CHAPTER 11 Integrative Management of Psychotic Symptoms

OVERVIEW

describes many phenomena associated with breaks from reality.

conditions that affect the mind, where there has been some loss of contact with reality

thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not”

a person may not distinguish internal sensory perceptions or ideas from the external reality. Primary symptoms of psychosis include hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms as well as dimensional aspects of depression and mania

presence of psychosis emphasizes the need for comprehensive and proficient investigation.

schizophrenia includes psychosis, whereas psychoses are not always schizophrenia.

diagnostic suspicion rely upon patterns of expression, age of associated expressional symptoms, and risk factors

use of opiate replacement treatment and the legalization of marijuana recognizes a temporal relationship with increased frequency of psychotic episodes.

Schizophrenia is a mental disorder in which—along with psychosis—the clinical presentation reflects impairments in social, relational, vocational, motor, and cognitive domains.

INCIDENCE AND PREVALENCE

schizophrenia favor women

DIFFERENTIAL DIAGNOSES FOR PSYCHOTIC SYMPTOMS

HISTORY

The term “paranoia” was first devised by Greek physicians and was used by Hippocrates to refer to a delirium or disorganized thinking.

paranoia was a persistent delusional illness

delusional content in both sexes came from the projection and reaction formation of ego development

“narcissistic neuroses,” that resulted from developmental fixations which produced defects in this ego development.

social withdrawal, grandiosity through magical omnipotence of thought processes, and absence of reality testing, in which the individual does not possess the capacity to distinguish internal fantasy from reality

“split personality”

splitting off of the mind between the functions of feeling and thinking.

chronic psychosis recovery should remain the goal of treatment with or without medical intervention.

The primary symptoms are denoted by the “four As” (i.e., autism, ambivalence, affective disturbance, and loosening of associations). Secondary symptoms include: illusions, delusions, hallucinations, symptoms related to muscular activity, withdrawal, and lack of touch with reality.

Type 1, or positive, syndrome was composed of florid symptoms, such as delusions, hallucinations, and disorganized thinking. Type 2, or negative, syndrome was characterized by deficits in cognitive, affective, and social functions, including blunting of affect and passive withdrawal. The DSM-5 organizes the presence of positive symptoms as the criterion combined with a second criterion that may or may not include negative symptoms.

hallucinations was eliminated, shifting the focus toward the chronicity and severity.

ETIOLOGY

schizophrenia is a manifestation of a brain disease rooted in genetics and impacted by the web of environment.

possible that both genetic and nongenetic forms of the disorder exist

interaction of environmental influences on gene expression varies and gene expression influences one’s environment.

Abnormal brain morphological structure has been identified as already present at the time of the first psychotic episode.

significant cortical gray matter deficits and lateral and third ventricular enlargements.

Loss of cortical gray matter without cell death is seen, specifically abnormal cortical thinning which is localized to the anterior and superior prefrontal cortex.

possible to recognize that the reduction of gray matter parallel to genetic expression is linked to the pathophysiology of schizophrenia.

specific degree or amount of gray matter reduction does not correlate with a specific threshold in which psychosis emerges.

Altered activation of dopamine receptors

believed that the dopamine hypothesis is too simplistic to explain the whole syndrome.

Excessive dopamine release has been associated with severity of positive symptoms (i.e., hallucinations, delusions, and paranoia).

dopamine hypothesis suggests that the symptoms of schizophrenia are due primarily to a functional hyperactivity in the dopamine system in limbic regions and the amygdala, and a functional hypoactivity in frontal regions.

hyperdopaminergic state existing in the mesolimbic pathway results in the positive symptoms and a hypodopaminergic state results in the mesocortical pathways; this leads to the negative, cognitive, and affective symptoms.

antipsychotic drugs used to treat schizophrenia was highly correlated with their ability to block dopamine (D2) receptors. Conversely, drugs that enhance dopamine transmission, such as amphetamines, tend to worsen the symptoms of schizophrenia.

abnormality in this illness might lie specifically in the D2 receptors.

individual ages and brain function deteriorates, there is less dopamine expression; thus, there is often an improvement and even complete remission over time.

Serotonin inhibits dopamine synthesis, and therefore, agents that occupy serotonin receptors may increase dopamine levels in areas that need it and improve negative symptoms. Positron emission tomography (PET) has been used to measure receptor occupancy.

Atypical antipsychotics (often referred to as second- or third-generation antipsychotics [SGAs and TGAs]) demonstrate a broad pharmacological profile. In addition to dopamine receptor blockade, they also block one or more serotonin type 2 (5-HT2) receptors (5-HT2A, 5-HT1A, and 5-HT2C), suggesting a role for serotonin in the pathophysiology of schizophrenia.

Other neuroreceptors associated with schizophrenia include norepinephrine, gamma-aminobutyric acid (GABA), neuropeptides, glutamate, acetylcholine, and nicotine.

glutamate pathways was the observation made more than three decades ago that phencyclidine phosphate-induced psychosis manifests all the symptom domains of schizophrenia—positive, negative, cognitive, and formal thought disorder.

glutamate hypothesis, excessive amounts of glutamate are released and exert a neurotoxic effect that leads to the signs and symptoms of schizophrenia.

This impairment likely correlates with variations in working memory, resulting in impairment of executive function.

The stress model suggests that individuals may carry a genetic predisposition, but this vulnerability is not “released” unless other factors also intervene.

factors include birth injuries, poor maternal nutrition, viral exposure, or maternal substance abuse. The incidence of schizophrenia is increased in children whose mothers were exposed to influenza in the second trimester of pregnancy. Perinatal asphyxia is also associated with the later development of schizophrenia.

Psychologically stressful life events may also have a connection to the onset of or relapse in a major psychotic illness.

Family psychoeducation becomes very important in clarifying symptom states, expectations, and communication strategies.

ASSESSMENT STAGES OF SCHIZOPHRENIA

prodromal phase of schizophrenia, which is identified as early signs of an already evolving disease.

“phase before the phase.”

premorbid period in which there are indications of “something,” typically recognized as another component of the individual’s personality or behavior.

prodromal phase- subtle changes in a person’s behavior, such as increasing isolation, withdrawal from usual activities, less affect or emotion, or strange or unusual thinking.

anxiety, including social and/or obsessive-compulsive behavior; preoccupation with perceptual experiences, distance from peers, somatic complaints such as increasing fatigue, or problems with focus and attention. attention deficit hyperactivity disorder (ADHD) symptoms later to be revealed as psychosis. disinterest in friends, perhaps giving up sports or other clubs, and a decrease in grades or motivation. “if their eyes and ears are beginning to play tricks”.

early treatment may improve the prognosis.

symptoms may overlap with another diagnosis, such as depression, anxiety, or substance use.

Often a diagnosis of ADHD

Amphetamines such as stimulants, or early substance use such as marijuana, may induce psychosis; both can result in schizophrenia or permanent psychosis or worsen the course of illness.

active phase of the illness occurs with the emergence of the psychotic symptoms, which may include hallucinations, delusions, or disorganized speech and behavior.

physiognomies of schizophrenia

Bleuler’s four A’s, which are specifically loose associations, affect, autism, and ambivalence.

Schizophrenia may be an additional diagnosis when there is the presence of delusions or hallucinations.

Hallucinations are one of the core “positive” symptoms. Although hallucinations in schizophrenia may involve different senses, such as visual or tactile, the majority of clients with hallucinations report auditory or verbal hallucinations. Auditory hallucinations are often prominent and, when assessed, have been present in some form for an extended period of time. “hear voices,”

hearing words, intrusive and disparaging comments, fragments of conversations, multiple voices arguing, and sometimes commands urging them to act. Most often the voices are different than one’s own. auditory hallucinations that are not responsive to medication treatment.

risk determination separates whether the client is responding to hallucinations by considering harm to themselves or others or if the content of the hallucination is more self-deprecating, in which case the client may respond to reality testing. The level of distress exhibited by the client, and the risk of harm and impact on function and/or health is the medical decision.

continues to hear voices when they are otherwise stable, the client could in fact be diagnostically considered schizoaffective, where the presence of psychotic material exists outside of a mood episode.

interventions focus on safety and security in meeting the client’s physical health and safety needs. Hospitalization is often necessary for the safety of the client or others. Crisis intervention, symptom resolution, development of a therapeutic alliance, and setting up adequate aftercare are keys to preventing further decompensation and additional relapse.

several hospitalizations within the first year of diagnosis.

comprehensive treatment plan that includes community support, family involvement (if appropriate), and education.

occurs in young adulthood, there is a period of grief and loss that ensues when an individual either knowingly or unknowingly loses a sense of their autonomy at a time when they should be increasingly independent.

The residual phase may reflect that the active phase symptoms are absent or no longer prominent.

role impairments, negative symptoms, or attenuated positive symptoms. Acute-phase symptoms may re-emerge during the residual phase (“acute exacerbation”); these may not progress to a full relapse but warrant attention.

goals at this stage are to prevent relapse, engage the client and family into a chronic treatment paradigm, reintegrate the client into the community, and, perhaps, give a referral to a vocational rehabilitation program.

comprehensive system of care that incorporates inpatient acute settings, outpatient follow-up, a partial day hospital program, case management services, and vocational rehabilitation programs. Long-term consistent care is desirable where both medication and psychosocial support and education can be provided.

relapse during this residual or transition phase include failure to take the medication, failure to connect or continue in aftercare, inadequate supports, and isolation.

social deficits as a barrier to recovery and a predictor of poor outcomes. Peer recovery support groups have long identified the eccentricity in social skills.

psychopathology of schizophrenia places social cognitive and meta-cognitive deficits as objectives, which, when addressed, improve recovery. During the residual phase, vocational, social, and psychological skill development, in addition to the medical surveillance of biological treatments, is compulsory for positive outcomes.

cognitive behavioral therapy (CBT) as a preferred treatment to address negative symptoms and cognitive remediation so as to improve vocational opportunities

cognitive defects - Memory deficits, reasoning, and inhibitory control impacts several areas of treatment including ability to accept treatment in a reasoned way.

