Schizophrenia Spectrum and Other Psychotic Disorders

Question 1

Schizophrenia spectrum and other psychotic disorders

Answer 1

are complex disorders that affect a person’s thinking, language, emotions, social behaviour, and ability to perceive reality accurately. These disorders are characterized by psychosis, which refers to altered cognition, altered perception, and/or an impaired ability to determine what is or is not real.

Question 2

LEAP approach

Answer 2

• Listen—Both nurses listened with compassion and genuineness.
• Empathize—It is clear that both nurses were able to convey that
  they cared about understanding what Tammy was feeling.
• Agree—Both nurses believed in Tammy, affirmed that she was in- deed worried and struggling. They supported her in her goals, never looking down on her or judging her but helping her on her own
  road to recovery.
• Partner—Clearly, both nurses respected Tammy and worked with
  her as partners for recovery.

It consists of four steps: (1) listen—try to put yourself in the other person’s shoes to gain a clear idea of their experience; (2) empathize—seriously consider and empathize with the other person’s point of view; (3) agree—find common ground and identify facts you can both agree on; (4) partner— collaborate on accomplishing the agreed-upon goals (Amador, 2021). In this way, trust can be gained, and an alliance can be formed.

Question 3

There are five key features associated with psychotic disorders:

Answer 3

1. Delusions: Alterations in thought content (what a person thinks about). Delusions are false fixed beliefs that cannot be corrected by reasoning or evidence to the contrary. Beliefs maintained by one’s
   culture or subculture are not delusions.
2. Hallucinations: Perception of a sensory experience for which no
   external stimulus exists (e.g., hearing a voice when no one is speaking).
3. Disorganized thinking: The loosening of associations, manifested as jumbled and illogical speech and impaired reasoning.
4. Abnormal motor behaviour: Alterations in behaviour, including bizarre and agitated behaviours (e.g., stilted, rigid demeanor; eccen- tric dress, grooming, and rituals). Grossly disorganized behaviours may include mutism, stupor, or catatonic excitement.
5. Negative symptoms: The absence of something that should be present but is not, for example, the ability to make decisions or to follow through on a plan. Negative symptoms contribute to poor social functioning and social withdrawal.

Question 4

Dopamine theory.

Answer 4

The dopamine theory of schizophrenia is de- rived from the study of the action of the first antipsychotic medications, collectively known as conventional (or first-generation) antipsychotic medication (e.g., haloperidol and chlorpromazine). These medications block the activity of dopamine D2 receptors in the brain, limiting the activity of dopamine and reducing some of the symptoms of schizophrenia.

However, because the dopamine-blocking medications do not alleviate all symptoms of schizophrenia, it is recognized that other neurochemicals are involved in generating the symptoms of schizo- phrenia.

Amphetamines, cocaine, methylphenidate (Ritalin), and levodopa increase the activity of dopamine in the brain and, in biologi- cally susceptible people, may precipitate the onset of schizophrenia. If schizophrenia is already present, these substances may also exacerbate its symptoms. Almost any drug of abuse, particularly marijuana, can increase the risk for schizophrenia in biologically vulnerable individuals

Other neurochemical hypotheses.

A newer class of medications, collectively known as atypical (or second-generation) antipsychotic medications, block serotonin as well as dopamine, which suggests that serotonin may play a role in schizophrenia as well. A better under- standing of how atypical medications modulate the expression and targeting of 5-hydroxytryptamine 2A (5-HT2A) and its receptors would likely lead to a better understanding of schizophrenia.

Question 5

Course of the Disorder

Answer 5

The onset of symptoms or forewarning (prodromal) symptoms may appear a month to a year before the first psychotic break or full-blown manifestations of the illness; such symptoms represent a clear deterio- ration in previous functioning. The course of the disorder thereafter typically includes recurrent exacerbations separated by periods of re- duced or dormant symptoms. Some people will have a single episode of schizophrenia without recurrences or have several episodes and none thereafter.

In the prodromal phase complaints about anxiety, phobias, obses- sions, dissociative features, and compulsions may be noted. As anxiety increases, indications of a thought disorder become evident. Concen- tration, memory, and completion of school- or job-related work dete- riorate. Intrusive thoughts, “mind wandering,” and the need to devote more time to maintaining one’s thoughts are reported.

The person may feel that something “strange” or “wrong” is hap- pening. Events are misinterpreted, and mystical or symbolic meanings may be given to ordinary events. For example, the person may think that certain colours have special powers or that a song on the radio is a message from a higher being. Reducing misunderstandings and fear of schizophrenia can reduce stigma and support individuals living with this illness

Question 6

Phases of Schizophrenia

Answer 6

Schizophrenia usually progresses through predictable phases, although the presenting symptoms during a given phase and the length of the phase can vary widely. The phases of schizophrenia are (Chung et al., 2008):
* Phase I—Acute: Onset or exacerbation of florid, disruptive symp-
toms (hallucinations, delusions, apathy, withdrawal) with resultant loss of functional abilities; increased care or hospitalization may be required.

• Phase II—Stabilization: Symptoms are diminishing, and there is movement toward one’s previous level of functioning (baseline); day hospitalization or care in a residential crisis centre or a super- vised group home may be needed.
• Phase III—Maintenance: The person is at or nearing baseline (or premorbid) functioning; symptoms are absent or diminished; level of functioning allows the person to live in the community. Ideally, recovery with few or no residual symptoms has occurred. Most people in this phase live in their own residences. Although this phase has been termed maintenance, current literature shows a trend toward reframing it with a greater emphasis on recovery.

Question 7

Prognosis

Answer 7

An abrupt onset of symptoms is usually a favourable prognostic sign, and those with good premorbid social, sexual, and occupational func- tioning have a greater chance for a good remission or a complete recovery.

Some patients may require repeated or lengthy inpatient care or institutionalization as part of their treatment. Factors associated with a less positive prognosis include a slow onset (e.g., more than 2 to 3 years), younger age at onset, longer duration between first symptoms and first treatment, longer periods of untreated illness, and more nega- tive symptoms. A childhood history of withdrawn, reclusive, eccentric, and tense behaviour is also an unfavourable diagnostic sign, as is a preponderance of negative symptoms .

Question 8

Early Detection

Answer 8

Some clinicians suggest that there is an earlier prodromal (or pre- psychotic) phase, in which subtle symptoms or deficits associated with schizophrenia are present. Detection and treatment programs in most major Canadian cities aim to detect psychosis in the prodromal phase and prevent acute episodes of schizophrenia. Strategies of health promo- tion to improve outcomes, include reducing the duration of untreated psychosis, reducing delay in treatment, and providing early and appro- priate interventions adapted for younger people (adolescents) and their families during the early course of the illness (Abidi et al., 2017; Srihari et al., 2012). A list of Canadian programs can be found on the website of IEPA Early Intervention in Mental Health at https://iepa.org.au

Question 9

Assessment

Answer 9

Nursing assessment of people who have or may have a psychotic dis- order focuses largely on symptoms, coping, functioning, and safety. Assessment involves interviewing the person and observing behaviour and other outward manifestations of the disorder. It also should include mental status and spiritual assessments, cultural assessments, biologi- cal, psychological, social, and environmental elements.

Medical records and history from family are crucial.

Sound therapeutic communica- tion skills, an understanding of the disorder and the ways in which the person may be experiencing the world, and the establishment of trust and a therapeutic nurse–patient relationship all strengthen the assessment.

LEAP approach

Question 10

During the Pre-psychotic Phase

Answer 10

Experts believe that detection and treatment of symptoms that may warn of schizophrenia’s onset lessen the risk of developing the disorder or decrease the severity of the disorder if it does develop. Early and appropriate interventions can improve symptoms since one-third of all adults with schizophrenia have their onset before the age of 18 (Abidi et al., 2017). Further, recommendations for children and young people experiencing first episode psychosis, include offering antipsychotic medication in conjunction with psychological/psychosocial interventions

Therefore early assessment plays a key role in improving the progno- sis for persons living with schizophrenia (Lieberman et al., 2019). This form of primary prevention involves monitoring those at high risk (e.g., children of parents diagnosed with schizophrenia) for symptoms such as abnormal social development and cognitive dysfunction. Intervening to reduce stressors (i.e., reduce or avoid exposure to triggers), enhanc- ing social and coping skills (e.g., building resilience), and administering prophylactic antipsychotic medication may also be of benefit.

