This document provides an overview of psychosis and psychotic disorders, their symptoms, and treatment including psychotropic medications. It discusses key psychotic symptoms like hallucinations, delusions, and thought disorders. It also outlines several psychiatric disorders that involve psychosis such as brief reactive psychosis, schizophrenia, and schizoaffective disorder. The document reviews treatment approaches for psychosis including supportive psychotherapy, cognitive behavioral therapy, and the use of psychotropic medications like antipsychotics.

1. Assessing and nursing the person
with a psychotic mental health
problem
Working with psychotropic
medications
Paul McNamara
RGN (RAH), RPN (SAMHS), BN (Flin.), MMHN (USQ), Cert IMH (WCHN), CMHN, FACMHN
@meta4RN
#NS3360

2. Acknowledgements
Tanya Park @Tanya_M_Park
Elizabeth Emmanual via @SCUonline
+ Nurses 1988-2015

3. Learning Outcomes
 Identify hallucinations and delusions
 Identify psychotic features
 Understand the impact of symptoms
 Identify nursing diagnosis & interventions
 Use of psychotropic meds
 Side effects vs symptoms
 Therapeutic relationship + education + meds
 Monitoring side effects
 Z-track IMI

4. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics

5. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics

6. Psychosis
“a condition in which a person has impaired
cognition, emotional, social and communicative
responses and interpretation of reality”
Elder, Evans & Nizette (2013) page 530

7. meta4RN.com/fineline

8. meta4RN.com/fineline

9. Psychosis
Causes not fully understood
Most likely to be a combination of hereditary
and other factors e.g. stress or drug use
2-3% of us will experience psychosis at some
time in our lives

10. Neurobiological Model

11. Biopsychosocial Model

12. Hallucination
“a sensory perception that seems real but occurs
without external stimulation (unlike an illusion,
which is a misinterpretation of real
phenomena)”
Elder, Evans & Nizette (2013) page 527

13. Types of Hallucinations
 Auditory
 Visual
 Olfactory
 Tactile
 Gustatory
 Somatic

14. Thought Disorder
“a disturbance of the form in which an individual
expresses their thoughts (structure, grammar,
syntax, logic), or sometimes the content of their
thoughts”
Elder, Evans & Nizette (2013) page 532

15. Types of Thought Disorder
 Clanging
 Circumstantiality
 Derailment
 Tangentiality
 Incoherence
 Thought Blocking
 Word Approximations
 Neologisms
 Word Salad

16. Delusion
“a false belief, based on incorrect inference
about external reality that is firmly sustained
despite what almost everyone else believes and
despite incontrovertible and obvious proof or
evidence to the contrary”
Elder, Evans & Nizette (2013) page 525

17. Types of Delusion
 Persecution
 Religious
 Nihilistic
 Jealous
 Grandiose
 Reference
 Somatic
 Thought Broadcasting
 Thought Insertion
 Erotomania
 Control
 Bizarre

18. Ponder on PEP
Is this person’s delusion a stand-alone symptom,
or does it serve to make sense of the other
symptoms (ie: hallucinations and thought
disorder) and circumstances (eg: social
disadvantage and isolation)?

19. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics

20. “When you hear hoofbeats,
think of horses not zebras".
Prof Theodore Woodward, circa 1948

21. Psychotic Symptoms
≠ Psychiatric Disorder
 Neurological conditions
 Metabolic or endocrine disturbances
 Vitamin deficiencies
 Auto immune disorders
 Medication/drug intoxication or withdrawal
 Dementia and/or Delirium

22. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

23. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

24. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

25. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

26. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

27. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

28. Schizophrenia
“a [group of] disorder[s] characterised by a
major disturbance in thought, perception,
cognition and psychosocial functioning”
Elder, Evans & Nizette (2013) pp 525 + 265

29. Dispelling Schizophrenia Myths
NOT split personality
NOT violent
NOT developmentally delayed
NOT low intelligence

31. DSM-V Diagnostic Criteria (1 of 6)
Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or
less if successfully treated). At least one of these must
be (1), (2), or (3):
1) Delusions.
2) Hallucinations.
3) Disorganized speech (e.g., frequent derailment or
incoherence).
4) Grossly disorganized or catatonic behaviour.
5) Negative symptoms (i.e., diminished emotional
expression or avolition)

32. DSM-V Diagnostic Criteria (2 of 6)
For a significant portion of the time since the onset of
the disturbance, level of functioning in one or more
major areas, such as work, interpersonal relations, or
self-care, is markedly below the level achieved prior to
the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of
interpersonal, academic, or occupational functioning).

