Class 5- Partnering with persons experiencing Schizophrenia, schizoaffective & psychosis conditions

Primary symptoms of psychosis

• Hallucinations (perceptual disturbances)

• Delusions (Thinking)

Hallucinations (Perceptual disturbances) (Primary symptoms of psychosis)

Perceptual experiences that occur in the absence of actual external sensory stimuli and may be auditory, visual, tactile, gustatory, or olfactory.

• Auditory 

• Visual

• Tactile

• Olfactory- smell

• Gustatory-taste

Delusions (Thinking) (Primary symptoms of psychosis)

A false, fixed belief based on an incorrect inference about reality, not shared by others, inconsistent with the individual’s intelligence or cultural background and which cannot be corrected by reasoning.

• Persecutory /Paranoid

• magical  thinking 

• Grandiose

• Somatic- related to perceived body abnormality 

Types of psychotic disorders (DSM-5, 2013)

• Brief psychotic disorder 

• Substance induced psychosis 

• Delusional disorder 

• Schizophrenia 

• Schizo-affective disorder 

• Schizophreniform disorder 

Schizophrenia

• Misunderstood and stigmatized condition not often talked about openly 

• Affects 1% of general population worldwide 

• About 25% to 30% of people with schizophrenia experience a complete remission after one or several psychotic episodes 

• Although schizophrenia is treatable, it remains serious and potentially disabling. The emphasis must be upon maximising wellness while minimising the effects on. 

Schizophrenia- Core symptoms categories

• Positive (active symptoms) 

• Negative 

• Neuro-cognitive 

• Disorganized

Positive (active symptoms)(Schizophrenia- Core symptoms categories)

reflect an excess of distortion of normal functions, including:

• Delusions 

• Hallucination 

Negative (Schizophrenia- Core symptoms categories)

reflect a lessening or loss of normal functions, such as: 

• Restriction or flattening in the range and intensity of emotion (affective flattening or blunting)* 

• Reduced fluency and productivity of thought and speech (alogia)*

• Withdrawal and inability to initiate and persist in goal-directed activity (avolition) 

• inability to experience pleasure (anhendonia)*

Anhedonia defined (Negative Schizophrenia- Core symptoms categories)

• Inability to experience pleasure 

Alogia (Negative Schizophrenia- Core symptoms categories)

• Reduced fluency and productivity of thought and speech

Avolition (Negative Schizophrenia- Core symptoms categories)

• Withdrawal and inability to initiate and persist in goal-directed activity

Affective flattening or blunting (Negative Schizophrenia- Core symptoms categories)

• Restriction or flattening in the range and intensity of emotion

Neuro-cognitive (Schizophrenia- Core symptoms categories)

• Neurocognitive impairment exists in schizophrenia and may be independent of positive and negative symptoms 

• Neurocognitive includes short and long-term memory, vigilance or sustained attention, verbal fluency or the ability to generate new words, and executive functioning, which includes violation planning, purposive action, and self monitoring behavior 

Disorganized (Schizophrenia- Core symptoms categories)

• symptom of schizophrenia that makes it difficult for the person to understand and respond to the ordinary sights and sounds of daily living 

• These include disorganized speech and thinking and disorganized behaviour 

• Examples of disturbed speech and thinking patterns can be found 

• Disorganized perceptions often crest oversensitivity to colours, shapes, and background activities. Illusions occur when the person misperceives or exaggerates stimuli that actually exist in the external environment 

Loosening of association (Alterations in thought process- manifestation of schizophrenia)

the lack of a logical relationship between thoughts and ideas; conversations shifts from one topic to another in a completely unrelated manner, making it confusing and difficult to follow

Circumstantiality (Alterations in thought process- manifestation of schizophrenia)

the individual take a long time to make a point because their conversation is indirect and contains excessive and unnecessary detail

Tangentially (Alterations in thought process- manifestation of schizophrenia)

similar to circumstantiality, except that the speaker does not return to a central point or answer the question posed

Thought blocking (Alterations in thought process- manifestation of schizophrenia)

 an abrupt pause or interruption in one’s train of thoughts, after which the individuals cannot recall what there were saying