Clinical Assessment

Clinical Interview

intentional listening

Parallel to listening is observation of affect and behavior, both of which are instrumental to the interpretation of the assessment.

assess not only the words, but the feelings, thoughts, and actions as well. The mental status examination is the observational summary of pertinent findings in all mental health conditions;

primary care provider (PCP) who is first made aware of psychotic symptoms or a change in an individual’s behavior.

psychiatric team that includes therapists, nurses, and case managers.

management of this disorder toward integration within the community.

PHASES OF SCHIZOPHRENIA

Prodromal

•Essentially the “beginning before the storm”

•Can be recognized in childhood with nonspecific changes in social connections, academics, engagement to later inability to sustain employment, relationships, social withdrawal

Active

•Prescence of psychosis ranging from variety of hallucinations, delusions, paranoia

Severity/Residual/Recovery

•DSM-5 does not identify residual phase, considers schizophrenia to be in remission or continuous

•Identified by number of episodes

pattern of onset, the duration, and the accompanying symptoms.

rule out any accompanying underlying medical etiology.

Substance abuse, substance ingestion, tumors, masses and lesions, infectious processes, endocrine disorders, medication adverse effects, and metabolic disorders.

serum evaluation including complete blood count (CBC), comprehensive metabolic profile (CMP), thyroid function tests, and serological tests for evidence of an infection with syphilis or human immunodeficiency virus (HIV). If lesions, brain injury, or other brain disorders are suspected, an MRI or CT scan may be warranted. A baseline lipid panel and fasting blood sugar are suggested if the client is prescribed an antipsychotic.

review of both history and present symptoms. Beginning with the history of current symptoms, past psychiatric history.

reproductive history and current menses patterns.

physical and neurological history.

history of falls, concussion, or possible traumatic brain injury (TBI).

A drug or poisoning history is essential as there are numerous prescription and street drugs and other toxic agents that can produce psychotic features that may be misdiagnosed as schizophrenia.

individuals with psychosis can develop medical conditions that may induce what appears as relapse when in fact it is a new onset of another malady.

Late-onset psychosis (LOP) and very-late-onset schizophrenia-like-psychosis (VLOSP).

not common, the emergence of schizophrenia can occur at any point in one’s life with first onset at or after age 40.

interviewing the individual who is demonstrating active psychotic symptoms.

challenging as the individual may be guarded, offering little information.

person may not believe there is a problem, or the presenting complaint might be a somatic or paranoid delusion with lack of insight.

adjunctive neuropsychological testing

case of clients who do not demonstrate insight, these tests may not result in confirmation of psychosis from the client perspective;

individuals living with schizophrenia, and a smaller percentage who live with bipolar disorder, demonstrate poor insight.

Anosognosia, or the lack of awareness of an illness, is often associated with psychosis. This is common in other neurological disorders such as stroke, dementia, and Alzheimer’s disease.

lack of awareness is associated with an increased risk of non-adherence to treatment.

assessment should include inquiry pursuant to adherence or in many cases non-adherence to treatment.

related to several factors including unpleasant side effects of treatment, memory deficits, or, in the case of a client with anosognosia, no recognition of the presence of the disorder.

Denial is often incorrectly used as a synonym for anosognosia.

denial is a psychological response to information that is distressing and a well-known defense mechanism; if it is understood properly, it complements and enriches conventional biological and behavioral methods.

Denial—when used in a clinically appropriate way—can be leveraged as a treatment measure, one where the clinician uses this level of unconsciousness to reveal identity where anosognosia cannot. Compliance is described as a passive behavior following a list of instructions.

plausible explanation? The consideration of plausibility along with additional symptomatology is important to address this. Trauma (addressed later in this chapter) and anxiety can induce psychosis and psychosis in itself can be traumatic.

acknowledgement of the mental energy required to fight these symptoms can be helpful.

recognizing the individual’s experience;

joining of goals where the discussion becomes not whether the symptoms are the result of mental illness, but whether the medication can help the paranoid individual manage stress, improve their overall life, and better tolerate people.

Client Comprehension

Symptoms of psychosis might change the person’s usual style of interaction and their ability to comprehend spoken word or environmental cues.

If the client becomes too disorganized or associations are loose, the clinician will need to be more active and redirect. The cognitive impairments can be subtle or more obvious; they can be frustrating for both the client and the clinician. The inability to process or recall information may require the interview to be done in parts or shortened altogether.

cognitive impairments are not diagnostic, but, as has been stated, they will certainly impact the functional outcome and course of the illness.

inability to externalize or show emotion may also be common and is frequently seen in the mental state examination. There may be a flat or blunted affect. There may be a cold, indifferent expression where little emotion is evident.

look through you or offer little recognition

baseline affect, is consistent with depression, or if in fact the individual is responding to internal stimuli. Internal stimuli related to psychotic material is best described as recognition that the client is distracted by something in their internal environment that is not recognized on the outside.

Individuals with psychosis may experience depression, trauma, or loss similar to those that an individual who is not psychotic experiences.

sorting through the impact of an individual’s experience circumscribed with their medical and psychosocial history.

coexistence of posttraumatic stress disorder (PTSD) is not uncommon nor is it often a stressful trigger of a psychotic event.

Early life trauma is a risk factor for the development of PTSD and psychosis, both of which can emerge at a much later time. The negative symptoms of PTSD, such as blunting, can be embedded in the overall symptoms of schizophrenia.

vulnerability of an individual who is experiencing psychosis and the risk of being the subject of a traumatic event.

stressful event such as death or loss of an individual can result in psychosis including preempting schizophrenia.

How to recognize a pattern of trauma and how this has impacted the individual’s internal experience requires skill, knowledge, wisdom, and experience.

rambling, disorganized, and illogical patterns of thinking- cardinal signs of schizophrenia.

disorganization and loose association can be a diagnostic pearl and an important part of the assessment.

Clinician Anxiety

Anxiety helps to protect us—makes us more attentive to and observant of things we see, hear, and feel.

potentially violent or assaultive usually has a prodromal pattern of behavior that precedes the overt aggression.

pay attention to the person’s posturing, motor activity, affect, and language.

be mindful of one’s own anxiety and how it is handled as this can certainly influence one’s effectiveness with others.

anxiety can become overwhelming and limit one’s endeavors.

client is uncooperative, hostile, or too paranoid to tolerate the interview. The clinician must be flexible, attend to immediate medical and safety issues, but also be sensitive to the client’s capacity, assessing whether the interview itself is agitating the client or escalating the symptoms.

Collateral Material

collateral material in the form of medical records and/or data gathered from previous clinicians can be invaluable in the interest of minimizing redundancy of treatment or repeating medication trials that were ineffective, tolerated poorly, or perhaps resulted in an allergic response to client care. Understanding previous episodes of illness or patterns of various episodes allows for them to be addressed in a preventative manner.

Eye contact, whether sustained or not at all, can be associated with paranoia or other symptoms such as anxiety. Often, paranoid clients will not tolerate extended direct eye contact.

PMH-APRN to sit at an angle or to one side as opposed to directly across from the client.

Open and Closed Questions

The use of closed questions followed by open-ended details enables both the client and the clinician to narrow the focus of the experiences, confirm consistency, and, in a sense, normalize the experience to minimize tension.

EXAMPLES OF QUESTIONS FOR ASSESSMENT OF PSYCHOTIC SYMPTOMS

•Do you feel as if other people can read your mind? Hear your thoughts?

•Does it feel like other people can put thoughts or ideas into your head?

•Do you feel that you receive special messages from other people without using words?

•Have you ever had an experience where the television, radio, or newspaper was talking to you or about you?

•Do you have a lot of worries or things on your mind? Can you tell me what those are?

•Does this interfere with your ability to do your usual routine or activities?

•Do you ever feel like people are out to get you or have it in for you?

•Have you ever had to get physical with someone to keep them from bothering you?

•Do you have any special powers, skills, or abilities?

•Do you ever hear sounds or voices when you are alone or no one else is around?

•Do you ever feel like your mind plays tricks on you?

•Do you have a special relationship with God?

Open-ended detailed questions might include:

•What is the experience like for you?

•How do you manage it?

•Do you think there are other explanations that might account for this?

•What do you do that makes it better or worse?

-Do you remember when this started?

Assessment Scales

evaluation and management (E&M) codes, which mandate clinicians have the diagnostic authority to identify problems within the context of medical decision-making.

provide an organized method to identify progress or regression over a period of time.

use of measurement scales has increasingly become a standard and provides an objective measure of severity and progress of particular disease or symptom states.

use of scales can provide more objective data for monitoring

COMMONLY USED TERMS IN CARE OF A PSYCHOTIC CLIENT

Affect

The instantaneous, observable expression of emotion. Affect differs from mood, which is the subjective experience of emotion. There is a saying, “Affect is to mood as weather is to climate.” Moods are symptoms; affects are signs. Common affect descriptions might include the following:

•Clients with blunted, flat, or constricted affects show almost no emotional lability, appear expressionless, look dulled, and speak in a monotone.

•Broad affect is a normal range of affect.

•Inappropriate affect is incongruous with the situation: A client smiles while hearing of the death of a family pet.

•Labile affect shows a range of expression with rapid and abrupt shifts of emotion, as when a client cries one moment and laughs the next.

Alogia

Impoverished speaking often as a result of slowed, empty thought processes; may be the result of thought blocking or thought disorganization.

Ambivalence

Having two strongly opposite ideas or feelings at the same time, which may make the individual unable to respond or decide. It is best to not offer too many choices or give too many details as this creates distress.

