Schizophrenia Flashcards
Who are the faces of Schizophrenia?
John Nash (Math professor at Princeton, Nobel Prize)
- paranoid schizophrenia “A Beautiful Mind”
Nathaniel Ayers (Julliard violinist) “The Soloist”
Elyn Saks (Law and psychiatric professor) “The Center cannot Hold: My Journey Through Madness”
- TedTalks
Ron Power: no one cares about crazy people
Schizophrenia is diagnosed when
late adolescence or early adulthood
Schizophrenia is based on a
spectrum or continuum of a broad range of disorders
Is schizophrenia acute or chronic?
chronic
- more disabling type of mental illness
- affects how a person thinks, feels, and behaves
The DSM-5 for Schizophrenia is
2+ of the following for 1-month duration
- delusions
- hallucinations
- disorganized speech
- disorganized or catatonic behavior
- negative symptoms
Schizophrenia Psychosis s/s
hallucinations
delusions - inside their head
disorganized thoughts
abnormal motor behavior
negative symptoms
Delusions
images or thoughts inside the person’s mind
Hallucinations
auditory, smell, tactile, see that is not there
Auditory
Voices
Somatic or tactile
Olfactory – gas, smoking
Visual
Gustatory – taste poison in their food
What does a schizophrenia patient sound like with disorganized speech?
Loose associations
Schizophrenia Psychosis is caused by
neurocognitive s/s impairing cognitive capacity
- deficits in perception, functioning, and social relatedness
Primary psychosis is derived from
schizophrenia spectrum disorders
Secondary Schizophrenia is derived from
substance intoxication and dementia
Can Primary and secondary schizophrenia coexist?
yes and potentiate the other
Schizophreniform Disorder
- duration
s/s must last at least 1 month but not more than 6 months
Schizophreniform Disorder
- descriptions
essential features identical to those of schizophrenia but shorter duration
Brief Psychotic Disorder
- duration
about a month
- returns to premorbid functioning
- precipitate by extreme stress
Brief Psychotic Disorder
- description
sudden onset of psychiatric s/s
Schizoaffective Disorder
- prognosis
better prognosis than schizophrenia
BUT significantly worse than a mood disorder
Schizoaffective Disorder
- description
Symptoms of a mood disorder:
- major depressive, manic, or mixed episode, concurrent with symptoms that meet the criteria for schizophrenia. Common psychotic disorder
Schizotypical Personality Disorder
- progression
May progress to developing schizophrenia
Schizotypical Personality Disorder
- description
Personality disorder considered part of the schizophrenia spectrum disorders (DSM-5); shares common genetics and neuropsychiatric characteristics. Intense discomfort with close relationships.
Delusional Disorder
- ranges from
Ranges from remission without relapse to chronic waxing and waning; symptoms must last at least 1 month
Delusional Disorder
- description
Involves nonbizarre delusions such as being followed, infected, loved at a distance, or deceived by a spouse; having some great or unrecognized insight; ability to function is not markedly impaired and behavior is not obviously odd or bizarre. Delusions of persecution are the most common.
Substance/Medication-induced Psychotic Disorder
- tx
psychosis usually resolves
Substance/Medication-induced Psychotic Disorder
- description
caused by ingestion of or withdrawal from a substance
Schizophrenia abrupt onset with good premorbid function has what prognosis
better prognosis and greater chance of remission/complete recovery
What onset of schizophrenia has a worse prognosis?
slow onset (2-3 years)
When schizophrenia is diagnosed as an early age of onset, what can occur?
structural brain abnormalities
more negative and disabling s/s
poorer progonosis
What age do men usually get schizophrenia?
18-25
What age do females usually get schizophrenia?
25-35
What is the comorbidity of schizophrenia?
50% substance use and 50% tobacco use disorder
What types of substances are usually used with schizophrenia
cannabis and psychotic disorders strong correlation
- Meth and LSD
Schizophrenia increases the abuse of what drug?
Cannabis
Why do most schizophrenic patients die prematurely?
non-psychiatric illnesses
- malnutrition
- insomnia
- criminal activity
- medication adverse effects not reported
- cooccurring disorders
What is co-occurring with schizophrenia?
