Neurobiological Responses and Schizophrenia and Psychotic Disorders



Neurobiological Responses and Schizophrenia and Psychotic Disorders


Mary D. Moller




Learning Objectives



1. Describe the continuum of adaptive and maladaptive neurobiological responses.


2. Identify behaviors associated with maladaptive neurobiological responses.


3. Analyze predisposing factors, precipitating stressors, and appraisal of stressors related to maladaptive neurobiological responses.


4. Describe coping resources and coping mechanisms related to maladaptive neurobiological responses.


5. Formulate nursing diagnoses related to maladaptive neurobiological responses.


6. Examine the relationship between nursing diagnoses and medical diagnoses related to maladaptive neurobiological responses.


7. Identify expected outcomes and short-term nursing goals related to maladaptive neurobiological responses.


8. Develop a family education plan to promote adaptive neurobiological responses.


9. Analyze nursing interventions related to maladaptive neurobiological responses.


10. Evaluate nursing care related to maladaptive neurobiological responses.



People often react to the word psychosis with fear and uncertainty. Psychosis refers to the mental state of not being in touch with reality. During an episode of psychosis, the person does not realize that others are not experiencing the same things and wonders why others are not reacting in the same way.


The overall goal of nursing care is to help the patient recognize the psychosis and develop strategies to manage the symptoms and achieve recovery. It is important to remember that these are complex neurobiological brain diseases affecting one’s ability to perceive and process information. The behaviors associated with psychosis are difficult to understand, are usually severe, and can be long lasting. Box 20-1 describes one person’s experience with psychosis.



BOX 20-1   A PATIENT SPEAKS


Psychosis is real. Its main feature is a loss of consciousness of the self in such a way that I can no longer discern my relationship to the reality that my body is in. This would not be destructive, except that I have done it inadvertently; I have done it without consciousness and have not provided for my body. My body, then, goes on without me. It wanders aimlessly and does not know to keep warm in the cold. It does not know how to avoid attack by violence. It does not know to protect itself from fire and deep water and the traffic that races down the highway.


My brain comes up with fantastical ideas about who I might be, since I am not there to tell it. Perhaps I am the Queen of Hearts, or a messenger from another planet, or even Jesus Christ himself. And why not? My brain distorts the reality of the senses: Is this burner hot or cold? Is this coat wet or dry? Is this chair a chair, or what exactly is this anyway, and for that matter, what in the world are you?


My brain chooses its manifestation according to what emotions were available to it when I was in charge. Only I am not there to add my discernment, my wisdom, and my awareness according to what I have learned. My brain goes haywire then. It has no person to guide it, no captain, no helm, and no rudder. It has no fingers at the keyboard.


What is this I, then, that is gone, and where did it go? It is consciousness. It is awareness. It is the presence of the I in me. It is ego. It is my separation. It is the part in me that tells me the difference between me and the world. It is the I-ness of me that holds me upright like a spine and says, “You will not fall into this tree, or this song, or this ocean of water or air, and it will not fall into you.” The I that is gone is the intelligence that says I am me, and you are you.


From Corday R: Psychosis, the inner experience, Boulder, Colo, 1991, Common Loon Productions.



Critical Reasoning


Read the patient’s description of psychosis in Box 20-1. Focus on identifying the feelings that might be associated with these experiences.



LEARNING FROM A CLINICAL CASE


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.


Case Background


He had been a star athlete, smart and witty. He finished near the top of his class and had won a fellowship to study abroad next year. He wanted to teach in Africa and work for a nonprofit agency on water purification. It seemed an interesting issue and could be the beginning of an engineering graduate degree. But he had the summer to spend with his friends. They got an apartment near the beach and took jobs either bartending or waiting tables. They partied and smoked weed together, philosophizing about life and the future. On their days off, they surfed.


But gradually he became withdrawn. He came in late at night and then slept all the next day. His friends thought maybe he had a girlfriend. His room was filthy, and he stopped shaving. Finally, one day when he was out, they went into his room and saw that he had written on the walls and taped things to them. When he came home, they asked him what it was about. He told them that people were spying on him and he was sending them messages to stop. His friends called his parents.


He was initially given the diagnosis of brief psychotic episode. But his behavior continued to deteriorate. He communicated very little and at times made little sense. However, when he was started on olanzapine, he improved. Although his trip had to be cancelled, he did start graduate school, but he could take only one course at a time, and looming deadlines made it difficult for him to cope. He eventually had to drop out. He just couldn’t keep up with the complexity of the work.


