Module 6 - Thought Disorders / Schizophrenia Flashcards
Thought Disorders
Serious and persistent mental illnesses of disorganized thought and speech
What things characterize Thought Disorders?
Disturbances in:
- Reality Orientation
- Thinking
- Social Involvement
What is the most prevalent thought disorder?
Schizophrenia
Most people with mental health problems are able to …
think logically, even when their behaviors are maladaptive
Psychosis
the inability to recognize reality, relate to other, and cope with life’s demands
reality is distorted and disturbed for psychosis
What is the most common form of psychosis
Schizophrenia - Identified as Schizophrenia Spectrum Disorders
Schizophrenia
“Splitting Off” of thoughts from emotions - “disconnected mind”
They lose the ability to think and respond in a logical fashion - very debilitating
There is a lack of coherence in mental functioning, thinking, feeling, perceiving, behaving, and experiencing without the linkages that make mental life comprehensible and effective
General Signs and Symptoms of Schizophrenia
Disturbed thinking
Preoccupation with frightening inner experiences
Marked disturbance in affect, behavior, and social interaction
How is Affect, Behavior, and Social interaction markedly disturbed by Schizophrenia?
Affect - Flat, Inappropriate
Behavior - unpredictable, bizarre
Social Interaction - Isolation
Is schizophrenia a dissociative disorder?
No, do not confuse it with multiple personalities
How many Americans are afflicted with schizophrenia
2.5 million
Schizophrenia is a result of …
complex genetic influences interacting with environmental factors
What is the major symptom of Schizophrenia
Altered sensory perception!
- Physical and psychological changes that affect brain functioning, behavior patterns, and the five senses
- Hallucinations can occur in any of the senses
When do schizophrenia symptoms begin to occur?
symptoms emerge during late adolescence to early 20’s
Has been diagnosed as early as 5 and as late in the 40s
What is the incidence and prevalence of Schizophrenia like among different people?
All cultures, races, and social classes are impacted
Disproportionately high in low socioeconomic class
The earlier the schizophrenia onset …
the greater the problems
What is the most expensive chronic illness to treat?
Schizophrenia (55.1 billion)
Costs in terms of ___ and ___ cannot be measured
distress and suffering
What is the etiology of Schizophrenia?
EXACT CAUSE UNKNOWN, it is a potential mix of:
Abnormalities that arise early in life, could be before birth that disrupt normal brain development
psychosocial theories
genetics
unbalanced neurobiological processes and neuroanatomical structures
brain development
substance abuse/dual diagnosis
stress
How long must schizophrenia symptoms last for diagnosis?
at least 6 months
They must include at least 1 month of two or more active phase symptoms
What is the key hallmark of schizophrenia?
Lack of Insight (do not realize they have the issues or symptoms)
Symptoms Symptoms of Schizophrenia
bizarre delusions
hallucinations
disorganized speech
grossly disorganized or catatonic behavior
negative behavior
other symptoms that interfere markedly in social and occupational functioning
LACK OF INSIGHT - v common
Closely Related Disorders to Schizophrenia
Brief Psychotic Disorder
Schizophreniform Disorder
Schizoaffective Disorders
Schizotypal Personality Disorder
What makes a brief psychotic disorder different from schizophrenia?
It only lasts 1-30 days
Schizophreniform Disorder
S/S last 1-6 months. (psychotic symptoms)
It can then progress to mania or schizophrenia
Schizoaffective Disorder
presence of mood S/S of depression or mania with Schizophrenia s/s as well
Schizotypal Personality
S/S not severe enough to be classified as psychosis
DSM V now includes this within the schizophrenia spectrum
3 Dimensions of Psychopathology in Schizophrenia
- Disorganization
- Psychotic (Positive Symptoms)
- Negative Symptoms
What things are disorganized in schizophrenia?
speech
behavior
incongruent affect
What are some Psychotic symptoms/dimensions of Schizophrenia?
Delusions and hallucinations
Positive symptoms - distortion or excess of normal functioning - often the initial symptoms
What are some Negative symptoms/dimensions of Schizophrenia:
loss of or lack of normal functioning - tend to develop over time:
alogia
affective blunting
avolition
anhedonia
attentional impairment
Alogia
lack of speech / poverty of speech (from disrupted thought process often)
Avolition
total lack of motivation that makes it hard to get anything done
What are some Bizarre and Disorganized Speech/Thought Patterns in Schizophrenia
loos associations
perseveration
clanging
neologisms
thought blocking
distractibility
word salad
Loose Associations
Absence of normal connectedness of thoughts ideas and topics - you’ll see sudden shifts in thoughts and topics with no connection
Perseveration
Stays on one topic and it is very hard for them to come off that topic
Clanging
repetition of words or phrases that sound similar, but they may rhyme, but they do not make sense
ex: My back likes to pat a rat
Neologisms
makes up own meaning for words
Thought Blocking
common in practice
individual is awake and coherent but the thought process is not connecting
Word Salad
Random words are said with absolutely no connections
“Yellow 49 carpet yesterday”
What are some key components of the cognitive impairment in schizophrenia?
