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Course: Mental Health Nursing

Topic: Schizophrenia Spectrum and Other Psychotic Disorders- Part I

The Nurses International Community

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Module Goals

Learners will be able to:

Define Psychosis.
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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Psychosis

A condition where there is loss of contact with reality

Perceptions are disturbed making it difficult to understand what is real

Symptoms involve one of these two experiences:

Hallucination
Delusions

National Institute of Mental Health [NIMH], n.d.

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Key Features of Psychosis

Psychotic disorders have one or more of the following abnormalities:

Hallucination
Delusions
Disorganized Thinking (Speech)
Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia)
Negative Symptoms

American Psychiatric Association, 2013

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Key Features of Psychosis (Continued)

Hallucination: Hearing, seeing and feeling things that do not exist.

Hearing voices (auditory).
Strange sensations or unexplainable feelings.
Seeing objects or people that are not there (visual).

Delusion: Strong beliefs that are not shared by others.

Believing external forces are controlling thoughts, feelings, behaviors.
Believing that trivial remarks, events or objects have personal meaning or significance.
Thinking one has special powers, or is on a special mission.

National Alliance on Mental Illness, n.d.a

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Key Features of Psychosis (Continued)

Disorganized Thinking (Speech):

Racing thoughts: Thoughts that occur in rapid succession, and are unable to control.
Flight of Ideas: Quickly moving from one idea to another, making links and seeing meanings between them that do not exist.
Rapid speech: Stumbling over words, jumbled speech, quickly changing topic.
Difficulty focusing.

Calabrese & Al Khalili, 2021

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Key Features of Psychosis (Continued)

Grossly Disorganized or Abnormal Motor Behavior

Unpredictable/inappropriate responses incongruent with the current situation. e.g., laughing in a solemn situation.

Catatonic Behavior: Marked decrease in reactivity to the environment. e.g., resistance to instructions (negativism), maintaining a rigid/bizarre posture, complete lack of verbal and motor responses (mutism and stupor).

Catatonic excitement: Purposeless and excessive motor activity without obvious cause.

Calabrese & Al Khalili, 2021

APA, 2013

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Key Features of Psychosis (Continued)

Negative Symptoms:

Diminished emotional expression: In the face, eyes, intonation, and movements of the hand, head, and face that normally give an emotional emphasis to speech.
Avolition: Decrease in self-initiated purposeful activities.
Alogia: Diminished speech.
Anhedonia: Decreased ability to experience pleasure from positive stimuli or a degradation in recollection of pleasure experiences.
Asociality: Lack of interest in social interactions.

Calabrese & Al Khalili, 2021

APA, 2013

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DSM-5 Classification of Psychotic Disorder

Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Brief Psychotic Disorder
Delusional Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to a Medical Condition

APA, 2013

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Critical Thinking Question:

To which of the following would the nurse assess as symptoms of delusion? (Select all that apply)

Client says, ‘I hear footsteps, Someone is coming up the stairs,” while sitting on the ground floor.
Client says,“The airplane above us is the government, and they want to kidnap me.”
While watching a reporter on the TV news, the client says,“The reporter is reporting directly about me.”
Client says“My aunt is sitting beside me,”when there is no one sitting beside her.

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Schizophrenia

Individual loses touch with reality causing significant distress for self, family, and friends.

Affects how individual thinks, feels, and behaves.

Manifests as impaired social and occupational functioning.

Affects approximately 24 million people or 1 in 300 people (0.32%) 1 in 222 adults (0.45%).

Is persistent and debilitating if left untreated.

Hany et al., 2021

NIMH, 2020

World Health Organization, 2022

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Schizophrenia: Risk Factors

Genetics: Though no specific gene implicated. May run in families
Environmental:

Poverty, stressful surroundings, and exposure to viruses or nutritional problems before birth.
Cannabis use: Early and higher doses linked to risk of rapid development or psychosis, frequent use significantly increases the risk.

