Psychosis NRS 317

Psychosis Definition

An abnormal condition of the mind that results in difficulties telling what is real and what is not, secondary to complex neurobiological changes.

Psychosis Attributes

• Alteration in perception of reality 

• Alteration in behavior 

• Culture variation 

Psychosis Attribute —> Alteration in perception of reality

• Hallucinations

• Delusions

Psychosis Attribute —> Alteration in Behavior

• Disorganized thoughts

• Disorganized motor behaviors

• Withdrawal from society

• Lack of interest or motivation 

Psychosis Attribute —> Culture Variation 

• "Madness" born of "poison, demons, fecal matter and blood trouble" (1500 BC)

• Term psychosis not coined until 1845

• How is the term "psychotic" used today?

Pathophysiology of Psychosis

• Many theories about the cause being related to neurotransmitter communication

Pathophysiology of Psychosis —> Dopamine

• Too much dopamine in the synaptic cleft = positive symptoms

• Not enough dopamine in the synaptic cleft = negative symptoms

• More on negative & positive symptoms soon!

• GABA, serotonin, glutamate, and acetylcholine likely also involved

Pre-frontal cortex 

• regulation of complex behavior: thoughts, actions, emotions​

Limbic system

emotional processing of sensory info

Psychosis Scope

1. absence of psychosis

2. subclinical symptoms

3. clinical mild

4. significant moderate

5. psychosis severe

Primary Psychosis —> Psychiatric etiology

• Ex: schizophrenia spectrum, major depressive disorder, bipolar disorder, brief psychotic disorder (such as postpartum psychosis)

Secondary Psychosis —> Organic Etiology

• Ex: intoxication, delirium, dementia, medication toxicity, medical illnesses such as hepatic encephalopathy

Primary and Secondary Psychosis Notes

These are not mutually exclusive --> they can occur at the same time and may even potentiate one another

Psychosis Consequences —> Physiologic

Physical symptoms

• Duration, intensity, impairment level are dependent on etiology

• Side effects from medication

Neural degradation

• Untreated psychosis is a persisting neurotoxic state --> inflammatory markers released

Psychosis Consequences —> Physiologic (Extra Notes)

Dementia occurs 2x as often in pts dx with schizophrenia spectrum disorder

Psychosis Consequences —>Psychosocial 

Behavior is influenced by symptoms and treatment

• Psychotic symptoms + sedating effects of medications

Substance abuse is well documented

Withdrawal from community

• The community does not always support this population

• Concerning for employment, housing, and having basic needs met = vulnerable population

Psychosis Consequences

—>Psychosocial (Extra Notes

Nearly 50% of those diagnosed with schizophrenia spectrum are alcohol or illicit drug dependent, 70% are nicotine dependent

Psychosis Risk Factors

• All individuals are potentially susceptible to psychosis regardless of age, gender, race, and/or ethnicity

• Common variables seen in patients experiencing psychosis include:

Psychosis TYPES OF Risk Factors

• Family history psychosis

• past psychotic episode

• substance use

• stress intolerance —> lack of sleep

• ineffective coping skills

• pre- existing psychiatric illness

Risk Factors of Psychosis —> Schizophrenia-specific Risk Factors

• Low IQ as a child

• Low SES

• Large population density

• Genetic – first degree relative increases risk, but 60% of pts have no family hx

• Increased stress, poor coping

Psychosis Assessment: Symptoms of Psychosis —> ADDED to behaviors positive

• Agitation

• paranoia

• delusions

• hallucinations

• catatonia

• disorganized thinking

• disorganized motor behavior

Psychosis Assessment: Symptoms of Psychosis —> cognitive

• memory deficits

• attention deficits

• loss of executive function

Psychosis Assessment: Symptoms of Psychosis —> REDUCED from behaviors negative

• Alogia,

• asociality/social withdrawal

• anhedonia

• avolition

• poor self-care

• poor judgment

• poor insight

• blunted affect

Assessment: Clinical Threshold of Symptoms

Psychosis Assessment: Nursing —> Medical hisotry & patient interview

• Can be difficult r/t impaired cognition and changes in reality

• Collect data from pt and also utilize another source like family or friends

• Keep questions straight forward and open-ended, provide extra time to answer

• Building rapport can be difficult r/t paranoia and delusions

• Avoid using words such as hallucination, delusion, etc. Instead ask, "Do you ever see or hear things that other people do not?"

