Mental Health Exam 3

Schizophrenia
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Schizophrenia
Schizophrenia spectrum disorders are disorders that share features with schizophrenia. These disorders are characterized by psychosis - the altered cognition, altered perception, and/or inability to determine what is or is not real.
Prodromal phase of schizophrenia
before diagnosis, phase is exemplified by clear evidence of deterioration, social withdrawal, role functioning impairment, peculiar behavior, inappropriate affect, and unusual experiences
Comorbities in Schizophrenia
Substance use disorder (EtOH and marijuana use)
Anxiety
Depression
Suicidal ideation

Physical Illnesses: more common among people with schizophrenia than the general population. 3.5 times greater risk of premature death. On average, they die more than 20 years prematurely.

Increased risk of poor health maintenance behaviors, poor nutrition, substance use, medication effects, poverty, limited access to healthcare, and reduced ability to recognize/respond to signs of illness.
Schizophrenia risk factors
Genetics
Neurobiological (dopamine abnormalities)
Brain structure abnormalities

Environmental Stressors: toxins (solvents used in dry cleaning, can be found in water pipes too); also urban areas with high-crime rates.

Psychological Stressors: sexual abuse, social adversity, moving to a new culture at a young age, psychological trauma or social defeat.
Phases of Schizophrenia
Prodromal
Acute
Stabilization
Maintenance or residual
Delusions
false beliefs despite a lack of evidence to support them. Often persecutory, grandiose, or religious.
clang associations
choosing words based on their sound, often rhyming.
neologism
pt has a different or nonexistent meaning for words, it can be a made up word.
associative looseness
(speech) looseness of association from haphazard and illogical thinking where concentration is poor and they loosely associate their feelings. "I need to get a band-aid. My friend was talking about AIDs. Friends talk about french fries but how can you trust the French?"
Word Salad
most extreme form of associative looseness. Jumble of words that are meaningless to the listener.
Echolaliapathological repeating of another's words, can be due to inability to generate speech of their own.Tangentalitywandering off topic or going off on tangents and never reaching the pointFlight of ideasmoving rapidly from one thought to the next, making it difficult for others to follow the conversationEchopraxiamimicking the movements of anotherthought insertionthe often uncomfortable belief that someone else has inserted thoughts into the patient's brainCommand hallucinationsAn individual hearing voices that direct the person to take action. **may be dangerous and need to be evaluated carefullycognitive deficits of schizophreniaConcrete thinking: impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. Impaired memory, impaired information processing, impaired executive function (difficulty reasoning, setting priorities, comparing options, placing things in logical groups etc).anosognosiaA patient's inability to realize that he or she is ill, which is caused by the illness itself.Outcomes in phase 1: acute schizophreniaSAFETY patient stabilizationOutcome in phase 2: stabilization (schizophrenia)focus on patient understanding of illness and treatment, achieving optimal medication and psych treatment, controlling or coping symptoms.Outcome in phase 3: maintenance (schizophrenia)focus on maintaining and increasing symptoms control and insight. Measures during this phase include adhering to treatment, preventing relapse, maintaining and increasing independence.Planning for schizophreniaPhase I: Acute - hospitalization is indicated if pt is at risk for harm to self or others. Even if they are refusing to eat etc. Phase II: Stabilization - provide patient and family education, support, and skills training. Incorporates interpersonal, functional, coping, healthcare, shelter, educational and vocational strengths. Relapse preventionfirst generation antipsychoticstraditional dopamine (D2 receptor) antagonists known as typical antipsychotics or neuroleptics (ie Haldol (haloperidol)) -Primarily affect positive symptoms (hallucinations, delusions) with little effect on negatives.Second Generation: (SGAs) antipsychoticsserotonin (5-HT2A receptor) and dopamine (D2) receptor antagonists (ie Clozaril (clozapine)). Other drugs are antagonists of high dopamine activity, but agonists in areas of low dopamine (ie Abilify (aripiprazole)) -Treat positive and helps negative symptoms ..though improvement in negative and cognitive symptoms is usually less.Long-acting Antipsychotics (LAIs)-Administered IM. -Only need to be administered every 2-4 weeks. -Dosing protocols - verify them. -Downside is lack of flexibility and patients may feel they have less control or are being coerced.Antipsychotics: general considerations-Take 2-6 weeks to reach desired effects. -Patient-specific dosage adjustment required. -Recommended monotherapy - using one medication at a time. -Polypharmacy is avoided as much as possible. -They are not addictive, but should not be abruptly discontinued. -Discontinuation syndrome: nausea, dizziness, tremors, insomnia, electric shock like pains, anxiety. -Unlikely to be lethal from overdose. -Lesser known sisk is impaired swallowing