Ch 17 Schizophrenia Spectrum and Other Psychotic Disorders Flashcards
(91 cards)
1
Q
Is a brain disorder
Thinking
Language
Emotions
Social behavior
Ability to perceive reality accurately - most imp; lot misperceptions; misperceive what does/see/hear
A
Schizophrenia is potentially a devastating brain disorder that affects:
2
Q
Schizophrenia is a spectrum disorders; there are a group of psychotic disorders
Psychosis is not a diagnosis but a symptom
Psychosis refers to a total inability to recognize reality (e.g., delusions and hallucinations) - when these come into mind
A
Schizophrenia facts
3
Q
Schizophrenia is probably caused by a combination of factors - multitude reasons for schizophrenia
Remember: It’s a disease; a person has schizophrenia—they are not a schizophrenic - not how define as an indiv - more than diagnosis
A
Intro
4
Q
Small percent worldwide
Typical symp onset late teens and early 20’s
Men earlier (15-25); Female (25-35) - often going to college; often very bright and + track and lots goals and doing well; symp showing up and having break in reality and diff for indiv and fams - dealing with totally diff person; more hallucinations and delusions in younger individuals; going to college/going to work - up to point bright and on great track
On great track and doing well then symp shows up (may have hallucinations/delusions) - some symp hard for indiv - feel like dealing with entirely diff person - goals may need be readjusted
Substance Abuse occurs in some individuals; high percentage where issue; idea self-medication - symp bother them take other substances to lessen symp; thoughts - self-medicate if having thoughts to make thoughts go away
High Nicotine dependence
A
schizophrenia/prevalence
5
Q
Occur frequently
Substance abuse disorders
Anxiety disorders
Depression
OCD
Panic disorders
Obesity (sometimes prob; probably due to antipsychotic medications); increased weight leads to comorbid diabetes and risk of cardiovascular disease; with newer antipsychotic meds - seeing this; leads to more metabolic syndrome, diabetes
A
Co-morbidity (Co-occurring illness)
6
Q
Positive
Negative
Person may have elements of + and -
Cognitive (Thoughts-impaired thinking and reasoning) - impaired thinking and reasoning; mood disorders go along with symp: depression, anxiety, suicide ideation
A
Course of the disorder
7
Q
Look at +/- symp
Identified with Positive or Negative SXS
Positive Symptoms: symp More Dramatic
A
Nursing process: assessment
8
Q
Not have all + but see variety
Tend to come on quickly
Thought Content Examples Below: - how thinking; very dramatic thinking
A
Positive Symptoms: symp More Dramatic
9
Q
Delusions:
Religiosity:
Paranoia:
Magical thinking:
Perseveration:
Ideas of Reference:
Concrete thinking:
Depersonalization:
Speech and Thought Patterns
Word salad:
Circumstantiality:
Tangentiality:
Mutism:
Identification and imitation:
Echolalia:
Echopraxia:
Perception:
Hallucinations:
Illusions:
A
Thought Content Examples Below: - how thining
10
Q
fixed false personal beliefs; to that indiv truly believe that and trying talk out of it/convince otherwise not happen and is frustrating for self and them; truly believe it
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Delusions:
11
Q
excessive demonstration of obsession with religious ideas and behavior; preoccupation with this; obsession with religion
A
Religiosity:
12
Q
extreme/very suspiciousness of others
A
Paranoia
13
Q
ideas/behaviors that one’s thoughts or behaviors have control over specific situations; if think should be harmed have power and person will be harmed
A
Magical thinking
14
Q
Persistent repetition of the same word or idea in response to different questions; repeat same one word/idea over and over again
A
Perseveration:
15
Q
Misinterpretation of others verbalizations or actions that is perceived as having personal meaning; how thinking; thought processes; walk into room and sev people talking and convo stops we interpret that talking about me and percervie it as personal; misinterpret verbalization and actions and take on as meaningful about you; in treatment have and start learning how check misperceptions out
A
Ideas of Reference:
16
Q
literal interpretations of the environment; think literally; very literal
A
Concrete thinking:
17
Q
feelings of unreality; feeling not real
A
Depersonalization:
18
Q
Tells lot about thought pattern
Associative looseness
Neologisms:
Clang associations:
All types of thinking patterns and comes out through speech pattern (why do mental status) to know what going on with brain/thinking
