Learn — Schizophrenia & psychotic disorders

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Erikson psychosocial stages

Erik Erikson's psychosocial theory describes development as eight stages that run from birth to old age, each carrying a central conflict between two opposing pulls that the person must settle before moving on. Resolving a stage favourably builds a lasting ego strength or virtue, while an unresolved conflict leaves a vulnerability that shows itself later as anxiety, mistrust or role confusion, so the theory is used at the bedside to pitch care at the patient's developmental task rather than at chronological age alone.

Trust versus mistrust runs from birth to about 1 year and turns on consistent, responsive feeding and comfort; the virtue gained is hope, and the nursing use is a consistent caregiver and the parent's presence during procedures.
Autonomy versus shame and doubt covers about 1 to 3 years, the age of toilet training and self-feeding; the virtue is will, and the toddler in hospital needs simple choices and a predictable routine rather than blanket restriction.
Initiative versus guilt covers about 3 to 6 years, when the child plans, questions and imitates adults; the virtue is purpose, and therapeutic play lets the preschooler act out a procedure instead of believing illness is a punishment.
Industry versus inferiority covers about 6 to 12 years, the school years of skill and comparison with peers; the virtue is competence, and a hospitalised child of this age should be allowed schoolwork and self-care tasks to keep the sense of mastery.
Identity versus role confusion covers roughly 12 to 18 years and centres on who the person is and where they belong; the virtue is fidelity, and adolescents need privacy, peer contact and a say in their own treatment decisions.
Intimacy versus isolation is the young-adult stage (roughly 18 to 40 years) with the virtue of love; generativity versus stagnation is middle adulthood (about 40 to 65 years) with the virtue of care and an investment in the next generation.
Integrity versus despair is late adulthood from about 65 years onward, with the virtue of wisdom; the nurse supports it through life review and reminiscence therapy, which reduce depressive symptoms in older people.
The examinable contrast is with Freud: Erikson's stages are psychosocial, cover the whole life span and are not fixed by libidinal zones, whereas Freud's five psychosexual stages end at puberty.

Antipsychotic medications — side effects

Antipsychotics are the drugs that control psychotic symptoms by blocking dopamine D2 receptors in the mesolimbic pathway, and they fall into first-generation or typical agents, which block D2 strongly, and second-generation or atypical agents, which block D2 more loosely and also block serotonin 5-HT2A receptors. The two groups are separated in the examination by their adverse effects rather than by efficacy: typical drugs cause extrapyramidal symptoms and hyperprolactinaemia, while atypical drugs cause weight gain, dyslipidaemia and diabetes.

First-generation drugs are divided by potency: high-potency haloperidol (usually 5 to 15 mg a day) and fluphenazine cause more extrapyramidal symptoms and less sedation, while low-potency chlorpromazine and thioridazine cause more sedation, postural hypotension and anticholinergic effects and fewer extrapyramidal symptoms.
Second-generation drugs in common Indian use are risperidone (about 2 to 6 mg a day, with extrapyramidal symptoms and a marked rise in prolactin at higher doses), olanzapine (about 5 to 20 mg a day, the worst for weight gain with quetiapine and clozapine), quetiapine (sedation and postural hypotension), aripiprazole (a partial agonist, weight-neutral, may cause akathisia) and clozapine.
Extrapyramidal symptoms in time order: acute dystonia within hours to days, akathisia within days to weeks, drug-induced parkinsonism within weeks to months and tardive dyskinesia after months to years; the first three respond to dose reduction, a switch, an anticholinergic or propranolol, while tardive dyskinesia is worsened by anticholinergics.
Metabolic syndrome is the dominant harm of the atypicals: weight gain, raised fasting glucose, raised triglycerides and low HDL cholesterol, so weight and waist circumference are recorded at baseline and monthly for three months, and fasting glucose and lipids at baseline, at three months and then yearly.
Hyperprolactinaemia from D2 blockade, most marked with risperidone, amisulpride and haloperidol, produces amenorrhoea, galactorrhoea, gynaecomastia, sexual dysfunction, infertility and long-term bone loss; it is a common reason for a young patient to stop the drug silently, so ask about it directly.
Anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention, confusion in older people), alpha-1 blockade (postural hypotension and dizziness on standing, with a real fall risk), sedation and antihistaminic weight gain, lowering of the seizure threshold, and QT prolongation with the risk of torsades de pointes, worst with thioridazine, ziprasidone, high-dose intravenous haloperidol and pimozide.
Clozapine is reserved for treatment-resistant schizophrenia, defined as failure of two adequate trials of different antipsychotics, and for persistent suicidality in schizophrenia; it causes almost no extrapyramidal symptoms but carries agranulocytosis, myocarditis, seizures, severe constipation and heavy salivation, and needs mandatory blood count monitoring.
Neuroleptic malignant syndrome is the emergency common to the whole class: fever, lead-pipe rigidity, altered consciousness and autonomic instability with a raised creatine kinase; long-acting depot injections such as haloperidol decanoate, fluphenazine decanoate, risperidone and paliperidone palmitate improve adherence but keep the drug in the body for weeks, which matters when a serious reaction occurs.

