Mental Health Nursing: Psychotic DisordersBy Mary B. Knutson, RN, MS, FCP

Psychotic Disorders Health problems including

Severe mood disorder Regressive behavior Personality

disintegration Reduced level of

awareness Great difficulty in

functioning adequately Gross impairment in

reality testing

Behaviors in Schizophrenia Four A’s

Associations (loose)

AffectAmbivalenceAutistic thinking

Additional A’sAttention defectsDisturbances of

activity

Schizophrenia relates to “split” between cognitive and

emotional aspects of the personality

Cognition Information processing effected

when neurotransmissions are delayed, accelerated, or blocked

People with schizophrenia are sometimes unable to produce complex, logical thoughts and express coherent sentences

Involves memory, attention, form and organization of speech (formal thought disorder), decision-making, and thought content (delusions)

Neurobiological Response Continuum

Adaptive responsesLogical thought, accurate perceptions, emotions consistent with experience, appropriate behavior, and social relatedness

Occasional distorted thought illusions, emotional overreaction, odd or unusual behavior, withdrawal

Maladaptive responsesThought disorder/delusions, hallucinations, inability to experience emotions, disorganized behavior, or social isolation

Delusions Personal belief based on an

incorrect inference of external reality Paranoid- Suspicious,

irrational distrust Grandiose- Greatness or

special powers Religious- Favored by a

higher being Somatic- Body is diseased

or distorted

Disordered Thought Content Thought broadcasting- Thoughts

being aired to the outside world Thought insertion- Thought are being

placed into mind by outside people Ideas of reference- Incorrect

interpretation on casual incidents and external events as having direct personal references

Magical thinking- thinking equates with doing, by lack of realistic relationship between cause and effect

Nihilistic- Thoughts of nonexistence or hopelessness

Obsession- An unwelcome idea, emotion, or impulse that repetitively and insistently forces itself into consciousness

Phobia- Morbid fear associated with extreme anxiety

Hallucinations Perceptual distortions that occur in

maladaptive neurobiological responses

Can occur in any illness that disrupts brain function

Perceptual problems are often the first symptoms in any brain diseases

Can affect any of five senses: Sight, sound, taste, touch, and smell

Sensory Integration Abnormal perceptual behavior can

lead to deliberate acts of self-harm Pain recognition Stereogenesis-recognition of object by

touch Graphesthesia-ability to feel writing

on the skin Right/left recognition Perception of faces

Often inaccurately assessed with behavioral, not perceptual context

Environmental Factors Can stimulate visual hallucinations

Reflective or glaring objects, like television screens, glass in frames, and fluorescent lights

Can stimulate auditory hallucinations Excessive noise Sensory deprivation

Patients may withdraw from sensory stimuli

Often mixed hallucinations/delusions

What is Emotion? Mood- Affects the person’s world

view Affect- Behaviors such as hand or

body movements, facial expression, and pitch of voice that can be observedBroad or restricted affect can be

normalBlunted, flat, or inappropriate

affect represent symptoms of disorder

Hypoexpression

Alexithymia- Difficulty naming and describing emotions

Apathy- Lack of feelings, emotions, interests, or concern

Anhedonia- Inability or decreased ability to experience pleasure, joy, intimacy, and closeness

Schizoaffective disorder includes major depression or bipolar disorder and schizophrenia

Maladaptive Movements Catatonia- state of stupor Extrapyramidal side effects of

psychotropic medications Abnormal eye movements- decreased or

rapid blinking, difficulty following moving object, staring, or avoidance of eye contact

Grimacing Apraxia- difficulty carrying out purposeful

tasks, such as dressing or grooming Echopraxia- Purposeless imitation of

movements by others Abnormal gait and mannerisms

Deteriorating Behavior Person may lack energy and drive Repetitive or obsessive-compulsive

behavior may be noted Aggression, agitation, and potential

for violence may be related to chronic illness feeling out of control

Performance anxiety may be a trigger when carrying out formerly simple tasks becomes more difficult

Effects on Socialization Socialization is the ability to form

cooperative and interdependent relationships with others

Social problems result from psychotic disorders directly or indirectly

May include socially inappropriate actions

Stigma presents major obstacles to developing relationships “Mark of shame” may affect family

Patient Example Usually deteriorated appearance

Several layers of clothingRefusal to bathe

Rocking and hugging oneself Lack of persistence at work or

school Lack of energy and drive Repetitive or stereotypical behavior Aggression, agitation, and

negativism

Predisposing Factors Genetic vulnerability Psychosocial stressors Environmental stressors Physiological stressors

Stress and problems with coping when person reaches internal stress tolerance threshold

Or brain abnormalities causing maladaptive neurobiologic responses

Psychotic Disorders

Alleviating Factors Family resources such as parental

understanding, and providing support.

