7.13 Psychosis and Schizophrenia

Psychosis

The term psychosis refers to disturbed thoughts and mental processing. The client loses contact with reality and has difficulty understanding what is real and what is not real. Many conditions can cause psychosis, such as severe mental illness, medical conditions such as hyperglycemia and hyperthyroidism, sleep deprivation, side effects of certain medications, and intoxication with alcohol or other substances.^[1]

Symptoms of psychosis may include illusions, delusions, and hallucinations. Illusions are misperceptions of real stimuli. For example, a client may misperceive tree branches blowing in the wind at night to be the arms of monsters trying to grab them.

Delusions are fixed, false beliefs that persist in spite of evidence to the contrary and can vary in their type. For example, a client may have the delusion that the CIA is listening to their conversations via satellite. Grandiose delusions refer to a state of false attribution to the self of great ability, knowledge, importance or worth, identity, prestige, power, or accomplishment. Clients may withdraw into an inner fantasy world that’s not equivalent to reality, where they have inflated importance, powers, or a specialness that is opposite of what their actual life is like. Paranoid delusions are characterized by delusions of persecution. Clients often experience extreme suspiciousness or mistrust or express fear. For example, a resident of a long-term care facility may have delusions that the staff is trying to poison them. Religious delusions can be difficult to separate from an individual’s religious beliefs. However, they can be summarized as fixed beliefs unique to an individual rather than an accepted belief by a cultural or existing religion. If the belief is shared with a religious group, it is not considered a delusion. An example of a religious delusion by an individual is that intergalactic deities are controlling their thoughts or actions.^[2],[3]

Hallucinations are sensations from any of the five senses that a client is experiencing that are not based on reality. Hallucinations feel very real to the person experiencing them and can be distracting during their interactions with others. Furthermore, it is often difficult for the person experiencing hallucinations to distinguish between sensations that are real and unreal. Hallucinations can be supportive or terrifying, faint or loud, or episodic or constant. The following are examples of five types of hallucinations:

• Visual: The individual sees something that is not there, such as bugs on the wall.
• Auditory: The individual hears noises such as voices, music, or clicks, that are not present.
• Tactile: The individual feels sensations such as bugs on their skin that do not exist.
• Gustatory: The individual experiences a false sense of taste, such as a bitterness that may contribute to paranoid delusions.
• Olfactory: The individual smells an odor that does not exist, such as smoke.

When working with a client who has a history of hallucinations, nurses watch for signs that hallucinations may be occurring, such as their eyes tracking an unheard speaker, muttering or talking to themself, appearing distracted, suddenly stopping a conversation as if interrupted, or intently watching a vacant area of the room. If a nurse suspects hallucinations are occurring, the client should be asked about the content of the hallucinations and if they are experiencing command hallucinations, meaning the voice is telling them to do something such as hurt themselves or another person. The nurse also assesses and documents how the client is reacting to the hallucinations, especially if they are exhibiting anxiety, fear, or distress.

Delirium

Temporary psychosis caused by medical issues is referred to as delirium. Delirium is a temporary mental state in which the client becomes confused, disoriented, and not able to think or remember clearly. The client may become agitated, combative, and experience hallucinations. Delirium usually starts suddenly and can indicate the onset of a life-threatening medical condition. It resolves when the underlying condition is effectively treated.

Schizophrenia

There is a spectrum of psychotic mental health conditions, and schizophrenia is one of the disorders on the spectrum. Psychosis is a common symptom of schizophrenia, a severe mental illness that affects how a person thinks, feels, and behaves. Psychosis also affects the person’s ability to recognize their symptoms as problematic, referred to as a “lack of insight.” Symptoms of schizophrenia are classified into three categories called positive, negative, and cognitive:

• Positive symptoms refer to symptoms of psychosis and include abnormal thoughts and perceptions such as illusions, hallucinations, delusions, and abnormal speech patterns. Review Table 7.2 in the “General Assessments for Mental Health Conditions” section for examples of abnormal findings related to thoughts and perceptions. People with positive symptoms lose a shared sense of reality and experience the world in a distorted way.
• Negative symptoms refer to loss of motivation, disinterest or lack of enjoyment in daily activities, social withdrawal, flat affect (i.e., reduced expression of emotions via facial expression or voice tone), and reduced speaking.
• Cognitive symptoms refer to problems in attention, concentration, and memory. Individuals may experience symptoms such as difficulty processing information to make decisions, problems using information immediately after learning it, trouble focusing or paying attention, and memory problems.

Assessment (Recognizing Cues)

Nurses assess, monitor, and document symptoms of schizophrenia, including positive, negative, and cognitive symptoms. If a client is experiencing worsening signs and symptoms, the health care provider is promptly notified for additional treatment.

Nurses also assess for suicidal ideation and implement safety interventions as indicated. Review information about assessments and interventions in the “Suicide Screening and Safety Interventions” section.

