psychosis and antipsychotic medications

Second Generation (SGA)

Atypical- 1980/90

Third Generation (TGA)

Subset of SGA

First Generation Antipsychotics (FGA)

•Dopamine antagonist (Potent D2 receptor antagonists)

•Block attachment of dopamine in several areas of the brain

•Shotgun approach – increased side effects due to more areas of the brain affected by FGA

Reduce dopaminergic transmission

Second Generation Antipsychotics (SGA)

•Less affinity for D2; D3 and D4 antagonism

•Has a more targeted approach

•D3 and D4 receptors are located in the limbic system and frontal lobe (thus affecting dopamine transmission in areas of the brain associated  with the pathology of schizophrenia)

Block D2 preferentially in the limbic system over the nigrostriatal tract leading to the basal ganglia

•Third Generation Antipsychotics

•Subset of second generation antipsychotics

•Dopamine system stabilizer (functional selectivity)

•Partial D2 antagonist / agonist

•Partial 5HT2a agonist / antagonist

•May improve positive, negative symptoms and cognitive function

First Generation (Typical) Antipsychotic Drugs

—Target positive symptoms of schizophrenia (delusions/hallucinations, illusion etc)

—Advantage

◦Less expensive than atypical antipsychotics

—Disadvantages

◦Do not treat negative symptoms

◦Higher incidence of extrapyramidal side effects (EPS)

High Potency

(low sedation++high EPS)

•fluphenazine (Prolixin)

•haloperidol (Haldol)

•pimozide (Orap)

•thiothixene (Navane)

•trifluoperazine

(generic only)

 

Low Potency

(high sedation + + low EPS)

chlorpromazine
(thorazine)

thioriadizine (Mellaril)

Mesoridazine (Serentil)

Medium Potency

loxaine (Loxitane)

molidone (Moban)

perphenazine (Trilafon)

Decanoate Preparations = Long acting

•Aripiprazole depot (Abilify Maintena )

•Aripiprazole lauroxil (Aristada)

•Haloperidol decanoate (Haldol decanoate)

•Fluphenazine decanoate (Prolixin decanoate)

•Olanzapine (Zyprexa Relprevv)

•Paliperidone (Invega Sustenna)

•Risperidone depot(Risperdal Consta)

Second Generation Antipsychotics

(atypicals)

—Advantages

◦Diminishes negative symptoms of schizophrenia (avolition, anhedonia, affective blunting)

◦Less side effects encourages medication compliance

◦Improves symptoms of depression and anxiety

◦Decreases suicidal behavior

—Disadvantages

◦Weight gain

Metabolic abnormalities – Metabolic Syndrome

Second Generation Antipsychotics

•Paliperidone (Invega, Invega Sustenna, Invega Trinza)

•Risperidone (Risperdal, Risperdal Consta)

•Quetiapine (Seroquel)

•Olanzapine (Zyprexa, Zyprexa Relprevv)

•Iloperodone (Fanapt)

•Ziprasidone (Geodon)

•Lurasidone (Latuda)

•Asenapine (Saphris)

•Brexpiprazole (Rexulti)

•Cariprazine (Vraylar)

Clozapine (Clozaril)

Third-Generation Antipsychotics

•aripiprazole (Abilify, Abilify Maintena)

•brexpiprazole (Rexulti)

•cariprazine (Vraylar)

•Improves positive and negative symptoms and cognitive function

•Low risk of EPS or tardive dyskinesia

Extrapyramidal Side Effects

(imbalance of dopamine/acetylcholine)

•Acute dystonic reactions

•Pseudoparkinsonism

•Akathisia

•Tardive dyskinesia

Abnormal Involuntary Movement Scale(AIMS test)

EPS:  Acute Dystonia

—Symptoms (few hours – 5 days)

◦Torticollis – spasm of the neck muscle

◦Opisthotonos - head and heels are bent backward and touch the surface

◦Oculogyric crisis – eyes staring upward and outward

Laryngeal spasm - ?

