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Please respond to each classmate with a 125 words and reference
Classmate 1:
Schizophrenia
Schizophrenia, a severe mental illness that is marked by hallucinations, delusions, disorganized speech, grossly disorganized behavior, and negative signs and symptoms such as reduced emotional expression, avolition, and cognitive impairment(Hany et al., 2023). The criteria diagnostic criteria of schizophrenia: Two (or more) of the following, each present for a significant portion of time during one month (or less if successfully treated). At least one of these must be Delusions, Hallucinations, Disorganized speech (e.g., frequent derailment or incoherence), Grossly disorganized or catatonic behavior, and negative symptoms (i.e., diminished emotional expression or avolition).
Schizoaffective disorder has features of both schizophrenia and mood disorders. In current diagnostic systems, patients can receive the diagnosis of schizoaffective disorder if they fit into one of the following six categories: patients with schizophrenia who have mood symptoms, patients with a mood disorder who have symptoms of schizophrenia, patients with both mood disorder and schizophrenia, patients with a third psychosis unrelated to schizophrenia and mood disorder, patients whose disorder is on a continuum between schizophrenia and mood disorder, and patients with some combination of the above.
Schizophrenia is equally predominant in men and women. The onset of the disease is earlier in men than in women. More than half of all male schizophrenia patients, but only one-third of all females. The peak ages of onset are 1 0 to 25 years for men and 25 to 35 years for women. Approximately 3 to 1 0 percent of women with schizophrenia present with disease onset after age 40 years. About 90 percent of patients in treatment for schizophrenia are between 15 and 55 years old. The onset of schizophrenia before age ten years or after age 60 years is sporadic.
Men typically exhibit an earlier onset of the disease, poorer functioning before the illness becomes apparent, more pronounced negative symptoms, and a higher incidence of alcohol and substance use disorders (Hany et al., 2023).
Pathophysiologic mechanisms of the Schizophrenia:
Dopamine, serotonin, glutamate, and gamma-aminobutyric acid (GABA) are neurotransmitters responsible for schizophrenia. The link between dopamine and schizophrenia emerged from the accidental discovery of dopamine D2 receptor blockers’ effectiveness in alleviating psychotic symptoms. the four key dopamine pathways present in the brain include mesolimbic, mesocortical, tuberoinfundibular, and nigrostriatal. Excessive dopamine activity in the mesolimbic pathway, which runs from the ventral tegmental area to the limbic regions, is responsible for positive symptoms of schizophrenia such as hallucinations, delusions, and any changes in thoughts or behaviors. Low dopamine levels in the mesocortical pathway, connecting the ventral tegmental area to the cortex, are responsible for negative symptoms and cognitive deficits. Negative symptoms include lack of motivation, inability to feel pleasure, lack of interest in social interactions, diminished expression of emotion, and reduced speech. It is essential to understand that negative symptoms may be either primary to a diagnosis of schizophrenia or secondary to a concomitant psychotic diagnosis, medication, or environmental factor.The primary goal of antipsychotic treatment is to alleviate symptoms and restore the patient’s normal functioning, followed by maintenance therapy to prevent symptom recurrence, reduce hospitalizations, and improve quality of life. Psychotherapy, in conjunction with pharmacological therapy, is an effective treatment for schizophrenia(Ruffalo, 2023).
Psychotherapy treatments for schizophrenia
some of the evidence-based psychotherapy treatments for schizophrenia include cognitive remediation, metacognitive training, social skills training, Psychoeducation, family interventions, cognitive behavioral therapy, physical exercise, lifestyle interventions, and supported employment (Stefano Barlati et al., 2024). Physical exercise can be considered for all intents and purposes as an entirely evidence-based psychosocial intervention for people living with SSD, capable of improving not only physical fitness but also psychopathological outcomes and cognitive performance. Cognitive Behavioral Therapy for psychosis (CBTp) is a structured psychotherapy intervention that focuses on the connections between thoughts, behaviors, and emotions targeted and adapted for the treatment of SSD. Also, Psychoeducation encompasses all the interventions focused on the education of an individual living with a psychiatric disorder regarding topics that may improve the outcomes of treatment and rehabilitation, enabling a behavioral change in the participant. Effective education is essential in patient compliance with treatment.
