Schizophrenia Spectrum Disorders Flashcards
what is psychosis?
altered cognition
altered perception
impaired reality testing
what is altered cognition?
disorganized thoughts
what is impaired reality testing?
ability to tell real/not real
loss of contact with distortion of reality
hallucinations or delusional thinking
when is the onset of schizophrenia?
late adolescence or early adulthood (15-25 years)
what age does childhood onset of schizophrenia occur?
before 15 years
what age does late onset of schizophrenia occur?
after 40 years
how many phases occur in the late onset of schizophrenia?
four phases
what is the prodromal phase of schizophrenia?
it can last a few weeks to a few years
deterioration in role functioning and social withdrawal
substantial functional impairment
what are the symptoms within the prodromal phase of schizophrenia?
sleep disturbance
anxiety
irritability
depressed mood
poor concentration
fatigue
what are the late symptoms of prodromal phase of schizophrenia?
ideas of reference
suspiciousness
imminent onset of psychosis
what are the symptoms of the acute phase of schizophrenia?
a patient needs 2 or more, where at least 1 of the symptoms have to be 1-3
- delusion
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behavior
- negative symptoms
decreased level of functioning in 1 or more major areas- social/occupational dysfunction
what is the duration of the symptoms within the acute phase of schizoprhenia?
must last at least 6 months with 1 month of symptoms (or less if successfully treated)
what must be ruled out first before the diagnosis of schizophrenia can be made?
schizoaffective disorders
mood disorders
substance abuse
medications
medical condition
if history of autism spectrum disorder or communication disorder, one must have prominent delusions or hallucinations for diagnosis
what are the classification of symptoms with schizophrenia?
positive symptoms
negative symptoms
cognitive symptoms
affective symptoms
what are examples of positive symptoms?
delusions
speech alterations
disorganized thinking
perception
catatonia
motor retardiation
motor agitation
alterations in behavior
what are examples of delusions?
persecutory
grandiose
referential
control or influence
somatic
nihilistic
religiosity
erotomantic
what is a delusion?
fixed false belief
what is persecutory delusion?
is the belief that a person or people are out to get them
what is a grandiose delusion?
the patient’s see themselves in an exaggerated way of importance
what is a referential delusion?
the patient thinks everything in the environment pertains to them
what is a control or influence delusion?
the patient believes someone has control over them
what is a somatic delusion?
the patient believes there is something physically wrong with them when there is not
what is a nihilistic delusion?
the patient thinks the “end of the world/days” is coming
what is a religiosity delusion?
the patient has an obsession of religion
what is an erotomantic delusion?
the patient believes someone likes or loves them and the other person may not even know them
what are examples of speech alterations?
associative looseness
word salad (schizophasia)
clang associations
neologisms
echolalia
cirumstantiality
tangentiality
pressured speech
flight of ideas
symbolic speech
what is associative looseness?
is the person is all over the place in their conversation, but each topic can loosely be put together
what is word salad (schizophasia)?
the patient is saying real words, but they are all jumbled up
what is clang associations?
when a patient rhymes all the words
what is neologisms?
the patient is saying words that do NOT exist, but they have meanings to the patient
what is echolalia?
the patient is repeating words or phrases and it is their way of trying to connect with the other person
what is circumstantiality?
the patient is giving a lot of details and then they get to the point
what is tangentiality?
the patient is going off on a tangent and not getting to the point
what is pressured speech?
the patient is talking really fast where another person may NOT be able to get a word in during the conversation
what is a flight of ideas?
the patient is all over the place in the conversation and changing the topics
what is symbolic speech?
the patient is utilizing symbols to describe their delusions
what are examples of disorganized thinking?
cognitive retardation
thought blocking
thought insertion
thought deletion
magical thinking
paranoia
what is cognitive retardation?
is a slowing of thoughts
what is thought blocking?
is when someone is talking and they completely forget
what is thought insertion?
is the patient believes someone may have put thoughts in their head
what is thought deletion?
the patient believes someone may have taken thoughts from their heads
what is magical thinking?
is normal in children, but not in adults’ when it is the patient thinks something about someone and something is bad happens to them the patient will blame themselves
what are some example of hallucinations?
auditory
visual
tactile
gustatory
olfactory
command
what are examples of altered perception in schizophrenia?
hallucinations
illusions
derealization
what are the most common hallucinations?
auditory hallucinations
what are the most dangerous hallucinations?
command hallucinations
what are command hallucinations?
are hallucinations telling them or showing them to do something; can lead to hurting themselves or others
what are illusions?
