Bipolar disorder, manic episode

y Schizoaffective disorder

DELUSIONAL DISORDERS

PERSONALITY DISORDERS

y Paranoid

y Schizotypal

y Borderline

Data from Introductory Textbook of Psychiatry, by N.C. Andreasen and D.W. Black, 1991, Washington DC: American

Psychiatric Press; and Comprehensive Textbook of Psychiatry (Vol.1., 5th ed.), by H.I. Kaplan and B.J. Sadock (Eds.), 1989,

Baltimore: Williams &Wilkins. Adapted with permission.




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III. What are the major types of Adult Schizophrenia?

A. Paranoid Type- characterized by persecutory (feeling victimized or

spied on) or grandiose delusions, hallucinations, and occasionally, excessive

religiosity (delusional religious focus), or hostile and aggressive behavior.

B. Disorganized Type- characterized by grossly inappropriate or flat affect,

incoherence, loose associations, and extremely disorganized behavior.

C. Catatonic Type- characterized by marked psychomotor disturbance,

either motionless or excessive motor activity. Motor immobility may be

characterized by catalepsy (waxy flexibility) or stupor. Excessive motor activity is purposeless and is not influenced by external stimuli. Other features include

extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and

echopraxia.

D. Undifferentiated type- characterized by mixed schizophrenic symptoms (of

other types) along with disturbances of thought, affect, and behavior.

E. Residual type- characterized by at least one previous, though not acurrent episode; social withdrawal; flat affect; and looseness of associations.

Note: When caring for the client who presents with symptoms of schizophrenia, it is important that the psychiatric ± mental health nurse carefully assess the cultural viewpoint in order to

make a differential diagnosis between a normal cultural practice and the presence of a pathologically based delusion, hallucination, or illusion. Behaviors or symptom expressions may

be misunderstood.




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EPIDEMIOLOGY AND PREVALENCE OF SCHIZOPHRENIA

Schizophrenia is a serious disorder of the mind and the brain, but is highly treatable. It

affects approximately 1.1% of the population of the world. In other words, at any one time, asmany as 51 million people worldwide suffer from Schizophrenia including:

y 6 to 12 million people in China (a rough estimate based on the population)

y 4.3 to 8.7 million people in India (a rough estimate based on the population)

y 2.2 million people in USA

y 285,000 people in Australia

y Over 280,000 people in Canada

y Over 250,000 diagnosed cases in Britain

Rates of schizophrenia are generally similar from country to country²about .5% to 1

percent of the population (there are variations - but the variance is difficult to track due todiffering measuring standards in many countries, etc.) (Schizophrenia Facts and Statistics, 1997-2010).

Schizophrenia is a disease that typically begins in early adulthood; between the ages of

15 and 25. Men tend to get develop schizophrenia slightly earlier than women; whereas mostmales become ill between 16 and 25 years old, most females develop symptoms several years

later. The incidence in men is noticeably higher in women after age 30. The average age of onsetis 18 in men and 25 in women (Schizophrenia Facts and Statistics, 1997-2010).

Schizophrenia onset is quite rare for people under 10 years of age, or over 40 years of

age. The diagram below demonstrates the general "age of onset" trends for schizophrenia in menand women, from a representative study on the topic (Schizophrenia Facts and Statistics, 1997-

2010).




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PREVALENCE OF SCHIZOPHRENIA IN COMPARISON TO OTHER DISEASES

Source: Schizophrenia Facts and Statistics. (1997-2010). Retrieved January 27, 2011, fromSchizophrenia.com: http://www.schizophrenia.com/szfacts.htm

After 10 years, of the people diagnosed with schizophrenia:

y 25% Completely Recover

y 25% Much Improved, relatively independent

y 25% Improved, but require extensive support network

y 15% Hospitalized, unimproved

y 10% Dead (Mostly Suicide)

After 30 years, of the people diagnosed with schizophrenia:

y 25% Completely Recover

y 35% Much Improved, relatively independent

y 15% Improved, but require extensive support network

y 10% Hospitalized, unimproved

y 15% Dead (Mostly Suicide)

Source: Schizophrenia Facts and Statistics. (1997-2010). Retrieved January 27, 2011, fromSchizophrenia.com: http://www.schizophrenia.com/szfacts.htm




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CAUSATIVE FACTORS: THEORIES AND PERSPECTIVES

Schizophrenia has been researched and examined since the late 1800s. A detailed casereport in 1797 concerning the case of James Tilly Matthews and accounts by Philippe Pinel

published in 1809, are often regarded as the earliest cases of the illness in the medical and psychiatric literature.

Schizophrenia was first described as a distinct syndrome affecting teenagers and young

adults by Bénédict Morel in 1853, termed démence précoce (literally 'early dementia').

The term dementia praecox was used in 1891 by Arnold Pick in a case report of a psychotic disorder. In 1893 Emil Kraepelin introduced a broad new distinction in

the classification of mental disorders between dementia praecox and mood disorder (termedmanic depression and including both unipolar and bipolar depression).

