psych exam 3: schizophrenia, depression, bipolar

anhedonia

inability to experience or image only pleasant emotions

anosognosia

symptom in which the individual is manifesting overt symptoms of illness but is unaware of the presence of symptoms/unaware that anything is wrong

catatonia

psychological disturbance typified by stupor or excitement. Stupor is characterized by extreme psychomotor retardation, mutism, negativism and posturing. Excitement by psychomotor agitation (movement is frenzied and purposeless)

circumstantiality

delay of an individual to reach the point of communication due to unnecessary and tedious detain

clang association

pattern of speech in which the choice of words is governed by sounds. Takes the form of rhyming

delusions

false personal beliefs not consistent with a persons intelligence or cultural background continues to have beliefs despite proof it is false and/or irrational

echolalia

parrot like repetition, by an individual with loose ego boundaries, of words spoken by others

echopraxia

an individual with a loose ego boundary attempting to identify with another person by imitating movements that another person makes

hallucinations

false sensory perceptions not associated with real external stimuli- may involve the 5 senses

illusions

a misperception of real external stimuli

loose associations

a thinking process characterized by speech in which ideas shift from one unrelated topic to the next. The individual is unaware that topics are unconnected

magical thinking

a primitive forms of thinking in which an individual believes that thinking about a possible occurrence can make it happen

negative symptoms

lack of symptoms that should be there

neologism

new words that an individual invents that are meaningless to others but have symbolic meaning to the psychotic person

neuroleptic malignant syndrome

rare but fatal complication with neuroleptic drugs. Symptoms include severe muscle rigidity, high fever, tachycardia, fluctuations in blood pressure, diaphoresis, rapid deterioration of mental status to stupor and coma

perseveration

persistent repetition of same word or ideas in response to different questions

positive symptoms

symptoms that are present but should not be

psychosis

mental state with a severe loss of contact with reality. May include delusions, schizophrenia, disorganized, speech patterns, and bizarre or catatonic behaviors

schizophrenia

one of the schizophrenia spectrum disorders characterized by disturbances in thinking, cognition, emotions, behaviors. Considered a serious mental illness, course is chronic with episodes of exacerbation and remission caused likely by a combination of genetic, neurodevelopment and environmental factors

serious mental illness

a mental, behavioral, or emotional disorder resulting in serious functional impairment that substantially interferes with or limits one or more major life activities

social skills training

educational opportunities through role play for the person with schizophrenia to learn appropriate social interaction skills and functional skills that are relevant to daily living.

tangentiality

inability to get to the point. Speaker introduces many unrelated topics until the original topic is lost

waxy flexibility

passively yields all moveable parts of the body to any efforts made at placing them in certain positions

word salad

a group of words put together in a random fashion without logical connection

what do you need to know about schizophrenia

-a progressive (will need treatment) neurodevelopmental serious mental illness.

-psychosis is not exclusive to schizophrenia- a severe mental condition in which there is disorganization of the personality. Deterioration in social functioning and loss of contact with or distortion of reality (auditory is the most common-> delusions are a form of psychosis)

-carries stigma

-around 20% of schizophrenia patients attempt suicide at some point in 5-6% completing suicide-> patients are hopeless because it is a progressive disease

-estimated average life span of 25 years less than the average population: schizophrenia is an enormous threat to life and happiness-> suicide, self-medication with substance abuse and cigarette use

what is phase 1 of schizophrenia?

premorbid phase- this phase occurs before any clear evidence of illness. Premorbid personality+ behavioral indicates may include shy and withdrawn, having poor peer relationships, doing poorly in school and demonstrating asocial behaviors-> you cant tell anything is going on

what is phase 2 of schizophrenia?

prodromal phase- more clearly manifests developing schizophrenia. Begins with change from premorbid functioning until onset of psychotic symptoms. Occurs between the ages of 13 to 15. Behaviors include isolation and niche interests that can mimic teenager and depression behaviors, making it hard to diagnose. Earlier diagnoses can result in better prognosis-> gets into remission earlier

what is phase 3 of schizophrenia?

active psychotic phase- diagnosis usually occurs between ages 18-25 (earlier diagnosis usually means worse prognosis). Characterized by acute episodes in which symptoms are more pronounced

what is phase 4 of schizophrenia?

residual phase- function is back to normal with some side effects- relapse can occur and usually occurs from the patient getting off of their meds

what causes schizophrenia?

no single cause- multifactorial: link between sick pregnant mothers, drugs can activate schizophrenia and genetic factors

what is important about genetics in schizophrenia

· Lifetime risk in general populations of developing schizophrenia is 0.3-0.7% but up to a 9% greater risk in first-degree relative

· Identical twins have a 50% concordance rate when raised together and separated which is 4 to 5 times the concordance of dizygotic twins and first degree relatives (closer genes increase the likelihood)

what are examples of positive symptoms?

