Test #4 Flashcards
What does ALS stand for
Amyotrophic lateral sclerosis
What is ALS
- Progressive loss of motor neurons in the cerebral cortex and spinal cord, which causes muscle atrophy
- Causes firmness in tissues = sclerosis
Breakdown the ALS name
Amyotrophic (muscles wasting away) lateral (happens symmetrically) sclerosis (leads to firmness of the tissues)
Is cognition affected in ALS
No - they are still there (think of steven hawking)
What is the most common complication of ALS
Respiratory (lose muscles to swallow and cough, etc)
Is there a genetic form of ALS
Yes, but most people don’t have the genetic form (autosomal dominant pattern of inheritance) (they might have a genetic predisposition though)
What are risk factors for developing ALS 9
- Smoking
- Exposure
- Severe stress
- Head trauma (football players, etc)
- Living in the western pacific islands
- Persistent physical exhaustion
- Viral infections
- MIs
- Malnutrition
Who is more at risk for ALS
Higher incidence in men, but after menopause, both men and women incidence is equal
What is an early symptom of ALS that people usually write off
- *Asymmetrical painless weakness in one limb (not loss of sensation - will eventually turn into symmetrical bilateral weakness, but typically starts in one part of the body first)
- Dominant arm more commonly affected
What are other common early symptoms of ALS
- Tripping/loss of balance
- Weight loss
- Speech problems
- Difficulty chewing/swallowing
- *Drooling
- Tongue tremors
- Breathing difficulties
- Choking
- Crying spells or periods of inappropriate laughter (caused by bulbar palsy)
- *Vesiculations (muscle twitching)
- Secretions in lungs
- Poor/absent gag reflex
What do we use to help monitor a pt’s ALS progression
The ALS Functional Rating Scale (the higher the number the better, a decrease in number indicates further decline)
How do we diagnosis ALS
- Through an electromyography (EMG)
- Muscle biopsy
- Cerebrospinal fluid analysis
- Pulmonary function tests
- Computed tomography scan
- MRI
- Genetic testing
- HIV testing (to rule out)
- Lyme disease (to rule out)
When do we see the typical onset of ALS? What if we see it earlier?
Typically ALS is seen around 65. If earlier, it is most likely the genetic form.
Are there any tx options for ALS?
Not really - tx is limited. There is riluzole, which can be given to help slow progression.
Go over vent management
What are some nursing interventions for ALS
- Keep upright for 30 min after a meal
- Chest physiotherapy
- IS
- Encourage periods of rest prior to eating
What is Guillain-Barre Syndrome (GBS)? What can it lead to?
- Acute autoimmune response that occurs a few days or weeks after a viral or bacterial infection, where demyelinating polyradiculoneuropathy (AIDP) occurs
- Can lead to paralysis and respiratory failure
What are most GBS patients on
Vents
What is happening in GBS
Immune response, usually from IgG immunoglobulins (antibodies formed from bacteria or virus), after a bacterial or viral infection
Is GBS permanent
No, re-myelination can occur, which can help your body regain functions
Symptoms of GBS
- Lower extremity weakness progresses to flaccidity (usually within hours or days) (starts as ascending)
- Motor loss is symmetrical
- Weakness will continue up and threaten respiratory muscles
- Pain, increasing at night
- Orthostatic hypotension or hypertension
- Abnormal vagal responses like bradycardia, or heart block
- Disfunction with bladder and bowel
- Facial flushing
- Diaphoresis
- Weak or absent reflexes
What is the main feature of GBS
Ascending, rapidly progressing, symmetrical weakness of the limbs
What is the most common cause of death for someone with GBS
Respiratory arrest
How do we diagnosis GBS
- Symptoms
- Cerebral spinal fluid (elevated protein, but normal cell count)
- Nerve conduction studies (will show decreased conduction)
How long can GBS last?
- 1-3 weeks for the paralysis to advanced completely up the body, then it plateaus for 2-4 weeks, then functions descends down the body
Is there a cure for GBS
No, we have to let the disease run its course
What are txs for GBS
- Plasmapheresis (giving plasma)
- Intravenous immune globulin (IVIG) (helps boost immune system)
What are some complications of GBS 5
- Atelectasis
- Pneumonia
- Pneumothorax
- Hypertension
- Tachycardia
Even though GBS can be reversible, what kind of care might they need afterwards
Will require PT/OT afterwards to regain sterngth and functions
What are nursing interventions for GBS
- Enteral feedings
- Helping control pain (can be painful just laying there)
Why would someone with GBS be in pain?
