Exam 3 Lecture 3 (LAST!)

Schizophrenia affects 1% of adults

Characterized by psychosis

-- Altered cognition, perception, and reality testing

75%: Develop gradually, presenting at 15 to 25 years of age

Child-onset and late-onset are more rare

clinical picture (schizophrenia)

Two or more of the following for a significant portion of time in 1 month:

- Delusions (fixed false beliefs)

- Hallucinations (sensing something that isnt here)

- Disorganized speech

- Gross disorganization or catatonia (just existing. not talking or eating etc.)

- Negative symptoms (diminished emotional expression or avolition)

- Functional impairment of some kind

Continuous disturbance for at least 6 months

DSM-V Criteria: Highlights for schizophrenia

Eric M, 18, has always been a good student. However, in his second semester of college, he begins, for the first time in his life, to have trouble concentrating. When his family doesn't hear from Eric, they contact the school, only to discover that his roommate says Eric is "talking weird."

Asked what he means, the roommate says, "Well, you know, he says stuff that doesn't connect, doesn't make any sense. I asked him if he was high or something, but he said no, and I believed him."

On further investigation, Eric's professors say he's been missing class, after starting out so well.

Eric's roommate says his speech "... doesn't connect; it doesn't make any sense. He sort of gets derailed." Which of the following symptoms is Eric displaying?

A. Avolitional speech

B. Delusional speech

C. Disorganized speech

D. Diminished emotional expression

C. Disorganized speech

Childhood-onset schizophrenia: 1 in 40,000 children

No difference related to

- Race

- Social status

- Culture

More frequently diagnosed:

- Among males

- In urban areas

Epidemiology (schizophrenia)

Substance abuse disorders

- Nicotine dependence

Anxiety, depression, and suicide

Physical health or illness

Polydipsia

comorbidity (schizophrenia)

Biological factors

- Genetics

Neurobiological

- Dopamine theory

- Other neurochemical hypotheses

Brain structure abnormalities

Psychological and environmental factors

- Prenatal stressors

- Psychological stressors

- Environmental stressors

- Prognostic considerations

etiology (schizophrenia)

Prodromal phase of schizophrenia

Onset; mild changes

Acute phase of schizophrenia

Exacerbation of symptoms

stabilization phase of schizophrenia

Symptoms diminishing

Movement toward previous level of functioning

maintenance or residual phase of schizophrenia

New baseline is established

Eric agrees to see a psychiatrist and an initial assessment and history indicate that he has only been experiencing some mild changes in his thinking and mood for about a month—ever since returning from the winter holiday. The examiner confirms that his speech is sometimes disorganized and his ability to concentrate and study is diminished from his previous longstanding as a strong student.

Given the evidence we have so far, if Eric has schizophrenia, which is suspected, which phase is he most likely experiencing?

A. Acute

B. Residual

C. Prodromal

D. Stabilization

C. Prodromal

During the prodromal phase

General ______________:

- Positive symptoms

- Negative symptoms (flat, restrictive)

- Cognitive symptoms (mini cog)

- Affective symptoms

assessment (schizophrenia)

Alterations in reality testing

- Delusions—false, fixed beliefs

- Alterations in speech

- Concrete thinking—inability to think abstractly

positive symptoms

Word salad—most extreme form; jumble of words meaningless to a listener

Associative looseness

Words chosen based on sound

Clang association

Meaning for the patient only, Using their own words

Neologisms

Pathological repetition of another's words

Echolalia

Circumstantiality

Tangentiality

Cognitive retardation

Pressured speech

Flight of ideas

Symbolic speech

Abnormal Speech Patterns

Thought blocking

Thought insertion

Thought deletion

Magical thinking

Paranoia

disorders or distortions of thought

During assessment, Eric has trouble staying on topic, zipping rapidly from one thought to the next, making it hard to follow what he's trying to say. Which speech disturbance is he exhibiting?