Eventually the diagnosis of schizophrenia was made. He had to stop taking olanzapine because his white blood cell count fell to a low level. He never adjusted to the other medications as well. The only job he could do was working for a landscaping company, and he didn’t like the work. His mother grieved for her son and the promise of his young life. Her pregnancy with him had been hard; she had caught the flu that winter, and everyone in the family had had it. His childhood had seemed normal, except that now, looking back, she realized he would never let anyone take his picture. He refused to go to camp. But he had always led his football and basketball teams to victory, so he had seemed fine. Now she knew he wasn’t.


When they placed him in special rehabilitation programs, he would just walk out and come home. He was not homicidal or suicidal, so no one could stop him. He simply refused to stay there. Then at home, he just sat for hours, watching television, eating, not doing or saying anything. He was mandated by the court to take his medication, and he would cooperate with that, but otherwise he just sat for hours.


Eventually, he began taking an atypical antipsychotic medication, and his symptoms improved, but he gained about 70 pounds, became diabetic, developed heart disease, and began using drugs. A group of addicts knew when his disability check came and hit him up for money. They would buy crack, marijuana, and alcohol with his money and come back to his place to smoke and drink with him. He thought they liked him. He thought they were his friends. The auditory hallucinations came back.




Continuum of Neurobiological Responses


The range of neurobiological responses includes a continuum from adaptive responses, such as logical thought and accurate perceptions, to maladaptive responses, such as thought distortions and hallucinations. The symptoms of psychosis are at the maladaptive end of this continuum (Figure 20-1).


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FIG 20-1 Continuum of neurobiological responses.

Schizophrenia is a serious and persistent neurobiological brain disease. It results in responses that can severely impair the lives of individuals, their families, and communities. Box 20-2 presents information on the impact of schizophrenia on the individual and society.



BOX 20-2   IMPACT OF SCHIZOPHRENIA ON THE INDIVIDUAL AND SOCIETY




• About 1 in every 100 people has schizophrenia, or 2.5 million people in the United States.


• In three of every four cases, the disease manifests between the ages of 15 and 34 years.


• Of those with schizophrenia, 95% have it for their lifetime.


• It affects people from all cultures, races, genders, economic classes, and levels of intelligence.


• More than 75% of taxpayer dollars spent on treatment of mental illness are used for people with schizophrenia.


• People with schizophrenia occupy 25% of all inpatient hospital beds.


• An estimated one third to one half of homeless people in the United States has schizophrenia.


• Schizophrenia is a chronic illness. It is five times more common than multiple sclerosis, six times more common than insulin-dependent diabetes, 60 times more common than muscular dystrophy, and 80 times more common than Huntington disease.


• Of patients with schizophrenia, 25% do not respond adequately to antipsychotic medication.


• Suicide is attempted by 10% to 20% of patients with schizophrenia, and 5% succeed.



Assessment


Schizophrenia is one of a group of psychotic disorders. Other psychotic disorders include schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder (folie a deux), psychotic disorder caused by a general medical condition, and substance-induced psychotic disorder (American Psychiatric Association, 2000).


Psychosis is sometimes present in other disorders, such as depression with psychotic features, manic episodes of bipolar disorder, posttraumatic stress disorder, delirium, and organic mental disorders.


About 50% of patients with schizophrenia have a co-occurring substance use disorder, most frequently alcohol or cannabis. These patients often have more severe symptoms; increased rates of hospitalization, violence, victimization, homelessness, and nonadherence to medication; and poor overall response to medication (Schmidt et al, 2011).



imageQUALITY AND SAFETY ALERT




The word schizophrenia is a combination of two Greek words, schizein, “to split,” and phren, “mind.” This does not refer to a “split personality,” as in multiple personality disorder, in which separate identities are present, but to the belief that a split has occurred between the cognitive and emotional aspects of the personality.


One way of categorizing the symptoms of schizophrenia lists them as positive symptoms (exaggerated normal behaviors) and negative symptoms (diminished normal behaviors) (Box 20-3). Another system defines five core symptom clusters, presented in Figure 20-2. This model incorporates the positive and negative symptoms of schizophrenia as well as other aspects, including cognitive symptoms, mood symptoms, and some of the social and occupational dysfunctions common in schizophrenia.



BOX 20-3   POSITIVE AND NEGATIVE SYMPTOMS OF SCHIZOPHRENIA


Positive Symptoms







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FIG 20-2 Core symptom clusters in schizophrenia. (Modified from Eli Lilly: Schizophrenia and related disorders: a comprehensive review and bibliography slide kit, Indianapolis, 1996, Lilly Neuroscience.)

Assessment involves understanding the way in which the brain processes information from the senses and the resulting behavioral responses. These behaviors are organized into the following categories:




Behaviors


Cognition


Cognition is the act or process of knowing. It involves awareness and judgment that allows the brain to process information in a way that provides accuracy, storage, and retrieval. People with schizophrenia are often unable to produce complex logical thoughts or express coherent sentences because neurotransmission in the brain’s information processing system is malfunctioning. These cognitive deficits are often present in patients who are at clinical high risk for psychosis before the onset of psychotic illness (Carrion et al, 2011).