Neologisms (Alterations in thought process- manifestation of schizophrenia)

the creation of new word

Word salad (Alterations in thought process- manifestation of schizophrenia)

an incoherent mixture of words and phrases

Preservation (Alterations in thought process- manifestation of schizophrenia)

a persistent response to a stimulus even after a new stimulus has been presented

Clang association (Alterations in thought process- manifestation of schizophrenia)

the use of words or phrases that have similar sounds but are not associated in meaning; may include rhyming or puns

Echolalie (Alterations in thought process- manifestation of schizophrenia)

the persistent echoing or repetition of words or phrases said by others

Verbigeration (Alterations in thought process- manifestation of schizophrenia)

the meaningless repetition of incoherent words or sentences; typically associated with psychotic states and cognitive impairment 

Pressured speech (Alterations in thought process- manifestation of schizophrenia)

speech that is increased in rate and volume and is often emphatic and difficult to interrupt typically associated with mania and hypomania

First episode Psychosis (schizophrenia)

• First-episode psychosis simply refers to the first time someone experiences psychotic symptoms or psychotic episodes. A psychotic episode occurs in three phrases. The length of each phases varies from person to person 

• Early intervention is key- if caught in prodromal phase better outcomes

Phases of schizophrenia

• Phrase 1 Prodrome

• Phase 2 Acute 

• Phase 3 Recovery 

Phase 1 Prodrome (Phases of schizophrenia)

the early signs may be vague and hardly noticeable. There may be changes in the way some people describe their feeling, thoughts, and perceptions, which may become more difficult over time

Phase 2 Acute (Phases of schizophrenia)

clear psychotic symptoms are experiences, such as hallucinations, delusions, or confused thinking

Phase 3 Recovery (Phases of schizophrenia)

 psychosis is treatable. Most people recover. The pattern of recovery varies from person to person. Despite common misconceptions, recovery from the first episode of psychosis is more probable than not. With help, many never have another psychotic episode

Early interventions (Schizophrenia)

• Delays in treatment are extremely stressful for patients and their families and may result in poorer clinical outcomes

• First few years or psychosis carry the highest risk for serious physical, social, and legal harm 

• The longer the duration of untreated psychosis (DUP) the pooer the outcome once treatment is initiated

• Average DUP is about one year 

• Involves symptoms remission and functional recovery (e.g. going back to school, maintaining employment, maintaining social relationships) 

• High rate of relapse within the first five years after onset of psychotic disorder 

Suicide (Early interventions Schizophrenia)

• 1/10 people with psychosis die by suicide

• ⅔ of thes deaths occur within the first five years of illness 

• Early intervention may reduce the risk of suicide 

Substance use (Early interventions Schizophrenia)

• People who have recently experienced psychosis are sensitive to the effects of substances 

• Cannabis and other substances can trigger symptoms and relapses of psychosis 

• Ongoing use can make recovery more difficult

Course of illness & recovery (schizophrenia)

• Acute illness period 

• Stabilization period 

• Maintenance & recovery period 

• Periods of relapse 

Neurobiology (Schizophrenia)

• Genes

• Psychosocial adversity in perinatal period/ childhood

• Ongoing or recent psychosocial stress 

• Dopamine

• Serotonin 

Dopamine (Neurotransmitter influence on psychotic symptoms)

• Influences decision making → disorganized behaviour→ disorganized thinking 

• Influencers motivation → Amotivation → avolition

• Influences arousal → Asociallity 

• Signals pleasure and reward → Anhedonia

Serotonin (Neurotransmitter influence on psychotic symptoms)

• Feeling → affective flattening –? Mood (negative symptoms)

• Energy level → Avolition (negative symptoms)

• Social behaviour → Asociality → Anhedonia (negative symptoms)

• Sexual desires → Amotivation → Anhedonia (negative symptoms)

• Perception → Hallucinations → delusions (positive symptoms) 

• Sensorium & cognitive functions → Memory → attention 

• Somatic functions → Appetite → sleep 

Symptoms (Schizophrenia: diagnostic Criteria DSM-5,2013) 

Two or more* of the following, each present for a significant portion of time during 1-month period (or less if successfully treated. At least one of them must be (1), (2), or (3):

• Delusions

• Hallucinations

• Disorganized speech (e.g frequent derailment or incoherence) 

• Grossly disorganized or catatonic behaviour 

• Negative symptoms (i.e. diminished emotional expression or avolition) 

• One of them must be positive symptoms or disorganized speech

Schizophrenia: diagnostic Criteria DSM-5,2013

• For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas

• Continuous signs of the disturbance persist for at least 6 months. This 6-month period at least 1 month of symptoms (or less is successfully treated) that meet criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms.

