Health and Illness

Concepts III
Psychosis

Ms. Zeina El-Jordi, MSN, RN

 LEARNING OBJECTIVES:
By the end of this session, participants will be able to:

 Define psychosis

 Discuss proposed etiologies for psychotic disorders

 Identify common signs and symptoms of psychotic

disorders

 Compare schizophrenia with other thought disorders.

 Describe the benefits and risks of antipsychotic

medications.

 Apply the nursing process to the care of clients with

psychosis.
 Concept Definition

 Psychosis: altered reality testing usually

present with hallucinations and delusions or
“loss of ego boundaries or a gross
impairment in reality testing”

 https://www.webmd.com/schizophrenia/video/
video-living-with-schizophrenia

 https://www.youtube.com/watch?v=k9vNA82
W_uA
Hallmarks of Psychotic Disorders
 Disturbed thinking

 Preoccupation with frightening inner experiences

(delusions, hallucinations)

 Marked disturbances in:

 Affect
 Behavior
 Social interactions
 Psychotic Disorder
Brief Psychotic Schizophrenifor
Delusional Disorder
Disorder m Disorder

Substance/Medicati
Schizoaffective
Schizophrenia on Induced
Disorder
Psychosis

Catatonic
Disorder Catatonic Disorder
Associated with due to Another
another Mental Medical Condition
Disorder
 Psychotic Disorder:
Schizophrenia
 “Schizo”→ fragmented or split apart & “phrenia” → mind
 Its not a “Split Personality”

 Most devastating illness psychiatrist treat.

 About 1% of the population worldwide suffers

from psychotic disorders.

 These disorders most often first appear when a

person is in his or her late teens, 20s or 30s.

 They also tend to affect men and women almost

equally.
 Psychotic Disorder:
Schizophrenia cont’d
 The characteristic symptoms of schizophrenia involve a
range of cognitive, behavioral, and emotional
dysfunctions
 No single symptom is pathognomonic of the disorder.
 Heterogeneous clinical syndrome.

 Insidious or acute onset

 There are three phases of schizophrenia — prodromal,

active, and residual.
 They tend to occur in sequence and appear in cycles
throughout the course of the illness.
 Psychotic Disorder:
Schizophrenia cont’d
 There are four phases of schizophrenia
1. Premorbid
2. Prodromal
3. Active
4. Residual.

 They tend to occur in sequence and appear in

cycles throughout the course of the illness.
 Psychotic Disorder: Schizophrenia
cont’d
Etiology and Pathophysiology
• Genetics
• Biochemical Factors
• Physiological Factors

Psychosocial
Biological
Factors

The
Environment
Transactional
al Factors
Model

• Sociocultural
Factors
• Stressful Life
Events
No single factor consider causative
 Psychotic Disorder:
Schizophrenia cont’d
 Schizophrenia requires treatment that is
comprehensive and presented in a
multidisciplinary effort.

 Of all mental illnesses, schizophrenia

probably causes more:
 Lengthy hospitalizations
 Chaos in family life
 Inflated costs to people and governments
 Fears
 Schizophrenia is more likely to develop in
children with one parent who has
schizophrenia than in those with unaffected
parents; when both parents have
schizophrenia, a child has a higher risk for
the illness
a. True
b. False
Family dynamics do not cause schizophrenia
a. True
b. False
 Psychotic Disorder:
Schizophrenia cont’d
 People with Schizophrenia may attempt suicide at
some time during the course of their illness.
 Studies show that 30% had attempted suicide at
least once during their lifetime.
 About 10% die through suicide.

 High mortality rate (accidents, medical illness,

smoking, weight gain with neuroleptics)

 Multiple psychiatric admissions

 Improper medication adherence
 Psychotic Disorder:
Schizophrenia cont’d

Comorbidity & Dual Diagnosis

 Substance abuse disorders (50-75)%
 Nicotine addiction
 Depression
 Anxiety disorders (especially OCD and Panic
disorder)
Symptoms of Schizophrenia-
DSM-V
 Lasts at least 6 months

 Includes at least 1 month of two or more

active-phase symptoms such as:
 Bizarre delusions
 Hallucinations
 Disorganized speech
 Grossly disorganized or catatonic behavior
 Negative behavior
 Key Features That Define the
Psychotic Disorders
1. Delusions: fixed beliefs that are not amenable to
change in light of conflicting evidence.

