Chapter 15: Psychotic Disorders

Chapter 15: Psychotic Disorders

Psychotic disorders (including schizophrenia) affect:

• Thinking

• Behavior

• Emotions

• Ability to perceive reality

Etiology (Causes)

• Likely due to a combination of:

  • Genetic factors

  • Neurobiological factors

  • Nongenetic factors (injury at birth, viral infection, nutritional factors)

Onset

• Typical age: mid-teens to mid-20s

• Can occur:

  • In young children

  • In later adulthood

Prodromal Period

• Early stage before full disorder develops

• Symptoms may include:

  • Negative symptoms (e.g., anergia = lack of energy)

  • Reduced positive symptoms (less intense hallucinations/delusions)

Impact

• Becomes problematic when symptoms interfere with:

  • Interpersonal relationships

  • Self-care

  • Ability to work

Types of Psychotic Disorders (DSM-5-TR)

Schizophrenia

• Psychotic thinking/behavior ≥ 6 months

• Significant impairment in work, self-care, relationships

Schizotypal Personality Disorder

• Impaired self/interpersonal functioning

• Not as severe as schizophrenia

Delusional Disorder

• Delusions ≥ 1 month

• Functioning not markedly impaired

Brief Psychotic Disorder

• Psychotic symptoms lasting 1 day – 1 month

Schizophreniform Disorder

• Symptoms like schizophrenia

• Duration 1 – 6 months

• Social/occupational dysfunction may not be obvious

Schizoaffective Disorder

• Meets criteria for both schizophrenia and mood disorder (depressive or bipolar)

Substance/Medication-Induced Psychotic Disorder

• Psychosis from intoxication, withdrawal, or medication exposure

• More severe than typical substance effects

Psychotic or Catatonic Disorder Due to Another Medical Condition

• Psychosis or catatonia caused by a medical condition

• Does not meet criteria for another specific psychotic disorder

Psychotic Disorder Expected Findings

Positive Symptoms (things not normally present, easily identifiable)

• Hallucinations

• Delusions

• Alterations in speech

• Bizarre behavior (e.g., walking backward constantly)

Negative Symptoms (absence of normal functions – harder to treat)

• Affect – Blunted/flat emotional expression

• Alogia – Poverty of speech/thought

• Anergia – Lack of energy

• Anhedonia – Lack of pleasure/joy

• Avolition – Lack of motivation (cannot initiate activities without prompting)

Cognitive Findings (thinking/processing difficulties)

• Disordered thinking

• Poor decision-making

• Poor problem-solving

• Difficulty concentrating

• Short-term memory deficits

• Impaired abstract thinking

Affective Findings (emotion-related)

• Hopelessness

• Suicidal ideation

• Unstable or rapidly changing mood

Alterations in thought (delusions)

Alterations in Speech

Alterations in Perception

Personal Boundary Difficulties

Alterations in Behavior

Determine which symptom to drag positive or negative symptoms of schizophrenia. Drag each symptom to the desired image. 

Hallucinations

Avolition

Alterations in speech

Delusions

Bizarre Motor movements

Flat affect

Anhedonia

Anergia

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Positive

Negative

Positive

• Bizarre Motor movements

• Delusions

• Alterations in speech

• Hallucinations

Negative

• Anhedonia

• Anergia

• Flat affect

• Avolition

Alterations in Thought (Delusions)

False, fixed beliefs that cannot be corrected by reasoning (often bizarre).

• Ideas of reference – Misinterprets trivial events as personal (e.g., others talking about them)

• Persecution – Believes others intend harm (e.g., hunted by FBI)

• Grandeur – Believes they are powerful/important (e.g., god-like)

• Somatic delusions – Believes body is changing unusually (e.g., growing extra limb)

• Jealousy – Believes partner is unfaithful without evidence

• Being controlled – Believes outside force is controlling their body

• Thought broadcasting – Believes others can hear their thoughts

• Thought insertion – Believes others’ thoughts are placed into their mind

• Thought withdrawal – Believes thoughts are removed by external force

• Religiosity – Preoccupation with religious beliefs

• Magical thinking – Believes actions/thoughts control events (e.g., special hat makes them invisible)

Alterations in Speech

Associative looseness – Incoherent, rapid shifting of topics (flight of ideas)