there is something in the environment, but they are perceiving it differently
what is derealization?
the reality around them seems weird or altered
what are examples of alterations in behavior?
catatonia
motor retardation
motor agitation
stereotyped behaviors
echopraxia
negativism
impaired impulse control
boundary impairment
what are symptoms are with catatonia?
catalepsy
waxy flexibility
what is waxy flexibility?
if someone was putting their arm for a BP, then after is taking it they will leave their arm up to the point of exhaustion
what is stereotyped behavior?
repetitive behavior
what is echopraxia?
repeating movement
what are examples of negative symptoms of schizophrenia?
anhedonia
avolition
alogia
asociality
apathy
affective blunting
concrete thinking
impaired memory
impaired information processing
impaired executive functioning
anosognosia
thermoregulation issues
social isolation
impaired social interaction
what is anhedonia?
inability to experience pleasure
what is avolition?
having a hard time with motivation
what is alogia?
is a poverty of speech; not many words to say, which can be due to the auditory hallucinations
what is asociality?
do not seek to be with other people; do NOT want to seek the comfort
what is apathy?
do not care and do not have strong feelings
what is anosognosia?
do not believe they are sick, so they may not be compliant with their treatment
what are the symptoms of maintenance or residual phase of schizophrenia?
the symptoms of acute phase are absent
the symptoms of prodromal phase are present
flat affect and impairment in role functioning
residual impairment increases between episodes
what are the genetic/epigenetic risk factors?
identical twins have a 50% chance
what are the biochemical risk factors of schizophrenia?
dopamine theory- high dopamine can lead to the positive symptoms of schizophrenia
what are environmental risk factors of schizophrenia?
marijuana usage
early childhood trauma
tetrachlorethylene
what are viral risk factors of schizophrenia?
human herpes virus 2 and human endogenous retrovirus 2
influenza
what are the risk factors/prenatal stressors of schizophrenia?
pregnancy or birth complications
viral
yeast
psychological trauma to mother
Father > 35 years
what are pregnancy or birth complications that potentially cause schizophrenia?
poor nutrition
hypoxia
infections
substance use/nicotine and marijuana included
what are the brain structure abnormalities that are risk factors of schizophrenia?
-enlarged, lateral cerebral ventricles, 3rd ventricle dilation, ventricular asymmetry
-reduced cortical, frontal lobe, hippocampal, and cerebellar volumes
-increased size of fissures
-reduced cortical thickness
-reduced connectivity in various brain regions
-lower rate of blood flow and glucose metabolism in prefrontal cortex
-reduced volume of gray matter
-excessive activity in limbic system
-disordering of pyramidal cells in hippocampus
what are psychological risk factors for schizophrenia?
stress- contributes to severity and course of illness; can precipitate psychotic episodes if genetically vulnerable
-childhood trauma
-downward shift hypothesis
what is the downward shift hypothesis?
those that live in low socio-economic status, where they have more epigenetic problems that can bring the genetic pre-disposition to develop schizophrenia
what are comorbidities with schizophrenia?
substance abuse
nicotine dependence
anxiety
depression
suicide
physical illness
polydipsia
what can the polydipsia in a schizophrenia patient lead to?
can lead to fatal water intoxication
hyponatremia
confusion that can worsen psychotic symptoms leading to a coma
what is schizoaffective disorder?
is the combination of a mood disorder and schizophrenia; mostly have positive symptoms
how long does brief psychotic disorder?
symptoms appear for at least 1 day but less than a month
what is schizophreniform disorder?
lasts 1 month but less than 6 months
what is delusion disorder?
is one delusion, but no other schizophrenia symptoms
what is folie a deux?
it is a shared psychotic disorder
what are different general medical conditions that can cause a psychotic disorder?
neurological
endocrine
metabolic
autoimmune
fluid/electrolyte imbalance
hepatic/renal disease
what are the treatment goal for the acute phase?
safety and stabilize
what are the treatment goals for once a schizophrenia patient is stable?
understanding of illness/treatment
optimal medications
psychosocial treatment regimen
what are the maintenance treatment goals for those with schizophrenia?
maintaining and increasing symptom control/insight
adhere to treatment
prevent relapse
maintain and increase independence
satisfactory quality of life
what happens during individual psychotherapy?
not insight oriented-reality oriented
what is the goal of individual psychotherapy?
improve compliance, enhance social/occupational functioning and prevent relapse
when is group therapy for schizophrenia patients successful?
during outpatient
what is the goal of group therapy for schizophrenia patients?
