Schizophrenia Spectrum & Psychotic Disorders Past Paper TOUW 2024 PDF

Schizophrenia Spectrum & Psychotic Disorders TOUW 2024  Introduction  Schizophrenia is thought to be caused by a combination of factors, including  Genetic predisposition  Biochemical dysfunction  Physiological factors  Psychosocia...

Schizophrenia Spectrum & Psychotic Disorders TOUW 2024  Introduction  Schizophrenia is thought to be caused by a combination of factors, including  Genetic predisposition  Biochemical dysfunction  Physiological factors  Psychosocial stress  Schizophrenia requires treatment that is comprehensive & presented in a multi- disciplinary manner October 03, 2021 UTMB SCHOOL OF NURSING COPYRIGHT 2021 2  Introducti on  Of all mental illnesses, schizophrenia causes the most:  Lengthy hospitalizations  Family stress and chaos  Exorbitant costs to families, 3rd party payers & government  Fear ******  Stigma ****** UTMB SCHOOL OF NURSING October 03, 2021 3 COPYRIGHT 2021 Schizophrenia causes disturbances in: Thought processes Perception & response to stimuli Affect Mood Sleep Occupational and other role functions October 03, 2021 UTMB SCHOOL OF NURSING COPYRIGHT 2021 4  5 UTMB SCHOOL OF NURSING COPYRIGHT 2021 September 7, 2024 https://commons.wikimedia.org/wiki/Category:The_Starry_Night_by_van_Gogh#/media/File:Van_Gogh_-_Starry_Night_-_Google_Art_Project.jpg/2 Creativity linked to schizophrenia? 6 UTMB SCHOOL OF NURSING COPYRIGHT 2021 September 7, 2024 https://commons.wikimedia.org/wiki/Category:The_Starry_Night_by_van_Gogh#/media/File:Van_Gogh_-_Starry_Night_-_Google_Art_Project.jpg/2  Predisposing Factors  Biological influences Schizophrenia may be  Viral caused by an excess of infection dopamine activity in the Biochemic brain.  Anatomical al Abnormalities in other abnormalities influences neurotransmitters i.e. serotonin,  Histological norepinephrine. changes in brain genetics plays an important role in the Genetics development of schizophrenia. UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 7  Varying degrees of severe deterioration in social & occupational functioning. Lifetime prevalence of schizophrenia is about 1 percent of the population in the USA. UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 8 03, 2021 How do we compare? UTMB SCHOOL OF NURSING COPYRIGHT 2024 September 8, 2024 9 Discrimination UTMB SCHOOL OF NURSING COPYRIGHT 2024 September 8, 2024 10  4 Phases of Schizophrenia October 03, UTMB SCHOOL OF NURSING COPYRIGHT 2021 11 2021  Phase I: Pre-Morbid  Social maladjustment  Antagonistic thoughts and behaviors  Shy & withdrawn  Poor peer relationships  Doing poorly in school  Antisocial-like behaviors  Differentiate from asocial UTMB SCHOOL OF NURSING October 03, 2021 12 COPYRIGHT 2021  Phase II: Prodromal  Duration is a few weeks to several years  Further deterioration in role functioning & social withdrawal  (ADL, Occupational, Role) functional impairment  Sleep impairment  Anxiety, irritability  Depression  Impaired concentration  Fatigue  Perceptual abnormalities, ideas of reference, & suspiciousness herald onset of overt psychosis UTMB SCHOOL OF NURSING October 03, 2021 13 COPYRIGHT 2021  Phase III: Schizophrenia  Active phase of disease  Overt symptoms are evident especially any combination of:  Delusions  Hallucinations  Illusions  Gross impairment in  Work /occupation  Social relationships  ADLs (self-care) UTMB SCHOOL OF NURSING October 03, 2021 14 COPYRIGHT 2021  Symptoms similar to that of the prodromal Phase IV: phase. Residual Flat affect & impairment in role functioning are prominent October 03, 2021 UTMB SCHOOL OF NURSING COPYRIGHT 2021 15  Prognosis  Factors associated with an  Minimal residual optimal prognosis: symptoms  ‘Good’ premorbid functioning  Absence of structural brain  Older age at onset of abnormalities symptoms  Normal neurological  Female functioning  Abrupt onset precipitated by a  Family history of mood stressful event disorder  Associated mood disturbance  No family history of  Brief duration of active-phase schizophrenia symptoms UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 16 Assessment Sense of self: The uniqueness and individuality a person feels about oneself How does the patient see him/herself? Playsa role in the assessment of de- personalization October 03, UTMB SCHOOL OF NURSING COPYRIGHT 2021 2021 17 Assessment https://www.mdcalc.com/calc/10414/positive-negative-syndrome-scale-panss-schizophrenia September 8, UTMB SCHOOL OF NURSING COPYRIGHT 2024 2024 18 Assessment: Positive Symptoms Content of thought Form of thought  Delusions  Associative looseness  (also called loose Religiosity associations)  Differentiate from  Neologisms religious devotion  Concrete thinking  Paranoia  Clanging  Magical thinking  Word salad  Also shared with the Schizotypal  Circumstantiality Cluster A  Tangentiality Personality Disorder  Mutism  Perseveration UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 19 Assessment: Positive Symptoms Perception: interpretation of stimuli through the senses Echolalia Echopraxia  Hallucinations Depersonalizatio  Illusions n UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 20 Assessment: Negative Symptoms Affect: Avolition: An inability to The visible initiate (what we see) goal-directed emotional tone activity  Inappropriate  Emotional ambivalence  Bland  Deterioration in  Flat appearance  Impaired ADLs  Apathetic  Can resemble apathy or depression UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 21 Assessment: Negative Symptoms Impaired Psychomotor interpersonal functioning and behavior relationship to the external world  Anergia  Inappropriate social  Waxy flexibility interactions  Posturing  Social isolation  Pacingand Associated Features rocking  Anhedonia  Regression UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 22 Nursing Diagnosis/ Outcome Identification  Social Isolation r/T to Disturbed Sensory inability to trust, panic Perception (auditory anxiety, weak ego and visual) related to development, delusional panic anxiety, extreme thinking, regression loneliness, & withdrawal into self Disturbed Thought Processes related to inability to trust, panic anxiety October UTMB SCHOOL OF NURSING COPYRIGHT 2021 23 03, 2021 Nursing Diagnosis/ Outcome Identification Risk for Violence: Self- Impaired Verbal directed or Other-directed Communication related to related to  Panic anxiety  Extreme  Regression suspiciousness  Withdrawal  Panic anxiety  Disordered  Catatonic excitement unrealistic thinking  Rage reactions  Command hallucinations UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 24  Nursing Process: Diagnosis/Outcome Identification  Ineffective Health maintenance related to Withdrawal disordered thinking or delusions Regression  Impaired ADL maintenance related to Self-Care Deficit Panic anxiety related to  Regression Disabled Family  Withdrawal Coping related Perceptual or to difficulty cognitive coping with impairment  Lack of knowledge or client’s illness resources Inability to trust  Impaired physical or cognitive functioning UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 25 Clinical Outcomes – The client will…  Demonstrate ability to Verbalize and Demonstrate an Verb alize ability to relate to others in a perceive the and Dem socially appropriate manner environment correctly onstr ate  Maintain anxiety at a Recognize distortions of reality manageable level Reco gnize  Relinquish the need for Have not harmed self or delusions & Have others hallucinations  Demonstrate the ability Perceive self realistically to trust others Perce ive  Use appropriate verbal communication in Perform self-care activities Perfo independently interactions with others rm UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 26  Nursing Process: Planning/Implementation Disturbed Sensory Disturbed Thought Perception: Audio/Visual Processes  Observe the client for  Do not argue or signs of hallucinations. deny the belief.  Help client recognize  Reinforce and & eventually understand the focus on reality. connection between anxiety & hallucinations.  