Because they have only lost their motor function, they have not lost their sensory function, so they can still feel
Is consciousness affected in GBS
No
When do we typically see pts show signs of Huntington’s
35-45
What are the symptoms of Huntington’s
- Chorea: excessive, involuntary movements that appear to be writhing and twisting movements of the face, limbs and body (these are progressive, and will continue to get worse and worse)
- Due to movement issues, there will be issues with speech, chewing, and swallowing = leads to aspiration and malnutrition
- Cognitive decline can vary and is usually suttle (involves perception, memory, attention, and learning = many pts will develop dementia in the end)
- Compulsive behaviors may develop
Huntington’s Chorea
Non-voluntary and uncontrolled movements
How does Huntington affect the mind
- Progressive, cognitive impairments
- Many will develop dementia towards the end
- Compulsive behaviors
How can we diagnosis Huntington’s
Genetic testing
How do you get Huntington
Through genetics (autosomal dominant trait - where there are at least 40 repeats of this CAG gene) (the more repeats, the earlier Huntington’s is going to show up)
What is the issue with Huntington’s
By the time it shows up, you have usually already had children, which means that you may have passed the gene to your kids
Is there a cure for Huntington’s
No, we just treat the symptoms
Besides being worried about respiratory, what else should we be worried about when someone is diagnosed with Huntington’s
Suicide - because these patients will know that it will progressively get worse and worse
What is myasthenia gravis
Autoimmune motor disorder, characterized by extreme fluctuating weakness and fatigue
What do we want people with myasthenia gravis to avoid
Want them to avoid any respiratory risks, like coming into contact with sick people, large crowds, etc. (developing a cold or respiratory issues can send them into crisis)
What is the basic pathophys going on in myasthenia gravis
Acetylcholine receptors are blocked due to antibodies produced by your immune system
The drug effects of what disease can make symptoms of myasthenia gravis worse
Drug side effects from RA
What does myasthenia gravis have to with the thymus
Over 70% of patients with myasthenia gravis have Hyperplasia thymus or tumors on the thymus - which causes higher level of antibodies, which can make the disease worse
If someone has myasthenia gravis with a hyperplasia thymus, what might be done
A thymectomy to take out your thymus
What are the 3 types of myasthenia gravis clinical manifestations
- Ocular (ptosis (drooping eyelids) or diplopia (double vision))
- Bulbar (face and neck)
- Generalized weakness
When do myasthenia gravis pts begin to experience symptoms
Within 2 years of onset
Why would we have ptosis or diplopia
Because of the muscle weakness, which can be the eye muscles
What is important to know about myasthenia gravis symptoms
Symptoms worsen with sustained activity (like staring at the computer)
What are specific bulbar symptoms
- Trouble speaking/slurring of speech
- Issues with chewing
- Issues with swallowing
What are generalized symptoms of myasthenia gravis
- Feeling fatigued doing just about anything
- Takes you longer to get dressed, etc.
- Voice fades after talking for a while
Do we see any cognitive issues with myasthenia gravis
No - they are fine cognitively, they also don’t have any sensory loss, issues with reflexes or muscle atrophy
How do we diagnosis myasthenia gravis
- Symptoms
- Serological testing (assay of acetylocholine antibodies)
- Repetitive nerve simulation test (conduction will become slower overtime, as fatigue sets in, which indicates a positive test)
- Tensilon test (give 10mg of Tensilon (short acting anticholinesterase), temporarily will improve neuromuscular weakness for 2-5 minutes and then weakness returns, shows a positive test)
- Chest CT to look at thymus
What are side effects of Tensilon
- Bronchospasm
- Bradycardia
- Diarrhea
What do we want to have on standby, if a pt is having a bad response to Tensilon
Atropine
What is the drug of choice to treat the long-term effects of myasthenia gravis
Pyridostigmine, which is an anticholinesterase inhibitor
Why would we want an anticholinesterase inhibitor for myasthenia gravis
Because acetylcholinesterase is is breaking down acetylcholine, which we need to make our muscles work (so we want to stop this action)
Would someone with myasthenia gravis be at risk for respiratory issues, like aspiration
Yes - due to bulbar symptoms (like issues swallowing) and generalized fatigue
What is the issue with myasthenic crisis
It can present like a cholinergic crisis
What is happening in myasthenic crisis? What symptoms might we see?
- Exacerbation of the weakness, which can lead to respiratory failure caused by an infection
- Tachycardia
- Flaccid muscles
- Cool, pale skin
- Lasts about 2 weeks
- Will need to be in the hospital
What causes a cholinergic crisis? What are the symptoms?
- Cholinergic crisis due to excessive intake of anticholinesterase agents
- Bradycardia
- Muscle twitching
- Pallor
- Excessive secretions
- Small pupils
What can help us distinguish between a myasthenic or cholinergic crisis
- Tensolin test (Give an anticholinesterase drug (Tensolin), which will either improve their symptoms of myasthenia gravis, but will not improve the symptoms if in a cholinergic crisis
What is multiple sclerosis
Autoimmune disease that affects the myelin sheath of neurons in the CNS (brain and spinal cord) causes these neurons to become inflamed and scarred - this leads to a decrease in nerve signal transmission
What is a good trick to remember that MS affects the myelin sheath
Remember that Myelin Sheath starts with MS
Why do people with MS have different symptoms
Well we all have a lot of different neurons, so it just depends which ones are affected, which can vary from person to person
What are MS symptoms if the cerebellar is affected
- Tremors
- Dysarthria (trouble articulating speech)
- Ataxia
- Cognition`
What are the 4 different patterns of MS
- Relapsing - remitting (most common - where they will have these unpredictable attacks followed by periods of remission)
- Primary progressive (steadily becomes worse)
- Secondary progressive (have earlier periods of remission, but you stop having periods of remission and it progressively gets worse)
- Progressive relapsing (steady decline, with with attacks but no remissions)