Schizophrenia in Children and Adolescents

Schizophrenia is typically diagnosed in the late teen years to the early thirties and tends to emerge earlier in males than females. Schizophrenia can occur in younger children, but it is rare for it to occur before late adolescence. Gradual changes in thinking, mood, and social functioning often begin before the first episode of psychosis. Early detection and treatment of psychosis can help people recover and lead fulfilling lives. Behavioral warning signs for developing psychosis include the following^[6]:

• Drop in grades or worsening job performance
• New trouble thinking clearly or concentrating
• Suspiciousness; paranoid ideas or uneasiness with others
• Social withdrawal; spending more time alone than usual
• Unusual, bizarre new ideas and behavior
• Strange feelings or having no feelings at all
• Decline in self-care or personal hygiene
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating
• Lack of motivation
• Impaired functioning
• Self-harm, suicidal ideation, or threats of violence toward others

Treatment

Early treatment of psychosis increases the chance of a successful remission. Treatments focus on managing symptoms and solving problems related to day-to-day functioning and include antipsychotic medications, psychosocial treatments, family education and support, coordinated specialty care, and assertive community treatment.

Many people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to live a fulfilling and productive life, even if psychotic symptoms return at times. However, if left untreated, psychotic symptoms can cause disruptions in school and work, strained family relations, and separation from friends. The longer the symptoms go untreated, the greater the risk for developing additional problems such as substance misuse, legal trouble, or homelessness. Research indicates that schizophrenia and other psychotic disorders are highly prevalent among homeless people, indicating an urgent need for better prevention, detection, and treatment efforts. See Figure 7.7^[7] for an image of a person experiencing homelessness.

Antipsychotic Medications

Type 1 or Type 2 antipsychotic medications are prescribed for clients experiencing psychosis related to mental illness. People respond differently to these medications, so medications are prescribed based on the client’s ability to tolerate the adverse effects. Review information about antipsychotic medications in the “Psychotropic Medications” section of this chapter.

Psychotherapy

A combination of antipsychotic medications and psychosocial treatments are commonly prescribed for clients with schizophrenia. Cognitive behavioral therapy, behavioral skills training, supported employment, and cognitive remediation interventions are examples of psychosocial treatments that address the negative and cognitive symptoms of schizophrenia. Psychosocial treatments can help improve coping skills with the everyday challenges of schizophrenia and help people pursue their life goals, such as attending school, working, or forming relationships. Individuals who participate in regular psychosocial treatments are less likely to relapse or be hospitalized.

Some people may experience relapse, meaning their psychosis symptoms come back or get worse. Relapses typically occur when people stop taking their prescribed antipsychotic medications or if they take them sporadically instead of as prescribed. Some people stop taking prescribed medications because they feel better or they feel that they don’t need them anymore, but antipsychotic medication should never be stopped suddenly due to the risk of withdrawal symptoms. In some situations, clients can gradually taper their medications after talking with a prescriber, but most people with schizophrenia must stay on antipsychotic medications continuously for months or years to maintain mental wellness.

Nursing Interventions

The top priority when caring for clients experiencing psychosis or “positive symptoms” of schizophrenia is to maintain safety for the client, staff, and other people on the unit. If a client, family member, or visitor demonstrates escalating agitation, the nurse implements de-escalation techniques and crisis intervention, if appropriate. Review verbal de-escalation techniques in the “Workplace Violence” section of the “Maladaptive Coping Behaviors” chapter. Review information about crisis and crisis intervention in the “Basic Concepts of Mental Health and Mental Illness” section in the “Mental Health Concepts” chapter. In some situations, severely agitated clients may require seclusion or behavioral restraints for safety. Review information about seclusion and restraints in the “Ethical and Legal Considerations in Mental Health Care” subsection of the “Mental Health Concepts” chapter.

Clients with psychosis and schizophrenia often experience physiological effects related to nutrition, sleep, elimination, and self-care deficits similar to those with mania. Review nursing interventions to address these physiological effects in Table in 7.12 in the “Bipolar Disorder” section.

Nurses play a significant role in monitoring and reporting side effects for clients taking antipsychotic medications. Common side effects of both first- and second-generation antipsychotics include anticholinergic symptoms such as dry mouth, constipation, blurred vision, urinary retention, drowsiness, dizziness, restlessness, weight gain, nausea or vomiting, and low blood pressure. First-generation antipsychotics (also called typical antipsychotics) may cause extrapyramidal side effects and tardive dyskinesia, which are characterized by involuntary movements that impact motor control and coordination. Second-generation antipsychotics (also called atypical antipsychotics) are associated with weight gain and the development of metabolic syndrome. Neuroleptic malignant syndrome is a rare but fatal adverse effect that can occur at any time during treatment with antipsychotics. Review additional information about these potential side effects of antipsychotics in the “Psychotropic Medications” section of this chapter.

If clients are experiencing delusions or hallucinations, nurses implement specific therapeutic techniques. Review information about helping clients who are experiencing delusions and hallucinations in the following boxes.

Health Teaching

Clients taking antipsychotic medications should be advised to contact their provider if involuntary or uncontrollable movements develop. They should be warned to not suddenly stop taking the medication because abrupt withdrawal can cause dizziness; nausea; vomiting; or uncontrolled movements of the mouth, tongue, or jaw.

If clients with schizophrenia experience chronic hallucinations, nurses provide health teaching on how to manage them. See the following box for tips on managing hallucinations.

Psychosis and schizophrenia can take a heavy toll on a client’s family members, significant others, and friends. Nurses provide information about schizophrenia symptoms, treatments, and strategies for assisting their loved one who is experiencing psychosis and schizophrenia. Increasing their understanding of psychotic symptoms, treatment options, and the course of recovery can lessen their distress, bolster their own coping strategies, and empower them to offer effective assistance to their loved one. Family-based services may be provided via individual or group therapy. Nurses also provide information on community resources and support groups.