Mental Health Week 6 PDF

**[Chapter 30: Personality Disorders]** Continuum of Social Responses: - Personality - A composite of behavioural traits and attitudes that identify one as an individual---the **[unique pattern of thoughts, attitudes, values, and behaviours]** that each human devel...

**[Chapter 30: Personality Disorders]** Continuum of Social Responses: - Personality - A composite of behavioural traits and attitudes that identify one as an individual---the **[unique pattern of thoughts, attitudes, values, and behaviours]** that each human develops to adapt to a particular environment and its standards - Highly functional people move freely along the continuum of social responses, recognizing and balancing their needs for intimacy with their needs for solitude. - Individuals who have personality problems struggle **[to define and meet their social needs.]** Personality Throughout the Life Cycle (1 of 5): - Personality in childhood - When an infant's needs for food, comfort, safety, and socialization are consistently met, a sense of trust and self-worth develops. - Toddlers develop object constancy: - Knowledge that a loved person or object continues to exist, even though it is out of sight. - 18months- 3 yrs, learn to separate from their caregivers and explore world - **Morality** begins to develop between 6 and 10 years of age. - Sense of self - Strong sense of right and wrong, peer interactions Personality Throughout the Life Cycle (2 of 5): - Personality in adolescence - Personality is well established. - Adolescents assert their independence from their parents. - Adolescents support each other in their struggles to assert themselves and cope with the stresses of becoming adults. - Personality in young adulthood - By young adulthood, most individuals are: - Self-sufficient - Involved in give-and-take relationships - Making occupational choices - Starting families - Growing in self-awareness - Sensitive to and accepting of the feelings of others Personality Throughout the Life Cycle (4 of 5): Personality in middle adulthood - By middle adulthood, most individuals are: - Comfortable enough with themselves and their relationships to encourage independence in others - Growing and evolving relationships with friends and significant others - Experiencing changes in demands on their time - Many experts believe that once established, personality remains stable and constant - However, adulthood offers opportunities for ind. to look within and decide - which aspects of their personality they wish to keep and develop - Which they would like to change Personality Throughout the Life Cycle (5 of 5): - Personality in older adulthood - Older persons must cope with loss and change. - Strength of their personality carries them through life's rougher times. - Do not assume that a personality change in an older person is normal. Theories Relating to Personality Disorders: - Biological theories - One's temperament (the biological bases that underlie moods, energy levels, and attitudes) is genetically linked. - Studies of families, twins, and relatives of inds with personality disorders have demonstrated that beh and personality have a strong genetic component. - Abnormalities in certain neurotransmitters, such as dopamine and serotonin, are linked to maladaptive behaviours. - The brain mechanism that connects emotions with intellect may be missing or inefficient in individuals with a personality disorder. - Behavioural theories - The behaviourist approach to psychology is that behaviour is learned - Personality disorders are the result of: - Conditioned responses caused by previous events - Unmet needs during critical developmental periods Theories Relating to Personality Disorders (continued): - Psychoanalytical theories - According to psychoanalytical theories, infants begin to discover the nature of "good/bad" and "love/hate" as the superego grows. - Superego: Embodies the restraints imposed on us by societal rules and moral values. This is in sharp contrast to the id. - If the mother responds in ways that cause frustration, distress, or pain, the child will have difficulty finding the proper fit between aggression and love. - Sociocultural theories - The causes of personality disorders are embedded in one's culture and society. - Research suggest lack of social cognition, the development of social awareness may play a role in their etiology - Lack of social structure/available social roles have been found to be a risk factor for develop of personality disorder - PD built on society\'s social and cultural stresses - Family instability, divorce, mobility isolate people Personality Disorders -- Clinical Picture: - Long-standing, maladaptive patterns of behaving and relating - Display significant challenges in self-identify and self-direction - Problems with empathy or intimacy in relationships - Difficulty owning or recognizing that difficulties are their own problems - May injure self - Characterized by continual difficulties with interpersonal relations - Some patients have maladaptive behaviours but are not given the diagnosis of mental illness. - The most important criterion is that behaviours are - "i**[nflexible and maladaptive and cause significant functional impairment or subjective distress."]