Schizophrenia Worksheet Term 2

Schizophrenia Worksheet Mental Health Nursing Watch the Schizophrenia documentaries at the links below prior to progressing through the assignment. 1. Explain what a “negative” symptom of schizophrenia is, and identify at least three negative symptoms of schizophrenia that “Swan” might be experiencing. - Lessening or absence of normal behaviors and functions related to motivation and interest, or verbal/emotional expressions o Alogia  poverty of speech o Anergia  lack of energy o Anhedonia  inability to feel pleasure o Apathy  lack of interest or enthusiasm o Avolition  lack of motivation 2. Explain what a “positive” symptom of schizophrenia is, and identify at least three positive symptoms of schizophrenia that “Swan” might be experiencing. - Highly exaggerated ideas, perceptions or actions so the person can’t tell what’s real from what isn’t. o Hallucinations o Thought disorders o Delusions o Neologisms o Concrete thinking o Loose associations o Echopraxia o echolalia 3. Give the definition for each of the following types of delusional thinking: a. Thought broadcasting  belief that a person’s thoughts can be heard or known by those around them b. Thought insertion  delusion that ones thoughts are not ones own but belong to someone else, and have been inserted into ones mind c. Grandeur  delusion that they are wonderful, successful, more important than others, or even miraculous; exaggerated importance d. Ideas of reference  sense of self-reference in one’s immediate environment e. Persecution  singled out for harm by others 1 f. Somatic delusions  body is changing in unusual way 4. What diagnostic screening is important to evaluate “Swan”? - Positive and negative syndrome scale (PANSS) - Brief psychiatric rating scale (BPRS) 5. What are the most important interventions to implement for “Swan”? - Personal safety and safety of those around him - Structured safe environment o Milieu therapy 6. Which class of antipsychotic medications are considered first-line therapy for schizophrenia? - Atypical antipsychotics (second generation) 7. If “Swan” was to receive treatment, he would need to be monitored closely. How could this be encouraged and carried out? - One-on-one monitoring - Inpatient treatment Case study progression: The information from this point forward is not part of the documentary and is made up for completion of the educational objective. Let’s say the physician has decided to treat “Swan” with olanzapine (Zyprexa). 8. Explain common side effects of atypical antipsychotics. - Weight gain - EPS - Decreased libido - Diabetes - Drowsiness - Photophobia - Anticholinergic effects - seizures 9. Describe the following: a. Tardive dyskinesia  involuntary neurological movement disorder that causes repetitive movements in the face, neck, arms, and legs. IRREVERSIBLE b. Neuroleptic malignant syndrome  life-threatening reaction characterized by fever, altered mental status, muscle rigidity, and altered blood pressure. Case Study Progression: “Swan” has decided to be admitted to the psychiatric unit. You go in to give him his medication. He speaks to you in fragmented sentences. “Is that a bird? The little flowers jump up and down. What says the moon?” Before you can say anything, he asks, “Do 2 you see that bird over my bed? She is telling me not to leave this room. If I move, she will swoop down and try to peck at my eyes. Be careful!” 10. Is he having an illusion or a hallucination? Explain you answer. - Visual hallucination  the stimuli is internally present and can only be perceived by the patient. 11. When “Swan” says, “If I move, she will swoop down and try to peck at my eyes. What type of delusion is this? - Persecutory 12. How will you respond to “Swan”? (Ensure that your answer contains therapeutic communication) - “I don’t see or hear anything, but you seem to be frightened. You are safe.” SCHIZOPHRENIA MANIFESTATIONS Identify the term that describes each example. Resource: ATI chapter 15, textbook 1. religiosity Kneels to pray in front of a water fountain; prays during group therapy and during other group activities. (e.g., God is awesome, he tells me to shine my light on everyone, every day.) An excessive demonstration of, or obsession with religious ideas and behavior. Because individuals vary greatly in their beliefs and level of spiritual commitment, this manifestation is often difÏcult to assess. The individual with schizophrenia may use these ideas in an attempt to provide rational meaning and structure to the demonstrated behavior. This type of preoccupation in this vein may therefore be considered a manifestation of the illness. However, clients who derive comfort from these types of beliefs should not be discouraged from employing this means of support. An example of this manifestation is the individual who believes the voice he or she hears is God and incessantly searches the Bible for interpretation. 2. Concrete thinking Literal interpretations of the environment, represents a regression to an earlier level of cognitive development. (e.g., When looking at photos of a wheelbarrow, a rake, and a hoe, a concrete thinker points to a shared characteristic instead of describing the general function, “They all have wooden handles,” rather than, “You can use 3 them all in the garden or both the orange and apple are round.) 