Early Signs of Psychosis

Typically, a person will show changes in their behavior before psychosis develops. Behavioral warning signs for psychosis include the following⁷:

• Drop in grades or worsening job performance
• New trouble thinking clearly or concentrating
• Suspiciousness; paranoid ideas or uneasiness with others
• Withdrawing socially; spending a lot more time alone than usual
• Unusual, bizarre new ideas
• Strange feelings or having no feelings at all
• Decline in self-care or personal hygiene
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating

Symptoms of a Psychotic Episode

See the following box for signs and symptoms of a psychotic episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5-TR) by the American Psychiatric Association.

A brief psychotic episode is defined by a psychotic event lasting at least one day but less than one month, with an eventual return to previous level of functioning. It does not include a culturally sanctioned response, such as a person’s response to the death of a loved one. The disturbance is not better explained by a major depressive disorder or bipolar disorder with psychotic features, another psychotic disorder, or the physiological effects of a substance or a medical condition. The mental health provider may specify if the symptoms are in response to significant stressors (i.e., significant events to anyone experiencing similar circumstances in the individual’s culture) or has a peripartum onset (i.e., during pregnancy or within four weeks of delivery).⁹

Review information about delusions, hallucinations, and disorganized speech in the “Application of the Nursing Process in Mental Health Care” chapter.

Treatment of Psychosis

Treating psychosis involves a comprehensive, long-term approach tailored to the underlying cause of the condition. For example, if psychosis is caused by a medical condition, side effects of medication, or withdrawal from a substance, it will resolve as these conditions are treated. If psychosis is a symptom of mental illness, treatment typically includes a combination of antipsychotic medicines and psychological therapies. The cornerstone of treatment is antipsychotic medication, which helps reduce or eliminate symptoms like hallucinations and delusions. These medications may be used long-term to prevent relapse, especially in chronic conditions such as schizophrenia. In addition to medication, individuals benefit from psychosocial interventions, including cognitive-behavioral therapy (CBT), which helps manage thought patterns and improve insight. Supportive services like case management, peer support, and vocational rehabilitation can also enhance recovery and quality of life. Family education is often included to promote a supportive environment. Treatment plans are individualized and often involve a multidisciplinary team including psychiatrists, nurses, social workers, and therapists. Read more about the treatment of psychosis associated with schizophrenia in the “Schizophrenia” section of this chapter.

A psychotic episode is typically treated as a medical emergency, especially if the person is at risk of harming themselves or others. The immediate goal is to stabilize the individual and reduce acute symptoms. Treatment usually begins with antipsychotic medication, often administered in a hospital or closely monitored outpatient setting. Short-term use of sedatives may be considered to manage agitation or insomnia. Once stabilized, care may transition to outpatient follow-up with a psychiatrist or mental health team. Identifying and addressing triggers such as stress, substance use, or underlying medical issues is essential to prevent future episodes. Education and early intervention following a first episode can significantly improve long-term outcomes, and clients are often referred to specialized early psychosis intervention programs when available.

Genetics

Schizophrenia tends to run in families. Genetic studies strongly suggest that many different genes increase the risk of developing schizophrenia, but that no single gene causes the disorder by itself. It is not yet possible to use genetic information to predict who will develop schizophrenia.⁹

Environment

Scientists think that interactions between genetic risk and aspects of an individual’s environment play a role in the development of schizophrenia. Environmental factors that may be involved include adverse childhood experiences (ACE) or exposure to viruses or nutritional problems before birth.¹⁰ Other environmental risk factors include urban upbringing, migration, and early life adversities.¹¹ A systematic review found that cannabis (marijuana) worsens symptoms of psychosis in genetically predisposed individuals and causes more relapses and hospitalizations.¹²

Brain Structure and Function

Scientists think that differences in brain structure, function, and interactions among neurotransmitters may contribute to the development of schizophrenia. For example, differences in the volumes of specific components of the brain; the manner in which regions of the brain are connected and work together; and neurotransmitters, such as dopamine, are found in people with schizophrenia. Differences in brain connections and brain circuits seen in people with schizophrenia may begin developing before birth. Changes to the brain that occur during puberty may trigger psychotic episodes in people who are already vulnerable due to genetics, environmental exposures, or the types of brain differences mentioned previously.¹³

