MAX
1. Action point: A prodromal phase often precedes the first
presentation of schizophrenia. Max may have been experiencing
this for the 9 months prior to this presentation. Describe the
prodromal phase and how this impacts on a client’s recovery.
 A prodromal phase often precedes the first presentation of
schizophrenia. Max may have been experiencing this for the 9
months prior to this presentation.
 Describe the prodromal phase and how this impacts on a client’s
recovery.
 Prodromal Phase – earliest manifestation of a psychotic disorder
which often develops in early adolescence:
-
Sleep/appetite disturbance
-
Marked unusual behavior
-
Feeling different to others (blunted or incongruent)
-
Speech difficult to follow
-
Marked pre occupation with unusual ideas
-
Ideas of reference things having special meaning
-
Persistent feeling of unreality
-
Changes in a way things appear, sound or smell

Prodromal features in Schizophrenia are vague and not specific.
Although when the illness becomes severe it can be diagnosed and
prodromal features can be identified.
2. Action point: Educating clients and their families about the
nature and process of the mental health act is an important role
for the mental health nurse.
Outline for Max’s parents, the
criteria for a person to be under the Mental Health Act and give
the family an overview of how antipsychotic /anxiolytic
medications are used in the management of psychosis.
Max’s
parents also ask you about the interview taking place in the
other room. Describe your response.
 Educating clients and their families about the nature and process
of the mental health act is an important role for the mental
health nurse.
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
The Mental Health (Compulsory Assessment and Treatment) Act 1992
defines the circumstances in which a person may be required to
undergo compulsory psychiatric assessment and treatment. The Act
aims to ensure that both vulnerable individuals and the public
are protected from harm with its rights of patients and proposed
patients and aims to protect those rights.
Under this act, the clients are entitled to:
• To have their culture respected
• To have an interpreter present
• To be supported by whanau or friends
• To have visitors and access to a phone
• The company of others
• Not to be video or audio taped
• Access to a District Inspector
• Full information on your status
• Receive appropriate health care
• To be informed of benefits of treatment
• To be informed of possible side effects
• To seek a second independent opinion
• To have access to legal advice
• To have a Judicial Review
The Summary of the Procedure for Assessment and Treatment
under the Mental Health Act 1992:
• Section
• Section
• Section
• Section
• Section
• Section
• Section
8A
Application for assessment
8B
Medical certificate
9
Notice to attend an assessment
10
Certificate of preliminary assessment
11
Further assessment and treatment (5 days)
13 (2 weeks)
15 (4 weeks)
Community Treatment Orders
• Section 29
Can last up to 6 months
Can be extended or made indefinite
Can be converted to an inpatient order
Must attend for treatment
Inpatient Orders
• Section 30
Provides for compulsory treatment
Lasts for up to six months
Can be extended or made indefinite
Can be converted to a community treatment order
• Section 31
Provides for conditional leave
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Revoked if conditions not adhered to

Outline for Max’s parents, the criteria for a person to be under
the Mental Health Act and give the family an overview of how
antipsychotic /anxiolytic medications are used in the management
of psychosis

Mental Disorder

Intermittent disorder – repeated or prolonged episodes of illness
- Severe consequences during phases of illness;
such as severe violence to self or others
- Early loss of insight during an episodes of
illness, with a pattern of failing to be able to
take the necessary steps to halt the development
of illness
- Changeable insight
consistent decision
=
inability
to
maintain
o
Degree of disorder – seriously diminishes the capacity of look
after himself or herself i.e. failure to comply with meds (i.e.
insulin); self-neglect such as inattention to cooking and high
risk fire; a person in a manic state who overspends to such an
extent that he or she finds himself or herself bankrupt when
symptoms of mania are no longer present
o
Poses a serious danger to the health or safety of that person or
others
o
Threshold for application for compulsory treatment
o
Abnormal state of mind
o
Disorders of volition and cognition (Volition: depression stupor;
catatonic excitement/withdrawal;passisivity;lack of motivation)
o
Head injury resulting to disturbance in behavior
o
Personality disorder
o
Substance abuse
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

Antipsychotics – previously referred to as major tranquilizers or
neuroleptics are effective for the treatment of a variety of
psychotic symptoms. All available antipsychotics antagonize
dopamine (d2) receptors in vitro.
Max’s parents also ask you about the interview taking place in
the other room. Describe your response.

