Mental health

CHAPTER 16 · PSYCHIATRIC MENTAL HEALTH NURSING

Schizophrenia Spectrum Disorders

Positive & negative symptoms, neurobiology, antipsychotic pharmacology, EPS, NMS, and priority nursing interventions.

🕐 30-min teachable

💊 1st vs 2nd gen antipsychotics

⚠ EPS & NMS priority

🎯 NCLEX-focused

✏ Fully editable

📖

Overview & Spectrum Disorders

⏱ 0–3 min

📌

Schizophrenia — DSM-5 Diagnostic Criteria (Know the Numbers!)

Two or more of the following for at least 1 month (at least one must be #1, #2, or #3): (1) Delusions, (2) Hallucinations, (3) Disorganized speech, (4) Grossly disorganized or catatonic behavior, (5) Negative symptoms. Continuous signs of disturbance persist for at least 6 months.

🗂 Schizophrenia Spectrum — Related Disorders

Schizophrenia— 6+ months total; 1+ month active symptoms Schizophreniform Disorder— same criteria but duration at least 1 month-less than 6 months; may resolve Brief Psychotic Disorder— sudden onset; duration <1 month; often stress-triggered Schizoaffective Disorder— schizophrenia symptoms + major mood episode (depression or mania); at least 2 weeks of hallucinations or delusions without mood symptoms, mood symptoms must be present for majority of illness Delusional Disorder— one or more delusions for at least 1 month. Function not impaired, no hallucinations, persecutory, erotomanic, grandiose, jealous, somaticSchizotypal personality disorder- odd eccentric behaviors, transient psychotic symptoms

📊 Epidemiology & Course

Affects approximately 1% of the world population Onset: typically late adolescence or early adulthood; earlier in males Males: earlier onset (15-25), more severe negative symptoms Females: later onset (25-35), better prognosis overall Chronic, relapsing course — requires long-term management Medication non-adherence is the leading cause of relapse Comorbidities: substance use disorders, depression, anxiety; high suicide risk

💡

The most common trigger for relapse in schizophrenia is medication non-adherence. Long-acting injectable (LAI) antipsychotics are a key strategy to address this. This is a priority nursing education topic.

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Positive vs. Negative Symptoms — Most Tested!

⏱ 3–8 min

🎯

Memory Hook: Positive = Added; Negative = Removed

Positive symptoms are behaviors or experiences added to the person's baseline — things that should NOT be there. Negative symptoms are behaviors or functions removed from the person — things that SHOULD be there but are absent. Negative symptoms are harder to treat and have greater impact on daily functioning and quality of life.

🔴 Positive Symptoms

Hallucinations— false sensory perceptions without external stimulus, do not exist in reality

Delusions— fixed false beliefs that have no basis in reality (persecutory most common)Disorganized speech/thinking— loose associations (fragmented thoughts or ideas), tangential, flight of ideas Disorganized behavior— unpredictable, agitated, inappropriate affect, Catatonia— extremes: stupor/waxy flexibility OR excessive motor activity Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation

Respond to antipsychotics

Acute crisis focus

🔵 Negative Symptoms

Affect (flat) — diminished emotional expression; monotone voice, blank face Blunted affect-restricted range of emotional feeling, tone, or mood

Alogia— poverty of speech, decrease amount, fluency, or spontaneity of speech Avolition— absence of will, ambition, or drive; lack of motivation Anhedonia— inability to experience pleasure or joy from previously enjoyed activities Inattention: Inability to concentrate or focus on a topic or activity, regardless of its importanceAsociality— social withdrawal; lack of desire for social interaction

Harder to treat

Atypicals more effective

Greater functional impact

🔍 Cognitive Symptoms — Often Overlooked

Impaired working memory — cannot hold information to complete a task Poor attention and concentration Concrete thinking — cannot think abstractly; interprets idioms literally

Executive function deficits — difficulty planning, problem-solving, decision-making Slow processing speed Cognitive deficits present before psychosis and are linked to poor functional outcomes

