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SCHIZOPHRENIA
History
 The word "schizophrenia" is less than 100 years old. However the
disease was first identified as a discrete mental illness by dr. Emile
kraepelin in the 1887.
 Written documents that identify schizophrenia can be traced to the
old pharaonic egypt, as far back as the second millennium before
christ.
 Depression, dementia, as well as thought disturbances that are
typical in schizophrenia are described in detail in the book of hearts.
The heart and the mind seem to have been synonymous in ancient
egypt.
 The physical illnesses were regarded as symptoms of the heart and
the uterus and originating from the blood vessels or from purulence,
fecal matter, a poison or demons.
• At one point, all people who were considered "abnormal,"
whether due to mental illness, mental retardation, or
physical deformities, were largely treated the same.
• Early theories supposed that mental disorders were caused
by evil possession of the body, and the appropriate
treatment was then exorcising these demons, through
various means, ranging from innocuous treatments, such as
exposing the patient to certain types of music, to
dangerous and sometimes deadly means, such as releasing
the evil spirits by drilling holes in the patient's skull.
 One of the first to classify the mental disorders into different categories was the
German physician, Emile Kraepelin. Dr. Kraepelin used the term "Dementia praecox" for
individuals who had symptoms that we now associate with schizophrenia.
 The nonspecific concept of madness has been around for many thousands of years and
schizophrenia was only classified as a distinct mental disorder by Kraepelin in 1887.
 He was the first to make a distinction in the psychotic disorders between what he called
dementia praecox and manic depression.
 Kraepelin believed that dementia praecox was primarily a disease of the brain, and
particularly a form of dementia. Kraepelin named the disorder 'dementia praecox' (early
dementia) to distinguish it from other forms of dementia (such as Alzheimer's disease)
which typically occur late in life.
 He used this term because his studies focused on young adults with dementia.
 The swiss psychiatrist, Eugen Bleuler, coined the term, "schizophrenia" in 1911.
 He was also the first to describe the symptoms as "positive" or "negative."
Bleuler changed the name to schizophrenia as it was obvious that Krapelin's
name was misleading as the illness was not a dementia (it did not always lead to
mental deterioration) and could sometimes occur late as well as early in life.
Meaning
 The term schizophrenia was coined by swiss psychiatrist Eugen Bleuler.
 The word was derived from Greek word “Skizo” (Split) and “Phren” (Mind)
 A chronic severe brain disorder , often they hear voices believe media are
broadcasting their thoughts to the world or may believe someone is trying to
harm them
 It is a most devasting disorder of thought and emotion characterized by
 Disorganized Thoughts
 Hallucination
 Bizarre Behaviors
Definition
Schizophrenia is defined by :
 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.
It refers to a group of mental illness characterized by specific psychological
symptoms that affect the mood, regulations of emotions, thoughts,
perceptions, movements and behaviors.
 The schizophrenic disorders are characterized in general by fundamental
and characteristic distortions of thinking and perception and affect that
are inappropriate or blunted. Clear consciousness and intellectual
capacity are usually maintained although certain cognitive deficits may
evolve in the course of time
EPIDEMIOLOGY
 Mostly begins in early adulthood, age between 15 and 25.
 Men tend to develop schizophrenia slightly earlier than women,
where as most of the males become ill between 16 and 25 female
develop symptoms several years later.
 Average age of onset in male 18 in men and 25 in women.
 Schizophrenia onset quite rare for the people before 10 years and
after 40 years.
Incidence
General population 0.8-1.5%
Father affected 10-18%
Mother affected 0-18%
Both parents affected 25-46%
Relatives affected/One sibling 8-10%
Second degree relative 2-3%
Monozygotic twins 40-50%
Dizygotic twins 12-15%
Adoptive parent – Adoptive with non Schizophrenic biological
parent
4.8%
 50% of males are hospitalized by age 25.
 People who experienced Schizophrenia are more likely to have
been born in winter/early spring least likely born in late spring
summer.
 Suicide is very prevalent- 50% attempt and 10-15% will complete
it.
 30-50% has substantial alcohol problems or drug problems.
 High risk for homelessness – social drift theory- the illness impairs
work ability and thus lower economic status.
CLINICAL SYMPTOMS
 (A) thought echo, thought insertion or withdrawal, and thought
broadcasting;
 (B) delusions of control, influence, or passivity, clearly referred to
body or limb movements or specific thoughts, actions, or
sensations; delusional perception;
 (C) hallucinatory voices giving a running commentary on the
patient’s behaviour, or discussing the patient among themselves,
or other types of hallucinatory voices coming from some part of
the body;
 (D) persistent delusions of other kinds that are culturally
inappropriate and completely impossible, such as religious or
political identity, or superhuman powers and abilities (e.G. Being
able to control the weather, or being in communication with aliens
from another world);
 (E) persistent hallucinations in any modality, when accompanied
either by fleeting or half-formed delusions without clear affective
content, or by persistent over-valued ideas, or when occurring
every day for weeks or months on end;
 (F) breaks or interpolations in the train of thought, resulting in
incoherence or irrelevant speech, or neologisms
 (G) catatonic behaviour, such as excitement, posturing, or waxy
flexibility, negativism, mutism, and stupor;
(H) "negative" symptoms such as marked apathy, paucity of speech,
and blunting or incongruity of emotional responses, usually
resulting in social withdrawal and lowering of social performance; it
must be clear that these are not due to depression or to neuroleptic
medication;
(I) a significant and consistent change in the overall quality of some
aspects of personal behaviour, manifest as loss of interest,
aimlessness, idleness, a self-absorbed attitude, and social
withdrawal.
 Pre morbid behavior can be viewed in following four
phases:
PHASE-I: The Schizoid Personality
PHAE-II: The Prodormal Phase
PHASE-III: Schizophrenia
PHASE-IV: Residual Phase
PHASE-I: The Schizoid Personality
 Disturbance in social relationship
 Limited range of emotional experience and expression
 They do not enjoy close relationship and prefer “Loners”
 They appear cold and aloof
 Not all who show these characteristic may develop to schizophrenia but
most individual who were affected showed this type of symptoms.
PHAE-II: The Prodormal Phase It include social withdrawl, impairement in role functioning ,
behavior that peculiar or eccentric
 Neglect in personal hygiene and grooming
 Blunted or inappropriate affect
 Disturbance in communication
 Unusual perceptual experience
 Lack of initiative
 Length of this phase is variable and may last for many years.