3. Paranoia Individuals with this type of manifestation have extreme suspiciousness of others and of their actions or perceived intentions (e.g., “I won’t eat this food. I know it has been poisoned or refuses to eat the food that comes on a tray, saying, “They are trying to poison me.”) 4. Autism A withdrawal inward into one’s own fantasy world. (e.g., Mr. Jones does not respond when spoken to as if he is disconnected from the world.) The psychotic person invents new words that are meaningless to others but have symbolic meaning to them (e.g., “She wanted to give me a ride in her new uniphorum” or “When I get out of the hospital, I’m going to buy me a sprongle.”) An individual’s inability or refusal to speak (e.g., The nurse is trying to admit Mr. Gregory but he just sits there and does not talk.) This manifestation in adults has a wide differential and can be difÏcult to evaluate. It can be further defined as being an absence or reduction of speech, either voluntary or avolitional, and is typically associated with catatonia. A condition in which the client with schizophrenia places body parts in bizarre or uncomfortable positions. Once placed in position, the arm, leg, or head remains in that position for long periods, regardless of how uncomfortable it is for the client. For example, the nurse may position the client’s arm in an outward position to take a blood pressure measurement. When the cuff is removed, the client may maintain the arm in the position in which it was placed to take the reading. (e.g., Roger keeps his arm in the position the nurse left it after taking his blood pressure. He assumed this position for hours.) The individual has an exaggerated feeling of importance, power, knowledge, or identity (e.g., “I am Jesus Christ” or “When I speak, presidents and kings listen.”) Doing the opposite of what is requested (e.g., Tommy screws his eyes up when the nurse asked him to open them). Additionally, the person may altogether fail to cooperate (e.g., the person stops eating) Involuntary excessive continuation or repetition of a single response, idea, or activity. (e.g., Mr. Leonard continues to draw cats even though the art therapists asked everyone to move on to drawing flowers.) Thinking is characterized by speech in which ideas shift 5. neologisms 6. Mutism (on purpose) 7. Waxy flexibility 8. Delusion of grandeur 9. Negativism 10. Perseveration 11. Associative looseness 4 from one unrelated subject to another. The individual is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent. (e.g., “We wanted to take the bus, but the airport took all the trafÏc. Driving is the ticket when you want to get somewhere. No one needs a ticket to heaven. We have it all in our pockets. “I’m going to the circus. Jesus is God. The police are playing for keeps.”) 12. Magical thinking The person believes that his or her thoughts or behaviors have control over specific situations or people (e.g., a mother who believes if she scolds her son in any way he will be taken away from her). This type of thinking is common in children (e.g., “Step on a crack and you break your mother’s back.” “An apple a day keeps the doctor away”). “We can’t close the drapes, for if we do, the sun won’t shine.” 13. Anergia A deficiency of energy. The individual with schizophrenia may lack sufÏcient energy to carry out activities of daily living or to interact with others. (e.g., Michael sits on the sofa slumped down, watching television unwilling to participate in the Bingo game.) Sudden stopping in the train of thought or in the midst of a sentence. (e.g., The nurse asks Calvin why he was admitted. Calvin says, “I am here because I was hearing voices that were telling me to ………………”, he stops speaking suddenly and without explanation in the middle of his sentence.) Choice of words is governed by sounds. This manifestation often takes the form of rhyming. (e.g., “It is very cold. I am cold and bold. The gold has been sold.” Or “Test, test, this is a test. I do not jest; we get no rest.”) Affect is inappropriate when the individual’s emotional tone is incongruent with the circumstances (e.g., a young woman who laughs when told of the death of her mother). The client with schizophrenia often demonstrates an indifference to or disinterest in the environment. The bland or flat affect is a manifestation of the emotional apathy. (e.g., Mr. Morton was very uncaring when asked about his willingness to participate in counseling.) The retreat to an earlier level of development. This manifestation is a primary defense mechanism of schizophrenia, it is a dysfunctional attempt to reduce 14. Thought blocking 15. Clang association 16. Inappropriate affect 17. apathy 18. Regression 5 19. Word salad 20. echolalia 21. Circumstantiality anxiety. It provides the basis for many of the behaviors associated with schizophrenia. (e.g., In response to stressful situation, Laura begins to suck her thumb and soils clothing.) A group of words that are put together randomly, without any logical connection (e.g., “Most forward action grows life double plays circle uniform” or “Get by for anyone just to answer fortune cookies.”) The client with schizophrenia may repeat words that he or she hears. This is an attempt to identify with the person speaking. (e.g., The nurse says, “John, it’s time for lunch.” The client may respond, “It’s time for lunch, it’s time for lunch” or sometimes, “Lunch, lunch, lunch, lunch”). Meaningless repetition of another person’s spoken words. The individual delays in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met but only with numerous interruptions by the interviewer to keep the person on track of the topic being discussed. Thought