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  2. 2. INTRODUCTION A Greek word splited as: SKCHIZO-To Divide PHREN-Mind Termed by kraplein in 1896 as ‘Dementia Precox’ In 1908 Eugene bleuler coined it as Schizophrenia
  3. 3. Schizophrenia  Schizophrenia occurs with regular frequency nearly everywhere in the world in 1 % of population and begins mainly in young age (mostly around 16 to 25 years).
  4. 4. It 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 It is a type of functional psychosis characterized mainly by disturbance in thinking and associated disturbances in psychomotor activity, affect, perception and behavior.
  5. 5. PREDISPOSING FACTORS. 1) 2) 3) 4) 5) IDOPATHIC HEREDITARY:-Incidence high in univolvar twins -Transmission through one or more autosomal recessive genes PERSONALITY-SCHIZOID CHILD DEVELOPMENT AND PARENT CHILD RELATIONSHIP AGE-Peak in between 15-30 and also some after30 yrs
  6. 6. SEX-Equal in both sexes 7) SOCIAL ISOLATION-Predisposed unstable personal relationship 8) INTELLIGENCE 9) OVERCROWDING SLUMS 10) PRECIPITATION-Stress, regarding ineffective disease, pregnancy, family problem, etc. 11) ENDOCRINE-Excess of dopamine dependent neuronal activity in brain 12) ASSOCIATED WITH OTHER DISEASESMore common in temporal lobe epilepsy 6)
  7. 7. ETIOLOGY   The exact cause of schizophrenia is still unknown Still there are some factors that are considered as risk factors.
  8. 8. Biological theories  Genetics / Hereditary
  9. 9. Immunologic factors e.g. Viral exposure in pregnancy.  High arousal level from stress , trauma, and drugs e.g. bombardment.  Severe disease e.g. encephalitis.  Trauma from complication such as obstetrical, head trauma, childhood accidents. 
  10. 10. BIO CHEMICAL INFLUENCES. Theories suggests that that schizophrenia may be caused by an excess of Dopamine dependent neuronal activity in the brain.  Abnormalities in the neurotransmitters nor epinephrine, serotonin, acetylcholine, an d gamma-amino butyric acid and in the neuroregulators such as prostaglandins and endorphins have been suggested. 
  11. 11. Physiological Influences  Viral Infection  Anatomical Abnormalities  Histological  Physical Conditions.  Psychological Influences Changes.
  12. 12. a) b) c) d) e) Autistic thinking-important feature Considers two things identical Disturbed thinking, emotions and behavior. Patient appears absurd and bizarre Social withdrawal from religion, philosophy, science, sex, and power
  13. 13. Absence of links between ideas, crowding and poverty of ideas, flight of ideas h) Word are linked without meaning(word salad) g) Emotional blunting or shallowness of affect b. Inappropriate affect-patient laughs when he is expected to cry and cries when he is expected to laughs c. Hypersensitiveness or insensitiveness of feelings d. Ambivalence-experience of 2 opposite of feelings a.
  14. 14. a) b) c) d) e) Irrelevant and inappropriate behavior Awkward actions Rowdy, violent, assaultive(a person has a physical or verbal violence), agitation Suicidal and homicidal tendencies Criminal and sexual over activity, pervasive Reduction of drive and desire to carry out routine work b) Avoiding mixing in family and friends c) Reduced efficiency and activity d) Feeling of passivity(mind and thoughts controlled by outside force a)
  15. 15. a) b) a) b) Hallucination –auditory and visual are common, others are very rare. Hallucinations are either structured(human or animal voice) or unstructured(vague voices) In catatonic, increased psychomotor activity, stupor, negativism, stereotype, mutism, verbegeration(repeating the same words) Waxy flexibility
  16. 16. a) b) c) d) e) f) g) Excessive day dreaming and fantasy Muttering Spells of laughter and crying without reason Childish behavior Patient passes urine and stool in his clothes and plays with has own excreta Absent mindedness Makes lot of mistakes in work
  17. 17. Positive and Negative Symptoms Negative Positive Alogia Hallucinations Affective flattening Delusions Avolition-apathy Bizarre behaviour Anhedonia-asociality Positive formal thought disorder Attentional impairment
  18. 18.  THE ILLNESS OF AS A PHENOMENON OF REGRESSION  E.G- Reversal to infantile and childhood patterns of psychological living a state of organization where reality does not exist. Thus the patient attempt to resolve his psychological conflicts by denying the harsh and painful reality world and living in a fantasy would full of pleasures
  19. 19. PHASES OF SCHIZOPHRENIA  Phase I - The schizoid personality  Phase II-The prodromal phase.  Phase III-Schizophrenia—active phase.  Phase IV- Residual phase
  20. 20. F20-F29 Schizophrenia, Schizotypal and Delusional Disorders F20 F20.0 F20.1 F20.2 F20.3 F20.4 F20.5 F20.6 F20.8 F20.9 Schizophrenia Paranoid schizophrenia Hebephrenic schizophrenia Catatonic schizophrenia Undifferentiated schizophrenia Post-schizophrenic depression Residual schizophrenia Simple schizophrenia Other schizophrenia Schizophrenia, unspecified
  21. 21. PARANOID SCHIZOPHRENIA: Early onset  ‘Paranoia’ means ‘delusional’  It occurs between 25-30 yrs  Seen more in males than females  Delusion of suspiciousness, persecution and grandeur  Disorganization of speech and thought  Hallucinatory voices of threatening or commanding, also voices of whistling and laughs A.