Antipsychotic Medications

Antipsychotic medications reduce the intensity and frequency of psychotic symptoms by inhibiting dopamine receptors. Certain symptoms of psychosis, such as feeling agitated and having hallucinations, resolve within days of starting an antipsychotic medication. Symptoms like delusions usually resolve within a few weeks, but the full effects of the medication may not be seen for up to six weeks.¹⁷

First-generation antipsychotics (also called “typical antipsychotics”) treat positive symptoms of schizophrenia and have several potential adverse effects due to their tight binding to dopamine receptors. Medication is prescribed based on the client’s ability to tolerate the adverse effects. Second-generation antipsychotics (also referred to as “atypical antipsychotics”) treat both positive and negative symptoms of schizophrenia. They have fewer adverse effects because they block selective dopamine D2 receptors, as well as serotonin, so they are generally better tolerated than first-generation antipsychotics. Clients respond differently to antipsychotic medications, so it may take several trials of different medications to find the one that works best for their symptoms.¹⁸

See Table 11.3 for a list of common antipsychotic medications. They are usually taken daily in pill or liquid form. Some antipsychotic medications can also be administered as injections twice a month, monthly, every three months, or every six months, which can be more convenient and improve medication adherence.

Table 11.3

Common Antipsychotic Medications^,,.

ADVERSE EFFECTS

Common side effects of both first- and second-generation antipsychotics include the following²⁴:

• Anticholinergic symptoms: dry mouth, constipation, blurred vision, or urinary retention²⁵
• Drowsiness
• Dizziness
• Restlessness
• Weight gain
• Nausea or vomiting
• Low blood pressure

First-generation antipsychotics, also known as neuroleptics or typical antipsychotics, have significant potential to cause extrapyramidal side effects and tardive dyskinesia due to their tight binding to dopamine receptors. The risk for developing these movement disorders is the primary difference between first-generation antipsychotics and second-generation antipsychotics (also known as atypical antipsychotics). In other respects, the two classes of medication have similar side effects and mechanisms of action.²⁶

Extrapyramidal (EPS) side effects refer to akathisia (psychomotor restlessness), rigidity, bradykinesia (slowed movement), tremor, and dystonia (involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures). See Figure 11.3²⁷ for an image of dystonia.

Figure 11.3

Dystonia.

Acute dystonic reactions affecting the larynx can be a medical emergency requiring intubation and mechanical ventilation. EPS symptoms usually resolve dramatically within 10 to 30 minutes of administration of parenteral anticholinergics such as diphenhydramine and benztropine.²⁸

Tardive dyskinesia (TD) is a syndrome of movement disorders that can occur in clients taking first-generation antipsychotics. Hallmark symptoms are smacking and puckering lips, eye blinking, grimacing, and twitching. TD persists for at least one month and can last up to several years despite discontinuation of the medications. Primary treatment of TD includes discontinuation of first-generation antipsychotics and may include the addition of another medication. Second-generation VMAT2 inhibitors such as deutetrabenazine and valbenazine are considered first-line treatment for TD. Clonazepam and ginkgo biloba have also shown good effectiveness for improving symptoms of TD.^29,30

View a supplementary YouTube video on tardive dyskinesia³¹: Understanding Tardive Dyskinesia.

Neuroleptic malignant syndrome (NMS) is a rare but fatal adverse effect that can occur at any time during treatment with antipsychotics. It typically develops over a period of days to weeks and resolves in approximately nine days with treatment. Signs include increased temperature, severe muscular rigidity, confusion, agitation, hyperreflexia, elevation in white blood cell count, elevated creatinine phosphokinase, elevated liver enzymes, myoglobinuria, and acute renal failure. The antipsychotic should be immediately discontinued when signs occur. Dantrolene and bromocriptine are typically prescribed for treatment. Nursing interventions include adequate hydration, cooling, and close monitoring of vital signs and serum electrolytes.³²

View a supplementary YouTube video³³ on NMS: Neuroleptic Malignant Syndrome in 3 Minutes.