Information processing involves the organization of sensory input by brain processes into behavioral responses (Figure 20-3). Sensory input from both internal and external senses is screened according to the focus of the person’s attention and ability to remember, learn, discriminate, interpret, and organize information. The result is seen in the person’s thinking, perceiving, feeling, behavior, and relatedness to others.


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FIG 20-3 Brain information processing model.


Critical Reasoning


Describe how your cognitive processing differs from that of someone of the opposite gender, an older generation, another ethnicity, and another socioeconomic class. What are the results of these differences?


The information processing of people with schizophrenia may be altered by brain deficits. However, interferences with cognitive function often keep people with schizophrenia from realizing that their ideas and behavior differ from those of others. This is particularly true in regard to their self-perception of worth and abilities and their interpretation of hallucinations and delusions.


People with schizophrenia tend to overestimate or underestimate their own capability. The abnormal brain dysfunction during an acute episode of schizophrenia makes it difficult for patients to realize that they need help. This lack of insight is a neurological deficit involving the frontal and prefrontal lobes of the brain. It is called anosognosia, a condition in which the patient does not recognize that there is anything wrong or that there are deficits of any kind (Amador, 2007).


Symptoms related to problems in information processing associated with schizophrenia are often called cognitive deficits. They include problems with cognitive functioning in all aspects of memory, attention, form and organization of speech, decision making, and thought content (Box 20-4).



BOX 20-4   PROBLEMS IN COGNITIVE FUNCTIONING


Memory










Attention

Attention is the ability to concentrate and focus on one activity. Disrupted attention does not allow one to pay attention, observe, focus, and concentrate on external reality. Disturbances in attention are common in schizophrenia and include difficulty completing tasks, difficulty concentrating on work, and distractibility. Distractibility refers to a patient’s attention being drawn easily to irrelevant external stimuli such as noises, books being out of order on a bookshelf, or people passing by. In addition, the patient who is experiencing auditory hallucinations often is distracted by them and thus has problems with attention.


These problems are not constant and may fluctuate, depending on brain activity required. This creates frustration for the patient, who often complains about an inability to complete tasks because “my mind wanders.” The nurse should be prepared to redirect the patient back to the task at hand. The nurse also will need to repeat directions often and in short, simple phrases.



Critical Reasoning


The parents of a young man who has schizophrenia tell you that they are frustrated by their son’s unwillingness to return to work. Based on your understanding of the cognitive disorders related to schizophrenia, how would you respond?



Form and organization of speech

Form and organization of speech are at the core of communication. Problems in information processing can result in incoherent communication. Problems with form and organization of speech (formal thought disorders) may include loose associations, word salad, tangentiality, illogicality, circumstantiality, pressured speech, poverty of speech, distractible speech, and clanging. These behaviors are described in Chapter 6. Box 20-5 presents nurse-patient dialogues that reflect problems in the form and organization of speech related to psychotic disorders.



BOX 20-5   FORM AND CONTENT OF SPEECH RELATED TO PSYCHOTIC DISORDERS


Loose Associations










Recognizing that speech is a sign of cognitive processing helps the nurse appreciate the difficulties a person with schizophrenia has in communicating clearly. The nurse will need to focus attention and use active listening to understand the patient. The nurse who tries to identify and clarify what a patient wants should not be afraid of offending the patient by clarifying the patient’s understanding. It is essential to remember that the patient is trying to answer, no matter how difficult or bizarre the answer is. The nurses’ responsibility is to identify one or two key verbal or nonverbal responses and seek validation.



Decision making

Decision making means arriving at a solution or making a choice. Problems with decision making affect one’s insight, judgment, logic, decisiveness, planning, ability to carry out decisions, and abstract thought. Lack of insight is probably one of the greatest problems in schizophrenia, because patients generally do not believe that they are ill or different in any way.


Unfortunately, many clinicians confuse lack of insight with denial and treat people who have schizophrenia as if their symptoms were intentional and in their control. When decision making includes cognitive deficits, the patient makes decisions based on incorrect inferences yet cannot understand that the judgment was faulty.


Some people with schizophrenia are simply unable to make a decision. For them, life is difficult at best. They wrestle with even simple decisions such as which coffee cup to use. Plans based on faulty decision making are not successful. This symptom creates much of the frustration experienced by patients with schizophrenia.


Following through on decisions is also a problem for people who have schizophrenia. Often this is mistaken for lack of motivation. Motivation involves having a desire; patients with schizophrenia lack not the desire but the ability to follow through. People with schizophrenia typically have difficulty initiating tasks of any kind because of problems related to decision making.


