Psychiatric Disorders and Treatment

Disadvantages of DSM-5 Specificity

  • Diagnosis can be delayed due to the specific criteria in DSM-5. For example, schizophrenia requires symptoms to be present for at least six months and must cause functional impairment in work, school, relationships, or self-care.

Schizoaffective Disorder

  • Schizoaffective disorder involves meeting the criteria for both schizophrenia and a mood disorder, such as major depression or bipolar disorder.

Brief Psychotic Episode

  • A brief psychotic episode lasts at least one day but resolves within thirty days.
  • Triggers can include trauma, accidents, disasters, or death.

Psychosis

  • Psychosis includes hallucinations, delusions, and negative symptoms.
  • Conditions other than schizophrenia can cause psychosis, such as:
    • Bipolar disorder, especially during extreme mania.
    • Severe depression.
    • Substance use, either induced by the substance or during withdrawal.

Positive vs. Negative Symptoms

Positive Symptoms

  • Positive symptoms are abnormal behaviors or experiences that are present but should not be like hallucinations, delusions, altered speech, and bizarre behavior.
Types of Hallucinations
  • Auditory Hallucinations: The most common type. Hearing voices.
  • Command Hallucinations: The most dangerous type. Voices telling the client to harm themselves or others. Nurses must screen for these.
  • Visual Hallucinations: Seeing things that are not there.
  • Tactile Hallucinations: Feeling sensations that are not real. Common examples include feeling bugs crawling on the skin or sensations of being stabbed.
  • Olfactory Hallucinations: Smelling odors that are not present.
  • Gustatory Hallucinations: Tasting things that are not present.
Screening for Command Hallucinations vs. Suicide
  • Screening for suicide involves asking the client if they are having thoughts of harming themselves.
  • Screening for command hallucinations involves asking if the voices are telling them to hurt themselves or someone else.
Delirium Tremens
  • Severe alcohol withdrawal can cause delirium tremens, which is a life-threatening emergency. Patients may experience both visual and tactile hallucinations, such as seeing and feeling bugs.
Delusions
  • Delusions are fixed, false beliefs.
  • Thought Broadcasting, Insertion, or Withdrawal: Believing others can hear or insert thoughts into one's mind. Wearing a tin hat example to prevent others from stealing thoughts.
  • Persecutory (Paranoid) Delusions: Believing that others are after them, often involving government entities like the police or FBI.
  • Delusions of Grandeur: Believing oneself to be someone important, like the Queen of England.
Alterations in Speech
  • Clanging: Meaningless rhyming of words (e.g., sing, ring, ding).
  • Neologisms: Making up words that have meaning only to the client.
  • Word Salad: Using real words in a meaningless way (e.g., bicycle, I'm eating lunch, I'm going to Europe).
Bizarre Behavior
  • Unusual or strange actions. Example: slithering like a snake instead of walking or constantly walking backwards.

Negative Symptoms

  • Negative symptoms are the absence of normal behaviors or characteristics that should be present.

    • Flat or Blunted Affect: Expressionless face regardless of the situation.
    • Alogia: Lack of speech.
    • Anergia: Lack of energy.
    • Anhedonia: Lack of pleasure or joy in activities that were once enjoyable.
    • Avolition: Lack of motivation, which can lead to poor self-care and hygiene.

  • Note: These symptoms can also be present in depression.

Antipsychotic Medications

First Generation (Typical or Conventional) Antipsychotics

  • Treat only the positive symptoms of schizophrenia.
  • Examples: haloperidol, fluphenazine, chlorpromazine.
  • Mechanism: Block dopamine D2D_2 receptors.
Potency
  • High Potency: (e.g., haloperidol) Higher risk of Extrapyramidal Symptoms (EPS), lower risk of sedation and anticholinergic effects.
  • Low Potency: (e.g., chlorpromazine) Lower risk of EPS, higher risk of sedation and anticholinergic effects.

Second Generation (Atypical) Antipsychotics

  • Treat both positive and negative symptoms of schizophrenia.
  • Mechanism: Primarily block serotonin, with a small effect on dopamine.
  • Examples: risperidone, olanzapine, clozapine, lurasidone.
  • Lower risk of EPS compared to first generation, but still have side effects.
    • Monitor for anticholinergic effects, metabolic syndrome, and Neuroleptic Malignant Syndrome (NMS).
Neuroleptic Malignant Syndrome (NMS)
  • Life-threatening emergency.
  • Symptoms: High fever (104-105°F), muscle rigidity, fluctuating vital signs (hypertension), diaphoresis, decreased LOC.
  • Interventions:
    • Notify charge nurse and call rapid response.
    • Apply cooling blankets.
    • Administer IV acetaminophen or antipyretics.
    • Transfer to ICU.
    • Administer dantrolene to stop muscle lysis.
    • Stat page the physician and stop the medication.
  • Can occur with any generation of antipsychotics, but more common with first generation or during dosage changes.
Metabolic Syndrome
  • Components: dyslipidemia (high cholesterol, triglycerides, low HDL, high LDL), hyperglycemia (type 2 diabetes), and obesity.
  • Monitor: cholesterol, triglycerides, glucose, BMI.
Specific Medications
  • Olanzapine: Smoking decreases its effectiveness, recommend smoking cessation.
  • Clozapine: Not first-line due to the risk of agranulocytosis.
Agranulocytosis
  • Can occur with any antipsychotic, but most common with clozapine.
  • Increased risk for infection due to decreased white blood cells.
  • Teach clients to report fever or sore throat immediately.
  • Stop medication and contact the physician if the white blood cell count is below 3,0003,000 (or 3.03.0).

Third Generation Antipsychotics

  • Help with positive, negative, and cognitive symptoms (disorganized thinking, poor memory, difficulty concentrating).
  • Mechanism: Stabilize dopamine receptors (block in some areas, don't block in others).
  • Lower risk for EPS, diabetes, and weight gain.

Other Side Effects of Antipsychotics

  • Sexual dysfunction (more common reason males stop taking medication).
  • Weight gain (more common reason females stop taking medication).
  • Interventions: Discuss with provider for potential medication change or dosage adjustment.

Delusions

  • Fixed, false beliefs. Examples include persecutory delusions and delusions of grandeur.

Alterations in Speech (Expanded)

  • Circumstantiality: Providing excessive, unnecessary details but eventually returning to the main topic.
  • Tangentiality: Changing topics and never returning to the original topic.

Abnormal Involuntary Movement Scale (AIMS)

  • Used to detect Extrapyramidal Symptoms (EPS).
  • Assesses abnormal movements.
  • Monitor regularly to prevent mild EPS from progressing to tardive dyskinesia (more severe, sometimes irreversible movements).

Medications for EPS

  • Benztropine: Commonly used to treat EPS symptoms.
    *Anticholinergic effects: dry mouth, constipation, urinary retention, blurred vision.
  • Interventions for Anticholinergic Effects:
    • Suck on sugar-free candy or chew sugarless gum for dry mouth.
    • Increase fluid intake to 2-3 liters per day.
    • Increase fiber in diet for constipation.
    • Urinate before taking medication for urinary retention.

Acute Dystonia

  • A type of EPS that usually occurs within the first five days of starting an antipsychotic medication.
  • Causes severe spasms of the tongue, face, and trunk.
  • Worrisome because of potential airway compromise.

Akathisia

  • Inability to sit still, constant movement of legs and extremities, pacing.
  • Uncontrolled akathisia increases the risk of suicidal ideation; provide education, treatment, and instill hope; always screen for suicide.