VERNALIN B. TERRADO, RN

MENTAL HEALTH AND PSYCHIATRIC NURSING

DYSFUNCTIONAL/ MALADAPTIVE COPING PATTERN

PSYCHOTIC DISORDER

PSYCHOSIS

a mental illness that markedly interferes with a person's capacity to meet life's everyday demands.

In a specific sense, it refers to a thought disorder in which reality testing is grossly impaired.

Brain disease that disrupts perceptions, thinking, feelings, and behaviors. It can cause

distortions of reality, false beliefs, hallucinations, and changes in speech

patterns, moods, and behaviors. It disrupts the person’s ability to function, socialize, and

work.

Just the facts!

Age: Adolescence or early AdulthoodStress: onset and relapse associationDopamine antagonists: drugs that block

dopamine receptors are therapeuticMen= womenDiagnostic term used to describe a major

psychotic disorder characterized by disturbances in perception, thought process, realty testing, feeling, behavior, attention, motivation.

Is Schizophrenia a Split personality or a deteriorating personality?

Affective disturbance- flat,bluntedAutism- thoughts on self, extreme

withdrawal, unable to relate to outside world.Associative looseness- verbalizations are

disorganized.Ambivalence- simultaneous opposite feelings

Bleuler’s Four A’s

CAUSES

DOPAMINE THEORY-D1 receptorsGENETIC FACTORSPrenatal infectionsPerinatal complicationsOther stressors

GENERAL ASSESSMENT

Speech Abnormalities

1. Clang Associations2. Echolalia3. Loose Association and flight of ideas4. Word salad5. Neologisms

Thought distortions

Overly concrete thinking DelusionsTYPES

1. Somatic2. Persecutory Type3. Jealous4. Erotomanic Type5. nihilistic delusion6. Delusion of control7. Delusion of reference8. Religious delusion

Hallucinations Thought

blocking Magical

thinking

Social Interactions

1. Poor interpersonal relationships2. Withdrawal and Apathy Other findings1. Regression2. Ambivalence3. Echopraxia

SYMPTOM CATEGORIES

POSITIVE SYMPTOMS

SYMPTOMS THAT ARE PRESENT BUT SHOULD BE ABSENT

e.g. hallucinations, delusions

Amenable by antipsychotics

NEGATIVE SYMPTOMS

Absence of normal characteristics

Apathy Lack of motivation Blunted affect Poverty of speech Anhedonia Asociality

SUBTYPES

Paranoid schizophreniaDisorganized SchizophreniaCatatonic SchizophreniaUndifferentiated SchizophreniaResidual Schizophrenia

Paranoid Schizophrenia

Characterized by persecutory or grandiose delusional thought content and possibly delusional jealousy.

Auditory hallucinations, tendency to argue, possible violence.

Treatment- antipsychotics, psychosocial therapies, and rehabilitation.

Nursing Intervention

Build trust, be honest and dependable.Avoid whispering or laughing with patient

around.Do not touch patients without warning them.Approach him in a calm, unhurried manner.If he tells you to leave him alone, do leave – but

make sure to return soon.Set limits firmly. Avoid a punitive attitude.Respond neutrally and don’t take his remarks

personally.Orient patients to time, person, and place.Be flexible and give patient some control.

Don’t try to combat delusions with logic.If suicidal thoughts are expressed or says he

hears voices telling him to harm himself, institute suicide precautions.

Make sure the nutritional needs are met.Postpone procedures that require physical

contact if patient becomes suspicious or agitated.

Don’t tease, joke, argue with or confront the patient.

Disorganized Schizophrenia

Disorganized schizophrenia is marked by incoherent, disorganized speech and behaviors and by blunted or inappropriate affect.

Signs and symptoms: incoherent, disorganized speech, with markly

loose associations.Grossly disorganized behaviorExtreme social withdrawalBlunted, silly, superficial, or inappropriate

affect.

Catatonic Schizophrenia

Tendency to remain in a fixed stupor for long periods.

May yield brief spurts of extreme excitement.Increased potential for destructive violent

behavior.May remain mute and refuse to move about

or tend to his personal needs.May show bizarre mannerisms, such as facial

grimacing and sucking mouth movements

Rapid swings between stupor and excitement.

Bizarre posturesDiminished sensitivity to painful stimuliNegative symptomEcholaliaechopraxia

Undifferentiated Schizophrenia

Presence of schizophrenic symptoms but criteria for paranoid, catatonic, or disorganized subtypes are not met.

Residual Schizophrenia

History of at least one schizophrenia episode Lacks prominent delusions, hallucinations,

disorganized speech, and grossly disorganized or catatonic behavior

Continuing evidence of schizophrenia because of the presence of negative symptoms.