real-life plans, problems, relationships
reduces social isolation and improves reality testing
what is the goal of behavior therapy for schizophrenia patients?
reduces bizarre, disturbing, deviant behaviors/increase appropriate behaviors
what are treatments for schizophrenia?
social skills training
milieu therapy
family therapy
program of assertive community treatment
recovery model
what are the goals of social skills training?
uses shaping and roleplaying- goal is functional skills needed for ADLs
immediate feedback/repititon
what are the reasons to utilize antipsychotics?
used for schizophrenia/other psychotic disorders
selected agents used for bipolar mania
some as antiemetic or tx of intractable hiccoughs
some for tics or vocal utterances in Tourette’s disorder
what are typical/first generation antipsychotic?
dopamine antagonists
what is the mechanism of action of dopamine antagonists?
inhibit dopamine- mediated transmission of nueral impulses at synpases
helps to get rid of positive symptoms
what are examples of typical/first generation antipsychotic?
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin)
Haloperiodol (Haldol)
Haloperiodol decanoate
why is Haldol usually utilized?
when patients are in the acute phase and experiencing agression
what are more potent agonists of serotonin type 2A receptors?
atypical/second generation antipsychotics
what are examples of atypical/second generation antipsychotics?
Risperdone (Risperdal)
Clozapine (Clozaril)
Olazapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasadone (Geodon)
Brexpiprazole (Rexulti)
Aripiprazole (Abilify)
Sasenapien (Saphris)
Illoperidone (Fnapt)
Lurasidone (Latuda)
Cariprazine (Vraylar)
Paliperidone (Invega)
what are the black box warning for typical and atypical antipsychotics?
elderly with neurocognitive disorders
related psychosis
increased risk of death if given antipsychotic, usually from stroke
what are contraindications/cautions of typical and atypical antipsychotics?
CNS depression
blood dyscrasias- no clozapine with myloprooliferative disorder
Parkinson’s disease
liver and renal
poorly controlled seizure disorders
history of prolonged QT interval
other medications that prolong QT interval
cardiac arrhythmias
recurrent MI, uncompensated HF
what drugs is a person with a prolonged QT interval NOT allowed to take?
haloperidol
ziprasidone
risperidone
paliperidone
what are some side effects of antipsychotic medications?
blocking cholinergic receptors (anticholinergic)- dry mouth, dry eyes, blurred vision, constipation, urinary retention, female sexual dysfunction
blocks alpha-adrenergic receptors- orthostatic hypotension, dizziness, reflex tachycardia, tremors
histamine blockade- weight gain and sedation
nausea; GI upset
sedation
photosensitivity
hormonal sexual effects- prolactin elevation; decreased libido, retrograde ejaculation, gynecomastia, possible reduced fertility, amenorrhea
reduction in seizure threshold
agranulocytosis- increase risk of infection
liver failure
extrapyramidal symptoms
neuroleptic malignant syndrome
what are extrapyramidal symptoms?
pseudo-parkinsonism
akinesia
akathisia
acute dystonia
oculogyric crisis
tardive dyskinesia
what are the symptoms of pseudo-parkinsonism?
tremor, shuffling gait, pill rolling finger movement, drooling from reduction in spontaneous swallowing, rigidity
these symptoms can occur 1-5 days after starting medicaiton
what is the treatment for pseudo-parkinsonism?
give antiparkinsonian
give more dopamine
IM or PO benztropine mesylate (Cogentin)
trihexyphenidyl (Artane)
what is akinesia?
muscular weakness
what is the treatment for akinesia?
carbidopa/levodopa (Sinemet) PO
what is akathisia?
continuous restlesness
severe feeling to have to constantly stay on the move
pacing, tapping
repetitive movement
what is the treatment for akathisia?
antiparkinsonian plus propranolol (INderal)
lorazepam (Ativan)
what is acute dystonia?
it is an emergency
sudden sustained contraction of muscles
spasms of face, arms, legs, neck (toricollis)
often in men/those < 25 years
what is oculogyric crisis?
it is an emergency
uncontrolled rolling back of eyes
can occur as a part of dystonia
what are the treatments for acute dystonia and oculogyric crisis?
stop medication
monitor airway
give antiparkinsonia
IM benztropine mesylate (Cogentin)
diphenhydramine (Benadryl)
what is tardive dyskinesia?
it is an emergency
bizarre facial and tongue movements
stiff neck
lip smacking. licking
difficulty swallowing
at risk long term-months/years
potentially irreversible
use abnormal involuntary movement scale (AIMS) rating scale every 3 months
what is the treatment for tardive dyskinesia?