• Schizoaffective disorder and depressive or bipolar with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms or (2) if mood episodes have occurred during active-phase symptoms\

• The disturbance is not attributable to the physiologic effects of a substance (e.g. a drug of abuse, a medication) or another medical condition 

• If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, i

Symptoms (Schizoaffective disorder: Diagnostic criteria DSM-5,2013)

At least 2 symptoms of a psychotic disorder for 2 or more weeks  

• Delusions 

• Hallucinations

• Disorganized speech 

• Grossly disorganized or catatonic behaviour 

• Negative symptoms flat-affect, anhedonia, avolition, amotivation, asociality 

• A major mood episode that lasts for an uninterrupted period of time

• Mood symptoms present for the majority of the illness 

Schizoaffective disorder: Diagnostic criteria (DSM-5,2013) 

• The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features 

• The episode is not attributable to the physiological effects of a substance 

• At least 2 symptoms of a psychotic disorder for 2 or more weeks

Other psychosis related disorders

• brief psychotic disorder

• substance/medication induced psychotic disorder

• psychotic disorder due to another medical condition 

• Schizophreniform

Brief psychotic disorder (Other psychosis related disorders)

•  Episode is brief (at least 1 day) but may last up to 1 month 

• Onset is sudden and included at least one of the the positive symptoms of schizophrenia 

Substance/medication induced psychotic disorder (Other psychosis related disorders)

• Involves prominent hallucinations or delusions that are direct physiologic effects of medication or a substance 

Psychotic disorder due to another medical condition (Other psychosis related disorders)

• Hallucinations and/or delusions causing clinically significant distress or impairment in functioning are the direct pathophysiologic consequence of another medical condition and are not better explained by another mental disorder or delirium 

Schizophreniform (Other psychosis related disorders)

• The essential features of schizophreniform disorder are identical to those of criteria A for schizophrenia with the exception of the duration of the illness, which is less than that for schizophrenia 

Societal and critical perspectives

• Culture affects the way we express our thought, emotions and behaviours 

• There are cultural differences in the way schizophrenia is manifested and treated 

• One of the main differences seen across cultures is the way schizophrenia are expressed 

Reframing psychosis and the hearing voices movement

• Hearing voices movement- an intentional movement that reframes how we think about experiences like hearing voices 

• Challenges pathologizing narratives that position psychosis “symptoms” like hearing voices or seeing visions abnormal and needing to be fixed 

• Focuses on reframing the experiences we label as psychosis, schizophrenia and other similar “conditions” as a difference, a natural part of human diversity 

 Psychotic disorders: pharmacotherapeutic interventions: antipsychotics 

Antipsychotics are always offered with adjunctive non-pharmacological interventions to improve clinical outcome

• First generation 

• Second generation 

First generation antipsychotics mechanism of action *

• Haloperidol

• Throazin

Second generation antipsychotics mechanism of action *

• Olanzapin 

• Quetiapine

• Risperidone 

• Clozapine

Long-acting Injectables

• Helpful for those who prefer not to take medication every day or forget to take their medication 

• More stable medication levels 

• Reduced risk of relapse

• Given every 2-4 weeks

Catatonia- Lorazpam

• 1st line treatment for catatonia 

• Lorazepam challenge - Oral or IM

• See response

• Scheduled medication 

• Positive response helps confirm catatonia diagnosis 

Clozapine 

Not first line option drug 

May take 4-5 weeks to get their effects 

Effective for those that haven’t responded to other antipsychotics 

Used when 2 antipsychotics have not produced good response 

Weekly blood tests 

• WBC 

• BM monitoring- constipation 

• ECG, trops- Myocarditis 

• Glucose metabolic 

Possible side effects of anti psychotics medication

• Anticholinergic affects

• Central nervous system effects 

• Metabolic symptoms 

• Sexual side effects 

• Movement disorders

• Tardive Dyskinesia

• Neuroleptic Malignant syndrome 

Anticholinergic effects (Possible side effects of anti psychotics medication)

dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, decreased sweating

Central nervous system effects (Possible side effects of anti psychotics medication)

dizziness, agitation confusion

Metabolic symptoms (Possible side effects of anti psychotics medication)

increased blood pressure, high blood sugar, weight gain, excess body fat around waist, abnormal cholesterol and triglyceride levels, diabetes