Types of delusion

A delusion is a fixed, false belief that is held with absolute conviction, is not amenable to reasoning or contrary evidence, and is out of keeping with the person's education, culture and social background. It is a disorder of the content of thought and is distinguished from an overvalued idea, which the person can be argued out of, and from an obsession, which the person recognises as their own senseless thought and resists.

Persecutory delusion, the commonest of all, is the belief of being followed, watched, poisoned or conspired against, and it is the one most often linked to violence and to refusal of food and medication.
Grandiose delusion is a belief in exceptional wealth, power, identity or a special mission and is typical of mania and of schizophrenia; delusion of reference is the belief that ordinary events, news broadcasts or strangers' conversation carry a personal message.
Nihilistic delusion is the belief that oneself, a body part or the world has ceased to exist or is rotting away, and in its full form is Cotard syndrome; it occurs in severe depression with psychotic features, carries a high suicide risk and may lead to refusal of food and fluids.
Delusion of guilt, sin, poverty and hypochondriacal or somatic delusion are mood-congruent delusions of severe depression, while erotomania, the belief that a person of higher status is in love with one, is also called de Clerambault syndrome, and delusional jealousy of a partner's infidelity is called the Othello syndrome and is strongly associated with chronic alcohol use and with violence against the partner.
The delusions of control and thought interference are the ones the examination calls first-rank symptoms of schizophrenia: thought insertion, thought withdrawal, thought broadcasting and passivity or made acts, feelings and impulses in which the person feels their body or will is being operated from outside.
Delusions are classified by form as well as content: primary or autochthonous delusions arise fully formed out of nothing and are characteristic of schizophrenia, while secondary delusions arise understandably from mood, hallucination or another experience; mood-congruent delusions match the mood, and mood-incongruent ones do not.
Delusional disorder is diagnosed when one or more non-bizarre delusions persist for at least one month, functioning outside the delusion is largely intact and the criteria for schizophrenia are not met; it contrasts with schizophrenia, which needs six months of disturbance including one month of active symptoms in DSM-5-TR.
The nursing response is the same whatever the content: do not argue with the belief and do not agree with it, acknowledge the feeling behind it, present reality once and calmly, avoid whispering or laughing within sight of the patient, and focus conversation on the here and now and on the distress rather than on the content.
A culturally sanctioned belief shared by the person's community, such as a religious or supernatural belief held by the family and neighbours, is not a delusion, and the assessment must involve a family member who knows what is normal in that community.

Types of hallucinations

A hallucination is a perception experienced in the absence of any external stimulus, occurring in the person's outer objective space, with the full force and clarity of a true perception and outside their voluntary control. It is distinguished from an illusion, which is the misperception of a real stimulus, and from a pseudohallucination, which is experienced in inner subjective space and is recognised by the person as not being a real perception.