A
Speech and Thought Patterns
19
Q
a shift of ideas from one unrelated topic to another; listen closely can follow and find thread what talking about; seen in other disorders; shift from one idea to another and often not related; pay attention may follow track
A
Associative looseness (also called loose association):
20
Q
made-up words that have meaning only to the person who invents them; invent words
Make up words - have own language - they understand it
A
Neologisms:
21
Q
choice of words is governed by sound (often/usually rhyming); usually names, colors, numbers
A
Clang associations:
22
Q
group of words put together in a random fashion; put bunch words and tossed together and hard make sense
Threw words in bowl and tossed up; cannot follow like potentially loose association
A
Word salad:
23
Q
delay in reaching the point of a communication because of unnecessary and tedious details; tell all details where almost there; hard reach point
Give every detail
A
Circumstantiality:
24
Q
type of thinking and inability to get to the point of communication due to introduction of many new topics; take side road
Not get to point
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Tangentiality:
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inability or refusal to speak; point where mute
Mutism:
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taking on the form of behavior one observes in another; observe someone else; one defense mechanisms; identify with them and imitate them
Identification and imitation:
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repeating words that are heard
Echolalia:
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repeating movements that are observed
Echopraxia:
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interpretation of stimuli through the senses; how interpret what going on around them; hallucination, delusion, illusion
Delusion - fixed, false belief
How handle illusion/delusion/hallucination:
Perception:
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false sensory perceptions not associated with real external stimuli; look at blank wall and see spiders and see nothing potentially this
With any sense; no external stimuli; seeing, hearing, feeling something you are not
Auditory - most common
Visual - most common
Tactile
Gustatory
Olfactory
Command Hallucinations -
See nothing on wall; no external stimuli creating that; handle this and illusions about same way
Hallucinations:
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misperceptions of real external stimuli; on blank wall and cord hanging down and look at cord and think cord is snake; is something there but misinterpreted what seen
Misperceiving it; actually something there but seeing something diff from what seeing; cannot argue with them; something there and misperceive it; is stimuli and misperceive it
Illusions:
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The client hears the word “match.” The client replies, “A match. I like matches. They are the light of the world. God will light the world. Let your light so shine.” Which communication pattern does the nurse identify?
A. Word salad
B. Clang association
C. Loose association
D. Ideas of reference
Correct answer: C
Loose association is characterized by communication in which ideas shift from one unrelated topic to another. The situation in the question represents this communication pattern
Listen closely can catch thread of how thinking but ofen very loose
Clang - rhyming
Word salad - bunch words
Ideas of reference - taking everything personal
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A client diagnosed with schizophrenia experiences identity confusion and communicates with the nurse using echolalia. What is the client attempting to do by using this form of speech?
A. Identify with the person speaking
B. Imitate the nurse’s movements
C. Alleviate alogia
D. Alleviate avolition
Correct answer: A
Echolalia is a parrot-like repetition of overheard words or fragments of speech. It is an attempt by the client to identify with the person who is speaking.
NOTE: Avolition: decreased motivation
Alogia: poverty of speech
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Negative Symptoms - social and communication difficulties; may be more diff than + symp; emotional tones
Tend to Develop insidiously over a long period of time.
Affect:
Inappropriate affect:
Bland affect:
Flat affect:
Apathy:
Tend to Develop insidiously over a long period of time.