and speech associated with excessive and unnecessary detail that is usually relevant to a question and an answer is ultimately given. (e.g., The nurse asked Tara, “How old was your mother when she died?” Tara responds by saying, “Accidents happen every day, people get into too many accidents when driving in cars, too many people die in accidents, my mother died when she was 52.”) The individual feels threatened and believes that others intend harm or persecution toward him or her in some way (e.g., “The FBI has ‘bugged’ my room and intends to kill me.” “I can’t take a shower in this bathroom; the nurses have put a camera in there so that they can watch everything I do.” “If the FBI finds me here, I’ll never get out alive.”) False sensory perceptions not associated with real 23. Hallucination  auditory external stimuli, may involve any of the five senses. (most common) When this manifestation in the auditory sense, which is the most common of all, a patient will stop talking in midsentence, tilt head to side, they will appear to be listening to something. (e.g., I hear the voices telling me to jump off the roof of my mother’s house.) The unstable self-identity of an individual with 24. Depersonalization schizophrenia may lead to feelings of unreality (e.g., feeling that one’s extremities have changed in size, or a Derealization  mental state where people and objects around sense of seeing oneself from a distance). 22. Persecutory delusion 6 may seem unreal, and other words an alteration in perception of external world causing sufferers to perceive it as unreal, distant, distorted, or falsified A person may have thoughts that feel foreign to him and 25. Thought insertion seem as if they have been inserted by an outside force or person (e.g., John has been finding himself thinking of highly offensive comments about women that he would never say out loud. He is convinced that his cell phone is somehow implanting these thoughts in his mind. 26. Alogia When conversing with a visitor, the client only mumbles or responds vaguely to questions (e.g., Mr. Jones in a soft whisper responds, “Yes”, when asked if he is able to tell the nurse about the voices he was hearing yesterday.) The individual has a false idea about the functioning of 27. Somatic delusion his or her body (e.g., “I’m 70 years old and I will be the oldest person ever to give birth. The doctor says I’m not pregnant, but I know I am” or the client believes his left arm is going to fall off.) 28. Flight of ideas Over productive speech characterized by rapid shifting from one topic to another and fragmented ideas. (e.g., I was a free-spirited little girl, my favorite commercial is the one with the Burger King in it, I think my feet are going to fall off because one toe is bigger than the other, look what do you think? I am sure Biden is the best President ever, he is going to save the world. I love daisies, they are the best flower and symbolize innocence, purity, loyalty, patience, and simplicity.) All events within the environment are referred by the 29. Delusions of reference psychotic person to him- or herself (e.g., “Someone is trying to get a message to me through the articles in this magazine [or newspaper or TV program]; I must break the code so that I can receive the message”). This manifestation is less rigid than delusions of reference. An example of this manifestation is irrationally thinking that one is being talked about or laughed at by other people (e.g., The client is sharing an elevator with strangers and believes they are talking about her. Whenever Jenny sees a blue car, she believes that God is sending her a message to leave school early.) 30. Avolition 31. Delusion of control OR The client is tasked with taking a shower but is not motivated to brush his teeth (e.g., LotÝe washed her face and then sat on the toilet and had to be told to brush her teeth.) The individual believes certain objects or persons have 7 influence 32. Tangentiality 33. Illusion control over his or her behavior (e.g., “The dentist put a filling in my tooth; I now receive transmissions through the filling that control what I think and do”). A disturbance in thought process that causes the individual to relate excessive or irrelevant detail that results in never reaching the essential point of a conversation or the desired answer to a question, similar to circumstantiality, but the person never returns to the central point and never answers the original question. (e.g., A therapist poses the question, “How was your week?” Gloria responds with, “When I was five, my cat was killed.” When the therapist asks about the cat, Gloria then begins to discuss her religious beliefs.) Misperceptions or misinterpretations of real external stimuli (e.g., The wind was blowing outside during the storm and Thomas thought he heard a little girl crying.) 34. Anhedonia The inability to experience pleasure (e.g., When asked if he wanted to go the movie something he has always enjoyed in the past, Derrick says, no, he would rather stay home.) 35. Thought broadcasting A person may believe that other people can hear or read her thoughts (e.g., Tamika has been avoiding her friends because she believes they can read her thoughts, especially when she is angry or thinking about something embarrassing. Tamika was at the Starbucks when someone cut in front of her while standing in line. Tamika thought to herself, “I hope he gets run over by a truck”, then looked around to see who had heard her.) 36. Delusion False personal beliefs that are inconsistent with the person’s intelligence or cultural background (e.g., Albert believes his boss is drugging the employees by adding a substance to the water cooler that makes people work harder.) 