Auditory hallucinations are the commonest in psychiatric illness and are typical of schizophrenia; the forms that carry diagnostic weight are a voice giving a running commentary on the person's actions, two or more voices discussing the person in the third person, and audible thoughts, which the older texts call thought echo or echo de la pensee.
Visual hallucinations point towards an organic cause until proved otherwise: delirium, alcohol and sedative withdrawal, hallucinogens, dementia with Lewy bodies, Parkinson's disease treated with dopaminergic drugs, temporal or occipital lesions, and Charles Bonnet syndrome in people with severe visual loss and intact insight.
Olfactory and gustatory hallucinations, usually of an unpleasant burning or foul smell or taste, suggest temporal lobe epilepsy, where they occur as the aura of a seizure, and also occur in severe depression with delusions of decay.
Tactile or haptic hallucinations include formication, the feeling of insects crawling on or under the skin, seen in cocaine and amphetamine use and in alcohol withdrawal; somatic or visceral hallucinations of things moving inside the body occur in schizophrenia.
Hypnagogic hallucinations occur while falling asleep and hypnopompic hallucinations on waking; both occur in healthy people and are part of the narcolepsy tetrad with excessive daytime sleepiness, cataplexy and sleep paralysis, so they are not by themselves a sign of mental illness.
The named special types are examinable: functional hallucination, in which a real stimulus such as running water is needed for the hallucination to occur and both are perceived; reflex hallucination, in which a stimulus in one sense produces a hallucination in another; extracampine hallucination, experienced outside the field of the sense organ, such as a voice from another city; autoscopy, seeing one's own double; and Lilliputian hallucinations of tiny figures, classically in delirium tremens.
The essential discriminators are that an illusion needs a real object and often corrects itself on closer attention, that a hallucination has no object, that a pseudohallucination lies in inner space with insight retained, and that a delusion is a false belief rather than a false perception.
The nursing response is not to argue about the voice and not to pretend to hear it: acknowledge that the experience is real to the person, state simply that you do not hear it, ask what the voice is saying because command hallucinations to harm oneself or others must be identified, and use distraction, engagement in activity and reality-based conversation.

Negative vs positive symptoms (schizophrenia)

The symptoms of schizophrenia are grouped into positive symptoms, which are experiences added to normal mental life, and negative symptoms, which are normal functions taken away. Positive symptoms are delusions, hallucinations, disorganised speech and grossly disorganised or catatonic behaviour, while negative symptoms are the loss of emotional expression, speech, drive, pleasure and social contact, and the distinction matters because the two groups differ in their course, their response to treatment and their effect on long-term function.

The negative symptoms are learned as the five As: affective flattening or blunting, alogia meaning poverty of speech, avolition meaning loss of drive and goal-directed activity, anhedonia meaning loss of the capacity for pleasure, and asociality meaning withdrawal from relationships; attention impairment is added in some lists.
Positive symptoms respond well to dopamine D2 blockade and usually improve within days to weeks, whereas negative symptoms respond poorly to antipsychotics; positive symptoms tend to fluctuate and recur in relapses, while negative symptoms are more persistent and are the main determinant of long-term disability.
Secondary negative symptoms must be excluded before the negative syndrome is accepted as primary, because they are treatable: drug-induced parkinsonism and sedation from the antipsychotic itself, a depressive episode, the effect of persistent positive symptoms causing withdrawal, and the understimulation of an institutional or empty environment.
Bleuler's fundamental symptoms, the four As of ambivalence, autism, affect disturbance and association disturbance, describe what are now largely negative and disorganisation symptoms, and Schneider's first-rank symptoms, such as thought insertion, withdrawal and broadcasting, third-person voices, running commentary and passivity, describe positive ones.
DSM-5-TR requires at least two of five symptoms, which are delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, and negative symptoms, with at least one of the first three present, for a significant part of one month, and continuous signs of disturbance for at least six months including the prodromal and residual phases.
The duration rules are the standard examination discriminator: brief psychotic disorder lasts at least a day and less than one month with return to full function, schizophreniform disorder lasts at least one month but less than six months, and schizophrenia requires six months of total disturbance.
Management differs by symptom group: antipsychotics for the positive symptoms, with clozapine when two adequate trials have failed, and psychosocial treatment for the negative ones, which means social skills training, cognitive remediation, supported employment, family psychoeducation to reduce high expressed emotion, and structured daily activity.
Nursing care of negative symptoms depends on not mistaking them for laziness or rudeness: allow more time for the person to reply, keep sentences short, set small achievable daily goals, use a written routine, involve the family in reducing criticism and over-involvement, and check adherence, because relapse usually starts with a quietly stopped tablet.
The Mental Healthcare Act 2017 frames the care: the person has a right to treatment in the least restrictive setting and to community living, may make an advance directive stating how they wish to be treated when they are unwell, and appoints a nominated representative to be involved in decisions, and admission without consent is a supported admission with defined safeguards rather than an open-ended committal.