Anergia:
Volition:
Emotional ambivalence:
Deterioration in appearance:
Impaired interpersonal functioning and relationship to the external world/world around them
Associated features
Nursing process: assessment: negative symptoms
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the feeling state or emotional tone; impact mood/affect; as imp as + symp; mood/affect congruient (look at in mental status exam)
Affect
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emotions are incongruent with the circumstances
Inappropriate affect:
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weak emotional tone; no emotion; same tone and face; flat face
Bland affect:
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appears to be void of emotional tone; sim to bland affect
Flat affect:
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disinterest in the environment; not interested in what going on
Apathy:
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deficiency of energy
Anergia:
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impairment in the ability to initiate goal-directed activity - motivation to get up and go; trouble to get things done; not goal-directed activity
Volition:
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coexistence of opposite emotions toward same object, person, or situation
Emotional ambivalence:
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impaired personal grooming and self-care activities can be diff; appearance deteriorates; self-care and poor personal grooming - prob; fairly common; difficulty for them in how react; not do ADLs; dress inappropriately/lay lot things; creates probs
Deterioration in appearance:
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Impaired social interaction:
Social isolation:
Impaired interpersonal functioning and relationship to the external world/world around them - may lose jobs
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clinging and intruding on the personal space of others, exhibiting behaviors that are not culturally and socially acceptable; personal space is an issue; not know boundaries; get really close to individuals; love to touch hair; ok to set boundaries in professional and matter of fact because part of treatment so not get in treatment and not invading space; helpful for them to knw
Impaired social interaction:
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a focus inward on the self to the exclusion of the external environment
Social isolation:
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Anhedonia:
Regression:
Associated features
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inability to experience pleasure
Anhedonia:
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retreat to an earlier level of development; one defense mechanisms
Regression:
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Nursing interventions for the client with schizophrenia or other psychotic disorders are aimed at: - planning care
Nursing process: planning/implementation
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Developing trust one things imp - perceiving world to get you who and how develop trust: do what going do; be honest and make honest attempt to get it done and help decrease anxiety; anxiety increases not think clearly one who misperceives creates prob
Role-play gen interactions with people and job interviews
Decreasing anxiety in firsst session and establishing trust
Assisting client to define and test reality and ask questions - not just assume; help them be able test reality and ask questions about it so interact with others
Encouraging interaction with others
Ensuring safety of client and others
Meeting client’s self-care needs
Promoting adaptive family coping; help fam - very diff for fam; was high functioning and now dealing with totally diff person
Nursing interventions for the client with schizophrenia or other psychotic disorders are aimed at: - planning care
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Be realistic - hoping for this
Re-hospitalization is common - because chronic illness and test by going off meds because tired of taking it
Hope May see reduction in sxs.—voices not as threatening or not hearing as much
Focus on here and now
Identify medication purposes (imp) and need to know S.E.
Will identify interventions which decrease sxs. - help fam members/support people understand how support them with sxs
Outcome criteria
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Therapeutic strategies for communicating with patients with schizophrenia focus on: - trying to help self-esteem; are person worth - show them that; give respect; keep med compliance and keep on meds; hallucinations/delusions validate seeing something and hearing something and believe something but present your reality then redirect
Communication guidelines
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Focus on Lowering the patient’s anxiety
Decreasing defensive patterns
Encouraging participation in therapeutic and social events - often tend withdraw since anxious and defensive and sometimes paranoia
Raising feelings of self-worth
Increasing medication compliance - often challenge; nature of chronic disease of schizophrenia - tired taking med and test if need it
Therapeutic strategies for communicating with patients with schizophrenia focus on:
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Paranoia - believe someone out to get them and is anxiety producing so imp keep validating reality and reassuring keep as safe can
Communication with someone who has impaired thinking…how?
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Schizoaffective Disorder:
The Catatonic Features Specifier
Types of schizophrenia and other psychotic disorders in DSM-5
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sxs. of schizophrenia accompanied by strong element of mood disorders (either mania or depression); combo of sxs of schizophrenia and bipolar I and II; delusional about anything; some psychotic disorders as well
Schizoaffective Disorder:
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Catatonic features may be associated with other psychotic disorders, such as brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance induced psychotic disorder.
one types schizophrenia and psychotic disorders - not seen often
Symptoms of catatonic disorder include:
The Catatonic Features Specifier
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Stupor and muscle rigidity at times or excessive, purposeless motor activity
Classic: Rolled up in ball; become very rigid
Waxy flexibility - individuals will let mold body like wax and not fight like where melding, negativism, echolalia, echopraxia; raise arm and can pose like statue
Symptoms of catatonic disorder include:
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A client is admitted with a diagnosis of brief psychotic disorder with catatonic features. Which symptoms are associated with the catatonic specifier?