Similarly, in people who have already developed the disorder, mini- mizing the onset and duration of relapses is believed to improve the prognosis. Research suggests that with each relapse of psychosis, there is an increase in residual dysfunction and deterioration. Recognition and personal tracking of the individual early warning signs of relapse, such as reduced sleep and concentration, are important to prevention of relapse. Limiting stress in work, relationships, and social or envi- ronmental domains, as well as enlisting the support of friends or loved ones and increasing the frequency of professional supports for moni- toring and intensification of treatment, are essential. For this reason, for some, adherence to a medication regimen of antipsychotic medica- tion can be more important than the risk of adverse effects because most adverse effects are reversible, whereas the consequences of relapse may not be (Brown & Gray, 2015).

Question 11

General Assessment

Answer 11

1. Positive symptoms: the presence of something that is not normally
   present
2. Negative symptoms: the absence of something that should be present but is not
3. Cognitive symptoms: abnormalities in how a person thinks
4. Affective symptoms: symptoms involving emotions and their expression

Question 12

Positive symptoms.

Answer 12

The positive symptoms presented here are categorized as alterations in thinking, speech, perception, and behaviour.

Alterations in thinking. All people experience occasional and mo- mentary errors in thinking (e.g., “Why are all these lights turning red when I’m already late? Someone must be trying to slow me down!”), but most can catch and correct the error by using intact reality testing— the ability to determine accurately whether an experience is based in reality. People with impaired reality testing, however, maintain the error, which contributes to delusions, or alterations in thought content. A person experiencing delusions is convinced that what they believe to be real is real.

Concrete thinking refers to an impaired ability to think abstractly. The person interprets statements literally. For example, the nurse might ask what brought the person to the hospital, and the person might answer, concretely, “a bus” (rather than explaining that they had been hearing voices). Traditionally, concreteness has been assessed through the patient’s interpretation of proverbs. However, this assessment is not accurate if the person is from another culture or is otherwise unfamil- iar with the proverb (Haynes & Resnick, 1993). It is preferable to use the similarities test, which involves asking the person to explain how two things are similar—for example, an orange and an apple, a chair and a table, or a child and an adult. A description of physical characteristics (“apples and oranges are both round”) would be a concrete answer, whereas an abstract answer recognizes ideas such as classifications (“apples and oranges are fruit”). Concreteness reduces one’s ability to understand and address abstract concepts such as love or the pas- sage of time or to reality-test delusions or other symptoms. Educational strategies need to take into account a person’s ability to think abstractly.

Alterations in speech. Alterations in speech demonstrate difficul- ties with thought process (how a person thinks). Associations are the threads that tie one thought logically to another. In associative loose- ness these threads are interrupted or illogically connected; thinking becomes haphazard, illogical, and difficult to follow:
Nurse: “Are you going to the picnic today?”
Patient: “I’m not an elephant hunter; no tiger teeth for me.”
At times, the nurse may be able to decipher or decode the patient’s
messages and begin to understand the patient’s feelings and needs. Any exchange in which a person feels understood is useful. Therefore the nurse might respond to the patient in this way:
Nurse: “Are you saying that you’re afraid to go out with the others today?”
Patient: “Yeah, no tiger getting me today.”
Sometimes it is not possible to understand the person’s meaning because their speech is too fragmented. For example:
Patient: “I sang out for my mother … for this to school I went. These little hills hop aboard, share the Christmas mice spread … the elephant will be washed away.”
If the nurse does not understand what the patient is saying, it is important that they let the patient know this. Clear messages, com- munication, trust, and honesty are a vital part of working effectively in psychiatric mental health nursing. An honest response lets the person know that the nurse does not understand, would like to understand, and can be trusted to be honest.
Other alterations in speech that can make communication chal- lenging are circumstantiality, tangentiality, neologisms, echolalia, clang association, and word salad:
* Circumstantiality refers to the inclusion of unnecessary and of-
ten tedious details in one’s conversation (e.g., describing attending
group therapy when asked how the day is).
* Tangentiality is a departure from the main topic to talk about less
important information; the patient goes off on tangents in a way
that takes the conversation off-topic.
* Neologisms are made-up words (or idiosyncratic uses of existing
words) that have meaning for the person but a different or nonexis- tent meaning to others (e.g., “I was going to tell him the mannerolo- gies of his hospitality won’t do”). This eccentric use of words repre- sents disorganized thinking and interferes with communication.
* Echolalia is the pathological repeating of another’s words and is often seen in catatonia.
Nurse: “Rowan, come get your medication.”
Rowan: “Come get your medication.”
* Clang association is the choosing of words based on their sound rather than their meaning, often rhyming and sometimes having a similar beginning sound (e.g., “On the track, have a Big Mac,” “Click, clack, clutch, close”). Clanging may also be seen in neuro- logical disorders.
* Word salad is a jumble of words that is meaningless to the listener— and perhaps to the speaker as well—because of an extreme level of disorganization.

Alterations in perception. Alterations in perception are errors in one’s view of reality. The most common form of altered perception in psychosis are hallucinations, but depersonalization, derealization, and boundary impairment are sometimes experienced as well:
* Depersonalization is a nonspecific feeling that a person has lost
their identity and that the self is different or unreal. People may feel that body parts do not belong to them or may sense that their body has drastically changed. For example, a person may see their fingers as snakes or arms as rotting wood.
* Derealization is the false perception that the environment has changed. For example, everything seems bigger or smaller, or familiar surroundings have become somehow strange and unfamiliar. Both depersonalization and derealization can be interpreted as loss of ego boundaries (sometimes called loose ego boundaries).
* Boundary impairment is an impaired ability to sense where one’s self ends and others’ selves begin. For example, a person might drink another’s beverage, believing that because it is in their vicinity, it is theirs.
* Hallucinations result from perceiving a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking).
* Hallucinations differ from illusions in that illusions are mispercep- tions or misinterpretations of a real experience; for example, a per- son sees their coat on a coat rack and believes it is a bear about to attack. They see something real but misinterprets what it is.
Causes of hallucinations include psychiatric disorders, substance use, medications, organic disorders, hyperthermia, toxicity (e.g., digitalis), and other conditions. Hallucinations can involve any of the five body senses.
Command hallucinations are “voices” that direct the person to take an action. All hallucinations must be assessed and monitored carefully because the voices may command the person to hurt self or others. For example, voices might command a person to “use a weapon or method to harm themselves” or “use a weapon or method to harm someone else.” Command hallucinations are often terrifying and may herald a psychiatric emergency.

Question 13

Alterations in behaviour.

Answer 13

Alterations in behaviour include bizarre and agitated behaviours involving such things as stilted, rigid demean- or or eccentric dress, grooming, and rituals. Other behavioural changes seen in schizophrenia include:

• Catatonia, a pronounced increase or decrease in the rate and
  amount of movement. The most common form is stuporous behav-
  iour, in which the person moves little or not at all.
• Psychomotor retardation, a pronounced slowing of movement. It is important to differentiate the slowed movements secondary to schizophrenia from those seen in depression; careful assessment of thought content and thought processes is essential for making this
  determination.
• Psychomotor agitation, excited behaviour such as running or pac-
  ing rapidly, often in response to internal or external stimuli. Psycho- motor agitation can pose a risk to others and to the person, who is at risk for exhaustion, collapse, and even death.
• Stereotyped behaviours, repeated motor behaviours that do not presently serve a logical purpose.
• Automatic obedience, the performance by a catatonic person of all simple commands in a robot-like fashion.
• Waxy flexibility, the extended maintenance of posture usually seen in catatonia. For example, the nurse raises the person’s arm, and the person retains this position in a statue-like manner.

*Negativism, akin to resistance but may not be intentional. In active negativism the person does the opposite of what they are told to do; passive negativism is a failure to do what is requested.
* Impaired impulse control, a reduced ability to resist one’s impuls- es. Examples include performing socially inappropriate behaviours such as grabbing another’s cigarette, throwing food on the floor, and changing TV channels while others are watching.
* Echopraxia, the mimicking of the movements of another. It is also seen in catatonia.