Sexual side effects (Possible side effects of anti psychotics medication)

decreased sex drive and function, amenorrhea-absence of menstruation, galactorrhea-production of milky discharge form breast men and women when not pregnant 

Movement disorders (Possible side effects of anti psychotics medication)

tremors, muscle stiffness, tices

Tardive Dyskinesia (Possible side effects of anti psychotics medication)* (extrapyrimidal side effects)

repetitive involuntary movements

• Abnormal dyskinetic movements of the face, mouth, and jaw, choreopathoid movements of the legs , arms, and trunk 

• Should call provider if symptoms appear

Neuroleptic Malignant syndrome (Possible side effects of anti psychotics medication)

fever, muscle stiffness, delirium

Extrapyramidal side effects of antipsychotics

• Parkinosonism or pseudoparkinoism

• Acute dystonia

• Akathisia- motor restlessness

• Tardive dystonia

• Tardive akathisia

Akathisia (Extrapyramidal side effects of antipsychotics)

• Obvious motor restlessness evidenced by pacing, rocking, and shifting from foot to foot; subjective signs of not being able to sit still; these symptoms may occur together or separately 

Dry mouth (Nursing interventions for Anti-cholinergic effects)

Sips of water; hard candies and chewing gum (preferably sugar-free)

Blurred vision (Nursing interventions for Anti-cholinergic effects) 

Avoid dangerous tasks; teach the patient that this side effect will diminish in a few weeks

Decreasd Lacrimation (Nursing interventions for Anti-cholinergic effects)

Artificial tears

Photophobia (Nursing interventions for Anti-cholinergic effects)

Sunglasses

Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy 

• Cognitive behavioural social skills training (CBSST) 

• Cognitive behaviour therapy for psychosis (CBT-P) 

• Family intervention training (FIT) 

• Cognitive adaptation Training (CAT) 

• Illness management and recovery (IMR) 

Cognitive behavioural social skills training (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

An empirically supported manualized interventions that helps individuals with schizophrenia achieve recovery goals 

Interweaves three evidence-based practices: 

• Cognitive behaviour therapy 

• Social skills training 

• Problem-solving training 

is delivered over 12 sessions by appropriately trained practitioners in individual or group context 

Offered as adjunct treatment to improve functioning and negative symptoms

Benefits of Cognitive behavioural social skills training (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

User friendly intervention structured activities are assigned to participants between sessions to reinforce new learning and solidify skills

Drawbacks of Cognitive behavioural social skills training & cognitive behaviour therapy for psychosis & Family intervention training (FIT)(Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• Initial training is expensive 

• Cost of weekly clinical supervision to maintain fidelity to the model 

• Intervention may not always be available in all jurisdictions 

Cognitive behavior therapy for psychosis (CBT-P)(Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• An evidence -based talk therapy that helps individuals diagnosed with psychosis to become aware of their thoughts and behaviours and explore how these impact their emotions 

• The "here and now” focus allows for the development of skills to identify and address unhelpful thinking patterns and behaviours 

•  is delivered over 12-16 sessions by appropriately trained practitioners in either individual or group contexts 

• is recommended as an adjunct too pharmacological treatment

Benefits of Cognitive behavior therapy for psychosis (CBT-P) (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• Well tolerated- not painful or disruptive 

• No hospitalization or anesthesia required 

• No systemic side effects 

• No memory loss 

Family Interventions training (FIT) (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

A family intervention that aims to improve family members’ support and resilience of one another and enhance the quality of their communication and problem solving

The intervention seeks to provide:

• Education about schizophrenia

• Skill teaching around identifying signs and symptoms of relapse

• Strategies to improve family members; ability to anticipate and help reduce the risk of relapse

Families are offered 10 planned sessions facilitated by an appropriately trained practitioner

Benefits of Family Interventions training (FIT) (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• Intervention is offered to anyone the client considers family relatives, caregivers or people from broader circle 

• Recognizes the vital role family members play in supporting a person’s recovery promoting their well-being and providing care 

• Can be delivered virtually or in person to meet needs of families

Cognitive adaptation training (CAT) (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

An evidence-based intervention designed to address functional impairment caused by cognitive deficits of schizophrenia

Individuals are taught environmental supports and compensatory strategies to use to improve their social & occupational functioning