When is the typical onset of MS
20-40 years
Where is MS more prevalent
In temperate climates 45-65 degrees (might be subjected to an environmental agent before puberty)
Do we know the cause of MS
No
What might be some contributing factors to MS
- Pre-disposed genetically (higher risk if you have a first degree relative)
- Infection
- Smoking
- Physical injury
- Emotional stress
- Excessive fatigue
- Pregnancy
- Poor health
Is the onset of MS usually gradual or aggressive
Gradual - symptoms come and go so you don’t really pay much attention to them
What is a unique symptom of MS
Lhemitte’s sign - when you flex your neck, you feel a shock wave go down your spine
What is a unique speech pattern that some may develop with MS
Scanning speech
What are the many potential symptoms of MS
- Muscle weakness
- *Lhermitte’s sign
- Positive Romberg’s sign
- Weakness or paralysis in limbs, trunk or head
- Spastic muscles
- Scanning speech
- Issues with coordination and balance (they feel drunk)
- Issues with walking or standing
- Tremors
- Dizziness
- Hearing loss
- Numbness and tingling
- Pain
- Vertigo
- Tinnitus
- Chronic neuropathic pain
- Nystagmus (involuntary movement of eyes)
- Dysarthria (speech slurring)
- Fatigue aggravated by heat and sun, deconditioning
- Exaggerated response to medications
- Issues with cognition in half of individuals (appears later)
- Incontinence
- Frequency or retention
- Diarrhea
- Constipation
- Spastic bladder (causes urinary frequency)
- Flaccid/hypotonic bladder (retention)
- ED
- Decreased libido
What is uhthoff’s sign and how does it relate to MS
Where heat actually makes the MS worse
How can we help prevent a person from relapsing with their MS (if they have that type)
- Avoid heat
- Avoid infections
- Avoid stress
- Avoid overexertion
What are vision issues with MS
- Nystagmus (involuntary movement of eyes)
- Optic neuritis, lead to:
- Double vision
- Blurry
- Dull/gray vision
- Pain moving eyes
What cognitive skills are usually safe from MS
Long term memory, conversational skills and reading comprehension
What do people with MS usually die from
Infection, like pneumonia (because you’re not moving around)
What bladder issue are we worried about with MS
Developing a UTI
What is interesting about a women during pregnancy who has MS? What about post-partum?
The pregnancy can cause them to go into remission due to the hormones, but then after pregnancy they are at a greater risk for exacerbation
Do we have a definitive diagnostic test for MS
No - basically we look at history, symptoms, and some tests
What kinds of diagnostic tests can we do for MS
- MRI of the brain and spinal cord looking for plaques, inflammation, atrophy, tissues breakdown and destruction
- Cerebral spinal fluid analysis (might see an increase in immunoglobulin G or the presence of oligoclonal banding, which indicates inflammation)
- Evoked potential study: responses are often delayed because of decreased nerve conduction from eye and ear to brain
So what things would we need in order to state that someone has MS
- Evidence of at least two inflammatory demyelinating lesions in at least two different locations within the CNS
- Damage or an attack occurring at different times, usually greater than 1 month apart
- Rule out all other possible diagnoses
What are the two biggest take away regarding drug therapy for MS
We try to treat the symptoms and prevent lymphocytes from reaching the CNS and causing damage through different drugs like immunomodulators (anti-inflammatory), corticosteroids, etc…
Besides drug therapies, what are other interventions to help slow down the progression of MS
- Exercise, especially early on
- Good sleep
- Proper nutrition
- Stay away from large crowds
Besides drug therapies, what are other interventions to help slow down the progression of MS
- Exercise, especially early on
- Good sleep
- Proper nutrition
- Stay away from large crowd
How can we treat the spasticity of MS
- Muscle relaxants
- Surgery (neurectomy, rhizotomy, cordotomy
- Dorsal column electrical stimulation
- Intrathecal baclofen pump
Should a person with MS exercise during a period of exacerbation
No
What are three benefits of exercise for someone with MS
- Decreases spasticity
- Increases coordination
- Retrains unaffected muscles to act for impaired ones
What is one of the best ways to exercise if you have MS
Water exercise
What are some potential triggers that may cause an exacerbation of MS
- Infections (especially respiratory and UTIs)
- trauma
- Immunizations
- Childbirth
- Stress
- Changes in climate
What are the characteristics of Parkinson’s Disease (PD)
- Bradykinesia (slowness in your movements)
- Rigidity
- Tremor at rest
- Gait changes
What are the causes of PD
Exact cause is unknown, but we think there are some genetic risk factors in combination with environmental risk factors.
What environmental things might increase your risk of developing PD
- Well water
- Pesticides
- Herbicides
- Industrial chemicals
- Wood pulp mills
- Rural residences
What does it mean when we say that someone can have secondary/atypical parkinsonism
Where someone doesn’t have PD, but they have the symptoms of PD caused by either:
- Exposure to chemicals (like carbon monoxide and copper mines)
- Drug induced, such as from lithium, Reglan, Haldol, etc.
- Illicit drug use (like meth)
- Hydrocephalies
- Hypoparathyroidism
- Infections
- Stroke
- Tumor
- Trauma
(Symptoms of PD will typically go away after exposure is gone)
Do Pts with PD, have Lewy bodies in their brain? If so, what does this indicate?
Yes, pts with PD have been found to have Lewy Bodies in their brain, which are clumps of protein and indicate abnormal brain functioning.
What hormone do people with PD have less of compared to others who do not have PD? Why is this important?
Dopamine - this hormone is important for the extrapyramidal motor system, which includes posture, support and voluntary movements.
How would you describe the progression of PD
Gradual and insidious
What are the beginning symptoms of PD
- Mild tremor
- Slight limp
- Decreased arm swing
What are the symptoms of later stage PD
- Shuffling
- Propulsive gait with arms flexed
- Loss of postural reflexes
Describe a tremor for someone with PD
- Often the first sign
- Initially minimal
- More prominent at rest
- Affects handwriting
- Aggravated by emotional stress or increased concentration
- Might look like they’re “pill rolling” with their hand.
