D.

NEUROBIOLOGICAL RESPONSES:
SCHIZOPHRENIA SPECTRUM DISORDER
and
COGNITIVE DISORDERS

I. NEUROBIOLOGICAL RESPONSES

Cognition

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 neurobiological disorder such as schizophrenia are often unable to produce complex logical
thoughts or express coherent sentences because neurotransmission in the brain’s information processing
system is malfunctioning.

Cognitive deficits are often present in patients who are at clinical high risk for psychosis and other
neurobiological disorders before the onset of psychotic illness (Carrion et al, 2011).

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II. NEUROBIOLOGICAL BRAIN DISORDERS

Neurobiological brain disorders - affects one’s ability to perceive and process information involving
numbers of syndrome. This makes an individual experience reality different from others (Psychosis)

Psychosis – refers to the mental state of experiencing reality different from others.

(TRIAD OF PSYCHOSIS 3Ds: Dereism, Disorganized Personality, Distorted Reality)

A. SCHIZOPHRENIA SPECTRUM DISORDERS

a. Schizophrenia Spectrum Disorders – Complex neurobiological brain disorders or
disruptions in brain functioning. Behaviors associated with this are:
1. Difficulty to understand
2. Frightened by their experience
3. Have difficulty forming close relationships
4. Alienated from society

Eugene Bleuler - A Swiss Psychiatrist introduced the word Schizophrenia in the world of
psychiatry in 1911.

It comes from two greek word:

“Schizein” (to split)
“Phren” (mind)

Schizophrenia is not split of personality

The split refers to separation between the cognitive and emotional aspect of the personality.

Positive Symptoms: An exaggeration or distortion of normal functions.

Disorder of Thinking
• Delusions (paranoid, somatic, grandiose, religious, nihilistic, or persecutory; thought
broadcasting, insertion or control)
• Hallucinations (auditory, visual, tactile, gustatory, olfactory, cenesthetic, kinesthetic)
• Illusion
Disorganization of speech and behavior
• Speech: Incoherence and illogicality, word salad and loose associations, tangentiality,
circumstantiality, pressured speech, distractible speech, or poverty of speech
• Bizarre behavior (catatonia, movement disorders, deterioration of social behavior)

Positive Symptoms
Usually responsive to traditional antipsychotic drugs (Typical-strong dopamine
blockers causing EPS)

Extrapyramidal Syndrome (EPS):

1. Tardive Dyskinesia - involuntary, irregular, muscle movements of the face,
tongue, trunk and extremities, (muscle twitches)
2. Akathisia – restlessness or intense need to move about (“Robot”)
3. Acute dystonia – painful muscular rigidity, spasm, contraction and cramps
Ex. Torticollis – twisted head and neck
Opisthotonus – tightness in entire body, head and back
Oculogyric - eyes rolled back in a lock position
4. Parkinsonism - muscle stiffness, shuffling gait, drooling, tremor; more
frequent in adults and the elderly
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 Negative Symptoms: An absence or lack of mental function involving thinking, behavior and
perception; resulting to absence or lack of emotional expression or avolition

Usually unresponsive to traditional antipsychotics and more responsive to atypical antipsychotics

(weak dopamine blocker – no EPS)

Problems of Emotion
• Affective flattening: Limited range and intensity of emotional expression
• Anhedonia: A reduced ability or inability to experience pleasure in everyday life
• Asociality: inability to experience pleasure or maintain social contacts

Speech:
• Alogia: Reduction in speech, sometimes called poverty of speech.

Impaired Decision Making

• Alogia: Restricted thought and speech
• Avolition / Apathy: Lack of motivation or initiation of goal-directed behavior
• Attentional impairment: Inability to mentally focus and sustain attention

TYPES OF SCHIZOPHRENIA

1. PARANOID SCHIZOPHRENIA
Preoccupied with one or more delusions or many auditory hallucinations but does not have
symptoms of disorganized schizophrenia.

