PSYCHOSIS

Psychotic episodes are among the most frightening and tormenting of human experiences. But
perhaps, even more frightening is their apparent uncontrollability

- A disruptive mental state in which an individual struggles to distinguish reality from

fantasy
- Impaired socialization
- Hallucinations, delusions, disorganizations of thought process
- Schizophrenia is one cause of psychosis

FACTS ABOUT SCHIZOPHRENIA

- Age onset – late adolescence or early adulthood
- Onset and relapse – related to stress
- Treated with antipsychotics (lifetime)
- More severe course in men
- 95% suffer a lifetime
- 50% experience serious side effects from medications (lifetime)
- 10% kill themselves

Schizophrenia
- Schizein “to split” phrenia “mind”
- Term coined by Eugen Bleuler
- Previous term “dementia praecox”
- According to Bleuler: 4 A’s
 Ambivalence – confused feeling towards environment and self
 Affect disturbance – cannot line mood with affect
 Associative looseness
 Autism – oblivious to other stimuli

DSM V Criteria
- Characterized symptoms: 2 or more of the following during a one-month period
 Delusions
 Hallucinations
 Disorganizations – speech and behavior
 Negative Symptoms (affect, alogia, avolition)
- Social or occupational dysfunction: work interpersonal or self-care below level achieved
prior to onset
- Duration: persistent up to 6 months
- Not attributed to substance or medical condition
Delusions:

-Paranoid -Reference
-Religious -Thought Broadcasting
-Grandiose -Thought insertion
-Nihilistic

Hallucinations:

-Auditory -Gustatory
-Tactile

Course of Illness:

Acute
Stabilizing
Stable

Subtypes of Schizophrenia
- Paranoid – auditory hallucinations or prominent delusion of persecutory or conspiracy
- Disorganized: disorganized speech, disorganized behavior, inappropriate, blunted or flat
affect
- Catatonic: psychomotor disturbance (resistance)
- Undifferentiated: symptoms of schizophrenia that are not sufficiently formed or specific
enough to permit classification of the illness into one of the other subtypes
- Residual: patient no longer displays prominent symptoms

Positive symptoms
-Abnormal thought form -Grandiosity
-Agitation, tension -Hostility
-Associational disturbance -Ideas of reference
-Bizarre behavior -Illusion
-Conceptual disorganization -Insomnia
-Excitement -Suspiciousness
-Feelings of persecution

Negative symptoms
-Alogia – lack of content -Difficulty with abstractions
-Anergia – lack of energy -Passive social withdrawal
-Anhedonia – lack of interest -Poor grooming and hygiene
-Avolition – lack of motivation -Poor rapport
-Blunted effect -Poverty of speech
-Communication difficulties
Causative Factor

- Biological
 Genetic
 Perinatal risk factors: exposure to virus, malformations, complications, during
labor and pregnancy and malnutrition
 Nuerochemical
 Dopamine – excess causes psychosis (excitatory neurotransmitter)
 Typical antipsychotic – blocks everything
 Serotonin – excess causes negative symptoms (inhibits dopamine)
 Atypical antipsychotic – selective blocking
 Neurostructural
 High VBR
 Brain atrophy
 Low CBF

- Psychodynamic
 The seeds of mental health and illness are sown in childhood
 Adverse events in early life
 Inadequate passage to the stage of trust vs mistrust
 Absence of warm nurturing attention during early years of life
 Poor ego boundaries, fragile ego, ego disorientation, inadequate ego
development superego dominance, regressed or id behavior, love hate
relationship and arrested psychosexual development.
 Inadequate passage through the first stage of development - mistrust, isolative
behaviors and other asocial behaviors
 Absence of warm nurturing environment – blocks the expression of these same
feelings, disordered social interactions, avoid social interaction

Family System Theories

- Primary care giver
- Family behavior
- Communication patterns
 Schizophrenogenic “to cause” mother theory
 Double bind model – damn if you do, damn if you don’t
- Blaming the family leads to a sense of alienation between the family and the treatment
team

Vulnerable Stress Model

1. Biological Psychodynamic
2. Stressful Event
3. Schizophrenia
- Multifactorial causes
- Susceptibility and environmental factors
Issues related to Schizophrenia
- Co morbidity - Relapse
- Depression and suicide - Stress vulnerability
- Cognitive dysfunction - Substance abuse

To prevent relapse:
- Monitor for “cheeking” – hiding medications in mouth
- Observe side effects
- Educate families and patient

Helping to cope with stress:

- Reduce the number of stressor accumulation
- Developing coping skills

Nursing Problems:

- Alterations in Personal Relationship

 Decrease attention to  Inadequate or inappropriate
appearance and socialization communication
requirement  Hostility
 Withdrawal

