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1. SEMINAR ON SCHIZOPHRENIA & OTHER PSYCHOTIC DISORDERS Visanth V S

2. SCHIZOPHRENIA & OTHER PSYCHOTIC DISORDERS Schizophrenia and other primary psychotic disorders are characterized by significant impairments in reality testing and alterations in behavior manifest in positive symptoms such as persistent delusions, persistent hallucinations, disorganized thinking (typically manifest as disorganized speech), grossly disorganized behavior, and experiences of passivity and control, negative symptoms such as blunted or flat affect and avolition, and psychomotor disturbances.

3. ICD Codes Sections/codes in this section (6A20-6A2Z) Code Disease 6A20 Schizophrenia 6A21 Schizoaffective disorder    6A22 Schizotypal disorder  6A23 Acute and transient psychotic disorder    6A24 Delusional disorder  6A25 Symptomatic manifestations of primary psychotic disorders   6A2Y Other specified primary psychotic disorder   6A2Z Schizophrenia or other primary psychotic disorders, unspecified  

4. SCHIZOPHRENIA

5. HISTORY OF SCHIZOPHRENIA 1.Emil Kraepelin This illness develops relatively early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia (“Dementia praecox” ) but was not followed by any organic changes of the brain, detectable at that time.

6. 2.Eugen Bleuler : He coined the term Schizophrenia (1908) and recognized the cognitive impairment in this illness, which he named as a “splitting” of mind.

7. 3.Kurt Schneider He emphasized the role of psychotic symptoms, as hallucinations, delusions and gave them the privilege of “the first rank symptoms” even in the concept of the diagnosis of schizophrenia.

8. MYTH Schizophrenia refers to multiple personality Schizophrenia is a rare disease People with schizophrenia are dangerous Bad parenting causes schizophrenia

9. MEANING The word Schizophrenia is derived from the Greek words; Skhizo (Split), Phren (Mind) ICD Classification ICD-10: F 20-29 ICD-11: 6A20

10. DEFINITION OF SCHIZOPHRENIA Schizophrenia is a psychotic condition characterized by a disturbance in thinking, emotions, volitions and faculties in the presence of clear consciousness, which usually leads to social withdrawal

11. Schizophrenia is defined by to social withdrawal. a group of characteristic positive and negative symptoms deterioration in social, occupational, or interpersonal relationships continuous signs of the disturbance for at least 6 months.

12. Schizophrenia is characterized by disturbances in multiple mental modalities, including thinking, perception self-experience, cognition, volition, affect, and behavior.

13. EPIDEMIOLOGY- INCIDENCE & PREVALENCE It is the most common of all psychiatric disorders and is prevalent in all cultures across the world. Approximately 1% of world population develops schizophrenia. 3-4 per 1000 cases Prevalence , Male = Female Onset 15-25 years for men, 25-35 years for women. 2/3 rd cases in age group of 15-30 years . 15% of new admissions in mental hospitals are schizophrenic patients. The disease is common in low socio-economic status

14. ETIOLOGY Biological Physiological Psychological Environmental/ Social Genetic Twin studies Biochemical Viral infections Anatomical abnormalities Physical factor Family theories Developmental Sociocultural Stressful life events

15. 1. BIOLOGICAL INFLUENCES Genetic Factors Schizophrenia can run in families Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than the general population . T he siblings or offspring of an identified client have a 5 to 10 percent risk of developing schizophrenia. How schizophrenia is inherited is uncertain

16. Twin Studies The rate of schizophrenia among monozygotic twins is four times that of dizygotic twins and approximately 50 times that of the general population.

17. Genetic Risk (Source: Gottesman, 1991)

18. Biochemical Influences Biochemical hypothesis of schizophrenia orientated towards the role of neurotransmitters and their receptors; dopamine, serotonin, glutamate & GABA . Dopamine plays a key role in biochemical hypothesis of schizophrenia. Classical dopamine hypothesis of schizophrenia Psychotic symptoms are related to dopaminergic hyperactivity. It is due to the increased sensitivity and density of dopamine D2 receptors in the different parts of the brain.