PHASE-III: Schizophrenia Psychotic symptoms are prominent in this phase
 Symptoms include
 Disturbance in
 Two types of symptoms are there
Positive or hard symptoms
 The symptoms that appear to reflect an excess or distortion of
normal functions.
 Positive symptoms are those that have positive reaction from
some treatment.
 Usually involve distinct abnormal behaviors includes-
Delusion
Hallucination
Disorders of thought
DEFINATION
It is a false, unshakable belief that is out
of keeping with the patients social and
cultural background
DELUSIO
Primary delusions
 Understandable
 In accordance with some other
psychopathological condition.
 Occur in other conditions
 .may be understood in terms of persons
background ,culture or emotional state
Secondary
delusions
Ununderstanble
Not in correlation with
some other
psychopathology
Occur in schizophrenia
Types of primary delusions
Autochthonous delusion(delusional intuition: sudden
delusional idea occurs out of the blue
Delusional percept:occurs in two stages perception and
then false interpretation
Delusional atmosphere/mood
Delusional memory/retrospective delusions
Content of delusions
delusion of persecution
Delusion of guilt
Morbid jealousy and delusion of infedility
Delusion of love
Grandiose delusion
Delusion of poverty and nihilistic delusion
Hypochondriacal delusion
Somatic delusions
Delusion of infestation
Delusions of control
Delusional misidentification(capgras syndrome)
Religious delusion
DELUSIONS
Distortions or exaggerations of
perception in any of the
senses.
Often they hear voices within
their own thoughts followed by
visual hallucinations.
HALLUCINATION
THOUGHT
Disorders of thought can be
 Disorganized
 Irrational
 Grossly disorganized behavior
 Difficulty in goal directed behavior, social disinhibition,
unpredictable agitation,.
 Catatonic behavior
 Marked in decrease reaction to immediate environment,
 Unaware of surroundings,
 Aimless motor activity
Negative symptoms
 Usually .occurs in during non psychotic period.
 Generally involves a loss of normal behavior.
 Symptoms include
 Alogia (poverty of speech)
Lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts including facial expression, voice, tone.
 Avolition
The reduction, difficulty or inability to initiate and persist in goal directed behavior.
 Lack of emotion
 Low energy
 Lack of interest in life
 Affective flattening
 Inappropriate social skills
 Social isolation
Cognitive symptoms
• Disorganized thinking
• Slow thinking
• Difficulty in understanding
• Poor concentration
• Poor memory
• Difficulty in expressing thoughts
• Difficulty in integrsating thoughts
PHASE-IV: Residual Phase
 Schizophrenia characterized by periods of remission and
exacerbation.
 A residual phase always follows an active phase of illness.
 Symptoms similar to prodromal phase with flat affect and role
functioning impairement.
 Residual impairment often increases between episodes of active
psychosis.
PATHOPHYSIOLOGY
 Occurs in 1% of general population, however this increases to 10% if a
1st degree relative has a history of schizophrenia.
 Risk of developingschizophrenia further increases to 40%
when both parents have a history of schizophrenia.
 Monozygotic twins have demonstrateda 48% risk of
 developing schizophrenia if one twin has the disease.
 Studies are going to locate specific genes to the development of
schizophrenia.
link exists for the development of
Genetic Theory:
•A strong genetic
schizophrenia.
Dopamine Theory:
• The dopamine hyperactivity in the brain is responsible for
psychotic symptoms present in schizophrenia.
 While dopamine hyperactivity is present in mesolimbic pathway, other areas
of the brain such as the prefrontal, frontal and temporal cortices have
decrease activity during acute psychosis.
 Other neurotransmitters thought to be involved in schizophrenia include 5-
HT, glutamate. The role of glutamate is also being evaluated because one of
its major functions is to regulate dopamine activity. Glutamate deficiency
has been found to cause similar effects to that of dopamine hyperactivity.
Neurodevelopmental Theory:
• Schizophrenia occurs as a result of an in
uterodisturbance during pregnancy. Potential
causes of this disturbance include upper
respiratory infection, obstetric complication and
neonatal hypoxia.
Psychosocial Theories:
• These theories propose that situation such
as stress, poor interpersonal skills,
conflicting family, communication and
various socio-economic influences are
linked to development of schizophrenia.
3. 5-HT Hypothesis
• Serotoninergic receptors are present on dopaminergic axons
and it is known that stimulation of these receptors will
decrease DA release in prefrontal cortex.
• Patients with schizophrenia with abnormal brain scans have
higher whole blood 5-HT concentrations and these
concentrations are correlated with increased ventricular size.
• Atypical antipsychotics with potent 5-HT2 receptor antagonist
effects reverse worsening of symptomatology induced by 5-HT
agonists in patients with schizophrenia.
3
7
SEROTONIN
 Serotonin excess causes positive and
negative symptoms.
Norepinephrine
 Degeneration in cortical noradrenergic reward
system
 Lack of goal oriented behavior
(Stein & Wise,1971)
Van Kammen and Colleagues
reported
Association between
NOREPINEPHRINE and 3 Methoxy-4-
Hydroxyphenyl- glycol with
neuroleptic withdrawl and severity
of positive and negative
symptoms.
GABA
GABA Glutamate
90%
Neurotrasmission
GABA Inhibitory
action Glutamate Stimulates brain
GABA
Glutamate
More
Stmulation
Normal brain
activity
Increased
work
NEUROPEPTIDES
 Neuropeptides, such as substance P and
neurotensin regulates neuronal activity.
 Alteration in neuropeptide mechanisms
could facilitate, inhibit, or otherwise alter
the pattern of firing these neuronal
systems.
ACETYLCHOLINE AND NICOTENE
 Post mortem studies demonstrated
decreased muscarinic and nicotinic
receptors
 These receptors play a role in the
regulation of neurotransmitter systems
involved in cognition, which is impaired in
schizophrenia
CEREBRAL VENTRICLES
 CT scan shows
 Enlargement of lateral and third ventricle.
REDUCED SYMMETRY
 There is a reduced symmetry in several
brain areas in schizophrenia, including the
temporal, frontal, and occipital lobes.