EPS:  Acute Dystonia

Treatment

◦Responds readily to anticholinergics/antihistamines (benztropine, diphenhydramine)

◦Notify MD/ hold neuroleptic

◦Take to quiet area

◦Stay with client until resolves

Continue benztropine

Torticollis

◦spasm of the neck muscle

Opisthotonos

head and heels are bent backward and touch the surface

Oculogyric crisis

eyes staring upward and outward

Laryngeal spasm

an involuntary, temporary contraction of the vocal cords that causes a sudden difficulty in breathing and speaking

EPS:  Akathisia

•Symptoms (2 hours – 60 days)

•Motor restlessness, urge to pace, shift weight

•Cannot sit or stand still

Always moving some body part

EPS:  Akathisia

Treatment

•Reduce dose

•Change to another antipsychotic

•Disappears once agent is stopped

Treat with antiparkinsonian, benzodiazepine or beta blocker

EPS:  Pseudoparkinsonism

•Symptoms (5 hours -30 days) r/t dopamine blockade

•Masklike face (flat affect)

•Tremor

•General rigidity 

Shuffling gait

EPS:  Pseudoparkinsonism

Treatment

•Anticholinergic: benztropine, trihexphenidyl

•Dopamine agonist: amantadine

Notify HCP

EPS:  Tardive Dyskinesia

—Symptoms (months to years)

◦Involuntary movement of the face, jaw, tongue

◦Bizarre grimaces, lip smacking/pursing, tongue protrusion, excessive eye blinking

◦Rapid movements of the limbs, torso and fingers (“piano playing”)

◦Rapid hip jerks

EPS:  Tardive Dyskinesia

—Treatment

—V-MAT-2 - vesicular monoamine transporter-2 inhibitor

—Inhibits the packaging of NT into vesicles for release in synapse

—valbenazine (Ingrezza)

—deutetrabenazine (Austedo)

Rare and Toxic Side Effects

•Agranulocytosis

•Cholestatic jaundice

•Anticholinergic toxicity

Neuroleptic malignant syndrome (NMS)

Neuroleptic Malignant Syndrome (NMS)

—Due to dopamine blockade

—Usually occurs early in therapy but can occur months after start of antipsychotic

Haloperidol and fluphenazine are most likely to cause NMS

Neuroleptic Malignant Syndrome (NMS)

—Symptoms:  extreme muscle rigidity, hyperpyrexia, altered consciousness, autonomic disturbance

—Considered a medical emergency (5-20% mortality rate)

—Needs immediate transfer (including 911) to emergency room

—Notify MD

No specific treatment -supportive measures instituted

Smoking and Antipsychotics

•Smoking induces the metabolism of some antipsychotics

•olanzapine (Zyprexa) 

•fluphenazine (Prolixin)

•clozapine (Clozaril)

•chlorpromazine (Thorazine)

•haloperidol (Haldol)

•perphenazine (Trilafon)

thioridazine (Mellaril) 

•What happens when a patient who smokes 2 packs/day is admitted to the hospital with limited nicotine replacement?

What about his/her discharge?

Smoking (specifically cigarette smoke) significantly impacts the effectiveness of many antipsychotic medications, forcing nurses and prescribers to adjust dosages and closely monitor patients.

Nursing Priority: When a patient is receiving one of these affected medications, the nurse must always ask about current smoking status and, if the patient plans to quit or relapse, notify the provider immediately so the medication dose can be adjusted downward to prevent toxicity.

Adjunct Treatments

•Antidepressants

•Mood stabilizers

•Benzodiazepines

•Electroconvulsive therapy (ECT)

•Suicidal, violent, self-starvation, psychotic depression

Lifestyle changes when taking antipsychotics

•Stop smoking

•Avoid alcohol, street drugs, marijuana

•Low calorie, high fiber diet

•Increase fluids

•Exercise

Avoid excess exposure to sunlight

SCHIZOPHRENIA SPECTRUM DISORDERS

•Delusional Disorder

•Brief Psychotic Disorder

•Schizophreniform Disorder

•Schizoaffective Disorder

•Substance-Induced Psychotic Disorder

•Psychotic Disorder due to a medical condition

Schizophrenia

is a severe, chronic mental health disorder that affects how a person thinks, feels, and behaves.

