Mental Health Exam 3 Review

schizophrenia

causes distorted and bizarre thoughts, perceptions, emotions, movements and behavior

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usually diagnosed in late adolescence/early adulthood-peak incidence is 15-25 for men and 25-35 for women

schizoprenia diagnosis

usually made when the person begins to display more actively positive symptoms of delusions, hallucinations and disordered thinking (psychosis)

schizophreniform disorder

The client exhibits an acute, reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. If symptoms persist over 6 months, the diagnosis is changed to schizophrenia. Social or occupational functioning may or may not be impaired.

catatonia

is characterized by marked psychomotor disturbance, either excessive motor activity or virtual immobility and motionlessness. Motor immobility may include catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and not influenced by external stimuli. Other behaviors include extreme negativism, mutism, peculiar movements, echolalia, or echopraxia. Catatonia can occur with schizophrenia, mood disorders, or other psychotic disorders.

younger clients

display a poorer premorbid adjustment, more prominent negative signs and greater cognitive impariment than older adults

high relapse rates

associate with nonadherence to medication, persistent substance use, caregiver criticism and negative attitude toward treatment

delusional disorder

The client has one or more nonbizarre delusions—that is, the focus of the delusion is believable. The delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre.

brief psychotic disorder

The client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month. The episode may or may not have an identifiable stressor or may follow childbirth.

shared psychotic disorder

(folie à deux): Two people share a similar delusion.The person with this diagnosis develops this delusion in the context of a closerelationship with someone who has psychotic delusions, most commonly siblings, parent and child, or husband and wife. The more submissive or suggestible person may rapidly improve if separated from the dominant person.

schizotypical personality disorder

This involves odd, eccentric behaviors, including transient psychotic symptoms. Approximately 20% of persons with this personality disorder will eventually be diagnosed with schizophrenia.

biologic theories

The biologic theories of schizophrenia focus on genetic factors, neuroanatomic and neurochemical factors (structure and function of the brain), and immunovirology (the body’s response to exposure to a virus)

genetic factors

Most genetic studies have focused on immediate families (i.e., parents, siblings,and offspring) to examine whether schizophrenia is genetically transmitted or inherited. Few have focused on more distant relatives.

The most important studies have centered on twins; these findings have demonstrated that identical twins have a 50% risk of schizophrenia; that is, if one twin has schizophrenia, the other has a 50% chance of developing it as well. Fraternal twins have only a 15% risk. This finding indicates a genetic vulnerability or risk of schizophrenia.

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Other important studies have shown that children with one biologic parent with schizophrenia have a 15% risk; the risk rises to 35% if both biologic parents have schizophrenia.

Children adopted at birth into a family with no history of schizophrenia but whose biologic parents have a history of schizophrenia still reflect the genetic risk of their biologic parents.

All these studies have indicated a genetic risk or tendency for schizophrenia, but Mendelian genetics cannot be the only factor; identical twins have only a 50% risk even though their genes are 100% identical. Rather, recent studies indicate that the genetic risk of schizophrenia is polygenic, meaning several genes contribute to the development

neuro factors

Findings have demonstrated that people with schizophrenia have relatively less brain tissue and cerebrospinal fluid than those who do not have schizophrenia; this could represent a failure in the development or a subsequent loss of tissue.

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Computed tomography scans have shown enlarged ventricles in the brain and cortical atrophy. Positron emission tomography studies suggest that glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain

immunovirologic factors

Popular theories have emerged, stating that exposure to a virus or the body’s immune response to a virus could alter the brain physiology of people with schizophrenia. Although scientists continue to study these possibilities, few findings have validated them. Cytokines are chemical messengers between immune cells, mediating inflammatory and immune responses. Specific cytokines also play a role in signaling the brain to produce behavioral and neurochemical changes needed in the face of physical or psychological stress to maintain homeostasis. It is believed that cytokines may have a role in the development of major psychiatric disorders such as schizophrenia. Recently, researchers have been focusing on infections in pregnant women as a possible origin for schizophrenia. Waves of schizophrenia in England, Wales, Denmark, Finland, and other countries have occurred a generation after influenza epidemics. Also, there are higher rates of schizophrenia among children born in crowded areas in cold weather, conditions that are hospitable to respiratory ailments.

bouffee delirante

is a syndrome found in West Africa and Haiti, characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. It is sometimes accompanied by visual and auditory hallucinations or paranoid ideation

ghost sickness

is preoccupation with death and the deceased frequently observed among members of some Native American tribes. Symptoms include bad dreams, weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, and a sense of suffocation

jikoshu-kyofu

is a condition characterized by a fear of offending others by emitting foul body odor. This was first described in Japan in the 1960s and has two subtypes, either with or without delusions.

locura

refers to a chronic psychosis experienced by Latinos in the United States and Latin America. Symptoms include incoherence, agitation, visual and auditory hallucinations, inability to follow social rules, unpredictability, and, possibly, violent behavior.

first generation antipsychotics

arget the positive signs of schizophrenia, such as delusions, hallucinations, disturbed thinking, and other psychotic symptoms, but have no observable effect on the negative signs.