Question 14

Hallucinations

Answer 14

Auditory
Hearing voices or sounds that do not exist in the environment
Juan is alone in his room and is heard yelling. When staff arrive in his room, Juan tells them that he is hearing an angry voice.

Visual
Seeing a person, object, animal, colours, or visual patterns that do not exist in the environment
Antonia became frightened and screamed, “There are rats coming at me!”

Olfactory
Smelling odours that do not exist in the environment
Theresa “smells” their insides rotting.

Gustatory
Tasting sensations that do not exist
Simon will not eat his food because he “tastes” the poison they are putting in it.

Tactile
Feeling strange sensations on the skin where no external objects stimulate such feelings; common in delirium tremens (DTs)
Jack “feels” bugs on/under skin.

Question 15

Positive Symptoms

Answer 15

Hallucinations

Delusions

Disorganized speech
(associative looseness)

Bizarre behaviour

Question 16

Negative Symptoms

Answer 16

• Blunted affect
• Poverty of thought (alogia)
• Loss of motivation (avolition)
• Inability to experience pleasure
  or joy (anhedonia)

Question 17

Affective Symptoms

Answer 17

• Dysphoria
• Suicidality
• Hopelessness

Question 18

Cognitive Symptoms

Answer 18

• Inattention, distractibility
• Impaired memory
• Poor problem-solving skills * Poor decision-making skills * Illogical thinking
• Impaired judgement

Question 19

All dimensions alter the individual’s:

Fig. 15.1 The four main symptom groups of schizophrenia.

Answer 19

• Ability to work
• Interpersonal relationships * Self-care abilities
• Social functioning
• Quality of life

Question 20

Delusions

Answer 20

Thought insertion
Believing that another person, group of people, or external force controls thoughts
Bruce explains he always wears a hat so that aliens don’t insert thoughts into his brain.

Thought withdrawal
Believing that others are taking thoughts out of a person’s mind
Bernadette explains she covers her windows with foil so the police can’t empty her mind.

Thought broadcasting
Believing that one’s thoughts are being involuntarily broadcasted to others
Marcel was convinced that everyone could hear what he was thinking at all times.

Ideas of reference
Giving personal significance to trivial events; perceiving events as relating to you when they do not
When Maria noticed staff talking, she believed they were plotting against her.

Ideas of influence
Believing that you have somehow influenced events that are, in fact, out of your control
Jean Pierre is convinced they caused the flooding in Manitoba.

Persecution
Believing that one is being singled out for harm by others; this belief often takes the form of a plot by people in power
Saied believed that the Royal Canadian Mounted Police were planning to kill him by poisoning his food. Therefore he would eat only food he bought from machines.

Grandeur
Believing that one is a very powerful or important person
Sam believed they were a famous playwright and tennis pro.

Somatic
Believing that the body is changing in an unusual way (e.g., rotting inside)
David told the physician that his heart had stopped, and his insides were rotting away.

Erotomanic
Believing that another person desires you romantically
Although she barely knew her, Millie insisted that Justine would marry her if only her current wife would stop interfering.

Jealousy
Believing that one’s mate is unfaithful
Harry wrongly accused his girlfriend of going out with other men. His proof was that she came home from work late twice that week, even though the girlfriend’s boss explained that everyone had worked late.

Question 21

Negative symptoms.

Answer 21

Negative symptoms develop slowly and are
those that most interfere with a person’s adjustment and ability to cope. They tend to be persistent and crippling because they render the per- son inert and unmotivated. Negative symptoms impede one’s ability to:
* Initiate and maintain conversations and relationships
* Obtain and maintain a job
* Make decisions and follow through on plans
* Maintain adequate hygiene and grooming
Negative symptoms contribute to poor social functioning and social withdrawal. During the acute phase, they are difficult to assess because positive symptoms (such as delusions and hallucinations) dominate.

• Flat—immobile or blank facial expression
• Blunted—reduced or minimal emotional response
• Inappropriate—emotional response incongruent with the tone or
  circumstances of the situation (e.g., a patient laughs when told a
  family member has died)
• Bizarre—odd, illogical, emotional state that is grossly inappropriate
  or unfounded; especially prominent in disorganized schizophrenia and includes grimacing and giggling

Question 22

Cognitive symptoms.

Answer 22

They include difficulty with attention, memory, information processing, cognitive flexibility, and executive functions (e.g., decision making, judgement, planning, problem solving)

Concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. For example, a nurse might ask how the patient found the relaxation class, and the patient answers “by walking down the hall” rather than describing their experience of the class. An abstract interpretation of “The grass is always greener on the other side of the fence” is that it always seems we would be happier given other circumstances. A concrete interpretation could be “That side gets more sun, so it’s greener there.” Concreteness reduces one’s ability to understand and respond to concepts requiring abstract reasoning, such as love or humour.

Impaired memory affects short-term memory and the ability to learn. Repetition and verbal or visual cues may help the patient to learn and recall needed information (e.g., a picture of a toothbrush on the patient’s wall and/or mirror as a reminder to brush their teeth).

Impaired information processing can lead to problems such as de- layed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in one’s peripheral vision. This can lead to overstimulation.

Impaired executive functioning includes difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipation and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inappropriateness in social situations.

These impairments have a considerable impact on longer-term functioning and can leave the person unable to manage personal health care, hold a job, initiate or maintain a support system, or live alone. Some psychosocial treatments, including cognitive behavioural therapy (CBT), cognitive remediation, social skills training, and com- puter-assisted training programs, have shown therapeutic benefits and should be offered in conjunction with antipsychotic medications (Carbon & Correll, 2014).

Question 23

Selected Negative Symptoms of Schizophrenia

Answer 23

Affective blunting
A reduction in the expression, range, and intensity of affect (in flat affect, no facial expression is present)

Anergia
Lack of energy; passivity or lack of persistence at work or school; may also be a symptom of depression, so needs careful evaluation

Anhedonia
Inability to experience pleasure in activities that usually produce it; result of profound emotional barrenness

Avolition
Reduced motivation; inability to initiate tasks such as social contacts, grooming, and other activities of daily living (ADLs)

Poverty of content of speech
While adequate in amount, speech conveys little information because of vagueness or superficiality

Poverty of speech (alogia)
Reduced amount of speech—responses range from brief to one-word answers

Question 24

Affective symptoms.

Answer 24

These involve the experience and expression of emotions. Mood may be unstable, erratic, labile (changing rapidly and easily), or incongruent (not what would be expected for the circumstances).
A serious affective change often seen in schizophrenia is depression. Depression may occur as part of a shared inflammatory reaction affect- ing the brain or may simply be a reaction to the stress and despair that can come from living with a chronic illness. Assessment for depression is crucial because it may indicate an impending relapse, further im- pair functioning, and increase risk for substance use disorders.

Question 25

Self assessment

Answer 25

Building personal resilience has been identi- fied as an essential strategy for coping with work-related stress and responding to and overcoming experiences of workplace adversity.

eople living with schizophrenia may experience fear, self-stigma, or shame related to their mental illness, leading them to conceal some aspects of their experience. Negativism and alogia (reduced verbaliza- tion) can also limit the person’s responses. Many people living with schizophrenia can experience anosognosia, an inability to realize that they are ill, which is caused by the illness itself. The resulting lack of in- sight can make assessment (and treatment) challenging, delaying com- pletion of a full assessment, and requiring additional skills on the part of the nurse.

Question 26

Interventions

Answer 26

Use empathic comments and observations to prompt the patient to provide information.
Empathy conveys understanding and builds trust and rapport.
Nurse: “It must be difficult to be admitted to a psychiatric unit. We are here to help and keep you safe.”
Patient: “Yes … it has been difficult, I am scared of being away from home, and I worry that people are going to harm me”

Minimize questioning, especially closed-ended questioning.
Seek data conversationally, using prompts and open-ended questions.
Extended questioning can increase suspiciousness, whereas closed-ended questions elicit minimal information. Both become wearying and off-putting.
“Could you please tell me more about … ?” “Tell me what life has been like for you lately.”

Use short, simple sentences and introduce only one idea at a time. Allow time for responses to questions.
Long sentences or rambling questions can confuse a person who has difficulty processing auditory information or is actively hallucinating. Also, a person with alogia requires more time to respond to questions.
Therapeutic: “Would you like to join us for a basketball game?” Nontherapeutic: “Would you like to join us for a
basketball game? Sports can be very good for you, you know, and you seem very lonely, so it would help you a lot. I really hope you will come play a game.”