A. Strong ego boundaries and abstract thinking
B. Ataxia and akinesia
C. Stupor, muscle rigidity, and negativism
D. Substance abuse and cachexia
Correct answer: C
Symptoms associated with the catatonic specifier include stupor and muscle rigidity or excessive, purposeless motor activity. Waxy flexibility, negativism, echolalia, and echopraxia are also common behaviors.
Catatonia - think waxy flexibility
61
To deal with a client's hallucinations therapeutically, which nursing intervention should be implemented?
A. Reinforce the perceptual distortions until the client develops new defenses
B. Provide an unstructured environment
C. Avoid making connections between anxiety-producing situations and hallucinations
D. Distract the client's attention
Correct answer: D
The nurse should first empathize with the client by focusing on feelings generated by the hallucination, present objective reality, and then distract or redirect the client to reality-based activities
If have someone having hallucination, they say see snakes on wall and you see cord how respond; they truly see it and hear voices and hear it and see it; would be frightening if thought were there; first thing is acknowledge that must be frightening to see snake; acknowledging emotion and what going on; present reality in neutral way; then redirect; best thing do is not dwell and distract - not change mind; when on meds hallucinations less; if indication hearing voices check with what hearing; voice could be giving them commands that are putting them or someone else at risk; voices can be harmful
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Provide safe environment - provide safety #1; role-playing
Limit stimuli - too much going on; not in group for awhile; limit stimuli getting in environment; providing safe environment is main goal
Responds to Rehab. (social skills training, self-monitoring of sxs., use of meds) - do respond to social skills training where role-playing - how talk; helps with prob solving
Behavior therapy: to meet social norms; do in social situations; impactful and helpful
Social skills: role-play—employment-communication-px.-solving
Watch personal space - if paranoid not get in space - need let know before getting close and if okay with that (imp to offer choices)
Give opportunity to make choices
Continued reassessment of mental status - remember + symp: what thinking and thought content
Implement plan to help pt. px. solve—to check out perceptions
Case Management—allows monitoring; helpful for people; often overwhelmed; support person for indivs; getting to doc and taking meds; imp for same person because consistency imp
Make sure if paranoid be consistent as possible: Nutrition and meds may be px. with someone experiencing paranoia-Be consistent to what tell; if med changes and someone paranoid question and not take it; keep food packaged so opening it themself so sometimes help
Therapeutic management
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Fam edu very imp
Help with this - Identification of triggers; bring up anxiety and hallucinations and delusions worsen
Help to recognize sxs. - when sxs worsen
Teach family coping skills, how to cope with hallucinations or relapse - how respond if having hallucination/delucion/illusion - acknowledge emotion and what person going through but present reality in matter of fact way then distract them; tend want argue with them with hallucinations
Antipsychotic meds very helpful in meds
Patient and family edu
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Antipsychotic used for off-label reasons: does help with agitation
1950 by Paul Charpentier (Chlorpromazine-Thorazine - grandfather of antipsychotics) First Antipsychotic Medication
By French surgeon who was attempting to develop a med. to control preop. Anxiety
Haldol another original - less AE
Thorazine and Haldol less expensive and are both good
Discovered this was effective in relieving hallucinations and delusions
Used to be called Major tranquilizers
Psychopharmacologic tx
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Antipsychotics
Treatment modalities: psychopharm
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Used to decrease agitation with someone in schizophrenia and other indivs and psychotic symptoms of schizophrenia and other psychotic disorders/symp
For variety reasons used
Antipsychotics
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Alleviate symptoms of schizophrenia but cannot cure underlying psychotic processes. - really good with hallucinations and delusions
Antipsychotic drugs are effective in:
For variety reasons used
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Psychotic symptoms return with medication noncompliance - noncompliance big issue
Alleviate symptoms of schizophrenia but cannot cure underlying psychotic processes.