Distract the client from hallucinations. UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 27 Nursing Process: Planning/Implementation Risk for Violence  Observe Impaired Verbal Communication client’s  Facilitate trust & behavior.  Maintain understanding. calm  Orient the client attitude.  Have to reality. sufficient staff. UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 28 Client/Family Education Nature of the Illness Management of Illness   Connection of exacerbation of What to expect symptoms to times as illness of stress progresses  Appropriate medication  management Symptoms  Side effects of medications associated with  illness Importance of not stopping medications  How to respond  When to contact health-care to behaviors provider associated  Relaxation techniques with illness  Social skills training  ADL skills training UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 29 Client/Family Education Support Services  Financial assistance  Legal assistance  Caregiver support groups  Respite care  Home health care UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 30 Evaluation Has the client Is anxiety level Is delusional established trust maintained at a thinking still with at least 1 manageable level? prevalent? staff member? Is client able to interrupt Is / are altered escalating anxiety Is client still easily perceptions still with adaptive agitated? prevalent? coping techniques? Is client able to interact with others in a socially appropriate manner? October UTMB SCHOOL OF NURSING COPYRIGHT 2021 03, 2021 31 RECOVERY MODEL  A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential  Research provides support for recovery as an obtainable objective for individuals with schizophrenia. UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 32 TREATMENT  Individual psychotherapy  Family  Group  Cognitive behavioral  Social skills and or ADL skills training  PACT  Psycho-Pharmacology October UTMB SCHOOL OF NURSING COPYRIGHT 2021 33 03, 2021 Program of Community Treatment (PACT)  Case management team approach  Comprehensive, holistic, community-based psychiatric treatment, rehabilitation, & support to persons with serious & persistent mental illness UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 34  Preparations Oral IM Decanoate – long-acting IM Antipsychot Common Side Effects ics C-V: orthostatic hypotension Weight gain (seen with 2nd generation) Endocrine & Sexual (seen with 2nd generation) Blood Dyscrasias – agranulocytosis (clozapine) Anticholinergic September 7, 2024 UTMB SCHOOL OF NURSING COPYRIGHT 2024 35  Preparations  Oral  IM  Decanoate – long-acting IM  Inhalant (to date, only Loxapine is available in an inhalant version) Common Side Effects Antipsychotics  C-V: orthostatic hypotension  Weight gain: blocking histamine receptor  Endocrine & Sexual:  blocking dopamine  interfere with prolactin  Blood Dyscrasias – agranulocytosis (clozapine)  Anticholinergic Property of UTMB - SON (2019)   Target positive and or negative symptoms of psychosis  Types  Conventional (aka typical or 1st generation)  Atypical (aka atypical or 2nd generation)  Absorption: variable Antipsychoti  clinical effects may be seen cs within 30-60 min (sedation)  When the patient is immobile there is less absorption  Metabolism and Excretion  Slow via the hepatic system  Accumulates in fatty tissues  1/2 life of 24 hours or more Property of UTMB - SON (2019) Antipsychotics: Actions and Indications Block postsynaptic dopamine receptors in the Schizophrenia & Block basal ganglia, other psychotic hypothalamus, limbic system, brainstem, & disorders medulla. Bipolar Mania Demonstrate varying Antiemetics Demonstrat affinity for cholinergic, e alpha-1-adrenergic, & Intractable histaminic receptors. Hiccoughs  Control of tics & Inhibit dopamine-mediated Inhibit transmission of neural vocal utterances seen impulses at the synapses. in Tourette’s disorder. Adjunct to antidepressant Property of UTMB - SON (2019) therapy Conventional / Typical Antipsychotic Drugs/ 1st-Generation Agents Thioxanthenes thiothixene (Navane) Phenothiazines