Chapter 12- schizophrenia and SCH spectrum disorder

Question 1

Psychotic Disorders other than SCH?

Answer 1

1. Delusional Disorder
   
   1. Altered thought process
2. Brief Psychotic Disorder
   
   1. Iv fluids, dehydration
3. Substance—Induced Psychotic Disorder
   
   1. Drugs
4. Psychosis or Catatonia Associated with another medical condition
   
   1. neurological conditon
5. Schizoaffective Disorder
   
   1. MDD and schizophrenia go together
6. Psychotic or Catatonic Disorder not otherwise
   
   1. neurological specified
      specified clearly and explicitly stated More (Definitions, Synonyms, Translation)

Question 2

Schizophrenia is?

Answer 2

• SCH is a spectrum of disorders with a broad range of symptoms
• It is a severe, disabling thought disorder of the brain (disconnected mind)
  
  • A psychotic disorder where behavior, thinking, feeling and perceiving are disorganized
  • Inability to distinguish reality from fantasy
• DSM-5 criteria: Continuous signs of disturbance exist for at least 6 months.

Question 3

SCH Epidemiology and onset?

Answer 3

• No difference in incidence of SCH related to:
  
  • Race
  • Social status
  • Culture
• Onset—most often occurs in late teens or early twenties.
  
  • Males often earlier onset Individuals have more physical illness and die on average 28 years prematurely than general population

Question 4

Comorbidity of SCH?

Answer 4

1. Substance abuse disorders (Dual DX) – 50% (Nicotine use 70-90%)
2. Anxiety, depression
3. Suicide—10% commit suicide (rate is 8.5x higher than general population).
4. Obsessions and Compulsions
5. Polydipsia (excessive thirst in 20%)
6. Alzheimer’s with late onset SCH >50

Question 5

Etiology of Schizophrenia?

Answer 5

1. . Genetics
   
   1. 1st degree relative increases risk to 10%
   2. Concordance rates in twins is 50% if identical twins and 15% if fraternal twins
   3. Genetics role in SCH is estimated at 65-80%.
2. Neurobiological
   
   1. Excess Dopamine in brain theory**** med we give to SCH to decrease dopamine
      
      1. Possible role of Serotonin, glunmate
   2. *Structure abnormalities, CT scan.

Question 6

Psychological and Environmental Factors?

Answer 6

1. Prenatal Stressors
   
   1. poor nutrition,
   2. Hypoxia,
   3. virus when mom was preg.
2. Psychological Stressors
   
   1. Stress increases cortisol which impedes hypothalamus development
3. Environmental Stressors
   
   1. Toxins, in water too.

Question 7

Positive Symptoms in SCH?

Answer 7

Presence of something not normally present

1. Alterations in thinking
   
   1. Delusions − False, fixed beliefs that are not corrected by reasoning (75% of people with SCH experience at some point) .
   2. Concrete thinking − Inability to think abstractly, no metaphors
2. Alterations in speech/thoughts − Associative looseness
   1. Clang associations “clock, dock, dirt, flirt”
   2. Word salad—a jumble of meaningless words
   3. Neologisms—made up words
   4. Echolalia—continuous repeating of an another word
3. Other disorders of thought or speech (cont.)
   
   1. Flight of ideas
   2. Thought blocking
   3. Thought insertion
   4. Thought deletion
4. Alterations in perception
   
   1. Depersonalization—body parts do not belong to them
   2. Derealization—false perception that surroundings have changed
   3. Illusions
   4. Ideas of reference or delusion on one selfs
   5. Hallucinations—
      
      1. Auditory –hearing voices or sounds (most common type; 60% of people with disorder will hear voices)
      2. Command
      3. Visual
5. Movement disorders may appear as agitated (restless, disconnected) body movements.
   
   1. A person with a movement disorder may repeat certain motions over an over. In the other extreme, a person may become catatonic (rare).

Question 8

Negative Symptoms of SCH?

Answer 8

Absence of something that should be present

1. Poorer Prognosis with Negative Symptoms
   
   1. Avolition/Anergia - lack of energy
   2. Affect—Flat or immobile facial expression Blunted or minimal emotional response
   3. Anhedonia - lack of pleasure
   4. Alogia—poverty of thought and content of speech
   5. Ambivalence cant make decisions by themselves
2. Develop slowly and most impede the ability to cope
3. Contribute to poor social functioning, grooming, withdrawal
4. During the acute phase are difficult to access

Question 9

Cognitive Symptoms SCH?

Answer 9

Poor executive functioning- be specific

People with Schizophrenia have difficulty with:

• Attention
• Memory
• Poor problem solving
• Poor decision making
• Illogical thinking
• Impaired judgment

Question 10

Assessment Guidelines SCH?

Answer 10

1. Medical problems b/c they dont notice dx.
2. Abuse of or dependence on alcohol or drugs (Dual Diagnosis) Marijuana
3. Risk of harm to self or others
4. Command hallucinations - audiory
5. Belief system/Delusions
6. Suicide risk (review history)
7. Ability to ensure self-safety
8. Medications, compliant with meds
9. Mental Status Examination
10. Patient’s insight into illness
11. Family’s knowledge of patient’s illness and symptoms

Question 11

Potential Nursing Diagnoses for SCH?

Answer 11

1. Positive symptoms
   
   1. Disturbed sensory perception
   2. Risk for self-directed or other-directed violence
   3. Disturbed thought processes
2. Negative symptoms
   
   1. Social isolation
   2. Chronic low self-esteem
   3. Self-care deficit
3. Family
   
   1. Impaired family coping
   2. Risk for and Caregiver role strain

Question 12

Outcomes for SCH?