Would we see someone with PD develop head tremors
Not usually - getting the head involved in usually from essential tremors.
Will there be any speech abnormalities with PD
Yes, most will develop hypokinetic dysarthria, which is the development of speech abnormalities
Would we say someone with PD has essential tremors?
Someone with PD does not have essential tremors
How would we describe the rigidity of someone with PD
There is a rigidity during passive ROM, where it feels like an increased resistance to that movement.
- Think of it like a cogwheel, where it’s not smooth motion, but jerky motion
What does rigidity cause in someone with PD
- Soreness
- C/o pain in head, upper body, spine and/or legs
What two types of kinesia can you have with someone with PD
- Akinesia - absence or loss of control of voluntary movements
- Bradykinesia - slow movements
What are examples of automatic movements that may be affected by someone with PD due to bradykinesia
- Blinking of the eyelids
- Swinging of the arms while walking
- Swallowing
- Drooling
- Festination (shuffling gait)
- Using facial and hand movements for expression (mask of PD)
- Adjusting posture
How might a doctor assess a person’s ability to stop themselves from falling forwards or backwards if they have PD
Using the “pull test” - give a tug on the pt to see if they can stop themselves
What are nonmotor symptoms of PD
- Depression, anxiety, apathy
- Fatigue
- Pain
- Urinary retention and constipation
- ED
- Memory changes
Are sleep problems common with PD? If so, what problems do we see?
Yes
- Difficulty staying asleep
- Restless sleep
- Nightmares
- Drowsiness during the day
- REM sleep behavior disorder characterized by violent dreams, and potentially dangerous motor activity during REM sleep (this can actually occur before diagnosis of PD - early sign)
What complications do we see develop from PD
- Dyskinesias (spontaneous, involuntary movements)
- Weakness
- Neurologic issues (dementia often develops during progression, which leads to an increase in mortality)
- Neuropsychiatric problems (hallucinations, depression)
- Dysphagia
- Pneumonia
- UTIs
- Orthostatic hypotension
- Loss of postural reflexes (leads to falls)
Is there a specific test to diagnosis PD
No, based on history and symptoms
What is a good way to remember the symptoms of PD
Think of TRAP
Tremors
Rigidity
Akinesia
Postural instability
In order to diagnosis PD, what things need to be present
- TRAP
- Asymmetric onset
- Positive response to antiparkinsonian drugs like levodopa
What is the primary drug tx for PD
Levodopa with carbidopa (helps improve motor symptoms)
What does levodopa with carbidopa do? How does it work?
Levodopa is a precursor of dopamine, and Levodopa can cross the blood-brain barrier and be converted into dopamine, which can help increase dopamine levels. Carbidopa inhibits an enzyme that breaks down levodopa before it reaches the brain.
What is the issue with levodopa/carbidopa
If you are on it for “too long” it may lead to dyskinesias and on/off periods of the drug actually working, so it is conservertial on when to start a pt on this drug. (basically some HCPs do not like to prescribe it early, because the early a person is started on it, the more likely they are to have it where off)
What are surgical therapies for PD
- Deep brain stimulation (used to tx tremors)
- Ablation (takes out part of the brain that they think is causing PD symptoms)
- Transplants of neural tissue where dopamine is being affected
What are the benefits of deep brain stimulation
- Reversible
- Improves motor function.
- Reduces need for medications.
What two things can impair Levodopa and should be mitted to eating at dinner time
Protein and vitamin B6
What is seborrhea
Flaky skin, especially on the hair line (can be seen with PD)
How many people will usually develop PTSD after experiencing a traumatic event in their life
Only 10% will develop PTSD, even though half of all individuals experience a traumatic event in their lifetime
What gender experiences PTSD more?
Women
What would you be diagnosed with if you have difficulties with stress reactions to more “normal” (and less extreme) daily events versus these traumatic PTSD events?
Adjustment disorder
When do we symptoms of PTSD
Symptoms may begin within the first 3 months or be delayed for several months or even years
What two things do you need to have in order to be diagnosed with PTSD
- Need to last at least one month
- Must also cause significant issues in a person’s daily life
What should you automatically do if someone is stating that they are feeling hopeless
Do a suicide assessment
What are symptoms of PTSD
- *Re-experiencing the traumatic event
- *A sustained high level of anxiety or arousal (hyperalert, exaggerated startle response)
- A general numbing of responsiveness
- *Intrusive recollections or nightmares
- Amnesia to certain aspects of the trauma
- Depression; survivor’s guilt (can lead to social isolation).
- *Substance abuse
- *Anger and aggression (can affect job / occupational functioning)
- Relationship problems (w/ feelings of detachment or estrangement from others)
What is someone diagnosed with if their symptoms following a trauma last less than one month
Acute stress disorder not PTSD (symptoms may be the same as PTSD though)
What are the 2 biggest predictors of PTSD
- Severity of the stressor
- Psychosocial isolation or the attitudes from society surrounding the event
What is trauma-informed care
Trauma-informed care generally describes a philosophical approach that values awareness and understanding of trauma when assessing, planning, and implementing care. (basically being aware that most people have experienced a trauma in their lifetime - and we should work to avoid doing things that might retraumatize them, like putting our hands on them)
How can trauma-informed care be helpful to individuals
It can provide them with the tools to lead their own care, which gives them a sense of power and control
What are two nursing diagnoses for trauma-related disorders
- Post-trauma syndrome
- Complicated grieving
What are our desired outcomes with pts with trauma and PTSD
- Can acknowledge the trauma and impact on his/her life
- *Can demonstrate adaptive coping strategies
- Has made realistic and healthy goals for the future
- Has worked through feelings of survivor’s guilt (encourage them to talk about trauma when they are able).
