Schizophrenia and Psychotic Disorders - Cheat Sheet
Your last-minute revision companion for recognizing psychotic symptoms, mastering antipsychotic pharmacology, managing extrapyramidal side effects, and delivering therapeutic care under RA 11036.
Understanding Psychosis & Schizophrenia Spectrum
Important facts
- Onset typically late adolescence to early adulthood; peak incidence ages 16–35.
- Affects ~1% of the population; equal prevalence in males and females but earlier onset in males.
- Genetic and environmental factors both contribute; stress-vulnerability model explains pathogenesis.
- Not split personality (dissociative identity disorder); schizophrenia = thought disorder, not personality fragmentation.
- Prognosis improves with early intervention, family support, medication adherence, and community-based care.
Key definitions
Psychosis
Example
Client hearing voices commanding self-harm or believing neighbors are monitoring thoughts.
Loss of contact with reality manifested by disturbances in thought, perception, and behavior.
Schizophrenia
Example
20-year-old male with auditory hallucinations, paranoid delusions, flat affect, and social withdrawal lasting 8 months.
Chronic, severe psychotic disorder with disturbances in thinking (delusions, disorganized thought), perception (hallucinations), affect, and social function; symptoms present ≥6 months.
Schizoaffective Disorder
Example
Client with delusions + auditory hallucinations + severe depression lasting 3 months together.
Schizophrenia symptoms concurrent with a major depressive, manic, or mixed mood episode.
Brief Psychotic Disorder
Example
Acute onset hallucinations and delusions after a traumatic event, resolving within 2 weeks.
Psychotic symptoms lasting <1 month, often following a psychosocial stressor.
Schizophreniform Disorder
Example
Client with 3-month duration of hallucinations and disorganized speech.
Psychotic symptoms lasting 1–6 months; intermediate between brief psychotic disorder and schizophrenia.
Delusional Disorder
Example
Client convinced spouse is unfaithful despite evidence to the contrary; no hallucinations.
Non-bizarre delusions (plausible scenarios) without other prominent psychotic features; ≥1 month duration.
Diagrams to know
- Positive vs. Negative symptom domains and their treatment response
- Psychotic disorder spectrum by duration: brief (<1 month) → schizophreniform (1–6 months) → schizophrenia (≥6 months)
Positive Symptoms (Excess/Distortion of Normal Function)
Important facts
- Positive symptoms are EXCESS/DISTORTION of normal function—things that are 'added.'
- Auditory hallucinations are the MOST COMMON type in schizophrenia; ALWAYS ask about command hallucinations first.
- Positive symptoms respond WELL to antipsychotic medication (especially dopamine antagonists).
- Delusions are deeply held; arguing with them entrenches belief and damages therapeutic rapport.
- Hallucinations often precede a psychotic break and intensify during stress or medication non-adherence.
Key definitions
Hallucination
Example
Hearing multiple voices conversing or commenting on behavior; seeing shadowy figures; tasting poison in food.
False sensory perception without external stimulus; auditory hallucinations (hearing voices) are MOST COMMON in schizophrenia.
Command Hallucination
Example
Voices commanding 'Cut yourself' or 'Attack the nurse'—SAFETY EMERGENCY.
Hallucinations that direct the client to perform an action; poses immediate risk if commands involve self-harm or harm to others.
Delusion
Example
Belief that the CIA is implanting thoughts; conviction that one is the President of the Philippines despite evidence.
Fixed, false belief not changed by logic or evidence; unshakeable even with contradictory data.
Persecutory Delusion
Example
Belief that neighbors are poisoning the water supply.
False belief that one is being harmed, followed, or conspired against.
Grandiose Delusion
Example
Conviction that one is Jesus Christ or has superpowers.
False belief of inflated importance, power, or special identity.
Referential Delusion
Example
Believing a news broadcast is sending secret messages directly to you.
False belief that unrelated events or communications refer to oneself.
Somatic Delusion
Example
Belief that internal organs are rotting or that insects are crawling under the skin.
False belief about one's body or physical sensations.
Thought Broadcasting
Example
Conviction that everyone can hear your thoughts as if broadcast aloud.
False belief that one's thoughts are audible to others.
Thought Insertion
Example
Belief that a demon is putting evil thoughts into your head.
False belief that thoughts are placed in one's mind by an external force.
Disorganized Speech
Example
Loose associations, word salad ('The sky is purple elephant dancing'), tangential replies.
Speech that is incoherent, tangential, or contains neologisms; reflects disordered thinking.
Disorganized Behavior
Example
Inappropriate laughter, repetitive movements, childish silliness, or complete immobility.
Bizarre, goal-less, or unpredictable behavior; may include catatonia.
Diagrams to know
- Types of delusions organized by belief content (persecutory, grandiose, referential, somatic, thought disturbances)
- Progression from hallucination to command hallucination and risk assessment pathway
Negative Symptoms (Loss/Absence of Normal Function – The 'A's')
Important facts
- Negative symptoms are LOSS/ABSENCE of normal function—things that are 'taken away.'
- Negative symptoms are OFTEN MORE DISABLING and harder to treat than positive symptoms.
- They respond LESS WELL to typical antipsychotics; atypical agents are generally more effective.
- Negative symptoms can be confused with depression or side effects of antipsychotics (secondary negative symptoms).
- Family and caregivers often find negative symptoms more frustrating because they impair functional recovery.
