Psychotic Disorders - Textbook

11 Psychotic Disorders

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LEARNING OBJECTIVES

After learning the content in this chapter, the student will be able to:

Define psychosis.

Differentiate between delusions and hallucinations.

Give examples of disorganized thinking and behavior alterations seen in psychosis.

Describe positive and negative symptoms seen in schizophrenia.

Describe treatment methods for clients with psychotic disorders.

Describe the relationship of antipsychotic medication agents to the treatment of psychosis.

Identify extrapyramidal side effects (drug-induced movement disorders) and their effect on medication therapy adherence.

Describe data collection of the client with a psychotic disorder.

Identify nursing interventions for the client with a psychotic disorder.

KEY TERMS

akathisia

alogia

anhedonia

antipsychotic agents

avolition

catalepsy

catatonic

delusion

delusions of reference

drug-induced parkinsonism

dystonia

echolalia

echopraxia

extrapyramidal side effects

hallucinations

illusions

loose associations

mannerisms

neologisms

neuroleptic malignant syndrome

posturing

prodromal phase

psychosis

schizoaffective disorder

schizophrenia

stupor

tardive dyskinesia

thought broadcasting

thought insertion

thought withdrawal

water intoxication

waxy flexibility

word salad

Introduction to Psychotic Disorders

Psychosis refers to a set of symptoms that includes perceptual disturbances, disorganized thinking, and behavior alterations. Psychosis is not an illness. These symptoms demonstrate the disorganization that is present in the individual’s mental processes and reflect the behavior, emotional response, and thought processes of the individual who has lost contact with reality. People usually associate the disturbances of “hearing voices” or other atypical behaviors with psychosis. Those who experience these symptoms also tend to withdraw from society.

There are a number of different situations in which the symptoms of psychosis are manifested. They may be seen in some medical conditions such as delirium, medication toxicity, dementia, mood disorders, and other delusional disorders (Box 11.1). In most situations, the symptoms are not present at all times. Psychotic disorders affect the mind and the individual’s ability to think clearly and respond effectively to the world around them.

The major symptoms of psychotic disorders are delusions and hallucinations. Some individuals may experience this as a single psychotic event, such as that seen after an extremely stressful event, trauma, or illegal substance ingestion. The episode may last a few days and usually resolves within several weeks. In other situations, such as in schizophrenia, symptoms are gradual, even unnoticed, in the beginning and recur for the rest of the individual’s life.

The most common and severe form of psychotic disorders is schizophrenia—a form of psychosis in which there are disorganized thoughts, perceptions, and atypical behaviors. The occurrence of schizophrenia is about 1%. About half of the clients admitted to mental units are diagnosed with schizophrenia. The cost of mental health care and social services related to schizophrenia in all age groups is significantly higher than that of other mental disorders.

BOX 11.1

Associated Causes of Psychosis

Alcohol or other substance use

Bipolar disorder

Brain tumor

Delirium

Dementia

Depression

Epilepsy

Huntington chorea

Parkinson disease

Stroke

Before discussing schizophrenia in depth and mentioning the other types of psychotic disorders, it is important to discuss the characteristic symptoms that are seen in psychosis.

Perceptual Disturbances

Hallucinations are false sensory perceptions that have no relation to reality and are not supported by actual environmental stimuli. When a hallucination occurs, the individual has the perception of seeing (visual), hearing (auditory), smelling (olfactory), feeling (tactile), or tasting (gustatory), although there is no stimulus present. Olfactory and gustatory misperceptions account for a small percentage of perceptual disturbances.

Although all of these may occur, auditory hallucinations are the most common. Most of these are in the form of voices or sounds that can only be heard by the one experiencing them. The voices may originate inside or outside the individual’s head and may be talking to them or commenting on their behavior. The voices can be commanding, telling the individual to harm themselves or others. Those who experience the command hallucinations may react in panic or demonstrate violence toward themselves or others. It is important to ask the individual what the voices are saying. If the individual feels the voice is coming from someone they know and/or trust, the individual is more likely to follow the commands. Auditory hallucinations can be very frightening to the individual.

