Psychiatry

Psychiatry

1 What are the five main diagnostic criteria for schizophrenia?

Disorganized speech

Grossly disorganized or catatonic behavior

Negative symptoms (i.e., flat affect, avolition)

2 Why is the duration of symptoms important with psychosis?

The time frame is important because, given the same symptoms, a patient is given one of three different diagnoses based only on their duration:

Less than 1 month = acute psychotic disorder.

1 to 6 months = schizophreniform disorder.

More than 6 months = schizophrenia.

3 List the positive symptoms of schizophrenia

Bizarre behavior

Thought disorder (e.g., tangentiality, clanging)

These symptoms respond well to all currently used antipsychotics.

4 List the negative symptoms of schizophrenia

Alogia (no speech)

Avolition (apathy)

These symptoms respond poorly to traditional antipsychotics (e.g., haloperidol) but may respond to “atypical” agents such as risperidone, olanzapine, aripiprazole, paliperidone, quetiapine, or ziprasidone.

5 What features of schizophrenia suggest a poor prognosis?

Poor premorbid functioning (most important)

Family history of schizophrenia

Negative symptoms

No precipitating factors

Poor support system

Single, divorced, or widowed status

6 What features suggest a good prognosis?

Good premorbid functioning (most important)

Family history of mood disorders

Positive symptoms

Obvious precipitating factors

Good support system

7 What is the difference in age of onset for schizophrenia in males and females?

The typical age of onset is 15 to 25 years for males (look for someone going to college and deteriorating) and 25 to 35 years for females.

8 True or false: Roughly 1% of the population has schizophrenia in almost every country in the world

9 True or false: In the United States, most schizophrenic people are born in the summer months

False. Most schizophrenic patients in the United States are born in the winter (reason unknown).

10 Roughly what percentage of patients with schizophrenia commit suicide?

In the United States, roughly 10% of patients with schizophrenia eventually commit suicide (a past attempt is the best predictor of eventual success).

11 True or false: Psychosocial treatment has been shown to improve outcome in schizophrenia

True. Antipsychotic medications are the mainstay of therapy, but psychosocial treatment has been shown to improve outcome. Medications are needed first, but the best treatment (as in most psychiatric illnesses) is medications plus therapy.

12 Differentiate among the classes of antipsychotic drugs

	HIGH POTENCY	LOW POTENCY	ATYPICAL AGENTS^∗
Prototype drug	Haloperidol	Chlorpromazine	Risperidone, olanzapine, aripiprazole, paliperidone, quetiapine, ziprasidone
EPS side effects	High incidence	Low incidence	Low incidence
ANS side effects^†	Low incidence	High incidence	Medium incidence
Positive symptoms	Works well	Works well	Works well
Negative symptoms	Works poorly	Works poorly	Works fairly well

ANS, Autonomic nervous system; EPS, extrapyramidal system.

^∗Atypical, newer antipsychotics are generally first-line treatment and maintenance therapy as a result of reduced extrapyramidal side effects and efficacy with negative symptoms. Choose them over older agents.

^†ANS side effects include anticholinergic effects (dry mouth, urinary retention, blurry vision, mydriasis), alpha₁ blockade (orthostatic hypotension), and antihistamine effects (sedation).

13 What are the four commonly tested extrapyramidal side effects of antipsychotics?

Acute dystonias, akathisia, parkinsonism, and tardive dyskinesia.

14 Define acute dystonia. How is it treated?

Acute dystonia is an extrapyramidal movement disorder that occurs in the first few hours or days of treatment with an antipsychotic medication. Patients develop muscle spasms or stiffness (e.g., torticollis, trismus), tongue protrusions and twisting, opisthotonos, and/or oculogyric crisis (forced sustained deviation of the head and eyes). Acute dystonia is most common in young men. Treat with antihistamines (e.g., diphenhydramine) or anticholinergics (e.g., benztropine, trihexyphenidyl).

15 Define akathisia

Akathisia occurs in the first few days of treatment with an antipsychotic medication (or other medications such as antidepressants). The patient has a subjective feeling of restlessness and may pace constantly, alternate sitting and standing, and be unable to sit still. Beta blockers can be tried for treatment.

