Nursing Management & Treatment Modalities ofSchizophrenia.pptx

All about Schizophrenia.

1. SCHIZOPHRENIA Ms. Nitika Bhatt Assistant Professor Dept. Mental Health Nursing HCN, SRHU

2. Character Neurosis Psychosis Definition A neurosis is a group of uncertain functional neuro-psychical disorders that exhibit themselves in specific clinical phenomena in the absence of psychical phenomena. Psychosis is a critical mental illness, occurs due to loss of contact with the reality and a deep disturbance of the relationships with other people, causing social unacceptance. Types The types of neuroses are neurasthenia, fearful neurosis, hysteria, neuroses of compulsive conditions, etc. The types of psychoses are schizophrenia, bipolar affective disorder; delusions: paranoia, chronic hallucinatory psychosis, paraphrenia; epilepsy; senile or pre-senile dementia, etc. Contact with Reality In this the contact with reality is partial. In this contact with reality is totally lost or changed. Personality  The neuroses do not affect the personality. The psychoses do change their personality. Language and Communication In this, there is no effect on language, communication, and thought processes. In this, the thought and speech processes are disorganized and irrational. Awareness The person with neurosis is aware of personal problems and difficulties. The person with psychosis does not realize the disorder. Hallucination and Delusion In general, no delusion and hallucination occur. Hallucination and delusion are the main symptoms. Organic Changes It is a mental disorder without organic reason. It changes the anatomical structure and functionalities of the neuro-cerebral substance. Behavior In this, the affected individual can handle themselves and are rarely suicidal. Hospitalization is not necessary. In this, the affected individual cannot manage themselves. They often practice to suicide and need hospitalization or care at home. Treatment The treatment consists of moral and social support, medicines can also be prescribed. The treatment consists of antipsychotic medicines, psychological therapy, social support. CHARACTER NEUROSIS PSYCHOSIS Definition Neurosis is characterized by anxiety, fear, other feelings of unhappiness or distress that are out of proportion to the circumstances of a person’s life. Psychosis is a critical mental illness, occurs due to loss of contact with the reality and a deep disturbance of the relationships with other people, causing social unacceptance. Types The types of neurosis are OCD, anxiety disorders, somatoform disorders, PTSD . The types of psychosis are schizophrenia, bipolar affective disorder; delusions: paranoia, chronic hallucinatory.

3. Character Neurosis Psychosis Definition A neurosis is a group of uncertain functional neuro-psychical disorders that exhibit themselves in specific clinical phenomena in the absence of psychical phenomena. Psychosis is a critical mental illness, occurs due to loss of contact with the reality and a deep disturbance of the relationships with other people, causing social unacceptance. Types The types of neuroses are neurasthenia, fearful neurosis, hysteria, neuroses of compulsive conditions, etc. The types of psychoses are schizophrenia, bipolar affective disorder; delusions: paranoia, chronic hallucinatory psychosis, paraphrenia; epilepsy; senile or pre-senile dementia, etc. Contact with Reality In this the contact with reality is partial. In this contact with reality is totally lost or changed. Personality  The neuroses do not affect the personality. The psychoses do change their personality. Language and Communication In this, there is no effect on language, communication, and thought processes. In this, the thought and speech processes are disorganized and irrational. Awareness The person with neurosis is aware of personal problems and difficulties. The person with psychosis does not realize the disorder. Hallucination and Delusion In general, no delusion and hallucination occur. Hallucination and delusion are the main symptoms. Organic Changes It is a mental disorder without organic reason. It changes the anatomical structure and functionalities of the neuro-cerebral substance. Behavior In this, the affected individual can handle themselves and are rarely suicidal. Hospitalization is not necessary. In this, the affected individual cannot manage themselves. They often practice to suicide and need hospitalization or care at home. Treatment The treatment consists of moral and social support, medicines can also be prescribed. The treatment consists of antipsychotic medicines, psychological therapy, social support. CHARACTER NEUROSIS PSYCHOSIS Contact with Reality In this the contact with reality is partial. In this contact with reality is totally lost or changed. Personality  The neurosis do not affect the personality. The psychosis do change their personality. Language and Communication In this, there is no effect on language, communication, and thought processes. In this, the thought and speech processes are disorganized and irrational.