** Characteristics of General Personality Disorder - All Criteria (A B C D E F) must be present (BOX 30.1) +-----------------------------------+-----------------------------------+ | **A** | A enduring pattern of behaviour, | | | deviates from person\'s culture. | | | Must be manifested in **[at least | | | TWO wa]**y | | | | | | 1.Cognition (way they perceive | | | self/others/events persistently | | | different from cultural norms. | | | | | | 2.Affect (emotional response to | | | event), range is outside cultural | | | norms | | | | | | 3.Impaired Interpersonal | | | functioning | | | | | | 4.Poor impulse control | +-----------------------------------+-----------------------------------+ | B | Persistent lack of flexibility | | | across all life situations | +-----------------------------------+-----------------------------------+ | C | Behaviour leads to significate | | | distress or impairment (social, | | | occ, other) | +-----------------------------------+-----------------------------------+ | D | Pattern of behaviour -- long | | | duration, back to adolescent | | | years | +-----------------------------------+-----------------------------------+ | E | No other mental health illness | | | can explain pattern of behaviour | +-----------------------------------+-----------------------------------+ | F | Persistent pattern of behaviour | | | not explained by med effect or | | | medical condition. | +-----------------------------------+-----------------------------------+ Personality Disorders -- 10 - The *Diagnostic and Statistical Manual of Mental Disorders,* Fifth Edition (*DSM-5*) has classified 10 separate personality disorders. - See Table 30.1 and know Clusters, Types under each cluster and main characteristics - Personality disorders are grouped into three clusters on the basis of similar behaviours: +-----------------------+-----------------------+-----------------------+ | **Cluster/Disorder | **Cluster/Disorder | **Cluster/Disorder | | A** | B** | C** | +-----------------------+-----------------------+-----------------------+ | Eccentric -- | Erratic- dramatic beh | Fearful - anxiety | | odd/strange beh | | | | | Antisocial | Avoidant | | Paranoid | | | | | Borderline | Dependent | | Schizoid | | | | | Histrionic | Obsessive Compulsive | | Schizotypal | | | | | Narcissistic | | +-----------------------+-----------------------+-----------------------+ Personality Disorders - Eccentric/Cluster A: - Eccentric cluster - Characterized by **[odd or strange behaviours ]** - Individuals with challenges in this cluster (group A) find it difficult to relate to others or to socialize comfortably. - Characteristics shared - Eccentric behaviors - Social isolation - Detachment - Unusual levels of suspiciousness - Magical thinking - Cognitive impairment - Perception distortions Personality Disorders - Eccentric/Cluster A +-----------------------+-----------------------+-----------------------+ | **Paranoid** | **Schizoid** | **Schizotypal** | +-----------------------+-----------------------+-----------------------+ | distrust and | Detachment from | | | suspiciousness, | social relationships, | | | believe people have | and a limited range | | | malicious intents | of emotional | | | | expression | | | More likely diagnosed | | | | in men | | | +-----------------------+-----------------------+-----------------------+ | **Beh you would | **Beh you would | **Beh you would | | see:** | see:** | see:** Odd beliefs or | | | | magical thinking, | | Reluctant to confide | Preference for | peculiar speech, | | in others, overly | solitude, | social anxiety that | | cautious, quick to | indifference to | does not diminish | | perceive threats | praise or criticism, | with familiarity. | | | little interest in | | | | forming close | | | | relationships. | | +-----------------------+-----------------------+-----------------------+ Personality Disorders - Erratic/Cluster B: - Read textbook for deeper insight into each type for midterm/exam - The defining characteristic is dramatic behaviour. - Characteristics shared - Respond to life demands with dramatic, emotional or erratic behavior - Problem with impulse control, emotion