Chapter 24: Schizophrenia Spectrum & Psychotic Disorders

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Welcome back to the Deep Dive.

It is great to have you with us.

Today we are looking at a stack of research that is arguably the heaviest, most complex, and most critical we have ever covered.

I would agree with that.

We are pulling apart chapter 24 of Psychiatric Nursing, seventh edition, and the topic is the schizophrenia spectrum and other psychotic disorders.

It is a heavy one.

Absolutely.

In fact, the author of the text, Norman Keltner, puts a note right at the front of the chapter that really, um, it just stopped me in my tracks.

Oh yeah.

What did it say?

He basically says, this might be the most important chapter in this entire book.

Wow.

Which is a massive claim when you think about it.

I mean, this book covers everything from anxiety to addiction to personality disorder.

To everything.

But I get the sense he isn't saying it's the most common disorder, is he?

No, and that's the paradox we have to start with.

Schizophrenia only affects about 1 % of the adult population, so it's not common, like say, major depression.

What Keltner's point is about the ripple effect.

It's just a devastating disorder.

It demands a disproportionate of healthcare resources, it fractures families, and it marginalizes people in a way almost no other illness does.

It changes everything.

It takes young people with bright futures and fundamentally alters the trajectory of their lives.

It's a profound illness.

It's the condition that scares people the most, isn't it, if we're being honest?

I think so.

When the average person on the street thinks of psychiatry or mental illness, they probably thinking about mild depression or test anxiety.

They're thinking about the person talking to themselves on the street corner, maybe responding to voices no one else can hear.

Exactly.

It represents the unknown.

It represents a break from reality.

And our mission today is to make that unknown clinically understandable.

If you are a nursing student listening to this, and I know many of you are, this is probably the chapter you've been dreading a little, it's complex.

It feels unpredictable.

But we're going to break it down from the history to the brain chemistry, and finally to what you actually say to a patient who is seeing things you can't see.

And we are going to move through this chronologically, just like the chapter does.

We want to give you a roadmap so that when you walk onto that psych unit, you aren't just reacting, you're assessing.

To kick things off, the text lists three inescapable facts about schizophrenia.

These are the things that the data keeps spitting back at us, no matter what theory is popular at the time.

Right.

These were laid out by a researcher named Weinberger back in 1987, and they still hold true today.

Fact number one is the age of onset.

The age of onset.

It is almost exclusively a disease of late adolescence or early adulthood.

So the transition years, the launch pad years, just when life is supposed to be starting.

Exactly that.

You rarely see a 10 -year -old diagnosed with schizophrenia, and you rarely see a first psychotic break in a 40 -year -old.

It strikes right when a person is supposed to be going to college, starting a career, falling in love, moving out of their parents' house.

That's what makes it so tragic.

That's what makes the disability so profound.

It cuts the legs out from under life just as it's getting started.

It's an interruption of the entire developmental timeline.

What is fact number two?

The role of stress.

We're going to talk a lot about the vulnerability stress model later in this deep dive, but the headline here is that onset and relapse are almost always tied to environmental stress.

So it's not just some random ticking time bomb in the genes that just goes off.

Right.

The environment pulls the trigger.

It's an interaction.

Okay.

An interaction between the person and their world.

And the third fact.

The efficacy of dopamine antagonists.

Put simply, drugs that block dopamine receptors work.

They are therapeutic.

Which gives us a huge clue about the biology, doesn't it?

It's like working backward from the cure to the cause.

Precisely.

If blocking dopamine reduces the symptoms,

then dopamine or an excess of it must be a central character in the story of this illness.

It gives us a biological target.

Okay.

So young onset stress triggers and dopamine blocking.

Those are our pillars.

Now, before we get into the weeds of the history and all that, we have to clear up some terminology.

We use the word psychotic so loosely in our culture.

You know, my boss is psychotic or that traffic was psychotic, but clinically that has a very, very rigid definition.

It does.

Psychosis is a drastic disruption of the highest mental functions.

We are talking about the breakdown of thought, language, emotion, and cognition.

So everything that makes us.

Pretty much.

Yeah.

It's the inability to distinguish what is real from what is inside your head.

It often involves hallucinations, seeing or hearing things that aren't there, and delusions, believing things that just aren't true.

And schizophrenia is just one type of psychosis.

Correct.