Pharmacological treatment for schizophrenia
The evidence-based practice, according to APA, recommends that patients with schizophrenia be treated with antipsychotic medication and observed for effectiveness and side effects. Antipsychotic drugs are divided into first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs). The “first-generation,” “typical,” or “conventional” antipsychotics include Chlorpromazine (Thorazine), Fluphenazine (Prolixin), Haloperidol (Haldol), Perphenazine (Trilafon), Thioridazine (Mellaril), Thiothixene (Navane) and Trifluoperazine (Stelazine) (Bhandari, 2016). The second-generation” or “atypical” antipsychotics include Aripiprazole (Abilify), Aripiprazole lauroxil (Aristada), Asenapine (Saphris), Brexpiprazole (Rexulti), Cariprazine (Vraylar), Clozapine (Clozaril), Iloperidone (Fanapt), Lumateperonee (Caplyta), Lurasidone (Latuda), Olanzapine , (Zyprexa), Olanzapine/samidorphan (Lybalvi), Paliperidone (Invega Sustenna), Paliperidone palmitate (Invega Trinza)., Quetiapine (Seroquel), Risperidone (Risperdal), Ziprasidone (Geodon) (Bhandari, 2016). The initial dose of antipsychotic medication is influenced by factors such as drug formulation, patient characteristics, and history of antipsychotic use. Clozapine is also recommended for patients with schizophrenia with resistant, persistent, substantial risks of suicide or aggression despite other treatments(Hany et al., 2023).
Requirement for Hospitalization
When the patient requires further assessment of their ability to control violent impulses (e.g., to commit suicide or homicide) that may be related to the delusional material and also if the behavior about the delusions may have significantly affected their ability to function within their family or occupational settings; they may require professional intervention to stabilize social or occupational relationships. The patient may require hospitalization for further complete medical and neurological evaluation to determine whether a nonpsychiatric medical condition is causing the delusional symptoms.
legal/ethical issues
The principles of autonomy and truth-telling may sometimes conflict directly with the principles of doing good (beneficence) and avoiding harm (nonmaleficence) when working with patients with schizophrenia(Beck & Ballon, 2020). Patients with acute symptoms of schizophrenia, such as delusions, hallucinations, disorganized thinking (speech), and grossly disorganized or abnormal motor behavior, may lack insight into the disorder and their need for treatment, patients and their families may impair one’s ability to meet one or more of the key components of informed consent, such as the capacity for decision making and voluntariness. Schizophrenia may be associated with diminished capacity to make certain kinds of decisions, under certain circumstances, especially if the decision intersects with specific delusional ideas(Beck & Ballon, 2020).
When the clinician is faced with the inability to manage severe symptoms, lack of progress or improvement in the symptoms with current interventions, and unfamiliarity with advanced treatment, the best approach to progress with the treatment the best approach will be to refer the patient to a higher level of care. This can be done by seeking consultation from the collaborating psychologist or collaborating with other healthcare professionals to provide a more comprehensive approach to treatment.
Interprofessional collaboration is essential, with each team member contributing specialized knowledge and skills to optimize patient care. Psychiatrists and mental health NP can work together to coordinate treatment with other mental health professionals and prescribe and manage medication among people with schizophrenia. The primary care provider is responsible for the majority of their health needs. People with schizophrenia are at higher risk of chronic diseases such as heart disease, diabetes, and obesity. Social workers can play a crucial role in helping people with schizophrenia set and accomplish goals for treatment and for living and participating in their communities (Roan, 2019). Pharmacists must perform medication reconciliation to ensure no drug-drug interactions could inhibit effective care and report any concerns they have to the prescriber or their nursing staff. The impact of interprofessional teams cannot be underestimated.
