Exam 7

Korsakoff's psychosis

(Korsakoff syndrome) refers to a chronic neurological condition that usually occurs as a consequence of untreated Wernicke's encephalopathy. Korsakoff syndrome is marked by difficulty/inability to learn new information, remember recent events, and long-term memory gaps. Although memory problems are clearly evidenced, other thinking and social skills may be relatively unaffected.

Treatment-Relevant Dimensions of Schizophrenia: Negative symptoms

(e.g., apathy, lack of motivation, anhedonia, poor thought processes) persist and are extremely destructive because they render a person inert and unmotivated. -apathy -lack of motivation -anhedonia -blunted or flat affect -poverty and speech -social withdrawal

Treatment-Relevant Dimensions of Schizophrenia: Positive symptoms

(e.g., hallucinations, delusions, bizarre behavior, paranoia) are referred to as florid psychotic symptoms; they are the ones that capture attention. Decades of analysis of treatment and study findings indicate that these florid psychotic symptoms may not be the core deficiency after all. -hallucinations -delusions -bizarre behavior -catatonia -formal thought disorder

akathisia

(internal restlessness and external restless pacing or fidgeting), and pseudoparkinsonism (stiffening of muscular activity in the face, body, arms, and legs).

associative looseness

(or looseness of association [LOA]), thinking becomes haphazard, illogical, and confused. Zelda Fitzgerald wrote her husband, the writer F. Scott Fitzgerald, an account of going mad: Then the world became embryonic in Africa—and there was no need for communication ... I have been living in vaporous places peopled with one-dimensional figures and tremulous buildings until I can no longer tell an optical illusion from a reality ... head and ears incessantly throb and roads disappear (Vidal, 1982).

anosognosia

(the inability of a person to recognize that he or she has an illness because of the illness itself).

The syndrome of schizophrenia: mood symptoms

-depression -anxiety -demoralization -suicidality -excitability -agitation

concrete thinking

-they take things extremely literal refers to an overemphasis on specific details and impairment in the ability to use abstract concepts. For example, during an assessment, the nurse might ask what brought the patient to the hospital. The patient might answer "a cab" rather than explaining the reason for seeking medical or psychiatric aid. When asked to give the meaning of the proverb "People in glass houses shouldn't throw stones," the person with schizophrenia might answer, "Don't throw stones or the windows will break." The answer is literal; the ability to use abstract reasoning is absent.

Assessment Guidelines Schizophrenias and Other Psychotic Disorders

1. Determine if the patient had a medical workup; if so, was medical or substance-induced psychosis ruled out? 2. Verify whether the person uses alcohol or drugs. 3. Assess for command hallucinations (e.g., voices telling the person to harm self or another). If present, ask the patient: • Do you plan to follow the command? • Do you believe the voices are real? • Do you recognize the voices? 4. Review the patient's belief system. Is it fragmented? Is it poorly or well organized? Is it systematized? Is the system of beliefs unsupported by reality (delusion)? If yes, then find out if: • Delusions focus on someone trying to harm the patient • The patient is planning to retaliate against a person or organization • Precautions need to be taken 5. Assess for co-occurring conditions, including: • Depression • Suicidality • Anxiety • Substance use • History of violence 254 6. Inventory the patient's medications and assess whether the patient is adhering to the medication regimen. a. If the person is nonadherent with medications, ask what makes it difficult for him or her to follow this medication regime (fear of side effects, forgetting, lack of money?). b. Make clear notations of the reasons for nonadherence and what will be done to help the person to become more adherent (social services for monetary reasons, recovery group, medication group, etc.). 7. Determine the family's response to increased symptoms. Are they overprotective? Hostile? Suspicious? Overwhelmed? 8. Assess the manner in which family members and the patient relate. 9. Review the support system. Is the family well informed about the disease? Does the family understand the need for medication adherence? Is the family familiar with support groups available in the community or locations where respite and family support may be offered? Have family members received or been referred for psychoeducation?

helpful guidelines to use when working with an individual who is very paranoid

1. Speak indirectly. Avoid speaking directly to the person. Substitute pronouns such as "it," "he," "she" or "they" for the words "I" and "you." Like the body positioning, the purpose is to deflect the patient's paranoid projections away from one-on-one interactions with the clinician. Instead, paranoid symptoms are directed toward external and more general "real world" issues. 2. Identify with, rather than fight, the patient. Whenever possible, your attitudes and emotional expressions should parallel the patient's attitudes and expressions. The goal is to help the patient feel understood. Meet anger with reciprocal anger, frustration with frustration (i.e., you also express anger and frustration with the difficult circumstances). A paranoid individual is not thinking rationally and your attempts to rationalize will not likely be successful. 3. Don't rationalize. Share mistrust. The intuitive approach with a paranoid person is to try to persuade him or her to be more trusting. It is often better to do the opposite; that is, for you—along with the patient—to mistrust the world together. No attempt is made to correct or contradict the patient, or to test reality. Temporarily, the patient's account of reality is accepted as reality. The assumption behind this technique is that, in the midst of a paranoid state, the patient is overburdened and overwhelmed by a mixture of real-life stresses and distress from psychotic symptoms. While carefully avoiding collusion with the psychotic symptoms, you should attempt to find certain believable or credible aspects of the paranoid belief system. This allows you to agree with the patient on something. You then move on to a symptom area, attempt to substitute a less paranoid, more benign (and general) explanation for the more highly personalized paranoid one. The process of exchanging more malignant to benign paranoid beliefs is best done in a step-wise fashion, where the alternate explanation is only a notch less paranoid than the previous one. For example, rather than confront a patient's own behavior that led to her being arrested, the clinician agrees that some police are not trustworthy and goes on to talk about his own outrage at the Rodney King case.

