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Course: Mental Health Nursing

Topic: Schizophrenia Spectrum and Other Psychotic Disorders - Part II

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Continuation of Part I

Schizophrenia Spectrum and Other Psychotic Disorders Goals:

Describe the various psychotic disorders.
Identify symptoms related to psychotic disorder.
Identify clinical manifestations of psychotic disorder.
Discuss evidence based management for psychotic disorder.
Identify appropriate nursing interventions for psychotic disorder.

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What is Schizophreniform Disorder ?

Affects how an individual thinks, feels, and behaves
Characteristic features are the same as that of schizophrenia but is time limited lasting between 1 to 6 months
Social, occupational, or academic functioning may or may not be affected
Risk factors:

May be inherited from close relatives
Poor social interactions or highly stressful event might trigger
Cannabis use

Gans, 2021

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Schizophreniform Disorder: Signs/Symptoms

Signs/Symptoms:

Delusions
Hallucinations
Disorganized speech
Odd or strange behavior such as pacing, walking in circles and writing constantly
Limited emotional expression, lack of energy
Poor hygiene/grooming habits
Loss of interest/pleasure in life
Withdrawal from family, friends and social activities

Gans, 2021

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Diagnostic and Statistical Manual of Mental Disorder

DSM-5 Criteria for Schizophreniform Disorder

Two (or more) of the following, must be present for a significant portion of time during a 1-month period (or less if successfully treated) including at least one noted with *
Delusions*
Hallucinations*
Disorganized speech*
Grossly disorganized or catatonic behavior
Negative symptoms,(i.e., diminished emotional expression or avolition)
An episode of the disorder (including prodromal, active, and residual phases) lasting at least 1 month but less than 6 months.

Substance Abuse and Mental Health Services Administration, 2016

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DSM-5 Criteria for Schizophreniform (Continued)

Schizoaffective and mood disorder are excluded because:

No major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms.
In the event that mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

Disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Substance Abuse and Mental Health Services Administration, 2016

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Schizophreniform Disorder: Management

Medical and psychiatric history conducted by a specialist.

Involves interviewing family and friends.

Careful assessment and management of suicidal tendency.
Management is tailored to individual needs.

Antipsychotics are the mainstay of the treatment.
Cognitive Behavioural therapy (CBT).
Client/Family education concerning the disorder and its management.

Gans, 2021

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Critical Thinking Question:

Presence of which of the following combination of sign/symptoms for a period of 1 month indicate diagnosis of Schizophreniform disorder? (Select all that apply)

Grossly disorganized or catatonic behavior and negative symptoms
Disorganized speech and hallucination
Hallucination and grossly disorganized behavior
Delusion and negative symptoms

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What is Brief Psychotic Disorder?

Sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission possibility of future relapses.
At least one of these psychotic behaviors must be present:

Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior

Risk factors are unknown.

Stephen & Lui, 2021

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DSM-5 Criteria for Brief Psychotic Disorder

At least one of these symptoms is present:
Delusions
Hallucinations
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior

Symptom(s) for at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.
Episodes not attributable to major depressive, bipolar disorder with psychotic features. or another psychotic disorder, or substance use.

Substance Abuse and Mental Health Services Administration, 2016

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Brief Psychotic Disorder: Evaluation

Medical and psychiatric history
Tests to rule out other potential diagnoses.

Serum pregnancy test in women to evaluate underlying triggers for behavioral disturbances.
Urine toxicology tests to exclude potential drug or medication intoxication or withdrawal.
CT and MRI of the brain to evaluate underlying structural causes for symptoms.
Other considerations for tests: ECG, serum electrolytes, glucose level, liver function tests, thyroid function tests, and urinalysis.

Stephen & Lui, 2021

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Brief Psychotic Disorder: Management

Level of care and need for hospitalization is based on:

Presenting symptoms
Socioeconomic stability
Presence supporting family/friends
If homicidal/suicidal ideation present

Pharmacotherapy:

Antipsychotics: First line of treatment for 1 to 3 months

Second generation used initially

Clozapine used in treatment-resistant
Benzodiazepines may alleviate symptom manifestation in acutely combative or agitated individuals

Use psychotherapeutic interventions effective for other psychotic disorders.

Stephen & Lui, 2021

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Critical Thinking Question:

Discussion:

What is the difference between Schizophreniform disorder and Brief Psychotic Disorder?

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What is Delusional Disorder?

