Exam 2 Flashcards
Epidemiology of Psychotic Disorders
About 1% of the population
Same percent is found internationally and across cultures
75% of all mental health expenditures
High Rates of Suicides 9-13% successful, 50% attempt
Life Span is 10 years less than average
Course of Psychotic Disorders
Onset in adolescence to early adulthood
Premorbid predictive factors: deficiencies in attention, poor coordination, lack of emotional warmth, high ratio of angry, sad, and fearful expressions to joyful ones.
Phases of Psychotic Disorders
Prodromal-before any active illness
Active- florid psychosis
Residual- Impairment between active episodes
Never go back to prodromal after first episode
Pathogenesis of Psychotic Disorders
Genetics, Perinatal insult, cognitive deficits, biology (Neuroanatomy, neurotransmission)
Cognitive Deficits of Psychotic Disorders
Consistent with frontal and temporal lobe dysfunction, more predictive of outcome then symptom severity, independent of acute phase symptoms (stable), May present premorbidly, more pronounced in higher cognitive function
Mild Cognitive Impairment
15th Percentile
Perceptual Skills
Confrontation naming
Moderate Cognitive Impairment
5th Percentile
Delayed recall and immediate memory
Distracted with irrelevant information
Visual Motor Coordination
Severe Cognitive Impairment
>1st Percentile
Serial Learning
Executive function
Verbal Fluency
Working Memory
CATIE Study
Clinical Antipsychotic Trials in Intervention Effectiveness
Cognitive Impairment: Present in almost all persons with schizophrenia, associated with poor functional outcomes, predicts poor work performance, more predictive of dysfunction than positive or negative symptoms
Dopaminergic Tracks in the Brain
Mesocortical
Negative Symptoms
Cognitive Deficits
Attention Deficits
Dopaminergic Tracks in the Brain
Mesolimbic
Positive Symptoms (Hallucinations, delusions, disorganized speech, and bizarre behavior)
Dopaminergic Tracks in the Brain
Turberoinfundibular
Endocrine function
Temp Control
Sexual Arousal
Circadian Rhythms
Dopaminergic Tracks in the Brain
Nigrostriatal
EPS
Tardive Dyskinesia
NMS
Serotonin and Schizophrenia
Has modulating effect on dopamine
SGAs are combination serotonin/dopamine blocking agents
Glutamate and schizophrenia
Is the major excitatory neurotransmitter in the brain
Of the eight genes for schizophrenia, all go through the glutamate pathways
May be potential pathway to improve cognitive function
DSM Criteria for Schizophrenia
Two of the following: Delusions, Hallucinations, Disorganized speech, grossly disorganized behavior, negative symptoms
Significant decrease in functioning over significant period of time
Six months continuous disturbance and at least one acute episode
Not a mood disorder or caused by drugs
not autism
Prevalence of Psychotic Symptoms
Delusions 90%
Auditory Hallucinations 50%
Visual Hallucinations 15%
Tactile Hallucinations 5%
Level One insight about hallucinations
Hallucinations of stopped and person has full understanding of their pathological nature
Level Two Insight about Hallucinations
Hallucinations have stopped, but the person believes they were real
Level Three Insight about Hallucinations
Patient understands a contradiction between reality and hallucinations, but is unable to resolve the contradiction and may choose to keep quiet
Level Four Insight about Hallucinations
Patient talks about hallucinations as real, but does not act on them
Level Five Insight about Hallucinations
Patient accepts the hallucinations as “real” and acts accordingly
Formal Thought Disorders
Tangentiality Claging Echolalia Self-Reference Neologisms Word Approximations Derailment Incoherence Poverty of Content
Positive Symptoms of Psychotic Disorders
Hallucinations Delusions Thought Disorder Ideas of Reference Agitation Violance
Negative Symptoms of Psychotic Disorders
Blunted affect Alogia Asociality Anhedonia Avolition
What is recovery-oriented treatment?
