Psychosis and Schizophrenia

what is psychosis?

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

what are the attributes for psychosis?

• alteration in perception of reality

• alteration in behavior

• culture variation

what is alteration in perception?

• hallucinations (hearing and seeing things)

• delusions

what is alteration in behavior?

• disorganized thoughts

• disorganized motor behaviors

• withdrawal from society

• lack of interest or motivation

what is culture variation?

• “Madness” born of “poison, demons, fecal matter and blood trouble

• term psychosis not coined until 1845

• how is the term “psychotic” used today?

what if there is too much dopamine in the synaptic cleft?

causes positive symptoms

what if there is not enough dopamine in synaptic cleft?

causes negative symptoms

what is the pre-frontal cortex?

regulation of complex behavior: thoughts, actions, emotions

what is the limbic system?

emotional processing of sensory info

what is the scope of psychosis?

Absence of psychosis → subclinical symptoms → clinical significant psychosis (mild-moderate-severe) →

what is primary psychosis: psychiatric etiology?

• schizophrenia spectrum

• major depressive disorder

• bipolar disorder

• brief psychotic disorder (such as postpartum psychosis

what is major depressive disorder?

a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities. 

what is bipolar disorder?

a chronic mental health condition characterized by extreme mood swings between mania (highs) and depression (lows)

what is secondary psychosis: organic etiology?

• intoxication

• delirium

• dementia

• medication toxicity

• medical illness such as hepatic encephalopathy

What does physical symptoms refer to with physiologic consequences?

duration, intensity, impairment level are dependent on etiology, and side effects from medication

what does neural degradation refer to with physiologic consequences?

untreated psychosis is persisting neurotoxic state → inflammatory markers released

Nearly 50% of those diagnosed with schizophrenia spectrum are?

alcohol or illicit drug dependent

70% of those diagnosed with schizophrenia spectrum are?

nicotine dependent

what are psychosocial consequences for psychosis?

• behavior is influenced by symptoms and treatment (psychosis symptoms + sedating effects of medication)

• substance abuse is well documented

• withdrawal from community (community doesn’t always support population and concerning for employment, housing, and having basic needs met=vulnerable pop.)

who’s at risk for psychosis?

all individuals are potentially susceptible to it regardless of age, gender, race, and/or ethnicity

what are some common variables (risk factors) seen in patients experiencing psychosis?

• family history of psychosis

• past psychotic episode

• substance use

• stress intolerance → lack of sleep

• ineffective coping skills

• pre-existing psychiatric illness

what are risk factors for schizophrenia-specific?

• low IQ as a child

• Low socioeconomic status

• large population density

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

• increased stress, poor coping

What are primary health promotions for psychosis?

• encourage home stability (triggers, consistency, and routine)

• sleep

• no drugs

• manage stress

• self-care

• parenting classes

what are secondary health promotion?

• screening

• mental health (family history)

• signs and symptoms

what are the different types of psychosis symptoms?

• positive (added)

• negative (withdrawing)

• cognitive

what are examples of positive symptoms?

• agitation (extreme discomfort and frustration)

• paranoia

• delusions

• hallucinations

• catatonia (disrupts a person’s awareness)

• disorganized thinking (like side tangents but normally doesn’t come back)

• disorganized motor behavior

what is catatonia?

disrupts a person’s awareness

what are examples of negative symptoms?

• alogia (lack of speech)

• asociality (lack of interest social interaction)

• social withdrawal (avoids social situations)

• anhedonia (no feeling joy or pleasure in experience)

• avolition (lack of motivation to do anything: wk, exercise, self-care)

• poor self-care

• poor judgement

• poor insight

• blunted affect (no showing emotions/react emotionally)

what is alogia?

lack of speech

what is asociality?

lack of interest for social interaction

what is social withdrawals?

avoids social situations

what is anhedonia?

no feeling joy or pleasure in experience

what is avolition?

lack of motivation to do anything: like work, exercise, self-care

what is blunted affect?

not showing emotions or reacting emotionally

what are examples of cognitive symptoms?

• memory deficits

• attention deficits

• loss of executive function

what to assess with medical history and patient interview?

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

  • collect data from pt, family, and friends

• keep questions straight forward, open-ended, allow extra time to answer

• building rapport can be hard r/t paranoia and delusions

• avoid using words (hallucinations, delusion, etc)

what to assess with a physical exam?

• physical symptoms often follow pt’s etiology of psychosis

• look for side effects from meds

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

what to assess for mental status assessment?

• mental status:

  • large picture including behavior (emotion, personality, mood) + cognitive functioning

what is the mini mental status exam?