chlorpromazine (Thorazine) fluphenazine (Prolixin) Trifluoperazine (Stelazine) thioridazine (Mellaril) Treat Positive Butyrophenones Symptoms haloperidol (Haldol) Of Schizophrenia Other mixed subclasses loxapine (Loxitane) molindone (Moban) pimozide (Orap)  Positive symptoms are outward expressions of psychosis, such as hallucinations, or delusions  Select Phenothiazines function as anti-emetics i.e. prochlorperazine (Compazine) but not as antipsychotics Property of UTMB - SON (2024)  Extrapyramidal Side (EPS) Effects & Adverse Drug Reactions More likely to be seen with Conventional / Typical / 1 st generation antipsychotic medications  Dystonia (muscle stiffness)  Akathisia (restlessness; constant movement)  Tardive dyskinesia (TD)  Drug-induced parkinsonism  Neuroleptic malignant syndrome (NMS); rare ADR that is life- threatening  Orthostatic hypotension – not an EPS or ADR but a fairly common side effect making the patient a fall risk Property of UTMB - SON (2019) Conventional / Typical Antipsychotic Medications/ 1st-Generation Agents MOST FREQUENTLY USED OF THIS CATEGORY chlorpromazine (Thorazine) Positive fluphenazine (Prolixin) Symptoms haloperidol (Haldol) Schizophrenia October 03, 2021 41 UTMB SCHOOL OF NURSING COPYRIGHT 2021  More likely to be seen with Conventional / Typical / 1 st generation antipsychotic medications  Dystonia (muscle stiffness) Extrapyramid  Akathisia (restlessness; constant al Side (EPS) movement)  Tardive dyskinesia (TD) Effects &  Drug-induced parkinsonism Adverse Drug  Neuroleptic malignant syndrome Reactions (NMS); rare ADR that is life- threatening  Orthostatic hypotension – not an EPS or ADR but a fairly common side effect making the patient a fall risk Property of UTMB - SON (2019) Neuroleptic Malignant Syndrome (NMS) Rare but potentially fatal complication of treatment with neuroleptic drugs. Symptoms include – *Clients severe muscle rigidity, exhibiting these high fever, tachycardia, symptoms need fluctuations in blood to be pressure, diaphoresis, transferred for close with rapid deterioration monitored in an of mental status into intensive care stupor & coma. environment!* Property of UTMB - SON (2019) Antipsychotics: Atypicals / 2nd Generation – Action  Weaker dopamine effects than the 1st generation /typical antipsychotics  Facilitates serotonin reuptake UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 44 Antipsychotic Medications: Atypical aka (2nd Generation)  aripiprazole (Abilify) *  asenapine (Saphris)  Produce fewer extrapyramidal side  brexpiprazole (Rexulti) effects (EPS)  cariprazine (Vraylar)  Targets both negative and positive  iloperidone (Fanapt) symptoms of schizophrenia  lurasidone HCl (Latuda)  olanzapine (Zyprexa)  paliperidone (Invega) *  Negative symptoms are those that  paliperidone palmitate (Erzofri) * are internal, such as diminished  pimavanserin (Nuplazid) emotional expression or avolition*  quetiapine (Seroquel)  Also indicated for treatment of  risperidone (Risperdal; Perseris) depression and mood disorders with  ziprasidone HCl (Geodon) psychotic features  clozapine (Clozaril) * Exert less influence on hypertension & obesity Property of UTMB - SON (2024)  Antipsychotics: Cross Interacting Drugs Adverse Effects Interactions Antihypertensives, CNS depressants Additive and potentially severe hypotension Epinephrine or dopamine in combination with haloperidol or phenothiazines Oral anticoagulants with phenothiazines Less effective anticoagulant effects Drugs that prolong QT intervals Additive effects Drugs that trigger orthostatic hypotension Additive hypotension Drugs with anticholinergic effects, prescription and Additive anticholinergic effects including over-the-counter drugs anticholinergic toxicity which includes flushing, dry mouth, mydriasis, altered mental status, tachycardia, urinary retention, tremulousness, hypertension (Ramnarine & Ahmed, 2015) Property of UTMB - SON (2019) Antipsychotics – Nursing Diagnoses  Risk for other- directed violence  Risk for injury  Risk for activity intolerance  Noncompliance Property of UTMB - SON (2019) ELDERLY AND ANTI PSYCHOTIC MEDICATIONS  reports of CVA and sudden death while taking antipsychotic Fall Fall precautions medication.  