Schizophrenia D/O

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Schizophrenia D/O
2014-10-14 11:19:37
Schizophrenia exam
Psych exam 4
Psych exam 4
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  1. Schizophrenia definition
    a potentially devastating brain disorder that affects a person's thinking, language, emotions, social behavior, and ability to perceive reality accurately
  2. Psychotic disorders other than schizophrenia
    • - schizotypal personality disorder
    • - delusional disorder
    • - brief psychotic disorder
    • - substance-induced psychotic disorder
    • - psychosis or catatonia associated with another medical condition
    • - schizophreniform disorder
    • - schizoaffective disorder
    • - psychotic or catatonia disorder not otherwise specified
  3. schizotypal personality disorder
    • patient demonstrates a personality alteration characterized by altered interpersonal boundaries. 
    • - eccentric behavior
    • - eccentric use of language
    • - restricted or socially inappropriate expression of emotion
    • - increase mistrust and sensitivity regarding the intent or responses of others
    • - difficulty setting goals, determining their own beliefs, and other alterations in identity

    • do not exhibit the frank psychotic features seen in psychotic disorders such as
    • - hallucinations and delusions
  4. delusional disorder
    a person with delusional disorder experiences nonbizarre delusions (e.g., situations that could occur in real life, such as being followed, being loved by another, or having a disease). Apart from the delusions, functioning is not significantly impaired and there are no other symptoms of psychosis. a related disorder, Capgrads syndrome involves delusions about significant other (e.g., family member pet) being replaced by an imposter; this disorder may be due to psychotic or organic brain disease
  5. Brief psychotic disorder
    this disorder involves and acute onset of psychosis (delusions, hallucinations disorganized speech) or grossly disorganized or catatonic behavior in response to extreme stress. it lasts less than 1 month, and a full recovery usually occurs
  6. substance induced psychotic disorder
    - psychosis induced by drugs of abuse, alcohol, medications, or toxins
  7. psychosis or catatonia with another medical condition
    psychosis or catatonia cause by a medical condition (e.g., delirium, neurological or metabolic conditions, hepatic or renal diseases, and many other). medical conditions and substance abuse must always be ruled out before a diagnosis of schizophrenia or other psychotic disorder can be made
  8. Schizophreniform disorder
    schizophreniform disorder is the diagnosis used in situations in which a person has many of the features of schizophrenia but has had these for a period of less than six month. it may or may not develop into schizophrenia
  9. schizoaffective disorder
    when an episode of major depression, mania, or mixed depression and mania occurs in the presence of symptoms of schizophrenia, it is called schizoaffective disorder
  10. psychotic or catatonia disorder not otherwise specified
    disorders that involve psychotic features such as impaired reality testing or bizarre behavior but do not meet the criteria for diagnosis as specified psychotic disorder are diagnosed as psychosis not othewise specified (NOS). similarly, persons exhibiting gross changes in the rate of motor behavior but who do not meet the criteria for catatonia disorder are categorized as catatonic disorder NOS
  11. children schizophrenic characteristics
    • - tend to do less well in school than their sibilings
    • - less socially engaged
    • - less positive
    • - exhibit unusual motor development

