Understanding Psychosis and Mania: Key Clinical Insights

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 

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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 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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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 7/16 Typically, symptoms of schizophrenia begin to manifest before the age of 25 and persist throughout the lifespan. Stressful life events, such as the loss of a loved one, the end of a relationship, abuse, or substance use may precipitate symptoms of schizophrenia in those already vulnerable. Positive symptoms tend to come and go throughout the illness while negative symptoms tend to be more stable throughout life. Cognitive symptoms impact a client's ability to function independently. Therapeutic agent (orange) Labels D1-expressing medium spiny neuron (MSN) D2-expressing medium spiny neuron (MSN) GABAergic interneuron 6. Indirect Inhibitory D2 Pathway The nigrostriatal pathway contains both D -like and D -like receptors. The D -like receptors form the indirect pathway. Stimulation of these receptors by the presence of dopamine or a dopamine partial agonist results in the inhibition of the neuron through the release of an inhibitory neurotransmitter, GABA. The final effect of the nigrostriatal pathway is the simultaneous stimulation of the direct pathway and inhibition of the indirect pathway. Over-inhibition of the indirect pathway will lead to bradykinesia, rigidity, and slow movements. Legend Therapeutic agent (orange) Labels D1-expressing medium spiny neuron (MSN) D2-expressing medium spiny neuron (MSN) GABAergic interneuron 7. Synapses and Neurons in the Normal Human Brain Under normal conditions, the brain can react to its neurotransmitters via the receptors. The receptors will release more neurotransmitters and produce a synapse that will create a domino effect. The synaptic signal will be relayed to other surrounding neurons until it reaches the effector neuron, and the intended action is performed. 8. Fewer Synapses and Neuron Branches When neurons become damaged and die, the synaptic signal cannot be transmitted. This lack of transmission results in deficient communication between the brain and the rest of the body, leading to disorganized thought and movements. 1 2 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 8/16 P r o d r o m a l P h a s e Prodromal symptoms usually develop before the first psychotic episode over a few days to a few months and may persist for a year or more before the onset of overt psychotic symptoms (Boland & Verduin, 2022). Symptoms that occur in the prodromal phase of the illness are typically negative and may be overlooked due to their similarity to other conditions, such as depression (Correll & Schooler, 2020). Clients may begin to show an interest in abstract ideas, philosophy, and occult or religious questions. Other prodromal signs and symptoms include noticeably strange behavior, abnormal affect, unusual speech, bizarre ideas, and odd perceptual experiences. C o u r s e The course of schizophrenia typically involves exacerbations and remissions. Often, after the first psychotic episode, clients may recover and function somewhat normally for a long time before relapsing. The pattern of illness during the first five years after the diagnosis generally indicates the client's course (Boland & Verduin, 2022). Each relapse leads to further decline in client functioning. Over time, positive symptoms tend to become less severe while negative symptoms may increase in severity. G e n d e r D i ff e r e n c e s i n S c h i z o p h r e n i a Genetically determined men and women may present with different symptoms and comorbidities. Women are more likely to receive a diagnosis of schizophrenia later in life and are more likely to have relatives who also have the diagnosis. Women often have more positive and affective symptoms; women typically have more success in maintaining employment and relationships than men. Men are more likely to have comorbid substance abuse and are more likely to die by suicide (Seeman, 2021). Medical Diagnoses that Mimic Psychotic Disorders Clients presenting with psychotic symptoms require a thorough history and physical examination to rule out an organic medical cause before a psychiatric diagnosis is made. A detailed history should be obtained if possible; if the client is unable or unwilling to provide information it may be necessary to obtain information from family or significant others. The history should include the onset of psychotic symptoms, duration, severity, and the impact they have had on daily life, as well 

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 9/16 as current and past substance use and/or abuse and past treatment attempts for any psychiatric condition. Diagnostic testing may be used to clarify or confirm a diagnosis based on the client's clinical presentation and the likelihood of other diagnoses in the differential. Diagnostic testing may include radiologic imaging and electroencephalography (EEG) to rule out an intracranial process or seizure disorder. Serum and urine lab tests may also be performed to rule out underlying metabolic disorders or substance use. L e a r n M o r e Complete the activity below to learn more about medical conditions that mimic psychosis. Which of the following medical conditions are likely to present with symptoms that mimic psychosis? Select all that apply. psoriasis  diabetes  Huntington disease  Alzheimer's disease  brain tumors  adrenal disorders  heart disease  Creutzfeldt-Jakob disease   Check  Learn More Transcript

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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 10/16 Lifespan Considerations Schizophrenia is a mental illness with psychotic symptoms and varies with age and presentation. Click each plus ( + ) sign in the activity below to learn more about schizophrenia onset varies across the lifespan. Question 1 Which of the following medical conditions are likely to present with symptoms that mimic psychosis? Select all that apply. Alzheimer's disease (Correct answer) Huntington disease (Correct answer) heart disease brain tumors (Correct answer) diabetes Creutzfeldt-Jakob disease (Correct answer) adrenal disorders (Correct answer) psoriasis Rationale: Medical conditions that commonly present with psychotic symptoms include Alzheimer's disease, Huntington disease, multiple sclerosis, brain tumors, head trauma, Creutzfeldt-Jakob disease, syphilis, viral encephalitis, hepatic encephalopathy, adrenal disorders, and vitamin B12 deficiency. Question 2 Which of the following medications or substances commonly cause symptoms that mimic psychosis? Select all that apply. cephalosporins (Correct answer) antihistamines steroids (Correct answer) amphetamines (Correct answer) ashwagandha alcohol (Correct answer) marijuana (Correct answer) beta-blockers Rationale: Medications with side effects mimicking psychosis include cephalosporins, penicillin, anticholinergics, steroids, amphetamines, cocaine, alcohol, marijuana, and hallucinogens. 