stop drug at first sign of the tongue feeling heavy and any issues chewing
monitor airway
IM benztropine mesylate (Cogentin)
IM/IV diphenhydramine (Benadryl)
dopaminergic agonsists- amantadine (Symmetrel)
valbenazine capsules (Ingrezza)
what are prophylactic treatment with an anticholinergic agent?
prevent an acute dystonic reaction in patients who receive IM haloperidol (e.g. in the treatment of acute agitation or psychosis)
when can neuroleptic malignant syndrome?
hours or years of starting medications
very rare
what are the side effects of neuroleptic malignant syndrome?
severe Parkinsonian muscle rigidity
hyperpyrexia (very high fever > 103 F)
tachycardia
tachypnea
fluctuations in BP
diaphoresis
rapid deterioration of mental status to stupor and coma
what is the treatment of neuroleptic malignant?
stop medication
give bromocriptine (Parlodel)
dopamine agonist dantrolene (Dantrium)
cooling blankets/IV fluids
what are the side effects of second generation antipsychotic?
metabolic syndrome
what is metabolic syndrome?
abdominal weight gain
dyslipidemia
insulin resistance- increased blood glucose
increased risk for diabetes, HTN, cardiovascular disease, cancer
which antipsychotic medication has a risk of cerebrovascular adverse reactions?
IM antipsychotics and long-acting injectable formulations
what is the client/family teaching for those taking antipsychotics?
do not stop taking abruptly
use sunscreen/wear protecting clothing
report weekly if receiving clozpine therapy for blood levels drawn and get weekly supply
women of child bearing age- need contraception
no alcohol, nicotine, or substances
no other medications including OTC or herbal suppplements
caution driving or operating machinery
need regular follow up with psych and primary provider
get up slowly
use gum/ice
watch body temperature
what signs and symptoms need to be reported immediately when taking antipsychotics?
tongue-twisting or weird feeling in tongue/jaw
sore throat
fever
malaise
unusual bleeding
easy bruising
persistent N/V
severe headache
rapid HR
fainting
difficulty urinating
excessive urination or thirst or hunger
weakness
pale stools
yellow skin or eyes
muscle incoordination or rash
what are the risk factors for suicide with those patients with schizophrenia?
highest risk > 45 years old
1st 10 years of illness
male
hx suicide attempt
family history of suicide
comorbid substance misuse
comorbid depression- anhedonia
high education
paranoid
active hallucinations/delusions
presence of insight
what are the only consistent protective factor for suicide?
delivery of and adherence of effective treatment
identifying those at risk
treating comorbid depression and substance misue
providing best available treatment for psychotic symptoms
what are nursing interventions for schizophrenia?
ensuring safety of clients and others- structured milieu
decreasing anxiety and establishing trust- therapeutic communication
assisting client to define and test reality
how to tell if a patient is hallucinating?
listening pose
laughing or talking to self
stopping mid sentence
tracking unheard speaker
watching vacant area of room
how to help patients with hallucinations?
assess content of hallucinations
don’t reinforce the hallucinations- say “the voices” instead of “they”
don’t negate- “I don’t hear an angry voice, but that must be scary for you”; can interject doubt where appropriate
focus on reality- guided reality testing; “The voice is part of your illness- it cannot hurt you. Try to listen to me and others you can see around you.”
concrete thinking- don’t use abstract phrases of cliches
distract them from the hallucination
if suspicious, use same staff, be honest and keep promises, avoid physical contact
extended focus on delusional material is not helpful- getting to underlying feeling, theme, or need is helpful
persistent auditory hallucinations after cute psychotic episode- distraction- listen to radio/watch TV; voice dismissal
how to help clients with association looseness?
don’t pretend or allow patient to think you understand-say you don’t; place difficulty understanding on yourself; tell what you do understand
look for recurring topics and themes in communications
summarize or paraphrase communication to role-model clearer communication and give chance to clear up misunderstanding
reduce stimuli, speak clear, concisely, concretely, and in short sentences- not paragraphs
what is some client/family education for schizophrenia?
ways for family to respond to behaviors associated with illness
connection of exacerbation of symptoms to times of stress
appropriate medication management- side effects of medication; importance of not stopping medications
promoting adaptive family coping
when to contact health-care provider- crisis information
relaxation and distraction technique
social skills training
daily living skills training
support services- financial assistance, legal assistance, caregiver support groups, respite care, home health care