37. Poverty of speech Minimal speech, rare to have spontaneous speech (e.g., Mr. Isaacson barely responds when questioned about his illness.) 38. Nihilistic delusion The individual has a false idea that the self, a part of the self, others, or the world is nonexistent (e.g., “The world no longer exists.” “I have no heart.”). Purposely imitates movements made by others (e.g., When observing the patient next to him touch his nose Jenner involuntarily begins to touch his own nose.) 39. Echopraxia 40. Positive symptoms are things you develop; negative symptoms are things you lose. 8 Identify the following as positive or negative: ____P____delusions ____P____hallucinations ____N____blunted affect ___N__avolition _____N___anhedonia ___N_____poverty of thought ___P_____bizarre behavior ____P____disorganized speech _____N___loss of speech ____N____social withdrawal 41. Name the hallucination: False perceptions of the sense of touch, often of something on or under the skin. One specific form is formication, the sensation that something is crawling on or under the skin. These are false perceptions of sound. Most commonly they are of voices, but the individual may report clicks, rushing noises, music, and other noises. Command hallucinations may place the individual or others in a potentially dangerous situation. “Voices” that issue commands for violence to self or others may or may not be heeded by the psychotic person. These are the most common type in psychiatric disorders. A false perception of taste. Most commonly, they are described as unpleasant tastes. These are false visual perceptions. They may consist of formed images, such as of people, or of unformed images, such as flashes of light. False perceptions of the sense of smell. TACTILE AUDITORY GUSTATORY VISUAL OLFACTORY a. Auditory b. Visual c. Tactile d. Gustatory e. Olfactory 42. Name the delusion: REFERENCE The queen is speaking to me on the TV and wants me to come to see her. 9 GRANDIOSE CONTROL I am the queen and you all are my subjects. The Son of Sam murdered believed the neighbor’s dog was telling him to kill young couples in cars. PERSECUTION The man in the ofÏce down the hall is out to get him. I have to get him before he gets me. SOMATIC I have cancer, but no one will believe me. I have had ten exploratory surgeries over the last 15 years, but the doctors cannot find it. a. Persecution b. Control c. Somatic d. Reference e. Grandiose 43. First generation antipsychotics are more helpful with positive or negative symptoms? - positive 44. Second generation antipsychotics are more helpful with positive or negative symptoms? - Both positive and negative symptoms Case Study Read the following case study and fill in the blanks with the description of the information that is underlined and numbered in the text. Answers may be selected from the following list: anergia apathy autism body rocking echolalia echopraxia delusion of reference magical thinking anhedonia nihilistic delusion regression paranoia Situation: Sandra was a 37-year-old woman who was picked up by the police after she ran away from her parents’ home. Sandra has had a history of schizophrenia for 17 years. She has had numerous hospitalizations. Police were called when Sandra began wandering through a local park screaming at everyone, “I know you are possessed by the devil!” During her initial interview, she is very guarded and suspicious of the nurse (1). (1) paranoia “I can read your mind, you know.” (2) (2) magical thinking Sandra is assigned to a room and oriented to the unit. At 5:00 p.m., The nurse says to Sandra, “Sandra, it’s time for dinner.” Sandra responds, “time for dinner; time for dinner; time for dinner.” (3) (3) echolalia The nurse notices that each time she wipes her mouth with her 10 napkin at dinner, Sandra does the same. (4) Sandra’s mother reports that Sandra stopped taking her medicine about a month ago, stating, “When you don’t have a brain, (5) you don’t need brain medicine.” Shortly afterward, she became totally despondent, taking no pleasure in activities she had always found enjoyable. (6) She stayed in her room, sitÝng on her bed moving back and forth in a slow, rhythmic fashion.(7) Sometimes she would not even get up to go to the bathroom, and instead soiled herself in an infantile manner. (8) She seemed to experience a total lack of energy for usual activities of daily living.(9) On the unit, Sandra appears disinterested in everything around her. (10) She sits alone, talking and laughing to herself. (11) At one point she hears a laugh track on TV and states, “They’re laughing at me. I know they are.” (12) (4) echopraxia (5) nihilistic delusion (6) anhedonia (7) body rocking (8) regression (9) anergia (10) apathy (11) autism (12) delusion of reference Sandra’s anxiety level starts to rise. She begins to pace the floor. Her agitation increases and she finally picks up a chair and hurls it toward the nurses’ station, yelling, “The devil says all blonds must be annihilated!” a. What would be Sandra’s priority nursing diagnosis? - Risk for self-harm b. What medication would you expect the physician to order for Sandra? - Haloperidol IM c. For what adverse effects would you be on the alert with this drug? - Extrapyramidal side effects - Anticholinergic effects - Diarrhea - Nausea 11