Positive Symptoms: Disorganized Speech, Cognitive and Behavioral Symptoms (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:00 So, here's another one of those positive symptoms when you think of disorganized speech.

    00:07 So remember, schizophrenia, it affects the way we think. Well, before I say anything to you, I quickly am thinking about what's going to come next. But if I have something that's blocking the way I'm thinking or really disorganizing my thoughts, my speech is going to reflect that. And sometimes, when I would have a conversation with somebody who has schizophrenia I might say to them "How are you, how are things going?" And they might say "Going, going gone." Not thinking about what my question was but hearing that last word "going" and making this association between something they know "going, going gone" and what I just said. And that's called loose association, you take a thread from one sentence and then you connect it to something that really is not related or if it is it's only a remote relation. We also have these neologisms. Remember, we put it into a latin neo meaning new, logism meaning words. So this is the making up of new words and we may not know what that word means because it doesn't exist. This person has given that meaning, it means something in their world and therefore when you hear a neologism it's okay to slow that person down and to say to them "Wow, that's a new word for me." What does it mean? And let them explain the two if they can. Also, we talked about it very briefly, echolalia.

    01:53 When you think about echo, it's that repetition and when you think of echolalia you're thinking of repeating words. So, this is when the person echoes or repeats whatever it is you're saying. "How are you today?" "How are you today?" "Well actually I was hoping you tell me." "Hoping you tell me." This is a true symptom and not anything that is funny, not anything to make fun of but it's something to jot down and make a note of that this patient is demonstrating some disorganized speech pattern. There's also the clang association where people rhyme and those rhyming words don't have to make any sense at all. I was just watching Princess Brides for the very first time and in it there is this whole part where everyone tries to rhyme with everyone else. Now, we're not going to say that that is clang associations because those persons are not diagnosed with schizophrenia disorders. But if you have somebody and you say "How are you?" and they say "Mer are you?" And you say "Well, I was hoping you would answer the phone" and they say "All alone", you're going to start thinking to yourself "Uhmmm, they're kind of doing a clang association in their mind." When you get to a person who has words that are not in any way related to each other, we're calling it a word salad. Think about tossing a salad. So you have your lettuce, you have your tomato, you have your carrots, you put it all in there, it could be nicely arranged and then you take your salad forks and you toss it around. And now suddenly everything is mixed with each other. Well, that's what a word salad is, when all these different words or phrases come together and it means nothing. You may see this in other diagnoses beside schizophrenia and that's something that you want to keep in mind. So you have cognitive and you have behavioral symptoms. So your cognitive are your thought processes. But your behavioral are your behaviors. So, this idea of depersonalization, this is when a person loses their identity. The self is somewhat unreal to them and different body parts are not actually connected to them. So they have an arm over here, but they don't even know it's their arm that's over there, that they are totally depersonalized. There's also derealization. Now, that is a perception and it's a false perception of a changed environment like believing in Alice in Wonderland. Again, I'm going to say depersonalization and derealization are not specific to only schizophrenia. We do see these as psychotic symptoms that can happen in other mental illnesses. But just remember them as cognitive symptoms.

    05:22 Memory becomes affected. Do you remember which part of your brain where memories are stored? If you said hippocampus you're 100% right. And schizophrenia affects our hippocampus. We also find that persons with schizophrenia need things to be concrete. They are concrete thinkers. If we start talking to them in the abstract, we lose them because they're functioning requires that we are more concrete so they can understand what we are saying. Oftentimes, they don't have very good concentration. They have a thought disorder going on and it's hard for them to keep track of one thought after another because of that neurotransmitters that we were talking about, that interfere with the processing of messages. So, because they have poor concentration, what do you think would be a good idea when we are working with them as nurses? And if you're saying bite-size things make things smaller, let them achieve small steps, you are absolutely correct. We also want to make sure that they have us to listen to because their judgment might not be very good.

    06:47 I'm sure that you have never made an impulse response to something and afterwards thought "Well, that wasn't such a good idea." Well, if you could not stop that impulse, if you were not able to think something through, if you were lacking a bit of insight, well naturally poor judgement and bad outcomes are going to follow. And if you have enough poor judgment, bad outcomes rather than understanding that this is a symptom, a cognitive symptom of a real disease, you might start thinking it was just your personality or you who is at fault instead of the disease. We also have to be careful because they have impaired processing. That's that neurotransmitter piece. So, processing an idea, a thought, it can get very messed up. And what starts one idea made by the end of the thought be something completely different. So, how does that affect the way we speak? If our thoughts are not being very coherent, if we are lacking insight, if our judgment now is affected, if we can't really get those neurotransmitters to work together to pull together insight and abstract thinking, how will that be reflected? It is going to be reflected in our speech, in our speech patterns and whether we repeat or so. So whether it's a word salad or whether it's a neologism, all these things are connected with each other. Then there is the stereotyped behavior. And that would be the constantly repeating, something that would normally be meaningful but now it's no longer meaningful or done in a meaningful way. For example, I have a clicker in my hand and if I was tapping the front of my clicker or I was using it and trying to move it around to open a door and I would ritualistically do a behavioral pattern with this to try and get something else to happen, it's not meaningful. So, when we think about automatic obedience. So this is somebody and you can imagine how dangerous this is for the human being who actually has automatic obedience who will do whatever they are told. If they are told to sit down, they sit down. They told to stand up, they stand up.

    09:37 They're almost like a little robot. And as soon as the commands command they do whatever they are told, never saying no. Waxy flexibility is an interesting symptom that I have seen a number of times and that is when you put a person in a position and they just keep it there.

    10:00 And it's not that they're doing it on purpose, it's that they don't know they're doing it at all. And then stupor. So, when a person is in a stupor, they're motionless. It's like they are in a coma. It is not that they are resisting you or being oppositional, they actually are non-responsive and unable to respond to you.

    About the Lecture

    The lecture Positive Symptoms: Disorganized Speech, Cognitive and Behavioral Symptoms (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Schizophrenia (Nursing).

    Included Quiz Questions

    1. The client that approaches another client who is quietly reading and begins yelling at them, telling the other client to stop laughing at them.
    2. The client that reports the government is contacting the hospital shortly to demand their release.
    3. The client who is the only one not laughing or smiling while watching a comedic movie in the common room.
    4. The client who is having significant difficulty telling the nurse what they did on their weekend pass.
    1. Echolalia
    2. Neologism
    3. Clang association
    4. Word salad
    1. Waxy flexibility
    2. Automatic obedience
    3. Stupor
    4. Depersonalization
    1. Stereotyped behavior
    2. Automatic obedience
    3. Waxy flexibility
    4. Stupor
    1. “Walk milk happy sun”
    2. “Saturday night fever!”
    3. “How was your night?”
    4. “Night right fight might”

    Author of lecture Positive Symptoms: Disorganized Speech, Cognitive and Behavioral Symptoms (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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