Delusion is the only long-standing dominant symptom
Delusion is fixed false belief

Belief contrary to evidence or reality
Belief incongruent with one’s culture or subculture
Almost everyone else knows it to be false

Some common types:

Jealousy: Partner is unfaithful
Bizarre: Impossible, not understandable
Grandiose: Having great talent, power, inflated self-worth
Persecutory: being conspired against, attacked, harassed
Somatic related to body functions, sensations

Joseph & Siddiqui, 2021

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Delusional Disorder

Exact cause unknown
Affected individual is relatively stable, however may lead to depression and social isolation if untreated.
Major risk factors:

Substance use
Neurological conditions involving limbic system and basal ganglia.
Hypersensitive traits, ego defense mechanisms like reaction formation, projection, denial.
Social isolation, envy, distrust, suspicion, and low self-esteem.
Immigrants with language barriers
Deaf, visually impaired, and elderly

Joseph & Siddiqui, 2021

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DSM-5 Criteria for Delusional Disorder

Presence of one (or more) delusions for 1 month or longer.
Criteria A for schizophrenia absent; Hallucinations are related to the delusional theme.
Functioning is not markedly impaired, behavior is not obviously bizarre or odd.
If manic or major depressive episodes occur, they are brief in duration relative to delusional periods.
Not attributable to effects of substance use, medical condition, or another mental disorder.

Substance Abuse and Mental Health Services Administration, 2016

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Delusional Disorder: Evaluation

Medical and psychiatric history conducted by a specialist.

Family/friends may provide further details on delusions and timeline of symptoms.
Client’s belief is checked before concluding it to be a delusion.

Complete neurologic examination
Imaging or laboratory tests for ruling out organic causes.

Urine drug test to rule out substance-induced conditions.

Hospitalization considered for clients with history of aggression.

Joseph & Siddiqui, 2021

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Delusional Disorder: Management

Build therapeutic relationship
Combination of pharmacotherapy and psychotherapy more effective.
Pharmacotherapy:

Antipsychotics based on medication compliance history.
One antipsychotic medication started for trial period of six weeks.

Switched to another drug class if first one is not effective.

Adjunct treatment with drugs like lithium, valproic acid, and carbamazepine considered if monotherapy with antipsychotics are unsuccessful.

Joseph & Siddiqui, 2021

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Nurse’s Role in Management of Delusion

Let client know nurse accepts that client has a belief but does not share that belief.
Do not discuss or deny client’s belief.

Reasonable doubt must be used as a therapeutic technique.
Validate any part that is real.

Reinforce reality: Talk about real things and real people.
Ensure client swallows food and/or prescribed medication.

May believe food/medication are harmful.

Pinho et al., 2017

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Examples of nurses responses to clients with delusions:
Accept client as a belief but nurse does not share it:

“I understand that you believe this to be true, but I do not think the same.”

Do not deny client’s belief but obtain details about the belief

“Who is trying to hurt you?” “Could you think why?” “How might this happen?”

Validate any part of the delusion that is real

Depending on the situation, nurse may say: “Yes, there was a doctor at the nurse’s desk, but I did not hear him talking about you.”

Let the client know that nurse recognises the feelings that can be evoked by the delusions.

“It must feel very frightening to think that there is a conspiracy against you.”

Respond to the underlying feelings and encourage discussion of these rather than the content of the delusion

(Pinho et al., 2017; Queensland Mind Essentials, 2010)

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Critical Thinking Question:

Which of the following is true regarding clients diagnosed with delusional disorder? (Select all that apply)

Are at risk of social isolation
Are at risk for depression
Usually has impaired functioning
Show obvious bizarre behavior

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What is Substance/Medication-Induced Psychotic Disorder?

Psychotic disorder symptoms are experienced within a month of using or withdrawing from prescription drugs, illegal drugs, and/or alcohol.

Some of the main signs/symptoms:

Hallucinations
Delusions
Disordered speech/thoughts
Hypersensitivity to sound, smells or other sensory input
Flat affect, or lacking emotional expressions
Poor hygiene and self-care

Umhau, 2021

Sheppard Pratt, n.d.

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DSM-5 Criteria for Substance/Medication-Induced

Psychotic Disorder

Presence of one or both of the symptoms below:

a. Hallucination b. Delusions

History, physical examination, or laboratory findings show evidence of both of the following:

Symptoms developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
Involved substance/medication capable of producing the symptoms.

Disorder causes clinically significant distress or impairment in important areas of functioning.

Substance Abuse and Mental Health Services Administration, 2016

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DSM-5 Criteria… (Continued)

Disturbance cannot be explained by other psychotic disorder that is not substance/medication-induced.

Disturbance does not occur exclusively during the course of a delirium.

Substance Abuse and Mental Health Services Administration, 2016

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Substance/Medication-Induced Psychotic Disorder:

Evaluation

Obtain medical, medication and psychiatric history.

Determine if onset of psychotic symptoms is associated with medication.

Monitor how long symptoms persist during withdrawal to ensure that other mental health disorders may need to be ruled out.

If symptoms persist for longer than a month after substance has cleared from the body, further investigations are needed to rule out other mental health disorder.

Umhau, 2021

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Substance/Medication-Induced Psychotic Disorder:

Treatment Management

Stop suspected medication/substance.
Closely monitor client in safe environment.
Pharmacotherapy for psychotic symptoms and mood:

Benzodiazepines, Selective serotonin reuptake inhibitors, Antipsychotics.

Psychotherapy to prevent relapse of psychosis:

Cognitive behavioral therapy.
Inpatient/Outpatient rehabilitation for drug and/or alcohol use.
Eye movement desensitization and reprocessing.
Dialectical behavior therapy.
Group therapy.

