Psych Disorders, Schizophrenia Flashcards
Psychosis
-Thought disorder which reality is Grossly impaired
-May be evidenced by symptoms of hallucinations delusions, disorganized thinking, disorganization of personality, deterioration of reality and bizarre behaviors
-Can be a sole diagnosis (NOS)
Hallucination
Alterations to the sensory system (5 senses)
-Command hallucinations can be harmful
Delusion
Alterations to their thought process
Biological factors contributing to schizophrenias
-Genetic
-Psychological
-Environmental
-Brain structure abnormalities (Holes in the brain)
-Neurobiological
Genetic contributions to Schizophrenia
-50% risk if both parents have it
-Sibling puts you at a 10% risk
-Essentially there is a strong genetic component in schizophrenia
Differences in sex and schizophrenia
-Male: Earlier onset (18-25 yrs), With More structural differences, prevalent Negative symptoms
-Female: Later onset (25-35yrs) with less structural differences, leading to better outcomes. Rare that symptoms occur before 19
Stigma of psych disorders
-Struggles to get insurance coverage
-Substance abuse, high prevalence of substance use (Self medication), complicates diagnosis and medications (Interactions with meds)
-A majority of people with schizophrenia smoke nicotine
Losses that occur with schizophrenia
-Schizophrenia is diagnosed usually after 18, and you can lose alot of your life with it
-Such as your role and routines, former friends/relationships, sense of self, Sense of belonging in society
Psych disorders
-Delusional disorder
-Brief psych disorder (Only for like a day)
-Schizophreniform disorder: similar to schizophrenia but its duration is usually 1-6 mo when schizophrenia is 6 mo+
-Schizoaffective disorder: Schizophrenia + Mania, hard to treat
-Substance/medication induced psychotic disorder
Comorbidities with psych disorders
-Substance use disorders
-Anxiety
-Depression
-Suicide: High prevalence of attempts and successes
-Psych polydipsia: Drink so much it causes severe hyponatremia
Medical conditions that can cause acute psychosis
-Alc withdrawal
-Huntington’s disease
-Hypo/hyper thyroidism
-Hypoglycemia
-Ca imbalances
-Temporal lobe epilepsy
-Wilson’s disease
-CNS neoplasms
-Encephalitis
-Meningitis
-Neurosyphilis (Stage 3 goes to brain)
-Stroke
-Hepatic encephalopathy
-DKA
-Vitamin B-12
Course of the disorder, schizophrenia
-Prodromal
-Acute psychosis
-Residual stage
Schizophrenia course: Prodromal
Stage of early change, precursor to the disorder
-Can begin in childhood
-Early recognition, early treatment
Schizophrenia course: Active Psychosis
-Acute psychotic phase
-Can be hospitalized
-Hallucinations and delusions
-Aggressive treatment find out the cause
Schizophrenia course: Residual
-Post acute psychosis
-Decrease in positive signs (Hallucination/delusions)
-More negative symptoms remain (Flat affect, impaired role functioning)
-Residual impairment increases after each episode of psychosis (It becomes harder and harder to bounce back to what you were)
Schizophrenia prognosis
-Difficult to predict
-Uncommon for people to return to full functioning
-Identify factors that lead to positive outcomes
Factors that lead to positive outcomes schizophrenia
-Early recognition (Early treatment)
-Female gender (Less brain degeneration)
-Abrupt onset of symptoms with obvious precipitating factors
-Rapid resolution of active phase symptoms
-Absence of structural brain abnormalities
-Normal neuro functioning
-No family history of schizophrenia
Factors that lead to negative outcomes schizophrenia
-Chronic medical conditions
-Substance abuse
-Stress
-Frequency and intensity of episodes (Long and often)
-Social deficits
Schizophrenia and suicide
They commit at high rates, comorbid mental disorders, younger people are more likely, Females are more likely
