Thought Disorders (Psychosis, Schizophrenia):

Definition/Etiology:

Acute psychosis is an emergency situation and requires rapid assessment and diagnosis. The etiology of psychosis can be varied from dementia, brain tumors, substance abuse and even schizophrenia. The interventions for schizophrenia will differ a little from those other organic causes. Either way, ensuring patient safety is a priority regardless of the etiology.

Schizophrenia is a disease of its own. The word schizophrenia literally means “to split the mind”. Kind of fitting seeing as how these patients seem to have a break from reality. While with certain psychosis we can treat an underlying cause (like a tumor, or the substance abuse), with schizophrenia, all we can do is treat the symptoms.

Pathophysiology:

So, the patho of thought disorders has a few theories. One is based on neurochemical abnormalities that cause an imbalance in things like dopamine, serotonin, and glutamate. Another states that diseases like schizophrenia are due to a neurodevelopmental disorder. Yet another believes psychosis is due to neuroanatomical changes. The point here is that there is no one concrete answer to the pathophysiology of thought disorders, and as well, you probably will not get any questions on this…so let’s move on.

Clinical Presentation:

An acute psychotic reaction can present with:

• Delusions
• Hallucinations – usually auditory
• Disorganized speech
• Disorganized thinking
• Grossly disorganized behavior

Schizophrenia can present with what we call positive or negative symptoms.

Positive symptoms:

• Hallucinations
• Delusions
• Thought disorganization – they frequently change topics or have irrelevant responses to questions… How are you feeling today, Jake? – Well, fish are people, and the president wants with no fire but clearly Tuesday. – and yes, I have heard responses like this
• Bizarre behavior or dress – if you live in LA or NY, you have no doubt seen someone like this on the street, whether you know it or not
• Preservation – which is the adherence to a single idea or behavior
• Ideas of reference – a false belief that external events have special meaning. Think… the light turned red when I got to it because they are watching me
• Ambivalence – seemingly contradictory beliefs about the same person or thing.

Negative symptoms:

• Apathy
• Alogia – speaking little with little content
• Flat affect
• Anhedonia – feeling no joy
• Avolition – lack of will, ambition, or drive to accomplish a task

Collaborative Management:

With any thought disorder, we need some labs to see if there is something specific affecting the patient. CBC, CMP, Tox, Urine. Possibly a CT head to rule out any brain lesion or bleed that’s causing the symptoms.

With acute psychosis, we want to:

• decrease external stimuli
• Attempt to make a connection with the patient
• Remove any items that may pose a danger – and if you have been doing this for any amount of time, you know that anything in a standard ER room can be used as a weapon
• Antipsychotic meds PRN
• Restraints as last resort

With schizophrenics, we want to do much of the above, as well as:

• Use simple, concrete expressions and brief sentences
• Avoid figures of speech, you don’t want them to misinterpret what you are saying and break the trust you are trying to build
• Be confident but non-threatening
• Listen when the patient talks to try and identify clues regarding thought distortions
• If they are paranoid, leave doors open, try not to make them feel cornered or locked-in
• Explain everything

Evaluation | Patient Monitoring | Education:

These patients will most likely be on 1:1 observation. We want to monitor them and document everything properly. The goal is to try and reduce the psychotic episode. If it’s an organic cause, we would treat it. If its psychiatric, as in schizophrenia, we need to treat the symptoms. Contact the proper consults, psych, infectious disease, medicine, whoever. Education for these patients is not a priority as they may not be receptive, however, if they have family or caregivers present, they will benefit from conversations with the providers about their loved ones’ situation.

Linchpins: (Key Points)

• Safety first
• Be direct
• No joking
• Everything out