Psychosis is a condition affecting the way in which the brain processes information, causing loss of touch with reality. An individual with psychosis may see, hear, or believe things which are not real, to a point where it becomes hard to dissociate what is true from what is not. Psychosis symptoms include delusions, hallucinations, abnormal behaviour and incoherent speech.
Psychotic Episode Risk Factors
- Severe Stress
- Lack of Sleep
- Alcohol Abuse Withdrawal Symptoms
- Psychiatric Conditions – dementia, schizophrenia, severe depression, bipolar disorder
- Medical Conditions – brain tumor, lupus, stroke, syphilis (bacterial infection), HIV/AIDS, malaria
- Substance Abuse – alcohol, cocaine, ketamine, cannabis, LSD, amphetamines, magic (psilocybin) mushroom
Schizophrenia, Schizotypal and Delusional Disorder
Schizophrenia
Schizophrenia is a chronic severe mental disorder affecting 20 million individuals worldwide. It may affect educational and occupational performance due to its effect on perception, mood, thinking, behaviour and contact with reality.
Individuals with schizophrenia are unfortunately more prone to stigma, discrimination, and violation of human rights, and are up to 3 times more likely to die early than the majority of the population, often due to preventable diseases eg. infections, metabolic disease and cardiovascular disease.
Through appropriate medicinal treatment and psychosocial support, schizophrenia can be treated.
Epidemiology
- Negative symptoms onset tends to occur 5 years prior to the initial psychotic episode
- Children of individuals with schizophrenia tend to have lower IQ, poor attention skills, poor social adjustment, and symptoms related to thought disorder.
- Individuals with schizophrenia tend to differ from their peers in developmental markers throughout childhood, especially when it comes to developmental milestones, cognitive function levels, educational achievements, neurological and motor development, social competence and psychological disturbances.
Schizophrenia Risk Factors
- 40% increased risk if both parents have schizophrenia
- 10% increased risk if first-degree relative has schizophrenia
- 3% increased risk if second-degree relative has schizophrenia
- 10% increased risk if born in winter
- 2-4 times higher risk if living in urban areas
- having older parents
- having an over-protective dominant mother and an over-submissive father
- experiencing hostility between parents
- experiencing highly expressed emotions
- having an infection during the fetal development stage
- abnormalities in pregnancy and delivery
- 2nd trimester maternal influenza
- low birth weight
- fetal malnutrition
- use of cannabis (past or present)
NOTE: A stressful life event may serve as a precipitating factor for the onset of schizophrenia, usually happening about 3 weeks later.
The Dopamine Hypothesis of Schizophrenia
The dopamine hypothesis goes back to the 1960’s and 1970’s when studies involving amphetamine (which increases dopamine levels) showed an increase in psychotic symptoms, whilst reserpine (which depletes dopamine levels) showed a reduction in psychotic symptoms.
The original dopamine hypothesis stated that hyperactivity of dopamine resulted in symptoms of schizophrenia, and drugs that blocked dopamine reduced psychotic symptoms.
There is however little direct evidence that abnormal dopaminergic transmission causes schizophrenia.
The 3 Phases of Schizophrenia
Phase 1: PRODROMAL PHASE:
75% of individuals with schizophrenia experience the prodromal stage. Signs and symptoms experienced in this phase include:
- Decline in normal functioning precedes the 1st psychotic episode
- Social withdrawal
- Irritability
- Physical complaints
- Poverty of speech
- Peculiar behaviour
- Role functioning impairment
- Lack of initiative, interests or energy
- Personal hygiene and grooming impairment
- Unusual perceptions
- New interest in religion or the occult, odd beliefs or magical thinking
Management of the Prodromal Phase focuses on the prevention of psychological and social disruption that results from psychosis. Anti-depressants, anxiolytics and mood stabilisers help the individual to deal with the symptoms. Anti-psychotics should be prescribed and started early, since studies indicate better prognosis. Psychoeducation of the individual and main caregivers increase coping mechanisms in relation to dealing with schizophrenia, while education about coping strategies in relation to stress help as prophylaxis against impending psychosis. Observation and monitoring should be performed in frequent intervals.
