Walden University NURS MISC Final Exam NRNP 2023/2024

Walden University NURS MISC Final Exam NRNP 2023/2024. Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia-symptoms are variable and include changes in perception, emotion, cognition, thinking, & behavior. The effects of these manifestations vary by person and can change over time, but the illness is always severe and is usually long-lasting. Onset is typically before age 25. Affects people of all socioeconomic backgrounds. Patients and families tend to suffer poor care due to lack of knowledge of schizophrenia. It is one of the most common of the serious mental disorders but its essential nature remains unclear. Sometimes it is referred to as a syndrome, the schizophrenias or the schizophrenia spectrum. There is no lab testing for schizophrenia. History-Symptoms of schizophrenia have been documented throughout history. Early Greek physicians noted patients with delusions of grandeur, paranoia, and deterioration in cognitive function and personality. It wasn’t until the 19th Century that schizophrenia became a medical condition worthy of being studied. Benedict Morel ()-coined the term demence precoce- to identify deterioration in patients who illness began in adolescence Emil Kraepelin ()-Identified dementia precox (from demece precoce)-a condition that identified an early onset change in cognition identified with hallucinations and delusions. He also distinguished manic and depressive episodes as well as paranoia Eugene Bleuler coined the term schizophrenia (replacing dementia precox). He chose the term for the schisms in the thoughts, behaviors, and emotions of the patients. He chose phrenia because he did not believe the disorder was associated with dementia. Schizophrenia is often misconstrued by lay people as multiple personality disorder, which is a separate disorder (schism-can mean split or division, but it can also mean differences in which he was describing the differences). 4As: Associations, Affect, Autism, Ambivalences. Secondary (Accessory): hallucinations, delusions Ernst Kretschmer ()- compiled data to support the idea that people with schizophrenia were more slender, athletic, and dysplastic body types rather than those with short, stocky physiques. Kurt Schneider ()- contributed a description of first-rank symptoms, which he stressed should not be rigidly applied. He stated that diagnoses should not be based solely on first-rank symptoms but if a patient presented with no first-rank symptoms, second-rank symptoms and clinical appearance should be observed. Karl Jaspers ()-psychiatrist and philosopher played a major role in developing existential psychoanalysis. His work paved the way to understand the psychological meaning of schizophrenic signs and symptoms of delusions and hallucinations. Adolf Meyer ()- founder of psychobiology saw schizophrenia as a reaction to life stresses. It was a maladaptation that was understandable in terms of the patient’s life experiences. Meyer’s view was represented in the nomenclature of 1950s, which was referred to the schizophrenic reaction. In later editions of DSM the term reaction was dropped. Epidemiology-The presence of Schizophrenia in the US is 1/100 or 1%. NIH reports the US lifetime percent is 0.6-1.9%. Total population lifetime percent is 0.5% in a single year. Only about half of those with schizophrenia will obtain treatment, despite the severity. Walden University NURS MISC Final Exam NRNP (1) (1) Gender and Age-Schizophrenia affects men and women equally. However, onset usually occurs earlier in men. Peak ages are 10-25 for men and 25-35 for women. Nearly 1/3 of all female schizophrenia patients are first diagnosed with hospitalizations. 3-10% of women onset after age 40. 90% of patients onset between 10-55 years of age. It is very rare to present before age 10 or after age 60, regardless of gender. In general, females typically have a better outcome than males. Reproductive Factors-first-degree relatives have a 10x greater risk of developing schizophrenia than the general population. Medical Illness- people will schizophrenia have a higher mortality rate from accidents and natural causes than the general population. Studies show that up to 80% of schizophrenia patients have concurrent medical illnesses and up to 50% of these conditions may be undiagnosed. Infection and Birth Season- People who develop schizophrenia are more likely to be born during the winter or early spring and less likely to be born during late spring or summer. Northern Hemisphere people with schizophrenia are more likely to be born January to April. Southern Hemisphere people with schizophrenia are more likely to be born July-September. Season-specific changes, such as infections, influenza, viral infections, epidemics, diet changes, maternal starvation during pregnancy, rhesus factor incompatibility, and genetic predisposition. Substance Abuse- Substance abuse occurs commonly in schizophrenia. Tobacco use occurs in greater than 50%, alcohol abuse