Directly but supportively seek the needed information, explaining the reasons for the assessment.
Being direct but supportive conveys genuineness, builds rapport, and helps reduce anxiety.
“I have noticed that you are not participating in group therapy or socializing with your peers like you have been previously. Has something happened? I am here to support you.”

Judiciously use indirect, supportive (therapeutic) confrontation.

Seek other data to support (validate) the person’s report (obtain further history from third parties, past medical records, and other treatment providers when possible), preferably with the person’s permission.
Blunt contradiction or premature confrontation increases resistance.
Patients may be unable or unwilling to provide information fully and reliably.
Validating their reports ensures the validity of the assessment.
“I realize that admitting to hearing voices might be difficult to do. I notice you talking as if to others when no one is there.”
“Your brother reports that he works at a factory. Is that your understanding?”

Prioritize the data you seek, and avoid seeking nonessential data.
Patients may have limited tolerance for the assessment interview and answer only a limited number of inquiries.
Seeking nonessential information does not benefit the person or assessment.
Patient: “Sometimes when I feel anxious, I take extra medication to fall asleep.”
Nurse: (less therapeutic) “Why do you take extra medication?”
Nurse: (more therapeutic) “Can you tell me more about taking extra medication when you are anxious.” (Paraphrasing prompts elaboration and confirmation or refutation of the comment.)

Question 27

Assessment guide

Answer 27

1. Assess for risk to self or others.
2. Assess for suicide risk (see Chapter 22).
3. Assess for command hallucinations (e.g., voices telling the patient to harm
   self or others). If present, ask the person:
   * Do you recognize the voices?
4. Do you believe the voices are real? Do you plan to follow the command? (A posi-
   tive response to any of these questions suggests an increased risk that the person will act on the commands). Assess for ability to ensure self-safety, addressing:
   * Adequacy of food and fluid intake
   * Hygiene and self-care
   * Handling of potentially hazardous activities, such as smoking and cooking
   * Ability to transport self safely
   * Impulse control and judgement
   * Appropriate dress for weather conditions. Assess whether the person
   abuses or is dependent on alcohol or substances. Assess the patient’s be- lief system. Is it fragmented or poorly organized? Is it systematized? Are the beliefs or content delusions? If yes, then ask:
   * Do you feel that you or your loved ones are being threatened or are in danger?
   * Do you feel the need to act against a person or organization to protect or avenge yourself or your loved ones? (A positive response to either of these questions suggests an increased risk of danger to others.)
5. Assess for the presence and severity of positive and negative symptoms. Complete a mental status examination, noting which symptoms are present, how they affect functioning, and how the patient is managing them.
6. Assess the patient’s insight, knowledge of the illness, relationships and support systems, other coping resources, and strengths.
7. Determine if the patient has had a medical workup. Are there any indica- tions of physical and/or medical problems that might mimic psychosis (e.g., digitalis or anticholinergic [ACh] toxicity, brain trauma, drug intoxication, delirium, fever)?
8. Assess for coexisting disorders: * Depression
   * Anxiety
   * Mood disorders
   * Substance use disorders or dependency
   * Medical disorders (especially brain trauma, toxicity, delirium, cardiovas-
   cular disease, obesity, and diabetes)
9. Assess medications the patient has been prescribed, whether and how the
   patient is taking the medications, and what factors (e.g., costs, mistrust of
   staff, adverse effects) are affecting adherence.
10. Assess the family’s knowledge of and response to the patient’s illness and
    its symptoms. Are family members overprotective? Hostile? Anxious? Are they familiar with family support groups and respite resources?

Question 28

OUTCOMES IDENTIFICATION

Answer 28

Outcomes should be con- sistent with the recovery model (see Chapter 29), which stresses hope, living a full and productive life, and eventual recovery rather than focusing on controlling symptoms and adapting to disability.

Phase I—Acute
During the acute phase, the overall goal is the person’s safety and medi- cal stabilization. Therefore if the person is at risk for violence to self or others, initial outcome criteria address safety issues (e.g., Person re- frains from self-harm). Table 15.6 gives selected short-term and inter- mediate indicators for the outcome Distorted thought self-control.

Phase II—Stabilization
Outcome criteria during phase II focus on helping the patient adhere to treatment, become stabilized on medications, and control or cope with symptoms. The outcomes target the negative symptoms and may include ability to succeed in social, vocational, or self-care activities.

Phase III—Maintenance
Outcome criteria for phase III focus on maintaining achievement, pre- venting relapse, and achieving independence and a satisfactory quality of life.

Question 29

PLANNING

Answer 29

Phase I—Acute
Hospitalization is indicated if the patient is considered a danger to self or others, refuses to eat or drink, or is too disorganized or otherwise impaired to function safely in the community without supervision. The planning process focuses on the best strategies to ensure the person’s safety and provide symptom stabilization. In addition, during the pa- tient’s hospitalization, this process includes discharge planning.

Phase II—Stabilization and Phase III—Maintenance
Planning during the stabilization and maintenance phases includes providing individual and family education and skills training (psycho- social education). Relapse prevention skills are vital. Planning identifies interpersonal, coping, health care, and vocational needs and addresses how and where these needs can best be met within the community.

Question 30

IMPLEMENTATION

Answer 30

Interventions are geared toward the phase of schizophrenia the person is experiencing. For example, during the acute phase, the clinical focus is on crisis intervention, medication for symptom stabilization, and safety. Interventions are often hospital based; however, people in the acute stage are increasingly being treated in the community.

Phase I—Acute
Settings
A number of factors affect the choice of treatment setting, including:
* Level of care and restrictiveness needed to protect the person from
harm to self or others
* Person’s need for external structure and support
* Person’s ability to cooperate with treatment
* Need for a particular treatment available only in particular settings
* Need for treatment of a coexisting medical condition
* Availability of supportive others who can provide critical informa-
tion and treatment history to staff and permit stabilization in less restrictive settings
The use of less restrictive and more cost-effective alternatives to
hospitalization that work for many people include:
* Partial hospitalization: Patients sleep at home and attend treat-
ment sessions (similar to what they would receive if admitted) dur-
ing the day or evening.
* Residential crisis centres: Patients who are unable to remain in the
community but do not require full in-person services can be admit- ted (usually for 1 to 14 days) to receive increased supervision, guid- ance, and medication stabilization.
* Group homes: Patients live in the community with a group of other people, sharing expenses and responsibilities. Staff are present in the house 24 hours a day, 7 days a week to provide supervision and therapeutic activities.
* Day treatment programs: Patients reside in the community and attend structured programming during the day.
These programs may include group and individual therapy, su-
pervised activities, and specialized skill training. It is vital that staff be aware of these and other community resources and make this in- formation available to discharged people and their families, ideally by directly connecting them with these resources. Patients and fam- ily members should be given telephone numbers and addresses of local support groups such as their provincial Schizophrenia Society. Northern and rural communities, however, may not have local sup- port groups. It is critical for staff in these areas to review services that are available for patients and/or advocate for increased services. Other community resources include community mental health centres (usu- ally providing medication services, day treatment, access to 24-hour emergency services, psychotherapy, psychoeducation, and case man- agement); home health services; supported employment programs, of- fering services from job training to on-site coaches, who help people learn to succeed in the work environment, often via peer-led services (e.g., drop-in centres, sometimes called “clubhouses,” that offer social contact, constructive activities, and sometimes employment opportu- nities); family educational and skills groups (e.g., Schizophrenia Soci- ety of Canada’s “Strengthening Families Together” program); and respite care for caregivers.
Interventions
Acute phase interventions include:
* Psychiatric, medical, and neurological evaluation * Psychopharmacological treatment
* Support, psychoeducation, and guidance
* Supervision and limit setting in the milieu

Phase II—Stabilization and Phase III—Maintenance
Effective long-term care of an individual with schizophrenia relies on a three-pronged approach: medication administration and adherence, nursing intervention, and community support. Family psychoeduca- tion, a key role of the nurse, is an essential intervention. All interven- tions and strategies are geared to the patient’s strengths, culture, per- sonal preferences, and needs.
Milieu Management
Effective hospital care provides (1) protection from stressful or dis- ruptive environments and (2) structure. People in the acute phase of schizophrenia show greater improvement in a structured milieu rather than on an open unit that allows for increased stimulation. A thera- peutic milieu is consciously designed to maximize safety, opportunities for learning skills, therapeutic activities, and access to resources. The milieu also provides guidance, supportive staff and peer contact, and opportunities for practicing conflict resolution, stress-reduction tech- niques, and dealing with symptoms.