- Attends support group of individuals recovering from similar traumatic experiences
- Verbalizes desire to put trauma in the past and progress with his or her life
- Obtain adequate sleep without medication.
Define adjustment disorders (when you are dealing with a stressor or trauma)
Characterized by a maladaptive reaction to an identifiable stressor or stressors that result in the development of clinically significant emotional or behavioral symptoms
What is the difference between PTSD and adjustment disorders
Symptoms of adjustment disorders occur within 3 months of the stressor and last no longer than six months, versus PTSD which can last a lifetime. (adjustment disorders have a resolution versus PTSD which may not have a resolution)
What type of adjustment disorder is most commonly diagnosed
Depressed mood
What are the symptoms of a depressed mood adjustment disorder
Not as bad as a major depressive disorder, but the pt is still depressed, tearful, feeling hopeless, but these symptoms exceed the expected or normative response to an identified stressor (basically they are responding in a very depressed manner, that is not typical)
What are biological factors that may predispose a person to adjustment disorders
- Genetics
- Vulnerability related to neurocognitive or intellectual developmental disorders
What are some psychosocial factors that may contribute to someone developing an adjustment disorder
- Childhood trauma, dependency, arrested development
- Constitutional factor (birth characteristics)
- *Developmental stage in life and timing of the stressor
- Available support systems
- Dysfunctional grieving process
- Situation factors (financial issues)
What treatments can we use to help with trauma-related disorders (like PTSD and acute stress disorder)
- Cognitive therapy
- Prolonged exposure therapy (may not be the best)
- Group/family therapy (helpful for military)
- *Eye movement desensitization and reprocessing
- Psychopharmacology
What is eye movement desensitization and reprocessing
Using rapid eye movements while processing painful emotions, which can lead to a decrease in imagery vividness and distress with an increase in memory access (think about the traumatic event and focus on the therapist finger)
What is the first line of tx for PTSD
SSRIs
What is the treatment for adjustment disorders
*Individual psychotherapy (most common)
- Family therapy
- Behavior therapy
- Self-help groups
- Crisis intervention
- Psychopharmacology
What is a paranoid personality disorder
Individuals with this disorder are SUSPICIOUS of others’ motives and assume that others intend to exploit, harm, or deceive them.
What gender is more affected by paranoid personality disorder
Men
What are 2 predisposing factors for a paranoid personality disorder
- Possible hereditary link
- Subject to humiliation and harassment
If someone with a paranoid personality disorder was subject to humiliation and/or harassment, why would they develop this mental illness
It has caused them to build up a wall and not trust people, so in order to protect themselves, they are ready to attack any threat
How would we approach someone with a paranoid personality disorder
Show confidence, and respond back in a calm and clear manner
What are signs of a paranoid personality disorder
- Constantly on guard
- Hypervigilant
*Ready for any real or imagined threat – can result in aggression - Trusts no one
- Constantly tests the honesty of others
- Insensitive to the feelings of others
- Oversensitive
- Tends to misinterpret minute cues
- Magnifies and distorts cues in the environment
- Does not accept responsibility for his or her own behavior
- Attributes shortcomings to others
What is a schizoid personality disorder
Person is unable to form relationships, as they appear eccentric, isolated, or lonely to others and show signs of not wanting to interact (the cat lady - they prefer to be alone)
What are the symptoms of schizoid personality
- Aloof and indifferent to others
- Emotionally cold
- No close friends; prefers to be alone
- Appears shy, anxious, or uneasy in the presence of others
- Inappropriately serious about everything and has difficulty acting in a lighthearted manner
What is the difference between schizoid and schizotypal personality disorders
Schizotypal is more graver and closer related to schizophrenia
What is interesting about schizotypal and schizophrenia
A person with schizotypal shows the odd and eccentric behavior of schizophrenia, but not as bad (basically you might think they’re schizophrenic, but they’re not)
What are symptoms of schizotypal
- *Aloof and isolated
- *Behaves in a bland and apathetic manner
- Magical thinking
- Ideas of reference
- Illusions
- Depersonalization
- Superstitiousness (believe in the 6th sense, may think that dead people are talking to them, etc)
- Withdrawal into self
How is an antisocial personality disorder described
- Socially irresponsible
- Exploitative
*Without remorse or guilt
(Think of Brooks)
As nurses, how can we help treat someone with an antisocial personality disorders
Set limits, define the rules and stick to them (don’t be flexible on these rules)
In prisons, what percentage of inmates have antisocial personality disorders
50%
What are common behaviors of antisocial personality disorder
- Exploitation and manipulation of others for personal gain (thinks it’s everyone for themselves)
- Belligerent and argumentative
- Lacks remorse
- Unable to delay gratification
- Low frustration tolerance
- Inconsistent work or academic performance
- Failure to conform to societal norms
- Impulsive and reckless
- Inability to function as a responsible parent
- Inability to form lasting monogamous relationship
- Use projection as a primary ego defense mechanism
What are possible predisposing factors for antisocial personality disorder
- Possible genetic influence
- Having a disruptive behavior disorder as a child (attention deficit/hyperactivity disorder; conduct disorder)
- History of severe physical abuse
- Absent or inconsistent parental discipline
- Extreme poverty
- Removal from the home as a child
Can a child be diagnosed with an antisocial personality disorder? If not, what are they diagnosed with?