LIMBIC SYSTEM
 Decrease in the size of the region,
including the amygdala, the
hippocampus, and the parahippocampal
gyms
Prefrontal Cortex
 Anatomical abnormalities in the prefrontal
cortex in schizophrenia.
 Functional deficits in the prefrontal brain
imaging region have also been demonstrated.
THALAMUS
 Some studies of the thalamus show
evidence of volume shrinkage or
neuronal loss, In particular subnuclei.
 The medial dorsal nucleus of the
thalamus, which has reciprocal
connections with the prefrontal cortex,
has been reported to contain a reduced
number of neurons.
BASAL GANGLIA & CEREBELLUM
 Basal ganglia and cerebellum are
involved in the control of movement,
disease in these areas is implicated in
the pathophysiology of schizophrenia.
 Second, the movement disorders
involving the basal ganglia (e.g.,
Huntington's disease, Parkinson's
disease) are the ones most commonly
associated with psychosis.
BRAIN METABOLISM
 Concentrations of N-acetyl aspartate, a
marker of neurons, were lower in the
hippocampus and frontal lobes of patients with
schizophrenia.
Viral infection
 A viral infection may responsible for
schizophrenia.
 Viral infection like flu affects development
of brain of child in 2nd trimester.
Eye movement dysfunction
 Inability to follow the visual target accurately is
a defining basis of disorder.
 It may be a trait marker for the schizophrenia.
 Various studies have reported abnormal eye
movements in 50 to 85 percent of patients with
schizophrenia compared with about 25 percent
in psychiatric patients without schizophrenia
Psychoneuroimmunology
 decreased T-cell interleukin-2 production,
 reduced number and responsiveness of
peripheral lymphocytes,
 abnormal cellular and humoral reactivity to
neurons, and
 the presence of braindirected (antibrain)
antibodies.
Has been found associated with the
Schizophrenia.
Psychoneuroendocrinology
 Some data suggest decreased
concentrations of luteinizing
hormone or follicle-stimulating
hormone, perhaps correlated with
age of onset and length of illness.
 Increased thyroid hormone leads to
psychotic symptoms.
PSYCHONEUROENDOCRINOLOGY
 Some studies reported there is
relation between
Leutinizing Hormone, age of illness
and duration of illness.
GH Association Thought Disorder
Psychoanalytic Theory
 A fixation is a persistent focus of the id’s pleasure-
seeking energies at an earlier stage
of psychosexual development.
 These fixations occur when an issue or conflict in a
psychosexual stage remains unresolved, leaving the
individual focused on this stage and unable to move
onto the next.
 For example, individuals with oral fixations may
have problems with drinking, smoking, eating or nail
biting.
 Schizophrenia developed from fixation in early life.
 fixations produce defects in ego development
 such defects contributed to the symptoms of
schizophrenia .
 Because the ego affects the interpretation of
reality and the control of inner drives, such as
sex and aggression, these ego functions are
impaired.
 Thus, intrapsychic conflict arising from the
early fixations provides fuels to psychotic
symptoms.
LEARNING THEORIES
 According to learning theorists, children who later
have schizophrenia learn irrational reactions and
ways of thinking by imitating parents who have
their own significant emotional problems.
 In learning theory, the poor interpersonal
relationships of persons with schizophrenia
develop because of poor models for learning
during childhood.
FAMILY DYNAMICS
Poor mother child relationship has six
time chances of developing
schizophrenia
VITAMINS AND Minerals
A few doctors feel that mental illness
are partly the result of deficiencies in
vitamins, minerals and amino acids.
Substance use
Drug and alcohol can induce psychosis.
TYPES OF SCHIZOPHRENIA
PARANOID SCHIZOPHRENIA
 Commonest type of schizophrenia.
 Mainly there is presence of
 most common paranoid symptoms are:
Delusions of persecution, reference, exalted birth, special
mission, bodily change, or jealousy
Hallucinatory voices that threaten the patient or give commands,
or auditory hallucinations without verbal form, such as whistling,
humming, or laughing.
Hallucinations of smell or taste, or of sexual or other bodily
sensations; visual hallucinations may occur but are rarely
predominant.
. DIAGNOSTIC GUIDELINES:
. General criteria for Schizophrenia.
. Hallucinations and/or delusions must be prominent,
and disturbances of affect, volition and speech
. Delusions can be of almost any kind but delusions of
control, influence, or passivity, and persecutory beliefs
HEBEPHRENIC SCHIZOPHRENIA
. It is characterized by disorganized thinking with blunted and
inappropriate emotions.
. Mostly begins at adolescent.
. Shows Bizarre behavior.
. Appearance of
 Diagnostic criteria
 General criteria of schizophrenia.
 The premorbid personality is characteristically, but not
necessarily, rather shy and solitary
 2-3 months of continuous observation is required.
Classic feature is
 Marked disturbance in motor function.
 This disturbance may involve stupor, negativism, rigidity, excitement, or
posturing.
 Sometimes the patient shows a rapid alteration between extremes of
excitement and stupor.
 Associated features include stereotypies, mannerisms, and waxy flexibility.
Mutism is particularly common.
Undifferentiated Schizophrenia
When the condition could not fit into
any of the criteria for the
Schizophrenia, then it is included in
Undifferentiated Schizophrenia.
Diagnostic guidelines
 This category should be reserved for disorders that:
(a) meet the general criteria for schizophrenia;
(b) are either without sufficient symptoms to meet the
criteria for
only one of the subtypes F20.1, F20.2, F20.4, or F20.5, or
with
so many symptoms that more than one of the paranoid
(F20.0),
hebephrenic (F20.1), or catatonic (F20.4) subtypes are met.
Residual Schizophrenia
 A type of Schizophrenia in which the following criteria are
met:
 A. Absence of prominent delusions, hallucinations,
disorganized speech, and grossly disorganized
or catatonic behavior.
 B. There is continuing evidence of the disturbance, as
indicated by the presence of negative symptoms or two or
more symptoms listed in Criterion A for Schizophrenia,
present in an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
 When delusions or hallucinations occur, even if
infrequently, they are not serious enough to cause
severe dysfunction.
 The residual evidence of schizophrenia is apparent by
the presence of a flattened affect, loose speech,.
 a general loss of goal-directed interests.
 Residual symptoms can last indefinitely, or they can lead
to complete recovery, though this is rare.
