PSYCHOTIC DISORDERS Psychosis A Definition: A severe mental condition in which there is 1 disorganization of the personality, 2 deterioration of social functioning,

and 3 loss of contact with, or distortion of reality (poor reality testing) 4 There may be evidence of hallucinations or delusional thinking 5 Psychosis can occur with or without the presence of organic impairment 6 Psychosis is a life-long (persistent) condition with no cure and one that often worsens 7 Usually presents in late teens/early 20s 8 1% world population (not necessarily related to genetics/culture) B Predisposing Factors: 1 Biological a Geneticsnot strong link (5-10% incidence) b Neurotransmitter i Dopamine D2 Either too much produced or More receptors ii Serotonin 5-HTimbalanced c Anatomical & associated diseases i Influenza while in utero may prredispose baby to psychosis ii Epilepsy may incr. risk d Brain anatomy i Smaller brain ii Larger ventricles iii Frontal lobe: judgment, morality, higher function 2 Psychological a FamilyNO evidence of family situation affecting psychosis b Stressusually underlying issues pesent and stessors mount, overwhelming persons COPING ability 3 Environmental a Sociocultural b Trend: lower socioeconomic increases incidence (but not clear which is causative: disorder or socioeconomic status) II Transactional Model (Figure 26-2, p. 520 Townsend)Stress results from an imbalance between demands and resources or when pressure exceeds ones perceived ability to cope. The TRANSACTION between people and their environment. (Stressors do not cause stress, inherently, but depending on persons ability to engage necessary and sufficient resources to cope with the effects of the given stressor.) A Precipitating eventany event sufficiently stressful to threaten an already weak ego B Predisposing Factors: 1 Genetic Influences a Family Hx of schizophrenia b Possible biochemical alterations c Possible birth defect 2 Past Experiences: Prenatal exposure to viral infection 3 Existing Conditions: a Abnormal brain structure b Physical condition: i Epilepsy ii Huntingtons disease iii Brain tumor iv Parkinsonism v Inadequate Coping Skills C Cognitive Appraisal 1 PrimaryPerceived threat to self-concept or physical integrity a Is it Good I

b Bad c Doesnt matter 2 SecondaryWhat coping strategies to deploy to combat the stress a Because of weak ego strength, patient is unable to use coping mechanisms effectively b Defense mechanisms utilized: i Denial ii Regression iii Projection iv Identification v Religiosity D Quality of Response 1 AdaptiveYay! 2 MaladaptiveInitial psychotic episode or exacerbation of schizophrenic symptoms a Hallucinations b Delusions c Social isolation d Violence e Inappropriate affect f Bizarre behavior g Apathy h Autism III Positive SymptomsExaggerations of functioning A Content of Thought 1 Delusions a Delusions of Persecutionperson feels threatened and that people are trying to harm or persecute him i E.g., The FBI has bugged my room and intends to kill me ii E.g., I cant take a shower because the nuses have put a camea in there so that they can watch everything I do b Delusions of Grandeurperson has exaggerated sense of importance i E.g., I am Jesus Christ ii E.g., I am the President c Delusions of Referenceall events within the environment ae referred by the person to him- or herself i E.g., Someone is trying to get a message to me though the articles in this magazine (or T.V. show, etc.) ii IDEAS of reference less rigidthinking its all about her such as thinking everyone is talking about her/him, etc. d Delusions of Control or Influenceperson believes certain objects have control over his/her behavior (THIS MEANS THE PERSON FEELS THEY ARE BEING CONTROLLED FROM OUTSIDE SOURCE? HOW IS THIS DIFFERENT FROM PERSECUTION? PARANOIA? IM NOT CLEAR HOW PARANOIA, ESPECIALLY, IS A SEPARATE TYPE OF THOUGHT CONTENT FROM DELUSIONS, AND PARTICULARLY THIS TYPE OF DELUSION AND DELUSION OF PERSECUTION.) i E.g., Dentist put a filling in my tooth and I now receive transmissions through the filling that control what I think and do. e Somatic Delusionsperson has false idea about the functioning of his/her body i E.g., Im 70 years old and I will be the oldest person ever to give birth. The doctor says Im not pregnant, but I know I am. f Nihilistic Delusionsperson has false idea that the self, a part of the self, others, or the world is nonexistent i E.g., The world no longer exists. ii E.g., I have no heart. 2 Religiosity(CAN THIS PRESENT WITH MAGICAL THINKING? E.g., If I pray hard enough, it will happen.) a Excessive demonstration of or obsession with religious ideas and behavior

