MANAGEMENT OF

PSYCHOTIC SYMPTOMS

What is PSYCHOSIS?
Psychosis is the term used to describe a mental
state in which the individual experiences a
distortion or loss of contact with reality, without
clouding of consciousness.
This mental state is characterized by the presence
of delusions, hallucinations and/or thought
disorder.
Psychosis can be caused by a number of
conditions.
These include organic causes (such as drug intoxication,
metabolic and infective causes)
Psychiatric Conditions manifesting Psychosis
Functional disorders such as
schizophrenia,
bipolar disorder,
schizophreniform disorder,
schizoaffective disorder,
brief psychotic disorder,
shared psychotic disorder

Who is affected by PSYCHOSIS?
According to the Stress/Vulnerability Model for Psychosis,
the onset and course of psychosis is determined by an
underlying vulnerability to psychosis coupled with the
impact of environmental stressors which may then trigger
active psychotic symptoms.

(Vulnerability [genetic predisposition] +
Environmental Stressors [biological- infection,
drugs, EtOH; or psychological- stressful situations,
trauma] = PSYCHOSIS)
Who is affected by PSYCHOSIS?

Risk factors for psychotic illnesses include:

Family history of psychosis
Schizotypal, schizoid and paranoid personality
disorders
Adolescence and young adulthood

Structural Model of Psychosis
Symptoms that arise reflect the attempt of the ego to
restore equilibrium between the opposing agencies
of ego and superego. As a result of psychological or
organic problems, the ego itself may regress, with
resultant pathology. In psychosis, there is a threat of
total dissolution of the ego. If the ego resumes
functioning characteristic of early childhood, it will
come to be dominated by irrational, magical
thoughts and uncontrolled impulses
Course of Illness of a Psychotic Episode
The Prodrome stage Something is not quite right
may start to experience a change in themselves although they have not yet started
experiencing clear-cut psychotic symptoms.
Some of the changes seen during this phase include:
Changes in affect such as anxiety, irritability and depression,
Changes in cognition such as difficulty in concentration or memory
Changes in thought content, such as a preoccupation with new ideas often of an
unusual nature
Physical changes such as sleep disturbance and loss of energy
Social withdrawal and impairment of role functioning
Attenuated positive symptoms such as mild thought disorder, ideas of reference,
suspiciousness, odd beliefs and perceptual distortions which are not quite of
psychotic
intensity or duration
remember that many patients with an underlying psychological/psychiatric disorder
will initially present with physical symptoms, which concern them, such as
tiredness, repeated headaches, or insomnia.

Course of Illness of a Psychotic Episode
The Active Phase
Characterized by the presence of positive psychotic
symptoms which include thought disorder, delusions
and hallucinations
Hallucinations: false sensory perceptions, or perceptual
experiences that do not exist in reality
Delusions: fixed, false beliefs with no basis in reality. External
contradictory information or facts cannot alter these
delusional beliefs
Thought disorder: refers to a pattern of vague or
disorganized thinking. The person with thought disorder
might find it hard to express themselves. Their speech is
disjointed and hard to follow.

Course of Illness of a Psychotic Episode
Recovery Phase
Once full recovery is achieved the major focus in on
maintaining and promoting wellness and the
prevention of relapse.
Each relapse represents a potential risk point for the
development of more enduring impairment and
disability and appears to contribute to treatment
resistance.
Management and Principles of Intervention
Detection
Immediate management
Early and Late recovery
Continuing care

Management and Principles of Intervention
At each stage, a respectful and collaborative
therapeutic relationship is required and key
principles include:
Explanation and education for the client and their
family
Combined pharmacological, psychological, family
and social interventions, which focus on managing
triggers and promoting resilience
Intervention focus
The initial focus of treatment is the control of positive
psychotic symptoms and secondary symptoms such as
insomnia, agitation and poor self-care .
Treatment then gradually progresses to:
Helping the person to make sense of their illness, and
overcoming the trauma associated with it
Making up for developmental delay lost skills (cognitive
and social)
Dealing with negative symptoms
The prevention of relapse, through decreasing risk
factors and promoting protective factors.

