Thought Disorders

1
Thought Disorders

• Adrianne Maltese

2
Etiology of schizophrenia

• Most likely caused by a convergence/interaction
  of genetic and environmental factors
• GENETIC factors
• Neurodevelopmental brain abnormalities
• Enlarged ventricles
• Cortex-left localized
• Temporal lobe dysfunction
• Phospholipid metabolism
• Frontal lobe dysfunction
• Brain circuitry dysfunction
• Neuronal density
• NEUROTRANSMITTER SYSTEM
• D

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Schizophenria

• BLEULERS four As
• Ambivalenceholding two different
  attitudes/emotions/feelings at the same time
• Autistic thinkingdisturbances in thoughts
  private fantasy world/abnormal responses to
  people/events of the real world

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Bleulers 4 As(cont)

• Loosening of Associations-rapid shift of ideas-
  unrelated manner
• Affective disturbance - may be blunt,
  flat,inappropriate/labile

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Positive Symptoms

• DELUSIONS(paranoid/reference)
• HALLUCINATIONS(auditory/visual)
• DISORANIZED SPEECH/THINKING(tangential/loa/incoher
  ent/neologisms
• GROSSLY DISORGANIZED BEHAVIOR(difficulty with
  goal setting/ADLsunpredictable
  agitation/silliness/social disinhibition/bizarre
  behaviors
• CATATONIC BEHAVIORS(decrease reaction to
  environment/bizarre postures/aimless motor
  activity)

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Negative symptoms

• AFFECTIVE FLATTENING
• ALOGIA (poverty of speech/slowed speech/decrease
  fluency/content)
• AVOLITION(inability to initiate goal directed
  behavior)

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• TYPES OF SCHIZOPHRENIA
• Disorganized
• Paranoid
• Catatonic
• Undifferentiated
• Residual
• Related Psychotic Disorders
• Schizoaffective Disorder
• Schizophreniform disorder
• Delusional disorder
• Brief Psychotic disorder

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Paranoid Type

• Persistent delusions/persecuatory nature
• Auditory hallucinations-single or associated
  theme
• Guarded,suspicious,hostile,angry,
• possibly violent
• Pervasive anxiety
• Intensive,reserved,controlled social interactions
• Onset- later in life
• Generally more favorable dx. re independent
  living/occupational functioning.

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Disorganized type

• Grossly inappropriate/flat affect
• Primitive / uninhibited behaivor
• Unusual mannerisms-giggle/cry out loud/distort
  facial expressions
• Hypochondriasis (multiple physical complaints)
• Socially inept/withdrawn
• Onset early- prepsychotic period- marked
  adjustment problems
• Hallucinations/delusions more fragmented

10
Catatonic Type

• Marked disturbance of psychomotor activity
• May be immobile/or with psychomotor excitation
• Displays negativism/mutism
• Posturing
• Bizarre positions-waxy flexibility

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Undifferentiated type

• Florid psychotic symptoms
• delusions/hallucinations
• incoherence
• disorganized speech/behavior
• do not clearly fit into other categories

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Scenario Client with Thought Disorder

• R.T.is a 28 y/o male is brought to the ER by
  police. R.T. barricaded himself in his single
  room apartment with a gun and called 911 saying
  that he needed to protect himself from aliens who
  were invading the planet. He was admitted to the
  in-patient unit on a 5150 hold as DTO. He was
  fearful on approach, appearance was disheveled,
  speech disorganized. He reports hearing voices
  telling him that he would be next. R.T. reports
  that he hitch-hiked across the country and has no
  family here. He ran out of meds 4 weeks ago. He
  is admitted with the dx. of Schizophrenia,
  paranoid type is started on Haldol 5 mg BID
  Cogentin 1 mg BID.
• 1.Prioritize TWO nursing Dx./outcomes/intervention
  s
• 2. How would the nurse evaluate the effectiveness
  of the medication?
• 3. Why is Cogentin being given?

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Schizophreniform Disorder

• Meets criteria for schizophrenia except
• 1) duration-at least 1 month but
• 2)Social/ Occupational functioning may or may
  not be impaired vs. schizophrenia where
  functional disturbances ierelationships,
  school,self care are present.