No - as a child they will be diagnosed with a conduct disorder, which can lead to a diagnosis of antisocial personality disorder in adulthood
Besides setting limits and rules, what other strategies can you implement when dealing with someone with antisocial personality disorder
- Do not try to coax or convince the pt to do the “right thing”
- Provide positive feedback
- Talk about past behaviors
What are common behaviors of borderline personality disorder
- Frequent mood swings (can even change within minutes)
- Always in a “crisis”, “everything is the end of the world”
- Thrive on chaos, particularly in interpersonal relationships
- Chronic depression
- Bipolar disorder
- Inability to be alone
- *Clinging and distancing behaviors
- *Splitting (“pit staff against each other)
- *Manipulation
- *Self-destructive behaviors (self-mutilation to get attention following feelings of abandonment, “they’ll cut themselves when they know someone is around”, they often attempt these behaviors when they know someone is around and looking)
- Impulsivity
Who develops borderline personality disorders more, men or women?
Women, may even be as high as 4:1
How should we approach someone with borderline personality disorder
Be firm, consistent and empathetic
Should you have one staff member always working with the same patient with borderline personality disorder
No, you should rotate staff, so they’re not manipulating one staff member against another to get their own desires
What are symptoms of histrionic personality disorders
- Self-dramatizing (“look I’m gonna bleed out”)
- Attention-seeking
- Overly gregarious
- Seductive
- Manipulative
- Exhibitionistic
- Highly distractible
- Difficulty paying attention to detail
- Easily influenced by others
- Difficulty forming close relationships
- Strongly dependent on others
- Somatic complaints are common
What are symptoms of narcissistic personality disorder
- Overly self-centered
- Exploits others in an effort to fulfill own desires
- Mood, which is often grounded in grandiosity, is usually optimistic, relaxed, cheerful, and care-free.
- Because of fragile self-esteem, mood can easily change if clients do not: Meet self-expectations and Receive the positive feedback that they expect
- Criticism from others may cause them to respond with rage, shame, and humiliation (basically - if they don’t receive attention, they throw a fit).
How is avoidant personality disorder characterized
- Extreme sensitivity to rejection
- Social withdrawal
What is interesting about avoidant personality disorder
They desire to have intimacy and form relationships, but they are extremely shy and fearful of rejection
What are symptoms of avoidant personality disorder
- Awkward and uncomfortable in social situations
- Desire close relationships and intimacy, but avoid them because of fear of being rejected
- Perceived as timid, withdrawn, or cold and strange
- Often lonely and feel unwanted
- View others as critical and betraying
What is the difference between schizoid and avoidant personalities
With schizoid, they don’t want to form relationships at all, but with avoidant, they do want to form relationships
What is an interesting predisposing factor that can influence a dependent personality disorder
When stimulation and nurturance is experienced exclusively from one source made in infancy
What are symptoms of a person with a dependent personality disorder
- Has notable lack of self-confidence that is often apparent in:
- Posture
- Voice
- Mannerisms
- Overly generous and thoughtful, while underplaying own attractiveness and achievements
- Low self-worth and easily hurt by criticism and disapproval
- Avoid positions of responsibility and become anxious when forced into them
- Assume passive and submissive roles in relationships
What is the difference between obsessive-compulsive personality disorder and obsessive-compulsive disorder
With obsessive-compulsive personality disorder, it’s about their personality, not their obsessive actions.
How would we characterize someone with obsessive-compulsive personality
Inflexible, with a lack of spontaneity, they are meticulous and like to do things a certain way.
How can we treat these different personality disorders?
- Interpersonal psychotherapy
- Psychoanalytical psychotherapy
- Milieu or group therapy
- Cognitive/behavioral therapy
- Dialectical behavior therapy
- Psychopharmacology (not used for antisocial personality - this disorder does not need any medication)
What fuels someone to be an aggressor
The aggression and violence itself give that person a sense of power and prestige that increases their self-esteem (these people want power, and thrive off of having it)
What is battering
a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner.
What does a victim of partner violence look or have
- *Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups
- Low self-esteem
- Inadequate support systems (feel isolated and unsupported)
- Some grew up in abusive homes
What is the profile of the victimizer
- Low self-esteem
- Pathologically jealous
- “Dual personality” - shows the public one thing, but is different behind closed doors
- Limited coping ability
- Severe stress reactions
- *Views spouse as a personal possession
- *Many times will ignore small children, but kids can become targets of abuse as they get older
What are the three phases of battering
- Phase one - tension - building (women can tell that something might happen, so the women is trying to do everything to prevent it, she may also be blaming the abuse on something else, “he’s just stressed from work”, “it’s just the alcohol”, minor battering may be occurring, woman feels guilty,)
- Phase two - Most violent, usually lasts 24 hours or less, acute battering incident (man may rationalize behavior - “it was her fault”, man at the end can’t understand what happened)
- Phase three - calm, loving phase. He will promise that he won’t do it again. The women thinks that this phase is the best phase in their relationship - this gives her hope, and can keep her from leaving. This is the best their relationship has ever been.
