Schizophrenia

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1. Schizophrenia Nabina Paneru

2. Introduction The term “Schizophrenia” was coined in 1908 by the Swiss psychiatrist Eugen Bleuler . The word was derived from Greek words “ Skhizo ”(split) and “ phren ”(mind ) It refers to a group of mental illness characterized by a specific psychological symptoms that affect the mood, regulation of emotions, thoughts, perceptions, emotions, movements, behavior and total personal integrity.

3. Definition Daneil Weinberger ,a psychiatrist has defined Schizophrenia as, “the mental cancer”. According to ICD-10, Schizophrenia is, "A group of disorders manifested by fundamental disturbances or distortions in thinking ,mood and behavior , which lasts for at least a month of active phase symptoms like delusions , hallucinations, disorganized or catatonic behavior, negative symptoms such as shallow or flat affect , alogia or avoilation and incongruous mood .”

4. Contd. Schizophrenia is “Disturbance in thinking is marked by alteration of concept formation , which may lead to misinterpretation of reality, hallucinations and delusions . Mood changes include ambivalent , constricted, inappropriate emotional responsivess , or blunted effect . Lack of empathy with others , disturbance in behaviour may be withdrawan , regressive and bizarre .” - American Psychology Association(APA )

5. Epidemiology By occurrence: According to World Health Report 2011,about 24 million people worldwide suffer from Schizophrenia . The point prevalence of schizophrenia is 0.3 to 0.7 %.

6. Contd. By age gender Each year, one in 10,000 people age 12 to 60 develops schizophrenia. It is diagnosed 1.4 times more frequently in males than females and typically appears earlier in men—the peak ages of onset are 20–28 years for males and 26–32 years for females. [8]   Onset in childhood  is much rarer, [9]  as is onset in middle- or old age.

7. Contd. By country In 2000, the  World Health Organization  found the prevalence and incidence of schizophrenia to be roughly similar around the world, which showed Indonesia containing the largest group of schizophrenic patients and Nepal on 56 th position for that and Australia on the last position.

8. Etiology There is no single factor that can be implicated in the etiology ,rather the disease probably results from a combination of influences including biological ,psychological and environmental factors.

9. Contd. Biological influences The biological factors of schizophrenia are:- Genetics : studies show that relatives of individual With schizophrenia have a much higher probability of developing the disease rather than the general population . Every individual has the chance of 1% of developing disease in the lifetime where as 5 to 10 % in those whose siblings are affected . ( Ho , Black & Anderson ,2003 ). Child from Schizophrenic parent (single) 12 % and 40 % in both parents .

10. Genetics contd. According to ( Sadock & Sadock , 2003) monozygotic twins are 4 times to dizygotic twins and 50% to general population , at risk of developing the disease.

11. Etiology contd. Biochemical influences: This theory attributes a pathogenic role to brain biochemistry . It has been found that alterations in the neuro transmitters systems of the brain in the people with the disease of which Dopamine and Serotonin are the leading ones.

12. Contd. Physiological factors: Viral infection in prenatal period and exposure of central nervous system to any viral infection in childhood and adult onsets schizophrenia. Abnormal anatomical structures such as ventricular enlargement cerebellar atrophy also causes the disease .

13. Physiological factors contd. Some times physical conditions also causes the disease, Epilepsy Head injury Cerebral tumor CVA Parkinsonism Systemic lupus Erythematosus Alcohol abuse

14. Etiology contd. Psychological influences: Poor parent child relationship and dysfunctional family system are the causes of schizophrenia this includes schizophrenogenic mothers , lack of real parent , anxious mother, overprotective parents and double bind communication etc. Person with Schizoid type of personality and Ego centric person also develops Schizophrenia.

15. Contd. Environmental factors: Sociocultural factors : more individuals from the lower socioeconomic classes experience symptoms associated with schizophrenia than that from higher socio-economic groups . This may occur as a result of the conditions associated with living in poverty , inadequate nutrition ,absence of prenatal care , and feeling of hopelessness for changing one’s lifestyle of poverty .

16. Environmental factors contd. Stressful life events : Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rate of relapses.

17. Clinical features (1 ) P ositive symptoms Ambivalence : holding seemingly contradictory beliefs or feelings about the same person ,event or situation. Associative Looseness : Fragmented or poorly related thoughts and ideas. Autistic thinking: This is most classical feature of Schizophrenia . Here thinking is governed by private and illogical rules. ,

18. Positive symptoms contd. Thought block : Sudden interruption of stream of speech before the thought is completed. Neologism : Formation of new words or phrases which is not understood by others. Delusions : Fixed false beliefs that have no basis in reality . Echopraxia : Imitations of the movements and gestures of another person whom the client is observing. Echolalia : Repetition of word or phrase .

