Psychosis and Schizophrenia Flashcards
(83 cards)
1
Q
What is abnormal motor behaviour?
A
Alterations in behaviour, including bizarre and agitated behaviours. Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.
2
Q
What is acute dystonia?
A
Acute sustained contraction of muscles, usually of the head and neck.
3
Q
What are affective symptoms?
A
Symptoms involving emotions and their expression.
4
Q
What is akathisia?
A
Psychomotor restlessness evident as pacing or fidgeting, sometimes pronounced and very distressing.
5
Q
What is associative looseness?
A
Disorganized thinking, manifested as jumbled and illogical speech and impaired reasoning (also known as looseness of association).
6
Q
What does schizophrenia and other realted disorders refer to?
A
Alterations in PERCEPTION, THOUGHT, LANGUAGE, EMOTIONS and SOCIAL BEHAVIOUR
When a person experiences significant alterations in these areas and also in their ability to determine what is real or is not real we use the term “psychotic” or “psychosis”
7
Q
What are five key areas of psychotic disorders?
A
1) Delusions +
2) Hallucinations +
3) Disorganized Thinking and Speech +
4) Abnormal motor behaviour +
5) Negative Symptoms -
8
Q
What is a negative symptom?
A
The absence of something that should be present but is not - for example, the ability to make decisions or to follow through on a plan.
9
Q
What are some circumstances where psychosis may be present?
A
- Brief Psychotic Disorder: lasts at least one day but not more than a month and may only ever have one occurrence.
- Schizophreniform Disorder: lasts at least one month but less than 6 months. Often a provisional diagnosis
- Delusional Disorder: Often a chronic illness. Delusions are plausible.
- Schizoaffective Disorder: Mood symptoms present simultaneously with psychosis for the majority of illness, but not dominant x 2 weeks.
- Substance Induced Psychosis
- Psychosis due to a medical condition
10
Q
What percentage of people are affected by schizophrenia?
A
1%
11
Q
What is the age of onset of schizophrenia for males and females?
A
First episode 15-25 males and 25-35 females
12
Q
What are common comorbidities with schizophrenia?
A
Substance use: in particular nicotine
Anxiety, depression, and suicide
Physical health (increased risk cardiovascular, respiratory and cancer)
Polydipsia
Psychogenic Polydipsia
13
Q
What causes schizophrenia?
A
Exact cause unknown
Multiple factors “Diathesis - stress model of schizophrenia”
* Inherited genes + brain structure abnormalities + neurochemistry alterations + prenatal stress (infection, poor nutrition, exposure to toxins, hypoxia) + psychological stress + environmental stress
14
Q
What is the importance of early detection and intervention?
A
- Duration of Untreated Psychosis associated with increased severity of illness and decreased level of functioning.
- Each relapse of psychotic symptoms = increased residual symptoms and decreased level of functioning.
- Although there is evidence of many people functioning at a high level alongside diagnosis of schizophrenia we must refrain from giving false hope. Must be realistic and honest.
15
Q
True or false: Studies indicate that nurses and healthcare providers have a negative attitude towards people with schizophrenia.
A
True
16
Q
What is the clinical picture of a first psychotic episode (Phase I - acute)?
A
Usually hospitalized
Presence of positive symptoms, affective symptoms and cognitive symptoms
Negative symptoms likely present as well.
17
Q
What is a positive symptom? List examples.
A
- Presence of something that should not be; alterations in thinking and perception; Hallucinations, Delusions, concrete thinking
- Alterations in Speech
- Difficulties with thought processes. We know this when a patient has associative looseness, circumstantial, tangential, neologisms, echolalia, clang association, word salad
- Alterations in Behaviour
1) Catatonia (may see automatic obedience, waxy flexibility or echopraxia, echocolia)
2) Psychomotor agitation or retardation
3) Stereotyped (repeated behaviour with no purpose)
4) Negativism: active (unintentional opposite act of request, also seen with catatonia) or passive (failure to do what is requested)
18
Q
What are negative symptoms?
A
- Take the oomph out of a person. Absence of something that should be present….our oomph! Usually take longer to develop.
- No motivation, no joy, appear blank (because experiencing alogia….who can tell me what that is and explain why that might make a person appear blank).
- These patients will lay on their bed all day every day.