Activities and Groups
Participation in activities and groups appropriate to the patient’s level of functioning may decrease withdrawal, enhance motivation, modi- fy unacceptable behaviours, develop friendships, and increase social competence. Activities such as drawing, reading poetry, and listening to music may be used to focus conversation and promote the recog- nition and expression of feelings. Self-esteem is enhanced as patients experience successful task completion. Recreational activities such as picnics and outings to stores and restaurants are not simply diversions; they teach constructive leisure skills, increase social comfort, facili- tate growth in social concern and interactional skills, and enhance the ability to develop boundaries and set limits on self and others. After discharge, group therapy can provide necessary structure within the patient’s community milieu.
Safety
A small percentage of people living with schizophrenia, especially dur- ing the acute phase, may exhibit a risk for physical violence. Several in- terrelated risk factors, including demographics (i.e., age, marital status, gender) and social factors (i.e., homelessness, limited education, his- tory of maltreatment or criminality), presence of persecutory delusions or command hallucinations, comorbid antisocial personality patholo- gy, concurrent substance use, inadequate insight, treatment nonadher- ence, and physiological factors, increase the risk for violence in patients with psychosis. Nonadherence to treatment is a key risk factor predict- ing violence in patients with psychosis

Question 31

Counselling and Communication Techniques

Answer 31

Therapeutic communication techniques for patients with schizophre- nia aim to lower the person’s anxiety, build trust, encourage clear com- munication, decrease defensiveness, encourage interaction, enhance self-esteem, and reinforce skills such as reality testing and assertive- ness. It is important to remember that people living with schizophrenia may have memory impairment and require repetition. They may also have limited tolerance for interaction, owing to the stimulation it cre- ates. Therefore shorter (<30 minutes) but more frequent interactions may be more therapeutic. Interventions for paranoia and other selected presentations are discussed later in this chapter.
Hallucinations
When a patient is experiencing a hallucination, the nursing focus is on understanding the person’s experiences and responses. Suicidal or homicidal themes or commands necessitate appropriate safety mea- sures. For example, “voices” that tell a patient a particular individual plans to harm them may lead to aggressive actions against that person; one-to-one supervision of the patient or transfer of the potential victim to another unit is often essential.

Delusions
Delusions may be the patient’s attempts to understand confusion and distorted experiences. They reflect the misperception of one’s circum- stances, which go uncorrected in schizophrenia due to impaired real- ity testing. When, as a nurse, you attempt to see the world through the eyes of the patient, it is easier to understand their experience. For example:
Patient: “You people are all alike … all in on the RCMP plot to destroy me.”
Nurse: “Quinn, I am a nurse, I am not going to harm you, you are safe with me. Thinking that people are plotting to destroy you must be very frightening.”
In this example the nurse acknowledges the patient’s experience, conveys empathy about the patient’s fearfulness, and avoids focusing on the content of the delusion, but identifies the patient’s feelings so they can be explored, as tolerated. Note that talking about the feelings is helpful, but extended focus on delusional material is not.
It is never useful to debate or attempt to dissuade the patient regard- ing the delusion. Doing so can intensify the patient’s retention of irra- tional beliefs and cause them to view you as rejecting or oppositional. However, it is helpful to clarify misinterpretations of the environment and gently suggest, as tolerated, a more reality-based perspective. For example:
Patient: “I see the doctor is here; he is out to destroy me.”
Nurse: “It is true the doctor is here. He does patient rounds every morning at 9:00 a.m. He will talk to you about how you are feeling and your treatment. Would you feel more comfortable talking to
him in the day room?”
Focusing on specific reality-based activities and events in the envi- ronment helps to minimize the focus on delusional thoughts. The more time the patient spends engaged in activities or with people, the more opportunities there are to receive feedback about and become comfort- able with reality.

Associative Looseness
Associative looseness often mirrors the person’s abnormal thoughts and reflects poorly organized thinking. An increase in associative looseness often indicates that the person is feeling increased anxiety or is overwhelmed by internal and external stimuli. The person’s speech may also produce confusion and frustration in the nurse. The follow- ing guidelines are useful for intervention with a patient whose speech is confused and disorganized:
* Do not pretend you understand the patient’s words or meaning when you do not; tell the person you are having difficulty understanding.
* Place the difficulty in understanding on yourself, not on the patient. Example: “I’m having trouble following what you are saying,” not “You’re not making any sense.”
* Look for recurring topics and themes in the patient’s communica- tions, and tie these to events and timelines. Example: “You’ve men- tioned trouble with your family several times, usually after visits. Can you tell me about your family and your visits with them?”
* Summarize or paraphrase the patient’s communications to role- model more effective ways of making their point and to give the person a chance to correct anything you may have misunderstood.
* Reduce stimuli in the vicinity, and speak concisely, clearly, and con- cretely.
* Tell the person what you do understand, and reinforce clear commu- nication and accurate expression of needs, feelings, and thoughts.

Question 32

Health Teaching and Health Promotion

Answer 32

Education is an essential strategy and includes teaching the patient and family about illness, including possible causes, treatment plans, medications and medication adverse effects, coping strategies, what to expect, and prevention of relapse. Understanding these things helps the patient and family to recognize the impact of stress, enhances their understanding of the importance of treatment to a good outcome, en- courages involvement in (and support of) therapeutic activities, and identifies resources for consultation and ongoing support throughout the illness.
Including family members in any strategies aimed at reducing symptoms of psychosis reduces family anxiety and distress and enables the family to reinforce the healthcare providers’ efforts. The family plays an important role in the stability of the patient. The patient who returns to a warm, concerned, and supportive environment is less like- ly to experience relapse. An environment in which people are critical or their involvement in the patient’s life is intrusive is associated with relapse and poorer outcomes.

Lack of understanding of the disease and its symptoms can lead others to misinterpret the patient’s apathy and lack of drive as “lazi- ness,” fostering a potential hostile response by family members, caregiv- ers, or community. Thus, public education/health teaching about the symptoms of schizophrenia can reduce tensions in families, as well as in communities. The most effective education occurs over time and is available when the family is most receptive (Brady et al., 2017). Patient and Family Teaching: Schizophrenia offers guidelines for patient and family teaching about schizophrenia.

1. Learn all you can about the illness.
   * Attend psychoeducational and support groups.
   * Join the National Network for Mental Health (https://nnmh.ca/).
   * Contact your provincial/regional Schizophrenia Society.
2. Develop a relapse prevention plan.
   * Know the early warning signs of relapse (e.g., isolation, difficulty sleep-
   ing, troubling/intrusive thoughts).
   * Know who to call, what to do, and where to go when early signs of
   relapse appear. Make a list and keep it with you.
   * Understand that relapse is part of illness, not a sign of failure.
3. Take advantage of all psychoeducational tools.
   * Participate in family, group, and individual therapy.
   * Learn new ways to act and coping skills to help handle family, work, and
   social stress. Get information from your nurse, case manager, physician,
   self-help group, community mental health group, or hospital.
   * Have a documented plan, of what to do to cope during stressful times.
   * Recognize that everyone needs a place to address their fears and losses
   and to learn new ways of coping. 4. Adhere to treatment.
   * People who adhere to treatment that works for them do the best in cop- ing with the disorder.
   * Engaging in struggles over adherence does not help but tying adherence to the patient’s own goals does. (“Staying in treatment will help you keep your job and avoid trouble with the police.”)
   * Share any medication side effects or concerns (e.g., sexual problems, weight gain, “feeling funny”) with your nurse, case manager, physician, or social worker; most side effects can be helped.
   * Discontinuing medication treatment suddenly can be dangerous and symptoms can re-emerge.
4. Avoid alcohol and illicit substances; they can act on the brain and cause a relapse.
5. Keep in touch with supportive people—those with shared patient and fam- ily experiences and others.
6. Maintain healthy lifestyle and balance.
   * Taking care of one’s diet, health, and hygiene helps prevent medical
   illnesses.
   * Maintain a regular sleep pattern.
   * Keep active (hobbies, friends, groups, sports, job, special interests).
   * Nurture yourself, and practice stress-reduction activities daily.
   * Mindfulness

Question 33

Pharmacological Interventions

Answer 33

Two groups of antipsychotic medications exist: conventional antipsychotic medications (traditional dopamine antagonists [dopa- mine D2 receptor antagonists]), also known as typical or first-generation antipsychotic medications, and atypical antipsychotic medications (se- rotonin–dopamine antagonists [5-HT2A receptor antagonists]), also known as second-generation antipsychotic medications. A “third gen- eration” of medications (aripiprazole and brexpiprazole [Rexulti]) give hope for enhanced effectiveness and adverse-effect reduction (Howland, 2015). Other medications, such as anticonvulsants and antiparkinsoninal medications, are also used to augment antipsychotic medications.

