Psychosis

Objectives
Ackley and Ladwig – Confusion, Identity, Loneliness, Self-Care

Giddens: Concept 32 Psychosis

Varcarolis: Chapter 17 Schizophrenia Spectrum Disorders and Other Psychotic Disorders

Chapter 24 Anger, Aggression, and Violence pg. 467-472

Psychosis: A change in the brain that disrupts a person’s interpretation and/or experience of the world.

Hallmark Characteristics: Hallucinations, delusions, and disorganized thinking.

1. Identify evidence-based data that supports the premise that schizophrenia is a neurological disease.

Numerous brain-imaging techniques, such as computed tomography (CT), magnetic resonance imaging
(MRI), functional magnetic resonance imaging (fMRI), and positron-emission tomography (PET), provide
substantial evidence that some people with schizophrenia have structural brain abnormalities.

MRI and CT scans - demonstrate lower brain volume, larger lateral and third ventricles, atrophy in the
frontal lobe, and more cerebrospinal fluid, among other findings, in some people with schizophrenia.

PET scans - show a low rate of blood flow and glucose metabolism in the frontal lobes of the cerebral
cortex, which govern planning, abstract thinking, social adjustment, and decision making.

2. Discuss the various disorders that psychosis presents in.

Psychotic Disorders
Schizophrenic Conditions - Schizophrenia is a serious, complex, and chronic neurobiological brain illness.
This disorder can affect all persons regardless of ethnic group, race, or gender. Schizophrenia is defined
as having two or more of the following positive or negative features during a 1-month period.
• Positive symptoms (distortion or exaggeration of normal behavior) - entail hallucinations and
delusions.
• Negative symptoms (a loss or diminution of normal function) - consist of disorganized speech,
grossly catatonic or disorganized behavior, affective flattening, alogia, avolition, apathy,
anhedonia, asociality, and attentional deficit.

Psychotic Disorder Not Otherwise Specified - This type of psychotic symptomatology includes disorders
where insufficient or contradictory information does not qualify for a diagnosis that meets the criteria
for any other specific psychotic disorder. Psychotic disorders not otherwise specified can occur across
the lifespan with the exception of postpartum psychosis, which emerges exclusively during child-bearing
years.

Personality disorder - Personality disorders (PDs) represent “an enduring pattern of inner experience
and behavior that deviates markedly from the expectations of the culture of the individual who exhibits
it.” Schizotypal is a PD that presents with psychosis.
• General symptomatology - comprises eccentric behavior, intense anxiety in interpersonal
relationships, lack of close friends, paranormal events, magical thinking, and bizarre fantasies.
• Hallmark features - are perceptual distortions, somatic delusions, bizarre speaking/speech, and
paranoid/suspicious ideation.

Mood Disorders
Mood disorders are a group of psychiatric diagnoses in which the underlying disturbance is a persistent
emotional state that impacts mood and behavioral and physical responses. Bipolar disorders fluctuate
between moods of depression, mania, or mixed depression/mania. Major depressive disorder and
bipolar disorder are the primary mood disorders that are at times present with psychosis.
• Major depressive disorder - manifests with symptoms of depressed mood, significant weight
loss or weight gain, a decrease in pleasure or interest in most activities, hypersomnia or
insomnia, loss of energy or fatigue, psychomotor retardation or agitation, excessive worry,
inappropriate guilt, decreased ability to concentrate or think, and/or suicidal behaviors.
• Bipolar disorder - fluctuates between moods of depression, mania, or mixed. Symptoms of
mania include affect of extreme elevation, grandiosity, inflated self-esteem, decreased sleep,
pressured speech, flight of ideas, excessive participation in pleasurable activities, and/or an
increase in goal-directed activity.

Anxiety Disorders
Anxiety disorders are characterized by a combination of psychologic, behavioral, physiologic, and
cognitive symptoms. Posttraumatic stress disorder (PTSD) is the only one of the anxiety problems that
presents with psychotic features.
Posttraumatic stress disorder is the encounter of a significant trauma or stressor that is outside the
normal range of experience; it is succeeded by subjective re-experiences of the event. The disorder
affects all age groups; however, symptomatology varies in children.
• Trauma that precedes PTSD - involves criminal attacks, interpersonal violence, terrorist attacks,
natural catastrophes, and military combat.
• Symptomatology of PTSD - entails flashbacks of intrusive images, perceptions, or thoughts (in
children the trauma may be expressed in thematic-related repetitive play); distressing
dreams/nightmares of the event (in children the dream may replicate the actual trauma);
psychologic affliction when exposed to memories; and/or physiologic hypervigilance when cues
trigger a fragment or larger piece of the event.
• Patients diagnosed with PTSD (if psychotic) - may experience hallucinations, illusions (false
response and false perception to stimuli), and/or dissociative flashbacks in addition to the
aforementioned symptoms.