Schizophrenia symptoms: Related to speech
-Echolalia
-Circumstantiality
-Word salad
-Neologism
-Clang association
-Metonymic speech
-Stilted language
-Pressured speech
Echoloalia
-repetition of another person’s for no reason
Circumstantiality
Can’t stay on track, gives useless details before arriving at the point
Word salad
They say words in a sentence in a random order in a sentence that doesnt make sense
Neologism
Making up words that only have meaning to them
Clang association
Rhyming words for no reason
Metonymic speech
Using words with similar meanings interchangeably
Stilted language
Words that are excessively formal, stilted as in high up and fancy
Pressured speech
Speaking so fast, not letting you get a word in
Interventions for alterations in speech
-Explain how their behavior can disturb others
-Anticipate their needs
-Orientate them to reality, call them by their name
-Be concrete in speech (direct)
-Avoid abstractions,phrases, cliche jokes
Schizophrenia: Alterations in thinking
-Loose associations
-Tangentiality
-Flight of ideas
-Paranoia
-Referential
-Autistic thinking
-Concrete
-Verbigeration
Loose associations
Cant connect the dots between things
Tangentiality
Perpetual tangent
-Mind doesnt let them get to the point
Flight of ideas
-Spitballing
-Babbling
Paranoia
Thinks there might be people after them
Irrational fear
Referential
-Feels like something that doesnt affect them at all is being directed at them
-Watching the news and thinks they are speaking directly to them
Autistic thinking/ Concrete
-Very literal
-Black and white
-Cant understand metaphors
Verbigeration
Repetition of words that don’t serve a purpose
-Example: dog cat ate car work
Schizophrenia symptoms, Alterations in perception
-DePersonalization
-Hallucinations: Perception with no external stimuli
-Illusions
-Derealization
Depersonalization
-Loss of self or identity
-Illusions
Misinterpretation of real experience
Derealization
False perception environment has changed
Schizophrenia symptoms: Alterations in behaviors 1
-Bizarre behavior stupor
-Stereotyped behavior
-Automatic obedience
-Waxy flexibility
-Extreme motor agitation
-Negativism
-Lack of impulse control
Waxy flexibility
-It you put the pt in a position, like stick their arm up, they will believe they are unable to move it, even if the are physically capable
-Kinda ties into the automatic obedience
Lack of impulse control
May result in agitated behaviors such as the pt abruptly taking the TV remote and changing channels
-Stealing the remote or something
Schizophrenia symptoms: Alterations in behaviors 2
-Aggression
-Agitation
-Catatonia
-Catatonic excitement
-Echopraxia
-Regressed behavior
-Stereotypy
-Hypervigilance
Catatonia
-Disruption of a person’s awareness to the world around them, described as being in a stupor
Catatonic Excitement
-Prolonged periods of psychomotor agitation
-Purposeless movements
-Grimacing
Echopraxia
Involuntary copying of someone else behavior
Hypervigilance
Expecting something to go down at any time even with no indication
Types of delusions
-Persecution
-Ideas of reference
-Grandiose
-Erotomaniac
-Somatic
-Thought insertion
-Thought broadcasting
-Delusions of being controlled
-Nihilistic delusion
-Paranoia
-Magical thinking
Types of delusions: Persecution
Someone is after you
Types of delusions Ideas of reference
Making a trivial event that doesnt really affect you into a huge deal all about you
Types of delusions: Grandiose
Feeling as if they are special, having powers, wealthy or identity
Types of delusions: Erotomaniac
Everyone loves you and wants to get with you
Types of delusions: Somatic
Believes they are experiencing a medical condition, when its really in their head
-Example is they believe they have TMJ but its just a delusion
