NLE Psychiatric Disorders — Schizophrenia and Psychotic DisordersCheat Sheet

Section Title

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

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)

Section Title

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

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

Section Title

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

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)

Section Title

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

Diagrams To Know

• Decision tree for responding to hallucinations vs. delusions
• Nurse communication script: Therapeutic vs. Non-therapeutic responses to psychotic symptoms

Section Title

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

Diagrams To Know

• Dopamine pathways affected by antipsychotics (mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular)
• Classification tree: Typical vs. Atypical antipsychotics with examples and side effect profiles

Common Values

Section Title

Extrapyramidal Side Effects (EPS) – The 4 Types

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

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

Section Title

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

Diagrams To Know

• Decision tree: Which anticholinergic to choose based on EPS type and route (IM/IV vs. oral)

Common Values

Section Title

Neuroleptic Malignant Syndrome (NMS) – Medical Emergency

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

Diagrams To Know

• NMS vs. Serotonin Syndrome comparison chart (differential diagnosis)
• NMS management flowchart: Recognition → Stabilization → Pharmacotherapy → Monitoring

Common Values

Section Title

Agranulocytosis & Clozapine Monitoring

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

Diagrams To Know

• Clozapine WBC monitoring schedule and thresholds for action
• Signs and symptoms of agranulocytosis that client must recognize and report

Section Title

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

Diagrams To Know

• Antipsychotic side effect profile comparison (typical vs. atypical)
• Client teaching checklist for antipsychotic therapy

Section Title

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

Diagrams To Know

• NANDA nursing diagnoses hierarchy for psychotic disorders
• Maslow's hierarchy applied to schizophrenia care plan

Section Title

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).

Rows

Columns

• Feature
• Typical (First-Generation)
• Atypical (Second-Generation)

Table Title

Typical vs. Atypical Antipsychotics

Rows

Columns

• Type
• Onset
• Manifestations
• Treatment
• Prevention

Table Title

Extrapyramidal Side Effects (EPS) – Quick Reference

Rows

Columns

• Feature
• Positive Symptoms
• Negative Symptoms

Table Title

Positive vs. Negative Symptoms

Rows

Columns

• Feature
• Neuroleptic Malignant Syndrome (NMS)
• Serotonin Syndrome

Table Title

NMS vs. Serotonin Syndrome (Differential Diagnosis)

Rows

Columns

• Parameter
• Baseline
• Frequency During Treatment
• Alert Values

Table Title

Antipsychotic Monitoring Checklist