psychotic
loss of contact with reality (delusions, hallucinations)
schizophrenia
most common thought disorder. Group of disorders that affect thinking, behavior, emotions and ability to perceive reality
schizoaffective thought disorder
meets criteria for schizophrenia AND an affective disorder (depression, mania, etc.)
Brief thought disorder
psychotic manifestations that last from 1 day to 1 month
schizophreniform thought disorder
clinical manifestations of schizophrenia, but duration is from 1 to 6 months and social/occupational dysfunction may or not be present
Shared psychotic thought disorders
one person begins to share delusional beliefs of another person with psychosis
Secondary (induced) thought disorders
manifestation od psychosis brought on by medical disorder (dementia) or chemical substances (alcohol abuse)
Schizophrenia onset
late teens to early 20’s
Schizophrenia diagnosis
Age 7 (rule out ADHD with violent tendencies)
Schizophrenia interferes with
interpersonal relationships
self-care
ability to work
Positive symptoms (symptoms there, but should not be there)
- Hallucinations
- Delusions
- Alterations in speech
- Alterations in behavior
Hallucinations (sensory perceptions)
- Auditory
- Visual
- Olfactory
- Gustatory
- Tactile
Delusions
alterations in thought that can’t be corrected by reasoning and are usually bizarre
Delusions of persecution
feeling of being singled out for harm by agencies, other people, or supernatural beings
Delusions of grandeur
believe they are powerful and important (God)
Ideas of Reference
believing that events or situations are occurring because of or specifically for them (people on TV sending them messages)
Somatic delusions
believe their body is changing in an unusual way
Jealousy
may believe spouse is having an affair
Being controlled
force outside their body is controlling them
Thought broadcasting
their thoughts can be heard by others
Thought insertion
others’ thoughts are being inserted into their mind
Thought withdrawal
thoughts have been removed from their mind
Religiosity
obsession with religious beliefs
Depersonalization
nonspecific feeling that the person has lost her identity
Derealization
perception that the environment has changed
Alterations in speech (Positive symptoms)
- Flight of ideas
- Neologisms
- Echolalia
- Clang
- Word salad
Flight of ideas
loose association between thoughts
Neologisms
made up words
Echolalia
repeating words spoken to him
Clang association
meaningless rhyming words
Word Salad
words jumbled together with little meaning
Alterations in behavior (Positive)
- Bizarre behavior
- Extreme agitation
- Stereotype
- Automatic
- Waxy flexibility
- Stupor
- Negativism
- Echopraxia
Bizarre behavior
like walking backwards all the time
Extreme agitation
pacing and rocking (give them space)
Stereotype behaviors
motor patterns with meaning to pt. but now are mechanical and lack purpose
Automatic obedience
responding in a robot-like manner
Waxy flexibility
excessive maintenance of position
Stupor
motionless for long periods of time
Negativism
doing opposite of what is requested
Echopraxia
purposeful imitation of movements made by others
Negative symptoms of schizophrenia
abilities or characteristics that are absent from the pt.
Types of Negative Symptoms
- Affect
- Alogia
- Avolition
- Anhedonia
- Anergia
Affect
facial expression
blunt - narrow range
flat - never changes
Alogia
not many thoughts or speech (mumble)
Avolition
lack of hygiene and activities (must be prompted)
Anhedonia
lack of pleasure or joy (no fun)
Anergia
lack of energy
Cognitive (thinking) symptoms
- Disordered thinking
- Inability to make decision
- Poor problem solving
- Difficulty concentrating
- Memory deficits (long-term or Working memory)
Depressive symptoms
Hopelessness
Suicidal ideation
Types of Schizophrenia
- Paranoid
- Disorganized
- Catatonic
- Residual
- Undifferentiated
Paranoid schizophrenia
suspicion
Hallucinations and delusions
May be violent
Disorganized schizophrenia
Homeless withdrawal from society inappropriate behavior Disorganized hallucinations and delusions Bizarre mannerisms Incoherent speech
Catatonic schizophrenia
Abnormal motor movements
- Withdrawn (psychomotor retardation, appear comatose, waxy flexibility, self-care needs)
- Excited (constant movement, posturing, danger to self and others)
Residual schizophrenia
No clinical manifestations
2 or more residual findings
Anergia, anhedonia, avolition, withdrawal, impaired role, speech problems, odd behaviors
Undifferentiated
No particular type
Any symptoms may be present
Schizophrenia Medications
positive psychotic symptoms
Conventional Antipsychotics:
Haldol (Haloperidol)
Thorazine (Chlorpromazine)
Schizophrenia Medications
negative and positive psychotic symptoms
Atypical Antipsychotics: Risperadal Zyprexa (Olanzapine) Seroquel (Quetiapine) Geodon (Ziprasidone) Abilify Clozaril
Schizophrenia Medications
Depression
Antidepressants:
Paxil
Watch suicide
Avoid abrupt cessation
Schizophrenia Medications
Anxiety + pos and neg
Anxiolytics/Benzodiazepines: Ativan (Lorazepam) Klonopin (Clonazepam) Sedative effect Monitor agranulocytosis
Medication dose
start low and gradually increased
Take medication on a
regular basis
Avoid
Alcohol
Sedatives