Schizoaffective Disorder
 A. An uninterrupted period of illness during which there is a major
mood episode (major depressive or manic) concurrent with
Criterion A of schizophrenia.
 B.Delusions or hallucinations for 2 or more weeks in the absence
of a major mood episode (depressive or manic) during the lifetime
duration of the illness.
 C. Symptoms that meet criteria for a major mood episode are
present for the majority of the total duration of the active and
residual portions of the illness.
 D. The disturbance is not attributable to the effects of a substance
(e.g., a drug of abuse, a medication) or another medical
condition.
FEATURES
Negative symptoms may be less severe
and less persistent than those seen in
schizophrenia.
Schizoaffective patients have high risk
for development of major depressive
disorder or bipolar disorder.
Schizphreniform Disorder
Identical to Schizophrenia
Difference in time period(1-6 month).
Have good prognosis
No blunted or flat affect.
Social and occupational functioning is satisfactory.
Catatonic features may be included.
Substance/Medication-Induced Psychotic
Disorder
 Prominent delusion and Hallucination.
 Diagnosis is done when excessive symptoms occur other than withdrawal
symptoms .
 Substances that are believed to induce psychotic disorders are
Drugs of abuse
 Alcohol
 Amphetamines and related substances
 Cannabis
 Cocaine
 Hallucinogens
 Inhalants
 Opioids
 Phencyclidine and related substances
 Sedatives, hypnotics, and anxiolytics
 Anesthetics and analgesics
 Anticholinergic agents
 Anticonvulsants
 Antidepressant medication
Antihistamines
Antihypertensive agents
Cardiovascular medications
Antimicrobial medications
Antineoplastic medications
Antiparkinsonian agents
Corticosteroids
Disulfiram
Gastrointestinal medications
Psychotic Disorder Due to Another
Medical Condition
 Acute intermittent porphyria
 Cerebrovascular disease
 CNS infections
 CNS trauma
 Deafness
 Fluid or electrolyte imbalances
 Hepatic disease
 Herpes encephalitis
 Huntington’s disease
 Hypoadrenocorticism
 Hypo- or Hyperparathyroidism
 Hypo- or Hyperthyroidism
 Metabolic conditions (e.g., hypoxia, hypercarbia,
 hypoglycemia)
 Migraine headache
 Neoplasms
 Neurosyphilis
 Normal pressure hydrocephalus
 Renal disease
 Systemic lupus erythematosus
 Temporal lobe epilepsy
 Vitamin deficiency (e.g., B12)
 Wilson’s disease
MANAGEMENT
 Effective management=Patient effort
+
Family participation
+
staff commitment
 Research studies shows 80% respond to drugs,
20% do not respond.
There are mainly three types of management are done i.e.
1. Chemical Method
2. Physical methods
3. Psychosocial methods
Chemical method
 Mainstream treatment for Schizophrenia is –
Antipsychotics.
 Also referred as Major tranquilizers or Neuroleptics.
 First Antipsychotic introduced for clinical application
was Chlorpromazine.
 Antipsychotic act on psychotic symptoms.
 It may take any time between 1-15 days to show the
effectiveness.
 Drug should be continued in lower dose even after
achievement of effectiveness.
This dose must be continued for at least 2
years after asymptomatic period.
Antipsychotics have calming effect due to
adrenolytic and antihistaminic property.
These types of drugs are useful for the violent
patients.
Treatment for acute Phase
 Simultaneously chlorpromazinee/ Haloperdol
and Antihistamine in IV.
 Depending on improvement parenteral
administration may be repeated in every 8
hours.
 If patients becomes cooperative oral medication
may be started.
 Reduction in positive symptoms may take more
than 2-4 weeks.
Long Term Treatment
 Once the symptoms are controlled patients have to review
periodically.
 Dosage are continued on maintainance level.
 Clinical researcher told that patient should be treated
prophylactically with antipsychotics
1-2 years after 1st episode
3-4 years after 2nd episode
 Maintaince medication may be in the form of
Oral only
Depot only
Oral+Depot
Depot Neuroleptics
The advantages of Depot injections
A. Guaranteed drug delivery
B. Improved compliance
C. Prevalence of deliberate overdose
D. Avoidance of first pass hepatic
metabolism
E. Maintainace of plasma level drug
Fluphenazine Deconate
 Fluphenazine Deconate has a half life of 22 days.
 The dosage must be gradually increased in the
acute phase and decreased in maintenance
phase.
 Dosage or maintenance therapy is 12.5-50mg
once in 2-4 weeks.
Side effects of antipsychotics
1. Dysphoria
 It occurs at initial stage of antipsychotic
medication.
 Patient complains off uneasiness, pains and aches
all over the body and being off colour.
 Patient may discontinue medication because of
this issues.
 They should be persuaded to continue
medication.
2. Dyskinesia
 Most common symptom among the patient with
high potency antipsychotics( except clozapine).
 It is absent during sleep.
 It occurs within hours of taking medications.
Acute dystonia
 This manifests as slow, involuntary contraction of
one or more muscle group.
 Commonest muscle which are involved are jaw,
neck, tongue, shoulder, trunk.
 May face difficulty in changing his position.
 Occur within 12-48 hours of taking medication.
Treatment
 Anticholinergic drugs prophylactically.
 Stopping antipsychotics.
 Administration of Antihistanine+ Diazepam IV
 Antipsychotic may started after symptoms subside
with anticholinergics.
 Dangerous types are pharyngeal and laryngeal
dystonia.
 These may treated with beztropine IV 2mg repeated
ater 5-10 minutes.
 If response is inadequate Lorazepam 1-2 mg IV.
3. Parkinsonism
Results because blocking dopamine system
in Nigrostriatal pathway.
Characteristics are lack of motivation,
restlessness, tremors of hands and rigidity
of extremities.
Treatments
Antiparkinsonian agents.
4. Akathisia
It is Neuroleptic induced movement Disorder.
It has two components
1. Subjective
2. Objective
Subjective is inability to remain still
Objective are leg swinging, foot tapping,
hand wringing, walking up and down.
It varies between 5-50%.
May be associated with parkinsonism.
Treatment
Reduce antipsychotic doses.
Administration of propranolol, 10-40mg t.i.d.
Administration of amantadine, 100-300 mg.
Anticholinergics.