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Schizoaffective Disorder

• Symptoms of both Schizophrenia and
• affective (mood)disorders
• delusions/hallucinations/disorganized speech
• Major depression, mania, mixed
• At least a two week period of psychotic symptoms
  only
• Onset is later than schizophrenia
• Prognosis is better than schizophrenia,but worse
  than Affective Disorder.

15
Residual Type

• Client has had at least one acute episode
• Free of psychotic symptoms
• Continues to exhibit persistent social
  withdrawal/emotional blunting/illogical
• thinking/eccentric behavior

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Delusional Disorder

• Presence of one or more nonbizarre delusions
  persist for ONE month or more
• Bizarre delusion iebrain removed by
  aliens-replaced with computer
• vs. nonbizarre delusion- more believable
  iebelieves the IRS is going to prosecute his
  family for his wrongdoings.

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Subtypes of Delusional Disorder

• Erotomanicmay involve stalking/spying
• Jealousefforts made to follow Catch
• Grandiosehas extraodinary talent/knowledge
• Persecutoy-victim of a conspiracy/poisining/spying
  
• Somatic-bodily sensations/believes body has a
  foul odor/insects or parasites on/in body/body
  part is nonfunctional

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SHARED PSYCHOTIC DISORDER

• Delusional disorder also known as
• folie a deux
• develops in a person who is involved in a
  relationship with another person who already has
  a psychotic d/o with prominent delusions.

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Psychotic Disorder due to medical conditions

• Characterized by prominent hallucinations and
  /or delusions due to physiologic effect of
  medical condition

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Substance Induced Psychotic Disorder

• Characterized by prominent hallucinations and
  /or delusions produced by the physiological
  effects of a substance ie
• Drugs of abuse,medications or toxins
• The disorder first occurs during intoxication or
  withdrawal stages, but can last for weeks
  thereafter.

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Human Needs AssessmentMaslow

• Biologic Physiologic Integrity
• (Air, Fluids , Comfort, Activity, Nutrition,
  Elimination, Skin Integrity)
• Overall Decline in health maintenance
• Poor grooming/hygiene/ADL functions
• Increased risk for communicable diseases r/t i.e.
  TB, PNA, Infection homelessness poor hygiene,
  poor judgment

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Oxygen Fluids Assessment

• Note hx. of cigarette smoking second hand in
  smoke filled facilities, Respiratory diseases
• Poor posture shallow breathing patterns
• May drink too little or too much water due to
  delusional beliefs
• May be dehydrated upon admission
• Check Chem panel and electrolytes(hypo-hyper
  nutremia hypo-hyper kalemia)

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Mental Status Assessment

• Altered mood/depressive symptoms
• Anxiety/agitation
• Social withdrawal/isolation
• Perceptual distortions
• Hallucinations, illusions,altered internal
  sensations,Agnosia,distorted body image,negative
  self-perception

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Comfort, Activity

• Assess Pain, discomfort ,injuries
• Activity level normal vs. Psychomotor
  retardation, psychomotor agitation

25
Mental Status Assessment

• Cognitive Distortions
• Delusions,derealizations,ideas of
  reference,errors in memory recall,problems with
  attention/concentration
• Incorrect use of language which interferes with
  socialization (neologosisms/clanging)
• Flight of ideas

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Nutrition, Elimination, Skin Integrity

• Assess food intake ?mal-nourishment where does
  client get food supply? meals daily, usual
  diet, eaten while on unit?
• B12 Folate levels, Liver Panel, CBC w/diff ,
  Protein levels
• Assess constipation/loose stools r/t S/Es of
  psychotropic meds.
• Assess Skin Integrity- condition of skin- dry,
  cracked, sun-burned
• Foot care may walk barefoot on surface streets

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Safety Security Assessment

• Assess suicidal ideation(50 suicide rate)
• Assess potential for violence/aggression
• Maintain safe/secure environment
• Assess orthostatic B/P changes
• Assess Mental Status changes

28
Belonging AttachmentAssessment (Psychosocial)

• Assess support system (effective or not?)
• Family attachments, friends, clergy, 12 step
  groups)
• Affect- may be labile, emotionless
• Coping ability
• Ability to form trusting reciprocal
  relationships

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Other Psychotic disorders

• BRIEF PSYCHOTIC DISORDER
• At least one of the following sxs
• Hallucinations,delusions,
• disorganized speech,
• behavior disturbance,(disorganized or catatonic)
• Sxz last at least one daybut less than one
  month.returns to premorbid level.

