Unit 5 Schizophrenia Spectrum Disorders Chapter 12 Flashcards
What is SCHIZOPHPHRENIA CHARACTERIZED BY?
A.Anxiety
B. Depression
C. Feeling of dread
D. Psychosis
D. Psychosis
Schizophrenia spectrum disorders are disorders that share features with schizophrenia.
*They are characterized by psychosis, which refers to altered cognition, altered perception, and/or an impaired ability to determine what is or is not real.
-cannot tell what is real or not, hallucinations, delusions, word salad, neologisms
S/S OF Schizophrenia? BOX 12.2
*Hears voices telling him or her to hurt self or others (command hallucinations)= RISK FOR VIOLENCE
*Delusions
*stigma=RISK FOR LONLINESS
*Despair, helplessness, hopelessness, sadness, thoughts of suicide=RISK FOR POWERLESSNESS , RISK FOR SUICIDE
*Lack of energy (anergia) Lack of motivation (avolition) Impaired self-care=POOR HYGEINE CARE
*Mistrust of others, paranoia=WITHDRAWN BEHAVIOR, RISK FOR VIOLENCE , LACK OF TRUST IN HCP, SUSPISICION
What are the Positive Symptoms of Schizophrenia?
1st Generation antipsychotics work ONLY on positive Symptoms of Schizophrenia
Positive symptoms indicate that these attributes should not be present.
-Positive symptoms include -hallucinations
-delusions,
-paranoia,
-disorganized
-bizarre thoughts, behavior, or speech.
such as walking backward constantly
What are the Negative Symptoms of Schizophrenia?
2nd Generation antipsychotics work on BOTH positive and negative Symptoms of Schizophrenia
The absence or removing or erasure of qualities that should be present.
Negative Symptoms include-
*inability to enjoy activities (anhedonia),
*social discomfort, or
* lack of goal- directed behavior.
● Affect: Usually blunted (narrow range of expression) or
flat (facial expression never changes)
● Alogia: Poverty of thought or speech. The client might
sit with a visitor but only mumble or respond vaguely
to questions.
● Anergia: Lack of energy
● Anhedonia: Lack of pleasure or joy. The client is
indifferent to things that often make others happy, such
as looking at beautiful scenery.
● Avolition: Lack of motivation in activities and hygiene.
For example, the client completes an assigned task, such as making his bed, but is unable to start the next common chore without prompting.
What is Alogia
Poverty of thought or speech. The client might sit with a visitor but only mumble or respond vaguely
to questions.
Which of the following is a finding of a patient experiencing psychosis?
A. They believe that with treatment their symptoms can remit.
B. They begin to speak about their parents life in war.
C. They see a huge spider on the wall that no one else can see.
D. Hyperflexibility.
C. They see a huge spider on the wall that no one else can see.
S/S of Schizophrenia
*delusions,
* hallucinations,
*disorganized speech, and *disorganized or catatonic (severely decreased motor activity) behavior.
Does schizophrenia have Onset or Chronic effect?
A. Onset
B. Chronic
A. Onset
Is schizophrenia experiences the same for eveyone?
A. Yes
B. No
B. No
Schizophrenia has a spectrum
spectrum def-used to classify something, or suggest that it can be classified, in terms of its position on a scale between two extreme or opposite points
How many Schizophrenia spectrum disorders are there?
*Delusional Disorder
*Brief Psychotic Disorder
*Schizophreniform Disorder
*Schizoaffective disorder
What is Delusional Disorder?
*Delusional disorder is characterized by delusions (i.e., false thoughts or beliefs) that have lasted 1 month or longer.
*The delusions include grandiose- “I am the president of the United States”,
*persecutory-“someone is out to get me”,
*somatic-, and referential themes- “the song is speaking to me”.
Which of the following statements would indicate your schizophrenic patient is currently on the delusion disorder spectrum?
A. “Whenever it get cold I shiver like a Chihuahua”.
B.” I am the God of the universe no one can kill me”.
C.” I get sad when I feel lonely”.
D. “Life has no meaning to me anymore”.
B.” I am the God of the universe no one can kill me”.
*The delusions include grandiose, persecutory, somatic, and referen- tial themes.
