Psychotic Disorders

psychosis

- disorganization of personality

- deterioration in social functioning

- distortion of reality

- hallucination or delusional thinking may be present

where does the word schizophrenia come from

greek words, skhizo (split), phren (mind)

what do thought disorders affect

emotions and function

what is schizophrenia probably caused by

- genetic predisposition

- biochemical dysfunction

- physiological factors

- psychosocial stress

what are predisposing factors to schizophrenia

- biological influences

- biochemical influences

biological influences of schizophrenia

genetics

how could genetics explain schizophrenia

- unknown how it is inherited

- studies going to determine which genes play a role in one's vulnerability

- twin studies: rate is 4-5x greater identical than fraternal

what do twin studies show about schizophrenia

50 times greater than the general population in identical

biochemical factors of schizophrenia

- one theory suggests that schizophrenia may be caused by an excess of dopamine in the brain

dopamine hypothesis

the brain of schizophrenic patients produces more dopamine than the brain of a "normal" person. Through further research, it is now thought that schizophrenics have an abnormally high number of D2 receptors

besides dopamine what other neurotransmitters are involved in the etiology of schizophrenia

- norepinephrine

- serotonin

- glutamate

- gamma-aminobutyric (GABA)

how does cannabis increase risk of schizophrenia

- adolescents who use cannabis and who have certain genes (COMT and ATK1) are at risk

- cannabis and synthetic cannabis can induce schizophrenia like symptoms

- exacerbates symptoms in those with preexisting psychosis

what does schizophrenia cause disturbances in

- thought processes

- perception

- affect

where are there severe deteriorations in a person which schizophreia

social and occupational functioning

what is the lifetime prevalence of schizophrenia in the US

0.7 percent

when do symptoms of schizophrenia typically occur

late adolescence or early adulthood

what is a leading cause of disability

schizophrenia

what percent of the schizophrenic population are smokers

80%

how much earlier do those diagnosed with schizophrenia die

25 years

DSM 5 criteria for schizophrenia

- two or more symptoms for 1 month: 1 symptoms must be 1,2,3

1. delusions

2. hallucination

3. disorganized speech

4. grossly disorganized or catatonic behaviors

5. negative symptoms

-function impacted: at least six months

- rule out: substance abuse/medical issues

- prominent delusions or hallucinations: pervasive developmental disability (DD)

premorbid behavior

the patient with schizophrenia can be viewed in four phases

Phase 1

the premorbid phase

phase 2

the prodromal phase

phase 3

schizophrenia

phase 4

residual phase

premorbid phase

- social maladjustment

- antagonistic thoughts and behavior

- shy and withdrawn

- poor peer relationships

- doing poorly in school

- antisocial behavior

prodromal phase

- lasts from a few weeks to a few years

- deterioration in role functioning and social withdrawal

- substantial functional impairment

- sleep disturbance, anxiety, irritability

- depressed mood, poor concentration, fatigue

- perceptual abnormalities, ideas of reference, and suspicious herald onset of psychosis

schizophrenia stage

- delusions

- hallucinations

- impairment in work, social relations, and self-care

residual stage

- symptoms similar to those of the prodromal phase

- symptoms of acute stage are either absent or not prominent

- flat affect and impairment in role functioning are prominent

factors associated with a positive prognosis include:

- good premorbid functioning

- later age at onset

- female gender

- abrupt onset precipitated by a stressful event

- brief duration of active-phase symptoms

- minimal residual symptoms

- absence of structural brain abnormalities

- normal neurological functioning

- no family history of schizophrenia

what is uncommon in schizophrenia

return to full premorbid functioning

positive symptoms of schizophrenia

- hallucinations

- delusions

- disorganized thinking (form of thought and thought content)

- movement disorders (catatonia)

negative symptoms of schizophrenia

- alogia

- anhedonia

- avolition

- apathy

- anosognosia

- ambivalence

alogia

reduced speaking or poverty of speech

anhedonia

inability to experience pleasure from enjoyable activities

avolition

difficulty beginning or sustaining actvities

apathy

lack of feeling emotion, interest, concern-state of indifference

anosognosia

lack of insight

cognitive symptoms of schizophrenia

- impaired judgement

- easily distracted

- decreased judgment

- memory issues

thought content examples for schizophrenia

- grandeur

- persecution

- ideas of reference

- somatic

delusions of grandeur

belief that you enjoy greater power and influence than you do

Persecution (Delusions of persecution)

convinced someone is mistreating, conspiring, or planning to harm them or a loved one

ideas of reference

The false impression that outside events have special meaning for oneself.

somatic delusions

believes that his body is changing in an unusual way, such as growing a third arm

Form of thought regarding pyschosis exmaples

- circumstantial

- concrete

- clang assocaitions

- loose associations

- tangential

- world salad

- neologisms

circumstantial form of thought

train of thought wanders but returns to the initial topic

concrete form of thought

thinking of objects/things as specific items rather than as abstract; found in children during development

clang associations

the stringing together of words that rhyme but have no other apparent link

loose associations

A common thinking disturbance in schizophrenia, characterized by rapid shifts from one topic of conversation to another. Also known as derailment.

tangential form of thought

Train of thought wanders and never returns to the initial topic. Lacks focus.

neologisms

made up words

ambivalence

the state of having contradictory or conflicting emotional attitudes

options for interdisciplinary treatment planning

- antipsychotics

- hospitalization

- therapy

- community resources

- nutritional support

- supportive education for client and family

how many hospitalization help a patient who is diagnosed with schizophrenia

control symptoms, milieu therapy

what kinds of therapy will help a patient who is diagnosed with psychosis

- individual

- group

- family

- social skills

what kinds of community resources will help a patient who is diagnosed with psychosis