Substance Abuse
Substance-induced psychosis - Psychosis can be associated with substance use (alcohol, illicit drugs, and
medications) and exposure to toxins.
• Diagnosis of this problem - occurs with presentation of prominent delusions and/or
hallucinations (excluding patient who has insight into the delusion or hallucination) and when a
history/physical examination and/or laboratory result validates the symptoms.

Alcohol withdrawal syndrome - Alcohol withdrawal occurs among alcoholics who cease drinking and
subsequently have a rapid decrease in blood alcohol levels. Approximately 95% of withdrawal is limited
to mild to moderate symptoms; however, in 3% to 5% of cases, severe symptoms may occur.
• Mild to moderate symptoms - include anxiety, insomnia, coarse hand tremors, and increased
heart rate, blood pressure, and body temperature.
• Severe symptoms - hallucinations, delusions, and/or convulsions may occur. Hallucinations are
transient, and visual, tactile, or auditory in nature. Illusions may also emerge.

Medical Conditions
Multiple medical conditions or treatments can result in psychosis—that is, psychosis can be secondary
to disease states that are physiologic in nature or to side effects of medical treatments such as
pharmacologic agents. A diagnosis of psychotic disorder attributable to a general medical disorder is
made when the presentation of prominent hallucinations and/or delusions and data from the
history/physical examination and/or lab findings and/or diagnostic testing confirm that the psychosis is
organic in nature.
Medical Conditions Medications
• Brain injury • Analgesics
• Neurologic disease • Anticholinergics
• Hepatic disease • Anticonvulsants
• Renal disease • Antihistamines
• Autoimmune disease • Antihypertensives, cardiovascular
• Fluid/electrolyte imbalances • Antimicrobials
• Huntington's chorea • Antiparkinsonians
• Epilepsy • Corticosteroids
• Migraines • Muscle relaxants
• Hyperthyroidism • Gastrointestinal medications
• Hypothyroidism • Antidepressants
• Hypoxia • Chemotherapeutic agents
• Hypoglycemia • Disulfiram
• Central nervous system infections

3. Discuss the early onset and course of Schizophrenia.

A premorbid condition can be an indication of the potential complexity and eventual outcome for an
individual who is later diagnosed with schizophrenia.
• Individuals with an early age of onset (18 to 25 years) - more often male and have poorer
premorbid adjustment, more evidence of structural brain abnormalities, and more prominent
negative symptoms.
• Individuals with a later onset (25 to 35 years) - more likely to be female, have less evidence of
structural brain abnormalities, and have better outcomes.

The younger the patient is at the onset of schizophrenia, the more discouraging the prognosis. An
abrupt onset of symptoms with good premorbid functioning is usually a more favorable prognostic sign.
A slow, insidious onset over a period of 2 or 3 years is more ominous. Those whose prepsychotic
personalities show good social, sexual, and occupational functioning have a greater chance for remission
or complete recovery. A childhood history of withdrawn, reclusive, eccentric, and tense behavior is an
unfavorable diagnostic sign.

4. Delineate ways that neurocognitive impairments impact a person who is struggling with
schizophrenia; including prognosis and quality of life indicators.

Often, individuals have varying degrees of neurocognitive impairments evidenced by disorganized