· Hallucinations visually and auditory, delusional thinking, disorganized behavior and speech, agitated or repetitive movements

what are examples of negative symptoms

· Flat/blunt affect, isolation, apathy, anergia, anhedonia and reduced speech

what is helpful to remember for positive/negative symptoms?

Think of positive as an addition sign meaning that something is being added to the baseline- think of negative as a subtraction sign meaning that something is being taken away from the baseline

dopamine pathways?

not entirely understood, but revolves around the idea that chemical imbalances of dopamine in certain neural pathways -> dopamine plays a role in addiction and reward seeking and psychosis

mesolimbic pathways?

excessive activity correlates with positive symptoms (psychosis/delusions)

neocortical pathways

diminished activity correlates with negative symptoms

nigrostriatal pathways

dopamine blockade (increases acetylcholine) correlates with movement disorders

tuberoinfundibular pathways

dopamine blockade from antipsychotics can cause galactorrhea (men producing breast milk), anorgasmia, and erectile dysfunction

what medical conditions must you rule out when trying to diagnose schizophrenia?

fluid/electrolytes imbalances, CNS infection, hypo/hyperthyroidism, temporal lobe epilepsy, vitamin deficiency (B12)

what kind of drug abuse must you rule out when trying to diagnose schizophrenia?

cannabis (laced or spiced can cause psychosis), alcohol, cocaine, amphetamines (increase dopamine and delirium), hallucinogens -can be seen on a drug screening

what kind of medication use must you rule out when trying to diagnose schizophrenia?

antidepressants, anticholinergic, corticosteroids and analgesics -can be seen on a drug screen

what toxins must you rule out when trying to diagnose schizophrenia

carbon monoxide, organophosphate insecticides, volatile substances (paint and gasoline)

what is delusional disorder?

(not schizophrenia)- delusions are the only prominent features (not rooted in reality); no bizarre behavior or hallucinations (stubborn)

what is brief psychotic disorder?

same criteria as schizophrenia except symptoms only last a month or less

what is schizophreniform disorder?

same criteria as schizophrenia except symptoms last a month to six months

what is schizophrenia?

lasts six months or longer

what is schizoaffective disorder?

shows signs and symptoms of schizophrenia as well as prominent features of a mood disorder (depression or mania)

what is substance/medication-induced psychotic disorder

psychosis induced by substances and medications

what is psychotic disorder due to another medical condition?

psychosis induced by medical conditions

how do you communicate with suspicious or paranoia patients?

-validating feelings is encouraged and is not the same as failing to reinforce reality

-maintain a calm and matter of fact demeanor that portrays you as genuine and consistent

-patients may refuse medications or food they do not see being prepared-> answer their questions and avoid physical contact

nursing education for schizophrenic patients

-educating patient and family/caregivers is essential for compliance of treatment and to grasp an understanding of the importance of continuing treatments-> keep on meds to prevent self-medicating with drug use

-discuss the reasons for the need to have indefinite treatment and what signs and symptoms to monitor-> difference from baseline and to understand what side effects will bother the patient and stopping them from taking their medication.

-provide resources such as crisis stabilization, hospital locations/numbers, day programs opportunities, financial assistance numbers/website and peer support

nonpharmacological treatments for schizophrenia?

-social skills training: teaches patients about how to function as a member in society

-family therapy: education on schizophrenia

-cognitive remediation therapy: teaches patients how to differentiate hallucinations versus reality

-assertive community therapy: for people who are not severe enough for inpatient but need eyes in them-> prevents hospitalization

what is important to know about pharmacologic treatments of schizophrenia?

-used for psychotic disorders, as well as bipolar disorders by regulating dopamine and sometimes serotonin

-older antipsychotics are referred to as typical/conventional antipsychotics or neuroleptics. Newer meds are atypical or second-generation psychotic or neuroleptic

nursing education for pharmacologic treatments for schizophrenia?

· Monitor for extrapyramidal symptoms and consider administering benztropine (Cogentin)

· Monitor for tardive dyskinesia and report to provider if unusual mouth movements like lip smacking or pursing and tongue protrusion

· Monitor for weight gain

safety concerns for pharmacologic treatments for schizophrenia?

· Neuroleptic malignant syndrome: caused by depleted dopamine due to antipsychotics resulting in CNS hyperactivity; symptoms include hypertension, fever, sweating, agitation, disorientation and lead pipe rigidity

· Clozapine (Clozaril)- agranulocytosis-> monitor for signs of infection and sickness like fever and monitor WBCs

what are examples of typical antipsychotics?

