Week 8 Psychosis

Question 1

Psychosis definition

Answer 1

Altered cognition, altered perception and/ or an impaired ability to determine what is or is not real (an ability known as reality testing)

Question 2

Schizophrenia spectrum disorders

Answer 2

Question 3

Schizophrenia definition

Answer 3

“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.”

Question 4

How many people does schizophrenia affect?

Answer 4

1 in 100 persons

Question 5

Schizophrenia prevalence in gender?

Answer 5

Equally

Question 6

Age of onset of schizophrenia

Answer 6

Men 15-25
Women 25-35

Question 7

Causes of schizophrenia

Answer 7

➢ 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

Question 8

DSM-V Diagnostic Criteria of Schizophrenia

Answer 8

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

Question 9

Prodromal Symptoms of Schizophrenia

Answer 9

➢ 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▪ Become socially withdrawn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

Question 10

Positive symptoms of schizophrenia

Answer 10

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

Question 11

Negative symptoms of schizophrenia

Answer 11

Affect
▪ Flat or “blunted”

Alogia (poverty of speech)
Anergia
Poverty of content of speech
Anhedonia
Avolition

Question 12

Neurocognitive impairment: when present in schizophrenia, may include:

Answer 12

Memory
Sustained attention
Verbal fluency (rate at which words are produced)
Executive functioning (processing information and making decisions)

Question 13

Anosognosia

Answer 13

People with schizophrenia may sometimes lack insight into their illness

Question 14

Schizophrenia intervention phases

Answer 14

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

Question 15

Types of antipsychotics (neuroleptics)

Answer 15

Typical/ conventional (1st generation)

Atypical (2nd generation, 3rd generation)

Question 16

1st generation antipsychotics

Answer 16

Haldol
Chlorpromazine

Question 17

2nd generation antipsychotics

Answer 17

Risperidone
Quetiapine
Clozapine

Question 18

3rd generation antipsychotics

Answer 18

Aripiprazole

Question 19

Long-acting injectables (depot medications)

Answer 19

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

Question 20

Extrapyramidal side effects

Answer 20

▪ 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

Question 21

EPS - Acute dystonia symptoms

Answer 21

▪ 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)

Question 22

EPS - Akathisia symptoms

Answer 22

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

Question 23

Tardive dyskinesia

Answer 23

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)

Question 24

Treatment of EPS: medication

Answer 24

Benztropine mesylate (Cogentin) Antiparkinson Agent
▪ for medication-related movement disorders: pseuodoparkinsonism, rigidity, akathisia
▪ acute or urgent situations (acute dystonias): Cogentin or Benadryl IM

Question 25

Tardive dyskinesia treatment

Answer 25

▪ is irreversible
▪ switch to a second generation neuroleptic or decrease dosage - individualized

Question 26

Assessment of EPS

Answer 26

Abnormal Involuntary Movement Scale (AIMS)/ Dyskinesia Identification System

Question 27

Neuroleptic Malignant Syndrome

Answer 27

▪ 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

Question 28

Risk factors for neuroleptic malignant syndrome

Answer 28

▪ dehydration
▪ history of NMS
▪ recent dose increase
▪ switching rapidly from one dopamine receptor agonist to another

Question 29

Neuroleptic Malignant Syndrome symptoms

Answer 29

▪ 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

Question 30

Treatment of Neuroleptic Malignant Syndrome

Answer 30

Discontinuation of antipsychotic medication, nursing care

Question 31

Side effects of atypical antipsychotics

Answer 31

▪ 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

Question 32

clozapine

Answer 32

▪ 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

Question 33

EPPIS

Answer 33

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