Psychotic Disorders

Learning Outcomes

Students will gain an understanding of:

• The different causation theories of psychosis and the lived experience of psychosis.
• Clinical presentation associated with schizophrenia.
• Nursing assessment and management of psychosis and alternative approaches to responding to psychosis.
• Exploration of a Kaupapa Māori understanding of psychotic symptoms.
• Antipsychotic medication and adverse effects.

Lived Experience of Psychosis

• Debra Lampshire: Hearing Voices : an Insiders Guide to Auditory Hallucinations | TED Talk
• The voices in my head | Eleanor Longden – YouTube

Psychosis

• Derives from Latin (from ancient Greek psykhē): Psyche = “mind, soul, life” and osis = “abnormal condition” meaning “illness of the mind”.
• Psychosis experienced by humans since recorded history began.
• Psychosis can occur as a result of brain injury, disease, substance exposure/ ingestion, or as a symptom of mental distress.

Impact of Psychosis

• The first episode of psychosis (FEP) is particularly dramatic.
• Usually occurs at a critical age, when the person is consolidating their identity and forming significant relationships.
• A psychotic episode can alter this process, impacting the person’s sense of self, experience of life and the world, and relationships.
• For some people, psychosis is an extremely spiritual experience from which they gain personal growth and they lead full and fulfilled lives.

Psychosis Symptoms

• People experiencing psychosis have impaired reality testing.
• They are unable to distinguish their personal, subjective experience from the reality of the external world.
• A cluster of symptoms comprising one or more of the following:
  • Hallucinations
  • Delusions
  • Disorganised thoughts and behaviours

Epidemiology of Psychosis

• Psychosis is an amalgamation of psychological symptoms resulting in a loss of contact with reality.
• The current thinking is that although around 1.5 to 3.5\% of people will meet diagnostic criteria for a psychotic disorder, a significantly larger, variable number will experience at least one psychotic symptom in their lifetime.
• The incidence of a first-time episode of psychosis is approximately 50 in 100000 people, while the incidence of schizophrenia is about 15 in 100000 people.
• The peak age of onset for males is teens to mid-20s, while for females, the onset tends to be teens to late-20s.
• Earlier onset correlates with poorer outcomes, although early intervention correlates with better results.
• Mortality at any given age is doubled for Schizophrenia, including death from all causes; 10\% by suicide.
• Occurrence is 0.97\% for Māori compared with 0.32\% for non-Māori.
• Psychosis risk for Māori is nuanced and likely reflects increased rates of systemic discrimination, trauma, and financial stress.
• Conceptualizations of psychosis risk in Māori need to be better understood in order to accurately measure and target those needing support, as our current measures may pathologize normal experiences.

Causation Theories

• Diathesis–stress model
  • Psychosis is the result of an interaction between a predisposition to vulnerability and stress caused by life experiences.
  • A person may have a strong predisposition, but low stress and they develop mental distress.
• Trauma
  • Such as child sexual abuse, physical abuse, and emotional and physical neglect, increase the risk of psychosis.
  • Intergenerational Trauma
  • Genetic imprints of traumatic experiences can be passed from one generation to another.
• Genetic link
  • Linked with genes on Chromosomes 22 and 6.
  • The closer the relative, the higher the probability.
  • Probably not caused by one gene, because this would show in all monozygotic twin studies.
• Recreational drug use
  • Relationship between recreational drug use, and psychotic symptoms has been established (specifically cannabis, synthetic cannabis, amphetamines and cocaine).
• Neurological development
  • Abnormality may occur in the 2nd trimester:
  • Incomplete cell migration during development.
• Pre-natal factors
  • Acute infection with Toxoplasma gondii
  • In utero stress, such as domestic abuse and poverty
  • Exposure to Flu virus in 2nd trimester
• Increased levels of Dopamine
  • Positive symptoms occur due to increased levels of Dopamine.
  • Amphetamines and cocaine increase dopamine levels.
  • Medication that blocks dopamine receptors can reduce symptoms.

