Care of Clients with

Psychotic Disorder
DR ANGIE LAM
DHS, MSC, PGD(MHN), DIP(CCN), BN(HONS), RN, RMN
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Learning Objectives

 Differentiate the positive, negative, and disorganized symptoms of

schizophrenia.
 Articulate the classification of the four phases of schizophrenia.
 Distinguish the types and the risk factors of schizophrenia.
 Construct therapeutic nursing interventions for a client with psychotic
disorders.
Schizophrenia spectrum and
other Psychotic Disorder
Psychosis Schizophrenia
 is a syndrome or group of symptoms  Greek, “splitting of the mind
 an abnormal mental state involving  a spectrum of mental disorder that
significant problems with reality causes psychosis,
testing
 schizophrenia also has other
 serious disruptions in perception, symptoms.
cognitive processing, and emotions
 such as delusions, hallucinations, and
significantly disorganized speech
 Schizophrenia Spectrum and
Other Psychotic Disorders
DSM5 definition
 Includes other psychotic disorders, schizophrenia, and schizotypal
(personality) disorder.
 They are defined by abnormalities in one or more of the following five
domains:
 delusions
 Hallucinations
 disorganized thinking (speech)
 grossly disorganized or abnormal motor behavior (including catatonia)
 negative symptoms
 that cause substantial social and occupational distress and impairment.
Core symptom
in
schizophrenia
 7

Positive Negative
symptom symptom
+ -
Increase of abnormal Absence or
behaviour or diminishing normal
experience behavour
Psychotic symptoms DSM 5 definition 8
Sz is defined by abnormalities in one or more
of the following five domains: delusions,
hallucinations, disorganized thinking
(positive symptoms) (speech), grossly disorganized or abnormal
motor behavior (including catatonia), and
negative symptoms,

Delusion Hallucination
 Persecutory delusion  Auditory
 Somatic delusion  Visual
 Grandiose delusion  Gustatory
 Jealous delusion  Tactile
 Thought  Olfactory
insertion/withdrawal/
broadcasting
 Idea of reference
 DSM5 definition

Psychotic symptoms Sz is defined by abnormalities in one or more

of the following five domains: delusions,
hallucinations, disorganized thinking
(positive symptoms) (speech), grossly disorganized or abnormal
motor behavior (including catatonia), and
negative symptoms,

 Disorganized thinking  Disorganized behavior

(speech)  Various way: e.g. unpredictable,
 Circumstantial agitation or silliness, social
disinhibition, bizarre
 Flight of ideas
 Catatonia
 Loose association
 Stupor / Motor retardation
 Word salad
 Waxy Flexibility
 Thought blocking
 Mutism
 Neologisms
 Negativism
 Echolalia
 Echopraxia
 DSM5 definition
Sz is defined by abnormalities in one or more
of the following five domains: delusions,
Negative Symptoms hallucinations, disorganized thinking
(speech), grossly disorganized or abnormal
motor behavior (including catatonia), and
negative symptoms,

 Affective flattening
 Anergia (lack of energy)
 Alogia (lack of spontaneity and flow of conversation)
 Asociality (lack of motivation to engage in social interaction)
 Anhedonia (loss of ability to experience pleasure)
 Avolition (decrease in the motivation to initiate and perform self-
directed purposeful activities)
 DSM5 definition 10
Social/occupational Sz is defined by abnormalities in one or more
of the following five domains: that cause

Dysfunction
substantial social and occupational distress
and impairment

Negative symptoms
Delusion/ Disorganized
hallucination behavior and
Social/occupational dysfunction speech
• work / activity
• Interpersonal
• self-care

Cognitive impairment Affective impairment

• Attention deficit • Dysphoria
• Memory deficit • Suicidality
• Executive function: problem • Hopelessness
solving, abstract thinking
Different types of disorders under
Schizophrenia spectrum and other psychotic disorders
 Schizotypal (Personality) Disorder
 Delusional Disorder
 Brief Psychotic Disorder
 Schizophreniform Disorder
 Schizophrenia
 Schizoaffective Disorder
 Catatonia
 Substance/Medication-Induced
Psychotic Disorder
 Psychotic Disorder Due to Another
Medical Condition
 Other Specified Schizophrenia
Spectrum and Other Psychotic Disorder
 Unspecified Schizophrenia Spectrum
and Other Psychotic Disorder
Diagnoses &
Phases
 Cognitive, motor or social deficits
Phase I: The Premorbid Phase e.g. quiet, passive, introverted; no close friends and poor
peer relationships

Brief/attenuated symptoms and/or functional

Phase II: The Prodromal Phase decline. (2 and 5 years)
e.g. Sleep disturbance; labile mood; mood problems,
deterioration in functioning; Social withdrawal; Suspiciousness

Phase III: Pronounced symptoms

Diagnosed the disorder according to
Active Psychotic phase DSM5/ICD11

Remission and exacerbation.