Haz activities
Teach to expect
side effects
Significant improvement takes
2 - 4 weeks
Full effect may take
several months
Depot preparations
IM injections every 2 -4 weeks (can’t maintain schedule) Risperidal
Oral disintegrating tablets
pt that cheeks or pockets meds or difficulty swallowing
Right to refulse
unless a risk for harm to self or others (order for involuntary administration)
Milieu therapy
structured, safe environment that helps decrease anxiety and distracts them from continually thinking about hallucinations
Therapeutic communication
goal-oriented to help them learn how to manage
Trusting relationship
Important for nurse - never lie
Nurse should encourage
Development of social skills and friendships
Participation in group work and psychotherapy
To address hallucinations and delusions
- Don’t argue or agree
- Acknowledge feelings (You seem to be)
- Offer reasonable explanations
- Provide for safety
- Focus conversations on reality-based (redirect)
- Be genuine and empathetic
- Identify symptom triggers
- Determine discharge needs
- Promote self-care (modelling and instruction)
- Relate wellness to symptom mgmt. (not going away)
- Teach and implement strategies to reduce auditory hallucinations (music, TV, say stop)
Personality disorders
enduring patterns of behavior for which there is no loss of contact with reality or impaired cognition
Personality disorders first observed
late adolescence or early childhood
Personality disorders co-occur with
depression and anxiety
Personality disorders diagnosis criteria
ongoing, inflexible pattern of behavior that is very different from the individual’s culture that causes distress in social or occupational functioning. Affected areas: cognition, affect, impulse control, interpersonal functioning
4 Characteristics of Personality Disorders
- Inflexible and maladaptive response to life events/stress
- Serious difficulty in areas of personal and work relationships
- Tendency to evoke personal conflict
- Tendency to evoke a negative emotional responses from others
Risk factors of Personality Disorders
Less educated or unemployed
Single or have marital difficulties
Comorbid substance use
May commit nonviolent or violent crimes (sex)
Defense Mechanisms
used by people with personality disorders to “protect” themselves
Repression
unconscious hiding of uncomfortable thoughts
Suppression
conscious avoidance of uncomfortable thoughts
Regression
reverting to patterns of behavior used in earlier development
Undoing
attempting to “undo” an unhealthy or destructive thought by behaving in an opposite way
Splitting
inability to incorporate both pos. and neg. aspects of oneself into a whole image (common with borderline personality disorder)
Cluster A (Odd and Eccentric)
- Paranoid
- Schizoid
- Schizotypal
Paranoid personality disorder (A)
distrust and suspiciousness
unfounded belief that others want to harm, exploit, or deceive them
Distort things, others trying to trick them
Schizoid personality disorder (A)
emotional detachment, no interest in close relationships, indifference to praise or criticism, prefers to be alone, shy, uneasy, no psychotic symptoms
Schizotypal personality disorder (A)
odd beliefs leading to interpersonal difficulties, eccentric appearance, magical thinking or perceptual distortions (not clear hallucinations or delusions). Ideas of reference, bizarre speech, superstitions
Cluster B (bouncing ball)
dramatic, emotional, or erratic traits
Antisocial personality disorder (B)
characterized by disregard for others with exploitation, repeated unlawful actions, deceit, and failure to accept personal responsibility (often incarcerated), playboy, no guilt, no rules HANNIBAL LECTOR
Borderline personality disorder (B)
instability of affect, identity, and fear of abandonment in relationships, splitting behaviors, manipulation, and impulsiveness (food, gambling, spending, substance abuse, unsafe sex). Self-mutilation, suicide.
Histrionic personality disorder (B)
characterized by emotional attention-seeking, in which the person needs to be the center of attention. Flirtatious, seductive, drama queen, easily influenced by others, emotional
Narcissistic personality disorder (B)
characterized by arrogance, grandiose views of self-importance, the need for consistent admiration, and a lack of empathy for others. Grandiosity. Tends to use others.
Cluster C (Scaredy cat)
anxious or fearful traits; insecurity and inadequacy
Avoidant personality disorder (C)
social inhibition and avoidance of all situations that require interpersonal contact, despite wanting close relationships, due to extreme fear of rejection; often very anxious in social situations (avoids situations where he/she might be criticized or ridiculed). Seen as cold and/or strange.
Dependent personality disorder (C)
Most common
characterized by extreme dependency in a close relationship with an urgent search to find a replacement when one relationship ends.
Clingy and passive with low self-worth
Obsessive/Compulsive personality disorder (C)
characterized by perfectionism with a focus on orderliness and control to the extent that the individual may not be able to accomplish a given task. Rigid about rules. Don’t repeat things in a ritual manner like OCD.