Bleuler 4 As of schizophrenia

Eugen Bleuler renamed dementia praecox as schizophrenia in 1911 and argued that the illness is recognised not by hallucinations and delusions, which he called accessory symptoms, but by four fundamental disturbances of thought and feeling present in every case: loosening of associations, disturbance of affect, ambivalence and autism. At the bedside this looks like talk that begins on one topic and ends on an unconnected one, a face that no longer matches what is being said, opposing wishes held at the same moment so that no decision can be reached, and withdrawal into a private inner world the family cannot enter.

Association loosening is a disorder of the form of thought rather than its content: the ideas follow one another without a logical link, so speech is fluent but the listener cannot follow it, and in the extreme it becomes word salad.
Affect disturbance covers blunting, which is a flat unreactive face and voice, and incongruity, such as laughing while describing a bereavement, together with emotional coldness towards people the person once loved.
Ambivalence is holding two opposite feelings, wishes or beliefs about the same person or act at the same time, so the person begins and abandons the same movement or cannot choose between two ordinary options.
Autism in Bleuler's sense means withdrawal from shared reality into a self-made inner world; it is not autism spectrum disorder, which is a neurodevelopmental condition present from early childhood, and confusing the two is a standard examination trap.
Bleuler called hallucinations, delusions, catatonia and behavioural disturbance accessory because they come and go, whereas Kurt Schneider took the opposite view and made first-rank symptoms the diagnostic core: thought insertion, withdrawal and broadcasting, third-person and running-commentary auditory hallucinations, made acts and feelings, somatic passivity and delusional perception.
Do not confuse Bleuler's four fundamental As with the As used today for negative symptoms, which are affective flattening, alogia, avolition, anhedonia and asociality.
DSM-5-TR requires two or more of delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour and negative symptoms, at least one of them from the first three, with continuous disturbance for six months including one month of active symptoms; DSM-5 and ICD-11 have both abolished the old subtypes such as paranoid and hebephrenic.
First-line drug treatment is a second-generation antipsychotic, risperidone about 2 to 6 mg a day, olanzapine 5 to 20 mg a day or aripiprazole 10 to 30 mg a day, and the named adverse effects to teach are extrapyramidal symptoms and raised prolactin with risperidone, weight gain and dyslipidaemia with olanzapine, and neuroleptic malignant syndrome with any antipsychotic.
Clozapine is reserved for treatment resistance, defined as failure of two adequate antipsychotic trials, and needs monitored blood counts because of agranulocytosis.
Under the Mental Healthcare Act 2017 a person with schizophrenia keeps the right to make an advance directive and to appoint a nominated representative, and capacity is judged decision by decision rather than assumed absent because of the diagnosis.

Korsakoff psychosis

Korsakoff syndrome is the chronic amnestic phase of thiamine deficiency, most often in long-term heavy drinkers, in which damage to the mammillary bodies and the dorsomedial nuclei of the thalamus leaves a dense inability to lay down new memories. The patient is alert, converses normally and has preserved intelligence and immediate recall, yet cannot remember the last conversation, is disoriented in time, and fills the gaps with confabulation, which is plausible invented material offered without any intention to deceive. DSM-5-TR names it alcohol-induced major neurocognitive disorder, amnestic-confabulatory type.