Symptoms are either absent or not prominent.
Phase IV: The Residual Phase Negative symptoms may remain
Impairment functioning
Phase III: Active Psychotic phase

DSM-5-TR (APA, 2022) diagnostic criteria for schizophrenia:*

A. Symptoms: Two (or more) of the following, during a 1-month
At least one of these must be (1), (2), or (3):
1) Delusions
2) Hallucinations
3) Disorganized speech(e.g. incoherence)
4) Grossly disorganized or catatonic behavior
5) Negative symptoms
B. Functioning: One or more functioning (e.g. work) are markedly
below the level achieved prior to the onset
C. Duration: at least 6 months
 Phase III: Schizophrenia (Cont’d)

D. Exclusion: Schizoaffective disorder / depressive or

bipolar disorder
E. Exclusion: effects of a substance or medical condition.
F. Specific criteria for autism spectrum disorder or a
communication disorder : must have prominent
delusions or hallucinations,
Different types of disorders under
Schizophrenia spectrum and other psychotic disorders

 Schizotypal (Personality) Disorder

 Delusional Disorder
 Brief Psychotic Disorder  at least 1 day but less than 1 month
 Schizophreniform Disorder  at least 1 month but less than 6 months
 Schizophrenia  at least 6 months
 Schizoaffective Disorder
 Catatonia
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Predisposing Genetics factors

Factors of Neurological influence
psychotic Biological influences
Disorders Environmental influences
 Genetics Factors

Genetic Risk for Schizophrenia

 Relatives of individuals with
Schizophrenia have a higher Person at Risk Risk
(%)
probability of developing the
disease. Monozygotic (identical) twin 50
Dizygotic (fraternal) twin 15
Sibling 10
One parent affected 15
Both parents affected 35
Second-degree relative affected 2-3
No affected relative 1
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Neurological Influence

 Larger ventricles, reduced grey

and white matter in the frontal
lobe, cerebellum and limbic
system.
Biological Influences

 Dopamine hypothesis :
 Mesolimbic pathway (motivation,
emotion, reward):
Overactive dopamine pathways
 Mesocortical pathway (cognition,
executive fx, emotion):
hypoactive dopamine pathways.
 Environmental influences

Early life Childhood Later life

• Prenatal/postnatal
• Adverse child rearing • Drug abuse
infection
• Maternal malnutrition • Child abuse • Migration/ethnicity

• Maternal stress • Head injury • Urbanization

• Social adversity

• Life events
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Nursing Care
Process
 30
Treatment stage
Goal of nursing care

Match the goal of care to the relevant patient stage:

 No harm to self and others
 Induce insight
 develop strategies to manage the symptoms and
achieve recovery
 Improve functioning
Outcome Criteria

 has not harmed self or others.

 Maintain a trusting relationship.
 recognizes distortions of reality.
 relinquishes the need for delusions and hallucinations.
 demonstrates the ability to perceive the environment correctly.
 maintains depression and anxiety at a manageable level.
 uses appropriate verbal communication in interactions with others.
 performs self-care activities independently.
Disturbed sensory perception

 Related to: altered sensory reception,

_____________________(types of hallucination)

 Short-term Goal:
 Identify the contributing factors of hallucination
 Recognize the hallucination is ‘not real’
 Report he will not act on the commands from
hallucination
 Intervention
 Assess the hallucination : contents , frequent, duration, intensity, any
commands /instruction (observing and questioning)
 Build up therapeutic relationship
 Show empathy and Acceptance attitude
 Decrease environmental stimuli
 Avoid reinforce the hallucination by Therapeutic communication
technique: presenting reality + empathy
 induce insight: try to promote linkage btw hallucination, feelings and
behavior  first step to learn how to handle hallucination
 Addressing underlying emotion
 Reality based activity (interpersonal activities, listen to music, exercising)
 Administer and monitor antipsychotic medication
Presenting reality

 Defines reality by indicating own perception of the situation for

the client
 Facilitate patient to contact to the reality
 Especially useful in psychotic patient
 Example:
 ‘I
understand that the voices seem real to you, but I don not
hear any voices.’
 ‘There is no one else in the room but you and me.’
DISTURBED THOUGHT PROCESSES

Related to: disintegration of thinking processes

Goal: client can differentiate delusional

thinking to reality
 Intervention
 Assess delusional contents
 Respond to suspicion in a matter-of-fact, acceptance and calm manners
 Never debate the delusional content
 Identify associated emotional changes and possible behaivour
 Focus on the feelings or themes of delusions
 Facilitate distinguish the false belief to the facts of situation by therapeutic
communication: presenting reality and showing doubt
 Focus on reality contents
 Reality-based activity
 Do not dwell excessively on the delusion
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Treatment • PHARMACOLOGICAL TREATMENT

Modalities • PSYCHOSOCIAL INTERVENTIONS (Non-

pharmacological treatment)
 Treatments
- ECT
- TMS
Others
- Cognitive behavioral therapy
- Family intervention

