schizophrenia Flashcards
spectrum of disorders
differ in presentation, disability, QOL
definition
structural and functional brain abn with genetic component
psychosis characterized by abn in perception, content of thought, thought process, extensive withdrawal of one’s interest from individual’s in outside world
psychosis
state in which individual is experiencing hallucinations, delusions, disorganized thoughts, speech, behavior
s of mental illness, loss of contacts with reality
seen in schizophrenia and mood disorders (bipolar)
dx criteria
2+ of following for significat amount of time during 1 mo period: delusions, hallucinations, disorganized speech (need 1 of first 3), disorganized or catatonic behavior, negative s/s
1 + major areas of social/occupational functioning below previously achieved level
continuous s >6 mo
absences or insignificant duration of major dep, manic, or mixed episodes occurring concurrently with active s/s
not physiologic effect of substance/med condition
prominent delusions or hallucinations present when prior hx of autistic disorder or another pervasive dev disorder exists
why is it so devastating
interferes with ability to…
think clearly, manage emotions, make decisions, relate to others
cant function to potential without tm
disconnected mind -> confused with multiple personalities
epidemiology
higher in M and urban areas
onset usually 15 - 35 (M earlier than F)
etiology
genetics -> env and heredity
env -> malN before birth (1 and 2 T), exposure to viruses, autoimmune -> psychosis
brian chem -> NT (dopamine and glutamate)
substance use -> mind altering drugs, marijuana (younger and freq = inc R)
vulnerability stress model
genetics and predisposition and stressors can trigger and accelerate
comorbidity
substance use, nicotine dependence, anx, dep, suicide, DM, CVD, obesity (meds), malignant neoplasm (dec survival), HIV/AIDS, osteoporosis, hep C
symptoms
very btw persons, episodes, some also found in other disorders
positive, negative, cog, affective
positive symptoms
exist but should not be there
most common
alterations in perception: paranoia, delusions, hallucinations
disorganized or alterations in speech/ behavior/thought
paranoia
delusions
hallucinations
paranoia
irrational fear -> mild to profound
deep mistrust/suspicion of others
can result in dangerous defensive actions
can dev into delusional thoughts
delusions
false beliefs despite lack of evidence, not corrected with reasoning
many different types
delusions - persecutory
watched, plotted against, ridiculed
delusions - referential
events or circumstances are related to you
delusions - grandiose
powerful or important
delusions - erotomanic
someone romantically desires you
delusions - nihilistic
things dont exist
delusions - somatic
body is changing
delusions - religious
special relationship with god
sinners
delusions - control
another person/group is controlling your thoughts, feelings, impulses
delusions - intervene
they feel real and are scary
calm, acknowledge, encourage to express, convey empathy, reassure about intentions and present reality, reorient
focus on helping pt feel safe -> focus on fear and causes
build rapport and trust with honesty and genuineness, dec anx
describe delusion, validate and present reality, dont debate or argue (dec trust)
assess intensity, freq, duration
identify trigger
as reality testing (determine what is real) improves, supportively convey doubt where appropriate, prior to this, dont prove delusion is incorrect -> can intensify and dec trust
clarify misinterpretations, gently suggest more reality based perspective as tolerated, focus on present reality and what is real, coping strategies
delusions - doc
type, theme, characteristics
use pt words (subjective)
behavior prior and during
actions taken to help, threat, actions for safety
hallucinations
alterations in perception, errors in how one interprets perception or perceives reality
sensory experience for which no external source exists: auditory, visual, olfactory, gustatory, tactile
very real, distracting, supportive or terrifying, faint or loud, episodic or constant, varying anx or stress
hallucinations - command
auditory, instruct pt, serious to innocuous
assess and monitor
hallucinations - intervene
introduce self, rapport, trust
approach in non threatening and calm manner (non verbal actions as well)
reassure safety
hallucinations - indicators
can ask pt
darting eyes, muttering/talking, distracted, suddenly stopping convo, intently watching vacant area
hallucination - assess
type and content -> ask directly
began, what pt feels -> distress, comfort
what are you hearing, is it telling you to do something (command), do you believe it is real (yes = inc r/o acting on it)
dont respond to them like they are real or deny their experience
