Schizophrenia Flashcards
what is schizophrenia?
psychosis characterized by abnormalities in perception, content of thought, and thought processes and extensive withdraw of interest from people and the outside world
“splitting of thoughts from emotions and people”
psychosis
loosing touch with reality
individual experiencing hallucinations, delusions, disorganized thoughts, speech, or behavior
what is the hallmark sign of schizophrenia
delusions, hallucinations, and disorganized speech
schizophrenia interferes with a persons ability to
think clearly
manage emotions
make decisions
relate to others
epidemiology of schizophrenia
leading cause of disability if diagnosed
most frequently diagnosed in males in urban areas
peek age of onset 15-35
men 15-25
women 25-35
children is uncommon
new cases are rare before age 10 and after 40
etiology of schizophrenia
genetics - heredity plays strong role
environmental- malnutrition in 2nd and 3rd trimester can play a part
brain chemistry
substance abuse- mind altering drugs during teen and early adult years can play a part.
comorbidities with schizophrenia
substance use disorders
nicotine dependence
anxiety, depression, and suicide
diabetes
cardiovascular disease
obesity
malignant neoplasm
HIV/AIDS
osteoporosis
Hep C
positive symptoms of schizophrenia
symptoms that exist but shouldn’t be there
hallucinations
delusions
disorganized behavior
disorganized speech
hallucinations
can include the 5 senses
auditory and visual are the most common
auditory- obscene, accusatory, or insulting
visual- usually sees something threatening
tactile
olfactory
gustatory
command hallucinations
telling them to do something
auditory hallucination
commands to harm themselves or others
must be carefully monitored
ask: Are you hearing a voice that is telling you to do something?
Do you plan to follow the command?
Do you believe the voices are real?
treating hallucinations
-observe for tracking eyes, mutterings, talking to self, distraction, talking and suddenly stopping as if interrupted, intently watching a vacant part of the room
ask about the content of hallucination
*do not refer to hallucinations as if they are real ( do not ask: what are the voices saying to you, instead say What are you hearing?)
-watch for signs of anxiety, these may indicate the hallucinations are intensifying
-do not negotiate with clients hallucinations (I don’t hear the voices that you hear, but it must be frightening for you)
-focus on reality, here and now activities (the voices you are hearing are part of your illness, they cannot hurt you)
-address underlying emotion- fear and guilt (remind them they are safe)
-promote and guide reality testing- ask client to look around and observe if anyone else appears frightened.
teaching for clients with schizophrenia
manage stress
use other sounds to compete with hallucinations (radio, tv, reading, etc.)
check with others to find out what is real and not
engage in activities to take your mind off hallucinations
talk (tell self voices are not real, tell voices to go away, tell yourself no matter what you hear you will be safe)
develop a plan to cope with hallucinations
delusions
erroneous fix beliefs that cannot be changed by reasonable arguments
grandiose delusions
belief that one has exceptional powers
nihilistic deluison
belief that one is dead or a disaster is impending
persecutor delusion
belief that one is being watched, plotted against, and ridiculed
somatic delusions
belief about abnormalities in the body function or structure
religious delsions
believe that they have a special relationship with God,, or on a mission from God, or they are sinners
referential delusion
believes that newspaper articles, TV shows or song lyrics are directed specifically at them
Treating delusions
-establish therapeutic relationship
-respond to suspicion in matter of fact, empathic, supportive and calm manner
-ask client to describe his beliefs (tell me more about someone trying to hurt you)
-never debate the delusional content (although it is frightening to you, it seems that it would be hard for a small girl to hurt you)
-validate if part of the delusion is real (yes there was a man at then nurses station but he was asking for water)
focus on feelings or themes
-use reality based interventions to help meet clients underlying needs (if client believes he is powerful he may really feel powerless)
-acknowledge that while belief seems very real to client, illnesses can make things seem true even though they aren’t
-don’t dwell excessively on the delusion, instead focus on reality-based topics
thought blocking
client is talking, and abruptly pauses and cannot remember what they were saying
thought broadcasting
“people can read their minds”
clients think people can hear their thoughts or know what they are thinking
thought withdraw
people are taking thoughts out of their brains
blames poor memory on government agents who steal their thoughts
thought insertion
repeatedly complains of having disturbingly violent thoughts, which she clans are being sent by satan
paranoia
irrational fear, ranging
circumstantiality
extremely detailed and lengthy talk about a topic but eventually gets to point
tangentiality
extremely detailed and lengthy talk but never gets to the point
loose associations
absence of normal connected thoughts, ideas and topics ( i was home when drum beating began, i flew too low)
Flight of Ideas