Second-generation antipsychotics have a significantly decreased risk of extrapyramidal side effects but are associated with weight gain and the development of metabolic syndrome.³⁴ Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart disease, stroke, and type 2 diabetes. Symptoms include increased blood pressure; high blood sugar; excess body fat around the waist (also referred to as having an “apple waistline”); and abnormal cholesterol, triglyceride levels, and high-density lipoprotein (HDL) levels. Weight, glucose levels, and lipid levels should be monitored before treatment is initiated then annually.

View a supplementary YouTube video³⁵ on metabolic syndrome: What is Metabolic Syndrome?

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View this PDF comparison: Adverse Effects of Antipsychotic Medications.

Psychosocial Treatments

Cognitive behavioral therapy, behavioral skills training, supported employment, and cognitive remediation interventions are types of psychosocial treatments that can help address the negative and cognitive symptoms of schizophrenia. A combination of these therapies and antipsychotic medication is a common treatment approach for schizophrenia. Psychosocial treatments can help improve an individual’s coping skills with the everyday challenges of schizophrenia. Therapies can also help people pursue their life goals, such as attending school, working, or forming relationships. Individuals who participate in regular psychosocial treatments are less likely to relapse or be hospitalized.³⁷

Family Education and Support

Psychosis and schizophrenia can take a heavy toll on a client’s family members, significant others, and friends. Educational programs offer instruction about schizophrenia symptoms, treatments, and strategies for assisting their loved one experiencing psychosis and schizophrenia. Increasing their understanding of psychotic symptoms, treatment options, and the course of recovery can lessen their distress, bolster their own coping strategies, and empower them to offer effective assistance to their loved one. Family-based services may be provided on an individual basis or through multi-family workshops and support groups.

Coordinated Specialty Care

Coordinated specialty care (CSC) is a general term used to describe recovery-oriented treatment programs for people with first-episode psychosis, an early stage of schizophrenia. A team of health professionals and specialists deliver CSC that includes psychotherapy, medication management, case management, employment and education support, and family education and support. The person with early psychosis and the team work together in a client-centered and family-centered approach to make treatment decisions. Compared to typical care for early psychosis, CSC is more effective at reducing symptoms, improving quality of life, and increasing involvement in work or school.³⁹

The goal is to link the individual with a CSC team as soon as possible after psychotic symptoms begin. There are many different programs that are considered CSC in the United States, including (but are not limited to) Comprehensive Community Support (CCS), Community Support Programs (CSP), NAVIGATE, Connection Program, OnTrackNY, Specialized Treatment Early in Psychosis (STEP) program, and Early Assessment and Support Alliance (EASA). Supported Employment/Education (SEE) is an important part of CSC that helps individuals return to work or school because it addresses the client’s personal goals. A SEE specialist helps clients develop the skills they need to achieve school and work goals. In addition, the specialist can be a bridge between clients and educators or employers.⁴⁰

Research from the RAISE project (Recovery After an Initial Schizophrenia Episode) has shown that treatments for psychosis work better when they are delivered closer to the time when psychotic symptoms first appear. The goal of the RAISE project is to help decrease the likelihood of future episodes of psychosis, reduce long-term disability, and help people to get their lives back on track so they can pursue their goals.⁴¹

With early diagnosis and appropriate treatment, it is possible to recover from psychosis. Many people who receive early treatment never have another psychotic episode. For other people, recovery means the ability to live a fulfilling and productive life, even if psychotic symptoms return at times. However, if untreated, psychotic symptoms can cause disruptions in school and work, strained family relations, and separation from friends. The longer the symptoms go untreated, the greater the risk for developing additional problems. These problems can include abusing substances, having legal trouble, or becoming homeless.⁴²

Assertive Community Treatment

Assertive Community Treatment (ACT) is designed for individuals with schizophrenia who are at risk for repeated hospitalizations or homelessness. Research has demonstrated a prevalence of psychosis as high as 21% among homeless people living on the street.⁴³ See Figure 11.4⁴⁴ for an image of a homeless man. ACT is based on a multidisciplinary team approach, including a medication prescriber, a shared caseload among team members, direct service provision by team members, high frequency of client contact, low client to staff ratios, and outreach to clients in the community. ACT has been shown to reduce hospitalizations and homelessness among individuals with schizophrenia.⁴⁵

Figure 11.4

Homelessness.