Concrete rather than abstract thinking characterizes schizophrenia, particularly during acute episodes. As a result, patients often have difficulty with multiple-step commands. For example, if the nurse presents a patient with the daily schedule and at the same time gives directions about the time and place of group and occupational therapies, all the information will not be processed because the brain perceives an overload. Therefore the patient will probably miss one or more of the directions.


Another example of concrete thinking is difficulty with time management. People with schizophrenia describe this behavior as “trying to tell time with clocks that have no minute or second hands.” This is why patients often are late or miss events and appointments altogether. This problem may create fear in patients who have to be alone for long periods or are required to be somewhere at specific times. Some patients have developed clever ways to determine time, such as getting watches with built-in alarms and monitoring certain television programs.


Difficulty managing money is another result of concrete thinking. People with schizophrenia often lose their ability to understand the concept of dollars and cents and are exploited by other people as a result. Patients may agree to buy items without having enough money just because they see some money in their wallet. They may not remember to pay for items they get in a store or may leave a restaurant without paying for the meal. Many patients get into legal trouble because of this cognitive problem.


Literal interpretation of words and symbols is one of the most problematic behaviors related to concrete thinking. People with schizophrenia have difficulty abstracting the English language. A patient’s description of literal interpretation is presented in the following clinical example: “I was standing in the medication line, and the nurse asked me to take my pills. So I took the medicine cup and held it in my hand. The nurse asked me again to take my pills, and I did not know what to do. She began to lose her patience as I stood there holding the medicine cup. She then told me to put the pills in my mouth and to swallow them with the water she handed me. I could follow each of the instructions and eventually ‘took my pills.’”


An example of literal interpretation of symbols is described by this patient: “It took me at least 15 minutes to walk down the street because I stopped every time the light changed from green to red. I did not understand that the traffic signal was only for cars.”


Sometimes this problem advances to a point at which the patient interprets a metaphor literally, as seen in this example: “I remembered the expression ‘step on a crack and break your mother’s back.’ One day I was walking down the street and stepped on a crack in the sidewalk. That same day my mother fell off a stepstool after getting a can of soup from the kitchen cupboard and fractured two vertebrae in her back. For 9 months I believed that I had caused this accident to happen.” This is also called magical thinking.


Nursing implications regarding patient teaching for the person experiencing concrete thinking are profound. Consider this example: During the admission of a new patient, a nurse instructed the patient to collect a sterile urine specimen. The patient exhibited terror and strongly resisted. When the nurse gently asked the patient why he was so frightened, he replied, “I do not want to become sterile.”


The role of the nurse is to help with decision making in a nonpunitive, supportive manner, recognizing that these symptoms represent neurological disabilities over which the patient has little control. The nurse functions in a rehabilitative role and needs to provide information as clearly and concretely as possible. The language used should involve simple words and short phrases that are easy to understand. The nurse also needs to seek validation regarding how instructions were heard to clarify confusion and misunderstanding.



Critical Reasoning


It is important to involve the patient in planning nursing care. Describe how you would accomplish this if the patient has cognitive problems that interfere with decision-making ability.



Thought content

Thought content is the final area for assessment of cognitive functioning. Problems with thought content includes the presence of delusions in persons with psychosis. A delusion is a personal belief based on an incorrect inference of external reality.


One of the mind’s primary functions is to produce thoughts. Thoughts provide a sense of identity. Thoughts are a result of screening and filtering internal and external stimuli and the use of multiple feedback loops in the brain. Knowledge of the cognitive deficits already described helps the nurse understand why people with schizophrenia sometimes have beliefs different from those of other people. It also is important to realize that a delusion does not always last. It is common for a belief to be fixed for only a few weeks or a few months, particularly in the less severe forms of schizophrenia.


The inability of the brain to process data accurately can result in paranoid, grandiose, religious, nihilistic, and somatic delusions. The delusions can be complicated further by thought withdrawal, thought insertion, thought control, or thought broadcasting. The various types of delusions are described in Chapter 6.


Delusions arise from one’s brain physiology, current environmental stimuli, and the person’s frame of reference regarding the world. Delusions can become connected to hallucinations. They may be a single thought, or they may pervade the person’s entire cognitive process. They can represent a complete thought or only a part of an idea.


Delusions may be limited to a specific area of belief, such as family or religion, or they may extend into many areas of a person’s life. Many patients have reported the relief they experienced as their symptoms remitted and they realized that their belief was really a delusion, just a symptom, not the true facts.



Perception


Perception is the identification and interpretation of a stimulus based on information received through sight, sound, taste, touch, and smell. Perceptual problems are often the first symptoms in many brain illnesses.