- Negative symptoms are associated with poorer prognosis and treatment response.
Key definitions
Affective Flattening (Blunted/Flat Affect)
Example
Client speaks about death of a loved one with no change in facial expression or tone.
Marked reduction in emotional expression; face appears immobile, voice monotone, minimal gesturing.
Alogia
Example
When asked about day, client replies only 'OK' and offers no further detail despite prompting.
Poverty of speech; minimal verbal output, brief responses, lack of elaboration.
Avolition
Example
Client sits passively for hours, unwilling to shower, eat, or participate in rehabilitation activities.
Lack of motivation and goal-directed activity; inability to initiate or persist in activities.
Anhedonia
Example
Client who loved music now shows no interest; eating is mechanical, not pleasurable.
Inability to experience pleasure from activities (hobbies, food, sex, social contact) previously enjoyed.
Asociality
Example
Client avoids all social activities, eats alone, declines conversation or group therapy.
Social withdrawal, preference for isolation, difficulty initiating or maintaining relationships.
Diagrams to know
- Mnemonic 'A-A-A-A-A' for five core negative symptoms
- Differential: Primary negative symptoms (disease-related) vs. Secondary negative symptoms (medication side effect or depression)
Therapeutic Communication & Nursing Interventions
Important facts
- WHEN HALLUCINATING: Ask directly about hallucinations ('Are you hearing voices?') to assess content and safety.
- DO NOT argue about hallucinations ('You're not really hearing voices'); DO NOT reinforce them ('Yes, the CIA is after you').
- State your own reality: 'I don't hear voices, but I understand they're real to you.'
- WHEN DELUSIONAL: Do NOT argue with or agree with the delusion; both entrench the false belief.
- Focus on the FEELING, not the delusion: 'You seem worried' rather than discussing the delusional content.
- Use clear, simple, concrete language; avoid abstract, figurative, or sarcastic statements that can be misinterpreted.
- Reduce environmental stimulation (noise, crowds, bright lights) which can exacerbate symptoms.
- Offer frequent, brief, non-threatening contacts rather than prolonged interactions if client is withdrawn.
- DO NOT demand eye contact or physical closeness; may feel invasive or threatening.
- Build trust through consistency, honesty, and respect for the client's autonomy.
- Involve family and establish continuity of care; assess understanding of illness and medication.
- Redirect to reality-based, structured activities (grooming, meals, simple tasks); offer choices.
- Screen for command hallucinations EVERY shift; document clearly and report to provider if risk escalates.
- Monitor for early relapse signs: increased suspiciousness, social withdrawal, sleep disruption, resurging hallucinations.
- Support medication adherence and discuss long-acting injectables for clients with adherence difficulty.
Key definitions
Reality Orientation
Example
Nurse states: 'I do not hear voices, but I believe you do. Let's focus on what you can do right now.'
Nursing approach of consistently presenting objective reality without arguing or reinforcing delusions/hallucinations.
Validation of Feeling
Example
'It must be frightening to believe someone is following you. Tell me more about how that makes you feel.'
Acknowledging the client's emotional experience without endorsing the delusional content.
Therapeutic Use of Self
Example
Returning to client at agreed times, maintaining calm demeanor, following through on promises.
Using the nurse-client relationship as a healing tool through consistency, honesty, and presence.
Diagrams to know
- Decision tree for responding to hallucinations vs. delusions
- Nurse communication script: Therapeutic vs. Non-therapeutic responses to psychotic symptoms
Antipsychotic Pharmacology – Classification & Mechanism
Important facts
- Dopamine hypothesis: Psychotic symptoms result from excessive dopamine activity in mesolimbic and mesocortical pathways.
- Antipsychotics block D2 receptors, reducing dopamine neurotransmission.
- TYPICAL antipsychotics: High potency (haloperidol, fluphenazine) = more EPS; low potency (chlorpromazine) = more sedation, anticholinergic effects, orthostatic hypotension.
- ATYPICAL antipsychotics: Better for negative symptoms, fewer EPS, but metabolic side effects (weight gain, hyperglycemia, dyslipidemia).
- Olanzapine and clozapine carry the MOST metabolic risk.
- Clozapine is reserved for TREATMENT-RESISTANT schizophrenia due to agranulocytosis risk.
- Long-acting depot injections (haloperidol decanoate, fluphenazine decanoate, paliperidone palmitate) improve adherence.
- Onset of therapeutic effect: 2–4 weeks; full benefit may take 8–12 weeks.
- NOT for first-line anxiety or sleep; use antipsychotics only for psychotic symptoms or specific mood/psychotic disorders.
Key definitions
Antipsychotic (Neuroleptic)
Example
Haloperidol, risperidone, olanzapine.
Psychotropic medication that blocks dopamine (D2) receptors; used to treat psychotic symptoms.
Typical (First-Generation) Antipsychotics
Example
Haloperidol, chlorpromazine, fluphenazine, perphenazine, thioridazine.
Earlier antipsychotics that primarily block D2 dopamine receptors; highly effective for positive symptoms but carry HIGH EPS risk.
Atypical (Second-Generation) Antipsychotics
Example
Risperidone, olanzapine, quetiapine, clozapine, aripiprazole, ziprasidone, paliperidone.
Newer antipsychotics that block D2 and also affect serotonin (5-HT2A); treat both positive and negative symptoms with FEWER EPS.
