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PMHNP License > Schizophrenia spectrum and other psychotic disorders > Flashcards

Schizophrenia spectrum and other psychotic disorders Flashcards

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1
Q

Psychotic disorders (generally)

A

psychotic implies inability to test reality

grouped r/t similarity in frequent psychotic sx but each has diff etiology

some of the most debilitating classes of psych dx
-determined by degree of functional impairment and financial burden of severe mental illness

known to have strong genetic component

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2
Q

psychotic sx

A

hallucinations
delusions
disorganized thinking/speech
referential thinking
abnormal motor behavior
negative sx

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3
Q

hallucination types in order of commonality

A

Auditory
Visual
Tactile
Olfactory
Gustatory

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4
Q

types of delusions

A

Persecutory
Religious
Grandiose
Somatic
Jealous
Erotomanic

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5
Q

types of disorganized thinking

A

Loose association
Derailment
Speaks tangentially
Word salad

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6
Q

definition and types of referential thinking and delusions of control

A

Belief that events, actions, or situations in the environment hold special significance or meaning

Thought insertion
Thought withdrawal
Thought control
Thought broadcasting

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7
Q

Schizophrenia areas of dysfunction

A

its a disease of info processing with behavioral and cognitive sx. The illness is associated with marked social and occupational dysfunction

cognition
perception
emotion
behavior
eye movement
socialization

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8
Q

Schizophrenia etiology theories

A

overall probably multifactorial

Neurobiological: genetics, neurodevelopment, neurobiological defect

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9
Q

Schizophrenia incidence and demographics

A

higher in urban, 1st born, lower SES

men>women

men more neg sx, earlier onset

women more dysphoria, delusions, hallucinations

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10
Q

schizophrenia down drift

A

decreased functionality over time
-academic, work, etc

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11
Q

schizophrenia DSM

A

2+ sx frequently for 1 mo AND 1 must be delusion, hallucination, or disorganized speech

Sx:
Hallucinations
Disorganized speech
Delusions
—thought withdrawal
—thought insertion
Negative sx
Grossly disorganized behavior
Significant impair social/occupational
Duration at least 6 mo.

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12
Q

positive sx explanation

A

Sx that respond positively to and can be controlled by antipsychotic medication

reflect excess/distortion of normal brain function

caused by inc dopamine in mesolimbic pathway

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13
Q

positive sx clinical manifestations

A

Hallucinations
delusions
referential thinking
disorganized behavior
hostility
grandiosity
mania
suspiciousness

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14
Q

negative sx explanation

A

Sx less responsive to antipsych rx but respond better to atypical antipsych rx

represent a dec or loss of normal function

caused by dec in dopamine in the mesocortical pathway

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15
Q

negative sx clinical manifestations

A

Affective flattening
alogia or poverty of speech
avolition
apathy
abstract thinking problems
anhedonia
attention deficit

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16
Q

other associates schizophrenia sx (not pos or neg) explanation and clinical manifestations

A

sx not required for dx but often present and a focus of tx

inappropriate affect
dysphoric mood
depersonalization
derealization
high anxiety

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17
Q

schizophrenia course of illness pos and neg sx

A

neg tend to appear first

pos decrease over time but neg persist

neg more debilitating

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18
Q

schizophrenia factors of good prognosis

A

high level premorbid function
acute onset
later age of onset
clear precipitating event
married/partner
good support system
pos sx
short interval b/t tx and onset of 1st sx
absence of structural brain abnormal
fam hx of mood disorder
no fam hx schizophrenia

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19
Q

schizophrenia physical exam soft signs

A

neurological nonlocalizing

astereognosis: loss of ability to judge the form of an object by touch

twitch/tics/rapid eye blinking

dysdiadochokinesia: impair ability to perform rapidly alternating movements

impair fine motor movement

left-right confusion

mirroring

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20
Q

schizophrenia physical exam hard signs

A

weakness
decreased reflexes

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21
Q

only drug for tx resistant schizophrenia

A

clozapine

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22
Q

primary 1st line tx for schizophrenia and why

A

atypical antipsychotics

less significant neuro AE vs 1st gen

less EPS/TD
–in Nigrostriatal: block 5ht so inc d2 which dec ACh which dec EPS (EPS caused by inc ACh)