thinking and disorganized speech. The neurocognitive aspects are perhaps one of the most destructive
features of schizophrenia. People with these disorders are usually socially isolated or alienated and have
deep feelings of inadequacy, and it goes without saying that these disabilities ensure a poor quality of
life. Impact on the quality of life from the disorder:
• Ability to work
• Interpersonal relationships
• Self-care abilities
• Social functioning
Some people with schizophrenia function well with the aid of medications and social supports. Others
are more disabled, and need a higher level of support in terms of housing, health maintenance,
monetary aid, and more.
Although schizophrenia is treatable, it is not curable and is a chronic and severe mental illness (SMI).
Many individuals diagnosed with schizophrenia, even if given formal and informal supports, live with
exacerbations and remissions of their active symptoms, and others have a chronic course of progressive
deterioration. Great progress in a person’s functional ability and quality of life has been even more
possible with supports and methods through the Recovery Movement applied to schizophrenia and
other psychotic disorders.
The course of schizophrenia usually includes recurrent acute exacerbations of psychosis. However, the
previous belief of schizophrenia as a disease with an unalterable advancement to progressive
deterioration might be inaccurate. A decade’s worth of longitudinal studies demonstrated that early and
aggressive treatment with antipsychotics may alter the course of the schizophrenias when given at the
time of the first psychotic break. Prevention of relapse can be more important than the risk of side
effects from medications because most side effects are reversible, whereas the consequences of relapse
may be irreversible. With each relapse of psychosis, there is an increase in residual dysfunction and
deterioration.
The DSM-5 states that 20% of individuals diagnosed with schizophrenia have a favorable outcome, and,
to a much lesser extent, some have recovered completely.

5. Compare and contrast positive and negative symptoms of schizophrenia. Include: thoughts,
perception, emotional, cognitive, behavioral and social symptoms that interfere with the patient’s
ability to function.

Positive Symptoms
Positive symptoms (e.g., hallucinations, delusions, bizarre behavior, and paranoia) are referred to as
florid psychotic symptoms; they are the ones that capture our attention.
They are associated with an acute onset, normal premorbid functioning, normal CT findings, normal
neuropsychological test results, and favorable response to antipsychotic medications.
The positive symptoms appear early in the first phase of the illness and often precipitate hospitalization.
They are, however, the least important prognostically and usually respond to antipsychotic medication.
The positive symptoms are presented here in terms of alterations in thinking, speech, perception, and
behavior.

Alterations in thinking
Delusions - most often defined as false fixed beliefs that cannot be corrected by reasoning.
They may be simple beliefs or part of a complex delusional system. In schizophrenia, delusions are often
loosely organized and may be bizarre. Most commonly, delusional thinking involves the following
themes: ideas of reference, persecution, grandiosity, somatic sensations, jealousy, and control.
Approximately 75% of people with schizophrenia experience delusions at some time during their illness.
The most common delusions are persecutory and grandiose, as well as those involving religious or
hypochondriacal ideas. A person experiencing delusions is convinced that what he or she believes to be
real is real. The person’s thinking often reflects feelings of great fear and isolation. Delusions may reflect
the person’s feelings of low self-worth through the use of reaction formation (observed as grandiosity).
Other common delusions observed in schizophrenia include the following:
• Thought broadcasting—belief that one’s thoughts can be heard by others (e.g., “My brain is
connected to the world mind. I can control all heads of state through my thoughts.”)
• Thought insertion—belief that thoughts of others are being inserted into one’s mind (e.g., “They
make me think bad thoughts.”)
• Thought withdrawal—belief that thoughts have been removed from one’s mind by an outside
agency (e.g., “The devil takes my thoughts away and leaves me empty.”)
• Delusion of being controlled—belief that one’s body or mind is controlled by an outside agency
(e.g., “There is a man from darkness who controls my thoughts with electrical waves”) and made
to feel emotions or sensations (e.g., sexual) that are not one’s own.
Concrete thinking - refers to an overemphasis on specific details and impairment in the ability to use
abstract concepts.
• For example, during an assessment, the nurse might ask what brought the patient to the
hospital. The patient might answer “a cab” rather than explaining the reason for seeking medical
or psychiatric aid.

Alterations in speech (e.g., frequent derailment or incoherence)