A.Pressured speech

B.Circumstantiality

C.Flight of ideas

D.Tangentiality

C.Flight of ideas

Depersonalization

Derealization

Hallucinations

- Auditory

- Visual

- Olfactory

- Gustatory

- Tactile

- Command

- Illusions

Alterations in Perception

Catatonia

Motor retardation (slowed)

Motor agitation (restless)

Stereotyped behaviors

Waxy flexibility

Echopraxia (copy motions)

Negativism

Impaired impulse control

Gesturing or posturing

Boundary impairment (intrusive)

Alterations in Behavior

The absence of essential human qualities

- Anhedonia

- Avolition

- Asociality

- Affective blunting

- Apathy

- Alogia

Affect: Outward expression of a person's internal emotional state

- Flat (no emotion at all)

- Blunted (may show slight emotion but nearly flat)

- Inappropriate

- Bizarre

negative symptoms

Concrete thinking

Impaired memory

Impaired information processing

Impaired executive functioning (requiring steps for completion)

cognitive symptoms

Assessment for depression is crucial

- May herald impending relapse

- Increases substance abuse

- Increases suicide risk

- Further impairs functioning

affective symptoms

Inability to realize they are ill

Caused by the illness itself

May result in resistance to or cessation of treatment

Often combined with paranoia so that accepting help is impossible

no insight

Anosognosia

Anxiety or fear

Frustration

Expectations

nonjudgemental culturally appropriate care!!!!!!!

Nurse's self-assessment (schizophrenia)

Eric becomes anxious and says, "There are worms under my skin eating the hair follicles." How would you classify this assessment finding?

A.Positive symptom

B.Negative symptom

C.Cognitive symptom

D. Depressive symptom

A.Positive symptom

Any medical problems

Medical problems that mimic psychosis

Drug or alcohol use disorders

Mental status examination

Include cognitive assessment (e.g., reality testing)

Assess for hallucinations

Assess for delusions

Assess for suicide risk

Assess ability to ensure personal safety and health

Assess prescribed meds

Assess symptoms' impact on functioning

Assess family knowledge

Assessment Guidelines (Schizophrenia)

The psychiatric nurse conducting Eric's assessment believes that he is also suffering from command hallucinations. Discuss what kinds of questions could help affirm this.

are you hearing voices? what are they saying? is it male or female? are there many voices or just one? do you know who it is?

Disturbed sensory perception

Risk for self-directed or other-directed violence

Impaired verbal communication

Positive symptoms - nursing diagnoses

Social isolation

Chronic low self-esteem

Negative symptoms - nursing diagnoses

Phase I—acute

- Patient safety and medical stabilization

Phase II—stabilization

- Help patient understand illness and treatment

- Stabilize medications

- Control or cope with symptoms

Phase III—maintenance

- Maintain achievement

- Prevent relapse

- Achieve independence, satisfactory quality of life

Outcomes Identification (schizophrenia)

After an acute admission, discharge is being planned for Eric. What are some things that need to be considered?

Home life? Medication adherence? Follow up appointments? transportation? orientation? money? fiduciary needed?

Phase I—acute

- Best strategies to ensure patient safety and provide symptom stabilization

Phase II—stabilization

Phase III—maintenance

- Provide patient and family education

- Relapse prevention skills are vital

planning (schizophrenia)

Psychiatric, medical, and neurological evaluation

Psychopharmacological treatment

Support, psychoeducation, and guidance

Supervision and limit setting in the milieu

Monitor fluid intake

Working with aggression

-- Regularly assess for risk and take safety measures

Acute phase - implementation (schizophrenia)

Stabilization and maintenance phases

- Medication administration/adherence

- Relationships with trusted care providers

- Community-based therapeutic services

- Teamwork and safety

- Activities and groups

Counseling and communication techniques

- Hallucinations

- Delusions

- Associative looseness

- Health teaching and health promotion

Interventions (schizophrenia)

Antipsychotic medications

- First-generation (target only + symptoms)

- Second-generation (targets both + and - symptoms, less side effects)

- Other Second-generation/Third-generation

Injectable antipsychotics

- Short-acting

- Long-acting, Table 12.4

Psychobiological Interventions (schizophrenia)

Dopamine antagonists (D2 receptor antagonists)

Target positive symptoms of schizophrenia

Advantage

- Less expensive than second generation

Disadvantages

- Extrapyramidal side effects (EPS)

- Anticholinergic (ACh) side effects

- Tardive dyskinesia (will not go away)

- Weight gain, sexual dysfunction, endocrine disturbances

First-Generation Antipsychotics

Serotonin (5-HT2A receptor) and dopamine (D2 receptor) antagonists, e.g., clozapine (Clozaril)

Treat both positive and negative symptoms

Minimal to no EPS or tardive dyskinesia

Disadvantage—tendency to cause significant weight gain; risk of metabolic syndrome

Second-Generation Antipsychotics

Really a subset of the SGAs

Aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar)

Dopamine system stabilizers (stops spikes in dopamine)

May improve positive and negative symptoms and cognitive function

-- Little risk of EPS or tardive dyskinesia

Other Second-Generation/Third-Generation Antipsychotics

ACh toxicity

Neuroleptic malignant syndrome (NMS) - antipsychotic toxicity

Agranulocytosis

Prolongation of the QT interval

Liver impairment

Potentially Dangerous Responses to Antipsychotics

Individual and group therapy

Psychoeducation

Medication prescription and monitoring

Basic health assessment

Cognitive remediation

Family therapy

Advanced Practice Interventions (schizophrenia)

Reevaluate progress regularly and adjust treatment when needed

Even after symptoms improve outwardly, inside the patient is still recovering.