in 40%, cannabis over 50%. Nicotine dependency occurs in up to 90% of schizophrenic patients. Population Density- The incidence of schizophrenia in children with 1-2 parents with schizophrenia is twice as high in cities as it is in rural areas. This suggests the social stressors in urban settings may influence the development of schizophrenia in at-risk persons. Socioeconomic & Cultural Factors- Schizophrenia is a life-long illness. Patients with schizophrenia account for 15%-45% of the homeless population in America. Development of effective antipsychotic medication, treatment, and better rights for persons with mental illness since the mid 1950s has improved the view of mental illness. Patients with schizophrenia occupy 50% of mental health hospital beds and 16% of psychiatric patients receiving treatment. Etiology- genetic contribution accounts for some, if not all, of cases. Some studies suggest the age of the father correlates with development of schizophrenia citing those born to fathers over age 60 were at a greater risk for developing schizophrenia. Biochemical Factors Dopamine Hypothesis- hypothesizes that schizophrenia results from too much dopaminergic energy. Excessive dopamine in patients with schizophrenia has been linked to more severe psychotic symptoms. There have been reports of increased dopamine in the amygdala, decreased density of dopamine transporter, and increased numbers of dopamine type 4 receptors in the entorhinal cortex. Walden University NURS MISC Final Exam NRNP (1) (1) Serotonin-current hypothesis suggest excess serotonin causes positive and negative schizophrenia symptoms. Clozapine and other 2nd gen antipsychotics coupled with the effectiveness of clozapine to decrease positive sx in chronically ill patients, contributing to the validity of this proposition. Norepinephrine-anhedonia (the inability to feel emotion or pleasure) is a noted feature of schizophrenia. A neuronal degeneration of norepinephrine has been linked to this. Pharmacological & biochemical data to support this theory is inconclusive. GABA- has been implicated. GABA in the hippocampus leads to hyperactivity of dopaminergic neurons. Neuropeptides- (substance P & neurotensin) in the catecholamine & indolamine neurotransmitters influence the actions of these neurotransmitters. Glutamate- implicated bc ingestion of phencyclidine, a glutamate antagonist, produces an acute syndrome similar to schizophrenia. The hypotheses proposed include those of hyperactivity, hypoactivity, & glutamate-induced neurotoxicity. Acetylcholine and Nicotine- postmortem studies indicate decreased muscarinic and nicotinic receptors in the caudate-putamen, hippocampus, and selected regions of the prefrontal cortex. These receptors play a role in regulation of neurotransmitter systems involved in cognition, which is impaired in schizophrenia. Neuropathology-In the 19th century, neuropathologists failed to identify a neuropathological cause for schizophrenia, so they classified it as a functional disorder. By the end of the 20th century, researchers had made significant strides in revealing a neuropathological causepredominantly in the limbic system & basal ganglia (in the cerebral cortex, thalamus, and brainstem). Loss of brain volume appears to result from reduce density of the axons, dendrites, and synapses that mediate associative functions of the brain. Synaptic density is highest at 1 year and then pares down to adult values in early adolescence. Cerebral Ventricles- CT scans consistently show lateral and 3rd ventricular enlargement and some reduction in cortical volume. Reduced volume of cortical gray matter has been indicated in the early stages of the disease. Some studies indicate that lesions present on CT are present at the onset of the illness and do not progress throughout the disease process. Reduced Symmetry- Reduced symmetry has been noted in several areas of the brain with schizophrenia: temporal, frontal, and occipital lobes. This is believed to have originated during fetal life. Limbic system- because of the role of the limbic system in emotional control, the limbic system is indicated in the development of schizophrenia. Post-mortem studies show decrease in the size of the region (including amygdala, hippocampus, and parahippocampal gyrus). MRI indicates the hippocampus is also functionally abnormal with glutamate distribution disturbances noted. Disorganized neurons are also noted in the hippocampus. Walden University NURS MISC Final Exam NRNP (1) (1) Prefrontal Cortex- considerable evidence from postmortem studies on the brain indicate anatomical abnormalities in the prefrontal cortex. Functional deficits mimic those who have had prefrontal lobotomies or prefrontal lobe syndromes. Thalamus- some evidence points to thalamus shrinkage or neuronal reduction by 30-40%. This appears to be due to effects of antipsychotic medication AEB those with schizophrenia chronically treated with medication have similar sized thalamus to those with neuroleptic-naïve