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PMHNP > Schizophrenia and Psychosis > Flashcards

Schizophrenia and Psychosis Flashcards

1
Q

Schizophrenia: Diagnostic criteria

A
  • Presence of 2 or more symptoms for a significant portion of a month
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Grossly disorganized catatonic behavior
    • Negative symptoms
  • Social/Occupational dysfunction
  • Four phases: premorbid, prodromal, acute/psychotic, stable/residual
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2
Q

Premorbid phase of Schizophrenia

A
  • Delayed motor milestones
  • Poor scholastic performance
  • Reduced concentration and motivation
  • Passivity
  • Depression, anxiety, irritability, anger
  • Sleep disturbance
  • Bedwetting/enuresis
  • Social withdrawal and isolation
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3
Q

Prodromal phase of schizophrenia

A
  • Marked peculiar behavior
  • Inappropriate expression of feeling
  • Speech difficult to follow
  • Poverty of speech and thought
  • Odd ideas and ideas of reference
  • Feelings of unreality
  • Suspiciousness
  • Deterioration in role functioning
  • Attenuated psychosis syndrome
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4
Q

Acute/Psychotic phase of schizophrenia

A
  • Delusions
  • Auditory hallucinations
  • Disorganized thinking/speech, confusion, loose associations
  • Disorganized behavior
  • Regressed behavior
  • Echopraxia/Mirroring
  • Waxy flexibility
  • Alteration in affect: dysphoria, lability
  • Alteration in attention
  • Problems in decision making/executive function: indecisiveness, lack of insight, impaired judgement, illogical or concrete thinking, loose associations, difficulty initiating actions
  • Deteriorating relationship: paranoia, withdrawal, lack of personal hygiene, inappropriate social behavior
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5
Q

Stable/residual phase of schizophrenia

A
  • Symptoms similar to prodromal
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6
Q

Schizophrenia: Predisposing factors

A
  • 81% Heritability
  • Children of 1 parent 13% risk; 2 parents 27-35% risk; sibling 9%-17%; twin 48%
  • Urban/pollution
  • Winter
  • Maternal starvation/viral infections
  • Delivery complications
  • High fevers in early childhood
  • Triggered by high exposure to psychosocial stressors
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7
Q

Schizophrenia: Neurobiology

A
  • decreased brain volume, larger third ventricles, atrophy of frontal lobe, cerebellum, hippocampus, amygdala
  • Decreased blood flow to the frontal cortex, over activity in the basal ganglia (limbic system)
  • Abnormal dopamine, serotonin, glutamate, GABA activity
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8
Q

Schizophrenia: Types

A
  • No longer used in the DSM 5
    ** Paranoid: Preoccupied with delusions and auditory hallucinations
    ** Disorganized: Disorganized speech and behavior with flat or inappropriate
    affect
    ** Catatonic: Multiple movement and behavior symptoms
    ** Residual: 1 year absence or attenuation of positive symptoms, evidence of
    at least one past psychotic episode, primarily presents with negative
    signs/symptoms
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9
Q

Schizoaffective disorder

A
  • A major mood episode concurrent with schizophrenia symptoms
  • Period of delusion/hallucinations for at least 2 weeks without prominent mood symptoms
  • Mood symptoms are present for a substantial period of illness
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10
Q

Schizophreniform disorder

A
  • Schizophrenia episodes last between 1 and 6 months

* About 2/3 develop schizophrenia

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11
Q

Brief psychotic disorder

A
  • Schizophrenia symptoms last between 1 day and 6 months with eventual return to full functioning
  • Delusions, Hallucinations, Disorganized speech, Disorganized or Catatonic behavior
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12
Q

Delusional Disorder

A
  • Non-bizarre delusions of at least a month’s duration
  • Other criteria for schizophrenia never met
  • Functioning not markedly impaired or obviously odd
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13
Q

Delusional Disorders: Types

A
  • Erotomanic: patient believes another individual loves them
  • Grandiose: Patient has unrecognized talent
  • Jealous: Patient believes spouse in unfaithful
  • Persecutory: Patients believes others are sabotaging him
  • Somatic: Delusions related to bodily functions
  • Mixed: No prominent theme
  • Unspecified: no classification
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14
Q

Shared psychotic disorder (folie a deux)

A
  • second person develops a similar delusion
  • Second person may not entirely meet the criteria for a delusional disorder
  • Categorized in the DSM 5 as “other specified spectrum and other psychotic disorder
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15
Q

Psychotic Disorder Rating Scales

A
  • Brief Psychiatric Rating Scale (BPRS)
  • Positive and Negative Symptoms Scale (PANSS)
  • Scale for Assessment of Negative Symptoms (SANS)
  • Scale for Assessment of Positive Symptoms (SAPS)
  • Moller-Murphy Symtom Management Assessment tool II
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16
Q