And that's a vital distinction for a student to make.

Schizophrenia is a syndrome,

but you can be psychotic because you're manic and bipolar eye.

You can be psychotic because of a severe major depression or because you took too much methamphetamine or LSD.

You can even be psychotic because of a brain tumor or a high fever.

Schizophrenia is a specific chronic condition

where psychosis is the main feature, but it's not the only cause.

Okay.

And while we are defining things, let's kill the biggest myth immediately.

The Jekyll and Hyde thing.

Oh, please.

I feel like pop culture has done so much damage here.

We need to just delete that from our collective hard drive immediately.

Schizophrenia is not multiple personality disorder.

It is not what we now call dissociative identity disorder.

There is no split into two different people.

It's not like there is a good John and a bad John living in the same body.

No, not at all.

The text describes it as a deteriorated personality.

A deteriorated personality.

Yes.

It's not a splitting of the self into different functional characters.

It's a crumbling of the self, a profound dismantling of the person's ability to function, to think clearly and to relate to the world.

It's much more heartbreaking, honestly, than some movie plot twist about hidden identities.

Exactly.

It's a tragedy, not a gimmick.

A crumbling of the self.

That's a heavy image, but I think it really helps set the stage for what we are actually looking at.

So let's look at how we even figured this out.

The history here is actually a battle between two different ways of seeing the human mind.

The text calls them the giants of psychiatry.

This really starts in the mid 1800s.

You have to imagine the asylum system back then.

I mean, doctors were seeing these young people, 18, 19 years old, who were bright and capable students, suddenly just stop functioning and regress.

They were just looking for a name for this.

What is this thing?

Exactly.

This is where a French physician named Morel comes in around 1860.

He was treating an adolescent boy who had been a star student and then just stopped.

Morel used the term dementia precox.

Dementia precox.

That translates to what?

Precocious senility.

Exactly.

Premature senility or early dementia.

He was essentially saying, this boy is losing his mind the way an 80 -year -old does with senility, but he's only a teenager.

So it implied a hopeless biological decay.

A death sentence for the mind.

That was the implication.

Then fast forward to the turn of the century and we get the heavyweight title fight.

The two names that really shaped how we see this today,

Emile Creplin and Oigen Bloyler.

This distinction is so crucial for nursing students to understand because it really shapes how we treat patients even today.

Okay.

So first you have Emile Creplin around 1899.

He was the great classifier.

He took all these weird symptoms that other doctors had named like catatonia, which is being frozen, and hebofrenia, which is being silly and bizarre.

And he said, these are all the same disease.

And he grouped them all under that label dementia precox, but he was a pessimist, wasn't he?

The ultimate pessimist.

He believed dementia precox was purely biological, progressive, and incurable.

He thought the brain was essentially rotting away.

So if you were a patient of Creplin, the message was, get comfortable.

You're never leaving the asylum.

That's pretty much it.

He didn't believe therapy or anything like that could touch it.

It was a broken brain.

End of story.

And then Oigen Bloyler enters the chat a few years later in the early 1900s.

And Bloyler is the one who coined the term schizophrenia.

Now, this is where all the confusion comes from.

Right.

The split mind thing.

Exactly.

Schizo means split and frame means mind, but he didn't mean a split personality.

He meant a split between the mind and reality, or a split between the emotional functions and the intellectual functions.

And crucially, he was more optimistic than Creplin.

Much more so.

He was influenced by Freud and the psychodynamic movement.

He was looking at patients and thinking, wait a minute, not everyone deteriorates completely.

Some people get a little better.

He thought there was a psychological component that could be treated.

And to help people diagnose it, he gave us the four A's.

The four A's.

This is classic nursing school exam material.

We need to walk through these slowly.

Okay.

So these were his criteria for the core symptoms.

Number one is affect.

This refers to the emotional expression.

The outside manifestation of emotion.

Exactly.

And in schizophrenia, the affect is often flat, which means no emotion, blunted, meaning very little emotion, or inappropriate, like laughing at sad news.

Okay.

So affect is number one.

Number two is autism.

Now, he didn't mean the autism spectrum disorder we diagnose in children today.

He meant a profound introspection and social withdrawal.

So living entirely in their own private internal world.

Yes.

Completely detached from social reality.

Okay.

Affect and autism.

What is the third A?

Associative looseness.

