UNIT 4- Schizophrenia Flashcards
What is schizophrenia?
- Brain disease diagnosed in late adolescence or early adulthood. Part of a spectrum or continuum of a broad range of disorders.
- SSDs some of the more disabling types of mental illness usually, chronic and it can effect how a person thinks, feels, and behaves
What is the DSM-5 criteria for schizophrenia?
Two (or more) of the following, present for 1 month duration:
1. Delusions
2. Hallucinations (any sensory)
3. Disorganized speech
4. Disorganized or catatonic behavior
5. Negative symptoms
Primary Schizophrenia psychotic disorder is characterized by?
- Psychosis
- Hallucination
- Delusions
- Disorganized thoughts
- Abnormal motor behavior
- Negative symptoms
What are the concept of psychosis (mainly review for me)
- Neurocognitive symptoms impairing cognitive capacity
- Deficits in perception, functioning and social relatedness
- Primary psychosis is derived from schizophrenia spectrum disorders
- Secondary psychosis derived from substance intoxication and dementia or withdrawal from drugs
- Primary and secondary can coexist and may potentiate each other
What is the course and description of schizophrenform disorder?
Course: Symptoms must last at least 1 month but NO more than 6 months
Description: Essential features are identical those of schizophrenia but of shorter duration
What is the course and description of brief psychotic disorder.
Course: Usually no longer than a month; person returns to premorbid functioning; usually precipitated by extreme stress
Description: Sudden onset of psychiatric symptoms
What is the course and description of schizoaffective disorder?
Course: Better prognosis than schizophrenia but significantly worse than a mood disorder
Description: Symptom of mood disorder; major depressive, manic, or mixed episode, concurrent with symptoms that meet the criteria for schizophrenia. Common psychotic disorder
What is the course and description of schizotypal personality disorder?
Course: May progress to developing schizophrenia
Description: Personality disorder considered part the schizophrenia spectrum disorders (DSM-5); shares common genetics and neuropsychiatric characteristics. Intense discomfort with close relationships
What is the course and description of delusional disorder?
Course: Ranges from remission without relapse to chronic waxing and waning; symptoms must last at least 1 month
Description: Involves nonbizarre delusions such as being followed, infected, loved at a distance, or deceived by a spouse; having some great or unrecognized insight; ability to function is not markedly impaired and behavior is not obviously odd or bizarre. Delusions of persecution are the most common
What is the course and description of substance/medication-induced psychotic disorder?
Course: Psychosis usually resolves
Description: Caused by ingestion of or withdrawal from a substance.
Which onset of schizophrenia is better? Slow onset or abrupt?
Abrupt onset with good premorbid functioning has better prognosis, greater chance of remission/complete recovery.
Slow onset usually has poorer prognosis (2-3 years)
Child onset of schizophrenia is…
RARE
Early age of onset for schizophrenia is associated with?
- Structural brain abnormalities
- More negative and disabling symptoms
- Poorer prognosis
What are some comorbidity to schizophrenia?
- 50% have substance use disorder
- 50% tobacco use disorder
- Strong correlation of cannabis use and psychotic disorder
- Methamphetamine and LSD
- Schizophrenia increases the abuse of cannabis
- Premature death due to non-psychiatric illness- malnutrition, criminal activity
- Concurring
- Depressive disorder
- 20% attempt suicide
- 6-10% commit suicide
- Anxiety/panic disorder
- OCD
- Schizotypal and paranoid personality disorder may develop into schizophrenia
What should we know about the course and prognosis of schizophrenia?
- Recurrent acute exacerbations of psychosis
- Periods of full or partial remission
What is primary and secondary interention of schizophrenia?
Primary: Target people at high risk
Secondary: Intervening early and reducing duration of untreated diagnosis
What are the phases of schizophrenia?
- Prodromal occur in 80-90% of people. Early reognition and treatment are vital
- Acute phase- severe and well-developed symptoms
- postive symptoms
- negative symptoms
- cognitive/neurocogntive symptoms
- Mood symptoms
- Stabilization phase- not having dulusions or psychosis because meds are working
- Maintenance phase- this is where we want our patient to stay as much as possible. Patient education is important esp. once patient is out of the psychosis
What are the risk factors associated with schizophrenia?
- Genetic factor
- Alteration in brain structure
- Brain’s neurotrasmitter system disruptions
- Alterations to neural circuts
What are some neurochemical contributing factors to schizophrenia?