4. Character Neurosis Psychosis Definition A neurosis is a group of uncertain functional neuro-psychical disorders that exhibit themselves in specific clinical phenomena in the absence of psychical phenomena. Psychosis is a critical mental illness, occurs due to loss of contact with the reality and a deep disturbance of the relationships with other people, causing social unacceptance. Types The types of neuroses are neurasthenia, fearful neurosis, hysteria, neuroses of compulsive conditions, etc. The types of psychoses are schizophrenia, bipolar affective disorder; delusions: paranoia, chronic hallucinatory psychosis, paraphrenia; epilepsy; senile or pre-senile dementia, etc. Contact with Reality In this the contact with reality is partial. In this contact with reality is totally lost or changed. Personality  The neuroses do not affect the personality. The psychoses do change their personality. Language and Communication In this, there is no effect on language, communication, and thought processes. In this, the thought and speech processes are disorganized and irrational. Awareness The person with neurosis is aware of personal problems and difficulties. The person with psychosis does not realize the disorder. Hallucination and Delusion In general, no delusion and hallucination occur. Hallucination and delusion are the main symptoms. Organic Changes It is a mental disorder without organic reason. It changes the anatomical structure and functionalities of the neuro-cerebral substance. Behavior In this, the affected individual can handle themselves and are rarely suicidal. Hospitalization is not necessary. In this, the affected individual cannot manage themselves. They often practice to suicide and need hospitalization or care at home. Treatment The treatment consists of moral and social support, medicines can also be prescribed. The treatment consists of antipsychotic medicines, psychological therapy, social support. CHARACTER NEUROSIS PSYCHOSIS Awareness The person with neurosis is aware of personal problems and difficulties. The person with psychosis does not realize the disorder. Hallucination and Delusion In general, no delusion and hallucination occur. Hallucination and delusion are the main symptoms. Organic Changes It is a mental disorder without organic reason. It changes the anatomical structure and functionalities of the neuro -cerebral.

5. Character Neurosis Psychosis Definition A neurosis is a group of uncertain functional neuro-psychical disorders that exhibit themselves in specific clinical phenomena in the absence of psychical phenomena. Psychosis is a critical mental illness, occurs due to loss of contact with the reality and a deep disturbance of the relationships with other people, causing social unacceptance. Types The types of neuroses are neurasthenia, fearful neurosis, hysteria, neuroses of compulsive conditions, etc. The types of psychoses are schizophrenia, bipolar affective disorder; delusions: paranoia, chronic hallucinatory psychosis, paraphrenia; epilepsy; senile or pre-senile dementia, etc. Contact with Reality In this the contact with reality is partial. In this contact with reality is totally lost or changed. Personality  The neuroses do not affect the personality. The psychoses do change their personality. Language and Communication In this, there is no effect on language, communication, and thought processes. In this, the thought and speech processes are disorganized and irrational. Awareness The person with neurosis is aware of personal problems and difficulties. The person with psychosis does not realize the disorder. Hallucination and Delusion In general, no delusion and hallucination occur. Hallucination and delusion are the main symptoms. Organic Changes It is a mental disorder without organic reason. It changes the anatomical structure and functionalities of the neuro-cerebral substance. Behavior In this, the affected individual can handle themselves and are rarely suicidal. Hospitalization is not necessary. In this, the affected individual cannot manage themselves. They often practice to suicide and need hospitalization or care at home. Treatment The treatment consists of moral and social support, medicines can also be prescribed. The treatment consists of antipsychotic medicines, psychological therapy, social support. CHARACTER NEUROSIS PSYCHOSIS Behavior In this, the affected individual can handle themselves and are rarely suicidal. Hospitalization is not necessary. In this, the affected individual cannot manage themselves. They often practice to suicide and need hospitalization or care at home. Treatment The treatment consists of moral and social support, medicines can also be prescribed. The treatment consists of antipsychotic medicines, psychological therapy, social support.