Agranulocytosis

A life-threatening drop in white blood cells. This condition is sometimes produced by the atypical antipsychotic drug clozapine. is also a serious side effect of the FGAs and can be fatal. Liver involvement also may occur. Nurses need to be aware of the prodromal signs and symptoms of these side effects and teach them to their patients and patients' families. Side effects often appear early in therapy and can be minimized with treatment. Treatment usually consists of lowering the dosage or prescribing antiparkinsonian drugs, especially centrally acting anticholinergic drugs. Commonly used drugs include trihexyphenidyl (Artane), benztropine mesylate (Cogentin), diphenhydramine hydrochloride (Benadryl), biperiden (Akineton), and amantadine hydrochloride (Symmetrel). However, treatment with antiparkinsonian drugs is not completely benign because the anticholinergic side effects of the antipsychotics may be intensified (e.g., urinary retention, constipation, failure of visual accommodation [blurred vision], cognitive impairment, and delirium).

Medical Comorbidity

A medical history, physical examination, and laboratory tests are used to gather data about drug-related physical problems. The extent of impairment depends on individual susceptibility as well as the amount of drug used and the route of administration. Numerous disorders affect the gastrointestinal system (e.g., esophagitis, gastritis, pancreatitis, alcoholic hepatitis, and cirrhosis of the liver). Cardiovascular risks are also significant. Alcohol can raise the levels of triglycerides in the blood. Excessive alcohol intake results in stroke, cardiomyopathy, cardiac dysrhythmia, and sudden cardiac death (American Heart Association [AHA], 2011). Also commonly associated with long-term alcohol use or abuse is tuberculosis, all types of accidents, suicide, and homicide.

ideas of reference

A paranoid individual misinterprets the messages of others or gives private meaning to the communications of others For example, a patient might see his wife talking to a man at a checkout counter at a supermarket and believe they are lovers and plotting to get rid of him. Minor oversights are often interpreted as personal rejection. It can be intimidating to be in the presence of an extremely paranoid individual.

abuse

Abuse refers to the habitual use of a substance that falls outside of medical necessity or social acceptance and is used for the single purpose of altering one's mood, emotion, or state of consciousness.

Phase I Intervention

Acute psychopharmacological treatment Limit setting Supportive and directive care Psychiatric, medical, neurological evaluation Meeting with family sub-acute: Psychosocial evaluation Linkage with: • Social services • Human services • Community treatment agencies Psychoeducational interventions with families

Phase I

Acute: Onset, Exacerbation, or Relapse Subacute or Convalescent

alcohol-related medical problems

Alcohol is the most prevalent of the substance use disorders; therefore, alcohol-related medical problems are the comorbidities most commonly seen in medical settings. The risks of health problems related to alcohol abuse are infinite. Excessive alcohol use damages the brain and most body organs.

limbic (reward) system.

All drugs (e.g., nicotine, stimulants, marijuana, caffeine, sedatives) directly or indirectly affect the limbic (reward) system. The reward system consists of the ventral tegmental area (VTA), the nucleus accumbens, and part of the cerebral cortex. These brain circuits allow us to feel pleasure, and they increase the response to dopamine as a reward from pleasurable activities (e.g., food, music, art, sex). However, the first time an individual uses a "substance," the neurons in the reward pathway release an unusually large amount of dopamine, resulting in unnaturally intense feelings of pleasure. The neurons in the reward pathway communicate through electrical signals that are passed from one neuron to another across a small gap called a synapse. Dopamine is then released into the synapse, crosses to the next neuron, and binds to that neuron's dopamine receptor (NIH, 2015). It is this binding that produces the initial intense feelings of pleasure. As a result of this flood of neurotransmitters (e.g., dopamine), the neurons try to regulate the level of dopamine in the brain either by reducing the number of dopamine receptors or by synthesizing less dopamine. In the case of many drugs, eventually dopamine's ability to stimulate the reward center becomes very ineffective, and the individual is encouraged to increase the amount of the drug to raise dopamine levels to normal or higher levels; this vicious cycle of taking increasing amounts of the drug to even feel "normal" begins the cycle of tolerance to the drug and eventual addiction. Other nerve cells release γ-aminobutyric acid (GABA), which is an inhibitory neurotransmitter that helps moderate neuronal activity and protects the receptor nerve from becoming overstimulated. Opioid drugs act on opioid receptors. Alcohol and other central nervous system (CNS) depressants act on GABA receptors. This finding helps explain the addictive and cross-tolerance effects that occur when alcohol use is combined with benzodiazepine use. Cross-tolerance occurs when one builds up a tolerance for one drug, while also building up a tolerance for another drug in the same class of drugs. Cocaine and amphetamines act on the dopamine and serotonin systems, producing the intense rush and resulting intense lows, reinforcing compulsive use. These two drugs also share the same receptors and are also cross-tolerant.

addictive personality type

Although no known addictive personality type exists, associated psychodynamic factors, such as lack of tolerance for frustration and pain, lack of impulse control, lack of success in life, lack of affectionate and meaningful relationships, low self-esteem, lack of self-regard, and strong propensity for risk-taking behaviors, have been identified. These characteristics and perceptions are thought to contribute to the substance user's need to self-medicate in order to mitigate against uncomfortable feelings and emotional pain. Sadock, Sadock, and Ruiz (2015) suggest that alcohol may be used to control panic, opioids to diminish anger, and methamphetamines to relieve depression.