conversation topic changes repeatedly and rapidly with only superficial associative connections ( a man begins talking about his business, but quickly shifts to talking about the economy, government, and other countries)
echolalia
repetition of another’s words, pathological repetition
clang associations
repetition of works with a similar sound but in no other way ( i heard a bell. well, hell then i fell)
stilted language
overly and artificially formal language
pressured speech
words are being forced out
word salad
string of words totally unconnected, jumbled, meaningless to a listener
(because is makes a twirl in life, my box is broken, help me blue elephant)
neologism
made up words meaning for the patient only ( I got to do angry, I picked up a dish and threw it at the geshinker)
paranoid disorganized speech
suspiciousness that is unrealistic
illogicaliy
conclusions are reached that do not follow logic
aggression
behaviors or attitudes that reflect rage
agitation
inability to sit still or attend to others, pacing
catatonic excitement
hyperactivity characterized by purposeless activity and abnormal movements
catatonia
waxy, hold same position for hours, not just specific to schizophrenia, can be immobile, non-responsive
echopraxia
involuntary imitations of another’s movements and gestures
regressive behavior
childlike/immature
stereotype
repetitive purposeless movements that are peculiar to the person
hypervigilance
sustained attention to external stimuli
waxy flexiblity
posture held in a flexible position, patient can be posed
negative symptoms
symptoms that should be there aren’t
affective flattening or blunting
ambivalence- presence of two opposing forces, leading to inaction, cant decide, stuck
alogia- poverty of speech
avolition- inability to complete projects, assignments, work, loss of motivation
anhedonia- loss of pleasure, hijacks joy
asociality- decreased desire for social interactions, isolation
cognitive symptoms
concrete thinking- inability to think abstractly
impaired memory- impacts short term memory and ability to learn
impaired information processing- delayed responses, misperceptions or difficulty understanding others
impaired executive functioning- difficulty with reasoning, setting priorities, comparing options, planning
prodromal phase of schizophrenia
mild changes in thinking
insufficient to meet DSM 5 criteria for schizophrenia
symptoms appear 1 month to more than 1 year before full blown episode
speech and thought may be odd or eccentric
anxiety, obsessive thoughts, and compulsive behaviors
deterioration in concentration
distressing thoughts, suspiciousness, memory impairment, significant disorganization in speech
Acute phase of schizophrenia
later symptoms from few and mild to many and disabling
symptoms include hallucinations, delusions, apathy, social withdraw, diminished affect, anhedonia, disorganized behavior, impaired judgement, and cognitive regression
difficulty coping as symptoms worsen
symptoms that were once concealed become apparent
hospitalization required
men late adolescents 15-25, women 25-35
stabilization phase of schizophrenia
symptoms are stabilizing and diminishing
movement toward a previous level of functioning
maintenance or residual phases of schizophrenia
condition has stabilized
new baseline established
positive symptoms are usually absent or significantly diminished but negative symptoms continue to be a concern
relapse with schizophrenia
can occur at any time during treatment
detrimental to the successful management
with each relapse takes a longer time to recover
combining meds with psychotherapy diminishes the severity and frequency of relapses
major reason for relapse is nonadherence with meds
stopping meds will certainly lead to relapse
is there a cure for schizophrenia?
no cure but can recover!
schizophrenia and violence
violence is a risk for those not medicated and experiencing command hallucinations and/or who have a substance abuse or alcohol abuse problem
schizophrenia and suicide
suicide attempts are common within 3 yrs of diagnosis
more common upon discharge following first episode
risk factors of suicide and schizophrenia
depressive symptoms
young age at onset
absence of supportive friends and family
schizophrenia and mortality rate
higher mortality rate from accidents and medical illnesses (die at younger age because they dont take care of their physical health)
high rates of smoking
wt gain with neuroleptic meds can cause metabolic syndrome, type 2 DM, and cardiac problems
late signs and symptoms of schizophrenia
hallucinations with auditory
delusions
lack of emotion
emotions are inappropriate
social withdraw
poor school performance
decreased ability to practice self care
strange eating rituals
incoherent speech
illogical thinking
agitation
anitpsychotics treat
severe thought disorders such as schizophrenia and bipolar
acute and chronic confusion
psychosis, extreme aggression, and dementia
target symptoms that antipsychotics treat
disorganized thinking, speech, and behavior
flat or inappropriate affect
delusions
hallucinations
catatonia
treatment goals of schizophrenia
safety in all settings
stabilization on antipsychotic
client and family education
physical care
psychosocial support
failure to take prescribed meds can result in
risk of relapse
risk of suicide
increased mortality rates
potential for hospital readmission
declined quality of life
social and occupational difficulty
antipsychotic meds are essential to treat
symptoms during both acute and long term phases of illness
what does early intervention with meds do for schizophrenia?