–in Tuberoinfundibular: block d2 so inc prolactin so more galactorrhea and gynecomastia

Tx pos and neg sx
–block d2 in mesolimbic to dec pos
–inc d2 in mesocortical to dec neg

serotonin-dopamine antagonists

improved compliance

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23
Q

EPS and NTs

A

EPS caused by inc ACh

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24
Q

hyperprolactinemia associated with antipsychotics may cause

A

sex problems
galactorrhea
amenorrhea
gynecomastia

bone demineralization in post menopausal women not on estrogen

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25
reasons for typical antipsychotics as treatment of schizophrenia
useful for tx of pos sx by block d2 in mesolimbic --can make neg sx worse by block d2 in mesocortical inexpensive generic can be used as sustained release injectable
26
clozapine type and brand name
2nd gen clozaril
27
clozapine AE common and rare
common: tachy, drowsy, dizzy, hypersalivation, wt gain, hyperlipidemia rare: agranulocytosis, myocardititis, NMS
28
clozapine also to know
REMS program need monitor ANC for neutropenia not in conjunction with WBC --1st 6 mo: weekly --2nd 6 mo: biweekly --then monthly if ANC WNL monitor for myocarditiis --assess family and personal hx CVD dose related sz risk metabolic disorder monitoring
29
REMS
risk evaluation and management strategy program
30
When to suspend clozapine based on ANC
<500
31
Quetiapine type and brand
2nd gen seroquel
32
Quetiapine AE common and rare
common: Sedation, ortho hypo, wt gain rare: cataract formation
33
Quetiapine other considerations
check LFTs monitor cataract divided doses BID/TID no prolactin elevation monitor metabolic disorder assess fam and personal hx CVD
34
olanzapine type and brand
2nd gen zyprexa
35
olanzapine dosage forms
tablet IM
36
olanzapine AE
sedation, metabolic, LFT, mild prolactin IM: requires monitor 3 hrs post injection r/t risk of delirium sedation syndrome
37
olanzapine other considerations
significant wt gain monitor metabolic assess fam and personal hx CVD
38
risperidone type and brand
2nd gen risperdal
39
risperidone dosage forms
tablet liquid ODT IM
40
risperidone AE
hypotension galactorrhea nausea insomnia
41
risperidone other considerations
dose >6mg associated with higher EPS less wt gain than clozapine or olanzapine most prolactin elevation among atypicals monitor lipid and glucose assess fam and personal hx of CVD
42
ziprasidone type and brand name
2nd gen geodon
43
ziprasidone dosage forms
tablet IM
44
ziprasidone common and rare AE
common: hypotension, sedation, dizzy rare: QTc, skin, DRESS (drug reaction with eosinophilia and systemic symptoms)
45
ziprasidone other considerations
Qtc monitoring --avoid coadmin with other QTc drugs --caution with risk for hypokalemia, hypomagnesemia, after MI, or with CHF With food increases absorption 2x monitor for metabolic assess fam and personal hx of CVD
46
paliperidone type and brand names
2nd gen Invega Invega sustenna Invega Trinza
47
paliperidone dosage forms
PO IM monthly IM q3mo
48
paliperidone AE
orthostatic hypotension hyperprolactinemia GI upset dizzy HA
49
paliperidone other considerations
XR risperidone so paliperidone is the active metabolite of risperidone and understanding this could have an affect on how i dose and understand the therapeutic effects
50
aripiprizole type and brand name
2nd gen abilify
51
aripiprizole dosage forms
PO IM (acute agitation) IM (long acting monthly)
52
aripiprizole AE
HA agitation anxiety insomnia somnolence akathisia GI
53
aripiprizole also to know
partial agonist of D2 receptors monitor metabolic Assess personal and fam hx of CVD
54
Iloperidone type and brand name
2nd gen fanapt
55
Iloperidone AE
orthostatic hypotension sedation dizzy
56
Iloperidone also to know
titrate slow due to alpha 1 antagonist properties poss helps PTSD hyperarousal sx due to alpha 1 blocking monitor metabolic assess family and personal hx of CVD