(e-cigarettes)

Although the rate of cigarette smoking among children, adolescents, and adults is tapering off, the use of electronic cigarettes (e-cigarettes) is exploding. E-cigarettes are advertised as safe, although they do contain nicotine. Many brands of e-cigarettes contain other health hazards as well. When tested, some brands of e-cigarettes contained toxic chemicals such as formaldehyde and acetaldehyde. One study found that "high-voltage use released enough formaldehyde-containing compounds to increase a person's lifetime risk of cancer five to 15 times higher than the risk caused by long-term smoking" (Thompson, 2015). Even though there is the consideration that e-cigarettes may help heavy smokers cut down or stop smoking, the concern is the nicotine in e-cigarettes that might become habit-forming for our youth and for young adults.

Paranoia

Any intense and strongly defended irrational suspicion can be regarded as paranoia. Paranoid ideas cannot be corrected by experiences and cannot be modified by facts or reality. Because people who are paranoid are unable to trust the actions of those around them, they are usually guarded, tense, and reserved. To ensure interpersonal distance, they may adopt a superior, hostile, and sarcastic attitude. A common defense used by paranoid individuals to maintain self-esteem is to disparage others and dwell on the shortcomings of others.

Phase III Maintenance Phase Health Promotion

Clinical Focus: Social, vocational, and self-care skills Learning or relearning Identification of realistic expectations Adaptation to deficits interventions: Attention to details of self-care, social, and work functioning Direct intervention with family and/or employers Cognitive and social skills enhancement Medication maintenance Continued psychoeducational intervention with families as needed Involvement with recovery groups and strategies Professional Collaboration: Group therapists Social, vocational, and self-care providers Family, employer, community support staff

Phase II: Stabilization Phase Adaptive Plateau

Clinical Focus: Understanding and acceptance of illness Intervention: Support and teaching Medication teaching and side effect management Direct assistance with situational problems Identification of prodromal and acute symptoms and signs of relapse Continued psychoeducational work with families as needed Professional Collaboration: Community support staff Family support groups Group therapists and self-help groups Practitioners of behavioral therapies using educational models and cognitive restructuring

Second-Generation Antipsychotics (SGAs)/Atypical Agents

Clozapine (Clozaril, Leponex), Risperidone (Risperdal, Risperdal Consta), Paliperidone (Invega) Invega Sustenna, Olanzapine† (Zyprexa Relprevv), Quetiapine† (Seroquel, Seroquel XL)Ziprasidone (Geodon) Injectable (short acting), Iloperidone (Fanapt),Asenapine (Saphris), Lurasidone HCl (Latuda),Brexpiprazole (Rexulti) Ach, Anticholinergic side effects (dry mouth, blurred vision, urinary retention, constipation, agitation); ECG, electrocardiogram; EPS, extrapyramidal symptoms; IM, intramuscular; NMS, neuroleptic malignant syndrome; ODT, orally disintegrating tablet; OH, orthostatic hypotension; PO, by mouth; Sed, sedation; TD, tardive dyskinesia; WBC, white blood cell count. ∗ An orally disintegrating tablet (ODT) is a fast-disintegrating tablet or wafer that dissolves on the tongue. ∗∗ At this writing, researchers are working on paliperidone (Invega Sustenna), a long-term injectable that can be given once every 3 months. † The safety of olanzapine at dosages >20 mg/day and quetiapine at dosages >800 mg/day has not been evaluated in clinical trials. ‡ Ziprasidone use may carry a risk for QT prolongation in patients with preexisting cardiac disease, low electrolyte levels, or family history of QTc syndrome, or in patients taking other drugs that cause long QTc profiles.

Nursing Diagnosis: (schizophrenia) Other

Compromised family coping Impaired parenting Caregiver role strain Deficient knowledge Deficient community health Nonadherence

Heroin Intravenous,∗ smoking physical complications

Constipation Dermatitis Malnutrition Hypoglycemia Dental caries Amenorrhea

Phase I Clinical Focus

Crisis intervention Safety Acute symptom stabilization sub-acute: Social supports Stress and vulnerability assessment Living arrangements Daily activities Economic resources

Phase I (Acute)

During phase I the clinical focus is on crisis intervention, acute symptom stabilization (medication), and safety. Since hospitalization is used mostly for crises (e.g., suicide), alternatives such as partial hospitalization, halfway houses, and day treatment centers are frequently used as cost-effective alternatives to hospitalization. Acute-phase interventions include acute psychopharmacological treatment (psychobiological intervention); supportive and directive communications; limit setting (milieu management and counseling); and psychiatric, medical, and neurological evaluation.

cerebral cortex

Especially vulnerable to alcohol-related damage is the cerebral cortex, which is responsible for higher brain functions, problem solving, and decision making.

Caffeine Ingestion physical complications

Gastroesophageal reflux Peptic ulcer Increased intraocular pressure in unregulated glaucoma Tachycardia Increased plasma glucose and lipid levels

Positive Symptoms(schizophrenia)

Hallucinations: Hears voices that others do not hears voices telling him or her to hurt self or others (command hallucinations) Distorted Thinking Not Based on Reality: Persecution: Thinks that others are trying to harm self Jealousy: Thinks that spouse or lover is being unfaithful, or thinks others are jealous of self when they are not Grandeur: Incorrectly thinks he or she has powers and talents or is someone powerful or famous Reference: Believes that all events within the environment are directed at or hold special meaning for self Looseness of association: Shows loose association of ideas Clang association: Uses words that rhyme in a nonsensical fashion Echolalia: Repeats words that are heard Mutism: Does not speak Circumstantiality: Delays getting to the point of communication because of unnecessary and tedious details Concrete thinking: Unable to abstract; uses literal translations concerning aspects of the environment

Nicotine Smoking, chewing physical complications

Heavy, chronic use associated with: Emphysema Cancer of the larynx and esophagus Lung cancer Peripheral vascular diseases Cancer of the mouth Cardiovascular disease Hypertension

Narcotics (e.g., Heroin), PCP, Cocaine or Crack, Methamphetamines Intravenous∗ Physical Complications

Human immunodeficiency virus (HIV) Acquired immunodeficiency syndrome (AIDS) Hepatitis Bacterial endocarditis Renal failure Cardiac arrest Coma Seizures Respiratory arrest Dermatitis Pulmonary emboli Tetanus Abscesses—osteomyelitis Septicemia

What Does This Actually Mean?