Diagrams to know
- Dopamine pathways affected by antipsychotics (mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular)
- Classification tree: Typical vs. Atypical antipsychotics with examples and side effect profiles
Extrapyramidal Side Effects (EPS) – The 4 Types
Common values
Value
Within hours to 4 days
Symbol
N/A
Quantity
Onset of acute dystonia
Value
Days to weeks
Symbol
N/A
Quantity
Onset of akathisia
Value
Days to weeks
Symbol
N/A
Quantity
Onset of pseudoparkinsonism
Value
Months to years
Symbol
N/A
Quantity
Onset of tardive dyskinesia
Important facts
- EPS result from dopamine blockade in nigrostriatal motor pathway.
- Acute dystonia is a MEDICAL EMERGENCY if it involves laryngeal spasm (airway obstruction). IMMEDIATE IM/IV benztropine or diphenhydramine.
- Akathisia is easily mistaken for anxiety or agitation; distinguish by: no anxiety trigger, constant restlessness, relief with movement.
- Pseudoparkinsonism mimics Parkinson disease but is drug-induced; reversed by anticholinergics or dose reduction.
- Tardive dyskinesia is the MOST SERIOUS and LEAST REVERSIBLE EPS; prevention through lowest effective dose is KEY.
- Anticholinergics (benztropine, trihexyphenidyl, diphenhydramine) treat acute dystonia, akathisia, and pseudoparkinsonism BUT do NOT treat tardive dyskinesia and may WORSEN it.
- Tardive dyskinesia screening: Use Abnormal Involuntary Movement Scale (AIMS) at baseline, every 3–6 months.
- If TD develops, reduce antipsychotic dose or switch to atypical; no reliable cure.
- Typical antipsychotics carry HIGHER EPS risk; atypicals carry LOWER EPS risk.
- Risk factors for EPS: older age, higher dose, typical antipsychotics, male gender.
- Clients with acute dystonia report severe fear and pain; provide immediate reassurance and medication.
Key definitions
Acute Dystonia
Example
Client's neck twists uncontrollably (torticollis); eyes roll backward (oculogyric crisis); jaw clenches painfully.
Sudden, sustained, painful MUSCLE SPASMS of neck (torticollis), face, jaw, tongue, eyes (oculogyric crisis); appears within HOURS TO DAYS; MEDICAL EMERGENCY if laryngeal spasm.
Akathisia
Example
Client constantly paces, taps feet, shifts weight; says 'I can't sit still' despite no anxiety.
Motor RESTLESSNESS, inability to sit/stand still, pacing, inner tension, fidgeting; appears within DAYS TO WEEKS.
Pseudoparkinsonism (Drug-Induced Parkinsonism)
Example
Client develops pill-rolling tremor, stiff movements, slow speech, expressionless face.
Tremor (resting), RIGIDITY (cogwheel), bradykinesia, mask-like face, shuffling gait, drooling; appears within WEEKS.
Tardive Dyskinesia (TD)
Example
Client on antipsychotics for 2 years develops involuntary tongue movements and lip-smacking.
LATE-ONSET (months to years), OFTEN IRREVERSIBLE involuntary movements, especially face/mouth/tongue (lip-smacking, chewing, tongue protrusion, grimacing), sometimes limbs/trunk.
Diagrams to know
- EPS Timeline: Acute dystonia (hours–days) → Akathisia (days–weeks) → Pseudoparkinsonism (weeks) → Tardive dyskinesia (months–years)
- EPS Treatment algorithm: Which medication treats which EPS and what to avoid
Anticholinergic Management of EPS
Important facts
- Anticholinergics WORK for acute dystonia, akathisia, and pseudoparkinsonism.
- Anticholinergics DO NOT WORK for tardive dyskinesia and may WORSEN it—avoid prophylactic anticholinergics.
- Side effects of anticholinergics: DRY MOUTH, blurred vision, constipation, urinary retention, increased heat stroke risk (critical in tropical Philippines climate).
- Teach client: Sugar-free fluids/candies for dry mouth; high-fiber diet for constipation; stay cool and hydrated.
- Do NOT give anticholinergics 'just in case' before starting antipsychotics; use ONLY when EPS develops.
- Anticholinergic toxicity: confusion, agitation, tachycardia, pupil dilation, urinary retention—rare but serious.
- Beta-blockers (propranolol) are alternative for akathisia if anticholinergics not tolerated.
- Diphenhydramine provides rapid relief in acute dystonia (onset 10–30 minutes) and is often preferred due to dual action (antihistamine + anticholinergic).
Key definitions
Benztropine
Example
1 mg IM/IV stat for acute dystonia; oral maintenance dosing for pseudoparkinsonism.
Anticholinergic agent used to treat acute dystonia, akathisia, and pseudoparkinsonism; given IM/IV for acute dystonia.
Trihexyphenidyl
Example
Typical dose 2–5 mg daily divided dosing.
Anticholinergic agent; oral form for maintenance treatment of pseudoparkinsonism and akathisia.
Diphenhydramine
Example
25–50 mg IM/IV for acute dystonia; rapid relief in 10–30 minutes.
First-generation antihistamine with anticholinergic properties; treats acute dystonia and akathisia; also causes sedation.