It is classified as a psychotic disorder because it is characterized by psychosis, meaning a loss of contact with reality, which often involves hallucinations and delusions.

It is a complex brain disorder that typically emerges in late adolescence or early adulthood (mid-teens to late 20s) and affects cognitive function, emotional expression, and behavior.

Schizophrenia

Affects 1% of population

No difference related to race or culture

75%

Develops gradually presenting at 15-25 years of age

Early onset, later onset

Before 15 or after 40

Child-onset and late-onset of schizophrenia are more rare

DSM-V CRITERIA: HIGHLIGHTS

•Two or more of the following for a significant portion of time in 1 month:

.Delusions

•Hallucinations

•Disorganized speech

•Gross disorganization or catatonia

•Negative symptoms (diminished emotional expression or avolition)

•Functional impairment of some kind

DSM-V CRITERIA: HIGHLIGHTS

•Continuous disturbance for at least 6 months

•Ruled out: substances or other disorders

Schizophrenia risk factors

 Biological factors

­Genetics

 Brain structure abnormalities

 Neurobiological

­Glutamate, dopamine, and serotonin

Acetylcholine

Genetics

Schizophrenia has a strong genetic component. Family, twin, and adoption studies have repeatedly shown that a person's risk of developing schizophrenia increases significantly if they have a close relative with the disorder. While there isn't a single "schizophrenia gene," researchers believe that a combination of multiple genes, along with environmental factors, contribute to the predisposition.

Brain Structure Abnormalities

People with schizophrenia often show structural differences in the brain compared to those without the disorder. Key findings from brain imaging studies include:

•Enlarged ventricles: These are the fluid-filled spaces in the brain. Enlarged ventricles suggest a loss of brain tissue.

•Reduced gray matter: This is particularly noticeable in the frontal and temporal lobes, which are responsible for planning, decision-making, and emotional regulation.

Hippocampal changes: The hippocampus, vital for memory and emotion, may be smaller or show abnormal function. These structural differences are not caused by the illness itself but are often present before the onset of symptoms, suggesting they are a predisposition.

Neurobiological Factors

Neurobiological factors involve the complex interplay of neurotransmitters in the brain. Schizophrenia is often explained by an imbalance in these chemical messengers.

•Glutamate: This is the main excitatory neurotransmitter in the brain. The glutamate hypothesis suggests that a dysfunction in glutamate signaling, particularly at NMDA receptors, may be a core cause of schizophrenia. This can lead to both positive symptoms (hallucinations, delusions) and cognitive deficits.

•Dopamine: The dopamine hypothesis is one of the oldest theories. It suggests that schizophrenia is caused by an overactivity of the dopamine system in certain parts of the brain. Antipsychotic medications work by blocking dopamine receptors, which helps to reduce the positive symptoms of the disorder.

•Serotonin: This neurotransmitter regulates mood, appetite, and sleep. Newer antipsychotic medications target both dopamine and serotonin receptors, suggesting that an imbalance in serotonin also plays a role in the symptoms of schizophrenia.

•Acetylcholine: Recent research points to the involvement of acetylcholine. People with schizophrenia often show abnormalities in the nicotinic acetylcholine receptors in the brain, which may contribute to the cognitive impairments seen in the disorder.

RISK FACTORS Of schizophrenia

 Psychological and environmental factors

­Prenatal stressors

­Psychological stressors

­Environmental stressors

Psychological and environmental factors, including prenatal and psychological stressors

can increase a person's vulnerability to developing schizophrenia. They don't directly cause the illness but can trigger its onset in genetically predisposed individuals.