This is all about how thoughts connect to each other.

In a healthy brain, one thought leads logically to the next.

In schizophrenia, the threads break.

The logic just disconnects.

The associations become loose and that leads to speech that is really, really hard to follow.

And finally, number four.

Ambivalence.

Ambivalence.

So that's having mixed feelings, right?

Like I'm ambivalent about what to have for dinner.

Yeah.

It's more intense than that.

It's holding two opposing very strong emotions toward the same person or object at the exact same time.

Like loving and hating your mother simultaneously.

And that leads to a kind of paralysis.

A paralysis of will.

You can't move because the opposing forces are equal.

So Kraepelin said, it's a broken brain.

They're doomed.

And Bloyler said, it's a troubled mind.

There is hope.

Who won the history war?

Well, for most of the 20th century, especially in America, we followed Bloyler.

We tried therapy.

We tried to talk people out of their psychosis.

We looked for reasons in their childhood.

But that's changed, hasn't it?

It has.

In the last 30 years or so, the pendulum has swung hard back to Kraepelin.

With the advent of MRI scans, genetic mapping, neurotransmitter research,

we now know this is a brain disease.

It is heavily biological.

It's fascinating how science can circle back like that.

So we realized Kraepelin was right about the biology, but we hope Bloyler was right about the optimism that with treatment, we can help.

That's a perfect way to put it.

Okay.

Let's move to the present day.

Let's look at the course of the illness.

If a student is observing a patient over time, what does the trajectory look like?

It's not just a flat line of crazy, is it?

No, not at all.

It moves through phases.

The text outlines three specific phases they can sort of overlap.

First, you have the acute phase.

This is the crisis.

This is the explosion.

This is the severe psychosis, the hallucinations, the delusions that disorganize behavior.

This is usually when the patient is brought to the hospital, often by police or terrified family members.

They're often a danger to themselves or others at this point.

Okay.

So that's the acute crisis.

Then what happens?

Then hopefully with treatment, we enter the stabilizing phase.

The medications are starting to kick in.

The acute symptoms are decreasing.

The voices might not be gone, but they're quieter.

The patient is no longer throwing chairs.

And final.

The stable phase.

And this is where we have to be really, really careful with our language and our expectations.

Because stable doesn't mean cured.

Right.

And that is the hardest expectation for families and new nurses to manage.

Stable might mean the patient still hears voices, but they know not to obey them.

It might mean they can live in a group home and sort mail at a sheltered workshop, but they can't handle a high -stress corporate job.

It's about finding a new baseline.

A new baseline.

The text uses the clinical example of a patient named Billy.

He's 39.

He still sees things.

But he's safe, he attends day treatment, and he isn't hurting anyone.

In the context of schizophrenia, that is success.

Okay, let's get to the diagnostic checklist.

The DSM -5 criteria.

If I'm a nurse assessing a patient with a clipboard, what boxes do I need to check to say,

this is schizophrenia?

It's a very strict list.

You can't just throw the label around.

You need two or more specific symptoms for a significant portion of a one -month period.

And this is the key rule.

At least one of those symptoms must be one of the big three.

The big three.

And what are they?

Delusions, hallucinations, or disorganized speech.

You have to have one of those.

You can't just be quiet and withdrawn.

You have to have that active distortion of reality to get the diagnosis.

And you need to see signs of this disturbance for how long?

Six months.

Continuous signs of the disturbance must persist for at least six months.

And that includes the prodromal or early warning periods or the residual periods.

So what if it looks exactly like schizophrenia, but it's only been happening for, say, three weeks?

Then it's likely a brief psychotic disorder if it's been two or three months.

It's schizophrenia disorder.

Once you cross that six -month line, you get the chronic schizophrenia label.

So it's a diagnosis of longevity.

It really is.

That's a heavy label to carry.

Now, the text makes a huge point.

And I think this might be the most useful clinical point in the entire chapter about distinguishing between type I and type II schizophrenia.

Oh, absolutely.

Or, as they are better known, positive versus negative symptoms.

This is probably the most useful concept for understanding medication and prognosis.

We need to forget the old subtypes like paranoid schizophrenia or catatonic schizophrenia.

Why is that?

The DSM -5 actually removed them because they weren't stable over time.

Patients would shift between them.

What really matters clinically is this distinction, positive versus negative.

