Schizophrenia and other Psychotic Disorders Flashcards
Psychosis
- Loss of contact with reality
- Disorganization of personality
- Deterioration of social functioning
Psychotic Disorders - Defined by Abnormalities in 1 of 5 Domains
- Delusions
- Hallucinations
- Disorganized Thinking
- Grossly disorganized or abnormal motor behavior, including catatonia (inability to move normally)
- Negative symptoms
Delusions
- Persecutory
- Referential
- Grandiose
- Somatic
Fixed False Beliefs
- Persecutory (think others are against you)
- Referential (think everything refers to them)
- Grandiose (think they are like god)
- Somatic (bodily delusions, think something is wrong with them)
Hallucinations
- Perception like experience without external stimulus
- Vivid and clear like normal perceptions
- Auditory, visual, olfactory, gustatory, and tactile
Disorganized Thinking
- Thought Disorder
- Inferred from person’s speech: loose associations, word salad, tangential speech
- Must be severe enough to substantially impair effective communication
Catatonic: definition and what disorders is it associated with?
- Marked Decrease in reactivity to the environment.
- schizophrenia, bipolar, and depression
Negative Symptoms
- Avolition
- Alogia
- Anhedonia
- Asociality
Diminished emotional expressions
- Avolition: lack of drive or motivation to pursue goals
- Alogia: inability to speak
- Asociality: not social
- Anhedonia: lack of pleasure
Schizophrenia
- Syndrome of variable but profoundly disruptive, psychopathology including cognition, emotion, perception, and other aspects of behavior.
- Peak onset 10-25 in men; 25-35 in women
Schizophrenia - Epidemiology
- High mortality rate
- 80% have comorbid illnesses (substance abuse is common comorbid)
Schizophrenia - Prevalence in Populations
- Child of 2 parents with Schizophrenia - 40%
- Monozygotic twin of schizophrenia - 47%
Schizophrenia - Biochemical factors
- Dopamine - dysregulation
- Serotonin - Excess
Schizophrenia - Anatomical Abnormalities
- Ventricular Enlargement
- Sulci enlargement
- Cerebellar Atrophy
- Decreased frontal lobe size
Schizophrenia - Positive Symptoms
- Hallucinations
- Delusions
- Illusions
- Disorganized thinking
- Bizarre Behavior
Schizophrenia - Negative Symptoms
- Flat Affect
- Anhedonia
- Avolition
- Social Isolation
- Diminished self-care
Schizophrenia - Mental Status Exam
- Appearance: ranges from disheveled, screaming, agitated, to obsessively groomed, silent and immobile
- Affect: reduced emotional response, inappropriate, flat, or overly active
- Mood: anxious, depressed, adhedonic
- Perceptual Disturbances: Hallucinations
- Memory: usually intact
- Judgment and insight - poor insight
- Cognitive Impairment: dysfunction in working memory, attention, functioning, episodic memory
Schizophrenia - Thought Disorders (thought content)
- Delusions
- Religiosity
- Paranoid
- Magical Thinking
Schizophrenia - Form of Thought
- Looseness of associations
- Concrete thinking
- Word salad
- Circumstantiality/Tangetiality
Psychomotor Behavior
- Anergia: lack of energy
- Waxy flexibility: person remains in position that they were placed in; also called catalepsy
- Posturing: Fixed, strange and bizarre positions; aka catatonic positioning
- Pacing and rocking
Suicide Risk
- Many have suicidal ideation
- May be related to command hallucinations
- Risk higher with unemployment, depression, period after psychosis and hospitalization (2 months)
Comorbidities
- substance
- over 50% tobacco
- Anxiety
- OCD
- Diabetes
- Weight gain
- Metabolic syndrome
- Cardiovascular disease
- Pulmonary disease
Treatment
- NAVIGATE
- Hospitalization
- Pharm
- Psychosocial therapy
- ECT
- Partial hospitalization program
- Etc..
