Psych Chapter 24: Schizophrenia

Side effects: Lurasidone (Latuda)

Atypical EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 3 Weight gain: 3

Side effects: Quetiapine (Seroquel)

Atypical EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 3 Weight gain: 4

Side effects: Iloperidone (Fanapt)

Atypical EPS: 1 Sedation: 3 Anticholinergic: 2 OH: 3 Weight gain: 3

Positive symptoms: Word salad

Group of words that are put together randomly and without any logical connection

Side effects: Clozapine (Clozaril)

Atypical: Lots of sedation, anticholinergic, weight gain, OH EPS: 1 Sedation: 5 Anticholinergic: 5 OH: 4 Weight gain: 5

Side effects: Aripprazol (Abilfy)

Atypical: OH EPS: 1 Sedation: 2 Anticholinergic: 1 OH: 3 Weight: 2

Side effects: Asenapine (Saphris)

Atypical: Sedation, OH, weight gain EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 3 Weight gain: 4

Side effects: Olanzapine (Zyprexa)

Atypical: weight gain EPS: 1 Sedation: 3 Anticholinergic: 2 OH: 2 Weight gain: 5

Substance/Medication Induced Psychotic Disorder

Hallucinations and delusions directly attributed to intoxication/withdrawal

Tourettes

Haloperidol, pimozide

Positive symptoms: Paranoia

Individuals have extreme suspiciousness of others and of their actions or perceived intentions

Positive symptoms: Mutism

Individuals inability or refusal to speak

Nursing implications: Reduction of seizure threshold (typical)

CLOZAPINE Closely observe clients with history of seizures

Nursing implications: Agranulocytosis

CLOZAPINE More common with typical Observe for sour throat, fever, malaise

Nursing implications: Urinary retention

Instruc client to report difficulty, monitor intake and output

Delusional disorder: Grandiose

Irrational ideas regarding their own worth, talent, knowledge, power, leads to the assumption of the identity of a diety or religious leader

Delusional disorder: Persecutory

Most common, individual believes they are being persecuted or malevolently treated Plotted against, cheated, spied on, followed, poisoned

Family education

Nature of illness, management of illness, support persons

Disabled family coping

Negelctful care of client in regard to basic human needs or illness treatment, extreme denial or prolonged overconceern regarding illness, depression, hostility, aggression

Antipsychotic drugs

Neuroleptics or major tranquilizers Typical: first generation Atypical: newer novel antipsychotics

Mutism

No or very little verbal response

Interventions: Disturbed sensory perception

Observe for signs of hallucinations, ask "are you hearing the voices again?" Avoid touching before warning client Attitude of acceptance, "What do you hear the voices saying to you?" Help client understant connection between increased anxiety and presence of hallucinations Distract client Voice dismissal

Catatonic disorder

Symptomatology is evidenced from medical history, physical examination, laboratory findings

Side effects: Perphenazine and Thiothixene (Navane) and Trifluoperazine

Typical: EPS EPS: 4 Sedation: 2 Anticholinergic: 2 OH: 2 No weight gain

Side effects: Pimozide (Orap)

Typical: EPS, anti cholinergic EPS: 4 Sedation: 2 Anticholinergic: 3 OH: 2 No weight gain

Side effects: Chloropromazine

Typical: Sedation/anticholinergic EPS: 3 Sedation: 4 Anticholinergic: 3 OH: 4 No weight gain

Side effects: Fluphenazine and Haloperidol (haldol)

Typical: high EPS EPS: 5 Sedation: 2 Anticholinergic:2 OH:2 No weight gain

Side effects: Loxapine and Prochlorperazine

Typical: little EPS EPS: 3 Sedation: 2 Anticholinergic: 2 OH: 2 No weight gain

Side effects: Thioridazine

Typical: sedation, anticholinergic, OH EPS: 2 Sedation: 4 Anticholinergic: 4 OH: 4 No weight gain

Oculogyric Crisis

Uncontrolled rolling back of eyes Part of dystonia EMERGENCY: contact physician, IV benztropine mesylate (Congentin), stay with client, offer reasurance/support

Impaired home maintenance

Unsafe, unclean, disorderly

Positive symptoms: Depersonalization

Unstable self identity of individual that leads to feelings of unreality

Avoid reinforcing hallucination

Use "the voices" in stead of words like "they" "Even though I realize the voices are real to you, I do not hear any voices speaking."