More so for review
- Hyperactive dopamine transmission in the mesolimbic area
- Hypoactive dopamine transmission in the prefrontal cortex
- Dyregulation in multiple other other areas of the brain
- abnomral levels of serotonin may cause some of the negative symptoms and mood symptoms
- NMDA (N-methyl-d-asparatate) an amino acid is iplicated in the psychotic, negative and cognitive symptoms
- Glutamate activity insuffcieency or excess with other neurotransmitters
If both parents have schizo what is the likely hood a child will have it?
46%
What are some non genetic risk factors of schizophrenia?
- viral infection affecting neurogensis
- poor maternal nutrition
- exposure to toxins
- perinatal complications and births
- closed head injuries after birth
- advacnced parental age
- overactive immune system
- first and second-generation immigrants stress
What are some cultural considerations for schizophrenia?
- Hallucinations shaped by cultural expectations
- Source of mental illness
- attributed to spiritual versus religious or supernatrual or biomedical
- can affect adherence to medication and other tx
- Hearing voices network believes it may be possible to improve relationships with voices by respecting, understanding and adapting to the voices
What are secondary causes of psychosis in schizophrenia?
- brain tumors
- cysts
- dementia
- neurological diseases
- environemental toxins
- misuse of and addictions to prescription meds
What are postive signs of schizophrenia?
KNOW
- Hallucinations
- Delusions
- Bizarre behavior
- Catatonia
- Formal thought disorder
What are negative symptoms of schizophrenia?
KNOW
- Apathy
- lack of motivation
- Anhedonia
- blunted or flat affect
- poverty and speech- doesnt respond with many words
- Social withdrawal
What are cognitive symptoms of schizophrenia?
KNOW
- Impairment in memory
- disruption in social learning
- Inability to reason, slve problems, focus attention
What are mood symptoms of schizophrenia?
- Depression
- Anxiety
- demoralization
- suicidality
- excitability
- agitation
What are some types of delusions?
- Mind reading
- Somatic:
- Idea of reference
- Persecution
- grandiose (religious)
- jealosuy
- Control
- Thought broadcasting
- Thought insertion
- Thouhght withdrawal
- Concrete thinking
What is somatic delusions?
A belief about the meaning of a phsycial sensation
Example: snakes are eating out my stomach
What are ideas of reference delusions?
The person believes a neutral event has a special and personal meaning
Example: a person drives by a billboard and starts to believe the message on the bill board was private and personal message
What is a delsuion of persecution?
A belief that “others” are out to harm that person. Paranoid delsions put the patient at risk for harm to self and others
Example: I know my enemies were actively trying to interfere with with activites, were trying to harm me, and even kill me
What are delsuions of grandiosity?
An unrealistic sense of superitiory
Example: I felt that I had the power to determin ethe weather, which responded to my inner beliefs
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What are delusions of jealousy?
A feeling of envy over someone else’s achievemetns or advantages or advantages or unfolded suspicion that someone is unfaithful
example: my spouce is always cheating on me
What is the delsuion of control?
- Belief that one’s body or mind is controled by outside force or agency
exmaple: There is a man from darkness who controls my thoughs with electrical waves
What is the delusion of thought broadcasting?
- Belif that one’s thoughts can be heard by others. This type of delsuion can make the assessment of a patients thinking more challenging for the nurse
Example: a women refuses to explain her problems, saying I know you know what I am thinking. Everybody hears what I am thinking
What is the delusion of thought insertion?
Belief that thoughts of others are being inserted into one’s mind
Example: They make me think bad thoughts
What is the delusion of thought withdrawal?
- Belief that thoughts have been removed from one’s mind by an outside agency. People experiencing thought withdrawal may experience other irregulatrities in speech and thinking such as thought blocking
exmaple: the devil takes my thoughts away and leaves my empty
What is concrete thinking?
Refers to an overemphasis on specific detail and a literal interpretation of ideas. It is contrasted with abstract thinking. The anwser is literal; the ability to use abstract reasoning is lessened or absent
What is associative looseness?
Thinking becomes haphazard, illogical and confused. Illogical shifts between topics
What is tangential speech?
It is when the train of thought of a speaker wanders off in another direction, never returning to the inital topic
example: I went downtown last night. Nighttime is the best ime of the day. Daybreak brings sunshine
What is circumstantility?
using excessive detail that distracts from the central idea of a conversation. The patient has difficulty separating relevant and irrelevant information when describing an event. The speaker does eventually complete the thought
What is neologisms?