difficulty concentrating and remembering
inability to organize time and events
inability to plan
inability to problem solve
difficult focusing enough to read, watch TV or a movie
difficulty or instability to follow direction, requires frequent to constant cueing
inability to make decisions for self
Goals and Treatment of Schizophrenia
Pharmacology and Psychosocial interventions, skills training
Social support building
Continuity of care - everyone on the same page
Discharge planning - prevent revolving door
Safety
Stabilization - can be hard, need help
Client and family education
Physical care
What is the suicide rate like in Schizophrenia
high risk for suicide
10-15% succeed
50% attempt
What gives the highest mortality rate for schizophrenics?
accidents and medical illnesses
What kind of issues and comorbidities are common i Schizophrenia?
smoking
weight gain
type II diabetes
cardiac issues
What leads to revolving door syndrome with schizophrenia?
medication non compliance
substance abuse
What is the typical treatment for Schizophrenics
Traditional Antipsychotic Medications that primarily treat hallucinations and delusions
Can also use atypical antipsychotics, neuroleptics
Haldol
common traditional antipsychotic medication for schizophrenia
primarily treats hallucinations and delusions
What are some side effects of Traditional Antipsychotic Medications
- EPS
- Tardive Dyskinesias
Orthostatic Hypotension (fall worry)
Dry mouth
blurred vision
erectile dysfunction
constipation
breast enlargement
weight gain
agranulocytosis
What is a major life threatening issue that can occur when taking traditional antipsychotic medications?
Neuroleptic Malignant Syndrome (NMS)
Extrapyramidal Side Effects (EPS)
Akathisia
Dystonia
Chronic Motor Problems
Pseudo parkinsonian symptoms
Tardive Dyskinesia
type of extra pyramidal side effect that causes involuntary irregular movements, lip smacking, neck twisting
can occur after several months to years of treatment
The best treatment for schizophrenia is?
Prevention
What to do to treat difficult SE or adverse effects of traditional antipsychotic medications
decrease or discontinue therapy
Medications can be sedative in nature, so …
it is important to keep fall risk in mind since even young patients can fall due to this
Neuroleptic Malignant Syndrome (NMS)
an emergency condition that can be induced by an antipsychotic or other neuroleptic medication
somewhat rare in practice
high safety risk
Symptoms of NMS
muscle rigidity
hyperthermia
mental status changes
vital sign changes
diaphoresis
incontinence
tremors
elevated creatinine phosphokinase (CPK) labs
How to treat NMS
withhold further doses of antipsychotic medication and any other anticholinergic medication and notify provider
lower temperature
maintain hydration
prepare to transfer to medical unit or ICU
Atypical Antipsychotics for Schizophrenics
relieves both negative and positive symptoms
less distressing extrapyramidal side effects
Clozapine
atypical antipsychotic
used for refractory schizophrenia, 30% of the total population whom are particularly prone to violence and suicide
requires regular WBC monitoring for agranulocytosis
A life threatening condition that can occur from Atypical Antipsychotics?
Agranulocytosis
S/S of Atypical Antipsychotics
hypotension
lowered seizure threshold (HIGHER SEIZURE INCIDENCE IN AA)
sedation
elevated liver enzymes
anxiety
constipation
weight gain (can lead to metabolic syndrome)
What are some classifications of meds used to treat schizophrenia?
Traditional Antipsychotics/Neuroleptics
Atypical Antipsychotics/Neuroleptics
Medications to treat side effects and prevent side effects
How do Neuroleptics/Antipsychotics work?
They block the NTs dopamine and serotonin
S/S of psychosis appear to be from excessive activity of cells sensitive to dopamine and serotonin, so we must block these sites
Unlike with antidepressants, risk of overdose with antipsychotics is ___ …
low (even with large amounts)
Assessment of the Schizophrenic client should look at ?