Antipsychotic medications are effective for most exacerbations of schizophrenia and for reduction or mitigation of relapse. Conventional antipsychotic medications primarily affect the positive symptoms of schizo- phrenia (e.g., hallucinations, delusions, disordered thinking). Atypical antipsychotic medications can improve negative symptoms (e.g., asocial- ity, blunted affect, lack of motivation) as well. The choice of antipsychotic medication should be made by both the patient and physician together, after the review of benefits and adverse effects

Evidence suggests medications should be trialed between 4 and 6 weeks for efficacy.

Question 34

Atypical Antipsychotic Medication

Answer 34

Atypical antipsychotic medication first emerged in the early 1990s with clozapine (Clozaril). Unfortunately, clozap- ine produces agranulocytosis in 0.8% to 1% of those who take it and also increases the risk for seizures. Due to the risk for agranulocytosis, people taking clozapine must have weekly white blood cell counts for the first 6 months, then frequent monitoring thereafter, to obtain the medication. As a result of nonadherence, clozapine use is declining.

Atypical medications are often discussed with patients as a potential first choice because they treat both the positive and the negative symp- toms of schizophrenia. Furthermore, they produce minimal to no extra- pyramidal side effects (EPSs) or tardive dyskinesia (TD) in most people, although these effects may still occur for some patients. Adverse effects tend to be significantly less, resulting in greater adherence to treatment.

Atypical antipsychotic medications include risperidone (Risperdal), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), que- tiapine (Seroquel), ziprasidone (Zeldox).

A subset of the atypical antipsychotic medications are those medi- cations referred to as third generation antipsychotic medications. These medications include aripiprazole (Abilify) and brexpiprazole (Rex- ulti). They can be described as dopamine system stabilizers that act by reducing dopamine activity in some brain regions while increasing it in others. Aripiprazole and brexpiprazole act as D2 partial agonists (meaning that they attach to the D2 receptor without fully activating it, reducing the effective level of dopamine activity).

One significant disadvantage of the atypical medication, with the exception of ziprasidone and aripiprazole, is metabolic syndrome, which includes weight gain, dyslipidemia, and altered glucose metabolism, a significant concern due to increased risk for diabetes, hypertension, and atherosclerotic heart disease

An additional disadvantage of atypical antipsychotic medications is cost: they are more expensive than conventional antipsychotic medication.

Question 35

Conventional Antipsychotic Medication

Answer 35

Conventional antipsychotic medication are antagonists at the dopamine D2 receptor site in both the limbic and the motor centres. This blockage of dopamine D2 receptor sites in the motor areas causes extrapyramidal side effects, which include akathisia, acute dystonias, pseudo-parkinsonism, and TD. The symptoms of EPS are debilitating, can interfere with social functioning and communication, motor tasks, and ADLs (D’Souza & Hoo- ten, 2020). EPS is often associated with poor quality of life and adherence to medication, which may result in disease relapse and rehospitalization (D’Souza & Hooten, 2020). Other adverse reactions include ACh effects, orthostasis, photosensitivity, and lowered seizure threshold.

Conventional antipsychotic medication must be used cautiously in people with seizure disorders, as they can lower the seizure threshold. Three of the more common EPSs are acute dystonia (acute sustained contraction of muscles, usually of the head and neck), akathisia (psy- chomotor restlessness evident as pacing or fidgeting, sometimes pro- nounced and very distressing to patients), and pseudo-parkinsonism (a medication-induced, temporary constellation of symptoms associ- ated with Parkinson’s disease: tremor, reduced accessory movements, impaired gait, and stiffening of muscles).

EPSs can usually be minimized by lowering dosages of antipsychotic medications or adding antiparkinson medication, especially centrally act- ing ACh medications such as trihexyphenidyl and benztropine mesylate. Diphenhydramine hydrochloride (Benadryl) is also useful. Lorazepam, a benzodiazepine, may be helpful in reducing akathisia.
Unfortunately, antiparkinson medications can cause significant ACh adverse effects and worsen the ACh adverse effects of conven- tional antipsychotic medication and other ACh medications. These adverse effects include ACh syndrome, which is seen in the peripheral nervous system (tachycardia, hyperthermia, hypertension, dry skin, urinary retention, functional ileus) and central nervous system (my- driasis, hallucinations, delirium, seizures, and, in some cases, coma) (Wilson et al., 2017). Other troubling adverse effects of conventional antipsychotic medications include sexual dysfunction, endocrine disturbances (e.g., galactorrhea), drooling, and tardive dyskinesia, dis- cussed next. Impotence and sexual dysfunction are occasionally re- ported (but frequently experienced) by men and may also necessitate a medication change.

Question 36

Tardive dyskinesia (TD)

Answer 36

is a persistent EPS that usually appears af- ter prolonged treatment and persists even after the medication has been discontinued. TD is evidenced by involuntary tonic muscular contrac- tions that typically involve the tongue, fingers, toes, neck, trunk, or pelvis.

Early symptoms of TD are fasciculations of the tongue (described as looking like a bag of worms) or constant smacking of the lips. These symptoms can progress into uncontrollable biting, chewing, or sucking motions; an open mouth; and lateral movements of the jaw. No reliable treatment exists for TD.

Question 37

Potentially Dangerous Responses to Antipsychotic Medication

Answer 37

neuroleptic malignant syndrome, agranulocytosis, liver impairment, and ACh-induced delirium

Question 38

Neuroleptic malignant syndrome (NMS)

Answer 38

Acute reduction in brain dopamine activity plays a role in its development. NMS is a life-threatening medical emergency and is fatal in about 10% of cases. It can occur any time during treatment.

NMS is characterized by reduced consciousness, increased muscle tone (muscular rigidity), and autonomic dysfunction, including hyper- pyrexia, labile hypertension, tachycardia, tachypnea, diaphoresis, and drooling. Treatment consists of early detection, discontinuation of the antipsychotic, management of fluid balance, temperature reduction, and monitoring for complications. Mild cases of NMS may be treated with benzodiazepines, vitamins E and B6, or bromocriptine.

Question 39

Antidepressants

Answer 39

are recommended along with antipsychotic medica- tion for the treatment of depression, which is common in schizophre- nia.

Question 40

Antimanic (mood-stabilizing)

Answer 40

medications have been helpful in enhancing the effectiveness of antipsychotic medication. Divalproex sodium/valproic acid (Epival, Depakene) are used during acute exac- erbations of psychosis to hasten response to antipsychotic medication (Freudenreich, 2020b). Lamotrigine may be given along with clozapine to improve therapeutic effects.

Question 41

Augmentation with benzodiazepines

Answer 41

(e.g., clonazepam) can reduce anxiety and agitation and contribute to improvement in positive and negative symptoms

Question 42

When to Change an Antipsychotic Regimen

Answer 42

• Inadequate improvement in target symptoms despite an adequate
  trial of the medication
• Persistence of dangerous or intolerable adverse effects

Question 43

Adverse Effects of Conventional Antipsychotic Medication and Related Nursing Interventions

Answer 43

Dry mouth
Provide frequent sips of water, ice chips, and sugarless candy or gum; if severe, provide moisture spray
(Important note: monitor patient’s fluid intake for potential water intoxication).

Urinary retention and hesitancy
Check voiding
Try warm towel on abdomen, and consider catheterization if no result. Review medication to ensure not a potential side effect.