Prenatal stressors

Prenatal stressors are events that occur before birth that can affect the developing brain and increase the risk for schizophrenia.

•Maternal viral infections or influenza during the first trimester of pregnancy have been linked to an increased risk of schizophrenia in the child.

•Maternal malnutrition, specifically severe famine, during pregnancy has also been associated with a higher risk.

•Obstetrical complications, such as bleeding during pregnancy, low birth weight, and a lack of oxygen at birth (hypoxia), can damage the fetal brain and increase the risk.

Psychological stressors

Psychological stressors, particularly those that are chronic or severe, can act as triggers for the first psychotic episode of schizophrenia in people who are already at risk.

•Adverse childhood experiences (ACEs), such as abuse, neglect, or trauma, can contribute to later mental health problems, including schizophrenia.

•Living in a high-stress family environment with a lot of conflict or criticism can increase the risk of a psychotic break.

•Significant life changes, such as leaving home for the first time, starting college, or a major relationship breakup, can be stressful enough to trigger the onset of the illness.

Environmental stressors

Environmental stressors include a wide range of factors in a person's surroundings that can contribute to the development of schizophrenia.

•Urban living has been consistently linked to an increased risk of schizophrenia. This may be due to factors like social isolation, crime, and exposure to pollutants, though the exact reasons are still being studied.

•Substance use, particularly of cannabis during adolescence, is considered a significant environmental risk factor. Cannabis use can trigger the onset of schizophrenia in individuals who are genetically vulnerable.

•Migration to a new country and being part of a minority group can also increase risk, potentially due to social stress, discrimination, and feelings of not belonging.

Phase I: Premorbid phase

•Personality and behavior indications include:

‒Shy and withdrawn

‒Poor peer relationships

‒Poor school performance

‒Asocial behavior

Current research focused on early intervention

Phase II: Prodromal phase

•Significant deterioration in function

‒50% have depressive symptoms

‒Social withdrawal

‒Cognitive impairment

Therapeutic interventions

Phase III: Active psychotic phase

•Acute episode where symptoms are more pronounced

Psychotic symptoms typically prominent

Phase IV: Residual phase

•Active symptoms absent or no longer prominent

‒Positive symptoms may be improved

‒Negative symptoms may remain

•Flat affect and impairment in role functioning

•Possible for negative symptoms to improve

Often worsen with additional episodes

PROGNOSIS Of schizophrenia

•Clinical improvement in about 44% of patients

•Associated factors include:

‒Good premorbid functioning

‒Later age at onset

‒Female sex

Abrupt onset with obvious precipitating factor

BEHAVIOURAL ALTERATIONS IN PSYCHOSIS

ALTERATIONS IN SPEECH- POSITIVE

­Flight of ideas

­Neologisms

­Echolalia

­Circumstantiality

­Tangentiality

­Clang associations

­Word salad

Associative looseness

ALTERATION IN THOUGHT- POSITIVE

Thought blocking

Thought insertion

Thought deletion

Magical thinking

ALTERATIONS IN PERCEPTION- POSITIVE

 Hallucinations

­Auditory

­Visual

­Olfactory

­Gustatory

­Tactile

 Illusions

 Depersonalization

 Derealization

ALTERATIONS IN BEHAVIOR

­Catatonia

­Motor retardation

­Motor agitation

­Stereotyped behaviors

­Waxy flexibility

­Echopraxia

­Negativism

­Impaired impulse control

­Gesturing or posturing

­Boundary impairment

Catatonia

is a state of severe psychomotor disturbance. It can manifest as either extreme immobility and stupor or excessive, purposeless motor activity. A person in a catatonic state may seem unaware of their surroundings.

Example: A patient sits motionless and silent for hours, not responding to questions or attempts to move them.

Motor Retardation

is a significant slowing of physical and emotional reactions. This includes slow speech, reduced body movements, and a decreased interest in their surroundings. It's often a symptom of depression.