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Perphanazine (Trilafon), Fluphenazine (Prolixin),Thioridazine (Mellaril), Haloperidol (Haldol), Loxapine (Loxitane), Perphenazine (Etrafon), Trifluoperazine (Stelazine)

second generation antipsychotics

not only diminish positive symptoms but also lessen the negative signs of lack of volition and motivation, social withdrawal, and anhedonia for many clients.

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Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Paliperidone (Invega), Asenapine (Saphris), Lurasidone (Latuda)

long acting injection antipsychotics

Fluphenazine (Prolixin) in decanoate and enanthate preparations

•Haloperidol (Haldol) in decanoate

•Risperidone (Risperdal Consta)

•Paliperidone (Invega Sustenna)

•Olanzapine (Zyprexa Relprevv)

•Aripiprazole (Abilify Maintena)

serious neurologic side effects

include extrapyramidal side effects (EPSs) (acute dystonic reactions, akathisia, and parkinsonism), tardive dyskinesia, seizures, and neuroleptic malignant syndrome

extrapyramidal side effects

are reversible movement disorders induced by neuroleptic medication. They include dystonic reactions, parkinsonism, and akathisia

dystonic reactions

appear early in the course of treatment and are characterized by spasms in discrete muscle groups, such as the neck muscles (torticollis) or eye muscles (oculogyric crisis).

These spasms may also be accompanied by protrusion of the tongue, dysphagia, and laryngeal and pharyngeal spasms that can compromise the client’s airway, causing a medical emergency.

\-are extremely frightening and painful for the client. Acute treatment consists of diphenhydramine (Benadryl) given either intramuscularly or intravenously, or benztropine (Cogentin) given intramuscularly.

akathisia

is characterized by restless movement, pacing, inability to remain still, and the client’s report of inner restlessness.

\-usually develops when the antipsychotic is started or when the dose is increased.

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\-Beta-blockers such as propranolol have been most effective in treating akathisia, and benzodiazepines have provided some success as well.

taradive dyskinesia

a late-appearing side effect of antipsychotic medications, is characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet.

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\-is also irreversible once it appears but medication can help

abnormal involuntary movement scale

(AIMS) is used to screen for symptoms of movement disorders. The client is observed in several positions, and the severity of symptoms is rated from 0 to 4. The AIMS can be administeredevery 3 to 6 months. If the nurse detects an increased score on the AIMS,indicating increased symptoms of tardive dyskinesia, he or she should notify the physician so that the client’s dosage or drug can be changed to prevent advancement of tardive dyskinesia.

neuroleptic malignant syndrome

is a serious and frequently fatal condition seen in those being treated with antipsychotic medications. It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly, creatine phosphokinase), and leukocytosis (increased leukocytes).

agranulocytosis

Clozapine has this potentially fatal side effect (failure of the bone marrow to produce adequate white blood cells).

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-This condition develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not be manifested immediately but can occur as long as 18 to 24 weeks after the initiation of therapy.

If it occurs, the drug must be discontinued immediately. Clients taking this anti-psychotic must have weekly white blood cell counts for the first 6months of clozapine therapy and every 2 weeks thereafter. Clozapine is dispense every 7 or 14 days only, and evidence of a white blood cell count above 3,500 cells/mm3 is required before a refill is furnished.

ambivalence

holding seemingly contradictory beliefs or feelings about the same person, event, or situation

associative looseness

fragmented/poorly related thoughts and ideas

delusions

fixed false beliefs that have no basis in reality

echopraxia

limitation of the movements and gestures of another person whom the client is observing

flight of ideas

continuous flow of verbalization in which the person jumps rapidly from one topic to another

hallucinations

False sensory perceptions or perceptual experiences that do not exist in reality

ideas of reference

False impressions that external events have special meaning for the person

perservation

Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

bizarre behavior

Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior

alogia

Tendency to speak little or to convey little substance of meaning (poverty of content)

anhedonia

Feeling no joy or pleasure from life or any activities or relationships

apathy

Feelings of indifference toward people, activities, and events

asociality

Social withdrawal, few or no relationships, lack of closeness

blunted affect

Restricted range of emotional feeling, tone, or mood

catatonia

Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance

flat affect

Absence of any facial expression that would indicate emotions or mood

avolition

Absence of will, ambition, or drive to take action or accomplish tasks

positive symptoms

ambivalence, associative loosesness, delusions, echopraxia, flight of ideas, hallucinations, ideas of reference, perservation, bizarre behavior

negative symptoms

alogia, anhedonia, apathy, asociality, blunted affect, catatonia, flat affect, avolition/lack of avolition, inattention

tartive dyskinesia

\-side effect of antipsychotic medications

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\-abnormal involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, etc.