Mind Jogger

Considering that the client hearing commanding voices is not in touch with reality, what is the best approach to communicating with them?

Visual hallucinations are less common but may involve seeing people or images that are not actually present. Feeling that something is crawling on the skin or moving inside the body parts are typical of tactile hallucinations. Illusions are experienced when sensory stimuli actually exist but are misinterpreted by the individual. For example, the individual may refer to spots on the floor as insects or to an electric cord as a snake.

Disorganized Thinking

In psychosis, the thought processes become confused and disrupted, leaving the individual with an inability to carry on a logical conversation. A delusion consists of fixed, false ideas or beliefs without appropriate external stimuli that are inconsistent with reality and that cannot be changed by reasoning. These thoughts usually involve a theme that is dominant in the mind. For example, the individual who thinks someone is trying to kill them will demonstrate this both verbally and behaviorally. The client might say, “I’m not taking this medication because you are trying to poison me,” or “I’m not eating my food because the FBI put poison in it.” Paranoid delusions are important to note as they may prevent the client from cooperating with the treatment plan. For example, if they fear being poisoned they may not eat meals or take medications. If the individual fears being a hostage they may resist going to a group home or leave a shelter and this may increase their risk of homelessness.

The content or theme of the delusions can include depressive, somatic, grandiose, or persecution. Box 11.2 lists the most common themes of delusions. There are also delusions of reference, which are false beliefs that the behavior of others in the environment is directed at them personally. For example, the individual may believe that something such as a newspaper article or television commercial is sending a special message to them. Content can also include a belief in thought broadcasting, in which the individual’s thoughts can be heard by others. An example of this is a client stating, “I have a direct wire attached to the commander of intelligence to rule the underground.” Thought insertion may also be claimed, in which the individual believes the thoughts of others can be inserted into their mind. A client stating, “Men from Mars are implanting seeds of destruction into the layers of my mental dirt,” is demonstrating thought insertion. Thought withdrawal indicates a belief that others are robbing thoughts from one’s brain. An example of this would be the client’s statement of, “I wear this hat so they can’t steal my ideas.”

BOX 11.2

Common Delusional Themes

Depressive (e.g., believing they have committed a terrible deed such as a terrorist attack)

Erotomatic (e.g., believing a famous actress is madly in love with them)

Grandiose (e.g., believing they are stronger than a superhero in a movie)

Jealous (e.g., being very possessive for the attention of the nurse and believing they have an intimate relationship with them)

Mixed (the individual has two or more delusional themes)

Nihilistic (e.g., believing that their arm no longer exists)

Persecutory (e.g., believing the mob is out to kill them)

Reference (e.g., believing that a television ad is speaking directly to them to and the message has a personal meaning)

Somatic (e.g., believing their body is disintegrating into another substance or infested with insects)

Just the Facts

The most common delusional themes are related to thoughts of persecution, religious ideas, or somatic reference.

A typical brain organizes and directs thought processes into spoken words, associations, or connections in a logical format. Content refers to the meaning of the words or conversation that is spoken. Individuals with disorganized thinking express the disorganization in the way they speak. They may be talking and suddenly change the course of the conversation to something with no logical connection to the original topic. The inability to organize and connect sudden changes in thought processes that are vague, unfocused, and illogical is exhibited by loose associations (sometimes called derailment), where the thoughts or ideas frequently jump from one topic to another that is unrelated. The individual will say a sentence such as, “This meat is tough, but I saw meat in the store and nails are keeping it together until the cows get home.” Here there appears to be a central idea of “meat” but the thoughts are fragmented and loosely connected. Word salad is when the individual expresses random unconnected and disorganized thoughts, which indicates severe impairment. An example of this is the statement of, “You see I am living in the sky where it snowed yesterday with thunderous wires darting in and out of the highway. Brilliant colors keep the orchestra moving the ball down the railroad track toward the divine intellect of my intestines.” In this example there are no thoughts that are loosely connected and the words or thoughts are mixed together randomly.

Alogia (sometimes called poverty of speech) is a decrease in the amount or speed of speech.