Psychotic Disorders Include

• Brief psychotic disorder
• Delusional disorder
• Substance-induced psychotic disorder
• Bipolar affective disorder
• Schizoaffective disorder
• Schizophrenia
• Schizophreniform disorder (less than 6 months)

Schizophrenia: Clinical Presentation

• Schizophrenia suggests a single illness; however, it is more accurately viewed as a cluster of conditions on a continuum, with many symptoms being shared by people with different diagnoses.
• Schizophrenia is commonly characterised by a disorder of perception, cognition and volition (motivation).
• Onset can be insidious or acute.

Schizophrenia: Prodromal Phase

• People may experience changes in behaviour and perception, known as a ‘prodrome’.
• Often evident in early adolescence.
• The prodromal period can last up to two years.
• Symptoms include:
  • Worsening of usual work or school performance
  • Worsening intellectual and organisational functioning
  • Social withdrawal
  • Emerging unusual beliefs
  • Changes in perception such as experiencing instances of hearing sounds/voices not heard by others.

Schizophrenia: Acute Phase

• Acute phase may be preceded by days/weeks of deteriorating behaviour leading to a florid psychosis marked by intense emotional and psychological upheaval.
• Symptoms persist for at least 6 months continuously and include at least 1 month of active phase symptoms.
• Symptoms include:
  • Hallucinations (mainly auditory)
  • Delusional thinking
  • Disorganised or bizarre behaviour
  • Social and emotional withdrawal
  • Anxiety, paranoia, depression or euphoria may be seen

Schizophrenia: Residual Phase

• Symptoms in this phase of the illness resemble symptoms in the first phase.
• They’re characterized by low energy and lack of motivation, but some elements of the active phase remain.
• Treatment can help reduce symptoms and prevent relapses.
• A person having experiences described as ‘psychotic’ may struggle to function at a level that they might previously have achieved.
• In one manner or another, a person diagnosed with schizophrenia may be managing symptoms or working to prevent a relapse for the majority of their life.

Positive Symptoms

• Positive symptoms ($+$) are thought processes, emotions and behaviours that are exaggerations of, or additional to, what an individual experiences when they are well.
• Hallucinations
  • Things a person sees, hears, smells, tastes or feels that no one else can see, hear, smell, taste or feel.
  • “Voices” are the most common type of hallucination.
  • Many people with the disorder hear voices.
  • Other types of hallucinations include seeing people or objects that are not there, smelling odours that no one else detects, and feeling things like invisible fingers touching their bodies when no one is near.

Positive Symptoms: Delusions

• Delusions are false beliefs that are not in keeping with the person's culture and do not change.
• The person believes delusions even after other people prove that the beliefs are not true or logical.
• Types of Delusions:
  • Persecutory delusions
  • Delusions of being controlled
  • Referential delusions
  • Religious delusions
  • Somatic delusions
  • Grandiose delusions

Positive Symptoms: Movement Disorders

• Movement disorders may appear as agitated body movements or catatonia.
  • stupor (a state close to unconsciousness)
  • catalepsy (trance seizure with rigid body)
  • waxy flexibility (limbs stay in the position another person puts them in)
  • mutism (lack of verbal response)
  • posturing (holding a posture that fights gravity)
  • mannerism (odd and exaggerated movements)
  • stereotypy (repetitive movements for no reason)
  • grimacing (contorted facial movements)
  • echolalia (meaningless repetition of another person’s word)
  • echopraxia (meaningless repetition of another person’s movements)

Negative Symptoms

• Negative symptoms (-) are absences or reductions of thought processes, emotions and behaviours that were present prior to the onset of the illness but have since diminished or are absent.
• For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset.
• Includes:
  • Anhedonia (lack of feelings)
  • Blunt affect (lack of expression)
  • Avolition (lack of motivation)
  • Poverty of speech/thought
  • Social withdrawal
  • Insomnia

Disorganised Thoughts and Cognition

• Cognitive symptoms affect our ability to reason, and problem solve (disorganised thinking, loosening of associations, incoherence).
• Disorganised thinking: This is when a person has trouble organising their thoughts or connecting them logically (racing thoughts). They may talk in a garbled way that is hard to understand.
• Thought blocking: This is when a person stops speaking abruptly in the middle of a thought. When asked why they have stopped talking, the person may say that it felt as if the thought had been taken out of their head.
• Other disorders: neologisms (meaningless words); clanging (rhymes) echolalia (echo).