Elderly with psychosis-related to neurocognitive disorder (NCD) Assess for other side effects and safety receiving treatment with issues i.e metabolic disturbances antipsychotic drug(s) are at Assess especially elevated glucose and or increased risk of death compared weight gain especially if prescribed a 2nd generation with those taking a placebo (Steinberg & Lyketsos, 2012).  Assess for EPS and Tardive Dyskinesia All antipsychotic drugs now carry Assess Risk for aspiration associated with tardive black-box warnings about these risks.  Not approved for treatment of Use a patient-centered, collaborative elderly patients with NCD- team approach to explore options in safe related psychosis. Use management of symptoms; psychological interventions). Property of UTMB - SON (2019)  Monitor client for the following side effects:  Anticholinergic effects, nausea, GI upset, skin rash, sedation, orthostatic hypotension, photosensitivity, hormonal effects, EKG changes, reduction of seizure threshold, agranulocytosis (especially with clozapine), Antipsychotic hypersalivation, EPS, tardive dyskinesia, neuroleptic malignant syndrome, s – Planning / hyperglycemia & diabetes, increased risk of mortality in elderly patients with Implementati neurocognitive disorder (NCD) - related psychosis, METABOLIC SYNDROME on  Educate client & family about medication(s) management  Side effects, dosing, after-care, cross interactions, when can optimal effects be expected.  Outcome criteria/evaluation Property of UTMB - SON (2024) Antipsychotic Medications: Atypical (2nd Generation)  Lower incidence of EPS  risperadone (Risperdal)  Target both negative &  quetiapine (Seroquel) positive symptoms of  olanzapine (Zyprexa) schizophrenia  iloperidone (Fanapt)  lurasidone HCl (Latuda)  Also indicated for treatment  ziprasidone HCl (Geodon) of mood disorders (mood stabilizers) especially if  aripiprazole (Abilify) there are psychotic features  paliperidone (Invega)  clozapine (Clozaril) UTMB SCHOOL OF NURSING September 8, 2024 50 COPYRIGHT 2024 Clozapine Black box warnings 1. Agranulocytosis 2. Seizures 3. Myocarditis 4. Orthostatic hypotension 5. Increased mortality in elderly patients September 8, 2024 51 UTMB SCHOOL OF NURSING COPYRIGHT 2024  Contraindications  Hypersensitive, comatose, or severely depressed patients  Elderly with dementia-related psychosis  History of QT prolongation and or Antipsychotics other cardiac issues unless the benefit outweighs the risk. - Caution with Contraindicatio  Elderly or debilitated patients (see ns/ Precautions above)  Cardiac, hepatic, or renal insufficiency  History of seizures  Diabetes or risk factors for diabetes  Conditions that may cause hypotension  Pregnancy  Children UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 52 Antipsychotics: Side Effects  Weight gain Anticholinergic Nausea effects  Hyperglycemia/ diabetes  Increased risk of Skin rash Sedation mortality in elderly clients with dementia Orthostatic  Reduction in seizure Photosensitivity hypotension threshold  Agranulocytosis Hormonal effects Electrocardiogra  Extrapyramidal m changes symptoms (EPS)  Tardive dyskinesia Hypersalivation  Neuroleptic malignant syndrome October(NMS) 03, 2021 53 UTMB SCHOOL OF NURSING COPYRIGHT 2021   More likely to be seen with 1st generation / Typical Symptoms can include one or a combination of extrapyramidal symptoms MOVEME (EPS): NT  Dystonia (muscle stiffness)  Akathisia (restlessness) DISORDE  Akinesia (absence of RS  movement) Tardive dyskinesia (TD)  Medication-induced parkinsonism  Neuroleptic malignant syndrome (NMS) UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 54 Extrapyramidal symptoms (EPS): Treatment  Anticholinergics  Benztropine (Cogentin)  Best for outpatient and other community settings  Antihistamines  Diphenhydramine (Benadryl)  Best for the acute care setting because of sedating features  Dopaminergic agents  Amantadine (Symmetrel).  