Clonidine,0.1mg t.i.d.
TARDIVE DISKINESIA
 It is characterized by choreo-athetoid or involuntary
movements of mouth, lips, tongue, arms, legs.
 Occurs when neuroleptics are given for long time.
 Continuation of neuroleptic drugs may have these
symptoms and discontinuation may reveal the same.
 Dissappear about 2-3 years after discontinuation of
medication.
 Calcium channel blocker and vit .E may be useful.
Hypotension
 It occurs with chlorpromazine and can lead to giddiness, fatigue
and fall.
 This can occur sometimes even in low doses.
Endocrine effects
 It includes decreased erections, delayed or
absent ejaculations, menstrual irregularities,
weight gain and increased appetite.
 Most common in Chlorpromazine, thioridazine,
triflupromazine.
 Side effects are distressing, especially to young
patients and may result poor compliance.
Anticholinergic Symptoms
 These are common with high potency , low
dosage drugs and antiparkinsonian agents.
 Symptoms include dry mouth, blurred vision,
constipation, nausea, urinary retention and
memory disturbances.
Neuroleptic Malignant Syndrome
 It is uncommon but a dangerous and life
threatening condition.
 This syndrome is characterized by fever( upto
107F), tachycardia, labile blood pressure,
impaired consciousness.
 High dose or rapid increase in dose , high
potency antipsychotics and malnourishment may
be responsible.
Treatment
Stopping neuroleptics.
Establishment of airway.
Vigorous antipyretic therapy.
Hydration IV fluids with vitamin.
Intensive care may be needed.
Recovery occurs about 7-15 days.
Physical Methods
Electroconvulsive therapy
Convulsive therapy was introduced by VON
MEDUNA.
He induced convulsion in camphor oil.
Cerleti and Binni used electricity to induce
seizure.
 ECT helps to control the excitement, violence,
and aggression in acute schizophrenia.
 There is evidence of clearing of all positive
symptoms .
 In acute phase ECT is better than neuroleptics.
 ECT + Neuroleptics is better than ECT alone/
Neuroleptic alone.
 ECT show faster effects and cheaper than
neuroleptics
Sargent and Slater and Kalinowsky suggest
every schizophrenic patients must be
given combination of ECT and Neuroleptic
therapy.
Psychosurgery
 Target at Limbic function, fronto limbic
or fronto limbic diencephalic neural tracts.
 It was practiced in 30s for severe mental illness.
Psychosocial Methods
 Individual Psychotherapy
 Reality oriented individual therapy is most
suitable approach for Schizophrenia patients.
 Decrease anxiety and Increase trust is main
goal.
 Patient respond to closeness with
suspiciousness.
 It become difficult to establish a relationship.
 Once therapeutic IPR is established reality orientation is
maintained through exploration with the client.
 Client is educated to provide source of real or perceived
danger.
 Individual psychotherapy is a long term process .
 Some times it may take years to give results .
 So it should be clarified to the patient and family
members.
Group therapy
 It is ineffective in inpatients.
 It is useful for the long term course of illness.
 Social interaction, sense of cohesiveness, and
reality testing has been achieved within the
group setting.
 Supportive group are more helpful for the
clients than confrontive groups.
Behavior therapy
 Behavioral modification has successfully changed
the frequency of Bizarre, disturbing and deviant
behaviors.
 In treatment setting Health care provider can
praise and use other positive reinforcement to
reduce maladaptive behavior.
Social skill training
 Social skill training focuses on role play.
 A series of scenarios are created which the client
face in his/her daily life.
 A healthcare provider may serve as a role model
for some behavior.
 Immediate feedback is provided regarding clients
presentation.
Milieu Therapy
 Researcher believes that psychotropic medications with milieu
therapy is more beneficial for the patient.
 Milieu therapy programmes emphasize group and social
interaction.
 When patient viewed as responsible individual, the patient role
becomes blurred .
 Milieu therapy emphasizes interdisciplinary participation, goal
oriented and clear communication.
Family therapy
 When family able to cope well there is notable
impact in mental status of relatives.
 The main aims of family therapy are:
 Support the family system
 Prevent or delay relapse
 Help to maintain client in community.
Nursing Management
 Disturbed thought process related to inability to
trust, panic anxiety, possible hereditary or
biochemical factors as evidenced by inability to
solving problem, abstract, conceptualize, extreme
suspiciousness to others.
 Disturbed sensory perception : auditory/ visual
related to panic anxiety extreme loneliness and
withdrawl into the self as evidenced by withdrawl,
sad or dull affect, need fear dilemma preoccupation
with own thoughts.
 Social isolation related to
Inability to trust/panic anxiety/weak ego development/delusional
thinking as evidenced by expression of feeling rejection/ withdrawl
sad or dull affect/ loneliness.
 Risk for violence: self directed/ other directed related to
Extreme suspiciousness/panic anxiety/catatonic
excitement/command hallucination as evidenced by overt and
aggressive acts/ goal directed destruction of a object in the
environment.
 Impaired verbal communication related to panic
anxiety/regression/withdrawl and disordered/unrealistic thinking
As evidenced by loose association of ideas/neologisms/word
salad/clang association/echolalia/poor eye contact.
 Self care deficit related to withdrwal/ regression/panic
anxiety/perceptual and cognitive impairement evidenced by
Difficulty carrying out tasks associated with hygiene dressing,
grooming, eating and toileting.
Major nursing Interventions
Promoting safety of client and others.
Maintain right to privacy and dignity.
Use therapeutic communication techniques.
Intervention for delusion
 Don’t openly confront the delusions or argue with the
client.
 Establish and maintain reality of the client.
 Use distracting techniques.
 Teach the client positive self talk, positive thinking and
delusional beliefs.
Hallucination
 Help present and maintain reality by frequent
contact and communication with the client.
 Elicit description of hallucination to protect
client and others.
 Engage client inn reality based activities such as
card playing.
 Occupational therapy or listening music.
Coping with socially inappropriate behavior
 Redirect client away from the problematic situation
 Deal with inappropriate behavior in non judgmental way
.
 Reassure others that clients behavior or comments are
not his/her fault.
 Don’t make the client feel punished or stunned for
inappropriate behaviors.
 Teach social skills through education, role modelling and
practice.
 Establish community support system and care.