👁

Hallucinations & Delusions

⏱ 8–12 min

👂 Types of Hallucinations

Auditory— most common in schizophrenia; hearing voices; voices may give commands (command hallucinations— assess safety immediately!) Visual— seeing things not there; more common in delirium than schizophrenia Tactile— feeling sensations on or under skin (formication — "bugs crawling") Olfactory— smelling odors others cannot detect Gustatory— tasting things without a stimulus

🧩 Types of Delusions

Persecutory— most common; belief of being followed, spied on, poisoned, or harassed Grandiose— belief of having exceptional power, wealth, or identity (e.g., "I am the president") Referential (Ideas of Reference)— belief that neutral stimuli (TV, radio) send personal messages Somatic— false belief about body or bodily functions Erotomanic— false belief that someone (often famous) is in love with them Nihilistic— belief that self, others, or the world does not exist or will be destroyed

🚨

Priority Assessment: Command Hallucinations

When a patient reports hearing voices, always ask: "What are the voices telling you to do?" Command hallucinations that instruct the patient to harm themselves or others require immediate safety assessment and intervention. This is the nurse's legal and ethical priority.

💬 Therapeutic Responses — Hallucinations & Delusions

🔊 Responding to Hallucinations

Do NOT pretend to see/hear what the patient perceives Do NOT argue or challenge the reality of the experience Acknowledge the patient's experience: "I don't hear the voices, but I can see they are frightening you."Focus on feelings: "That sounds very scary. You are safe here."Redirect to present activity or environment Assess for command hallucinations — safety first

🧩 Responding to Delusions

Do NOT agree with or reinforce the delusion Do NOT directly argue or try to convince patient the belief is false Acknowledge the feeling behind the delusion: "It sounds like you feel very unsafe."Focus on reality-based aspects of the conversation Avoid detailed discussion of the delusional content Maintain consistent, calm, non-threatening approach

💭

Thought Process Disturbances

⏱ 12–14 min

🌀 Disordered Thought Processes

Loose associations— ideas shift from topic to topic with no logical connection Tangential thinking— responses go off on a tangent and never return to the point Circumstantial thinking— eventually gets to the point but through excessive, unnecessary detail Flight of ideas— rapid, continuous speech jumping between loosely related topics Word salad— severe; random words strung together with no meaningful connection Neologisms— patient invents new words with meaning only to them Clang associations— words chosen for their rhyming sound, not meaning Thought blocking— sudden interruption mid-sentence; patient loses the thought Echolalia— meaningless repetition of another person's words Concrete thinking— inability to think abstractly; interprets idioms literally (e.g., "raining cats and dogs" = actual animals falling)

🔄 Thought Content Disturbances

Thought insertion— belief that thoughts are being placed into their mind by an outside force Thought withdrawal— belief that thoughts are being removed or stolen from their mind Thought broadcasting— belief that one's thoughts are being transmitted and can be heard by others Ideas of reference— belief that external events carry special personal meaning (see Referential Delusions) Depersonalization— feeling detached from one's own mental processes or body Derealization— environment feels unreal or dreamlike

💡

When communicating with disorganized patients, use simple, direct sentences, one idea at a time. Repeat key points. Avoid idioms or abstract language — patient may interpret them literally.

🔬

Neurobiology — Why the Brain? Why These Drugs?