SAFETY of client and others - is there a history of violence or suicidal behavior
medical history and recent medical workup
positive, negative, cognitive, mood symptoms and insight
behavior including range emotional expressiveness, sleep, recent stressors
current meds and compliance to it
chemical dependency
family response and the support system
Potential Nursing Diagnoses r/t Schizophrenia
Risk for self-directed or other-directed violence
Disturbed sensory perception
Disturbed thought processes
Impaired verbal communication
Ineffective coping
Interrupted Family Process
Social Isolation
Noncompliance with medication, treatment
It is important to reinforce ___ with schizophrenics
reality
When listening to schizophrenics speak it is important to…
understand language content, listen for themes and reflect back
watch their verbal and nonverbal cues
How should one go about intervening in hallucinations with schizophrenics?
do not argue with them, dismiss them, or ignore them
Make it clear that its not seen or heard
do not leave the client alone
draw them into reality based activities
The main 3 things to do when implementing care for someone with schizophrenia is…
- DEVELOP TRUST
- initiate interactions
- model behaviors
Interventions for Acute Phase Schizophrenia
safety
psychiatric and medical interventions
individual and group therapy
cognitive behavioral therapy (CBT)
family education
Interventions for Maintenance and Stabilization Phases
Health teaching
health promotion and maintenance
vocational rehabilitation
assertive community treatment (ACT)
intensive case management (ICM) - for housing, food, occupation
continuum of care
Activities done in inpatient milieu therapy for schizophrenics?
provide support and structure
encourage development of social skills and friendships (as well as how to do ADLs)
Safety is important with schizophrenics because there is a potential for physical violence due to …
hallucinations or delusions
What priorities for safety are least to most restrictive ?
- Verbal de escalation
- Medications
- seclusion or restraints
The most common hallucination?
Hearing voices
How to act when someone schizophrenia is having a hallucination
Approach client in nonthreatening and nonjudgmental manner
Do not challenge delusions or hallucinations
Assess if messages are suicidal or homicidal
Initiate safety measures if needed
Client is anxious, fearful, lonely, brain not processing stimuli accurately so allow time to process information, USESHORT SIMPLE EXPLANATIONS IN CONVERSATION
How to act when a client is having a delusion?
Be open, honest, matter-of-fact, and calm
Have client describe delusion
Avoid arguing about content
Interject doubt if client is able to process information
Validate the part of the delusional thoughts expressed that are real
Listen for reality based thought and steer it back toward there
How to act in regard to loose associations?
Do not pretend that you understand
Look for reoccurring topics and themes
Emphasize what is going on in the client’s environment
Involve client in simple, reality-based activities
Reinforce clear communication of needs, feelings, and thoughts
Coping Techniques to teach the Schizophrenic Client during maintenance?
Distraction (using external stimuli)
Interaction (avoid isolation)
Activity
Social involvement - tasks, games
Physical activity
Things to teach and do with the client and family regarding the client’s schizophrenia?
Educate about the illness
Develop a relapse prevention plan (prevent decomposition)
Encourage avoidance of alcohol and drugs
Learn ways to address fears and losses
Learn new ways of coping
Comply with treatment
Maintain communication with supportive people
Stay healthy by managing illness, sleep, and diet
What is the incidence and prevalence of suicide in the US and worldwide?
38,000 commit suicide annually in US, one deathe very 13.7 minutes
1 million complete suicide annually worldwide
What gender has a higher rate for committing suicide?
males
4 times more likely
What gender has a higher rate for attempting suicide?
Females
2-3x more likely to attempt
What type of person has the highest suicide risk?
White males 85+
(LGBTQ are at a very high risk as well)
Common comorbidities that attempt suicide?
severe mood disorders - particularly major depression
schizophrenia
substance abuse
borderline and antisocial personality disorders
panic disorders
Suicide
act of killing oneself
Suicidal Ideations
thoughts of injury or demise of self but without a plan
Suicidal Intent
degree to which the person intends to act on his suicidal ideations
Suicidal Threat
verbalization of an imminent self destructive action
Suicidal Gesture (Parasuicide)
acts that result in little or no injury but communicate a message of suicidal intent
Suicidal Plan
refers to organization of a time frame and method for killing oneself
Self Mutilation
causing deliberate harm to your body without intent to commit suicide
Causes tissue damage (ex: cutting) or other types of mutilation like biting nails and/or cuticles, injurious masturbation, head banging or rocking
May use scissors, razors, knives, or other sharp objects to cut or may burn self
Self mutilation is common in what population?
adolescents
Increase in self mutilation in adolescents parallels…
prevalence of depression, hostility, and anxiety
Self mutilation can be used as a …
coping mechanisms
to cope with despair, hopelessness, distress, low self esteem, and intense emotional states
Direct Patterns for Killing Oneself/ Harming Oneself
suicide
anorexia
alcohol and substance abuse
self mutilation
Indirect Patterns for Killing oneself/ Harming oneself
unsafe sexual practices
abusive relationships
dangerous sports
compulsive gambling
Medical Conditions Associated with Suicide
HIV/AIDS
Cancer
Cardiovascular Disease
Cerebrovascular Disease
Chronic Renal Failure with Dialysis
Cirrhosis
Dementia
Head Injury
Multiple Sclerosis
Epilepsy
2 Biggest Risk Factors for Suicide Attempts
- prior suicide attempts
- family history of suicide
What are some risk factors for suicide?