If you're a woman and you drink two medium-sized glasses of wine (8 oz.) every night after work, you're over the limit before you even reach the weekend. For men, one night out with friends during which you drink three beers and a couple of shots would put you over the daily limit. Do this just twice in 1 week and you're probably drinking close to 10 to 14 standard drinks in just 2 days, depending on the size and strength of the drinks (Aronson, M. (2015). Patient information: Alcohol use—when is drinking a problem?

Nursing Diagnosis: (schizophrenia) positive symptoms

Impaired environmental interpretation syndrome Defensive coping Disturbed personal identity ∗Impaired environmental interpretation syndrome Impaired verbal communication

Marijuana Smoking, ingestion physical complications

Impaired lung structure Chromosomal mutation—increased incidence of birth defects Micronucleic white blood cells—increased risk of disease as a result of decreased resistance to infection Stroke Possible long-term effects on short-term memory

Phase I professional collaboration

Inpatient treatment team Residential alternative to hospitalization Community crisis intervention Internist Neurologist sub-acute: Social work department Health and human services Day treatment or a variety of community support services

Psychiatric Comorbidity

It seems that certain areas of the brain, such as the circuits in the brain that use the neurotransmitter dopamine, can affect both substance use disorders and other mental illnesses. The neurotransmitter dopamine is typically affected by addictive substances. This in part may explain the high rate of dual diagnoses (substance use disorders co-occurring with a psychiatric disorder). For example, psychiatric patients have about a 50% to 60% higher chance of having alcohol use disorder than those in the general population (Black & Andreasen, 2014). According to Sadock, Sadock, and Ruiz (2015), some studies indicate that up to 50% of addicts have a co-occurring psychiatric disorder. Other studies claim that 35% to 50% of individuals with a substance use disorder meet the criteria for antisocial personality disorder (Sadock, Sadock, & Ruiz, 2015). Among the highest percentage of people with psychiatric disorders with a co-occurring substance use disorder are those with schizophrenia and depression. Other common co-occurring psychiatric disorders include acute and chronic cognitive impairment disorders, attention deficit disorder, borderline personality disorder, and anxiety disorders.

neologisms

Made-up words that typically have only meaning to the individual who uses them. making up ur own language basically

Phase III

Maintenance Phase Health Promotion

Phase II (Stabilization) and Phase III (Maintenance)

Once the acute symptoms are somewhat stabilized, if the individual was hospitalized, he or she is discharged to the community, where appropriate treatment can be carried out during the maintenance and stabilization phases. Effective long-term care of an individual with schizophrenia relies on a three-pronged approach: medications, nursing interventions, and community support. Family psychoeducation, as well as community support, is a key component of effective treatment. Phase II and phase III interventions include the following: Health teaching includes teaching: • Patient and family about the disease • Patient and family about medication management • Cognitive and social skills enhancement • Strategies to minimize stress and to control anxiety levels Health promotion and maintenance: • Help patient and family identify signs of relapse and take preventive steps • Improve deficits in self-care, social, and work functioning • Encourage participation in nonthreatening activities • Encourage social relationships • Encourage family interaction

acute phase: schizophrenia

Onset or exacerbation of symptoms with loss of functional abilities -florid positive and negative symptoms; cognitive symptoms -patient is usually in hospital during this phase

Cocaine, Methamphetamines Intravenous, ∗ intranasal, smoking physical complications

Perforation of nasal septum (when taken intranasally) Respiratory paralysis Cardiovascular collapse Hyperpyrexia Intracerebral hemorrhage

schizotypal personality disorder

Person has several traits that causes interpersonal problems, including inappropriate affect, paranoid/magical thinking, off beliefs -typically does not have hallucinations

schizoaffective disorder

Psychotic disorder featuring symptoms of both schizophrenia and major mood disorder.

PCP Ingestion physical complications

Respiratory arrest

Nursing Diagnosis: (schizophrenia) Negative symptoms

Social isolation Impaired social interaction Risk for loneliness Ineffective relationship Risk for compromised human dignity Chronic low self-esteem Risk for self-directed violence Risk for suicide Ineffective coping Bathing self-care deficit Dressing self-care deficit Self-neglect Constipation Deficient diversional activity

Phase II

Stabilization Phase Adaptive Plateau

Inhalants Sniffing, snorting, bagging (inhalation of fumes from a plastic bag), huffing (placing an inhalant-soaked rag over the mouth) physical complications

Tachycardia Dysrhythmias Nervous system damage Hearing loss Bone marrow damage Suffocation caused by displacing oxygen in the lungs, leading to respiratory depression/arrest

Anabolic-Androgenic Steroids

The effects of anabolic-androgenic steroids (AASs) can be serious and permanent if an individual does not stop taking these drugs (e.g., liver damage, renal failure, heart attack, elevated cholesterol levels, and serious depression, especially in withdrawal). Some of the untoward effects of steroid use in men are shrinking of the testicles, infertility, development of breasts, and increased risk for prostate cancer. Women often show male pattern baldness, changes in menstrual cycle, growth of facial hair, and a deepening of the voice. Stunting of growth attributable to premature skeletal maturation and accelerated pubertal changes can occur in adolescents using AASs (NIDA, 2012a). Research also suggests that users may experience paranoia, jealousy, delusions, and violent mood swings (NIDA, 2012a).

hippocampus

The hippocampus, which is the center of memory and learning, is also affected, as well as the cerebellum, which helps coordinate our movements. Specific disorders that involve the central nervous system include Wernicke's encephalopathy and Korsakoff's psychosis.