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Acute exacerbations of schizophrenia
Preventing or mitigating a relapse
Antipsychotic drugs are effective in:
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Older antipsychotic indicated for psychosis—given for the positive signs—hallucinations, delusions, aggression - thorazine and haldol - grandfather of first gen; Haldol and Thorazine
May also use antipsychotics for bipolar, tics, and intractable hiccups
Newer antipsychotics: indicated/good for negative sxs—blunted affect, social withdrawal, lack of interest, poverty of speech and help with positive symptoms; given more often; social/communication symp
May get combo of both meds
Target symptoms
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Atypical agents have fewer side effects.
Atypical agents treat anxiety, depression, and decrease suicidal behavior - used for variety symp
Newer antipsychotics (atypical second generation): indicated for negative sxs—blunted affect, social withdrawal, lack of interest, poverty of speech and help with positive symptoms; given more often
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Antipsychotic med think Extrapyramidal symptoms (EPSs) - imp to look for these; imp catch these; mainly deals with muscles
Other adverse reactions include
Conventional (first-gen) antipsychotics - thorazine, haldol; AE of first gen
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Regarding muscles
Akathisia
Acute dystonia - neck, jaw aches; treat with anti parkinsonia drug
Pseudo parkinsonism
Tardive Dyskinesia - watch for; do not recognize it soon enough cannot correct it; watch for lip smacking, puffing out cheeks
all muscular rxns/AE
Antipsychotic med think Extrapyramidal symptoms (EPSs) - imp to look for these; imp catch these; mainly deals with muscles
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Anticholinergic effects - things dry up
Photosensitivity - must wear sunscreen; more prone to rxns to sun
Lowered seizure threshold
Neuroleptic malignant syndrome - like serotonin syndrome but in regards to antipsychotics: rxns: muscle rigidity, high fever, twitching; watch for this; not commonly seen
Other adverse reactions include
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Extrapyramidal symptoms (EPS) include:
Antipsychotics
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Pseudo parkinsonism - shuffling walk/feet; head in front of self
Akathisia– inner restlessness, shaking leg quickly; things feel like crawling inside; leg going fast
Dystonia—twisting movement abnl. Movement; in head and neck typ; usually seen early if given antipsychotic: muscle rigidity/abnormal movement in any part of body but typ neck and jaw feels weird and then impacts resp
Tardive dyskinesia (TD)—irreversible if not identified early—Reason for the Abnormal Involuntary Movement Scale (AIMS) - watch for muscles; always have this that checking that not exhibiting these movements; smacking lips, cheeks out, tongue out - if not recongize soon enough and get treatment is permanent/irreversible
Extrapyramidal symptoms (EPS) include:
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See dystonia - in jaw/neck give Antiparkinsonian agents
Side effects often appear early in therapy and can be minimized with treatment
Antiparkinsonian/anticholinergic agents may be prescribed to counteract EPS (esp dystonia)
**Complete Abnormal Involuntary Movement Scale (AIMS) ** if on antipsychotic because looking for muscle changes
TD - d/c drug or decrease dose
Should be PRN
Tardive dyskinesia: decrease dose, change drug, take off drug
Treatment usually consists of:
EPS considerations
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Sec-gen - newer meds: given more often
Target some positive and/or lot of negative symptoms
Metabolic syndrome -
Atypical (sec-gen) antipsychotics
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Watch for weight gain (impacts body - heart and metabolic sys), altered glucose, Agranulocytosis with clozapine (Clozaril)
Tendency with newer gen of antipsychotics for Weight gain - stopped taking because of this, dyslipidemia, altered glucose - drives it up
Risk of diabetes - more DM, hypertension, atherosclerosis, and increase in heart disease
Agranulocytosis with clozapine (Clozaril)
Metabolic syndrome -
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Notes: clozapine is also more expensive than other Second Generation Antipsychotics
WBC down and so increased risk for infection - need watch that and blood work
Diligent that come in to do blood work because decreases WBC count and susceptible to infections
Need make sure come in for blood work regularly
Abilify causes less weight gain and little increase in glucose and cholesterol levels. Good for someone with obesity or heart disease.