19. Contd. Hallucinations: false sensory perceptions or perceptual experience. Disorder of motor behavior: There can be either a decrease or increase in psychomotor activity. Inappropriate mood : The mood of the patient inappropriate to the situation. Perseveration : Persistent adherence to a single idea or topic ,verbal repetition of a sentence ,word or phrase resisting attempt to change the topic

20. Clinical features contd. (2 ) Negative symptoms :   Alogia : tendency to speak very little or to convey little substance of meaning. Anhedonia : Feeling no joy or pleasure from life or any activities or relationships. Apathy : Feelings of indifference toward people , activities and events.

21. Negative symptoms contd. Blunted affects : Restricted range of emotional feeling ,tone or mood. Catatonia : Psychological induced immobility occasionally marked by periods of agitation or excitement ; the client seems motionless as if in a trance. Flat affect : Absence of any facial expressions that would indicate emotions or mood.

22. Contd. Lack of volition : Absence of will, ambition or drive to take actions or accomplish task. Social withdrawn Self care deficit .

23. Clinical features contd. Cognitive symptoms disorganized thinking. slow thinking. difficulty understanding . poor concentration. poor memory. difficulty expressing thoughts. difficulty integrating thoughts, feelings and behavior.

24. Diagnosis History: Diagnosis is based on the self reported experiences of the patient as well as abnormalities in the behavior reported by the patient self or relatives or friends. Mental status examination CT scan and MRI show enlarged ventricles .

25. Contd. Diagnostic criteria A)Two or more of the following ,each present for a significant portion of time during a 1 month period or more. Delusions Hallucination Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms such as apathy, alogia etc.

26. Contd. B)Social occupational dysfunction such as work ,interpersonal relations or self care functioning is below the previous level C)The disturbance is not due to the direct physiological effects of a substance or general medical condition

27. Types Paranoid Schizophrenia: This type is characterized mainly by the presence of the delusions of persecution or grandeur and auditory hallucinations related to a single theme . The individual is often suspicious , tense, argumentive , hostile and aggressive . Social impairment may be minimal.

28. Contd. Disorganized (Hebephrenic)Schizophrenia: In this type of schizophrenia , behavior is regressive, less contact to reality , affect is flat , personal appearance is neglected ,social impairment is extreme , communication is consistently incoherent and facial grimaces and bizarre mannerisms are common . Onset of the symptoms is usually before 25 , and the course is commonly chronic.

29. Contd. Catatonic Schizophrenia: Catatonic Schizophrenia is characterized by marked abnormalities in motor behavior and may be manifested in the form of stupor or excitement. Catatonic stupor is characterized by extreme psychomotor retardation .Mutism is common and negativism may be evident .Waxy flexibility may be exhibited. Catatonic excitement is manifested by a state of extreme psychomotor agitation . The movements are purposeless usually accompanied by continuous incoherent verbalizations and shouting . Clients in catatonic excitement urgently requires physical and medical control.

30. Contd. Undifferentiated Schizophrenia: Sometimes clients with schizophrenic symptoms not meet the criteria for any of the subtypes ,or they may meet the criteria for more than one subtype . The behavior is clearly psychotic ; there is evidence of delusions ,hallucinations ,incoherence and bizarre behavior.

31. Contd. Residual Schizophrenia: When the individual has a history of at least one previous episode of schizophrenia with the prominent psychotic symptoms , the type of schizophrenia is Residual type . The symptoms may include social isolation, behavior ,impairment in personal hygiene and grooming ,blunted or inappropriate affect , poverty of or overly elaborate speech , illogical thinking or apathy.

32. Contd. Post schizophrenic depression: Some schizophrenic patient develop depressive features within 12 months of an acute episode of schizophrenia with an increased risk of suicide.

33. Contd. Simple Schizophrenia: It is characterized by early onset ( in younger age ); very insidious and may be arrested its own or may be progressive . The symptom may be marked social withdrawal . Shallow emotional response with loss of initiative and drive and wandering aimlessly.

34. Management Pharmacological management Psychosocial treatment Electroconvulsive therapy

35. Pharmacological Treatment Antipsychotic medicines (e.g., olanzapine, paliperidone , risperidone etc.) Antiparkinsonian agents may be prescribed to counteract the extrapyramidal symptoms associated with antipsychotic medications . (levodopa, pergolide , amantadine etc ) Generally , the treatment is continued for 6 months to 1 year for the first episode , for 1-2 years for the subsequent episode , and for indefinite period for repeated episodes or persistent symptoms.