Mental Status Examination

The nursing assessment adapts to the client’s phase of illness, with a focus on acute symptom management in the acute phase, treatment response and stabilization in the stabilization phase, and long-term functional and psychosocial support in the maintenance phase.

During the acute phase, the assessment focuses on identifying and managing positive psychotic symptoms such as hallucinations, delusions, and disorganized speech or behavior and assessing the severity and impact of these symptoms on the client’s functioning, as well as assessing for any immediate safety concerns, including risk of harm to self or others.

In the stabilization phase, the assessment shifts towards monitoring the reduction of acute symptoms and the emergence of any residual symptoms. This phase often involves evaluating the client’s response to treatment, adherence to medication, and the presence of any side effects. The focus is also on assessing the patient’s cognitive function, mood, and overall ability to engage in daily activities.

During the maintenance phase, the assessment is more comprehensive and long-term, focusing on the management of residual symptoms, particularly negative symptoms such as social withdrawal, apathy, and flat affect. The assessment should include evaluating the client’s support systems and any potential stressors that could trigger a relapse.

Common findings during a mental status examination for a client with schizophrenia who is experiencing an acute psychotic episode are described in Table 11.4a. Review information about performing a mental status examination and psychosocial assessment in the “Application of the Nursing Process in Mental Health Care” chapter. It is also important to assess for suicide risk for clients with psychosis. Review how to assess for suicide risk in the “Foundational Mental Health Concepts” chapter.

Table 11.4a

Common Findings During a Mental Status Examination for Individual With Schizophrenia Experiencing an Acute-Psychotic Episode.

When assessing hallucinations, do not imply the perceptions are real. For example, a nurse should ask the client, “What do you hear?” not “What are the voices saying?” It is important to assess for command hallucinations, such as, “Are you hearing a voice that is telling you to do something,” followed by, “Do you believe what you hear is real?” If the answer is “Yes,” the client is at increased risk for acting on the command. Assess when the hallucinations began, their content, and the manner in which the client experiences them (i.e., Are they supportive or distressing? In the background or intrusive?). Ask what makes them worse or better, how the client responds, and what they do to cope with the hallucinations.²

When assessing delusions, determine if the client is capable of reality testing (i.e., questioning their thoughts and determining what is real). Ask the client if they believe there is any danger related to the delusion.³

Countertransference, which refers to the nurse’s or health care professional’s emotional reactions to a client, can be particularly complex when working with individuals diagnosed with schizophrenia. These reactions can be intense and multifaceted. Understanding and managing countertransference is crucial for effective interventions with this population, as it can significantly impact the nurse-client therapeutic relationship and the client’s progress.

Psychosocial Assessment

As previously discussed in the “Application of the Nursing Process in Mental Health Care” chapter, a psychosocial assessment obtains additional subjective data that detects risks and identifies treatment opportunities and resources^4,5:

• Reason for seeking health care (i.e., “chief complaint”)
• Thoughts of self-harm or suicide (both current and historical)
• Cultural assessment
• Spiritual assessment
• Family dynamics
• Current and past medical history
• Current medications
• History of previously diagnosed mental health disorders
• Previous hospitalizations
• Educational background
• Occupational background
• History of exposure to psychological trauma, violence, and domestic abuse
• Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
• Family history of mental illness
• Coping mechanisms
• Functional ability/Activities of daily living

After identifying the reason the client is seeking health care, additional focused questions are used to obtain detailed information used to plan care. The mnemonic PQRSTU can be used to ask questions in an organized fashion. See Table 11.4b for a sample PQRST assessment for a client with schizophrenia and sample responses.

Table 11.4b

Sample PQRSTU Questions for Assessing Depression.