processing and regulation, and interpersonal difficulties - Limited insight - Resort to behaviours that are desperate or entitled, acting out, committing antisocial acts, manipulating Personality Disorders - Erratic/Cluster B: - The erratic cluster consists of four separate disorders: - Antisocial -- one of the most pressing MH issues -- read notes under slide - Borderline - Histrionic - Narcissistic - Psychopaths and sociopaths may carry criteria from some or even all four disorders within this cluster. Erratic/Cluster B: Antisocial Personality Disorder: - Prevalence-most researched, about 1.1% in community studies - Central feature: persistent pattern of disregard/violation of rights of others (\~15 years of age) and 3 more of the following - Failure to follow social norms - Repeated lying/conning others for personal profit/pleasure - Impulsivity Irritability/aggressiveness; constant fighting or assaults - Disregard for safety of others/self - Consistent failure to sustain obligation - Lack of remorse. - Other Characteristics - History of [conduct disorder] as a child-no remorse for hurting others or animals - Some children have trouble controlling their impulses, so they become disruptive and develop antisocial ways of coping, inc risk for develop APD - Deceive, lie, destroy property, break important rules -- this is how they get their way - Men more often affected than women - Fail to self support and then spend years impoverished, Erratic/Cluster B: Borderline Personality Disorder: - P**attern of instability** in mood, thinking, self image, behaviour and personal relationships - **Relationships** -- rapid shifts from adoring/idolizing to devaluing/cruel punishment - **Sudden, dramatic changes** in career plans, values, types of friends, sexual identities - Borderline -- Between neurosis and psychosis - Neurosis -- pattern of anxiety responses to relationships often rooted in childhood response to conflict with one\'s parent - Psychosis, paranoid delusion about why people are against them - Worry excessively how other\'s perceive, negative perception leads to abandonment Erratic/Cluster B: Borderline Personality Disorder (continued): - Impulsivity - Gamble, abuse food/drugs, practice unsafe sex with multiple partners, spend money, self mutilating - Antagonism marked by hostility, inappropriate anger, irritability in relationships - Emotions range from great joy to deep depression, change in minutes to hours - **Behaviours to watch for**: Intense emotional responses, impulsive behaviors, feelings of emptiness, difficulty controlling anger, and self-harm tendencies. - **Histrionic** - Pattern of excessive emotional expression accompanied by attention seeking behaviour - Flashy, dramatic in style/dress/mannerisms/speech to draw attention - Emotionally shallow, romantic fantacy world - **Behavior:** Need to be the center of attention, exaggerated emotions, suggestibility, discomfort when not in the spotlight - **Narcissistic** - Pattern of grandiosity and the need to be admired (self importance) - They are \"special, unique, extra important\" - Attention seekers - Crave admiration - Become angry if criticized or outshone - Quickly take advantage and explore others without guilt or remorse - Behavior: Exaggerated sense of self-importance, entitlement, lack of understanding of others' feelings, exploitation of relationships. Psychopath vs Sociopath: An individual with **antisocial personality disorder** is often referred to as a *psychopath* or a *sociopath (but they are slightly different)* Serial killer Ted Bundy: Psychopath vs Sociapath: - Psychopath: The hallmark of a psychopath is the [lack of a conscience.] - Sociopath -- weak conscience - Fearful cluster - The common characteristic is **anxiety.** - Show patterns of anxious and fearful behaviors, rigid patterns of social shyness, hypersensitivity, need for orderliness, and relationship dependency - The three personality disorders in this cluster are: - Avoidant - Dependent - Obsessive-compulsive - Each disorder is related to certain expressions of anxiety. Fearful/Cluster C: Avoidant Personality Disorder: - Anxiety - **Fear of rejection and humiliation** - Narrow interests to small range of activities - Minimal support system, afraid of reactions - Hypersensitive to criticism and often feel inadequate/inferior - Extremely shy in social situations - May also suffer from - Generalized personality disorder - Depression - Somatic Symptom disorder - Illness anxiety disorder - **Behavior:** - Avoiding social activities - Fear of being criticized or embarrassed, - Desire for close relationships but extreme fear of disapproval. Fearful/Cluster C: Dependent Personality Disorder: - Anxiety -- **Separation and