36. Psychosocial treatment Psychotherapy (psychosocial treatment) aims at re-establishing the bond of human relatedness with the patient ,attacking psychotic symptoms , understanding the psychodynamic history ,and helping the patient unfold towards new nonpsychotic patterns of living.-( ARIETI,1976) . Psychotherapy is planned and systemic application of psychological facts and theories to alleviate a large variety of human ailments and disturbances , particularly those of psychogenic origin.

37. Individual psychotherapy Individual psychotherapy is a method of bringing about change on a person by exploring his or her feelings , attitude, thinking and behavior . It involves a one to one relationship between the therapist and the client. Establishing a relationship with schizophrenic patient is often difficult as they yet defend against closeness and trust and is more likely to become suspicious , anxious ,hostile , or regressed when someone attempts to draw closeness . Successful intervention may be achieved with honesty , simple directness and a manner that respects the client’s privacy and human dignity.

38. C ontd. Once the therapeutic interpersonal relationship has been established reality orientation is maintained through exploration of the client’s behavior. Education is provided to help the client identify sources of real or perceived danger and ways of reacting appropriately. Individual psychotherapy for clients with schizophrenia is seen as a long-term endeavor that requires patience on the part of the therapist, as well as the ability to accept that a great deal of change may not occur.

39. Group therapy This is a form of psychological treatment ,in which a number of clients meet together with a therapist for the purposes of sharing , gaining personal insight and improving interpersonal coping strategies . Group therapy in the Schizophrenia has been most useful over the long-term course illness.

40. Behavior therapy Behavior therapy can be used for helping clients change their undesirable behaviors. This therapy focus upon the application of certain principles of learning theory in order to create favorable changes. Operant Conditioning : The patient is rewarded for desired behavior and punished for undesirable behavior. Social skill training: This is to improve social manners like encouraging eye contact ,speaking appropriately and relating to the people.

41. Milieu Therapy Since disorganization in living is a major aspect of the schizophrenic experience , milieu therapy can provide schizophrenic patients opportunities to learn or relearn interpersonal skills and to become competent in the activities of daily living . It includes treatment in a living, learning , or working area.

42. Family therapy It is a type of therapeutic modality in which the focus of treatment is in the family as a unit . It represents a form of intervention in which members of a family are assisted to identify and change problematic , maladaptive, self-defeating, repetitive relationship patterns . Here the family is used as resource than a stressor and the therapy helps in preventing relapses and maintain the client in the community .

43. Electroconvulsive Therapy (ECT): ECT is the artificial induction of a grandmal type seizure through the application of electrical current to the brain . Depending upon the conditions ECT is given. The indications for ECT in schizophrenia are: Catatonic stupor. Uncontrolled catatonic excitement. Acute exacerbation not controlled with drugs. Severe side effects with drugs , in presence of untreated schizophrenia. Usually 8-12 ECTs are needed , administered two or three times a week.

44. Nursing Management Assessment History of onset of disorder Delusional ideation ,and or hallucinations Stress factors History of work and social functioning Family background ,stress factors and relationship Violence or risky behaviour Level of anxiety Disturbed family relationship

45. Contd. Nursing diagnosis Anxiety related to disturbed thought process , pervasive, ambivalence, mistrust of others, and difficulty in coping with reality. Impaired verbal communication related to inappropriate use of words and unique pattern of speech and disrupted thought process. Acute confusion related abrupt onset or global changes and disturbances in attention ,cognition ,and psychomotor level of consciousness and changes in the wake /sleep cycle resulting from disturbed thinking patterns. Compromised family coping related to ambivalent family relationship and abusive or destructive behavior.

46. Contd. Implementation: Ensure the safety of the patients by keeping siderails , removing the dangerous things from the patient’s site. Observe for the adverse drug reactions whenever large dose of antipsychotic medications are being administered. Teach client to recognize and report extra pyramidal side effects (EPS) to avoid physical discomfort. Encourage the client to continue medications even after symptoms abate. Encourage the client to follow a plan of organized activity and the prescribed drug regimen.

47. Implementation Contd. Accept the client at his or her present level of functioning ; set limits on unacceptable behavior. Avoid trying to argue the client out of delusions or hallucinations. Accept that the client’s hallucinations and delusions are real and possibly frightening ; stay and support the client. Encourage the development of interpersonal relationship between the clients and others ; help client learn to trust. Respect the client as a human being with both dignity and worth. Recognize that the client’s ability to test reality is distorted by pathologic use of defenses.

48. Contd. Evaluation Remains free from injury to self and others. Differentiates between reality and hallucinations. Continues therapeutic/pharmacological regimen. Demonstrates a reduction in anxiety through verbalization or body language.