 Persecutory delusions  Delusion of control

 Ideas of reference
 Grandiose delusions
 Erotomanic delusions
 Nihilistic delusions
 Somatic delusions
 Religious delusions
 Thought broadcasting
 Thought insertion
 Thought withdrawal
 Self-accusation delusions
 Bizarre delusions
 Delusions of infidelity
 Key Features That Define the
Psychotic Disorders cont’d
2 Hallucinations: perception-like experiences
that occur without an external stimulus.
 Auditory: commenting, arguing,
commanding
 Visual
 Tactile
 Olfactory
 Gustatory

https://www.youtube.com/watch?v=fp
LQ0U14Qqc
 Key Features That Define the
Psychotic Disorders cont’d
3. Disorganized thinking (formal thought disorder): refers
to disorganized thinking as evidenced by disorganized
speech

 Neologisim  Flight of ideas

 Circumstantiality  Incoherence- Word salad

 Tangintiality  Clang association

 Loose of association  Illogicality

 Perseveration  Echolloala

 Thought blocking
The client hears the word “match.” The client
replies, “A match. I like matches. They are the
light of the world. God will light the world. Let your
light so shine.” Which communication pattern
does the nurse identify?

A. Word salad

B. Clang association

C. Loose association

D. Ideas of reference
 Key Features That Define the
Psychotic Disorders cont’d
4. Negative symptoms: thoughts, feelings, or
behaviors normally present that are absent or
diminished in a person with a mental disorder.

Affective
Avoliation/ Anhedonia Attentional
Alogia Flattening or
Apathy /Asociality impairment
Blunting
• Lack of • Poor • Loss of • Reduced • Trouble
basic drive thinking capacity to intensity of focusing
& capacity experience emotional (attention)
to formulate pleasure expression or able to
& pursue subjectively focus
goals sporadically
and
erratically
 Key Features That Define the
Psychotic Disorders cont’d
Grossly Disorganized or Abnormal Motor Behavior

1. Psychomotor agitation/retardation

2. Bizarre behaviors : behavior that is out of the ordinary or far from normal..

3. Coprophagia: eating of filth or feces

4. Echopraxia: mimicking another's movements

5. Mannerism: These are repetitive, goal-directed movements (e.g. saluting).

6. Stereotypy These are repetitive, regular movements that are not goal-directed
(e.g. rocking).
 Key Features That Define the
Psychotic Disorders cont’d
Grossly Disorganized or Abnormal Motor Behavior cont’d

 Waxy flexibility: a decreased response to stimuli and a tendency to remain in an

immobile posture.

 Posturing: spontaneous and active maintenance of a posture against gravity.

Patient is able to maintain same posture for long period. Extreme version of
posturing

 Catalepsy: characterized by muscular rigidity and fixity of posture regardless of

external stimuli, as well as decreased sensitivity to pain.

 Stupor: the classic and most striking catatonic sign. It is a combination of

immobility and mutism, although the two can also occur independently.

 Negativism: opposition or no response to instructions or external stimuli. Patient

resist the attempts to move parts of their body.
 Culture Issues
 Cultural and socioeconomic factors must be
considered
 Particularly when the individual and the clinician
do not share the same cultural and socioeconomic
background.

 Ideas that appear to be delusional in one culture

(e.g., witchcraft) may be commonly held in
another.

