Psychosis-

− People who have changes in their:

  • Perception– see or hear things that others may not
  • Thinking– disordered; inability to think logically/rationally
  • Behaviour– withdrawal, irritability
  • Emotional responses- blunted affect; incongruence of mood & affect

 

 

Schizophrenia & Psychotic Spectrum

Causes are multifactorial

− Genetics – family history  

− Brain chemicals – Neurotransmitters e.g ^ in dopamine  

− Neurodevelopment (birth complications)- foetal brain injury, obstetric complications, low birth weight  

− Environmental – high expressed emotion, adverse life events (trauma), socioeconomic deprivation

− Drug induced (Cannabis) – gene interaction  

 

 

Schizophrenia

−  A mental illness that affects the way a person thinks  − Can be noticed as:  

  • Prodromal phase (early stage)
  • Acute
  • Chronic (continuous symptoms)

− Can be stigmatising/discriminating

− Often the reason for people to withdraw from the community

− Can cause distress

 

− Onset usually early adulthood (early stage is called prodromal phase)

− Can be rapid or develop over months or years

 

FACTS-

− Sufferers are more likely to be victims of crime

− IQ rates are similar to general population & is NOT a characteristic of the illness

− Major advancements in psychopharmacology to increase lives of sufferers

− Treatment encourages for holistic, community-based treatment

− Individuals have a 20% decrease in life span due to CVD

− Whilst people with the illness don’t have high rates of cancers, they’re more likely to present with metastases at diagnosis

− Increased risk of: Metabolic syndrome, smoking, poverty, poor nutrition, reduced access to medical care

− History of cannabis misuse is more common in schizophrenia

 

Prodromal- The Warning

− Differs from frank psychotic features in intensity, frequency & duration

− Pre-hallucinatory perceptual abnormalities

  • Brief subtle changes (hearing or seeing things others cant)
  • Usually once or twice/month, lasting only a few minutes

− Subtle changes in behaviour (deterioration of school work/work performance)  − Social withdrawal

− Pre-delusional unusual thoughts (emergence of strange beliefs)

− Non-specific symptoms such as depression/anxiety

− Motor disturbance

− Impaired tolerance to stress

 

 

SIGNS OF SCHIZOPHRENIA 

Positive symptoms

− Best described as “excess” of, or additional symptoms/experiences

− Positive doesn’t mean ‘good’

− Respond well to unconventional antipsychotics

− rxamples:

  • Delusions
  • Hallucinations
  • Disorganised speech
  • Disorganised behaviour

 

Negative symptoms

− Best described as withdrawal of normal everyday functioning

− Absence of normal patterns of behaviour (emotional responsiveness, spontaneous speech)  − Respond to poorly to typical antipsychotics

− rxamples:

  • Lack of motivation, slow movement
  • Reduced range of emotions
  • Significant impact on work, interpersonal relations or self-care
  • Anhedonia (lack of interest)
  • Avolition (lack of motivation)
  • Alogia (poverty of speech)
  • Asociality (social withdrawal)
  • Change in sleep patterns
  • Poor hygiene & grooming

 

*Secondary negative symptoms 

− Are a result of the primary condition

− Caused by unresolved positive symptoms that are existing in the illness

 

 

HALLUCINATIONS-

− rxperiences that affect your sensory perceptions

− These experiences feel real for the person, however they’re not to others  − It can affect the following senses:

  • AUDITORY (sound)
  • VISUAL (sight) Ø TACTILr  (touch) Ø GUSTATORY (taste)
  • OLFACTORY (smell)

DELUSIONS- 

− Fixed, false beliefs

− rxperiences feel real to the person, but aren’t to others

− The beliefs may be illogical or irrational

− Can be bizarre

− Different delusional themes people may experience:

  • IDrAS OF RrFrRrNCr – e.g “the television sends me special messages”
  • PARANOID – e.g. “I think my mum is poisoning my food”
  • PrRSrCUTORY – e.g “I am going to be harmed by the police”
  • SOMATIC – e.g. “I have cancer, I don’t believe the doctors tests”
  • GRANDIOSr e.g. “I am Donald Trump, I have power”
  • RrLIGIOUS e.g. “I am God”
  • rROTOMANIC e.g. when a person believes that a person of a higher stasis is in love with them Ø NIHLISTIC e.g. “I believe the world is coming to an end”

 

 

DISORGANISED THINKING-

− rxpressed through speech

− rxamples:

  • Neologism
  • Word salad
  • Flight of ideas
  • Thought broadcasting- (believing other people can read your thoughts)
  • Thought insertion- (believing someone’s put a thought in your head)
  • Thought withdrawal- (believing someone’s taken/removing your thoughts) Ø Obsessional & abnormal thoughts

 

 

PROGNOSIS

Better outcomes are associated with:

− Female

− Older age onset

− Married

− Living in a developed country

− Functional premorbid personality (healthy personality pre-illness)