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Self-Esteem Self EfficacyAssessment

• What is clients view of self ?(was education
  interrupted by illness?)
• Body image (distorted or realistic)
• What stage of development was effected by onset
  of illness?
• Decision making capacity
• Sense of control over life

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The Nursing Process

• Assessment Subjective/Objective
• Use of the Mental status exam
• Focus on four areasdisturbances in perceptions,
  Language thought Process, affect feelings, and
  Psychomotor behavior.
• Direct questions towards assessment of these
  areas

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Self Actualization Self-Transcendence Assessment

• Ability to maintain health- compliance with med
  regime
• Ability to seek help when needed keeps Dr.s
  appts for f/u of illness
• Seeks ways to control stress

33
Psychosocial Assessment

• Behavioral disturbances
• Poor impulse control/anger management problems
• High risk for self harm (50 risk for Suicide)
• Lack of social support systems
• Substance abuse/med noncompliance

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Psychosocial Assessment

• Poor peer relationships-has few friends
• Social/occupational areas poor functions
• Preoccupied/detached
• Poor achievements-lacks competativeness
• Avolition- lacks initiative to engage in
  self-initiated, goal directed activity.
• Social withdrawal/self isolation

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Developmental Assessment

• Autistic like behaviors-lacks social skills
• Delayed development- immature
• Strikes in late adolescenceearly adulthood
  effecting emotional development.
• Eriksons stage(identity vs. role confusion)
• (intimacy vs. isolation)

36
Spiritual Assessment

• Religiosity- delusional beliefs centered around
  religious beliefs
• Values and beliefs with which one is raised
• Impact of these beliefs on delusional system

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Nursing Diagnosis(Actual or Potential)

• Communication, Impaired verbal
• Disturbed personal Identity
• Coping, Ineffective Individual
• Family Process, altered
• Sensory/ perceptual alterations
• Thought processes, altered
• Violence, risk for self/other directed
• Altered nutrition
• Self care deficit (bathing/hygiene/grooming/
• bathing/feeding/toileting)

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Outcome Identification/goals

• The client will
• Demonstrate reduction in psychotic symptoms
• Demonstrate absence of self-mutilating,violent or
  aggressive behaviors
• Demonstrate reality based thinking behaviors
• Socialize with peers/staffparticipate in groups
• Comply with medication regimen
• Verbalize the role of medications in reduction of
  psychotic symptoms.

39
Nursing Interventions/Rationales

• Involve client/family in treatment process
  (avoids misunderstandingsresistance from
  client/family/or financial/environmental
  constraints)
• Establish a therapeutic relationship with client
  first (the client must first feel he can trust
  the nurse-assists with safety and security)
• Institute measures to maintain/regain physical
  health (the clients safety and physical health
  are priority!)

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Interventions/rationales

• Use clear/concrete statements vs. generalizations
  (they may exacerbate misperceptions or
  hallucinations)
• Determine stressors that may trigger
  sensory-perceptual disturbances (hallucinations
  may be exacerbated by external/environmental
  stressors)
• Distract client from delusions that exacerbate
  aggressive/potentially violent episodes (engaging
  the client in more functional,less anxiety
  provoking activities increases the reality base
  and decreases risk of violent episodes that may
  be provoked by delusions)

41
Interventions/rationales

• Begin with one to one interactions, accompany
  client to group activities starting with more
  structured, less threatening groups and
  progressing to more informal spontaneous
  activities(limited contact at first-often better
  tolerated later increase in socialization to
  assist with social skills to expand reality
  base)
• Focus on meaning behind delusion rather than
  content-recognize as clients perception of the
  environment(meets clients needs,reinforces
  reality,non challenging or threatening)

42
Questions-Thought disorders Schizophrenia

• A client is a withdrawn catatonic state exhibits
  waxy flexibility. During the initial phase of
  hospitalization for this client the nurses first
  priority is to
• Watch for edema and cyanosis of the extremities.
• Encourage the client to discuss concerns that led
  to the catatonic state.
• Provide warm, nurturing, relationship, with
  therapeutic use of touch.
• Identifying the predisposing factors to the
  illness.