Associative looseness - Associations are the threads that tie one thought to another and one concept to
another.
• In schizophrenia, these threads are missing, and connections are interrupted. In associative
looseness (or looseness of association [LOA]), thinking becomes haphazard, illogical, and
confused.
Neologisms - are made-up words that have special meaning for the person.
• For example: “I was going to tell him the mannerologies of his hospitality just won’t do.” “I want
all the vetchkisses to leave the room and let me be.”
• Children and creative writers often make up their own words, but their creation of neologisms is
imaginative, constructive, and adaptive. Neologisms in people with schizophrenia represent a
disruption in thought processes.
Echolalia - the pathological repeating of another’s words by imitation and is often seen in people with
catatonia.
• Counterpart of echopraxia (mimicking of the movements of another) which is also seen in
catatonia.
Clang association - the meaningless rhyming of words, often in a forceful manner, in which the rhyming
is often more important than the context of the word.
• This form of speech pattern may be seen in individuals with schizophrenia; however, it may also
be seen in people in the manic phase of a bipolar disorder or in individuals with a cognitive
disorder, such as Alzheimer’s disease or HIV-related dementia.
Word salad - a term used to identify a jumble of words that is meaningless to the listener and perhaps to
the speaker as well. It may include a string of neologisms.
• For example, “I sang out for my mother…for this to hell I went. How long is road? These little
said three hills hop aboard, share the appetite of the Christmas mice spread…within three round
moons the devil will be washed away.”
Alterations in perception
Hallucinations - sensory perceptions for which no external stimulus exists.
When they occur, “they are vivid and clear, with the full force and impacts of normal perceptions, and
not under voluntary control”
The most common types of hallucination are the following:
• Auditory—hearing voices or sounds • Gustatory—experiencing tastes
• Visual—seeing persons or things • Tactile—feeling bodily sensations
• Olfactory—smelling odors
It is estimated that up to 90% of people with schizophrenia experience hallucinations at some time
during their illness.
Auditory hallucinations - most common in schizophrenia. Voices may seem to come from outside or
inside the person’s head. The voices may be familiar or strange, single or multiple. Voices speaking
directly to the person or commenting on the person’s behavior are most common. A person may believe
that the voices are from God, the devil, deceased relatives, or strangers. The auditory hallucinations may
occasionally take the form of sounds other than voices.
• Evidence of possible auditory hallucinatory behavior is turning or tilting of the head—as if the
patient is listening to someone—or frequent blinking of the eyes and grimacing. Sometimes,
patients verbally respond to “unseen others.”
• Command (auditory) hallucinations - must be assessed carefully because the voices may
command the person to hurt self or others. For example, a patient might state that “the voices”
are saying “jump out the window” or “take a knife and kill your child.” Command hallucinations
are often terrifying for the individual. Command hallucinations may signal a psychiatric
emergency. Patients who can give an identity to the hallucinated voice are at somewhat greater
risk of compliance with the hallucinated command than are those who cannot.
• Visual hallucinations occur less frequently in people with schizophrenia and are more likely to
occur in people with organic disorders.
Personal boundary difficulties - People with schizophrenia often lack a sense of where their bodies end
in relationship to where others begin. Patients might say that they are merging with others or are part of
inanimate objects.
• Depersonalization - a nonspecific feeling that a person has lost his or her identity; the self is
different or unreal. People may be concerned that body parts do not belong to them, or they
may have an acute sensation that the body has drastically changed.
o For example, a woman may see her fingers as snakes or her arms as rotting wood. A
man may look in a mirror and state that his face is that of an animal.
• Derealization - the false perception by a person that the environment has changed.
o For example, everything seems bigger or smaller, or familiar surroundings have become
strange and unfamiliar.
Alterations in behavior (grossly disorganized or catatonic)
Bizarre and agitated behaviors are associated with schizophrenia and may have a variety of
manifestations. Bizarre behavior may take the form of a stilted, rigid demeanor and eccentric dress,
grooming, and rituals. Many of these behaviors are associated with catatonia and may be seen in other
conditions as well (e.g., brain damage, extreme manic phase of bipolar disorder, substance abuse).
• Extreme motor agitation - excited physical behavior, such as running about, in response to inner
and outer stimuli, which can be harmful to self as well as to others.
• Stereotyped behaviors - motor patterns that originally had meaning to the person (e.g.,
sweeping the floor, washing windows) but are now mechanical and lack purpose.
• Automatic obedience - the performance by a catatonic patient of all simple commands in a
robot-like fashion.
 • Waxy flexibility - seen in catatonia, is evidenced by excessive maintenance of posture. Patients
can hold unusual postures for long periods.
• Stupor - refers to a state in which the catatonic patient is motionless for long periods and may
even appear to be in a coma.
• Negativism - equivalent to resistance. In active negativism, the patient does the opposite of
what he or she is told to do. When a person does not perform activities that are normal
expectations, such as getting out of bed, dressing, and eating, the behavior is termed passive
negativism (catatonia).
When patients with schizophrenia are acutely ill, impulse control is lacking. Frequently the lack of
impulse control is expressed in socially inappropriate agitated behaviors such as grabbing another’s
cigarette, throwing food on the floor, and obtaining the television remote control and changing channels
abruptly.

