Week 2_ Psychosis and Mania_ Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-

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12/4/23, 10:20 PM Week 2: Psychosis and Mania: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-Briggs https://chamberlain.instructure.com/courses/135010/pages/week-2-psychosis-and-mania?module_item_id=19723605 1/16 Week 2 Psychosis and Mania Background The family nurse practitioner (FNP) may be the first healthcare provider to identify symptoms that indicate mental illness, including schizophrenia and bipolar disorder. Although treatment for these disorders is typically provided by a mental health specialist, the FNP is instrumental in recognizing symptoms and referring clients to appropriate care resources. Psychosis Psychosis is characterized by disruptions in thought and perception that lead to a disconnection from reality. Psychotic symptoms may include abnormal behaviors and sensations, including catatonic behavior. Psychosis may be acute or chronic. Although psychosis is categorized as a psychiatric disorder, it commonly occurs as a secondary condition due to underlying endocrine, vascular, immunologic, or metabolic problems. Drugs, other substances, or other psychiatric conditions such as depression or mania may also cause psychotic symptoms. C l i n i c a l P r e s e n t a t i o n Symptoms of psychosis are divided into several clinical domains, including positive, negative, cognitive, affective, and motor. Positive symptoms occur when clients experience things in addition to reality, such as hearing voices or seeing things that are not there, whereas negative symptoms involve a loss of something, such as the ability to experience pleasure or loss of motivation. Cognitive symptoms relate to disorganization in thoughts, memories, focus, or attention. Affective symptoms involve the client's feelings and emotions, while motor symptoms may include abnormalities in gait, balance, and coordination, irregular muscle contractions, or tremors. Click through the activity below to learn more about the positive symptoms of psychosis.
12/4/23, 10:20 PM Week 2: Psychosis and Mania: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-Briggs https://chamberlain.instructure.com/courses/135010/pages/week-2-psychosis-and-mania?module_item_id=19723605 2/16 Symptoms of Psychosis Transcript Slide 1 Hallucinations: perceptual experiences in the absence of external stimuli Examples of hallucinations include: Auditory: hearing things that are not there (may include command hallucinations in which voices direct the client to perform actions, often related to self-harm or violence towards others) Visual: seeing things that are not there Tactile: feeling sensations in the body in the absence of stimuli Olfactory: smelling things that are not there Gustatory: tasting things that are not there Slide 2
12/4/23, 10:20 PM Week 2: Psychosis and Mania: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-Briggs https://chamberlain.instructure.com/courses/135010/pages/week-2-psychosis-and-mania?module_item_id=19723605 3/16 Schizophrenia Schizophrenia is a diagnosis associated with psychotic symptoms. According to the National Institute of Mental Health (NIMH, n.d.a.), schizophrenia affects between 0.25% and 0.75% of the population in the United States and is one of the top 15 leading causes of disability worldwide. Those with schizophrenia are at risk of premature mortality due to co-occurring medical conditions that are often undiagnosed or undertreated. Common comorbidities include heart and liver disease Delusions: fixed false, irrational beliefs Examples of delusions include: Persecution: delusions related to being threatened, victimized, or spied on Reference: delusions related to receiving personal messages from television (TV), radio, or actions of others Somatic: delusions related to the body, including illness or the presence of foreign objects (e.g. Sometimes people believe there are objects in their bodies; for example they might think they are infested with insects.) Grandeur: delusions related to beliefs of special abilities or powers Control: delusions that actions and thoughts are controlled by others Slide 3 Thought Disorder: impairment in the process of thinking and difficulty organizing thoughts in a logical pattern Examples of thought disorder include: incoherent speech loose associations meaningless words perseveration Slide 4 Disorganized behavior: disordered or impaired behavior or communication Examples of disorganized behavior include: childlike silliness unpredictable agitation inappropriate clothing for the weather poor hygiene
