Psychotic Disorders

What are 5 Key Features of Psychotic Disorders?

• Hallucinations

• Delusions

• Disorganized thinking/speech

• Grossly disorganized behavior

• Negative s/s

What are associated key features of psychotic disorders?

Disturbed sleep, anxiety, cognitive deficits, inattention, lack of insight, depression or anger, flat affect

What is schizo-affective disorder?

Meets criteria for schizophrenia, but also for bipolar OR depression

What is Schizophreniform?

s/s last >1mo, but <6mo

What is Delusional Disorder?

strictly delusions!! very fixed beliefs, not as much decline in daily life

What is Substance-Induced Psychotic Disorder?

• Can be caused by ETOH or cannabis

• Higher rate of developing schizo from cannabis if have genetic predisposition or if used in developing brain

• Education → buy at dispensary, eat it, dont smoke it

Schizophrenia: Age of Onset

• Btwn late teens-mid 30s (onset before 16yo is rare)

  • Men: early-mid 20s

  • Women: late 20s

• Late onset (after 40yo) is usually in women

Cultural consideration of Psychotic Disorders

• Some ideas that might seem delusional are normal in other cultures (witchcraft, ghosts)

• Visual/auditory hallucinations might be religious experiences for some

• “disorganized speech” may just be a different language

What is the main neurotransmitter involved in schizophrenia?

Dopamine (specifically hyperactivity of dopamine)

What does the clinical course of schizo look like?

• Prodromal period: early changes that can indicate schizo (anxiety, sleep issues, strange thinking, lack of interest)

• Acute Illness: 1ST PSYCHOSIS EPISODE (FEP) → pt terrified of surroundings, can become danger to themself or others

• Stabilization: ongoing tx, s/s may be present but milder, pt better at reality-testing

• Recovery: acceptance of illness, better social connection

• Relapse: can happen at any time (but usually when they discontinue meds)

Nursing Assessment for Schizophrenia

• Hx of psychotic episodes

• Baseline functioning

• MSE

• Family Hx

• Safety Risk Assessment

• Medications

• Positive or Negative s/s

Positive vs. Negative schizo s/s?

• Positive: disorganized thinking, catatonia, delusions, hallucinations

• Negative: blunted affect, alogia (less talking), loss of motivation (avolition), inability to feel joy (anhedonia)

Types of Delusions

• Grandiose: believe they are exceptional, have grand power or destiny

• Nihilistic: impending doom will occur

• Persecutory: similar to paranoia

• Somatic: believe something is happening inside their body

• Thought Insertion: believe other people are putting thoughts in their head

What is the most concerning type of hallucination?

Command Auditory Hallucinations (CAH) → a voice is demanding them to do something

Nursing Interventions: Schizo

• SAFETY!!

• Create a routine

• Develop social skills

• Establish coping skills

• Ensure family involvement

• Relapse prevention

Communication in those w/ hallucination

• Ask about hallucination

• Avoid reacting to hallucinations as if they are real

• Do not negate the experience, but offer your own perception

• Reality-based diversion

Communication in those w/ delusions

• Be matter-of-fact and calm

• Avoid arguing, but interject doubt

• Observe triggers for delusions

• Validate true parts of the delusions

Antipsychotic Medications (General Know.)

• Indicated for schizo, positive psychotic s/s

• Metabolized by liver

• DECREASE dopamine levels

What are some side effects of antipsychotics?

• CV

• Sexual side effects

• Weigh gain

• hyperprolactinemia (RISPERIDONE)

• Sedation

• Lower seizure threshold

• Blood disorders (especially CLOZAPINE d/t agranulocytosis)

Anticholinergic Crisis

• LIFE THREATENING → usually from an OD or sensitivity

• s/s: hot as a hare (fever), blind as a bat (blurred vision), mad as a hatter (agitation), dry as a bone (dry mouth)

• Tx: discontinue med, ANTIDOTE → physostigmine (IV or IM), gastric lavage, charcoal

Neuroleptic Malignant Syndrome

• LIFE THREATENING

• s/s: altered mental status, muscle rigidity, fever, HTN, tachycardia, sweating, leukocytosis, muscle injury

• Tx: hold med → give benzo + treat fever → ICU transfer

Extrapyramidal S/s

• Dystonia (twitching/jerking), pseudoparkinson, akathisia (restlessness)

• THESE ARE TREATABLE side effects

• Tx w/ Benadryl, Benztropine (Cogentin)

• More common in typical antipsychotics

Scale used to monitor s/s of tardive dyskinesia?

AIMS Scale

Black box warning for some antipsychotics

• Increased mortality in elderly pts w/ dementia-related psychosis

• Aripiprazole (Abilify): compulsive urges to gamble, binge-eat, have sex

Long-Acting Injectables (LAI)

• Useful to improve compliance

• May cause irritation, granuloma, or abscess at injection site

• Post Injection Delirium Syndrome (PDSS): occurs 1 hr after injection (dizziness, confusion, slurred speech, altered gait). Resolves in 3-72hrs

Olanzapine LAI

• Has BLACK BOX WARNING for PDSS

• Facility giving it must have ER

• Pt MUST be observed for 3 HRS if given this med