Let's break this down then.

Start with type I, positive symptoms.

OK, think of positive like a plus sign in math.

It is something added to the person's normal functioning.

It's an embellishment or an exaggeration of normal function.

So hearing voices is a positive symptom because it's an added experience.

Exactly.

Normal functioning does not include hearing voices.

A patient with positive symptoms has that added to their experience.

Delusions are an addition, agitation, pacing, talking in word salads.

These are all extra behaviors.

And biologically, what is driving this?

What's the theory?

Dopamine.

Specifically, a hyper dopaminergic process.

Too much dopamine in the limbic system of the brain.

OK.

And because it's a chemical excess, our traditional medications, which are dopamine blockers, work really well on these symptoms.

If a patient comes in screaming at invisible people, which is a positive symptom, we can treat that effectively with typical antipsychotics.

The text mentions a clinical example, a patient named John.

He enters the unit.

His eyes are darting everywhere.

He's anxious.

He says he's hearing voices.

It's classic type I.

Now flip it.

Type II or negative symptoms.

OK.

So think of a minus sign.

Something has been taken away from normal functioning.

The personality has lost something.

OK.

Like what?

Avalition.

The loss of motivation or will.

Energia.

The loss of energy.

Antidonia.

The loss of pleasure.

Flat effect.

The loss of emotional expression.

It's an absence of normal behaviors.

The text mentions a patient, Philip Wilson.

And he just sits.

He stared out the window.

He doesn't speak.

He doesn't bathe.

He has no drive.

That is classic negative schizophrenia.

And here is the tragedy.

Because this is thought to be caused by too little dopamine in another part of the brain, the cortex, or by actual structural brain damage like atrophy or enlarged ventricles.

The traditional dopamine blocking drugs often don't help.

Right.

In fact, they could make it worse.

Really?

How?

Well, if you block dopamine in a brain that already has too little dopamine in the cortex, you might just make the patient more withdrawn, more apathetic, more zombie -like.

So what works then?

This is why type 2 responds better to atypical antipsychotics, the newer generation drugs, which try to balance both serotonin and dopamine.

But generally speaking, negative symptoms are much, much harder to treat.

That is such a critical piece of knowledge for a nurse to have.

You need to know what you're treating.

And there's one more nuance regarding negative symptoms the text highlights.

Primary versus secondary.

Yes.

This is so important.

Primary negative symptoms are caused by the disease itself, the apathy that's caused by the brain structure.

We can't do a lot about that.

But secondary symptoms.

Secondary negative symptoms are caused by something else.

Maybe the medication is too sedating.

Maybe they are profoundly depressed because they're stuck in a hospital.

Maybe they have lost all their friends and have no social support.

And the good news about those is that they're treatable.

Exactly.

We can lower the med dose.

We can treat the depression.

We can improve their social support.

So we shouldn't just write off a withdrawn patient as untreatable.

We have to investigate the cause.

Let's move into the clinical presentation.

The text divides the section into objective signs, what the nurse can see, and subjective symptoms, what the patient feels.

Start us off with the objective.

What does schizophrenia look like from the outside?

Well, the most visible sign is usually alterations in personal relationships.

And this often happens way before the formal diagnosis.

A breakdown in the social glue.

That's a great way to put it.

We all shower.

We dress nicely.

We use manners because we care what other people think.

A person with schizophrenia often loses that social tether.

There's the example of William.

The text paints a really vivid picture.

He goes to Starbucks every morning.

He wears the same dirty clothes.

He smells bad.

He gets a free cup of water and just sits there for hours staring, not talking to anyone.

That is a heartbreaking, very accurate picture.

He is physically present,

but socially he is gone.

Hygiene is a major indicator.

Nurses often have to prod patients just to bathe or brush their teeth because the apathy, the abolition, is just so deep.

And then there are alterations of activity.

It seems like it can go to either extreme.

It does.

On one end, you have psychomotor agitation.

This is pacing, rocking, the inability to sit still.

Just constant purposeless movement.

And on the other end?

You have catatonia.

This is immobility.

The patient might assume a bizarre posture and just hold it for hours.

You could lift their arm up and they would just hold it there against gravity.

That's called waxy flexibility.

Okay, there is a massive safety warning here in the text for nurses regarding activity.

This feels like a stop and listen moment.

Yes.