6. Introduction to SCHIZOPHRENIA It is a psychotic condition characterized by disturbances in thinking, emotions and perception which leads to social withdrawal. Emil Krapelin (1896) recognize this form of illness and coined the term ‘dementia precox’ means premature deterioration of mental functions. 6

7. Schizophrenia coined in the year 1908 by the Swiss psychiatrist Eugene Bleuler . Derived from Greek “ schizo ” means spliting and “ phren ” means mind. 7

8. DEFINITION Schizophrenia is characterized in general by fundamental and characteristic distortion of thinking, perception and inappropriate or blunted affect. According to ICD 10 8

9. Schizophrenia is a severe mental disorder that affects thinking, perception, language and sense of self and o ften includes hearing voices and delusions. According to WHO 9 DEFINITION

10. PREDISPOSING FACTORS

11. 11 1. Biochemical theories a) Neurotransmitter b) Genetic c) Anatomical 2. Environmental a) Family b) Social 3. Psychological a) Psychoanalytical PREDISPOSING FACTORS

12. 12 a) Neurotransmitter- Increase in dopamine levels in patient with positive symptoms. Increased serotonin leads to positive & negative symptoms. Other are- GABA, acetylcholine, norepinephrine (paranoid type), glutamate. BIOCHEMICAL THEORIES

13. 13 b) Genetic theories Scientists have long known that schizophrenia runs in families. It occurs in 10 % of people who have first degree relative with the disorder PREVALENCE OF SCHIZOPHRENIA General population 1% Dizygotic twin of Schizophrenic patients 12% Monozygotic twin of Schizophrenic patients 47% Child with 2 parents of Schizophrenic patients 40% Child with 1 parent of Schizophrenic patients 12%

14. 14 c) Anatomical Enlarged brain ventricles. Low activity in frontal lobe. Brain undergoes changes while pubertal changes. Problems during brain development.

15. 15 Prenatal exposure to viral infection. Hypoxia during delivery of baby. Exposure to virus during infancy. Early parent loss. ENVIRONMENTAL

16. 16 a) Family theory -Double bind theory (child receive conflicting message from parents about their behavior) -Expressed emotion b) Social theories Low Socioeconomic status Social isolation

17. 17 a) Psychoanalytic theory Fixation at oral stage will produce defects in ego development. Fixation at stage trust vs mistrust PSYCHOLOGICAL

18. PSYCHODYNAMICS lots of psychological conflicts person try to resolve them by denying the reality lives in fantasy world which is full of pleasure ego & superego get weakened so decreases ability to socializes Detachment from reality Lives in two world (reality & fantasy) Appears bizarre behaviour and find difficulty to express emotions Symptoms of schizophrenia will appear 18

19. PHASES

20. PHASES OF SCHIZOPHRENIA Prodromal This phase of schizophrenia begins with a change from premorbid functioning and extend until the onset of psychotic symptoms. No obvious symptoms, but everyday functioning is beginning to deteriorate . 20

21. PHASES OF SCHIZOPHRENIA Active : In the active phase full-blown schizophrenia or psychotic symptoms are prominent. Example: delusions, hallucination, negative symptoms and social dysfunctional etc. Residual : In residual phase either symptoms subsides or no longer prominent, prodromal- like state and negative symptoms are present. 21