Phase 2: PSYCHOTIC (ACUTE) PHASE:
- Positive symptoms
- Perceptual disturbances such as auditory hallucinations
- Delusions
- Disordered thought process
Auditory hallucinations, which are frequently experienced in schizophrenia, include simple noises, complex sounds, voices, music, single words, whole conversations, commands or running commentary.
Visual hallucinations rarely occur without other kinds of hallucinations, but are less frequent than auditory hallucinations.
Other type of hallucinations may be olfactory (smells that aren’t truly present), tactile (sensation of touch or movement on the skin or inside the body) or gustatory (taste).
Delusions may be classified as primary (occurring occasionally) or secondary (preceded by a hallucination). Persecutory Delusions are delusions in which the person thinks that people are trying to inflict harm; Delusions of Reference are delusions which hold direct reference to the person (eg. television program referring to the individual with schizophrenia); Delusions of Control are delusions in which the person feels or beliefs that he/she is being controlled by someone else; Delusions of Possession of Thought are delusions in which the person feels thoughts are being inflicted, withdrawn or forecast on him/her.
In Disorder of Thoughts, the person has difficulty dealing with abstract ideas, and may experience mystical ideas. The person also features loosening of association (where ideas seem confused), pressure of thought (rapid, abundant and varied thoughts), poverty of thought (slow, few and unvaried thoughts) and blocking of thoughts (where the mind seems to go blank).
Phase 3: RESIDUAL (CHRONIC) PHASE:
- Happens between psychotic episodes
- Features negative symptoms such as social withdrawal
- Odd thinking
- Odd behaviour
Negative symptoms include the flat effect, in which reduced expression of emotions on the face or voice can be noted; alogia (reduced speech), avolition (inability to start and sustain activities), anhedonia (inability to experience pleasure), asociality (social withdrawal) and being reluctant to perform daily tasks.
Diagnosis
Schizophrenia can be diagnosed by:
- taking a detailed history
- excluding other possible conditions
- excluding substance abuse and withdrawal
- noting positive, negative and cognitive symptoms
- noting that symptoms are experienced frequently
- noting impaired social and occupational functioning
- at least experienced for 1 month
Differential diagnosis include:
- F21: Schizotypal Disorder
- F22: Persistent Delusional Disorder
- F23: Acute Transient Psychotic Disorder
- F24: Induced Delusional Disorder
- F25: Schizoaffective Disorder
Schizophrenia Comorbidities
- Substance Abuse
- Smoking
- Violence
- Depression
- Anxiety
- Self-Harm
- Suicide
Schizophrenia, Schizotypal and Delusional Disorder ICD-10 Reference: https://icd.who.int/browse10/2016/en#/F20-F29
Drug-Induced Psychosis
Drug-induced psychosis refers to a psychotic episode which is directly related to abuse of an intoxicant, such as an illicit intoxicant, use of prescription medication without GP direction, or excessive use of alcohol or other legal substances.
Drug-induced psychosis happens when a person takes too much of a certain drug, or as an adverse reaction following the mixing of substances, or during drug withdrawal, or if the person has underlying mental health issues.
Drug detox can help reverse the effects of drug-induced psychosis.
Drug-Induced Psychosis ICD-10 Reference: https://www.icd10data.com/ICD10CM/Codes/F01-F99/F10-F19
Institutional Neurosis
Institutional Neurosis is a psychiatric disorder where a person assumes a dependent role and passively accepts a paternalist approach following long-time confinement in a hospital, mental hospital, prison, or such institutions.
In institutional neurosis, the person features signs of apathy, lack of initiative, loss of interest, submissiveness, and at times lack of emotional expression.
Psychosis Management
The APA Guidelines for Schizophrenia divide management in 3 phases:
- Acute Phase: treatment for acute psychotic episode lasting 4-8 weeks
- Stabilisation Phase: time-limited transition to continuing treatment lasting up to 3 months (in reality, sometimes this phase takes more than 3 months as many individuals with psychosis keep switching from the stabilisation phase to the stable phase over and over)
- Stable Phase: stable treatment
Psychosocial Interventions
- Individual Therapy
- Social Skills Training
- Family Therapy
- Vocational Rehab and Supported Employment
- Cognitive Behavioural Therapy
Electroconvulsive Therapy (ECT)
ElectroConvulsive Therapy (ECT) induces brain seizure and momentary unconsciousness; this method can be considered for treatment of resistant schizophrenia, such as in catatonic stupor (significantly decreased reactivity to environmental stimuli and events), worsening of symptoms regardless of medication, and in individuals exhibiting high risk of suicide, homicide or physical assault.