This is a critical thinking moment for any nurse.

If you see a patient who is restless and pacing, you might think, oh, that's the schizophrenia.

They are agitated.

But it might not be.

It could be akathisia.

Akathisia is a side effect of the medication.

A terrible internal restlessness where you feel like you have to move or you'll jump out of your skin.

It's torment.

And if you give them more medication?

You make it worse.

Yeah.

Or if they're rigid and frozen, it could be catatonia or it could be neuroleptic malignant syndrome or NMS.

Tell us about NMS.

That sounds terrifying.

It is a life -threatening reaction to antipsychotic drugs.

Your muscles go rigid as a board.

Your temperature spikes to 103 or 104 degrees.

And your blood pressure goes completely unstable.

And if you mistake that for catatonia?

And give them more of the drug that's causing it to calm them down,

you could kill them.

So the takeaway for the student is assessment is everything.

Restlessness and rigidity are medical emergencies until proven otherwise.

Check the vitals.

Precisely.

Don't just assume.

Assess.

Now let's go inside the mind.

The subjective symptoms.

This is where it gets really disorienting.

Let's start with altered perception.

Hallucinations are the hallmark here.

These are false sensory perceptions.

There is no external stimulus, but the brain perceives one anyway.

And in schizophrenia, they're almost always auditory.

Overwhelmingly.

The text says about 90 % of them are auditory.

Hearing voices.

And these aren't friendly voices usually.

Rarely.

They are accusations.

You're filthy.

You're stupid.

Everyone hates you.

Or most dangerously, they can be command hallucinations.

Voices that tell them to do things.

Hit that nurse.

Jump out the window.

Take that knife.

It is an absolute requirement that nurses always ask, what are the voices telling you to do?

We have to know if there's a command to harm themselves or others.

The text notes that visual hallucinations are much less common in pure schizophrenia.

Right.

And that's a great diagnostic clue for a nurse.

If a patient is seeing things like spiders on the wall or fire or snakes, you should actually step back and check for toxins.

Oh, interesting.

Is this alcohol withdrawal?

Is this a high fever causing delirium?

Is this poisoning?

Seeing things is often organic or medical, while hearing things is more often psychiatric.

And then we have illusions.

How is an illusion different from a hallucination?

An illusion is a misinterpretation of something that is really there.

Okay, you mean example.

If I look at a coat rack in a dim room and scream because I think it's a man with a knife, that's an illusion.

There's a coat rack there.

My brain just messed up the processing.

Right.

If I look at a completely empty corner and scream because I see a man with a knife, that's a hallucination.

There's nothing there at all.

Got it.

Illusion equals misinterpretation.

Hallucination equals creation.

Now let's talk about alterations of thought.

This is where the language gets really strange.

We talked about loose associations.

The word salad.

It's when the connections between thoughts just completely fall apart.

The text has this incredible tragic transcript from a patient named Bill.

I saw that.

It's wild.

He says,

It sounds like complete nonsense to us.

But if you look closely, you can kind of see the threads, can't you?

You can.

It's not random words.

It's just that the connections are so loose and private that only the patient can follow them.

Bologna is meat.

Meat is flesh.

Charles Manson killed flesh.

Helter Skelter was his motto.

It's just a rapid fire connection of loose concepts.

One concept that I found really helpful for communication with these patients is concrete thinking.

This is absolutely vital for nurses to understand.

Schizophrenia often robs you of the ability to think abstractly.

You become incredibly literal.

So if I say to you, hey, you're pulling my leg, you know I'm joking.

Right.

But a patient with schizophrenia will look down at your leg to see if I'm physically touching it.

They can't grasp the metaphor.

So idioms are dangerous territory.

Very.

If you say reviewing these side effects is a piece of cake,

they might get confused and look for the cake.

Or the classic example from the book, people in glass houses shouldn't throw stones.

What do they say?

A patient will say, right, because the glass would break.

They miss the moral about hypocrisy entirely.

So the advice for the nurses, be boringly literal.

Be direct.

Be clear.

It is time to take your pill, not let's get your meds down the hatch.

Now, delusions.

These are fixed false beliefs.

Fixed, meaning you can't argue them out of it.

False, meaning they aren't true.

And it seems there's a flavor for every fear.

Oh, yeah.

You have delusions of grandeur.

I am the messiah.

I am the president of the United States.