decreases some associated long term co-morbid, co-existing conditions
typical antipsychotics
chlorpromazine (thorazine)
haloperidol (haldol)
side effects of typical antipsychotics
anticholinergic
sedation
EPS
hypotension
seizure
photosensitivity
skin rash
GI upset
EKG changes
hormonal/endocrine
agranulocytosis
neuromalignant syndrome
tardive dyskinesia
Liver impairment
prolonged QT
first generation typical antipsychotics
D2 receptor agonist
target positive symptoms of schizophrenia
less expensive than second generation
disadvantages: EPS, Anticholinergic side effects, tardive dyskinesia, WT gain, sexual dysfunction, endocrine disturbances
anosognosia
inability to realize they are ill
may cause resistance to treatment plan or cessation of treatment
combined with paranoia so that accepting help is impossible
anticholinergic side effects
hot as a hare
dry as a bone
red as a beet
mad as a hatter
Extrapyramidal Symptoms
psudoparkinsonism
akathisia
actue dystonia
tardive dyskinesia
usually start within a few weeks of starting antipsyhotics
symptoms may cause discomfort, social stigma, and poor compliance
psudoparkinsonism
simulates parkinsons disease
is reversible and includes tremors in hands and arms
bradykinesia, akinesia, hypersalivation, masked faces, and shuffling gate
treatment of psudoparkinsonism
dose reduction or addition of oral anticholinergic med
Akathisia
inner restlessness manifested by excessive pacing or inability to remain still for any length of time
treatment of akathisia
dose reduction of antipsychotic or addition of low-dose beta blocker, such as propranolol (inderal)
dystonia’s Extrapyramidal side effects
dystonic reactions caused by antipsychotics need to be monitored for and acted on emergently
torticollis, oculogyric crisis, opisthotonus, laryngospasm, oral-facial maxillary spasm
torticollis
spasmodic and painful spasm of muscles (head pulled to one side)
ocylogyric crisis
eyes roll back, only white visible
emergency situation
opisthotonus
a type of spasm om which the head and heels arch backward in extreme hyperextension and the body forms a reverse bow
laryngospasm
spasm of throat impairing breathing and swallowing
oral-facial maxillary spasms
treat emergently as the may progress (resembles bells palsy)
treatment for mild side effects of EPS
reduce dosage
d/c med- taper them off
switch to another med in same class- one is tapered down while one is tapered up
add an anticholinergic- benztropine (Cogentin), diphenhydramine (Benadryl), trihexyphenidyl (atrane)
sometimes anticholinergics are given with antipsychotics to reduce likelihood of EPS
add beta blocker- propranolol
tardive dyskinesia
involuntary movement that can occur with long term antipsychotic treatment and may not be reversible even when med discontinued
usually involves orofacial region, can include myoclonic jerks, tics, chorea, dystonia, symptoms become more evident when patient is aroused, and ease when pt is relaxed or disappear during sleep
attempts to treat TD usually begin with discontinuing the offending agent or switch to one with lower risk
risk factors for developing tardive dyskensia
long term therapy with FGA’s at higher doses
older age
female
concurrent affective disorders
late onset tardive dyskinesia
after many years of antipsychotics
often permanent dysfunction of voluntary muscles effects mouth (tongue protrudes, smacking of lips, mouth movements)
routinely evaluate client on AIMS scale
changes may be gradual or mild and slowly progress, providers can miss signs
often irreversible
important to catch early
treating tardive dyskinesia
depends on severity, med may be discontinued
thorough exam and documentation of symptoms
use AIM scale
close and continued follow up
clozapine (Clozaril) has shown efficacy in symptom reduction
new medication for TD
avobenzone
NMS: neuroleptic malignant syndrome
serious and potentially fatal
usually associated with antipsychotics ( or drugs that block dopamine receptors)
dehydration is predisposing factor
more common in warm climates
may have genetic predisposition
signs and symptoms of NMS
fever 103-105
diaphoresis
muscle rigidity: arm/abdomen board like with corresponding increase in CPK levels
labile BP swings from hypo to HTN
tachycardia >130
Tachypnea >25
agitation r/t respiratory distress
mental status changes; stupor/coma
interventions for NMS
stop all antipsychotics
symptomatic; supportive treatment
hospitalization required
drugs to treat NMS
dantrolene (dantrium)
bromocriptone (parlodel)