57
asenapine type and brand name
2nd gen saphris
58
asenapine AE
akathisia somnolence
59
asenapine also to know
monitor metabolic assess personal and fam hx CVD
60
Lurasidone type and brand name
2nd gen latuda
61
Lurasidone AE
akathisia sedation nausea
62
Lurasidone also to know
take with food to inc absorption caution and lower dose with patients that have renal and hepatic impairment monitor metabolic assess personal and fam hx CVD
63
Brexpiprazole type and brand name
2nd gen rexulti
64
Brexpiprazole AE
akathisia wt gain
65
Brexpiprazole also to know
monitor metabolic assess personal and fam hx CVD
66
Cariprazine type and brand
2nd gen Vraylar
67
Cariprazine AE
EPSE akathisia GI upset restlessness somnolence
68
Cariprazine also to know
monitor metabolic assess personal and fam hx CVD
69
apripiprazole lauroxil type and brand name
2nd gen aristada
70
apripiprazole lauroxil dosage form
IM monthly
71
apripiprazole lauroxil AE
akathisia
72
apripiprazole lauroxil Also to know
monitor metabolic assess personal and fam hx CVD
73
adjunctive rx to achieve full sx control to manage schizophrenia
antidepressants anxiolytics anticonvulsants
74
EPSE
extrapyramidal side effects Akathisia akinesia dystonia pseudo-parkinsons tardive dyskinesia
75
akathisia
motor restlessness --cant remain still --rocking, pacing --constant motion of unilateral limb could also manifest as subjective sense of restlessness without objective finding often mistaken for increasing anxiety
76
akinesia
Absence of movement --difficulty initiating motion --subjective feeling of lack of motivation to move often mistaken for laziness or lack of interest
77
dystonia
muscle spasm --spasticity of muscle group --especially back or neck --subjectively painful often mistaken for agitation or unusual, stereotypic movements characteristic of schizophrenia
78
pseudo-parkinsons
Presence of sx of parkinsons dz produced by D2 blockade --shuffling gait --motor slowing --mask-like facial expression --pill rolling --tremors --muscle rigidity mask like facial expression often confused as affective blunting or flattening
79
tardive dyskinesia
involuntary abnormal muscle movement --mouth, tongue, face, and jaw --may progress to limbs --can be irreversible --can occur as an acute process at initiation of meds OR as chronic condition at any point in tx
80
chlorpromazine type and brand name
1st gen thorazine
81
chlorpromazine dosage form
Tablet SR liquid
82
chlorpromazine AE high and moderate
high: sedation, hypotension moderate: EPSE, anticholinergic
83
chlorpromazine also to know
allergic dermatitis photosensitivity ECG changes--QTc
84
mesoridazine type and brand name
serentil
85
mesoridazine dosage forms
tablet liquid injection
86
mesoridazine AE high and low
high: anticholinergic, sedation, hypotension low: EPSE
87
mesoridazine also to know
ECG changes: QTc
88
Thioridazine type and brand name
1st gen mellaril
89
Thioridazine AE high and low
high: anticholinergic, sedation, hypotension, prolonged QT Low: EPS
90
Thioridazine also to know
ECG changes: QTc irreversible retinal pigmentation at doses >800mg dec libido retrograde ejaculation
91
fluphenazine type and brand name
1st gen permitil proloxin
92
fluphenazine dosage forms
tablet liquid IM q2wks
93
fluphenazine AE
very high: EPSE Low: anticholinergic, sedation, hypotension
94
perphenazine type and brand name
1st gen trilafon
95
perphenazine dosage forms
tablet liquid injection
96
perphenazine AE
high: EPSE low: anticholinergic, sedation, hypotension
97
trifluoperazine type and brand name
1st gen stelazine
98
trifluoperazine dosage forms
tablet injection
99
trifluoperazine AE
high: EPSE low: anticholinergic, sedation, hypotension
100
haloperidol type and brand name
1st gen haldol
101
haloperidol dosage forms
tablet liquid injection qmo
102
haloperidol AE
very high: EPSE high: anticholinergic, sedation low: hypotension
