Mental Health- Schizophrenia

psychosis

What is the central theme for schophrenic diagnosis?

Emil Krapelin

Who first described schizophrenia as dementia praecox?

Eugene Bleuler

Who determined the presence of several types of schizophrenia?

men: 18-25

Women: 25-35

Age of onset of schizophrenai for men and women

Dopamine (main neurotransmitter) HIGH

serotonin, glutamate & GABA, NMDA also influence

what are the neurotransmitters invovled in schizophrenia? Are they high or low?

Downward drift hypothesis

= poor social conditions seen as a consequence of, rather than cause of, schizophrenia

Prodromal period —> acute illness period (active psychosis)—> stabilization period—> maintenance and recovery period—> relapse

What is the clincial course for schizophrenia?

prodromal period

part of the schizophrenia clinical course that can last weeks-years

see deterioration in social function, sleep disturbances, anxiety, poor concentration

acute illness period (active psychosis)

• part of schizophrenia clinical course that is known as psychotic break

• suddenly delusional, hallucinating, up all night, incoherent conversations,

• less able to care for basic needs; more dependent on family; functioning at school/work deteriorates

• usually when people are diagnosed for first time or when they relapse

stabilization period

• use medications to get patient back on track

• symptoms are present, treatment regimen established, family and patient adjust

maintenance and recovery period

• living as well as possible with schizophrenia and symptoms

• could last years or months

Relapse

occurs when patients fail to take meds consistently

2 or more of the following present for at least 6 months

• one of these MUST be included: delusions, hallucinations, disorganized thinking

• disorganized or catatonic behavior, negative symptoms

Diagnostic criteria for schizophrenia

positive symptoms

an excess of normal function; something there that shouldn’t be

grandiose delusion

• belief that one is famous, has special power, wealthy

patient with schizophrenia believes he is famous and has lots of money. What kind of positive symptom is this?

Nihilistic delusion

• belief one is ded, doesn’t exist, not there in the world

patient with schizophrenia believes she does not exist. What kind of positive symptoms is this?

Persecutory delusion

• belief one is being watched, plotted agaisnt, harmed

Patient with schizophrenia believes the FBI is watching him at all times. What kind of positive symptom is this?

somatic delusion

• belief about irregularities in body functions/structures

Patient with schizophrenia believes there is a snake in place of her large intestine. What kind of positive symptom is this?

Alexithymia

difficulty/inability to express emotion

apathy

lack of interest/desire to do things

avolition

lack of motivation

difficulty making decisions

ambivalence

anhedonia

lack of pleasure

alogia

lack of speech fluency

anergia

lack of energy

Echolalia

person repeats what you say word for word; copycat

ex: RN- “are you going to group today?” Pt- “are you going to group today?”

Circumstantiality

extremely detailed story and the person gets to the point finally

loose associations

thoughts are not really connected

Ex: “the sky is blue, blue is pretty”

Tangentiality

person goes on a tangent and never gets to the point/answers the question

Flight of ideas

conversation topic changes repeatedly and rapidly; thoughts are not related

ex: “i love pizza, speaking of which my dog needs a walk, oh, did you see that movie last night?”

word salad

bunch of random words, no meaning behind them

neologisms

new word patient made up

paranoia

feel like someone is out to get them

Referential thinking

believe neutral stimuli have special meaning to the individual

ex: person watching news thinks the news person is talking to them specifically

Austic thinking/concrete thinking

literal/immediate thinking

Verbigeration

purposeless repetition

ex: “help” “help” “help”

metonymic speech

use wrong word but its related to the proper word

Clang association

repeat similar sounding words

ex: “that light is bright, sight, might, fight, right”

stilted language

formal speaking

Pressured speech

speaking as if they cannot get the words out fast enough

aggression

behavior that reflects rage

agitation

inability to sit still

catatonia

state of immobility, stupor, repetitive behavior

catatonia excitement

purposeless hyperactivity and unexpected movements

Echopraxia

involuntary imitation of anothers movements and gestures

regressed behavior

childlike behavior

sterotypy

repetitive, rhythmic behaviors

Hypervigilance

sustained attention to external stimuli as if expecting something to happen

• most likely experienceing hallucinations

• Ask pt if they are hearing voices then ask them what the voices are saying (assess content of hallucination)