Types of delusions: Thought insertion
Aliens are in their head
Types of delusions: Thought broadcasting
-Their thoughts can be heard by someone else
-Thinks you are reading their mind
Types of delusions: Delusions of being controlled
Feels like they are being controlled by another entity
Types of delusions: Nihilistic delusion
-Feels like they are invisible, not human, or dead
Types of delusions: Magical thinking
Think they have control over the situation
Interventions for delusions
-Never argue or agree with delusions
-Acknowledge feelings
-Respond calm and matter fact
- ** Dont touch a paranoid person (or generally dont touch people) **
-Be aware of your verbal and non verbal gestures
-Be honest
-Take a neutral stance and change topic to something neutral
-Interject doubt when appropriate, don’t interrupt them
-Observe events that Trigger delusions
-Distract them from delusions and focus on reality
Negative symptoms of Schizophrenia
Negative symptoms mean taking away, or they are less than the normal
-Diminished emotions (Blunted affect)
-Avolition (Lack of motivation)
-Alogia (Dont speak much)
-Anhedonia
-Asociality
Positive symptoms of schizophrenia
-Hallucinations
-Delusions
(Disorganized speech, Bizarre behaviors)
More receptive to meds
Types of hallucinations
False sensory perceptions that are not involved with any external stimuli
-Auditory
-Visual
-OlFactory
-Gustatory
-Tactile
Command Hallucinations
Can indicate a psych emergency (risk of suicide or harming others)
-May be at risk of violence
-Must be assessed
-Can be terrifying for the individual
-Can have multiple voices with personalities and gender
-Can be at greater risk if you give identity to the voice
Interventions for hallucinations
-Ask pt what they are seeing, reorientate as much as possible
-Assess for command hallucinations: ask directly are the voices telling you to hurt yourself or others
-never react to the hallucinations as if they are real
-Observe S+S that the pt might be hallucinating
-Offer support without being negative to the pt
-Dont touch the pt
-Distraction from the hallucination
-Be aware of the increasing anxiety of the pt
-Be Calm
-Assess suicide risk
-Low stim environment
-Observe behaviors frequently
Hallucination assessment
-Is it substance induced
-Command hallucinations
-Belief system (Need cultural considerations)
-Co-occurring disorders
-Current meds, adherence?
-Family understanding
-Support systems
Treatment/ team and community approach
-Therapy, group allegiance
-Social skills training
-Behavioral therapy, family therapy
-Psych meds
-Health teaching
-Mileu
-INstill hope
-Social support
-Have collaboration between Primary and Psych team
** family needs to be included**
Antipsychotic meds
-Help with symptoms of schizophrenia but do NOT cure
-Psych symptoms return with med non-adherance
Antipsych meds are effective in
-Acute exacerbation of schizophrenia
-Preventing or mitigating a relapse
First gen antipsych meds target
-Positive symptoms only
-Lots of EPS
Second gen antipsych meds target
Positive and negative symptoms
-Have fewer motor side effects
-Treat anxiety depression and decrease suicidal behavior
Typical antipsych MOA
Blocking postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system , brainstem and medulla
-More dopamine available
Also high affinity for cholinergic, alpha 1 adrenergic and histamine
-Sedative effects
Minimize anticholinergic effect of antipsych
-Chew sugarless gum, food high in fiber, eat and drink 2-3 L a day
Postural hypotension and antipsych
High incidence, need to get up and down slowly to minimize the effects
Adverse effects of antipsych drugs
Main thing is the postural hypotension
-Anticholinergic effects
-EPS
Typical antipsych, drugs
-Haloperidol (Haldol)
-Chlorpromazine (Thorazine)
-Fluphenazine (Prolixin)