Answer 12

1. Patient safety and medical stabilization
2. Help patient understand illness and treatment
3. Stabilize medications
4. Control or cope with symptoms
5. Maintenance
   
   1. Prevent relapse
   2. Achieve independence, acceptable quality of life

Question 13

Interventions of SCH?

Answer 13

1. Psychopharmacology
2. Counseling and communication techniques
   
   1. Hallucinations
   2. Delusions
   3. Associative looseness—do not pretend you understand
   4. Health teaching and health promotion
3. Social Skills education (group)
4. Relapse Prevention Teaching
5. Family Education (National Association of Mental Illness NAMI.org)
6. Vocational Rehabilitation
7. Health Screening (minimum yearly)

Question 14

Psychobiological Interventions?

Answer 14

• Antipsychotic medications
  
  • First-generation ( older more S/e)
  • Second-generation ( focus more on)
• noncompliance b/c of s/e

Question 15

Various Side effects of Antipsychotics?

Answer 15

1. Sedation–Drowsiness ( give at night)
2. Dizziness when changing positions—orthostatic hypotension
3. Insomnia
4. Sensitivity to the sun
5. Skin rashes
6. Hyperprolactinemia (gynecomastia, >prolactin) d/c
7. Dry mouth/or increased salivation ( drink water but not to much)
8. Constipation
9. Sexual dysfunction
10. Increased appetite
11. Blurred vision

Question 16

Extrapyramidal Side Effects- EPS?

Answer 16

1. Acute dystonia
   
   1. contraction of muscle of head of trunk, dificulty in breathing, early on, mostly common 1st gen
2. Akathisia**** Can be especially disturbing to patient, restlessness.
3. Pseudoparkinsonism - slow movement
4. Tardive dyskinesia- face movement, irriversiable, chronic.

Question 17

conventional Antipsychotics-AKA Typical, First generation?

Answer 17

• Dopamine antagonists (Dopamine 2 receptor antagonists)
• Thorazine (Chlorpromazine), Haldol (Haloperidol), Loxitane (Loxapine), Prolixin (Fluphenazine)
• Target positive symptoms of schizophrenia
• Advantage
  
  • Less expensive than second generation antipsychotics
  • Some studies have shown conventional meds to be as effective as second generation meds

Question 18

Disadvantages of 1st generation Conventional/Typical Meds?

Answer 18

• Do not treat negative symptoms
• Extrapyramidal side effects (EPSs) more likely to occur
• Anticholinergic side effects- dry mouth, dry eyes, constipation may occur more often
• Weight gain, sexual dysfunction, endocrine disturbances

Question 19

second Generation Antipsychotics AKA—Atypical Antipsychotics?

Answer 19

• Considered first—line of med treatment
• Atypical antipsychotics work on serotonin receptors in addition to dopamine receptors
  
  • Treat both positive and negative symptoms
• Reduced incidence of extrapyramidal side effects (EPSs)
  
  • Disadvantages –
    
    • tendency to cause significant weight gain. Metabolic syndrome may occur more often, which increases diabetic risk factors.
    • Cost more than typical antipsychotics

Question 20

2nd gen Atypical Antipsychotics? -pine and one

Answer 20

1. Clozapine (Clozaril) – last resort
   
   1. use declining due to agranulocytosis (1-2%)
2. Risperidone (Risperdal)
3. Olanzapine (Zyprexa) highest wt. Gain
4. Quetiapine (Seroquel)
5. Ziprasidone (Geodon) Low weight gain. Patients with history of arrhythmias need EKG before beginning med and ongoing EKG monitoring
6. Paliperidone (Invega)

Question 21

Aripiprazole (Abilify)?

Answer 21

• Dopamine system stabilizer
• not effective as other 2nd gen meds
• Improves positive and negative symptoms and cognitive functioning
  
  • Little risk of EPS or tardive dyskinesia
  • Little or no weight gain

Question 22

Medications to reduce EPS?

Answer 22

• Anticholinergics: Used for parkinsonism and dystonia; may reduce akathisia (see more meds for akathisia below)
  
  • Benztropine –Cogentin
  • Trihexyphenidyl –Artane, Tritane
• Antihistamine: Used IM for rapid relief of acute dystonia
  
  • Diphenhydramine –Benadryl
• Akathisia ( restlessness): May use Inderal, Ativan, Valium

Question 23

Potentially Dangerous Responses to Antipsychotics?

Answer 23

• Neuroleptic malignant syndrome (NMS) >1% of patients. Acute reduction in dopamine is the suspected cause (excessive blockade of dopaminergic receptors) lessened consciousness, increased muscle rigidity (lead pipe), hyperpyrexia ( look for spike in fever), labile hypertension, tachycardia, diaphoresis, incontinence, drooling.
  
  • NMS occurs more often with conventional, first generation antipsychotics
    
    • NMS can also be associated with antidepressants
    • Agranulocytosis (Clozapine)
• Liver damage
• Should not be given for dementia-related psychosis. “Black box” warning of sudden heart failure, cerebral vascular events, infections (pneumonia).

Question 24

Recovery Model SCH?

Answer 24

1. Individualized and person centered
2. Self-direction
3. Empowerment
4. Holistic
5. Nonlinear
6. Strengths based
7. Peer support
8. Respect
9. Responsibility
10. Hope