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• 2. A client with schizophrenia, disorganized type
  is admitted to the inpatient unit. He frequently
  giggles and mumbles to himself. He hasnt taken
  a shower in 3 days. His appearance is disheveled
  and unkempt. The nurse would best persuade the
  client to shower by saying
• Clients on this unit take showers daily.
• Its time to shower, I will help you.
• Youll feel better if you shower.
• Would you like to take a shower?

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• 3. The nurse identifies the nursing diagnosis of
  Disturbed thought process related to exhibiting
  delusions of reference for a client with
  schizophrenia. Which outcome would be most
  appropriate?
• Client will talk about concrete events in the
  environment without talking about delusions.
• Client will state 3 symptoms that occur when
  feeling stressed.
• Client will identify 2 personal interventions
  that decrease intensity of delusional thinking.
• Client will use distracting techniques when
  having delusions.

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• 4. During a community meeting, a client with
  schizophrenia begins to shout and gesture in an
  angry manner. Which nursing intervention would be
  the priority?
• A. Determine the reason for the clients
  agitation.
• B. Encourage appropriate group behavior?
• C. Facilitate group process in responding to the
  client.
• D. Maintaining safety of client and others.

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• A male client who has schizophrenia is admitted
  to the inpatient psychiatric unit. The client is
  actively hallucinating and is unable to provide
  information for the admission process. What is
  the nurses best option for getting information?
• Wait until the medication works
• Ask the next shift to do the admission
• Get the information from the physician
• Ask the clients family for information.

47

• A 32 year-old client admitted with catatonic
  schizophrenia has been mute and motionless for 2
  days. The priority nursing diagnosis is
• High risk for fluid and electrolyte imbalance
• Impaired mobility
• Impaired verbal communication
• Ineffective individual coping.

48

• In planning care for a client experiencing
  paranoid delusions, which of the following is the
  priority goal?
• Absence of delusions
• Establishing trust
• Participation in all unit activities
• Performing independent activities

49

• Which nursing response would be most appropriate
  when a client is hearing voices?
• I do not hear the voices that you say you hear.
• Those voices will disappear as soon as the
  medicine works.
• Try to think about positive things instead of
  the voices.
• Voices are only in your imagination.

50

• The nurse expects to assess which of the
  following in a client diagnosed with
  schizophrenia, paranoid type?
• Anger, auditory hallucinations, persecutory
  delusions.
• Abnormal motor activity, frequent posturing,
  autism.
• Flat affect, anhedonia, alogia.
• Silly behavior, poor personal hygiene, incoherent
  speech.

51

• Which of the following comments by a client
  indicate the need for an urgent dose of an
  antipsychotic drug?
• The voices are mumbling and I cant hear them
  very well.
• The voices are telling me to rip my bed sheets
  and hang myself.
• The voice I heard this morning sounded like my
  dead grandmother.
• The voices told me to kill my neighbor when I
  get home.

52

• . A client with catatonic schizophrenia has sat
  mute and rigid for two hours. Which nursing
  action would be most appropriate?
• Encourage the client to participate in a group
  sporting activity
• Put the clients extremities through passive
  range of motion.
• Seclude the client until voluntary movement is
  observed.
• Offer short but frequent verbal phrases to
  communicate caring.

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AGGRESSIVE BEHAVIORS

• Aggressive behavior - is an acting out of
  aggressive or hostile impulses in a violent or
  destructive manner may be directed towards
  objects, others, self.
• ETIOLOGY- r/t feelings of anger/hostility/homicid
  al ideation,psychotic process,substance use,
  personality disorders

54
De-escalating Aggressive Behaviors

• GENERAL INTERVENTIONS
• SAFETY most important- protect client others
• Provide safe, non-threatening Therapeutic
  environment

55

• LEGAL /ETHICAL ISSUES Staff is responsible to
  provide control to protect client others
• MANAGING THE ENVIRONMENT-
• Persuade client to move to another area have
  colleagues remove others from area (prevents
  anxiety/contagious responses from other
  clients/provides sense of safety/protects others)

