Chapter 8

Psychosis is a state someone is in when they can't comprehend reality and has difficulty communicating
or relating to other people (incapable of processing what's happening in the environment and may lose contact
with reality). Patients who are hallucinating or delusional may exhibit impulsive behavior that may cause them
to be violent towards someone else or to themselves (ex: self-mutilation) and requires immediate intervention.
If the pt uses verbal/non-verbal force meant to harm or abuse someone else, we call this aggression. Impulsivity
is the failure to resist an impulse, urges, or respond after a period of reflection. Impulsive behavior is d/t:
low levels of serotonin (5-HT)
hyperactivity of limbic system (plays a role in motivation, emotion, memory)
- Hippocampus
- Amygdala
- Thalamus
- Hypothalamus
inadequate control by cortex
Common S/S of psychosis
exhibit minimal distress (emotional tone = flat, bland, inappropriate)
exhibit a flight from reality into a less stressful world (one in which they are attempting to adapt)
unaware of their own behavior as maladaptive
unaware of any psychological problem
Psychosis is serious psychiatric disturbances (nonspecific indicator of severe mental illness) characterized by the
presence of delusions or hallucinations; it's an impairment of interpersonal functioning and relationship to the
external world.






Chapter 8
Hallucinations Delusions (table 14.3)

- occurrence of 5 senses without external stimulus
- experience is very real to pt
- often an early symptom in mental disorders
- most commonly associated with schizophrenia even
though only 70% of pt will experience hallucinations
- also in manic phases of BAD, severe depression,
substance dependence + withdrawal.
- false beliefs that can't be changed by reasoning or
evidence (misunderstanding reality; someone is out to
harm or get them).
- pt firmly fixed; providing evidence to contrary does not
change their false beliefs
- single thought or pervade entire cognitive process
*90% of pt experiencing delusions have concurrent
hallucinations.
- dysfunction in information-processing circuits within and
between brain's 2 hemispheres (reality distortion and
activity in medial temporal, ventral limbic areas).
- occurs in schizophrenia, depression, BAD, anorexia, OCD,
dementia, body dysmorphic disorder, delusional disorder,
hypochondriasis.
Chapter 8
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1. Auditory (~70% of hallucinations)
- dysfunctional temporal lobe
- derogatory remarks, voice to voice talking about pt
- voice talking about what pt is thinking
- makes pt say or do something potentially harmful to
SoO
2. Command
- potentially dangerous type of auditory hallucinations
- orders pt do something frightening and cause harm
- pt can become fearful, jumping out windows (or
dangerous behaviors)
3. Visual
- dysfunctional occipital lobe
- flashes of light, geometric figures, cartoon figures
- often accompanied by auditory hallucinations
4. Gustatory
- putrid, foul, rancid taste
5. Olfactory
- repulsive smells
6. Tactile
- sensation of being felt when no one's around
- brushing off invisible things like bugs
7. Kinesthetic
- involves feeling of body processes; blood pulsing
through veins, food digesting, urine formation.
- associated with organic changes d/t stroke, brain
tumor, seizure, substance dependence/withdrawal
1. Grandiosity (delusions of grandeur)
- exaggerated sense of self-worth, importance.
- beliefs of magical thinking
"Do you believe you're someone very important?"
"Have you ever thought you have special powers that other
people don't have?"
2. Persecution
- someone is out to spy or harm pt; harming others to
protect themselves.
- excessive amygdala activity (responsible of processing
threat stimuli and social meaning of that stimuli)
"Do you feel that anyone is trying to harm you?"
3. Control
- believes feelings, impulses, thoughts, actions are not their
own but imposed by external force (computer chip
controls the pt).
"Do you feel that anyone is controlling you?"
4. Religious
- refer to table 8.2
5. Erotomanic
- believes that a person, sometimes famous, is in love with
pt.
6. Sin, Guilt
- refer to table 8.2; "Do you believe you are very guilty for
something you have done?"
7. Somatic
- pt believes something abnormal and dangerous is
happening to their body
"Do you believe something abnormal is happening to your
body?"
8. Ideas of Reference (IR)
- remarks or actions by someone else that isn't related to
pt at all. Pt believes it is related to them.
"Do you believe people are talking to you often?"
9. Thought broadcasting
- pt believes people can read his/her mind.
"Do you believe others can hear your thoughts?"
10. Thought withdrawal
- believes other people are able to remove thoughts from
pt (someone stole pt's thoughts)
"Do you believe others can take away your thoughts?"
11. Thought insertion
- other people are putting thoughts into pt's mind
"Do you believe others can put thoughts into your head?"
Chapter 8
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- talk to pt re hallucinations for reassurance and self-
validating.
- behaviors that appear inappropriate may be d/t
hallucinations (inappropriate laughter, conversations
with unseen people, difficulty paying attention to task
at hand, slow verbal response).
- ask how distressful the voices are; is it negative?
derogatory? origin of voices?
*this tells us pt's level of fx and how much it interferes
with ADL.
- behaviors often perceived as inappropriate may be a
response to delusional thoughts
- What kind of thoughts are bothering you the most?