abandonment** - Deep fear of rejection - Need to be cared for/find people to care for them - Excessive need to be taken care of - To avoid turning people away, they become submissive, over-cooperative, docile, clingy - Do not make demands or disagree - When alone, feel helpless - Causes them to seek out overprotective, dominating, abusive relationships - Refuse responsibilities for their actions; unwilling to begin task alone/take on any responsibility - **Behavior:** - Difficulty making decisions without reassurance - Fear of separation - Quickly seeking new relationships for support when one ends. Fearful/Cluster C: Obsessive Personality Disorder (OCPD): - Anxiety -- uncertainty about future - Extremely orderly/preoccupied with details/rules, perfectionism, control - Delegating tasks to others is difficult, no one can do as well - Desire to be in control of people, tasks, situations - Excessive commitment to work /consumed by perfection - Rigid, stubborn, miserly - **Behavior:** Rigidity, inflexibility, excessive attention to details, unwillingness to delegate tasks, discomfort when things are not done perfectly. OCD vs OCPD: (hmmmmm test question?) - OCD -- have obsessions and compulsions, **[well-aware]** of these - OCPD -- will see their desire to control people and their environment as natural A patient admitted to your unit has a personality disorder.What are some important areas to assess: - Evaluation for change in personality---may signal a need for a thorough medical workup or assessment for unrecognized substance use disorder - Therapeutic relationship may be initially rejected, then takes an upward curve of idealization, followed by devaluation because the client thinks hcps are not meeting their unrealistic expectations - Upon assess - Therapeutic relationship begins now - Pt may be manipulative, charm or subtle behaviours to achieve their purposes - **Splitting -- emotionally dividing staff** - Consistent limit setting, communicate freqently with others on team A patient admitted to your unit has a personality disorder.What are some important areas to assess: - Mental Status Exam -- very important for this patient!!! - Observation of patient behaviour to see how they cope with interprofessional relatonsihps and aspects of daily life - Assess for suicidal or homicidal thoughts - Determine whether client has medical disorder or another psychiatric disorder that may be responsible for the symptoms (ie substance use) - View the assessment about personality functioning from within the person's ethnic, cultural, and social background - Determine whether the person experienced a recent loss (personality disorders are exacerbated after the loss of significant supporting people or in a disruptive social situation) Therapeutic Interventions: - Treatment and therapy - Complex -- diverse tx needs and no single treatmentI appropriate for every patient - Treatment decisions are guided by the patient's presenting symptoms, complaints, and issues - Many do not seek out treatment or refuse to accept it because of Hx of conflict, basic mistrust of others, extreme lack of insight - Types of psychotherapy used successfully include: - Psychodynamic therapy - Cognitive therapy - Behavioural therapy - Schema Therapy -- new, help pt recognize/replace long standing neg thinking/feeling/beh with healthier ones - Group therapy - Family therapy - Dialectic behaviour therapy (DBT) Therapeutic Interventions (continued): - Nurses must exercise great care when administering medications to individuals with personality disorders. - Nurses must frequently monitor pts' adherence to prescribed meds and put in place safeguards to prevent or reduce the risk for suicide. - Pts may hoard their medications until they have enough for a lethal dose. - Review why and how to do this in textbook for further details - If the patient is being treated on an outpatient basis, the amount of any prescribed medication must never be large enough to allow a successful suicide. - Hoarding - Adherence - Do not hesitate to assess every medicated patient for suicidal thoughts or plans. Therapuetic Interventions - Medicaitons +-----------------------------------+-----------------------------------+ | **Med** | **Use** | +-----------------------------------+-----------------------------------+ | Antianxiety/ | Relieve depression and anger | | | associated with disorder | | antidepressants | | +-----------------------------------+-----------------------------------+ | Mood stabilizers | Impulsivity, irritability, | | | aggression | +-----------------------------------+-----------------------------------+ | Antipsychotics | \* only indicated when pt acutely | | | and dangerously psychotic | | | | | | \- limited amounts for short | | | period | +-----------------------------------+-----------------------------------+ Therapeutic Interventions (continued): - Nursing (therapeutic) process - **[Cure is not the goal of therapy.]