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Schizophrenia is a chronic and complicated mental disease with symptoms of disruptions in thought, cognition, and behaviors (Kahn & Sommer, 2015). This illness commonly has a poor prognosis and create enormous health, financial, and social stresses among patients, families, and communities. However, the pathophysiology of schizophrenia is inadequately recognized. The article by Kahn and Sommer (2015) summarized shreds of evidence from recent studies and demonstrated the disturbance of brain development, including three underlying pathomechanisms, which may contribute to cognitive decline and psychotic symptoms in the first occurrence of schizophrenia.
Pathophysiology of Schizophrenia
Intracranial volume reduction has been significantly noted in patients with schizophrenia. After the completion of brain growth around age 13, some other abnormal brain development continues, such as white and grey matter volume loss. White matter deficit is associated with genetic risk and loss of oligodendrocytes in the frontal cortex and hippocampus area. Cannabis use, medications use, and psychotic relapses can likely induce cortical thinning in frontal and temporal regions, and eventually causing decreased grey matter volume. These brain abnormalities are related to cognitive decline in the early stage of schizophrenia. These changes can cause schizophrenia by three mechanisms: dopaminergic dysregulation, hypofunction of N-methyl-D-aspartate receptor (NMDAr), and increased chronic inflammation in the brain.
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Abnormalities of brain development may lead to dopaminergic dysregulation. Raising dopamine synthesis in the striatum and release capacity can rise dopamine levels. The elevated dopamine turnover is the most widespread mechanism of schizophrenia. It may be the general terminal pathway to generate psychotic symptoms in schizophrenia. During brain development, the NMDAr has a vital role in brain maturation and the construction of learning and memory. The hypofunction of NMDAr diminishes the activation of NMDAr, which result in less effectiveness of GABA-ergic signaling. With less inhibition on the mesolimbic dopamine pathway, a strong excitatory effect performs on striatal dopamine neurons to release more dopamine that induces psychotic symptoms.
The immature brain can be more easily infected by viruses or bacteria and develop brain inflammatory status. First, anti-NMDAr antibodies produce during the inflammation. Anti-NMDAr antibodies against the NMDAr and reduce the activation of the NmDAr. Second, the alteration of tryptophan catabolism can occur during low-grade inflammation. Kynurenic acid becomes its end product and inhibits the NMDAr. Eventually, dopamine release increases through the inactivation of NMDAr and causes psychosis. Third, microglial cells are activated and produce neurotoxicity by releasing some neurotoxic matters, such as free radicals and cytokines. Activation of microglial cells also enhances the production of glutamate, which is also neurotoxic at a high level. The effect of neurotoxicity can lead to cognitive dysfunction.
Applicability of Information to the Clinical Setting
The symptoms of schizophrenia usually present in early youth to mid-twenties. The process of abnormalities has already been progressing for many years when psychotic symptoms manifest in patients. Impaired cognition can be discovered in the early stage of schizophrenia, including confusion, disorganized thoughts, and trouble in concentration. Patients with schizophrenia can also present psychosis, such as delusions, visual hallucinations, auditory hallucinations, and negative symptoms. Having a thorough awareness and knowledge about various pathological characteristics in schizophrenia, patients or their families and friends can identify the early signs and timely investigate treatments.
With technological advancements, the biological changes can be visualized through several neuroimaging devices. In the clinical settings, health providers can utilize PET and MRI to display the synthesis of dopamine, glutamine levels, and microglial cells activation. By assessing the origin and onset of illness, APRNs will be able to provide referrals and connect patients to relevant mental health facilities. APRNs will be capable of providing involuntary service as needed when patients in the acute stage and dangerous to themselves or others.
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Remarkably, most of the current antipsychotic medications are dopamine receptor blocking agents, such as Chlorpromazine and Haloperidol. However, the blockade of dopamine receptors on cholinergic interneurons can put patients in high risk of extrapyramidal side effects. Knowing NMDAr dysfunction and the inflammatory status of the brain in schizophrenia may open up new effective ways to possibly treat schizophrenia. Without requiring dopamine receptor antagonists, the potential side effects can be minimized. APRNs can explore new treatment strategies by using NMDAr activators or anti-inflammatory agents. Moreover, some GABA-ergic drugs may be used in promoting cognitive function in schizophrenia (Kahn & Sommer, 2015). APRNs can also provide education about physical exercise. Kahn and Sommer (2015) recommended that physical exercise has beneficial effects on mood, self-esteem, antipsychosis, antiinflammation, and prevention of brain volume loss.
Influence to Patient Care
This author works in an adult inpatient behavioral health unit. This author recently had a 20-year-old male patient, who was brought to the crisis response center by his family for acute psychotic behaviors and admitted to this inpatient unit under an involuntary commitment. This patient appeared to be listening to someone who was not visible, was seen laughing, yelling, and talking to himself with disorganized words. This patient sometimes also gestured, shouted angrily, and stopped shouting in mid-sentence. This patient had no eye contact when this author approached him. The family reported that this patient had increased disorganized and bizarre behaviors for weeks. This patient had not taken care of himself and dropped from college. This patient was diagnosed with schizophrenia.
With the knowledge of schizophrenia from this article, this author recognized that the patient was experiencing psychotic symptoms and cognitive deficit. By learning the multiple pathophysiological changes of schizophrenia, this author accepted the indifference and limitation of this patient. During his hospitalization, this author maintained patient safety and reduced stimuli. This author asked simple questions with a calm tone to assess whether this patient had command hallucinations, which might tell the patient to hurt himself or others. This author explained to this patient any staff changes to build a therapeutic relationship. This author provided antipsychotic medications as needed. This author also encouraged this patient to participate in community groups, art activities, and physical activities to promote self-esteem.
In the future, this author will educate coworkers and behavioral health assistants about the knowledge of possible mechanisms of schizophrenia. This author can reinforce that schizophrenia is a brain disorder to avoid the stigma of schizophrenia about the behaviors of violence and craziness. Staff will have a better perception that patients can react to music, light, voices, or color differently. The team will also understand that emphasis and patience are crucial in taking care of these patients. This author will also assist social workers and psychiatrists in involving family in the treatment plan. This author will support the family to understand this illness and provide education on different treatment strategies by using the information from this article.
A better understanding and insight of schizophrenia will be helpful for health professions in promoting care and optimizing treatment outcomes. APRNs can apply this information in comprehensive assessment, alternative diagnostic tests, and individualized treatment service in clinical practice. It will also be advantageous to share knowledge with the treatment team as well as the family to decrease the stigmas and frustrations from taking care of patients with schizophrenia.
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