You have somatic delusions.

Right.

My intestines have turned to snakes.

I have brain cancer, despite a perfectly clear MRI.

Nihilistic delusions are really bizarre.

I am dead.

I do not exist.

It's hard to even wrap your head around that.

And then, of course, the most common, paranoid delusions.

The FBI has parked vans outside my house to monitor me.

The text makes a point that paranoia is harder to treat than simple suspicion.

Why is that?

Because it's organized.

A disorganized patient makes no sense at all.

A paranoid patient makes perfect sense, provided you accept their one crazy premise.

Yeah, OK.

If you accept that the FBI is after them, then the fact that the mailman looked at them funny is evidence.

Everything fits the narrative.

And if you try to disprove it, you just become part of the conspiracy.

Of course, you'd say there's no van.

You're working for them.

Exactly.

You cannot win an argument with a delusion.

It's a futile effort.

OK.

If we've covered the what, now let's go deeper into the why.

The etiology.

We touched on genetics earlier.

Mm -hmm.

The genetics are strong.

The data is very clear.

If you have no family history, your risk is about 1%.

If one parent has it, it jumps to about 10%.

And what about for twins?

If your identical twin has schizophrenia, your risk is 50%.

50%.

That is a massive genetic component.

But what I'm hearing is it's not 100%.

And that's the key.

It's not 100%, which means genetics isn't destiny.

There has to be something else.

Correct.

Even with identical DNA, one twin can get it and the other might not.

That brings us back to the environment.

There has to be a second hit.

And one of the most fascinating theories regarding this second hit is the viral theory.

It's so interesting.

There's a statistical anomaly that researchers have found all over the world.

People with schizophrenia are more likely to be born in the late winter or early spring.

Why?

That seems so random.

How could the season you're born in affect this?

It points to the prenatal environment.

If you were born in March, your mother's second trimester of pregnancy, which is a critical period for brain development, occurred during flu season, October, November.

Okay.

The theory is that the mother contracted influenza or some other virus.

The virus itself or maybe the mother's immune response to it interferes with the fetal brain organization.

It leaves a tiny biological scar that doesn't show up until the brain fully matures in early adulthood.

That is wild.

It connects the flu season from 20 years ago to a psychotic break today.

It really highlights how biological this illness is, which is why we have to be very, very firm about dismissing the old psychodynamic theories.

You mean the schizophrenogenic mother.

It's a shameful period in the history of psychiatry.

For decades, doctors told families,

your son is sick because the mother was cold, domineering, and sent mixed signals.

They blamed the moms.

Imagine the guilt.

You have a child with this devastating illness and the doctor tells you you caused it by not hugging them enough.

It was horrible.

And it alienated families from the treatment process for decades.

We now know this is absolutely false.

Bad parenting does not cause schizophrenia.

It is a brain disease.

But stress does matter.

Yes.

And this brings us to the vulnerability stress model, which is really the modern synthesis of all these theories.

How does that work?

Think of it like a bridge.

Some people are born with a steel bridge, meaning really good genetics.

Some are born with a wooden bridge, meaning a genetic vulnerability.

Okay.

If a semi -truck, which is a major life stress, drives over the steel bridge, it's fine.

If that same truck drives over the wooden bridge, it collapses.

So schizophrenia is the collapse of a vulnerable brain under stress.

The stress didn't build the faulty bridge, but it caused the failure.

That is a great analogy.

Let's pivot to special issues and comorbidities.

These patients aren't just dealing with psychosis.

They're often very, very sick physically.

The statistics are grim.

Their life expectancy is 20 years shorter than the average person.

20 years?

That's unbelievable.

20 years.

Part of that is lifestyle poverty, poor diet, lack of exercise.

But a huge part of it is cigarette smoking.

The statistic in the text blew my mind.

Something like 85 % of people with schizophrenia smoke.

Compared to about 23 or 24 % of the general population, that is not a coincidence.

They're not just smoking for social reasons?

No.

They are self -medicating.

Nicotine directly affects dopamine receptors in the brain.

It actually transiently improves their cognition.

It helps them filter out some of the sensory noise.

It even reduces the side effects of their heavy medications, like the stiffness.

So they are chemically treating their own symptoms with nicotine.

That's exactly right.

Which makes quitting smoking a very complex ethical and clinical issue for nurses.