** - Goals of care for patients with personality disorders: - To help patients identify and then become responsible for their own behaviours - Need them to become aware of how their behaviour is affecting their life. - Need them to become responsible for beh so that all other treatment will be effective - To assist patients in developing satisfactory interpersonal relationships - Interventions and evaluations are developed for each diagnosis and are specific to the individual patient. Things to Consider Studying for Midterm Exam: - How PDs understood from varying theoriests - Characteristics of General Personality Disorder (ABCDEF) - Personalities - How many clusters and their types - Main features, what kinds of behaviours would manifest in each type - Which PD fall under each (Cluster A,B,C and Erratic/Fearful/Eccentric - If given example, be able to determine which cluster or type of PD - Psychopath vs Sociopath - What type of personality disorder does it fall under - OCD vs OCPD - Types of treatments used -- more so how they would work to help treat - Goal of care - Types of medications used and why/help with what, patient teaching or special nursing implications **[Chapter 31:Brain Function, Schizophrenia, and Other Psychoses]** Normal Brain Function: - Brain information processing and storage are very complicated processes. - Our brain has billions of cells, some of which are called neurons. - Each neuron has short branches called dendrites and may have one or two long branches called axons. - The small space between two branches of two or more neurons is called a synapse. - Information travels inside the branches to the synapse. - Within the synapse, information is transmitted by chemicals called neurotransmitters. Normal Brain Function (continued): - Perceptions - From outside of our body, information comes to us through our external receptors in different organs. - This information makes its way to the corresponding brain centre. - From the eyes, the information goes to the vision centre. - From the ears, the information goes to the hearing centre. - Thoughts - Our thoughts in the command centre (frontal lobe) are responsible for our behaviour. - We do not need to pay active attention to the majority of our behaviour, as most of it is automatic and unconscious. - **Positive symptoms** - Include delusion, hallucination, disorganized speech, and disorganized behaviour \*\* - **Called "positive" because they add something to the person's presentation** - Created when meaningless information is generated in the brain as a result of dopamine malfunction - As natural as all other thoughts - The types of thoughts generated are called *delusions*. - Thoughts that do not come from person\'s cultural background - When describing delusions for documentation - Avoid generalization (terms like paranoid, grandiose, bizarre) - Use patient\'s own words Abnormal Brain Function: - **Negative symptoms** - Automatic thoughts are compromised during psychosis. - **Called "negative" because they take away from a person's presentation** - Create a serious functional challenge to the person who experiences them - The informational highways that helped a person to react to and do many things are automatically overloaded with meaningless information. - Activities that required no effort now are almost impossible to execute - **Avolution** -- extreme difficulty with imitating any purposeful activity - **Alogia** -- diminished speech output - **Anhedonia** -- decreased ability to experience pleasure - **Asociality** -- lack of interaction in social interactions Abnormal Brain Function: - **Cognitive symptoms** - Sometimes identified as a separate group of symptoms from those that are "positive" and "negative" - These symptoms are associated with gibberish information that impacts cognition, which can decrease a person's capacity to concentrate, reason, and form memories. Schizophrenia and Other Psychoses: - Psychosis - The inability to recognize reality, relate to others, or cope with life's demands - Combination of positive, negative, and cognitive symptoms that lead to impaired assessment of reality. - Alterations in perception, thought, language, emotion and social interaction - The most common psychosis is schizophrenia. - Other psychotic disorders -- Review on own for your own knowledge - Brief psychotic disorder - pg. 388 - Delusional disorder -- pg. 388 - Schizophreniform disorder - pg. 388 - Psychoses related to medical conditions or drug use As You