2. DISORGANIZED SCHIZOPHRENIA
Disorganized speech and behavior, as well as flat or inappropriate affect. The person does not
have enough symptoms to be characterized as suffering from catatonic schizophrenia.

3. CATATONIC SCHIZOPHRENIA
Difficulty moving, resistance to moving, excessive movement, abnormal movements, and/or
repeating what others say (Echolalia ) or do (Echopraxia)

4. UNDIFFERENTIATED SCHIZOPHRENIA:
Characterized by episodes of two or more of the following:
• Positive symptoms: delusions, hallucinations, disorganized speech or behavior, and negative
symptoms
• But the individual does not qualify for a diagnosis of paranoid, disorganized, or catatonic type
of schizophrenia

5. RESIDUAL SCHIZOPHRENIA
While the full-blown characteristic positive symptoms of schizophrenia are absent, the sufferer
has a less severe form of the disorder or has only negative symptoms such as withdrawal,
disinterest, and not speaking

4 A’s OF SCHIZOPHRENIA
• Affect - external expression of emotion
• Ambivalence - mixed feelings or emotions
• Associative looseness
• Autism

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 OTHER PSYCHOTIC DISORDERS:

1. Schizoaffective
An uninterrupted period of illness including a major depressive episode or manic episode
concurrent with signs and symptoms of schizophrenia.

Substantial part of the illness is the presence of mood episodes.

In the absence of prominent mood symptoms, delusions and hallucinations occur lasting for about
two weeks only

2. Schizophreniform
Signs and symptoms are similar to schizophrenia except for the onset of illness that last for 1
month but less than 6 months only

3. Delusional disorders
Non-bizarre delusions (being followed, poisoned, or having a disease) lasting at least a month.

Has never meet criteria for schizophrenia.

Functioning and behavior are not markedly affected

4. Brief psychotic disorder / Brief Reactive Psychosis

Presence of at least one of the following:
Delusions
Hallucination
Disorganized speech
Disorganized behavior / catatonic
Duration is between 1 day to 1 month only with eventual return to pre-morbid functioning

5. Shared Psychosis (folie a deux)

A delusion develops in a patient in the context of close relationship with someone who already
has a delusion. The delusion of the people involved is similar in content.

6. Psychotic disorder secondary to general medical condition

7. Substance-induced psychotic disorder

PREDISPOSING FACTORS:
Biological
• Genetics - 1st to 2nd degree relative
• Neurobiology (imaging studies - decreased brain volume)
• Frontal cortex, implicated in the negative symptoms of schizophrenia
• Limbic system (in the temporal lobes), implicated in the positive symptoms of
schizophrenia
• Neurotransmitter studies (dopamine, serotonin, recent research: Glutamate)
• Neurodevelopment - underdevelopment of brain tissues

Psychological

• Sociocultural
• Environment
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 PRECIPITATING STRESSORS:
Health:
• Poor nutrition, rest and sleep
• Fatigue
• Infection
• CNS drugs
• Lack of exercise
Attitudes/Behaviors:
• “Poor me” (low-self concept)
• “Hopeless” (lack of self-confidence)
• “I’m a failure” (loss of motivation to use skill)
• “Lack of control” (demoralization)
• Poor social skills / support system
• Aggressive behavior
• Violent behavior
• Poor medication management
• Poor symptom management
Environment:
• Hostile/critical environment
• Changes in life events, &
• in daily patterns of activities
• Interpersonal difficulties
• Lack of social support
• Stigmatization
• Poverty
• Inability to get / keep a job

B. COGNITIVE DISORDERS

The ability to think, reason and behave accordingly is a distinguished human feature.
Higher Level Cognitive Domain:
• Planning and Problem Solving
• Learn and retain information in long-term memory
• Use of language
• Perception
• Social function
Lover Level Cognitive Domain:
• Attention
• Orientation

Maladaptive cognitive responses make the affected person:

1. In a state of confusion
2. Unable to understand and learn from experience
3. Unable to relate current to past events
4. Inability to interact reasonably with people.

