Learning Objectives
By the end of this section, you will be able to:
- Recall the different types of schizophrenia spectrum disorders
- Outline evidence-based approaches to treating and caring for a client with a schizophrenia spectrum disorder
Schizophrenia is a disturbance that includes positive, negative, and cognitive symptoms in those who have expressed them for over six months. Several other disorders, though resembling schizophrenia symptomatically, do not quite meet this criterion. This section reviews these disorders, how they differ from schizophrenia, and their management.
Schizophrenia Spectrum Disorders
Psychotic disorders include brief psychotic disorder, substance/medication-induced psychotic disorder, psychotic disorder due to a medical condition, schizophreniform disorder, schizoaffective disorder, and catatonia. Schizophrenia spectrum disorders are other psychotic disorders that share similar symptoms with schizophrenia: delusions, hallucinations, disorganized thinking or speech, disorganized behavior, and negative symptoms. The three schizophrenia disorders are schizophreniform disorder, schizoaffective disorder, and schizophrenia.
Schizotypal personality disorder is considered on the spectrum for schizophrenia spectrum disorders, but it is a personality disorder. Those with schizotypal personality disorder have shared genetic and neuropsychiatric commonalities with schizophrenia; a small number of those diagnosed with the disorder do go on to develop schizophrenia. More information on schizotypal personality disorder can be found in Personality Disorders. Schizophrenia is a diagnosis of exclusion, meaning that providers rule out medical, substances, and all other causes for psychotic behaviors before diagnosing schizophrenia. This next section will discuss the diagnostic criteria and treatments for schizophrenia spectrum disorders (American Psychiatric Association [APA], 2022).
Brief Psychotic Disorder
Brief psychotic disorder is the presence of psychotic symptoms for one day and less than one month. Symptoms include delusions, hallucinations, disorganized speech, or disorganized behavior. At least one of the symptoms must be delusions, hallucinations, or disorganized speech to qualify for the disorder. These symptoms cannot be caused by any other mental health disorder or by a substance. In some cases, there can be a clearly defined precipitating stressor for psychotic symptoms, such as a peripartum onset; in other cases, there is not. The brief psychotic disorder accounts for 2 to 7 percent of psychotic presentations globally. It can be present across the lifespan but usually occurs in late teens or early adulthood. Despite the symptoms lasting less than a month, almost half of those diagnosed with brief psychotic disorder experience another psychotic episode (APA, 2022).
Substance/Medication-Induced Psychotic Disorder
A substance or medication-induced psychotic disorder is the presence of hallucinations or delusions soon after use, intoxication, withdrawal, or exposure to a substance or medication. These symptoms cannot occur during a delirium (a transient state of altered consciousness due to a medical condition or substance) and the substance must be capable of producing the psychotic effect. Substances known to cause these effects include alcohol, cannabis, phencyclidine, hallucinogens, inhalants, sedatives, hypnotics, anxiolytics, stimulants, cocaine, toxins, insecticides, and fuel or paint. Medications known to cause these effects include anesthetics, anticholinergics, cardiovascular drugs, antiparkinsonian medications, and muscle relaxants. The symptoms can present differently depending on the substance, medication, or toxin. The symptoms may abate immediately or persist, even to the point of a later diagnosis of a schizophrenia spectrum disorder.
Psychotic Disorder Due to Another Medical Condition
Psychotic disorder due to a medical condition is more prevalent in older age groups due to comorbid medical conditions that are more common later in life. Causative conditions affiliated with this disturbance include neurological (head injury, neoplasms, cerebrovascular accidents, epilepsy), hypo and hyper thyroid, hypoxia, hypercarbia, hypoglycemia, hepatic insufficiency, renal insufficiency, infection, and fluid or electrolyte imbalances. The diagnostic criteria are the presence of hallucinations or delusions as the direct consequence of a medical condition. The symptoms cannot be due to a mental health disorder or substance. The course of the symptoms depends on the course of the medical illness or disease. Once the client has managed the underlying condition, the psychotic symptoms will resolve.
Schizophreniform Disorder
Consider the timeline of symptoms that falls between brief psychotic disorder and schizophrenia; this is schizophreniform disorder. The diagnostic criterion for this disorder is the presence of delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms for at least one month but less than six months. At least one of the symptoms must be delusions, hallucinations, or disorganized speech. The symptoms cannot be attributed to a substance or a medical condition. The course of the illness is dependent on whether the client continues to experience symptoms or they remit. If the symptoms continue, the diagnosis may evolve to a diagnosis of schizophrenia.