Schizoaffective Disorder

• Schizoaffective disorder is a thought disorder that includes both psychotic features and mood symptoms that may be either depressive or manic in presentation.
• The psychotic and mood symptoms may occur together or at different times.
• Schizoaffective disorder is diagnosed in fewer people than is schizophrenia.
• At least two psychotic symptoms must be present, as well as mood symptoms of a specific duration.

Nursing Management

• Establish trust and rapport: may require persistence, flexibility, reliability, consistency.
• Complete full Mental State Assessment.
• Consider symptoms and severity and impact of symptoms.
• Focus on the intent (feelings) of delusions/hallucination rather than the content.
• Avoid arguing about delusions/ hallucinations.
• Tell them you do not see, hear, smell, or feel it but explain that you know that these hallucinations are real to them.
• Keep it real.
• Engage the person in reality-oriented activities that involve contact and connection.
• Consider the impact of symptoms on the individual (and their whānau families).
• What strategies the person has developed to cope with them.

Nursing Management Cont.

• Assess the person for a risk to themselves or others that justifies compulsory treatment.
• Provide access to talking therapies (psychotherapy), include support around diagnosis and/or hospitalisation.
• Antipsychotic drugs remain the primary treatment for psychosis (in NZ).
• Require regular monitoring.
• Assess for ongoing issues with physical health; constipation, cardiac problems, metabolic risk and movement disorders.
• Importance of Hope; “Recovery is expected”.

Nursing Considerations: Psychosis

• Explore
  • Explore negative symptoms, physical and psychosocial needs.
  • Promote healthy diet/exercise and social interaction.
• Understand
  • Spiritual and cultural understanding; psychosocial paradigm and persons understanding of causation rather than medical model.
• Assess
  • Assess support system.
  • Involve whānau and friends and acknowledging their views and needs.
• Promote
  • Promote social skills.
  • Provide support in assisting the acquisition of social skills and relationships.
  • Importance of occupying time with work/study/ and maintaining social contact.

Cultural Assessment

• Every culture has nuanced perspectives on wellbeing, mental health and origins of distress and appropriate interventions.
• Cultural assessment is the process through which the relevance of culture to mental health is determined.
• Key element of mainstream mental health service delivery and responsiveness to Māori.
• Supports providers to develop and maintain culturally effective and relevant services to tangata whaiora and whānau.
• Complementary to clinical assessment and should only be carried out by those trained to do so.
• When working with Māori, Kaupapa Māori, expertise in Tikanga (customs), Te Reo (language) and Matauranga (knowledge) Māori are fundamental prerequisites.
• For Pacific people mental distress may be understood as traditional illness that requires the expertise of a healer rather than a psychiatrist (In Tonga this distress is called Avea Avanga, in Fiji it is referred to as Lilia, and in Samoa it is known as Mai Aitu.

Māori Perspectives of Psychosis

• “Māori have always had those who hear and see what others don’t. Those who walk within wairua. This is nothing new and it’s not this pakeha word ‘psychosis’ either. Those who gaze into Te Ao Wairua (spirit world) are our Tohunga (Healers), our Matakite (Seers), and they were highly valued amongst the Iwi…not cast off and shunned like many are now. I truly believe many Māori who are said to be ‘psychotic’ are Matakite – or even Tohunga – and they need awhi (support) to understand that and awhi to use those taonga (gifts) properly”
  • Whaea Jane (Waikato/Hauraki)

Mate Māori

• Refers to a cause of ill health or uncharacteristic behaviour which stems from an infringement of tapu (a tribal law) or the infliction of an indirect punishment by an outsider (a mākutu).
• Related to spiritual causes, and requires the intervention of a tohunga or priest.
• Applies to physical as well as mental illnesses and has increasingly become a focus to explain emotional, behavioural and mental distress.
• Māori may be reluctant to discuss mate Māori fearing ridicule or pressure to choose between psychiatric and Māori approaches.