Health education regarding medication
 Drink sugar free fluids and eat sugar free hard candy
to ease to ease the anticholinergic effect of dry
mouth.
 Drink more amount of water and exercise to prevent
constipation.
 Use sun screen and wear protective clothes to
prevent burning.
 Change position slowly from orthostatic hypotension.
 Avoid potentially hazardous works.
 Self care and proper nutrition.
Schizophrenia and Other Psychotic Disorders
Schizophrenia and Other Psychotic Disorders

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Schizophrenia and Other Psychotic Disorders

  • 2. History  The word "schizophrenia" is less than 100 years old. However the disease was first identified as a discrete mental illness by dr. Emile kraepelin in the 1887.  Written documents that identify schizophrenia can be traced to the old pharaonic egypt, as far back as the second millennium before christ.  Depression, dementia, as well as thought disturbances that are typical in schizophrenia are described in detail in the book of hearts. The heart and the mind seem to have been synonymous in ancient egypt.  The physical illnesses were regarded as symptoms of the heart and the uterus and originating from the blood vessels or from purulence, fecal matter, a poison or demons.
  • 3. • At one point, all people who were considered "abnormal," whether due to mental illness, mental retardation, or physical deformities, were largely treated the same. • Early theories supposed that mental disorders were caused by evil possession of the body, and the appropriate treatment was then exorcising these demons, through various means, ranging from innocuous treatments, such as exposing the patient to certain types of music, to dangerous and sometimes deadly means, such as releasing the evil spirits by drilling holes in the patient's skull.
  • 4.  One of the first to classify the mental disorders into different categories was the German physician, Emile Kraepelin. Dr. Kraepelin used the term "Dementia praecox" for individuals who had symptoms that we now associate with schizophrenia.  The nonspecific concept of madness has been around for many thousands of years and schizophrenia was only classified as a distinct mental disorder by Kraepelin in 1887.  He was the first to make a distinction in the psychotic disorders between what he called dementia praecox and manic depression.  Kraepelin believed that dementia praecox was primarily a disease of the brain, and particularly a form of dementia. Kraepelin named the disorder 'dementia praecox' (early dementia) to distinguish it from other forms of dementia (such as Alzheimer's disease) which typically occur late in life.  He used this term because his studies focused on young adults with dementia.
  • 5.  The swiss psychiatrist, Eugen Bleuler, coined the term, "schizophrenia" in 1911.  He was also the first to describe the symptoms as "positive" or "negative." Bleuler changed the name to schizophrenia as it was obvious that Krapelin's name was misleading as the illness was not a dementia (it did not always lead to mental deterioration) and could sometimes occur late as well as early in life.
  • 6. Meaning  The term schizophrenia was coined by swiss psychiatrist Eugen Bleuler.  The word was derived from Greek word “Skizo” (Split) and “Phren” (Mind)  A chronic severe brain disorder , often they hear voices believe media are broadcasting their thoughts to the world or may believe someone is trying to harm them  It is a most devasting disorder of thought and emotion characterized by  Disorganized Thoughts  Hallucination  Bizarre Behaviors
  • 7. Definition Schizophrenia is defined by :  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. It refers to a group of mental illness characterized by specific psychological symptoms that affect the mood, regulations of emotions, thoughts, perceptions, movements and behaviors.
  • 8.  The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception and affect that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time
  • 9. EPIDEMIOLOGY  Mostly begins in early adulthood, age between 15 and 25.  Men tend to develop schizophrenia slightly earlier than women, where as most of the males become ill between 16 and 25 female develop symptoms several years later.  Average age of onset in male 18 in men and 25 in women.  Schizophrenia onset quite rare for the people before 10 years and after 40 years.
  • 10. Incidence General population 0.8-1.5% Father affected 10-18% Mother affected 0-18% Both parents affected 25-46% Relatives affected/One sibling 8-10% Second degree relative 2-3% Monozygotic twins 40-50% Dizygotic twins 12-15% Adoptive parent – Adoptive with non Schizophrenic biological parent 4.8%
  • 11.  50% of males are hospitalized by age 25.  People who experienced Schizophrenia are more likely to have been born in winter/early spring least likely born in late spring summer.  Suicide is very prevalent- 50% attempt and 10-15% will complete it.  30-50% has substantial alcohol problems or drug problems.  High risk for homelessness – social drift theory- the illness impairs work ability and thus lower economic status.
  • 12. CLINICAL SYMPTOMS  (A) thought echo, thought insertion or withdrawal, and thought broadcasting;  (B) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;  (C) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;
  • 13.  (D) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.G. Being able to control the weather, or being in communication with aliens from another world);  (E) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;  (F) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms
  • 14.  (G) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor; (H) "negative" symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication; (I) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
  • 15.  Pre morbid behavior can be viewed in following four phases: PHASE-I: The Schizoid Personality PHAE-II: The Prodormal Phase PHASE-III: Schizophrenia PHASE-IV: Residual Phase
  • 16. PHASE-I: The Schizoid Personality  Disturbance in social relationship  Limited range of emotional experience and expression  They do not enjoy close relationship and prefer “Loners”  They appear cold and aloof  Not all who show these characteristic may develop to schizophrenia but most individual who were affected showed this type of symptoms.
  • 17. PHAE-II: The Prodormal Phase It include social withdrawl, impairement in role functioning , behavior that peculiar or eccentric  Neglect in personal hygiene and grooming  Blunted or inappropriate affect  Disturbance in communication  Unusual perceptual experience  Lack of initiative  Length of this phase is variable and may last for many years.
  • 18. PHASE-III: Schizophrenia Psychotic symptoms are prominent in this phase  Symptoms include  Disturbance in
  • 19.  Two types of symptoms are there
  • 20. Positive or hard symptoms  The symptoms that appear to reflect an excess or distortion of normal functions.  Positive symptoms are those that have positive reaction from some treatment.  Usually involve distinct abnormal behaviors includes- Delusion Hallucination Disorders of thought
  • 21. DEFINATION It is a false, unshakable belief that is out of keeping with the patients social and cultural background DELUSIO
  • 22.