offer own perceptions, convey empathy, present reality
after: identify triggers, worse/better, how they respond, cope
hallucinations - help
name, clearly speak, simple sentences, loud enough
support, eye contact, redirect focus
alert for anx -> may be intensifying
engage in reality based activities
hallucinations - doc
type, theme, characteristics
use pt words (subjective)
behavior prior and during
actions taken to help, threat, actions for safety
hallucinations - educate
manage stress and stim, use other sounds to compete, check with others for reality activities to distract, contact others (friend, fam, staff, help line), dev plan to cope
talk: self = symptom, not real, tell voices to go away, tell yourself you are safe
disorganized or alterations in speech -circumstantiality
extremely detailed and lengthy convo, eventually gets to point
disorganized or alterations in speech - tangentiality
going on tangents, never reach point
disorganized or alterations in speech - loose associations
absence of normal connectedness of thoughts, ideas, topics
disorganized or alterations in speech - flight of ideas
topic of convo changes repeatedly and rapidly with superficial associative connections, difficult to follow
disorganized or alterations in speech - echolalia
repeat others words
disorganized or alterations in speech - clang association
choose words based on sound rather than meaning, often rhyme or similar beginning sound
disorganized or alterations in speech - symbolic speech
using words based on what they symbolize
disorganized or alterations in speech - pressured speech
urgent/intense, reluctant to allow comments from others
disorganized or alterations in speech - word salad
string of words totally unconnected, jumble of words meaningless to listener
disorganized or alterations in speech - neologisms
made up words, pt meaning only
disorganized or alterations in thought - thought blocking
dec or stoppage of thought, usually ralking about something importnat
disorganized or alterations in thought - thought insertion
someone else inserted thoughts into brain
disorganized or alterations in thought - thought delusion
thoughts have been taken or are missing
disorganized or alterations in behavior - paranoia
previously defined
disorganized or alterations in behavior - catatonia
pronounced inc or dec in rate and amount of movement, excessive motor activity is purposeless
disorganized or alterations in behavior - echopraxia
invol imitation of anothers movements and gestures
disorganized or alterations in behavior - motor retardation
pronounced slowing of movement
disorganized or alterations in behavior - motor agitation
excited behavior, running or pacing rapidly, often in response to internal or external stim
disorganized or alterations in behavior - negativism
tendency to resist or oppose requests or wishes of others
disorganized or alterations in behavior - stereotyped behavior
repetitive purposeless movements, peculiar, serve no purpose
disorganized or alterations in behavior - gesturing or posturing
posture held in fixed position
disorganized or alterations in behavior - impaired impulse control
they have it
disorganized or alterations in behavior - boundary impairment
impaired ability to sense where one’s body or influence ends and another’s begins
negative s/s
should be there but arent -> absense of essential human qualities
dec social functioning
tm more difficult, frustration, disabling, dec function, persistent
negative s/s - affective blunting
can sometimes be caused by meds
reduced affect (flat, blunted, constricted, inappropriate, bizarre)
dec spont movement, poor eye contact, no vocal inflection
affect - flat
immobile or blank facial expression
affect - blunted
reduced or minimal emotional response
affect - constricted
reduced in range or intensity
affect - inappropriate
incongruent with the actual emotional state or situation
affect - bizarre
odd, illogical, inappropriate, unfounded, includes grimacing
negative s/s - apathy
dec interest in activities or beliefs that would otherwise be interesting or important or little attention to them
negative s/s - alogia
dec speech
negative s/s - avolition
dec or loss of motivation or goal directed behavior
apathy and avolition cause deficits in basic activities
negative s/s - anhedonia
dec ability to experience pleasure or joy
negative s/s - asociality
dec desire for social interaction or discomfort while doing it
cog symptoms - concrete thinking
cant think abstract, interpret or percieve thoughts in literal manner
cog symptoms - impaired mem
short term, impact ability to learn
cog symptoms - impaired info processing
delayed reponse, misperceptions, difficulty understanding others
cog symptoms - impaured executive functioning
difficulty with reasoning, setting priorities, compare options, planning
cog symptoms - anosognosia