Agranulocytosis with clozapine (Clozaril)
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Antidepressants are administered for severe depression
Lithium and other mood stabilizers reduce aggressive behavior
Benzodiazepine augmentation improves positive and negative symptoms - may be on antidepressant/antianxiety (benzo)
The benzopdiazepine Clonazepam (Klonopin) decreases anxiety, agitation, and possibly psychosis
See on variety of meds and diff classifications
May be on antidepressant, antianxiety; on variety classifications
Adjuncts to antipsychotic drug therapy
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Clozapine (Clozaril): can cause bone marrow toxicity—watch decrease in WBC-agranulocytosis - WBC going down so Need a frequent blood test; consider WBC count while on it
Med considerations
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A client who has been taking chlorpromazine (Thorazine) for several months presents in the ED with extrapyramidal symptoms (EPS) of restlessness, drooling and tremors. What medication will the nurse expect the physician to order?
A. Paroxetine (Paxil)
B. Carbamazepine (Tegretol)
C. Benztropine (Cogentin)
D. Lorazepam (Ativan)
Correct answer: C
Benztropine (Cogentin) is an anticholinergic medication that blocks cholinergic activity in the central nervous system, which is responsible for EPS. Anticholinergics are the drugs of choice to treat extrapyramidal symptoms associated with antipsychotic medications
Antiparkinsonism drug of choice
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Need have lot support: Like dealing with new person; lot edu on meds
Family needs to be included in: and involved
Remember the families
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Very stressful - need lot edu; teach about illness and effects of stress on loved one
Psychologic strategies aimed at reducing psychotic symptoms
Teaching patient and family about illness
Recognizing effect of stress
Psychosocial activities
Identifying support sources - support groups for fam
Medication groups for patients and family - understand diff meds and side effects and symp so can watch for muscular symp to see
Family needs to be included in: and involved
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County - mental health center
Mental Health America
National Alliance on Mental Illness (NAMI) - great resource
Abnormal Involuntary Movement Scale (AIMS) - AIMS test for the detection of tardive dyskinesia (TD).; eval if on antipsychotic
Examples: - Available resources for fams
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What is your best intervention when you assess that a patient is responding to an auditory hallucination?
A.Ask the patient, “Can you tell me what you are hearing?”
B.Ask the patient, “Are you afraid of the voice you are hearing?”
C.Tell the patient, “Try to ignore the voices you hear.”
D.Tell the patient, “The voices you hear are not real.”
Answer: A
Knowing what the patient is hearing is important. A command hallucination could result in injury to self or others. For example, the voice may be telling the patient to self-mutilate or to harm someone else
See what hearing via command hallucination - delve into it to know what hearing - safety issue for them and others around them; not hearing command to do something harmful
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Not that if have schizophrenia are aggressive
Know the Indicators - aware surroundings and aware if getting anxious and concerned if getting more aggressive
Posture of Crisis Intervention
Aggressive behaviors
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Stand on the side - not in front
Keep hands open and out in open so can see; open handed and see ahdns
Be concise and brief in what talking - simple; not pile up on requests; simple in directions
Always have backup
Goal is to avoid escalation to aggression - not want further aggression/aggressive height to diffuse it
Posture of Crisis Intervention
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Observe behavior
Attend to your instincts and listen to gut
Intervene early
Goal is to avoid escalation - not want further aggression to diffuse it
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Start with emotion but not seeing that or see what see; validate that do see and is frightening; best then to go onto something else; validate feelings, nonjudgmental then move onto something else
Antipsychotics great - trick staying on them since chronic
How handle illusion/delusion/hallucination:
