Quiz #3: Schizophrenia Flashcards
Psychosis
Refers to the mental state of not being in touch with reality. Person does not realize that others are not experiencing the same things and wonders why others are not reacting in same way.
Schizophrenia
- Serious and persistent neurobiological involvement
- Can severely impair the lives of individuals, their families, and communities
- Is one form of psychotic disorders
Other forms of Schizophrenia
- Schizophreniform disorder
- Schizhoaffective disorder
- Delusional disorder
- Brief psychotic disorder
- Shared psychotic disorder
- Substance-induced psychotic disorder
Etiology of Schizophrenia
Occurs when multiple inherited gene abnormalities combine with nongenetic factors (e.g., viral infections, birth injuries, environmental stressors, prenatal malnutrition), altering the structures of the brain, affecting the brain’s neurotransmitter systems, and/or injuring the brain directly
Assessment of Schizophrenia: Positive Symptoms
Presence of something that is not normally present (e.g., hallucinations, delusions, bizarre behavior, paranoid, abnormal movements)
Assessment of Schizophrenia: Negative Symptoms
Absence of something that should be present (e.g., interest in hygiene, motivation, ability to experience pleasure)
Assessment of Schizophrenia: Cognitive Symptoms
Often subtle changes in memory, attention, or thinking
Assessment of Schizophrenia: Affective Symptoms
Symptoms involving emotions and their expression
Positive Symptoms of Schizophrenia: Alteration in Thoughts
- Delusions
- False, fixed belief, cannot be corrected by reasoning. (Grandiose, religious, nihilistic, somatic, paranoid)
- Concrete thinking (impaired ability to think abstractly)
Grandiose
fantastical belief that one is famous, omnipotent, wealthy, or otherwise very powerful (usually supernatural or sci-fi theme)
Nihilistic Belief
believe that nothing is real, including themselves
Somatic thinking
thinks body is diseased in some way (infested with parasites)
Schizophrenia: Alterations in Speech
- Associative looseness (interrupted and disjointed, illogical)
- Clang associations (words based on sound than meaning)
- Word salad (jumbled words)
- Neologisms (made up words, have meaning for client)
- Echolalia (repeating of another’s words)
Schizophrenia: Other disorders of thoughts or speech include
- Religiosity
- Magical Thinking
- Paranoia
- Circumstantiality
- Tangentiality
- Cognitive Retardation
- Alogia
- Rapid pressured speech
- Flights of Ideas
- Thought blocking
- Thought insertion
- Thought deletion
- Illogical or bizarre thinking
- Inability to maintain attention
Religiosity
Preoccupation of religious themes
Magical thinking
Thoughts or actions can control others
Circumstantiality
Unnecessary details in conversation
Tangentiality
Going around the bush, leaving the main topic
Cognitive retardation
Slow pace of thinking
Alogia
Poverty of speech, lack of comments
Though blocking
Abrupt stopping
Thought insertion
Ones thought is not ones own and has been inserted
Thought deletion
Ones thought is taken
Depersonalization
One’s thoughts/feelings seem unreal or not to belong to oneself
Derealization
External world seems unreal or change
Hallucinations
(No external stimuli)
- Auditory
- Command
- Visual
- Olfactory
- Tactile
- Command Hallucination
Positive Symptoms of Schizophrenia: Alterations in Behavior
- Motor agitation
- Echopraxia
- Meaningless repetition or imitation of the movements of others
- Echolalia (Involuntary parrotlike repitition (echoing) of a word or phrase just spoken by another person; Especially seen in catatonia)
- Impaired impulse control
- Gesturing or posturing – assuming unuasual posture or position
- Boundary impairment
Negative Symptoms of Schizophrenia
- Affect (blank, blunted, inappropriate bizarre)
- Alogia (poverty of speech)
- Avolition
- Anhedonia
- Attentional deficit
Avolition
Decreased motivation to perform self-directed purposeful activities
Anhedonia
Inability to feel pleasure
Cognitive Symptoms of Schizophrenia: Person will have difficulty with
- Attention
- Memory
- Information processing
- Cognitive flexibility
- Executive functions (decision making, judgement, planning and problem solving)
Cognitive flexibility
Concrete, rather than abstract thinking, characterizes schizophrenia (especially during acute episode)
Executive functions
Lack of insight is one of the greatest problems – patients generally don’t believe that they are ill or different in any way
Affective symptoms include
- Dysphoria
- Suicidal
- Hopelessness
Assessment Guidelines for Schizophrenia
- Any medical problems
- Abuse of or dependence on alcohol or drugs
- Risk to self or others
- Command hallucinations
- Delusions
- Suicide risk
- Ability to ensure self-safety
- Medications
- Mental status examination
- Patient’s insight into illness
- Family’s knowledge of patient’s illness and symptoms
Nursing Diagnosis for Positive Symptoms of Schizophrenia
- Disturbed sensory perception
- Risk for self-directed or other-directed violence
- Impaired verbal communication
Nursing Diagnosis for Negative Symptoms of Schizophrenia
- Social isolation
* Chronic low self-esteem
Schizophrenia Outcomes: Acute
Patient safety and stabilization
Outcomes: Stabilization
- Help patient understand the illness and treatment
- Become stabilized on medications
- Control or cope with symptoms
Outcomes of Schizophrenia: Maintenance
- Maintaining achievement
- Adhering to treatment Preventing relapse
- Achieving independence and satisfactory quality of life
Schizophrenia: Patient Safety
- Patients may accidentally harm themselves because of impaired judgment or as a response to their hallucinations or delusions
- Patients often have difficulty distinguishing between people who are trying to help them and those who they believe want to harm them
- Patients should not feel threatened, belittled, anxious, ignored, rejected, or controlled by staff
- Should resist touching patient during acute phase
Communication Techniques: Delusions
- Requires developing trust. (More readily accomplished through nonverbal communication; approach with calmness and empathy)
- Once trust is established, use clear, direct and simple statements.
- With insight into the illness and symptoms, the patient can differentiate experiences with delusions from those that are reality based.
- Do not reinforce the delusion.
- Do not attempt to prove the person is wrong
- Listen to the delusion and identify emotional components of the delusion (underlying feelings rather than the illogical nature of the delusion)
- Observe for evidence of concrete thinking (is patient taking you literally)
- Promote the patient’s ability to reality test
- Promote distraction to stop focusing on the delusion
Managing Delusions (in laymen terms)
- Do not try and understand the content of delusions – they are delusions!
- Do not reinforce the delusions or ask a lot of questions about the content of the delusions
- Do not try and make the patient see that their delusions are wrong – to them, their delusion is real!
- You can listen to them and identify the underlying feelings
- You can question them about the feelings… “You sound angry” or “You sound sad”
- Determine if the patient can still tell reality from delusions
- If not, the patient may potentially make a decision based on delusions and not based on reality
- Still to need to assess safety! Is the patient responding to the delusions? Ex: Mass murders responding to the “devil”; post-partum psychosis
- Redirect the conversation, especially if the delusion is upsetting the patient
Goal of Communication Techniques for Hallucinations
- Goal is to help them increase awareness of these symptoms so they can distinguish between the world of psychosis and the world of reality experienced by others with schizophrenia
- Goal is facilitative communication
Communication Techniques: Hallucinations
- Nurses need to be able to talk to the person about their hallucinations
- Honest, genuineness, and openness are the foundation for effective communication during hallucinations
- Establish a trusting interpersonal relationship
- Assess for hallucinations
- Identify whether drugs or alcohol have been used
- If asked, point out simply that you are not experiencing the same stimuli
- Help the patient describe and compare current and past hallucinations
• Determine the impact of the patient’s symptoms on ADLs
Assessing Hallucinations:
- Assess for cues of hallucinating, such as “tracking”
- “Do you ever see or hear things that others do not see or hear?”
- May need to give examples
- “What are you hearing?”
- “What are you seeing?”
- Assess if they are command hallucinations
- These tell the patient to take some specific action, such as to kill oneself or harm another (remember, safety is always priority!)
Psychopharmacology: Typical Antipsychotics
- 1st generation
- Predominantly are dopamine antagonists
- Targets positive symptoms
Side effects of typical antipsychotics to treat Schizophrenia
- Extrapyramidal Symptoms (EPS)
- Tardive Dyskinesia
- Neuroleptic Malignant Syndrome
- Weight gain, sexual dysfunction, endocrine disturbances
Schizophrenia Psychopharmacology: Atypical Antipsychotics (2nd generation)
- Blocking effects at the dopamine and serotonin postsynaptic receptors
- Targets positive and negative symptoms
- First-line
- Minimal risk of EPS
Side effects of atypical antipsychotics used to treat schizophrenia
- Metabolic Syndrome (weight gain, diabetes, dyslipidemia)
* Sedation
Atypical Antipsychotics include
- Arpiprazole (Abilify)
- Clozapine (Clozaril)
- Lurasidone (Latuda)
- Olanzapine (Zyprexa)
- Paliperidone (Invega)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- Ziprasidone (Geodon)
Typical Antipsychotics include
- Chlorpromazine *(Thorazine)
- Loxapine (Loxitane)
- Molindone (Moban)
- Perphenazine (Trilafon)
- Thiothixene (Navene)
- Fluphenazine (Proloxin)*
- Haloperidol (Haldol)*
Extrapyramidal Symptoms include
- Parkinsonism
- Akathisia
- Dystonia
- Tardive Dyskinesia (late, bad movement)
- Restlessness
- Sudden and painful muscle stiffness
- Others
Treating EPS
- May reduce dosage of antipsychotic initially
- Anticholinergics: Benztropine (Cogentin)* - Most common!
- Antihistamine: Diphenhydramine (Benadryl)
- Dopamine Agonist: Amantadine (Symmetrel)
- Benzodiazepines: Diazepam (Valium), Lorazepam (Ativan), Clonazepam (Klonopin)
Neuroleptic Malignant Syndrome
Potentially lethal side effect of antipsychotic medication that requires emergency treatment
Neuroleptic Malignant Syndrome: Symptoms
- Hyperthermia*
- Muscle Rigidity
- Tremors
- Altered consciousness
- Tachycardia*
- Hypertension*
- Incontinence
Neuroleptic Malignant Syndrome: Treatment
- Can lead to death if untreated
- Consult provider immediately
- Stop antipsychotics
- Treat hyperthermia aggressively (cooling techniques)
- Will probably require ICU support
Other treatments for schizophrenia (aside from medications)
- Cognitive Behavioral Therapy: Effective and helps with social skills training, life goals, etc.
- Family education: Key to preventing relapse, which is unfortunately common in patients with schizophrenia
- Life skills training
- Physical activity should be encouraged
- Smoking cessation: Smoking can affect the dosing
- Healthy diet