subjects. Basal Ganglia and Cerebellum- bc people with schizophrenia can have awkward movements, facial grimacing, and odd gaits, the basal ganglia and cerebellum are implicated. They control movement. Studies have shown increased D2 receptors in the caudate, putamen, & nucleus accumbens. The question is, is the increased D2 receptors due to antipsychotic medication? Neural Circuits- Rather than look at schizophrenia as a disorder affecting specific areas of the brain, this perspective views it as a disorder involving neuronal circuits of the brain. Early developmental lesions of the dopaminergic tracts to the prefrontal cortex results in disturbances of the prefrontal and limbic system function resulting in positive and negative symptoms associated with schizophrenia. The observation of the disturbance between the prefrontal and limbic system demonstrates a relationship with hippocampal morphological abnormalities & disturbances in prefrontal cortex metabolism. Data suggests that this circuit involvement is responsible for the hallucinations associated with schizophrenia. Brain Metabolism- lower levels of phomonoester and inorganic phosphate and higher levels of phosphodiester noted with schizophrenia. Lower levels of N-acetyl aspartate in the hippocampus and frontal lobes as well. Applied Electrophysiology- schizophrenia patients have more sensitivity to activation procedures (spike in activity after sleep deprivation), decreased alpha activity, increased theta and delta activity, likely more epileptiform activity, and more left-sided abnormalities. These patients may not have the ability to filter out background noise, which may contribute to auditory hallucinations. Complex partial epilepsy-schizophrenia-like psychoses have been reported more frequently in patients with complex partial seizures. Associated factors include left-sided seizure focus, medial temporal location of the lesion, and early onset of seizures. Evoked potentials- the P300 has been identified as a large, positive evoked-potential wave that occurs about 300 milliseconds after a sensory stimulus is detected. The P300 wave is located in the limbic system structures of the medical temporal lobes. In patients with schizophrenia, the P300 has been noted to be significantly smaller. It is also noted to be significantly smaller in children who, bc they have affected parents, are at higher risk for schizophrenia. Other evoked potentials for schizophrenia are N100 and contingent negative variation. Eye movement dysfunction- inability to follow a moving visual target accurate is seen in 50- 85% of patients with schizophrenia, 25% of patients with other psychiatric illnesses, and less than 10% of nonpsychiatrically ill individuals Walden University NURS MISC Final Exam NRNP (1) (1) Psychoneuroimmunology-decreased T cells interleukin-2 production, reduced number and response of peripheral lymphocytes, abnormal cellular and humoral reactivity to neurons, and presence of brain-directed (antibrain) antibodies. The possibility of autoimmune brain antibodies has some data to support it. Psychoneuroendocrinology- persistent nonsuppression of dexamethasone-suppression test in schizophrenia is correlated with poor long-term outcomes. Some data also suggests decreased concentrations of luteinizing hormones or follicle-stimulating hormone (could be correlated with age of onset and length of illness). Two additional abnormalities: blunted release of prolactin & growth hormone on gonadotropin-releasing hormone or thyrotropin-releasing hormone stimulation & blunted release of growth hormone on apomorphine stimulation. Psychosocial & Psychoanalytic Theories- clinicians should consider psychosocial and biological factors affecting schizophrenia. It is a disease of the brain and should be paralleled to other diseases affecting other organs. Psychoanalytic Theories-all propose psychotic symptoms have meaning. Sigmund Freud postulated schizophrenia results from developmental fixations early in life. Margaret Mahler postulates insecure identity from infancy. The child is never able to separate from mother. Paul Federn postulates a defect in ego functions and that intense hostility and aggression distort infant-mother relationship which leads to personality disorganization and vulnerability to stress. This comes evident in adolescence when the teens need a strong ego to function independently. Harry Stack Sullivan postulated various symptoms have significant meaning for the patient ie hallucinations may stem from inability to deal with objective reality. Learning Theories- children learn irrational reactions and ways of thinking by imitating parents with significant emotional problems. Family Dynamics- a study of British 4 year olds had a 6-fold increase of developing schizophrenia when the child had a poor mother-child relationship. Offspring of schizophrenic parents were more inclined to develop schizo when raised in adverse circumstances as compared to those raised in loving homes with stable