Treatment Modalities for Psychotic Disorders

A
  • Assertive community treatment: core services team, assertive outreach, long term relationship with primary provider
  • Clubhouse: psychosocial rehabilitation
  • CBT for 4-9 months
  • Family services: 6-9 months
  • Group therapy; Self-help and support groups
  • Multisystemic therapy for youth: services at home and school
  • Fairweather Lodge Model: clients move into a residence from the hospital and operate a business; group norms and peer support
  • 3 Rs Psychiatric rehabilitation: Relapse, Recovery, Rehabilitation; 12 week psychoeducation
17
Q

Schizophrenia: Smoking cessation

A
  • High incidence and morbidity associated with smoking
  • Clozapine correlates with lower smoking as it increases acetylcholine release which activates nicotinic receptors
  • Cigarette smoking increases the activity of CYP 1 A2 enzymes thus decreasing concentrations of clozapine and olanzpaine
  • Smoking also increases clearance of fluphenazine and haloperidol
18
Q

Schizophrenia: Pharmacologic Management

A
  • First choice for newly diagnosed is the atypical antipsychotics except for clozapine and olanzapine because of metabolic effects.
  • Initial doses should be lower by 1/2
  • Consider clozapine after two trials of other antipsychotics; serum levels need to reach 350 nanograms/ml
19
Q

Atypical Antipsychotics: Pharmacological effects

A
  • Antagonize 5-HT2 serotonin and D2, D3, and E4 receptors
  • Effective for both positive and negative symptoms
  • Lower incidence of EPS
  • Side effects: sedation, orthostatic hypotension, weight gain, glucose dysfunction, sexual dysfunction, GI complaints, QT interval prolongation (nl. .4-.44)
20
Q

Atypical Antipsychotics “PINES”

A
  • Clozapine (Clozaril): agranulocytosis
  • Olanzapine (Zyprexa) 5-20 mg /day; IM formulation
  • Quetiapine (Seroquel) 150-600 mg/day: Potential for cataracts, FDA approved for bipolar depression
  • Asenapine (Saphis)
21
Q

Atypical Antipsychotics: “DONES”

A
  • Respiridone (Resperdal) 2-6 mg/day: sexual dysfunction, EPS at high doses; IM form
  • Ziprasidone (Geodon) 40-160 mg/day: low in weight gain, QT prolongation, take with food, IM form
  • Paliperidone (Invega): IM
  • Lurasidone (Latuda)
  • Iloperidone (Fanapt)
22
Q

Atypical Antipsychotics: “PIPS”

A
  • Aripiprazole (Abilify) 15-30 mg/day: partial agonist of D2 and 5DT2a receptors, complete antagonist of 5HT2a receptor; IM available; orthostatic hypotension, anticholinergic, FDA indication for MDD adjunct
  • Brexpiprazole (Rexulti): partial agonist D2, 5HT1a, Antagonist of 5HT2a
23
Q

Antipsychotics: First generation

A
  • Haloperidol (Haldol): 1-30 mg/day
  • Fluphenazine (Prolixin): 0.5-40 mg/day
  • Perphenazine (Trilafon): 8-64 mg /day
  • Trifluoperazine (Stelazine): 1-40 mg/day
  • Thiothixene (Navane): 2-30 mg/day
  • Loxapine (Loxitane): 20-250 mg/day
  • Molindone (Moban): 50-225 mg/day
    • Act effectively on positive symptoms and agitation
    • EPS and Tardive Dyskinesia
24
Q

Extrapyramidal symptoms

A
  • Dystonia
  • Pseudoparkinsonism
  • Bradykinesia
  • Akathisia
  • Assess for EPS every 6 months using Abnormal Involuntary Movement Scale (AIMS)
  • Treat with anticholinergic meds: Benztropine (Cogentin), trihexyphenidyl (Artane); Dopaminergic agent amantadine (Symmetrel)
  • Acute dystonia is life threatening, treated with IV or IM benadryl
25
Q

Tardive Dyskinesia

A
  • Lip smacking
  • Sucking
  • Tongue protrusion
  • Athetoid movements
  • Grimacing
  • Eye-blinking
  • Rocking
  • Toe or finger tapping
  • Strumming or pill rolling movements
26
Q

Neuroleptic Syndrome

A
  • Older antipsychotics more likely to cause: e.g. Fluphenazine (Prolixin) and Haloperidol (Haldo)
  • Also caused by metoclopramide (Reglan), Prochlorperazine (compazine), Promethazine (Phenergan)
  • High fever, muscle stiffness, diaphoresis, tachycardia, BP fluctuations
  • Treat with Dantrolene (Dantrium) to treat muscle stiffness; or dopamine agonists amantadine (symmetrel); bromocriptine (parlodel)
27
Q

Treatment for acute psychotic agitation

A
  • oral Resperdal, Zyprexa, Haldol, Ativan, Valium

* IM Zyprexa, Geodon, Haldol, Ativan

PMHNP (19 decks)

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