Made up words that have special meaning for the person
example: I was going to tell him the mannerologies of his hospitaltiy wont do. I want all the vetechkisses to leave the room and let me be
Use of neologism in children and creative writers is considered imaginatives, contstructive and adaptive. In people with a diagnosis of schizophrenia, neolgisms represent a disruption in thought and speech
What is word salad?
- represents futher deterioration of the ability to connect thougths in a coherent fashion. It is a term used to identify a jumble of words that is meaningless to the listener and perhaps to the speaker as well. It may include a string of neologisms
2.
What is echolalia?
- It is pathological repeating of anthers words by imitation. Echolalia is the counterpart of echopraxia, defined as mimicking the movments of another. Both are often seen in people with cataonia
What are clang associations?
- is the meaningless rhyming of words, often in a forceful manner. The rhyming is more often more important than the context of the word. This disruptive speech pattern may be associated with schizophrenia;bipolor disorder during a manic phase; or a cognitive disorder such as alzheimers disease or HIV related dementia
Exmaple: On the track….have a big mack… or get the sack
What is pressured speech?
Talking fast to the point others dont have a chance
What is thought blocking?
- Patient stops talking the the middle of a sentence and remains silent
What are exmaples of alterations in speech?
- Associative looseness
- Tangential
- Clanging
- Neologisms
- Echolalia
- Word salad
- Circumstantilality
- Pressured speech
- Thought blocking
What are some examples of alterations in perception?
- Hallucinations- auditory, somatic (tactile), olfactory, visual, gustatory
- Illusions- misinterpretations of real experiences
Why do schizophrenia patients have difficulty with personal boundries?
- Lack of sense where bodies end and other’s begin
- Depersonalization: feeling disconnected or detached from ones body and thoughts- “feeling like I am observing myself outside of my body” or I am not connected to my arm
- Derealization: Alteration in perception or experiences of the external world so that it seems unreal. sights and sounds may be described as muted, strange, or unreal.
What are some examples of alterations in behavior?
- Catatonia
- Bizarre behavior
- Eccentric dress, groming rituals (may not groom and may wear unrelated items of clothing)
- Agitation or agressivness
- Impaired boundaries
- Impaired impulse control- whatever comes to mind they do. They cannot stop themselves
- Odd social or sexual behaviors- may take off clothes, inappropriate sexual behaviors in public…
What is catatonia?
- Extreme motor agitation or extreme psychomotor retardation
- sterotyped behaviors
- automatic obedience
- bizarre posturing
- waxy flexibility - strange postering where the hold positions
- negativism- sometimes do the oppisite of what they are told
- Stupor- Talk to them but they do not respond they just look at you like they dont understand what you are saying
What are some negative symptoms of schizophrenia?
- Apathy/avolition
- Lack of motivation
- Blunted or flat affect
- poverty or speech- aliogia is the same thing
- Social withdrawal
- Anhedonia- lack of pleasure in things they once found pleasurable
- Asociality- social withdrawal… few relationships and just very socially inattentive
What are some neurocognitive/cognitive symptoms of schizophrenia?
- Affects 40-60% of people with schizophrenia
- Poor executive function
- inability to sustain attention
- Problems with working memory
- inability to reason
- Inability to problem solve
What are some mood symptoms of schizophrenia?
- Anxiety
- Depression
- Suicidality
- Dysphoria
- Postpsychotic depressive disorder (25%) increases risk of suicide- this is where patient becomes aware they have an issue
- demoralization- loss fo confidence
- excitability
- agitation
- increase in substance abuse
What should we know about paranoia in schizophrenia?
- Projection
- Speak indirectly. Do not use I and you. Use he or she, directing paranoid symptoms towards eternal and more general issues
- Identify with the patient, helping patient feel more understood. Emphathize
- Share mistrust without supporting delusions find something to agree on with patient
What should we know about disorganization and schizophrenia?
- Poor premorbid functioning
- Poor prognosis
- Social withdrawal
- severe cognitive impairment
- requires structured and well supervised settings
What should we know about schizoaffective disorders?
- Features of schizophrenia and symptoms of mood disorders of either bipolar or major depression
- Treat psychosis as well as the mood disorder
Assessment guidelines for schizophrenia include?