The word schizophrenia ²which translates roughly as "splitting of the mind" and comes

from the Greek roots schizein ("to split") and phrn, phren- ("mind")²was coined by EugenBleuler in 1908 and was intended to describe the separation of function

between personality, thinking, memory, and perception.

a. Genetic Theory

The genetic theory is connected to the structural changes that have been seen oncomputer tomography within the brains of persons diagnosed with schizophrenia. It is postulated that these structural changes lead to the development of neurological and

developmental alterations. These alterations then increase a person¶s risk to develop

schizophrenia (Antai-Otong, 2003).

In addition, there seems to be a genetic pattern for development of schizophrenia within

family systems.

>Risk of getting Schizophrenia




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y First degree relatives of individuals with schizophrenia have 6% greater chance of developing the disorder than do persons within the general population.

y Statistics indicate that there is almost a 50% chance of the other identical twin

developing schizophrenia when one twin is diagnosed (Antai-Otong, 2003).y There have been some studies regarding the effect of influenza on fetal

development. This research indicates that there is an increase risk for the

development of schizophrenia when mothers incur influenza during their secondtrimester. The risk is based on structural cell proliferation changes within the

hippocampus (Antai-Otong, 2003).

b. Psychodynamic Theory

This theory evolved from the work of Bleuler (1950) and Freud (1959). Their worksindicate that schizophrenia developed because of the psychic alterations that occurred

within a person.

These alterations are also contingent on the poor caregiving that is provided in the child¶senvironment. However, both Bleuler and Freud believed that the alterations are somehow

tied to the genetic or physiological changes that develop within the child¶s environment.

c. Neurobiologic Theories

The neurobiologic theories involve the changes that occur within the brains of personsdiagnosed with schizophrenia. The neurochemical system coordinates the communication

between the five system areas:

Three Anatomic Systems

y Prefrontal

y Limbic

y Basal ganglia

Two Functional Systems

y Language

y Memory

Anatomic Systems Symptomatolog y

Overall, normal anatomic brain tissue and capacity are reduced in persons who have

schizophrenia. For example, scans of these persons¶ brains illustrate an enlarged third ventricle,decreased tangles, and less electrical activity.




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>Cortex of the Brain

The cortex of the brain is responsible for the coordination of the information into the rest of

the brain, controls arousal, and emotions, focuses attention, and assists in the formation of abstract thinking. For example, people with schizophrenia often have trouble concentrating andthinking abstractly. In addition, she is often impulsive and may exhibit inappropriate behavior

and actions.

>Limbic System

This is located under the cortex. It is comprised of the hippocampus, amygdale, and fornix.This regulates an individual¶s emotion and memory. Someone with the diagnosis of

schizophrenia has a structural change within the limbic system that often creates impulsivity,aggression, and sexually inappropriate behavior. These individuals may also have problems in

learning new information owing to the damage to the hippocampus area.

>Basal Ganglia

The basal ganglia is responsible for the initiation and control of muscle activity andmovements as well as structural changes. A person diagnosed with schizophrenia may have

problems with her ability to determine whether her body is in relationship with others. Thus, shemay accidentally run into others as she walks and moves.

Functional Systems Symptomatolog y

The functional system is composed of the language and memory systems located within theamygdala (Broca¶s area), and the hippocampus (Wernicke¶s area) regions.

The system is responsible for the integration of learning and memory within a person¶s brain.

It is postulated that structural changes within these areas may lead to the development of alteredsensory perception problems such as hallucinations and delusions. In addition, persons with

schizophrenia may have problems understanding language as well as communicating with other persons.

Neur ochemical System

Groupings of neurons are involved in the release of the neurotransmitters of dopamine (DZ),norepeinephrine (NE), serotonin (5-HT), acetylcholine (M), and gamma-aminobutyric acid

(GABA) within the cell body. There is a compatibility with a neurotransmitter and receptor thatcauses the activation mechanism of the process. Persons with schizophrenia may have too much

or too little of the neurotransmitters available. The imbalance creates the development of the positive and negative symptoms that are associated with the disorder.




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d. Substance Abuse Theory

This proposes that persons¶ use or abuse of alcohol and other substances create physical

and psychological changes that predispose the development of schizophrenia. Althoughthere seems to be a number of reported cases fitting this profile, there has not beenadequate research on the subject. Consequently, this theory has less support than the

aforementioned theories.

e. Diathesis Stress Theory

Otherwise known as the combination theory, the diathesis theory is one of the most popular theories regarding the development of schizophrenia. According to this theory,

individuals develop schizophrenia based on the interaction of a number of factors. Thesefactors include genetics, environmental, anatomic, and functional systems, and the

contribution of stressors. This combination approach is supported by research, and a it isa more holistic examination of the development of the disorder.

SYSTEMS INVOLVEMENT AND B EHAVIOR

The development of schizophrenia in persons is contingent on changes that occur in theanatomic, functional, and neurochemical systems of the brain. This is what makes the disorder of

the schizophrenia difficult to diagnose and complicated to treat appropriately.

Anatomic or structural changes may lead to functional changes in language and memorysections of the brain. In addition, alterations in the neurotransmitter system, at the release,

receptor, activation, or reuptake locations, may alter the anatomic or functional systems. Theconsequence of these changes is the development of the positive and negative symptoms in

persons incurring schizophrenia.