    child schizophrenia has a worse prognosis than adult-onset version, and is diagnosed before the age of 12
  12. adolescent schizophrenic characteristics
    • S/S tends to be prodromal symptoms (e.g., early symptoms that indicate that a problem may be developing) for a few months or a few years
    • - social withdrawl
    • - irritability
    • - depression
    • - antagonistic
    • - conduct problems
    • - academic decline
    • - suspisiousness
    • - low-level distortions
  13. schizophrenia epidemiology
    • - prevalence of schizophrenia is 1% worldwide
    • - more frequent in males
    • - among those in urban areas
    • - presents during late teens and early twenties
    • - early onset of schizophrenia (18-25) occur more often in males and then so exhibit poor functioning before onset, more structural brain abnormality, increased levels of apathy
    • - late onset of schizophrenia (25-35) occurs more often in females. they have less structural brain abnormality and have a better outcome
  14. schizophrenia cormorbidity
    • - substance abuse disorders
    • - nicotine dependence
    • - anxiety, depression, and suicide
    • - physical health illness
    • - polydipsia
  15. schizophrenia cormorbidity: substance abuse disorder
    -occur in nearly 50% of persons with schizophrenia and are associated with treatment nonadherence, relapse, incarceration homelessness violence, suicide, and poorer prognosis
  16. schizophrenia cormorbidity: nicotine dependence
    • - range from 70 to 90% 
    • - contribute to increase incidence of cardiovascular and respiratory disorders
  17. schizophrenia cormorbidity: physical health illness
    • - risk of premature death is 1.6 to 2.8 times greater than in general population (28 years prematurely)
    • - greater risk due to apathy poor health habits,medications, poverty, limited access to health care, and failure to recognize signs of illness
  18. schizophrenia cormorbidity: polydipsia
    - can lead to fatal water intoxication (indicated by hyponatremia, confusion,worsening psychotic symptoms, and ultimately come)
  19. schizophrenia etiology:neurotransmitters
    • - Dopamine
    • - serotonin
    • - glutamate
    • - Acetylocholine
  20. brain structure abnormalities
    • - enlargement of the lateral cerebral ventricles, third ventricle dilation,and/or asymmetry 
    • - reduced cortical, frontal lobe, hippocampal, and/or cerebellar volumes
    • - increased size of the sulci (fissures) on the surface of the brain
    • - reduced cortical thickness
    • - reduced connectivity in various brain regions 
    • - PET scan show a lowered rate of blood flow and glucose metabolism in the frontal lobe
  21. prenatal factors
    • - poor nutrition and hypoxia 
    • - herpes virus 2 and human endogenous retrovirus  2 
    • - psychological trauma to mother during pregnancy 
    • - father over age 35
    • - being born during late winter or early spring
  22. phases of schizophrenia
    • 1. phase I- acute
    • 2. phase II - stabilization 
    • 3. phase III - maintenance
  23. phase I - acute
    onset exacerbation of florid, disruptive symptoms (e.g., hallucinations,delusions, apathy, withdrawal) with resultant loss of functional abilities; increased care of hospitalization may be required
  24. phase II - stabilization
    symptoms are diminishing, and there is movement towards one's previous level of functioning (baseline); partial hospitalization or are in a residential crisis center or a supervised group home may be needed
  25. phase III - maintenance
    the patient is at or nearing baseline (or premorbid) functioning; symptoms are absent or diminished; level of functioning allows the patient to live in the community. idealy, recovery with reduced or no residual symptoms has occured
  26. prepsychotic phase
    • monitoring those at high risk (children with parents with schizophrenia)  for 
    • - abnormal social development and cognitive dysfunction
  27. positive symptoms characteristics
    • The presence of something that is not normally present  
    • - hallucination
    • - delusions
    • - bizarre behavior
    • - paranoia
    • - abnormal movements
    • - gross errors in thinking
    • - disorganized speech
  28. negative symptoms characteristics
    • the absence of something that should be present (interest in hygiene, motivation, ability to experience pleasure)
    • -blunted affect
    • - poverty of thought (alogia)
    • - loss of motivation (avolition)
    • - inability to experience pleasures or joy (anhedonia)
  29. cognitive symptoms characteristics
    • often subtle changes in memory, attention or thinking (e.g., impaired executive functioning [ability to set priorities or make decisions])
    • - inattention, easily distracted
    • - impaired memory 
    • - poor problem-solving skills
    • - poor decision-making skills
    • - illogical thinking
    • - impaired judgment
  30. affective symptoms characteristics
    • symptoms involving emotions and their expression
    • - dysphoria
    • - suicidality
    • - hopelessness