Depressive disorders
20% attempt suicide
6-10% commit suicide
Anxiety/panic disorders
Obsessive-compulsive disorders
Schizotypal and paranoid personality disorder may develop into schizophrenia
Schizophrenia has what Type of duration
Recurrent acute exacerbations of psychosis
Periods of full or partial remission
Schizophrenia Primary Interventions
target people at high risk or see the start of the s/s
Schizophrenia Secondary Interventions
intervening early and reducing the duration of untx dx
Schizophrenia Phases
Prodromal
Acute
Stabilization
Maintenance
Schizo Prodromal Phase
80-90%
- early recognition and tx vital
- usually ignore s/s
Acute Phase of Schizophrenia
severe well developed s/s (positive, negative, neurocognitive, mood)
Maintenance Phase of Schizophrenia
What to keep in as long as possible
Risk Factors of Schizophrenia
Genetic factors
Alteration in brain structure
Brain’s neurotransmitter system disruptions
Alterations to neural circuits
Neurochemical Contributing Factors of Schizophrenia
Hyperactive dopamine transmission in the mesolimbic areas
Hypoactive dopamine transmission in the prefrontal cortex
Dysregulation in multiple other areas of the brain
Abnormal levels of serotonin may cause some of the negative and mood symptoms
NMDA (N-methyl-D-aspartate) an amino acid is implicated in the psychotic, negative and cognitive symptoms
Glutamate activity insufficiency or excess with other neurotransmitters
genetic Contributing Factors of Schizophrenia
One parent with schizophrenia leads to 5-6% chance
Both parents 46% chance
Group of 8 genetically different types of schizophrenia
Synaptic pruning, gene C-4
Neuroanatomical Factors of Schizophrenia
Decrease in both gray and white matter especially in the frontal lobe
Decrease brain volume
Larger lateral and third ventricles
Atrophy in the frontal lobe
More cerebral spinal fluid
Lower rate of blood flow and glucose metabolism in the prefrontal cortex
Non-genetic Factors of Schizophrenia
Viral infection affecting neurogenesis – in pregnancy
Poor maternal nutrition
Exposure to toxins
Perinatal complications and birth injuries
Closed head injuries after birth
Advanced paternal age
Overactive Immune system
First and second-generation immigrants - stress
Stress
Synaptic pruning
brain cuts back on neurons in adolescents
Cultural considerations for schizophrenia
Rural Africans may hallucinate about ancestor worship
Christians may hallucinate about Christ, Mary, Satan
- possessions
- punishment from God
Patients in US may report auditory hallucinations of violent commands
- religious, supernatural or biomedical
Sources of schizophrenia for cultures
Attributed to spiritual versus religious or supernatural, or biomedical
Can affect adherence to medication and other treatment
Hearing Voices Network believes it may be possible to improve relationship with voices by respecting, understanding and adapting to the voices
Secondary causes if psychosis
Brain Tumors
Cysts
Dementia
Neurological Diseases
Environmental Toxins
Misuse of and addictions of prescription meds
Positive symptoms of Schizophrenia
hallucinations
delusions
bizarre behavior
catatonia
formal thought disorder
Negative symptoms of Schizophrenia
apathy
lack of motivation
anhedonia
blunted or flat affect
Poverty and speech
social withdrawal
Cognitive symptoms of Schizophrenia
inpaired memory
disruption in social learning
inability to reason, solve problems, and focus attention
Mood symptoms of Schizophrenia
depression
anxiety
demoralization
suicidality
excitability
agitation
dysphoria
postpsychotic depressive disorder
demoralization
increase substance use
Different types of delusional alternatives in thinking
Mind Reading
Somatic
Ideas of reference
Persecution
Grandiose
Religious
- Jealousy
Control
Thought broadcasting
Thought insertion
Thought withdrawal
Mind Reading -
read other minds or others can read their mind
Somatic Thinking
false believe the body is changing in an unusual way – little men inside of them, new limb, nose disappears
Ideas of reference
misinterpret normal day to day events - 2 people talking and they are plotting to hurt him
Persecution
plot of being singled out by others – poisoned, followed
Gradiose - Religious
they are some very important and powerful (Jesus, devil, married to an important person)
Jealousy
think they are being cheated on but there is no reality proof
Control Thinking
being controlled by an outside person or organization (agency)
Thought Broadcasting
personal thoughts are heard by others and control the thoughts of others
Thought insertion
people are putting thoughts in their heads
Thought withdrawal
people are erasing their thoughts
Concrete Thinking
only see words at face value
Associative Looseness
flight of ideas
- can not tie thoughts together
- start with one thought and move to another thought at the end
Tangential:
train of thought wonders off and never returns
Clanging:
meaningless rhyming or sound alike words
- tik tak, click clank, monster track
Neologisms:
made-up words
Echolalia:
repeating words
Word Salad:
mix of meaningless words
- Kamala do not form one complete thought
Circumstantiality:
excessive detail. Cannot separate relevant from irrelevant.