Study: - Explain the differences between a psychosis and other mental health disorders. - Remember: Schizophrenia is not a single disorder, but rather a group of psychoses. - Schizophrenia involves the most complex and frightening symptoms. - For example, individuals may hear voices, think other people or machines are controlling them, feel bugs crawling on their bodies, or believe other people are plotting against them. Schizophrenia -- Clinical Picture: - A condition in which **[at least TWO]** of the following symptoms are present **[for most of a 1-month period]** (**with at least one being one of the first three symptoms in the list**) - Delusions **\*** - Hallucinations **\*** - Disorganized speech **\* - see next slide and for midterm/exam** - Grossly disorganized or catatonic behaviour - Negative symptoms - These symptoms must be responsible for at least **[6 months of significant disturbances in major areas of a person's life]** (e.g., self-care, work, relationships). Table 31.1:  Schizophrenia (continued): - Lack of insight (e.g., an unawareness of the symptoms of schizophrenia) is also present. - This is a major prediction for nonadherence to treatment, a high number of involuntary admissions, a high rate of relapses, aggression, and poor outcomes. - Lack of insight is not a coping mechanism, but an actual symptom of schizophrenia. - **Development and course \*\*** - First psychotic episode usually occurs in early to mid-20s for males and in late 20s for females. - Earlier onset is usually associated with worse prognosis. - Onset can be abrupt, but people usually start to experience different clinical signs gradually. Schizophrenia (continued): - Prevalence - Lifetime prevalence is 0.3% to 0.7% - Males more than females - Females tend to have later onset, with more positive mood and symptoms; females also tend to have a better outcome. - Suicidal risk - Around 5% of people who have schizophrenia die by suicide. - About 20% to 40% attempt suicide at least once. - Many have suicidal ideation. Four Stages of Schizophrenia -- Prodomal: - Quiet, passive, obedient, prefer to be alone\' - Few/no friends because of odd, suspicious, eccentric behaviour - Hallucinations and delusions may be present, beh not completely disorganized - Family members may report sense ind \" slipping away Four Stages of Schizophrenia -- Acute Phase: - Vary widely - Includes disturbances in thought, perception, behaviour and emotion - Freq individuals lose contact with reality and unable to function in the most basic ways - Onset or exacerbation of symptoms that may require hospitalization - Follows acute episode - Marked by lack of energy - No interest in goal directed activities - Negative outlook - Many behaviours in prodomal phase are also present in this phase - *Relative* Remission - Ability to manage some basic ADLs return - Ind experiences some relief from distresses of psychosis - Course of schizophrenia alternates between acute and periods of decreased symptoms - Unfortunately, majority will require some level of support in their lives - Will experience priors of exacerbation and remission - Psychotic symptoms diminish with time - Negative symptoms tend to persist - Other psychoses - Schizoaffective disorder -- we will discuss at end of chapter - Psychotic disorder due to a medical condition - Catatonia associated with a mental disorder - Other specific schizophrenia spectrum and other psychotic disorder - Unspecified schizophrenia spectrum and other psychotic disorder Schizophrenia - Assessment: - Focus on symptoms, coping, functioning and safety: During the prepsychotic phase - General assessment - Positive symptoms-presence of something that should be absent - Negative symptoms-absence of something that should be present - Cognitive symptoms-thinking - Affective symptoms-emotions and expression - important to detect and intervene early to decrease severity and increase prognosis - Interview Tips - Two approaches (Read, p, 389) - Purposefully explore entire psychosis region in one intervention section - Explore psychosis in little bits, as patient spontaneously raise it Uncovering Dangerous Psychotic Process (1 of 2): - Some symptoms of psychosis may lead a person to act violently. - Three main scenarios that are associated with an increased risk of aggression or violence in patients who have psychosis (against themselves or against others): - Important to determine - Are they dangerous/not dangerous, intensity of hallucinations, degree of control of hallucination and their closeness to patient - Usually some kind of technology - Risk is high when control is accompanied by threat - Particularly dangerous during postpartum period of psychotic depression because