Anhedonia

Mood where there is pervasive inability to perceive and experience pleasure in actions and events that would be normally pleasurable or satisfying for the individual or most people.

Apathy

A sense of detachment or indifference.

Autistic thinking

An individual being preoccupied with their own private world or where thoughts are derived from fantasy; individual may base their environment on internal fantasies instead of on external realities. This term is not to be confused with a diagnosis of autism.

Avolition

Lack of initiative or goals; seen as a negative symptom in schizophrenia.

Blocking

The train of thought may abruptly and unexpectedly stop. It can be important to give the individual time to respond as this slowness may not reflect the absence of thought but trouble accessing.

Cataplexy

Sudden, unexpected, purposeless, generalized, and temporary loss of muscle tone.

Circumstantiality

Pattern of speech that may be filled with detours, irrelevant remarks, and excessive details, but eventually does reach its point; tangentiality is when the point is not reached.

Clang associations

Type of language in which the sound of a word, instead of its meaning, dictates the course of subsequent associations (e.g., “ding, dong, dell . . .”). Rhyming and punning may be substituted for logic. For example, when asked about mood, the client responds with “crude, that’s rude, not my attitude.”

Compulsions

Repeated, overtly senseless actions or rituals that are performed to prevent anxiety. Compulsions are obsessions expressed in actions or behaviors.

Concrete thinking

The inability to think abstractly, metaphorically, or hypothetically. Ideas and words are usually limited to a single meaning. Figures of speech are taken literally and nuances of language are missing. For example, “What brought you in today?” “A car.”

Delusions

Fixed, blatantly false convictions deduced from incorrect inferences about external reality; they are maintained despite clear proof to the contrary.

Depersonalization

When a person perceives their body as unreal, floating, dead, or changing in size, for example, the arm may feel like wood or seem detached from the body.

Derealization

A person perceives the environment as unreal or strange. The individual feels removed from the world, as if he is viewing it on a movie screen.

Echolalia

A parrot-like, meaningless, persistent, verbal repetition of words or sounds heard by the client.

Echopraxia

The repetitive imitation of another person’s movements.

Ego-dystonic

A sign, symptom, or experience that the client finds uncomfortable or does not want.

Ego-syntonic

A sign, symptom, or experience that the client finds acceptable and consistent with their personality. Many, but not all, delusions, hallucinations, and overvalued ideas can be ego-syntonic.

Flight of ideas

Accelerated speech with many rapid changes in subject from understandable associations, distracting stimuli, or play on words. In flight of ideas, the connections linking thoughts may be understandable, whereas in looseness of associations (LOAs) they are not.

Folie à deux

“Madness for two,” when two closely related persons, usually in the same family, share the same delusions.

Hallucinations

False perceptions in the senses, hearing, seeing, touching, tasting, and smelling, based on no external reality. Differ from illusions, which are false perceptions based on real stimuli. Hallucinations are disorders of perception; delusions are disorders of thinking. Delusions are always psychotic, hallucinations only sometimes.

Ideas of reference

Overvalued ideas or faulty interpretations where the client is convinced that objects, people, or events in their immediate environment have personal significance for them or reference to self.

Illogical thinking

Conclusions that contain clear, internal contradictions or are blatantly erroneous given the initial premises.

Looseness of associations

Speech patterns characterized by leaps from subject to subject without clear connections or the client being aware of the rapid shifts.

Magical thinking

When the person is convinced that words, thoughts, feelings, or actions will produce an outcome that defies all laws of cause and effect.

Mood

Subjectively experienced feeling state, differing from affect that is transitory and apparent to others.

Mood-congruent/ Mood-incongruent

Delusions or hallucinations are consistent with the client’s dominant mood. Mood-congruent delusion in mania might be, “I’m the Second Christ.”

Delusions and hallucinations are those that are inconsistent with the client’s dominant mood.

Mood-incongruent delusions can be distressing or persecutory.

Neologism

Distortion of words or new words that a client invents; may have idiosyncratic meanings to the client.

Paranoid delusion

A delusion of persecution.

Paranoid ideation

An overvalued idea that one is being persecuted. Thinking predominantly suspicious, but not delusional.

Perseveration

A persistent pathological repetition of speech or movement to different stimuli.

Poverty of speech

A remarkable restriction or lack of speech; answers are brief or monosyllabic or not answered at all.

Psychosis

A severe mental state in which the person is unable to distinguish reality from fantasy. Classic characteristics include: impaired reality testing, delusions, and hallucinations.

Tangentially

A disturbance of speech where the person “goes off on a tangent”; it differs from circumstantiality in that it does not return to the point.

Thought disorder

General term to describe disturbance in speech, thought content, or communication. Range can be mild to severe where there may be profound delusions, looseness of associations, and so on. The term is often used synonymously with psychosis.

Word salad

Mixture of words or phrases that lack logic or understandable meaning.

Cross–Cutting Symptom Measurement

Prior to DSM-5 the standard Global Assessment of Functioning (GAF) Scale had been the standard of essentially a subjective summary of identifying the level of functional impairment.

scale also provides a clinician with the opportunity to resist a diagnosis and recognizes that particular symptoms may not always indicate an illness and can be a component of expected coping.

psychosis, however, always necessitates further inquiry, with the threshold of anything above “slightly” requiring further inquiry

Clinician-Rated Dimensions of Psychosis Symptom Severity

rates the items of psychotic symptoms over a 7-day period with higher scores consistent with severity of psychosis. It can be used to track any changes in severity of symptoms.

World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

used tool to determine the level of disability.

this scale is to determine how any medical disorder impacts an individual’s ability to maintain and function in their daily life. Domains of understanding and communicating; getting around; self-care; getting along with people; life activities; and participation in society are assessed.

Brief Psychiatric Rating Scale

simplify the assessment of psychopathology and provide rapid identification.

symptoms such as somatic concern, anxiety, depressive mood, hostility, and hallucinations. The scale is used to measure the severity of and persistence of psychiatric symptomatology

Positive and Negative Syndrome Scale (PANSS)

evaluating positive, negative, and other symptom dimensions in schizophrenia.

behavioral information collected from a number of sources including observations during the interview; a clinical interview; and reports by primary care or hospital staff or family members.

The PANSS constitutes four scales measuring positive and negative syndromes, their differential, and the general severity of illness.

PANSS is the standard tool for assessing the clinical outcome in treatment studies of schizophrenia

Scale for the Assessment of Negative Symptoms and Scale for the Assessment of Positive Symptoms (SAPS)

two validated scales that identify positive and negative symptoms of schizophrenia.

divide symptoms into psychoticism, negative symptoms, and disorganization. Psychoticism recognizes hallucinations and delusions; negative symptoms relate to flattening of affect, social withdrawal, apathy/avolition, and anhedonia; and finally disorganization covers bizarre behavior and elements of a thought disorder.

differentiate the sometimes overlap of several symptomatologies that may be present in other psychiatric conditions.

Calgary Depression Scale for Schizophrenia

severe Major Depressive Disorder can present with psychotic features. Depression scales contain items that do not distinguish depressed psychotic symptoms from nondepressed psychotic clients. The Calgary Depression Scale for Schizophrenia (CDSS) was designed to assess symptoms of depression in the presence of schizophrenia. It measures the severity of symptoms such as depressed mood, hopelessness, guilt, insomnia, and suicide.

CONCORDANCE AND SHARED DECISION-MAKING

leverage a client’s insight into ancillary symptoms, such as impaired sleep, anxiety, and dysphoria, to encourage a therapeutic alliance and hopefully adherence.

be sensitive to the client’s fixed belief system.

there is a careful balance between being authentic with the client and supportive. Being direct and honest so as to acknowledge the client’s belief is a fundamental basis in which to address the delusion. As a therapeutic relationship builds, some gentle reality testing may be tolerated. Contrarily, if the material is initially confronted and challenged before there is a therapeutic relationship, the client may likely retreat into the world of psychotic experience.

sensitivity and honesty

Educating the client that there is hope and giving reason to believe that they will have relief from symptoms becomes important in the engagement process.

instilling hope is important.

Setting goals should be client driven. Short-term goals again can be geared to their more immediate concerns of sleep, safety, and symptom reduction with longer term goals geared toward needed social support, recovery, and improved functioning. Outlining expectations

The goals and objectives should align appropriately to the phase of illness and the individual characteristics of each client. Having the discussion about diagnosis, prognosis, and the expected benefit of treatment is part of the decision-making process.

If the person is too disorganized in responding to internal stimuli, or seems to be having trouble processing the interaction, it is important to keep communication simple and straightforward. Avoid lengthy, intense verbal interactions.

It is best to ask for one task at a time.

The acutely psychotic client, by nature of their very symptoms, may be so ill or agitated that they cannot participate in the treatment planning process. Treatment may need to be initiated with medicating the individual against their will or even hospitalizing as an involuntary status.

addressing the client’s safety in a timely manner supersedes lack of action.

laws with definitions of disability, inability to care for self, and signs of presenting danger to self or others.

outpatient commitment; this is generally for the severe or chronically nonadherent clients targeted at reducing hospitalizations. Progressive treatment plans (PTPs) are designed for clients who are at risk for relapse that results in danger to themselves or others;

EXPECTED OUTCOMES

prevention and early detection suggest a better chance of a successful outcome.

early in the course of illness as possible may improve outcomes. On average, there is a delay of 1 year between the development of psychosis and the initiation of treatment.

the longer the delay from the onset of psychosis to the onset of treatment, the worse the outcome in terms of symptom relief and return of social and vocational function.