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 TYPES OF MALADAPTIVE COGNITIVE RESPONSES

1. DELIRIUM –

A mental disturbance of relatively short duration usually reflecting a toxic state, marked by
illusions, hallucinations, delusions, excitement, restlessness, incoherence.

The cognitive functioning may return to normal state except of amnesia for the time during
which patient is delirious.

It is a behavioral response to widespread disturbances in cerebral metabolism.

It is usually considered a medical emergency that can lead to death or permanent cognitive
decline in some cases if not treated

• Delirium results in disturbances in the following areas:

• Consciousness – reduced clarity of awareness of the environment
• Attention – poor mental focus
• Memory impairment, disorientation, language disturbance
• Perception – misinterpretation: illusions or hallucinations
• Motor ability – poor balance, ambulation or coordination

2. DEMENTIA –

A maladaptive cognitive response that features organic loss of intellectual abilities and
interferes with patient’s usual social or occupational activities.

The loss of intellectual ability: memory, judgment and abstract thinking.

Dementia does not have the clouding of awareness or the rapid onset that is seen in delirium.

Onset - usually gradual or a result of a progressive deterioration (ageing)

Or due to neurochemical changes in the brain: trauma, infection, cerebrovascular disruptions,
substance abuse or an unknown cause.

7A’s of Dementia:
Aphasia
Apraxia
Agnosia
Affect Flattening
Agraphia
Amnesia
Abstract thinking diminishing

Other Hallmarks of Dementia:

• SUNDOWNING - mood deteriorates and agitation increases in the later part of the day or
at night
• HYPERORALITY - the tendency to taste, chew, and put everything in the mouth
• PERSEVERATION - the persistent repetition of a word, phrase, or gesture.
Ex. What is your name? Okra, how old are you? okra, where do you stay? Okra

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 • HYPERMETAMORPHOSIS - the urge to touch everything
• WANDERING – Walking around aimlessly

ALZHEIMER’S DISEASE (AD) - The most common type of dementia

Three Stages of ALZHEIMER’S DISEASE

Stage 1: Mild
• Socially normal
• Impaired memory – Forgetfulness (hallmark of a beginning AD)
• Insidious loses in activities of daily living (ADL)
• Subtle personality changes

Stage 2: Moderate
• Obvious memory impairment
• Overt ADL impairment
• Prominent behavioral difficulties
• Variable social skills
• Supervision needed
• Wandering

Stage 3: Severe
• Fragmented memory
• No recognition of familiar people
• Assistance needed in basic ADL
• Usually with few troublesome behaviors
• Reduced mobility

3. AMNESTIC DISORDER –

Development of memory disorder, as evidenced by impaired ability to learn more information

or to recall previously learned information resulting to impairment in social or occupational
functioning and represents a significant decline from previous level of functioning.

It does not exclusively occur during the course of delirium or dementia

It can be due to general medical condition or physical trauma

PREDISPOSING FACTORS
• Ageing
• Neurobiological
• Genetic
• Underlying psychiatric and medical disorders

PRECIPITATING STRESSORS
• Drugs or substance abuse
• CNS disorder
• Metabolic disorder
• Cardiopulmonary disorder
• Systemic illness
• Sensory deprivation or stimulation

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III. NURSING PROCESS

A. ASSESSMENT
a. Mental status examination
b. Review of spiritual, cultural, biological, psychological, social, and environmental elements
c. History of present Illness
d. Past Medical / Family History

e. Laboratory / Diagnostic Examinations

f. Battery of Psychological Examinations
g. DSM-5

B. NURSING DIAGNOSIS
a. Risk for injury directed to: self or others
b. Disturbed sensory perception
c. Acute or chronic confusion
d. Altered thought process
e. Disturbed belief system
f. Impaired Verbal Communication
g. Impaired Social Interaction
h. Ineffective coping
i. Self-care deficit
j. Care giver role strain
k. Altered Nutrition
l. Altered Sleeping Pattern