  • 23. Primary delusions  Understandable  In accordance with some other psychopathological condition.  Occur in other conditions  .may be understood in terms of persons background ,culture or emotional state Secondary delusions Ununderstanble Not in correlation with some other psychopathology Occur in schizophrenia
  • 24. Types of primary delusions Autochthonous delusion(delusional intuition: sudden delusional idea occurs out of the blue Delusional percept:occurs in two stages perception and then false interpretation Delusional atmosphere/mood Delusional memory/retrospective delusions
  • 25. Content of delusions delusion of persecution Delusion of guilt Morbid jealousy and delusion of infedility Delusion of love Grandiose delusion Delusion of poverty and nihilistic delusion Hypochondriacal delusion Somatic delusions Delusion of infestation Delusions of control Delusional misidentification(capgras syndrome) Religious delusion
  • 27. Distortions or exaggerations of perception in any of the senses. Often they hear voices within their own thoughts followed by visual hallucinations. HALLUCINATION
  • 28. THOUGHT Disorders of thought can be  Disorganized  Irrational  Grossly disorganized behavior  Difficulty in goal directed behavior, social disinhibition, unpredictable agitation,.  Catatonic behavior  Marked in decrease reaction to immediate environment,  Unaware of surroundings,  Aimless motor activity
  • 29.
  • 30. Negative symptoms  Usually .occurs in during non psychotic period.  Generally involves a loss of normal behavior.  Symptoms include  Alogia (poverty of speech) Lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts including facial expression, voice, tone.  Avolition The reduction, difficulty or inability to initiate and persist in goal directed behavior.
  • 31.  Lack of emotion  Low energy  Lack of interest in life  Affective flattening  Inappropriate social skills  Social isolation Cognitive symptoms • Disorganized thinking • Slow thinking • Difficulty in understanding • Poor concentration • Poor memory • Difficulty in expressing thoughts • Difficulty in integrsating thoughts
  • 32. PHASE-IV: Residual Phase  Schizophrenia characterized by periods of remission and exacerbation.  A residual phase always follows an active phase of illness.  Symptoms similar to prodromal phase with flat affect and role functioning impairement.  Residual impairment often increases between episodes of active psychosis.
  • 33. PATHOPHYSIOLOGY  Occurs in 1% of general population, however this increases to 10% if a 1st degree relative has a history of schizophrenia.  Risk of developingschizophrenia further increases to 40% when both parents have a history of schizophrenia.  Monozygotic twins have demonstrateda 48% risk of  developing schizophrenia if one twin has the disease.  Studies are going to locate specific genes to the development of schizophrenia. link exists for the development of Genetic Theory: •A strong genetic schizophrenia.
  • 34. Dopamine Theory: • The dopamine hyperactivity in the brain is responsible for psychotic symptoms present in schizophrenia.  While dopamine hyperactivity is present in mesolimbic pathway, other areas of the brain such as the prefrontal, frontal and temporal cortices have decrease activity during acute psychosis.  Other neurotransmitters thought to be involved in schizophrenia include 5- HT, glutamate. The role of glutamate is also being evaluated because one of its major functions is to regulate dopamine activity. Glutamate deficiency has been found to cause similar effects to that of dopamine hyperactivity.
  • 35. Neurodevelopmental Theory: • Schizophrenia occurs as a result of an in uterodisturbance during pregnancy. Potential causes of this disturbance include upper respiratory infection, obstetric complication and neonatal hypoxia.
  • 36. Psychosocial Theories: • These theories propose that situation such as stress, poor interpersonal skills, conflicting family, communication and various socio-economic influences are linked to development of schizophrenia.
  • 37. 3. 5-HT Hypothesis • Serotoninergic receptors are present on dopaminergic axons and it is known that stimulation of these receptors will decrease DA release in prefrontal cortex. • Patients with schizophrenia with abnormal brain scans have higher whole blood 5-HT concentrations and these concentrations are correlated with increased ventricular size. • Atypical antipsychotics with potent 5-HT2 receptor antagonist effects reverse worsening of symptomatology induced by 5-HT agonists in patients with schizophrenia. 3 7
  • 38. SEROTONIN  Serotonin excess causes positive and negative symptoms.
  • 39. Norepinephrine  Degeneration in cortical noradrenergic reward system  Lack of goal oriented behavior (Stein & Wise,1971)
  • 40. Van Kammen and Colleagues reported Association between NOREPINEPHRINE and 3 Methoxy-4- Hydroxyphenyl- glycol with neuroleptic withdrawl and severity of positive and negative symptoms.
  • 41. GABA GABA Glutamate 90% Neurotrasmission GABA Inhibitory action Glutamate Stimulates brain GABA Glutamate More Stmulation Normal brain activity Increased work
  • 42. NEUROPEPTIDES  Neuropeptides, such as substance P and neurotensin regulates neuronal activity.  Alteration in neuropeptide mechanisms could facilitate, inhibit, or otherwise alter the pattern of firing these neuronal systems.
  • 43. ACETYLCHOLINE AND NICOTENE  Post mortem studies demonstrated decreased muscarinic and nicotinic receptors  These receptors play a role in the regulation of neurotransmitter systems involved in cognition, which is impaired in schizophrenia
  • 44. CEREBRAL VENTRICLES  CT scan shows  Enlargement of lateral and third ventricle.
  • 45. REDUCED SYMMETRY  There is a reduced symmetry in several brain areas in schizophrenia, including the temporal, frontal, and occipital lobes.
  • 46. LIMBIC SYSTEM  Decrease in the size of the region, including the amygdala, the hippocampus, and the parahippocampal gyms
  • 47. Prefrontal Cortex  Anatomical abnormalities in the prefrontal cortex in schizophrenia.  Functional deficits in the prefrontal brain imaging region have also been demonstrated.
  • 48. THALAMUS  Some studies of the thalamus show evidence of volume shrinkage or neuronal loss, In particular subnuclei.  The medial dorsal nucleus of the thalamus, which has reciprocal connections with the prefrontal cortex, has been reported to contain a reduced number of neurons.
  • 49. BASAL GANGLIA & CEREBELLUM  Basal ganglia and cerebellum are involved in the control of movement, disease in these areas is implicated in the pathophysiology of schizophrenia.  Second, the movement disorders involving the basal ganglia (e.g., Huntington's disease, Parkinson's disease) are the ones most commonly associated with psychosis.
  • 50. BRAIN METABOLISM  Concentrations of N-acetyl aspartate, a marker of neurons, were lower in the hippocampus and frontal lobes of patients with schizophrenia.
