Week 8 Psychosis Flashcards
Psychosis definition
Altered cognition, altered perception and/ or an impaired ability to determine what is or is not real (an ability known as reality testing)
Schizophrenia spectrum disorders
Schizophrenia definition
“a complex biochemical brain illness - affecting a variety of aspects of behaviors, thinking and emotions - the cause of which is not yet known. The illness affects each person differently and can follow a varying course over time.”
How many people does schizophrenia affect?
1 in 100 persons
Schizophrenia prevalence in gender?
Equally
Age of onset of schizophrenia
Men 15-25
Women 25-35
Causes of schizophrenia
➢ Genetic Predisposition
▪ First-degree biologic relatives have 10 times greater risk
➢ Neurotransmitters
▪ Dopamine
▪ Serotonin
▪ Glutamate
➢ Structural Abnormalities in the Brain
➢ Neurodevelopmental
▪ Prenatal exposure – viruses, infections
➢ Psychosocial Factors
▪ Developmental & social stressors, ACEs, environmental toxins
DSM-V Diagnostic Criteria of Schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
B. Social/occupational dysfunction
C. Continuous signs of the disturbance persist for at least 6 months.
D. … not attributable to the physiological effects of a substance or another medical condition
Prodromal Symptoms of Schizophrenia
➢ Preceeds the acute phase of illness
➢ Symptoms are mild or “soft” not meeting criteria for schizophrenia
➢ Individuals may:
▪ Report feeling strange or unusual (e.g., sense the presence of an unseen person),
▪ Hold unusual or odd beliefs (ideas of reference/magical thinking)
▪ Exhibit odd behaviours (e.g., mumbling in public)
▪ Become socially withdrawn
▪ Lose interest in activities they previously enjoyed
Positive symptoms of schizophrenia
Hallucinations
▪ visual, auditory
Delusions
▪ grandiose, persecutory, ideas of reference, thought broadcasting, religious
Disorganized thinking
▪ tangentially, loose associations, incoherence, thought blocking
Behaviours
▪ agitation, potential aggression, repetitive/ ritualistic activity
Negative symptoms of schizophrenia
Affect
▪ Flat or “blunted”
Alogia (poverty of speech)
Anergia
Poverty of content of speech
Anhedonia
Avolition
Neurocognitive impairment: when present in schizophrenia, may include:
Memory
Sustained attention
Verbal fluency (rate at which words are produced)
Executive functioning (processing information and making decisions)
Anosognosia
People with schizophrenia may sometimes lack insight into their illness
Schizophrenia intervention phases
Phase 1 - Acute
▪ Safety and crisis intervention
▪ pharmacotherapy
Phase 2 - Stabilization
▪ promoting medication interest
▪ strengthening coping with positive and negative symptoms
▪ promoting recovery
Phase 3 - Maintenance
▪ ongoing recovery
▪ health education
▪ encouraging family involvement
▪ liaising with community supports
Types of antipsychotics (neuroleptics)
Typical/ conventional (1st generation)
Atypical (2nd generation, 3rd generation)
1st generation antipsychotics
Haldol
Chlorpromazine
2nd generation antipsychotics
Risperidone
Quetiapine
Clozapine
3rd generation antipsychotics
Aripiprazole
Long-acting injectables (depot medications)
Antipsychotic medications given by needle
Frequency depends on the medication and ranges from 2 weeks to 1 month
Paliperidone (Invega Trinza) can be given every 3 months
Extrapyramidal side effects
▪ tremors
▪ bradykinesia/ akinesia (slowness, absence of movement)
▪ cogwheel rigidity (slow regular muscular jerks)
▪ postural instability
▪ stooped/ hunched posture
▪ shuffling gait
▪ restricted movements
▪ masked face (loss of mobility in facial muscles)
▪ hypersalivation and drooling
EPS - Acute dystonia symptoms
▪ Torticollis (neck muscle contraction - pulling head to side)
▪ Oculogyric crises (eyes twist up and can’t look down)
▪ Opisthotonos (severe dorsal arching of neck and back)
EPS - Akathisia symptoms
Akathesia - “not sitting”
▪ pacing, motor restlessness, rocking, foot tapping
▪ subjective complaints of inner restlessness, irritability, inability to sit still or lie down
▪ need to differentiate between akathisia and psychomotor agitation or restlessness
▪ if possible, dosage is decreased, or propranolol may be added
Tardive dyskinesia
Late occurring abnormal movements
▪ affects 4% of persons taking antipsychotics
▪ choreoathetoid movements (rapid, jerky and slow, writhing movements) may occur anywhere in the body - arms, feet, legs, trunk
▪ classic description - oral, buccal, lingual, & masticatory movements (tongue thrusting, lip pursing and smacking, facial grimaces and chewing movements)
Treatment of EPS: medication
Benztropine mesylate (Cogentin) Antiparkinson Agent
▪ for medication-related movement disorders: pseuodoparkinsonism, rigidity, akathisia
▪ acute or urgent situations (acute dystonias): Cogentin or Benadryl IM
Tardive dyskinesia treatment
▪ is irreversible
▪ switch to a second generation neuroleptic or decrease dosage - individualized
Assessment of EPS
Abnormal Involuntary Movement Scale (AIMS)/ Dyskinesia Identification System
Neuroleptic Malignant Syndrome
▪ Rare (1-2% of individuals receiving typical/ high potency antipsychotics)
▪ Potentially fatal (up to 10% of cases) - from acute renal failure to rhabdomyolysis
▪ Usually occurs within first 30 days of antipsychotic use
Risk factors for neuroleptic malignant syndrome
▪ dehydration
▪ history of NMS
▪ recent dose increase
▪ switching rapidly from one dopamine receptor agonist to another
Neuroleptic Malignant Syndrome symptoms
▪ hyperpyrexia
▪ tachycardia
▪ labile hypertension
▪ tachypnea or hypoxia
▪ diaphoresis
▪ lead pipe muscle rigidity
▪ tremor
▪ drooling
▪ incontinence
▪ changes in mental status: confusion, delirium, stupor, coma
▪ dehydration
▪ potential renal failure
▪ elevated creatinine phosphokinase
Treatment of Neuroleptic Malignant Syndrome
Discontinuation of antipsychotic medication, nursing care
Side effects of atypical antipsychotics
▪ hyperpyrexia
▪ orthostatic hypotension
▪ “metabolic syndrome”
-weight gain
-hyperlipidemia
-impaired glucose metabolism and diabetes
-hypertension
-increased waist circumference
▪ sedation
▪ cardiac arrhythmias
▪ sexual side-effects eg. amenorrhea; gynecomastia; decreased libido
clozapine
▪ used effectively for management of symptoms of treatment-resistant schizophrenia
▪ not a first line treatment because of the risk of developing serious side effects (eg. agranulocytosis)
▪ requires regular and ongoing blood monitoring
▪ regulated by health canada-pharmacists may only dispense it after confirming regular bloodwork was done and within a normal range
▪ nursing in-patient protocols exist for administration and monitoring of side effects
EPPIS
Early Psychosis Prevention and Intervention Service
Criteria for admission to EPPIS
▪ Presence of symptoms of psychosis (delusions, hallucinations and/or thought disorder) or a recent diagnosis of a primary psychotic disorder not related to substance use alone or other non-psychiatric medical condition
▪ The individual has not received treatment for a diagnosed psychotic disorder for longer than 3 months therefore still in the early intervention phase
▪ Ability to participate in treatment plan and service components (groups) within EPPIS
▪ Living within the Winnipeg region