− No previous psychiatric history

− Good education & employment history

− Acute onset (affective symptoms)

− Medication compliant

 

 

Other spectrum disorders

Schizoaffective Disorder- •  Affects 1 in 200 people

  • Symptoms of schizophrenia (positive symptoms) and major mood disorder (mania or depression)
  • Typical onset age is early adulthood
  • Can be more complicated to diagnosis

 

Brief Psychotic Disorder-

  • Characterised by positive symptoms- hallucinations, delusions, disorganised speech & gross thought disorder

 

Delusional disorder-

  • People who don’t meet the criteria for schizophrenia
  • Characterised by one or more delusions lasting longer than one month

 

Schizophreniform- 

  • “Pre- schizophrenia”
  • Symptoms of schizophrenia
  • Both positive and negative symptoms

 

Catatonia- 

  • Associated with other neurodevelopment & psychotic disorders
  • Characterised by psychomotor disturbance
  • Unresponsiveness
  • Severe stupor
  • Moderate waxy flexibility

 

 

Treatment & Interventions

− Strengths & recovery orientated practices

− Family therapy

− Cognitive behavioural therapy (CBT)

− rlectroconvulsive therapy (rCT) − Antipsychotic medication

  • Dopamine antagonists
  • Work by decreasing dopamine activity in the brain
  • Typical/1st generation agents
  • Atypical/2nd generation (novel) agents

 

NURSING ASSESSMENT 

  • MSr- to gather baseline on cognitive, behavioural & emotional responses
  • RISK- to ensure no risk to self, others, or vulnerability
  • PHYSICAL HrALTH- ensuring individual’s physical health is prioritised (e.g. cardiac function, respiratory etc) RrLATIONSHIPS- family/friends/carers
  • SOCIAL & rNVIRONMrNTAL- housing, finances

 

EFFECTIVE COMMUNICATION

  • Listen carefully
  • Assist them with their stressors
  • Keep conversations brief
  • Give one message at a time
  • Don’t dismiss what’s being said, despite they’re unusual thoughts
  • Don’t argue
  • Gentle reality feedback
  • Avoid touch

 

RECOVERY & STRENGTH BASED

  • Supporting individuals in shared decision making
  • Balancing risk (positive risk taking)
  • Working on wellness plans that supports the person, families and carers to identify early warning signs (helps to reduce relapse)
  • Helping the person to incorporate their illness into their day to day life   Understanding that there may be acute episodes

 

ATYPICAL ANTIPSYCHOTIC MEDICATIONS

 

 

 

TYPICAL ANTIPSYCHOTIC MEDICATIONS

 

DEPOT ANTIPSYCHOTIC MEDICATIONS (LAI)

  • Incidence- about 30% of Australian users with schizophrenia are on LAI
  • Indications for use are for non adherence of oral medications
  • Oral medication MUST be used before a LAI (due to unknown side effects)

 

 

 

METABOLIC SYNDROME

  • Impacted by second-generation antipsychotic agents
  • Screening tests include: Ø BMI testing (every week)
    • Fasting glucose test (every 3-6 months)
    • Fasting lipids test (every 3-6 months)
    • Measure BP (every week)

 

Characterised by-

  • Abdominal obesity/BMI/waist measurements
  • rlevated triglycerides
  • High density cholesterol levels
  • rlevated fasting glucose
  • Hypertension rxacerbated by-   Increased sedation
  • Appetite stimulation
  • Thirst & hypersalivation
  • Negative symptoms
  • Poverty
  • Access to healthcare

 

SMOKING, CAFFEINE & PSYCHOTROPIC DRUGS 

  • Cigarette smoking significantly induces the metabolism of Clozapine & Olanzapine
  • Results in requiring higher doses of medication to achieve therapeutic effect
  • rxercise caution in smoking cessation while on Clozapine and Olanzapine

POTENTIAL SIDE EFFECTS 

  • Neuroleptic malignant syndrome (NMS)
    • Potentially lethal
    • More common in typical high potent antipsychotics (e.g. Haloperidol)
    • Usually occurs within one week of treatment
    • Symptoms: Hyperthermia (>42o)

Rigidity

Impaired ventilation

Tremor

Altered consciousness

Tachycardia

Death

 

  • Agranulocytosis
  • Extra pyramidal side effects (EPSE) Akathisia
    • Restless legs
    • ‘Jittery’ feelings
    • Nervous energy
    • Pacing, agitation

 

  • Pseudoparkinsonism
    • Blank mask-like presentation
    • Tremor in limbs
    • Muscle rigidity
    • Stiffness
    • Shuffling gait
    • Drooling

 

  • Acute dystonia’s
    • Oculogyric crisis (persons eyes roll up)
    • Neuroleptic induced torticollis (neck pain)

 

  • Tardive dyskinesia (TD)
    • Late occurring movement disorder
    • Can be irreversible

rmbarrassing & troublesome symptoms (tongue writhing, teeth grinding, lip smacking, spasm-like movements)