A process of restoring or developing a positive and meaningful sense of identity apart from one’s condition and then rebuilding a life despite or within the limitations imposed by that condition
Principles of Recovery-Oriented Services
Primacy of participation Access and engagement Continuity of care Strengths-based assessment Individualized recovery planning Recovery Guides Community Mapping and development Identifying and addressing barriers to recovery
First Generation Antipsychotics (FGAs)
All have similar action and efficacy Act by blocking dopamine Vary from high potency to low potency High potency have greater risk for EPS -Haldol, Navane Low potency have greater risk of sedation and orthostatic hypotension -Thorazine, Melleril, Compazine
Second Generation Antipsychotics (SGAs or Atypicals)
First line treatment
Vary more in action than FGAs
All act on D2 - Same as FGAs
But some also act on 5HT in meso-cortical track and may have effect on negative symptoms
Lower risk of EPS
Greater risk of weight gain and metabolic syndrome
Some findings of SGAs from the CATIE study
account for 90% of the antipsychotic market in the US, In 2005 cot 10.5 billion, appear to have no greater benefit than FGAs, No difference in EPS, 3600-6000 more costly, Risk of weight gain and metabolic syndrome, Risk for TD 1-1.5%
Side Effects of Antipsychotic Drugs
Movement problems (EPS) Weight Gain Sedation Neuroleptic malignant syndrome Agranulocytosis Anti-cholinergic CNS depression Lower seizure threshold Photosensitivity Elevated prolactin levels ECG Changes Elevated LFTs Sexual Dysfunction Temp Dysregulation
Acute Dystonia
Involuntary sustained muscle contraction
- Torticollis
- Oculogyric Crisis
- Can be very frightening
- Appears early in treatment
- Treated with diphenhydramine
Akathisia
Motoric Reslessness Subjective sense of tension/restlessness Can be extremely uncomfortable Appears early to mid-treatment Difficult to treat
Parkinsonism
Muscle rigidity
Tremor
Bradykinesia
Robotic gait
Tardive Dyskinesia
Lip smacking Choreathetoid movements of limbs/trunk Appears late in treatment Can be permanent Difficult to treat Severe social disability Assessed with AIMS
Anticholinergic side effects
Dry Mouth (Dry as a bone) Blurred vision (Blind as a bat) Flushed (Hot as the sun) Memory, concentration difficulties (Mad as a hatter) Urinary retention Constipation
Neuroleptic Malignant Syndrome
Autonomic Dysregulation Delirium, progressing to lethargy, stupor, coma Muscle breakdown with increased CK Rigidity Shuffling gait Psychomotor agitation Termor Incontinence Pallor
Neuroleptic Malignant Syndrome Symptoms
Excitement Diaphoresis Rigidity Hyperthermia Tachycardia Hypertension
Primary Nursing Diagnosis for Psychotic disorders
Risk for self-harm and/or harm to others Disturbed thought process Disturbed sensory perception Impaired verbal communication Social Isolation or impaired social interaction Self-care deficit Ineffective role performance Impaired memory Anxiety Nonadherance
Nursing Interventions for acute psychotic phase
Management of hallucinations and delusions
-antipsychotic medication
Therapeutic Milieu
-Safety, structure, support, symptom management
Definition of Personality
ingrained, enduring, and habitual ways of psychological functioning that characterizes one’s style
Attitudes, perceptions, habits, emotions, and behaviors.
Traits
enduring characteristics and features of a person
Introverison vs. Extroversion
60% Inherited
States
Condition of mind or temperament
Moods, Habits
40% of our personality is learned
DSM Criteria of PD
Inner experience and behavior that deviates markedly from the expectations of an individuals culture Cognitive Distortions Affectively Interpersonal functioning Poor Impulse control
Cognitive Distortions
all things black or all things white
Ways of perceiving and interpreting self, others, and events
Common themes of all personality disorders
Adaptive inflexibility Vicious Cycles Cluelessness Pathological Problem-Solving Intense transference/counter-transference reactions
Paranoid PD
Odd/Eccentric Cluster A
A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts
Male
Paranoid PD Features
They are tense, suspicious, guarded, self-righteous, petty, and vengeful. The bear grudges and demonstrate overt acts of violence. They are controlling and easily angered. they suspect without sufficient basis that others out to exploit, harm or deceive them. Is reluctant to confide in others out of fear that the information will be used against them.