PSYCHOSIS AND ISSUES OF CARE

y PSYCHOSIS is a person¶s symptom state that refers to the presence of realitymisinterpretations, disorganized thinking, and lack of awareness regarding true and false

reality (APA, 2000).

This may occur owing to the presence of medical, neurobiological, or psychiatricconditions, or a person¶s use or abuse of agents. Differential diagnosis involves a careful

and exhaustive examination of an individual¶s physical and psychological state.

Individuals who incur psychosis may experience altered sensory perceptions of their smell, taste, sight, hearing or touch senses. Psychiatric based hallucinations, delusions

and illusions are best treated by antipsychotic medications.




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H all uci nations

Hallucinations are distorted perceptions of reality. There are four stages to thehallucinatory process: comforting, condemning, controlling, and threatening. These

stages and the symptomatology correspond to the anxiety levels: mild, moderate, severe,

and panic.

y Comforting stage - hallucinations are familiar, comforting, and friendly. Anxiety is at

the mild level.

y Condemning stage - hallucinations with angry accusatory nature. The person mayexperience guilt, isolation, and discomforts. Because the hallucinations are difficult toignore, the patient¶s anxiety becomes moderate.

y Threatening stage - hallucinations become stronger, threatening and begins to affect

all aspects of the person¶s functioning. It is stronger and more entrenched in ruling the person¶s behaviors and actions.

y Controlling stage - person is at the panic level. Affected persons may injurethemselves, or attempt suicide or homicide.

Del usions

Delusions are fixed false beliefs. An affected person may think he is Napoleon or thePresident of USA.

y Somatic - injury or illness regarding their body.

y Nihilistic - world is ending or they are dying.

y Persecutory - being threatened, or spied on.

y Religious -having special/religious powers

y Sexual




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I ll usions

Illusions are misinterpretations of actual occurring events. For example, someoneexperiencing an illusion may see an electrical cord and misinterpret it as a snake.

Illusions often occur concomitantly with delusions and hallucinations.

OVERVIEW OF OTHER B RAIN DISORDERS

A. Schizoaffective Disorder

Schizoaffective disorder is a disturbance that has at least one month of symptoms

that include two or more of the following:

y Hallucination

y Delusions

y Disorganized speechy Inappropriate behaviors

y Catatonia

y Negative symptoms

y Mood disturbance (depressed, manic, mixed)

Schizoaffective disorder is of a shorter duration and intensity than schizophrenia.

B. Delusional Disorder

Delusional disorders involve false beliefs. Subtypes include grandiosity, jealousy,

persecutory, and somatic.

C. Mood Disorders

Mood disorders include those that have a disturbance in mood as the primary

diagnostic and symptoms factor.

y Major Depressive Disorder

MDD is characterized by one or more episodes of major depression i.e., at least 2weeks of depressed mood and anhedonia and at least four additional symptoms:

weight changes, suicidal ideation, sleep changes, thinking and concentration problems, fatigue, and psychomotor agitation.

y Dysthymic Disorder

Dysthymic Disorder is characterized by at least 2 years of depressed mood throughoutmost of a person¶s daily life. Persons diagnosed with dysthymia do not meet the

criteria for MDD.




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y Bipolar Disorder

BPD is characterized by a combination of cycling between manic and depressivemoods. Mania is manifested by abnormal energy in the areas of speech, thinking,

behaviors, and movements.

Persons who are manic usually exhibit a flight of ideas and are easily distracted.Persons with BPD who are depressed exhibit the symptoms of depression. They may

also incur altered sensory perception symptoms.

SUMMARY

y Schizophrenia and other psychotic disorders have biopsychosocial etiology.

y These disorders have a profound effect on the lives of persons affected by them aswell as the persons who care about and for them.

y Physical and structural alterations are affected by the presence and intensity of

stressors.y This combination effect may lead to the development of schizophrenia and other

psychotic disorders within persons¶ lives.

y The onset of schizophrenia generally occurs within adolescence or early 20s.However, older adults may also incur the disorder.

y Treatment issues involve the use of pharmacologic agents, counseling techniques, and psychotherapy.

Bibliography

Antai-Otong, D. (2003). Psychiatric Nursing: Biological and Behavioral Concepts. Singapore:

Thomson Learning Asia.

APA. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th edition Revision).

Washington DC: American Psychiatric Association.

NIMH. (2009). Schizophrenia. Maryland: National Institute of Health Publications.

Regier DA, N. W. (1993, February). The de facto US mental and addictive disorders service

system: E pidemiologic catchment area prospective 1 - year prevalence rates of of disorders and

services. Archives of General Psychiatry , 85-94.

Schizophrenia Facts and Statistics. (1997-2010). Retrieved January 27, 2011, fromSchizophrenia.com: http://www.schizophrenia.com/szfacts.htm

Videbeck, S. L. (2005). Psychiatric Mental Health Nursing. In S. L. Videbeck, Schizophrenia

(pp. 297-325). Lippincott Williams and Wilkins; Third Edition.




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