Neologisms – Made-up words with meaning only to client

Echolalia – Repeats words spoken to them

Clang association – Rhyming words, often forceful (“fox, box, lox”)

Word salad – Jumbled words without meaning (“Hip hooray, the flip is cast…”)

Circumstantiality – Excessive, unnecessary details before getting to the point

Tangentiality – Wanders off-topic; never returns to original point

Alterations in Perception (hallucinations – no external stimulus)

Auditory – hearing voices/sounds

• Command hallucinations – voices instruct actions (e.g., harm self/others → high risk)

Visual – seeing persons/things

Olfactory – smelling odors

Gustatory – experiencing tastes

Tactile – feeling bodily sensations

Personal Boundary Difficulties

Disconnection with body, identity, or perception.

• Depersonalization – feeling identity is lost/unreal

• Derealization – perceiving environment as altered (e.g., shrinking objects)

• Illusions – misinterpretation of real external stimuli

Alterations in Behavior

Extreme agitation – pacing, rocking

Stereotyped behaviors – repetitive, purposeless movements (e.g., sweeping motions)

Automatic obedience – robot-like compliance

Waxy flexibility – maintaining rigid posture for long time

Stupor – motionless, coma-like

Negativism – doing the opposite of requests

Echopraxia – mimicking movements of others

Catatonia – decreased/increased movement; rigid positioning possible

Motor retardation – slowed movements

Impaired impulse control – inability to resist urges

Gesturing/posturing – unusual, illogical expressions

Boundary impairment – inability to see distinction between self and others

Personality Disorder Standardized Screening Tools

AIMS (Abnormal Involuntary Movement Scale) – used to monitor involuntary movements and tardive dyskinesia in clients on antipsychotic medications

Personality Disorder Nursing Care

Therapeutic Approaches

• Milieu therapy – structured, safe environment to reduce anxiety & distraction from hallucinations

• Assertive Community Treatment (ACT) – intensive case management & interprofessional support for community-living needs

• Promote therapeutic communication – reduces anxiety, defensive patterns, and increases participation

• Establish trusting relationship with client

Communication for Hallucinations & Delusions

• Ask directly about hallucinations (acknowledge feelings without agreeing/disagreeing)

• Do not argue with delusions; instead, focus on client’s feelings and provide supportive responses

• Monitor for paranoid delusions (risk for violence)

• Ensure safety if client has command hallucinations (↑ risk for harm to self/others)

• Use reality-based topics in conversation

• Identify manifestation triggers (e.g., loud noises can worsen auditory hallucinations)

• Be genuine and empathetic

Additional Nursing Interventions

• Determine discharge needs (ADLs, ability to live independently)

• Promote self-care by teaching/modeling within facility

• Link wellness to manifestation management

• Teach coping strategies for hallucinations/anxiety:

  • Music, attending activities, walking, talking with trusted person, directly addressing hallucination (“go away”)

• Provide medication education

• Involve family when possible

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Client Education

• Develop social skills and friendships

• Participate in group work and psychoeducation

• Comply with medications

​​​​​​​A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse’s questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

a

​​​​​​​Stop the interview at this point, and resume later when the client is better able to concentrate.

b

Ask the client, “Are you seeing something on the ceiling?”

c

Tell the client, “You seem to be looking at something on the ceiling. I see something there, too.”​​​​​​​ 

d

Continue the interview without commenting on the client’s behavior.

Submit

b Ask the client, “Are you seeing something on the ceiling?”

When taking action, the nurse should ask the client directly about the hallucination to identify client needs and monitor for a potential risk for injury.

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The nurse should address the client’s current needs related to the possible hallucination rather than to stop the interview.

Avoid agreeing with the client, which can promote psychotic thinking

The nurse should address the client’s current needs related to the possible hallucinations rather than ignoring the change in behavior.

Medications for Psychotic Disorders

Schizophrenia often has acute exacerbations with intervals of semi-remission (symptoms persist but are less severe).