Umhau, 2021

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Substance/Medication-Induced Psychotic Disorder:

Treatment Management

Considerations for Alcohol-Induced Psychotic Disorder:

Close monitoring of client in hospital during withdrawal.

May experience delirium tremens, symptoms of alcohol-induced psychosis, and bodily function failure.
Closely monitor and stabilize vital signs.
Replenish electrolytes and vitamins, and test for liver disease.
Sedation using antipsychotics or benzodiazepines, if needed.
Suicide evaluation and monitoring.

Follow up with Inpatient/outpatient rehabilitation soon after withdrawal completion.

Umhau, 2021

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Psychotic Disorder Due to Another Medical Condition

DSM-5 Criteria:

Prominent hallucinations or delusions.

Evidence from the history, physical examination, or laboratory findings that the disturbance is direct physiological consequence of a general medical condition.

Disturbance is not explained by another mental disorder.

Disorder does not occur exclusively during the course of delirium.

Taminga, 2020

Substance Abuse and Mental Health Services Administration, 2016

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Psychotic Disorder Due to Another Medical Condition:

Management

Evaluation:

Medical, medication and psychiatric history.
Complete physical exam, mental, neuro exam.
Suspected medical conditions specific Laboratory/diagnostic tests.

Treatment Management:

Treat medical condition causing the disorder.

This often reduces psychotic symptoms.

Specific medication management might be necessary to reduce psychotic symptoms.

Taminga, 2020

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Nurse’s Role in Management of Psychotic disorders

Build therapeutic relationship.
Identify signs and symptoms and make early referral.
Assess for risk harm to self or others, communicate with the team if present.

Ensure safe environment.

Monitor clients nutrition, and hygiene.
Provide client/family education about psychotic disorders management, and medication.
Identify signs/symptoms of non-adherence to treatment, and refer appropriately.
Ensure client/family has resources needed for recovery.

Calabrese et al., 2021

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What Would the Nurse Do?

Which of the following considerations are appropriate for a client who shows psychotic symptoms longer than a month after clearance of the substance (prescription drugs, illegal drugs, and/or alcohol)from the body? (Select all that apply)

Substance induced psychotic symptoms can persist for two months after clearance of substance from body
Psychotic symptoms might be caused by other mental health disorder
Psychotic symptoms might be caused by other medical condition
‘Psychotic Disorder Due to Another Medical Condition’ is diagnosed

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References:

Calabrese, J., Al Khalili, Y., & Shaheen, K. (2021, July 19). Psychosis (Nursing) . In: StatPearls [Internet]. TStatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568796/

Gans, S. (2021, June 9). What is Schizophreniform Disorder?. [Review of article What is Schizophreniform Disorder?, by Renton, C. ]. Verywellhealth. https://www.verywellhealth.com/schizophreniform-disorder-5100997

Joseph, S.M.,& Siddiqui, W. (2021). Delusional Disorder. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

Pinho, L.G.D., Pereira, A., & Chaves, C. (2017). Nursing interventions in schizophrenia: the importance of therapeutic relationship. Nurse Care Open Acces J., 3(6):331-333. https://medcraveonline.com/NCOAJ/nursing-interventions-in-schizophrenia-the-importance-of-therapeutic-relationship.html

Contact info: info@nursesinternational.org

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References:

Queensland Mind Essentials.(2010). State of Queensland. https://www.health.qld.gov.au/__data/assets/pdf_file/0029/444773/mindessentialsfinal.pdf

Tamminga,C. (2020, May). Psychotic Disorder Due to Another Medical Condition. MSD Manual Professional Version. https://www.msdmanuals.com/professional/psychiatric-disorders/schizophrenia-and-related-disorders/psychotic-disorder-due-to-another-medical-condition

Sheppard Pratt. (n.d.). Substance-Induced Psychotic Disorder. https://www.sheppardpratt.org/knowledge-center/condition/substance-induced-psychotic-disorder/

Skelton, M., Khokhar, W., & Thacker, S.P. (2015). Treatments for delusional disorder. Cochrane Database of Systematic Reviews, Issue 5,. Art. No.: CD009785. https://www.cochrane.org/CD009785/SCHIZ_treatments-for-delusional-disorder

Contact info: info@nursesinternational.org

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References:

Stephen, A., & Lui, F. (2021, October 10). Brief Psychotic Disorder. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539912/

Substance Abuse and Mental Health Services Administration. (2016, June). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health: Table 3.20DSM-IV to DSM-5 Psychotic Disorders [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t20/

Umhau, J.C. (2021, May 16). What Is Substance/Medication-Induced Psychotic Disorder?. [Review of the article What Is Substance/Medication-Induced Psychotic Disorder?, by Hartney, E.]. verywellmind. https://www.verywellmind.com/what-is-substance-medication-induced-psychotic-disorder-21938

Zieve, D. (2021, January 17). Delirium tremens. National Library of Medicine, MedlinePlus [Internet]. https://medlineplus.gov/ency/article/000766.htm

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