may lead to filicide (child killing by a parent) - Most often include intent to act violently against self or others - People are typically open about delusions and plans - Should be taken very seriously - These types of delusions must be monitored for intensity and frequency to allow proactive intervention, diminish suffering, and ensure safety. - If danger to staff or patients is identified, proactive interventions are required in two domains: - Environmental (ensure staff safety) - Increased distance between staff and patient until restraints can be applied (as last resort) - Medical (pharmacological antipsychotic intervention to decrease intensity of delusions) Speech Disturbances and Other Characteristics of Schizophrenia: - Speech Disturbances - Table 31.1 - know speech problems and descriptions for midterm and exam - Other Characteristics - Though Processes - Perseveration - Poverty of Thought - Emotional Realm - Affect -- blunted, flat, inappropriate, labile - Alexithymia - Apathy - Anhedonia - Other Characteristics - Behaviourally - Little impulse control, mobility to manage anger - May injury self or others - Lack of energy -- poor performance in school, work (unemployment, homelessness) - Lack of social supports -- lead sot high risk for suicide - Abuse of alcohol/street drugs - Socially - Unable to establish or maintain relationship with others - Self-esteem is low - Have few friends, little interest in hobbies or other activities - Many prefer to be alone because of hallucinations/feelings of paranoia **Definition**: A mental health condition characterized by a combination of symptoms of **schizophrenia** (such as hallucinations and delusions) and **mood disorder** symptoms (like depression or mania) **Symptoms**: **Psychotic Symptoms**: Hallucinations, delusions, disorganized thinking. **Mood Symptoms**: Major depressive episodes, manic episodes, or a mix of both. **Types**: **Bipolar Type**: Includes manic or mixed episodes, and sometimes major depressive episodes. **Depressive Type**: Only includes major depressive episodes. **How are they different** **Schizoaffective Disorder** is a blend of schizophrenia and mood disorder symptoms. **Bipolar Disorder** is primarily about mood episodes, with psychosis possible but only during these episodes. **Schizophrenia** focuses mainly on psychotic symptoms, with mood symptoms being minimal or secondary. Diagnosis of Schizoaffective Disorder: **Diagnostic Criteria** (per DSM-5): **Challenges in Diagnosis**: Therapeutic Interventions: - Due to impaired judgment/lack of insight, many individuals do not try to voluntarily try to receive treatment - Admission often involuntary - Patients with acute psychoses are treated with a combination of therapies and medication. - Goals of inpatient, short-term care: - Stabilize the patient. - Prevent further decline in functioning. - Assist the patient in coping with their disorder. Therapeutic Interventions (continued): - Long-term goals include multidisciplinary treatment: - Social skills training - Supported housing and employment - Vocational rehabilitation - Personal, family, or behavioural therapy - Psychotherapy: - Cognitive behavioural therapy -- identify/change ineffective patterns of thinking and behaviour - Cognitive enhancement therapy -- computer based brain training, to organize thoughts and increase cognitive functioning - Supportive therapy -- teach patients how to live with psychosis in more healthy ways - Family psychoeducation -- support to help teach ind and family how to bond, problem-solve, collaborate, learn from each other Therapeutic Interventions (continued): - Pharmacological therapy - Antipsychotic or neuroleptic medications - Slow the central nervous system (CNS) - After an antipsychotic medication is taken, hallucinations and delusions decrease, thought processes change, and hyperactivity subsides - Antipsychotic medications - **First-generation** (1950s)-**Typical** (Conventional) Antipsychotics (dopamine receptor antagonists)-**best with positive symptoms** - **Second-generation**-\***Atypica**l Antipsychotics (serotonin-dopamine antagonists)-**best with negative symptoms** - **Third-generation** - are effective for most exacerbations, take 2-6 weeks to works, may be prescribed many meds for symptoms, **need to monitor for adverse effect** First-Generation/Conventional or Typical Antipsychotics: - Dopamine antagonists (D~2~ receptor antagonists-blocking causes the SE of EPS) - Examples: Chlorpromazine (CPZ), Haldol - **Target positive symptoms of schizophrenia with little effect on negative symptoms** - **[Advantage]** - Less expensive than second generation; come in depot LA injections (once every 1-4 weeks) - **[Disadvantages]** - Extrapyramidal