Pharmacological Management
Antipsychotics
Typical (ex: Haloperidol, Chlorpromazine)
Atypical (ex: Risperidone, Olanzapine, Quetiapine,
Amisulpride)
Anti-EPS

Psychosocial Treatment
Individual and group therapy sessions- supportive in
nature; gives clients opportunities for social contact
and meaningful relationships with other people.
Family education and therapy- to diminish the
negative effects of schizophrenia and reduce the
relapse rate. Families often have a difficult time
coping with the complexities of the clients illness.
Family education helps make family members part of
the treatment team.

Psychosocial Treatment
Social Skills training- for improved social functioning.
Complex social behavior is broken down into simpler
steps, practiced through role-playing, applying concepts
to real-world settings. These help the clients be
reintegrated into the society.
Cognitive Adaptation Training- using environmental
supports designed to improve adaptive functioning in the
home setting.
Cognitive-Behavioral Therapy (CBT)- psychotherapeutic
treatment that helps patients understand the thoughts
and feelings that influence behaviors

Nursing Management
GENERAL INTERVENTIONS FOR
PSYCHOTHERAPEUTIC NURSE-PATIENT
RELATIONSHIP
Maintain the safety of client and others in the
environment from possible harmful effects of the clients
psychosis.
Be calm when talking to patients
Accept patients as they are, but do not accept all
behaviors.
Keep promises
Be consistent

Nursing Management
GENERAL INTERVENTIONS FOR
PSYCHOTHERAPEUTIC NURSE-PATIENT
RELATIONSHIP

Be honest
Do not reinforce hallucinations or delusions
Orient patients to time, person, and place
Do not touch patients without warning them
Avoid whispering or laughing when patients are unable
to hear all of a conversation
Reinforce positive behavior
Allow and encourage verbalization of feelings

Nursing Management
Interventions for Disruptive patients:

Set limits on disruptive behavior
Decrease environmental stimuli
Modify the environment to minimize objects that can
be used as weapons

Nursing Management
Interventions for Withdrawn patients:

Arrange non-threatening activities that involve these
patients doing something (ex: drawing, painting)
Arrange furniture in a semicircle or around a table,
which forces patients to sit with someone
Help patients participate in decision-making as
appropriate
Reinforce appropriate grooming and hygiene
Nursing Management
Interventions for Suspicious patients:

Be matter-of-fact when interacting with these patients
Do not laugh or whisper around patients unless the
patients can hear what is being said. The nurse should
clarify any misperceptions that the clients have
Do not touch suspicious patients without warning. Avoid
close physical contact
Be consistent in activities
Maintain eye contact
Nursing Management
Interventions for patients with Hallucinations:

Attempt to provide distracting activities
Monitor for command hallucinations that might
increase the potential for patients to become
dangerous to self and to others
Orient the patient to reality. Do not reinforce the
hallucinations
Engage the client in reality-based activities
Nursing Management
Interventions for patients with Delusions:

Be sincere and honest when communicating with the
patient
Recognize the clients delusions as the clients perception
of the environment
Do not argue with the client, or try to convince the client
that the delusions are false or unreal
Interact with the client on the basis of real things. Do not
dwell on the delusional material
Never convey to the client that you accept the delusions
as reality
Nursing Management
Interventions for patients who are Disorganized:

Move disorganized patients to a less stimulating
environment
Provide a calm environment. The nurse should
appear calm.
Provide safe and relatively simple activities for the
patients.

Client/Family Education
Both the client and the family members undergo
major adjustments in relation to the clients
psychotic symptoms
Understanding the illness, the need for continuous
medication and follow-up, and the uncertainty of the
prognosis or recovery are key issues
Client/Family Education
Teaching is focused on providing facts about the
psychiatric illness, teaching about the importance of
psychopharmacology, identifying early signs of
relapse, and teaching health practices to promote
physical and psychological well-being.
Teaching also tackles self-care and proper nutrition,
teaching social skills, and medication management
Throughout the course of the clients lifetime
treatment, it is important to involve the family in the
pharmacological treatment and the psychological or
behavioral therapies