Person may use religious ideas to provide rational meaning and structurre to his/her behavior (this can be considered a manifestation of the disease.) 3 Paranoia a Extreme suspiciousness of others and their actions and perceived intentions b E.g., I wont eat this food. I know it has been poisoned. (IS THIS DIFFERENT THAN A DELUSION OF PERSECUTION?) 4 Magical Thinkingperson believes his/her thoughts or behaviors have control over specific situations or people a E.g., the mother who believes that if she scolded her son in any way, he would be taken away from her b E.g., It snowed last night because I wished very very hard that it would. B Form of Thought 1 Associative Loosenessspeech in which ideas shift from one unrelated topic to another (IS THIS DIFFERENT FROM TANGENTIALITY IN THAT SHIFTS HAVE NO CONNECTION AND WITH TANGENTIALITY THE SHIFTS LEAD FROM ONE POINT LOGICALLY TO ANOTHER BUT FURTHER AND FURTHER FROM THE MAIN POINT?) 2 Neologismsinventing new words that mean nothing to others but have symbolic meaning to the patient 3 Concrete Thinkingrepresents regression to earlier stage of cognitive development; no abstraction of thought process (e.g., understands its raining cats and dogs literally) 4 Clang Associationsoften in the form of rhyming, choice of words dictated by sounds of the words 5 Word Saladwords put together randomly, without logic. (IS THIS LIKE ASSOCIATIVE LOOSENESS EXCEPT THAT THIS IS JUST WORDS, NOT WHOLE PHRASES OR THOUGHTS RANDOMLY STRUNG TOGETHER?) 6 Circumstantialityunnecessary and tedious details delay the person getting to the point; interviewer can interrupt the person to keep them on track. 7 TangentialityDIFFERENT from circumstantiality in that person does not ever get to the point; original focus is lost. 8 Mutisminability OR refusal to speak 9 Perseverationpersistently repeats same word or phrase in response to different questions. C Perception 1 Hallucinationsfalse sensory perceptions not associated with real external stimuli, which may involve any of the 5 senses. a Auditory b Visual c Tactile d Olfactory e Gustatorycan be associated with brain tumor or some other physiological condition 2 Illusionsmisperceptions or misinterpretations of real external stimuli (e.g., the chair is a wild animal about to pounce) D Sense of Self 1 Echolaliarepeating words in an attempt to identify with the person speaking 2 Echopraxiapurposelessly imitating movements of others 3 Imitationego defense mechanism in which person CONSCIOUSLY emulates anothers behavior; it reflects patients inability to discern ego boundaries between self and others 4 Identificationego defense mechanism in which person UNconsciously mimics anothers behavior; like imitation, this reflects patients inability to discern ego boundaries between self and others. 5 Depersonalizationunstable self-identity can lead to feelings of unreality (e.g., feeling ones extremities have changed size; sense of seeing oneself from a distance.) IV Negative SymptomsDiminished, decreased or loss of function A Affect 1 Inappropriate affecte.g., laughing at the death of a loved one 2 Bland or flat affectconstricted 3 Apathyno interest/concern with what is going on B Volition