103
haloperidol other to know
in older adults, monitor for oculogyric crisis and pneumonia
104
loxapine type and brand name
1st gen loxitane
105
loxapine AE
high: EPSE moderate: sedation, hypotension low: anticholinergic
106
molindone type and brand name
1st gen moban
107
molindone AE
high: EPSE moderate: anticholinergic, hypotension low: sedation
108
molindone other to know
little or no weight gain
109
thiothixene type and brand name
1st gen navane
110
thiothixene dosage forms
capsule liquid injection
111
thiothixene AE
high: EPSE low: anticholinergic, sedation, hypotension
112
decanoate
As a component of a medication, like LA antipsychotics, are formulated as decanoate esters. Theyre slowly released into the body after IM, prolonging the medication's effects and allowing for less frequent dosing. Ex: Proloxin-D, Haldol-D
113
high potency 1st gen AE
greater risk of EPSE but less risk of sedation and anticholinergic sx
114
low potency 1st gen AE
greater risk of sedation and anticholinergic side effects but less risk of EPSE
115
Medications for treating EPSE
anticholinergics antihistamines dopamine agonists BZDs anticholinergics like Benztropine treat most of the symptoms antihistamines like Benadryl treat akinesia, dystonia, and pseudoparkinsons Dopamine agonists like amantadine treat akinesia and pseusoparkinsons there are other meds for akatheisia like inderal and klonopin etc. For the TD, best treatment is prevention through monitoring but if present you need to reduce the dose or change to atypical agent
116
EPSE cause
D2 receptor antagonism --when dopamine receptors are blocked, ACh inc, this causes EPSE due to the reciprocal relationship b/t the 2 NTs
117
Tardive dyskinesia
possibly irreversible movement disorder people treated for 1+ yr with typical antipsychotics sx: abnormal involuntary movements like lip smacking, chewing, tongue dart, twisting movements of trunk/limbs Perioral movements most common Tx is d/c and starting atypical
118
how often to screen patients on 1st gen for involuntary muscle movements and what else do they need to know
q6 mo educate client and family on early s/sx of abnormal movements if noted, reduce or switch risk factors: long term, older, female, mood/cognitive disorder
119
Scale for assessing TD
AIMS --Abnormal involuntary movement scale DISCUS --dyskinesia identification system condensed user scale SAS --simpson angus rating scale
120
NMS
rare but life threatening can occur any point in tx more common with 1st gen but poss with 2nd
121
NMS risk factors
rapid dose inc use of high potency 1st gen parenteral admin of antispsyhcotics
122
NMS assessment labs
elev CPK Elev WBC Elev LFT
123
NMS 1st sx
altered sensorium hyperthermia hyperreflexia
124
NMS sx of autonomic instability
hypotension extreme muscle rigidity hyperthermia tachycardia diaphoresis tachypnea coma and potential death
125
NMS tx
seek immediate care d/c agent Give dantrolene or bromocriptine --this is for antipsychotic induced dopamine receptor blockade antipyretic and cooling blanket IV hydration Benzo for muscle rigidity
126
other common AE r/t 1st gen on receptors other than dopamine
alpha adrenergic blockade --CV --orthostatic hypotension muscarinic cholinergic blockade --dry mouth --blurred vision --constipation --urinary retention Endocrine AE --Wt gain --Inc prolactin levels neurologic AE --lower Sz threshold other --photosensitvity --agranulocytosis
127
nonpharm tx for schizophrenia
individual therapy -supportive > insight -establish reality testing -build life skills -life goals -CBT for mgmt of hallucinations/delusions group therapy - problem solving -education Proactive crisis mgmt ACT -assertive community treatment Education modules Milieu therapy client and family education
128
children with schizophrenia considerations
hallucinations/delusion less rich visual more common than auditory
129