What is Brief Psychotic Disorder?
*SUDDEN UNSET OF PSYCHOSIS
Brief psychotic disorder involves the sudden onset of at least one of the following:y delusions, hallucinations, disorganized speech, and disorganized or catatonic (severely decreased motor activity) behavior.
-Symptoms must last longer than 1 day no longer than 1 month.
Is Brief Psychotic Disorder acute or chronic?
A. Acute
B. Chronic
A. Acute
The symptoms must last longer than 1 day, but no longer than 1 month, with the expectation of a return to normal functioning.
Your patient has been recently diagnosed with brief psychotic disorder. Which of the following teachings are true about this disorder?
A. Brief psychotic disorder usually last longer than 2 months.
B. Brief psychotic disorder has an expectation to return back to normal functioning.
C.This disorder is chronic you may hear people speaking to you all your life.
D. This disorder is most chronic out of the 4 spectrums of Schizophrenia
B. Brief psychotic disorder has an expectation to return back to normal functioning.
- Patients with BPD should expect to return to normal functioning
The symptoms must last longer than 1 day, but no longer than 1 month, with the expectation of a return to normal functioning.
What is SCHIZOPHRENIFORM DISORDER
SHORTER TIME FRAME TO BE DIAGNOSED FULL SXHIZPHRENIA
the following:y delusions, hallucinations, disorganized speech, and disorganized or catatonic (severely decreased motor activity) behavior.-lasting less 6 months
The essential features of this disorder are exactly like those of schizophrenia except that symptoms have thus far lasted less than 6 months.
-Also, impaired social or occupational function- ing may not be apparent. Some people with schizophreniform disorder return to their previous level of functioning, whereas others develop a persistent or recurrent psychosis.
Whjat is SCHIZOAFFECTIVE DISORDER?
Mixture of 3
*manic,
*depressive disorder, and *psychosis
This disorder involves a major depressive, manic, or mixed episode concurrent with symptoms that meet the criteria for schizophrenia.
*The symptoms must not be caused by any sub- stance use or general medical condition. It has a lifetime prevalence of 0.3%.
Cannot be caused by substance abuse or general
SUBSTANCE-INDUCED PSYCHOTIC DISORDER AND PSYCHOTIC DISORDER DUE TO ANOTHER MEDICAL CONDITION
Illicit drugs, alcohol, medications, or toxins can induce delusions and/or hallucinations.
Hallucinations or delusions can also be caused by a general medical condition, such as delirium, neurological disease, hepatic or renal disease, and many more.
*Substance use and medical conditions should always be ruled out before a primary diagnosis of schizophrenia spectrum dis- order is made.
What should be initially ruled out before diagnosing a patient with Schizophrenia?
Substance use and medical conditions should always be ruled out before a primary diagnosis of schizophrenia spectrum dis- order is made.
Risk factors for schizophrenia
Genetics
Increased Dopamine(antipsychotics block dopamine)
Prenatal Stressors – Infection during pregnancy, winter or early spring birth, father older than 35
Psychological stressors – manifests in times of developmental and family stress. (college, moving away from
family, childhood abuse, trauma)
Environmental Stressors – toxins
Does schizophrenia occur in men or women early in teenage years?
A. Men
B. Women
A. Men
Onset
Men 15 – 25 years of age
Women 25 – 35 years of age
Comorbidity – Substance use disorders, depression, suicide, physical illness
Is schizophrenia easily treated?
A. Yes
B. No
B. No
What are the phases of Schizophrenia
-Prodromal
-Acute
-Stabilization
-Maintenance
Why occurs during the Prodromal phase in Schizophrenia?
MILD SYMPTOMS (BEFORE PSYCHOSIS OCCURS
S/S
Speech and thoughts may be odd, and anxiety, obsessive thoughts, and compulsive behaviors may present. Concentration, school or job performance, and social functioning can deteriorate.
*The person may feel “not right” or that “something strange” is happening.
Why occurs during the Acute phase in Schizophrenia?
Hallucinations, delusion , and disturbed speech occurs
Sx vary from few/mild to many/severe. Functioning is impaired. Need for increased support.