C. PLAN / IMPLEMENTATION OF TREATMENT

a. Establish a trusting NP relationship
b. Self-awareness / insight into current condition
c. Safety / protection of patient
d. Modify environment / External control
e. Use of Attitude therapy
f. Encourage activity (ADL – Self Care)
g. Treatment modalities – Psychotherapy
• Use counseling, milieu therapy, promotion of self-care activities, and
psychobiological and health teaching interventions as appropriate
• Community Support:
o Identify community resources that can offer the patient specialized
treatment proven to be highly effective for people with the same
condition
o Identify community support groups for people with the same condition
• Somatic Therapy: ECT, Pharmacotherapy
h. Pharmacotherapy:

ANTIPSYCHOTICS are Major Tranquilizer

• Often called “neuroleptics”
• They are useful in three major functions:
o Relieving symptoms of psychosis
o Relieving nausea and vomiting
o (ex. Prochlorperazine or Compazine)
o Potentiation of analgesics (ex. Promethazine or Phenergan)

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 • TYPICAL ANTIPSYCHOTICS - strong dopamine blocker

o FGA - First Generation Antipsychotics

o Effective on positive symptoms
o Frequently causes EPS
o Common Drug List:
a. Haloperidol (Haldol)
b. Chlorpromazine (Thorazine)
c. Prochlorperazine (Compazine)
d. Trifluoperazine (Stelazine)
e. Thiothixine (Navane)

• ATYPICAL ANTIPSYCHOTICS – weak dopamine blocker and binds with

serotonin receptors as well
o SGA – Second Generation Antipsychotics
o Equally effective for positive and negative symptoms
o Less potential for EPS
o Common Drug List:
a. Aripiprazole (Abilify)
b. Olanzapine (Zyprexa)
c. Risperidone (Risperdal)
d. Quetiapine (Seroquel)
• CONTRAINDICATIONS:
o Seizure disorder
o Parkinson’s disease
o Cerebral vascular disease
o Severe depression
o Pregnancy
o Blood dyscrasias
• GENERAL HEALTH TEACHINGS
o Potential side effects
o Potential for abuse and dependence with prolonged use
o Take early in the morning to prevent sleep problems
o Tapered dosage rather than abrupt withdrawal
o Children: watch for signs of Tics, gastric disturbance, insomnia, weight
loss or nervousness and report to physician at once
o Avoid chemical abuse / intake during therapy
o Avoid grapefruit juice: potentiate drug effects
o Minimize sun exposure as antipsychotics increases sun-sensitivity
reactions to skin such as itching, redness, rashes, discoloration
o Regular liver profile test

D. EVALUATION OF CARE

• Outcomes should focus on illness knowledge, management, coping, and quality of life.
• Outcomes should be consistent with the recovery goal, which stresses hope, living a full
and productive life, and eventual recovery rather than focusing on controlling symptoms
and adapting to disability.

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 • Nursing care is considered effective if after evaluation, the Outcome criteria is met
whether the patient is experiencing psychosis or delirium or dementia, it must include:
• Patient’s safety.
• Gradual progress and return to utmost functional level if not premorbid condition
• Patient will be oriented to time, place, and person by discharge.
• Patients’ progress should be reevaluated regularly and treatment adjusted when needed.
Staff, patents, and families should remember that progress may occur erratically or
slowly, and that gains may be small and difficult to see. Even after the person’s
symptoms seem to have improved considerably to others, inside the patient may still be
recovering. As with other serious illnesses, full recovery can take months

Sample Desired Outcomes for Schizophrenia Spectrum and Cognitive Disorders

Signs and Symptoms Nursing Diagnosis Outcomes

Wanders, has unsteady gait, acts out fear Risk for injury Remains safe in hospital or at
from hallucinations or illusions, forgets home
things (leaves stove on, doors open), falls

Awake and disoriented during the night Disturbed sleep Sleep pattern is regular,
(sundowning), frightened at night pattern balances rest and activity

Unable to take care of basic needs, Self-care deficit
incontinence, imbalanced nutrition, (bathing/
insufficient fluid intake
hygiene, dressing,
feeding, toileting)
Self-care needs are met with
optimal participation by the
patient