Abnormalities in brain neurotransmitters

Dopaminergic, Serotonergic, Alpha-adrenergic hyperactivity, Glutaminergic, GABA hypoactivity.

Hany et al., 2021

NIMH, 2020, Patel et al., 2020

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Diagnostic and Statistical Manual -5 (DSM-5)

Criteria for Schizophrenia Diagnosis

At least one of the following symptoms must be clearly present for a significant portion of the time during a 1 month period:

Delusions
Hallucinations
Disorganized speech

Grossly disorganized or catatonic behavior and negative symptoms may also be present.
Signs of above disturbances must persist for at least 6 months.
Causes of disturbances not attributable to drug use or other medical condition(s).

Center for Behavioral Health Statistics and Quality, 2016

APA, 2013

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Schizophrenia: Evaluation

Full psychiatric history
Systems review and mental state examination.

Appearance, behavior, mood, speech, cognition, insight.
Determine evidence of perceptual delusions or formal thought disorders.

Risk assessment for harm to self and/or others.
Rule out other potential causes: Electrolyte imbalance, thyroid problems, adrenal glands dysfunctions, recreational drugs use, neurological impairment, HIV/Syphilis.

Hany et al., 2021

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Critical Thinking Question:

A client came to the clinic and told the nurse, “My heart has stopped and my veins have turned to glass!” Nurse is aware that this is an example of which of the following?

Somatic delusions
Visual hallucination
Depression
Auditory hallucination

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Schizophrenia: Pharmacological Management

Initial acute psychosis treatment: Second-generation antipsychotics.
Benzodiazepine for behavioral disturbances and non-acute anxiety.
Depot preparations considered after acute psychosis under control.

To increase medication adherence & reduce relapses.

During maintenance period, use the minimal dose of antipsychotic required for effect.
Management of treatment resistance:

Combination antipsychotics
Clozapine: Monitor white blood cell count weekly due to risk of agranulocytosis.

Hany et al., 2021

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Schizophrenia: Non-pharmacological Management

Cognitive behavioral therapy (CBT), art, and drama therapies:

Counteracts negative symptoms of the disease, improves insight, and assists in relapse prevention.

During maintenance phase:

Rehabilitation back into the community is vital.

Electroconvulsive therapy (ECT) has a limited role.

Hany et al., 2021

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Nurse’s Role in Management of Schizophrenia

Assess for and refer promptly if signs and symptoms are noted.
Develop a therapeutic relationship.
Provide client/family education about prescribed medication.
Emphasize to client and family that non-treatment or non-acceptance may present a danger to self or others.

Pinho et al., 2017

Nursing Times, 2009)

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Nurse’s Role in Management of Schizophrenia

Appropriate approach for delusion

Express that nurse accepts that the client has a belief although nurse does not share that belief.
Do not discuss or deny client’s belief

Reasonable doubt is used
“I understand that you believe this to be true, but I do not see the same thing.”

Reinforce reality
Ensure food/medication is swallowed

May have delirium about food/medication being harmful.

Pinho et al., 2017

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Nurse’s Role in Management of Schizophrenia

Encourage client to share content of hallucination.

Especially in command hallucinations to prevent harm to self or others.

In auditory hallucination:

Avoid touching the client without warning.
Use term ‘voices’ instead of ‘he/she/they’ which shows validation.
Express that the nurse does not share the same perception.

“I know voices seem real to you, but I do not hear any voices.”

Encourage distractions: listening to music, watching television.

Pinho et al., 2017

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Nurse’s Role in Management of Schizophrenia

Identify signs/symptoms of non-adherence to treatment regime and make appropriate referrals.

Coordinate care between client, family/caregivers, and multidisciplinary team.

Be knowledgeable and provide information about resources in the community that provide support to clients/families suffering from these disorders.

Pinho et al., 2017

Nursing Times, 2009

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Critical Thinking Question:

Which of the following are negative symptoms of schizophrenia?