References
Beck, N. S., & Ballon, J. S. (2020). Ethical issues in schizophrenia. FOCUS, 18(4), 428–431. https://doi.org/10.1176/appi.focus.20200030Links to an external site.
Bhandari, S. (2016, August 31). Which medications treat schizophrenia? WebMD; WebMD. https://www.webmd.com/schizophrenia/medicines-to-treat-schizophreniaLinks to an external site.
Boland, R. J., Verduin, M. L., Ruiz, P., Arya Shah, & Sadock, B. J. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2023). Schizophrenia. NIH.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/Links to an external site.
Roan, S. (2019). People with schizophrenia can benefit from coordinated care teams. EverydayHealth.com. https://www.everydayhealth.com/hs/schizophrenia-caregiver-guide/building-a-schizophrenia-care-team/Links to an external site.
Stefano Barlati, Nibbio, G., & Vita, A. (2024). Evidence-based psychosocial interventions in schizophrenia: A critical review. Current Opinion in Psychiatry, 37(3). https://doi.org/10.1097/yco.0000000000000925Links to an external site.
Classmates 2:
Compare/contrast Schizophrenia with Schizoaffective disorder in terms of the following parameters. Discuss the following in your post.
Schizophrenia and schizoaffective disorder are both serious mental health conditions that affect a person’s perceptions, thoughts, and behaviors. Although they share similar symptoms such as hallucinations, delusions, and disorganized thinking, they are distinct disorders.
Schizophrenia is characterized by periods of psychosis, during which the individual loses touch with reality. Symptoms must be present for at least six months, with active symptoms, such as hallucinations or delusions, persisting for at least one month.
In contrast, schizoaffective disorder is characterized by a combination of schizophrenia symptoms and mood disorder symptoms like depression or mania. The key difference is that in schizoaffective disorder, the mood symptoms are present for a substantial portion of the illness.
Age-appropriate, culturally responsive, comprehensive assessment.
When assessing for age-appropriate, culturally responsive, and comprehensive evaluation, it is crucial to recognize that these disorders typically manifest in the early-to mid-20s for men and in the late-20s for women (APA, 2022). However, early onset schizophrenia is also a possibility, and identifying and treating it early can significantly enhance client outcomes.
Cultural considerations are paramount in the assessment, diagnosis, and treatment of these disorders. Cultural and religious beliefs can profoundly impact a person’s understanding and interpretation of symptoms, as well as their help-seeking behavior. For example, in some cultures, symptoms of these disorders may be attributed to spirits or witchcraft and may be perceived differently.
A thorough assessment of the client should encompass pharmacological, medical, surgical, psychological, and familial history. This should involve a comprehensive review of the present illness, physical examination, mental status evaluation, and any pertinent lab results. It should be tailored to the individual’s age, cultural background, and personal beliefs and experiences. This approach can help ensure an accurate diagnosis and an appropriate and effective treatment plan. Furthermore, obtaining any collateral information that may assist in the comprehensive assessment is important.
Description of postulated pathophysiologic mechanisms of the disorder- these should be linked to common symptoms observed in clients who present with this illness.
The pathophysiology of both schizophrenia and schizoaffective disorder is complex and not fully understood. It is generally believed that a combination of genetic, environmental, and neurobiological factors contributes to the development of these disorders.
In schizophrenia, there is evidence of structural brain abnormalities, including enlarged ventricles and reduced size of certain brain regions (Jauhar et al., 2022). Imbalances in neurotransmitters, particularly involving dopamine and glutamate, are also thought to play a role. The primary positive, negative, and cognitive symptoms of schizophrenia have been associated with many neurotransmitters, but subcortical dopamine dysfunction remains a key factor in psychotic symptoms (Luvsannyam et al., 2022). Alterations in dopamine function within the striatum cause psychosis in clients with schizophrenia. These abnormalities can lead to the characteristic symptoms of schizophrenia, such as hallucinations, delusions, and disorganized thinking.