12/4/23, 10:20 PM Week 2: Psychosis and Mania: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-Briggs https://chamberlain.instructure.com/courses/135010/pages/week-2-psychosis-and-mania?module_item_id=19723605 4/16 and diabetes. Approximately half of the individuals with schizophrenia have co-occurring mental and/or behavioral health disorders (NIMH, n.d.a.). Those with schizophrenia are at increased risk for suicide. Clients and their families often receive inadequate care and face social ostracism due to stigmas surrounding the disorder. Click below to explore schizophrenia using 3D interactive technology: Interact in 3D Interact in 3D Schizophrenia Transcript 1. Receptors in the Brain Dopamine is a neurotransmitter that plays a major role in regulating human behavior, mood, motivation, and motor control, among others. It exerts its effects through dopaminergic pathways. These originate in areas of the brain that have high concentrations of dopamine receptors. There are 5 types of dopamine receptors: D1, D2, D3, D4, and D5. D1 and D5 make up the D1- like family, which are mainly located in the caudate, putamen, nucleus accumbens, and frontal
12/4/23, 10:20 PM Week 2: Psychosis and Mania: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-Briggs https://chamberlain.instructure.com/courses/135010/pages/week-2-psychosis-and-mania?module_item_id=19723605 5/16 cortex. D2, D3, and D4 make up the D2-like family, mainly found in the basal ganglia, ventral tegmental area, midbrain, hippocampus, thalamus, cerebellum, and cerebral cortex. Legend D1-like receptors (green) D2-like receptors (blue) Labels Caudate nucleus Hippocampus Midbrain Putamen Thalamus Nucleus accumbens Ventral tegmental area 2. Disruption of Dopamine Pathways Leads to Predictable Effects From the dopamine receptors, nerve cells extend to other parts of the brain, creating the dopaminergic pathways and producing specific effects. When these pathways are altered, neuropsychiatric conditions occur, such as schizophrenia. The mesocortical pathway is thought to have reduced activity in schizophrenia, resulting in negative symptoms (apathy) and depression. The mesolimbic pathway is thought to be hyperactive in schizophrenia, resulting in positive symptoms (psychosis and hallucinations). The sensorimotor striatum of the nigrostriatal pathway regulates motor movements. Its alteration leads to movement disorders. The associative striatum of the nigrostriatal pathway is associated with psychosis and mania. The tuberoinfundibular pathway is associated with the inhibition of the release of prolactin (the hormone of lactation). A blockage of this pathway leads to amenorrhea (loss of menstruation), galactorrhea (leakage of breast milk), and sexual dysfunction. Legend Mesocortical Pathway (blue) Mesolimbic Pathway - "Limbic Striatum" (orange) Nigrostriatal Pathway 1 - "Sensorimotor Stiatum" (yellow) Nigrostriatal Pathway 2 - "Associative Striatum" (red) Tuberoinfundibular Pathway (purple) 3. Role of Dopamine Partial Agonists In normal circumstances, dopamine is the full agonist of all dopamine receptors. Partial agonists for dopamine receptors (such as aripiprazole) have a less powerful effect on receptors than
12/4/23, 10:20 PM Week 2: Psychosis and Mania: Advanced Clinical Diagnosis and Practice across the Lifespan Practicum-Briggs https://chamberlain.instructure.com/courses/135010/pages/week-2-psychosis-and-mania?module_item_id=19723605 6/16 natural dopamine. By binding to the receptors, partial agonists prevent the binding of the full agonist, dopamine, and its full effect. Thus, they act as either antagonists or agonists depending on the base level of dopamine in the body. Legend Dopamine (blue) D2 partial agonist (yellow) D3 partial agonist (red) Labels D2 receptor D3 receptor Dopamine transporter 4. Dopamine Intrinsic Activity in Schizophrenia In schizophrenia, some dopaminergic pathways have reduced activity (mesocortical pathway) while others are hyperactive (mesolimbic pathway). This leads to a mix of negative and positive symptoms. With the use of partial agonists, the dopaminergic pathways can be regulated. In pathways where dopamine levels are naturally high, partial agonists will lower the activity. Where levels are naturally low, partial agonists will increase dopaminergic activity. Legend Dopamine (blue) D2 partial agonist (yellow) D3 partial agonist (red) Labels D2 receptor D3 receptor Dopamine transporter 5. Direct Excitatory D1 Pathway The nigrostriatal pathway contains both D -like and D -like receptors. The D -like receptors form the direct pathway. Stimulation of these receptors by the presence of dopamine or a dopamine partial agonist results in the excitation of the neuron. The final effect of the nigrostriatal pathway is the simultaneous stimulation of the direct pathway and inhibition of the indirect pathway. Overactivity of the direct pathway will lead to tremors, hypertonicity, and dyskinesia. Legend 1 2 1
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