 In some cultures, visual or auditory hallucinations

with a religious content (e.g., hearing God's
voice) are a normal part of religious experience.
 Psychotic Disorder:
Schizophreniform Disorder
 Symptoms similar to those of schizophrenia
except that they last at least 1 month and
resolve within 6 month and then return to
baseline level of functioning

 Two-third of individuals with schizophreniform

disorder, eventually receive a diagnosis of
schizophrenia or schizoaffective disorder

 Development of disorder similar to that of

schizophrenia
 Psychotic Disorder:
Schizoaffective Disorder
 A disorder with concurrent features of both
schizophrenia and mood disorder that cannot
be diagnosed as either separately

 Lifetime prevalence is estimated to be 0.3%.

 Higher in females than in males

 Mainly due to an increased incidence of the
depressive type among females.

 The typical age at onset is early adulthood

 Psychotic Disorder: Catatonia
 Catatonia can occur in the context of several
disorders
 neurodevelopmental, psychotic, bipolar,
depressive disorders, and other medical
conditions

 Occurs in up to 35% of individuals with schizophrenia

 Essential feature of catatonia is a marked

psychomotor disturbance
 Decreased motor activity, decreased
engagement
 Excessive and peculiar motor activity

 Potential risks from malnutrition, exhaustion,

hyperpyrexia and self-inflicted injury.
 Psychotic Disorder: Catatonia
cont’d
 Catatonia is defined by the presence of three or more of
12 psychomotor features in the diagnostic criteria
 Catatonia associated with another mental
disorder
 Catatonic disorder due to another medical
condition

 A variety of medical conditions may cause catatonia

 neurological conditions: neoplasms, head trauma,
cerebrovascular disease, encephalitis
 metabolic conditions: hypercalcemia, hepatic
encephalopathy, homocystinuria, diabetic
ketoacidosis.

 Judged to be attributed to the physiological effects of

another medical condition
Catatonia Associated With Another Mental Disorder
(Catatonia Specifier)

A. The clinical picture is dominated by three (or more) of the following

symptoms:
1. Stupor
2. Catalepsy
3. Waxy flexibility.
4. Mutism
5. Negativism
6. Posturing
7. Mannerism
8. Stereotypy
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia
12. Echopraxia
Catatonic Disorder Due to Another Medical Condition
Diagnostic Criteria (DSM V)

A. The clinical picture is dominated by three (or more) of the following

symptoms:
1. Stupor
2. Catalepsy
3. Waxy flexibility.
4. Mutism
5. Negativism
6. Posturing
7. Mannerism
8. Stereotypy
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia
12. Echopraxia

B. There is evidence from the history, physical examination, or laboratory

findings that the disturbance is the direct pathophysiological consequence
of another medical condition.

C. The disturbance is not better explained by another mental disorder (e.g., a

manic episode).
D. The disturbance does not occur exclusively during the course of a delirium.
 Differential Diagnosis
 Rule out medical causes (especially in rapid onset psychosis)

Substance Neurologic Endocrine Infectious

Abuse Conditions Disorders Conditions

Nutritional Metabolic
Head Trauma Delirium
Abnormalities Imbalances

 Thorough physical examination and history

 Laboratory tests: CBC, urine analysis, liver enzymes, serum

creatnine, BUN, TSH, serology tests

 EEG, MRI
 The Nursing Process: Nursing
Diagnosis

 Disturbed sensory perception

 Disturbed thought processes
 Impaired verbal communication
 Social isolation
 Risk for Violence: self-directed or other-directed
Self-care deficit
 Disabled family coping
 Ineffective health maintenance
 Impaired home-maintenance
 Imbalanced nutrition: Less/More to body
requirment
To deal with a client's hallucinations
therapeutically, which nursing intervention
should be implemented?

A. Reinforce the perceptual distortions until the

client develops new defenses

B. Provide an unstructured environment

C. Avoid making connections between anxiety-

producing situations and hallucinations

D. Distract the client's attention

A client, diagnosed with schizophrenia, states,
“My roommate is plotting to have others kill
me.” Which is the appropriate nursing
response?