Recovery After an Initial Schizophrenia Episode (RAISE) is a NIMH research project that seeks to fundamentally change the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of illness.

coordinate care so that there is a reduced long-term disability that people with schizophrenia often experience.

aims to reduce the financial impact on the public systems often tapped to pay for the care of people with schizophrenia. Treatment models being tested focus on intervening as soon as possible after the first episode of psychosis. Each model integrates medication, psychosocial therapies, family involvement, rehabilitation services, and supported employment. Each component is aimed at promoting symptom reduction and improving life functioning.

poorer outcomes associated with the presence of premorbid symptoms, persistent negative symptoms, and even gender. The course of illness is generally more favorable in women, who tend to have a later onset of the illness, fewer negative symptoms, and a better treatment response. Early-onset schizophrenia shows a male preponderance, poor outcome (chronicity), low familial predisposition for psychosis, and the presence of structural cerebral pathology.

individuals with an at-risk mental state are often reluctant to take medication, and frequently express a preference for psychological intervention.

low-dose antipsychotics and CBT can improve presenting symptoms.

greatest unmet need in schizophrenia is the lack of treatments for the primary positive, negative, and cognitive symptoms, all of which account for the functional disability of schizophrenia. Persistent negative and cognitive symptoms are the real cause of long-term vocational and social disability in schizophrenia. Cognitive deficits are now recognized as a core feature of schizophrenia and include deficits in attention, learning and memory, working memory, speed of processing, reasoning, and problem-solving.

Cognitive impairment is a better predictor of level of function than is the severity of the psychotic symptoms.

remissions and exacerbations.

mental illnesses can be extreme, progressive, and just as deadly and malignant as the most metastatic cancers.

only a small proportion of persons suffering from a psychotic illness exhibit violent behavior.

more likely to be victims than perpetrators of crime.

Homelessness is common in this population, in part because of social policy decisions and in part as a direct result of negative symptoms.

shift from symptom control to role, level of functioning, establishment of natural supports, and improved self-esteem

Suicide and Psychosis

suicide as the leading cause of premature death among people with schizophrenia.

Risk factors with a strong association for later suicide include being young, male gender, and a high level of education. The first episode of psychosis is associated with more frequent suicide attempts, and a longer duration of untreated illness is twice as likely to result in suicide attempts. Illness-related risk factors are important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions.

A family history of suicide and comorbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment.

The majority of suicides for individuals with schizophrenia occur within the first 10 years after illness onset, and 50% occur within the first 2 years. Persons are at higher risk in the years directly following their initial diagnosis, and, further, are also more likely to commit suicide within the first few weeks or months following a hospital discharge.

risk assessment is an ongoing process.

risk of suicide and connection to a post-psychotic depression.

client’s symptoms may have improved in the hospital, but consequently may have increased their sense of the seriousness and lifelong course of their illness.

“demoralization syndrome”

time following hospital discharge is considered a high-risk period for suicide

antipsychotic medications may protect against suicidal risk

SGAs, particularly clozapine, which is the only medication approved by the U.S. Food and Drug Administration (FDA) for preventing suicide in clients with schizophrenia. Lithium has been recognized as a medication that has evidence to address suicidal ideation although in a client with psychosis it may not be relevant to treat thoughts of suicide when often the risk is related to “being told to act on suicide.”

Although selective serotonin reuptake inhibitors (SSRIs) ameliorate depressive symptoms in clients with schizophrenia, suicide may not be associated with depression; subsequently, these may only reduce or attenuate suicidal thoughts.

“Black Box Warning”

The overall message in the warning is to be aware of the temporal relationship and follow the client in the appropriate manner.

Prevention of suicide in schizophrenia will rely on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing best available treatment for symptom management.

DIAGNOSIS

rely on the assessment and the presence of a constellation of symptoms and factors.

careful assessment and interviewing skills, and collaboration and coordination of data with others when possible.

objective diagnosis based on presenting information, the presence of the disruption in the client’s life, interpreted by clinical knowledge.

psychosis as a symptom and not a diagnosis in itself.

“clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Psychotic disorder specifiers are most often identified by number of episodes (i.e., one or multiple) versus severity since the emphasis on the first episode is important for treatment.

DSM as it is the shared common language among clinicians, helps initiate a treatment pathway, and is required by third-party payers including Medicaid and Medicare.

priority was to identify the level of impairment.

expected symptoms of delusions, hallucinations, disorganized speech, unusual behaviors, or negative symptoms. However, not all of these symptoms are always present all of the time. There must be a disturbance in social or occupational functioning and the duration of symptoms must be greater than 6 months.

psychosis as a prime symptom.

schizoaffective disorder, delusional disorder, and brief psychotic disorder. In short, schizoaffective disorder has features of both schizophrenia (thought) disorder and an affective (mood) disorder.

Delusional disorder is characterized by the presence of non-bizarre delusions, such as those that could actually occur in real life;

being followed or their spouse is having an affair.

seven types of delusional disorders

erotomanic (an individual is in love with them), grandiose, jealous, persecutory, somatic, mixed, and unspecified type.

individuals typically do not have impaired functioning, and they do not appear odd or bizarre.

In brief psychotic disorder, the psychotic symptoms are sudden, last for at least a day or more, but do not persist beyond a month. The symptoms are acute and the individual makes a full recovery and returns to a previous level of functioning.

qualifiers that would indicate if there are stressors present or not or if the onset was within 4 weeks postpartum.

Differential Diagnoses

thorough medical evaluation is required in all cases.

Psychotic symptoms are found in many other illnesses, including substance abuse, toxicity from prescribed medications, infectious processes, metabolic and endocrine disorders, tumors.

Routine laboratory tests should be obtained to rule out physiological problems. Testing may include a CBC, urinalysis, liver enzymes, serum creatinine, blood urea nitrogen, thyroid function tests, and serological tests for evidence of an infection with syphilis or HIV. As previously noted, CT or MRI may be useful in selected clients to rule out brain disorder (e.g., tumors, strokes).

Schizophrenia has a deteriorating course. This is not to say that the illness may not have remissions, but, in general, it is a declining condition. Another general feature is that between psychotic episodes, clients with schizophrenia do not completely recover from the psychosis, whereas clients with a mood disorder or a psychosis from substances or general medical problems usually do.

differential diagnosis - schizoaffective disorder, schizophreniform disorder, mood disorder, delusional disorder, and personality disorder.

schizophrenia, a full depressive or manic syndrome is either absent, develops after the psychotic symptoms, or is brief relative to the duration of psychotic symptoms.

schizoaffective disorder is applied to clients who have co-occurring mood symptoms and schizophrenic-like mood-incongruent psychosis.

Schizophreniform disorder is usually diagnosed in clients who have the symptoms of schizophrenia but recover without residual symptoms within a 6-month period of time.

symptoms last at least 1 month but less than 6 months.

classified into those with good prognostic features and those without good prognostic features. Good prognostic features must include two or more of the following: acute onset, confusion in height of the episode, good premorbid functioning, and the absence of flat affect.

Extreme elevated or depressed mood symptoms associated with mood disorder and mood-congruent delusions without a formal thought disorder may be clues to a mood disorder diagnosis.

normal baseline functioning and they will report previous episodes of mood symptoms of depression or mania. Family history - relatives with a mood disorder.

schizophrenia is characterized by the presence of bizarre delusions and hallucinations with delusional disorder, the client will have non-bizarre delusions that last for at least 1 month. The behavior is generally not odd or unusual, and the delusion is one that, although it is not real, is technically possible. The type of delusion is significant and can be associated with personal or community risk.

brief psychotic disorder have psychotic symptoms that last at least 1 day but no more than 1 month, with gradual recovery. Remission is expected.

acute precipitant, a rapid onset, delusions and hallucinations that pertain to the stressor, and a quick and complete recovery.

Postpartum onset must be specified in brief reactive disorder if the symptoms had onset within 4 weeks postpartum;

Postpartum blues, last for a few days after delivery, and are considered normal. They are generally thought to be related to the rapidly changing hormone levels and reactions to childbirth. Symptoms that persist longer than 2 weeks should be evaluated further with a complete risk assessment for the mother and the child. Postpartum psychosis, on the other hand, is considered a psychiatric emergency. The presence of delusions, depression, and often thoughts of harming self and/or the baby requires immediate intervention. Typically, there are prodromal symptoms of mood lability, insomnia, and agitation prior to the onset of the florid psychosis. Again, safety to both mother and baby are priorities.

Schizotypal, paranoid, and borderline personality disorders may present as psychosis and resemble the prodromal or acute phase of schizophrenia; however, unlike schizophrenia, the psychotic symptoms remit in hours or days. Severe schizoid personality disorder may produce a schizophrenic-like social withdrawal; these clients, however, rarely become psychotic. Unlike schizophrenia, personality disorders have mild symptoms, history of occurring throughout a person’s life, and they lack an identifiable date of onset.

emergency rooms will recognize an increased rate of evaluations during winter months when homeless individuals often present with a variety of symptoms not limited to the presence of hallucinations.

Clients with factitious disorder will “fake” illnesses. They may undergo great pain or injury to themselves to be in the “sick role” or to receive emotional care and attention. Malingering differs from factitious disorder in that the motivation for symptoms is an external incentive where a specific goal is involved, whereas in factitious disorder, the symptoms are intentionally produced.

Cultural Considerations

variations in the symptoms show the influence of culture.

It can shape one’s experiences (including the experience of schizophrenia), one’s interpretations, and one’s actions. It thereby orients people in their ways of thinking, feeling, and being in the world.

Culture may provide a framework for one’s bizarre and extraordinary experiences.

cultural influences may direct the individual with psychotic symptoms to conceal the experience from others. This can create additional isolation and present barriers to treatment.

Cultural understanding is critical in nearly every aspect of the schizophrenic illness experience: the identification, definition, and meaning of the illness during the prodromal, acute, and residual phases; the timing and type of onset; symptom formation in terms of content, form, and constellation; gender and ethnic difference; the personal experience of the schizophrenic illness, social response, support, and stigma; and perhaps, most important, the course and outcome of disorders.

centered on wholeness such that the recognition of cultural variances.