Diagrams to know
- Decision tree: Which anticholinergic to choose based on EPS type and route (IM/IV vs. oral)
Neuroleptic Malignant Syndrome (NMS) – Medical Emergency
Common values
Value
>38–40°C (often >39°C)
Symbol
T
Quantity
Temperature threshold for NMS
Value
>1000 U/L (often >4000 U/L)
Symbol
CK
Quantity
Typical CK elevation in NMS
Value
24–72 hours after antipsychotic start
Symbol
N/A
Quantity
Onset of NMS
Value
5–7 days
Symbol
N/A
Quantity
Recovery time after medication stop
Important facts
- NMS is a MEDICAL EMERGENCY with mortality 5–20% if untreated.
- Cardinal features (ALL four often present): HYPERTHERMIA (often >38–40°C) + LEAD-PIPE RIGIDITY + AUTONOMIC INSTABILITY (labile BP, tachycardia, tachypnea, diaphoresis) + ALTERED MENTAL STATUS (confusion, stupor, delirium).
- ELEVATED CREATINE KINASE (CK) is a key lab finding; can indicate rhabdomyolysis and risk of acute kidney injury.
- Other labs: leukocytosis, electrolyte disturbances, elevated liver enzymes.
- Risk factors: male gender, young age, high-potency typicals, high doses, rapid dose escalation, dehydration, hot weather, agitation.
- Onset typically 24–72 hours after antipsychotic start or dose increase; can occur anytime during therapy.
- IMMEDIATE MANAGEMENT: (1) STOP the antipsychotic, (2) aggressive supportive care (cooling, IV fluids, cardiac/respiratory monitoring), (3) give DANTROLENE (muscle relaxant), (4) consider BROMOCRIPTINE (dopamine agonist).
- Cooling measures: ice packs, cooling blanket, cold IV saline, evaporative cooling.
- Monitor: temperature, CK, renal function, electrolytes, urine myoglobin.
- Recovery typically 5–7 days after stopping medication; prolonged recovery with depot injections.
- After recovery, rechallenge with antipsychotic is possible but high-risk; if necessary, use atypical (lower risk) at low dose with close monitoring.
- Distinguish NMS from SEROTONIN SYNDROME: both cause hyperthermia and autonomic instability, but NMS has RIGIDITY (lead-pipe) while serotonin syndrome has HYPERREFLEXIA/CLONUS; NMS from antipsychotics, serotonin syndrome from serotonergic drugs (SSRIs, tramadol, MAOIs).
- Distinguish NMS from malignant hyperthermia: both rare and life-threatening, but malignant hyperthermia is anesthetic-related (succinylcholine, volatile anesthetics), not psychiatric medication.
Key definitions
Neuroleptic Malignant Syndrome (NMS)
Example
Client on haloperidol develops sudden high fever (39.5°C), severe muscle rigidity, rapid heart rate, and confusion within 24 hours.
RARE but LIFE-THREATENING idiosyncratic reaction to antipsychotics (esp. high-potency typicals, but can occur with ANY antipsychotic); characterized by hyperthermia, lead-pipe rigidity, autonomic instability, altered mental status, and elevated CK.
Lead-Pipe Rigidity
Example
All muscles equally stiff and resistant to passive movement.
Sustained muscle rigidity (NOT cogwheel) felt throughout passive range of motion; sign of NMS.
Diagrams to know
- NMS vs. Serotonin Syndrome comparison chart (differential diagnosis)
- NMS management flowchart: Recognition → Stabilization → Pharmacotherapy → Monitoring
Agranulocytosis & Clozapine Monitoring
Common values
Value
4500–11000/μL
Symbol
WBC
Quantity
Normal WBC range
Value
2500–7500/μL
Symbol
ANC
Quantity
Normal ANC range
Value
<3500/μL
Symbol
WBC
Quantity
Hold clozapine if WBC
Value
<3000/μL
Symbol
WBC
Quantity
Discontinue clozapine if WBC
Value
1–2% of clients
Symbol
N/A
Quantity
Incidence of agranulocytosis with clozapine
Value
First 3–6 months of therapy
Symbol
N/A
Quantity
Time of highest risk for agranulocytosis
Important facts
- Clozapine causes agranulocytosis in ~1–2% of clients; can be FATAL if not detected early.
- MANDATORY WBC/ABSOLUTE NEUTROPHIL COUNT (ANC) MONITORING: Weekly for first 6 months, then every 2 weeks for next 6 months, then every 4 weeks (if stable).
- Baseline WBC and differential BEFORE starting clozapine.
- HOLD clozapine if WBC <3500/μL or ANC <2000/μL; DISCONTINUE if WBC <3000/μL or ANC <1500/μL.
- Client education: REPORT IMMEDIATELY if fever, sore throat, mouth ulcers, chills, malaise, or flu-like symptoms develop—these are signs of agranulocytosis.
- Agranulocytosis usually develops within first 3–6 months but can occur anytime during therapy.
- Other clozapine risks: seizures (dose-dependent), myocarditis, severe metabolic effects (worst of all antipsychotics for weight gain, diabetes), severe constipation (risk of impaction/ileus).
- Clozapine does NOT cause EPS (so no dystonia, akathisia, pseudoparkinsonism, or TD risk).
- Monitor blood glucose and lipids; assess weight at baseline and monthly.
- Orthostatic hypotension is common, especially with dose escalation; take BP lying and standing.
- Teach client about medication and adherence; clozapine is not a 'last resort' but a valuable treatment option for severe, resistant illness.
Key definitions
Clozapine
Example
Used when ≥2 antipsychotics fail; minimal EPS, good negative symptom response.