Hospitalization may be needed
*Acute symptoms vary, from few and mild to many and disabling. Symptoms such as hallucinations, delusions, apathy, social withdrawal, diminished affect, anhedonia, dis- organized behavior, and impaired judgment and cognition result in functional impairment.
Why occurs during the Stabilization phase in Schizophrenia?
Sx stabilizing and return to level of functioning if possible
I*n this phase, symptoms are stabilizing and diminishing, and there is movement toward a previous level of functioning. This phase can last for months.
Care in mental facility for months based on conditions
What occurs during the Maintence phase in schizophrenia?
—In this phase, the condition has stabilized and a new baseline may be established. Pos- itive symptoms (described later) are usually significantly diminished or absent, but negative and cognitive symptoms continue to be a concern.
Interventions for a patient with Schizophrenia? Are they at risk for falls?
A. Yes
B. No
Table 12.3
Poor Hygiene(foul odor self neglect)
Resistance to treatment(they have the right to consent or refuse treatment)
Cheeking or palming medications(does not swallow medication)
Anosognosia(unable to recognize familiar faces)
Avoiding Peer Interaction
Depression
Poor Self-Esteem
Fall Risk(secondary to first gen antipsychotics, EPS syndrome)
Choking Risk
Restlessness/Agitation
Risk for other directed violence
Risk for self directed violence
Which of the following drugs is a fist generation antipsychotic?
A.Amtriptyline
B.Clonzapine
C. Valproate
D. Haloperidol
D. Haloperidol
The assessment of the Hallucinating patient BOX 12.2, What are the signs of a patient who is currently hallucinating?
*such as eyes tracking an unheard speaker,
*muttering or talking to self, appearing distracted,
*suddenly stopping conversing as if interrupted, or
* intently watching a vacant area of the room.
The interventions for the Hallucinating patient
Ask about the content of the hallucinations and how the patient is reacting to them. Assess for command hallucinations, and assess for resulting fear or distress.
ex-What do you see/hear?
Are they commanding you to do anything? (priority)
-DO NOT ASK “WHAT ARE THE VOICES SAYING TO YOU”
-Do not ask, “What are the voices saying to you?” Ask, “What are you hearing?”
Do not negate the patient’s experience but offer your own perceptions and convey empathy. *“I don’t hear angry voices that you hear, but that must be very frightening for you.”
Focus on reality-based “here and now” activities, such as conversations or simple projects.
- Promote and guide reality testing. If the patient has frightening hallucina- tions, guide her or him to scan the area to see if others appear frightened; if they are not, encourage the patient to consider that these might be halluci- nations. Teach the patient to compare such beliefs and perceptions to those of trusted others.
Patient teaching -Hallucinations
Manage stress and stimulation
* Avoid overly loud or stressful places or activities.
* Learn assertive communication
skills so you can tell others “no” if they pressure or upset you.
**
Find out what is and isn’t real (called promoting reality testing).**
* Look at others; do they seem to be hearing/seeing what you are?
* Ask trusted others if they are experiencing what you are.
** Engage in activities that can take your mind off what you hear.**
* Walk.
* Clean.
* Take a relaxing bath or shower.
. Talk (if others are nearby, quietly or silently to self).
* Tell the voices or thoughts to go away.
* Tell yourself that the voices and thoughts are a symptom and aren’t real. * Tell yourself that no matter what you hear, you will be safe and you can
ignore what you hear.
Make contact with others.
* Talk with a trusted friend, relative, or staff member.
* Call a help line or go to a drop-in center.
* Visit a public place where you are comfortable.
Develop a plan for how to cope with hallucinations; options include
* Any of the activities already mentioned that work for you
* Taking extra medication when ordered (call your prescriber)
* Using breathing exercises and other relaxation methods
Interventions with a patient Experiencing Delusion
Build trust
Respond in a matter of fact, empathetic, supportive and calm manner
Don’t debate
Validate parts that are real
Focus on feelings and themes
Use reality-based interventions to meet underlying needs
Acknowledge that while the delusion seems real to the patient it doesn’t seem real to others
Don’t dwell on delusion, refocus on reality
Help identify triggers
Promote Reality testing
Therapeutic communication - Patient experiencing delusions
Focus on the feelings or themes within the delusion. If a patient believes
that he is a famous leader, comment: “It would feel good to be more pow- erful.” If the patient believes that others intend to hurt him, comment: “It must feel frightening to believe others want to hurt you.”