How so?

If you are a nurse and you just strip the nicotine patch off a patient, or you force them cold turkey, you might actually see their psychosis get worse.

The text suggests the QIT mnemonic question, understand, identify, time.

But it emphasizes patience.

You have to understand why they smoke before you can help them stop.

There's another weird but very dangerous comorbidity mentioned.

Polydipsia.

Psychosis -induced polydipsia.

This is compulsive water drinking.

Some patients will drink 4 to 10 liters of water a day.

10 liters?

Why?

We think the disease itself affects the thirst regulation center in the hypothalamus.

They just feel pathologically thirsty all the time.

And the danger is?

And what?

Drowning.

The danger is water intoxication or hyponutremia.

You dilute your blood sodium so much that your electrolytes crash.

You can have seizures, go into a coma, and die.

So if you're a nurse and you see a patient hugging the water cooler or, God forbid, drinking from the toilet.

That is a major red flag.

That is a medical emergency.

You need to restrict fluids and check their sodium levels immediately.

And finally, the ultimate risk.

Suicide.

It is the leading cause of premature death in this population.

About 20 % attempt it and 5 to 10 % succeed.

That's a huge number.

It's massive.

And here is a counterintuitive and heartbreaking fact.

It's often not when they are at their craziest, most psychotic point.

It's when they are getting better.

Wait, really?

When they are improving?

Yes.

When the psychosis clears enough for them to have insight into what they have lost.

I'm 25.

I dropped out of college.

My friends are all scared of me.

And I have a chronic brain disease for the rest of my life.

The insight brings despair.

So nurses need to be hypervigilant during the recovery phase, just as the patient seems to be stabilizing.

That's exactly when the risk is highest.

That is a profound insight.

The danger is in the realization.

Okay, let's bring this to the bedside.

Psychotherapeutic management.

You are the nurse.

You are standing in the room.

The patient is scared and paranoid.

What do you do?

The text has a beautiful goal for this.

Help them become stronger than their symptoms.

I love that phrase.

We aren't trying to fix everything instantly.

We aren't trying to argue them out of their illness.

We are trying to empower them to cope.

And it all starts with the relationship.

The foundation is the nurse -patient relationship.

And the core of that is trust.

These patients are suspicious by nature.

If you say, I'll be back in 10 minutes and you come back in 20, you have just confirmed their paranoia.

You proved you are a liar.

So you have to be a clockwork human.

Consistent, reliable,

honest.

Do what you say you will do every single time.

Now the million -dollar question every student asks,

how do you talk to the delusions?

The patient says, the mafia is in the hallway with guns.

What do you say?

Okay, so you don't say no, they aren't, you're crazy.

And you don't say, oh my God, let's hide under the bed.

Both are wrong.

Both are wrong.

If you argue, you lose rapport.

They just get defensive and hold on to the belief even tighter.

If you agree, you validate the illness.

You make them sicker.

So what's the middle ground?

You use reality testing.

You acknowledge the feeling, but you deny the fact.

Give me the script.

What does that sound like?

I know that you are afraid.

I know it feels very real to you that the mafia is there, but I do not see anyone in the hallway.

I believe you are safe here.

So you validate the fear.

I know you are afraid.

Yes.

And then you present your own reality.

And then you offer safety.

You are safe.

And for hallucinations, if a patient says, I hear voices telling me to die.

A very similar approach.

You state your reality clearly.

I do not hear the voices that you hear.

It's simple.

It's factual.

You aren't calling them a liar, but you are grounding them in your shared reality.

I only hear your voice and mine.

And then you have to ask about the content.

Always.

Are the voices telling you to hurt yourself?

You have to know the content to assess the risk.

What about physical touch?

Never touch a psychotic or paranoid patient without warning.

Ever.

Why is that?

If their reality is distorted, a friendly hand on the shoulder might feel like a claw or a knife or an electric shock.

You use your voice first.

I am going to check your blood pressure now before you reach out with a cuff.

And whispering.

The text is adamant about this.

Do not whisper in the vicinity of these patients.

If they see two nurses whispering at the nursing station, they know with 100 % certainty that you are plotting against them.

It feeds the paranoia directly.

Speak clearly and openly.

Let's talk meds.

Psychopharmacology.

We can't fix the broken brain without chemistry.

We have two main buckets.

Typical or traditional and atypical.

