Schizophrenia Spectrum Disorders and Psychosis

psychosis

Disconnect from reality resulting in hallucinations and/or delusions.

found in bipolar, schizophrenia, alcohol withdrawal/ SUD (cannabis, amphetamines), Parkinson, infection, Rx, trauma, illness/ injury( AD, stroke, brain tumor)

psychosis dx

gradual during late teen- early 20s

• Hallucinations

• Persistent troubling thoughts or beliefs

• Emotional changes: inappropriate or no expression of emotions

• Withdrawal or isolation from friends and family

• Changes in cognition 

• Lack of self-care

schizophrenia

chronic illness hallucinations, delusions, disorganized behaviors, and abnormal behaviors.

16-30 dx more in males

2 < s/s must be present for a period of 1 month or longer with signs of continuous disturbance for at least 6 months.

• delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (i.e., diminished emotional expression or avolition

• impaired of major function

schizophrenia spectrum

• Schizophrenia

• Schizoaffective disorder

• Schizophreniform disorder

• Schizotypal personality disorder

experience ep of unusual behaviors in cognitive and social function before psychosis = at-risk mental state (ARMS) = transition to mental health disorder

psychotic disorder

• Brief psychotic disorder

• Delusional disorder

• Psychotic disorder due to another medical condition

• Substance/medication-induced psychotic disorder

• Other specified schizophrenia spectrum and other psychotic disorder

• Unspecified schizophrenia spectrum and other psychotic disorders

schizo spectrum education

• can lead lives w/ proper tx

• bias → underdx/tx

• social isolation → inc psychosis

• co-occurring mental disorder, are no more dangerous than anyone else

• undercounted due to no housing → in prison, no house, institution

schizo risk

genetic

poverty, traumatic events, sexual abuse, cannabis

pregnancy complication → hypoxia, parental age, viral infections, starvation, and stress,

adversities related to prenatal or early childhood (ACE)

neuro: decrease gray matter, disruption in synch in neuro → low cognitive process

schizo autoimmune link

link include celiac disease, multiple sclerosis, systemic lupus erythematosus, Graves’ disease, psoriasis, Guillain-Barré syndrome, and hepatitis.

schizo biochemical

dysregulation of the hypothalamus-pituitary-adrenal axis → cortisol → inc dopamine

chronic stress → degeneration of hippocampal dendrites.

schizo environmental

cannabis + genetic = diathesis-stress model

in dense cities and poverty due to high stress

schizo comorbidy

usually underdx

metabolic syndrome, diabetes mellitus, hypertension, cardiovascular disease, and liver disease

SUD, depression, OCD, anxiety

suicide

positive s/s

at least 1m for dx

• delusion

• hallucination

• disorganized speech

disorganized motor: childlike behavior, silliness, or agitation

catatonic: severe decrease in environmental stimuli. ignoring commands → complete lack of response + purposeless hyperactive or unusual facial expression

lack of impulse control

negative s/s

Missing feelings and behaviors that are usually present, resulting in a decrease or loss of function → difficulty socializing

Bleuler's fundamental symptoms of alogia, autism, ambivalence of feelings, and affect blunting​​​​​​​

apathy

anhedonia: inability ot find pleasure

alogia: lack of language speech

flat affect

self- neglect

avolition/ psychomotor retardation: lack of motivation, slowed movement/ thought process

reduced speech

delusion types:

Persecution: Something or someone (actual or imaginary) is going to harm them

Grandiose: Believing they have exceptional fame, abilities, or wealth, including believing they are of royalty or a deity

Thought insertion/Withdrawal: Someone or something is giving or taking away thoughts or ideas

Control: An outside force is controlling their mind or parts of their body

cognitive s/s

Anxiety, depression, anger, cognitive deficiencies, disordered motor behavior, and disturbed sleep pattern

unaware of s/s : anosognosia

aggressive or inappropriate behavior

Depersonalization, derealization, and somatic episodes

disorganized speech

• echolia

• pressured speech

• tangentiality

• loose association

• incoherency

• clanging speech

• circumstantiality

• neologism

phases of schizo

1. prodromal: initial → full manifestations

   1. disruption of sleep, loss of concentration, and increased anxiety

   2. low motivation

   3. ~hallucinations/ delusions but mild

   4. uncharacteristically withdrawn/ suspicious

   5. negative s/s inc

2. active: severe → hallucinations/ mania/ depression

   1. speech and behavior are disorganized

3. residual

   1. less severe s/s → more negative s/s, perception somewhat altered

   2. may continue ADL w/ tx

schizoaffective

impairment of mood or affect, psychosis

a major depressive or manic episode happens at the same time as active phase manifestations of delusions, hallucinations, or disorganized speech.

negative s/s + impaired + anosognosia less severe

brief psychotic disorder

sudden onset → confusion

1d<x<month

brief psychotic break, delusions, hallucination, or disorganized speech may occur along with grossly disorganized or catatonic behavior

major depressive disorder

depressed mood most of time and no pleasure in life

ep of psychosis and losses touch w/ reality

bipolar

manic, depressive

only during mania or severe depression → psychosis

medical psychosis

anesthesia, pain, epilepsy, allergies, blood pressure, Parkinson's disease, chemotherapy, gastrointestinal disorders, muscle relaxation, inflammation, depression, or alcoholism