parents and relationships. Double-blind-formulated by Gregory Bateson & Donald Jackson. Children withdraw to escape the confusion of double-blind ie parent encourages child to share cookies with friends during playdate, then chastises for eating/sharing too many cookies. Schisms & Skewed Families- Theodore Lids described family schisms as one parent who is abnormally close to one child of the opposite gender. A skewed family describes a power struggle between parents that results in one parent being the dominant power. These dynamics stress the tenuous adaptive capacity of the patient with schizophrenia. Pseudomutual and Pseudohostile Families- Lyman Wynne says some families surpress emotional expression with pseudomutual or pseudohostile verbal communication. When the child leaves the home, he has problems communicating and relating to others. Expressed Emotion- Families with high emotional expression have high levels of relapse for schizophrenia patients. Diagnosis: Diagnosis is based on the DSM-5 with several options with specifiers for clinicians to detail symptoms. Subtypes: Walden University NURS MISC Final Exam NRNP (1) (1) Paranoid-characterized by preoccupation with one or more delusions or frequent auditory hallucinations as well as delusions of persecution or grandeur. Usually occurs at a later age than catatonic schizophrenia or disorganized. Disorganized-Marked regression to primitive disinhibition, and unorganized behavior, and lack of symptoms to meet catatonic type. Onset usually before age 25. Disorganized, aimless, nonproductive. Appear disheveled. Social and emotional responses are inappropriate. Catatonic- previously common several decades ago is now rare in Europe & North America. Marked disturbance in motor function (stupor, negativism, rigidity, excitement, or posturing). Mutism is common. May show rapid alterations in extremes of excitement and stupor. Need careful supervision bc of malnutrition, hyperpyrexia, exhaustion, and self-inflected injury. Undifferentiated-when the patient does not easily fit into another category, he is categorized as undifferentiated type. Residual-continuing evidence of the schizophrenic disturbance in the absence of a complete set of active symptoms or sufficient symptoms to meet the diagnosis of another type. Emotional blunting, social withdrawal, eccentric behavior, illogical thinking, and mild loosening of associations are common among residual type. When delusions or hallucinations occur, they are neither prominent nor accompanied by strong affect. Other Subtypes Bouffée Délirante (acute delusional psychosis)-French diagnosis differs based on symptom duration of less than 3 months. Similar to DSM-5 dx schizophreniform disorder. French clinicians report approximately 40% of their Bouffée Délirante patients will eventually be classified as having schizophrenia. Latent-developed during a time when theorists conceived the disorder in broad diagnostic terms. Only patients who were severely ill with schizophrenia symptoms would be diagnosed with schizophrenia. Patients who presented with more mild symptoms (peculiar behaviors or thought disorders without psychotic symptoms) were given the diagnosis of Latent schizophrenia. These patients are who would now be diagnosed as borderline, schizoid, and schizotypal personality. In the past, the syndrome was also called borderline schizophrenia. Oneiroid- refers to a dream-like state in which patients may be deeply perplexed and may not be fully oriented to time & place. Has been used to describe patients who are engaged in their hallucinatory experiences to escape involvement in the real world. Paraphrenia-sometimes used synonymously with paranoid schizophrenia or for either a progressively deteriorating course of illness or the presence of a well-systemized delusional system. The multiple meanings make it ineffective for accurately communicating information. Psuedoneurotic Schizophrenia-characterized by patients who initially have anxiety, phobias, obsessions, and compulsions and later reveal thought disorders and psychosis. These patients are characterized by pananxiety, panphobia, panambivilance, and sometimes chaotic sexuality. Pseudoneurotic patients have free-floating anxiety that rarely subsides. They seldom become overtly and severely psychotic. This condition is currently dx as borderline personality disorder. Simple Deteriorative Disorder (Simple Schizophrenia)-gradual, insidious loss of drive and ambition. Typically patients are not overly psychotic and do not experience persistent hallucinations or delusions. Primary symptom is withdraw from work or social situations. Must be differentiated from depression, a phobia, dementia, or an exacerbation of a personality trait. Postpsychotic Depressive Disorder of Schizophrenia-after an acute schizophrenia episode, some patients become depressed. These symptoms can resemble residual schizophrenia as well Walden University NURS MISC Final Exam NRNP (1) (1) as medication side effects to treat the