33. DSM-V Diagnostic Criteria (3 of 6)
Continuous signs of the disturbance persist for at least 6
months. This 6-month period must include at least 1
month of symptoms (or less if successfully treated) that
meet Criterion A (i.e., active-phase symptoms) and may
include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of
the disturbance may be manifested by only negative
symptoms or by two or more symptoms listed in
Criterion A present in an attenuated form (e.g., odd
beliefs, unusual perceptual experiences).

34. DSM-V Diagnostic Criteria (4 of 6)
Schizoaffective disorder and depressive or bipolar
disorder with psychotic features have been ruled out
because either 1) no major depressive or manic
episodes have occurred concurrently with the active-
phase symptoms, or 2) if mood episodes have occurred
during active-phase symptoms, they have been present
for a minority of the total duration of the active and
residual periods of the illness.

35. DSM-V Diagnostic Criteria (5 of 6)
The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.

36. DSM-V Diagnostic Criteria (6 of 6)
If there is a history of autism spectrum disorder or a
communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations, in addition to the
other required symptoms of schizophrenia, are also
present for at least 1 month (or less if successfully
treated).

37. DSM IV (old speak)
1. Paranoid type
2. Catatonic type
3. Disorganised type
4. Undifferentiated type
5. Residual
DSM V (new speak) = no subtypes

38. Positive & Negative Symptoms
+ve [excess]
 Hallucinations
 Delusions
 Thought Disorder
-ve [deficit]
 Avolition (↓ drive)
 Anergia (↓ energy)
 Anhedonia (↓ pleasure)
 Affect Blunted
 Alogia (↓ speech)

39. Schizophrenia
Prevalence = 1%
Onset = late teens / early twenties
↑ Diabetes
↑ Cardiovascular disease
↑ Lipidemia
↑ Smoking
↑ Suicide
↓ Life Expectancy (getting worse)

41. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

42. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

43. Psychotic Symptoms
= Psychiatric Disorder
 Brief Reactive Psychosis
 Puerperal Psychosis
 Delusional Disorder
 Mood-related (eg: BPAD or Depression)
 Schizophrenia
 Schizophreniform
 Schizoaffective

44. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics

45. Treatment
1. Supportive Psychotherapy
Table 15.4, page 273

46. Treatment
2. Therapeutic Use of Self
Containment
Awareness
Resilience
Engagement

47. Treatment
3. Cognitive Behavioural Therapy (CBT)
Unlearn & Relearn
Skills vs Reactions
EBP
Pages 270-272

48. Treatment
3. Psychotropic Medications
“You can medicate the
brain but you have to
talk to a mind.”
Sandy Jeffs

49. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics

50. Psychotropic Medications
Either:
1. Modify reuptake
into the neuron
(nerve cell)
2. Activate receptors
3. Inhibit receptors
4. Inhibit enzyme
activity

51. Neurotransmitters
 Knowledge incomplete
 At least 40 different types
 Serotonin
 Noradrenaline (aka Norepiniphrene)
 Dopamine
 5 different subtypes of dopamine D1 –D5
 Antipsychotics act as antagonists at dopamine receptors
 Interfere with the binding of dopamine to the receptor
 Acetylcholine
 GABA (gamma-aminobutyric acid)

