Psychosis or Psychotic Disordersrepresent a group of serious, chronic and persistent brain disease. The group includes schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, and shared psychotic disorder. Schizophrenia is the most serious of them all. Psychotic disorders are characterized by five major problems, i.e. disorder of thought, disorder of perception, emotional difficulty, disorganized behavior, and impaired ability for relationships.

1. Disorder of Thought: Patients with psychosis may suffer from a disorder of thought. This problem is classified into disorder of thought content and disorder of thought content. Problems of thought content include various delusions such as paranoid, grandiose, religious, somatic, nihilistic, persecutory, thought broadcasting, thought insertion, thought control, hypochondriacal, erotomanic, and jealous delusions. Delusions are fixed false beliefs held by the patient. Paranoid patients believe there is someone out there persecuting or trying to do some harm to them. Grandiosity means the patient believes he has some special powers or possessions. In religious delusions, the patients may claim to be God. Delusion of thought broadcasting means the patient believes someone, or some media is broadcasting what is in his mind. The second aspect of thought disorder is disorder of thought process. This includes memory difficulty, attention difficulty, poor concentration, poor insight, poor judgment incoherence, circumstantiality (in a conversation, patient responds with various digressions before making his point), tangentiality (patient veers off completely with various digressions and never comes back to the original topic), and clanging (patient responds, using meaningless combination of words that rhyme together).

2. Disorder of Perception: This includes various hallucinations such as auditory hallucination (hearing sound or voice that does not exist), visual hallucination, olfactory hallucination (smelling odor that does not exist), gustatory hallucination (unreal taste), tactile hallucination (unreal touch such as a bug crawling on his skin), cenesthetic hallucination (feeling internal body functions such as urine forming in his kidneys), kinesthetic hallucination (feeling that his body or part of his body is moving while it is not), and command hallucination (hearing a voice commanding him to do something such as to kill himself or hit somebody).

3. Emotional Difficulty:The patient may experience a mood or affect disorder. Mood is the patient’s tone of feeling as expressed by the patient. Affect is the patient’s tone of feeling as observed by someone else, such as the nurse or therapist. Patient’s mood may be sad, depressed, alexithymic (inability to describe the mood), apathetic (lack of feeling or interest), anhedonic (inability to experience pleasure), anxious, or angry. The affect may be described as bizarre (e.g. grimacing, giggling, mumbling), blunted (i.e. minimal emotional response), flat (completely blank look), incongruent (inappropriate with reality, e.g. laughing while saying something sad), or labile (rapidly changing).

4. Disorganized Behavior.The patient may exhibit the following behavior: motor agitation e.g. running around, apraxia (difficulty with motor activity), echopraxia (imitation of the movements of someone else), echolalia (imitating what someone else says), waxy flexibility (prolonged maintenance of a posture), agitation and aggressive behavior, and stereotyped behavior (repeating  the same action over and over).

5. Impaired Ability for Relationships: The patient may exhibit withdrawal to himself or isolation. This may be due to delusions, hallucinations, apathy, anhedonia, deteriorating social skills, lowered self esteem, anxiety, stigma and sense of helplessness.

Classification of Symptoms:All the symptoms classified into the 5 categories above may actually be classified into 2 categories, i.e. positive and negative symptoms of psychosis. Positive symptoms include delusions, hallucinations, thought disorders, disorganized speech, bizarre behavior, and inappropriate affect. Negative symptoms include flat affect, anhedonia, apathy, attention deficit, social withdrawal, and poverty of speech.

Causes:There are various theories put forward to explain schizophrenia and other forms of psychosis. The genetic theory explains that 15-35% of schizophrenia is genetic. The neural theory says problems with the frontal, temporal and limbic regions of the brain are the cause. Some have implicated poor blood flow and metabolism in the frontal lobe. The must popular theory is that there is high Dopamine level in the synapses of the brain. Some say a low serotonin level causes the negative symptoms. Other theories are intrauterine neural damage, viral infection, psychosocial stressors, and multifactorial causes.

Schizophrenia:There are 5 types of schizophrenia: Paranoid, Disorganized, Catatonic, Undifferentiated, and Residual.

1. Paranoid Schizophrenia:Patients suffering from paranoid schizophrenia are usually suspicious and untrusting of everyone. They are on guard, hyperalert and hypervigilant. They use projection (blaming others) frequently. They can be argumentative, hostile and exhibit poor interpersonal relationships. They may experience delusions of persecution, grandeur, thought insertion, thought control, and thought broadcasting. Because of the delusions, suspicion and lack of trust, they may refuse food and medication. They may also suffer hallucinations. Therefore, there is a need for the care provider to first establish and maintain trust with the patient. Assess potential for violence, command hallucinations, suicidal and homicidal ideations. Encourage patient to discuss his feelings. Do not argue delusions because they, after all, false fixed beliefs. Be very cautious in using touch since this aggravates the anxiety of an already untrusting patient. Be nonjudgmental and respectful. Be honest and consistent. Use presence and silence in caring if patient is mute. Use brief, clear and concise statements in communicating with the patient. Always keep your promises to sustain trust. Explain planned care before you do it. Beware of your actions that may trigger or worsen the patient’s suspicion. Maintain a low level of stimuli. Avoid threatening environments. Avoid competitive and group activities. Assess for signs of anxiety and hostility. Provide verbal and physical limits when necessary. Let the patient know that you will not allow you him to hurt himself or others and if he becomes unable to control himself, you and others around will help him. You may initially have to offer foods in cans, containers, or skins if patient continuously refuses other foods because of mistrust. You may also have to initiate suicidal and homicidal precautions.