Set small goals; recovery can take months.

Active, ongoing communication and caring is essential.

Evaluation (schizophrenia)

Loose associations in a person with schizophrenia indicate

A.paranoia.

B.mood instability.

C.depersonalization.

D. poorly organized thinking.

D. poorly organized thinking.

Which assessment finding represents a negative symptom of schizophrenia?

A.Apathy

B.Delusion

C.Motor tic

D. Hallucination

A.Apathy

Clinical picture

- Reactive attachment disorder

- Disinhibited social engagement disorder

- Posttraumatic stress disorder (PTSD) in preschool children

Trauma-Related Disorders in Children

Reactive attachment disorder

Disinhibited social engagement disorder

Attachment Disorders

Post traumatic stress disorder (PTSD)

Epidemiology

Comorbidity

Etiology

- Genetic

- Neurobiological

- Psychological

- Environmental

Post traumatic Stress Disorder in Children and Adolescents

Genetic

- How individuals react to trauma

Neurobiological

- Trauma dysregulates neural pathways that integrate emotional regulation and arousal

- Triggers hypoaroused state leading to dissociation

- Polyvagal theory

Environmental factors

- Dependence on adults and systems

- External factors that support or add stress

Etiology: Biological Factors (PTSD in children)

Assessment

- Developmental assessment

Nursing diagnoses

Outcomes identification

Implementation

Evaluation

Application of the Nursing Process (PTSD in children)

Stage 1: Provide safety and stabilization

Stage 2: Reduce arousal and regulate emotion through symptom reduction

Stage 3: Catch up on developmental and social skills; develop a value system

Intervention Stages (PTSD in children)

Establish trust and safety

Use developmentally appropriate language

Teach relaxation techniques

Use art and play to promote expression of feelings

Involve caretakers in 1:1s, unless they are the cause of trauma

Educate child and caretakers about grief process

Assist caretakers in resolving personal distress

Coordinate with social work for protections

Interventions for Child with PTSD

1. The child's safety has been maintained.

2. Anxiety has been reduced, and stress is handled adaptively.

3. Emotions and behavior are appropriate for the situation.

4. The child achieves normal developmental milestones for his or her chronological age.

5. The child is able to seek out adults for nurturance and help when needed.

Evaluation for Child with PTSD

Max, age 6, has been traumatized by a history of violence from an alcoholic father. A neighbor calls the police one night, and the father is taken in for questioning and agrees to enroll in rehab. Max is taken to the hospital for assessment of his arm, which is covered with bruises. His mother is distraught and says she wants help for the whole family, including her husband. The nurse prepares to assess Max's mental health.

The nurse prepares to assess Max's mental health. Identify some broad areas of mental health assessment for this child.

play therapy, assess arm, ask how he is doing, ask about school, adaptability? does he flinch? is he isolated? PTSD? depression?

Before going home from the hospital, Max and his family begin intervention therapy. Which is probably the least useful strategy at this time?

A.Establish trust and safety in the therapeutic relationship.

B.Use art to help Max express his feelings.

C.Bring Max's father into 1:1 play therapy sessions.

D. Teach Max and his parents about grief.

C.Bring Max's father into 1:1 play therapy sessions.

Which of the following should be established first in working with a child with PTSD?