ACT teams

what is important about family in the treatment of psychosis

they are included in the treatment

who may the nurse work with when treating a patient with schizophrenia

- social worker

- chaplain

- psych nurse

- rehab specialist

what is a priority nursing intervention when treating a patient diagnosed with psychosis

establish trust and build an alliance

how should the nurse intervene if the patient is mistrustful

short repeated contacts

examples of nursing interventions for a patient diagnosed with psychosis

- maintain safe environment

- minimize stimulation

- use clear, unambiguous language (concrete thinking)

- inform the person exactly what you are doing (especially if mistrustful)

- inform if you are touching him

- engage in reality-based conversation

- empathize "these thoughts must be really scary for you"

- clarify content of thoughts/perceptions

- promote independence

- planning for relapse prevention

- use least restrictive intervention

what kinds of hallucinations should we be sure to prioritize and clarify

command hallucinations

how should we help our patients cope with delusions or hallucinations

- distraction

- reality-based activities

- structured routine

- engage with others

- listen to music, especially with headphones

- avoid isolation

- education regarding illness process

how may we educate our patients regarding illness process

"these thoughts are part of your illness"

examples of other psychotic disorders

- delusional disorders

- brief psychotic disorder

- substance induced psychotic disorder

- psychotic disorder associated with another medical condition

- schizophreniform disorder

- schizoaffective disorder

examples of substances that can induce a psychotic disorder

- cannabis

- amphetamines

- hallucinogens

- opiates

- corticosteroids

- anesthetics

examples of psychotic disorders that are associated with another medical condition

- alcohol withdrawal

- dementia

schizophreniform disorder

schizophrenia present at least one month but less than 6 months

schizoaffective disorder

schizophrenia symptoms associated with mood disorder symptoms (depression or mania)

is schizoaffective disorder hospitalized often

yes

what are antipsychotic medications used for

to decrease agitation and psychotic symptoms of schizophrenia and other psychotic disorders

do antipsychotic medications treat negative symptoms

NO

which typical antipsychotic should the nurse use first

haloperidol (Haldol)

what is the mechanism of action for haloperidol (Haldol)

- blocks receptors in the brain's dopamine pathways

- antagonist

what is an atypical antipsychotic medication

clozapine (Clozaril)

what is the mechanism of action for clozapine (Clozaril)

- blocks serotonin and to a lesser degree dopamine

- antagonist

common side effects of antipsychotic medications

- nervousness, drowsiness, headache

- tachycardia

- blurred vision

- dry mouth, constipation, nausea, vomiting

- paralytic ileus

- urinary hesitancy/retention

- cognitive functioning impairment and hallucinations

- weight gain

- metabolic symptoms

is paralytic ileus common when taking antipsychotic medications

no, it is rare

what are extra pyramid symptoms

- akathasia

- tardive dyskinesia (TD)

- acute dystonic reactions

- Parkinsonism

if a patient taking an antipsychotic med suddenly experiences metabolic syndrome, what does that tell the nurse

we are messing up physical symptoms

what should the nurse monitor when taking care of a patient who is taking antipsychotic medications

- assess for abnormal involuntary movements (AIMS)

- MONITOR FOR DYSTONIC REACTION

- assess gait

- monitor weight

- monitor blood sugar

- chemistries (CBC, renal, liver panel lab tests)

- education

what is Neuromalignant syndrome

side effect of taking antipsychotic drugs

is Neuromalignant syndrome common

no, it is rare but potentially life threatening

what are signs and symptoms of Neuromalignant syndrome

- fever

- severe muscle rigidity

- tachycardia

- BP fluctuations

- Acute change level of consciousness (LOC)

if a patient taking antipsychotic medications suddenly develops a fever, what should the nurse recommend

holding meds

what are nursing interventions if a patient develops symptoms of Neuromalignant syndrome

- hold antipsychotic

- contact provider

- treat medically

- document

what is acute dystonic reaction

Involuntary muscle spasms or tightening of the mouth, jaw, face, and neck. most frightening is oculogyric crisis where the eyes involuntarily look in a certain direction, commonly upward.

What is oculogyric crisis?

- dystonic reaction

- sudden spasm or twisting of eye muscles

- fixed position

what is oculogyric crisis a side effect of

antipsychotics

how long does an oculogyric crisis last

minutes to hours

how do you treat an oculogyric crisis

with Cogentin (benzotropine) or Benadryl (diphenhydramine)

nursing implications of dystonic reaction

- anticipate andministration of benzotropine (Cogentin) or diphenhydramine (Benadryl)

- anticholinergic agents

- anticipate lower dose of antipsychotic or discontinuation

- EMERGENCY SITUATION

why should you avoid an oral pill when a patient is experiencing dystonic reactions

dysphasia, may not be able to swallow pill

what is major side effect of taking clozapine (Clozaril)

risk of agranulocytosis

what is agranulocytosis

body has too few granulocytes, white blood cells

symptoms of agranulocytosis

- fever, sore throat, general malaise

- look for any signs of infection

what other side effects are common of clozapine (Clozaril)

- hyper-salivation

- hypersomnia

- orthostatic hypotension

is clozapine (Clozaril) a first line antipsychotic

no

what are the two common treatment modalities of psychosis

- psychological treatments

- social treatments

what are examples of psychological treatments for psychosis

- individual psychotherapy

- group therapy

- behavior therapy

- social skills training