Pressured speech:
talking fasT
- OTHER PEOPLE cannot say anything
Thought blocking:
Patient stops talking in the middle of a sentence and remains silent
- they can not complete their thought
Illusions
misinterpretation of real experiences
Schizophrenic patients have trouble with personal boundaries because of
Lack of Sense Where Bodies End and Other’s Begin
Depersonalization
Derealization
Depersonalization –
loss of identity and the body parts are not theirs
Derealization –
the environment is different
- larger or smaller than they really are
What are the alterations in behavior for schizophrenia patients?
Catatonia
Bizarre behavior
Eccentric dress, grooming, rituals
Agitation or aggressiveness
Impaired boundaries
Impaired impulse control
Odd social or sexual behavior
Catatonia –
no mvmt or slow mvmt, to very active strange mvmt (weird posture)
Impaired impulse control –
can not stop themselves from experiencing (throat punch)
Odd social or sexual behavior –
take off clothes, inappropriate sexual behavior in front of others and do not stop
If a person has schizophrenia and starts undressing in the main room, what should the nurse do?
get a blanket and redirect to the room
Catatonia consists of
Extreme motor agitation or extreme psychomotor retardation
Stereotyped behaviors
Automatic obedience
Bizarre posturing
Waxy flexibility – strange posturing
Negativism
Stupor – do not respond and look like they don’t understand
Poverty of speech is aka
alogia
Anhedonia
loss of pleasure
Asociality
few relationships and no social and don’t mingle with people
Avolution
no motivation and will not take care of themselves
Neurocognitive/Cognitive Symptoms of schizophrenia
40-60% of people
-poor executive functioning
- inability to sustain attention - slow calculations
- problems with working memory
- inability to reason
- inability to problem solving
- can not learn new things
Postpsychotic depressive disorder
- aware of their illness and become depressed
- deterioration and hopeless
Demoralization
disheartened loss of confidence, enthusiasm, and hope
Excitability
capable of being readily roused into action
state of excitement or irritability
Paranoia Communication
projection
Speak indirectly. Do not use I and you. Use he or she, directing paranoid symptoms toward external and more general issues
Identify with the patient, helping patient feel understood. Empathize.
Share mistrust without supporting delusion. Find something to agree on with patient
Disorganized S/S for Schizophrenia
Poor premorbid functioning – before dx the s/s are bad
Poor prognoses
Social withdraw
Severe cognitive impairment
Require structured and well supervised setting
When the schizophrenia patient has delusions and hallucinations, then the nurse would
support the person but not the delusions
Schizoaffective Disorder s/s either of
bipolar or major depression
With a schizoaffective disorder tx is
treat psychosis and the mood disorder
The nurse needs to assess what in schizophrenia patients
Suicide risk (harm to self)
Risk of violence (harm to others)
Command hallucinations
Delusions
Substance use/abuse
Medical workup
Co-occurring disorders: depression, anxiety
Self care and safety
Medication use and adherence
Positive & negative symptoms
Patient’s insight & coping
Support system - need a good one but might have burned those bridges and pushed away family
Standardized Screening Tools for Schizophrenia
BPRS –
PANSS –
**AIMS – **
MMSE -
Most of the screening tolls for schizophrenia patients are used for physicians, which one used by nurses?
AIMS - see for s/s – abnormal of involuntary mvmts from the medications LIKE TARDIVE DYSKINESIA
Nursing Dx for Schizophrenia patients
Risk for self-directed/other-directed violence
Ineffective impulse control
Social isolation
Distorted thinking process
Impaired verbal communication
Impaired family coping
Self care deficit
Difficulty coping
Risk for suicide
Ineffective health maintenance
Planning for Schizophrenia patient’s order
crisis hospitalization
observe
stabilization
teach relapse prevention
D/C planning
Implementation of Schizophrenia
psychopharmacology
milieu
establish trusting relationship
- positive reinforcement
therapeutic communication
health teaching and promotion
- educate frequently and repeated
social services
Communication for a Schizophrenia Pt
Be cautious with touch as it may be perceived as threatening
Use calm, quiet tone of voice
Elicit description of hallucination/delusions to ensure safety
Don’t confront or argue truth/falsehood of their ideas
Help present and maintain reality **
Focus on feelings**
Deal with inappropriate behaviors in non-judgmental manner
Teach social skills through education, role-modeling, and practice
If a schizophrenia patient is having delusions, what should the nurse ask before going forward?