Matakite and Tohunga

• Mata = Face
• Kite = To see, all-seeing
• Matakite = All seeing face
• The Matakite is the person who experiences. (The ‘Seer’, the “Hearer”)
• Tohu = sign, symptom, indication
• Nga = Plural, all of
• Tohunga = A person who can read all the signs; who is in their ‘knowing place’; who understands the experience and has been ‘empowered’ to utilise the experience. The ‘Healer’.
• Not all Matakite are or are destined to be Tohunga. All Tohunga, however, by the nature of their abilities, are Matakite.

Kaupapa Māori Approaches

• Kaupapa Māori (cultural philosophies and practices) approaches cannot be defined through any particular method or model.
• This cultural healing pathway explores and reconnects Māori to their spiritual, physical, emotional and whānau origins of well being wherein lie deeply powerful and transformative components.
• Kaupapa Māori approaches, formulated and delivered ‘for, by and to Māori’ where Māori thinking, values, relationships, knowledge, language, stories and songs, protocols and world views and their relationship to today’s environment form the basis of engagement, are considered best practice when working with Māori.
• Kaupapa Māori refers to “Māori” ways of doing things – like speaking te reo Māori and practicing tikanga – that are based on the values that underpin Māori ways of being – such as mana, tapu, and whānau.

Kaupapa Māori Approaches Cont.

• In both clinical and cultural roles, kaimahi Māori bring a kaupapa Māori way of working by their backgrounds and worldviews, not by any particular guidance or training.
• This is manaaki, mana protecting and mana enhancing practice that contributes to the outcome manaakitanga.
• Kaupapa Māori approaches are most often demonstrated in informal, day-to-day interactions between kaimahi and whaiora. Examples include:
  • use of te reo Māori, sharing kai with whaiora (manaakitanga), using karakia or waiata to whakawātea or clear the energy of a tense situation (wairuatanga), creating familial connections with whaiora through whakapapa centred care and hui (whanaungatanga)
• Extensive evidence shows kaupapa Māori approaches contribute improved mental health outcomes for Maori and to lower rates of seclusion and restraint.

Alternative Approaches to Understanding Psychosis

• Intervoice: The International Hearing Voices Network.
  • Founded by Professor Marius Romme, Sandra Escher and Patsy Hage and people who had lived experience in 1987.
  • Psychotic experiences such as voices (also known as auditory hallucinations) need to be understood from the perspective of their meaning for the person who experiences them.
  • The network also supports theories that traumatic experiences can often be the origin of voice-hearing rather than interpreting voices as being an aberrant symptom of mental illness.
• Open Dialogue Therapy/ Open Dialogue Approach (ODT/ ODA)
  • Developed by Yrjö Alanen in Finland in the 1980s. Positive results seen in Lapland. Trialled elsewhere across the world.
  • The primary goal of ODT/ ODA is increased engagement of a person’s social network/family in an informal, therapeutic way.
  • Creates a more open dialogue about experiences related to psychosis in the home environment and is less about medical interpretation and intervention. (Move away from “Dr knows best”).

Alternative Approaches Cont.