side effects (EPS): acute dystonia (acute sustained contraction of muscles); akathisia (psychomotor restlessness pacing or fidgeting); cogwheel rigidity (reversible) - Anticholinergic (ACh) adverse effects-tachycardia, hyperthermia, hypertension... - Tardive dyskinesia: after prolonged treatment, involuntary muscle contractions involving the tongue, fingers, toes, neck, trunk or pelvis (smacking of lips, pill rolling of fingers, sucking motion), no certain treatment - Weight gain, sexual dysfunction, endocrine disturbances Second-Generation/Atypical Antipsychotics: - Treat both positive and negative symptoms - Examples: Clozapine (Clozaril); Risperdal, Lurasidone (Latuda); Olanzepine (Seroquel); Ziprasidone (Zeldox) - Minimal to no extrapyramidal side effects (EPS) or tardive dyskinesia---compliance to treatment - Disadvantage---expensive, tendency to cause [significant weight gain, metabolic syndrome, dyslipidemia, altered glucose metabolism, increased risk of diabetes, hypertension and atherosclerotic heart disease] (not Zeldox) - Clozaril-agranulocytosis weekly monitoring of WBCs x 6 months; not with others listed above Third-Generation Antipsychotic: - Aripiprazole (Abilify). \*\*\*\* - Dopamine system stabilizer - Improves positive and negative symptoms and cognitive function - Little risk of EPS or tardive dyskinesia Therapeutic Interventions (continued): - Nursing (therapeutic) process - Primary nursing diagnoses - Disturbed thought processes - Disturbed sensory perceptions - Social isolation - Impaired communications - Ineffective management of therapeutic regimen - The basic goals of care are to assist patients with controlling their symptoms and achieving the highest possible level of functioning. Therapeutic Interventions (continued): - Special considerations - The most common side effects of antipsychotic medications reflect alterations in CNS and peripheral nervous system functions - Extrapyramidal side effects - Tardive Dyskinesia - Sedation - Anticholinergic effects - Most common is dry mouth, blurred vision and urinary retention - Akathisia - Akinesia - Bradykinesia - Dyskinesia - Dystonia - Neuroleptic malignant syndrome Potentially Dangerous/Fatal Responses to Antipyschotics: - [Anticholinergic toxicity] (Anticholinergic-Induced Delirium) - S&S-dry mouth, absent peristalsis, mydriasis, nonreactive pupils, hot dry red skin, hyperpyrexia without diaphoresis, tachycardia, agitation, unstable vital signs - [Neuroleptic malignant syndrome (NMS) -- know the 4 signs] - life-threatening medial emergency, occurs early in therapy, often when two or more psychotherapy meds used - S&S- sudden rapid change in LOC/rapid increase muscle tone (rigidity), hyperpyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling - Cardinal sign - high body temp (38 to 40 Degrees Celsius) - - Tx-discontinue antipsychotic , fluid balance, temp reduction - [Agranulocytosis] - Serious potentially fatal; may involve liver impairment - S&S-dry mouth, constipation, blurred vision, dry eyes, urinary retention, delirium, photosensitivity, dystonic reactions Therapeutic Interventions (continued): - Nursing responsibilities - Nurses should review desired actions, side effects, and incompatibilities for each medication prescribed. - Monitor patient response to each medication. - First 1-2 weeks, assess vitals, record fluid intake/output, routinely assess skin conditions - Assess for adverse effects - Patient and family education has a direct impact on the patient's level of functioning. - **Discharge planning needs to include medication teaching.** - Not taking medications correctly or not understanding the need for compliance leads to relapse of symptoms. Studying for Midterm/Exam: - Positive Symptoms/Negative Symptoms - Their definitions - What is considered a positive vs negative, be able to identify in a scenario given to you, definitions for types of behaviours you might see with each - I.e. hallucinations vs delusions, vs catatonia, vs alogia, asociality - Schizophrenia - Dx criteria - Four stages of schizophrenia - Assessment and interview tips - three main scenarios that are associated with an increased risk of aggression or violence - Characteristics of Schizophrenia and terms used to describe these different areas for speech, thought, emotional realm, behaviour - What is schizoaffective disorder - How is similar and different to schizophrenia - How do these individuals present - Medications - 1st generation vs 2nd generation vs 3rd, specifics of how they work, advantages/disadvantages - Nursing responsibilities, monitoring, lab work, patient teaching - Special Considerations -- Adverse Effects - Terms, descriptions, S & S, treatments, nursing monitoring