Hallucinations are false perceptual distortions that occur in maladaptive neurobiological responses. The patient actually experiences the sensory distortion as being real and responds accordingly. However, with a hallucination, there is no identifiable external or internal stimulus. Hallucinations can arise from any of the five senses, as described in Table 20-1.



Although hallucinations are most commonly associated with schizophrenia, only about 70% of people with this illness experience them. They also can occur in patients with a manic or depressive illness, delirium, organic mental disorder, or substance abuse disorder. It is important to understand that hallucinations and delusions can occur in any illness that disrupts brain function.


Finally, the nurse should distinguish between the auditory hallucinations that occur in schizophrenia and the sensory and auditory flashbacks that often occur in those with posttraumatic stress disorder, dissociative identity disorder, or borderline personality disorder, and in survivors of trauma and abuse. These are two very different symptoms.



Critical Reasoning


A young woman is hospitalized in a forensic psychiatric unit because she attempted to kill her preschool children. She says her dead mother’s voice told her to do this because the devil would get them unless they were in heaven with her. Is this a delusion, a hallucination, or both?


Another category of perceptual behaviors involves sensory integration and includes pain recognition, soft neurological signs, right/left recognition, and recognition and perception of faces. Symptoms related to these perceptions are common in schizophrenia. Disruptions of sensory integration often lead to deliberate acts of self-harm, as described in the following clinical example.



CLINICAL EXAMPLE


During an initial physical assessment a nurse noted many superficial scars on the left arm of a young woman who had just completed an 8-week education program on symptom management in schizophrenia. The nurse said, “Tell me about those scars,” to which the patient replied, “Before I knew it was okay to talk about my symptoms I often lost sensation in my left arm and hand and thought my arm was poisoned or dead. I tried to determine if I was alive or not. I could see myself walking and see and feel my right arm, so I thought I was probably alive, but I did not know for sure, so I used to take a knife and poke tiny holes in my skin. I could not feel the knife yet I saw blood. It was when I saw the blood that I knew I was still alive.”


Selected Nursing Diagnosis




Knowing that the parietal lobe is the major site of pain recognition helps the nurse see this as a neurobiologically based symptom. Visceral pain recognition involves integration of stimuli from the spinal cord through the brainstem, diencephalon, and cortex using intricate feedback circuits. People with schizophrenia generally have poor visceral pain recognition and need to have an in-depth assessment of physical complaints, as described by the patient in the next clinical example.



CLINICAL EXAMPLE


“I told my case manager that I had a stomachache, some diarrhea, and vomiting and felt like I had the flu. I had a fever, so she took me to the doctor, who said I probably had the flu and should just go home and rest. After a few days I got real sick and had to be taken to the emergency room, where they discovered my appendix had ruptured. I had to have a very long and complicated surgery.”


It is not uncommon for people with schizophrenia to think they just have a bad cold and have it diagnosed as pneumonia. Unfortunately, the physical needs of psychiatric patients often can be neglected or disregarded by the individual, as well as by the health care system.


Sensory integration perceptions are included in standard neurological examinations under the category soft signs, meaning that they represent a neurological deficit in an undetermined location but are consistent with brain injury to the frontal or parietal lobes. These terms refer to the ability to identify objects by touch.


Box 20-6 lists several neurological soft and hard signs commonly seen in schizophrenia that should be assessed carefully during a baseline evaluation of each patient. Problems in these functions contribute to difficulty with fine motor actions of the hand, and the patient may appear clumsy. Problems with right/left discrimination also contribute to a lack of coordination and ability to carry out directions involving concepts of right and left.



BOX 20-6   PREFRONTAL CORTICAL DYSFUNCTION IN SCHIZOPHRENIA


Neurological Soft Signs





Misidentification and misperception of faces can contribute to fear, aggressiveness, withdrawal from interactions, and hostility. This symptom also involves self-recognition and often is present when patients refuse to look in a mirror or avoid eye contact.


Environmental factors can stimulate hallucinations. In general, objects that are reflective, such as television screens, photo frames, and fluorescent lights, can contribute to visual hallucinations. Auditory hallucinations can be caused by excessive noise and by sensory deprivation. The nurse should be acutely aware of environmental stimuli and the patient’s response or lack of response. Patients may withdraw from sensory stimuli in an attempt to decrease sensory responses.


About 90% of people who experience hallucinations also have delusions, whereas only 35% of those who experience delusions also have hallucinations. Approximately 20% of patients have mixed sensory hallucinations, usually auditory and visual.



Emotion


Emotions are described in terms of mood and affect. Mood is an extensive and sustained feeling tone that can be experienced for a few hours or for years and affects a person’s world view. Affect refers to behaviors such as hand and body movements, facial expression, and pitch of voice that can be observed when a person is expressing and experiencing feelings and emotions.


