NU 125 Mental Health Nursing: Psychotic Disorders

Psychosis

abnormal condition of the mind in which personality is disorganized, social function deteriorates, reality is distorted, and hallucinations or delusions may be present

Schizophrenia

a group of thought disorders that affect emotions and function, characterized by disorganized and delusional thinking, disturbed perceptions, and inappropriate emotions and actions

Schizophrenia is probably caused by a combination of factors, such as..

Genetics

Biochemical dysfunction

Physiological factors

Physosocial stress

Genetics in Schizophrenia

unknown how it is inherited but genes play a role in one's vulnerability

Biochemical factors

Excess dopamine activity in the brain

Dopamine Hypothesis

Dopamine Hypothesis

the idea that schizophrenia involves an excess of dopamine activity due to abnormally high number of D2 receptors

Cannabis and schizophrenia

Adolescents who use cannabis and have certain genes are at risk, and cannabis can induce schizophrenia symptoms or exacerbate preexisting psychosis

Nature of Schizophrenia

Disturbances in thought processes, perception, and affect

Lifetime prevalence of schizophrenia in the US

0.7%

When do schizophrenia symptoms begin?

late adolescence or early adulthood

Schizophrenia is a _____ cause of disability.

leading

80% of schizophrenics are _____ and die ______ years earlier.

smokers, 25

DSM-5 Criteria for Schizophrenia

Two or more symptoms for one month, and one must be delusions, hallucinations or disorganized speech

Function is impacted for at least 6 months

Prominent delusions or hallucinations

What should be ruled out before diagnosis?

substance abuse or medical issues

Symptoms of Schizophrenia

Delusions

Hallucinations

Disorganized speech

Grossly disorganized or catatonic behaviors

Negative symptoms

Premorbid behavior

a pattern of behavior that precedes the onset of the schizophrenia that can be viewed in 4 phases

Phase I: Premorbid Phase

Social maladjustment

Shy and withdrawn

Poor peer relationships and school performance

Antisocial behavior

Antagonistic thoughts and behavior

Phase II: Prodromal Phase

lasts for weeks to years and is characterized by deterioration in role functioning and social withdrawal, functional impairement, sleep disturbances, anxiety, irritability, depressed mood, poor concentration, fatigue, and perceptual abnormalities

Perceptual abnormalities

hallucinations, delusions

Ideas of reference

client's inaccurate interpretation that general events are personally directed to him or her

Suspiciousness

a generalized distrustful view of others and their motivations

Phase III: Schizophrenia

the active phase of the disorder in which psychotic symptoms are prominent

Symptoms may include..

Delusions

Hallucinations

Impairment in work, social relations, and self-care

Phase IV: Residual Phase

Symptoms similar to prodromal, as symptoms of acute stage are absent or not prominent

In the residual phase, the patient may appear..

flat affect and impairement in role functioning

Prognosis of Schizophrenia

return to full premorbid functioning is not common

Factors associated with a Positive Prognosis

Good premorbid functioning

Later age at onset

Female

Abrupt onset due to stressful event

Brief duration of active phase symptoms

Minimal residual symptoms

Absence of structural abnormalities

Normal neurological functioning

No family history of schizophrenia

What should be assessed when assessing symptoms of schizophrenia?

Positive Symptoms

Negative symptoms

Cognitive deficits

Thought content and process

Positive Symptoms

should not be there and include hallucinations, delusions, disorganized thinking, and movement disorders

Disorganized thinking

form of thought and thought content

Movement disorders

catatonia

Negative symptoms

symptoms of schizophrenia that are marked by deficits in functioning

Examples of negative symptoms

Alogia

Anhedonia

Avolition

Apathy

Anosognosia

Ambivalence

Alogia

reduced speaking or poverty of speech

Anhedonia

inability to experience pleasure from enjoyable activities

Avolition

difficulty beginning or sustaining activities

Apathy

lack of emotion, interest, concern or a state of indifference

Anosognosia

lack of insight

Ambivalence

the state of having mixed feelings or contradictory ideas

Cognitive Symptoms

impaired judgement, easily distracted, decreased judgment

Thought Content

what the person thinks, such as specific ideas or beliefs

Common delusions

Grandeur

Persecution

Ideas of reference

Somatic

Delusions of Grandeur

a false impression of one's own importance

Delusions of Persecution

the belief that people are out to get you

Somatic delusions

belief that something highly abnormal is happening to one's body

Form of Thought (process)