  22. 22.  Affect is usually of hostility, anger or suspiciousness  Negative symptoms like flat affect, poverty of speech and poor activity  Prognosis is good
  23. 23. B.            HEBEPHRENIC SCHIZOPHRENIA:Early and insidious onset Occurs between the age of 20-25 yrs Thinking disturbances Regression Childish behavior Inappropriate affect Somatic delusion Unpredictable, giggling and silliness Irrelevant Poverty of ideas Prognosis is poor
  24. 24. SIMPLE SCHIZOPHRENIA: Insidious and gradual course  Occurs between age of 15-20 yrs  More incidence in males  Disturbances in affect  Disturbances in thinking  Delusions and hallucinations are rare  Wandering aimlessly  Prognosis is poor C.
  25. 25. CATATONIC SCHIZOPHRENIA: Occurs between age of 20-25 yrs  Equal in both sexes  Disturbances of thinking, affect and behavior  Acute or sub-acute onset  Autism  Purposeless excitement and destructive behavior  Delusion and hallucinations are common  Prognosis is good but reoccurs are common D.
  26. 26. CATATONIC STUPOR: Absence of speech  Maintenance of rigid posture against efforts to be moved  Negativism  Bizarre postures for longer period of time  Stuporous reaction towards surrounding  Ecolalia-mimicking of phrases and words  Echopraxia-mimicking of actions observed  Waxy flexibility  Ambitendency E.
  27. 27. F.     G.    RESIDUAL SCHIZOPHRENIA:Emotional blunting Eccentric behavior Social withdrawal A type of schizophrenia which has been at least one episode in the past but without prominent psychotic symptoms at present UNDIFFERENTIATED SCHIZOPHRENIA:Late schizophrenia occurs after 40 yrs of age Schizoaffective psychosis with symptoms of depression and mania and also neurosis Prognosis is poor.
  28. 28. CHILDHOOD OR JUVENILE SCHIZOPHRENIA: Not common but seen between age of 5-10 yrs and 12-14 yrs  Onset is acute or gradual  Prognosis is poor I. SCHIZOAFFECTIVE PSYCHOSIS: Symptoms of schizophrenia associated with symptoms of depression and mania H.
  29. 29. PSEUDO-NEUROTIC SCHIZOPHRENIA: Core of illness is schizophrenia but presenting symptoms are suggestive of neurotic symptoms like anxiety state, phobic reactions, obsessive compulsive neurosis or hysteria  Treatment such as psychotherapy, abreactive therapy or drug therapy is not satisfactory  Careful psychiatric examination done through repeated interview, reveals the true nature of illness J.
  30. 30. Postschizophrenic 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. 
  31. 31. Duration of illness:Shorter duration carries better prognosis 2) Type of schizophrenia:Catatonic and paranoid type carries good prognosis. simple, hebephrenic, juvenile, pseudoneurotic types do not carry good prognosis. 3) Personality:Non schizoid and stable personality respond better 1)
  32. 32. 4) 5) 6) Precipitating factor:Presence of precipitating factor carries good prognosis. Age:20-30 yrs of age carries better prognosis than other ages. Type of onset:Acute onset carries better prognosis than gradual onset.
  34. 34. A.  TREATMENT MODALITIES PHARMACOTHERAPY:- Conventional antipsychotics are now used less frequently, because of their only partial efficacy and adverse effects.  The following are the drugs given to non-compliant patients; -Chlorpromazine:50100mg/day -Fluphenazine decanoate:2025mg IM every 1-3 wks -Haloperidol:5-20mg/day IM -Trifluoperazine:1-5mg/day IM
  35. 35.   Commonly used atypical antipsychotics; -Clozapine:25-450mg/day PO -Resperidone:2-10mg/day PO -Olanzapine:10-20mg/day PO -Ziprasidone:20-80mg/day PO Other drugs used in schizophrenia are mood stabilizers, anti depressants, benzodiazepines, etc.
  36. 36. B.     C.  D.  ELECTROCONVULSIVE THERAPY(ECT):Indications are catatonic stupor, catatonic excitement Severe side effects with drugs Usually 8-10 ECT’s are required to be given About 8-10 convulsions spread over a period of 4-6 weeks PSYCHOLOGICAL THERAPIES:Cognitive therapy, group therapy, behavior therapy, family therapy PSYCHOSURGERY:Prefrontal leucotomy
  37. 37. Psychosocial therapy
  38. 38. ROLE OF A NURSE
  39. 39. Responsibility while dealing with disease problem Non compliance to management  Explain the management to patient shortly or as you required.  Develop therapeutic relationship with the patient.  Develop trust with the patient.  Listen any complain of patient carefully.  Don’t ignore anything that related to drugs.