Schizoaffective Disorder
Schizoaffective disorder is the presence of a mood disorder, either a major depressive disorder, a manic episode or bipolar disorder, in conjunction with the symptoms for schizophrenia. The client must have six months of symptoms to meet the diagnosis of schizophrenia. They then either have a major depressive episode or a manic episode during that same six months. A depressive episode means a sad mood, decreased energy/motivation, guilt, decreased/increased appetite, insomnia/hypersomnia, anhedonia, and/or suicidal thoughts for at least two weeks. A manic episode is characterized by the presence of an elevated mood, decreased need for sleep, pressured speech/talkative, flight of ideas, distractibility, increase in goal-directed activity, and increase in risky behaviors for at least one week. During the remission of the mood episode, the client must continue to experience psychotic symptoms (delusions or hallucinations) for at least two weeks, and a substance, another mental health condition, or a medical condition cannot bring on the symptoms. Males and females equally express the bipolar subtype, while females are twice as likely to express the depressive subtype.
Catatonia
Catatonia is a disturbance caused by neurotransmitter signal disruptions manifesting as motor, affective, and cognitive symptoms. It can happen in the context of another mental health disorder, such as schizophrenia spectrum disorder, depression, bipolar disorder, or a medical condition. It stems from neurodevelopmental, mental health, and medical disorders. Twelve types of behaviors are part of the diagnostic criteria for catatonia, and they are divided into three subtypes (Healthline, 2024b):
- retarded, which entails mutism, inhibited movement, posturing, rigidity, negativism, and staring
- malignant, characterized by fever, autonomic instability, delirium, and rigidity
- excited, which looks like excessive motor activity, stereotypy, impulsivity, and combativeness
Malignant catatonia can be life-threatening and usually warrants admission to the intensive care unit for treatment and monitoring. The diagnostic criteria include the presence of three of the clinical symptoms of catatonia (Table 15.8). These symptoms resolve with the management of the underlying psychiatric or medical condition. Most evidence-based treatment recommends using either benzodiazepines or ECT to manage catatonia. It is important to know the symptoms of catatonia because the nurse needs to be able to recognize them, although they might not be seen very often or could be mistaken for the symptoms of another condition. Table 15.8 outlines the full range of symptoms that might be experienced by a client with catatonia.
| Symptom | Description |
|---|---|
| Stupor | No motor activity, not relating to the environment |
| Catalepsy | Passive induction of a posture held against gravity |
| Waxy flexibility | Positioning by examiner held by client |
| Mutism | Little or no verbal response |
| Negativism | Opposition to or no response to instructions or external stimulus |
| Mannerism | Acting out mannerisms in an odd way |
| Posturing | Spontaneous and active maintenance of posture against gravity |
| Stereotypy | Repetitive, frequent, non-goal directed movements |
| Agitation | Excited or irritable |
| Grimacing | Of the facial features |
| Echolalia | Mimicking other’s speech |
| Echopraxia | Mimicking other’s movements |
Evidenced-Based Approaches to Treatment for Schizophrenia Spectrum Disorders
The approaches to treatment of those with schizophrenia spectrum disorders are similar to those of schizophrenia. Medication includes the use of first- and second-generation antipsychotics. Adding mood stabilizers and antidepressants to paliperidone (the only second-generation antipsychotic FDA-approved for schizoaffective disorder) sometimes helps minimize the symptoms of depression and mania seen in schizoaffective disorder. For conditions resulting from substance use, medications, or medical disturbances, psychotic symptoms resolve when the underlying causes have been treated. Treatment for catatonia entails first stopping any offending agent and treating the underlying disorder, be it bipolar disorder, psychotic disorder, or psychotic depression. First-line treatments for catatonia include benzodiazepines or electroconvulsive therapy depending upon the type of catatonia and severity of presentation. Nursing care involves monitoring clients with malignant catatonia for hyperthermia, hypertension, and lethal arrhythmias. Avoid dopaminergic-blocking drugs in those with catatonia, including antipsychotic medications. They are contraindicated in clients with malignant catatonia.
Psychosocial approaches to managing spectrum disorders are also similar to those that are effective for clients with schizophrenia. These treatments include psychosocial therapy, family therapy, cognitive behavioral therapy, and social skills training for those with longer-standing disturbances. Successful outcomes rely upon medication adherence, successful transition from higher levels of care to community care models, and integration into social, educational, and occupational functioning.
Nursing treatments for those with catatonia must first consider symptoms, vital signs, fluid intake and output, cardiopulmonary status, and nutrition. For clients with limited movement, managing skin integrity is critical to decreasing the incidence of pressure ulcers. This includes passive range of motion exercises to decrease the potential for muscle contractures.
Clients with excited catatonia and excessive motor activity require the least restrictive interventions to mitigate risk of injury. Interventions that reduce environmental stimuli may be the most effective management strategies for aggressive behaviors.