\-irreversible once it appears but decreasing/disocontinuing the medication can help

neuropletic malignant syndrome

is a serious and frequently fatal condition seen in those being treated with antipsychotic medications. It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly, creatine phosphokinase), and leukocytosis (increased leukocytes).

It is estimated that 0.1% to 1% of all clients taking antipsychotics develop NMS. Any of the antipsychotic medications can cause NMS, which is treated by stopping the medication. The client’s ability to tolerate other antipsychotic medications after NMS varies, but use of another antipsychotic appears possible in most instances.

agranulocytosis

Clozapine has the potentially fatal side effect of agranulocytosis (failure of the bone marrow to produce adequate white blood cells). Agranulocytosis develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not be manifested immediately but can occur as long as 18 to 24 weeks after the initiation of therapy.
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The drug must be discontinued immediately. Clients taking this antipsychotic must have weekly white blood cell counts for the first 6 months of clozapine therapy and every 2 weeks thereafter. Clozapine is dispensed every 7 or 14 days only, and evidence of a white blood cell count above 3,500 cells/mm3 is required before a refill is furnished.

anorexia nervosa

is a life-threatening eating disorder characterized by the client’s restriction of nutritional intake necessary to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists. Clients with anorexia have a body weight that is less than the minimum expected weight considering age, height, and overall physical health. In addition, clients have a preoccupation with food and food-related activities and can have a variety of physical manifestations

binge eating

means consuming a large amount of food (far greater than most people eat at one time) in a discrete period of usually 2 hours or less

purging

involves compensatory behaviors designed to eliminate food by means of self-induced vomiting or misuse of laxatives, enemas, and diuretics. Some clients with anorexia do not binge but still engage in purging behaviors after ingesting small amounts of food.

bulimia nervosa

often simply called bulimia, is an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to avoid weight gain, such as purging, fasting, or excessively exercising. The amount of food consumed during a binge episode is much larger than a person would normally eat. The client often engages in binge eating secretly. Between binges, the client may eat low-calorie foods or fast. Binging or purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or self-contempt.

The weight of clients with bulimia is usually in the normal range, though some clients are overweight or underweight. Recurrent vomiting destroys tooth enamel, and incidence of dental caries and ragged or chipped teeth increases in these clients. Dentists are often the first health care professionals to identify clients with bulimia.

orthorexia nervosa

sometimes called orthorexia, is an obsession with proper or healthful eating.

weight gain meds

for anorexia: amitryptyline (Elavil) and cyproheptadine (Periactin)

eating disorder meds

olanzapine (Zyprexa) for antipsychotic effect on bizarre body image distortions

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Fluoxetine (Prozac) has some effectiveness in preventing relapse

mania

is a distinct period during which mood is abnormally and persistently elevated, expansive, or irritable.

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symptoms: decreased sleep, excessive/pressured speech, flight of ideas, increased activity

hypomania

is a period of abnormally and persistently elevated, expansive, or irritable mood and some other milder symptoms of mania. The difference is that hypomanic episodes do not impair the person’s ability to function (in fact, he or she may be quite productive), and there are no psychotic features (delusions and hallucinations). A mixed episode is diagnosed when the person experiences both mania and depression nearly every day for at least 1 week

bipolar 1

one or more manic or mixed episodes usually accompanied by major depressive episodes

bipolar 2

one or more major depressive episodes accompanied by at least one hypomanic episode

SSRI antidepressants

\-fluoxetine (prozac)

\-sertaline (zoloft)

\-paroxetine (paxil)

\-citalopram (celexa)

\-escitalopram (lexapro)

\-vortioxetine (trinellix)

SSRI’s

\-the most frequently prescribed category of antidepressants

\-Their action is specific to serotonin reuptake inhibition; these drugs produce few sedating, anticholinergic, and cardiovascular side effects, which make them safer for use in older adults.

Because of their low side effects and relative safety, people using SSRIs are more apt to be compliant with the treatment regimen than clients using more troublesome medications.