Atypical antipsychotic reserved for TREATMENT-RESISTANT schizophrenia; highly effective for both positive and negative symptoms but carries AGRANULOCYTOSIS risk.
Agranulocytosis
Example
ANC drops from 5000 to <500/μL; client at risk for sepsis from even minor infection.
Dangerous drop in white blood cells (especially neutrophils), leaving client vulnerable to severe, life-threatening infection.
Diagrams to know
- Clozapine WBC monitoring schedule and thresholds for action
- Signs and symptoms of agranulocytosis that client must recognize and report
Other Antipsychotic Side Effects & Client Teaching
Important facts
- ANTICHOLINERGIC EFFECTS: dry mouth, blurred vision, constipation, urinary retention, increased heat stroke risk—teach fluids, fiber, cool environment.
- ORTHOSTATIC HYPOTENSION: dizziness on standing, especially with initial dosing or dose increase; teach rise slowly, sit if dizzy, avoid sudden position changes.
- SEDATION: common with low-potency typicals (chlorpromazine) and some atypicals (quetiapine, olanzapine); counsel avoid driving/machinery until tolerance develops.
- PHOTOSENSITIVITY: increased sun sensitivity with some antipsychotics (esp. chlorpromazine); teach sunscreen, protective clothing, avoid sun exposure—important in tropical Philippines.
- WEIGHT GAIN & METABOLIC EFFECTS: olanzapine and clozapine worst; risperidone and quetiapine intermediate; aripiprazole and ziprasidone least. Monitor monthly weight, blood glucose, lipids.
- HYPERGLYCEMIA/NEW-ONSET DIABETES: especially atypicals; monitor fasting glucose at baseline, 3 months, then annually. Teach dietary modification, exercise, diabetes screening.
- DYSLIPIDEMIA: elevated triglycerides and cholesterol; manage with diet, exercise, consider statin if needed.
- HYPERPROLACTINEMIA: manage with dose reduction or switch to aripiprazole (which lowers prolactin). May affect sexual function and menstrual regularity.
- LOWERED SEIZURE THRESHOLD: risk increases with dose; counsel precautions (avoid driving if uncontrolled seizure disorder, assess seizure history before prescribing).
- CARDIAC EFFECTS: QT prolongation with some antipsychotics (ziprasidone, thioridazine); baseline ECG may be needed; assess for syncope, palpitations.
- NEUROLEPTIC MALIGNANT SYNDROME: see separate section—rare but life-threatening emergency.
- CLIENT TEACHING: importance of adherence; medication takes 2–4 weeks to show effect; long-acting injectables for clients struggling with daily dosing; report side effects promptly; avoid stopping medication abruptly (risk of relapse and withdrawal dyskinesia); communicate any new symptoms or medication changes to provider.
- PREGNANCY & LACTATION: atypicals generally safer than typicals; discuss risks/benefits; some antipsychotics pass into breast milk.
- INTERACTION CAUTION: avoid combining with other CNS depressants; additive sedation with alcohol, benzodiazepines, opioids.
Key definitions
Metabolic Syndrome
Example
Client gains 10 kg, develops new-onset diabetes, and triglycerides rise to 300 mg/dL.
Constellation of side effects (weight gain, hypertension, dyslipidemia, hyperglycemia) associated with atypical antipsychotics.
Hyperprolactinemia
Example
Female client develops irregular periods and breast discharge; male client reports erectile dysfunction.
Elevated prolactin levels due to dopamine blockade in tuberoinfundibular pathway; causes galactorrhea, menstrual changes, sexual dysfunction.
Diagrams to know
- Antipsychotic side effect profile comparison (typical vs. atypical)
- Client teaching checklist for antipsychotic therapy
Nursing Process & Legal/Ethical Context (RA 11036 & RA 9173)
Important facts
- RA 11036 mandates recovery-oriented, community-based care; discourages prolonged institutionalization.
- Involuntary admission allowed ONLY through court order and in life-threatening situations; client retains most rights.
- Right to refuse treatment (unless court-ordered) applies even with psychotic illness; capacity is presumed unless proven otherwise.
- Nurses must use least restrictive interventions; physical/chemical restraints only as last resort with documentation and regular reassessment.
- Confidentiality and privacy protected; sharing info only with treatment team and with client consent (except imminent danger).
- RA 9173 requires documentation of all assessments, interventions, medications, and client response; nursing notes are legal records.
- Therapeutic use of self and therapeutic communication are core nursing responsibilities in psychiatric care.
- Mandatory reporting: suspected abuse, neglect, or danger to self/others.
- Nursing diagnoses per NANDA: Risk for self-directed violence, Risk for other-directed violence, Disturbed thought processes, Hallucinatory behavior, Ineffective coping, Social isolation, Imbalanced nutrition, Self-care deficit, Compromised family coping, Non-adherence.
- Maslow-based prioritization: Safety (assessing command hallucinations, removing dangerous objects) → Physiological (nutrition, hydration, sleep, medication administration) → Love/Belonging (therapeutic relationship, family involvement) → Esteem/Self-actualization (rehabilitation, social skills, vocational support).
- Advocacy: promoting client autonomy, advocating for adequate mental health resources in the community, reducing stigma, supporting family education.
Key definitions
Mental Health Act (Republic Act No. 11036)
Example
Client cannot be institutionalized without court order; treatment focuses on community integration and autonomy.