- Makes it impossible to have meaningful social connections, obtain employment or develop interests.
19
Q
What is alogia?
A
With schizophrenia, alogia involves a disruption in the thought process that leads to a lack of speech and issues with verbal fluency. For this reason, it is thought that alogia that appears as part of schizophrenia may result from disorganized semantic memory.
20
Q
What are cognitive and affective symptoms?
A
- These are the symptoms that impede recovery.
- Concrete thinking, poor memory, poor ability to process information, impaired executive functioning which makes decision making difficult and social situations awkward.
- Unstable mood (often experience depression which INCREASES RISK OF SUICIDE).
21
Q
What does recovery look like for patients with schizophrenia? (Phase II and Phase III)
A
- Individualized
- Some people with schizophrenia can live independently, others in a group home setting and still others in a long term hospital.
- The goal is for as much independence as possible.
- Variety of community services promote independence.
- Relapses are common, residual symptoms are common and unfortunately a decreased level of functioning is associated with every relapse.
22
Q
What are treatment areas for schizophrenia?
A
Medication
Psycho-education (family and patient)
Community Support
Structured Routines
23
Q
What is anosognosia?
A
Anosognosia, also called “lack of insight,” is a symptom of severe mental illness experienced by some that impairs a person’s ability to understand and perceive his or her illness. It is the single largest reason why people with schizophrenia or bipolar disorder refuse medications or do not seek treatment
24
Q
Generally, what is the mode of action of first generation antipsychotics?
A
Prevent dopamine from activating dopamine receptors = decrease circulating dopamine
25
What was the downside of 1st generation antipsychotics?
These were wonder drugs…they treated symptoms such as hallucinations and delusions very effectively (positive symptoms of schizophrenia) but did not treat negative symptoms
BUT AHHH the side effects:
Two major groups of side effects
1) EPS
2) Tardive Dyskinesia
26
What are extrapyramidal side effects?
Dopamine plays a major role in the regulation of movement so when we inhibit it we get motor like side effects.
EPS:
1) Acute Dystonia: sustained contraction of muscles, most often in head and neck
TREATMENT: IM COGENTION OR IM BENADRYL
2) Akathisia: patients usually complain of inner restlessness, looks like pacing/fidgeting
3) Pseudoparkinsonism, looks like have parkinson's: tremor, shuffling gait, muscle stiffening.
TREATMENT 2) and 3): PRN or regular doses of antiparkinson/anticholinergic meds such as Cogentin or Artane
27
What is the treatment for acute dystonia?
IM COGENTION OR IM BENADRYL
28
What is the treatment for akathisia or pseudoparkinsonianism?
PRN or regular doses of antiparkinson/anticholinergic meds such as Cogentin or Artane
29
What was the worst effect of 1st generation antipsychotics?
**Tardive dyskinesia**
-Irreversible
-No reliable treatment
- Affects up to 50% of individuals receiving high dose long term treatment
30
What does tardive dyskinesia look like?
-Facial grimacing, tongue protrusion, lip smacking, involuntary tonic muscular contractions of tongue, fingers, toes , neck, trunk or pelvis.
-Contributes to stigmatization of mental illness
31
What was the first 2nd gen antipsychotic and what unfortunate side effect did it produce?
* **Clozaril **introduced in early 1990’s as first second generation drug….again seen as a wonder drug. EPS and Tardive Dyskinesia risks were greatly reduced BUT still can occur.
* Acts on both positive and negative symptoms of schizophrenia and dramatic improvement was evident in many. But a major issue soon was identified: risk for **agranulocytosis**.
* All patients on clozaril MUST have weekly WBC tests x first 6 months and then regular monitoring. Must monitor for signs of infection. Clozaril has become a last resort 2nd generation choice when other second generation anti-psychotics are not effective.
32
What are first line treatments using 2ns gen antipsychotics?
- Risperidone (risperidal)
-Lurasidone (latuda)
-Olanzapine (Zyprexa)
-Quetiapine (Seroquel)
- Ziprasidone (zeldox)
33
What are common Side Effects of 1st Generation and to a lesser degree 2nd Generation?