• focus on

  • memory

  • language skills

  • attention level

  • ability to engage in mental tasks

what’s wrong with the mini mental status exam?

• language barrier

• inability to hear

• vision issues

• limited education

• cultural bias

• stress

• IQ

what are the lab tests between primary and secondary etiologies?

• rule out organic etiologies with 

  • CBC

  • thyroid

  • RPR (syphilis)

  • urinalysis

  • urine drug screen

what is the diagnostic criteria for schizophernia?

• 2+ of the main 5 symptoms 

• duration of symptoms

• social or occupational disfunction

what are the main symptoms of schizophrenia?

• delusions

• hallucinations

• disorganized or incoherent speaking

• disorganized or unusual movements

• negative symptoms 

what would be the duration of key symptoms?

lasting for at least 1 month

what would be the duration of general effects?

must last for at least 6 months

what is a way of social or occupational dysfunction?

disrupting ability to work or relationships (friends, romantic, professional, etc)

what is the general goal for schizophrenia?

• treat underlying cause when applicable

• emphasis on recovery and rehabilitation

• prevention of relapse and independence

what are some collaborative interventions for schizophrenia?

• pharmacological

• non-pharmacological (social skills and differing types of behaviors)

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

• community integration

• group therapy and support groups

what are some independent interventions for schizophrenia?

• 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 pt

what is a dopamine antagonist?

blocks activity at the synapse and decreases the effect that dopamine has on the brain

what are the 2 major groups of antipsychotic drugs?

• first-generation antipsychotics

• second-generation antipsychotics

what are first-generation antipsychotics?

typical/conventional antipsychotics

what are second-generation antipsychotics?

atypical antipsychotics; block serotonin receptors in addition to dopamine

what is the prototype drug for dopamine blockers?

Haloperidol (haldol)

what is the mechanism of action for haloperidol?

blocks actions of dopamine

what are the primary symptom targets for Halperidol?

decreases:

• hallucinations

• delusions

• agitation

what are the adverse outcomes for Halperidol?

• Extrapyramidal symptoms (EPS)

• Tardrive Dyskinesia (TD) (not expected)

• Sedation

• Anticholinergic effects

• Neuroleptic Malignant Syndrome (NMS) (not expected)

What to monitor for extrapyramidal symptoms?

• Muscle stiffness

• tremors

• rigidity

• bradykinesia

• akathisia (restlessness)

• dystonia (sustained muscle contractions)

what is the response for extrapyramidal symptoms (for Olanzapine, Aripiprazole, Risperidone, and haloperidol)

• hold and notify provider

• anticipate order for anticholinergic

what to monitor for tardive dyskinesia?

involuntary movements of the face, tongue, or extremities

what to respond for tardive dyskinesia?

hold and notify provider

what to monitor for sedation?

• excessive sleepiness

• drowsiness

• low LOC (sometimes desired effect if agitation is present)

what is the response for sedation?

• hold and notify provider

• educate on taking at night time

what to monitor for anticholinergic effects?

• dry mouth

• constipation

• urinary retention

• blurred vision

what is the response for anticholinergic effects?

• provide symptomatic treatments (stool softeners, artificial saliva)

• monitor for severe complications (urinary retention or notify provider)

what to monitor for neuroleptic malignant syndrome?

• hyperthermia

• muscle rigidity

• altered mental status

• autonomic instability (tachycardia, BP changes)

what is the response for neuroleptic malignant syndrome?

• hold and notify provider

• RRT

• anticipate order for dantrolene

what is the prototype for dopamine and serotonin blockers?

• Olanzapine (Zyprexa)

• Aripiprazole (Abilify)

• Risperidone (Risperdal)

what is the mechanism of action for Olanzapine, Aripiprazole, and Risperidone

blocks action of dopamine and serotonin

what are the primary symptom targets for Olanzapine, Aripiprazole, and Risperidone?

decreases:

• hallucinations

• delusions

• agitation

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

what are the adverse outcomes for Olanzapine, Aripiprazole, and Risperidone?

• Metabolic syndrome

• QT Prolongation (not expected)

• extrapyramidal symptoms

what to monitor for metabolic syndrome (weight gain, hyperglycemia, and dyslipidemia)?

• weight

• blood glucose levels

• lipid profiles

• waist circumference

what is the response for metabolic syndrome (weight gain, hyperglycemia, and dyslipidemia)

hold and notify provider

what to monitor for QT prolongation?

• ECG for QT interval prolongation

• potassium and magnesium levels

what is the response for QT prolongation?

hold and notify provider