- **Suicide ** risk (harm to self)
- Risk of** violence** (harm to others)
- Command hullucinations
- Delusions
5.** Substance **use/abuse - Medical work up
- Co-occuring disorders: depression and anxiety
- Self care and safety
- Medication use and adherence
- **Postive & negative **symptoms
- Patient’s insight & coping
- **Support **system– key to succsess but a huge problem is that these patients tend to have burned most of there bridges prior to an diagnosis because it came so late
What are some standardized screening tool for schizophrenia?
- Brief psychiatric rating scale (BPRS)
- Postive & Negative syndrome scale
- Abnormal involuntary movement scale (AIMS)- nurses can do this one it helps detect invountary movments
- Mini-mental state examination (MMSE)
Nursing diganosis and problems for schizophrenia patients?
Mostly review
- Risk for self-directed/other directed violence
- Ineffective impulse control
- Social isolation
- Distorted thinking process
- Impaired verbal communication
- Impaired family coping
- Self care deficit
- Difficulty coping
- Risk for suicide
- Ineffective health maintenance
What our nursing plan for patients with schizophrenia?
- Crisis intervention-hospitalization
- Observation
- Symptoms stabilization
- Teach relapse prevention strategies
- Discharge planning
How can we implement our nursing plan for patients with schizophrenia?
- Psychopharmacological- if medication adherence is suspected to be an issue think about long term meds
- Milieu
- Establish a trusting relationship
- Therapeutic communication
- Health teaching and promotion- done more than once and not during the acute phase
- Social services
What should we keep in mind regarding touching of a schizophrenic patient
- Be cautious with touch as it may be perceived as threatening
What tone of voice should be used when communicating with a schizophrenic patient?
Calm, quiet tone
How should we communicate with a schizophrenic patient regarding their hallucinations/delusions?
- Elicit descriptions of hallucinations/dulustions to ensure safety
- Don’t comfornt or argue truth/falsehood of their ideas
- Help present and maintain reality
- Focus on feelings
How should we handle inappropriate behavior with a schizophrenic patient?
Deal with inappropriate behaviours in a non-judgmental manner
What should we teach a patient with schizophrenia regarding communication?
(general)
Social skills through education, role modeling and practice
How should we deal with a schizophrenic patient who is highly suspicious & hostile?
Allow the patient as much control as possible within limits, explain the treatments, meds, lab tests before initiating them. They may see us a as a threat if we do not explain
How should we handle a schizophrenic patient whi is aggressive and agitated?
Increase supervision, decrease stimulus, desculate verbally, offer medication
How should we handle a schizophrenic patient with hullucinations/delusions?
Ask directly, “are you hearing voices?”, “what are they saying?” reduce stimulus. focus on feelings and reality, not delusions
What are our interventions for hallucinations?
- Empathy
- Identify the feelings patient is experincing within the hallucination
- Explain that we do not hear the coice
- Ask the patient to turn away from the voices
- Distract attention
- Calm demeanor and milieu
What are our interventions for delusions?
- Empathy
- Identify the feelings patient is experiencing
- explain that we do not hear the voices
- Ask the patient to turn away from the voice
- Distract attention
- Calm demonor and mileu
- Do not touch patient and use gestures carefully
- Do not arguee with the patients beliefs
What are our interventions for paranoia?
- Place yourself beside the patient, not face to face
- Avoid eye contact
- Offer food and drinks in CLOSED containers
- DIstraction with reality based activites
- Use restrictive interventions if anxiety escalates
What are our interventions for associative looseness?
- Do not pretend that you understand the patients communication
- State “I am having diffult time understanding or I am having trouble following what you are saying”
- Piece together what they are saying by looking for recurring topics
- Involve patient in simple reality based activites
What can we teach our patient and family about regarding schizophrenia?
general
- Illness (causes, self-care)
- Medication side effects, management and follow-up
- Early signs of relapse & develop a prevention plan
- avoiding alcohol and drugs
- Building a support team
- community resources
What psychotherapy and psychoeducation should we inform our patients about with schizophrenia?
- PACT (psychobiological approach to couples therapy)
- ACT (acceptance and commitment therapY)
- Family psychoeducation therapy- engages family, improves caregivers’ postive well-being and reduce burden of care
- Cognitive behavioral therapy- correct self- defeating behavior
- Cognitive remediation- improve cognitive skill such as memory, attention
- social skills training
What are some pharmacological interventions for schizophrenia?