acute episode. Careful consideration and assessment must be done. This occurs in nearly 25% of patients with schizophrenia and are associated with increased risk for suicide. Early-Onset Schizophrenia- a small minority of people develop symptoms of schizophrenia in childhood. Symptoms used to diagnose childhood schizophrenia are the same as adult. The prognosis is mostly unfavorable for those diagnosed in childhood. Late-Onset Schizophrenia-diagnosed after 45 years of age. Trends more in females than males. Typically characterized by paranoid symptoms. Prognosis is favorable and they tend to do well on antipsychotic medication. Deficit Schizophrenia- in the 1980s patients who presented with idiopathic negative schizophrenia symptoms were identified as deficit schizophrenia patients. Those who presented with positive symptoms were said to have nondeficit schizophrenia. Deficit patients have a more severe course of illness with a higher prevalence of abnormal involuntary movements and poorer social functioning before onset of psychotic symptoms. Six features (restricted affect, diminished emotional range, poverty of speech, curbing of interests, diminished sense of purpose, diminished social drive). Less long-term recovery of function & less likely to marry. Decreased risk of depression and suicide. Associated with summer births, greater familial risk, and higher prevalence in men. Their cognitive impairment, lack of motivation, lack of distress, and asocial nature affects their ability to adhere to medication regimen and achieve remission of symptoms. Psychological Testing: typically perform poorly on neuropsychological tests. Vigilance, memory, and concept formation are most affected & are consistent with pathological involvement in the frontotemporal cortex. Intelligence Tests: Patients who have schizophrenia typically perform lower on intelligence tests. Lower intelligence is typically presented at onset and continues to deteriorate throughout the progression of the disorder. Projective and personality tests: Projective tests such as Rorschach and the Thematic Apperception may indicate bizarre ideation. Personality inventories, like Minnesota Multiphasic Personality Inventory often gives abnormal results in persons with schizophrenia but the contribution to diagnosis and treatment plan is minimal. Clinical Features- (3 key issues) 1. No clinical sign or symptom is pathognomonic for schizophrenia-every sign or symptoms occurs in other psychiatric and neurologic disorders. Patient’s history is essential for diagnosis. 2. A patient’s symptoms change with time. 3. Clinicians must take into account the patient’s educational level, intellectual ability, and cultural and subcultural membership. Premorbid Signs and Symptoms-Appear before the prodromal phase of the illness (meaning they appear before the disease process presents itself). These may be few friends during childhood, or avulsion to social activities, or somatic complaints (headache, back or muscle pain, weakness, digestive problems). Initial diagnosis may be chronic fatigue syndrome, malingering, or somatization disorder. Family & friends may notice the person no longer functions well in social, occupational, and personal activity settings. During this time, he may develop an interest Walden University NURS MISC Final Exam NRNP (1) (1) in abstract ideas, philosophy, and the occult. SX include peculiar behavior, abnormal affect, unusual speech, bizarre ideas, and strange perceptual experiences. Mental Status Examination- Appearance can range from disheveled and ungroomed, agitated, screaming, to obsessively groomed and completely silent or anywhere in between. Patients with schizophrenia are often poorly groomed, unbathed, and dressed overly warm for the temperatures (dressed in layers). Other odd behaviors include tics, stereotypies, mannerisms, and occasionally echopraxia (imitating the posture or behavior of the examiner). Precox Feeling-some experienced clinicians report a precox feeling, an intuitive experience of their inability to establish an emotional rapport with a patient. The feeling is common but there is no reliable date linking it to schizophrenia Mood, Feelings, & Affect- 2 common affective symptoms 1. Reduced emotional responsiveness (anhedonia if severe enough) 2. Overly active and inappropriate emotions (rage, happiness, anxiety) Other feeling tones include perplexity, sense of isolation, overwhelming ambivalence, depression, blunted affect. Perceptual Disturbances: Hallucinations-Any of the 5 sense can be affected by hallucinations. The most common hallucination is auditory-hearing threatening, obscene, accusatory, or insulting voices. 