OTC: decongestant medications, such as phenylephrine or pseudoephedrine,

condition psychosis

sensory modality→ temporal lobe epilepsy can result in olfactory hallucinations

endocrine or metabolic conditions, fluid or electrolyte imbalances, autoimmune diseases, or liver or kidney disease,

dementia

mental condition

posttraumatic stress (PTSD),

autism spectrum: negative s/s

obsessive-compulsive disorder: preoccupations become delusions

schizo dx

mental status assess (MSA):

• history of suicide, hallucinations, substance use, and prior mental health issues

• appearance; speech patterns; affect; mood; and thought content and thought processes.

MRI, EEG, CT: abnormal in white matter and specific thalamic regions

catatonia, tardive dyskinesia, parkinsonism

noticeable differences in eye-tracking, coordination, sensory function, the ability to perform complex movements in a sequence, and left-right awareness.

sensitive care

Cultural formulations, interview (CFI) strategies, and motivational interviewing (MI)

SDOH: where people live, learn, work, and play that affect a wide range of health and quality of life risks and outcomes

ask current living situation, food insecurity, education/employment

cognitive impair to see how the nurse should provide information

orientation

nurse’s bias

pt challange to express feelings and to consider changes

obstacles:

• pt does not recognize need for assistance

• close relatives unwilling to help

• psychosis s/s

• bias

• cognitive deficit of pt

identification

pt needs to be aware of the issues

consider psychosis phases

exploitation

pt explores interventions (medications and therapies) + recognize triggers and express difficulties and need for assistance.

keeping the client safe, setting clear limits on what actions and behaviors are acceptable, and clearly explaining the plan of care

resolution

recovery have been met and the client is able to live on their own with the disorder

direct communication

mention by name, don’t touch pt

• “What are you hearing?”

• “What are you seeing?”

• “How does this make you feel?”

never argue, reorient, reassure environment is safe

tx

antipsychotic, CBT< family education and support

recovery-oriented approach focuses on symptom management

assertive community tx: community resources vs hospitalization and homelessness

antipsychotic

FGA: phenothiazine , chlorpromazine, and haloperidol (Haldol)= positive s/s + psychosis

SGA: risperidone, clozapine, and olanzapine = positive and negative

delusions and halluciantion

acknowledge w/ response based on fact

determine details, triggers, feelings

assess ability to function, relationship, behaviors, frequency, intensity, duration

encourage participating in current activates, emphasize safety, and mindfulness for reality, remove triggers, ask other if it is real ( reality checking)

relapse prevent plan

sings of relapse: ex change in sleep pattern and cognitive function such as increased day-dreaming or lack of concentration

consideration if relapse occurs:

• Who will care for family or pets?

• Who will manage finances?

• Which providers, hospitals, or facilities does the client prefer?

• Who does the client want to inform about relapse?

shared psychotic disorder

when a person without a history of psychosis or mental illness develops psychosis after interacting with an individual who has an existing psychotic disorder.

late-onset schizo

>40

may experience delusions or disorganized thoughts and behaviors, but their personality is typically unchanged

ADR antipsychotic

• Akathisia, Tardive dyskinesia, Parkinsonism, Dystonia

• Impulse control disorder

• Sialorrhea

• Sedation

• Sexual function

• Orthostatic hypotension

• Neuroleptic malignant syndrome

• Metabolic effects

• Agranulocytosis

recovery-oriented approach

1. Remediations of Function: Reduce the impact of mental illness  by collaborating with the client to reduce relapse.

2. Restoration: Engage with the client to regain confidence in themselves for coping with daily living, manage residual symptoms of the disorder, and develop and support the client as needed.

3. Reconnection: Reconnect with the community and explore independence, gaining confidence and a sense of hope.

serious mental illness (SMI)

resulted in functional impairment which substantially interferes with or limits one or more major life activities:

• schizophrenia-spectrum disorders,

• severe bipolar disorder

• severe major depression

jail/prison

45% have been tx for SMI→ inadequate treatment, relapses, and victimization

• diff for employment→ more likely to get incarcerated

isolation and loneliness

poor hygiene, lowered social skills, and poor self-image, negatively impacting family and social relationships.

victimization

someone might have possessions or clothing taken, but it can also include becoming a victim of a violent crime such as physical or sexual assault or murder

economic challenges

job losses, trouble finding employment, inability to work due to disability, or issues with finding and keeping housing

caregiver burden: more focus on pt than themselves

anosognosia

damage to the frontal lobe of their brain → when someone is either unaware or cannot accurately perceive their own mental health

nonadherence

anosognosia

side effects of medications, negative attitude toward using medication, lack of family or social support, stigma of taking medication, inability to pay for services, or limited access to mental health care.