2. Disorganized Schizophrenia:This type of schizophrenia is characterized by the following disorganized speech and behavior. Disorganized speech includes: word salad, e.g. “Birds and fishes framewoes mud and stars and thump-bump going”; neologisms, e.g. “I want all the vetchkisses to leave the room and leave me alone”; echolalia; clanging, i.e. “Lack on the track in big Mac or get the sack”; and loose associations, e.g. “The world became embryonic and no talking in wet places”. Disorganized behavior includes: grimacing, incongruent affect, and bizarre behaviors. Delusions and hallucinations are minimal in disorganized schizophrenia.

3. Catatonic Schizophrenia:This is characterized by stupor, waxy flexibility (staying fixed and motionless in one position for a long time), agitation, negativism, mutism, posturing, stereotyped movements, grimaces, echolalia (repeating what someone says) and echopraxia (repeating what someone does).

4. Undifferentiated Schizophrenia:This has the combined features of catatonic, paranoid and disorganized schizophrenia. Delusions, hallucinations and bizarre behavior are present. No one clinical presentation dominates.

5. Residual Schizophrenia:The patient no longer has the active phase of any type of schizophrenia. However, some residual symptoms still persist. There may be some residual isolation, withdrawal, impairment in role function, eccentric behaviors, neglect of personal hygiene, apathy, and blunted affect.

6. Other Psychotic Disorders:The patient with Schizophreniform Disorder has fewer psychotic symptoms than schizophrenia. The patient with Schizoaffective Disorder has schizophrenia alternating with depression and manic behavior. The patient with Delusional Disorder experiences delusions that are relatively plausible and non-bizarre. A patient with Brief Psychotic disorder has psychotic symptoms lasting 1-30 days and returns to ‘normal’. A patient with Shared Psychotic Disorder shares a delusion with another delusional person.

Clinical Hints for Helping Patients with Psychosis:Listen actively to understand the patient. Teach patient to focus on the important. Teach patient to avoid noise and excessive stimulations. Give patient time to process information. Be clear and simple in your communication. Help patient with vocabulary as needed. Use literal meaning of words – no sarcasms, no metaphors, and no proverbs. Have patient repeat back your teaching, so you are sure there is no miscommunication. Help patient understand his or her illness. Help patients understand their medications. Help and teach patients to identify and prioritize their needs daily. Teach patient to rise and lie slowly in case spychotropic medications are causing hypotension that may trigger dizziness. Motivate the patient for medication adherence.

Treatment Modalities: Treatment modalities for psychoses include psychopharmacology, individual psychotherapy, group therapy, family therapy, milieu therapy, psychoeducation, psychiatric rehabilitation, and self help groups.

Antipsychotics: Typical (older) antipsychotics include haldol, thorazine, prolixin, trilafon, mellaril, navane, moban and stelazine. They block dopamine at mesolimbic pathways in the temporal lobes. Atypical (newer) antipsychotics include zyprexa, risperdol, abilify, and clozaril. In addition to blocking excess dopamine, they also block serotinin at mesocortical pathways in the frontal lobe. This makes atypical antipsychotic good with controlling both positive and negative symptoms. Patients taking Clozaril need frequent and regular blood checks because the medication can cause fatal agranulocytosis. Haldol and prolixin decanoate (given by injection every two weeks) are good for patients who are non-adherent with their medications. Encourage patients not to stop taking their medications simply because symptoms have subsided. Watch out for side effects of antipsychotics, e.g. extrapyramidal symptoms (EPS) such as dystonia, akathysia, tardive dyskenesia, neuroleptic malignant syndrome, and pseudoparkinsonism. Dystonias are spasms, stiffness and contractions of muscles especially of the face and neck. They can be painful and frightening to patient especially if airways are compromised.  Benadryl or cogentin are usually given to treat dystonias. Reassure the patient. Provide a quiet non-stimulating environment. Akathisia is restlessness, restless leg syndrome, and inability to sit still. It may make patient very anxious. Benadryl, cogentin, clonidine, propanolol, diazepam or lorazepam can be given. Dose of the antipsychotic might be reduced. Tardive Dyskinesia is a late occurring irreversible side-effect of antipsychotics. It manifests by abnormal involuntary movement e.g. tongue-thrusting, writhing of wrists, lip pursing, lip smacking, facial grimacing, and grunting. Teach patient to recognize and report early warning signs. Administer the Abnormal Involuntary Movement Scale (AIMS) every 6 months for early detection. Reduce antipsychotics or change from typical to atypical. Neuroleptic Malignant Syndrome (NMS) is a clinical emergency resulting from antipsychotics. It involves altered consciousness; unstable blood pressure, breathing and pulse rates; fever; lead pipe rigidity; diaphoresis; tremors; and drooling. Withhold the antipsychotic immediately and notify the prescriber. Care for the patient’s breathing, fever, anxiety, and hydration. Dantrolene or Bromocryptine may be prescribed. NMS is fatal in 15-20% cases. Pseudoparkinsonism involves muscle rigidity, slow movement, shuffling gate, tremors, masklike face, hypersalivation and drooling. Notify the prescriber of the antipsychotic. The dose may be reduced. Artane or cogenting may be ordered. Other side effects of antipsychotics are sedation, drowsiness, orthostatic hypotension, increased appetite, agranulocytosis (from clozaril), hyperglycemia, allergy, rash, and photosensitivity.

References:

Copstead, L. C., & Banasik, J. L. (2005).Pathophysiology(3rd ed.). St. Louis, MO: Elsevier   Saunders.

Stuart, G. W. & Laraia, M. T. (2005).Principles and practice of psychiatric nursing(8th ed.). St. Louis, MO: Elsevier Mosby.