Route of Ingestion

The route of drug administration influences medical complications and affects addictive potential. For example, intravenous drug users have a higher incidence of infections, venous sclerosis, and testing positive for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Intranasal users may have sinusitis and a perforated nasal septum. Smoking a substance (e.g., marijuana, nicotine) increases the likelihood of respiratory tract problems. Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure that lasts a short period of time, necessitating taking more of the drug more often to recapture the high. Refer to Table 19-1 for a description of physical complications associated with various classes of drugs and their routes of administration.

dissociative fugue

The sudden loss of memory for one's personal history, accompanied by an abrupt departure from home and the assumption of a new identity

Neurobiology and Neurotransmitters

There are many different chemicals in the brain that function as neurotransmitters, but a small handful do most of the work. Neurotransmitter Functions Affected Drugs that Affect Functions Inhibitory Neurotransmitters Gamma-aminobutyric acid (GABA) -Anxiety, memory, anesthesia -Sedatives, tranquilizers, alcohol Serotonin -Mood (depression/ anxiety/impulsivity), sleep quality, sexual desire, appetite -MDMA (ecstasy), LSD, cocaine Acetylcholine -Formation of memories, verbal and logical reasoning, and the ability to concentrate. Involved in stimulation of muscles, memory, motivation, and attention -Nicotine Endorphins and Enkephalin (Endogenous opioids) -Analgesia, sedation, substances involved with reward/ punishment, mood -Heroin, morphine, prescription painkillers (oxycodone) Excitatory Neurotransmitters Dopamine -Dopamine neurotransmitters can be both inhibitory or excitatory Pleasure and reward, movement, attention, memory, and energy. -Dopamine is critical in the early stage of addiction -Virtually all drugs of abuse directly or indirectly augment dopamine (e.g., cocaine, PCP, opiates, marijuana, etc.) Norepinephrine (noradrenaline) -Elevated levels can cause anxiety. Low levels associated with low energy, decreased ability to focus, and problems with sleep and memory. Stimulants (e.g., cocaine, methamphetamine) Epinephrine (also called adrenaline) -Excitatory neurotransmitter involved in arousal and alertness Stimulants Glutamate -Neuron activity (increased rate), learning, cognition, memory. It can also facilitate maintaining addiction and inducing its long-term effects. -Ketamine, phencyclidine, alcohol

acute dystonia

Three of the more common EPS are acute dystonia (severe spasms of the muscles of the tongue, head, and neck; fixed upward deviation of the eyes; and severe back spasms that arch the trunk forward and thrust the head and lower limbs backward)

Negative Symptoms(schizophrenia)

Uncommunicative, withdrawn, makes no eye contact Preoccupied with own thoughts Expresses feelings of rejection or aloneness (lies in bed all day, positions back to door) Is stigmatized for diagnosis of schizophrenia Talks about self as "bad" or "no good" Feels guilty because of "bad thoughts"; extremely sensitive to real or perceived slights Shows lack of energy (anergia) Shows lack of motivation (avolition), unable to initiate tasks (social contact, grooming, and other aspects of daily living)

Who Is a Heavy Drinker?

When we really start to think about drinking, we need to know what "too much" actually looks like. Heavy drinking, which is often called "at risk" drinking, is alcohol consumption that exceeds the recommended daily limits: • For men: More than 4 standard drinks on any 1 day, or more than 14 standard drinks in any 1 week. • For women: More than 3 standard drinks on any 1 day, or more than 7 standard drinks in any 1 week.

Schizophrenia

a psychological disorder characterized by delusions, hallucinations, disorganized speech, and/or diminished, inappropriate emotional expression -dopamine levels are too high -affects the individuals thinking, language, behavior, emotions, and ability to perceive reality accurately.

Nicotine

addiction is high in all groups of people with substance dependence, as well as in those with psychiatric mental health issues. At least 20% of the U.S. population meet the criteria for tobacco use disorder, and nicotine causes 443,000 deaths a year (Burchum & Rosenthal, 2016). Nicotine is the psychoactive drug in tobacco, and nicotine dependence is considered the most common form of addiction in the United States today. In the United States, one in five deaths results from tobacco use and on average, smokers die 10 years earlier than nonsmokers

Genetic factors

are believed to account for between 40% and 60% of a person's vulnerability to addiction (Black & Andreasen, 2014). It is 300generally accepted that genetic factors are an important risk factor for psychoactive drug use. For example, alcoholism is three to four times more likely to occur in children of alcoholic parents than in children of nonalcoholic parents. Currently, molecular genetic techniques are being employed to define alcohol-related genes. Recent research has identified specific gene alleles believed to be risk factors for cannabis dependence (Hand, 2016). There is also potential evidence for genetic factors that can link the comorbidity of cannabis dependence with major depression and risk of schizophrenia (Hand, 2016).

Treatment-Relevant Dimensions of Schizophrenia: cognitive symptoms

are perhaps the most debilitating symptoms. Cognitive symptoms include impairment in memory; disruption in social learning; and inability to reason, solve problems, or focus attention. The greater the degree of negative and cognitive symptoms, the more likely it is that the person will be unable to function on a job, engage in social activities, and care for self adequately and safely.