Philippine law protecting rights of persons with severe mental illness; promotes recovery-oriented, community-based, rights-based care; restricts involuntary admission and ensures informed consent.
Nursing Practice Act (Republic Act No. 9173)
Example
Nurse must obtain informed consent, assess mental status, administer medications safely, and document thoroughly.
Philippine law defining scope of nursing practice; nurses are accountable for assessment, care planning, therapeutic intervention, and advocacy within legal/ethical bounds.
Informed Consent
Example
Before starting antipsychotic, nurse explains hallucinations/delusions, how medication works, side effects, and gets signed consent.
Client understanding of diagnosis, treatment options, risks, and benefits and voluntary agreement to treatment.
Diagrams to know
- NANDA nursing diagnoses hierarchy for psychotic disorders
- Maslow's hierarchy applied to schizophrenia care plan
High-Yield Summary & Quick Recall
Important facts
- POSITIVE SYMPTOMS = EXCESS (hallucinations, delusions, disorganized speech/behavior); respond WELL to antipsychotics.
- NEGATIVE SYMPTOMS = LOSS (affective flattening, alogia, avolition, anhedonia, asociality); respond LESS WELL to typicals; better with atypicals.
- AUDITORY HALLUCINATIONS (hearing voices) are MOST COMMON in schizophrenia; ALWAYS ask about command hallucinations.
- COMMAND HALLUCINATIONS = SAFETY EMERGENCY if directing self-harm or harm to others.
- DELUSIONAL CLIENTS: Do NOT argue or agree; acknowledge FEELING, focus on REALITY.
- TYPICAL ANTIPSYCHOTICS (haloperidol, chlorpromazine) = more EPS; ATYPICAL (risperidone, olanzapine, quetiapine, clozapine, aripiprazole) = fewer EPS, more metabolic effects.
- EPS TIMELINE: Acute dystonia (HOURS–DAYS, EMERGENCY if laryngeal) → Akathisia (DAYS–WEEKS) → Pseudoparkinsonism (DAYS–WEEKS) → Tardive dyskinesia (MONTHS–YEARS, OFTEN IRREVERSIBLE).
- TREAT ACUTE DYSTONIA: IM/IV benztropine or diphenhydramine STAT.
- ANTICHOLINERGICS treat acute dystonia, akathisia, pseudoparkinsonism; DO NOT treat tardive dyskinesia and may WORSEN it.
- NEUROLEPTIC MALIGNANT SYNDROME: Hyperthermia + Lead-pipe rigidity + Autonomic instability + Altered mental status + High CK = MEDICAL EMERGENCY; STOP antipsychotic, cool, give dantrolene/bromocriptine.
- CLOZAPINE: Best for treatment-resistant; MANDATORY WBC/ANC monitoring; agranulocytosis risk; minimal EPS.
- RA 11036: Recovery-oriented, community-based, rights-based care; restrict involuntary admission; informed consent required.
- RA 9173: Nursing accountability for assessment, intervention, documentation; therapeutic communication, confidentiality, least restrictive care.
- NANDA diagnoses: Risk for violence, Disturbed thought processes, Hallucinatory behavior, Ineffective coping, Social isolation.
- MASLOW PRIORITY: Safety (prevent harm) → Physiology (meds, nutrition, sleep) → Belonging (therapeutic relationship, family) → Self-actualization (rehabilitation, community integration).
Must remember
- AUDITORY HALLUCINATIONS (hearing voices) are THE MOST COMMON positive symptom in schizophrenia. ALWAYS ask directly about hallucinations and ESPECIALLY screen for COMMAND HALLUCINATIONS directing self-harm or harm to others—they are a SAFETY EMERGENCY.
- POSITIVE SYMPTOMS (hallucinations, delusions, disorganized speech) are EXCESS/DISTORTION and respond WELL to antipsychotics. NEGATIVE SYMPTOMS (the 5 'A's: affective flattening, alogia, avolition, anhedonia, asociality) are LOSS/ABSENCE and respond POORLY to typical antipsychotics; atypicals are better for negative symptoms.
- When client has DELUSIONS: DO NOT argue with the delusion (entrenches it) and DO NOT agree with it (reinforces it). Instead, acknowledge the FEELING ('I understand that's frightening') and redirect to reality-based topics or activities.
- ACUTE DYSTONIA is a MEDICAL EMERGENCY, especially if LARYNGEAL INVOLVEMENT (airway obstruction). Onset is HOURS TO DAYS. Treat IMMEDIATELY with IM/IV benztropine (1 mg) or diphenhydramine (25–50 mg). Client will be terrified—reassure immediately.
- TARDIVE DYSKINESIA (late-onset, involuntary facial/tongue movements) is OFTEN IRREVERSIBLE. Prevention is key: use LOWEST effective dose, prefer atypicals, and screen regularly with AIMS. Anticholinergics DO NOT HELP tardive dyskinesia and may WORSEN it.
- NEUROLEPTIC MALIGNANT SYNDROME (NMS) is a RARE but LIFE-THREATENING emergency: Hyperthermia (>38–40°C) + LEAD-PIPE RIGIDITY + Autonomic instability (labile BP, tachycardia, diaphoresis) + Altered mental status + ELEVATED CK. IMMEDIATE action: STOP antipsychotic, provide aggressive supportive care (cooling, IV fluids), administer dantrolene and/or bromocriptine.