freq relapse
dont believe ill, resist/cease tm, often combo with paranoia, impossible to accept help
affective s/s
altered experience and expression of emotion
mood unstable, erratic, labile, incongruent
schizoaffective disorder
schizophrenia and serious mood s/s (mania, dep)
schizoaffective disorder - tm
antipsychotics and mood stabilizing mes, fam, psychosocial strategies, self care, psychotherapy, integrated care if substance abuse
rx meds: combo antipsych, mood stabilizing, anti dep
CBT: long term recovery, recognize, understand, change behaviors
group therapy: feel alone and misunderstood, supportive env
schizoaffective disorder - what is it
uninterrupted, either major dep, manic, or mixed episode with s/s schizophrenia, many experience major mood episodes day or weeks while s/s schizophrenia persist after
often mis dx with bipolar or schizophrenia
rare, M and F same rate, M earlier
manage with meds and therapy
schizoaffective disorder - types
bipolar: dep and manic and schizo s/s
depressive: no highs and lows, just low, psychotic s/s of schizo and dep
schizoaffective disorder - dx criteria
major mood and schizo affective
hallucinations and delusions 2+ wk w/o major mood
s/s of mood episode present for most of duration
disturbance not from substance or med
schizoaffective disorder - depressive s/s
lethargy, dont want to do anything, no pleasure form fav activities, no sleep or excessive sleep, dec appetite, feel you will never be happy again
constant or eb and flow of these feelings
schizoaffective disorder - schizophrenia s/s
near constant
delusions, hallucinations, difficulty holding work or staying enrolled in school, problems with hygiene or taking care of self, difficulty comm with individuals, not being understood by those around you
nursing
assess (holistically) metnal status, phys health, social support systems
identify priority problems -> hct
dev care plan with goals and interventions
implement interventions that address pt s/s, promote safety, support recovery
continuously eval effectiveness and adjust prn
potential priority problems
safety, violence, suicide, self harm, disturbed thought processes, disturbed sensory perception, treatment non adherence, ineffective coping, social isolation, self care deficits, knowledge deficits, hopeless or powerless
potential outcomes
short and long term goals, SMART goals
slide 56
potential interventions
slide 57
utilize priority problems -> s/s management, enhance function, inc QOL
need variety to help meet goals, may need to adjust
eval
adjust prn, identify progress, dec helpless
safety in all settings
phys care of pt
stabilize on meds
pt and fam edu on illness and tm
psychosocial support of pt and fam
smart goals inc buy in and coop
treatment facts
failure of prescribed meds: relapse, suicide, self harm, violence, inc mortality, readmit, dec qol, social and occupational difficulty
antipsych crucial in short and long term
early intervention with med dec some associated long term co morbid or co existing conditions
relapse
at any time, v high rate
longer recovery period with each relapse
combo med and psychotherapy diminishes severity and freq of recurrent relapse
one of major reasons for relapse in non adherence with med
stopping med almost certainly leads to relapse (anosognosia)
recovery is process, not outcome
anosognosia, paranoia, auditory hallucinations, persecutory delusions: long acting injectable antipsych and family psychosocial edu cbt, social skills
antipsychotics
2-6 wk for effectiveness, pt specific dosages -> effective and SE balance
not addictive, routes per risks (cheeking, mouth, nonad)
typical = first gen
atypical = 2nd gen
monotherapy recommended
IM = more intense and less easily managed SE
typical
dec positive s/s
little effect on negative s/s
used less often, less expensive
SE: eps, antichol, sedation, weight gain, met syndrome, neuroleptic malignant syndrome, sexual dysF, endocrine disturbances, CV issues (orthostatic hypoT and arrhythmias), inc r/o seizure
SE often lead to nonadherence and stigma
chlorpromazine, haloperidol, fluphrenazine, thioridazine, perpherazine
atypical
+ and - s/s, fewer and better tolerated SE
same potential SE but usually milder and better tol
clozapine, risperidione, olanzipine, quetiapine, ziprasidone
less TD or EPS
more weight gain, met syndrome, costly
antipsychotics: common SE
extrapyramidal -> motor control and coordination, cause discomfort, social stigma, poor adherence; acute dystonic, akathisia, pseudoparkinsonism, tadrive dyskinesia (first 3 w/n few weeks of starting or inc dosage
antichol
neuroleptic malignant syndrome
metabolic syndrome
EPS - acute dystonic rxns
sudden sustained contraction of 1+ muscle groups, usually head/neck
painful, scary, uncomfy, anx -> only dangerous if airway muscles (emergency!)
