Untitled

Study Guide Exam II

I. Schizophrenia (Chapter 24)

  • Dopamine Dysregulation
    • Dysregulation of dopamine is responsible for many symptoms of schizophrenia.
    • Conventional antipsychotics block dopamine and treat positive symptoms, specifically hallucinations and delusions.
    • Hyperactivity in the mesolimbic tract at the D2 receptor site in the striatal area (associated with memory and emotion regulation) is thought to cause these symptoms.
    • Conversely, chronic low levels of dopamine in the prefrontal cortex may underlie cognitive dysfunction in schizophrenia.
    • Current research focuses on molecular links to dopamine synthesis and increased dopamine release.
    • Dopamine's role in the pathogenesis of schizophrenia is complex and interconnected with other disorders, cortical functioning, and stress.

II. Positive and Negative Symptoms of Schizophrenia

  • Positive Symptoms

    • Hallucinations: sensory experiences that appear real but are created by the mind. Distinction: Hallucinations involve senses; delusions involve thoughts.
    • Delusions: fixed, false beliefs resistant to change, even with conflicting evidence.
    • Disorganized Speech: can reflect disorganized thinking and impair communication.
    • Disorganized or Catatonic Behavior: includes patterns that profoundly impair daily activities.

  • Negative Symptoms

    • Alexithymia: difficulty expressing emotion, flat affect.
    • Avolition: profound lack of motivation.
    • Anhedonia: inability to experience pleasure.
    • Alogia: limited speech and conversation.

III. Types of Hallucinations and Delusions

A. Hallucinations
  • Auditory: most common; involves hearing voices or sounds not heard by others, which can be critical or conversational.
  • Visual: seeing things that are not there, ranging from vague shadows to vivid objects or patterns.
  • Tactile: feeling sensations on or under the skin without external stimuli, such as crawling insects.
  • Olfactory and Gustatory: experiencing phantom smells or tastes, can be pleasant or unpleasant.
B. Delusions
  1. Persecutory (paranoid): belief of being harmed or plotted against.
  2. Referential: conviction that gestures or comments are directed at oneself.
  3. Grandiose: belief in exceptional abilities or status.
  4. Somatic: preoccupation with health, such as believing one has a severe illness despite medical reassurance.

IV. Disorganized Thinking, Speech, and Behavior

  • Disorganized Behavior: may include slow, rhythmic, or ritualistic movements, impairing daily functioning.

    1. Aggression: rage and hostility behaviors.
    2. Agitation: inability to sit still with heightened emotions.
    3. Catatonia: psychomotor disturbances, including stupor and mutism.
    4. Catatonic Excitement: purposeless hyperactivity and unexpected movements.
    5. Echopraxia: involuntary imitation of movements/gestures.
    6. Regressed Behavior: displays of less mature life-stage behavior.
    7. Stereotypy: idiosyncratic, repetitive purposeless movements.
    8. Hypervigilance: sustained attention anticipating significant events.
    9. Waxy Flexibility: maintaining odd postures for extended periods.

  • Disorganized Thinking and Speech: reflects fundamental thought disruptions.

    1. Echolalia: parrot-like repetition of others' words.
    2. Circumstantiality: excessive detail in discourse.
    3. Loose Associations: abrupt topic shifts without logical connection.
    4. Tangentiality: completely derailing from the original topic but maintaining a logical flow.
    5. Flight of Ideas: rapid changes of topic.
    6. Word Salad: nonsensical stringing of unrelated words.
    7. Neologisms: creation of unrecognizable words.
    8. Paranoia: unrealistic suspicion and guardedness.
    9. Referential Thinking: believing neutral stimuli have personal significance.
    10. Autistic Thinking: restricted to literal interpretations.
    11. Concrete Thinking: inability to understand figurative language.
    12. Verbigeration: purposeless repetition of phrases.
    13. Metonymic Speech: interchangeable use of similar-meaning words.
    14. Clang Associations: sound-based repetition of words.
    15. Stilted Language: overly formal or artificial speech.
    16. Pressured Speech: overwhelming urge to speak rapidly or continuously.

V. Risk Factors for Developing Schizophrenia

  • Genetic Factors: First-degree relatives have a tenfold increased risk; multiple genes related to brain function and structure implicated.
  • Early Development: Prenatal complications, obstetric issues, neurological insults, viral infections.
  • Environmental Stressors: Migration, urban living, childhood abuse, social isolation, lifetime cannabis use.
  • Age and Timing: Most commonly diagnosed in late adolescence to early adulthood; early diagnosis correlates with more severe outcomes.

VI. Factors Increasing Risk of Suicidality

  • Presence of psychotic episodes.
  • Command hallucinations urging self-harm.
  • Delusional thinking leading to dangerous behaviors.
  • Depression, demoralization, and negative symptoms.
  • Talking about suicide or expressing suicidal thoughts.
  • Lack of social support.
  • Poor engagement in relationships or meaningful activities.
  • Feelings of burdening loved ones.
  • Substance use/dependency issues.
  • Acute illnesses necessitating hospitalization.