Terms related to affect include broad, restricted, blunted, flat, and inappropriate (see Chapter 6). What is considered normal varies greatly among cultures. Broad or restricted affect is usually considered to be within the range of normal, whereas blunted, flat, or inappropriate affect represents symptoms of an underlying problem. Disorders of affect refer to the expression of emotion, not the experience of emotion. Patients describe affective symptoms in the following examples:



Patients describe frustration with these affective symptoms because other people assume that they do not experience any emotion. As a result, patients are often misjudged as appearing bored, disinterested, or unmotivated.


Emotion refers to moods and affects that are connected to specific ideas. Emotions are generated from an interplay of neural activity among the hypothalamus, limbic structures (amygdala and hippocampus), and higher cortex centers. The hypothalamus, in addition to its hormonal functions, is the emotional coordinating center.


Emotions can be hyperexpressed (too much) or hypoexpressed (too little). People with schizophrenia commonly have symptoms of hypoexpression. Some patients perceive that they no longer have any feelings and that they have a decreased ability to feel intimacy and closeness. Problems of emotion usually seen in schizophrenia include the following:



In addition to problems with emotions and affect, people with schizophrenia also can have mood disorders. A diagnosis of schizoaffective disorder is given to the patient who meets the diagnostic criteria for schizophrenia as well as those for bipolar disorder or major depression.



imageQUALITY AND SAFETY ALERT




Understanding the effect of brain malfunctions on the emotions and affect of the person with schizophrenia is important for promoting communication and problem solving. People with brain illnesses often have an uncanny ability to sense the emotions of others, yet they may have difficulty identifying their own emotions. This creates special problems in caring for the patient and requires nurses to be aware of and in control of their own emotional reactions.


Caregivers often confuse feelings that are a direct result of brain malfunction and those that are an indirect product of social difficulties resulting from illness. Examples of feelings that are a direct result of brain malfunction include paranoid hostility and emotional flattening. An example of feelings that are an indirect product of social difficulties caused by illness is frustration over not being able to achieve one’s potential. When patients and caregivers have difficulty identifying feelings and emotions, barriers to good communication often result.



Behavior and Movement


Definition of “normal” behavior and movement is based on culture, age appropriateness, and social acceptability. Maladaptive neurobiological responses cause behaviors and movements that are odd, unsightly, confusing, difficult to manage, dysfunctional, and puzzling to others. With exploration, many behaviors can be explained and movements can be understood. Some make sense based on the information provided by the patient or the patient’s neurobiological illness.



Critical Reasoning


Describe unusual behaviors or movements that you have observed in patients with maladaptive neurobiological responses. Were you able to discover the reason for them? Can you think of possible explanations for wearing several layers of clothing in very hot weather? Refusing to bathe? Hugging oneself and rocking?


Maladaptive behaviors in schizophrenia include deteriorated appearance, lack of persistence at work or school, avolition, repetitive or stereotyped behavior, aggression, agitation, and negativism. Deterioration in appearance includes disheveled and dirty clothes, sloppy and unkempt appearance, poor or absent personal grooming, and lack of personal hygiene. This is often the first set of symptoms to occur and is a signal to the family that something is happening to their loved one.


Lack of persistence at work or school typically accompanies deterioration in appearance. As problems in brain function begin to appear, the cognitive skills seem to “short circuit,” and the person can no longer perform routine tasks. As deterioration continues, the person begins to experience avolition, which means lack of energy and drive. This is a result of the brain changes (that may be occurring rapidly) and of frustration with inability to accomplish tasks that required little effort in the past. Unfortunately, at this point, most people with schizophrenia are mislabeled as lazy, disinterested, and unmotivated.


As deterioration continues, patients often engage in repetitive or stereotyped behaviors. These appear similar to obsessive-compulsive behavior but are related to a private meaning rather than to thoughts. Examples include having to eat foods in a certain way, wearing only certain clothes, walking four steps forward and one step back, or being able to drink only half a glass of water at a time.


The terms aggression, agitation, and the potential for violence are often used to describe a person with schizophrenia. However, people experiencing psychoses are not typically violent. Those who do become violent usually have stopped taking their medications or have been abusing substances.


Agitation is common for anyone who is living with a chronic illness for which there is no cure. It is important to identify and document situations that seem to trigger agitated behavior. People who have schizophrenia tend to become agitated when experiencing performance anxiety, particularly when they have difficulty carrying out tasks that previously were easy to do.


Abnormal behaviors and movements in schizophrenia are summarized in Box 20-7.