torticollis = head pulled to 1 side
oculogyric crisis = eyes roll back
laryngeal dystonia = spasm of throat, impair breathing and swallowing
EPS - akathisia
restless: pace, rock, shift
distressing, mistaken for anx or agitation -> give more drug and make worse -> assess!
tardive form can persist despite treatment
treatment: dec dose, change med, antichol (benztropine), add med - short term (BB, lorazepam, diazepam), relaxation exercise
can persist 6+ mo after dose or med change or become tardive
EPS - pseudoparkinsonism
stiff and stooped posture, shuffling gait, bradykinesia, pill roll, rest tremor, dysphagia, drool
tm: identify med, slow and safe d/c (not always possible), dec dose, add antichol (benztropine, trihexyphenidyl)
EPS - tardive dyskinesia
invol rhythmic movement with long term meds, severity varies, F > M
usually oral and facial muscles, progress fingers, toes, neck, trunk, pelvis, tongue protrudes, lip smack, mouth move
gradual change, can miss signs -> AIMS q3 mo
tm: d/c or dec dose based on severity, switch to 2nd gen (opposite taper), s/s usually persist, meds to manage s/s (valbenazine, deutetrabenazine)
anticholinergic SE
dry mouth, blurred vision, dry eyes, c, urinary retention/hesitancy, drowsy, dizzy, confusion, hallucinations, tachy, skin flush, dec sweat
can progress to tox
neuroleptic malignant syndrome
rate but serious and fatal
usually early SE, early detection through hx improves survival
muscle rigid, altered mental status temp >103, htn, tachy, tachypnea, diaphoresis, incont
complications: rhabdomylosis (P in blood, organ fail), acute resp fail (strongest predictor of mortality), AKI, sepsis, systemic infection
neuroleptic malignant syndrome - tm
detect with prompt and freq assessment, stop all antipsych, supportive tm, ICU
supportive = oral and IV hydration -> e imbalance, VS, monitor for comp
dantrolene Na, bromocriptine mesylate for muscle rigidity and fever
lorazepam for agitation
cool body for fever -> blanket, OH bath, water/ice bath
dysR treat
3rd gen antipsychotics
subset of 2nd
improve positive and negative and cognitive function
little r/o EPS or TD
aripiprazole, brexpiprazole, cariprazine
2nd gen SE
sedation
major weight gain, met changes, endocrine problems (DM, hyperprolactinemia, dyslipidemia), cancers, htn, CV disease
cardiac dysR/sudden death
sexual dysF
less likely: antichol, orthohypoT, seizures, eps
met syndrome
monitor weight and girth, initial glucose tolerance test, monitor BG, provide nutrition and activity support, consider lifestyle
clonzapine
I: refractory schiz, unresponsive schiz (2+ meds), eps with other drugs
prone to violence and suicide when untreated/other treatment methods dont work
dec negative, inc impulse control, dec violence, inc QOL
not 1st line -> agranulocytosis
agranulocytosis
potentially fatal SE
a dec in # of circulatory granulocytes and dec production of granulocytes, limit ability to fight off infeciton
inc r during first months: monitor wbc weekly for 18 wks, continue based on orders, d/c med if <3.06 leukopenia or neutropenia (<1.56)
reversible with early tm
long acting injectable meds
r/o nonadherence
q2-4 wk or months
need transportation
typical: fluphenazine decanoate, haloperidol decanoate
atypical: risperidone microspheres, paliperidone palmitate, olazipine pamoate, aripiprazole
additional tm
ect -> catatonia
cbt, group, fam, social skills, case management, support gorups
prognosis
most have s improve and good QOL
doesnt always respond to tm
some need lengthy or repeated inpt -> slow onset 2-3 yrs, younger onset, delayed tm, long periods untreated, more negative s/s