Positive symptoms: Echolalia

Uses words that he or she hears, in attempt to identify with person speaking

Interactions: Atypical antipychotics

Additive hypotensive effects Additive CNS effects Additive anticholinergic effects with resperidone or paliperidone with other drugs with anticholinergic properies Additive effects of QT prolongation Decreased effects of levodopa and dopamine agonists

Predisposing anatomical abnormalities

Ventrical enlargement, cerebellar atrophy, pyramidal cell disorganization in hippocampus

Negative symptoms: Posturing

Voluntary assumption of innapropriate or bizzare postures

Action: Atypical antipsychotics

Weaker dopamine receptor antagonists More potent antagonist for serotonin type 2A receptors Antagonism for cholinergic, histaminic and adrenergic

Family education: Nature of illness

What to expect as illness progresses, symptoms, ways for family to respond to behaviors associated with illness

Interactions: Typical Antipsychotics

Additive hypotensive effects with antihypertensive Additive CNS effects whent taking with CNS depressend Additive anticholinergic effects Additive effects of QT prolongation concurrently with other drugs Haloperidol and carbamazepine = decreased theraputic effect of haloperidol increased carbamazepine

Social isolation

Withdrawal, sad dull affect, need fear dilemma, preoccupation with own thoughts, expression of feelings or rejection or of aloneness imposed by others, uncommunicative, seeks to be alone

Nursing implications: Sedation

Discuss with physician admission of med at bedtime, possible decrease in dosage, order for less sedating drug No driving or operating dangerous equipment

Side affects

Dopamine blockage causes extrapyramidal symptoms, prolactin elevation Cholinergic blockade: anticholinergic side effects Alpha adrenergic Blockage: Dizzy, orthostatic hypertension Histamine blockade: weight gain, sedation

Phases of Schizophrenia

1. Premorbid 2. Prodromal 3. Schizophrenia/Psychotic 4. Residual

Side effects: Risperidone (Risperdal)

Atypical EPS: 1 Sedation: 2 Anticholinergic: 1 OH: 3 Weight gain: 4

Extrapyramidal effects

Acute dyskinesias and dystonic reactions, tardive dyskinesia, Pseudoarkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome, oculogyric crisis

Side effects: Ziprasidone (Geodon)

Atypical EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 2 Weight gain: 2

Risk for violence

Aggressive body language, verbal aggression, catatonic excitemnt, command hallucinations, rage reactions, history of violence, overt and aggressive acts, goal directed destruction of objects in environment, self destructive behavior, active/aggressive suicide acts

Positive symptoms: Delusion of reference

All events within environment are referred by the psychotic person to themselves, "Someone is trying to communicate with me through the TV."

Nurse must monitor for following side effects

Anticholinergic: dry mouth, blurred vision, constipation, urinary retention Nausea, GI upset Skin rash Sedation Orthostatic hypertension Photosensitivity Hormonal effects Amenorrhea Weight gain ECG changes Reduces seizure threshold Agranulocytosis EPS Tardive dyskinesia

Atypical Antipsychotic Agents

Aripprazol (Abilfy) Asenapine (Saphris) Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) weight gain

Side effects: Paliperidone (Invega)

Atypical EPS: 1 Sedation: 2 Anticholinergic: 1 OH: 3 Weight gain: 2

Action: Typical antipsychotis

Block postsynaptic dopamine receptors in basal ganglia, hypothalamus, limbid system, brainstem and medulla. Inhibition of dopamine mediated transmission Affinity for cholinergic alpha 2 adrenergic and histamine receptors

Typical Antipsychotic Agents:

Chloropromazine Fluphenazine Haloperidol (Haldol) Loxapine Perphenazine Pimozide (Orap) Prochlorperazine Thioridazine Thiothixene (Navane) Trifluoperazine

