Psychosis and Schizophrenia Flashcards
What is abnormal motor behaviour?
Alterations in behaviour, including bizarre and agitated behaviours. Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.
What is acute dystonia?
Acute sustained contraction of muscles, usually of the head and neck.
What are affective symptoms?
Symptoms involving emotions and their expression.
What is akathisia?
Psychomotor restlessness evident as pacing or fidgeting, sometimes pronounced and very distressing.
What is associative looseness?
Disorganized thinking, manifested as jumbled and illogical speech and impaired reasoning (also known as looseness of association).
What does schizophrenia and other realted disorders refer to?
Alterations in PERCEPTION, THOUGHT, LANGUAGE, EMOTIONS and SOCIAL BEHAVIOUR
When a person experiences significant alterations in these areas and also in their ability to determine what is real or is not real we use the term “psychotic” or “psychosis”
What are five key areas of psychotic disorders?
1) Delusions +
2) Hallucinations +
3) Disorganized Thinking and Speech +
4) Abnormal motor behaviour +
5) Negative Symptoms -
What is a negative symptom?
The absence of something that should be present but is not - for example, the ability to make decisions or to follow through on a plan.
What are some circumstances where psychosis may be present?
- Brief Psychotic Disorder: lasts at least one day but not more than a month and may only ever have one occurrence.
- Schizophreniform Disorder: lasts at least one month but less than 6 months. Often a provisional diagnosis
- Delusional Disorder: Often a chronic illness. Delusions are plausible.
- Schizoaffective Disorder: Mood symptoms present simultaneously with psychosis for the majority of illness, but not dominant x 2 weeks.
- Substance Induced Psychosis
- Psychosis due to a medical condition
What percentage of people are affected by schizophrenia?
1%
What is the age of onset of schizophrenia for males and females?
First episode 15-25 males and 25-35 females
What are common comorbidities with schizophrenia?
Substance use: in particular nicotine
Anxiety, depression, and suicide
Physical health (increased risk cardiovascular, respiratory and cancer)
Polydipsia
Psychogenic Polydipsia
What causes schizophrenia?
Exact cause unknown
Multiple factors “Diathesis - stress model of schizophrenia”
* Inherited genes + brain structure abnormalities + neurochemistry alterations + prenatal stress (infection, poor nutrition, exposure to toxins, hypoxia) + psychological stress + environmental stress
What is the importance of early detection and intervention?
- Duration of Untreated Psychosis associated with increased severity of illness and decreased level of functioning.
- Each relapse of psychotic symptoms = increased residual symptoms and decreased level of functioning.
- Although there is evidence of many people functioning at a high level alongside diagnosis of schizophrenia we must refrain from giving false hope. Must be realistic and honest.
True or false: Studies indicate that nurses and healthcare providers have a negative attitude towards people with schizophrenia.
True
What is the clinical picture of a first psychotic episode (Phase I - acute)?
Usually hospitalized
Presence of positive symptoms, affective symptoms and cognitive symptoms
Negative symptoms likely present as well.
What is a positive symptom? List examples.
- Presence of something that should not be; alterations in thinking and perception; Hallucinations, Delusions, concrete thinking
- Alterations in Speech
- Difficulties with thought processes. We know this when a patient has associative looseness, circumstantial, tangential, neologisms, echolalia, clang association, word salad
- Alterations in Behaviour
1) Catatonia (may see automatic obedience, waxy flexibility or echopraxia, echocolia)
2) Psychomotor agitation or retardation
3) Stereotyped (repeated behaviour with no purpose)
4) Negativism: active (unintentional opposite act of request, also seen with catatonia) or passive (failure to do what is requested)
What are negative symptoms?
- Take the oomph out of a person. Absence of something that should be present….our oomph! Usually take longer to develop.
- No motivation, no joy, appear blank (because experiencing alogia….who can tell me what that is and explain why that might make a person appear blank).
- These patients will lay on their bed all day every day.
- Makes it impossible to have meaningful social connections, obtain employment or develop interests.
What is alogia?