22. SIGN & SYMPTOMS 22 Eugene Bleuler’s 4 A’s Positive & negative symptoms Schneider’s first & second rank symptoms

23. BLEULER’S 4A’S AMBIVALENCE: Presence of two contradictory or opposite feelings, attitudes, or beliefs towards object, person, or situation. AUTISM: Patient is preoccupied with ideas derived from excessive day dreaming or fantasy. Patient is unaffected by what is happening in the environment. AFFECT DISTURBANCE: Mood of the patient is inappropriate flat or blunt. Deduction of will power, drive and desire to carryout routines. ASSOCIATION DISTURBANCE: It is thought disorder. Thinking appears irrelevant, illogical, bizarre. Ideas have no or very less connections. 23

24. POSITIVE VS NEGATIVE SYMPTOMS Presence of inappropriate symptoms Absence of appropriate ones. Positive Symptoms Negative Symptoms

25. POSITIVE AND NEGATIVE SYMPTOMS HALLUCINATIONS( auditory, visual, olfactory, gustatory, tactile) DELUSIONS(persecution, grandeur, reference, influence) DISORGANIZED THINKING OR SPEECH(loose association, incohorence , word salad, neologism, echolalia, tangentiality, circumstantiality) DISORGANIZED BEHAVIOR unchanging facial expression, affect flattening, poor eye contact, reduced body language, diminished emotional expression, decreased content & fluency of speech, inability to initiate goal directed activity, no interest in work, impaired hygiene, social isolation POSITIVE SYMPTOMS NEGATIVE SYMPTOMS

26. SCHNEIDER’S DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA Voices arguing or discussing Thought withdrawal Thought broadcasting Delusional perceptions Disorder of perception Sudden delusional ideas Depressive and euphoric mood changes FIRST RANK SYMPTOMS SECOND RANK SYMPTOMS

27. F20-F29 Schizophrenia F20 Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified

28. F20.0 PARANOID SCHIZOPHRENIA Paranoid schizophrenia characterized mainly by delusions of persecution , feelings of passive or active control feelings of interference The delusions are not usually systemized too much, without tight logical connections and are often combined with hallucinations of different senses, mostly with hearing voices . Disturbances of affect, speech, and catatonic (react little or not at all) symptoms.

29. F20.1 HEBEPHRENIC SCHIZOPHRENIA Hebephrenic schizophrenia disorganized thinking with blunted and inappropriate emotions. disorganized behavior: mannerisms, inappropriate laugh and joking, and sudden impulsive reactions without external stimulation. disorganized speech: loosening of association, perseveration (repetitive & continuous), neologism, clang association Prognosis - poor because of "negative" symptoms, particularly flattening of affect and loss of volition . Denoted also as disorganized schizophrenia

30. F20.2 CATATONIC SCHIZOPHRENIA Catatonia is a group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion, and restlessness. STUPOR & EXCITEMENT

31. F20.3 UNDIFFERENTIATED SCHIZOPHRENIA Psychotic conditions meeting diagnostic criteria for schizophrenia but not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics. This subgroup represents also the former diagnosis of atypical schizophrenia .

32. F20.4 POST SCHIZOPHRENIC DEPRESSION A depressive episode, which may be prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms, either “positive ” or “negative ” , must still be present but they no longer dominate the clinical picture. These depressive states are associated with an increased risk of suicide .

33. F20.5 RESIDUAL SCHIZOPHRENIA A chronic stage in the development of schizophrenia with clear succession from the initial stage with one or more episodes characterized by general criteria of schizophrenia to the late stage (residual stage) with long-lasting negative symptoms and deterioration (not necessarily irreversible) .

34. F20.6 SIMPLE SCHIZOPHRENIA Simple schizophrenia is characterized by early and slowly developing initial stage with growing social isolation, withdrawal, small activity, passivity, avolition and dependence on the others. The patients are indifferent, without any initiative and volition. There is not expressed the presence of hallucinations and delusions.

35. Other Schizophrenia

36. F21 Schizotypal disorder Eccentric behavior and by deviations of thinking and affectivity, which are similar to that occurring in schizophrenia, but without psychotic features and expressed symptoms of schizophrenia of any type.