16 Describe the relationship between antipsychotics and parkinsonism

Parkinsonism usually occurs in patients taking antipsychotics within the first few months of treatment. Parkinsonism is thought to develop because of dopamine depletion, whereas psychosis is thought to develop because of too much dopamine in the brain (a gross oversimplification). Thus antipsychotics create an iatrogenic lowering of effective dopamine in the brain by blocking dopamine receptors. The patient develops stiffness, cogwheel rigidity, shuffling gait, masklike facies, and drooling. Parkinsonism is most common in older women. Treat with antihistamines (e.g., diphenhydramine) or anticholinergics (e.g., benztropine, trihexyphenidyl).

17 Define tardive dyskinesia. When does it occur?

Tardive dyskinesia appears after years of treatment with antipsychotics. Most commonly the patient develops perioral movements (darting, protruding movements of the tongue, chewing, grimacing, and puckering). The patient may also have involuntary, choreoathetoid movements of the head, limbs, and trunk. There is no known treatment for tardive dyskinesia. If you are asked to make a choice when the patient develops tardive dyskinesia, discontinue the current antipsychotic and consider switching to a second generation agent (e.g., clozapine, risperidone).

18 What is neuroleptic malignant syndrome? How do you recognize and treat it?

Neuroleptic malignant syndrome is a life-threatening condition that can occur at any time during antipsychotic treatment. Patients classically develop rigidity, mutism, obtundation, agitation, high temperature (up to 107°F), very high levels of creatine phosphokinase (more than 10 times the normal range), sweating, and myoglobinuria. Treat by first discontinuing the antipsychotic; then give supportive care for fever and potential renal failure caused by myoglobinuria (primarily intravenous fluids). Lastly, consider dantrolene (just as in malignant hyperthermia, which is thought to be a similar condition).

19 Describe the relationship between antipsychotics and prolactin

Dopamine blockade causes increases in prolactin levels because dopamine is a prolactin-inhibiting factor in the tuberoinfundibular tract of the brain. The end result may be high serum prolactin levels, resulting in galactorrhea and impotence, menstrual dysfunction, and/or decreased libido.

20 What are the classic side effects of thioridazine, chlorpromazine, and clozapine?

Thioridazine: Retinal pigment deposits

Clozapine: Agranulocytosis (white blood cell counts must be monitored)

Chlorpromazine: Jaundice and photosensitivity

21 What are the side effects of the atypical antipsychotics?

Olanzapine: Weight gain, sedation, hypotension, dry mouth

Quetiapine: Sedation, orthostatic hypotension, akathisia, weight gain, dry mouth

Ziprasidone: Nausea, weakness, mild QT prolongation

Aripiprazole: Headache, nausea, akathisia, tremor, constipation

Paliperidone: Parkinsonism, dystonia, dyskinesia, akathisia, QT prolongation

Clozapine: Orthostatic hypotension, weight gain, metabolic syndrome, sedation, constipation

22 Define bipolar disorder. What are the classic symptoms?

Mania is the only criterion required for a diagnosis of bipolar disorder, but a history of or future episodes of depression are classically present. Classic symptoms of mania include decreased need for sleep, pressured speech, sexual promiscuity, shopping sprees, and an exaggerated self-importance or delusions of grandeur. Look for initial onset between 16 and 30 years old.

23 How is bipolar disorder treated?

Both lithium and valproic acid are mood stabilizers and first-line agents. Typical antipsychotics (haloperidol), atypical antipsychotics (risperidone, quetiapine, clozapine, ziprasidone, and aripiprazole), carbamazepine, and gabapentin are second-line agents. Antipsychotics or antidepressants may be needed if the patient becomes psychotic or depressed; use at the same time as the mood stabilizer.

24 What are the side effects of lithium, valproic acid, and carbamazepine?

Lithium: Renal dysfunction (diabetes insipidus), thyroid dysfunction, tremor, and central nervous system (CNS) effects at toxic levels

Valproic acid: Liver dysfunction

Carbamazepine: Bone marrow suppression

25 Define bipolar II disorder and cyclothymia

Bipolar II disorder is hypomania (mild mania without psychosis that does not cause occupational dysfunction) plus major depression. Cyclothymia is at least 2 years of hypomania alternating with depressed mood, but there are no full-blown episodes of mania or major depression.

26 List the major risk factors for suicide

Age older than 45 years

Prior psychiatric history

Alcohol or substance abuse

History of rage or violence

Recent loss or separation

Prior suicide attempts

Male gender (men commit suicide three times more often than women, but women attempt it four times more often than men)

Unemployed or retired status

nSingle, widowed, or divorced status

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Apr 8, 2017 | Posted by admin in NURSING | Comments Off

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