⏱ 14–16 min

⚗ Dopamine Hypothesis

Mesolimbic pathway:excess dopamine activity → positive symptoms(hallucinations, delusions) Mesocortical pathway:deficient dopamine activity → negative symptomsand cognitive deficits Explains why typical antipsychotics (D2 blockers) treat positive symptoms but can worsen negative symptoms Nigrostriatal pathway:D2 blockade here → extrapyramidal side effects (EPS) Tuberoinfundibular pathway:D2 blockade → elevated prolactin → galactorrhea, amenorrhea, sexual dysfunction

🧪 Other Neurobiological Factors

Glutamate/NMDA hypothesis:NMDA receptor hypofunction contributes to symptoms; basis for newer treatment targets Structural brain changes:enlarged lateral ventricles (most consistent finding); reduced gray matter volume; hippocampal changes Genetics:strong hereditary component; concordance in identical twins ~50%; first-degree relatives have 10x increased risk Prenatal factors:maternal infections, malnutrition, stress during pregnancy associated with increased risk Onset during period of high synaptic pruning (adolescence/young adulthood)

💊

Antipsychotic Medications — 1st vs. 2nd Generation

⏱ 16–20 min

📌

Core Mechanism: Both Generations Block Dopamine D2 Receptors

First-generation (typical) antipsychotics are primarily D2 blockers. Second-generation (atypical) antipsychotics block both D2 and serotonin (5-HT2A) receptors — this dual blockade gives better efficacy for negative symptoms and a lower risk of EPS. Neither generation cures schizophrenia; they manage symptoms.

Feature

🟠 1st Generation (Typical)

🔵 2nd Generation (Atypical)

MECHANISM

Primarily D2 receptor blockade

D2 + serotonin (5-HT2A) blockade

KEY DRUGS

haloperidol (Haldol) chlorpromazine (Thorazine) fluphenazine (Prolixin) perphenazine

clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) aripiprazole (Abilify) ziprasidone (Geodon)

POSITIVE SYMPTOMS

Effective

NEGATIVE SYMPTOMS

Minimally effective / may worsen

More effective — major advantage

EPS RISK

GREAT — major concern

Lower (except risperidone at high doses)

METABOLIC SIDE EFFECTS

Moderate

HIGH — weight gain, glucose/lipid abnormalities, metabolic syndrome (especially olanzapine, clozapine)

TARDIVE DYSKINESIA

HIGH risk — long-term use

Lower risk (not zero)

SEDATION

Varies — chlorpromazine very sedating; haloperidol less so

Varies — quetiapine, olanzapine more sedating; aripiprazole less so

PROLACTIN ELEVATION

Significant — amenorrhea, galactorrhea, sexual dysfunction

Less (aripiprazole actually lowers prolactin)

NURSING PRIORITY

Monitor for EPS; teach patient to report muscle stiffness, restlessness, involuntary movements

Monitor metabolic panel; weight, fasting glucose, lipids; clozapine requires ANC monitoring

💡

Antipsychotics do not work immediately — therapeutic effect takes 2–6 weeks for full benefit. Educate patients and families to continue medication even if they feel no different at first. Stopping medication is the #1 cause of relapse.

⚠

EPS & NMS — Critical Side Effects

⏱ 20–24 min

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Extrapyramidal Symptoms (EPS) — Know All Four Types

EPS are movement side effects caused by dopamine D2 blockade in the nigrostriatal pathway. They are most associated with first-generation antipsychotics. Onset timing helps differentiate each type. The nurse must identify EPS early and report immediately — some are reversible; tardive dyskinesia may not be.

Acute Dystonia

ONSET: Hours to days after starting or increasing dose

Sudden, painful muscle spasms and contractions Oculogyric crisis— eyes roll back involuntarily (very distressing!) Torticollis— neck twisting to one side Opisthotonos — arching of the back Laryngospasm — airway emergency if severe

Tx: benztropine (Cogentin) IM/IV

or diphenhydramine (Benadryl)

Reversible with treatment

Akathisia

ONSET: Days to weeks after starting

Subjective feeling of extreme inner restlessness Unable to sit still; constant pacing, foot-tapping, shifting Patient describes it as intolerable agitation "from the inside" Often mistaken for anxiety or psychotic agitation— do not increase antipsychotic! A major cause of medication non-adherence