type of delusions
- when stable give teachings and social skills by role modeling
Patients who are highly suspicious & hostile: the nurse should
Allow patient as much control as possible within limits, explain treatments, meds, lab tests before initiating them
Might see as a threat
Patients who are aggressive & agitated: the nurse should
increase supervision, decrease stimulus, de-escalate verbally, offer medication
Patients with hallucinations/delusions: the nurse should
Ask directly, “Are you hearing voices?” “What are they saying?” Reduce stimulus. Focus on feelings and reality, not delusions
Hallucinations nursing interventions
Empathy
Identify the feelings patient is experiencing
Explain you do not hear voice – do not argue, but validate they do hear them
Ask the patient to turn away from the voices
Distract attention
Calm demeanor and milieu
Delusions nursing interventions
Same as hallucination except:
Do not touch patient and use gestures carefully
Do not argue with the patient’s beliefs
Paranoia Interventions
Place yourself beside the patient, not face to face
Avoid eye contact
Offer foods and drinks in closed containers – avoid poisoning
Distraction with reality-based activities
Use restrictive interventions if anxiety escalates
avoid confrontation and be at a degree angle and not to look at them for a long time
Associative Looseness Intervention
Do not pretend you understand the patient’s communication
State “I am having difficult understanding” or
State “I am having trouble following what you are saying”
Piece together what they are saying by looking for recurring topics
Involve patient in simple reality-based activities
Teach the patients and family about what in schizophrenia
Illness (causes, self-care)
Medication side effects, management and follow-up
Early signs of relapse & develop a prevention plan
Avoiding alcohol and drugs
Building support system
Community resource
Recovery Model and Recovery Oriented Care
Anyone can recover and manage their condition successfully
Health
Home
Purpose
Community
Recovery after initial schizophrenia episode project
Medication
Psychosocial therapy
Case management
Family involvement
Supportive education
Employment services
Psychotherapy and Psychoeducation for Schizophrenia
PACT
ACT
Family Psychoeducation Therapy – engages family, improves caregivers’ positive well-being and reduce burden of care.
Cognitive Behavioral Therapy – correct self-defeating behavior – correct how they see things
Cognitive Remediation – improve cognitive skill such as memory, attention
Social Skills Training
Family Psychoeducation Therapy –
engages family, improves caregivers’ positive well-being and reduce burden of care.
Cognitive Behavioral Therapy –
correct self-defeating behavior – correct how they see things
Cognitive Remediation –
improve cognitive skill such as memory, attention
Therapy of Schizophrenia aims to
- in community, prevents relaspee, reduce hospital, improve quality of life, and med adherence, no criminal activity and out of jail
Typical (Conventional or first-generation) Antipsychotics (FGA)
Target + Symptoms
Dopamine (D2) receptor antagonist
Greater risk of EPS symptoms
What pharmacology is used for schizophrenia
Antipsychotics (1st and 2nd gen)
Atypical (second-generation) Antipsychotics (SGA)
Target + and – symptoms
Serotonin-dopamine antagonists
Higher risk of metabolic syndrome; lower risk of EPS
More costly
Typical (Conventional or first-generation) Antipsychotics medication types
Haloperidol (Haldol)
Chlorpromazine (Thorazine)
Trifluoperazine (Stelazine)
Thiothixene (Navane)
Fluphenazine (Prolixin)
Thioridazine (Mellaril) (***QT prolongation)
Loxapine (Loxitane)
Perphenazine (Trilafon)
What 1st gen antipsychotic can cause QT prolongation?
Thioridazine
Typical Antipsychotics Black box warnings
Not approved for dementia-related psychosis
Typical antipsychotic side effects
anticholinergic effects
wt gain
sexual or reproductive organ issues
increased prolactin levels
seizures
sedation
agranulocytosis
NMS
cardiac events
EPS
drug-induced liver disease
Agranulocytosis
decrease in WBCs
EPS
akathesia - restless msucles
pseudoparkinsonism- shuffling and rigidity
acute dystonia torticollis
Torticollis is treated
Treat right away as it can cause aspiration when eating
-IM Benadryl is used for tx
Tardive Dyskinesia
Serious and irreversible EPS side effect after prolonged treatment that consists of involuntary tonic muscle spasms involving the face, lips, tongue, trunk, and extremities.