First-Generation (Conventional) Antipsychotics

• Used mainly for positive symptoms

• Reserved for clients who:

  • Can tolerate adverse effects

  • Cannot afford second-generation medications

Potency levels:

• Low potency – low EPS, high sedation, high anticholinergic effects

• Medium potency – moderate EPS, sedation, anticholinergic effects

• High potency – high EPS, low sedation, low anticholinergic effects

Second-Generation (Atypical) Antipsychotics

(Current first-line treatment for schizophrenia)

Advantages:

• Relieve both positive and negative symptoms

• Reduce depression, anxiety, suicidality

• Improve neurocognitive deficits (e.g., poor memory)

• Few or no EPS (less dopamine blockade → less tardive dyskinesia)

• Fewer anticholinergic effects (exception: clozapine has high incidence)

• Lower relapse risk

Third-Generation Antipsychotics

• Treat both positive and negative symptoms

• Improve cognitive function

Advantages:

• Decreased EPS/tardive dyskinesia

• Lower risk for weight gain & anticholinergic effects

Goals

• Suppress acute episodes

• Prevent acute recurrence

• Maintain highest possible level of functioning

Health Teaching

• Understanding of disorder

• Self-care to prevent relapse

• Medication adherence & side effects

• Importance of support groups

• Avoid alcohol/substances

• Keep log/journal of feelings & behavior changes (monitor effectiveness)

Nursing Evaluation of Medication Effectiveness

• Improvement/prevention of acute psychosis (↓ hallucinations, delusions, anxiety, hostility)

• Improved ADLs

• Improved social interaction with peers

• Better sleep & eating habits

Extrapyramidal Symptoms (EPS) Types (DTAP)

(Acute) Dystonia

• Manifestations: Severe spasms of tongue, neck, face, back → crisis situation

• Nursing actions:

  • Monitor 1–5 days after start

  • Treat: benztropine (antiparkinsonian), diphenhydramine IM/IV

  • Stay with client until resolved (5–15 min)

Tardive Dyskinesia (TD)

• Manifestations: Late EPS (months–years); involuntary movements (tongue, face, arms, trunk)

• Nursing actions:

  • Evaluate at 12 months, then every 3 months

  • Switch to 2nd-gen antipsychotic if possible

  • No reliable treatment; instruct client on controlling purposeful movements

Akathisia

• Manifestations: Inability to sit still, pacing, agitation

• Nursing actions:

  • Monitor during first 2 months (5–60 days)

  • Treat with antiparkinsonians, beta-blockers, lorazepam/diazepam

  • Monitor suicide risk

Pseudoparkinsonism

• Manifestations: Bradykinesia, rigidity, shuffling gait, drooling, tremors (pill-rolling), mask-like face

• Nursing actions:

  • Monitor during first month (5–30 days)

  • Treat with benztropine/trihexyphenidyl

Positive vs Negative Symptoms

Agitation, bizarre behavior, delusions, hallucinations, flight of ideas, loose associations

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Social withdrawal, flat affect, low energy, low motivation, anhedonia

Antipsychotics: First-Generation (Conventional) (-azine, -thixene, Loxapine, Haloperidol) Action / Use

Blocks dopamine (D2), acetylcholine, histamine, norepinephrine receptors in brain & periphery

• Antipsychotic effects primarily from D2 blockade in the brain

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Acute & chronic psychotic disorders

Schizophrenia spectrum disorders

Bipolar disorder (manic phase)

Tourette disorder

Agitation

Nausea/vomiting (blocks dopamine in chemoreceptor trigger zone of medulla)

Antipsychotics: First-Generation (Conventional) (-azine, -thixene, Loxapine, Haloperidol) Complications / Contraindications

Agranulocytosis

• Nursing actions: Monitor for infection (CBC, discontinue if WBC < 3,000/mm³)

Anticholinergic Effects

• Dry mouth, blurred vision, photophobia, urinary hesitancy/retention, constipation, tachycardia

Extrapyramidal Symptoms (EPS)

• D - Benztropine (antiparkinsonian), diphenhydramine IM/IV

• T - Switch to 2nd gen, eval every 3 mo., instruction

• A - Eval first 2 mo., antiparkinsonians, beta-blockers, lorazepam/diazepam, suicide watch

• P - Eval first mo., benztropine/trihexyphenidyl, fall prevention

Neuroendocrine Effects

• Manifestations: Gynecomastia, weight gain, menstrual irregularities, galactorrhea

Neuroleptic Malignant Syndrome (NMS)

• Manifestations: Sudden high fever, BP fluctuations, diaphoresis, tachycardia, muscle rigidity, ↓ LOC, coma

• Nursing actions:

  • Stop antipsychotic immediately

  • Monitor vitals, apply cooling, give antipyretics

  • Administer dantrolene or bromocriptine for muscle rigidity

  • Treat arrhythmias as prescribed

  • Increase fluid intake

  • ICU transfer

  • Resume therapy only after 2 weeks; consider atypical antipsychotic

Orthostatic Hypotension

Sedation

Seizures

Severe Dysrhythmias

• Monitor potassium and avoid concurrent QT-prolonging meds

Sexual Dysfunction (Lower dose or switch to high-potency agent)

Skin Effects (Photosensitivity, contact dermatitis)

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Coma

Parkinson’s disease

Liver damage

Severe hypotension

Dementia

Use cautiously in:

• Prostate enlargement

• Heart disorders

• Glaucoma

• Paralytic ileus

• Liver/kidney disease

• Seizure disorders

Antipsychotics: First-Generation (Conventional) (-azine, -thixene, Loxapine, Haloperidol) Interactions / Admin

Other anticholinergic meds – ↑ anticholinergic effects

• Client education: Avoid OTC sleep aids, antihistamines

Alcohol, opioids, antihistamines – additive CNS depression

• Client education: Avoid alcohol, CNS depressants, driving/hazardous activity

Levodopa/dopamine agonists – counteract antipsychotic effects

• Client education: Avoid concurrent use

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Use AIMS to monitor for EPS

Differentiate between EPS vs worsening psychosis

May administer anticholinergics, beta blockers, benzodiazepines for EPS

Depot injections (haloperidol decanoate, fluphenazine decanoate) IM every 2–4 weeks

• Lower doses with depot preparations reduce risk of adverse effects and tardive dyskinesia

Start with BID dosing → switch to bedtime dosing to ↓ daytime drowsiness

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Client Education

• Antipsychotics rarely cause dependence

• Must take consistently as prescribed

• Effects may be noticeable within a few days, but full improvement takes 2–4 weeks (sometimes several months)

Antipsychotics: First-Generation (Conventional) Meds

Prototype

• Chlorpromazine

Other Medications

• Haloperidol (high potency)

• Fluphenazine (high potency)

• Loxapine (medium potency)

• Thioxthixene (high potency)

• Perphenazine (medium potency)

A nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the nurse identify as being effectively treated by first-generation antipsychotics? ​​​​​​​

Select all that apply.

a

Auditory hallucinations

b

Withdrawal from social situations

c

Delusions of grandeur

d

Severe agitation

e

Anhedonia

a Auditory hallucinations

c Delusions of grandeur

d Severe agitation

When taking action, the nurse should identify that auditory hallucinations, delusions of grandeur, and severe agitation are positive symptoms of schizophrenia that are effectively treated by first-generation antipsychotics.

A nurse is caring for a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)?

Select all that apply.

a

Decreased level of consciousness

b

Drooling

c

Involuntary arm movements

d

Urinary retention

e

Continual pacing

b Drooling

c Involuntary arm movements

e Continual pacing

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Decreased level of consciousness = Neuroleptic malignant syndrome

Urinary retention = anticholinergic

1st vs 2nd vs 3rd Gen Atypical Antipsychotics

Primarily blocks dopamine (D2) receptors

No effect on NT systems (only treats positive symptoms)

Side Effects: Neuroendocrine, Neuroleptic Malignant Syndrome (NMS)

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Primarily blocks dopamine (D2) and serotonin (5HT2A) receptors

Treats positive and negative symptoms

Side Effects: Metabolic Syndrome, Elevated Prolactin

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Primarily PARTIALLY BLOCKS (partial agonist) dopamine (D2) (stabilizes levels) and block serotonin (5HT2A) receptors

Treats positive and negative symptoms

Side Effects: Metabolic Syndrome, Elevated Prolactin

What is the lead theory in what causes positive vs negative symptoms?