56
De-escalation techniques

• Encourage Verbalization
• Ask the client open-ended ,non-threatening
  questions
• How? What? Where? When? obtain details
  from client .
• Do NOT ask WHY?
• Keep voice calm,modulated(focuses on client
  problem-stops anger from escalating

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De-escalating techniques contd

• Use of Non-Verbal expression
• Allow client body space 8 feet
• Keep your body at a 45 degree angle
• Assume OPEN POSTURE hands at side,palms
  outward. this conveys a non-threatening message,
  gives client message that you are willing to
  listen and help

58
De-escalating techniques

• Personalize self and show concern
• Remind client who you are (that you are his
  nurse-he is in the hospital and is safe here)
• Use words ie we or us
• Use encouraging responses ie go
  ondemonstrates empathy/encourages and reflects
  cooperation on your part

59
Managing aggressive Behaviors

• Hold regular drills with staff to practice
  strategies
• Practice use of disengagement breakaways
• Rehearse procedures regarding the removal of
  client to seclusion or restraints
• Document all events and hold debriefing sessions
  with staff allows staff to de-escalate and learn
  from event

60

• A client who is agitated begins to shout insults
  and threats at others, and starts demolishing the
  recreation room. What is the best response or
  action by the nurse?
• Firmly set limits on the behavior.
• Allow the client to continue, because this is an
  expression of his/her feelings.
• Let the client know that he/she does not need to
  express anger at the nurse by demolishing the
  recreation room.
• Tell the client that he/she is trying to
  intimidate other clients.

61

• Which nursing intervention is inappropriate to
  use with a person who is expressing anger?
• Stating observations of the expressed anger.
• Assisting the person to describe his/her
  feelings.
• Helping the person find out what preceded the
  anger.
• Helping the person refrain from expressing the
  anger verbally.

62

• A teenager with acting-out behaviors tells the
  nurse, I want you to go tell my teacher that I
  am sick and I should be allowed to do whatever I
  want. The nurse determines that this statement
  best represents
• Insight
• Manipulation
• Dependency
• Trust

63

• A client who is acutely agitated becomes
  increasingly aggressive despite staffs verbal
  attempts to stop the aggression. The client
• shout threats at other clients, throws
  furniture,
• and begins to kick and bite clients and
  staff.
• A prn order for medication when agitated is
  available. Which action should the nurse take
  initially?
• A. Orient the client to reality, and place the
  client in
• a well lit, quiet room.
• B. Give the ordered tranquilizer and pout the
  client
• in bed with the side rails up.
• C. Lock the client in his/her room and call the
  doctor.
• D. Have at least two staff members physically
• restrain the client and take the client to a
  quiet room.

64

• Which nursing action would be best for a client
  who is hospitalized , and is constantly upset
  with the staff, easily angers, and frequently
  shouts at the nurses?
• A Request that the client be moved to another
  unit.
• B. Schedule a conference with the MD, nurse
  manager, and client about his behavior.
• C. Contact social services to meet with the
  client and family about the problem.
• D. Involve the client and the family in the
  development of the care plan.

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PSYCHOPHARMACOLOGY

• ANTIPSYCHOTIC MEDICATIONS

66
Mode and Mechanisms

• Dopamine receptor blockers drug occupies
  dopamine receptor at the post synaptic neuron
  blocks endogenous dopamine from having its
  effect
• Dopamine receptors confined primarily to four
  major areas of the brain
• Mesolimbic cortical(positive sxs of schizo.)
• nigrostriataltuberoinfundibular pathways

67
Dopamine 2 receptor

• Responsible for many s/es of antipsychotics
• Nigrostriatal pathway begins at substantia nigra
  ascend to caudate nucleus putamen in the
  extrapyramidal system.
• Blockade in the nigrostriatal is responsible for
  pseudoparkinsonism or EPS
• Atypical antipsychotics also block dopamine
  receptors as well as seratonin

68
Side Effects r/t Receptor Blockade

• Histamine 1 Blockade causes sedation,
• Cholinergic Blockade causes anticholinergic
  side effects (dry mouth, blurred vision,sinus
  tachycardia,constipation,impaired memory
  cognition)
• Alpha 1 Blockade causes (hypotension reflex
  tachycardia)

69
CLINICAL USE //EFFICACY

• MOST TOXIC DRUGS USED IN PSYCHIATRY!!
• Use lowest possible dose esp in Geriatric client
  start low go slow!
• Positive (aggressive symptoms) most
  responsive-relieved within hours
• Negative( Affective symptoms)- may take up to 2-4
  weeks to respond.