What is the biggest reason why women stay in abusive relationships
Fear for their lives and the lives of their children, they feel powerless
If a women leaves an abusive relationship, what is the percentage that she is going to be killed by her partner
75% risk of being killed by their partner
What is an indicator that a child has been abused
They are rightened of adults and *SHRINK when an adult approaches
What are signs of emotional child abuse
- Extremes of behavior
*Delayed physical or emotional development - Lack of attachment to parent
What are behavioral indicators of neglect
- Seems apathetic, depressed and tired
- Is frequently absent from school
- Begs or steals food or money
- Lacks needed medical or dental care, immunizations, or glasses
- Is consistently dirty and has severe body odor
- Lacks sufficient clothing for the weather
- Abuses alcohol or other drugs
- States that there is no one at home to provide care
What are indicators that a child has been sexually abuse
- Has difficulty walking or sitting
- Reports nightmares or bedwetting
- Experiences a sudden change in appetite
- Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior
- Becomes pregnant or contracts a sexually transmitted disease
What are the characteristics of child abusers
- Parents who abuse their children were likely abused as children themselves.
- Numerous stresses
- Poverty
- Social isolation
- Absence of adequate support systems
- Lack of knowledge of child development or care needs
What are 4 victim responses to rape
- Expressed response pattern (survivor has fear or anxiety, basically has issues expressing their response to the rape)
*Controlled response pattern (monotone response to the rape) - Compounded rape reaction (depression and suicide features)
- Silent rape reaction
What are 2 ways that we can care for someone who has been raped
- Stay with them to provide a sense of security
- Promote trust through nonjudgmental active listening
- Don’t try to probe for information
What are the causes of PD
Exact cause is unknown, but we think there are some genetic risk factors in combination with environmental risk factors.
Do we see any cognitive issues with myasthenia gravis
No - they are fine cognitively, they also don’t have any sensory loss, issues with reflexes or muscle atrophy
What is the difference between obsessive-compulsive personality disorder and obsessive-compulsive disorder
With obsessive-compulsive personality disorder, it’s about their personality, not their obsessive actions.
What is a crisis
- sudden event in one’s life, during which usual coping mechanisms cannot resolve the problem; the crisis disturbs homeostasis
What are the 6 types of emotional crises
- Dispositional crisis (acute response to an external situational stressor)
*2. Crisis of anticipated life transitions (anticipated event occurs but the individual feels overwhelmed and feels like they have lack of control) - Crisis resulting from traumatic stress
- Maturational/developmental crisis (just didn’t didn’t develop in a way to help deal with stressors)
- Crisis reflecting psychopathology (can’t function due to mental disease)
- Psychiatric emergency (self-harm)
What is happening in a crisis of anticipated life transitions? What can we do?
Normal life-cycle transition that may be anticipated but over which the individual may feel a lack of control (and may feel overwhelming) (like John - in school and just had a baby)
- Reassurance and guide the patient as needed, and refer the patient to services that can assist.
What is happening in a psychiatric emergency
A crisis situation in which general functioning has been severely impaired and the individual is rendered incompetent or unable to assume personal responsibility, which can lead the individual towards actions to self harm or harm others
(high school student has a terrible breakup, then takes pills to try and end their life)
What are the four phases in a crisis intervention
- Assessment: gather information on the stressors that caused the crisis and why the individual seeked help and desire to confront the source of the problem
- Planning:
- Select a diagnoses and actions, *taking into consideration the type of crisis, as well as their strengths, desires, and available resources for support)
- State desired outcome - Interventions: build a relationship and guide through problem-solving process.
- Evaluation: Terminating relationship after resolution, also assess to see if they need follow-up care and help them find this follow-up care.
When were doing interventions for a pt in crisis, what are we helping them do, overall?
Helping them through problem solving (how can we solve this crisis?)
Why do we call anger a secondary emotion
Because it’s a learned behavior - we can learn to control these angry behaviors
What is one of the strongest influences of anger
Role modeling - if a child witnesses when they are younger, than they tend to use anger more for expression
What are symptoms of aggression
- Pacing; restlessness
- Verbal/physical threats
- Threats of homicide or suicide
- Loud voice; argumentative
- Tense facial expression and body language
- Want to punish someone
What is the broset violence checklist
quick, simple, reliable tool to assess risk of potential violence. Assesses things like confusion, boisterousness, irritability, threats, attacks. (helps to see where people lie in terms of aggression)
What is one of the strongest forms of learning
Role modeling - make sure you are being calm, don’t raise your voice, the other person will usually match this behavior.
For someone who has anger/aggression, what should we do
Set firm limits on behavior, remain calm, clearly outline consequences for behavior.
How many phases are there in the development of schizo
4
What is phase 1 of schizophrenia
Called the premorbid phase:
- Shy and withdrawn
- Poor peer relationships
- Doing poorly in school
- Antisocial behavior
What is phase 2 of schizophrenia
Prodromal phase:
- Lasts 2-5 years
- Deterioration in role functioning and social withdrawal
*Substantial functional impairment
- Depressed mood, poor concentration, fatigue
- Sudden onset of obsessive-compulsive behavior
What is phase 3 of schizophrenia
Acute phase:
- In the active phase of the disorder, psychotic symptoms are prominent.
Delusions
Hallucinations
Impairment in work, social relations, and self-care
What is phase 4 of schizophrenia
Residual phase:
- Symptoms similar to those of the prodromal phase.
- The hallucinations and/or delusions are either absent or weak
- Flat affect and impairment in role functioning are prominent.
If schizo is a chronic illness, why do we have phases?