Extrapyramidal symptoms (EPS)
-Caused by dopamine blockage
-Acute dystonia
-Pseudo parkinsonism
-Akathisia
-Tardive dyskinesia
EPS: Acute dystonia
-Painful muscle spasms of tongue jaw, face or neck
-Scary for pt
-Quick onset, hours to days after taking antipsych
-More often in young males
Includes opisthotonos , oculogyric crisis, torticollis
Opisthotonos
-Tetanic spasm which head and heels are bent back and the body forwards
-Symptom of acute dystonia
Oculogyric crisis
Eyes are fixed upwards
-Symptom of acute dystonia
Torticollis
Spasm of the neck which forces the head to one side, and the chin is pointed to opposite side
Acute dystonia mgmt
Benadryl 25-50 mg stat, instant relief
EPS: Pseudo parkinsonism
-All the symptoms of parkinson, Pill rolling, mask face, shuffling gait
-Slowed down (Bradykinesia)
-Cogwheeling
-Appears early into drug therapy
-Too little dopamine and too much Ach
-Tremors
Pseudo parkinsonism mgmt
-Anticholinergics like Artane or cogentin or dopamine agonist, or lower dose of antipsych
EPS: Akathisia
-Inner restlessness, or inability to sit still. Compulsion to walk
-Feels distressful, not in their control
-Schizophrenia symptom as well as drug
Akathisia mgmt
-Propranolol or ativan
-May need finger foods
EPS: Tardive dyskinesia
-Occurs after prolonged treatment
-Irreversible if not caught early
-Involuntary muscle spasms (Tongue, mouth, fingers, toes, pelvis. trunk)
-Affects 1/2 of people in long term anti psych meds
-AIMS scale for worsening symptoms
-Anticholinergics can make it worse
Early signs and symptoms of tardive dyskinesia
-Lip smacking and tongue movements
Mgmt of EPS
-Catch it early to minimize
Treatment includes
-Lowering the dose
-Giving parkinson’s drugs (Anticholinergics)
-Only 2 at a time, too many drugs can make TD worse
Med mgmt of EPS
-Trihexyphenidyl (Artane)
-Benztropine Mesylate (Cogentin)
-Diphenhydramine hydrochloride (Benadryl)
-Amantadine hydrochloride (Symmetrel)
Atypical antipsychotics
-Risperidone (Risperdal)
-Quetiapine (Seroquel)
-Olanzapine (Zyprexa)
-Zapine (Zyprexa)
-Clozapine (Clozaril)
-Paliperidone (Invega)
Ziprasidone (Geodon)
Only third generation antipsych
Aripiprazole (Abilify)
Clozapine
-Clozaril (Brand name)
-Used in more treatment resistant cases
-Not first line due to severe adverse reactions
-Agranulocytosis
Severe reduction in WBC count, neutropenia
Rare but fatal
S+S are a sore throat fever malaise and mouth sores
Any flu like S+S should be reported to the provider
Benefits of second gen (Atypical) antipsych
-Fewer SE, better tolerated
-Helps with negative symptoms
-Decreases Suicidal ideation
-Improves neurocognitive functioning
-May cause weight gain tho
Minimal EPS
Negative of Second gen (Atypical ) antipsychotics
-May cause weight gain due to abnormal metabolism of glucose
-Anticholinergic SE
-Monitor weight, BMI, Glucose (Metabolic syndrome)
-Sexual dysfunction
-Very expensive
Metabolic syndrome
-Associated with atypical anti psych with metabolic disruption
-Need 3/5
-Weight gain
-Type 2 diabetes
-Increased LDL
-Decreased HDL
-Elevated triglycerides
Can lead to DKA
Neuroleptic Malignant Syndrome
-Rare medical emergency with Atypical anti psych
-Possibly caused by a acute reduction in DA
S+S
-Hyperthermia
-Muscle rigidity
-Tremors
-Fluctuating BP
-Altered consciousness
Antipsych meds education
-Dont drive when drowsy
-Dont abruptly discontinue, you can have withdrawal
-Photosensitivity
-Get blood work if needed
-Report flu like symptoms, Unusual bleeding, bruising, N+V, HA, rapid HR, difficulty urinating, muscle twitching or tremors, dark urine, excessive urination, polyphagia polyphagia, jaundice, skin rash
-Orthostatic hypotension precautions
-Sugarless gum for anticholinergics
-Good oral care
-Avoid alc and drugs
-Take meds even if you feel fine