70
Use/clinical efficacy cont

• Cognitive/Perceptual symptoms ie hallucinations,
  delusions, thought broadcasting 2 to 8 weeks to
  respond
• Increasing meds will not hasten relief of slow
  responding symptoms
• Usually start with divided doses(minimizes s/es)
• Once effective change to QD or Bid
  dosing(increases med compliance)

71

• Absorption absorbed well in GI tract
• Metabolism metabolized in the liver
• Half Life Adults (20 40 hours)
• Half Life Elderly client may be doubled
• Adult steady state 4-7 days
• Monitor liver functions esp. elderly and
  physically compromised

72
Medication Forms

• INJECTABLE form I M use for emergencies only
• (client imminent danger to self/others)
• Simultaneous use of a benzodiazepine may help
  client to gain control more rapidly ie
  combination of Haldol and Ativan
• LIQUID form-used when client has hx. Of
  non-compliance or has been suspected of
  cheeking meds.

73
Additional medication forms

• LONG ACTING INJECTABLE
• Used to increase compliance
• Eg. Haldol Decanoate/Prolixin Decanoate
• Given monthly or bi-weekly
• Half life Haldol decanoate- 21 days
• Half-life for Prolixin decanoate 14 days
• Monitor carefully as out patient

74
SIDE EFFECTS (EPS)

• ACUTE DYSTONIA- MUSCLE SPASMS
• Symptoms may include
• Blepharospasm eye closing
• Torticolis neck muscle contraction pulling head
  to side
• Oculogyric Crisis severe upward deviation of
  eyeballs
• Opisthotonos severe dorsal arching of neck and
  back
• Larngospasm/involvement of tongue dysphasia-
  difficulty swallowing

75

• PARKINSONISM symptoms include
• Tremors
• Bradykinesia/akinesia slowness, absence of
  movement
• Cogwheel rigidityslow regular muscular jerks
• Postural instability
• Stooped/hunched posture
• Shuffling gait
• Restricted movements
• Masked faceloss of mobility in facial muscles
• Hypersalivation drooling

76

• AKATHISIA not sitting
• Pacing, Motor restlessness,Rocking, Foot taping
• Subjective c/o inner restlessness, irritability,
  inability to sit still or lie down.
• Need to differentiate between Akathisia and
  psychomotor agitation or restlessness

77

• TARDIVE DYSKINESIA(means late occurring abnormal
  movements)
• effects 4 of persons taking antipsychotics
• Choreoathetoid movements rapid,jerky and
  slow,writhing movements may occur anywhere in
  the body arms,feet,legs,trunk
• Classic descriptionoral,buccal, lingual,
  masticatory movements tongue thrusting,lip
  pursing smacking,facial grimaces and chewing
  movements.

78
NEUROLEPTIC MALIGNANT SYNDROME

• NMS- A medical emergency
• Potentially fatal reaction to an antipsychotic
  medication
• Occurs in 0.5 1.4 of persons taking APs
• May occur at any stage of tx.
• SXs include high fever,
• muscular rigidity,altered consciousness
• Autonomic dysfunction

79
NMS Lab findings

• LEUCOCYTOSIS (15,000 30,000 cells)
• Elevated Creatine Phosphokinase
• Myoglobinuria(large amounts of myoglobin released
  in urine due to destruction of muscle tissue)
• Predisposing factors---
• Rapid tranquilization
• Increased number of IM injections

80
NMS COMPLICATIONS

• Myocardial Infarction
• Hepatic failure
• Disseminated Intravascular Coagulation
• Pulmonary Edema
• Rhabdomyolysis(rapid destruction of muscle
  tissue)- can result in renal failure