BOX 20-7   ABNORMAL BEHAVIORS AND MOVEMENTS IN PATIENTS WITH SCHIZOPHRENIA


Behaviors





Maladaptive movements associated with schizophrenia include catatonia, abnormal eye movements, grimacing, apraxia/echopraxia, abnormal gait, mannerisms, and extrapyramidal side effects of psychotropic medications. Catatonia is a stuporous state in which the patient may require complete physical nursing care, similar to that for a comatose patient, sometimes with unpredictable outbursts of aggressive behavior or strange posturing.


Abnormal eye movements include difficulty following a moving target, absence or avoidance of eye contact, decreased or rapid eye blinking, and frequent staring. These are common oculomotor symptoms found in 40% to 80% of people with schizophrenia.


Grimacing refers to abnormal facial movements that are beyond the patient’s control and are not caused by psychotropic medications.


Apraxia is difficulty carrying out a purposeful, organized task that is somewhat complex, such as dressing. Echopraxia is purposeless imitation of movements made by other people. This symptom may not always be purposeless but can illustrate a delusion, as described by the patient in the following clinical example.



CLINICAL EXAMPLE


“I thought the nurse was my mirror and I had to do what the mirror showed me, so I copied everything she did. As long as I could see her I could feel connected to myself and my surroundings, but she did not understand how important it was for me to be around her and watch what she did. Of course I could not explain what was happening to me at the time because I was psychotic, so she put me in seclusion and restraints.”



Staggering, intentional stepping, and walking with the toes touching the ground first are abnormal gaits common in people with schizophrenia. Mannerisms involve gestures that seem contrived and are not appropriate to the situation, such as stopping in the middle of a sentence to whirl two fingers around.



Socialization


Socialization is the ability to form cooperative and interdependent relationships with others. This was placed last among the five major brain functions because problems with the other functions must be understood to appreciate the relational consequences of maladaptive neurobiological responses. Social problems are often the major source of concern to families and health care providers, because these tangible effects of illness are often more prominent than the symptoms related to cognition and perception.


Social problems may result from the illness directly or indirectly. Direct effects occur when symptoms prevent the person from socializing within accepted sociocultural norms or when motivation deteriorates, resulting in social withdrawal and isolation from life’s activities. Behaviors directly causing these problems include inability to communicate coherently, loss of drive and interest, deterioration of social skills, poor personal hygiene, and paranoia.


Indirect effects on socialization are secondary consequences of the illness. An example is low self-esteem related to poor academic and social achievement. Significant social discomfort and further social isolation may result. Specific problems in the development of relationships include social inappropriateness, disinterest in recreational activities, inappropriate sexual behavior, and stigma-related withdrawal by friends, families, and peers.


Social inappropriateness relates directly to cognitive deficits and results in behaviors such as suddenly beginning loud evangelistic prayer in public, toileting in public, standing in the middle of a street trying to direct traffic, dressing bizarrely, and engaging in intimate conversation with total strangers. Social inappropriateness often involves bizarre sexual behavior, such as public masturbation, running nude in the street, or making inappropriate sexual advances.


Stigma also presents major obstacles to developing relationships and adversely affects quality of life. It is a major cause of the social isolation of people with schizophrenia, and it often spreads to the whole family, who may be having their own schizophrenia-related social problems stemming from embarrassment about having the illness in the family (Marcussen et al, 2010; McCann et al, 2011). They may avoid talking about it, or if they do want to talk, they may not know how to broach the subject. Stigma and rejection may discourage them from talking.


Family members may feel like social outcasts for having this illness in the family (see Chapter 10). One family member explained, “For the rest of my life, I will be dealing not only with the heartbreak of my brother’s illness but also with negative response, stigma, and ignorance in my hometown that affects me deeply.”



Critical Reasoning


Describe your own attitudes and behaviors and those of your peers toward people who have maladaptive neurobiological responses and their families.



Physical Health


Individuals with schizophrenia have higher morbidity and mortality because of physical illness (Lawrence et al, 2010; Platt et al, 2010; Jeste et al, 2011). These conditions, especially obesity and its cardiovascular consequences, lead to the well-documented shortening of the average life span in persons with schizophrenia by about 20 years. In addition, persons with schizophrenia who are hospitalized for medical or surgical reasons have twice the chance of adverse events, associated with poorer clinical and economic outcomes.


Part of the problem is the high-risk lifestyle of persons with schizophrenia, which includes sedentary living, smoking, unhealthy dietary habits, and obesity. This can result in diabetes, hypertension, and coronary artery disease (Megna et al, 2011). Atypical antipsychotics also contribute to these medical conditions.


In addition, there is a serious disparity of health care for patients with severe mental illness, with neither the primary care system nor the mental health system providing basic physical health screening, treatment, and monitoring for these individuals (Kreyenbuhl et al, 2010; Minsky et al, 2011).