• DONT ASK “WHY” questions —> its judgemental

Psychosis Assessment: Nursing —> Physical Assessment

• Physical symptoms often follow pt's etiology of psychosis

• Look for side effects from medications

• Assess pt's ability to provide self-care, evidence of drug/alcohol abuse

Psychosis Assessment: Nursing —> Mental Status Assessment

• Mental status = a large picture including behavior (emotion, personality, mood) + cognitive functioning

psychosis mini mental status exam

• Focus on memory, language skills, attention level, and ability to engage in mental tasks

• Can be modified for use in children over the age of 4

Psychosis Diagnostics 

• Lab tests to differentiate between primary and secondary etiologies

  • Ex: rule out organic etiologies with CBC, thyroid, RPR (syphilis), urinalysis, urine drug screen, and more)

• A psychiatric evaluation of the patient performed by a provider can medically diagnose a primary etiology such as schizophrenia

Schizophrenia Diagnosis —> 2+ of the main 5 symptoms

•Delusions

•Hallucinations

•Disorganized or incoherent speaking

•Disorganized or unusual movements

•Negative symptoms

Schizophrenia Diagnosis —> Duration of symptoms

•Key symptoms lasting for at least 1 month

•General effects must last for at least 6 months

Schizophrenia Diagnosis —> Social or Occupational Disfunction

•Disrupts ability to work or relationships (friends, romantic, professional, etc

Clinical Management: Planning & Interventions —> General Goals

• Treat underlying cause when applicable

• Emphasis on recovery and rehabilitation. Goal = prevention of relapse & independence

Clinical Management: Planning & Interventions —> Collaborative Interventions

• Pharmacological

• Non-pharmacological (social skills & differing types of therapy)

• Lifestyle modifications (address behaviors that could worsen condition, case management, and more)

• Community integration

• Group therapy & support groups

Clinical Management: Planning & Interventions —> Indepenedent Interventions

• Therapeutic communication/rapport building – important to validate pt experiences but also ground them in reality

• Prevent injury/promote a safe environment

• Close monitoring and documentation of symptoms

• Provide treatment as ordered

• Provide education to patient and support system

´Advocate for the patient

Background

´Dopamine antagonists = block dopamine activity at the synapse and decrease the effect that dopamine has on the brain​

´Antipsychotic drugs fall into two major groups: ​

´First-generation antipsychotics (FGAs) = typical/conventional antipsychotics​

´Second-generation antipsychotics (SGAs) = atypical antipsychotics; also block serotonin receptors in addition to dopamine

Dopamine Blockers: Prototype drugs

aka. first gen. antipsychotics

haloperidol (Haldol)

Dopamine Blockers: How does it act? (mechanism of action)

block actions of dopamine

Dopamine Blockers: What does it do? (primary symptom target)

↓ hallucinations

↓ delusions

↓ agitation

Dopamine Blockers: TYPES OF Adverse outcomes

• Extrapyramidal Symptoms (EPS)

• Tardive Dyskinesia (TD)

• Neuroleptic Malignant Syndrome (NMS) (Rare but Life-Threatening)

• Sedation

• Anticholinergic Effects

Dopamine Blockers: Adverse outcomes —> Extrapyramidal Symptoms (EPS) (Monitor)

Muscle stiffness, tremors, rigidity, bradykinesia, akathisia (restlessness), dystonia (sustained muscle contractions)

Dopamine Blockers: Adverse outcomes —> Extrapyramidal Symptoms (EPS) (Response)

hold and notify provider, anticipate order for anticholinergic

Dopamine Blockers: Adverse outcomes —> Tardive Dyskinesia (TD) (monitor)

 involuntary movements of the face, tongue, or extremities, often irreversible.