Constipation
Usually short term
May use stool softener
Ensure adequate fluid intake
Increase fibre intake
Use dietary laxatives (e.g., prune juice)

Blurred vision
Usually abates in 1–2 weeks
May require use of reading or magnifying glasses
If intolerable, consider consult regarding change in medication

Photosensitivity
Encourage person to wear sunglasses, sunscreen, and sun-blocking clothing Limit exposure to sunlight

Dry eyes
Use artificial tears
Inhibition of ejaculation or impotence in men
Consult prescriber: person may need alternative medication

Anticholinergic-induced delirium: dry mucous membranes; reduced or absent peristalsis; mydriasis; nonreactive pupils; hot, dry, red skin; hyperpyrexia without diaphoresis; tachycardia; agitation; unstable vital signs; worsening of symptoms of psychosis; delirium; urinary retention; seizure; repetitive motor movements
Potentially life-threatening medical emergency
Consult physician immediately
Hold all medications
Implement emergency cooling measures as ordered (cooling blanket, alcohol, or
ice bath)
Implement urinary catheterization as needed
Administer benzodiazepines or other sedation as ordered Physostigmine may be ordered as a special access toxicology antidote

Pseudo-parkinsonism: mask-like facies, stiff and stooped posture, shuffling gait, drooling, tremor, “pill-rolling” phenomenon
Onset: 5 hours–30 days
Consult physician, administer as needed antiparkinson medication (e.g., trihexyphenidyl or benztropine)
Consult physician regarding medication change Provide towel or handkerchief to wipe excess saliva

Acute dystonic reactions: acute contractions of tongue, face, neck, and back (usually tongue and jaw first)
Opisthotonos: tetanic heightening of entire body, head and belly up
Oculogyric crisis: eyes locked upward
Laryngeal dystonia: could threaten airway (rare)
Cogwheel rigidity: stiffness and clicking in elbow joints felt by the examiner during passive range of motion (early indicator of acute dystonia)
Onset: 1–5 days
Consult physician immediately
Administer anti-parkinson medication as above—give IM for more rapid effect and because of swallowing difficulty
Also consider diphenhydramine hydrochloride (Benadryl) 25–50 mg IM or IV Relief usually occurs in 5–15 minutes
Prevent further dystonias with antiparkinson medication (see Table 15.8) Experience can be frightening, and person may fear choking
Accompany to quiet area to provide comfort and support
Assist person to understand the event and avert distortion or mistrust of medications
Monitor airway

Akathisia: motor inner-driven restlessness (e.g., tapping foot incessantly, rocking forward and backward in chair, shifting weight from side to side)
Onset: 2 hours–60 days
Consult physician regarding possible medication change
Give antiparkinson medication
Tolerance to akathisia does not develop, but akathisia disappears when neuroleptic is discontinued
Propranolol (Inderal), lorazepam (Ativan), or diazepam (Valium) may be used
(Important note: In severe cases may cause great distress and contribute to potential suicidality, physician must be aware)

Tardive dyskinesia (TD):
Face: protruding and rolling tongue, blowing, smacking, licking, spastic facial distortion, smacking movements
Limbs:
Choreic: rapid, purposeless, and irregular movements
Athetoid: slow, complex, and serpentine movements
Trunk: neck and shoulder movements, dramatic hip jerks and rocking, twisting
pelvic thrusts
Onset: Months to years
No known treatment
Discontinuing the medication rarely relieves symptoms
Possibly 20% of people taking these medications for >2 years may develop TD Nurses and physicians should encourage people to be screened for TD at least
every 3 months
Onset may merit reconsideration of medications
Changes in appearance may contribute to stigmatizing response
Teach patient actions to conceal involuntary movements (purposeful muscle contraction overrides involuntary tardive movements)

Hypotension and postural hypotension
Check blood pressure before giving medication: a systolic pressure of 80 mm Hg when standing is indication not to give the current dose
Advise person to rise slowly to prevent dizziness and hold on to railings or furniture while rising to reduce falls
Effect usually subsides when medication is stabilized in 1–2 weeks Elastic bandages may prevent pooling
If any abnormal reading of blood pressure, consult physician immediately
regarding medication change, volume expanders, or pressure medications

Tachycardia
Always evaluate patients with existing cardiac problems before antipsychotic medications are administered
Haloperidol (Haldol) is usually the preferred medication because of its low ACh effects

Agranulocytosis (a rare occurrence, but a possibility the nurse should be aware of): symptoms include sore throat, fever, malaise, and mouth sores; any flulike symptoms should be carefully evaluated
Onset: During the first 12 weeks of therapy, occurs suddenly
A potentially dangerous blood dyscrasia
Blood work usually done every week for 6 months, then every 2 months
Physician may order blood work to determine presence of leukopenia or agranulocytosis
If test results are positive, the medication is discontinued, and reverse isolation may be initiated
Mortality is high if the medication is not ceased and if treatment is not initiated Teach person to observe for signs of infection

Cholestatic jaundice: rare, reversible, and usually benign if caught in time; prodromal symptoms are fever, malaise, nausea, and abdominal pain; jaundice appears 1 week later
Consult physician regarding possible medication change Bed rest and high-protein, high-carbohydrate diet if ordered Liver function tests should be performed every 6 months

Neuroleptic malignant syndrome (NMS): rare, potentially fatal
Severe extrapyramidal: severe muscle rigidity, oculogyric crisis, dysphasia, flexor-extensor posturing, cogwheeling
Hyperpyrexia: elevated temperature (over 39°C or 103°F)
Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence Delirium, stupor, coma
Onset: variable, progresses rapidly over 2–3 days
Risk factors: concomitant use of psychotropics, older age, female, presence of a mood disorder, and rapid dose titration (increase)
Acute, life-threatening medical emergency
Consult physician immediately
Stop neuroleptic
Transfer stat to medical unit
Bromocriptine can relieve muscle rigidity and reduce fever
Cool body to reduce fever (cooling blankets, alcohol, cool water, or ice bath as
ordered)
Maintain hydration with oral and IV fluids; correct electrolyte imbalance Arrhythmias should be treated
Small doses of heparin may decrease possibility of pulmonary emboli Early detection increases patient’s chance of survival

Question 44

Paranoia

Answer 44

Any intense and strongly defended irrational suspicion can be regarded as paranoia.

Communication guidelines. People with paranoia can have dif- ficulty trusting those around them, and may be guarded, tense, and/ or reserved. To ensure interpersonal distance, they may adopt a supe- rior, aloof, hostile, or sarcastic attitude, disparaging and dwelling on the shortcomings of others to maintain their self-esteem. Although they may shun interpersonal contact, functional impairment other than paranoia may be minimal. These people frequently misinterpret the intent or actions of others, perceiving oversights as personal rejec- tion. They also may personalize unrelated events (ideas of reference, or referentiality). For example, a patient might see a nurse talking to the psychiatrist and believe that the two are talking about them.
During care, a patient suffering from paranoia may make offensive yet accurate criticisms of staff and unit policies. It is important that responses focus on reducing the patient’s anxiety and fear and not be defensive reactions or rejections of the patient. Staff conferences and clinical supervision help maintain objectivity and a therapeutic per- spective about the patient’s motivation and behaviour, increasing pro- fessional effectiveness.

Self-care needs. People with paranoia usually have stronger ego resources than do individuals in whom other symptoms predominate; this is particularly evident in occupational functioning and capac- ity for independent living. Grooming, dress, and self-care may not be problems and may, in fact, be meticulous. Nutrition, however, may be affected by a delusion, such as that the food is poisoned. Providing foods in commercially sealed packaging, for example, peanut butter and crackers or nutritional drinks in cartons, can improve nutrition. If people worry that others will harm them when they are asleep, they may be fearful of going to sleep, a problem that impairs restorative rest and warrants nursing intervention.
Milieu needs. A person with paranoia may become physically ag- gressive in response to paranoid hallucinations or delusions. The per- son projects hostile drives onto others and then acts on these drives.
cont’d.
An environment that provides a sense of security and safety minimizes anxiety and environmental distortions. Activities that distract the pa- tient from ruminating on paranoid themes also decrease anxiety.