Schizoid PD
Odd/Eccentric cluster A
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts
Does not enjoy close relationships , chooses solitary activities, little interest in sexual experiences
Male
Schizoid Features
Social detachment. They have little or no desire to be with people and are typically content to live a routine, quiet life. They are self- absorbed. Lack close friends or confidants other than first-degree relatives. Shows emotional coldness, detachment or flattened affect. Almost always chooses solitary activities.
Schizotypal PD
Odd/Eccentric Cluster A
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in variety of contexts
No sex ratio
Schizotypal PD Features
They are peculiar, highly eccentric, often bizarre in thought, appearance or behavior. They may look schizophrenic but will not meet criteria. Odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms
(Superstitious beliefs, telepathic)
Antisocial PD
Emotional/Impulsive/Erratic Cluster B
There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years
Antisocial PD Features
They are pervasively dishonest, manipulative, exploitative and disloyal. They lack a well developed superego and experience little or no guilt when they break rules, violate laws, and shatter the lives of others. They are capable of experiencing intense insecurity and anxiety and tend to project their insecurity and anxiety by raising it in others. They are constantly irresponsible, lack remorse, anger and aggressiveness problems. They lie and con others for their personal profit
Male
Borderline PD
Emotional/Impulsive/Erratic Cluster B
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts
Female
Borderline PD Features
Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between idealization and devaluation. Impulsive. Chronic feelings of emptiness. Inappropriate, intense anger, or difficulty controlling anger. They crave intimacy buy sabotage relationships by childish, overly demanding, jealous, possessive and verbally and physically abusive. They have primitive defense mechanisms most notably splitting, projection, and denial, they tend to self mutilate and are at high risk for suicide
Histrionic PD
Emotional/Impulsive/Erratic Cluster B
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood, uncomfortable if he/she is not the center of attention
Female
Histrionic PD Features
Is uncomfortable when she/he is not the center of attention. Uses physical appearance to draw attention to self. Shows self dramatization, theatrically, and exaggerated expressions. They demand constant reassurance and gratification. They have rapidly changing and shallow moods. They are vain individuals who are phobic about aging. They can be talented, quick witted, beautiful, and a must at any party. they are seductive and provocative. Superficial and stormy relationships; lively.
Narcissistic PD
Emotional, Impulsive, Erratic Cluster B
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, beginning by early adulthood and present in a variety of contexts
Male
Narcissistic PD Features
They believe that they are superior to just about anybody on the planet. They demand constant adulation and special treatment from everywhere they go. They have fantasies of perfection, may be preoccupied with envy and have a need for power, wealth prestige and attention. They are sensitive to shame and embarrassment. If you work for them they will take credit for you success and blame you for their failures. They project blame onto people and circumstances outside themselves.
Avoidant PD (Anxious, fearful Cluster C)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and presents in a variety of context.
No Sex Ratio
Avoidant PD Features
They are painfully, pathologically, shy persons who long for human contact but fear being criticized or judged, they often experience fear or panic in social situations. Views self as socially inept, socially unappealing or inferior to others. Is reluctant to take risks or engage in new activities.
Dependent PD
Anxious, fearful cluster C
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of seperation, beginning by early adulthood
Female
Dependent PD Features
They see themselves as inadequate and have pervasive feelings of low self esteem and insecurity. They overcompensate of their perceived shortcomings by encouraging others to develop a strong dependency on them for emotional nurturance. They are profoundly passive and content with being in the passenger seat. They have great difficulty making everyday decisions without excessive amount of advice and reassurance. They urgently seek another relationship as a source of care and support when a close relationship ends.
Obsessive Compulsive PD Features
All about order and structure. Perfectionist and inflexible. Focus on detail. Unable to express affection; overly cold and rigid. Crippling preoccupation with trivial things. Very controlling and attend to lists and schedules. They are riddled with free floating anxiety and tend to keep this at bay by creating meticulously ordered, efficient environment. Devoted to work. Hard working and self-critical. Does not believe work is ever good enough. Judges others harshly. demands perfection from others.
Obsessive Compulsive PD
Anxious, fearful Cluster C
Male
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency beginning by early adulthood and present in variety of contexts
