Thought Disorders & Adults

1. Thought Disorders &Adults Jaymie McAllister and Jessica Nemerovsky October 31, 2012 EBP Presentation

2. Schizophrenia • A thought disorder that affects cognitive, emotional and behavioral functioning • Linked to genetic vulnerability and environmental factors

3. Incidence & Prevalence • 1.2% of the U.S. population over the age of 18 • 10% of these people have a first-degree relative with the disease (mother, father, siblings) • Average onset: 15-35 years old • Diagnosed most frequently in men in their early 20’s and women in their late 20’s • Affects 24 million people worldwide • >50% are not receiving appropriate care

4. Symptoms • Must be present for at least 6 months before diagnosis can be made • Positive symptoms: • Excess or distortion of normal functioning • i.e. Hallucinations, distortions, disorganized speech • Negative Symptoms • Represents a deficit in functioning • i.e. Flat affect, apathy, avolition, anhedonia, alogia • Self Care deficit

5. Self-care deficit

6. Positive Symptoms • Hallucinations: perceptual disturbances, subjective experiences that are not caused by external stimuli • Can be visual, auditory, olfactory, gustatory or tactile • Most common: hearing voices (auditory) • Can be hostile or friendly • Delusions: Mistaken or false beliefs about self or the environment that are firmly believed • i.e. patient believes the FBI is following them

7. Positive Symptoms • Disorganized speech/behavior • Outward sign of disorganized thoughts • Flight of ideas/Loose associations (less severe) • Word Saladspeech cannot be logically understood (more severe) • Clanging (rhyming) • Echolalia • Behavior can be agitated, nonpurposeful or random • Disorganized • Catatonic: waxy flexibility

8. Negative Symptoms • Flat Affect: absence of affective expression • Alogia: brief, empty verbal responses • Poverty of speech • Apathy: Feelings of indifference towards people and the environment • Anhedonia: Lack of pleasure • Avolition: Lack of motivation

9. Self Care Deficit • Patient may appear dirty and unkempt • Indifference about personal care • May be wearing dirty clothes or clothes inappropriate for the season • Neglect to bathe or brush hair/teeth

10. Paranoid Schizophrenia • Prominent delusions and hallucinations • Persecutory and grandiosity • Delusions of government conspiracy common • False abilities (flight) • Beliefs of power (God, Jesus, King) • Auditory Hallucinations • Commonly hostile • Linked to delusions • Can make commands • Other characteristics: social isolation, suspicious/guarded behavior

11. NCLEX • Which of the following client statements demonstrates the major symptoms of schizophrenia? • “I’ve had too much to drink last night, started feeling all-powerful, and stupidly drove my truck into a tree.” • “A stitch in time saves nine’ means that prevention is easier than fixing a real problem.” • “I’ve been depressed ever since our house was destroyed by fire.” • “You can read my mind. This light of mine will shine, fine; blinding world will end at nine.”

12. NCLEX • “You can read my mind. This light of mine will shine, fine; blinding world will end at nine.”

13. NCLEX • A family member asks you, “As both of my siblings have schizophrenia, why are my brother’s symptoms so different from my sister’s? He withdraws when there’s a change in his environment or routine. She starts cursing and yelling about the Mafia and the CIA when I do something that’s less than perfect.” Based on your knowledge, your response should address:  • The effect on gender on clinical presentation in schizophrenia. • The many differences in the presentation of schizophrenia. • The significance of paranoid content in the differential diagnosis of paranoid schizophrenia. • The typical progression of symptoms with an individual over time.

14. NCLEX • The many differences in the presentation of schizophrenia.

15. NCLEX • You have presented your client with written aftercare medication directions: “Take one capsule three times per day.” Your client informs you that she has reviewed the material. Which response specifically addresses your concerns about adherence? • “This medications work best if you take one capsule three times per day.” • “What might get in the way of taking your medications?” • “Do you understand everything?” • “If you forget one dose, you can double the next one.”