Tx: propranolol (first choice)

or benzodiazepine

Reduce dose or switch drug

Pseudoparkinsonism

ONSET: Weeks after starting

Drug-induced parkinsonism mimics Parkinson's disease Tremor— pill-rolling at rest Rigidity— cogwheel or lead-pipe muscle stiffness Bradykinesia— slowed movements Shuffling, festinating gait; mask-like facies (flat expression) Drooling, difficulty swallowing

Tx: benztropine (Cogentin)

or amantadine

Reversible

Tardive Dyskinesia (TD)

ONSET: Months to YEARS of antipsychotic use

Involuntary, repetitive movements from prolonged D2 blockade Classic: lip smacking, tongue protrusion, chewing movementsChoreiform movements of face, limbs, trunk Assessed with AIMS (Abnormal Involuntary Movement Scale)— done at baseline and every 3–6 months May be irreversibleeven after stopping the drug Action: notify provider; consider tapering or switching to atypical

⚠ May be IRREVERSIBLE

Monitor with AIMS scale

Valbenazine (Ingrezza) or deutetrabenazine (Austedo) — FDA approved for TD

🚨

MEDICAL EMERGENCY

Neuroleptic Malignant Syndrome (NMS)

Classic Signs — "FARM"

Fever — high-grade hyperthermia (up to 107°F / 41.7°C) Autonomic instability — BP fluctuations, tachycardia, diaphoresis, tachypnea Rigidity — severe "lead-pipe" muscle rigidity Mental status change — confusion, altered consciousness, stupor, coma Lab: elevated CPK (creatine phosphokinase)— from muscle breakdown; elevated WBC

Nursing Action & Treatment

STOP the antipsychotic immediately— first and most important action Call provider STAT — this is a medical emergency Transfer to ICU level care Cooling measures — fever management Dantrolene— muscle relaxant to treat rigidity Bromocriptine— dopamine agonist to restore dopamine activity IV fluids, supportive care; fatal if untreated

⭐

Clozapine (Clozaril) — Special Considerations

⏱ 24–25 min

⭐

Most Effective Antipsychotic — Reserved for Treatment-Resistant Cases

Clozapine is the most effective antipsychotic available and the only one FDA-approved for treatment-resistant schizophrenia and for reducing suicidal behavior in schizophrenia. However, it carries unique life-threatening risks that require strict monitoring protocols (previously through the Clozapine REMS Program).

⚠ Agranulocytosis — Life-Threatening Risk

Clozapine can cause agranulocytosis (severe reduction in white blood cells — specifically neutrophils) Incidence: approximately 1–2%; can be fatal if undetected Requires mandatory ANC (Absolute Neutrophil Count)monitoring: Weekly for first 6 months → every 2 weeks for months 6–12 → monthly thereafter Drug is dispensed ONLY with compliant ANC results — no lab, no medication Teach patient: report immediately — fever, sore throat, mouth sores, fatigue (signs of agranulocytosis)

📋 Other Clozapine-Specific Side Effects

Seizures— dose-dependent risk; highest concern at higher doses Orthostatic hypotension— especially early in treatment; fall risk Hypersalivation (sialorrhea)— excessive drooling; very common and distressing Significant weight gain— monitor BMI, glucose, lipids closely Sedation— often significant, especially initially Myocarditis / Cardiomyopathy— rare but serious; monitor cardiac symptoms Advantage: very low EPS risk; does not raise prolactin significantly

🏥

Nursing Interventions

⏱ 25–27 min

🤝 Therapeutic Relationship & Communication

Maintain a calm, consistent, non-threatening presence Use simple, direct language — one idea per sentence Do not whisper, laugh, or have side conversations near the patient Avoid touch unless patient is comfortable — can be misinterpreted Be honest — never deceive the patient about medications or treatment Maintain appropriate personal space — do not crowd the patient

🛡 Safety & Environment

Assess for command hallucinations and suicidal/homicidal ideation — every shift Provide a structured, predictable environment with consistent routines Reduce environmental stimulation — quiet, low-stimulus milieu during acute phase Remove hazardous objects during acute psychosis Ensure medication is swallowed — observe for "cheeking" (holding medication under tongue) Consider long-acting injectable (LAI) formulations for adherence problems

