Mental Health Nursing: Psychotic Disorders

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Mental Health Nursing Psychotic Disorders

• By Mary B. Knutson, RN, MS, FCP

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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

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Behaviors in Schizophrenia

• Four As
• Associations (loose)
• Affect
• Ambivalence
• Autistic thinking
• Additional As
• Attention defects
• Disturbances of activity

Schizophrenia relates to split between
cognitive and emotional aspects of the personality
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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)

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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 ?

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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

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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

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• 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

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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

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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

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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

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What is Emotion?

• Mood- Affects the persons 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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 pts awareness (learn difference
  between the world of psychosis and the world of
  others)

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Psychopharmacology

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

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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
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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
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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
• Parkinsons syndrome- cogwheel rigidity, fine
  tremor, akinesia

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Tardive Dyskinesia

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

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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

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Anticholinergic Effects

• Constipation
• Dry mouth
• Blurred vision
• Orthostatic hypotension
• Tachycardia
• Urinary retention
• Nasal congestion

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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

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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

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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

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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?

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References

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