19. 2. Physiological Viral Infections Prenatal exposure to influenza. Viral infections of the central nervous system during childhood Viral infections during pregnancy and delivery. Physical Factors Researchers reported a link between schizophrenia and epilepsy, head injury in adulthood, alcohol abuse, cerebral tumor and Parkinsonism.

20. Structural Changes In Brain Increased loss of gray matter in adolescence Brains of patients with schizophrenia are lighter and smaller. Cortical atrophy in the frontal and temporal lobes of left side is seen in 10-35% cases. Larger lateral and third ventricles.

21. 3. Psychological Influences Family Theories Family relationships act as major influences in the development of illness. Broken homes , unstable parents and eccentric child rearing practices were seen in many cases. Two family situations leading to the onset of schizophrenia are: Deviant role relationship : Marital skew and marital schism Discarded communication: “ Double bind” communication

22. Developmental theories The individuals with poor ego boundaries Inadequate ego development Superego dominance Regressed to behavior Love-hate relationships Arrested psychosocial development

23. 4. Environmental Influences Sociocultural Factors Statistics have shown that many schizophrenic cases are from the lower socioeconomic classes. Living in poverty Congested housing accommodations Inadequate nutrition Absence of prenatal care Few resources for dealing with stressful situations Feelings of hopelessness for changing one’s lifestyle of poverty. The incidence is high among migrants due to the effect of new environment and challenges .

24. Stressful Life Events There is no scientific evidence to explain that stress causes schizophrenia. Stress may contribute to the severity and course of the illness. The stress can be biological, environmental, or both. Stressful life events may increase schizophrenic symptoms and increased rates of relapse.

25. Psychopathology

26. KEY DOPAMINE PATHWAYS Mesolimbic pathway Hyperactivity on this pathway is associated with positive symptoms of schizophrenia Mesocortical pathway Deficit in dopamine in this pathway is associated with negative and cognitive symptoms of schizophrenia

27. Nigrostriatal pathway Part of extrapyramidal system and controls motor movement Blockade of D2 receptors causes: -- deficiency in dopamine in this pathway causes EPS Tuberoinfundibular pathway Increased neuronal activity of this pathway inhibits prolactin release Blockade of D2 receptor increases prolactin release and causes: Galactorrhea amenorrhea

28. Source: https://bepharco.com

29. Transactional Model Of Stress Adaptation

30. CLINICAL FEATURES

31. Bleuler’s Classification Primary symptoms 1.Ambivalence 2.Autistic Thinking 3.Association Disturbances 4.Affective Blunting Secondary Symptoms 1.Hallucinations 2. Delusions 3. Catatonic Symptoms 4. Behavioral Abnormalities

32. BLEULER’S 4 A’S Ambivalence The co- existence of strongly conflicting feelings, attitudes and ideas Autistic Thinking W ithdrawal in thinking and behavior Affective Disturbances I nability to show appropriate emotions Association Disturbances F ragmented Thinking

33. Kurt Schneider’s Symptoms of Schizophrenia Kurt Schneider (1957) described the features of schizophrenia into first rank and second rank symptoms. First Rank Symptoms Second Rank Symptoms Audible thought or thought echo Voices commenting on him in the third person or voices heard arguing Passivity feelings(patient thinks that he is in the grip of a superior force which controls his action) Thought withdrawal Thought broadcasting Delusional perception Other perceptual, motor, and affective symptoms were called second rank symptoms.

34. ACCORDING TO ICD 11 According to ICD-11 schizophrenia and other primary psychotic disorders are characterized by significant impairment in reality testing and alterations in behavior. Positive symptoms : P ersistent delusions , persistent hallucinations , disorganized thinking , grossly disorganized behavior and experiences of passivity and control .

35. Negative symptoms : Blunted or flat affect and avolition and psychomotor disturbances. Symptoms occurring with sufficient frequency and intensity to deviate from expected cultural or subcultural norms. Symptoms not arising as a feature of another mental and behavioral disorder.

