Exam 1 Mental Health Chapter 24

chapter 24 Schizophrenia Spectrum & Other Psychotic Disorders Brief psychotic D/O Schizotypal Personality D/O Schizoaffective D/O Impairments of Disorder meets criteria for personality functioning schizophrenia & BP D/O 1 day-1 month At least 1 month Delusional D/O 1-6 months At least 6 months Schizophreniform D/O Schizophrenia Psychosis -A mental state in which individual struggles to distinguish external world from interna generated perceptions -Common S/S: hallucinations (hearing voices is most common type), delusions, disorganized thinking 3!inescapable!“facts”!about!schizophrenia 1. Age at onset: almost always during late adolescense or early adulthood 2. Role of stress: onset & relapse are almost related to stress 3. Efficiency of dopamine antagonists: drugs that block dopamine receptors are therape Schizophrenia! 1% of population worldwide effected -Not characterized by a changing personality as some think; it is -Schizophrenia is a diagnostic term used to describe a major psychotic disorder charact by disturbances in theses areas: LOSSES IN LIFE >perception (hallucinations) -2/3 never marry -Few friends/social contacts >thought processes (thought derailment) -20% homeless >reality testing (delusions) -40% incarcerated >feeling (flat or inappropriate affect) -<15% hold competitive employment >behavior (social withdrawal) -Pervasive isolation, hopelessness stigma >attention (inability to concentrate) >motivation (cannot initiate or persist in goal directed activities) DSM-5!Terminology!&!criteria! -DSM-5 has abandoned the subtyping of schizophrenia 1. Two or more of the following, each present for a significant time during 1 month pe >Delusions >Hallucinations >Disorganized speech >Grossly disorganized or catatonic behavior >Negative symptoms 2. For a significant portion of the time since onset of disturbance, the level of function or more major areas (work, interpersonal relationships, self care) is markedly below of achieved before onset 3. Continuous signs of disturbances persist for at least 6 months 4. Schizoaffective D/O & depressive or BP D/O with psychotic features ruled out 5. Substance abuse & mood ruled out -Hallucinations are sensory perceptions that do not have any apparent external stimuli -Hearing voices or sounds -A type of auditory hallucination -The voice instructs the client to perform an action (to hurt self or others) -Seeing people or things -Smelling odors -Delusions are fixed, false beliefs >fixed because they cannot be changed by logical persuasion >false because they are not based in reality -Pt believes Sandra Bullock is in love w him -After medial test confirm otherwise, still insist he has cancer -Pt states “I am the president” -Woman attempts to kill her kids becau she believes the devil want her to -Experiencing tastes -A pt believes he’s dead -Feeling -Feeling bodily bodily sensations sensations -“The TV is talking about me. The gue on Oprah are making fun of me” -“I can control her with my thoughts” “They“They all think all think that I that am aI am homosexual” a homose Positive!vs.!negative!schizophrenia! -Type 1 -Type 2 -Positive in the sense that symptoms are an -Symptoms are essentially an absence or embellishment or exaggeration of normal cognition diminution of normal cognition & percep & perception -Symptoms caused by too little dopamine in -Symptoms caused by too much dopamine in mesolimbic mesocoritcal tract tract -Subtle symptoms -Has favorable response to -Responds best to -Alterations in thinking: -Apathy >delusions are false, fixed beliefs -Anxiety >concrete thinking is an inability to think abstractly -Anhedonia: loss of pleasure -Alterations in speech: -Affect: >neologisms: speech pattern characterized by >flat production of unknown words >blunted >echolalia: repeating what others say >inappropriate >clang association: “clang, tang, sang, bang, rang” >word salad: confused or unintelligible mixture of -Alogia:decreased thought & speech productiv random words & phrases -Anergia >flight of ideas -Avolition: decreased initiation of goal directe -Alterations in perception: behavior >depersonalization: nonspecific feeling that client has-Asocial behavior lost their identity -Communication difficulties >derealization: perception that the environment has -Poor rapport changed (pt believing items have shrunk) -Poverty of speech >hallucinations: auditory, command, visual -Difficulty with abstractions >boundary impairment -Alterations in behavior: >catatonia >motor retardation >motor agitation >stereotyped behaviors >echopraxia: mimicking movements of people >automatic obedience >waxy flexibility >negativism >impaired impulse control -Insomnia -Suspiciousness -Excitement -Bizarre behavior Behavior! 1. Alterations in personal relationships 1. Altered perception >decreased attention to appearance & >hallucinations ( , visual, social amenities related to introspection olfactory, tactile, gustatory, som & autism >illusions >inadequate or inappropriate communication >paranoid thinking >hostility 2. Alterations of thought >withdrawal >loose associations (pattern of spee 2. Alterations of activity in which a person’s ideas slip of >psychomotor agitation one tract onto another that is >catatonic rigidity completely unrelated >echopraxia (repetitive movement) >retardation (slowing of mental >stereotypy (repetitive acts or words) activity) >blocking >autism Bleuler’s!4!A’s! >ambivalence (love/hate) 1. Affective disturbance >delusions (fixed, false beliefs) >inappropriate, blunted, flat >poverty of speech 2. Autistic thinking >ideas of reference >preoccupation with self >mutism >little concern for external reality 3. Altered consciouness 3. Associative looseness >confusion >stringing together unrelated topics >incoherent speech 4. Ambivalence >clouding >simultaneously opposing feelings >sense of “going crazy” 4. Alterations of affect >inappropriate, blunted, flattened, labile (tone changes quickly) aff >apathy (lack of concern or interes >ambivalence >overreaction >anhedonia Etiology -Many suggest that multiple factors