Families

The fear, stigma, and uncertainty of mental illness present a unique and heavy burden on families.

taken a toll in many areas, whether it is resources, mental energy and reserves, impacts on siblings.

grieving process and may want to share the loss of their dreams and expectations they may have had for their loved ones. Families are often not comfortable expressing their own emotions for fear of upsetting or distressing their loved ones.

unsure how to relate to their families and friends who may be celebrating their children’s successes in marriages, college, or employment.

Recommending family or individual therapy.

Family therapy, combined with antipsychotic medication, has been shown to reduce relapse rates in schizophrenia. Providing families with an understanding of the illness, its causes, its prognosis, and the available treatment and services will benefit the client and the long-term outcome. Educating families about precipitants, warning signs, management of stress, and medications will be an important aspect of the treatment plan.

Family psychoeducation is a method and model that acknowledges the essentially chronic nature of this disease and seeks to engage families in the rehabilitation process by creating a long-term working partnership.

clear, accurate information about mental illness with training in problem-solving, communication skills, coping skills, and developing social support. The goals are to markedly improve consumer outcomes and quality of life, as well as to reduce family stress and strain.

may inadvertently exacerbate the condition.

TREATMENT

Acute treatment most often refers to the phase in which the client has experienced either their first episode of psychosis, relapse, or exacerbation of the illness. This is often recognized as an increase in the positive symptoms of delusions, hallucinations, or agitated behavior. An exacerbation of schizophrenia may occur rapidly, or it may occur gradually. Often this is associated with a variation in medication adherence. Several antipsychotics are long acting.

First-episode treatment determines that the client remains in active treatment for a minimum of 1 year, at which point medications may be reduced for maintenance.

Antipsychotics are indicated early on, especially when the client is highly agitated or experiencing great emotional turmoil. In the acute phase of the illness where psychotic symptoms are present, safety and physical needs take precedence. To provide a secure environment, a crisis unit or hospitalization may be necessary for the safety of the client or others. Many psychotic clients may be so delusional or distraught that they will need protection from any self-destructive tendencies.

The goals of intervention in the acute phase of a psychotic experience are to reduce stimulation and provide a safe and structured environment where clear communication, little demand for performance, and firm limit-setting by tolerant and supportive staff can complement the use of medication in achieving a rapid resolution of symptomatic behavior.

crisis intervention to resolve stress that may have caused or been caused by the client’s relapse, and planning for future treatment. Hospitalization allows monitoring of the individual’s physical needs.

not overwhelm the individual with too many choices, as ambivalence can be distressing. Be clear and direct about the expectations and the initial treatment goals. Set small daily goals that are realistic and can be accomplished with success.

provide reality testing and reassurance with the client but to not directly confront the symptoms.

therapeutic to be genuine, honest, and accept the reality of their experiences;

Medications may be indicated for only a brief period as the individual clears. For acute episodes of schizophrenia, doses in the range of 400 to 600 mg of chlorpromazine.

Most of the treatment occurs in the maintenance phase of the process, which is typically outpatient and centers around psychopharmacology.

psychosocial and vocational supports, will need to be combined and implemented for the best outcome. The principal goals of treatment at this stage are to prevent relapse while adjusting medication to a maintenance level and to help the client reintegrate into the community.

antipsychotic medication

maintenance strategy is to find the lowest dose of antipsychotic that will protect against psychotic relapse while not interfering with the psychosocial functioning of the individual, thus reducing the risk for tardive dyskinesia (TD).

agitated psychotic client, a sedating drug would be beneficial, whereas in a client with pronounced psychomotor retardation, a sedating drug would not be your first choice.

The mechanism of action of antipsychotics is their ability to block postsynaptic dopamine D2 receptors in the limbic forebrain.

block serotonergic, nonadrenergic, cholinergic, and histamine receptors to differing degrees

clinician will prescribe the medication, it is the client who must agree to take it.

complex and collaborative process.

clinician understand the client’s challenges, beliefs, barriers, and concerns.

moved away from compliance where the clinician tells the client what they must do, to use the term “adherence,” which suggests a more collaborative agreed-upon treatment plan.

Treatment adherence is often a problem in clients with severe and persistent mental illness.

diagnosis of schizophrenia have the highest noncompliance rates”

schizophrenia clients experience extended gaps in their treatment in a 1-year period, which leads to increased hospitalizations and other adverse outcomes.

Lack of adherence is often the primary cause of re-hospitalization of those who suffer from schizophrenia (or the affective disorders).

uncomfortable side effects, breakthrough symptoms, lack of insight about illness or need for treatment, ambivalence about the medications, misunderstanding of the lifelong commitment to treatment, confusion or memory issues, and financial constraints. Efforts to address and to improve the client’s adherence have utilized psychosocial interventions based on motivational interviewing methods, other cognitive behavioral approaches, psychoeducation, medication self-management, and, more recently, environmental support.

understand the client’s thoughts and beliefs about the treatment and help them with improved medication adherence because relapse can add to the severity of the illness, increase the associated risks of the disease, and worsen the prognosis.

“neurotoxic effects” of the presence of psychosis

possible treatment-resistant effects that can occur from chronic relapse.

always prescribe the simplest regimen. When taking medicines once daily, nighttime is preferred.

encouraged to ask questions and to report side effects early.

There are intramuscular (IM) or depot forms of antipsychotics available with dosing ranging from weekly, monthly, or now quarterly, depending on the medication and the client’s symptoms and tolerance profile. These medications can provide an alternative for the client who is ambivalent or disorganized to take medication on a daily basis. The recommendation of long-acting injectable (LAI) often comes after an exacerbation or relapse when the discussion should be included in the first episode.

The use of depot (injections) medications has often been associated with some negativity and reserved for treatment-resistant clients who exhibit lack of insight or have had histories of poor adherence.

Inpatient units, higher levels of care such as assertive community treatment (ACT), or partial hospitals typically house nurses and systems that meet the regulatory and safety requirements that coincide with the storing and dispensing of medications including injections.

a barrier for some settings that are outside of community-level care. In some cases, the client or case manager must bring their own medication to the clinic.

Some clinics schedule an “injection clinic” where clients come in at a scheduled time, which can be a social opportunity with peers. The injection clinic may also pose another opportunity for contact, engagement, and assessment of the client. Several typical (conventional/first generation) antipsychotics are available in injectable form, such as fluphenazine (Prolixin) or haloperidol (Haldol), or second generation atypical (SGA), such as olanzapine pamoate (Zyprexa Relprevv), risperidone microspheres (Risperdal Consta), aripiprazole (abilify maintena), aripiprazole lauroxil (Aristada), and paliperidone palmitate (Invega Trinza, Invega Sustenna)

when there is a risk of non-adherences.

when there is a risk of non-adherences.

MEDICATIONS

algorithms are not clinical trials but are an organization of evidence that determines a road map to treatment. The TMAP guidelines provide specifics, whereas APA practice guidelines define steps and groupings rather than specific medications.

Antipsychotics are identified as first generation (FGA) whereas atypical antipsychotics are referred to as second-generation and third-generation (SGA and TGA, respectively) atypical antipsychotics. FGAs remain widely used across the globe, while in the United States it is often SGAs as initial treatment often determined by evidence underscored by cost.

SGAs and TGAs are preferable over FGAs because of the reduction in risk of TD.

The first SGA, clozapine, is recommended after failure of at least two SGA/TGA and one FGA. Clozapine, while one of the more effective medications, carries the inherent risk of agranulocytosis among other potential serious side effects. Clients who are treated with clozapine are required to be enrolled in the Risk Evaluation and Mitigation Strategies (REMS).

(initially weekly for 6 months) absolute neutrophil count (ANC) levels are determined via serum CBC for monitoring. These levels are recorded within the REMS system where the pharmacy cannot dispense the medication unless the lab data is current.

SGA/TGAs carry the risk of neutropenia and require regular monitoring

Treatment-resistant or nonresponding schizophrenia is complex and requires combining agents and/or inclusion of electroconvulsive therapy (ECT).

addition of a second antipsychotic for the treatment of residual or relapse of symptoms can be later transitioned to a single agent. The inclusion of antidepressants or mood stabilizers is determined by client presentation as it relates to clinical assessment of symptoms.

adequate trial is defined as at least 3 weeks with the exception of clozapine, which can take up to 3 months.

Positive, negative, and cognitive symptoms, as well as social functioning, can present differently across the life span. The psychopharmacological and psychosocial interventions used for an adult client would typically not be appropriate for the pediatric client or the senior adult with schizophrenia.

Treatment Resistance or Inadequate Response

defined to include any persons with residual symptoms that cause distress or impairment despite several treatment attempts.

most of our clients with schizophrenia

client with no response to the antipsychotic

assessment and ascertaining if the diagnosis is correct. Next, the clinician needs to research if the client is actually taking the medication.

Has there been an adequate trial period?

expectations may need to be managed. Is the dose prescribed therapeutic?

too high and cause side effects or doses that are too low to be of benefit.

Does the client smoke or take other agents that impact metabolism?

switching from a conventional antipsychotic to an SGA may result in enhanced response. Last, switching from another SGA to clozapine may offer response in up to 50% of clients.

Rate of switching or cross-tapering should be slower in older adults and in young clients.

MEDICATIONS AND AGE-RELATED CONSIDERATIONS

PEDIATRIC CONSIDERATIONS

SGAs are used as first-line therapy in most clinical situations due to decreased risk for EPS, dysphoric effects, and TD.

Conventional antipsychotics are often used only on a PRN or short-term basis, or in persons who do not respond or cannot tolerate novel agents.

Antipsychotics are found useful for the following indications: pervasive developmental disorder (autism), schizophrenia, conduct disorders, and tic disorders.

Used to reduce target symptoms such as aggression, temper tantrums, psychomotor excitement, stereotypies, and hyperactivity unresponsive to other therapy.

Start doses low and increase slowly.