Negative Symptoms
The negative symptoms (e.g., apathy, lack of motivation, anhedonia, and poor thought processes)
persist and are extremely destructive because they render a person inert and unmotivated.
They are most likely a result of the neurocognitive defects and are associated with an insidious onset,
premorbid history of emotional problems, chronic deterioration, demonstration of atrophy on CT scans,
abnormal results on neuropsychological tests, and poor response to antipsychotic therapy.
The negative symptoms of schizophrenia develop over a long period of time. These are the symptoms
that most interfere with the individual’s adjustment and ability to survive. The presence of negative
symptoms impedes the person’s ability to initiate and maintain relationships and conversations, hold a
job, make decisions, and maintain adequate hygiene and grooming.
The presence of negative symptoms contributes to the person’s poor social functioning and social
withdrawal. During an acute psychotic episode, negative symptoms are difficult to assess because the
positive and more florid symptoms, such as delusions and hallucinations, dominate.
Affect - the observable behavior that expresses a person’s emotions. In people with schizophrenia,
affect may not coincide with inner emotions, and there is a prominent lack of emotional response.
Affect can usually be categorized in one of three ways: flat or blunted, inappropriate, or bizarre.
• Flat affect - immobile facial expression or a blank look. (commonly seen in schizophrenia)
• Blunted affect - minimal emotional response. (commonly seen in schizophrenia)
• Inappropriate affect refers to an emotional response to a situation that is not congruent with
the tone of the situation.
o For example, a young man breaks into laughter when told that his father has died.
• Bizarre affect is especially prominent in the disorganized form of schizophrenia and includes
grimacing, giggling, and mumbling to oneself. Bizarre affect is marked when the patient is
unable to relate logically to the environment.



Neurocognitive Symptoms
Cognitive symptoms include impairment in memory; disruption in social learning; and inability to reason,
solve problems, or focus attention. The greater the degree of negative and cognitive symptoms the
more likely it is for the person to be unable to function on a job, engage in social activities, and care for
self adequately and safely.
Disruption in cognitive symptoms (organize, plan, concentrate, etc.) is possibly the most damaging of all
the symptoms. Neurocognitive symptoms represent the third dimension and affect at least 40% to 60%
or more of people with schizophrenia.
Cognitive impairment also causes difficulty with attention, memory, and executive functions (e.g.,
decision making and problem solving); impedes the person’s ability to manage his or her own health
care and/or participate fully in relapse prevention programs; and generally devastates the person’s
quality of life.
The degree of cognitive deficit is associated with the severity of negative symptoms; disorganized
thinking reflects the degree to which disorganized speech, disorganized behavior, or inappropriate affect
is present. Good verbal memory is one cognitive indicator that the individual eventually can function
within the community because it helps with acquisition of psychosocial skills or learning and with
retention of skills. These are all necessary for eventual rehabilitation.

6. Differentiate among the three phases of schizophrenia in terms of symptoms, focus of care and
interventions.

Phase 1: Acute (our primary focus) – In patient hospitalization (safety is key)

Symptoms
Periods of florid positive symptoms (more fully developed and flagrant) (e.g.,hallucinations, delusions)
as well as negative symptoms (e.g., apathy, withdrawal, lack of motivation) and cognitive symptoms.
Focus of care
During the acute phase of the illness, the overall goal is patient safety and medical stabilization.
Therefore, if the patient is at risk for violence to self or others, initial outcome criteria should address
safety issues (e.g., patient consistently refrains from inflicting serious injury to self or others).
Another outcome might be patient consistently refrains from acting on delusions or hallucinations.
Medication adherence is a vital outcome for all phases of recovery. Ideally, outcomes should focus on
enhancing the patient’s strengths and minimizing the patient’s deficits.
Interventions
During phase I the clinical focus is on crisis intervention, acute symptom stabilization (medication), and
safety. As a result of the recent trend toward decreasing the length of hospital stays, alternatives such
as partial hospitalization, halfway houses, and day treatment centers are frequently used as cost-
effective alternatives to hospitalization.
Acute-phase interventions include:
• Acute psychopharmacological treatment (psychobiological intervention)
• Supportive and directive communications
• Limit setting (milieu management and counseling)
• Psychiatric, medical, and neurological evaluation.