2 or more voices may talk among themselves and even comment on the patient’s life choices or behaviors. Visual hallucinations are also common. Tactile, olfactory, and gustatory hallucinations are uncommon and the clinician should look for an underlying medical or neurological cause. Cenesthetic Hallucinations- unfounded sensations of altered states in bodily organs ie burning sensation in the brain or bodily distortions. Illusions-are distortions of real images. Whereas hallucinations are not based on real sensations. Thought- thought disorders are the most difficult symptoms for many clinicians & students to understand but they are the core of schizophrenia. Dividing thought content, form of thought, and thought process helps to clarify them. Thought Content-reflects the persons ideas, beliefs, and interpretations of stimuli. Delusions are the most obvious example of a disorder of thought content. Some experience persecutory, grandiose, religious, or somatic forms. Loss of ego boundaries. They can believe they control the sun, or aliens are controlling them, the television/radio, is referring to them, etc. Form of Thought- objectively observable in patents spoken and written language. Loose association, derailment, incoherence, tangentiality, circumstantiality, neologisms, echolalia, verbigeration, work salad, and mutism. This can be evident with preoccupation with religion and religious views, mixed with philosophy. Thought Process- concerns the way ideas and language are formulated. Examiner infers a disorder based on how the patient speaks, writes, or draws. Examiner can also examine thought process based on behavior, especially with discrete tasks (OT). Disorders of thought include flight of ideas, thought blocking, impaired attention, poverty of thought content, poor abstraction abilities, perseveration, idiosyncratic associations (identical predicates, clang associations), overinclusion, and circumstantiality. Patients think others can read their minds, or ther thoughts are broadcast on television or radio. Walden University NURS MISC Final Exam NRNP (1) (1) Impulsiveness, Violence, Suicide, & Homicide- patients with schizophrenia may be agitated and have little self-control when ill. Some can exhibit impulsive behaviors like smoking cigarette butts from a can to physical violence. Violence- violent behavior is common among untreated schizophrenia. Delusions of persecutory nature, previous episodes of violence, and neurological deficits are precursors for violent or impulsive behaviors. If a clinician feels fearful of a patient, it could be a precursor of a patient on the verge of a violent outburst. In such cases, terminate the interview or have an attendant present. Suicide- Single-leading cause of premature death among people with schizophrenia. Suicide attempts are made by 25-50% of patients with long-term rates of suicide estimated to be 10-13%. According to the DSM-5 suicide rate of patients with schizophrenia is 5-6%. 2/3 or more of schizophrenia patients who commit suicide have seen an apparently unsuspecting clinician within 72 hours of death. Up to 80% of patients with schizophrenia will experience a depressive episode. Those at greatest risk are young males who had high expectations, declined from a higher level of functioning, realizes that his dreams are not likely to come true, and has lost faith in the effectiveness of treatment. Clozaril may be particularly effective in reducing suicidal ideation in schizophrenia patients. Homicide-when a patient with schizophrenia does commit murder, it may be for bizarre reasons based on hallucinations or delusions. Possible predictors of homicide include history of previous violence, dangerous behavior while hospitalized, and hallucinations or delusions involving such violence. Sensory & Cognition: Orientation-Typically oriented to person, place, and time. Lack of such orientation should prompt further medical and neurological investigation. Some patients with schizophrenia may give bizarre answers, ie, “I am Jesus Christ, this is Heaven, AD 35” Memory- Memory is usually intact with some minor cognitive deficiencies. It may not be possible to get the patient to focus enough to test the memory adequately. Cognitive Impairment- Cognitive impairment is one of the classic traits of schizophrenia. Patients with schizophrenia tend to exhibit subtle cognitive dysfunction in the domains of attention, executive function, working memory, and episodic memory. By the time the first episode is experienced, cognitive impairment is present. Although a substantial number of patients with schizophrenia show an average IQ, it is possible that they have cognitive impairment compared to what they could have accomplished/level of functioning without schizophrenia. Cognitive impairments have become the focus of pharmacological and psychosocial treatments. Judgment & Insight-classically described as having poor judgment and insight into the nature and severity of their disorder. This creates poor compliance with treatment. When interviewing, define various aspects of insight such as relationships and getting along with people, awareness of symptoms, reasons for these problems. Reliability- a patient with schizophrenia is no less reliable than other patients, however, the important data given should be verified through additional sources