Treatment of intractable hiccoughs

Chlorpromazine

Antiemetics

Chlorpromazine, perphenazine, prochlorperazine

Positive symptoms: Clang associations

Choice of words governed by sounds, rhyming

Negative symptoms: Waxy flexibility

Client allows body parts to be placed in uncomfortable positions, will not move it

Negative symptoms: Apathy

Client demonstrates indifference or disinterest in environment

Positive symptoms: Echopraxia

Client who purposelessly imitates movements made by others

Negative symptoms: Impaired social interaction

Cling to others, intrude personal space of others

Negative symptoms: Emotional ambivalence

Coexistence of opposite emotions towards same object, person, situation Challenging to make decisions or fulfill satisfying relationships Simultaneous need for and fear of intimacy

Family education: Management of illness

Connection of exacerbation of symptoms to times of stress, appropriate medication management, side effects, adherence, when to contact PCP, relaxation techniques, social skills training, daily living skill training

Interventions: Disturbed thought process

Convey acceptance of clients need for false belief, indicate you do not share belief Do not argue or deny belief Use reasonable doubt Reinforce and focus on reality, real events, real people Promote trust, avoid physical contact, avoid laughing, whispering, talking quietly where client can see but not hear, canned foods, mouth checks, one to one relationship activities, assertive, mater of fact, genuine

Hormonal Effects

Decreased libido, retrograde ejaculation (into bladder rather then vagina...ouch), gynecomastia Amennorrhea

Negative symptoms: Anergia

Deficiency of energy

Disturbed thought processes

Delusional thinking, inability to concentrate, impaired volition, inability to problem solve, abstract, or conceptualize, extreme suspiciousness of others, inaccurate interpretation of environment

Delusional disorder

Delusions for at least one month No hallucinations No bizarre behavior 1. Erotomanic 2. Grandiose 3. Jealous 4. Persecutory 5. Somatic 6. Mixed

Delusional disorder: Somatic

Delusions of general medical conditions

Delusional disorder: Mixed type

Delusions prominent, no single theme

Delusional disorder: Jealous

Delusions that ones sexual partner is unfaithful, without cause but will search for evidence

Positive symptoms:

Delusions, religiosity, paranoia, magical thinking, associative looseness, neologisms, concrete thinking, clang associations, word salad, circumstantiality, tangentiality, mutism, preservation, hallucinations, illusions, echolalia, echopraxia, identification and imitation, depersonalization

Self care deficit

Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, toileting

Anticholinergic side effects

Dry mouth, blurred vision, constipation, urinary retention

Positive symptoms: Identification (unconscious) and imitation (conscious)

Ego defense mechanism reflecting confusion with self identity behavior takes form of that which they see in other person

Negative symptoms: Bland or flat Affect

Emotional tone is very week, void of emotional tone

Positive symptoms: Religiosity

Excessive demonstration of or obsession with religious ideas

Nursing implications: Blurred vision

Explain symptom will subside after a few weeks Advise client not to drive car util clears Fall prevention: clear things out of way!

Phase 2: Prodromal

Extends from premorbid to psychosis Brief or long (weeks or years) Anxiety and sleep disturbances, depressed mood, fatigue Perceptual abnormalities, suspiciousness

Akinesia

Extrapyramidal effect: Muscle weakness, loss or impairment of the power of voluntary movement Symptoms appear 1-5 days after initiation of treatment, more in women, elderly, dehydrated

Akathisia

Extrapyramidal effect: feeling of inner restlessness and a compelling need to be in constant motion, fidgeting More in women, symptoms 50-60 days following start of therapy

Neuroleptic malignant syndrome

Extrapyramidal effect: fever, muscular rigidity, altered mental status, and autonomic dysfunction, BP fluctuations, deterioration of mental status to stupor or coma DISCONTINUE IMMEDIATELY: monitor vital signs, intake and output, LOC Physician may order bromocriptine (Parlodel) or dantrolene (Dantrium)

Dystonic reactions/Dystonia

Extrapyramidal effect: intermittent spasmodic or sustained involuntary contractions of muscles in the face, neck, trunk, pelvis, extremities, and even the larynx More often in men, younger then 25 years EMERGENCY: contact physician, IV benztropine mesylate (Congentin), stay with client, offer reasurance/support