  40. 40. Set the diet according to the drugs.  Give medicine regularly  Check the blood level regularly to maintain adequate drug level. 
  41. 41. Impaired perception • Assess the level of orientation. • Allow the patient to talk about hallucination. • Avoid reinforcing the hallucination. • Avoid saying that you are wrong. • Support the patient in initial stage by saying that you are just thinking but the reality is just opposite. • Remove all the injurious thing. • Diversion of activity.
  42. 42. Impaired sleep • • • • • • • • • Asses the pattern of sleep. Provide calm and quite environment. Isolate the disturbing patient. Provide a glass of warm milk before sleep. Provide a warm bath before sleep. Maintain a daily routine of sleeping and awakening. Put off the light in around at 100 clock every day. Provide comfort measure as pillow ,back rub. Give p.r.n as prescribed.
  43. 43. Impaired Bowel and Bladder activity • Assess the type of alteration of b/b. • In case of constipation encourage high fiber diet • Increase fluid intake • Food Intake should be frequently. • Take the choice of food to patient. • Serve the food in attractive manner. • Encourage patient to take proper sleep or rest. • Encourage for light exercise or walking jogging. • If the patient not taking food than explain politely that food is compulsory for recovery.
  44. 44. impaired thought process • • • • • • • • • • Assess the level of thought process. Convey acceptance of the patient’s need for false belief but that you do not share. Do not argue . Do not force. Do not say you are wrong. Use same language in front of patient. Avoid physical contact in form of touch. Avoid laughing ,whispering there. Avoid competitive activities. Reinforce focus on reality.
  45. 45. impaired physical activity • • • • • • • • • Assess the level of activity pattern of patient. Give high calories diet. Remove all things near to bed. Maintain calm and quite environment. Avoid argument with the patient. Give the medicine timely to maintain drug level. Avoid talking excessively. Give some simple task to do the patient. Encourage for light rest in day as well as night.
  46. 46. Anxiety. • • • Asses the level of anxiety. Maintain therapeutic relationship. Explain everything before doing . • Hold the hand of patient if patient threatened (if required). • Explain queries of patient clearly. • Don’t ignore patient . • Stay with patient. • Use same language in front of patient. • Ask patient to explain his/her anxiety more and more. • Give tranquilizer as prescribed. • Provide safe environment. • Use relaxation technique if possible.
  47. 47. Impaired orientation. Assess the level of perception.  Provide a safe environment.  Ask the patient to express impaired perception.  Help the patient to get oriented.  Focus on reality. 
  48. 48. Impaired nutrition • • • • • • • • • Assess the level of nutrition. Provide calories according to activity. Find out patient like and dis like. Provide 6-8 glass water (if not contraindicated). Maintain accurate record of intake and out put. Supplement diet with vitamin and mineral. Walk or sit with the patient. Serve food attractively. Instruct to relatives to take food with patient if suspiciousness is there.
  49. 49. Impaired socialization. Maintain therapeutic relationship with patient.  Encourage patient to talk with other people or patient.  Encourage to play with other patient.  Offer patient for group activity.  Give a positive reinforcement for participation. 
  50. 50. Other nursing problems Impaired communication  Violent behaviour  withdrawn behaviour.  Self care deficit.  Impaired family coping. 
  51. 51. OTHER PSYCHOTIC DISORDERS Psychosis is defined as gross impairment in reality testing, marked disturbance in personality with impaired social and occupational functioning and presence of characteristic symptoms like delusions and hallucinations.
  52. 52. F22- persistent delusional disorders  F23- Acute and transient psychotic disorders  F24- induced delusional disorders  F25- schizoaffective disorders  F26- capgras syndrome (delusion of doubles) 
  53. 53. Persistent delusional disorders Non- bizarre type delusions  Persistent at least for 3 months  Absence of significant hallucinations  Absence of organic mental disorders, schizophrenia and mood disorder. 
  54. 54. Acute and transient psychotic disorders      Neither follow the course of schizophrenia or mood disorders. Abrupt, acute onset, and associated with identifiable acute stress. Several type of hallucinations, delusions changing in both type and intensity from day to day or within same day. Emotional turmoil ( ecstasy to anxiety and irritability) Do not fulfill the criteria of schizophrenia.
  55. 55. Induced delusional disorders  Sharing of delusion between usually two or more persons who usually have a closely knit emotional bond.
  56. 56. schizoaffective disorders Depressed type  Manic type  Mixed type 
  57. 57. capgras syndrome  Delusional misidentification syndromes
  58. 58. Rehabilitation
  59. 59. Social skills training  Vocational rehabilitation  Half –way homes  Long- term homes  Day hospitals 