Right.

The traditionals like Haldol, which is heloperidol, and Thorazine, which is chlopromazine.

These are the sledgehammers.

They block dopamine hard across the whole brain.

And they're good for?

They are great for the positive symptoms.

Stopping the voices.

Stopping the agitation.

And they are cheap.

The text implies they might cost only $20 a month.

But the side effects?

The side effects are brutal.

Stiffness, shaking, the Thorazine shuffle, and eventually a risk of tardive dyskinesia, which is a permanent disfiguring twitching.

And the atypicals.

The newer ones like Zaprexa, Risperdal, Clauser.

These are more like scalpels.

They target specific dopamine and serotonin receptors.

So they can help with the negative symptoms, like withdrawal and apathy.

And they have fewer of those terrible movement side effects.

With cost.

The cost is the issue.

The text mentions upwards of $500, $800 a month for some of these.

Which brings us to the biggest nursing challenge with meds.

Adherence.

Absolutely.

If a patient has to choose between paying rent and buying their Zaprexa, they choose rent.

If the hall doll makes their hands shake so bad they can't drink a cup of coffee, they're going to stop taking it.

So what can a nurse do?

Nurses have to watch for cheeking that's hiding the pill in their cheek to spit out later.

We have to educate them.

And sometimes we have to use depot injections.

Long -acting injectables that last for two to four weeks.

So they don't have to remember to take a daily pill.

And finally, there's milieu management.

Managing the environment itself.

Yes.

You can't just put a schizophrenic patient in a busy, loud ER waiting room and expect them to be calm.

Their brain can't filter the stimuli.

Exactly.

A chaotic room feels like a physical attack to them.

You need low lights.

Low noise.

Simple decor.

And you have to manage the media.

What do you mean by that?

If a patient has religious delusions, do not let them watch the televangelist on TV screaming about demons.

If they're paranoid,

turn off the violent crime drama.

The environment feeds the mind for better or worse.

Before we wrap up, we should probably briefly mention that psychosis isn't always schizophrenia.

The book lists a few lookalikes.

Right.

Just some quick definitions to keep things clear.

Schizophreniform disorder.

This looks exactly like schizophrenia, but it hasn't lasted six months yet.

It's a provisional diagnosis.

Okay.

Brief psychotic disorder.

This is a sudden break, usually due to a major stress that lasts less than a month, and the person has a full recovery.

And delusional disorder.

This one is really interesting.

It is.

With this one, there are no hallucinations, no word salad, just one specific fixed delusion.

My wife is cheating on me.

Denzel Washington is in love with me.

Other than that one weird belief, they function totally normally.

They hold down jobs.

They aren't crazy in the general sense.

And last, schizoaffective disorder.

This one seems to confuse a lot of students.

Think of it as a hybrid.

It's a mashup of schizophrenia and a mood disorder, like bipolar or major depression.

So they have both sets of symptoms.

Exactly.

They have the psychosis, the hallucinations and delusions, but they also have the distinct manic highs or the depressive lows.

The prognosis is sort of in the middle.

Better than pure schizophrenia, but worse than pure bipolar.

So with all of this, what is the future?

Is there any good news on the horizon?

The hope lies in early identification.

That's where the research is heading.

Looking for the signs before the break.

Yes.

Looking for the prodromal signs.

The warnings before the crash.

A teenager who suddenly stops showering.

Who drops all their friends.

Who starts writing pages and pages of bizarre nonsense in a journal.

Who gets obsessed with the occult or strange philosophies.

And if we can catch them then?

If we can catch them then and get them into treatment before the full psychotic break happens, we think we can save a lot of brain function and improve the long -term outcome dramatically.

That's the mission then.

Pay attention.

Catch it early.

Treat with compassion.

Absolutely.

That's the whole game.

We have covered a huge amount of ground today.

From the 1800s asylums all the way to dopamine receptors in the brain.

But I want to end on that quote you mentioned at the very beginning.

From PJ Rukio.

Right.

That's a powerful one.

Most schizophrenics go on for years struggling alone without anyone to help them become stronger than their symptoms.

If you are a student listening to this,

be that person.

Be the one who sees the human being behind the hallucination.

That's the job.

That's what nursing is.

Thanks for diving deep with us.

And a warm thank you from the Last Minute Lecture Team.

Take care.