37. F22 Persistent Delusional Disorders Includes a variety of disorders in which long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic or affective. Their origin is probably unknown, but it seems, that there is some relation to schizophrenia.

38. F23 Acute and Transient Psychotic Disorders The criteria should be the following features: acute beginning (to two weeks) presence of typical schizophrenic symptoms. Complete recovery usually occurs within a few months , often within a few weeks or even days . The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.

39. MANAGEMENT MODALITIES OF SCHIZOPHRENIA

40. PSYCHOPARMACOLOGY Mainly anti-psychotics are used for treatment: Atypical anti-psychotics : these newer antipsychotics medications at effective in managing hallucinations, delusions and other symptoms. Olanzapine (5-15 mg) Clozapine (300-900 mg) Quetiapine (150- 750 mg) Risperidone (2-8 mg) 40

41. Typical anti-psychotics: These medications are thought to control symptoms by affecting brain chemicals called neurotransmitters. Trifluoperazine (0.25- 10 mg) Haloperidol (5- 100 mg) Chlorpromazine (300-1500 mg) 41

42. HOSPITALISATION During crisis period or times of severe symptoms, hospitalization may be necessary. This can help ensure patients own safety and that of others, and make sure that the patient is getting proper nutrition, sleep and hygiene . 42

43. PSYCHOTHERAPY 43

44. GROUP THERAPY FAMILY THERAPY INDIVIDUAL THERAPY ELECTRO-CONVULSIVE THERAPY

45. ELECTRO-CONVULSIVE THERAPY ECT is a procedure in which electric current is passed through brain to trigger a brief seizure results in reducing symptoms of certain mental illnesses such as paranoid schizophrenia. 45

46. CONVULSIVE THERAPY Indicated in: Acute psychotic episode Stupor, excitement and violent behaviour Suicidal and homicidal tendencies Not responding to drugs 46

47. COMMUNICATION TECHNIQUE USED BY NURSES Confrontation Presenting the patient with a different reality of the situation. Doubt Expressing or voicing doubt when a patient relates a situation.

48. NURSING APPROACH FOR SCHIZOPHRENIA PATIENT Nurse must approach these clients in a firm and formal manner. Don’t show aggressive behaviour to client because it may serve to reinforce the feelings of paranoia. 48

49. NURSING DIAGNOSIS OF SCHIZOPHRENIA

50. Disturbed thought process r/t disruption in cognitive operations and activities as evidenced by disorganized and fragmented thoughts . INTERVENTIONS RATIONALE 1) Be sincere and honest when communicating with the client. Avoid vague remarks. Delusional clients are extremely sensitive about others and can recognize insincerity. Vague ideas reinforces mistrust or delusion. 2) Do not argue with client or try to convince him that delusions are false or unreal. Arguments can interfere with the development of trust. 3) Do not make promise that you cannot keep. Broken promises reinforce the client’s mistrust of others. 4) Interact with the client on the basis of real things, don’t dwell into delusional material. Interacting about reality is healthy for client. 50

51. Disturbed sensory perception r/t change in incoming stimuli accompanied by diminished response to such stimuli as evidenced by hallucinations . INTERVENTIONS RATIONALE 1) Explore the context of client’s hallucinations during the initial assessment to determine nature of hallucinations. To determine nature of hallucinations. 2) Be aware of all surrounding stimuli, including sounds from other rooms (such as T.V or stereo). Many normal stimuli can trigger or intensify hallucinations. 3) Observe client for signs of hallucination. Avoid touching client without warning. It is more difficult for the client to respond to hallucination when he or she is engaged in real activities and interactions. 4) Provide simple activities that the client can realisticaly accomplish. Long and complicated tasks may be frustrating for the client. He or she may be unable to complete them. 51