older adult with schizophrenia considerations
women have more late onset more often married better prognosis black box warning for older predominance of pos sx persecutory delusions less disorganized preserved social/work interest less neg sx
130
Schizophreniform disorder
closely resembles schizophrenia Occurs much less often 1/3 recover completely within 6 mo --the rest develop schizophrenia or schizoaffective disorder 2 key dx differences -Total duration 1+ mo but less than 6 mo including prodrome/residual -Doesnt require impaired social/occupational function though they may be present
131
Schizophreniform disorder assessment
2+ -delusions -hallucinations -disorganized speech -grossly disorganized behavior -presence of neg sx Duration of sx 1+ mo but <6mo Assess acuity level may require hospital during acute psychotic or affective episodes
132
Schizoaffective disorder
uninterrupted period of illness where experiences psychotic sx similar to schizophrenia but also mood sx similar to MDD/BP so could be psychotic spectrum, mood spectrum, or both
133
Schizoaffective disorder demographics
<1% M=F depressed type more common in older men with it have more antisocial behaviors
134
Schizoaffective disorder risk
family hx of schizophrenia or bipolar --need to screen for
135
Schizoaffective disorder assessment
Sx Schizophrenia -2+ frequently during 1 mo ---delusions ---hallucinations ---disorganized speech ---grossly disorganized behavior ---presence of neg sx but less severe than schizophrenia Sx of 1+ mood disorder -MDD episode -Mania episode -mixed mood episode presence of delusions/hallucinations for 2+ wks in absence of prominent mood sx
136
Schizoaffective disorder subtypes
Depressive: when prominent mood sx are of the depressive type only bipolar: when predominant mood are manic or mixed
137
Schizoaffective disorder tx
pharm and non pharm are similar to schizophrenia and similar to MDD/BP
138
Delusional disorder
1+ nonbizarre delusions lasting 1+ mo psychosocial function and daily behavior NOT impaired except for content of delusion Seldom other sx --rare may have hallucinations or mood disturbances
139
Delusional disorder assessment
Presence of delusions --well organized and potentially believable --any unusual behavior is explainable if content of delusion is understood assess for subtypes MSE is normal except for delusions
140
Delusional disorder subtypes
Erotomanic ---another person is in love with them ---usually idealized/spiritual love (less sexual) ---famous/powerful person ---leads to obsessive behavior Grandiose ---some great talent/skill/knowledge ---poss religious component/prophecy Jealous ---partner is unfaithful ---no connection with realistic evidence ---usually men ---may try to control partner Persecutory ---others out to get them ---often hostile/angry at perceived persecution Somatic ---focus on bodily function/sensation ---body part is infected/absent/odor/malformed Mixed ---no clear predominant theme
141
Brief Psychotic Disorder
sudden onset 1+ day but less than 1 mo more in younger 20-30 RF: fam hx
142
Brief Psychotic Disorder assessment
Age of onset positive type psychotic sx --delusions --hallucinations --grossly disorganized behavior --disorganized speech with/without stressor always returns to premorbid level of function
143
Brief Psychotic Disorder mgmt
similar to schizophrenia Acute episode needs frequent monitoring for safety r/t: -confusion -rapid emotion shifts -impaired judgement -inability to meet nutrition/hygiene needs
144
Shared Psychotic Disorder
Folie A Deux delusion in client who has close relationship with another person who already has a psychotic disorder with a prominent delusion --usually the other has schizophrenia, is the dominant one, imposes the delusion on them, and is a long term and close relationship behavior otherwise normal mgmt similar to schizophrenia

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