Privacy Act 1993
3. Action point: Describe what needs to be undertaken for a holistic
assessment of Max in a first assessment interview.
Psychiatric Assessment
 The purpose of the psychiatric assessment is to develop an
understanding of the person presenting for help. It involves
taking a basic psychiatric history and a mental status
assessment. The following information is required in conducting a
comprehensive psychiatric assessment:
1. Identifying Information
 Includes; name, age, sex, present address, telephone number,
languages
spoken,
general
practitioner,
marital
status,
occupation and next of kin.
2. Reason for Referral
 This should include;
 Who has asked for the client to be seen and why
 The nature of the problem
 Events that led to this presentation
 Any recent suicide attempts
 Any recent episodes of self-harm
3. Presenting Problem and/or precipitating factors
 Information needed include;
 Specific symptoms that are present and their duration
 Time relationships between the onset or exacerbation of symptoms
and the presence of social stressors/physical illness
 Any disturbance in mood, appetite, sexual drive or sleep
 Any treatments given by other doctors or specialists for this
problem
 The individual response to treatment
4. Mental Health/Medical/Drug History
 Information required includes the number of admissions to mental
health inpatient units, number of episodes of self-harm,
attempted suicide or occasions of assault, and an indication of
any mental health treatments received. This information is
usually obtained from the client, previous clinical notes, a
letter from the doctor, or history provided by relatives or
friends.
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5. Psychosocial/Relationship History
 This
outlines
circumstances
that
are
significant
for
understanding current issues, and covers many aspects of the
individual’s life, such as relationships, family background, work
or school history and, possibility, developmental stages.
6. Determining Risk Factors
 Several risk factors need to be assessed for each client;
 Harm to others, harm to self, suicide, absconding, vulnerability
to exploitation or abuse (sexual)
 Vulnerability to exploitation or abuse (violence)
7. Assessment of Strengths
 The focus on strengths of individuals and their opportunities
rather than pathology creates opportunity for growth. The
strengths identified in this conceptual framework include the
individual’s interests, aspirations, skills, competencies and
talents.
8. Mental State Examination (BATOMI)
 A semi- structured interview used mainly as a screening tool to
assess a person’s current neurological and psychological status
along several components. The exam involves observations as well
as an interview.
 It involves;
o Appearance and Behaviour
o Speech, Mood and Affect
o Form of Thought
o Thought Content
o Perception
o Sensorium and Cognition
9. Physical Assessment
 Involves past and present health status, physical functions
(elimination,
activity
and
exercise,
sleep,
appetite
and
nutrition, hydration, self-care), Laboratory results
20. Spiritual Assessment
 It is important because it provides a deeper understanding of the
client, their social setting and the possible origins of the
problem.
21. Cultural Assessment
 Mental health nurses need to engage the client and the family so
that appropriate care should be given. In New Zealand, the
principle of Cultural Safety is applied to provide quality care
that is also culturally sensitive to the patients.
22. Triage Assessment
 Refers to the decision-making process that occurs when
alternatives for acute care are being considered
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ADAM SMITH
1. Action point: What information are you going to pass on to Agnes?
 Schizophrenia is a chronic, severe, and disabling brain
disorder that has affected people throughout history.

People with the disorder may hear voices other people
hear. They may believe other people are reading
minds, controlling their thoughts, or plotting to
them. This can terrify people with the illness and
them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they
talk. They may sit for hours without moving or talking.
Sometimes people with schizophrenia seem perfectly fine
until they talk about what they are really thinking.

