PSYCHOTIC DISORDERS

A psychotic disorder involves a loss of contact with reality. Psychotic disorders are rare, affecting just 1% of the population, and often begin in the individual’s late teens to early 30s (Mercy, 2023).

Psychotic disorders include:

• Schizophrenia
• Schizoaffective disorder
• Schizophreniform disorder
• Brief psychotic disorder
• Delusional disorder
• Shared psychotic disorder (also called folie à deux)

Psychotic disorders, primary or medically related, are defined by abnormalities in one of the following domains:

• Delusions: Fixed false beliefs for which the person lacks insight, even in the face of evidence that proves contrary to their validity
• Hallucinations: Perceived experiences (auditory, visual, tactile) in the absence of external stimuli
• Disorganized thoughts: Speech and communication patterns that may include:
• Loose associations: Sequences of unrelated or loosely related ideas
• Circumstantial thought: Inability to give a direct answer to a question without excessive unnecessary detail
• Tangential thought: Drifting from a topic never to return to the original point
• Word salad: unintelligible or incoherent jumble of words
• Neologisms: Made up words or phrases
• Perseveration: Repetition of words and statements
• Disorganized behavior: Bizarre or inappropriate behavior, actions, or gestures that may include:
• Faulty goal-directed activity that leads to a decline in daily functioning
• Inappropriate and/or unpredictable impulse control
• Socially inappropriate, nonsensical actions
• Catatonic behavior: Decrease in reactivity to the external environment
• Negative symptoms: Withdrawal and absence of interest in everyday social interactions that may include:
  • Decrease or loss in normal functioning (which can be confused with depressive disorders)
  • Inexpressive or emotional blunting, with “flat affect”
  • Simplistic or prosodic speech patterns along with alogia (poverty of speech)
  • Psychomotor retardation
  • Lack of energy
  • Loss of interest, concentration, and pleasure in formerly pleasure activities (anhedonia)
  (Calabrese et al., 2022)

Treatment for Psychotic Disorders

Some patients with psychosis require inpatient care. Residential and inpatient psychosis treatment facilities provide around-the-clock care for those who need more help than an outpatient program offers. Others may have a condition that can be managed at home along with outpatient psychotherapy.

ANTIPSYCHOTIC MEDICATIONS

Antipsychotic medications are universally indicated for the treatment of psychotic disorders. These medications are effective in the treatment of acute and chronic psychotic disorders and for maintenance therapy to prevent exacerbation of symptoms. These are referred to as “typical” (first-generation, conventional antipsychotics) or “atypical” (second-generation or newer antipsychotics).

The many benefits of antipsychotic medications are often negated by their many adverse effects. It is important for healthcare providers to be aware of the many problems that can arise in patients they are caring for who are being treated with these medications and to monitor them carefully. Side effects of antipsychotic medications may include:

• Extrapyramidal symptoms: Drug-induced movement disorders, including akathisia, dystonia, dyskinesia, akinesia, Parkinsonism, tardive dyskinesia
• Neuroleptic malignant syndrome: One of the most dangerous adverse effects of antipsychotics; a medical emergency often requiring intensive care that manifests with fever, autonomic instability, rigidity, and altered mental status
• Neutropenia/agranulocytosis: Most commonly a side effect of clozapine (Clozaril) that causes reduction of infection-fighting neutrophils, and the more serious form, agranulocytosis; both of which increase susceptibility to infection and require monitoring of granulocyte counts
• Excessive production of saliva (sialorrhea): A side effect common for those treated with clozapine and that can result in aspiration pneumonia
• Metabolic syndrome: A significant issue that increases the risk of adverse health outcomes; requires those taking an atypical antipsychotic to have weight, glucose levels, and lipid levels monitored regularly
• Cardiovascular events: QT interval prolongation and sudden death
• Cholestatic jaundice: Psychiatric drug-induced hepatic injury
• Orthostatic hypotension: A risk factor for all antipsychotics, requiring blood pressure monitoring to prevent dizziness, syncope, falls, and worsening of angina
• Anticholinergic side effects: Dry mouth, constipation, blurred vision, increased pupil size, tachycardia, and urinary incontinence
• Prolactin elevation: A side effect that can lead to sexual dysfunction, galactorrhea, and gynecomastia
  (Freudenreich & McEvoy, 2023; Wijdicks, 2022; Jibson, 2022)