• Dissociachotic theory:
  • Developed by mental health nurse practitioner Matthew Ball, Dissociachotic theory provides an alternative way of understanding experiences traditionally referred to as psychosis
  • Psychotic disorders are meaningful forms of dissociation that serve to create experiential separation from perceived threats.
  • Believes that extraordinary experiential realities are often mislabelled as symptoms like hallucinations and delusions and should be viewed as human coping strategies, designed to satisfy the innate human need for social, emotional and physical safety.
  • When dissociachotic theory is put into practice the role of nurses and other supporters becomes focused on uncovering the meaning that dissociachotic phenomena holds for people and using therapeutic communication to explore and remedy the sense of threat and need for safety experienced by the individual concerned.
• The Power Threat Meaning Framework (PTM):
  • The PTF was published by the British Psychological Society and it provides a conceptual and intellectual alternative to diagnostic and medicalised thinking and practice in the treatment of mental distress.
  • PTM highlights that personal stories and meaning offer rich and meaningful alternatives to psychiatric diagnosis.
  • The PTM framework provides a more pragmatic way to develop a collaborative formulation of people’s experiences, empowering individuals to formulate their own meaning and sense of whether they have a disorder or not.
  • There is a significant power imbalance between a person being treated for mental distress and the psychiatrist treating them. (The patient- doctor relationship.) People who feel threatened will react to that threat whether it is perceived or real. Language associated with diagnoses often reflects this imbalance.
  • Nurses may find the PTM framework useful to understand the negative experience of power in a person’s life and the potential for the positive

Anti-psychotic Medication

• First generation or typical antipsychotics
  • Trifluperazine
  • Pimozide
  • Chlorpromazine
  • Fluphenazine
  • Haloperidol
  • Flupenthixol
• Second generation, atypical antipsychotics
  • Clozapine (1959, 1989)
  • Risperidone (1994)
  • Olanzapine (1996)
  • Quetiapine (1997)
  • Sertindole (1997)
  • Ziprasidone (2001)
  • Amisulpride (2002)
• Third generation, atypical antispychotics
  • Paliperidone (2006)
  • Asenapine (2009)
  • Iloperidone (2009) and Lurasidone (2009) (last two are not available in NZ)

First Generation Typical Anti-Psychotic

• Interfere with dopaminergic neurotransmission in the limbic system and in the cerebral cortex (areas involved in the control of motivated and emotional behaviour and in facilitating organised thought).
• Can be helpful in alleviating the positive symptoms of schizophrenia.
• However, typical antipsychotics affect other D2 pathways in the brain, including those the extrapyramidal dopamine pathway involved in voluntary muscle movement (namely, the basal ganglia and cerebellum).
• As a result, when these drugs are administered to patients, many experience symptoms of motor dysfunction referred to as EPSE.
• Ataractic: Major tranquilizing or sedating effect

Extrapyramidal Side Effects

• Pseudoparkinsonism
  • Stooped posture
  • Shuffling gait
  • Rigidity
  • Bradykinesia
  • Tremors at rest
  • Pill-rolling motion of the hand
• Acute dystonia
  • Facial grimacing
  • Involuntary upward eye movement
  • Muscle spasms of the tongue, face, neck and back (back muscle spasms cause trunk to arch forward)
  • Laryngeal spasms
• Akathisia
  • Restless
  • Trouble standing still
  • Paces the floor
  • Feet in constant motion, rocking back and forth
• Tardive dyskinesia
  • Protrusion and rolling of the tongue
  • Sucking and smacking movements of the lips
  • Chewing motion.
  • Facial dyskinesia
  • Involuntary movements of the body and extremities

Second Generation Atypical Antipsychotic

• Have a lower affinity for D2 receptors yet readily bind with D3 and D4 dopamine receptors.
• Antagonise the 5-HT2A (serotonin) receptor with at least equal (or near equal) affinity to their blockade of the D2 receptor that, somehow, (this serotonin- dopamine balance confers atypicality which is where the name comes from).
• Have a high selectivity - since D3 and D4 is restricted to the neurons of the limbic system and cerebral cortex only.
• Thought to work by antagonising (blocking) the dopamine D2 receptor.
• Bind more loosely to the D2 receptor (fast-off theory) than the previous generation of antipsychotics.
• Bind to the D2 receptor for long enough to produce their therapeutic effects, but not long enough to produce extrapyramidal side effects.
• The 5-HT2A receptor regulates the release of dopamine in striatal structures including the basal ganglia which is responsible for the control of voluntary movement.
• Act as adrenergic, cholinergic, histaminic and serotonergic antagonist which accounts for side-effect profile.