-
Typical (conventional or 1st gen) antipsychotics (FGA)
- Target+symptoms
- Dopamine (D2) receptor antagonist
- greater risk of EPS symptoms
- Atypical (second-gen) antipsychotics (SGA)
- Target + and - symptoms
- serotonin-dopamine antagonists
- higher risk of metabolic syndrome and lower risk of EPS
- most costly
What are some examples of typical (FGA) antipsychotics
KNOW- esp full caps— 8 total
- HALOPERIDOL (HALDOL)-give with benadryl
- chlorpromazine (thorazine)
- Trifluoperazine (Stelazine)
- Thiothixene (navane)
- Fluphenazine (prolixin)
6.** THIORIDAZINE (mellari) (QT prolongation)** - Loxapine(loxitane)
- Perphenazine (trilafron)
Black box warning: not approved for dementia-related psychosis
What are the FGA side effects for schizophrenia medication?
- anticholinergic effects
- weight gain
- sexual and or reproductive organ issues
- increased prolactin levels
- seizures
- sedation
- agranulocytosis
- nms
- cardiac events
- EPS
- Drug induced disease, liver disease
What are some signs of EPS?
- Akathisia
- Psudeoparkinsonism
- Acute dystonia
- Torticollis
What is tardive dyskinesia? (TD)
- Serious and irreversible EPS side effect after prolonged treatment that consists of involuntary tonic muscle spasms involving face, lips, tongue, trunk and extremities
- Symptoms may subside after meds are discontinued or may become permanent
What is the rhyme to help us remember anticholinergic effects
Red as a beet
Dry as a bone
Blind as a bat
Hot as a hare
Full as a flask
What are examples of our atypical SGA?
must know esp the cap one total of 9
1. CLOZAPINE (CLOZARIL) (agranulocytosis)- weight gain
2. RISPERIDONE (RISPERDAL)
3. OLANZAPINE (ZYPREXA)-weight gain
4. Quetiapine (seroquel)
5. Ziprasidone (geodon) (QT prolongation) LESS WEIGHT GAIN
6. PALIPERIDONE (INVEGA)
7. LURASIDONE (LUTUDA)
8. Iloperidone (fanapt)
9. Cariprazine (vraylar)- considered 3rd gen
10. Aripipazole (abilify) considered 3rd gen less weight gain
Black box warning- not aprroved for dementia related psychosis
What are the side effects of SGA for schizophrenic patients?
KNOW
- Anticholenergic effects
- EPS- less common
- Gynecomastia
- Seizures
- NMS
- Metabolic syndrome
- Sedation
- Sexual problems
- Cardiac events
What is metabolic syndrome and how is it dx?
Cluster of conditions the increase the risk for heart disease, diabetes, stroke. dx with 3 or more of the following
1. Obesity; excess weight gain, increased BMI, increased abdominal girth
2. High b/p
3. high blood sugar level
4. High cholesterol; triglycerides at least 150mg/dl, HDL less than 40mg/dl in women and 50mg/dl in men
What are long-acting antipsycotics and what are some exmaples
Know
Depot(long-acting) injection give q 2-4 weeks;
1. Haloperidol deconate (haldol)
2. Fluphenazine deconate (prolixin)
3. Risperadone (risperadal consta)
4. Paliperidone palmitate (invega sustenna)
5. Olanzapine pamote (zyprexia relprevv)
What should we know about the AIM assessment tool?
- Stands for abnormal involuntary movment scale: Used to assess for rardive dyskinesia
- Rates movement of facial/oral extremities and trunk on a scale of 0-4.
What increases chances of Neuroleptic malignant syndrome?
- Frequency increases with high potency antipsychotics and cognitive impariment (stroke, dementia)
What is our memory tool for remember the s/s of NMS (neuroleptic malignant syndrome)
F: Fever >103f
E: Elevated CPK/WBC
V: Vital sign instability (autonomic instability)
- Fluctuating BP, Pallor, tachycardia
- Sweating, salivation, tremors, incontinece
E: Encephalopathy
- Confusion, altered level of consciousness
R: Rigidity mucle
What is our tx of NMS?
- Stop drop
- Antipyretics
- Dantrolene
- IV fluids
- Treat other compication symptoms
What are some antiparkinson’s drugs?
- Trihexyphenidyl (artane)
- Benztropine (cogentin)
- Diphenhdryamine (benadryl)
- Biperiden (akineton)
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