A.Provide safety and stabilization

B.Reduce symptoms

C.Develop a value system

D.Provide support for catching up on developmental and social skills

A.Provide safety and stabilization

Re-experiencing of the trauma

Avoidance of stimuli associated with trauma

Persistent symptoms of increased arousal

Alterations in mood

Assessment

Outcomes identification

- Manage anxiety

- Increase self-esteem

- Improve ability to cope

Implementation

- The same 3-stage model used for children

- Psychoeducation

- Psychopharmacology

Advanced practice

- EMDR therapy

Evaluation

- The patient recognizes symptoms as related to the trauma

- The patient is able to use newly learned strategies to manage anxiety

- The patient experiences no flashbacks or intrusive thoughts about the traumatic event

- The patient is able to sleep adequately without nightmares

- The patient can assume usual roles and maintains satisfying interpersonal relationships

Post traumatic Stress Disorder in Adults

Immediately after a highly traumatic event

Symptoms persist for 3 days

Diagnosis made within month

After 1 month

- Resolution or

- Becomes PTSD

Diagnosis

- Alterations in concentration

- Anger

- Dissociative amnesia

- Headache

- Irritability

- Nightmares

- Related to:

-- Victimization

Implementation

- Establish therapeutic relationship

- Assist to problem solve

- Connect person to supports

- Collaborate for coordination of care

- Ensure and maintain safety

- Refer to a licensed mental health provider

- Monitor response and/or adherence to treatment

Advanced practice: cognitive-behavioral therapy (CBT)

Acute Stress Disorder

Adjustment disorder

- Precipitated by stressful event

- Debilitating cognitive, emotional, and behavioral symptoms that negatively impact normal functioning

- Responses to stressful event may include combinations of depression, anxiety, and conduct disturbances

Trauma-Related Disorders in Adults

Occur after significant adverse experiences/traumas

Individuals respond to stress with severe interruption of consciousness

Unconscious defense mechanism

Protects individual against overwhelming anxiety through emotional separation

Dissociative amnesia

Depersonalization/derealization disorder

Dissociative identity disorder

Cognitive factors

Environmental factors

Cultural considerations

Epidemiology

Etiology

Biological factors

- Genetic

- Neurobiological

Dissociative Disorders

Inability to recall important personal information

Often of traumatic or stressful nature

Dissociative fugue

- Subtype characterized by sudden, unexpected travel and inability to recall one's identity

Dissociative Amnesia

Depersonalization—focus on self (im not real)

Derealization—focus on outside world (nothing is real)

Depersonalization/Derealization Disorder

Presence of two or more distinct personality states

Each alternate personality (alter) has own pattern of

- Perceiving

- Relating to and

- Thinking about the self and environment

Dissociative Identity Disorder aka multiple personality disorder

History

Moods

Impact on patient and family

Suicide risk

Self-assessment

Dissociative Disorders Assessment

Phase 1: Establishing safety, stabilization, and symptom reduction

Phase 2: Confronting, working through, and integrating traumatic memories

Phase 3: Identity integration and rehabilitation

Dissociative Disorders Planning

Interventions

- Psychoeducation

- Pharmacological interventions

Advanced practice interventions

- CBT, psychodynamic psychotherapy, exposure therapy, modified EMDR therapy, hypnotherapy, neurofeedback, ego state therapies, somatic therapies, and medication

Dissociative Disorders implementation

A nurse assesses a patient diagnosed with dissociative identity disorder. Which finding would likely be part of the patient's history?

A.Travel to a foreign country

B.Physical or sexual abuse

C.Thyroid dysfunction

D.Eating disorder

B.Physical or sexual abuse

Expression of stress through physical symptoms that are often manifestations of psychological and emotional distress

Symptoms expressed in place of anxiety, depression, or irritability

Holistic approach: multidimensional interplay of biological, psychological, and sociocultural needs and its effects on somatization

somatization

Somatic symptom disorder (SSD) (physical symptoms)

Illness anxiety disorder

Conversion disorder (convert mental illness to physical)

Psychological factors affecting medical condition

Factitious disorder (make yourself sick or injured for the attention)

clinical picture (somatic symptom disorder)

One or more distressing symptoms

Excessive thoughts, anxiety and behaviors around symptoms, or health concerns

Without significant physical findings and medical diagnosis

Suffering is authentic

High level of functional impairment

Somatic Symptom Disorder

Misinterpretation of physical sensations

Preoccupation with having or acquiring serious illness for at least 6 months

High anxiety about health

Excessive health-related behaviors or maladaptive avoidance

May be care-seeking or care-avoidant

Illness Anxiety Disorder

Neurological symptoms in the absence of a neurological diagnosis

Presence of deficits in voluntary motor or sensory functions

Common symptoms—paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or episodes resembling epilepsy

"La belle indifférence" versus distress

Conversion Disorder

Psychological factors that increase risk for medical diseases, magnify them, or interfere with their treatment

Depression

- Cardiovascular diseases and cancer

Stress

Psychological Factors Affecting Medical Condition

Mr. Brazzali is brought to the Emergency Department by a cab driver who walks with him into the entrance and says, "This guy says he just lost his sight! He just went blind after he got into my cab."