levodopa
lorazepan (ativan)
10% fatality rate
difficult to diagnose in emergent situation
atypical antipsychotics second generation
treat both positive and negative symptoms
minimal to no EPS
disadvantages- tendency to cause significant weight gain, risk of metabolic syndrome
atypical antipsychotics
clozapine (clozaril)
olanzapine (zyprexa)
respiridone (respiradol)
respiradol consta
ziprasidone (geodon)
third generation antipsychotic meds
subset of second
dopamine system stabilizers
may improve positive and negative symptoms and cognitive function
little risk of EPS or TD
aripiprazole (abilify)
brexpiprazole (rexulti)
caripazine (vraylar)
side effects of atypical antipsychotics
sedation
n/v- usually stops after 2 weeks
less likely to cause anticholinergic effects, orthostatic hypotension, seizures, EPS
more likely to cause major weight gain, changes in person metabolism leading to DM, hypoprolctinemia
potential for cardiac dysrhythmias/ even sudden cardiac death
rhinitis
sexual dysfuntion
more costly than antipyschotics
metabolic syndrome
special concern with atypical antipsychotics
heart disease, lipid problems, HTN, type 2 DM, dementia, cancer, PCOS, Non-alcoholic fatty liver disease
monitor wt and girth, initial glucose tolerance test, monitor glucose, provide nutritional support and activity support, consider lifestyle changes
clozaril
treats refractory schizophrenia or schizophrenia that doesn’t respond to normal tx
pts with refractory are prone to violence and suicide
med results in decreased negative symptoms, increased pulse control, reduced violence to self harm and others, improved quality of life
has potentially fatal side effect of agranulocytosis
agranulocytosis
low production of granulocytes
body cannot fight off infection
WBC drops dangerously low
monitor WBC weekly for first 6 months, then every other week
discontinue Clozaril if WBC falls below 3000 or granulocytes fall below 1500
reversible if treated early
parenteral drugs
for patients that are severely disturbed or present serious compliance risk
also available in injectable form
long acting only require administration once every 2 to 4 weeks
fluphenazine decanoate
haloperidol decanoate
risperidone microspheres
paliperidone palmitate
olanzapine long acting injectable
aripiprazole microspheres
Long Acting Anti-psychotics meds
long lasting 2 weeks
haloperidol (Haldol decanoate)
risperidone (consta)
paliperidone (Invega Sustenna)
implications for Long acting anti-psychotic meds
schizophrenia
bipolar 1
and those unable to adhere to treatment
be aware of patients travel/transportation, cognitive deficits, lack of social support
* must have transportation to receive injection
paliperidone palmitate (Invega Trinza)
3 month injection
atypical antipsychotic for schizophrenia after successful treatment with Invega Sustenna (1 month injections) for at least 4 months
Dissolvable anti-psychotic meds
olanzipine (zydis)
risperidone ( Risperdal M-tab)
asenapine (saphris)
indicated for severe agitation, inability to follow directions on how to take me, or inability to swallow tablets
Toxins affecting efficacy of anti-psychoitc meds
CANS
Caffeine
alcohol
nicotine
sugar
additional schizophrenia treatments
ECT
behavior therapy
group therapy
family therapy
social skills training
case management
support groups
prognosis of schizophrenia
for most symptoms improve with meds and psychosocial interventions
can experience good quality of life, family and occupations
sometimes does not respond fully to tx leaving mild to severe residual symptoms and varying degrees of dysfunction/disability
factors that require repeated or lengthy inpatient care
slow onset of disease (more than 2-3 yrs)
younger age at onset
longer duration between first symptom and first treatment
longer periods of untreated illness
more negative symptoms
dichotomous
often seen in borderline personality disorder
tend to perceive and evaluate every thought or situation as black or white, good, or bad, all or nothing.
unable to see grey areas
perservation
persistent repetition of words or ideas
racing
does not just mean thinking fast. Thoughts wont be quiet ; they can be in the background of other thoughts or take over a persons consciousness; they can gallop around in the persons head like a carousel gone out of control
referential
belief that neutral, everyday occurrences carry specific personal meaning to the individual. Varies in intensity. may be seen in someone with schizoaffective disorder
Alogia
Poverty of speech