Indications for Hospitalization
- Acute psychosis (focuses on safety and alleviating severe symptoms. May use IM antipsychotics with benzodiazepine)
- Suicidal ideation
- Homicidal ideation
- Threatening behavior/severe agitation
- Inability to care for self
- Grossly disorganized or inappropriate behavior
Pharmacotherapy + FGA vs SGA + goals of both
FGA: first generation antipsychotics or typical antipsychotics
- Associated with immediate or long-term motor problems
SGA: second generation antipsychotics or atypical antipsychotics
- less likely to cause EPS or TD
- Equally effective; SGA more widely used
- Symptom reduction usually within 1-2 weeks
- Goal is reduction of positive symptoms
Clozapine (Clozaril)
- risks
- type
- SGA
- First effective antipsychotic with low Extrapyramidal symptoms
- Given to those who failed standard therapies
- Associated with substantial risk of agranulocytosis: assess for infection and report immediately
- Risk for myocarditis
- Monitor WBC: first 6 months weekly, second 6 months bi-monthly, maintenance monthly
- Slow titration 300 mg/qd
SGA Side Effects
- Weight Gain
- Dyslipidemia (elevated levels of fat or cholesterol in blood)
- Type II Diabetes
- Accelerated Cardiovascular disease
Metabolic Syndrome with SGA
- what is it?
- diagnosis criteria
- Cluster of abnormalities associated with obesity, contribute to an increased risk of Type II Diabetes
- Diagnosed when patient has 3 or more of the following: Abnormal obesity, low HDL cholesterol levels, high triglyceride levels, Hypertension and elevated glucose levels
Metabolic Syndrome Criteria (Values) - Abnormal obesity, waist circumference, triglycerides
- Men: > 102 cm (40 in)
- Women: > 88 cm (35 in)
- Triglycerides: Greater than or equal to 150 mg/dL
Metabolic Syndrome Criteria (Values) - HDL Cholesterol, BP, Fasting Glucose
- Men
Monitoring Metabolic Syndrome
Before Initiation of Treatment of SGA:
- Baseline weight and BMI, vitals, fasting glucose and lipid profile
- Every 3 months for first 6 months
- Every 6 months after
FGA (Typical) Side Effects
EPS:
- Cogwheeling
- Dystonia (involuntary muscle contractions that cause twisting or repetitive movements)
- Akathisia (state of agitation, distress, and restlessness)
- Tardive dyskinesia (TD)
- Parkinsonianism
Orthostatic hypotension
NMS - Neuroleptic Malignant Syndrome: potentially life threatening
Medications to Counter EPS
- Congentin (Benztropine)
- Symmetrel (Amantadine)
Tardive Dyskinesia (TD)
Syndrome characterized by abnormal involuntary movements of patient’s mouth, trunk, face, or limbs
affects 20-30% particularly those taking FGA
Monitor with AIMS Scale
Abnormal Involuntary Movement Scale (AIMS)
Aids in early detection and ongoing assessment of movement disorders
Psychiatric Disorders with Psychotic Symptoms
- Major depression with psychotic features
- Bipolar disorder, manic episode
- Shizoaffective disorder
- Delusional disorders
- Personality Disorders: Paranoid disorders, shizotypical and borderline personality disorder
Substances associated with psychosis
- Alcohol
- Cannabis
- Hallucinogens,
- Cocaine,
- Methamphetamine
- Sedatives
- Hypnotics
- Anxiolytics
- Etc.
Toxins Associated with Psychosis
- Anticholisterase
- Organophosphate insecticides
- Sarin
- Carbon Monoxide
- Volatile Substances: Paint, fuel
Nursing Interventions
- Provide safe environment
- Do not argue or deny delusional material
- Attitude of acceptance
- Reinforce and focus on reality
- Intervene at first sight of increased anxiety, irritation, or verbal or behavioral aggression
- Administration of Medications: PRN, monitor side effects, Teach client and patients
- Assist with ADLs if necessary
- Paranoid Patients: avoid physical contact, maintain assertive approach, and explain what you do
Nursing Diagnosis
- Social Isolation
- Ineffective coping
- Disturbed Thought Process
- Disturbed Sensory Perception
- Impaired verbal communication
- Self-care deficit
- Insomnia