36. Positive Symptoms of Schizophrenia

37. Delusions False beliefs that are firmly and consistently held despite disconfirming evidence, culture or logic. Types Meaning Delusions Of Persecution Belief that one is the target of others’ mistreatment, evil plots, and/or murderous intent Delusions Of Reference Belief that all happenings revolve around oneself, and/or one is always the center of attention Delusions Of Grandeur Belief that one is a famous or powerful person from the past or present Delusions Of Control Belief that some external force is trying to take control of one’s thoughts , body, or behavior

38. Disorders Of Perception Hallucinations : Imaginary perception or false/wrong perception in the absence of external stimuli Elementary auditory hallucinations Thought echo Third person hallucination Voice commenting on one’s action

39. Thought & Speech Disorder Autistic thinking Loosening of association Thought blocking Neologisms Echolalia Verbigeration Clang association Word salad Delusions Circumstantiality Tangentiality Preservation

40. Disorders of Motor Behavior Increased or decreased psychomotor activity, anergia Waxy flexibility Posturing , stereotypes Disorganized Behavior and Self Decreased ADL Lack of inhibition and impulse control Unpredictable emotional response Social/occupational dysfunction Echopraxia Depersonalization Emotional ambivalence

41. N egative Symptoms-6A’s Anhedonia I nability to express pleasure Apathy L ack of interest/attention Alogia R educed Speech Avolition L ack of Motivation Asocial R educed Socialization Affective Flattening R estricted range of emotions

42. Cognitive Impairment Impaired Judgement Poor Insight Less reliable Poor Attention & Concentration Poor Memory Picture courtesy: shutterstock.com

43. Types of Schizophrenia Disorganized Schizophrenia Catatonic Schizophrenia Paranoid Schizophrenia Undifferentiated Schizophrenia Residual Schizophrenia

44. 1.DISORGANIZED SCHIZOPHRENIA Disorganized schizophrenia is characterized by disorganized thinking with blunted and inappropriate emotions. It begins mostly in adolescent age; the behavior is often bizarre. There could be mannerisms, grimacing, inappropriate laugh and joking.

45. There is a tendency for social isolation. Usually, the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults . Denoted also as Hebephrenic schizophrenia

46. CATATONIC SCHIZOPHRENIA Catatonic schizophrenia is characterized mainly by motoric activity, which might be strongly increased (hyperkinesis) or decreased (stupor), or automatic obedience and negativism.

47. There are two forms: 1.productive form — which shows catatonic excitement, extreme and often aggressive activity. Treatment by neuroleptics or by electroconvulsive therapy. 2. stuporous form — characterized by general inhibition of patient’s behavior or at least by retardation and slowness, followed often by mutism, negativism, fexibilitas cerea or by stupor. The consciousness is not absent.

48. PARANOID SCHIZOPHRENIA Paranoid schizophrenia is characterized mainly by delusions of persecution, feelings of passive or active control and feelings of intrusion. 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, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.

49. UNDIFFERENTIATED SCHIZOPHRENIA Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes above, 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 .

50. RESIDUAL SCHIZOPHRENIA A chronic stage in the development of schizophrenia This category should be used when there has been at least one episode of schizophrenia in the past but without prominent psychotic symptoms at present Symptoms of residual schizophrenia include emotional blunting, eccentric behavior, illogical thinking, social withdrawal and loosening of associations.

51. 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.

52. PROGNOSIS Good Poor 1. Abrupt or acute onset Insidious onset 2. Later onset Younger onset 3. Presence of precipitating factor Absence of precipitating factor 4. Good premorbid personality Poor pre-morbid personality 5. Paranoid and catatonic subtypes Simple, undifferentiated subtypes 6. Short duration: (<6 months) Long duration:(>2 years) 7. Predominance of positive symptoms Predominance of negative symptoms 8. Family history of mood disorders Family history of schizophrenia 9. Good social support Poor social support 10. Female sex Male sex 11. Married Single, divorced or widowed 12. Out-patient treatment Institutionalization

53. OTHER PSYCHOTIC DISORDERS Schizotypal Disorder Delusional Disorder Brief Psychotic Disorder Schizoaffective Disorder Schizophreniform Disorder Shared Psychotic Disorder Psychotic Disorder Due to a General Medical Condition Substance-Induced Psychotic Disorder

54. SCHIZOTYPAL DISORDER This disorder is characterized by eccentric behavior and 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.