• intervention: accept NOT agree, and distract patient from hallucination

A patient is sitting in the corner talking to themselves. What should you ask this patient? What are they likely experiencing? What interventions should you as the nurse do?

convey acceptance, do not argue

if pt is suspicious: no whispering/laughing, promote trust, avoid touching

A patient is experienceing disturbed thought processes, what intervention should you as the nurse do?

low stimuli environment, keep calm, remove dangerous objects from the room

A patient is pacing with clenched fists. What interventions should be done?

short: remain on topic, use eye contact

long: able to communicate in socially acceptable manner with others

What are the goals for patietns with imparied verbal communication?

Antipsychotics

pharmacological intervention used to decrease agitation and psychotic symptoms

Typical antipsychotics

• block dopamine

• help reduce positive symptoms

• s/e: prolactin elevation & gynecomastia, weight gian, EPS, NMS

Atypical Antipsychotics

• target dopamine, serotonin, and glutamate

• help reduce positive and negative symtoms

• less risk for EPS and NMS

haloperidol (haldol), chlorpromazine (thorazine), fluphenazine (prolixen)

typical antipsychotics

Risperidone (Risperdal)

Quetiapine (Seroquel)

Paliperidone (Invega)

Olanzapine (Zyprexa)

Ziprasidone (Geodon)

Clozapine (Clozaril)

Iloperidone (Fanapt)

Asenapine (Saphris)

Lurasidone (Latuda)

Atypical antipsychotics

Pseudoparkinsonism

• Extrapyramidal symptom (EPS)

• tremors, slow movements, shuffling gait

• caused by imbalance of dopamine and acetylcholine

Dystonic reactions

oculogyric crisis, torticollis, retrocollis

Benztropine (Cogentin), Biphenhydramine (Benadryl)

used acutely to treat pseudoparkinsons and dystonic ractions

can be given long term daily PO anticholinergic

Akathisia

EPS symptom resulting in restlessness, patient feels like they are “jumping out of their skin”

Propranolol (beta blocker)

used to treat akathisia

Tardive dyskinesia

• impairment of voluntary movement, constant motion (lip smacking, tongue in cheek, body rocking)

• more common with typical antipsychotics

• later onset

deutetrabenzine (austedo) and valbenazine (ingrezza)

treat tardive dyskinesia

Clonzapine (Clozaril)

used after other 2 treatments fail

black box warning: agranulocytosis, orthostatic hypotansion, bradycardia, syncope, seizures, myocardistis, cardiomyopathy, mitral valve incompetence. Not approved for use in dementia related psychosis

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assess for agranulocytosis

Why do we need to do CBC w/ diff at baseline and ANC (absolute neutrophil count) for patients on Clozapine?

Neuroleptic Malignant Syndrome (NMS)

severe muscle rigidity, mental status changes, autonomic instability (diaphoresis, fever, tachycardia, unstable BP)

generally occurs with typicals

rapid progression

bromocriptine and dantrolene/benzodiazepine

treatment for neuroleptic malignant syndrome

Fever

Altered mental status

Leukocytosis

Tremors

Elevated CPK

Rigidity

explain “FALTER” with symptoms of NMS

Dry mouth

Blurred vision

Decreased tearing

Photophobia

Constipation

Urinary hesitancy

Urinary retention

Tachycardia

What are some side effects of anticholinergic meds?

anticholingergic crisis

Pt is given an injection of cogentin then suddenly is confused and has incoherent speech. What is happening?

stop med, administer physostigmine

Anticholinergic crisis treatment

Schizoaffective disorder

schizophrenic symptoms accompanied by symptoms associated with mood disorders (manic or depressive)

Delusional disorders

have a delusion that could happen. No hallucination or disorganized thoughts/behaviors

Schizophreniform disorder

psychosis for 1-6 months

Brief psychotic disorder

psychosis up to 1 month