Dopamine Blockers: Adverse outcomes —> Tardive Dyskinesia (TD) (response)

hold and notify provider

Dopamine Blockers: Adverse outcomes —> Neuroleptic Malignant Syndrome (NMS) (Rare but Life-Threatening) (monitor)

hyperthermia, muscle rigidity, altered mental status, autonomic instability (e.g., tachycardia, blood pressure changes)

Dopamine Blockers: Adverse outcomes —> Neuroleptic Malignant Syndrome (NMS) (Rare but Life-Threatening) (response)

hold and notify provider, RRT, anticipate order for dantrolene

Dopamine Blockers: Adverse outcomes —> Sedation (monitor)

excessive sleepiness, drowsiness, ↓LOC (sometimes desired effect if agitation is present)

Dopamine Blockers: Adverse outcomes —> Sedation (response)

hold and notify provider, educate on taking at night time

Dopamine Blockers: Adverse outcomes —> Anticholinergic Effects (monitor)

Dry mouth, constipation, urinary retention, blurred vision

Dopamine Blockers: Adverse outcomes —> Anticholinergic Effects (response)

provide symptomatic treatments (e.g., stool softeners, artificial saliva), monitor for severe complications like urinary retention, notify provider

DOPAMINE & SEROTONIN BLOCKERS: Prototype Drugs 

aka. second gen. antipsychotics

olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)

DOPAMINE & SEROTONIN BLOCKERS: How does it act (mechanism of action)

block actions of dopamine and serotonin

DOPAMINE & SEROTONIN BLOCKERS: what does it do (primary symptom target)

↓ hallucinations

↓ delusions

↓ agitation

↓ negative symptoms of schizophrenia (anhedonia, avolition, etc.)

DOPAMINE & SEROTONIN BLOCKERS: TYPES OF adverse outcomes

• Metabolic Syndrome (Weight Gain, Hyperglycemia, Dyslipidemia)

• Extrapyramidal Symptoms (EPS)

• QT Prolongation

DOPAMINE & SEROTONIN BLOCKERS: Metabolic Syndrome (Weight Gain, Hyperglycemia, Dyslipidemia) (monitor)

weight, blood glucose levels, lipid profiles, waist circumference

DOPAMINE & SEROTONIN BLOCKERS: Metabolic Syndrome (Weight Gain, Hyperglycemia, Dyslipidemia) (response)

hold and notify provider

DOPAMINE & SEROTONIN BLOCKERS: QT Prolongation (monitor)

ECG for QT interval prolongation, potassium and magnesium levels

DOPAMINE & SEROTONIN BLOCKERS: QT Prolongation (response)

hold and notify provider

DOPAMINE & SEROTONIN BLOCKERS: Extrapyramidal Symptoms (EPS) (monitor)

Muscle stiffness, tremors, rigidity, bradykinesia, akathisia (restlessness), dystonia (sustained muscle contractions)

DOPAMINE & SEROTONIN BLOCKERS: Extrapyramidal Symptoms (EPS) (response)

hold and notify provider, anticipate order for anticholinergic

Mechanism of Action: Dopamine Blockers First-Generation (Typical)

Primarily block dopamine (D2) receptors

Mechanism of Action: Dopamine & Serotonin Second-Generation (Atypical)

Block dopamine (D2) and serotonin (5-HT2A) receptors

Symptom Target: Dopamine Blockers First-Generation (Typical)

Effective for positive symptoms (hallucinations, delusions)

Symptom Target: Dopamine & Serotonin Blockers Second-Generation (Atypical)

Effective for both positive and negative symptoms

Examples: Dopmaine Blockers First-Generation (Typical)

haloperidol (Haldol)

Examples: Dopamine & Serotonin Blockers Second-Generation (Atypical)

olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)

Key side effects: Dopamine Blockers First-Generation (Typical)

High risk of EPS (tardive dyskinesia, dystonia)

Key side effects: Dopamine & Serotonin Second-Generation (Atypical)

Higher risk of metabolic side effects (weight gain, diabetes)

Nursing Considerations: Dopamine Blockers First-Generation (Typical)

Monitor for movement disorders (EPS)

Nursing Considerations: Dopamine & Serotonin Blockers Second-Generation (Atypical)

Monitor for metabolic changes, weight gain, diabetes

Too much dopamine in the synaptic cleft is

positive symptoms

Not enough dopamine in the synaptic cleft is

negative symptoms

Is Catatonia a positive or negative symptom? What does it mean?

a positive symptom where it disrupts the person’s awareness of the world around them 

is Alogia a positive or negative symptom? What does it mean?

a negative symptom where causes patient to speak less or use fewer words

is Anhedonia a positive or negative symptom? What does it mean?

a negative symptom where the patient has a persistent loss of interest and pleasure in activities that were once enjoyable

is Avolition a positive or negative symptom? What does it mean?

a negative symptom where the patient has a lack of motivation or inability to start or complete goal-directed activities