55. DELUSIONAL DISORDERS The essential feature of this disorder is the presence of one or more non bizarre delusions that persist for at least 1 month. If present at all, hallucinations are not prominent, and apart from the delusions, behavior is not bizarre.. Their origin is probably heterogeneous, but it seems, that there is some relation to schizophrenia.

56. ACUTE AND TRANSIENT PSYCHOTIC DISORDERS The criteria should be the following features: acute beginning ( to two weeks ) presence of typical symptoms (quickly changing “polymorphic symptoms”) presence of typical schizophrenic symptoms.

57. 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.

58. INDUCED DELUSIONAL DISORDER The essential feature of this disorder, also called folie à deux, is a delusional system that develops in a second person as a result of a close relationship with another person who already has a psychotic disorder with prominent delusions.

59. The person with the primary delusional disorder is usually the dominant person in the relationship, and the delusional thinking is gradually imposed on the more passive partner. This occurs within the context of a long-term close relationship, particularly when the couple has been socially isolated from other people.

60. SCHIZOAFFECTIVE DISORDERS Episodic disorders in which both affective and schizophrenic symptoms are prominent ( during the same episode of the illness or at least during few days ) but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes. Patients suffering from periodic schizoaffective disorders, especially with manic symptoms, have usually good prognosis with full remissions without any remaining defects.

61. They are divided in different subgroups: Schizoaffective disorder, manic type Schizoaffective disorder, depressive type Schizoaffective disorder, mixed type Other schizoaffective disorders Schizoaffective disorder, unspecified

62. BRIEF PSYCHOTIC DISORDER The essential feature of this disorder is the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month, and there is an eventual full return to the premorbid level of functioning.

63. INVESTIGATIONS Reliable and detailed psychiatric history MSE Psychological testing CT Scan, MRI Necessary Lab Investigations

64. ICD DIAGNOSTIC CRITERIA DSM V and ICD- 11 omit the traditional clinical subtypes of schizophrenia (paranoid, hebephrenic, simple etc.) De-emphasize the importance of first rank symptoms due to their lack of utility and relevance in treatment selection. S ymptoms must not have been a manifestation of another health condition or due to the effect of a substance or medication.

65. ICD DIAGNOSTIC CRITERIA At least two of the following essential symptoms must be present for a period of 1 month or more. At least one of the qualifying symptoms should be from item (a) through (d) below: Persistent delusions Persistent hallucinations Disorganized thinking Experiences of influence, passivity or control Negative symptoms Grossly disorganized behavior Psychomotor disturbances

66. MANAGEMENT Somatic treatment Pharmacological Management Electroconvulsive therapy Psychological treatment Nursing management

67. PHARMACOLOGICAL Treatment is aimed at reducing symptoms and preventing psychotic relapses. Medication needs to be continued for long term. There are two types of antipsychotics: Typical Atypical Other drugs used are; Antidepressants Mood stabilizers Benzodiazepines

68. Typical Antipsychotics Chlorpromazine 300-1500 mg/day Haloperidol 5-100 mg/day Pimozide 4-12 mg/day Triflupromazine 100-400 mg/day Atypical Antipsychotics Clozapine 25-450 mg/day Resperidone 2-8 mg/day Olanzapine 5-20 mg/day Ziprasidone 40-160 mg/day

69. ELECTRO CONVULSIVE THERAPY Patient with catatonia or suicidal behavior acute exacerbation not controlled by drugs, severe side effects of drugs in presence of untreated schizophrenia. Usually, 8-10 ECT’s are needed. Given three times a week, although up to 18 have been given in poor responders.

70. PSYCHOLOGICAL TREATMENT Psycho Education Group Therapy Individual Psychotherapy Behavior Therapy Family Therapy Mileu Therapy Psychosocial Rehabilitation

71. NURSING DIAGNOSES Risk for Other-Directed Violence Risk for Suicide Disturbed Thought Processes Disturbed Sensory Perception Disturbed Personal Identity Impaired Verbal Communication Self-Care Deficits Social Isolation Deficient Diversional Activity Ineffective Health Maintenance Ineffective Therapeutic Regimen Management

72. NURSING INTERVENTIONS Promoting the safety of patient and others Establish therapeutic relationship Utilizing therapeutic communication Help client cope with socially inappropriate behaviors Teaching self care and proper nutrition Teaching social skills Medication management Establish and maintain reality for the client.