    mood may be depressed, elated, unstable, erratic, or hostile
  31. positive symptoms
    • - usually associated with an acute onset
    • - respond well to medication 
    • - function normally during remission 
    • - alteration in thought, speech, and perception
  32. positive symptoms: alteration in thought
    • - impaired reality testing 
    • - delusions
    • - impaired concrete thinking
  33. reality testing
    • (positive s/s when impaired) automatic and unconscious process by which we sort out what is and is not real 
    • - when impaired, people make, maintain, and build upon errors in thinking which contribute to delusions
  34. delusions
    • (positive symptoms) false fixed beliefs that cannot be corrected by reasoning
    • - common delusions are persecutory, grandiose, or those involving religious or hypochrondracial ideas
  35. concrete thinking
    • (positive S/S) refers to an impaired ability to think abstractly 
    • - reduces ones ability to understand and address abstract concepts such as love or the passage of time
  36. positive symptoms: alteration in speech
    • - associative looseness 
    • - clang associatation 
    • - word salad
    • - neologism 
    • - echolalia 
    • - relgiousity 
    • - magical thinking
    • - paranoia 
    • - circumstantiality 
    • - tangentiality 
    • - cognitive retardation 
    • - alogia/poverty speech
    • - rapid or pressured speech
    • - flight of ideas
    • - thought blocking
    • - thought insertion
    • - thought deletion
    • - illogical, disorganized, or bizarre thinking
    • - inability to maintain attention
  37. associative looseness
    • (pos) these threads are interrupted or disjointed
    • - thinking becomes haphazard, illogical and difficult to follow. 
    • - i.e. "i need to get a band-aid for my paper cut. my friend was talking about AIDs. Friends talk about french fries and how can you trust the french...."
  38. clang association
    (pos) choosing words based on their sound rather than their meaning, often rhyming or having similar begining sounf (on the track....have a big mac). can also be seen in neurological d/o
  39. word salad
    • (pos
    • - also known as schizophasia 
    • - a jumble of world that is meaningless to the listener - and perhaps to the listener as well - because of an extreme level of disorganization
  40. Neologisms
    • (pos
    • - are made up words (or idiosyncratic uses of existing words) that have meaning for the patient but a different or non-existing meaning to other ("i was going to tell him the mannerologies of his hospitality won't do")
    • - represent disorganized thinking and interferes with communications
  41. Echolalia
    • (pos
    • pathological repeating of another's words and often seen in catatonia 
    • - nurse: mary, come get your medicine
    • - mary: come get your medicine
  42. religiosity
    • (pos
    • an excessive preoccupation with religious themes
  43. magical thinking
    • (pos
    • believing that ones thoughts or actions can affect others; this is common in children (wearing pajamas inside out to make it snow)
  44. paranoia
    • (pos
    • an irrational fear of other, ranging from mild (weariness, gaurdedness) to profound (believing that another person intends to kill you). Note that persons who fear others may sometimes act defensively, harming the other person before that person harm the patient; this creates a risk to other
  45. circumstantiality
    • (pos
    • including unnecessary and often tedious details in one's conversation (describing your breakfast when asked how your day is going)
  46. tangentiality
    • (pos
    • leaving the main topic talk about less important information; going off on tangents in a way that takes the conversation off-topic
  47. cognitive retardation
    • (pos
    • a generalized slowing in the pace of thinking, represented by delays in responding to questions or difficulty finishing one's thoughts
  48. alogia/poverty of speech
    • (pos
    • a reduction in spontaneity or volume of speech, represented by a lack of spontaneous comments and overly brief responses
  49. flight of ideas
    • (pos
    • moving rapidly from one thought to the next, making it difficult for other to follow the conversation
  50. thought blocking
    • (pos
    • a reduction in the amount of thinking an abrupt stoppage of thought that derails conversations
  51. thought insertion
    • (pos
    • feeling that one;s thought are not one's own or that they were inserted into one's mind
  52. thought deletion
    • (pos
    • belief that one's thoughts have been taken or are missing
  53. inability to maintain attention
    • (pos
    • represented by easy distractibility, off-topic comments in group, or unfinished tasks
  54. positive symptoms: alterations in perceptions
    • involves errors in how one perceives reality; hallucination being the most common form 
    • - depersonalization 
    • - derealization
    • - hallucination 
    • - illusion
  55. depersonalization
    • (pos
    • a feeling that one is somehow different or unreal or had lost his identity. people may feel that body parts do not belong to them or may sense that their body has drastically changed
  56. derealization
    • (pos
    • a false perception that the environment had changed (everything seems bigger or smaller, or familiar surroundings seem somehow strange or unfamiliar)
  57. hallucinations
    • (pos
    • involve perceiving a sensory experience for which not external stimulus exists (e.g., hearing a voice when no voice is speaking)
  58. illusions
    • (pos
    • misperceptions or misinterpretations of a real experience
  59. causes of hallucinations
    • (pos
    • psychiatric d/o,drugs abuse, medications, organic d/o, hyperthermia, toxicity, and other conditions
  60. types of hallucinations
    • (pos
    • - auditory - hearing
    • - visual - seeing
    • - olfactory - smelling
    • - gustatory - taste
    • - tactile - touch
  61. command hallucination
    • (pos
    • direct the person to take an action. assess
    • - what patient hears
    • - ability to recognize hallucination as not real 
    • - ability to resist any command