Tardive dyskinesia

Extrapyramidal effect: involuntary movements of the face and jaw, bizarre facial and tongue movements, stiff neck difficulty swallowing Potentially irreversible, drug withdrawn at first sign

Acute dyskinesias

Extrapyramidal effect: involuntary muscle movements

Pseudo parkinsonism

Extrapyramidal effect: tremor, shuffling gait, drooling, rigidity, bradykinesia: slowness of initiation of voluntary movement Symptoms appear 1-5 days after initiation of treatment, more in women, elderly, dehydrated

Positive symptoms: Olfactory hallucination

False perception of smell

Positive symptoms: Gustatory hallucination

False perception of taste, mostly unpleasant

Positive symptoms: Auditory Hallucination

False perceptions of sound Voices, clicks, music, rushing noise Commands, voices Most common

Positive symptoms: Tactile hallucination

False perceptions of touch Formication: sensation something is crawling under skin

Hallucinations

False sensory perceptions not associated with real external stimuli

Positive symptoms: Visual hallucination

False visual perceptions, formed images (physical things: people) or unformed images (flashes of light)

Family education: Support services

Financial assistance, legal assistance, caregiver support groups, respite care, home health care

Nursing implications: Constipation

High fiber foods Encourage increase in physical activity Increase in fluid intake

Contraindications: Atypical antipsychotics

Hypersensitivity Comatose Severely depressed Psychosis related to neurocognitive disorder QT prolongation/cardiac arrhythmias/MI: Ziprasidone, resperidone, paliperidone, asenapine, iloperidone Temp extremes, hypertenstion

Contradictions: Typical Antipsychotics

Hypersensitivity Comatose states or when CNS depression Blood dyscrasias Parkinsons Narrow angle glaucoma LIver/renal/cardiac insufficiency Poorly controlled seizures Psychosis related to neurocognitive disorder Haloperidol, pimozide, thioridazine = causes long QT interval contradicted with other meds that cause this Extreme temperatures

Schizophreniform Disorder

Identical to schizophrenia except duration at least 1 month but less then 6 months

Disturbed sensory perception

Impaired communication ,disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in middle of sentences, tilts heat to side as if to be listening

Negative symptoms: anhedonia

Inability to experience pleasure

Volition

Inability to initiate goal directed activity

Ineffective health maintenance

Inability to take responsibility for meeting basic health practices, history of lack of health seeking behavior, lack of expressed interesed in improving health behaviors, demonstrated lack of knowledge regarding basic health practices

Negative symptoms

Inappropriate affect, bland or flat affect, apathy, emotional ambivalence, deteriorated appearance, impaired social interaction, social isolation, anergia, waxy flexibility, posturing, pacing and rocking, anhedonia, regression

Acute schizophrenia

Increased dopamine

Prenatal exposure to influenza

Increased risk of developing Schizophrenia

Positive symptoms: Delusion of Control/Influence

Individual believes certain objects or persons have control over his/her behavior

Delusional disorder: Erotomanic

Individual believes someone of a higher status is in love with them

Positive symptoms: Circumstantiality

Individual delays in reaching the point of a communication because to tedious to get there, numerous interruptions to keep individual on track of topic being discussed

Positive symptoms: Delusion of Grandeur

Individual exaggerated feelings of importance, power, knowledge or identity

Positive symptoms: Delusion of Persecution

Individual feels threatened, believes others intend to harm or persecute

Positive symptoms: Delusion of Somatic

Individual has false idea about functioning of his or her body

Positive symptoms: Nihilistic delusion

Individual has false idea that themselves, a part of themselves, others or the world is non existent

Positive symptoms:Perseveration

Individual who persistently repeats the same word or idea in response to different questions

Negative symptoms: Inappropriate Affect

Individuals emotional tone incongruent with circumstances (laugh with death of mother)

Negative symptoms: Social isolation

Individuals focus inward on themselves to the point of exclusion of the external environment

Positive symptoms: Concrete thinking

Literal interpretations of environment, regression to earlier level of cognitive development, abstract thinking very difficult