Limit dose and duration of therapy.

Assess dosage requirements and continued need for drug.

Monitor for early signs of TD.

GERIATRIC CONSIDERATIONS

Start dose low and increase slowly; elimination half-life tends to be increased in older adults.

Clearance of drugs metabolized by CYP3A4 (e.g., quetiapine, ziprasidone, haloperidol, etc.) appears to decline with age.

Monitor for excessive CNS and anticholinergic effects; aim for drugs least likely to cause these effects.

Older adults are more sensitive to anticholinergic SE (e.g., tachycardia, constipation, difficulty urinating, impairment in concentration & memory, delirium).

Older adults are more sensitive to EPS; more vulnerable with moving, eating, and sleeping; and have a greater risk of falls.

Balance need for antiparkinsonian drug with type of antipsychotic used.

Caution combining with other drugs with CNS properties (sedation lasts longer in older adults; can impair arousal levels during the day and increase risk of falls; additive effects can result in confusion, disorientation, delirium).

•As most SGAs and TGAs and some conventional agents (e.g., phenothiazines) can cause orthostatic hypotension, use caution with dose titration and other hypotensive agents (fall risk).

•High incidence TD in older adults with conventional antipsychotics—risk about 30% per year in persons older than age 45.

REASONS FOR SWITCHING ANTIPSYCHOTIC DRUG REGIMENS

•Persistent positive symptoms—Switch to a conventional or a second-generation antipsychotic

•Persistent negative symptoms—Switch to a second-generation antipsychotic or lower the dose; consider aripiprazole

•Relapse despite compliance

•Noncompliance—Consider a depot preparation

•Persistent extrapyramidal symptoms (EPS) despite dosage decrease

•Tardive dyskinesia (TD)—Clozapine and quetiapine offer minimal risk

•Persistent/chronic side effects (e.g., galactorrhea, impotence, weight gain)

Biological Treatments Outside of Psychopharmacology

ECT has consistently demonstrated effective treatment for clients with schizophrenia and may be useful, either alone or in combination with an antipsychotic.

antipsychotic medications remain the mainstay treatment along with ECT and should be administered during and after ECT treatment.

Neurostimulation of the cerebellum has been recognized as a treatment for many neurological disorders such as Parkinson’s disease, epilepsy, and other movement disorders such as tremors. Invasive cerebellum stimulation such as deep brain stimulation (DBS) was initially developed specifically for movement disorders and impacted specific regions of the brain.

Specific simulation (invasive and non-invasive) treatments in addition to DBS such as transcranial direct current stimulation (tDCS) and theta burst stimulation (TBS) impact regions of the brain that are responsible for cognition, emotion, attention, and language.

These treatments are gaining attention as symptom relief recognizing that the cerebellar circuit responds to neuromodulation. Transmagnetic stimulation (rTMS) is not used specifically for schizophrenia; it has, however, been utilized for adjunctive depressive symptoms.

brain receptor targets or pathways for the successful development of new cognition-enhancing drugs.

Cautiously approach any off-label use of medications with clients with psychosis. The temptation to address impairment in cognition with either stimulants or agents such as cholinesterase inhibitors (used for dementia) should be considered carefully.

case reports of dopamine agonists inducing or exacerbating psychosis, which in a client with underlying psychosis can result in a sentinel event.

reduce the duration of untreated psychosis show a potential to mitigate the severity of negative symptoms. Psychotherapeutic interventions, especially if utilized early in the course of illness, may result in improved cognitive function as well as decreased positive and negative symptoms and may even prevent neuroprogression as evaluated with brain magnetic resonance structural imaging.

MANAGING SIDE EFFECTS

serotonin syndrome or neuroleptic malignant syndrome (NMS); both are medical emergencies that require immediate hospitalization

Neuroleptic Malignant Syndrome

Rare

involves the relationships between multiple central and systemic pathways and neurotransmitters.

drug-induced parkinsonism or catatonia.

dopamine blockade

mild signs and symptoms – d/c medications, agitated and sedation is desired, lorazepam 1 to 2 mg parenterally.

advanced NMS cases with extreme hyperthermia, severe rigidity, and hypermetabolism, treatments are more aggressive. Severe hyperthermia requires volume resuscitation and cooling measures, intensive medical care, and careful monitoring for complications

There are guidelines to follow that may lower the risk and allow continued safe antipsychotic coverage.

educational process where the risk of recurrence is reviewed with the client and family.

Serotonin Syndrome

Serotonin syndrome occurs when an excess of serotonin builds up in the bloodstream. This condition, which once was considered rare, is now seen more frequently with the widespread use of SSRIs to treat depression, migraine, anxiety disorders.

over-the-counter medications, such as St. John’s wort, or they may even be prescribed serotonergic agents for other conditions, such as fibromyalgia.

Serotonergic drugs work by blocking the reuptake of the neurotransmitter serotonin, which results in an increase in serotonin levels.

other drugs that can increase the CNS’s serotonin activity.

MAOIs, tricyclic antidepressants, SSRIs, opiate analgesics, serotomimetic drugs such as over-the-counter cough medicines, weight reduction agents, and antiemetics. There are other psychiatric medications added, including lithium, some antipsychotic medications, and herbal supplements such as St. John’s wort and ginkgo biloba. Anti-migraine medications in the triptan family, such as sumatriptan and naratriptan, have also been implicated. Drugs of abuse such as lysergic acid diethylamide (LSD), amphetamines, and cocaine have all also been connected. The combination most likely to cause serotonin syndrome is an MAOI given with an SSRI.

 serotonin syndrome typically resolve within 24 hours after the initiation of therapy and the discontinuation of the serotonergic drugs, but symptoms may persist in clients taking drugs with long half-lives, active metabolites, or an extended duration of action. Supportive care, comprising the administration of intravenous fluids and correction of vital signs, remains a mainstay of therapy. Mild cases (e.g., with hyperreflexia and tremor, no fever) can usually be managed with supportive care, removal of the precipitating drugs, and treatment with benzodiazepines. Moderately ill clients should have a more aggressive approach and may benefit from the administration of 5-HT2A antagonists. Hyperthermic clients (higher than 41.1 °C) are severely ill and should receive these therapies as well as immediate sedation, neuromuscular paralysis, and orotracheal intubation.

severe cases, serotonin syndrome can progress to seizures, disseminated intravascular coagulation, renal failure, coma, and death.

Extrapyramidal Side Effects

antipsychotics is EPS.

results from dysfunction of the EPS. SGAs have a lower liability for EPS as compared with FGAs (Perkins, 2011).

The EPS are involved in the unconscious control of all voluntary musculature. Neuroleptics have complex effects on the EPS that are exacerbated by anxiety, disappear during sleep, and can be consciously controlled for a limited time with effort. EPS can be classified into those that can happen early or late in treatment.

Acute dystonic reactions are among the EPS that occurs early on in treatment. These are involuntary spasms of voluntary muscle groups that are often painful and frightening to clients. They usually occur in the upper body, such as the face, head, and neck areas, but any part of the body may be involved. Young men on high-potency neuroleptics are at the greatest risk for the development of acute dystonic reactions.

presumed mechanism of action is an imbalance induced by antipsychotic agents blocking dopamine receptors that are in balance with the cholinergic system. The use of neuroleptics with an anticholinergic agent or dopamine agonist results in the reestablishment of this dopamine–cholinergic balance.

Akathisia, an extreme inner sense of restlessness.

primary causes for client-initiated discontinuation.

responds to neuroleptic treatment and then worsens. It is not as responsive as other EPS to anticholinergic agents. Some clients with akathisia respond to the use of beta-blockers such as propranolol. The most effective treatment for akathisia is a reduction in neuroleptic dose.

excessive activity, impulsivity, or irritability in clients treated with neuroleptics. Excessive use of caffeine (cola, coffee, tea, chocolate) may worsen anxiety and agitation and counteract the beneficial effects of antipsychotics.

Parkinsonian side effects may occur that include tremor, muscle stiffness and rigidity, shuffling gait, drooling, and bradykinesia. Bradykinesia is diminished spontaneous motor movements associated with reduction in spontaneous speech, general apathy, and trouble with initiation.

 accompanied by cognitive impairment or bradyphrenia

Bradykinesia can be difficult to differentiate from depression and negative symptoms. Because anticholinergic agents are effective in treating bradykinesia.

Parkinsonism can be treated with anticholinergic agents such as cogentin or diphenhydramine. They should be withdrawn after 4 to 6 weeks to assess whether tolerance to the parkinsonian effects has developed.

may be required during the first few weeks of treatment with conventional antipsychotics and prophylactically, on a temporary basis, by young males or by individuals with a history of EPS on low doses of antipsychotics or when prescribed FGAs.

should only be used for the EPS of antipsychotics as excess use of these agents may precipitate an anticholinergic (toxic) psychosis. Anticholinergic medications given to reverse EPS can significantly worsen memory and exacerbate already severe primary memory impairment. Excessive dopamine blockade (resulting from too high a dose of the antipsychotic) impairs the executive cognitive function of the prefrontal cortex. This secondary cognitive deficit can be reversed by simply lowering the antipsychotic dose

Tardive Dyskinesia

TD is an involuntary movement disorder that is associated with dopamine-receptor antagonism.

 older agents (FGA) have been associated with TD, it is estimated that it occurs in up to 20% to 30% of the clients who are prescribed antipsychotics.

higher in older adults. TD presents as an involuntary movement disorder, most often with nonrhythmic, repetitive, purposeless hyperkinetic symptoms. It usually affects orofacial and lingual musculature with chewing, bruxism, protrusion, and curling or twisting of the tongue. Lip-smacking, puckering, sucking, grimacing, eye blinking, blepharospasm, or pursuing.