NOTE: In Malta this method is not used in the case of schizophrenia.
Psychopharmacology
All persons making use of anti-psychotics need to undergo ECG PR interval monitoring at least every 3 months since these medications may cause heart problems if used long term especially in high doses.
1st Generation Typical Anti-Psychotics eg. Haloperidol (seranace), Chlorpromazine (largactil) and Trifluoperazine (stelazine) act by inhibiting central dopaminergic neurotransmission, whilst producing antagonism at cholinergic, histamine and alpha receptors, causing extrapyramidal symptoms. These drugs may also be used for their sedative side-effects.
NOTE: In Malta, the use of Chlorpromazine (largactil) led to long-term psychotic patients to be finally discharged after many years in a mental health facility.
2nd Generation Atypical Anti-Psychotics eg. Clozapine (clozaril), Risperidone (risperdal), Quetiapine (seroquel), Olanzapine (zyprexa) and Aripriprazole (abilify) act on both dopamine and serotonin receptors. They are effective at dealing with both positive and negative symptoms, with a lower risk of extrapyrimidal effects.
Clozapine
Clozapine is only supplied upon prescription and blood results. Baseline blood tests that include full blood count, blood glucose, and liver function, as well as an ECG and weight, should be taken prior to administration of the drug.
Clozapine side effects include agranulocytosis (low number of granulocytes – type of white blood cells – in the blood) and extrapyramidal symptoms (EPS) such as tardive dyskinesia (involuntary neurological movement disorder), parkinsonism (a combination of movement abnormalities as seen in Parkinson’s disease such as tremor, slow movement, impaired speech or muscle stiffness) and dystonias (a movement disorder in which muscles contract involuntarily causing repetitive/twisting movements).
Clozapine administration requires monitoring for side-effects especially in the initiation phase, blood temperature monitoring, as well as weekly blood tests for WBC (number of white blood cells) for the first 18 weeks, every 2 weeks for the first year, followed by monthly testing.
Extrapyramidal Symptoms:
Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome is a life-threatening reaction to anti-psychotic drugs in which the person experiences fever, altered mental status, muscle rigidity, and autonomic dysfunction within hours or days of exposure to the drug. A patient with NMS may die within a few hours if untreated.
Psychosis Nursing Approach
- immediate goal as in all types of mental health problems is to prevent harm to self and others
- establish a therapeutic nurse-patient relationship
- notice signs or symptoms of hallucinations
- acknowledge that hallucinations and other positive symptoms may be true to the person but not true to others
- encourage the person to describe the positive symptoms being experienced, as well as related thoughts and feelings
- provide help in the development or maintenance of life skills
- offer support to the person and family/caregivers
Psychosis Nursing Care Plan
The following Psychosis Nursing Care Plan is based on the situation shown in the above video…
Immediate Goals
- establish a therapeutic nurse-patient relationship based on trust and understanding
- compile full history including current psychotic episode and any other similar episodes in the past
- compile a list of current medications and other comorbidities to ensure that therapy suggested is suitable for the person
- offer support to the person and his mother by providing information about the condition
- person should be prescribed anti-psychotics so as to tackle psychotic symptoms
- refer for psychological therapy such as CBT or Individual Therapy
- suggest Family Therapy if lack of understanding between the person and his mother is evident, so as to promote understanding and support within the family unit
- since the person feels safe at his parents’ house, it could be suggested that he moves back in with his parents for the time being until his condition is stabilised and under control; this could also mean that the person starts to eat well again as he may feel safer
Short Term Goals
- review situation and make adjustments to the plan accordingly
- review medication and see if any changes in dose or type of prescribed drugs need to be adjusted/changed, especially in the case of undesired side-effects
- educate about compliance to medication so as to avoid relapse as much as possible
- educate the person about the importance of continuing psychological therapy so coping techniques can be learned
- review food intake and fluid intake and ensure the person has started eating/drinking again
- teach the importance of keeping with follow-up appointments
Long Term Goals
- re-assess symptoms
- review medication and psychological therapy and their effectiveness
- consider change of treatment if need be
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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