• Voice alarm clocks

• Large Calendars

• Checklists/schedules

• Reminder signs

Benefits of Cognitive adaptation training (CAT) (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• In-depth cognitive assessments is conducted with FRISBEE tool prior 

• Approach can be used to address goals related to living, learning, working, and socializing 

• Studies have found CAT improves community functioning, adaptive functioning, medication adherence, performance of ADLs and quality of life

Drawbacks of Cognitive adaptation training (CAT) & Illness management & recovery (IMR)  (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• training/receertification is expensive 

• Costs of weekly clinical supervision 

• Intervention may not always be available in all jurisdiction 

Benefits of Illness management & recovery (IMR)  (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

• Can be delivered in individual or group contexts 

• User friendly intervention delivered by trained practitioners over 6 months 

Illness management & recovery (IMR)  (Psychotic disorders: Non-pharmacotherapeutic interventions: psychotherapy)

An evidence-based intervention designed to promote illness self-management

Psychoeducational content includes:

• Recovery strategies

• Using medication effectively

• Building social supports

• Coping with stress

• Managing persistent symptoms

• Reducing relapses

• Getting needs met by the mental health system

Wellness recovery action planning (Psychotic disorders: peer support interventions)

A peer support group intervention developed & delivered by people with lived experience of psychosis

The foundation of WRAP is a wellness toolbox

A WRAP plan has six components:

• Daily plan

• Stressors

• Early warning signs

• Signs that things are breaking down or getting worse

• Crisis plan

Benefits of Wellness recovery action planning (Psychotic disorders: peer support interventions)

• Interventions incorporates key recovery concepts and wellness tools 

• Helps individuals to develop simple, safe and effective tools to create and maintain wellness 

• Helps individuals to develop a daily plan to stay on track with life and wellness goals 

• Encourages people to identify challenges that throw them off track 

• Helps people to identify ways to gain support and stay in control in a crisis

Drawbacks of Wellness recovery action planning (Psychotic disorders: peer support interventions)

• Level 2 Master trainer certification courses may be cost prohibitive for many people 

• Level 1&2 courses may not be available in all jurisdictions especially in smaller communities

Hearing voices group (Psychotic disorders: peer support interventions)

A peer support group intervention developed & delivered by people with lived experience of auditory hallucinations

Living and making sense of voices groups aim to:

• Raise awareness of the diversity of voices

• Challenge negative stereotypes, stigma and discrimination

• Help create more spaces for people to talk freely about voice hearing

• Raise awareness of different ways to manage distressing, confusing or difficult voices

Benefits of Hearing voices group (Psychotic disorders: peer support interventions)

• Groups are based firmly on an ethos of self help, mutual respect and empathy

• Provide a safe space for people to share their experiences of hearing voices and support one another 

• Hearing Voices groups are available in large cities around the world

Drawbacks of Hearing voices group (Psychotic disorders: peer support interventions)

• Group facilitator training is expensive which limits access for many individuals

• Groups are not usually available in smaller communities

Psychotic Disorders: Tiered Model of Community Mental Health Treatment 

All individuals should receive Early Intervention in Psychosis (EPI) services to reduce the duration of untreated psychosis and reduce the probability of relapse

• Many individuals should receive community-based Intensive Case Management (ICM) services to promote optimal social & occupational functioning

• Individuals with the most functional disability should receive community- based Assertive Community Treatment (ACT) or Flexible Assertive Community Treatment (FACT) services provided by interprofessional teams

Bio/psycho/social/spiritual assessments (Nursing assessments)

Screening

• Brief Psychiatric Rating Scale (BPRS-6)

Assessment

• Positive and Negative Symptom Scale (PANSS)

• Scale for the Assessment of Negative Symptoms (SANS)

• Scale for the Assessment of Positive Symptoms (SAPS)

• Clinical Global Impression Schizophrenia Scale (CGI-SCH)

Mental Status Examination

Suicide Risk Assessment

Nursing interventions (Bio/psycho/social/spiritual assessments)

• Symptom and Behavior Monitoring & Management

• Facilitating CAT

• Skill Teaching- illness self- management

• Supportive Counselling

• Facilitating CBT-P

• Facilitating CBSST

• Facilitating FIT

• Facilitating IMR

• Crisis prevention & intervention

• Delivering EPI, ICM, ACT & FACT Services 

• Individual & systems level advocacy