(first used) chlorpromazine (Thorazine), haloperidol (Haldol/Haldol decanoate), fluphenazine (prolixin/prolixin decanoate), loxapine (loxitane)

what are common side effects of typical antipsychotics?

EPS (more likely in typical), sedation, weight gain, risk of insulin resistance, constipation, dry mouth

black box warning for typical antipsychotics?

can increase risk of death in elderly dementia patients

examples of atypical antipsychotics?

clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), aripiprozole (abilify), ziprasidone (Geodon), lurasidone (latua), quetiapine (Seroquel)

what are common side effects of atypical antipsychotics?

EPS (more likely in typical), sedation, weight gain, risk of insulin resistance, constipation, dry mouth

black box warnings for atypical antipsychotics

can increase risk of death in elderly dementia patients and agranulocytosis with clozapine

affect

behavioral expression of emotion; may be appropriate, inappropriate, constricted or blunted (diminished range + intensity) or flat

depression

an alteration in mood that is expressed by feelings of sadness, despair, pessimism. Loss of interest in visual activities and symptomatic symptoms may be evident. Changes in appetite and sleep patterns are common

melancholia

severe form of major depressive episodes. Symptoms are exaggerated and interest or pleasure in virtually all activities lost

mood

an individual sustained emotional tone, which significantly influences behavior, personality and perception

postpartum depression

may be related to hormonal changes, tryptophan metabolism, or alterations in membrane transport during early postpartum period

premenstrual dysphoric disorder

characterized by depressed mood, anxiety, mood swings and decreased interest in activities during the week before menses and subsiding shortly after onset of menstruation

psychomotor retardation

extreme slowdown of physical movements. Posture slumps, speech is slowed, digestion becomes sluggish. Common in severe depression

history of depression

-commonly known as major depressive disorder

-one of the oldest and still commonly diagnosed psychiatric illnesses. It was described in many cultures as being caused by evil spirits

-formerly known as melancholia. Hippocrates believed it was due to an excess of black bile from the spleen to the brain

-during renaissance it was believed to be caused by a combination of excess brooding, poor air circulation and circumstances outside of a persons control

-contemporary thinking supports multiple factors for the development of depression, trauma, family dynamics, genetics and socioeconomic status

epidemiology of depression?

-one of the leading causes of disability in the united states

-estimated 20.6% of people will develop depression at some point in their lives

-often comorbid with other psychiatric illness (like anxiety) as well as increasing risk of CAD

-In adolescents aged 12-17, rates of significant impairment from depressive episodes increased by double in 2020 as a result of covid-19 and isolation

-4.1 million adolescents had at least one major episode (17% of the US population of that group) and 70% of them reported significant impairment (school, interactions, substance abuse) due to depression

-more common in women- could be due to hormones, likelihood of abuse/trauma, higher concentration of monoamine oxidase (NT associated with depression) possibly men not getting diagnosed

-bicasual relationship with poverty and mental illness

-unclear consistent link due to access to healthcare resources, accurate diagnosis, immigration status, etc.

-healthy marriages can have a positive effect on wellbeing, closeness is more indicative of wellbeing

-seasonal patterns can be seen in individuals with depression- decreased depression in warmer months

what is major depressive disorder?

characterized by depressed mood or loss of interest or pleasure in usual activities. Impaired social and occupational functioning that has lasted for two weeks, no history of mani behavior and symptoms that cannot be attributed to the use of substances or general medical conditions can have specifiers such as MDD with anxious distress, MDD with seasonal patterns and MDD with atypical features, etc.

what is persistent depression disorder?

less severe than MDD but longer lasting. Individuals with this described their moods as sad or "down in the dumps." No evidence of psychotic symptoms-essential feature is depressed mood (or possibly irritability in adolescents and children) for most of the day, nearly every day, for at least 2 years (1 year for children). Early onset if it occurs before 21, or late onset after 21

what is premenstrual dysphoric disorder?

involved markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week before menses. Improving shortly after the onset of menstruation and becoming minimal or absent after menses. Major difference between PMDD and PMS is a matter of intensity and frequency of symptoms. If severe enough it can interfere with one's ability to function socially, at work, or at school. They are recurrent for the majority of menstrual cycles over the course of a year.

what is substance/medication induced depressive disorder?

considered the direct result of physiological effects of a substance. This causes clinically significant distress or impairment in social, occupational or other important areas of functioning

what intoxication or withdrawals can induce depression?

alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine-like substances, sedatives, hypnotics or anxiolytics

what medications can induce depression

anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac meds, oral contraceptives, psychotropic meds, muscle relaxers, steroids and sulfonamides

what is depressive disorder due to another medical condition?

characterized as symptoms associated with a major depressive episode that are direct physiological consequences of another medical condition. Depression causes clinically significant distress or impairment in social, occupational or other important areas of functioning

what medical conditions can induce depression

stroke, traumatic brain injuries, thyroid disorders, Cushing's disease, Huntington's disease, Parkinson's disease and multiple sclerosis

what is postpartum depression?

can be as mild as "baby blues" which can affect up to 80% of mothers for the first couple of weeks to as severe depression with psychotic features.

how does genetic play a role in depressive disorders?

a genetic link is suggested however a definitive mode of genetic transmission has not been demonstrated. First degree relatives are at a greater risk. Studies have found genetic variants associated with depression

what did twin studies indicate about depressive disorders?

· strong genetic factors in the etiology of affective illness including depression and bipolar. Monozygotic have a 2 to 4 times greater incidence of depression- 70% to 80% of both twins having illness suggest that genetics does not explain all depressions. Environmental risks are also important

what did family studies indicate about depressive disorders?

depression is 7 times more common in first degree relatives

what did adoption studies indicate about depressive disorders?

indicate biological children of parents with mood disorders are at increased risk of developing mood disturbances even when they are reared by adoptive parents who do not have mood disorders- also suggest that environmental factors play a role in etiology of depressive illnesses

what are important biochemical influences?

important monoamines include serotonin, norepinephrine and dopamine. More neurotransmitters include NMDA, glutamate and GABA

what is psychoanalytical theory?

loss of person/object through death or rejection leading to self-directed rage (low self esteem leads to self harm)

what is learning theory

learned helplessness through experiences of the past- they are told that they are not good enough-> schemas or modeled behaviors

what is object loss theory?

depression occurs due to a significant loss within first 6 months of life

what is cognitive theory?

believes depression is the result of negative thinking (opposite from other theories). Believe negative expectations towards self, the environment, and the future are core beliefs leading to depression. CBT aims to correct negative thought distortion

what is the transactional model?

suggests no one theory or model substantiates a clear-cut explanation for depression. Mounting evidence suggests multiple factors including biogenetics and psychosocial influences

what is important about background assessment data?

-depression exists on a continuum from mild, transient sadness to severe, disabling depression

-severe depression causes major impairment in social, occupational, cognitive and emotional functioning

-may include loss of reality contact, psychomotor retardation, anhedonia (loss of pleasure) and suicidal thoughts; MDD represents this severe form

what are self rated scales to measure depression severity?

· Zung self-rating depression scale, Beck depression inventory

what is clinical rated depression severity assessments?

Hamilton depression rating scale- assesses mood, guilt, suicide risk, sleep, anxiety and weight loss

what is the scale used for the hamilton depression rating scale?

o 0-6= no evidence of depressive illness

o 7-17= mild depression

o 18-24= moderate depression

o >24= severe depression

what is transient depression?

not necessarily dysfunctional, they may be considered part of the broad range of typical human emotional responses that accompany everyday disappointments in life- subsides quickly and the individual is able to refocus on other goals and achievements.

what are symptoms of transient depression?

-affective: sadness, dejection, feeling downhearted, having the blues

-behavioral: some crying

-cognitive: some difficulty getting mind off of one's disappointments

-physiological: feeling tired and listless

what is mild depression?

associated with uncomplicated grieving.

what are symptoms of mild depression?

-affective: denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency

-behavioral: tearfulness, regression, restlessness, agitation, withdrawal

-cognitive: preoccupation with the loss, self-blame, ambivalence, blaming others

-physiological: anorexia or overeating, insomnia or hypersomnia, headache, backache, chest pain, or other symptoms associated with the loss of a significant other

what is moderate depression

a more chronic disturbance, which is characterized by symptoms that endure at least 2 years.

what are symptoms of moderate depression

-affective: feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self esteem; difficulty experiencing pleasure in activities

-behavioral: sluggish physical movement; slumped posture; slowed speech; limited verbalization, possibly consisting of ruminations about life's failures or regrets; social isolation with a focus on the self; increased use of substances possible; self destructive behavior possible; decreased interest in personal hygiene and grooming

-cognitive: slowed thinking processes; difficulty concentrating and directing attention; obsessive and repetitive thoughts, generally portraying pessimism and negativism; verbalizations and behavior reflecting suicidal ideation

-physiological: anorexia or overeating, insomnia or hypersomnia, sleep disturbances, amenorrhea, decreased libido, headaches, backaches, chest pain, abdominal pain, low energy level, fatigue and listlessness