THERAPY INTERVENTIONS

While medications are central in the treatment of psychotic disorders, therapy can also be essential. Types of therapy may include:

• Cognitive Behavioral Therapy (CBT): An approach that helps patients monitor and analyze thought processes more closely, make rational connections, and recognize when symptoms are arising; also helps strengthen reality testing skills
• Acceptance and Commitment Therapy (ACT): Assists in understanding that it is counterproductive to try to control painful emotions or psychological experiences and that suppression of these feelings ultimately leads to more distress; teaches alternatives to change the way one thinks, including mindful behavior, attention to personal values, and commitment to action
• Cognitive Enhancement Therapy (CET): A recovery phase intervention that uses a combination of medicines, computer-based exercises, and group therapy to treat psychotic disorders
  (Hairston, 2022)

How to Respond to and Care for a Patient with Signs and Symptoms of a Psychotic Disorder

HALLUCINATION

A patient with a psychotic disorder may present with signs of hallucinating, which can include:

• Evidence of intently listening when there is nothing to hear
• Wild eye movements
• Talking to persons who are not present
• Inappropriate facial expressions
• Increased signs of fear and/or agitation
• Preoccupation or being unaware of surroundings
• Isolating and using radio or TV to drown out the “voices”

Responding to and interacting effectively with a patient who is hallucinating requires the healthcare professional to:

• React calmly and quickly with reassuring words. Speak slowly, clearly, and keep sentences simple, as the person may have difficulty concentrating.
• Ask the patient directly if they are hallucinating.
• Do not respond as if the hallucinations are real (e.g., do not say, “Hey, you voices, stop telling her these things!”).
• Do not argue with the patient or deny the patient’s experience, but do suggest your own perceptions.
• Be alert for signs of increasing fear, anxiety, or agitation; the patient may act upon command hallucinations.
• Use touch only after asking permission to do so; some psychotic patients are prone to react negatively.
• Acknowledge the feelings behind the hallucination and try to find out what it means to the person.
• Use distraction. Hallucinations often subside in well-lit areas where others are present. Try to distract with music, conversation, or other enjoyable activity.
• Modify the environment by turning off the television or radio or turning on lights to reduce shadows.
• Help with reality testing by comparing the patient’s perceptions with those of others.
• Stay with hallucinating patients and direct them to tell the voices to go away; repeat often in a matter-of-fact manner. The patient can learn to push the voices aside when given repeated instructions to do so.
• Monitor medication compliance as well as physical health; be certain antipsychotic medications are being prescribed.
• If voices are telling the patient to harm self or others, follow unit protocol (in an inpatient environment) or notify physician, police, or facility administration (in an outpatient environment) and evaluate for need for hospitalization.
  (Townsend, 2018; Martin, 2022b)

DELUSIONS

Patients with psychotic disorders may show signs that they are experiencing delusions, or fixed false beliefs. Delusions are based on a theme, including:

• Erotomania: The belief that someone is in love with them, usually someone important or famous, which can contribute to stalking behaviors
• Grandiosity: An overinflated sense of worth, power, knowledge, or identity, or the belief that they have a special talent or made a great discovery
• Jealousy: The belief that a spouse or sexual partner is unfaithful
• Magical thinking: The belief that their thoughts or behaviors have control over specific situations or people
• Persecutory: The belief that they or someone close to them is being mistreated, spied upon, or planning to harm them; may include repeated complaints to legal authorities
• Reference: The view that all events occurring in the environment refer to oneself
• Somatic: The belief that they have a physical defect or medical problem
• Mixed: A combination of two or more types listed above
  (Casarella, 2020)

Responding to and interacting with a person who is experiencing a delusion requires an understanding that the delusion cannot be challenged and that the patient cannot be dissuaded despite evidence to the contrary. Effective measures include:

• Present reality concisely and briefly and do not challenge illogical thinking or try to convince the patient that the delusion is false.
• Use touch cautiously, particularly if thoughts reveal ideas of persecution, since patients who are suspicious may misinterpret touch as either sexual in nature or threatening and respond with aggression.
• Recognize the delusion as the patient’s perception, which can help with understanding the patient’s underlying feelings.
• Try to distract from the delusion by focusing on reality-based activities.
• Explain and try to be sure the patient understands procedures prior to carrying them out.
• Show empathy to convey caring, interest, and acceptance of the patient.
  (Martin, 2022b; Townsend, 2018)