With schizophrenia, alogia involves a disruption in the thought process that leads to a lack of speech and issues with verbal fluency. For this reason, it is thought that alogia that appears as part of schizophrenia may result from disorganized semantic memory.
What are cognitive and affective symptoms?
- These are the symptoms that impede recovery.
- Concrete thinking, poor memory, poor ability to process information, impaired executive functioning which makes decision making difficult and social situations awkward.
- Unstable mood (often experience depression which INCREASES RISK OF SUICIDE).
What does recovery look like for patients with schizophrenia? (Phase II and Phase III)
- Individualized
- Some people with schizophrenia can live independently, others in a group home setting and still others in a long term hospital.
- The goal is for as much independence as possible.
- Variety of community services promote independence.
- Relapses are common, residual symptoms are common and unfortunately a decreased level of functioning is associated with every relapse.
What are treatment areas for schizophrenia?
Medication
Psycho-education (family and patient)
Community Support
Structured Routines
What is anosognosia?
Anosognosia, also called “lack of insight,” is a symptom of severe mental illness experienced by some that impairs a person’s ability to understand and perceive his or her illness. It is the single largest reason why people with schizophrenia or bipolar disorder refuse medications or do not seek treatment
Generally, what is the mode of action of first generation antipsychotics?
Prevent dopamine from activating dopamine receptors = decrease circulating dopamine
What was the downside of 1st generation antipsychotics?
These were wonder drugs…they treated symptoms such as hallucinations and delusions very effectively (positive symptoms of schizophrenia) but did not treat negative symptoms
BUT AHHH the side effects:
Two major groups of side effects
1) EPS
2) Tardive Dyskinesia
What are extrapyramidal side effects?
Dopamine plays a major role in the regulation of movement so when we inhibit it we get motor like side effects.
EPS:
1) Acute Dystonia: sustained contraction of muscles, most often in head and neck
TREATMENT: IM COGENTION OR IM BENADRYL
2) Akathisia: patients usually complain of inner restlessness, looks like pacing/fidgeting
3) Pseudoparkinsonism, looks like have parkinson’s: tremor, shuffling gait, muscle stiffening.
TREATMENT 2) and 3): PRN or regular doses of antiparkinson/anticholinergic meds such as Cogentin or Artane
What is the treatment for acute dystonia?
IM COGENTION OR IM BENADRYL
What is the treatment for akathisia or pseudoparkinsonianism?
PRN or regular doses of antiparkinson/anticholinergic meds such as Cogentin or Artane
What was the worst effect of 1st generation antipsychotics?
Tardive dyskinesia
-Irreversible
-No reliable treatment
- Affects up to 50% of individuals receiving high dose long term treatment
What does tardive dyskinesia look like?
-Facial grimacing, tongue protrusion, lip smacking, involuntary tonic muscular contractions of tongue, fingers, toes , neck, trunk or pelvis.
-Contributes to stigmatization of mental illness
What was the first 2nd gen antipsychotic and what unfortunate side effect did it produce?
- **Clozaril **introduced in early 1990’s as first second generation drug….again seen as a wonder drug. EPS and Tardive Dyskinesia risks were greatly reduced BUT still can occur.
- Acts on both positive and negative symptoms of schizophrenia and dramatic improvement was evident in many. But a major issue soon was identified: risk for agranulocytosis.
- All patients on clozaril MUST have weekly WBC tests x first 6 months and then regular monitoring. Must monitor for signs of infection. Clozaril has become a last resort 2nd generation choice when other second generation anti-psychotics are not effective.
What are first line treatments using 2ns gen antipsychotics?
- Risperidone (risperidal)
-Lurasidone (latuda)
-Olanzapine (Zyprexa)
-Quetiapine (Seroquel) - Ziprasidone (zeldox)
What are common Side Effects of 1st Generation and to a lesser degree 2nd Generation?
- Weight gain**
- Sexual dysfunction
- Sedation**
- Orthostatic hypotension
-Lower seizure threshold - stiffness (cogwheel rigidity)
- Anticholingeric effects: dry mouth, blurred vision, constipation, urinary retention, tachycardia