Impared verbal communication

Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization

Echopraxia

Mimicking anothers movement

Echolalia

Mimicking anothers speech

Positive symptoms: Illusions

Misperceptions or misinterpretations of real external stimuli

Mannerism

Odd, circumstatial caricature of normal actions

Selected agents used in treatment of bipolar mania

Onlanzapine, aripirazole, chlorpromazine, quetiapine, risperidone, asenapine, ziprasidone

Negativism

Opposition or no response to instructions or external stimuli

Catalepsy

Passive induction of a posture help against against gravity

Positive symptoms: Neologisms

Person invents new words, meaningless to others but have symbolic meaning to self

Positive symptoms: Tangentiality

Person never gets to point of communication, unrelated topics introduced

Negative symptoms: Deteriorated appearance

Personal grooming self care neglected, disheveled and untidy, need to be reminded

Treatment

Pharmacotherapy, psychosocial care, social skills training, family therapy

Agranulocytosis

Potentially fatal disorder, WBC count drops,

ECG changes

Prolongation of QT interval Ziprasidone, thioridazine, pimosize, haloperidol, paliperidone, iloperidone, asenapine, clozapine

Nursing implications: Hormonal effects

Provide explanation of effects, reassurance of reversibility, alternative med from physician

Negative symptoms

Reflect a diminution or loss of normal functions, inert/unmotivated

Stereotypy

Repetitive, abnormal frequent, non goal directed movements

Nursing implications: Skin rash

Report appearance to physician, avoid spilling any liquid concentrate on skin

Negative symptoms: Regression

Retreat to an earlier level of development, primary defense mechanism, attempt to reduce anxiety Basis for many behaviors associated with schizo

Nursing implications: Orthostatic hypotension

Rise slowly from lying or sitting position Monitor BP lying and standing each shift, document significant changes

Schizoaffective disorder

Schizophrenic behaviors with strong element of symptomatology associated with mood disorders (depression or mania) Presence of hallucinations/delusions that occur for at least 2 weeks in absence of major mood episode

Psychosis

Severe mental condition, disorganization of personality, social functioning decreased, loss of contact/distortion of reality, hallucinations/delusional thinking

Waxy flexibility

Slight/resistance to positioning by examiner

Negative symptoms: pacing and rocking

Slow, rhythmic, backward and forward swaying ot the trunk from the hips

Phase 1: Premorbid

Social withdrawal, irritability, shy/withdrawn, poorly in school, antisocial, enjoy solitary activity

Schizophrenia

Split mind Genetic predisposition, biochemical dysfunction, psychosocial stress NO ONE TREATMENT

Posturing

Spontaneous and active maintenance of a posture against gravity

Catatonia Specifier

Stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, sterotpy, agitation, grimacing, echolalia, echopraxia

Brief Psychotic Disorder

Sudden onset, may/may not be preceded by severe psychosocial stressor Symptoms at least a day, less then a month Turmoil, overwhelmed, impaired reality, incoherent speech, hallucinations, delusions, bizzare behavior, disorientation, catatonic features

Nursing implications: dry mouth

Sugarless candy, bum, ice, sips of water Ensure client practices strict oral hygein

Nursing implications: Photosensitivity

Sunblock lotion, protective clothing, sunglasses when outdoors

Nursing implications: Nausea

Tablets or capsules administered with food to minimize GI upset Concentrated diluted Administered with fruit juice (mixed immediately before administration

Positive symptoms: Associative Looseness

Thinking characterized by speech in which ideas shift from one unrelated subject to another Individual unaware topics are unconnected Could be incoherent

Downward Drift

Those with schizophrenia drift down social class ladder because of difficulty functioning

Indications for Antipsychotics

Treatment of schizophrenia and other psychotic disorders

Phase 3: Schizophrenia

Two or more of following for at least 1 month 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Disorganized/catatonic behavior 5. Negative symptoms (decrease emotional expression)

Delusions

false personal beliefs that are inconsistent with persons intelligence or cultural background, continues to have belief in spite of obvious proof that it is false positive symptom

Stupor

no psychomotor activity, not actively related to environment

Positive symptoms: Magical thinking

person believes his or her thoughts or behaviors have control over specific situations or people

Positive symptoms

reflect an alteration or distortion of normal mental functions