Phase 2: Stabilization phase – Acute sign and symptoms decrease

and
Phase 3: Maintenance phase: Period in which symptoms are in remission
Focus of care
Outcome criteria during the maintenance and stabilization phases focus on helping the patient to
adhere to medication regimens, understand schizophrenia, and participate in available
psychoeducational activities for both the patient and the family.
During the stabilization phase, goals are directed toward continual recovery, improvement in
functioning, and enhancement of the individual’s quality of life. Improvement in functioning includes the
ability to participate in social, vocational, or self-care skills’ training and involvement in social groups at
various levels.
It is also important to include outcomes that address anxiety control and relapse prevention. Desired
outcomes to reduce the patient’s vulnerability to psychosis include the following: maintain a regular
sleep pattern; reduce alcohol, drug, and caffeine intake; keep in touch with supportive friends and
family; stay active (engage in exercise, hobbies, employment); have a routine daily and weekly schedule
including enjoyable activities; and take medication regularly.


Interventions
Once the acute symptoms are somewhat stabilized, the hospitalized patient is discharged to the
community, where appropriate treatment can be carried out during the maintenance and stabilization
phases. Effective long-term care of an individual with schizophrenia relies on a three-pronged approach:
medications, nursing interventions, and community support. Family psychoeducation, as well as
community support, is a key component of effective treatment.
Phase II and phase III interventions include the following:
• Health Teaching:
o For the patient and family about the disease
o For the patient and family about medication management
o In cognitive and social skills enhancement
o Of strategies to minimize stress and to control anxiety levels
• Health promotion and maintenance:
o To identify signs of relapse and take preventive steps
o To improve deficits in self-care, social, and work functioning
o To encourage participation in nonthreatening activities
o To encourage social relationships
o To encourage family interaction

7. Discuss the shift to community based treatment for patients with schizophrenia.

With the shifting of care for the seriously mentally ill from inpatient to community-based treatment
centers, the need for transitional care is heightened, and the role of the nurse in providing a therapeutic
milieu is broadened. Alternatives to hospitalization include:
• Partial hospitalization: Patients sleep at home and attend treatment sessions during the day or
evening.
• Halfway houses: Patients live in the community with a group of other patients, sharing expenses
and responsibilities. Staff are present in the house 24 hours a day, 7 days a week.
• Day treatment programs: Patients live in a halfway house or on their own, sometimes with
home visits, or in residential programs. Patients attend a structured program during the day.

8. Discuss evidenced based psychosocial therapies for patients with schizophrenia and their families.

All evidence-based approaches emphasize the value of family participation in treatment. Families with
members who are struggling with schizophrenia often endure considerable hardships while coping with
the psychotic and residual symptoms of the illness. Often these families become isolated from their
relatives and communities. Families are perhaps the most consistent factor in patients’ lives. More than
half of patients discharged from a psychiatric facility return to their family of origin.
Programs that provide support, education, coping skills training, and social network development are
extremely effective. Medication and psychosocial treatments with family interventions have been
shown to reduce relapse rates in the treatment of early schizophrenia; a popular approach with patients
and families is a psychoeducational approach. It brings educational and behavioral approaches into
family treatment. The psychoeducational approach recognizes that families are secondary victims of a
biological illness. In family therapy sessions, fears, faulty communication patterns, and distortions are
identified. Improved problem-solving skills can be taught, and healthier alternatives to situations of
conflict can be explored. Family guilt and anxiety can be lessened, which facilitates change.
Families that receive psychoeducational treatment in multiple-family groups do even better than those
treated in single-family groups. Although single- and multiple-family treatments are cost-effective,
multiple-family groups are even more so and are the most beneficial both to families and to family
members with schizophrenia. Improvement seems to stem from an expansion of the social network
available to the family and patient as well as an expansion in problem-solving capacity afforded by a
group. Multiple-family groups also decrease emotional over-involvement while increasing the overall
positive tone, which is characteristic of such groups.