💊 Medication Adherence — Priority Concern

Non-adherence is the most common reason for relapse — address every visit Educate patient: medication treats symptoms; stopping leads to relapse Teach: therapeutic effect takes weeks — do not stop if "don't feel different" Discuss and document side effects — address them proactively Use motivational interviewing to explore ambivalence about medications LAI antipsychotics (Haldol decanoate, Risperdal Consta, Abilify Maintena) — monthly/bimonthly injections

❤ Psychosocial Rehabilitation & Recovery

Recovery model: focus on hope, self-determination, and community integration Social skills training — teaching interpersonal skills lost to illness Supported employment / vocational rehabilitation Assertive Community Treatment (ACT) — intensive community-based support teams Family education — NAMI (National Alliance on Mental Illness) support groups Teach family: expressed emotion (hostility, criticism) increases relapse risk — communication skills training

⚙

CJM Case Study — Clinical Judgment in Action

⏱ 27–29 min

📋 Case Scenario

Mr. James T., 24-year-old male, is brought to the psychiatric ED by his mother, who states he has not slept in 4 days, has been refusing to eat ("the government is poisoning the food"), and was found outside talking loudly to himself. He has a diagnosis of schizophrenia and was prescribed risperidone (Risperdal) 3 months ago. His mother states he stopped taking his medication 6 weeks ago because he felt it was "making him stiff and restless." On assessment, James makes poor eye contact, mutters quietly in response to internal stimuli, and suddenly states: "The voices are telling me I have to get out of here — they say I'm in danger."

Command hallucinations — safety concern

Persecutory delusions (food poisoning)

6 weeks med non-adherent

EPS as reason for stopping meds

Prior dx: Schizophrenia

STEP 1

Recognize Cues

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STEP 2

Analyze Cues

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STEP 3

Prioritize Hypotheses

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STEP 4

Generate Solutions

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STEP 5

Take Action

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STEP 6

Evaluate Outcomes

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🎯

NCLEX Practice Questions

⏱ 29–30 min

📝

Click an answer to reveal the rationale

Select the best answer for each question. Feedback and rationale are revealed immediately after your selection.

QUESTION 01 · SAFETY PRIORITY

A patient with schizophrenia tells the nurse, "The voices are telling me to hurt myself." Which nursing action is the highest priority?

Administer the scheduled antipsychotic medication immediately

Reassure the patient that the voices are not real and will stop

Stay with the patient and perform a thorough safety assessment

Notify the family and ask them to come to the facility

QUESTION 02 · EPS RECOGNITION

A patient who started haloperidol (Haldol) 2 days ago suddenly reports that his neck is twisting to one side and his eyes are rolling back. He is extremely distressed. The nurse recognizes this as which adverse effect?

Akathisia

Acute dystonia

Tardive dyskinesia

Pseudoparkinsonism

QUESTION 03 · CLOZAPINE MONITORING

A patient with treatment-resistant schizophrenia has been prescribed clozapine (Clozaril). Which assessment finding requires the nurse to withhold the medication and notify the provider immediately?

The patient reports feeling drowsy after each dose

The patient has gained 4 pounds since starting the medication

The patient complains of excessive drooling at night

The patient's ANC result is below the required threshold and a sore throat is reported

QUESTION 04 · THERAPEUTIC COMMUNICATION — DELUSIONS

A patient insists that her hospital food is poisoned by government agents and refuses to eat. Which nursing response is most therapeutic?

"That's not true. The kitchen staff here are all certified and the food is completely safe."

"I understand — those agents sound very dangerous. Let's report them together."

"I can see you're feeling unsafe. Would you like to choose a sealed, packaged food that you open yourself?"

"You need to eat or we will have to place a feeding tube."

📖 Based on Videbeck's Psychiatric Mental Health Nursing · Chapter 16: Schizophrenia Spectrum Disorders

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