Prior suicide attempts
Family history of suicide
Misuse and abuse of alcohol and other drugs
Mental disorders, particular depressions and other
mood disorders
Access to lethal means
Social isolation
Chronic disability and disease
Lack of access to behavioral health care
History of child and sexual abuse
Environmental Risk Factors for Suicide
Job or financial loss
Relational or social loss
Easy access to lethal means
Local clusters of suicide that have a contagious
influence
Natural disasters
Veterans returning from war with PTSD
Sociocultural Risk Factors for Suicide
Lack of social support and sense of isolation
Stigma associated with help-seeking behavior
Barriers to accessing health care, especially mental health and substance abuse treatment
Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
Exposure to, including through the media, and influence of others who have died by suicide
Mnemonic for Suicide Warning Signs
IS PATH WARM
IS PATH WARM
Ideation
Substance Abuse
Purposelessness
Anxiety
Trapped
Hopelessness
Withdrawal
Anger
Recklessness
Mood changes
Protective Factors against suicide
Effective clinical care for mental, physical and substance use disorders
Easy access to a variety of clinical interventions and support for help-seeking
Restricted access to highly lethal means of suicide
Strong connections to family and community support
Support through ongoing medical and mental health care relationships
Skills in problem solving, conflict resolution and nonviolent handling of disputes
Cultural and religious beliefs that discourage suicide and support self preservation
ALMOST all suicidal persons…
send out clues
Clues that a suicidal person may give out ?
- Overt Statements (I wish I was dead)
- Covert Statements (You wont have to worry about me anymore)
- Non Verbal Cues - sudden brightening of mood with more energy
Asking someone if they are thinking of suicide…
WILL NOT GIVE THAT PERSON IDEAS
*there is a far greater risk of not assessing or asking
When assessing the risk for suicide, always determine what things?
- Intent to die
- severity of ideation
- availability of means
- degree of planning
Things to ask in order to assess lethality
Do you have plans for the time, place and method for suicide?
Do you own a gun or have access to firearm?
Do you have access to potentially harmful medications?
Have you imagined your funeral and how people will react to your death?
Have you “practiced” your suicide? (e.g., put the gun to your head or held the medications in your hand)?
Have you changed your will or life insurance policy or given away your possessions?
If person psychotic, assess for command hallucinations ordering him/her to kill him/her self
History of attempts
Need to complete full mental status evaluation
Suicide Related Nursing Diagnoses
Risk for suicide
Powerlessness
Hopelessness
Chronic low self-esteem
Ineffective coping
Interventions (and levels) for Suicide/Ideation
Primary - Prevention!!!
Secondary - Treat acute suicidal crisis
Tertiary - interventions with family and friends of those who have committed suicide
What sort of therapy may be beneficial to a suicidal eprson
Milieu therapy
What are some suicide precautions to enact?
- SAFETY comes first! Always act safely
- May need a staff 1:1 observation within arms reach
- Document verbalizations and behaviors every 15-30 minutes
- Carefully watch client swallow their medications
- No unsafe objects around the patient (sharp or dangerous objects)
- Remove clothing that could be used as a tourniquet (belt, stockings, etc)
Interventions regarding Counseling of Suicidal Person
Commitment to treatment statement (CTS)
No-Suicide Contract
Therapeutic communication- develop rapport
Interventions for underlying disorder
Interventions regarding Health Teaching of suicidal person
teach about underlying disorders they have
teach coping skills
teach appropriate expressions of anger
Interventions for Survivors of Completed Suicide
Ascertain how the loss has affected them
Encourage survivors to get counseling or survivor support groups
Loss of a loved one by suicide is not the same as the loss of a loved one to a physical health problem or even an accidental death - keep that in mind
What to evaluate regarding suicidal person outcomes
Development of coping alternatives
Denial of desire to commit suicide
Support system in place
What may occur when a client does commit suicide?
- can be devastating to nurses, other health professionals, and families
- feelings of guilt, helplessness, inadequacy and anger are common staff and family responses
- family may project anger on healthcare professionals
- self anger and guilt for failing to prevent suicide is common