Wernicke encephalopathy and Korsakoff syndrome are two ends of one disease: Wernicke is the acute treatable phase of confusion, ataxia and ophthalmoplegia, and Korsakoff is the chronic phase that follows when it is missed or undertreated.
The memory defect is mainly anterograde with a patchy retrograde loss, while procedural memory, immediate registration and general intelligence are preserved, which is why the patient can still lay a table or ride a bicycle yet not recognise the nurse who fed him an hour ago.
Confabulation is not lying: reorient the patient gently rather than confronting the story, because arguing about a confabulation only distresses them and changes nothing.
The lesions sit in the mammillary bodies and the dorsomedial thalamic nuclei, and the classic Wernicke triad is complete in only a minority of patients, so the absence of eye signs never excludes it.
Thiamine is both the treatment and the prevention: parenteral thiamine is given before any glucose-containing fluid, and magnesium must be corrected because it is the cofactor without which thiamine cannot act.
Prognosis divides the pair: Wernicke eye signs improve within hours to days of thiamine and the ataxia over weeks, whereas established Korsakoff memory loss recovers fully in only a minority and many patients need supervised care.
The differential is delirium, which fluctuates and clouds consciousness over hours to days; dementia, which is a global decline across several cognitive domains; and transient global amnesia, which is a single episode lasting hours. Korsakoff syndrome is a selective, stable memory disorder in a clear sensorium.
Nursing management is a memory environment: a fixed daily routine, a visible clock, a calendar and an orientation board, written reminders, the same staff where possible, and active fall prevention for a person who cannot remember the hazard he was warned about.
Because capacity under the Mental Healthcare Act 2017 is decision-specific, a person with Korsakoff syndrome is assessed for each decision rather than declared globally incapable, and a nominated representative supports decisions where capacity is genuinely absent.

Psychotic disorders — distinguishing features

The schizophrenia spectrum disorders share the same symptoms — delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour and negative symptoms — and are separated mainly by how long the illness has lasted and by whether a mood episode is part of it. Getting that boundary right matters at the bedside because it decides how long treatment continues and what the family is told about prognosis.

Duration is the spine of the group: brief psychotic disorder lasts at least a day and less than a month with full return to premorbid functioning, schizophreniform disorder lasts one to six months, and schizophrenia requires six months of continuous disturbance including at least one month of active symptoms.
Schizophrenia needs two or more of the five characteristic symptoms, at least one of which must be delusions, hallucinations or disorganised speech.
Delusional disorder needs one or more delusions for at least a month with functioning otherwise little impaired and behaviour not obviously odd; its types are persecutory, jealous, erotomanic, grandiose, somatic and mixed.
Schizoaffective disorder requires a major mood episode concurrent with the active symptoms of schizophrenia, plus delusions or hallucinations for at least two weeks in the absence of a mood episode, with mood symptoms present for most of the illness; that two-week rule is what separates it from a mood disorder with psychotic features.
Before any of these is diagnosed, delirium, substance-induced psychosis and psychosis due to another medical condition must be excluded, so check temperature, blood glucose and oxygen saturation, take a drug and alcohol history, and remember that autoimmune encephalitis can present as a first episode of psychosis.
DSM-5 and ICD-11 have both abolished the old subtypes of schizophrenia — paranoid, hebephrenic or disorganised, catatonic, undifferentiated and residual — replacing them with dimensional ratings, and catatonia is now a specifier that can accompany many disorders.
Postpartum onset within four weeks of delivery is a specifier for brief psychotic disorder, and postpartum psychosis is a psychiatric emergency because of the risk to both mother and infant.
Prognosis: acute onset, an identifiable stressor, prominent mood symptoms, good premorbid adjustment, later onset, female sex and a short duration of untreated psychosis all predict a better outcome, while insidious onset, prominent negative symptoms, early onset and continued substance use predict a worse one.
Treatment across the spectrum begins with a second-generation antipsychotic such as risperidone 2 to 6 mg, olanzapine 5 to 20 mg or aripiprazole 10 to 30 mg daily, continued for at least one to two years after a first episode; clozapine is used only after two adequate trials have failed and requires blood-count monitoring for agranulocytosis.

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