Example: A patient speaks in a slow, monotonous voice, takes a long time to answer questions, and moves sluggishly as if they are weighed down.

Motor agitation

is a state of restless, purposeless, and non-goal-directed motor activity. This can range from pacing and hand-wringing to an inability to sit still. It's often a symptom of anxiety, mania, or psychosis.

Example: A person paces back and forth in a room, wringing their hands and unable to calm down, even when asked to sit.

Stereotyped behaviors

are repetitive, ritualistic, and non-functional motor actions. These behaviors don't serve a specific purpose and can be a symptom of schizophrenia or autism spectrum disorder.

Example: A person repeatedly rocks back and forth, claps their hands, or makes a specific series of facial tics.

Waxy flexibility

is a type of catatonia where a person's limbs or body parts can be moved into a position and will remain in that position for a long time, like a wax figure.

Example: If a nurse raises a patient's arm, the patient holds their arm in that raised position for an extended period, even after the nurse lets go.

Echopraxia

is the involuntary and meaningless imitation of another person's movements or gestures.

Example: If a doctor scratches their nose during a conversation, the patient will immediately and unconsciously mimic the same action.

Negativism

is a passive or active opposition to external suggestions or commands. The person resists instruction and may do the opposite of what is asked.

Example: When a nurse asks a patient to stand up, the patient actively resists or refuses to move.

Impaired impulse control

is the inability to resist a sudden urge or impulse to perform an act that is harmful to oneself or others.

Example: A person suddenly breaks a window in a fit of rage, or lashes out verbally at a staff member without provocation.

Gesturing or posturing

involves assuming and maintaining unusual or bizarre bodily positions for extended periods. This is often seen in catatonia and can be uncomfortable or seemingly pointless.

Example: A person stands on one leg with their arm held straight out in the air, maintaining the position for several minutes.

Boundary impairment

is the inability to recognize personal and physical boundaries. This can manifest as an unawareness of personal space or a confusion between one's own thoughts and the thoughts of others.

Example: A person stands uncomfortably close to someone during a conversation or talks about personal information as if it were a shared experience, showing a lack of understanding of social distance and privacy.

NEGATIVE SYMPTOMS

 The absence of essential human qualities

­Anhedonia

­Avolition

­Asociality

­Affective blunting

­Apathy

Alogia

Anhedonia

is the inability to experience pleasure. An individual with anhedonia may not find joy in activities they once loved.

•Example: A person who used to love playing guitar no longer gets any satisfaction from it and stops playing altogether. They might say that nothing feels good or fun anymore.

Avolition

is a lack of motivation or drive to complete goals or engage in purposeful activities. It's not about being lazy; it's a profound inability to initiate and persist in goal-directed behaviors.

•Example: A person with avolition might sit at home all day and be unable to initiate simple tasks like washing dishes, getting dressed, or going to the grocery store, even though they know they need to.

Asociality

is a severe impairment in social relationships. This isn't just about being shy; it's a lack of interest in social interactions and a withdrawal from relationships.

Example: A person might stop returning phone calls from family and friends, avoid social gatherings, and prefer to spend all their time alone. They may seem indifferent to social contact.

Affective blunting

 (or flattened affect) is a reduction in the intensity of emotional expression. The person's face may seem unresponsive, and their voice may lack the normal range of tone and inflection.

•Example: When told a joke, a person with affective blunting might show no facial expression, no smile, and their voice would remain flat, even if they internally understood it was meant to be funny.

Apathy

is a lack of feeling, emotion, interest, or concern. It often manifests as indifference and a lack of emotional responsiveness.

•Example: A person might show no reaction to news that would typically evoke a strong emotional response, like a family member's illness or a significant achievement. They appear to be emotionally empty or unconcerned.

Alogia

is a reduction in the fluency or productivity of speech. A person with alogia may respond to questions with a minimal number of words, have long pauses in their speech, or seem to struggle to find the right words. This is often referred to as "poverty of speech."