73. NURSING INTERVENTIONS Use distracting techniques. Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs Redirect client away from problem situations. Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give factual statements; do not scold. Try to reintegrate the client into the treatment milieu as soon as possible. Do not make the client feel punished or shunned for inappropriate behaviors. Establishing community support systems and care

74. PATIENT AND FAMILY EDUCATION Explain to the patient and family members regarding schizophrenia and its symptoms especially regarding thought disturbances, mood changes, hallucinations etc. Teach about medication compliance and effects of antipsychotic medications. Instruct the family members that if the patient poses any threat or danger to self-harm or aggressive behavior, hospitalize him immediately. Teach the patient and family members to recognize family stressors which increase the symptoms and methods to prevent them.

75. Rehabilitation of Schizophrenic Clients People who have schizophrenia can have repetitive inpatient hospitalizations. Psychiatric rehabilitation strengthens the self care and improves the quality of life. There are number of services available in community to improve the quality of the life .It may be as follows; Social Skill training Vocational rehabilitation Day hospitals Community mental health centers Wellness centers etc. Nurses should be familiar with the services available in the community and link the client with these services.

76. Other Psychotic Disorders

77. Schizoaffective Disorder-6A21 Schizoaffective disorder is a condition where both symptoms of schizophrenia and a are accompanied by typical symptoms of a moderate or severe depressive episode, a manic episode or a mixed episode occur simultaneously or within days of each other. Symptoms must last for at least a month and cannot be attributed to another medical condition or substance use. Psychomotor disturbances like catatonia may also be present.

78. Schizotypal Disorder -6A22 Schizotypal disorder is characterized by an enduring pattern of eccentricities in behavior, appearance and speech, accompanied by cognitive and perceptual distortions, unusual beliefs, and discomfort with and often reduced capacity for interpersonal relationships. Symptoms may include constricted or inappropriate affect and anhedonia.

79. Schizotypal Disorder -6A22 Paranoid ideas, ideas of reference, or other psychotic symptoms, including hallucinations in any modality, may occur. The symptoms are not of sufficient in intensity or duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, or delusional disorder. The symptoms cause distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

80. Acute and Transient Psychotic Disorder -6A23 Acute and transient psychotic disorder is characterized by acute onset of psychotic symptoms with their maximal severity within two weeks. Symptoms may include delusions, hallucinations, disorganization of thought processes, perplexity or confusion, and disturbances of affect and mood. Catatonia-like psychomotor disturbances may be present.

81. Acute and Transient Psychotic Disorder -6A23 Symptoms typically change rapidly, both in nature and intensity, from day to day, or even within a single day. The duration of the episode does not exceed 3 months, and most commonly lasts from a few days to 1 month. The symptoms are not a manifestation of another medical condition and are not due to the effect of a substance or medication on the central nervous system, including withdrawal.

82. Delusional Disorder -6A24  This is characterized by the development of a delusion or set of related delusions, last for at least 3 months and often much longer, in the absence of a Depressive, Manic, or Mixed mood episode. Other characteristic symptoms of Schizophrenia are absent, various forms of perceptual disturbances may be observed. A ffect, speech, and behavior are typically unaffected. The symptoms are not a manifestation of another medical condition, effect of a substance or medication.

83.   Symptomatic Manifestations Of Primary Psychotic Disorders - 6A25 It describe the clinical presentation of individuals diagnosed with Schizophrenia or another primary psychotic disorder. They should not be used for individuals without such a diagnosis. Multiple categories can apply simultaneously. Symptoms resulting from the direct physiological effects of a health condition, substances or medications or injury not classified under Mental, behavioral or neurodevelopmental disorders.

84. SUMMARY

85. CONCLUSION

86. BIBLIOGRAPHY Sreevani R, A guide to mental health & Psychiatric Nursing, 6 th Edition Mary C Townsend, Psychiatric Mental Health Nursing https://icd.who.int/en https://www.findacode.com/icd-11

87. Thank You