A. “I find that hard to believe.”

B. “What would make you think such a thing?”
C. “I know your roommate. He would do no
such thing.”
D. “I can see why you feel that way.”
Treatment Modalities
 Psychological treatment:
 Individual therapy
 Group therapy
 Behavior therapy
 Social skills training

 Social treatments
 Milieu therapy
 Family therapy
 Program of Assertive Community Treatment (PACT)
 The Recovery Model

 Psychopharmacological treatment
 Treatment Modalities
 Psychological Treatments
 Individual psychotherapy: long-term therapeutic
approach; is difficult because of client’s impairment in
interpersonal functioning
 Group therapy: some success if occurring over the long-
term course of the illness; less successful in acute, short-
term treatment
 Behavior therapy: chief drawback has been inability to
generalize to community setting after client has been
discharged from treatment
 Social skills training: use of role play to teach client
appropriate eye contact, interpersonal skills, voice
intonation, posture, etc.; it is aimed at improving
relationship development.
 Treatment Modalities cont’d
 Social Treatments
 Milieu therapy: best if used in conjunction with
psychopharmacology

 Family therapy: aimed at helping family members cope

with long-term effects of the illness

 Program of Assertive Community Treatment (PACT): a

program of case management that takes a team approach in
providing comprehensive, community-based psychiatric
treatment, rehabilitation, and support to persons with serious
and persistent mental illness
 Treatment Modalities cont’d
 Program of Assertive  Services are provided by a
Community Treatment multidisciplinary team of:
(PACT) cont’d:  Psychiatrists
 Services are available 24  Nurses
hours a day, 365 days a
year  Social workers

 Services include:
 Vocational rehabilitation
therapists
 Substance abuse  Substance abuse counselors
treatment
 Services are provided wherever
 Psychoeducational
assistance by the client is required:
programs
 In the person’s home
 Family support and
education  Within the neighborhood
 Mobile crisis intervention  In local restaurants
 Attention to health-care  Parks
needs
 Stores
 Treatment Modalities cont’d
 Program of Assertive Community
Treatment (cont.)
 The primary goals of PACT are:
1. To meet basic needs and enhance quality of
life
2. To improve role functioning
3. To enhance independent living
4. To lessen family burden of providing care
5. To decrease debilitating symptoms of
mental illness
6. To minimize recurrent acute episodes of the
illness
 Treatment Modalities cont’d
 The Recovery Model
 A concept of healing and transformation
enabling a person with mental illness to live a
meaningful life in the community while
striving to achieve his or her full potential.
 Research provides support for recovery as an
obtainable objective for individuals with
schizophrenia.
 Functional Recovery
Focus is on the individual’s level of
functioning in areas of relationships, work,
independent living, and other kinds of life
functioning.
 Process Recovery
There is no defined end point. Recovery is
viewed as a process that continues
throughout the individual’s life, and involves
collaboration between client and clinician.
Treatment Modalities cont’d
Atypical (2nd generation) Typical (1st generation)

• Risperidone (Risperdal)* High potency

• Clozapine (Leponex)
• Olanzapine (Zyprexa)
• Quetiapine (Serquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)*
• Haloperidole (Haldol)*
• Zuclopenthixol (Clopixol)
Low potency
• Chlorpromazine (Largactil)

* Long-acting injectable formulation available, may be used to improve

adherence (noncompliant patients )

Typicals: dopaminergic blockers with various affinity for

cholinergic, α-adrenergic, and histaminic receptors

Atypicals: weak dopamine antagonists; potent 5HT2A

antagonists; also exhibit antagonism for cholinergic, histaminic,
and adrenergic receptors
 Treatment Modalities cont’d
Side Effects
 Nausea  Photosensitivity  Hypersalivation

 Skin rash  Tarvid

 Hormonal Effect dyskinesia
 Sedation
 EEG changes  Neuroleptic
 Orthostatic Malignanrt
hypotension  Agranulocytosis Syndrom (NMS)

 Extrapyramidal Symptoms (EPS): pseudoparkinsonisim,

Akinesia, Akathisia, Dystonia, Oculogyric crises,

 Anticholinergic effect: dry mouth, blurred vision, constipation,

urinary retention