Use reality-based interventions that help meet underlying needs. If the patient believes that he is powerful, it may represent a sense of power- lessness. Increase the patient’s control, such as asking the patient when he would like to take his medications.
Do not dwell excessively on the delusion. Instead, refocus onto reality- based topics.
* Help the patient to identify triggers of delusions and find ways to avoid them.
Which of the following statements would the patient state if the patient is experiencing command hallucinations?
A. “I see a huge Tarantula on the side of the room.”
B. “They are telling me to punch you in the face.”
C. “I feel like sleeping and never waking up.”
D. “I do have thought of harming myself and others.”
A command hallucination is a particularly concerning symp- tom wherein the person is directed to take an action.
COMMAND HALLUCINATIONS ARE DANGEROUS*
-May need further evaluation that can lead to seclusion
What is an example of a command hallucination
*For example, they may be telling a patient to “jump out the window” or to “hit that nurse.”
***Command hallucinations are often frightening and may be a flag warning of a psychiatric emergency.
It is essential to assess what the patient hears, the source to which it is attributed, the patient’s ability to recognize the hallucination as “not real” and resist commands.
Patient and Family teaching -Schizophrenia
Stay in contact with support systems
Physical Health is important, self care and hygiene
Healthy Diet, Weight and regular exercise
Regular sleep pattern
Stress reduction – Self-care
Support Groups (NAMI)
Educate yourself about the Dx
Minimize tobacco and caffeine, as they may make your medicines less effective and hurt your health.
-Read books about severe mental illness, such as the following:
* Surviving Schizophrenia
Trusted sources
-National Institute of Mental Health:
-National Alliance on Mental Illness:
-Living with Schizophrenia
Which of the following Syndromes does that first generation antipsychotics may induce?
A. Serotonin Syndrome
B. Metabolic Syndrome
C. Serotonin Withdrawal Syndrome
D.Extrapyramidal Side Effects
D.Extrapyramidal Side Effects
What disorders fall under Extrapyramidal Side Effects
Acute dystonia
Pseudoparkinism
Akathisia
Tardive dyskinesia
What is the #1 Syndrome that is acute and life threatening when taking first generation Antipshychotics?
Neuroleptic malignant syndrome (NMS)
RARE but DANGEROUS
*Severe muscle rigidity(LEAD PIPE), *Dysphasia(TROUBLE SPEAKING), *flexor-extensor posturing,
*reduced or absent speech and movement, decreased respon-
siveness.
*Hyperpyrexia is the main feature: temperature over 103°F Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence, Delirium(onset and sudden confusion),
*stupor(near unconsciousness), *coma
- rhabdomyolysis (protein in the blood from muscle breakdown), which can cause organ failure (30%), acute respiratory failure (16%), acute kidney injury (18%), sepsis (6%), and other systemic infections. Respiratory failure is the strongest predictor of mortality.
What are the s/s of Acute dystonia
*Acute painful contractions of limited muscle groups (e.g., tongue, face, neck, and back; usually tongue and jaw first)
*Spasm of the muscles causing backward arching of the head, neck (torticollis), and spine
*Eyes roll back (oculogyric crisis)
Laryngeal dystonia: could threaten airway (rare)
What is the signs and symptoms of Pseudoparkinism
*Masklike face,
*stiff and stooped posture,
*shuffling gait,
*bradykinesia,
*drooling,
*tremor,
*“pill-rolling” finger movements,
*dysphagia or reduction in spontaneous swallowing
What is the s/s of akathisia
Motor restlessness (e.g., pacing, patient unable to stand still or stay in one location, rocking while seated or shifting from one foot to other while standing)
What is the s/s of Tardive Dyskinesia
protruding or writhing tongue; blowing, smacking, licking; facial distortion
Limbs:
Chorea: rapid, purposeless, and irregular movements Athetoid: slow, complex, and serpentine movements
Trunk: neck and shoulder movements, hip jerks and rocking, or
twisting pelvic thrusts
What is the treatment for Tardive Dyskinesia
-ingrezza drug
can cause QT prolongation which can cause death.
