Mental Health Nursing: Psychotic Disorders

1. Mental Health Nursing: Psychotic Disorders By Mary B. Knutson, RN, MS, FCP

2. 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

3. Behaviors in Schizophrenia • Four A’s • Associations (loose) • Affect • Ambivalence • Autistic thinking • Additional A’s • Attention defects • Disturbances of activity Schizophrenia relates to “split” between cognitive and emotional aspects of the personality

4. 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)

5. Neurobiological Response Continuum • Adaptive responses Logical thought, accurate perceptions, emotions consistent with experience, appropriate behavior, and social relatedness  Occasional distorted thought illusions, emotional overreaction, odd or unusual behavior, withdrawal • Maladaptive responses Thought disorder/delusions, hallucinations, inability to experience emotions, disorganized behavior, or social isolation 

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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 observed • Broad or restricted affect can be normal • Blunted, flat, or inappropriate affect represent symptoms of disorder

13. 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

14. 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

15. 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

16. 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

17. Patient Example • Usually deteriorated appearance • Several layers of clothing • Refusal 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

18. 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

19. 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

20. 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

21. 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

22. 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 individual • Time to achieve goal varies- may be several months to several years

23. 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

24. 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)

25. Psychopharmacology • Phenothiazines and derivatives provide some sx relief for 80% of patients • Caffeine and nicotine consumption can affect the action of psychotropic medication

26. 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

27. 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

28. 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

29. Tardive Dyskinesia • Involuntary movements • Tongue protrusion • Lip smacking, chewing • Grimacing, blinking • Choreiform movements of limbs and trunk • Foot tapping

30. 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

31. Anticholinergic Effects • Constipation • Dry mouth • Blurred vision • Orthostatic hypotension • Tachycardia • Urinary retention • Nasal congestion

32. 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

33. 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

34. 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

35. 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?

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