Circumstantial

Concrete

Clang associations

Loose associations

Tangenitial

Word salad

Neologisms

Circumstantial thought

the focus of the conversation drifts, but often comes back to the point

Concrete thought

literal way of thinking

Clang associations

the stringing together of words that rhyme but have no other apparent link

Loose associations

disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts

Tangential thinking

wandering off the topic and never returning to the topic

Word Salad

Incoherent mixture of words, phrases, and sentences

Neologisms

made up words

Treatments for Schizophrenia

Antipsychotics

Hospitalization

Therapy

Community resources

Nutrition

Education

Goal of Nursing Interventions for Schizophrenia

Establish trust and build an alliance through short and repeated contacts

Nursing Interventions for Schizophrenia

Maintains a safe environment

Minimize stimulation

Use clear language

Inform the person exactly what you are doing

Inform if you are touching them

Engage in reality-based conversation

Clarify content of thoughts

Promote independence

Planning for relapse prevention

Least restrictive interventions

What should the nurse emphasize to a patient having delusions/disorganized thoughts?

"These thoughts must be really scary for you"

How can a nurse help patient cope with delusions or hallucinations?

Distraction

Reality-based activities

Structured routine

Engage with others

Listen to music

Avoid isolation

Educate them that these thoughts are a part of their illness

Other Psychotic Disorders

Delusional disorder

Brief psychotic disorder

Substance induced psychotic disorder

Psychotic disorder associated with another medcial condition

Substance-induced psychotic disorder

Cannabis, amphetamines, hallucinogens, opiates, corticosteroids, and anesthetics

Psychotic disorder associated with another medical condition

Alcohol withdrawal or dementia

Schizophreniform Disorder

psychotic disorder involving the symptoms of schizophrenia but lasting at least one month but less than 6 months

Schizoaffective Disorder

schizophrenia symptoms associated with mood disorder symptoms such as depression or mania

Antipsychotic medications

used to decrease agitation and psychotic symptoms of schizophrenia and other disorders

Typical antipsychotics (First Generation)

Haloperidol (Haldol)

haloperidol (Haldol)

typical antipsychotic

Mechanism of action of typical antipsychotics

antagonist that block receptors in the brain's dopamine pathways (D2)

Atypical antipsychotics (Second Generation)

Clozapine (Clozaril)

Mechanism of action of atypical antipsychotics

antagonist that blocks serotonin and to a lesser degree dopamine

Side effects of antipsychotics

Nervousness, drowsiness, headache

Blurry vision

Tachycardia

Dry mouth, constipation, nausea

Hallucinations

Acute dystonic reaction

Extra Pyramidal Symptoms

Parkinsonism

Weight gain

Acute Dystonic Reaction

emergency situation that is a side effect of antipsychotics that results in a sudden spasm or twitching of eye muscles that may last minutes to hours

Monitoring Side Effects

Assess for Abnormal Involuntary Movements

Monitor for dystonic reaction

Assess gait

Monitor weight

Monitor blood sugar

Labs

Education

Neuromalignant Syndrome

rare but potentially life threatening scenerio resulting in fever, muscle rigidity, tachycardia, BP changes, and change in LOC

Nursing Interventions for Neuromalignant Syndrome

HOLD antipsychotic and contact provider

How is dystonic reaction, or oculogyric crisis, treated?

Cogentin (benztropine) or Benadryl (dipenhydramine)

Why are benztropine or diphenhydramine administered?

they are anticholinergic agents

After a dystonic reaction, what should be anticipated?

lower dose or discontinuation of antipsychotic

Clozaril (clozapine) poses risk of..

Agranulocytosis

Agranulocytosis

body has two few granulocytes, or white blood cells, resulting in fever, sore throat, or malaise

Psychological treatments

Individual Psychotherapy

Group Therapy

Behavior Therapy

Social Skills Training

Individual psychotherapy

long-term approach, difficult due to impairment in interpersonal functioning

Group therapy

some success if occuring over long-term course of illness, less successful in acute/short-term treatment

Behavior therapy

chief drawback has been inability to generalize community setting after discharge

Social skills training

role play to teach client social skills and improve relationship development

Social therapies

Milieu therapy

Family therapy

Milieu therapy

best if used with psychopharmocology

Family therapy

aimed at helping family members cope with long-term illness effects