Prolongation of the QT interval is a delay of ventric- ular repolarization. This condition may result in tachycardia, fainting, seizures, and even sudden death.
What is the treatment for EPS
Benztropine and Benadryl
Name (2) FIRST gen antipsychotics, medications
● Haloperidol, high potency
● Fluphenazine, high potency
● Loxapine, medium potency
● Thioridazine, low potency
● Thiothixene, high potency
● Perphenazine, medium potency ● Trifluoperazine, high potency
●Chlorpromazine, high potency
Name (2) Second gen antipsychotics medications
*Clozapine
*Aripiprazole
*Quetiapine
*Risperidone
*Ziprasidone
Common side effect of Haloperidol(1st gen antipsychotics
Sedation, Orthostatic Hypotension, Lowered seizure threshold, photosensitivity,
cataracts or other visual changes
Increased prolactin levels – sexual dysfunction, galactorrhea, gynecomastia
Would first generation or second generation antipsychotics is the first line of treatment?
A. second gen
B. first gen
A. second gen
Clozapine
Aripiprazole
Quetiapine
Risperidone
Ziprasidone
Does Haloperidol treat the positive or negative of Schizophrenia?
A. Positive
B. Negative
A. Positive
-Positive symptoms include -hallucinations
-delusions,
-paranoia,
-disorganized
-bizarre thoughts, behavior, or speech.
Which of the following drugs is a second generation Antipsychotics medication?
A. Clozapine
B. Amtriptiline
C. Haloperidol
D.Thiothixene
A. Clozapine
Does 2nd gen Antipsychotics works on positive, negative , both symptoms of Schizophrenia?
Both
Positive symptoms
hallucinations
-delusions,
-paranoia,
-disorganized
-bizarre thoughts, behavior, or speech.
Negative Symptoms
*inability to enjoy activities (anhedonia),
*social discomfort, or
* lack of goal- directed behavior.
2nd gen Antipsychotics
Dopamine & Serotonin (some have
antidepressant properties)
Newer Medications
Positive and Negative Symptoms
Less likely to cause Tardive Dyskinesia or EPS
Side Effects are usually fewer and milder
Metabolic Syndrome
Weight gain (specifically in abdominal area)
Increased lipids
Increased blood glucose and insulin resistance
Which disorder should you monitor for when your patient is taking a second gen antipsychotic medication(Clozapine)
A. Hypertensive crisis
B. Lithium toxicity
C. Metabolic syndrome
D. Serotonin Syndrome
C. Metabolic syndrome
S/s of metabolic syndrome
Weight gain,
dyslipidemia (abnormal lipid levels),
and increased insulin resistance leading to increased risk of cardiovascular disease,
diabetes, and other serious medical conditions
Interventions for Metabolic Syndrome
*Teach the patient how to minimize weight gain through proper nutrition and physical activity (e.g., help the patient to identify low-calorie snacks that he enjoys, engage the patient in regular physical activity, and help the patient to identify and pursue enjoyable physical activities, such as walking or cycling.
*Teach the patient and family about the importance of regular medical evaluation and care to identify and correct possible changes that could lead to this syndrome, which can increase the risk of premature illness and death.
*Metformin has been used off label to reduce diabetes in patients with metabolic syndrome.
Which of the following would warrant immediate attention when your patient has been taking Clozapine?
A. White blood cells 500
B. Urinary rertension
C. Orthostatic hypotension
D. Weight gain
A. White blood cells 500
is a finding of agranulocytosis, the patient may have difficulty fighting off infections which can lead to death
Intervention
-“monitor temperature”
-Advise clients to observe for indications of infection (fever, sore throat), and to notify the provider if these occur.
- If indications of infection appear, obtain a CBC. Medication should be discontinued if laboratory test indicates the presence of infection.
Risk of myocarditis, life-threatening bowel
emergencies, agranulocytosis
Agranulocytosis is a condition in which the absolute neutrophil count (ANC) is less than 100 neutrophils per microlitre of blood
Liver Impairment
Liver impairment may also occur during antipsychotic therapy, particularly with first-generation agents. Second- generation drugs also lead to serum enzyme elevations but rarely to injury or jaundice. Liver impairment usually occurs in the first weeks of therapy.