•Example: When asked about their day, a person with alogia might simply say, "Fine," and offer no further details. They don't engage in conversation and provide very little information.

NEGATIVE SYMPTOMS

 Affect: Outward expression of a person’s internal emotional state

­Flat

­Blunted

­Constricted

­Inappropriate

Bizarre

Affect

is the outward, observable expression of a person's inner emotional state. It can be categorized into various types based on the range, intensity, and appropriateness of the emotional display.

Flat affect

is characterized by a lack of emotional expression. The person's face remains immobile, and their voice is monotonous. It's often associated with conditions like schizophrenia, severe depression, or brain injuries.

•Example: A person with flat affect would show no change in facial expression or vocal tone when told a joke, or when speaking about a traumatic event.

Blunted affect

is a severe reduction in the intensity of emotional expression. While not completely emotionless like flat affect, the emotional response is significantly dampened.

Example: When a loved one visits in the hospital, a person with blunted affect might smile slightly and say, "It's nice to see you," but their voice and facial expression would lack the warmth or enthusiasm you would expect.

Constricted affect

involves a mild reduction in the range and intensity of emotional expression. The person shows some emotion, but it is limited in scope.

•Example: A person with constricted affect might express happiness and sadness appropriately, but their expressions of anger, fear, or surprise would be minimal or absent.

Inappropriate affect

 is when the emotional expression does not match the content of the conversation or situation. This is often seen in schizophrenia.

Example: A person with inappropriate affect might laugh uncontrollably while talking about a tragic or sad event, or cry while discussing a happy memory.

Bizarre affect

refers to a peculiar, often illogical, and unusual emotional expression that is not easily understandable to others. It's often associated with disorganized schizophrenia.

Example: A person with bizarre affect might make strange, seemingly random facial grimaces or suddenly burst into an odd, sing-song voice for no apparent reason, without any accompanying feeling.

COGNITIVE SYMPTOMS

•Concrete thinking

•Impaired memory

•Impaired information processing

•Impaired executive functioning

Anosognosia

Anosognosia

is a lack of awareness or denial of one's own illness, even in the face of strong evidence. A person with anosognosia doesn't think they're sick and may refuse treatment, not because they're being difficult, but because they genuinely can't perceive their illness.

Examples

A person with schizophrenia who experiences anosognosia may not believe they are having hallucinations, delusions, or disorganized thoughts. They may insist that the voices they hear are real or that their bizarre beliefs are logical, despite family and doctors telling them otherwise.

A person with bipolar disorder in a manic episode may not recognize their own grandiosity, risky behavior, or sleeplessness as symptoms. They may feel they've never been better, even if their actions are causing significant problems in their life.

A person with dementia may deny having any memory problems, even when they're unable to remember recent events or conversations. They might become defensive or angry when a family member tries to remind them of something they've forgotten.

AFFECTIVE SYMPTOMS

 Assessment for depression is crucial

­May herald impending relapse

­Increases substance abuse

­Increases suicide risk

Further impairs functioning

Priority 1: Immediate Safety and Physical Integrity

These diagnoses address the most immediate, life-threatening concerns and must be addressed first.

Risk for Self-Directed Violence

R/T: Command hallucinations, persecutory delusions, or overwhelming hopelessness.

Goal: Patient will remain free from self-harm or injury.

Risk for Other-Directed Violence

R/T: Paranoia (believing staff or others are plotting harm), extreme psychomotor agitation, or cognitive disorganization.

Goal: Patient will maintain control over impulses and actions.

Imbalanced Fluid Volume / Imbalanced Nutrition

R/T: Refusal to eat or drink due to paranoid delusions (fear of poisoning) or catatonia.

Goal: Patient will maintain adequate hydration and nutritional intake

Priority 2: Acute Psychotic Stabilization

Once physically safe, the focus shifts to addressing the acute symptoms that distort reality and drive unsafe behavior.