Thus it is essential that nurses complete a thorough biological assessment of these patients (see Chapter 5) to fully evaluate their physical health needs (Roberts and Bailey, 2011). This assessment should include scheduling of cancer screening, vision tests, and other preventive examinations. Then a biopsychosocial treatment plan should be developed that ensures adequate monitoring of body mass index, plasma glucose level, lipid profiles, and signs of prolactin elevation or sexual dysfunction, among other indicators.



imageQUALITY AND SAFETY ALERT





Predisposing Factors


Schizophrenia is a neurodevelopmental brain disorder. No one thing causes schizophrenia. It is the end result of a complex interaction among thousands of genes and many environmental risk factors, none of which on its own causes schizophrenia. Schizophrenia is a complex neurobiological disorder of brain neurotransmitter circuits, neuroanatomical deficits, neuroelectrical abnormalities, and neurocirculatory dysregulation. These ultimately lead to a miswired brain and clinical symptoms (Gilmore, 2010).



Genetics


Genetics plays a role in schizophrenia but it is difficult to separate out the influence of genetics and the environment. The aim of genetic research is to eventually map the genetic susceptibility for schizophrenia and then develop genetic interventions as treatment modalities. The specific genetic defects that cause schizophrenia have not yet been identified, but progress has been made toward identifying the mechanisms and potential gene locations (MacDonald and Schulz, 2009).


The most significant risk factor for developing schizophrenia is having a first-degree relative with schizophrenia. Family, twin, and adoption studies have shown an increased risk for the disease in people with both a first-degree relative (parent, sibling, offspring) or a second-degree relative (grandparents, aunts and uncles, cousins, grandchildren) with schizophrenia (Gottesman et al, 2010). More than 40% of monozygotic twins of those with schizophrenia are also affected. However most people with schizophrenia do not have an affected relative, and while the overall genetic contribution to schizophrenia may be large, the contribution of specific genes is very small.


Schizophrenia is caused by the interaction of a variety of mechanisms that are biological, environmental, and experiential. Children who have a biological parent with schizophrenia and are adopted at birth by a family with no incidence of the disorder have the same risk as if their biological parents had raised them. There is evidence for both a genetic predisposition for the disorder and an influence of environmental or random factors, as evidenced by studies of identical twins, who share 100% of genes but only a 50% risk for schizophrenia.



Neurobiology


Studies show anatomical, functional, and neurochemical abnormalities in the living and postmortem brains of people with schizophrenia. Research suggests that the prefrontal cortex and the limbic cortex may never fully develop in the brains of persons with schizophrenia. The two most consistent neurobiological research findings in schizophrenia are decreased brain volume and alterations of many neurotransmitter systems.


The decreased brain volume includes decreases in both gray matter and white matter (neuronal axons) (Arnsten, 2011). This is due to faulty myelination occurring at about age 6 years and again at about age 13 years and relates to a theory of abnormal pruning of neurons during adolescence (Faludi and Mirnics, 2011).


Particular attention has been focused on the following:



Therefore psychotic behaviors may be related to lesions in the frontal, temporal, and limbic regions of the brain and to dysregulation of neurotransmitter systems connecting these regions.



Imaging studies

Computed tomography and magnetic resonance imaging studies of brain structure show decreased brain volume in people with schizophrenia (Figure 20-4). Findings include:


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FIG 20-4 Magnetic resonance imaging scans through the bodies of the lateral ventricles in a pair of monozygotic twins who are discordant for schizophrenia. Note the increase in the cerebrospinal fluid spaces in the twin with schizophrenia (right) compared with the unaffected twin (left). (From Roberts GS, Leigh PN, Weinberger DR: Neuropsychiatric disorders, London, 1993, Mosby-Wolfe.)


These findings suggest loss or underdevelopment of brain tissue. Enlarged ventricles have been associated with two indicators of poor prognosis: early age at onset and poor premorbid functioning (functioning before the first diagnosis).


Positron emission tomography scans usually demonstrate decreased cerebral blood flow to the frontal lobes during specific cognitive tasks in people with schizophrenia. This frontal hypometabolism is thought to account for some problems with attention, planning, and decision making (Figure 20-5).


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FIG 20-5 Blood flow demonstrated by positron emission tomography during the performance of the Wisconsin Card Sort Task (a task that activates the prefrontal cortex in normal subjects) in a twin with schizophrenia (right column) and an unaffected twin (left column). The arrows indicate the relatively focused failure of activation in the affected twin compared with the unaffected twin. (From Roberts GS, Leigh PN, Weinberger DR: Neuropsychiatric disorders, London, 1993, Mosby-Wolfe.)

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Neurobiological Responses and Schizophrenia and Psychotic Disorders
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