-Monitoring of liver function values is essential. Signs of liver problems include jaundice, abdominal pain, ascites, vomiting, lower extremity edema, dark urine, pale or tarcolored stool, and easy bruising. The patient may complain of itchy skin, chronic fatigue, nausea, and decreased appetite
NMS VS SEROTONIN SYNDROME
Neuromalignant Syndrome
Rare but dangerous.
Severe muscle rigidity, dysphasia, flexor-extensor posturing,
reduced or absent speech and movement, decreased respon-
siveness.
Hyperpyrexia is the main feature: temperature over 103°F Autonomic dysfunction: hypertension, tachycardia, diaphoresis,
incontinence Delirium, stupor, coma
SEROTONIN SYNDROME
* Hyperactivity or restlessness
* Tachycardia → cardiovascular shock
* Fever → hyperpyrexia
* Elevated blood pressure
* Altered mental states (delirium)
* Irrationality, mood swings, hostility
* Seizures → status epilepticus
* Myoclonus, incoordination, tonic rigidity
* Abdominal pain, diarrhea, bloating
* Apnea → death
Types of hallucination
Types of hallucination include the following.
* Auditory: Hearing voices or sounds * Visual: Seeing people or things
* Olfactory: Smelling odors
* Gustatory: Experiencing tastes
* Tactile: Feeling bodily sensations (e.g., feeling an insect crawling on one’s skin)
Speech alterations
associative looseness,
Word salad,
Clang association
Neologisms
Echolalia
Circumstantiality
Thought insertion
Thought deletion
Magical thinking:
associative looseness
One, associative looseness, or looseness of association, results from haphazard and illogical thinking where concentration is poor and thoughts are only loosely connected. For example: “My friends talk about French fries but how can you trust the Bacon?”
Word salad
The most extreme form of associative looseness, is a jumble of words that is meaningless to the listener (e.g., “agents want strength of policy on a boat reigning supreme”).
-mixed up words with no sense
Clang association
rhyming
choosing words based on their sound rather than their meaning and often involves words that rhyme or have a similar beginning sound (“On the track … have a Big Mac” or “Click, clack, clutch, close”).
Neologisms
Neologisms Making your own words
words that have meaning for the patient but a different or nonexistent meaning for others. A patient may use a known word differently than others or create a completely new word that others do not understand (e.g., “His mannerologies are poor”).
Echolalia
repetition of what is heard
repetition of another’s words, occurring perhaps because the patient’s thought processes are so impaired that she is unable to generate speech of her own.
EXAMPLE
Nurse: Mary, come get your medication.
Mary: Come get your medication.
Circumstantiality:
Including unnecessary and often tedious details in conversation but eventually reaching the point.
ex- Nurse: what is your mothers name,
Patient: She was born in the 1980’s in a small town on Bahamas called free port . She lived on the fourth street of little haiti back in the 1990’s she came to live in the united States in the 2000’s. My mom’s name is Kimberly Joe.
Tangentiality:
Wandering off topic or going off on tangents
\and never reaching the point.
ex- Nurse: what is your mothers name,
Patient :She was born in the 1980’s in a small town on Bahamas called free port . She lived on the fourth street of little haiti back in the 1990’s she came to live in the united States in the 2000’s.
Pressured Speech
rapid speech. speaking without pauses. talking even when interrupted
-Urgent or intense speech; reluctance to
allow comments from others.
Thought insertion:
Thought insertion: The often uncomfortable belief that someone else has inserted thoughts into the patient’s brain.
Thought deletion
Thought deletion: A belief that thoughts have been taken or are missing.
Magical thinking
Magical thinking: Believing that reality can be changed
simply by thoughts or unrelated actions. This thinking is common in children (e.g., “Because I was mad at him, he fell down”).
What would a patient say or experience if they are going are experiencing paranoia?
Paranoia: An irrational fear, ranging from mild (being sus- picious, wary, guarded) to profound (believing irrationally that another person intends to kill you). Fear may result in dangerous defensive actions, such as harming another per- son before that person can harm the patient.