Echolalia

automatic and immediate repetition of what others say is the pathological repeating of another's words by imitation and is often seen in people with catatonia. Echolalia is the counterpart of echopraxia, mimicking the movements of another, which is also seen in catatonia.

substance addiction

brain starts craving this substance

hallucinations

can be defined as sensory perceptions for which no external stimulus exists. When they occur, "they are vivid and clear, with the full force and impacts of normal perceptions, and not under voluntary control" (APA, 2013, p. 87). The most common types of hallucination are the following: • Auditory—hearing voices or sounds (most common hallucination in schizophrenia) • Visual—seeing persons or things (possible, more probable in delirium or dementia) • Olfactory—smelling odors (most common in temporal lobe epilepsy) • Gustatory—experiencing tastes (rare, part of delusion of persecution, e.g., tasting poison in food) • Tactile—feeling bodily sensations (common in cocaine/amphetamine/alcohol withdrawal)

conversion disorder

changing emotional difficulties into a loss of a specific voluntary body function

Central Nervous System Stimulants

cocaine/nicotine

Blood alcohol level (BAL)

determines level of intoxication and tolerance

Delusions

false beliefs, often of persecution or grandeur, that may accompany psychotic disorders are most often defined as false fixed beliefs that cannot be corrected by reasoning. They may be simple beliefs or part of a complex delusional system. In schizophrenia, delusions are often loosely organized and may be bizarre. Most commonly, delusional thinking involves the following themes: ideas of reference, persecution, grandiosity, somatic sensations, jealousy, and control.

Delusions

fixed false beliefs not corrected by reasoning -thought broadcasting-thoughts are being thrown at them, from a tv, radio, dental fillings, they will sometimes try to protect themselves by covering their crown.

substance abuse

for the single purpose of altering the mood, emotion, consciousness, it habitual

hallucination vs illusion

hallucination- seeing things w/o external stimuli illusion- misinterpreting external stimuli A hallucination is a false sensory perception for which no external stimulus exists. Hallucinations are different from illusions in that illusions are misperceptions or misinterpretations of a real experience. For example, a man sees his coat hanging on a coat rack and believes it to be a bear about to attack him. He does see something real but misinterprets it.

Catatonia

in terms of immobility, the essential feature of catatonia is extreme abnormal motor behavior. In fact, patients who exhibit either extreme motor agitation or extreme psychomotor retardation (with mutism, or even stupor) are rare when catatonia is present with a diagnosis of schizophrenia. During the very withdrawn phase, the person does not move or eat, thus becoming vulnerable to pressure ulcers, contractures, and malnutrition. Patients may exhibit bizarre posturing, such as holding arms or legs rigid or bent at severe angles for a long period of time. Also, waxy flexibility may occur; for example, when a leg or arm is placed in an awkward position by someone else, the patient will hold that position for an uncomfortable length of time. Another trait of catatonia is stereotyped behavior or following a routine obsessively, such as continually arranging and rearranging objects. Other characteristics of catatonia are extreme negativism and resistance. Speech patterns may include echolalia (persistently repeating the words of others), and echopraxia (mimicking the movements or gestures of others) may also be present. During the extreme motor activity phase, the patient may run about ceaselessly and without purpose, leading to exhaustion, cardiac difficulties, or physical collapse. The onset of catatonia is usually abrupt, and the prognosis is favorable. Fortunately, with the advances in pharmacotherapy and improved individual management, severe catatonic symptoms are rarely seen today.

Nicotine

in the form of cigarette smoking remains the greatest single cause of preventable illness and premature death (Burchum & Rosenthal, 2016). Smoking tobacco can cause chronic lung disease, coronary heart disease, chronic obstructive pulmonary disease (COPD), and stroke, as well as cancer of the lungs, larynx, esophagus, mouth, and bladder. Approximately 50% of Americans who do not smoke are exposed to secondhand smoke (SHS). A comprehensive scientific report concluded that there is no risk-free level of exposure to SHS. Secondhand smoke is responsible for heart disease and lung cancer in nonsmoking adults, is extremely harmful to infants and children (CDC, 2014b; U.S. Department of Health and Human Services [USDHHS], 2006), and is thought to be related to sudden infant death syndrome (SIDS). There is evidence that cigarette smoke contains more than 7000 chemicals, and about 70 of those cause cancer (American Cancer Society, 2015).

Specific disorders that involve the central nervous system

include Wernicke-Korsakoff's syndrome, which is two separate entities but both are caused by thiamine (B1) deficiency. In the Western world, thiamine deficiency is characteristically associated with chronic alcoholism, because chronic alcoholism affects thiamine uptake and utilization. Wernicke-Korsakoff's syndrome can also be caused by malabsorption syndrome, AIDS, or chronic infection, poor nutrition, eating disorders, or the effects of chemotherapy.

alcohol withdrawal delirium (DTs)

initial symptoms within 48 to 72 hours after the last drink, peak on day 4, and last 2 to 3 days. dangerous medical condition person is confused, agitated, combative

Addiction

is a chronic, relapsing brain disease characterized by compulsive drug-seeking behavior motivated by cravings, despite harmful consequences, and by long-lasting changes in the brain. Tolerance and withdrawal are no longer mandatory for the definition of addiction in the DSM-5 (APA, 2013); although within many classes of drugs they do occur and can be part of the criteria for making a diagnosis.