False belief that partner is cheating
Lack of motivation, blunted affect, and apathy
Disorganized speech
Difficulty concentrating

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Schizoaffective Disorder

Includes features of both schizophrenia and mood disorders
Prefix "schizo-" refers to psychotic symptoms of schizophrenia that affect thinking, sense of self, and perceptions
Term "-affective" refers to extreme shifts in mood, energy, and behavior such as mania or depression
Lifetime prevalence is rare (only 0.3% of cases)
May be managed effectively

Co-occurring substance use disorders are a serious risk and require integrated treatment.

National Institute of Health, 2018

National Alliance on Mental Illness, n.d.b

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DSM-5 Criteria for Schizoaffective Disorder Diagnosis

“A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.”

APA, 2013

Wy & Saadabadi, 2021

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DSM-5 Criteria for Schizoaffective Disorder Diagnosis

“C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.

D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.”

APA, 2013

Wy & Saadabadi, 2021

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Schizoaffective Disorder:

Evaluation

Complete medical and psychiatric history

Focus on the diagnostic criteria

Comprehensive physical exam
Determine if neurologic exam deviates from normal: MRI (magnetic resonance imaging), EEG (electroencephalography), or CT (computed tomography).
Optional laboratory tests for atypical presentation:

Complete blood count (CBC), lipid panel, urine drug screen, urine pregnancy test, urinalysis, thyroid-stimulating hormone (TSH) level, rapid plasma reagent, Human Immunodeficiency Virus (HIV) test.

Wy & Saadabadi, 2021

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Schizoaffective Disorder:

Pharmacological Management

Antipsychotics are the mainstay of treatment

Targets management of psychosis and aggressive behavior.
Clozapine considered for treatment resistant cases.

Mood stabilizers for client with history of manic or hypomanic symptoms.

Antidepressants are used to target depressive symptoms.

Selective-serotonin reuptake inhibitors (SSRIs) are preferred.

Wy & Saadabadi, 2021

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Schizoaffective Disorder:

Non-Pharmacological Management

Individual Therapy:

Sessions focused on everyday goals, social interactions, and conflict; social skills training and vocational training.

Family and/or group therapy:

Family education aids in compliance with medications, appointments, helps provide structure throughout individual’s life.
Supportive group programs provide sense of shared experiences among participants.

ECT (Electroconvulsive Therapy) usually last resort

Used in urgent cases and treatment resistance, to augment pharmacotherapy.

Wy & Saadabadi, 2021

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Nurse’s Role in Management of Schizoaffective Disorder

Assess for signs and symptoms, early referral if present.
Develop therapeutic relationship.
Care during manic episodes:

Remain patient, calm, focused
Set firm limits/boundaries without be confrontational:

What is allowed, with or without supervision
How client engages with others
Methods of dress
Topics of discussion, reasonable/unreasonable requests

Boundaries included in care plan should be consistently reinforced by all team and family.

McColm et al., 2006

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Nurse’s Role in Management of Schizoaffective Disorder

Care for manic episodes (continued…)

Restrict stimulant based food/beverages, create calm environment.
Monitor side-effects of mood stabilizers, and manage accordingly.

Care for episodes of depression:

Prioritize safety, alleviate risk of suicide

Environment free of items that may be used for self-harm.

Support performing activities of daily living.
Encourage participation in activities.
Reinforce elements of therapy such as challenging negative thoughts about self, world, and future.

McColm et al., 2006

Chand et al., 2021

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Nurse’s Role in Management of Schizoaffective Disorder

Educate client and family/caregiver about:

Warning signs of mania or depression, their management.
Importance of adherence to medication regimen.

Monitor effectiveness of medications, side-effects, manage accordingly.
Monitor clients for adequate nutrition and hygiene.
Ensure clients/families/caregivers have continuous support for long-term management of the illness.

McColm et al., 2006

Chand et al., 2021

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Cultural Considerations

Understanding of, beliefs, manifestations, and practices of schizophrenia and schizoaffective disorders vary across cultures and religions.