The symptoms of schizophrenia
categories: positive symptoms,
cognitive symptoms

don't
their
harm
make
fall into three broad
negative symptoms, and
Positive symptoms
Positive symptoms are psychotic behaviours not seen in
healthy people. People with positive symptoms often "lose
touch" with reality. These symptoms can come and go.
Sometimes they are severe and at other times hardly
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noticeable,
depending
on
whether
the
individual
receiving treatment. They include the following:





is
Hallucinations are things a person sees, hears, smells, or
feels that no one else can see, hear, smell, or feel.
"Voices" are the most common type of hallucination in
schizophrenia. Many people with the disorder hear voices.
The voices may talk to the person about his or her
behaviour, orders the person to do things, or warn the
person of danger. Sometimes the voices talk to each other.
People with schizophrenia may hear voices for a long time
before family and friends notice the problem.
Other types of hallucinations include seeing people or
objects that are not there, smelling odours that no one
else detects, and feeling things like invisible fingers
touching their bodies when no one is near.
Delusions are false beliefs that are not part of the
person's culture and do not change. The person believes
delusions even after other people prove that the beliefs
are not true or logical. People with schizophrenia can have
delusions that seem bizarre, such as believing that
neighbours can control their behaviour with magnetic waves.
They may also believe that people on television are
directing special messages to them, or that radio stations
are broadcasting their thoughts aloud to others. Sometimes
they believe they are someone else, such as a famous
historical figure. They may have paranoid delusions and
believe that others are trying to harm them, such as by
cheating, harassing, poisoning, spying on, or plotting
against them or the people they care about. These beliefs
are called "delusions of persecution."
Thought disorders are unusual or dysfunctional ways of
thinking.
One
form
of
thought
disorder
is
called
"disorganized thinking." This is when a person has trouble
organizing
his
or
her
thoughts
or
connecting
them
logically. They may talk in a garbled way that is hard to
understand. Another form is called "thought blocking." This
is when a person stops speaking abruptly in the middle of a
thought. When asked why he or she stopped talking, the
person may say that it felt as if the thought had been
taken out of his or her head. Finally, a person with a
thought disorder might make up meaningless words, or
"neologisms."
Movement disorders may appear as agitated body movements. A
person with a movement disorder may repeat certain motions
over and over. In the other extreme, a person may become
catatonic. Catatonia is a state in which a person does not
move and does not respond to others. Catatonia is rare
today, but it
was more common when treatment for
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schizophrenia was not available."Voices" are
common type of hallucination in schizophrenia.

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










the
most
Negative symptoms
Negative symptoms are associated with disruptions to normal
emotions and behaviours. These symptoms are harder to
recognize as part of the disorder and can be mistaken for
depression or other conditions. These symptoms include the
following:
Flat affect
(a person's face does not move or he or she talks in a dull
or monotonous voice)
Lack of pleasure in everyday life
Lack of ability to begin and sustain planned activities
Speaking little, even when forced to interact.
People with negative symptoms need help with everyday
tasks. They often neglect basic personal hygiene. This may
make them seem lazy or unwilling to help themselves, but
the problems are symptoms caused by the schizophrenia.
Cognitive symptoms
Cognitive symptoms are subtle. Like negative symptoms,
cognitive symptoms may be difficult to recognize as part of
the disorder. Often, they are detected only when other
tests are performed. Cognitive symptoms include the
following:
Poor "executive functioning" (the ability to understand
information and use it to make decisions)
Trouble focusing or paying attention
Problems with "working memory" (the ability to use
information immediately after learning it).
How is schizophrenia treated?
Because the causes of schizophrenia are still unknown,
treatments focus on eliminating the symptoms of the
disease. Treatments include antipsychotic medications and
various psychosocial treatments.
Antipsychotic medications
Clozapine (Clozaril) is an effective medication that treats
psychotic
symptoms,
hallucinations,
and
breaks
with
reality. But clozapine can sometimes cause a serious
problem called agranulocytosis, which is a loss of the
white blood cells that help a person fight infection.
People who take clozapine must get their white blood cell
counts checked every week or two. This problem and the cost
of blood tests make treatment with clozapine difficult for
many people. But clozapine is potentially helpful for
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