Choreoathetoid movements of the fingers, hands, or upper or lower extremities also are common. Severe dyskinesias can affect breathing, swallowing, or speech and can interfere with walking and activities of daily living.

writhing in pain from truncal TD, unable to easily sit in a chair, or is self-conscious and embarrassed from the constant involuntary movements.

treatments for TD until the release of vesicular monoamine transporter-2 (VMAT 2) inhibitors.

treatment really starts with prevention.

conservative measures for dosing and using the newer or lower potency medication choices.

Abnormal Involuntary Movement Scale (AIMS).

onset approximately 3 months after antipsychotic exposure. and may begin with tic-like movements or increased eye blinking. TD is often suppressed or masked by ongoing antipsychotic medication and will become noticeable when the medication has been stopped, the dose is lowered, or the medication is switched to another agent. Dyskinesias increase with emotional arousal, activation, or distraction, and diminish with relaxation, sleep, or volitional efforts.

Initially consider tapering any anticholinergic agents unless there is acute EPS or tardive dystonia present. These medications can worsen TD but not tardive dystonia; 60% of TD cases improve after stopping the anticholinergic.

The next treatment decision point would be to explore if the antipsychotic can be safely tapered, switched, or stopped. If the clinical condition does not warrant a taper, consider if there is a less-potent antipsychotic choice available. Stopping the medication is an option, but there is insufficient evidence to support drug cessation or reduction as effective treatment for TD, especially when compared with the high risk of psychotic relapse after drug withdrawal.

initial worsening of the dyskinesia is expected as the drug not only causes the syndrome but also tends to mask it.

gradually lower the dose over time

Haldol, suppress TD in approximately 67% of clients and may need to be considered in clients with severe and disabling symptoms. Clozapine in particular has been recommended for suppressing TD, especially in cases of tardive dystonia.

levetiracetam (Keppra) has been effective for TD.

reducing neuronal hypersynchrony in basal ganglia

less expensive than the use of VMAT2 inhibitors.

All clients receiving antipsychotics should sign an informed consent form that explains the risk of TD.

be safer than others. The newer agents (i.e., clozapine, quetiapine, risperidone, and olanzapine) seem to have lower risk and are felt to have antidyskinetic effects.

a baseline assessment for movement disorders, and monitor regularly (e.g., every 6–12 month

AIMS examination is considered the reliable tool for assessment of TD.

Abnormal Involuntary Movement Scale

early detection of TD

A baseline AIMS score should be documented upon initiation of any antipsychotic medication. This is followed by monitoring at regular intervals, preferably at each encounter

Other Side Effects to Consider

use of the atypical or SGA medications has further contributed to the medical problems of clients. There needs to be awareness for proper monitoring of metabolic parameters and interventions to reduce the risk of future comorbidities.

substantial weight gain with all antipsychotic drugs, old or new, after 1 year of treatment with haloperidol and several SGA/TGA. The newer TGAs such as Vrayler and Caplyta, along with the now generic ziprasidone, are less likely to cause metabolic syndrome.

older FGAs have a higher risk of movement disorders, but the newer agents have higher risk of metabolic problems of weight gain, elevated labs of blood glucose, triglycerides, and cholesterol.

Metabolic syndrome is a name for a group of risk factors that occur together, which include dyslipidemia, obesity, hypertension, and type 2 diabetes.

guidelines recommend regular screening in all clients prescribed antipsychotics for metabolic syndrome and/or type 2 diabetes mellitus: baseline weight, BMI, and lipids HbA1C/FBS followed by 3 month recheck and annually depending on individual risk.

direct order or coordinating with primary care.

regularly review the risk factors for diabetes, diet, and exercise as components of treatment. Screening is done most simply by ordering a fasting plasma glucose test or HgbA1C.

atypical with a lower risk of diabetes, that is, aripiprazole or ziprasidone. Newer agents, such as lurasidone (Latuda), brexpiprazole (Rexulti), cariprazine (Vrayler), and lumateperone (Caplyta), have lower metabolic profiles than the SGAs.

monitor the client’s weight and BMI

proper diet, exercise, and avoidance of calorie-laden beverages

write a prescription for activity, indicating a frequency, time, and duration matched to the client’s stamina and tolerance.

chronically mentally ill clients smoke

prevalence in schizophrenic clients are thought to be at least partially related to enhancement of brain dopaminergic activity, which, in turn, results in behavioral reinforcement due to the stimulant effects. Smoking stimulates dopaminergic activity in the brain by inducing its release and inhibiting its degradation. In addition, smoking can reduce deficits relative to dopamine hypofunction in the prefrontal cortex.

Smokers use more caffeine due to interacting metabolic effects.

Smoking may be an attempt by schizophrenic clients to alleviate cognitive deficits and to reduce extrapyramidal side effects induced by antipsychotic medication

Nicotine has been linked to lowering neuroleptic levels, improving parkinsonism, and possibly improving cognition

sustained attention, focused attention, working memory, short-term memory, and recognition memory. Nicotine not only may improve information processing, but may also reduce side effects of antipsychotic medications

Cigarette smoke increases the activity of cytochrome P450 (CYP) 1A2 enzymes, thus decreasing the concentration of many drugs, including clozapine and olanzapine. Cigarette smokers receive significantly higher neuroleptic doses because of a smoking-induced increase in neuroleptic metabolism.

Schizophrenic clients who smoke may require higher doses of antipsychotics than nonsmokers. Conversely, smokers may require a reduction in the dosage of antipsychotics when quitting.

There are some potentially serious additional side effects that can occur with antipsychotic medications, including agranulocytosis, possible prolongation of QTc interval, impaired temperature regulations, and thus increased risk of heat stroke or hypothermia.

Hematological complications can be a risk for clients on antipsychotics. These blood effects may include neutropenia, agranulocytosis, eosinophilia, thrombocytopenia, purpura, and anemia. Agranulocytosis is usually most closely associated with clozapine, carbamazepine, and typical antipsychotics. It is now recommended that CBC be obtained minimally annually and, in many cases, every 6 months on any antipsychotic to minimize the risk of undiagnosed blood dyscrasia such as neutropenia or agranulocytosis, particularly in older adults.

Hypersalivation has been a well-documented side effect of clozapine and may affect nearly 30% of the clients taking the drug. As clozapine has anticholinergic properties that would be expected to reduce secretions, this hypersalivation is considered a paradoxical effect.

Clients who chew gum during the day will increase their swallowing unconsciously. Recommend a sugarless gum to help avoid tooth decay and gum disease.

Many clients report the drooling is particularly worse at night and this can be both annoying and frightening. Raising the head of the bed with additional pillows or risers under the legs may help as well as putting a towel over the pillow.

opposing muscarinic agonism, adrenergic antagonism, or both. Antimuscarinic medications such as benztropine, trihexyphenidyl, amitriptyline, or pirenzepine.

antipsychotics, clozapine and chlorpromazine carry the highest seizure risk.

Concerns in Prescribing

promote improved health and functioning with minimal side effects.

any change in medications from other providers, and any over-the-counter medicines or herbal supplements. Inquiring about illicit substances, alcohol, and nicotine.

antiepileptics commonly are combined with antipsychotics

carbamazepine should recognize the potential for drug–drug interactions with antipsychotics

Lithium is also commonly used with dopamine antagonists and is typically safe and effective, yet co-administration of higher doses of the antipsychotic may result in a synergistic effect. Lithium-induced neurological side effects and neuroleptic EPS can occur. In rare circumstances, encephalopathy has been reported with this combination.

quetiapine for its sedative, anxiolytic, and calming effects.

snorting crushed quetiapine tablets combined with cocaine for “hallucinogenic” effects. “Q-ball” refers to a combination of cocaine and quetiapine.

Quetiapine and olanzapine have been used to treat cocaine and alcohol abuse, and work perhaps by decreasing the dopamine reward system response to substance use. Quetiapine’s rapid dissociation from the dopamine receptor has been theorized to contribute to the drug’s abuse potential.

switch to another agent with less abuse potential, can prescribe a limited amount that can be monitored more closely, can opt to try depot preparations, or can increase the follow-up to assess adherence.

TREATMENT: PSYCHOSOCIAL AND OTHERS

psychosocial and rehabilitative treatments can improve the long-term functioning and course of recovery.

social skills training, CBT, cognitive remediation, and social cognition training.

clinical case management. MRT provided an atheoretical form of compassionate care that mobilized individual social casework and vocational rehabilitation for persons with schizophrenia returning to the community after hospitalization.

not fulfilling major life roles

increased risk of homelessness and associated adverse social health outcomes, such as victimization and sexually transmitted diseases. These clients often need the help of a case manager to negotiate the elaborate maze of social service organizations and to obtain housing and other needed social services.

compliance with appointments, providing a glimpse at how things are in the home, and connecting to other needed resources.

ACT program  The model was targeted for an intensive care delivery system for clients with chronic mental illness. The model is made up of a multidisciplinary team consisting of nurses, psychiatrists, social workers, case managers, and so on. All care is managed by the team and is staffed round the clock, 7 days a week. The team is mobile and responds to the needs of the clients at the time, that is, seeing the client in their home, delivering medications daily if indicated, and accompanying to appointments. ACT programs have been shown to lower the risk of re-hospitalization and relapse, but they are labor intensive and expensive to administer.

Support and psychoeducation regarding management of the illness needs to be offered to the client and the family alike.

family psychoeducation, a psychosocial approach

This approach to reduce stress within the family was developed as a promising method for preventing relapse among this population. He defined the problem of relapse in schizophrenia based on a “core psychological deficit” that was manifested by sensitivity to intense stimuli and a biological susceptibility to stress. He linked this theoretical understanding of the pathogenesis of relapse in schizophrenia to emerging evidence that stress within the family environment (particularly those environments characterized by high levels of “expressed emotion” or criticism and emotional overinvolvement) was a substantial predictor of positive symptom exacerbations.