Insomnia decreases in 3 to 4 days, appetite returns to a more normal state in 5 to 7 days, and energy returns in 4 to 7 days. In 7 to 10 days, mood, concentration, and interest in life improve.

cyclic antidepressants

They relieve symptoms of hopelessness, helplessness, anhedonia, inappropriate guilt, suicidal ideation, and daily mood variations (cranky in the morning and better in the evening).

Other indications include panic disorder, obsessive–compulsive disorder, and eating disorders.

Each drug has a different degree of efficacy in blocking the activity of norepinephrine and serotonin or increasing the sensitivity of postsynaptic receptor sites.

\-have a lag period of 10 to 14 days before reaching a serum level that begins to alter symptoms; they take 6 weeks to reach full effect. Because they have a long serum half-life, there is a lag period of 1 to 4 weeks before steady plasma levels are reached and the client’s symptoms begin to decrease. They cost less, primarily because they have been around longer and generic forms are available.

Tricyclic antidepressants are contraindicated in severe impairment of liver function and in myocardial infarction

(acute recovery phase). They cannot be given concurrently with MAOIs

trycyclic antidepressants

\-amitryptyline (elavil)

\-amoxapine (asendin)

\-doxepin (sinequan)

\-despriamine (norpramin)

\-nortitryptiline (pamelor)

atypical antidepressants

are used when the client has an inadequate response to or side effects from SSRIs.

atypical antidepressant medications

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\-venlafaxine (Effexor)

\-duloxetine (Cymbalta)

\-bupropion (Wellbutrin)

\-nefazodone (Serzone)

\-mirtazapine (Remeron)

\-vilazodone (Viibryd)

maois

\-have been used infrequently because of potentially fatal side effects and interactions with numerous drugs, both prescription and over-the-counter preparations

\-may be superior to typical medications for treatment of typical and treatment-resistant depression

\-side effect is hypertensive crisis, a life-threatening condition that can result when a client taking MAOIs ingests tyramine-containing foods and fluids or other medications.

\-Symptoms are occipital headache, hypertension, nausea, vomiting, chills, sweating, restlessness, nuchal rigidity, dilated pupils, fever, and motor agitation. These can lead to hyperpyrexia, cerebral hemorrhage, and death. The MAOI–tyramine interaction produces symptoms within 20 to 60 minutes after ingestion. For hypertensive crisis, transient antihypertensive agents, such as phentolamine mesylate, are given to dilate blood vessels and decrease vascular resistance

maoi medications

Isocarboxazid (Marplan)

Phenelzine (Nardil)

Tranylcypromine (Parnate)

maoi drug intercations

Amphetamines

•Ephedrine

•Fenfluramine

•Isoproterenol

•Meperidine

•Phenylephrine

•Phenylpropanolamine

•Pseudoephedrine

•SSRI antidepressants

•Tricyclic antidepressants

•Tyramine

serotonin syndrome

Serotonin syndrome occurs when there is an inadequate washout period between taking MAOIs and SSRIs or when MAOIs are combined with meperidine. Symptoms of serotonin syndrome include:

•Change in mental state: confusion and agitation

•Neuromuscular excitement: muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, and muscle paralysis

•Autonomic abnormalities: hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis

grief

the subjective emotions and effect that are a normal response to the experience of loss

bereavement

the process by which a person experiences grief

mourning

outward expression of grief such as a funeral, wake, etc.

physiologic loss

amputation of a limb, mastectomy, etc.

safety loss

loss of a safe environment that is evident in domestic violence, child abuse, or public violence. A person’s home should be a safe haven with trust that family members will provide protection, not harm or violence. Some public institutions, such as schools and churches, are often associated with safety as well. That feeling of safety is shattered when violence occurs on campus or in a holy place.

loss of security and a sense of belonging

The loss of a loved one affects the need to love and the feeling of being loved. Loss accompanies changes in relationships, such as birth, marriage, divorce, illness, and death; as the meaning of a relationship changes, a person may lose roles within a family or group.

loss of self esteem

Any change in how a person is valued at work or in relationships or by him or herself can threaten self-esteem. It may be an actual change or the person’s perception of a change in value. Death of a loved one, a broken relationship, loss of a job, and retirement are examples of change that represent loss and can result in a threat to self-esteem.

loss related to self actualization

An external or internal crisis that blocks or inhibits striving toward fulfillment may threaten personal goals and individual potential. A person who wanted to go to college, write books, and teach at a university reaches a point in life when it becomes evident that those plans will never materialize or a person loses hope that he or she will find a mate and have children. These are losses that the person will grieve.

kubler ross stages of grieving

1. denial


2. anger
3. bargaining
4. depression
5. acceptance

bowlby’s phases of grieving

1\.Experiencing numbness and denying the loss

2\.Emotionally yearning for the lost loved one and protesting the permanence of the loss

3\.Experiencing cognitive disorganization and emotional despair with difficulty functioning in the everyday world

4\.Reorganizing and reintegrating the sense of self to pull life back together

engels stages of grieving

1\.Shock and disbelief: The initial reaction to a loss is a stunned, numb feeling accompanied by refusal to acknowledge the reality of the loss in an attempt to protect the self against overwhelming stress.