- CLOZAPINE is reserved for TREATMENT-RESISTANT schizophrenia and carries AGRANULOCYTOSIS risk (1–2% incidence). MANDATORY monitoring: WBC/ANC weekly × 6 months, then q2 weeks × 6 months, then q4 weeks. Client MUST REPORT fever, sore throat, mouth ulcers, or flu-like symptoms immediately (signs of agranulocytosis).
- TYPICAL antipsychotics (haloperidol, chlorpromazine, fluphenazine) have HIGHER EPS risk. ATYPICAL antipsychotics (risperidone, olanzapine, quetiapine, clozapine, aripiprazole) have LOWER EPS but HIGHER metabolic effects (weight gain, hyperglycemia, dyslipidemia). Olanzapine and clozapine carry the MOST metabolic risk; monitor weight, glucose, and lipids monthly.
- ANTICHOLINERGIC agents (benztropine, trihexyphenidyl, diphenhydramine) treat ACUTE DYSTONIA, AKATHISIA, and PSEUDOPARKINSONISM. However, they DO NOT treat tardive dyskinesia and may WORSEN it. Side effects: dry mouth, blurred vision, constipation, urinary retention, heat stroke risk—critical in tropical climates like the Philippines.
- RA 11036 (Mental Health Act) mandates RECOVERY-ORIENTED, COMMUNITY-BASED, RIGHTS-BASED care. Involuntary admission only by court order. Clients retain autonomy and right to refuse treatment (unless court-ordered). RA 9173 (Nursing Practice Act) requires informed consent, therapeutic communication, confidentiality, use of least restrictive interventions, and thorough documentation. Nurses are accountable for advocacy, safety, and therapeutic relationship.
Last minute tips
- When answering NLE questions on hallucinogenic/delusional management: NEVER argue with delusions or hallucinations. The correct response is always to acknowledge the FEELING, present reality gently, and offer distraction/redirection. Look for answer choices with 'reassurance,' 'acknowledge feelings,' 'reality-based activities,' or 'consistent presence.'
- For EPS questions: Memorize the TIMELINE (acute dystonia = hours–days → akathisia/pseudoparkinsonism = days–weeks → tardive dyskinesia = months–years). Know that ACUTE DYSTONIA is the only EPS that is a medical EMERGENCY (especially laryngeal). Anticholinergics treat acute dystonia, akathisia, pseudoparkinsonism BUT NOT tardive dyskinesia.
- For clozapine questions: The keyword is AGRANULOCYTOSIS. Know the WBC/ANC monitoring schedule (weekly, then q2 weeks, then q4 weeks) and alert values (WBC <3500 = hold; <3000 = discontinue). Test always asks 'What should the nurse do?' = Check WBC/ANC immediately, inform provider, hold clozapine if low.
- For NMS questions: Recognize the 'quad' = Hyperthermia + Rigidity + Autonomic instability + Altered mental status + HIGH CK. The correct action is STOP the antipsychotic and provide SUPPORTIVE CARE (cooling, fluids, dantrolene/bromocriptine). Do NOT restart the same antipsychotic; if needed, use lower-risk atypical with close monitoring.
- For medication side effect questions: Typical antipsychotics cause MORE EPS; atypicals cause MORE metabolic effects. If question asks 'Why switch from typical to atypical?' → Answer is EPS. If question asks 'Why monitor weight/glucose with atypicals?' → Answer is metabolic effects. Use this rule to eliminate wrong answers quickly.
Comparison tables
Typical vs. Atypical Antipsychotics
| Feature | Typical (First-Generation) | Atypical (Second-Generation) |
|---|---|---|
| Examples | Haloperidol, chlorpromazine, fluphenazine, perphenazine, thioridazine | Risperidone, olanzapine, quetiapine, clozapine, aripiprazole, ziprasidone, paliperidone |
| Mechanism | Primarily D2 dopamine antagonist | D2 antagonist + serotonin (5-HT2A) antagonist |
| Positive Symptoms | Highly effective | Highly effective |
| Negative Symptoms | Poor response | Better response |
| EPS Risk | HIGH (esp. high-potency) | LOW |
| Metabolic Effects | Minimal | Moderate to HIGH (olanzapine, clozapine worst) |
| Anticholinergic Effects | Moderate (esp. low-potency like chlorpromazine) | Minimal to low |
| Sedation | Moderate to high (esp. low-potency) | Variable (quetiapine highest) |
| Agranulocytosis Risk | Rare | Clozapine only: 1–2% |
| Onset of Action | 2–4 weeks | 2–4 weeks |
| Cost | Inexpensive | More expensive |
| Long-Acting Injectables | Yes (haloperidol decanoate, fluphenazine decanoate) | Yes (paliperidone palmitate, others) |
Extrapyramidal Side Effects (EPS) – Quick Reference
| Type | Onset | Manifestations | Treatment | Prevention |
|---|---|---|---|---|
| Acute Dystonia | Hours to 4 days | Painful muscle spasms (neck/face/jaw/tongue/eyes); torticollis, oculogyric crisis; possible laryngeal spasm (AIRWAY EMERGENCY) | IM/IV benztropine or diphenhydramine STAT | Low dose or atypical; avoid high-potency typicals |
| Akathisia | Days to weeks | Restlessness, inability to sit still, pacing, inner tension, fidgeting | Lower dose, beta-blockers (propranolol), benzodiazepines | Use atypicals; monitor for akathisia early |