- **Weight gain****
- Sexual dysfunction
- Sedation**
- Orthostatic hypotension
-Lower seizure threshold
- stiffness (cogwheel rigidity)
- Anticholingeric effects: dry mouth, blurred vision, constipation, **urinary retention**, tachycardia
34
In general, how do 3rd generation antipsychotics work?
Both increase and decrease dopamine (dopamine system stabilizer)
35
What are side effects of 2nd and 3rd generation antipsychotics?
Metabolic Syndrome:
- Weight Gain (a lot!!)
- Dyslipidemia
- Altered glucose metabolism
High risk for diabetes, hypertension, atherosclerotic heart disease
Fun Fact: Ziprasidone (zeldox) and Aripiprazole (abilify) do not cause weight gain.
EPS risk is minimal in these drugs but it still can occur (more often in risperidone) and must be monitored for.
36
What antipsychotic medications are available in a long term/depot format?
a) Risperdal Consta
b) Fluphenazine (modecate)
c) Haloperidol (Haldol)
d) Aripiprazole (abilify)
e) Olanzapine
f) Paliperidone (invega sustenna)
g) Zuclopenthixol (Clopixol depot)
37
What is a dangerous physiological response to antipsychotics?
Neuroleptic Malignant Syndrome (NMS)
-can occur with 1st , 2nd or 3rd generation
-acute reduction of dopamine
- life threatening, fatal 10% of the time, occurs in 0.2 to 1% of people.
- Often will happen shortly after treatment begins but not always
38
What does neuroleptic malignant syndrome look like?
- decreased consciousness, increased muscle rigidity, fever, labile hypertension, sweating, drooling, change in breathing
39
What are the interventions if neuroleptic malignant syndrome is detected?
- notice it early, stop anti-psychotic, inform physician, fluid balance, decrease temp, may need to transfer to medical unit, bromocriptine to relieve muscle rigidity
40
What is involved in nursing care of someone taking an antipsychotic medication?
* Monitor movements, often a scale is used
* Medication adherence: teaching and developing a rapport most important
* **** Always monitor for EPS, tardive dyskinesia, NMS, infection****
* Monitor level of sedation, weight, blood glucose, blood pressure
* Liver, renal, cardiac function
41
What are important pieces of the overall assessment?
1) Risk (self/others)
2) Medical Problems
3) Abuse of or dependence on alcohol/drugs
4) Command hallucinations
5) Delusions
6) Ability to ensure self-safety
7) Medication Adherence
8)Mental Status Exam
9) Insight
10) Family’s knowledge
42
What are appropriate nursing interventions for someone with disturbed thought process/content (delusions)?
- be sincere and honest when communicating, avoid vague or evasiveness
- be consistent in setting expectations, enforcing rules etc.
- do not make promises you cannot keep
- explain all procedures and try to make sure they understand
- give positive feedback
- recognize delusions as the client’s perception
- do not argue with or try to convince that delusions are false
- do not dwell on delusional material, interact about reality
- show empathy, no judging
- never convey acceptance of delusions
43
What are appropriate nursing interventions for someone with disturbed sensory perceptions (hallucinations)?
-be aware of all surrounding stimuli, may intensify hallucinations for client
try to decrease stimuli
-avoid conveying belief, “i don’t hear any voices-what are u hearing’
-if appears to be hallucinating, attempt to engage
-maintain simple topics of conversation to provide base in reality
-use concrete, specific communication
-avoid giving too many choices
-reinforce reality based conversation
-encourage to tell staff about hallucinations
-show acceptance
44
What is a boundary impairment?
An impaired ability to sense where one's self ends and others' selves begin.
45
What is circumstantiality?
The inclusion of unnecessary and often tedious details in one's conversation.
46
What are cognitive symptoms?
Difficulty with attention, memory, information processing, cognitive flexibility, and executive functions (e.g., decision making, judgment, planning, problem solving).
47
What are command hallucinations?
“Voices” that direct the person to take an action.
48
What is concrete thinking?
An impaired ability to think abstractly. The person interprets statements literally
49
What is a delusion?
Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning
50
What is depersonalization?
A nonspecific feeling that a person has lost his or her identity, that the self is different or unreal, or that the person is an observer of his or her own body or mental processes. An aspect of depersonalization/derealization disorder.
51
What is derealization?
An aspect of depersonalization/derealization disorder that results in individuals' experiencing a recurring feeling that their surroundings are unreal or distant—an external or outside feeling of disconnect.