Suicide

is a high risk factor among individuals who abuse alcohol and/or drugs and is about 10% higher than in the general population and about 15% higher than in those who abuse or are addicted to alcohol (Sadock, Sadock, & Ruiz, 2015). Substance use increases the risk of suicide among children, adolescents, adults, and older adults.

Wernicke's encephalopathy

is a neurological disorder marked by acute/subacute confusional states, abnormal eye movements (nystagmus), and unsteady gait (ataxia). Wernicke's encephalopathy is a medical emergency that causes life-threatening brain disruption but if treated is often reversible. If not treated it can lead to chronic dementia and/or death.

Dopamine

is a neurotransmitter that plays a major role in all addictions, but the concepts that apply to dopamine can relate to other neurotransmitters as well. Dopamine is the brain chemical present in regions of the brain that regulate motivation, emotion, cognition or learning, and the ability to experience pleasure and pain.

depersonalization

is a nonspecific feeling that a person has lost his or her identity; the self is different or unreal. People may be concerned that body parts do not belong to them, or they may have an acute sensation that the body has drastically changed. For example, a woman may see her fingers as snakes or her arms as rotting wood. A man may look in a mirror and state that his face is that of an animal.

Tardive dyskinesia (TD)

is an EPS that usually appears after prolonged treatment, is more serious, and is not always reversible. Tardive dyskinesia consists of involuntary tonic muscular spasms that typically involve the tongue, fingers, toes, neck, trunk, or pelvis. This potentially serious EPS is most frequently seen in women and older patients. Tardive dyskinesia varies from mild to moderate and can be disfiguring or incapacitating. Early symptoms of tardive dyskinesia are fasciculations of the tongue or constant lip smacking. These early oral movements can develop into uncontrollable biting, chewing, or sucking motions; an open mouth; and lateral movements of the jaw. In many cases, the early symptoms of tardive dyskinesia disappear when the antipsychotic medication is discontinued. In other cases, however, early symptoms are not reversible and may progress. No proven cure for advanced tardive dyskinesia exists. The National Institute of Mental Health developed a brief test for the detection of tardive dyskinesia referred to as the Abnormal Involuntary Movement Scale (AIMS). The AIMS test is one of the tools nurses and physicians can use to detect TD. The AIMS test can be obtained on the Internet.

Neuroleptic malignant syndrome (NMS)

is estimated to occur in about 0.2% to 1% of patients who have taken antipsychotic agents. It is believed that the acute reduction in brain dopamine activity plays a role in the development of NMS, which is fatal in about 10% of cases. It usually occurs early in the course of therapy but has been reported in people after 20 years of treatment. Neuroleptic malignant syndrome is characterized by decreased level of consciousness; greatly increased muscle tone; and autonomic dysfunction, including hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic agent, management of fluid balance, reduction of temperature, and monitoring for complications. Mild cases of neuroleptic malignant syndrome are treated with bromocriptine (Parlodel), whereas more severe cases are treated with intravenous dantrolene (Dantrium) and even with electroconvulsive therapy in some cases. See Table 17-10 for the side effects, onset, and nursing measures for EPS and NMS.

Marijuana

is still the most commonly used illicit drug in the United States and is exceeded only by caffeine, alcohol, and nicotine as the most commonly used psychoactive substance by adults in the United States (Sadock, Sadock, & Ruiz, 2015). Cannabis is a major part of the youth culture and, as of 2012, 11.4% of eighth-graders, 28% of tenth-graders, and 36.4% of twelfth-graders use marijuana (Miech et al., 2015). A New Zealand study found that teenagers who were heavy users of marijuana were likely to lose 8 IQ points. During the time young users' brains are rapidly building new connections and maturing, marijuana is known to play a role in interfering with the connections between neurons. The damage to these connections is irreversible

Derealization

is the false perception by a person that the environment has changed. For example, everything seems bigger or smaller, or familiar surroundings have become strange and unfamiliar.

Anhedonia

is the inability to feel pleasure. It's a common symptom of depression as well as other mental health disorders. Most people understand what pleasure feels like. They expect certain things in life to make them happy.

clang association

is the meaningless rhyming of words, often in a forceful manner ("On the track ... have a Big Mac ... or get the sack"), in which the rhyming is often more important than the context of the word. This form of speech pattern may be seen in individuals with schizophrenia; however, it may also be seen in people in the manic phase of a bipolar disorder or in individuals with a cognitive disorder, such as Alzheimer's disease or HIV-related dementia.

Projection

is the most common defense mechanism used by people who are paranoid. For example, when paranoid individuals feel self-critical, they experience others as being harshly critical toward them. When they feel angry, they experience others as being unjustly angry at them, as if to say, "I'm not angry, you are!"

affect

is the observable behavior that expresses a person's emotions. In people with schizophrenia, affect may not coincide with inner emotions, and there is a prominent lack of emotional response. Affect can usually be categorized in one of three ways: flat or blunted, inappropriate, or bizarre. A flat affect (immobile facial expression or a blank look) or blunted affect (minimal emotional response) is commonly seen in schizophrenia. Inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. For example, a young man breaks 251into laughter when told that his father has died. Bizarre affect is especially prominent in the disorganized form of schizophrenia and includes grimacing, giggling, and mumbling to oneself. Bizarre affect is marked when the patient is unable to relate logically to the environment.