Regarding schizoaffective disorder, its pathophysiology is thought to involve a combination of the mechanisms involved in schizophrenia and those involved in mood disorders. This can result in a mix of symptoms, including those seen in schizophrenia as well as symptoms of depression or mania.
What behaviors on the part of the client (with either condition) would lead you to believe that they may be experiencing a psychiatric emergency?
Hospitalization is typically required when an individual’s psychotic symptoms pose a risk of harm to themselves or others, or when they struggle to manage daily tasks or control their behavior (Huang et al., 2023). Stahl (2023) points out that positive symptoms of schizophrenia are easily recognizable because they are typically dramatic and often lead to individuals being brought to the attention of medical professionals and law enforcement. These symptoms are also the primary focus of drug treatments for schizophrenia. Positive symptoms include delusions, hallucinations, and abnormal motor behavior of varying severity. More complex to diagnose, negative symptoms are linked to high morbidity as they disrupt a client’s emotions and behavior. Diminished emotional expression, avolition (decreased initiation of goal-directed behavior), alogia, and anhedonia are common negative symptoms. It is crucial to note that negative symptoms may be primary to a diagnosis of schizophrenia or secondary to a concomitant psychotic diagnosis, medication, or environmental factor, which constitutes a psychiatric emergency.
During such emergencies, clients may display signs of aggression and agitation, potentially posing a risk of harm to themselves or others. It’s important to assess them for suicide risk, violence risk, inability to care for themselves, and the risk of being the victim of a crime (Lawrence & Bernstein, 2024).
Develop a general treatment plan for either disorder- what evidence-based psychotherapies would you plan to include? What evidence-based psychopharmacologic approaches would be appropriate?
The treatment of schizophrenia and schizoaffective disorder typically involves a combination of pharmacotherapy and psychotherapy. A crucial part of most treatment regimens is the use of antipsychotics tailored to the individual, aiming to bring about significant improvements in psychiatric symptoms, functioning, service utilization, and overall quality of life, while minimizing adverse effects. Antipsychotics are used to address psychosis and aggressive behavior in these disorders, with most blocking dopamine receptors, and second-generation antipsychotics also impacting serotonin receptors (McDonagh et al., 2017).
First-generation antipsychotics (FGAs) like haloperidol have demonstrated effectiveness but are associated with adverse effects such as extrapyramidal symptoms and, in some cases, tardive dyskinesia, which can hinder long-term adherence. Second-generation antipsychotics (SGAs) like Abilify were introduced as having comparable or better efficacy, particularly with negative symptoms, and a lower risk of extrapyramidal symptoms and tardive dyskinesia. However, SGAs can also have potentially serious adverse effects (e.g., cardiovascular and endocrinologic effects), resulting in a less definite overall risk/benefit profile than initially expected.
According to Wy and Saadabadi (2023), individuals with schizoaffective disorder often require treatment with mood stabilizers and antidepressants. It is important to consider mood stabilizers for those who have a history of manic or hypomanic symptoms. These medications, such as lithium, valproic acid, carbamazepine, oxcarbazepine, and lamotrigine, specifically target mood dysregulation. When it comes to antidepressants, selective serotonin reuptake inhibitors (SSRIs) are preferred due to their lower risk of adverse effects and better tolerability compared to tricyclic antidepressants and selective norepinephrine reuptake inhibitors. Common SSRIs include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and fluvoxamine. It is crucial to rule out bipolar disorder before starting an antidepressant to avoid the risk of triggering a manic episode.
Clients diagnosed with schizophrenia or schizoaffective disorder can benefit from psychotherapy, as is often the case with various mental disorders. Comprehensive treatment plans should incorporate individual therapy, family therapy, and psychoeducational programs. The aim is to enhance their social skills and cognitive functioning to minimize the risk of relapse and potential hospital readmission. Additionally, this treatment plan involves providing education about the disorder, its underlying causes, and available treatments.