Sees frightening things that are not there Anxiety (severe/ Anxiety is reduced to a mild-
(hallucinations), mistakes everyday objects moderate level, acknowledges
for something frightening (illusions), may panic) the reality of an object or sound
become paranoid and think that others are after it is pointed out
doing bad things (delusions)

Absence of eye contact, difficulty Impaired verbal Exchanges messages

expressing thoughts, difficulty in communication accurately with others,
comprehending usual communication uncompromised spoken
pattern, inappropriate verbalization language, accurately interprets
messages received

Withdrawal, inappropriate interpersonal Impaired social Engages others, appears

behavior, social discomfort, lack of interaction relaxed, cooperates with
belonging others, uses assertive
behaviors as appropriate,
exhibits sensitivity to others

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DEFINITION OF TERMS:

• Agnosia- is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not
defective nor is there any significant memory loss. It is usually associated with brain injury or neurological illness,
particularly after damage to the occipitotemporal border, which is part of the ventral stream.

• Aphasia- is an impairment of language ability. This class of language disorder ranges from having difficulty remembering
words to being completely unable to speak, read, or write.

• Apraxia- is characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the
desire and the physical ability to perform the movements. It is a disorder of motor planning, which may be acquired or
developmental, but is not caused by incoordination, sensory loss, or failure to comprehend simple commands (which can
be tested by asking the person to recognize the correct movement from a series). It is caused by damage to specific
areas of the cerebrum.

• Catalepsy- is a nervous condition characterized by muscular rigidity and fixity of posture regardless of external stimuli, as
well as decreased sensitivity to pain

• Cataplexy-is a sudden and transient episode of loss of muscle tone, often triggered by emotions. The exact cause of
cataplexy is unknown, but the condition is strongly linked to experiencing intense emotions and reduced levels of the
neurochemical hypocretin.

• Catatonia- is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor

• Clang Association - are groupings of words, usually rhyming words, that are based on similar-sounding sounds, even
though the words themselves don't have any logical reason to be grouped together. A person who is speaking this way
may be showing signs of psychosis in bipolar disorder or schizophrenia

• Delusion- (Paranoia) a false perception directed to self. Is a belief held with strong conviction despite superior evidence
to the contrary. Unlike hallucinations, delusions are always pathological
o Delusion of grandeur, grandiose delusion- delusional conviction of one's own, power, or knowledge or that one
is, or has a special relationship with, a deity or a famous person.
o Delusion of reference - a delusional conviction that ordinary events, objects, or behaviors of others have
particular and unusual meanings specifically for oneself.
o Delusion of jealousy - a delusional belief that one's spouse or lover is unfaithful, based on erroneous inferences
drawn from innocent events imagined to be evidence.
o Delusion of negation, nihilistic delusion- a depressive delusion that the self or part of the self, part of the body,
other persons, or the whole world has ceased to exist.
o Delusion of persecution a delusion that one is being attacked, harassed, persecuted, cheated, or conspired
against.
o Delusion of control- the delusion that one's thoughts, feelings, and actions are not one's own but are being
imposed by someone else or other external force.
o Depressive delusion- one that is congruent with a predominant depressed.

• Echolalia- is the automatic repetition of vocalizations made by another person. It is closely related to Echopraxia, the
automatic repetition of movements made by another person. (echokinesis)
• Euphoria - is medically recognized as a mental and emotional condition in which a person experiences intense feelings of
well being, elation, happiness, excitement, and joy.

• Elation- is an emotion of extreme happiness.