    • behavioral indicators 
    • - tracking movements (turning or tilting head as if listening to someone)
    • - suddenly stopping current activity as if interrupted
    • - talking to oneself
    • - moving the lips silently
  62. positive symptoms: alteration in behavior
    • include bizarre behaviors involving stilted, rigid demeanor or eccentric dress grooming, and rituals
    • - catatonia
    • - motor retardation 
    • - motor agitation 
    • - stereotyped behaviors
    • - waxy flexibility 
    • - echopraxia
    • - negativism 
    • - impaired impulse control 
    • - gesturing or posturing 
    • - boundary impairment
  63. catatonia
    • (pos
    • a pronounced increase or decrease in the rate and mount of movementl the most common form is stuporous behavior in which the person moves little or not at all
  64. motor retardation
    • (pos
    • slowing of movement
  65. motor agitation
    • (pos
    • excited behavior such as running or pacing rapidly, often in response to internal or external stimuli; can pose a risk to patient or others
  66. alteration in behaviors: stereotyped behaviors
    • (pos
    • repeated motor behaviors that do not serve a logical purpose
  67. waxy flexibility
    • (pos
    • the extended maintenance of posture, usually seen in catatonia. 
    • - ex. the nurse raises the patient's arms, and the patient continues to hold this position in a statue like manner
  68. echopraxia
    • (pos
    • the mimicking of movements of another. it is also seen on catatonia
  69. negativism
    • (pos
    • akin to resistance but may not be intentional. the patient does the opposite of what he or she is told to do (active negativism) or fails to do what is requested (passive negativism)
  70. impaired impulse control
    • (pos
    • a reduced ability to resist one's impulses.
  71. gesturing or posturing
    • (pos
    • assuming unsual and illogical expressions (often grimaces) or positions
  72. boundary impairment
    • (pos
    • an impaired ability to sense where one's body or influence ends and another begins. might stand too close, might drink another's drink
  73. negative symptoms
    • develop slowly and are the ones that interfere the most. impedes on one's ability to do the following:
    • - initiate and maintain conversations and relationships
    • - obtain and maintain employment
    • - make decisions and  follow through on plans 
    • - maintain adequate hygiene and grooming
  74. affect
    • (Neg)
    • outward expression of a person's internal emotional state
    • - flat
    • - blunted
    • - inappropriate
    • - bizarre
  75. flat
    immobile or blank facial expression
  76. blunted
    reduced or minimal emotional response
  77. inappropriate
    incongruent with the actual emotional state it situation (a man laughs when his peer threatens him)
  78. bizarre
    odd, illogical, grossly inappropriate, unfounded; includes grimacing and giggling
  79. anosognosia
    many persons with schizophrenia experience this which is the inability to realize they are ill (caused by the illness itself)
  80. OUTCOME: phase I acute
    overall goal is patient safety and stabilization. another is patient consistency labels hallucinations as "not real - a symptom of of an illness"
  81. OUTCOME: phase II stabilization
    focus on helping patient understand the illness and treatment
  82. OUTCOME: phase III maintenance
    focus on maintaining achievement, adhering to treatment, preventing relapse, and achieving independence and a satisfactory quality of life
  83. Positive symptoms relate to ?
    • - excess dopamine function in the mesolimbic system
    • - Also see an increase in norepinephrine and decrease in GABA and glutamate
  84. Negative symptoms are due to ?
    decreasing dopamine function in the mesocortical pathway of the brain. Serotonin may also be involved
  85. The Prodromal phase
    • begins with a change from premorbid
    • functioning and extends until onset of frank psychotic symptoms