9. Discuss the importance of psycho-pharmacological management of schizophrenia.

There is greater focus on producing pharmacological treatments that have fewer neurological side
effects; treating medical concerns like diabetes, weight gain, and heart disease; targeting cognitive
defects; and finding strategies to better personalize treatments. This focus incorporates the recovery
model for schizophrenia.
Drugs used to treat psychotic disorders are called antipsychotic medications. Although they may
alleviate many of the symptoms of schizophrenia, they cannot cure the underlying psychotic processes.
Therefore, when patients stop taking their medications, psychotic symptoms usually return.
An additional concern is that with each relapse following medication discontinuation it takes longer to
achieve remission after restarting medications. This leads to the possibility that the patient will
eventually become unresponsive to treatment.
Although most individuals prefer oral medications, those who are nonadherent to medication therapy
and are prone to frequent relapse, or would find it more convenient for their situation, are candidates
for long-lasting injectable formulations.
Antipsychotic agents usually take effect 3 to 6 weeks after the regimen is started. Most patients with
schizophrenia respond at least partially to antipsychotic drug therapy. However, without drug
treatment, up to 70% to 80% of individuals will relapse within a year.

First-generation agents/conventional antipsychotic agents - target the positive symptoms of

schizophrenia (hallucinations and delusions).
Second-generation agents/(atypical) antipsychotic agents - thought to diminish some of the negative
symptoms as well. SGAs have fewer side effects and thus are better tolerated.
The newer atypical agents also help with symptoms of anxiety and depression, decrease suicidal
behavior, and are thought to increase neurocognitive functioning.
However, as discussed more thoroughly later, SGAs do come with some serious considerations. The
SGAs have a higher risk for metabolic syndrome (weight gain, diabetes, and dyslipidemia), which can
lead to cardiovascular events and premature death. These agents are also 10 to 20 times more
expensive than the more traditional FGAs.

10. Identify extra-pyramidal side effects (EPS) including tardive dyskinesia, acute dystonic reaction and
akathisia that may result from psychotropic medications.

Dopamine (D2) neurotransmission plays a role in psychosis. The conventional antipsychotics are
antagonists at the D2 receptor site in both the limbic and the motor centers. This blockage of D2
receptor sites in the motor areas is responsible for some of the most troubling side effects of the
conventional antipsychotics, namely, the extrapyramidal symptoms (EPS) of akathisia, dystonia,
parkinsonism, and tardive dyskinesia.
Tardive dyskinesia - an EPS that usually appears after prolonged treatment, is more serious, and is not
always reversible. Tardive dyskinesia consists of involuntary tonic muscular spasms that typically involve
the tongue, fingers, toes, neck, trunk, or pelvis. This potentially serious EPS is most frequently seen in
women and older patients, and affects up to 50% of individuals receiving long-term high-dose therapy.
Tardive dyskinesia varies from mild to moderate and can be disfiguring or incapacitating.
Early symptoms of tardive dyskinesia are fasciculation of the tongue or constant lip smacking. These
early oral movements can develop into uncontrollable biting, chewing, or sucking motions; an open
mouth; and lateral movements of the jaw. In many cases, the early symptoms of tardive dyskinesia
disappear when the antipsychotic medication is discontinued. In other cases, however, early symptoms
are not reversible and may progress. No proven cure for advanced tardive dyskinesia exists. The
National Institute of Mental Health developed a brief test for the detection of tardive dyskinesia
referred to as the Abnormal Involuntary Movement Scale (AIMS).
Acute dystonia - muscle cramps of the head and neck.
Akathisia - internal restlessness and external restless pacing or fidgeting.
Pseudoparkinsonism - stiffening of muscular activity in the face, body, arms, and legs.
Treatments usually consists of:
• Lowering the dose
• Prescribing antiparkinsonian drugs:
• Trihexyphenidyl (Artane)
• Benztropine mesylate (Cogentin)
• Diphenhydramine hydrochloride (Benadryl)
• Biperiden (Akineton)
• Amantadine hydrochloride (Symmetrel)




11. Identify specific times when teamwork and collaboration with other health care professionals are
paramount for the implementation of safe and effective care for a patient with schizophrenia.

Phase 1 Phase 2 Phase 3

ACUTE: ONSET, SUBACUTE OR STABILIZATION PHASE MAINTENANCE PHASE

EXACERBATION, OR CONVALESCENT ADAPTIVE PLATEAU HEALTH PROMOTION
RELAPSE

Inpatient treatment Social work Community Group therapists

team department support staff
Social, vocational,
Residential alternative Health and human Family support and self-care
to hospitalization services groups providers

Community crisis Day treatment or a Group therapists Family, employer,

intervention variety of and self-help community
community groups support staff
Internist
support
Practitioners of
Neurologist
behavioral
therapies using
educational models
and cognitive
restructuring.