| Pseudoparkinsonism | Days to weeks | Tremor (resting), cogwheel rigidity, bradykinesia, mask-like face, shuffling gait, drooling | Anticholinergics (benztropine, trihexyphenidyl) or amantadine | Low dose or atypical; monitor motor status |
| Tardive Dyskinesia | Months to years (often IRREVERSIBLE) | Involuntary movements of face/mouth/tongue (lip-smacking, chewing, tongue protrusion, grimacing); may affect limbs/trunk | Reduce dose or switch to atypical; NO reliable cure | Use lowest effective dose, atypicals preferred, regular AIMS screening |
Positive vs. Negative Symptoms
| Feature | Positive Symptoms | Negative Symptoms |
|---|---|---|
| Definition | EXCESS or DISTORTION of normal function (added) | LOSS or ABSENCE of normal function (taken away) |
| Examples | Hallucinations (auditory most common), delusions, disorganized speech, disorganized behavior, agitation | Affective flattening, alogia, avolition, anhedonia, asociality |
| Most Common Type | AUDITORY HALLUCINATIONS (hearing voices) | Avolition (lack of motivation) |
| Response to Medication | WELL (rapid, even with typical antipsychotics) | POOR with typicals; better with atypicals |
| Impact on Functioning | Acute distress but may respond quickly | OFTEN MORE DISABLING; harder to treat; poor prognosis |
| Family Perspective | Often frightening but visible/recognizable | Frustrating; appear as laziness or lack of caring |
NMS vs. Serotonin Syndrome (Differential Diagnosis)
| Feature | Neuroleptic Malignant Syndrome (NMS) | Serotonin Syndrome |
|---|---|---|
| Causative Drug Class | Antipsychotics (esp. high-potency typicals) | Serotonergic drugs (SSRIs, tramadol, MAOIs, linezolid) |
| Hyperthermia | YES (often >38–40°C) | YES (usually <39°C) |
| Rigidity | YES (lead-pipe rigidity, sustained) | NO |
| Hyperreflexia/Clonus | NO | YES (hyperreflexia, myoclonus, clonus) |
| Autonomic Instability | YES (labile BP, tachycardia, diaphoresis) | YES (tachycardia, hypertension, tachypnea) |
| Altered Mental Status | YES (confusion, stupor, delirium) | YES (agitation, confusion, restlessness) |
| Elevated CK | YES (often >4000 U/L; rhabdomyolysis) | Rare |
| Onset | Usually 24–72 hours after antipsychotic start | Hours to days after serotonergic drug interaction |
| Treatment | STOP antipsychotic, supportive care, dantrolene, bromocriptine | STOP serotonergic drug, supportive care; cyproheptadine (serotonin antagonist) |
Antipsychotic Monitoring Checklist
| Parameter | Baseline | Frequency During Treatment | Alert Values |
|---|---|---|---|
| Weight | Yes | Monthly | >7% increase = significant; consider switch |
| Blood Glucose | Yes (fasting) | At 3 months, then annually | >126 mg/dL fasting = diabetes; monitor closely |
| Lipid Panel | Yes | At 3 months, then annually | Triglycerides >200 mg/dL, LDL >100 mg/dL |
| Blood Pressure | Yes (lying & standing) | With each visit | Systolic drop >20 or diastolic >10 = orthostasis |
| EPS Screening (AIMS) | Yes (baseline) | Every 6–12 months | Any involuntary movements = assess for TD |
| WBC/ANC (Clozapine ONLY) | Yes (before starting) | Weekly × 6 months, then q2 weeks × 6 months, then q4 weeks | WBC <3500 = hold; <3000 = discontinue |
| Mental Status & Symptoms | Detailed at baseline | Every visit; assess positive/negative symptoms, suicidality | Worsening symptoms = medication failure; reassess |
Diagrams
Schizophrenia & Psychotic Disorders – Comprehensive Overview
Complete mind map showing the psychotic disorder spectrum, symptom domains (positive and negative), antipsychotic classes, adverse effects (EPS, NMS, agranulocytosis, metabolic), and nursing care priorities aligned with recovery-oriented practice under RA 11036.
EPS Recognition & Management Algorithm
Flowchart guiding nurses through EPS recognition by onset time, clinical features, and appropriate management. Emphasizes acute dystonia as medical emergency, distinguishes between EPS types, and highlights that anticholinergics DO NOT treat tardive dyskinesia.
NMS Recognition & Emergency Management
Step-by-step flowchart for recognizing NMS (hyperthermia + lead-pipe rigidity + autonomic instability + altered mental status + elevated CK) and immediate emergency management: stop antipsychotic, provide cooling and IV fluids, administer dantrolene and/or bromocriptine, and monitor in ICU setting.
Clozapine WBC Monitoring Timeline & Action States
State diagram showing the clozapine WBC monitoring timeline, action thresholds (WBC <3500 = hold; <3000 = discontinue), and three phases of monitoring (weekly → every 2 weeks → every 4 weeks). Client must report fever, sore throat, and flu-like symptoms immediately.
Therapeutic Communication with Hallucinations vs. Delusions
Detailed flowchart distinguishing therapeutic responses to hallucinations (ask directly, screen for command hallucinations, validate experience, provide reality-based interventions) versus delusions (do NOT argue or agree, focus on feeling, redirect to reality, build trust). Emphasizes command hallucinations as safety emergency.