due to effects on dopamine blockage or sedation.Anticholinergic toxicityDry mouth, decreased peristalsis, mydriasis (or prolonged pupil dilation), non reactive pupils, hot dry skin, hyperpyrexia without sweat, tachycardia, agitation, unstable vital signs, delirium, seizure, repetitive motor movements. Hold meds, emergency cooling, medical transfer, consult prescriber!Metabolic syndromeA syndrome marked by the presence of usually three or more of a group of factors (as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and high fasting levels of blood sugar) that are linked to increased risk of cardiovascular disease and Type 2 diabetes. **common side effect from second generation antipsychoticsanorexia nervosaRefusal to maintain a minimally normal weight for height and express extreme fear of gaining weight. Loss of intake is rare. Many restrict while some binge-eat and purge. This can require long-term treatment including brief inpatient stays, outpatient therapy, medication. Combo of group, individual, family therapy provides greatest chance of successful outcome.Anorexia Nervosa: ComorbiditiesIncludes bipolar, depressive and anxiety disorders. Obsessive compulsive disorder is prevalent in some, particularly the restrictive type. Alcohol and substance use disorders are associated with the binge-eating/purging type.Anorexia Nervosa: Risk FactorsNeurobiological: altered serotonin function can cause dysregulation of appetite, mood and impulse control in eating disorders. Psychological: currently believe it is based on learned behavior that has positive reinforcement. Other theories as well. Environmental: Cultural influence of self-concept and satisfaction with body size. No research has been able to fully explain why 0.3-3% of population develops an eating disorder.Refeeding syndromeCan lead to circulatory collapse Too much TPN too fast. Monitory VS, B/P, Skin color, extremity temps, cap refill and weight **Stop TPNInterventions to consider for anorexia nervosa●Acute Care ●Psychosocial Interventions ●Pharmacological Interventions ●Complementary and Integrative Therapies ●Health Teaching and Health Promotion ●Teamwork and Safety ●Advanced Practice Interventions: Psychotherapy,Concept: Addiction Diag: Insomnia-Can lead to reduced tolerance and increased chance of engaging in ETOH, drug use, cannabis use...Concept: Sleep Diagnosis: Insomnialack of sleep causes increase in b/p, decreased immunity, increased weight, decreased coordinationConcept cognition Diag: insomniadecreased ability to retain information sluggish thinking is off timing is off forgetfulConcept: Psychosis Diag: insomniaPresent like having mental breakdown Delusions, paranoia, alternate reality, incoherantConcept: Psychosis Diag: ETOHHallucinations in detox Symptoms of psychosis: delusions, paranoia, altered reality, hallucinationsConcept: Cognition Diag: ETOHIntoxication can lead to blackouts, no memory Detox: Hyperfocused on reconnection of neurons too fast leading to decreased memory, decreased ability to make informed decisionsConcept: Addiction Diag: ETOHETOH is #1 addiction self medicatingConcept: Sleep Diag: ETOHDon't stay in REM sleep- leads to no restorative sleepConcept: nutrition Diag: ETOHDecreased B vitamins, folic acid, vit K. *clotting and absorption concernsConcept: Psychosis Diag: DelirumDecreased cognitive function Hallucinations DelusionsConcept: cognition Diag: deliriumImpaired ability to: understand recall remember Very fearfulConcept: sleep Diag: deliriumDecreased sleep patterns Leads to insomnia type symptomsConcept: nutrition Diag: DeliriumAltered nutrition Forgets to eat Can't cook Paranoid that they are being poisonedConcept: psychosis Diag: anorexiaSeverely malnourished which leads to classic psychosis symptoms such as delusions, hallucinations, altered realityConcept: Cognition Diag: anorexiaSlower ability to respond Decreased ability to recall Short term memory is off Input is delayed Increased suicide riskConcept: Nutrition Diag: AnorexiaSevere malnourishment Risk of refeeding syndrome!Concept: sleep Diag: anorexiaMore sleep because body is using more energyConcept: psychosis Diag: schizophreniaDelusions Paranoia Visual/auditory hallucinations Altered sense of realityConcept: Cognition Diag: SchizophreniaDecreased ability to concentrate Altered cognition due to psychosis symptoms Needs constant redirection and orientation Assistance with ADL's Decreased memory, learning, and ability to thinkConcept: nutrition Diag: schizophreniaForget to eat Can't cook paranoid that they are being poisonedSymptoms of ManiaElevated mood Increased energy and overactivity Decreased need for sleep or food Irritable Rapid thinking/speech Grandiose plans and beliefs lack of insight Distractabilityhypomanic episodeless severe and less disruptive version of a manic episode that is one of the criteria for several mood disordersnursing goals for a manic patientDevelop a relationship based on empathy and trust Ensure patient remains free from injury or harm Assist to decrease agitation and hyper activity Promote understanding and management of manic symptoms Promote engagement in social network Promote healthy behaviors- exercise, healthy eating etc. support and promote self-care activities for patient and familyPressured speechrapid, frenzied, or loud, disjointed communicationCircumstantial speechadding unnecessary