See the next slides for treatment for TD and NMS UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 55  Involuntary repetitive, jerking movements of the face, neck, & or tongue. Tardive Severe and potentially Dyskines irreversible ia May occur with: Any antipsychotic Antiemetics at any dosage UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 56 Tardive Dyskinesia: Assessment and Treatment  AIMS When should the AIMS test be  given? Goal is to prevent Tardive by administering the lowest effective dosage. If that fails then: Administer either: Discontinue Switch to Hold the next Deutetrabenazine the another (Austedo) dosage antipsychotic antipsychotic Valbenazine (Ingrezza) UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 57   Rare but potentially fatal complication of treatment with neuroleptic medications. Neurolep  Can develop with any antipsychotic tic or antiemetic  More often seen with 1st generation malignan due to more powerful dopamine effect t  Characterized by a syndrome of syndrom hyperthermia, musculo-skeletal rigidity, mental status deterioration, e (NMS) and dysautonomia  Can be misdiagnosed as Serotonin Syndrome UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 58 UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 59 UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 60 UTMB SCHOOL OF NURSING COPYRIGHT 2024 September 7, 2024 61 Neuroleptic Malignant Syndrome (NMS): Other Symptoms  Tachycardia  Labile blood pressure  Diaphoresis  Rapid deterioration of mental status into stupor & coma. * Patient requires ICU UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 62 Neuroleptic Malignant Syndrome (NMS): Treatment Contact provider and  (immediately) Bromocriptine hold dosage (Parlodel) Discontinue all  Dantrolene (Dantrium) antipsychotic(s )  Acetaminophen  Na Bicarbonate IV Hydration  Benzodiazepines  Mannitol Cooling blankets Correct Anticipate elevated metabolic Creatinine abnormalities Phosphokinase (CPK) UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 63   Medication(s) management  side effects & management  dosing  after-care Pharmacologi  cross interactions cal Education  when can optimal effects be expected UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 64   Not stop taking medication(s) abruptly.  Use sunscreen & wear protective clothing including sunglasses when spending time outdoors. Antipsycho  Report as prescribed, usually weekly tic (if receiving clozapine therapy) to have blood levels drawn. Medication  Be aware of possible risks of taking Education antipsychotics during pregnancy. for the  Not use any ETOH, nicotine or caffeinated products while receiving Client & antipsychotic therapy Family  Not consume other medications (including OTC medications) without the primary care provider’s knowledge UTMB SCHOOL OF NURSING COPYRIGHT 2021 October 03, 2021 65 References  ATI Nursing Education Content Mastery Series. (2019). RN pharmacology for nursing.  Schonfeldt-Lecuona, C., Kuhlwilm, L., Cronemeyer, M., Neu, P., Connemann, B., Gahr, M., Sartorius, A., Mühlbauer, V. Treatment of the Neuroleptic Malignant Syndrome in International Therapy Guidelines: A Comparative Analysis. Pharmacopsychiatry. 2020; 53(02): 51-59. DOI: 10.1055/a-1046-1044.  Townsend, MC, Morgan, KI. (2020). Davis advantage for psychiatric mental health nursing. 10th Ed. FA Davis.  https://www.nature.com/articles/s41380-023-02138-4  https://commons.wikimedia.org/wiki/Category:The_Starry_Night_by_van_Gogh#/media/Fil e:Van_Gogh_-_Starry_Night_-_Google_Art_Project.jpg/2  https://doi.org/10.1192/bjp.2018.23  https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2023.1098292/full  https://www.mdcalc.com/calc/10414/positive-negative-syndrome-scale-panss-schizophre nia  https://www.nami.org  https://www.fda.gov/drugs/guidancecomplianceregulatoryinformation/surveillance/advers edrugeffects/ retrieved 12/30/2022.  https://www.webmd.com/mental-health/tardive-dyskinesia retrieved 01/03/2023 UTMB SCHOOL OF NURSING COPYRIGHT 2024 September 8, 2024 66