•
• Flight of Ideas- nearly continuous flow of rapid speech that jumps from topic to topic, usually based on discernible
associations, distractions, or plays on words, but in severe cases so rapid as to be disorganized and incoherent. It is most
commonly seen in manic episodes but may also occur in other mental disorders such as in manic phases of
schizophrenia

• Hallucination – a false perception in the absence of stimulus

5 types of Hallucination
o Auditory: The false perception of sound, music, noises, or voices. Hearing voices when there is no auditory
stimulus is the most common type of auditory hallucination in mental disorders. The voice may be heard either
inside or outside one's head and is generally considered more severe when coming from outside one's head.
The voices may be male or female, recognized as the voice of someone familiar or not recognized as familiar,
and may be critical or positive. In mental disorders such as schizophrenia, however, the content of what the
voices say is usually unpleasant and negative. In schizophrenia, a common symptom is to hear voices
conversing and/or commenting. When someone hears voices conversing, they hear two or more voices
speaking to each other (usually about the person who is hallucinating). In voices commenting, the person hears
a voice making comments about his or her behavior or thoughts, typically in the third person (such as, "isn't he
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 silly"). Sometimes the voices consist of hearing a "running commentary" on the person's behavior as it occurs
("she is showering"). Other times, the voices may tell the person to do something (commonly referred to as
"command hallucinations").
o Visual hallucination: A false perception of sight. The content of the hallucination may be anything (such as
shapes, colors, and flashes of light) but are typically people or human-like figures.
o Somatic/tactile hallucination: A false perception or sensation of touch or something happening in or on the
body. A common tactile hallucination is feeling like something is crawling under or on the skin (also known as
formication). Other examples include feeling electricity through one's body and feeling like someone is touching
one's body but no one is there. Actual physical sensations stemming from medical disorders (perhaps not yet
diagnosed) and hypochondriacal preoccupations with normal physical sensations, are not thought of as somatic
hallucinations
o Gustatory: A false perception of taste. Usually, the experience is unpleasant. For instance, an individual may
complain of a persistent taste of metal. This type of hallucination is more commonly seen in some medical
disorders (such as epilepsy) than in mental disorders.
o Olfactory hallucination: A false perception of odor or smell. Typically, the experience is very unpleasant. For
example, the person may smell decaying fish, dead bodies, or burning rubber. Sometimes, those experiencing
olfactory hallucinations believe the odor emanates from them. Olfactory hallucinations are more typical of
medical disorders than mental disorders.

• Illusion- a false perception of an existing stimulus.

o Example: A post lamp perceived by a psych patient as a tall burning building

• Loosening of Association - a thought disturbance demonstrated by speech that is disconnected and fragmented, with
the individual jumping from one idea to another unrelated or indirectly related idea. It is essentially equivalent to
derailment.

• Neologism- Invented words by the user. Use of words that have meaning only to the person who uses them, independent
of their common meaning. This tendency is considered normal in children, but in adults can be a symptom of psychopathy
or a thought disorder (indicative of psychotic mental illness, such as schizophrenia). People with autism also may create
neologisms

• Obsession - a persistent unwanted idea or impulse that cannot be eliminated by reasoning

o Compulsion - an overwhelming urge to perform an irrational act or ritual; the repetitive or stereotyped action
that is the object of such an urge

• Poverty of Speech- A negative symptom of schizophrenia, characterized by brief and empty replies to questions. It
should not be confused with shyness or reluctance to talk.

• Tangentiality- a pattern of speech characterized by oblique, digressive, or irrelevant replies to questions; the responses
never approach the point of the questions.

• Thought Blocking- occurs when a person's speech is suddenly interrupted by silences that may last a few seconds to a
minute or longer.

• Waxy Flexibility- is a psychomotor symptoms of catatonic schizophrenia which leads to a decreased response to stimuli
and a tendency to remain in an immobile posture.
For instance, if one were to move the arm of someone with waxy flexibility, they would keep their arm where one moved it
until it was moved again, as if it were made from wax. However, it is important to note that although waxy flexibility has
historically been linked to schizophrenia, there are also other disorders which it may be associated with, for example,
mood disorder with catatonic behavior.

• Word Salad - is a "confused or unintelligible mixture of seemingly random words and phrases", most often used to
describe a symptom of a mental disorder. The words may or may not be grammatically correct, but the meaning is
hopelessly confused.

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