extrapyramidal symptoms (EPS)

of akathisia, dystonia, parkinsonism, and tardive dyskinesia (TD). TD is perhaps the biggest concern of all the EPS since it is irreversible and can be socially isolating. Other adverse reactions include anticholinergic effects, orthostasis, and lowered seizure threshold. 1. Pseudoparkinsonism: masklike facies, stiff and stooped posture, shuffling gait, drooling, tremor, "pill-rolling" phenomenon 5 hours to 30 days 1. Alert medical staff. An anticholinergic agent (e.g., trihexyphenidyl [Artane] or benztropine [Cogentin]) may be used. 2. Acute dystonic reactions: acute spasms of tongue, face, neck, and back (tongue and jaw first) • Opisthotonos: tetanic heightening of entire body, head and belly up • Oculogyric crisis: eyes locked upward A few hours to 5 days 2. Diphenhydramine hydrochloride (Benadryl) IM/IV or benztropine IM/IV. Relief occurs in minutes. Prevent further dystonias with any anticholinergic agent (see Table 17-11). Experience is very frightening. Take patient to quiet area and stay with him or her until medicated. 3. Akathisia: Distressing motor inner-driven restlessness (e.g., tapping foot incessantly, rocking forward and backward in chair, shifting weight from side to side). 2 hours to 60 days 3. Reduced dosage or switched to a low-potency antipsychotic. Treat with anticholinergic, benzodiazepine, or beta blockers. 4. Tardive dyskinesia (TD)∗ • Facial: protruding and rolling tongue, blowing, smacking, licking, spastic facial distortion, smacking movements • Limbs • Choreic: rapid, purposeless, and irregular movements • Athetoid: slow, complex, and serpentine movements • Trunk: neck and shoulder movements, dramatic hip jerks and rocking, twisting pelvic thrusts Months to years 4. No known treatment. Discontinuing the drug does not always relieve symptoms. Occurs in 15% to 20% of patients taking these drugs for more than 2 years. Eating difficulties; malnutrition can occur because of tongue and mouth involvement. Frequent screening with the AIMS test can help detect TD in early stages.

first-generation antipsychotics (FGAs)/conventional drugs

only treats positive symptoms costs more than 2nd The first-generation antipsychotics/conventional drugs were being less widely used because of their troubling side effects; however, the FGAs are being revisited because of the concern over the higher incidence of metabolic side effects with the SGAs and because FGAs are more cost-effective. The National Institute of Mental Health has conducted groundbreaking clinical antipsychotic trials of intervention effectiveness (CATIE) studies to compare continuation rates of the FGAs and SGAs. Important findings so far are that people quit taking older medications because of side effects, and that they quit taking the newer ones because of weight gain. Although there are many uncomfortable and some serious side effects with the FGAs, they are generally safe and when taken regularly can greatly reduce the rate of relapse.

disorganized thinking

reflects the degree to which disorganized speech, disorganized behavior, or inappropriate affect is present. The presence of good verbal memory is one cognitive indicator that the individual will eventually be able to function within the community because verbal memory is necessary to acquire psychosocial skills and retention of these skills.

cognitive style

the way an individual deals with information while making decisions

Second-Generation Antipsychotics/Atypical Agents

treats both negative and positive symptoms less likely to get EPS The second-generation antipsychotics first emerged in the early 1990s with clozapine (Clozaril). Unfortunately, clozapine produces agranulocytosis in 1% to 2% of people who take it. Agranulocytosis occurs when the bone marrow does not make enough of a certain type of mature white blood cells (neutrophils), exposing a person to increased infections and fever, and can be fatal. Clozapine also increases the risk for seizures. This drug is rarely used today except for treatment-refractory patients. The SGAs developed after clozapine do not share these same disadvantages. Although there does seem to be increasing use of first-generation antipsychotics (FGAs), the SGAs are still often chosen as first-line antipsychotics.

Cocaine

users may experience extreme weight loss and malnutrition, myocardial infarction, brain damage, and stroke. Methamphetamine users are likely to suffer from hypothermia, seizures, brain damage, kidney damage, stroke, and death.

When does substance related addiction start to become a problem?

when the person becomes disabled from it

substance use disorder

which covers 10 classes of substances. The DSM-5 defines substance use as "A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of 11 items, occurring within a 12-month period" (APA, 2013, p. 483). The 10 classes of psychoactive substances in the DSM-5 are alcohol, caffeine, cannabis, hallucinogens (phencyclidine or similarly acting arylcyclohexylamines), other hallucinogens such as lysergic acid diethylamide (LSD), inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and other or unknown substances.

Alcohol withdrawal

within 8 hours symptoms appear

The Neurobiology of Addiction

• Brainstem—controls basic functions such as heart rate, breathing, and sleeping. • Limbic system—contains the brain's "reward circuit" that links brain structures controlling feelings of pleasure, thereby motivating us to repeat behaviors that cause pleasure and support survival (such as eating and sex), and stimulating creative pleasures such as viewing or participating in art and playing or listening to music. The limbic system is involved in the perception of both negative and positive emotions. Along with positive activation for feelings of pleasure, the limbic system is also activated by alcohol and drug use, explaining many of the negative moods common in those with addictions. • Cerebral cortex—includes areas that process information from our senses (seeing, hearing, feeling, taste, and touch). One of the most important areas in the cerebral cortex is the forebrain, often referred to as the frontal cortex. The frontal cortex allows us to think, plan, solve problems, and make decisions.

Other common delusions observed in schizophrenia include the following:

• Thought broadcasting—belief that one's thoughts can be heard by others (e.g., "My brain is connected to the world mind. I can control all heads of state through my thoughts.") • Thought insertion—belief that thoughts of others are being inserted into one's mind (e.g., "They make me think bad thoughts.") • Thought withdrawal—belief that thoughts have been removed from one's mind by an outside agency (e.g., "The devil takes my thoughts away and leaves me empty.") • Delusion of being controlled—belief that one's body or mind is controlled by an outside agency (e.g., "There is a man from darkness who controls my thoughts with electrical waves.")