2\.Developing awareness: As the individual begins to acknowledge the loss, there may be crying, feelings of helplessness, frustration, despair, and anger that can be directed at self or others, including God or the deceased person.

3\.Restitution: Participation in the rituals associated with death, such as a funeral, wake, family gathering, or religious ceremonies that help the individual accept the reality of the loss and begin the recovery process.

4\.Resolution of the loss: The individual is preoccupied with the loss, the lost person or object is idealized, and the mourner may even imitate the lost person. Eventually, the preoccupation decreases, usually in a year or perhaps more.

5\.Recovery: The previous preoccupation and obsession ends, and the individual is able to go on with life in a way that encompasses the loss.

horowitz’s stages of loss and adaptation

1\.Outcry: First realization of the loss. Outcry may be outward, expressed by screaming, yelling, crying, or collapse. Outcry feeling can also be suppressed as the person appears stoic, trying to maintain emotional control. Either way, outcry feelings take a great deal of energy to sustain and tend to be short-lived.

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2\.Denial and intrusion: People move back and forth during this stage between denial and intrusion. During denial, the person becomes so distracted or involved in activities that he or she sometimes isn’t thinking about the loss. At other times, the loss and all it represents intrudes into every moment and activity, and feelings are quite intense again.

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3\.Working through: As time passes, the person spends less time bouncing back and forth between denial and intrusion, and the emotions are not as intense and overwhelming. The person still thinks about the loss, but also begins to find new ways of managing life after loss.

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4\.Completion: Life begins to feel “normal” again, though life is different after the loss. Memories are less painful and do not regularly interfere with day-to-day life. Episodes of intense feelings may occur, especially around anniversary dates but are transient in nature.

grieving tasks

1\.Recognize: Experiencing the loss, understanding that it is real, and that it has happened

2\.React: Emotional response to loss, feeling the feelings

3\.Recollect and reexperience: Memories are reviewed and relived

4\.Relinquish: Accepting that the world has changed (as a result of the loss) and that there is no turning back

5\.Readjust: Beginning to return to daily life; loss feels less acute and overwhelming

6\.Reinvest: Accepting changes that have occurred; reentering the world, forming new relationships and commitments

schizoaffective disorder

diagnosed when pt is extremely ill and has a mixture of psychotic and mood symptoms

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\-treatment is focused on both psychotic and mood symptoms

first generation antipsychotics

\-target the positive signs of schizphrenia (such as delusions, hallucinations, disturbed thinking and other psychotic symptoms)

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\-have no observable effect on the negative signs

second generation antipsychotics

\-not only diminish positive symptoms but also lessen the negative signs of lack of volition and motivation, social withdrawal and anhedonia for many clients

nursing interventions for antipsychotic medication effects

\-AIMS scale

\-increased fluid and dietary fiber intake

\-avoid sun exposure

\-rise slowly when changing positions

\-have patient report and frequency/burning urination

early signs of schizophrenia relapse

\-impaired cause/effect reasoning

\-poor nutrition

\-lack of sleep/exercise

\-mood swings

\-disinhibition

\-anxiety/worry

\-forgetfulness

anorexia nervosa

typically begins between the ages of 14 and 18

early anorexia

negative body image/anxiety regarding appearance

late anorexia

dieting and compulsive behaviors increase, clients isolate themselves, increased sense of paranoia

cognitive response to grief

changing values, re-evaluating religious/spiritual beliefs, trying to keep lost one present

physiological response to grief

lack of energy, palpitations, indigestion, changes in immune/endocrine systems

acculturation

altering cultural values/behaviors as a way to adapt to another culture

disenfranchised grief

grief over a loss than is not/cannot be acknowledged openly, mourned publicly/supported socially

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\-ex: abortion, death of a pet, placing a child for adoption

complicated grieving

response outside of the norm when person is void of emotion, grieves for prolonged periods or has expressions of grief that seem disproportionate to the event

mixed mania

when pt gets both mania and depression nearly every day for at least 1 week

major depressive disorder

2 weeks or more of a sad mood/lack of interest in activities and at least 4 other depression symptoms