Because it can have periods of exacerbation and remission, so someone can move continuously through the phases
What factors can allow someone to have less exacerbations of schizophrenia
- Good premorbid functioning
- Later age at onset
- Female gender
- Abrupt onset precipitated by a stressful event
- Associated mood disturbance
- Brief duration of active-phase symptoms
- Minimal residual symptoms
- Absence of structural brain abnormalities
- Normal neurological functioning
- No family history of schizophrenia
What are biochemical factors that may predispose someone to schizo
- The dopamine hypothesis suggests that schizophrenia may be caused by an excess of dopamine activity in the brain - this chemical imbalance of the brain leads to altered perceptions
What are physiological factors that may predispose someone to schizo
Viral infection
Anatomical abnormalities
Electrophysiology
* Epilepsy (neurological conditions)
Huntington’s disease
Birth trauma
Head injury in adulthood
Alcohol abuse
Cerebral tumor
Cerebrovascular accident
How do we think schizo appears
Someone is already predisposed genetically, but then they have something happens in their life that triggers that schizo to appear
What 7 disorders fall into the category of schizotypal personality disorders (from least to most severe)
- Delusional disorders
- Brief psychotic disorder
- Substance and medication induced psychotic disorder
- Psychotic disorder due to another medical condition
- Catatonic disorder due to another medical condition
- Schizophreniform disorder
- Schizoaffective disorder
What are the 6 types of delusional disorders
- Erotomanic type (believes someone, usually of higher status is in love with them)
- Grandiose type (exaggerated feeling of importance)
- Jealous type (sexual partner is unfaithful)
- Persecutory type (being persecuted in some way)
- Somatic type (thinks they have something wrong with them medically)
Mixed type
What is the grandiose type of delusional disorder
Think they’re a famous person or they’re higher up “thinks their the owner of the hospital.
What is schizoaffective disorder
Schizophrenic signs and symptoms accompanied by a strong element of symptomatology associated with mood disorders of either mania or depression
24-2 box in book (look at positive and negative symptoms, “you are giving a client, here is what they are doing, what word fits them” (from slide 40)
Look at box 24-2
What are forms of thoughts (speech) do we see from schizos
- *Associative looseness (also called loose association): Shift of ideas from one unrelated topic to another within same set of sentences.
- *Neologisms: Made-up words that have meaning only to the person who invents them
- Concrete thinking: Literal interpretations of the environment
- Clang associations: Choice of words is governed by sound (often rhyming)
- Word salad: Group of words put together in a random fashion
- Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details
- Tangentiality: Inability to get to the point of communication due to the introduction of many new topics
- Mutism: Inability or refusal to speak
Perseveration: Persistent repetition of the same word or idea in response to different questions - *Echolalia: Repeating words or phrases spoken by another person (they repeat back the exact same thing you said)
What is interesting about hallucinations
*They can involve all 5 sense - in your hallucinations you may smell oranges, even though there aren’t any oranges around
What are the 5 senses described
- Auditory
- Visual
- Tactile
- Gustatory (taste)
- Olfactory
What is echopraxia
Imitating movements made by others
What are examples of negative symptoms
- Affect (such as a flat affect)
- Avolition (can’t complete ADLs)
- Asociality (withdrawal from others)
- Anosognosia (lack of insight - inability to perceive illness)
- Anergia - deficiency in energy
- Anhedonia - inability to experience pleasure
Can we ask what the voices are telling the patient
Yes - so we know if the voices are telling them to try and kill themselves, etc.
Should we tell a pt with schizo that the voices that they hear aren’t real
No - just tell them that you don’t hear them
What types of affects might a shizo have
Inappropriate affect: Emotions are incongruent with the circumstances
Bland: Weak emotional tone
* Flat: Appears to be void of emotional tone
Apathy: Disinterest in the environment
458-460 look at the interventions
What should you do and not do with schizo
- Don’t touch them unless you tell them that you’re going to touch them
- Don’t hold eye contact for too long
Can group therapy be effective for schizo?
Yes, in an outpatient setting
What are some social skills training that we can do for someone with schizo
- Social skills training: Use of role play to teach client appropriate eye contact, interpersonal skills, voice intonation, posture, and so on; aimed at improving relationship development
- Supportive family therapy: Aimed at helping family members cope with long-term effects of the illness
What symptoms should you tell a pt or family member to look for while on a psychotic
IMMEDIATELY report any of the following sx to DR: sore throat, fever, malaise, unusual bleeding, easy bruising, persistent nausea and vomiting, severe headache, rapid heart rate, difficulty urinating, muscle twitching, tremors, darkly colored urine, excessive urination, excessive thirst, excessive hunger, weakness, pale stools, yellow skin or eyes, muscular incoordination, or skin rash.
What is some good pt education while on an antipsychotic
- Use sunscreen and wear protective clothing when spending time outdoors.
- Do not drink alcohol while receiving antipsychotic therapy.
- Do not consume other medications (including over-the-counter drugs) without the physician’s knowledge.
- Be aware of possible risks of taking antipsychotics during pregnancy.
- Rise slowly from a sitting or lying position to prevent a sudden drop in blood pressure.
What medication will people need to receive weekly blood draws to check the therapeutic levels
Clozapine
What type of medication might also be prescribed to a schizo that can help restore the balance between acetylcholine and dopamine
Antiparkinsonian agents may be used to help treat schizo
What are some side effects of the antiparkinsonian meds
- Anticholinergic (dry mouth, constipation, urinary retention)