Question 45

Catatonia: Withdrawn Phase

Answer 45

The essential feature of catatonia is abnormal levels of motor behaviour, either extreme motor agitation or extreme motor retardation. Other as- sociated behaviours include posturing, waxy flexibility (described lat- er), stereotyped behaviour, muteness, extreme negativism or automatic obedience, echolalia, and echopraxia (discussed earlier in this chapter). The onset of catatonia is usually abrupt, and the prognosis favourable. With pharmacotherapy and improved individual management, severe catatonic symptoms are rarely seen today. Useful nursing strategies for intervening in catatonia are discussed in the following sections.

Communication guidelines. People with catatonia can be so with- drawn they appear stuporous or comatose. They can be mute and may remain so for hours, days, or even weeks or months if untreated. Al- though such patients may not appear to pay attention to events going on around them, they are acutely aware of the environment and may accurately remember events at a later date. Developing skill and confi- dence in working with withdrawn patients takes practice. The person’s inability or refusal to cooperate or participate in activities challenges staff to work to remain objective and avert frustration and anger.
Self-care needs. In extreme withdrawal a person may need to be hand- or tube-fed to maintain adequate nutritional status. Aspiration is a risk. Normal control over bladder and bowel functions may be inter- rupted, so the assessment and management of urinary or bowel reten- tion or incontinence is essential. When physical movements are mini- mal or absent, range-of-motion exercises can reduce muscular atrophy, calcium depletion, and contractures. Dressing and grooming usually require direct assistance.
Milieu needs. The catatonic person’s appearance may range from decreased spontaneous movement to complete stupor. Waxy flexibility is often seen; for example, if the patient raises arms over the head, they may maintain that position for hours or longer. Caution is advised because, even after holding a single posture for long periods, the pa- tient may suddenly and without provocation show brief outbursts of gross motor activity in response to inner hallucinations, delusions, and changes in neurotransmitter levels.

Catatonia: Excited Phase
Communication guidelines. During the excited stage of catatonia, the patient is in a state of greatly increased motor activity. They may talk or shout continually and incoherently, requiring the nurse’s com- munication to be clear, direct, and loud (enough to focus the patient’s attention on the nurse) and to reflect concern for the safety of the pa- tient and others.
Self-careneeds. Apersonwhoisconstantlyandintenselyhyperac- tive can become completely exhausted and be at risk of death if medical attention is not available. Patients with co-existing medical conditions (e.g., congestive heart failure) are most at risk. Intramuscular adminis- tration of a sedating antipsychotic is often required to reduce psycho- motor agitation to a safer level. During heightened physical activity, the patient requires stimulation reduction and additional fluids, calories, and rest. It is not unusual for the agitated person to be destructive or aggressive to others in response to hallucinations or delusions or inner distress. Many of the concerns and interventions are the same as those for mania.

Question 46

Disorganization

Answer 46

A person with disorganization may have marked associative looseness, grossly inappropriate affect, bizarre mannerisms, and incoherence of speech and may display extreme social withdrawal. Delusions and hallucinations are fragmentary and poorly organized. Behaviour may be considered odd, and a giggling or grimacing response to internal stimuli is common.

e persistent and severe perceptual and communication problems. Communication should be concise, clear, and concrete. Tasks should be broken into discrete tasks that are performed one at a time. Repeat- ed refocusing may be needed to keep the patient on topic or to allow task completion. This repetition can be frustrating to the nurse and others, requiring special effort to identify and correct counter-transfer- ence and nontherapeutic responses.
Self-care needs. In people with disorganization grooming is ne- glected; hair is often unkempt and matted, and clothes are unclean and often inappropriate for the weather (presenting a risk to self). Cognition, memory, and executive function are grossly impaired, and the person is frequently too disorganized to carry out simple ADLs. Areas of nurs- ing focus include encouraging optimal levels of functioning, preventing further regression, and offering alternatives for inappropriate behaviours whenever possible. Significant direct assistance for ADLs is also needed.

Milieu needs. People with disorganization need assistance with their behaviour and social expectations. Creating a care plan is im- portant to assist patients with structure, initiation of ADLs, increased supervision, and offering alternatives for inappropriate behaviours. Equally important is modifying the care plan as the patient develops more organization in thoughts and behaviours. Nurses must provide for the patient’s privacy needs. A sense of safety and decreased stimula- tion is of utmost importance. Peer education about the disorder may reduce peer frustration and acting out.

Question 47

EVALUATION

Answer 47

Evaluation is especially important in planning care for people who have psychotic disorders. Outcome expectations that are unrealistic discourage the patient and staff alike. It is critical for staff to remember that change is a process that occurs over time. For a person with schizo- phrenia, progress may occur erratically, and gains may be difficult to discern in the short term.
Chronically ill people must be reassessed regularly so that new data can be considered and treatment adjusted when needed. Questions to be asked include:
* Is the patient not progressing because a more important need is not
being met?
* Are the staff making the best use of the patient’s strengths and inter- ests to promote treatment and achieve desired outcomes?
* Are any other possible interventions being overlooked?
* Are new or better interventions/treatments available?
* How is the patient responding to existing or recently changed medi-
cations or other treatments?
* Is the patient becoming discouraged, anxious, or depressed?
* Is the patient participating in treatment? Are adverse medication
effects controlled or troubling?
* Is functioning improving or regressing?
* What is the patient’s quality of life, and is it improving?
* Is the family involved, supportive, and knowledgeable regarding the
patient’s disorder and treatment?
Active staff involvement and interest in the patient’s progress communicate concern and caring, help the patient to maximize progress, promote participation in treatment, and reduce staff feel- ings of helplessness and burnout. Input from the patient can offer valuable information about why a certain desired outcome has not occurred.

Question 48

KEY POINTS TO REMEMBER

Answer 48

• Schizophrenia is a complex disorder of the brain. It is not one dis- order but a group of disorders with overlapping symptoms and treatments.
• Recovery is possible with early identification, new treatments, and adequate social supports.
• The primary differences among subtypes involve the spectrum of symptoms that dominate their severity, the impairment in affect and cognition, and the impact on social and other areas of func- tioning.
• Symptoms of psychosis are often more pronounced and obvious than are symptoms found in other disorders, making psychosis and schizophrenia more likely to be apparent to others and increasing the risk of stigmatization.
• Neurochemical (catecholamines and serotonin), genetic, and neu- roanatomical findings help explain the symptoms of schizophre- nia. However, no one theory accounts fully for the complexities of schizophrenia.
• There are four categories of symptoms of schizophrenia: positive, negative, cognitive, and affective. Symptoms vary considerably among people and fluctuate over time.
• The positive symptoms of schizophrenia (e.g., hallucinations, delu- sions, associative looseness) are more pronounced and respond best to antipsychotic medication therapy.
• The negative symptoms of schizophrenia (e.g., social withdrawal and dysfunction, lack of motivation, reduced affect) respond less well to antipsychotic therapy and tend to be more debilitating.
• The degree of cognitive impairment (cognitive symptom) warrants careful assessment and active intervention to increase the patient’s ability to adapt, function, and maximize their quality of life.
• Coexisting depression (affective symptom) must be identified and treated to reduce potential risk for suicide, substance use, nonad- herence, and relapse.
• Some applicable nursing diagnoses include Disturbed sensory per- ception, Disturbed thought processes, Impaired communication, In- effective coping, Risk for self-directed or other-directed violence, and Impaired family coping.
• Outcomes are chosen based on the type and phase of schizophrenia and the person’s individual needs, strengths, and level of function- ing. Short-term and intermediate indicators are also developed to better track the incremental progress typical of schizophrenia.
• Interventions for people living with schizophrenia include trust build- ing, therapeutic communication techniques, support, assistance with self-care, promotion of independence, stress management, promo- tion of socialization, psychoeducation to promote understanding and adaptation, milieu management, cognitive behavioural interventions, cognitive enhancement or remediation techniques, and medication administration.
• Because antipsychotic medications are essential in the care of people living with schizophrenia, the nurse must understand the properties, adverse and toxic effects, and dosages of conventional and atypical antipsychotic medication and other medications used to treat schizophrenia. The nurse helps the patient and family un- derstand and appreciate the importance of medication to recovery.
• Schizophrenia can produce counter-transference responses in staff; clinical supervision and self-assessment help the nurse remain ob- jective and therapeutic.
• Hope is closely tied to recovery; it is essential for nurses to hold hope for people living with schizophrenia.