must be the cause -The prevailing biochemical explanation is referred to as d >excessive dopminergic activity in lambic areas causes acute positive (type 1) symp -The following are the apparent POSITIVE effects of smoking on schizophrenia: >improved cognition >improved negative symptoms >protective against EPSEs -relatives of patients with >improved auditory gaining schizophrenia have a greater >improved memory & attention incidence of the disorder than chance would allow on its own -3 specific neurostructural changes mentioned: >enlarged ventricles (ventricular brain ratios) >brain atrophy -Some researchers believe that >decreased cerebral blood flow schizophrenia can be linked to prenatal exposure to influenza; birt during the winter; prenatal exposur -Meyer & Freud believed that the seeds of mental to lead; minor malformations health & illness are sown in childhood developing during gestation; expos -Erikson & Sullivan believed a child who is deprived to viruses from house cats; of a nurturing, loving environment or is neglected complications of pregnancy particu or rejected is vulnerable to mental disturbances during L&D -To illustrate, a wealthy person might -If the family (environment in which most people be spared the brunt of some grow) is significant to the development of mental health or illness then lack of a loving stressors because of wealth, wherea a poor person, struggling to make & nurturing primary caregiver, inconsistent ends meet, confronts stressors on a family behaviors, & faulty communication daily basis patterns are thought to be responsible for mental problems later in life Special!issues!related!to!schizophrenia! -The majority of schizophrenic patients have a comorbid condition >HTN, DM, CVD, metabolic syndrome, accelerated aging -Memory, attention, & executive function are affected -Research has substantiated the state of turmoil in -Nonadherance to medications & these families exposure to significant stressors -Individuals with schizophrenia can be a disruptive are most common cause of influence on the family, particularly when they are relapse non compliant with medications -Occur in 80% of pt. within 5 year -Blame may be warranted in some families -Common stressors: >biologic -Depressive symptoms are frequently in a part of >psychosocial the psychopathology of schizophrenia >sociocultural >symptoms can occur at any time >emotional -Suicide is the leading cause of premature death -Therapeutic mandate is to minimi in patietns with schizophrenia the impact of stress on >risk factors: depression r/t schizophrenia, vulnerable individuals by: hopelessness r/t schizophrenia, being >reducing stress & stressor unemployed, & comorbid substance use accumulation >developing coping skills -Most common comorbid psychiatric condition associated with schizophrenia -Alcohol, marijuana, & cocaine account for most -Compulsive water drinking is seen of drugs abused significant # of pt. with psychosi -Major concern is hyponatremia wh can cause lightheadedness, n/v -The lack of work, inability to work, & lack of a weakness, lethargy, muscle cramp desire to work are al features of schizophrenia confusion, convulsion, coma -Adds to inability to fit in -Treatment: frequent weighing, restricted fluid intake, Na replaceme Continuum!of!care!for!people!with!schizophrenia! -Acute symptoms: short term hospitalization -Treatment resistant: long term hospitalization -Stable but chronic: day treatment -Some level of supervision needed: if family is unable, supportive housing including f a board and care home, or a nursing home Developing!a!therapeutic!nurse-patient!relationship! -Be calm when talking to patients -Accept patients as they are -Keep promises (but be careful) -Be consistent -Be honest -Do not reinforce hallucinations or delusions -Orient patient to time, person, & place -Do not touch patients without warning -Avoid whispering or laughing when pt is unable to hear conversation -Reinforce positive behaviors -Avoid competitive activities with some patients -Do not embarrass patient -For withdrawn patients, start with one-to-one interactions -Allow & encourage verbalization of feelings **Key nursing interventions** -Do not argue about delusions -Do not reinforce hallucinations -Focus on real people & real events -Be diligent in attempting to understand patients -Attempt to balance siding with inappropriate behavior & crushing a fragile ego Milieu!Management! -Set limits on disruptive behavior -Observe escalating patients frequently to interven -Modify environment to minimize objects that can be used as weapons -Be careful in stating what the staff will do if a patient acts out; however follow throug a violation occurs -When using restraints, provide for safety by evaluation the patients status of hydration nutrition, elimination, & circulation -Arrange non threatening activities that involve patients in doing something -Arrange furniture in a semicircle or around a table, which forces patients to sit with so -Help patients to participate in decision making as appropriate -Reinforce appropriate grooming & hygiene -Provide psychosocial rehabilitation - training in community living, social skills, & he -Be matter of fact when interacting with these patients -Remove disorganized pt to le -Staff members should not laugh or whsper around patient stimulating environment -Provide a calm environment; -Do not touch without warning staff should appear calm -Be consistent in activities -Maintain eye contact -Provide safe & relatively sim activities -Be patient & do not pressure pt to make sense -Do not place patients in group activities that would frustrtae them, danger their self e or overtax their abilities -Provide opportunities for purposeful psychomotor activity -Attempt to provide distracting activites & monitor TV selections -Discourage situations in which patients talk to others about their disordered perceptio -Monitor for common hallucinations that might increase the potential for pt to become dangerous -Have staff available in day room so that patients can talk to real people