16. NCLEX • “What might get in the way of taking your medications?”

17. EBP Article • “Many of the available instruments measure all of the abilities relevant to competency, including the MacCAT-T, MacCAT-CR, CAT, SICIATRI, CCTI, and CIS. Of these instruments,the MacCAT-T and MacCAT-CR have been tested in more diagnostic categories than any others, and can be said to be the GOLD STANDARDS.” • “Nevertheless, some measures may be preferred over the MacCAT instruments for particular populations. For instance, the CCTI has been tested extensively in patients with dementia, especially Alzheimer's disease. Likewise, the CAT may be a useful instrument for primary care patients.” (Sturman, 2005)

18. MacCAT-T • “Gold Standard” assessment tool for patients with schizophrenia. • “The instruments assesses patients’ competence to make treatment decisions by examining their capacities in four areas - understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices, appreciating the nature of their situation and the consequences of their choices, and expressing a choice.” (Grisso, Appelbaum & Hill-Fotouhi, 1997)

19. MacCAT-T • “The MacCAT-T offers a flexible yet structured method with which caregivers can assess, rate, and report patient’s abilities relevant for evaluating competence to consent to treatment.” • The MacCAT-T is basically an assessment tool comprised of smaller assessment tools that is very complex and takes a great deal of time. Within the MacCAT-T patients are given the DISSI (Diagnostic Interview Schedule Screening Instrument). • “Understanding is assessed by exploring the patient’s ability to paraphrase what has been disclosed concerning the disorder, the recommended treatment, and the treatment’s benefits and risks. The interview typically requires 15-20 minutes.” (Grisso, Appelbaum & Hill-Fotouhi, 1997)

20. BPRS • In addition to the DISSI, patients completed the 19-term Brief Psychiatric Rating Scale (BPRS) which was used to assess severity of psychiatric symptoms. BPRS scores above 40 commonly are associated with the need for in-patient treatment. • “BPRS total scores were not significantly related to MacCAT-T performance, although greater symptom severity tended to correlate with lower MacCAT-T ratings. (Grisso, Appelbaum & Hill-Fotouhi, 1997)

21. BPRS • The Brief Psychiatric Rating Scale (BPRS) is a widely used instrument for assessing the positive, negative, and affective symptoms of individuals who have psychotic disorders, especially schizophrenia. It has proven particularly valuable for documenting the efficacy of treatment in patients who have moderate to severe disease. • It should be administered by a clinician who is knowledgeable concerning psychotic disorders and able to interpret the constructs used in the assessment. Also considered is the individual's behavior over the previous 2-3 days and this can be reported by the patient's family. • The BPRS consists of 18 symptom constructs and takes 20-30 minutes for the interview and scoring. The rater should enter a number ranging from 1 (not present) to 7 (extremely severe). 0 is entered if the item is not assessed. (Grisso, Appelbaum & Hill-Fotouhi, 1997)

22. BPRS Rating • http://www.youtube.com/watch?v=kvdw4b7tC-8

23. Reference Page • Grisso, T., Appelbaum, P. S., & Hill-Fotouhi, C. (1997). The maccat-t:a clinical tool to assess patients' capacities to make treatment decisions. Psychiatric services, 48(11), 1415-1419. Retrieved from http://psychrights.org/Research/Digest/Decisionmaking/themaccat-t.pdf • Hafner, H. (1997, March 02). Pubmed.gov. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9067063 • Kneisl, C. R., & Trigoboff, E. (2013). Contemporary psychiatric-mental health nursing. (3rd ed.). Upper Saddle River, NJ: Pearson Education, Inc. • Mayo Clinic Staff. (2010, December 16). Mayo clinic. Retrieved from http://www.mayoclinic.com/health/paranoid- schizophrenia/DS00862/DSECTION=symptoms

24. Reference Page • Nclex review questions. (1985-2012). Retrieved from http://wps.prenhall.com/chet_kneisl_contempora ry_2/95/24454/6260344.cw/content/index.html • Sturman, E. D. (2005). The capacity to consent to treatment and research: A review of standardized assessment tools. Clinical Psychology Review, 25(7), 954-974. Retrieved from http://www.sciencedirect.com.ezproxy.lib.usf.edu /science/article/pii/S0272735805000498 • World Health Organization. (2011, May 6). Mental health: Schizophrenia. Retrieved from http://www.who.int/mental_health/management/schizophrenia/en/