Lastly, electroconvulsive therapy (ECT) can be an effective treatment for schizophrenia or schizoaffective disorder, and it is generally considered a last resort (Wy & Saadabadi, 2023). However, it has been used in urgent cases and when other treatments have not worked. Additionally, it should be considered as an option in addition to current medication. The most common symptoms that indicate the use of ECT are catatonia and aggression. ECT is considered safe and effective for most clients who have been hospitalized for a long time.
Discuss any legal/ethical issues inherent in the care of the individual with either condition (schizophrenia or schizoaffective disorder).
When treating a client with either disorder, legal and/or ethical challenges may arise. In psychiatric emergencies, if the client poses a risk to themselves or others, they may need to be involuntarily admitted to an inpatient facility or placed under a certificate of need. Another ethical issue in both cases involves making assumptions during diagnosis and the risk of causing harm (maleficence). Providers may overlook small differences between the two disorders, potentially leading to harm to the client, especially if they have other mental health issues. Additionally, the client’s conservator, power of attorney, or surrogate should be involved in the care plan. Since both diseases have almost similar causes and processes, providers tend to ignore slight gaps. As such, clients may be subjected to undue harm, especially if they suffer from other psychoses. In addition, the client’s conservator, POA, or surrogate must be included in the care plan.
How would you know if the care of this client (either in an acute episode or chronic care) exceeded your clinical competence? How would you proceed with the client’s care in this case?
If the client did not show significant improvement, I would recognize that my clinical abilities may not be sufficient for their care. As nurse practitioners cannot work independently in Georgia, I would first consult my colleagues or supervising psychiatrist to benefit from their clinical expertise. Boland et al. (2021) recommend that students in training should acknowledge their limitations and seek supervision when necessary. If, after consulting them, I still felt that the client’s care was beyond my scope of practice, I would then involve my supervising provider or refer the client to a more suitable healthcare provider. It is crucial for professionals to recognize their limitations in terms of clinical competence.
What other professionals would you consider including in the care/treatment of this client, and why?
An interdisciplinary team can provide valuable support for clients with chronic psychiatric illnesses by ensuring continuity of care. It’s important to involve the client’s primary care provider in the treatment plan to reduce the risk of medication interactions and improve overall client outcomes. In addition to psychiatrists, including nurses, counselors/therapists, social workers, case managers, and primary care providers in the team can offer a holistic approach to care. These specialists often have personal experience with mental health conditions or substance use disorders and are trained to assist with recovery by helping individuals set goals and develop strengths, as well as providing support, mentoring, and guidance.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th Ed, text revised). American Psychiatric Association Publishing.
Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Wolters Kluwer Health.
Hannawa, A., Wu, A., Kolyada, A., Potemkina, A., & Donaldson, L. (2022). The aspects of healthcare quality that are important to health professionals and patients: A qualitative study. ScienceDirect, 105(6), 1561-1570, https://doi.org/10.1016/j.pec.2021.10.016
Huang, Z., Wang, F., Chen, Z., Xiao, Y., Wang, Q., Wang, S., He, X., Migliorini, C., Harvey, C., & Hou, C. (2023, January 19). Risk factors for violent behaviors in patients with schizophrenia: 2-year follow-up study in primary mental health care in China. Frontiers in Psychiatry. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2022.947987/full
Jauhar, S., Johnstone, M., & McKenna, P. (2022). Schizophrenia. The Lancet, 399(10323), 473–486. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01730-X/abstract
Luvsannyam, E., Jain, M., Pormento, M., Siddiqui, H., Balagtas, A., Emuze, B., & Poprawski, T. (2022). Neurobiology of schizophrenia: A comprehensive review. Cureus, 14(4), e23959. https://doi.org/10.7759/cureus.23959Links to an external site.
McDonagh, M., Dana, T., Selph, S., et al.(2017, October). Treatments for schizophrenia in adults: A systematic review. Agency for Healthcare Research and Quality (US).https://www.ncbi.nlm.nih.gov/books/NBK487620/
Stahl, S. (2023). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
Wy, T., & Saadabadi, A. (2023, March 27). Schizoaffective disorder. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK5
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