52. Nursing Roles
Administration
Education
Effects
Unwanted side effects
Adherence vs Non-adherence

53. Nursing Strategies
Correct misconceptions
Emphasis personal choice
Empathy
Support
Goal-setting/Motivational Interview
Explore
Lifestyle changes
Alternatives
How long will I need to take medications?
Cost

54. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics


55. Antipsychotic Indications Dx
 Acute Psychosis
 Chronic Psychosis
 Delusional Disorder
 Schizophrenia

56. Antipsychotic Indications Sx
+ve [excess]
 Hallucinations
 Delusions
 Thought Disorder
-ve [deficit]
 Avolition (↓ drive)
 Anergia (↓ energy)
 Anhedonia (↓ pleasure)
 Affect Blunted
 Alogia (↓ speech)

57. First Generation (1950s)
aka Typical, Traditional Antipsychotics:
 Phenothiazine's – Thioridazine (cardiotoxic)
 Thioxanthines - Flupenthixol
 Butyophenones - Haloperidol
 Diphenylbutylpipridines – Pimozide
 Trifluoperazine – Stelazine
 Chlorpromazine – Largactil
 Zuclopenthixol - Clopixol

58. Typical Antipsychotics
dopamine antagonists
primarily block
postsynaptic D2
receptors
reduce positive
symptoms

59. Second Generation (1990s)
aka Atypical Antipsychotics
 Clozapine
 Risperidone
 Olanzapine
 Quetiapine
 Amisulpride
 Sulpiride
 Aripiprazole
 Paliperidone

60. Atypical Antipsychotics
block action of dopamine
receptor D2 & serotonin
receptor 5HT2
Reduce positive symptoms
Reduce negative
symptoms
Less EPSE

61. Routes
Oral: tablet, wafer, liquid
eg: Zuclopenthixol dihydrochloride
tablets 10 & 20mg
Intramuscular Injection (IMI):
Depot or Long Acting Injection (LAI) = 1- 6 weeks
eg: Zuclopenthixol deconate
200mg/ml; typical dose = 200-400mg every 2-4 weeks
Short Acting = 1 hour to 3 days
eg: Zuclopenthixol Acuphase
50mg/ml; typical dose = 50-150 mg every 2-3 days; max. 400mg

62. Depot IMI
 Oily based solution
 Regular Administration
 Typically Weekly or Fortnightly
 Monthly more likely to be non-oily LAI (eg: Paliperidone)
Advantages?
Disadvantages?
 Z-Track Technique

63. Z-Track Technique
picture via thenursepath.com

64. Injection Site
picture via thenursepath.com

65. picture via gumtree.com.au

66. Potential Side Effects:
 Extrapyramidal Side Effects (EPSE)
 Sedation
 Photosensitivity
 Anticholinergic
 Endocrine
 Metabolic

67. EPSE
Acute Dystonic Reaction
involuntary movement characterised by sustained muscle contraction of head,
back & torso, occurs suddenly
Oculogyric Crisis
transient stare followed by upward & lateral rotation of the eyes
Akathisia
restlessness, leg aches, cannot sit still
Parkinsonism
rigid , mask like facial expression, shuffling gait, drooling

68. EPSE
Tardive Dyskinesia
involuntary movement of the tongue, lips & feet; results from prolonged use of
typical antipsychotics
Neuroleptic Malignant Syndrome
potentially fatal with hyperthermia, EPS, sweating, muscle rigidity, clouding of
consciousness
Seizures
Typical antipsychotics reduce the seizure threshold risk by about 1%

69. EPSE Treatment
Anticholinergic drugs
Benztropine mesylate – Cogentin – IM, IV, Oral
Shorter half life than the causative agent
Reduction in dose or cease antipsychotic
Change traditional antipsychotic to atypical

70. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics


71. Antidepressants
Tricyclic (TCAs)
Monoamine Oxidase Inhibitors (MAOIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin-Norepinephrine Reuptake Inhibiters
(SNRIs)