Mr. Brazzali is very patient and says, during assessment, "Well, I've had several episodes like this. I guess this just happens sometimes."

During assessment, Mr. Brazzali says that when these "episodes of blindness" come over him it is often immediately after "an epileptic fit." Testing, however, shows no signs of recent seizure.

The ED physician records that Mr. Brazzali has neurological symptoms but in the absence of a neurological diagnosis. He also makes note of this patient's lack of distress about what should be an alarming condition.

Which diagnosis best describes Mr. Brazzali's condition?

A.Psychological factors affecting medical condition

B.SSD

C.Illness anxiety disorder

D. Conversion disorder

D. Conversion disorder

Psychosocial factors

Coping skills

Spirituality and religion

Secondary gains

Cognitive style

Ability to communicate feelings and emotional needs

Dependence on medication

Self-assessment

assessment (somatic symptom disorder)

Ineffective coping

Anxiety

Risk for loneliness

Powerlessness, hopelessness

Social isolation

Pain

Altered family processes

Risk for suicide

Nursing Diagnoses (somatic symptom disorder)

Shared decision making

Patient participation

Outcome criteria realistic and attainable

Small steps or increments

- Patient can see concrete evidence of progress

Outcomes Identification (somatic symptom disorder)

Establish therapeutic relationship

Educate patient regarding treatment

Refer to support groups or systems

Teach effective coping

Focus on strengths and reinforce skills

Psychosocial interventions

- Coping strategies that preclude somatization

- Promotion of self-care activities

- Assertiveness training

Pharmacological interventions

Health teaching and promotion

Case management

implementation (somatic symptom disorder)

1. Provide continuity of care

2. Avoid unnecessary procedures

3. Provide frequent, brief, and regular visits

4. Always conduct a physical exam

5. Avoid disparaging comments

6. Set reasonable therapeutic goals

Six Key Elements for Effective Treatment (somatic symptom disorder)

Psychotherapy or consultation

Holistic approach

- Biological, environmental, psychological, spiritual, and sociocultural needs

Cognitive-behavioral therapy (CBT)

Act as nurse consultant or liaison

Advanced Practice Interventions (somatic symptom disorder)

Based on clear, realistic, measurable outcomes

Goals often reported as partially met

Patients

- Often report continuing somatic symptoms

- Often report less concern about them

evaluation (somatic symptom disorder)

Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injury

Goal of assuming a sick role

Compulsivity

FAKE FAKE FAKE

Munchausen by proxy: done to the other person ex: gypsy rose

Factitious Disorder

Factitious disorder imposed on self (ATTENTION)

Factitious disorder imposed on another

Malingering (faking being sick for secondary gain)

- Condition related to factitious disorders

- Conscious fabrication of illness or exaggerating symptoms for secondary gain such as insurance fraud, prescription medication, avoidance of prison or military service

Types of Factitious Disorder

Assessment and diagnosis

- Determine if symptoms are conscious or unconscious

- Avoid confrontation

- Self-assessment: Frustrations related to countertransference

Planning and implementation

- Monitor for safety

- Prevent dangerous unnecessary treatments

Evaluation

- New coping strategies

Application of the Nursing Process (Factitious disorder)

Which problem does NOT fit the group?

A.Malingering

B.Conversion disorder

C.Illness anxiety disorder

D.SSD

A.Malingering

Which is an example of malingering?

A.Mr. Harris injures his foot to avoid military service.

B.Mrs. Adams has been making her child vomit and lose weight to pretend he has cancer.

C.Mr. Singleton has difficulty walking and uses a wheelchair, but without neurological deficits, which began 2 months after the death of his wife of 32 years.

D.Ms. Munini frequently calls or comes to the clinic in a panic, believing she is ill. Her suffering is genuine, but she never has concrete signs of any illness.

A.Mr. Harris injures his foot to avoid military service.

Which is an example of illness anxiety disorder?

A.Mr. Harris injures his foot to avoid military service.

B.Mrs. Adams has been making her child vomit and lose weight to pretend he has cancer.

C.Mr. Singleton has difficulty walking and uses a wheelchair, but without neurological deficits, which began two months after the death of his wife of 32 years.

D.Ms. Munini frequently calls or comes to the clinic in a panic, believing she is ill. Her suffering is genuine, but she never has concrete signs of any illness.

D.Ms. Munini frequently calls or comes to the clinic in a panic, believing she is ill. Her suffering is genuine, but she never has concrete signs of any illness.