Psychosocial - Social skill training

- Psychoeducation

treatment - Rehabilitation program

- Antipsychotic
- Anxiolytics
- Antidepressants
Psychopharmacology
 Mechanism of Antipsychotic drug
Typical Atypical Antipsychotics /
Antipsychotics/ FGA SGA
• Potent D2 • ↓ D2 blockage
receptor • ↑ D3, D4 receptors
blockage blockage
• 5HT blockage
Mesolimbic D2 blockage  D3 & D4 antagonism 
pathway: Overactive reduce positive reduce positive symptoms
dopamine pathways symptoms
Mesocortical D2 blockage  5HT blockage  reduce
pathway: further decrease serotonin level  reduce
Hypoactive dopamine level  inhibition on dopamine
dopamine pathways. worsen negative neuron/increase
symptoms dopamine level 
improve negative
symptoms
Nigrostriatal D2 blockage Lesser affected
pathway EPS/TD
 Mechanism of Antipsychotic drug
Typical Atypical Antipsychotics /
Antipsychotics/ FGA SGA
• Potent D2 • ↓ D2 blockage
receptor • ↑ D3, D4 receptors
blockage blockage
• 5HT blockage
Mesolimbic D2 blockage  D3 & D4 antagonism 
pathway: Overactive reduce positive reduce positive symptoms
dopamine pathways symptoms
Mesocortical D2 blockage  5HT blockage  reduce
pathway: further decrease serotonin level  reduce
Hypoactive dopamine level  inhibition on dopamine
dopamine pathways. worsen negative neuron/increase
symptoms dopamine level 
improve negative
symptoms
Nigrostriatal D2 blockage Lesser affected
pathway EPS/TD
 Mechanism of Antipsychotic drug
Typical Atypical Antipsychotics /
Antipsychotics/ FGA SGA
• Potent D2 • ↓ D2 blockage
receptor • ↑ D3, D4 receptors
blockage blockage
• 5HT blockage
Mesolimbicpathway: D2 blockage  D3 & D4 antagonism 
Overactive dopamine reduce positive reduce positive symptoms
pathways symptoms
Mesocortical D2 blockage  5-HT2A antagonist (high
pathway: Hypoactive further decrease affinity for 5HT2A
dopamine pathways. dopamine level  receptors)  reduce
worsen negative inhibition on dopamine
symptoms neuron  increase
dopamine level  improve
negative symptoms
Nigrostriatal D2 blockage Lesser affected
pathway EPS/TD
Antipsychotic drug

Typical Antipsychotics / Atypical Antipsychotics /

FGA SGA

↓ positive symptoms treat both positive and

negative symptoms

• Haloperidol (Haldol) • Clozapine (Clozaril)

• Chlorpromazine • Risperidone (Risperdal)
(Largactil) • Olanzapine (Zyprexa)
ECT , TMS

 Electroconvulsive Therapy (ECT)

 Treatment-resistant schizophrenia;
Treatment-resistant Catatonia
 the condition is considered to be potentially
life-threatening
 adjunct to antipsychotic medication
(NICE, 2009; SIGN, 2013)

 Transcranial magnetic stimulation

(TMS) – current insufficient evidence (APA, 2019)
Cognitive behavioral therapy for psychosis/SZ
(NICE guideline 2014)

 on a one-to-one basis
 at least 16 planned sessions
 follow a treatment manual to help patient:
 establish links between thoughts, feelings and
their behavior, symptoms, and functioning
 Monitor and re-evaluate the perceptions,
beliefs or reasoning relates to the symptoms
 promoting ways to cope with the symptom
 improving functioning
Family Intervention & psychoeducation

Family Intervention (Grade of recommendation 1B, APA 2020) Psychoeducation (Grade of recommendation 1B, APA 2019)

• between 3 months and 1 year • Either individual or group

• at least 10 planned sessions • 10 – 12 sessions
• either single-family intervention or
multi-family group intervention
Promote:
• The relationship between carer and patient (family intervention)
• Insight and Knowledge related to disease and treatment
• Stigma and problem solving
• Stress coping & Relapse prevention
• Health maintenance and recovery
Other psychosocial interventions
recommended by American Psychiatric Association (APA), 2020

 Coordinated Specialty Care Programs (1B, APA)

 Supported Employment Services (1B, APA)
 Social skill training (2C, APA)
 Assertive Community Treatment (1B, APA)
 50
Summary

 Clinical symptoms: positive, negative, and disorganized

symptoms.
 Five phases of schizophrenia: Premorbid, Prodromal,
Onset & Progressive, Residual / Chronic.
 Nursing care for psychotic disorder: nursing care plan for
hallucination and delusion
 Treatment modality: Antipsychotic, Psychosocial
interventions (CBT, family therapy etc)
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References

 Lippincott Williams & Wilkins (2012). Basic concepts of Psychiatric-mental

health nursing (8th ed.). Wolters Kluwer.
 National Institute for Health and Care Excellence (NICE) (2014). Psychosis
and Schizophrenia in Adults: Prevention and Management. NICE guideline
CG178 (March 2014). NICE: London, UK.
 Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing:
concepts of care in evidence-based practice. (9th ed.). New York: F.A. Davis.
 Stuart, G. W. & Laraia, M. T. (2012). Principles and practice of psychiatric
nursing (10th ed.). St. Louis: Mosby. Williams & Wilkins.