52
What is disorganized thinking?
The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning
53
What is echolalia?
The pathological repeating of another's words, often seen in catatonia.
54
What is echopraxia?
The mimicking of the movements of another
55
What are extrapyramidal side effects?
Adverse effects, including akathisia, acute dystonias, pseudoparkinsonism, and tardive dyskinesia, caused by blockage of D2 dopamine receptor sites in the motor areas
56
What is a hallucination?
The perception of a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking).
57
What are ideas of reference?
The giving of personal significance to trivial events; the perception that events relate to one when they do not.
58
What are illusions?
Misperceptions or misinterpretations of a real experience
59
What is paranoia?
Any intense and strongly defended irrational suspicion.
60
What is psychosis?
Altered cognition, altered perception, or an impaired ability to determine what is or is not real (an ability known as reality testing).
61
What is reality testing?
The ability to determine accurately whether or not an experience is based in reality.
62
What is the recovery model?
A patient-centred approach that stresses hope, living a full and productive life, and eventual recovery. Patients partner with health care providers and aim to extend their improvement beyond stability.
63
What are stereotyped behaviours?
Repeated motor behaviours that do not presently serve a logical purpose.
64
What is tangentiality?
A departure from the main topic to talk about less important information; going off on tangents in a way that takes the conversation off-topic.
65
What is word salad?
A jumble of words that is meaningless to the listener—and perhaps to the speaker as well—because of an extreme level of disorganization
66
What are the phases of schizophrenia?
* Phase I: acute: onset or exacerbation of florid, disruptive symptoms
* Phase II: Stabilization: Symptoms are diminishing, and there is movement toward one's previous level of functioning
* Phase III: Maintenance: The person is at or nearig baseline (or premorbid) functioning; symptoms are absent ordiminished; level of functioning allows the person to live in the community.
67
What does the LEAP acronym stand for?
Listen
Empathize
Agree
Partner
68
What is involved in early prevention?
Primary prevention is monitoring those at high risk (children of parents with schizophrenia) for symptoms such as abnormal social development and cognitive dysfunction. Reduce stressors, enhance social and coping skills
69
WHat is involved in milieu management of schizophrenia?
* Protection from stressful or disruptive environments
* structure
70
What is schizophrenia?
A biological disorder of the brain. It is not one disorder but a group of disorders with overlapping symptoms and treatments.
71
Is psychosis a symptom or a diagnosis?
Symptom
72
What is a brief psychotic disorder?
Last one day but not more than a month and may only ever have one occurrence
A lot of education and reconstructing what happened
Helps inform what can be done to prevent that
73
What types of medication conditions may result in psychosis?
Liver disorders
Brain tumours
Metabolic disorders
If a patient tells you that they start smelling or seeing something, but no other symptoms, likely a medical condition
74
Is schizophrenia more common in males or females?
Males
75
What are signs of psychogenic polydipsia?
Person wants to drink continually
Thirst is never satisfied
Hyponatremia
Decreased urine specific gravity (urine concentration) <1.005
Mental status changes: increased symptoms, behavioural changes, fatigue, headache, muscle weakness, confusion
Can lead to seizures, cerebral edema and death
76
What medication may be administered to rule out diabetes insipidus?
desmopressin
77
What interventions whould be put in place when psychogenic polydipsia is taking place?
Assess fluid intake
Be aware of risk factors
Restrict water intake
Monitor Na+ and urine specific gravity
Weigh daily (***remember this****)
78
What presentations are associated with catatonia?
Waxy flexibility
Negativism
Obedience
Stupor most likely
Incongruent affect
(remember the video)
79
Which antipsychotic often causes metabolic syndrome?
olanzapine
80
Which 2nd generation antipsychotic causes highest rate of EPS?
risperidone
81
Which 2nd gen antipsychotic causes high risk of metabolic syndrome?
olanzapine
82
What is metabolic syndrome>
2nd and 3 rd gen antipsychotic put at risk for weight gain and metabolic syndrome. Involves weight gain, dyslipidemia and altered glucose metabolism. Puts at risk for diabetes, hypertension, and heart disease.
83
what generation of antipsychotic causes neuroleptic malignancy syndrome?
1st, 2nd or 3rd