Disturbed Sensory Perception (Auditory, Visual)

R/T: Biochemical alterations (e.g., dopamine dysregulation) leading to hallucinations.

Goal: Patient will identify and verbally report the onset of hallucinations and use learned coping strategies.

Disturbed Thought Process

R/T: Inability to logically process information R/T delusional thinking (e.g., grandiosity, referential delusions) or loose associations.

Goal: Patient will be oriented to reality and demonstrate logical thought progression.

Priority 3: Self-Care and Basic Function

These diagnoses address the functional deficits (often negative symptoms) that impair daily living.

Self-Care Deficit (e.g., bathing, dressing, hygiene)

R/T: Avolition (lack of motivation), apathy, or preoccupation with internal stimuli.

Goal: Patient will perform daily hygiene tasks with minimal assistance.

Disturbed Sleep Pattern

R/T: Psychomotor agitation, hyperactivity, or internal preoccupation (hallucinations).

Goal: Patient will report 6-8 hours of continuous sleep per night.

Priority 4: Psychosocial and Rehabilitation

These are long-term goals aimed at building skills for community integration and recovery.

Social Isolation

R/T: Withdrawal, anhedonia (inability to experience pleasure), or fear of scrutiny/judgment.

Goal: Patient will voluntarily participate in one staff-led or group activity per day.

Ineffective Coping

R/T: Inability to use reality-based problem-solving skills R/T cognitive impairment.

Goal: Patient will identify two adaptive coping strategies to manage anxiety.

Chronic Low Self-Esteem

R/T: Repetitive failures, social stigma, or internalized negative views of the illness.

Goal: Patient will verbalize positive statements about self and recognize personal strengths.

POTENTIAL NURSING DIAGNOSES

Positive symptoms

•Risk for self-directed or other-directed violence

•

•Disturbed sensory perception

•Formerly Disturbed Thought Process

•

•Impaired verbal communication

POTENTIAL NURSING DIAGNOSES

Negative symptoms

•Social isolation

•Chronic low self-esteem

•Powerlessness

•Impaired Health Maintenance 

IMPLEMENTATION: ACUTE PHASE

•Psychiatric, medical, and neurological evaluation

•Psychopharmacological treatment

•Support, psychoeducation, and guidance

•Supervision and limit setting in the milieu

•Monitor fluid intake

•Activities and groups

•Working with aggression

•Regularly assess for risk and take safety measures

IMPLEMENTATION STABILIZATION AND MAINTENANCE PHASE

­Medication administration/adherence

­Relationships with trusted care providers

­Community-based therapeutic services

Teamwork and safety

COMMUNICATION GUIDELINES

•Therapeutic strategies for communicating with patients with schizophrenia focus on:

•Lowering the patient’s anxiety

•Decreasing defensive patterns

•Encouraging participation in therapeutic and social events

•Raising feelings of self-worth

•Increasing medication compliance

COUNSELING: COMMUNICATION GUIDELINES

—Delusions

−Be open, honest, and calm

−Have patient describe delusion

−Avoid arguing about delusional content

−Interject doubt  when appropriate

−Focus on feelings generated by the delusion

−Once delusion is described, do not dwell on it

Observe events that trigger delusions

COUNSELING: COMMUNICATION GUIDELINES

—Hallucinations

−Hearing voices (auditory hallucinations) most common

−Approach patient in nonthreatening and     nonjudgmental manner

−Assess if messages are suicidal or homicidal

−Ask directly what the voices are saying

−Do not argue or negate patient perception

−Offer your own perceptions (present reality)

−Focus on reality-based diversions, Patient anxious, fearful, lonely, brain not processing stimuli accurately

−Initiate safety measures if needed

Associative looseness

COUNSELING: COMMUNICATION GUIDELINES

­Do not pretend that you understand

­Look for reoccurring topics and themes

­Emphasize what is going on in the patient's environment

­Involve patient in simple, reality-based activities

Reinforce clear communication of needs, feelings, and thoughts