Schizoaffective Disorder

symptoms of psychosis and thought disorder along with all the features of a mood disorder

Schizophreniform

symptoms of schizophrenia are experienced for less than the 6 months required for a diagnosis of schizophrenia.

Delusional Disorder

one or more non-bizarre delusions with no impairment in psychosocial functioning

Shared psychotic disorder

similar delusion shared by two people, one of whom has psychotic delusions.

Drug therapy

Conventional AntipsychoticsChlorpromazine(Thorazine)Fluphenazine(prolixin)Haloperidol(Haldol)Molindone(Moban)Perphenazine(Trilafon)Thioridazine(Mellaril)Thiotixine(Navane)Trifluoperazine(Stelazine)

Atypical AntipsychoticsClozapineOlanzapine(Zyprexa)Quetiapine(Seroquel)Risperidone(Risperdal)Ziprasidone(Geodon) Relive positive symptoms Improve negative symptoms Enhance serotonin and stabilize dopamine Less likely to cause motor adverse effects

Other drugs are used such as mood stabilizing agents such as lithium, carbamazepine(Tegretol), and valproic Acid(Depakote) manage negative symptoms\

ECT- used in acute schizophrenia and is effective in reducing depressive and catatonic symptoms of schizophrenia.

Dissociative Disorders

Marked by the disruption of the fundamental aspects of waking consciousness, and the general experience and perception of oneself and the surroundings.

Dissociation is unconscious defense mechanisms to prevent anxiety-provoking feelings and thoughts from the conscious mind.

Dissociation is a common occurrence from normal to pathologic.

CAUSES

Psychological theoriesBiological theoriesLearning theory

Dissociative amnesia

A dissociative amnesia may be present when a person is unable to remember important personal information, which is usually associated with a traumatic event in his/her life. The loss of memory creates gaps in this individual's personal history. 

Recent Amnesia- occur immediately after a traumatic experience

Localized Amnesia-occurs when the individual cannot remember what occurred during a specific period of time.

Selective amnesia- ability to recall some events during a specific period of time.

Dissociative fugue

A dissociative fugue may be present when a person impulsively wanders or travels away from home and upon arrival in the new location are unable to remember his/her past.

Travel and behavior may appear to casual observersFugue states lasts from a few hours to several days.Rare and usually follows severe psychosocial stress,

such as marital quarrels, personal rejections, military conflict, natural disaster, financial difficulty, and suicidal ideation.

The condition is usually diagnosed when relatives find their lost family member living in another community with a new identity.

Dissociative identity disorder

Dissociative identity disorder was formerly called "multiple personality disorder."

Each personality has its own personal history and identity and takes on a totally separate name.

These patients are admitted to inpatient psychiatric units when they are suicidal

Medications are given symptomatically.Safe environment and trusting relationship

should be provided.

Depersonalization disorder

Feelings of detachment or estrangement from one’s self are signs of depersonalization.

Individuals with this disorder will report feeling as if they are living in a dream or watching themselves on a movie screen.

They feel separated from themselves or outside their own bodies. People with this disorder feel like they are "going crazy" and they frequently become anxious and depressed.

Sense of Depersonalization may be restricted to a single body part, such as a limb—or it may encompass the whole self.

Paranoid Personality Disorder

PPD is a type of psychological personality disorder characterized by an extreme level of

distrust and suspicion of others. Paranoid personalities are generally difficult to get

along with, and their combative and distrustful nature often elicits hostility in

others.

Diagnosis of PPD

Paranoid PD is considered a Cluster A personality disorder along with Schizoid and Schizotypal, and characterized by odd or eccentric behavior. A diagnosis of PPD should be considered when these paranoid behaviors become persistent anddisabling.

According to the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders), a patient must fit at least four of the following criteria in order to be diagnosed with PPD:

unfounded suspicion that others are exploiting, harming, or deceiving him or her

preoccupation with unjustified doubts about the loyalty of friends or associates

reluctance to confide in others because of unwarranted fear that the information will be used against him or her

finds hidden demeaning or threatening meanings in benign remarks or events .

persistently bears grudges and is unforgiving

frequently perceives attacks on his or her character and is quick to react angrily or to counterattack

unjustified suspicions regarding fidelity of spouse or sexual partner

Prevalence of Paranoid Personality The prevalence of Paranoid Personality Disorder has been estimated

to be as high as 4.5% of the general population and occurs more commonly in males

Cause of PPD threatening domestic atmosphere experienced during childhood This disorder is more common among first-degree biological

relatives of those with Schizophrenia and Delusional Disorder, Persecutory Type

Course of Paranoid Disorder PPD often first becomes apparent in early adulthood. The course of

this disorder is chronic

Treatment of Paranoid Personality Disorder Psychotherapy Medications is given symptomatic