- Alterations in Activity
 Psychomotor agitation  Echopraxia
 Catatonic rigidity  Stereotypy

- Altered thought process

 Looseness of association  Delusion
 Retardation  Poverty of speech
 Blocking  Ideas of reference
 Autism  Mutism
 Ambivalence

- Altered Sensory perception

 Hallucinations
 Illusion
 Paranoid thinking

- Altered Affect
 Inappropriate  Labile
 Flat  Apathy
 Blunted  Ambivalence
  Overreaction

Nurse – Client Relationship Focuses on:

- Interpersonal communication
- Socialization skills
- Independence
- Survival skills for post Hospitalization
- Family involvement in the treatment
- Support education

General Principles in Communication

- Do not reinforce hallucinations or delusions
- Orient patient to reality
- Do not touch patient without warning them
- Avoid whispering or laughing when patients are unable to hear your conversion
- Reinforce positive behavior
- Avoid competitive activities
- Do not embarrass patient
- Allow and encourage verbalizations of feelings

Milieu Management:

- Disrupted behavior
 Set limits
 Decrease environment stimuli
 Observe escalation of aggression
 Remove objects potential weapon
 Once violation of limits occurs, remind the patient of the consequences
 For restraints, assure the safety of client`

- Withdrawn behavior
 Arrange for a non-threatening activities and socialization
 Arrange in semicircle group activities
 Provide decision making activities/opportunities
 Reinforce appropriate grooming and hygiene
 Provide remotivation and resocialization
 Provide psychosocial rehabilitation

- Suspicious behavior
 Matter of fact
 Do not laugh of whisper around patients who are suspicious
 Do not touch patients without warning
 Be consistent in activities
  Prepare client’s mea; in his presence
 Maintain eye contact during interaction
 Do not slip medications in client’s juices or food

- Impaired communication
 Provide opportunities for decision making
 Be patient and do not pressure patients to make sense
 Involve clients to non-threatening activity
 Provide purposeful psychomotor activities (painting, ceramic works, exercise)

- Disordered perception
 Provide distracting activities
 Monitor television selections
 Monitor hallucinations
 Presence and availability of staff for interaction
 Present reality

- Disorganized
 Provide les stimulating and calm environment
 Provide safe and simple activities
 Provide and use information boards
 Protect patient from embarrassing himself
 Assist in grooming and hygiene

- Hyperactivity
 Provide safe environment and place
 Activities that does not require fine motor skills or intense concentration

- Immobility
 Minimize circulatory problems and loss of muscle tone
 Provide adequate diet, exercise, and rest
 Maintain bladder and bowel management
 Protect client form victimization

Somatic Therapies

Medications
- Antipsychotics
 Neuroleptics
 Regulates the amount of dopamine
 CNS directly targeted and PNS affected first = side effect
 Nursing consideration for adverse side effects
 Anticholinergic side effects = constipation, drying of mouth, tachycardia,
blurred vision, orthostatic hypertension
  Do health teaching to counteract side effects
 Precaution for pregnant, elderly, and children

Antipsychotic
Action: dopamine blockers
Serotonin
Glutamate
Effects: sedation, emotional quieting, slowed psychomotor
Side effects: anticholinergic – low potency drug
EPS

EXTRAPAPYRAMIDAL
- Akathisia
- Akinesia
- Dystonia
- Parkinsonism
- Tardive dyskinesia
- Pisa syndrome
- Neuroleptic malignant syndrome

ENDOCRINE
- Increased prolactin

SEXUAL
- Decreased libido
- Impotency
- Impaired ejaculation

Gastrointestinal
- Weight gain

Types of Antipsychotics
- Traditional or typical
 Haloperidol
 Chlorpromazine
 Fluphenezine
 = positive symptoms
- Atypical
 Risperidone
 Clozapine
 Olanzapine
- Dopamine System Stabilizer
 Regulates the dopamine
  Aripiprazole
- Depot injection
 Haldol decanoate

Nursing Considerations
- High potency drug are less sedating than low potency drugs
- PNS side effects are caused by low potency drug
- EPSEs are more likely caused by high potency drug such as haloperidol
- Anticholinergic SE and EPSEs may increase the likelihood of non-compliance leading to
relapse
- TD may be permanent; may be aggravated by anticholinergic drugs such as benztropine
(Cogentin) and trihexyphenidyl (artane). May be treated by bromocriptine (parlodel)
- NMS is potentially fatal side effect and usually occurs when high potency drugs are
prescribed. Temperature of client should be monitored
- Dantrolene and bromocriptine are used to treat NMS and continued 8-12 days.
Antipsychotic and instituted 2 weeks after resolution

Biperiden HCl (akineton, Akiden) = antidote for side effects

Diphenhydramine HCl (benedryl)