Yesterday we discussed important features of the mental status exam as it relates to schizophrenia and other psychotic disorders. We will finish that discussion today with a similar format as we outline the important considerations in these patients in regards to thought process, thought content, perceptual disturbances, cognition, insight, and judgement.
Today's Content Level: Beginner; Intermediate
Reminder of the Mental Status Exam Components
•Appearance
•Behavior
•Speech/Language
•Mood
•Affect
•Thought process
•Thought content
•Perceptual Disturbances
•Cognition
•Insight
•Judgement
Thought Process
•I apologize in advance but this section is going to be somewhat heavy on defining terms since there is very specific terminology in regards to the various types of thought processes that can be seen in psychosis.
•Disorders in thought process relate to the way in which ideas and languages are formulated and organized. A disordered thought process is one of the core features of schizophrenia and related disorders. See below for examples:
•Mutism: inability, unwillingness, or refusal to speak.
•Thought blocking: sudden cessation in speech without explanation.
•Perseveration and Verbigeration and Echolalia
Perseveration is repetition of random words in response to a stimulus/question.
Verbigeration occurs when a person repeats words without a stimulus.
Echolalia is when a person repeats another persons words
•Clang Associations: patient will speak in groupings of words, usually rhyming words, that are based on similar-sounding sounds, even though the words themselves don't have any logical reason to be grouped together. Example: “the train brain rained on me.”
•Neologisms: creation of new words that are meaningless except to the person coining the term.
•Magical thinking: statements highlighting their belief in causal relationships that their thoughts, words, or action will cause or prevent a specific outcome in some way that defies commonly understood laws of cause and effect.
•Alogia: there is a lack of unprompted speech. Another term for this is paucity of speech. This is considered a negative symptom of schizophrenia.
•Poverty of thought: an overall reduction in the quantity of thought. This is a negative symptom of schizophrenia and also present in severe depression or dementia.
•Poverty of content: speaking without substance. This type of speech requires excessive speech to convey their message.
•Circumstantiality and Tangentiality:
Circumstantiality: inability to answer a question or make a point without unnecessary detail, however usually returns to and completes the original points. This is fairly common among all patients regardless of disorder depending on their personality type.
Tangentiality: shifts thoughts and speech away from the original topic and does not return to the original points.
•Flight of ideas: a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When the condition is severe, speech may be disorganized and incoherent. Most classically associated with mania.
•Loosening of associations: lack of obvious logical relationship between two thoughts expressed in sequence. This was once described as pathognomonic (super specific) for schizophrenia, however this is also frequently seen in mania.
•Incoherence: speech or thought is difficult or impossible to understand because words or phrases are not connected in a logical way.
•Word Salad: the most extreme spectrum of incoherence. Random words and phrases with no comprehensible organization.
Of note, patient with schizophrenia likely also have impaired attention and poor abstraction.
Thought Content
•Disorders of thought content reflect the patient's ideas, beliefs, and interpretations. Below are some examples of disordered thought content commonly seen in psychotic spectrum disorders.
•Delusions: Firmly held false beliefs despite incontrovertible evidence. Delusions can be a major cause of distress, anxiety, and paranoia for patients. Types of delusions are varied and may assume persecutory, grandiose, religious, or somatic forms. See day # 4 for full discussion on types of delusions. Two common delusions to note here.
Thought control: outside forces are controlling what the patient thinks or feels.
Thought broadcasting: patients think others can read their minds or their thoughts are broadcast through television sets, phones, or radios.
•Preoccupations: Complete absorption in a particular thought and may have difficulty or inability to shift away from these thoughts. They may have an intense preoccupation with abstract, symbolic, or religious ideas. They may also worry about bizarre and implausible bodily conditions that are life-threatening. An example from one of my own patients -> he believed that nazi aliens were inside his brain and shooting out radiation to the rest of his body.
•Ideations: Patient may be preoccupied with killing themselves (suicidal ideation) or killing another person (homicidal ideation). This may be secondary to paranoia, severe depression, or command hallucinations ordering them to become violent. Patients are often paranoid and involve suspiciousness or the belief that they are being harassed, persecuted, or unfairly treated.
•Ideas of Reference: This term describes the false belief that irrelevant occurrences or details in the world relate directly to oneself. For example, patients may think that other people, the television, or the newspapers are referring to themselves. They may also believe their actions are somehow causing these events. Other "loss of ego" boundaries include the sense that the patient has physically fused with an outside object (e.g. a tree or another person) or fused with the entire universe (e.g. "cosmic identity").
Perceptual Disturbances
•It should go without saying, as discussed in our previous readings, that perceptual disturbances are core features of psychotic disorders and critical for their diagnosis.
•We already provided an overview and description of hallucinations, illusions, and delusions in one of our first articles, so we won't describe them again here but remember that these may involve any of the five senses. The most common type of hallucination in non-substance induced psychotic disorders are auditory and are often threatening, obscene, or insulting. Auditory hallucinations can vary. They may sound like distant whispers or sounds or it may sound like yelling/screaming. Two or more voices may converse among themselves. The voices may comment on the patient’s life or behavior or command them to act out certain behaviors. Visual hallucinations are the next most common perceptual disturbance. Tactile, olfactory, and gustatory hallucinations are unusual and should prompt further medical and neurological workup.
Cognition
•Orientation: Patients with schizophrenia are usually oriented to person, time, and place. The lack of such orientation should prompt the possibility of delirium, substance use, or other medical or neurological disorders. However, keep in mind that they may give incorrect or bizarre answers based on their delusions. For example, "I am Jesus Christ and it is AD 35."
•Cognitive Impairment: As discussed on day # 4, patients with schizophrenia experience high rates of cognitive deficits and this is not explicitly laid out in the DSM criteria. In outpatients, cognitive impairment is a better predictor of level of function than is the severeity of psychotic symptoms. Typically cognitive dysfunction is subtle. Here is a memory aid to help remember some of these deficits.
•Speed of Processing
•Memory (visual, verbal, working)
•Attention
•Reasoning
•Tact / Social cognition (emotional processing, social cues, mentalizing)
Insight / Judgement
•Classically, patients with schizophrenia are described as having poor insight into the nature and severity of their disorder. This is associated with poor compliance with treatment. Try to carefully define various aspects of insight/judgement such as awareness of symptoms, difficulties getting along with others, and reasons for these problems. This information is useful for tailoring treatment.
•Be aware that one component of insight is often reality testing such as in psychotic disorders. If you or your supervisor prefers, there are a number of validated insight rating scales designed for use in psychotic disorders (e.g., Beck Cognitive Insight Scale, Markov's Insight Scale) which include examples of insight-based questions.
Conclusion
Nice work today. This reading was longer than I like to make these posts, but there is a ton of high yield information here. Consider re-reading it if you have some extra time today. Check back in for the next lesson as we will cover the diagnostic work-up for a first psychotic episode.
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