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













people
who
do
not
respond
to
other
antipsychotic
medications.
Other atypical antipsychotics were also developed. None
cause agranulocytosis. Examples include:
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega).
When a doctor says it is okay to stop taking a medication,
it should be gradually tapered off, never stopped suddenly.
What are the side effects?
Some people have side effects when they start taking these
medications. Most side effects go away after a few days and
often can be managed successfully. People who are taking
antipsychotics should not drive until they adjust to their
new medication. Side effects of many antipsychotics
include:
Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.
Atypical antipsychotic medications can cause major weight
gain and changes in a person's metabolism. This may
increase a person's risk of getting diabetes and high
cholesterol. A person's weight, glucose levels, and lipid
levels should be monitored regularly by a doctor while
taking an atypical antipsychotic medication.
Typical antipsychotic medications can cause side effects
related to physical movement, such as:
Rigidity
Persistent muscle spasms
Tremors
Restlessness.
Long-term use of typical antipsychotic medications may lead
to a condition called tardive dyskinesia (TD). TD causes
muscle movements a person can't control. The movements
commonly happen around the mouth. TD can range from mild to
severe, and in some people the problem cannot be cured.
Sometimes people with TD recover partially or fully after
they stop taking the medication.
TD happens to
fewer people who take the atypical
antipsychotics, but some people may still get TD. People
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who think that they might have TD should check with their
doctor before stopping their medication.







How are antipsychotics taken and how do people respond to
them?
Antipsychotics are usually in pill or liquid form. Some
anti-psychotics are shots that are given once or twice a
month.
Symptoms of schizophrenia, such as feeling agitated and
having hallucinations, usually go away within days.
Symptoms like delusions usually go away within a few weeks.
After about six weeks, many people will see a lot of
improvement.
However, people respond in different ways to antipsychotic
medications, and no one can tell beforehand how a person
will respond. Sometimes a person needs to try several
medications before finding the right one. Doctors and
patients can work together to find the best medication or
medication combination, as well as the right dose.
Some people may have a relapse -- their symptoms come back
or get worse. Usually, relapses happen when people stop
taking their medication, or when they only take it
sometimes. Some people stop taking the medication because
they feel better or they may feel they don't need it
anymore. But no one should stop taking an antipsychotic
medication without talking to his or her doctor. When a
doctor says it is okay to stop taking a medication, it
should be gradually tapered off, never stopped suddenly
Psychosocial treatments
Psychosocial treatments can help people with schizophrenia
that is already stabilized on antipsychotic medication.
Psychosocial treatments help these patients deal with the
everyday challenges of the illness, such as difficulty with
communication, self-care, work, and forming and keeping
relationships. Learning and using coping mechanisms to
address these problems allow people with schizophrenia to
socialize and attend school and work.
Patients who receive regular psychosocial treatment also
are more likely to keep taking their medication, and they
are less likely to have relapses or be hospitalized. A
therapist can help patients better understand and adjust to
living with schizophrenia. The therapist can provide
education about the disorder, common symptoms or problems
patients may experience, and the importance of staying on
medications.
Illness management skills. People with schizophrenia can
take an active role in managing their own illness. Once
patients learn basic facts about schizophrenia and its
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treatment, they can make informed decisions about their
care. If they know how to watch for the early warning signs
of relapse and make a plan to respond, patients can learn
to prevent relapses. Patients can also use coping skills to
deal with persistent symptoms.

Integrated treatment for co-occurring substance abuse.
Substance abuse is the most common co-occurring disorder in
people with schizophrenia. But ordinary substance abuse
treatment programs usually do not address this population's
special needs. When schizophrenia treatment programs and
drug treatment programs are used together, patients get
better results.

Rehabilitation.
Rehabilitation
emphasizes
social
and
vocational training to help people with schizophrenia
function better in their communities. Because schizophrenia
usually develops in people during the critical careerforming years of life (ages 18 to 35), and because the
disease makes normal thinking and functioning difficult,
most patients do not receive training in the skills needed
for a job.
Rehabilitation programs can include job counselling and
training, money management counselling, help in learning to
use public transportation, and opportunities to practice
communication skills. Rehabilitation programs work well
when they include both job training and specific therapy
designed to improve cognitive or thinking skills. Programs
like this help patients hold jobs, remember important
details, and improve their functioning.


Family education. People with schizophrenia are often
discharged from the hospital into the care of their
families. So it is important that family members know as
much as possible about the disease. With the help of a
therapist, family members can learn coping strategies and
problem-solving skills. In this way the family can help
make sure their loved one sticks with treatment and stays
on his or her medication. Families should learn where to
find outpatient and family services.