72. Antidepressants
SSRI: selective serotonin
reuptake inhibiter
SNRI: serotonin-
norepinephrine reuptake
inhibiter

73.  Anxiety
 Agitation
 Loss of libido
 Abdominal pain
 Weight gain
 Headache
 Nausea
 GI disturbance
 Erectile problems
 Sleep disruption
 Sedation
 Inability to achieve
orgasm
 Dry mouth
 Blurred vision
 Cardiac problems
 Constipation
 Restlessness
 Loss of appetite
 Dizziness
 Fatigue
Potential Side Effects:

74.  Anxiety
 Agitation
 Loss of libido
 Abdominal pain
 Weight gain
 Headache
 Nausea
 GI disturbance
 Erectile problems
 Sleep disruption
 Sedation
 Inability to achieve
orgasm
 Dry mouth
 Blurred vision
 Cardiac problems
 Constipation
 Restlessness
 Loss of appetite
 Dizziness
 Fatigue
Potential Side Effects:

75.  Anxiety
 Agitation
 Loss of libido
 Abdominal pain
 Weight gain
 Headache
 Nausea
 GI disturbance
 Erectile problems
 Sleep disruption
 Sedation
 Inability to achieve
orgasm
 Dry mouth
 Blurred vision
 Cardiac problems
 Constipation
 Restlessness
 Loss of appetite
 Dizziness
 Fatigue
Potential Side Effects:

76. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics


77. Mood Stabilisers
1. Lithium Carbonate
2. Anticonvulsants
 Carbamazepine
 Sodium Valproate
 Topiramate

78. Mood Stabilisers
Lithium: compromises
ability of neurons to
release, activate or
respond to
neurotransmitters
Sodium Valproate:
believed to affect the
function of GABA

79. Lithium
 250mg tablets
 Dosage titrated until stable blood level
 Therapeutic range 0.6mmol/L-1.2mmol/L
 Regular blood tests- weekly then monthly
Watch for toxicity – vomiting, diarrhoea, tremor,
polydipsia, polyuria, drowsiness, anorexia,
muscle weakness, ataxia, blurred vision,
disorientation.

80. Dr John Cade On discovering the therapeutic
usefulness of lithium in 1949:
“I describe myself as an
enthusiastic amateur full of
curiosity with fair
determination, golden
opportunities, inadequate
knowledge and woeful
technique. But even the small
boy fishing a muddy pond after
school with string and bent pin
occasionally hauls forth a
handsome fish.”

81. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics

82. Anxiolytics/Anti-Anxiety
Benzodiazepines
 Diazepam
 Clonazepam
 Alprazolam
 Lorazepam
 Temazepam*
 Nitrazepam*
*hypontic
Non-benzodiazepines
Buspirone
Propanolol

83. Anxiolytics/Anti-Anxiety
Benzos: presumed to
potentiate GABA
Non-benzos: block beta-
noradrenergic receptors
reducing physiological
symptoms of anxiety (eg
tachycardia)

84. Anxiolytic Indications
 Anxiety
 Insomnia
 Agitation
 Muscle relaxation
 Withdrawal states
 Seizures

85. Diazepam
Oral – tablet.
Diazepam 2 mg & 5 mg tablets available
Dose varies depending on situation, usually 5-40mg per day
Oral - liquid.
E.g. Diazepam Elixir 10mg/10ml
Injection
Diazepam Injection 10mg/2ml
IV give slowly (IM absorption is erratic & therefore not recommended)
Dose varies depending on situation
NB Benzodiazepines are capable of producing all levels of CNS
depression e.g. mild sedation – coma.

86. Anxiolytic Side Effects
 Sedation/Drowsiness*
 Reduced mental acuity*
 Impaired motor
performance*
 Headache
 Dizziness
 Hypotension*
 Restlessness
 Rebound insomnia*
 Rebound anxiety*
 Tolerance*
 Dependence*
 Withdrawal syndrome
if abruptly ceased*
*rationale for limiting use to short-term only

87. Today’s Presentation
 Psychosis
 Symptoms
 Disorders
 Treatment
 Psychotropic Medications
 Antipsychotics
 Antidepressants
 Mood Stabilisers
 Anxiolytics