details when communicating with others; person eventually gets to the pointTangential speecha communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversationClang associationsthe stringing together of words that rhyme but have no other apparent linkLoose associationsdisorganized thinking that jumps from one idea to another with little or no evident relation between the thoughtsGrandiose delusionsbeliefs that one holds special power, unique knowledge, or is extremely importantpersecutory delusionsa patient's belief that someone is persecuting her or him or that the person is a special agent/individualCommon nursing diagnosis for maniaRisk for injury Risk for violence Sleep deprivation Impaired cognition impaired concentration self-care deficit impaired socializationSerotonin syndrome s/shyperactivity or restlessness tachycardia -> cardiovascular shock Fever -> hyperpyrexia Elevated BP Altered mental status Irrationality, mood swings, hostility Seizures Myoclonus, incoordination, tonic rigidity Abdominal pain, diarrhea, bloating Apnea -> deathSerotonin syndrome interventions• Remove offending agent(s) • Initiate symptomatic treatment: • Serotonin-receptor blockade with *cyproheptadine, methysergide, propranolol* • Cooling blankets, chlorpromazine for hyperthermia • Dantrolene, *diazepam* for muscle rigidity or rigors • Anticonvulsants • Artificial ventilation • Induction of paralysisPt and family teaching: SSRI'sCommon side effects: fatigue, nausea, diarrhea, dry mouth, dizziness, tremor, sexual dysfunction Interactions with Digoxin and Warfarin, and some OTC meds. Potential for drowsiness- do not operate heavy machinery LFT's, renal panel and CBC should be checked frequently. Do NOT stop abruptly Reasons to stop SSRI: Increase in depression or SI Rash/Hives Tachycardia ST Difficulty urinating Fever/malaise Anorexia/weight loss Initiation of hyperactive behavior Severe HAFoods that interact with MAOI's**Foods high in Thiamine** avocados, figs, ripe banana, smoked or cured meats, pickled herring, smoked salmon, all cheeses, yeast products, some beers and wines, Chianti, soy sauce, chocolate, fava beans, ginseng, caffeinated beveragesPatient and Family Teaching: MAOI's-Avoid foods high in thiamine -Avoid OTC meds- especially cold remedies -Go to ER immediately if severe HA occurs -BP should be monitored for the first 6 weeks -After MAOI is stopped, keep on diet regimen for 14 more days -Tell patient to avoid Asian restaurants. Foods high in thiamine may be used to prepare such dishesCommon side effects with TCA's-Dry mouth -Constipation -urinary retention -blurred vision -hypotension -cardiac toxicity -sedation **use cautiously in older adults with cardiac disorders elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorder, liver and kidney dysfunctionDrugs that interact with MAOIsOTC medications for colds, allergies, or congestion; TCAs, narcotics, antihypertensives, amine precursors, sedatives, general anesthetics, stimulantsLithium toxicityN/V/D, thirst, polyuria, lethargy, sedation, fine hand tremor, renal toxicity, goiter, hypothyroidism Severe signs: Convulsions, oliguria, and death can occurBipolar Disorder Risk FactorsNeuropathic changes in the amygdala: abnormal levels of the neurotransmitters norepinephrine, serotonin, dopamine, glutamate, and gamma-aminobutyric acid (GABA)in this area Evidence suggests that levels of norepinephrine, serotonin, anddopamine are decreased in people with depression. Increasing GABA levels and decreasing glutamate levels can improve or stabilize mood. Brain trauma injuries •Genetic issues such as 18 Q minus and other chromosomal deficits •Environmental factors: adverse childhood events (ACE) can cause a more severe form of the illness. Children who have genetic and biological risk of dev. Bipolar are most vulnerable in bad environments. •Stress can trigger mania and depression in adults •Psychological factors: truly unknown. Theories were once used to explain the disorder ...rapid cycling bipolar disorderdiagnosis given when a person has four or more cycles of mania and depression within 1 yearComorbidities typical with MDD•Substance abuse disorder •Anxiety disorders •Borderline personality disorder •Oppositional defiant disorder •Social phobia and other phobias •Seasonal affective disorderOutcome Identification with Bipolar Disorder•Be well hydrated •Maintain stable cardiac status •Maintain/obtain tissue integrity •Get sufficient sleep/rest •Demonstrate thought self-control with aid of staff or medication •Make NO attempt at self harmAnhedonialack of interest in previously pleasurable activities /inability to feel happyAnergialack of energy and physical passivityEtiology of depressionA. genetics play a role as shown in twin studies, serotonin level low B. Biochemical: serotonin circuit dysfunction and norepinephrine and other neurotransmitters decrease or increase with stress C. Hormonal: neuroendocrine and hyperactivity of the hypothalamic-pituitary-adrenal-cortical axis. D. Inflammation: physical and psychologic injury can cause systemic inflammation in the body... those with depression can have elevated inflammation markers (C-reactive protein and interleukin-6)Nursing Diagnosis: MDDRisk for Self-Directed violence 2. Disturbed thought process 3. Chronic low self esteem 4. Spiritual distress 5. Impaired social interaction 6. Self-Care deficit