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 11/16     Lifespan Considerations in Schizophrenia Transcript Pediatric Schizophrenia Although schizophrenia usually presents initially in late adolescence or early adulthood, in rare cases, onset may occur during childhood. Pediatric schizophrenia has been estimated to be present at a rate of 0.5 per 1,000 (Sicotte et al., 2021). Children with pediatric schizophrenia often show delays in language and other development and may display behaviors such as rocking, posturing, or flapping before the onset of psychotic symptoms, which usually appear at age seven or later. Differentiating between developmental delays and symptoms of schizophrenia can be challenging. Another challenge with assessing schizophrenia in pediatric

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 12/16 Treatment The treatment of psychotic disorders is complex. Psychotic symptoms can wax and wane leading to exacerbations and remissions. Treatment includes antipsychotics as well as other medications, psychotherapy, and close collaboration between providers and the client's support system. Referral to a mental health specialist is required. A G S B e e r s C r i t e r i a Clients with dementia may present with psychotic symptoms. According to the American Geriatric Society (AGS) Beers Criteria (2019), clients with dementia and with dementia-related psychosis should not receive clients involves distinguishing between normal childhood fantasies and delusions or hallucinations. Adolescence Schizophrenia onset in adolescence is often insidious. Initial signs may include withdrawal from friends or interests, changes in personal hygiene, or decreased school performance. When providing treatment with antipsychotic medications, weight gain may be problematic for clients' self-esteem and body image as well as increasing the risk for chronic health conditions such as diabetes, hypertension, and heart disease. Client and parent nutritional education and possible concomitant use of metformin may be indicated. Adolescent boys may be more vulnerable to acute dystonic reactions than adult clients. Prophylactic use of antiparkinsonian medication may be appropriate. Older Adults Late-onset schizophrenia is rare. It is more common in women and can occur after age 45. Presentation is more often the paranoid type. Delusional disorder can also develop in older adulthood, often presenting as a paranoid-persecutory type. Older adults with schizophrenia have a higher incidence of comorbid disease, including heart failure, COPD, hypothyroidism, and dementia (Taube et al., 2023). Although antipsychotic medications may be used successfully for the treatment of older adults with schizophrenia, precautions should be taken as older adults are more likely to experience extrapyramidal symptoms. Doses may need to be reduced to prevent side effects. 

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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 13/16 haloperidol, ziprasidone, and olanzapine due to an increased risk of cerebrovascular accident, cognitive decline, and death. Mania Mania, as a symptom, may present alone or as part of another health condition such as bipolar disorder. To be diagnosed with mania, the client must experience an elevated, expansive, or irritable mood for at least one week with the mood present most of the day and nearly every day. The mood disturbance must be severe enough to cause significant impairment in social or occupational functioning, to require hospitalization to prevent harm to the client or others, or symptoms include psychotic features (American Psychiatric Association [APA], 2022). During this period, three or more of the symptoms in the image below must be present and represent a significant change from usual behavior (APA, 2022). 

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 14/16 Hypomania is a milder form of mania. To be diagnosed with hypomania, the client must experience symptoms for at least four consecutive days with symptoms present most of the day and nearly every day. The client’s energy level is higher than normal but not as high as with mania. Hypomanic episodes can lead to challenges but do not tend to lead to significant issues with daily functioning. Hypomanic episodes do not involve psychotic symptoms and are less likely to lead to hospital visits. L e a r n M o r e To diagnose mania, all other causes of the symptoms must be ruled out. Complete the activity below to learn more about conditions and substances that mimic mania. Symptoms of Mania Image Description Inflated self-esteem or grandiosity Decreased need for sleep Increased talkativeness Racing thoughts Distracted easily Increase in goal-directed activity or psychomotor agitation Engaging in activities that hold the potential for painful consequences, e.g., unrestrained buying sprees

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 15/16 Which of the following medical conditions are likely to present with symptoms that mimic mania? Select all that apply. diabetes  muliple scelrosis  hyperthyroidism  hyperaldosteronism  neurocognitive disorder  brain tumor  delirium   Check  Learn More Transcript Question 1 Which of the following medical conditions are likely to present with symptoms that mimic mania? Select all that apply. hyperthyroidism (Correct answer) diabetes hyperaldosteronism (Correct answer) brain tumor (Correct answer) neurocognitive disorder (Correct answer) multiple sclerosis delirium (Correct answer)

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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 16/16 Tr e a t m e n t Treatment depends on the cause of the mania. Medication and psychotherapy can be used to treat mania associated with mood disorders. Clients with mania should be referred to a psychiatric mental health specialist. Rationale: Medical conditions that commonly present with symptoms that mimic mania include hyperthyroidism, hypercortisolemia, hyperaldosteronism, brain tumor, neurocognitive disorder, acromegaly, delirium, lupus, HIV, or syphilis. Question 2 Which of the following medications or substances commonly cause symptoms that mimic mania? Select all that apply. steroid medications (Correct answer) clonidine hallucinogens (Correct answer) proton pump inhibitors methamphetamine (Correct answer) marijuana (Correct answer) anti-inflammatory medications Rationale: Medications and substances with effects that mimic mania include levodopa, hallucinogens, antidepressants, methamphetamine, marijuana, or cocaine.

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