Nurses should be aware of cultural differences and address them in treatment planning for effective interventions and outcomes.

Dein, 2017

Viswanath & Chaturvedi, 2012

National Alliance on Mental Illness, n.d.c

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References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Publishing.

Calabrese, J., & Al Khalili, Y. (2021). Psychosis. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK546579/

Center for Behavioral Health Statistics and Quality. (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health: Table 3.22DSM-IV to DSM-5 Schizophrenia Comparison. In: National Center for Biotechnology Information [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22/

Chand, S.P., Arif, H., & Kutlenios, R.M. (2021, July 26). Depression (Nursing). In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568733

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References:

Dein, S. (2017). Recent work on culture and schizophrenia: Epidemiological and anthropological approaches. Global Journal of Archaeology and Anthropology, 1(3). https://juniperpublishers.com/gjaa/GJAA.MS.ID.555562.php

Hany, M., Rehman, B., Azhar, Y., et al. (2021, May 29). Schizophrenia. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/

Joseph SM, Siddiqui W. (2021, Jul 13). Delusional Disorder. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/

McColm, R., Brown, J., & Anderson, J. (2006). Nursing interventions for the management of patients with mania. Nursing Standard, 20(17); 46-49. https://www.researchgate.net/publication/7346610_Nursing_interventions_for_the_management_of_patients_with_mania

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References:

McDonald, W. & Fochtmann, L. (2019, July). What is electroconvulsive therapy (ECT)?. American Psychiatric Association. https://www.psychiatry.org/patients-families/ect

Meaden, A., Birchwood, M., & Trower, P. (2013). Cognitive Therapy for command hallucinations. Oxford Medicine Online. https://oxfordmedicine.com/view/10.1093/med/9780199548590.001.0001/med-9780199548590-chapter-007

National Alliance on Mental Illness. (n.d.a). Psychosis. Retrieved on December 6, 2021 from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Psychosis

National Alliance on Mental Illness. (n.d.b). Schizoaffective Disorder. Retrieved on December 9, 2021 from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-Disorder

Contact info: info@nursesinternational.org

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References:

National Alliance on Mental Illness. (n.d.c). Schizoaffective Disorder. Retrieved on December 9, 2021 from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-Disorder/Treatment

National Institute of Health. (2018, February 1). Schizoaffective disorder. https://medlineplus.gov/genetics/condition/schizoaffective-disorder/

National Institute of Mental Health. (n.d.). What is psychosis?. Retrieved on December 6, 2021 from https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis

National Institute of Mental Health. (2020, May). Schizophrenia. https://www.nimh.nih.gov/health/topics/schizophrenia

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References:

Nursing Times. (2009, May 6). Mental health nurses have a key role in implementing new schizophrenia guidance. https://www.nursingtimes.net/roles/mental-health-nurses/mental-health-nurses-have-a-key-role-in-implementing-new-schizophrenia-guidance-06-05-2009/

Patel, S., Khan, S., M, S., & Hamid, P. (2020). The Association Between Cannabis Use and Schizophrenia: Causative or Curative? A Systematic Review. Cureus, 12(7), e9309. https://doi.org/10.7759/cureus.9309

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

Royal College of Psychiatrists. (n.d.). Depot medication. https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/depot-medication#:~:text=It%20is%20a%20special%20preparation,your%20body%20in%20tablet%20form

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References:

Viswanath, B., & Chaturvedi, S. K. (2012). Cultural aspects of major mental disorders: a critical review from an Indian perspective. Indian journal of psychological medicine, 34(4), 306–312. https://doi.org/10.4103/0253-7176.108193

Wy, T.J.P., & Saadabadi, A.(2021, August 6). Schizoaffective Disorder. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/

World Health Organization. (2022, January 11). Schizophrenia. https://www.who.int/news-room/fact-sheets/detail/schizophrenia#:~:text=Schizophrenia%20affects%20approximately%2024%20million,as%20many%20other%20mental%20disorders.

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