52. Disturbed personal identity r/t inability to distinguish between self and non-self as evidenced by suicidal and homicidal tendency . INTERVENTIONS RATIONALE 1) Reassure the client that the environment is safe by briefly and simply explaining routines, procedures and so forth. The client is less likely to feel threatened if the surrounding are known. 2) Protect the client from harming himself or herself or others. Client safety is a priority. Self destructive ideas may come from hallucinations or delusions. 3) Reorient the client to person, place and time as indicated 4) initially, assign the same staff members to work with the client. Consistency can reassure the client. 52

53. Risk of violence r/t aggressive behavior as evidenced by homicidal tendencies . INTERVENTION RATIONALE 1) Maintain low level of environment in client environment. This helps in reduction of stimulating environment and decrease the sensitivity of client. 2) Observe the client behaviour frequently. Helps in keen observation of the client and thus reduction of violent behaviour. 3)Redirect violent behaviour with physical outlets for anxiety. It helps in loss of energy and redirecting the mind toward another channels. 4) Staff should maintain calm attitude toward client. This provide peace and calmness and promote worthiness among client and staff. 53

54. Impaired communication R/T perceptual deficit as evidenced by word salad . INTERVENTIONS RATIONALE 1) Motivate client to initiate conversation. To know the feelings of client. 2) Encourage the client to participate in social activities. 3) Do not provoke personalized questions, agitating questions in the beginning. It will result into volition. 4) Never argue or criticize with the client, related to delusions. It will results into distrust. 5) Explain to the client, the reason of his behaviour and the attitude. To maintain smooth relationship. 54

55. ACTIVITIES Solitary non competitive activities in the beginning that take some concentration should be given to the client. Such as: Cross word puzzles Photographing Typing Drawing Reading poetry Listening to music 55

56. Engage the client in reality based activities. Plan daily schedule plan Assist the client in meeting the daily activities. Encourage the client to take medications Monitors the client judgment and decision making. Suggest that client “ not listen to the voices right now” or “not focus on those ideas right now” Ensure that client receive adequate sleep and rest Assess improvement Use distraction methods such as exercise, activities, listening to music etc. 56 WAYS TO REDUCE OR MINIMIZE PSYCHOSIS

57. Take your medications as directed. Resist any temptation to skip your medications. If you stop, schizophrenia symptoms are likely to come back. 57 LIFE STYLE MODIFICATIONS

58. Avoid drugs and alcohol. Alcohol and illicit drugs can worsen schizophrenia symptoms. Get appropriate treatment for a substance abuse problem. 58 LIFE STYLE MODIFICATIONS

59. Check first before taking other medications. Contact the doctor who's treating you for catatonic schizophrenia before you take medications prescribed by another doctor or before taking any over-the-counter medications, vitamins, minerals or supplements. These can interact with your schizophrenia medications. 59 LIFE STYLE MODIFICATIONS

60. Learn about catatonic schizophrenia. Education about your condition can empower you and motivate . Join a support group. Support groups can help you reach out to others facing similar challenges. Stay focused on your goals. Stay motivated by keeping your recovery goals in mind. Remind yourself that you're responsible for managing your illness and working toward your goals. 60 COPING AND SUPPORT

61. Find healthy outlets Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities. Learn relaxation and stress management. Try such stress-reduction techniques as meditation, yoga or tai chi. Structure your time. Plan your day and activities. Try to stay organized. You may find it helpful to make a list of daily tasks. 61 COPING AND SUPPORT

62. PROGNOSIS of schizophrenia Duration of illness: shorter duration carries better prognosis. Type of schizophrenia: catatonic and paranoid carries better prognosis. Undifferentiated type has poor prognosis. Precipitating factors : Their presence carries good prognosis Age : Schizophrenia between age of 20-30 years carry better prognosis. Type of onset: acute onset carries better prognosis. Number of attacks and family history also effect. 62

63. ANY QUERY?