Coping resources to manage fear and anxiety can be learned: Regression Projection Withdrawal Denial- gradually gather internal

and external resources to adapt to stressors gradually

Medical Diagnosis Schizophrenia- Paranoid, Disorganized,

or Catatonic type Schizophreniform disorder (1-6 mo.)

with good social and work function Schizoaffective disorder Delusional disorder- non-bizarre

delusions with functioning unaffected Brief psychotic disorder (1-30 days) Shared psychotic disorder- delusions of

people in close relationship are similar

Examples: Nursing Diagnosis Impaired verbal communication r/t formal

thought disorder as e/b loose associations Sensory/perceptual alteration (auditory) r/t

physiological brain dysfunction e/b verbal reports of hearing voices

Social isolation r/t inadequate social skills e/b inappropriate sexual advances toward members of both sexes

Altered thought processes r/t physiological brain dysfunction e/b stated belief that staff members are really actors who were hired by parents to watch him

Treatment Stabilize health Maintain wellness Recognize early signs of relapse Facilitate habilitation Goal: To live, learn, and work at a

maximum possible level of success as defined by the individualTime to achieve goal varies- may

be several months to several years

Nursing Care

Assess subjective and objective responses in order to develop individualized care plan Recognize behavior challenges Assist to maintain appropriate level

of responsibility to own behavior Work on other complicating issues,

such as substance abuse Facilitate integration into family

and community

Treatment

Physical care and monitoring in safe, supportive environment Manage delusions- calm, empathic

non-verbal communication, and gentle eye contact

Manage hallucinations- listen and observe, with goal to increase pt’s awareness (learn difference between the world of psychosis and the world of others)

Psychopharmacology

Phenothiazines and derivatives provide some sx relief for 80% of patients

Caffeine and nicotine consumption can affect the action of psychotropic medication

Typical Anti-Psychotic Drugs Phenothiazines

Chlorpromazine (Thorazine) Thioridazine (Mellaril), or

Mesoridazine (Serentil) Fluphenazine (Prolixin)- can be

injection lasting 2-4 weeks Haloperidol (Haldol)

Side effects can range from uncomfortable, treatable ones to painful and disabling extrapyramidal symptoms to life-threatening emergency like neuroleptic malignant syndrome

Atypical Antipsychotic Drugs Clozapine

(Clozaril) Resiperidone

(Risperdal) Olanazapine

(Zyprexa) Quetiapine

(Seroquel) Ziprasidone

(Geodon) Aripiprazole

(Ablify)

Extrapyrimidal syndrome (EPS) or tardive dyskinesia (TD) is rare

Usually improve mood and cognitive impairment

May cause sedation, wt gain, metabolic disturbances, risk of diabetes

The biggest disadvantage is their high expense

Extrapyramidal Symptoms Acute dystonic reactions- Sudden

muscle spasms in neck, back, or eyes that may be painful and frightening

Akathisia- Pacing, inner restlessness, leg aches relieved by movement

Parkinson’s syndrome- cogwheel rigidity, fine tremor, akinesia

Tardive Dyskinesia

Involuntary movements Tongue protrusion Lip smacking, chewing Grimacing, blinking Choreiform movements of limbs

and trunk Foot tapping

Other Potential Side Effects Neuroleptic Syndrome- Fever,

tachycardia, sweating, muscle rigidity, tremor, incontinence, stupor, leukocytosis, renal failure

Agranulocytosis- Fever, malaise, ulcerative sore throat, leukopenia

Seizures Photosensitivity

Anticholinergic Effects

Constipation Dry mouth Blurred vision Orthostatic hypotension Tachycardia Urinary retention Nasal congestion

General Pharmacological Principles

Dosages vary- Must be adjusted May start feeling sedating effects in 1-

3 days Full benefit of typical antipsychotics

may take 4 or more weeks Atypical drugs may begin to work in a

week, but take several months to reach maximum effect

Slowly taper off meds to prevent dyskinetic reactions, rebound side effects, and relapse

Social Aspects of Treatment Assess social skills and plan

activities and education plan for enhancing social skills

Family involvement Group therapy Mental health education

involving both patient and family Discharge planning to include

supervision and support groups

Interventions Teach health management, hygiene,

health care, nutrition, sleep/rest pattern Educate regarding diagnosis and tx

options Assist with medication management Develop acceptable tx plan Teach relapse planning and prevention Identify symptom triggers Assist with avoidance of substance

abuse, sensory overload, and isolation

Evaluation Patient Outcome/Goal

Relapse can not always be prevented because these are serious, long-term illnesses

Patient will be satisfied with his/her level of functioning and ability to communicate either improvement or impending relapse

Nursing Evaluation Was nursing care adequate,

effective, appropriate, efficient, and flexible?

References

Stuart, G. & Sundeen, S. (1995). Principles & practice of psychiatric nursing (5th Ed.). St. Louis: Mosby