Goal-directed activityinability to get STARTED with activity Emotional ambivalenceconflict of need and fear that impedes fulfilling the neede.g., I need to interact with people, but Im afraid to talk to people. C Impaired Interpersonal Functioning and Relationship to the External World 1 Autismretreating inside; not interacting with environment 2 Deteriorated appearancemalodorous, unkempt, not caring for self D Psychomotor Behavior 1 Anergianot enough energy to do anything 2 Waxy flexibilitybizarre, uncomfortable body positioning that can be moved out of but is returned to 3 Posturinga position that the person resists changing, more rigid than waxy flexibility 4 Pacing and rockingself-explanatory E Associated Features 1 Anhedoniaperson experiences no pleasure; HIGH SUICIDE RISK 2 Regressionreverse to earlier stage of development often as a defense mechanism against anxiety V Phases of Psychotic Disorder A Phase I: Premorbid 1 Mostly normal functioning B Phase II: Prodromalnot pronounced 1 Starting to have S/S 2 2-5 years before psychotic break 3 Social isolation, mutism, affect, sleep disturbance, role function failing C Phase III: Schizophrenia/Psychosis 1 Break occurs 2 Full S/S present D Phase IV: Residual 1 May come back to some degree from the break 2 May be reduction of positive S/S 3 Usually NEGATIVE S/S will remain VI Types of Schizophrenia A Schizophrenia 1 Disorganized a Worst prognosis b Many negative S/S c Usually presents at young age 2 Catatonic a Frozen in one position; stupor b OR catatonic excitability: extreme, non-purposeful movement which is dangerous and can lead to death through physical exhaustion 3 Paranoid a Most common b Both positive and negative S/S but WITH paranoia 4 Undifferentiated (NOSnot otherwise specified)difficult to characterize with mutiple featurres from others 5 Residual a Coming out of it but not curedits a lifelong condition b Still have NEGATIVE S/S 6 Schizoaffective disorder 7 Brief psychotic disorder 8 Schizophreniform disorder 9 Delusional Disorder a Erotomanicconvinced someone of higher status is in love with him/her b Grandioseperson believes they have much higher status than reality; irrational ideas about own worth, talent, knowledge or power c Percusatory(most common) someone is out to destroy me; often a small rebuff can begin a fixation and premise of a delusional system 1 2

d Somaticbelief that they have some physical defect, disorder or disease e Jealousyfixation on sexual partners infidelity 10 Shared psychotic disorder (a.k.a., folie a deux) dominant person in relationship is has psychotic disorde that is imposed upon and eventually supported by more passive person in relationship; esp. common in long-term relationships in which the couple has been socially isolated 11 Psychotic disorder due to medical condition a Neuroneoplasms, cerebrovascular disease, epilepsy, deafness, migraines, CNS infections b EndocrineHyper/Hypothyroidism, Hyper-/Hypoparathyroidism, Hypoadrenocorticism c MetabolicHypoxia, hypecarbia, hypoglycemia d Autoimmunesystemic LUPUS, erythematosus e OthersF&E imbalances, hepatic or renal diseases 12 Substance-induced psychotic disorder a Alcohol b Drugs, especially methamphetamine c VII Phases of Treatment A Active Phasemost seen in the psych rotation B Maintenance Phase 1 More functional 2 Improve quality of life; ADLs; coping; social interaction C Rehabilitation Phase 1 Life skills r/t famly, working 2 As productive in society as possible

Nursing Diagnoses Risk for Violence: Selfdirected or Other-directed at risk for behaviors in which an individual demonstrates that he/she can be physcially, emotionally and/or sexually harmful either to self or to others Disturbed Thought Processes disruption in cognitive operations and activities Disturbed Sensory Perception change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli Social Isolation Risk factors: Aggressive body language (e.g., clenching fists/jaw, pacing, threatening stance), verbal aggression, catatonic excitement, command hallucinations, rage reactions, history of violence, overt and aggressive acts, goal-directed destruction of objects in the environment, self-destructive behavior, or active aggressive suicidal acts

Delusional thinking; inability to concentrate; impaired volition; inability to problemsolve, abstract, or conceptualize; extreme suspiciousness of other; inaccurate interpretation of the environment

Impaired communication (inappropriate responses), disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, tilts head to side as if listening

aloneness experienced by the individual and perceived a imposed by others andas a negative or threatening state Loose association of ideas, neologisms, word salad, clang associations, echolalia, Impaired Verbal verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing Communication thoughts verbally, inappropriate verbalization decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, and Self-Care Deficit toileting Neglectful care of client in regard to basic human needs or illness treatment, extreme Disabled Family Coping denial or prolonged overconcern regarding clients illness, depression, hostility and aggression Inability to take responsibility for meeting basic health practices, history of lack of healthIneffective Health seeking behavior, lack of expressed interest in improving health behaviors, demonstrated Maintenance lack of knowledge regarding basic health practices

Withdrawal, sad dull affect, need-fear dilemma, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others, uncommunicative, seeks to be alone