VII. Impact of Unrelieved Negative Symptoms

  • Can lead to social isolation and decreased quality of life through impairments in engaging in relationships, self-care, work, or daily activities.

VIII. AIMS Scoring

  • It's crucial to obtain a complete list of medications, including OTC and herbal supplements, and to perform standardized assessments of motor movements.
  • Assessment tools like the Abnormal Involuntary Movement Scale (AIMS) should be used.

IX. Approaching Someone in Psychosis

  • Communication: Utilize calm, empathetic, non-threatening verbal communication.
  • Focus on de-escalation techniques, active listening, and a supportive environment.
  • Compassionate interactions and maintaining a predictable setting help reduce distress.
  • Caregiver and clinician support, along with safety planning, enhances stability and reduces risk.

X. Neuroleptic Malignant Syndrome

  • Rare but life-threatening reaction to antipsychotic medications, indicative of dopamine receptor blockage.
    • Key Symptoms: Sudden high fever, muscle rigidity, altered mental status (confusion/delirium), autonomic instability (tachycardia, hypertension, sweating).
    • Causes: Primarily driven by antipsychotic-induced dopamine blockade.

XI. Side Effects of Antipsychotic Medications

  • Extrapyramidal Symptoms (EPS):

    1. Parkinsonism: tremors, rigidity.
    2. Dystonia: muscle spasms.
    3. Akathisia: restlessness.
    4. Tardive Dyskinesia: involuntary movements.
    • Regular assessments using scales like AIMS are important for early detection.

  • Metabolic Side Effects:

    • Significant weight gain.
    • Increased blood glucose levels.
    • Dyslipidemia (abnormal cholesterol levels).
    • Routine monitoring of weight, waist circumference, fasting glucose, and lipid profiles is necessary.

  • Cardiovascular Effects:

    • Orthostatic hypotension.
    • QT interval prolongation, increasing arrhythmia risks.
    • Regular monitoring of blood pressure and ECGs for high-risk patients.

  • Sedation and Cognitive Impact:

    • Drowsiness, fatigue, cognitive dulling.
    • Monitor patient self-reports; consider adjustments in dosing schedules or alternative medications.

  • Anticholinergic Effects:

    • Symptoms include dry mouth, blurred vision, constipation, urinary retention.
    • Symptom management includes hydration and dietary advice.

XII. Management and Treatment of Side Effects

  • Immediate discontinuation of the offending medication is critical.
  • Supportive care includes cooling and hydration.
  • Pharmacological interventions may include dantrolene for rigidity and bromocriptine to manage dopamine activity.

XIII. Cognitive Behavioral Therapy (CBT)

  • Design and goals of CBT involve altering distorted beliefs and problem behaviors via evidence-based techniques.
  • Encourages engagement in journaling, assertive training, social skills training, and exposure therapy.
  • Focuses on changing irrational beliefs about events to more rational thoughts.

XIV. Motivational Interviewing (MI)

  • Principles include developing client partnerships, acceptance, and emphasizing individual autonomy and strengths to facilitate change.

XV. Schema and Cognitive Distortions

  • Schemas are early-developed patterns influencing perception, potentially leading to distorted thinking.
  • Common cognitive distortions include:
    • Filtering, Overgeneralization, Catastrophic Thinking, Personalization, Emotional Reasoning, Black-and-White Thinking, Labeling, Jumping to Conclusions, Disqualifying the Positive, Should Statements.

XVI. Group Interventions (Chapter 14)

  • Small vs. Large Groups: Small groups foster deeper interpersonal experiences; large groups may be more cost-effective for specific therapies.
  • Open vs. Closed Groups: Open groups allow new members and ongoing participation; closed groups enhance cohesiveness but can dissolve if members leave.

XVII. Depressive Disorders (Chapter 25)

A. Characteristics of Major Depressive Disorder
  • Characterized by depressed mood or anhedonia for two weeks plus five other criteria, including appetite changes and feelings of worthlessness.
B. Risk Factors
  • Prior depressive episodes, family history, stressful life events, and substance use increase risk.
C. Signs & Symptoms
  • Symptoms include appetite and weight changes, sleep disturbances, and fatigue.
D. Nursing Care
  • Essential elements include therapeutic relationships, comprehensive assessments, monitoring for suicidal ideation, and psychoeducation.
E. Medications for Depression
  • Categories include SSRIs, SNRIs, TCAs, and MAOIs. Each class has specific considerations for efficacy and safety.

XVIII. Suicide Prevention (Chapter 22)

  • Suicidal Behavior Across the Lifespan: Understanding statistics on age groups most affected and demographic considerations.
  • Epidemiology: Identifying risk factors such as substance use, previous attempts, and mental health conditions.

XIX. Family Assessment & Interventions (Chapter 15)

  • Components include communication patterns, problem-solving skills, and stress/coping abilities.
  • Use of genograms to depict family health and social issues is encouraged.