    •   can
    • be brief but studies show average length is 2 to 5 years

    •   Substantial
    • functional impairment, non-specific symptoms such as sleep disturbance,
    • anxiety, fatigue, social withdrawal, and positive symptoms such as perceptual
    • abnormalities
  86. three groups of anti-psychotics
    • - first generation (traditional dopamine antgonist)
    • - second generation (serotinin-dopamine antagonist)
    • - third generation
  87. anti-psychotics
    • - take awhile to take full affect so other drugs may be used in congruent 
    • - increase mortality rates in elderly patients with dementia 
    • - not addictive
  88. first generation antipsychotics
    • - affect primarily positive symptoms
    • - minimal impact on negative symptoms 
    • - a lot of SE, cheaper 
    • - can cause EPS (lowering dose can help relive)
    • -
  89. second generation antipsychotic
    • - improves negative and pos symptoms
    • - fewer SE
    • - also tx anxiety, depression, and dec suicidal behavior
  90. third generation antipsychotic
    improves negative and pos symptoms

    • - fewer SE
    • - also tx anxiety, depression, and dec suicidal behavior
  91. common EPS
    - acute dystonia (acute sustained contraction of muscles, usually of the head and neck)

    - akathisia (psychomotor restlessness evident as pacing/fidgeting)

    - pseudoparkinsonism (a medication-induced, temporary constellation of symptoms associated with parkinson's disease)
  92. high potency antipsychotic dugs
    • - trifluoperazine (generic only)
    • - thiothixene (Navane)
    • - fluphenazine (Prolixin)
    • - Haloperidol (Haldol)
    • - pirozide (Orap)

    low sedation, low anticholinergic effect, high EPS
  93. medium potency antipsychotic drugs
    • - loxaine (Loxitane)
    • - molidone (Moban)
    • - perphenazine (Trilafon)
  94. low potency antipsychotic drugs
    • - chlorpromazine (thorazine)
    • - thioriadizine (Mellaril)

    high sedation + high anticholinergic effect + low EPS
  95. first generation antipsychotic adverse effects
    • Extrapyramidal symptoms (EPSs)
    • - Akathisia
    • - Acute dystonia
    • - Pseudoparkinsonism

    Tardive dyskinesia (TD)

    Neuroleptic malignant syndrome (NMS)

    Agranulocytosis (required blood work)

    Anticholinergic effects


    Lowered seizure threshold
  96. Neuroleptic Malignant Syndrome
    • Neuroleptic malignant syndrome (NMS) → this is an Emergency – life threatening
    • - stop medication, transfer to ICU, give bromocriptine (parlodel) to relieve muscle rigidity and fever
    • remember FALTER
    • F- Fever
    • A- Automatic instability 
    • L- Leukocytosis 
    • T- Tremors
    • E- Elevated enzymes (cpk)
    • R- Rigidity of muscle
  97. Serotonin Syndrome
    • - Proserotonergic drugs
    • - <12 hours to develop
    • - Hypertension, tachycardia, tachypnea, hyperthermia
    • - Mydriasis
    • - Sialorrhea
    • - Diaphoresis
    • - Hyperactive bowel sounds
    • - Increased neuromuscular tone
    • - Hyperreflexia, clonus
    • - Agitation, coma
  98. Neuroleptic Malignant Syndrome s/s
    • - Dopamine agonist drugs
    • - 1-3 days to develop
    • - Hypertension, tachycardia, tachypnea, hyperthermia
    • - Normal pupilsS
    • - ialorrhea
    • - Diaphoresis
    • - Normal or decreased bowel sounds
    • - “lead-pipe” rigidity
    • - Bradyreflexia
    • - Stupor, alert mutism, coma
  99. Extrapyramidal Side Effects tx
    administer antiparkisonian agent (Artane, Cogentin), also use diphenhyrdamine (benadryl) po or IM
  100. Tardive dyskinesia
    • •Late appearing
    • •Abnormal Involuntary Movement Scale (AIMS) Characteristics:

    FACE -protruding and rolling tongue, blowing or lip smacking, spastic facial grimacing, smacking movements

    LIMBS- choreic movements, rapid purposeless and irregular movements,

    TRUNK-neck and shoulder movements, dramatic hip jerks, rocking & twisting pelvic thrusts