SPIRITUAL ASSESSMENT

The FICA© spiritual history tool is a widely used assessment model for evaluating a client’s spiritual beliefs and how they may influence health, illness, and coping. FICA© is a mnemonic for the domains of Faith, Importance, Community, and Address in Care.⁹ The data obtained from a FICA assessment can be helpful in understanding how clients with schizophrenia draw on spirituality or religion for support. Addressing a client’s spirituality and advocating spiritual care have been shown to improve clients’ health and quality of life.^10,11

Table 11.4c summarizes a sample spiritual assessment questions and sample responses from a client with schizophrenia.

Table 11.4c

Sample FICA Spiritual Assessment Questions for Clients With Schizophrenia.

Clients with schizophrenia may expresses religious delusions or spiritual distress. They may express a desire for clarity and connection. Nurses may recognize cues of spiritual distress and offer to connect the client with a chaplain or spiritual care services. Spiritual goals may be included in the nursing care plan if the client finds them valuable.

Laboratory Testing

The potential laboratory tests and diagnostic procedures for a client with schizophrenia vary depending on whether the client is in the acute phase, stabilization phase, or maintenance phase. During the acute phase, the focus is on identifying any immediate medical issues that could be contributing to the psychotic symptoms and ensuring the client’s safety. Ensure the client has had a medical workup for other potential causes of psychosis. For example, dehydration, infection, electrolyte imbalances, abnormal blood glucose level, substance use, or withdrawal from substances can cause psychosis. Concurrent medical disorders are common and should be treated in addition to treating schizophrenia.

In the stabilization phase, the focus shifts to monitoring the client’s response to treatment and managing any side effects of medications. During the maintenance phase, the goal is to ensure long-term stability and prevent relapse. If the client is currently taking psychotropic medications, therapeutic drug levels of some types of medications are required. As always, review current information from a medication reference before administering medications.

Life Span Considerations

Life span considerations influence how the client is assessed, as well as the selection of appropriate nursing interventions. It is important to individualize all interventions to the age and developmental level of the client. Review developmental stages in the “Application of the Nursing Process in Mental Health Care” chapter.

Safety

Clients with command hallucinations require close monitoring for suicide, homicide, and other violence risk. Implement interventions to reduce risk of suicide as described in the “Application of the Nursing Process in Mental Health Care” chapter.

Interpersonal conflict, paranoia, delusions, impaired judgment, limited impulse control, fear, and disagreement with unit rules increase the risk for aggressive behavior.²⁴ Nursing interventions addressing increased risk for violence to self and others are described in the following box. Read more about recognizing signs of crisis and crisis interventions in the “Stress, Coping, and Crisis Intervention” chapter.

Acute Phase of Schizophrenia

Hospitalization is indicated during the acute phase of schizophrenia if the client is considered a danger to self (e.g., refuses to eat or is too disorganized to function in the community) or to others (e.g., is behaving in a threatening manner to others).²⁶ During this phase, planning focuses on selecting interventions that focus on client safety and management of acute symptoms.

During the acute phase of schizophrenia, hospitalization provides safety, structure, and support. As discussed earlier, anosognosia may impair the client’s ability to recognize their mental illness. In this case, court-ordered hospitalization may be required.²⁷ Read more about court-ordered hospitalization in the “Legal and Ethical Considerations in Mental Health Care” chapter. Nursing interventions focus on providing safety, promoting hygiene and nutrition, improving socialization, encouraging hope and self-esteem, preventing falls, using specific therapeutic techniques, addressing physiological needs, and implementing collaborative interventions.

Stabilization and Maintenance Phases

During the stabilization and maintenance phases, planning focuses on education, support, and skills training for the client and family. It also addresses how and where these needs can be met within the community. As explained previously in this chapter, relapse prevention efforts are vital. Each relapse can increase residual dysfunction, and deterioration and can contribute to despair, hopelessness, and suicide risk. Additionally, recognizing early signs of relapse (e.g., reduced sleep, social withdrawal, and worsening concentration) and implementing intensive treatment are needed to minimize the disruption of the client’s life.²⁸

Acute Phase

CATEGORIZING NURSING INTERVENTIONS ACCORDING TO THE APNA STANDARD OF IMPLEMENTATION

Interventions for clients experiencing psychosis previously discussed in this chapter can also be categorized by the standard of Implementation by the American Psychiatric Nursing Association (APNA). Read more about this standard in the “Application of the Nursing Process in Mental Health Care” chapter. See Table 11.4e for categorization of nursing interventions by this standard.