Self-assessment
nurses need to talk about feelings with more experienced nurses
Angry, hostile, and aggressive behavior
Nursing interventions
- Assess non-verbal cues
- Be calm and self-assured
- Show you care
- Be culturally aware
- Allow adequate personal space
- Encourage to find quiet, safe place
- Maintain own safety
- Stand sideways (nonthreatening)
- Watch exits
- Ask for permission before touching
- Verbalize pt.’s options
- PRN meds
- Allow de-escalation rime
- Document measures before restraints
Manipulative behavior
Nursing interventions
- Set clear and realistic limits (explain and refuse negotiation)
- Set realistic, enforceable consequences
- Make sure whole team is aware of limits & agree
- Document limits
- Entire staff should decide when to discontinue the limit
Paranoid behavior
Nursing Interventions
- Assign only one or two staff
- Make brief contact at beginning of shift
- Do not make unnecessary demands
- Be honest, adhere to stated schedule, and follow through (Build trust)
- Don’t touch a patient
- Don’t mix meds with food
- Supply food in commercially wrapped pkgs
Communication strategies
Nursing Interventions
- Be firm, supportive approach and provide consistent care
- Offer realistic choices
- Model appropriate behavior
- Maintain professional boundaries and communication
- Respect the need for social isolation of some clients (safe place)
cognitive disorder
disruption of thinking, memory, processing, and problem solving (learning and remembering)
delirium
acute confusion seen by a change in overall cognition and level of consciousness
dementia
multiple cognitive deficits (especially memory) that tends to be chronic and appear over time
aphasia
impaired speech
anomia
difficulty remembering words
agraphia
inability to understand written language
agnosia
inability to recognize familiar objects
apraxia
inability to perform activity even though motor function is intact
illusions
misinterpretation of reality
hallucination
seeing or hearing something that is not there
delusion
belief in a false idea
depression
may be confused with delirium or dementia
poor personal hygiene, diff. concentrating
Quiet/withdrawn OR agitated
Logical speech, but very negative, hopeless
amnestic disorder
involves decreased awareness of surroundings, inability to learn new information, inability to recall previously learned info, possible disorientation to place and time. NO personality change. NO impaired cognition.
Dementia defense mechanisms
to avoid embarrassment
- denial
- confabulation
- perseveration
denial
refuse to accept the truth
confabulation
make up stories to fill in gaps in their memories
perseveration
won’t change their story (repeat same response)
JAMCO
helps determine depression vs. delirium vs. dementia Judgement Affect/Mood Memory Cognition Orientation
Causes of delirium
Substance-induced
Physical needs
Substance-induced delirium causes
withdrawal
intoxication
side effects
elderly - lower metabolism, liver and kidney fx
Alzheimer’s Disease causes/risk factors
No known cause or cure Risks: advanced age female prior head injury family history of Alzheimer's or Down Syndrome
Stage 1 Alzheimer’s
No impairment
No memory problems
Stage 2 Alzheimer’s
Very mild cognitive decline
Forgetfullness
Stage 3 Alzheimer’s
Mild cognitive decline
Misplacing important objects, short-term memory loss, Decreased attention span, Difficulty remembering words or names
Stage 4 Alzheimer’s
Moderate cognitive decline
Personality change
Obvious memory loss
Difficulty with money and math
Stage 5 Alzheimer’s
Moderately severe cognitive decline
Inability to recall important details, Can remember who you are and family. Disorientation to time and place
Stage 6 Alzheimer’s
Severe cognitive decline
Loss of awareness of recent events and surrounding
Knows name, but not personal history
Significant personality changes
Wandering and Incontinence
Abnormal sleep/wake cycles
Violent tendencies with potential to harm self or others
Stage 7 Alzheimer’s
Very severe cognitive decline
Loss of ability to respond to environment, speak, and control movement, Ataxia, Stupor and coma,
Death frequently by choking or infection
Alzheimer’s meds
Cholinesterase inhibitors:
Aricept (donepezil)
Exelon (patch)
Razadyne
S/E- N/D, bradycardia, bronchoconstriction, bleeding with NSAIDS
Alzheimer’s meds
Calcium channel blocker
Namenda (moderate to severe)
S/E - dizziness, headache, confusion, constipation
Vascular dementia
Caused by vascular disease
Risks-hypertension, hyperlipidemia, DM, alcohol and nicotine abuse
More rapid progression
AIDS Dementia Complex
Possibly HIV infection of brain
Slow cognition, then incontinence, bed-bound, psychosis, mania. Treat with anti-virals and symptoms (antianxiety, depress, etc.)
Dementia nursing interventions
Home
Scatter rugs Door locks and alarms Lower water heater temp. Good lighting Hand rails Mattress on floor Establish routine Provide support and care for family/caregiver Power of Attorney/Living will
Dementia nursing interventions
Healthcare Setting
Room close to Nurse's station Low visual/auditory stimuli Well-lit with windows PRN meds for anxiety or agitation Routines with food and fluids Limit number of choices Introduce yourself every time Don't argue or question Eye contact and short, simple sentences