Side Effects of Atypical Antipsychotics

• Weight Gain
• Diabetes
• Hyperglycemia
• Insulin Resistance
• Dyslipidemia
• CVD
• Sexual dysfunction
• Seizure
• Arrhythmias and sudden cardiac death
• Sedation
• Extrapyramidal symptoms
• Dry mouth
• Urinary retention
• Postural hypotension

The Glasgow Antipsychotic Side-Effect Scale

• The Glasgow Antipsychotic Side- effect Scale (GASS; Waddell & Taylor, 2008) is a self-rating scale to detect the side effects of second-generation antipsychotics.
• This scale was designed to allow a timely, sensitive and reliable method of gathering information on the number and severity of side effects an individual suffers from.

The Metabolic Syndrome

• Heart Disease
• Lipid Problems
• Hypertension
• Type 2 Diabetes
• Dementia
• Cancer
• Polysistic ovarian syndrome
• Non-alcoholic fatty liver disease

Long Acting Injections (LAI) (Depots)

• Typical: e.g. Fluphenazine decanoate (Modecate); haloperidol decanoate (Haldol); Zuclopenthixol (Clopixol).
• Atypical: e.g Risperdal Consta; Zyprexa Ralprev (Olanzapine); Paliperidone palmitate.
• Olanzapine found to have 5 fold increase in peak plasma levels compared to oral.
• Paliperidone (similar to Respiridone as injection) funded 1 May 2014: potential advantage of monthly dosing.
• Post injection Syndrome (only in Olanzepine): delirium, tachycardia, agitation/aggressiveness, dysarthria, various extrapyramidal symptoms and reduced level of consciousness potentially ranging from sedation to coma.

Clozapine

• First introduced in 1959 but withdrawn due to patient deaths (agranulocytosis).
• Reintroduced 1989 but with strict monitoring protocols.
• US trials found 30% of patients who did not respond to other antipsychotics responded to Clozapine, may be up to 60% long term.
• Significant Adverse effects: Blood Disorders, Reversible Neutropenia (lowered neutrophil count), Reversible Leukopenia (lowered white blood cell count), Potentially fatal Agranulocytosis (approx 1% -2% Clozapine patients Can occur at any time, risk first 18 weeks)
• Mandatory blood monitoring required.
• Treatment: stop dose and challenge should not be attempted

Clozapine Prescribing Protocol

• Patient required to have been prescribed 2x other antipsychotic medications without good effect.
• Check register to see if patient previously been prescribed.
• 10 days before treatment: FBC, LFT, fasting blood sugar, electrolyte.
• Full baseline assessment: height, weight, waist circumference, lipid levels, sitting and standing PB, TPR.
• Baseline ECG
• Blood tests weekly for the first 18 weeks and then 4 weekly (FBC; looking for a drop in baseline WBC or absolute neutrophil count (ANC).
• Dose titration: 12.5mg day one and then double for a period of 2-3 weeks to a dose of 300/400 mg a day; max dose 900mg.
• Pharmacy cannot dispense without satisfactory blood test in previous 72 hours.
• Advise patient of flu like symptoms (fever and sore throat).

Neuroleptic Malignant Syndrome (NMS)

• Increase risk of developing NMS
  • Young Male
  • Exhaustion
  • Dehydration
  • Hyponatraemia (low sodium)
  • Affective disorder
  • Thyrotoxicosis (high thyroxin)
  • Anaemia
  • Leucocytosis
  • Elevated CPK (enzyme)
• Risk factors
  • Mortality rate 4% (reduced from 20% with early detection by nurses).
  • Increased risk with SSRIs, and street drugs.
• Treatment
  • Stop antipsychotic immediately.
  • Rehydrate.
  • Supportive (full) nursing care.
• Drug Treatment
  • Bromacryptine (a dopamine agonist).
  • Muscles relaxants.
  • Benzodiazepines for sedation.
• Rechallenge with close monitoring.
  • Base line recordings
  • Monitor temperature and BP.
  • Monitor and report effects and side effects promptly.
  • Advocate for the lowest possible dose.