Table 11.4e

Nursing Interventions for Clients With Psychosis Based on the Categories of the APNA Implementation Standard.

NURSING INTERVENTIONS FOR PHYSIOLOGICAL SIGNS OF SCHIZOPHRENIA

While schizophrenia is a psychiatric condition, it frequently presents with or leads to physiological health concerns due to self-neglect, poor insight, medication side effects, and lifestyle disruptions. Nursing interventions target common physiological signs of schizophrenia and associated self-care deficits as described in Table 11.4f.

Table 11.4f

Nursing Interventions Targeting Physiological Signs of Schizophrenia.

Stabilization Phase

During the stabilization phase of schizophrenia, care is focused on ongoing medication therapy, education, and CBT therapy.⁴¹

• Medication Management: Continue to monitor the effectiveness and side effects of antipsychotic medications. Adjust dosages as needed to minimize side effects and ensure therapeutic efficacy.
• Psychoeducation: Educate the client and their family about the illness, treatment options, and the importance of medication adherence.
• Therapeutic Interventions: Introduce cognitive-behavioral therapy for psychosis (CBTp) to help the client develop coping strategies and reduce the impact of psychotic symptoms.

Maintenance Phase

Effective long-term management of individuals with schizophrenia requires a comprehensive, multidisciplinary approach that extends beyond symptom control.

• Ongoing Monitoring: Regularly assess the client’s mental status, medication adherence, and side effects. Monitor for signs of relapse and intervene early to prevent full-blown episodes.
• Supportive Services: Provide supported employment services and assertive community treatment to help the client maintain social and occupational functioning.
• Lifestyle and Wellness: Encourage healthy lifestyle choices, including regular exercise, a balanced diet, and smoking cessation. Monitor metabolic parameters, as antipsychotic medications can increase the risk of metabolic syndrome. Ongoing monitoring of the client’s functional status, social integration, and quality of life.

Acute Phase

During the acute phase of schizophrenia treatment, the primary focus is on symptom severity, safety, and the client’s immediate response to intervention. Clinicians assess changes in the Positive and Negative Syndrome Scale (PANSS) scores to determine whether there has been a reduction in the frequency and intensity of hallucinations, delusions, or other psychotic features. Monitoring for safety is also crucial—evaluating any shifts in the client’s risk of harm to self or others and observing improvements in their ability to follow safety protocols within the treatment setting. In addition, the client’s immediate response to antipsychotic medications is closely observed. Providers track how quickly the symptoms respond to treatment and whether any side effects emerge that could impact further care decisions.⁴³

Stabilization Phase

In the stabilization phase, ongoing symptom monitoring helps ensure the client’s progress continues. Updated PANSS scores are compared to both the baseline and acute-phase scores to evaluate trends. Clinicians identify any residual symptoms that persist and outline strategies for their management, such as medication adjustments or therapeutic interventions. Medication adherence becomes a central concern—providers assess whether the client is consistently following the prescribed regimen and address any side effects that may compromise adherence. This phase is key in solidifying gains made during acute care and building a foundation for long-term stability.⁴⁴

Maintenance Phase

The maintenance phase focuses on sustaining symptom remission and promoting recovery. Long-term tracking of PANSS scores helps clinicians evaluate symptom stability over time and detect early signs of relapse. Intervention strategies are adjusted accordingly to prevent deterioration. Equally important is evaluating the client’s quality of life using standardized tools like the Heinrichs-Carpenter Quality of Life Scale (QLS). Providers assess improvements in the client’s ability to engage in meaningful social relationships and maintain occupational or educational roles. Preventing relapse remains a central goal during this phase; clinicians monitor medication adherence rates and identify any new stressors or triggers that could threaten stability. Preventive measures, such as psychoeducation, structured routines, and early intervention strategies, are implemented to support ongoing recovery and well-being.⁴⁵