Tardive Dyskinesia symptoms
may subside after meds are discontinued or may be permanent.
Anticholinergic effects
Red as a beet – flushed
Dry as a bone – everything dries up
Blind as a bat – blurry visiosn
Hot as a hare – increase temp
Full as a flask – difficulty urinating
Atypical (2nd generation)Antipsychotics medications
Clozapine (Clozaril) (agranulocytosis) – wt gain
Risperidone (Risperdal)
Olanzapine (Zyprexa) - wt gain
Quetiapine (Seroquel) -
Ziprasidone (Geodon) (QT prolongation)
Less for wt gain
Paliperidone (Invega)
Lurasidone (Latuda)
Iloperidone (Fanapt)
Cariprazine (Vraylar)(considered 3rd generation by some sources)
Aripiprazole (Abilify) (considered 3rd generation by some sources)
Less for wt gain
Atypical antipsychotics have wt gains
Clonzapine
Olanzapine
Atypical antipsychotics have less wt gain
Zisperadone
Aripiprazole
Atypical antipsychotics have what agranulocytosis
Clozapine
Atypical antipsychotics have what QT Prolongation
Ziprasidrone
Black box warning for Atypical antipsychotics
Not approved for dementia-related psychosis
2nd gen antipsychotics side effects
anticholinergics
EPS less common
gynecomastia
seizures
NMS
metabolic syndrome
sedation
sexual problems
cardiac events
Metabolic syndrome
Cluster of conditions that ↑ risk for heart disease, diabetes, stroke. Dx with 3 or more of the following:
Obesity: excess weight, ↑ BMI, ↑ abdominal girth
↑ B/P
High blood sugar level
High cholesterol: Triglyceride at least 150mg/dL, HDL less than 40mg/dL (women) & 50mg/dL (men)
Long-acting Antipsychotics - Depot medication types
Haloperidol decanoate (Haldol)
Fluphenazine decanoate (Prolixin)
Risperadone (Risperdal Consta)
Paliperidone palmitate (Invega Sustenna)
Olanzapine pamoate (Zyprexa Relprevv)
Why are depot shots given for schiophrenia patients
noncomplicance
AIMS is the
Abnormal involuntary movement scale (AIMS): assessment screen for tardive dyskinesia
When should this be used?
Rates movement of facial/oral, extremities, and trunk) on a scale of 0-4
NMS frequency increases with
high potency antipsychotics and cognitive impairment (stroke, dementia, etc)
NMS is an
emergency
NMS s/s
low consciousness, muscular rigidity, ↑ muscle enzymes, hyperpyrexia (103 or above), hypertension, tachycardia, tachypnea, diaphoresis, drooling.
NMS Tx
admit, stop the drug, antipyretics Dantrolene - spasms and IV fluids, for muscle spasms,TX OTHER COMPLICATIONS
Memory TOOL for NMS
Fever >103F
Elevated CPK/WBC
Vital sign instability (autonomic instability)
Fluctuating BP, pallor, tachycardia
Sweating, salivation, tremors, incontinence
Encephalopathy
Confusion, altered level of consciousness
Rigidity muscle
Antiparkinson Drugs
Trihexyphenidyl (Artane)
Benztropine (Cogentin)
Diphenhydramine (Benadryl)
Biperiden (Akineton)
Evaulation for Schizophrenia effectiveness
Have symptoms lessoned? Why or why not?
Is the patient taking medications? If not, why?
Explore issues with nonadherence.
Are the family involved? Do they understand the disease and treatment?
Are the patient and family aware of relapse issues?
Are the patient and family utilizing community resources available to them?
Promote recovery model focusing on patient’s goals and strengths
Self-Awareness Issues with Schizophrenia
Challenges: A patient who is psychotic may be intensely anxious, fearful, or agitated and can evoke strong emotions in caregivers
May experience fear, anxiety, avoidance
Frustration if patient nonadherent
Need not take patient’s success or failure personally
Focus on patient’s strengths, time out of hospital
No nurse has all answers