Psychoeducational multifamily groups (PMFG) is a treatment modality designed to help individuals with mental illness attain as rich and full participation in the usual life of the community as possible. The intervention focuses on informing families and supporters about mental illness, developing coping skills, solving problems, creating social supports, and developing an alliance between consumers, practitioners, and their families or supporters.

meets every other week for at least 6 months. Family is defined as anyone committed to the care and support of the person with mental illness.

their behavior is amenable to change using learning principles. A final tenet was that although symptoms such as hallucinations, delusions, and formal thought disorder were important aspects of the illness, social skills could be taught even in persons experiencing these symptoms.

social skills training interventions to include not only primary reinforcement but also behavioral demonstrations, role-playing, prompting, coaching, modeling, shaping, secondary reinforcement, and planned generalization training through out-of-session assignments.

Social skills training, which focuses on initiating and maintaining interpersonal relationships to better integrate clients into their communities, has also shown not just improved relationships, but the ability to improve function.

Offering social skills training in group settings can also provide opportunities to bolster social support.

The social and cognitive deficits remain the largest determinants of poor functional outcome in schizophrenia.

social cognition, with impairments in the following: affect perception, such as perceiving facial and vocal expressions of emotion; social perception, including the ability to judge social cues and nonverbal gestures; attributional style, which refers to the way individuals characteristically explain the causes for positive and negative events in their lives; and theory of mind, the ability to understand that others have mental states that differ from one’s own and the capacity to make correct inferences.

CBT can be useful is minimizing worry/anxiety and target symptoms that may lead to improvements in social functioning and quality of life. CBT is based on a cognitive model of psychopathology that proposes that biological factors are understood to be the cause of the initial diathesis or vulnerability to develop symptoms under stress, but faulty appraisals of these experiences are hypothesized to result in the development of the complete illness syndrome.

challenge, and ultimately shape, the meaning of various negative emotions or aberrant experiences into something less threatening.

CBT was significantly more efficacious than other interventions pooled in reducing positive symptoms. Social skills training was significantly more efficacious in reducing negative symptoms.

Perceptions of events, rather than the events themselves, are seen as the key to emotional states and are selected as targets of treatment in the cognitive therapy model of psychotic symptoms.

CET is to broadly provide clients with enriched cognitive experiences through computer training and secondary socialization opportunities. The goal is that individuals will develop the social and nonsocial cognitive abilities needed to succeed in complex interpersonal interactions.

Treatment begins with computer-based cognitive exercises that focus on attention, memory, and problem-solving.

Cognitive adaptation training (CAT) is a compensatory cognitive remediation program that uses in-home environmental supports (e.g., alarms, signs, and checklists) and structure (e.g., reorganizing placement of belongings) to facilitate independent living in the home environment. CAT has been used to improve medication and appointment adherence, grooming and hygiene, care of living space, and leisure and social activities.

ultimate goal of the schizophrenia PORT has been to increase the use of evidence-based treatments in order to optimize outcomes by reducing illness symptoms and the disability and burden associated with the illness.

PEDIATRIC POINTERS

need to rule out any medical conditions, any substance use, or any other organic causes

type of assessment and therapy will vary depending on the age of the child.

play therapy versus verbal therapy

information and involvement of others.

Schizophrenia often presents initially during adolescence, but in rare instances the onset is during childhood.

prevalence increases after puberty, approaching adult levels in late adolescence. Neurodevelopmental damage seems to be greater in childhood schizophrenia than in adult onset. Most schizophrenic children show delays in language and other functions long before their psychotic symptoms (hallucinations, delusions, and disordered thinking) appear, usually at age 7 or later.

Schizophrenia in adolescence often begins insidiously; examples may be withdrawal from usual interests and friends, a change in personal hygiene, and a decrease in performance in school.

In adolescence, boys seem to be more vulnerable to acute dystonic reactions than adult clients, so prophylactic antiparkinsonian medication may be indicated. Weight gain may be problematic with the long-term use of the low-potency neuroleptics, so parent and client education on nutrition, activity, and monitoring.

determining the difference between normal childhood fantasies and frank delusions and hallucinations. Additionally, disorganized speech and behavior must be distinguished from abnormalities of speech and behavior that might be due to developmental slowness or mental retardation.

Treatment- medications, psychotherapies, social skills treatments, cognitive therapies, group therapies

five FDA-approved SGAs in children ages 13 to 17: olanzapine, risperidone, paliperidone, quetiapine, and aripiprazole. There are no antipsychotics approved for under age 5.

AGING ALERTS

common in women and can occur after age 45. The presentation is more often the paranoid type. Delusional disorder can also occur later in life and will most likely present as a paranoid-persecutory type.

“start low and go slow” with the older adult population.

slower metabolism, decreased receptor sensitivity, decreased bowel motility, increase in body fat relative to body water, and decreased liver and kidney clearance.

risk for falls, delirium or confusion, sedation, orthostatic hypotension, constipation, and toxicity

drug–drug interactions

SUMMARY

1.Psychosis is not actually a specific disease but a symptom where the individual has a loss of contact with reality.

2.Although psychosis can occur with a relatively rapid onset of serious symptoms, just as often, severe mental illness can begin with gradual, more insidious onset of symptoms.

3.Psychotic symptoms should be treated aggressively with antipsychotic treatment, regardless of the cause of the psychosis.

4.Schizophrenia is a brain disease where the clinical presentation reflects impairments in areas of thinking and cognition. It is a chronic and relapsing disorder.

5.As schizophrenia still is believed to have many possible etiologies, it is also true that the disease has a heterogeneous outcome.

6.Psychotic illness continues to have many misconceptions and myths surrounding it. There remains much fear, stigma, and stereotyping about the concept of psychosis. Nurses are in an excellent position to help educate about these disorders and to help destigmatize these ideas.

7.Suicide is the leading cause of premature death among people with schizophrenia.

8.There are no laboratory tests yet that can confirm a diagnosis of schizophrenia, so we rely on the assessment and the presence of a constellation of symptoms and factors.

9.Given the advances in biological psychiatry, treatments of mental health disorders have evolved with a more holistic biopsychosocial perspective.

10.Although psychopharmacology is a foundation of the treatment for psychotic disorders, there are other treatment modalities to be integrated for a comprehensive treatment plan. It has been well demonstrated that the most effective treatment for schizophrenia involves a combination of neuroleptic medication and psychosocial treatment modalities.

11.Treatment approaches will vary to some degree based on the timing and setting of the client’s presentation.

12.An adequate trial of an antipsychotic agent should include 4 to 6 weeks of the full dose to target active symptoms with SGAs as the first-line therapy.

13.Injectable medication can be used with clients who are agitated, uncooperative, or have a history of problems with compliance.

14.Family therapy is important and families should be offered education about chronic illness management. Support may also be found through local chapters of NAMI (2011).

15.Psychosocial rehab is an important component of all clients no matter what phase of illness they present.

OVERVIEW

• Psychosis involves conditions affecting the mind with a loss of reality contact.

• Symptoms include hallucinations, delusions, disorganized speech, and negative symptoms. Schizophrenia includes psychosis but is not synonymous with all types of psychoses.

• Diagnostic suspicion relies on expression patterns, age, and risk factors.

• Treatments, such as opiate replacement and marijuana legalization, correlate with psychotic episode frequency.

INCIDENCE AND PREVALENCE

• Schizophrenia has a higher prevalence in women.

DIFFERENTIAL DIAGNOSES FOR PSYCHOTIC SYMPTOMS
It's important to differentiate between various conditions that may exhibit psychotic symptoms.

HISTORY

• The term “paranoia” was introduced by Greek physicians and later associated with delusional illnesses.

• Symptoms can involve social withdrawal, grandiosity, and a loss of reality testing capability.

• The “four As” of psychosis: autism, ambivalence, affective disturbance, and loosening of associations.

ETIOLOGY

• Schizophrenia is a brain disorder influenced by genetic and environmental factors.

• Genetic predisposition interacts with the environment affecting gene expression.

• Structural brain abnormalities can be present at the first psychotic episode.

• The dopamine hypothesis explains positive symptoms through altered receptor activation.

• Serotonin also plays a role in some medications.

ASSESSMENT STAGES OF SCHIZOPHRENIA

1. Prodromal Phase

   • Early symptoms include withdrawal and strange thoughts.

2. Active Phase

   • Involves classic psychotic symptoms such as hallucinations.

3. Residual Phase

   • Symptoms may be less prominent, with role impairments and the potential for relapse.

CLINICAL ASSESSMENT

• Importance of intentional listening and observational skills during assessment.

• Consideration of family and external information as part of the assessment process.

EXAMPLES OF QUESTIONS FOR ASSESSMENT OF PSYCHOTIC SYMPTOMS

• Do you feel as if other people can read your mind?

• Do you hear voices that others do not?

• Does this interfere with your daily life?

MEDICATIONS

• Treatment typically includes antipsychotics, with SGAs usually as the first line.

• Clozapine is used for treatment-resistant cases.

• Regular monitoring for side effects, particularly metabolic issues like weight gain and diabetes.

PSYCHOSOCIAL AND OTHER TREATMENTS

• Social skills training, cognitive behavioral therapy, and peer support.

• Family education and psychoeducation for support and effective management of the disorder.

EXPECTED OUTCOMES

• Early treatment is linked to better outcomes; efforts focus on reducing disability and fostering community integration, as well as managing medication adherence.

• Suicide risk is significant, particularly after treatment initiation; prevention is vital.

DIAGNOSIS

• Diagnosis relies on the assessment of symptoms across social and occupational functioning.

• Rule out other contributing factors through thorough evaluation.

CULTURAL CONSIDERATIONS

• Cultural context influences symptom interpretation and treatment approaches.

CONCLUSION

• Psychosis and schizophrenia are complex disorders necessitating comprehensive approaches for management and treatment. Recovery may involve a combination of pharmacological and psychosocial interventions to optimize outcomes.