Positive symptoms = glutamate imbalance → dopamine receptor overstimulation

Negative symptoms =

Antipsychotics: Second- and Third-Generation (Atypical) (-apine, idone, -ipra-) Action / Use

Second-gen: Block serotonin (main) and dopamine (lesser degree) receptors

Third-gen: Stabilize dopamine system as agonist + antagonist (partial agonist)

Both block norepinephrine, histamine, acetylcholine receptors

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Treat positive & negative symptoms of schizophrenia spectrum disorders

Psychosis induced by levodopa therapy

Relief of psychotic manifestations in other disorders (e.g., bipolar disorder)

Impulse control disorders

Antipsychotics: Second- and Third-Generation (Atypical) (-apine, idone, -ipra-) Complications / Contradications

Agranulocytosis

• Nursing actions: Monitor for infection (CBC, discontinue if WBC < 3,000/mm³)

Anticholinergic Effects

• Dry mouth, blurred vision, photophobia, urinary hesitancy/retention, constipation, tachycardia

Orthostatic Hypotension

Metabolic Syndrome

• New onset diabetes or loss of glucose control

• Dyslipidemia → ↑ risk for cardiovascular disease

• Weight gain

Agitation, Dizziness, Sedation, Sleep Disruption

Mild EPS (e.g., Tremor) - Use AIMS test

Elevated Prolactin Levels

• Client education: Report galactorrhea, gynecomastia, amenorrhea

Sexual Dysfunction

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Risperidone

• Dementia (↑ risk of cerebrovascular accident, infection, death)

• Avoid alcohol

• Use cautiously with cardiovascular/cerebrovascular disease, seizures, or diabetes (monitor glucose carefully)

Antipsychotics: Second- and Third-Generation (Atypical) (-apine, idone, -ipra-) Interactions / Admin

Immunosuppressants (anticancer meds) – further suppress immune function

• Nursing actions: Avoid with clozapine

Alcohol, opioids, antihistamines, CNS depressants – additive CNS depression

• Client education: Avoid alcohol, CNS depressants, driving/hazardous activity

Levodopa & dopamine agonists – counteract antipsychotics

• Nursing actions: Avoid concurrent use

Tricyclic antidepressants, amiodarone, clarithromycin – prolong QT interval → ↑ dysrhythmia risk

• Nursing actions: Avoid combining with other QT-prolonging agents

Barbiturates & phenytoin – ↓ levels of aripiprazole, quetiapine, ziprasidone

• Nursing actions: Monitor effectiveness

Fluconazole – ↑ levels of aripiprazole, quetiapine, ziprasidone

• Nursing actions: Monitor effectiveness

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Depot/long-acting injections:

• Risperidone: IM every 2 weeks

• Paliperidone ER injection: every 28 days

• Invega Trinza (paliperidone palmitate, generic): every 3 months

• Aripiprazole LAI: monthly

• Therapeutic effect: 2–6 weeks after first depot dose

Use orally disintegrating tablets if client might “cheek” or has difficulty swallowing

Administer lurasidone and ziprasidone with food for absorption

Monitor cost barriers → may require case management support

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Client Education

• Start with low dose, titrate gradually (“Start low and go slow”)

• Take consistently as prescribed

• If taking asenapine → avoid eating/drinking ×10 min after dose

Antipsychotics: Second- and Third-Generation (Atypical) Meds

Prototype

• Risperidone

Other Medications

• Second-generation: Asenapine, Clozapine, Iloperidone, Lurasidone, Olanzapine, Paliperidone, Quetiapine, Ziprasidone

• Third-generation: Aripiprazole, Cariprazine, Brexpiprazole

Adjunct Medications for Psychotic Disorders

Antidepressants (STaMiNA)

• Example: Paroxetine

• Purpose: Treat depression in clients with psychotic disorders

• Nursing actions:

  • Monitor for suicidal ideation (esp. at start of therapy)

  • Report worsening depression

• Client education: Avoid abrupt cessation (prevents withdrawal)

Mood Stabilizers & Benzodiazepines

• Examples: Valproate, Lamotrigine, Lorazepam

• Purpose: Treat anxiety, agitation, some positive/negative symptoms

• Nursing actions: Use cautiously in older adults

• Client education:

  • Sedative effects possible

  • Case management & follow-up support

  • Group, family, individual psychoeducation (problem-solving, social skills, ADLs)

Determine to which category each medication listed below belongs. Drag each medicate to the desired image.

Risperidone

Haloperidol

Quetiapine

Loxapine

Olanzapine

Clozapine

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Typical antipsychotics

Atypical antipsychotics

Typical antipsychotics

• Loxapine

• Haloperidol

Atypical antipsychotics

• Clozapine

• Olanzapine

• Quetiapine

• Risperidone