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- stay with pt, esp. during intense and frightening
moments with hallucinations
- remain nearby b/c having a real person to talk and
listen to will help pt return to reality
* pt may not be able to hear, but seeing the mouth
move may tell them that we are real (helps validate
they are alive); aware of HCP's presence.
- may need to talk slightly louder
- use very short, simple phrases
- use pt's preferred name
- maintain friendly eye contact
- ask pt to describe what is happening to avoid trying to
hide the experience
- environment: ID possible triggers
- encourage pt to describe feelings re hallucinations
*do not argue about what is or isn't occurring
* helps pt validate and to know we are not
experiencing the same phenomenon.

- provide comfort to reassure safety for pt
- provide opportunity to discuss pt's delusions may lessen
fear
- refocus conversation to another topic to distract from
troubling thoughts, after listening and reassuring.
- help pt ID situations that are inappropriate and socially
unacceptable to discuss delusions to Px public rejection
and social isolation
- monitor delusions for content; encourage pt to verbalize
delusions to HCP before impulsively acting (ID beliefs that
may be harmful to SoO).
- ID triggers for delusion (focus on underlying feelings;
unexpressed feelings can trigger delusions). Try to help
problem-solve with pt to avoid or eliminate stressor that
trigger the delusion.
- present reality without implying pt is wrong; if pt asks if
you are experiencing the delusion (do not attempt to
logically explain delusion or reason, argue, challenge b/c pt
will get defensive. Only pt understands logic behind
delusional content).
- teach coping techniques; reinforce and focus on reality.
Talk with pt about real people and real events, or
participate in light recreational activities that require
attention and skill can help provide temporary relief from
delusions.











Chapter 8
Self-mutilation is when someone deliberately causes destruction of body tissues without the intention
of committing suicide (we might call it deliberate self-harm, self-injurious behavior, aggression against self). This
behavior is generally impulsive, and the onset is often linked to stressful situations. Females are more likely to
self-mutilate than males and starts in adolescence, affecting people of all ethnic background. Self-mutilation
might occur b/c of the person's inability to control his/her temper in response to an argument (impulsive
behavior, which is more common among males) or it may be a response to delusions, hallucinations, substance
abuse/dependence. Dysfunction in dopamine (DA) and serotonin (5-HT) influence self-mutilative behavior along
with impulsive and aggressive behavior. We'll tend to find self-harm behavior in pts who have:
borderline personality disorder
eating disorder
cognitive impairment disorders
OCD
PTSD
dissociative identity disorder
cognitive impairment
HX childhood/physical abuse
Self-Mutilation



Types
[Box 8.2]
1. superficial - moderate
- skin cutting (most common), carving, burns
- severe skin scratching, needle sticking, self-hitting, ingesting sharp objects, interfering with
wound healing.
2. severe (pt with psychosis d/t delusions or command hallucinations).
- eye enucleation, castration, amputations
3. stereotypic
- rhythmic, fix patterns (head banging, finger biting).
Assessments
(p.153)
Behavior has meaning to pt, often hidden from others. We need to understand unique
meaning for behavior for each pt. Ask what the act of self-harm does for pt.
Interventions
[Box 8.3]
[Box 8.4]
- must establish therapeutic relationship with pt d/t much criticism and little understanding re
self-injurious behavior.
- let pt know that we understand what they're going through to validate their personhood.
- nonjudgmental and accepting attitude, caring approach.
- limit setting to minimize potential for physical injury.
1. Encourage communication
2. Improve related QOL (reduce shame, isolation, self-criticism; receive medical attention).
3. Diminish/extinguish use of self-mutilation
Chapter 8
Agression