    • Treatment: none known; discontinue drug
    • and relieve symptoms
  101. antiparkinson drugs
    • trihexyphenidyl (Artane)

    •  benztropine mesylate (Cogentin)

    •  diphenhydramine hydrochloride (Benadryl)

    •  biperiden (Akineton)

    •  amantadine hydrochloride (Symmetrel)
  102. Atypical (Second-Generation) Antipsychotics drugs
    • •aripiprazole (Abilify)

    •clozapine (Clozaril)

    •olanzapine (Zyprexa)

    •paliperidone (Invega)

    •quetiapine (Seroquel)

    •risperidone (Risperdal)

    •aiprasidone (Geodon)
  103. Atypical (Second-Generation) Antipsychotics drug disadvantage
    • Metabolic syndrome
    • •Weight gain, dyslipidemia, altered glucose
    • •Risk of diabetes, hypertension, atherosclerotic and increase in heart disease

    Is more expensive than conventional antipsychotics.
  104. Agranulocytosis
    A serious side effect of antipsychotics that can be fatal.

    • Symptoms
    • sore throat, fever, malaise, and mouth sores.

    • Treatment: blood work ordered to check
    • leukopenia or agranulocytosis;
    • tests positive d/c drug and reverse isolation may be initiated
  105. Anticholinergic Toxicity
    Potentially life threatening medical emergency!!

    Anticholinergic effects present with both typical and atypical antipsychotics although degree varies

    Symptoms: dry mouth, reduced or absent peristalsis, mydriasis, nonreactive pupils, hot, dry, red skin, hyperpyrexia without diaphoresis, tachycardia, agitation, unstable VS, àurinary retention, delirium seizure

    • Treatment: HOLD all meds; implement
    • cooling measures, urinary cath as needed; Physostigmine may be ordered.
  106. Zyprexa
    First atypical approved for the treatment of acute bipolar mania.  Derived from Clozaril. Was often used in agumentin severe MDD.

    This medication was initially outstanding with aspects of clearing cognitive function.  Long term is now associated with high triglycerides and cholesterol, weight gain, and Type II Diabetes onset.  High cardiac risks due to adverse side effects
  107. Seroquel-
    - studies support good use in the management of aggression, cognitive, and affective symptoms in schizophrenia. Also, now approved for mood.

     - Initially led to very high weight gain, risk with diabetes, and extreme lethargy.

     - Extended Release form recently released is demonstrating corrective action of previous risk symptoms of weight gain and lethargy.
  108. Geodon
    • Least likely of all atypicals to cause
    • weight gain, pharmachological profile suggests advantages for anxiety and
    • depression.

    Cardiac safety is a serious concern (QTC prolongation), and assessment of the client’s cardiac risks and family history pertinent. Not optimal with serious symptoms of Schizophrenia.
  109. Atypical (antipsychotic drugs) Agents Side Effects
    Common Reactions: Sedation, Insomnia, agitation, sadness, dry mouth, constipation, headaches, dizziness, blurry vision, tremors, restlessness, diarrhea. 

    • Adverse Reactions: Hypotension, syncope, involuntary movements, dystonia, NMS (neuroleptic malignant syndrome), seizures, hypothyroidism, diabetes, low blood counts, cataracts, OT
    • prolongation, depression, SI, stroke, dystonic reactions.

    • Important health care issues: monitor
    • weight, consistent lab work for triglycerides, cholesterol, and blood sugar
    • levels, monitor liver function tests, blood pressure, and eye exams.
  110. Abilify
    • Abilify-only drug in the thrid generation 
    • - safety is better but can be less effective
    • - Improves positive and negative symptoms and cognitive functioning
    • - less risk for EPS and TDK and anticholinergic effect. 
    • - Demonstrating low instances of weight gain, or metabolic syndrome.  This medication is also easier on the liver.
  111. Adjuncts to Antipsychotic Drug Therapy
    •Antidepressants are administered for severe depression.

    •Lithium and other mood stabilizers reduce aggressive behavior.

    •Benzodiazepine augmentation improves positive and negative symptoms.

    • Clonazepam
    • decreases anxiety,
    • agitation,
    • and possibly psychosis