Cognitive
behavioural
therapy.
Cognitive
behavioural
therapy (CBT) is a type of psychotherapy that focuses on
thinking and behaviour. CBT helps patients with symptoms
that do not go away even when they take medication. The
therapist teaches people with schizophrenia how to test the
reality of their thoughts and perceptions, how to "not
listen" to their voices, and how to manage their symptoms
overall. CBT can help reduce the severity of symptoms and
reduce the risk of relapse.
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
Self-help
groups.
Self-help
groups
for
people
with
schizophrenia and their families are becoming more common.
Professional therapists usually are not involved, but group
members support and comfort each other. People in self-help
groups know that others are facing the same problems, which
can help everyone feel less isolated. The networking that
takes place in self-help groups can also prompt families to
work together to advocate for research and more hospital
and community treatment programs. Also, groups may be able
to draw public attention to the discrimination many people
with mental illnesses face.

Short term in the inpatient setting
Principles of treatment for the first episode
Medication
 Proper treatment of the first psychotic episode is of the
utmost importance. Inadequate management at this stage may
foster the development of secondary
 Consequences which can snowball and lead to a substantial
deterioration in long-term outcome. For instance, lack of
insight (i.e. unawareness of illness) is
 A frequently encountered problem in schizophrenia. If the
degree of insight is low after the first episode, it can
lead to reduced compliance to treatment, which
 In turn can increase the relapse rate and worsen the longterm outcome. Likewise, residual psychotic symptoms after
the first episode may affect social and occupational
functioning of patients and indirectly predispose them to
stressful experiences (eg relationship or occupational
problems). Difficulties like these
 Lead to relapses and a poor long-term outcome. Hence, the
thorough and vigorous treatment of the first episode is
very important.




Maintenance therapy
One further issue is the length of maintenance therapy
needed after a single episode of illness. Existing data
suggests that a number of patients may not suffer a
second
episode
even
without
maintenance
treatment.44
Unfortunately, it is not yet possible to identify those who
will relapse and those who will not.28 As yet, data
from double-blind controlled studies that specifically
address the optimal length of maintenance therapy are not
available.28,45 It appears, however, that continuing
medication after the first episode seems to reduce the
relapse rate in the subsequent 12 months from approximately
70% to approximately 40%.46
Management of depressive symptoms and suicide risk
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

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Depression
is
common
in
first-episode
schizophrenic
patients, with prospective studies reporting rates of
identifiable depressive syndrome of around 50% of
First episode patients. The actual rate of depressive
symptoms detected varied considerably between individual
studies (from 20% to 80%), depending on
The rating instruments used. In most cases, depressive
symptoms are worse at the time of the acute episode and
tend to subside as the psychosis comes under
Control. If depressive symptoms persist, antidepressant
therapy should be commenced. The risk of suicide occurring
is substantially increased in first-episode schizophrenia,
especially among male patients.
Psychosocial intervention
Apart from medication, psychosocial rehabilitation efforts
are particularly important for managing negative symptoms.
Negative symptoms can be substantially
Present in the first episode. Vigorous rehabilitation
directed at these symptoms is particularly important in
minimising secondary disabilities. Competence in social
skills is also important in sustaining a social support
network and is a crucial element in long-term management. A
further disability is the presence of
Substantial neurocognitive deficits. By giving adequate
medication treatment, some of these deficits may improve
with time, but the improvement takes
Longer than does the improvement in symptoms. The efficacy
of
cognitive
remediation
programmes
in
reducing
neurocognitive deficits is still not established.
In general, it is known that a high level of expressed
emotion among carers of schizophrenics is predictive of
more frequent relapses. Family behavioural therapy may be
effective in modifying the amount of expressed motion and
the lower relapse rate in selected patients.
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References:
Elder, R., Evans, K. & Nizette, D. (2009). Psychiatric and mental
health nursing (2nd ed.). Sydney:
Mosby.
Johannessen, J. O. (2001). Early recognition and intervention: The key
to success in the treatment of schizophrenia?. Dis Manage Health
Outcomes, 9(6), 317-327.
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