  • 51. Viral infection  A viral infection may responsible for schizophrenia.  Viral infection like flu affects development of brain of child in 2nd trimester.
  • 52. Eye movement dysfunction  Inability to follow the visual target accurately is a defining basis of disorder.  It may be a trait marker for the schizophrenia.  Various studies have reported abnormal eye movements in 50 to 85 percent of patients with schizophrenia compared with about 25 percent in psychiatric patients without schizophrenia
  • 53. Psychoneuroimmunology  decreased T-cell interleukin-2 production,  reduced number and responsiveness of peripheral lymphocytes,  abnormal cellular and humoral reactivity to neurons, and  the presence of braindirected (antibrain) antibodies. Has been found associated with the Schizophrenia.
  • 54. Psychoneuroendocrinology  Some data suggest decreased concentrations of luteinizing hormone or follicle-stimulating hormone, perhaps correlated with age of onset and length of illness.  Increased thyroid hormone leads to psychotic symptoms.
  • 55. PSYCHONEUROENDOCRINOLOGY  Some studies reported there is relation between Leutinizing Hormone, age of illness and duration of illness. GH Association Thought Disorder
  • 56. Psychoanalytic Theory  A fixation is a persistent focus of the id’s pleasure- seeking energies at an earlier stage of psychosexual development.  These fixations occur when an issue or conflict in a psychosexual stage remains unresolved, leaving the individual focused on this stage and unable to move onto the next.  For example, individuals with oral fixations may have problems with drinking, smoking, eating or nail biting.  Schizophrenia developed from fixation in early life.
  • 57.  fixations produce defects in ego development  such defects contributed to the symptoms of schizophrenia .  Because the ego affects the interpretation of reality and the control of inner drives, such as sex and aggression, these ego functions are impaired.  Thus, intrapsychic conflict arising from the early fixations provides fuels to psychotic symptoms.
  • 58. LEARNING THEORIES  According to learning theorists, children who later have schizophrenia learn irrational reactions and ways of thinking by imitating parents who have their own significant emotional problems.  In learning theory, the poor interpersonal relationships of persons with schizophrenia develop because of poor models for learning during childhood.
  • 59. FAMILY DYNAMICS Poor mother child relationship has six time chances of developing schizophrenia
  • 60. VITAMINS AND Minerals A few doctors feel that mental illness are partly the result of deficiencies in vitamins, minerals and amino acids.
  • 61. Substance use Drug and alcohol can induce psychosis.
  • 62.
  • 65.  Commonest type of schizophrenia.  Mainly there is presence of
  • 66.  most common paranoid symptoms are: Delusions of persecution, reference, exalted birth, special mission, bodily change, or jealousy Hallucinatory voices that threaten the patient or give commands, or auditory hallucinations without verbal form, such as whistling, humming, or laughing. Hallucinations of smell or taste, or of sexual or other bodily sensations; visual hallucinations may occur but are rarely predominant.
  • 67.
  • 68. . DIAGNOSTIC GUIDELINES: . General criteria for Schizophrenia. . Hallucinations and/or delusions must be prominent, and disturbances of affect, volition and speech . Delusions can be of almost any kind but delusions of control, influence, or passivity, and persecutory beliefs
  • 69. HEBEPHRENIC SCHIZOPHRENIA . It is characterized by disorganized thinking with blunted and inappropriate emotions. . Mostly begins at adolescent. . Shows Bizarre behavior. . Appearance of
  • 70.  Diagnostic criteria  General criteria of schizophrenia.  The premorbid personality is characteristically, but not necessarily, rather shy and solitary  2-3 months of continuous observation is required.
  • 71.
  • 72. Classic feature is  Marked disturbance in motor function.  This disturbance may involve stupor, negativism, rigidity, excitement, or posturing.  Sometimes the patient shows a rapid alteration between extremes of excitement and stupor.  Associated features include stereotypies, mannerisms, and waxy flexibility. Mutism is particularly common.
  • 73.
  • 74. Undifferentiated Schizophrenia When the condition could not fit into any of the criteria for the Schizophrenia, then it is included in Undifferentiated Schizophrenia.
  • 75. Diagnostic guidelines  This category should be reserved for disorders that: (a) meet the general criteria for schizophrenia; (b) are either without sufficient symptoms to meet the criteria for only one of the subtypes F20.1, F20.2, F20.4, or F20.5, or with so many symptoms that more than one of the paranoid (F20.0), hebephrenic (F20.1), or catatonic (F20.4) subtypes are met.
  • 76.
  • 77. Residual Schizophrenia  A type of Schizophrenia in which the following criteria are met:  A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.  B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
  • 78.  When delusions or hallucinations occur, even if infrequently, they are not serious enough to cause severe dysfunction.  The residual evidence of schizophrenia is apparent by the presence of a flattened affect, loose speech,.  a general loss of goal-directed interests.  Residual symptoms can last indefinitely, or they can lead to complete recovery, though this is rare.
  • 79. Schizoaffective Disorder  A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia.  B.Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.  C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.  D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
  • 80. FEATURES Negative symptoms may be less severe and less persistent than those seen in schizophrenia. Schizoaffective patients have high risk for development of major depressive disorder or bipolar disorder.
  • 81. Schizphreniform Disorder Identical to Schizophrenia Difference in time period(1-6 month). Have good prognosis No blunted or flat affect. Social and occupational functioning is satisfactory. Catatonic features may be included.
  • 82. Substance/Medication-Induced Psychotic Disorder  Prominent delusion and Hallucination.  Diagnosis is done when excessive symptoms occur other than withdrawal symptoms .  Substances that are believed to induce psychotic disorders are Drugs of abuse  Alcohol  Amphetamines and related substances  Cannabis  Cocaine  Hallucinogens  Inhalants  Opioids
  • 83.  Phencyclidine and related substances  Sedatives, hypnotics, and anxiolytics  Anesthetics and analgesics  Anticholinergic agents  Anticonvulsants  Antidepressant medication Antihistamines Antihypertensive agents Cardiovascular medications Antimicrobial medications Antineoplastic medications Antiparkinsonian agents Corticosteroids Disulfiram Gastrointestinal medications
  • 84. Psychotic Disorder Due to Another Medical Condition  Acute intermittent porphyria  Cerebrovascular disease  CNS infections  CNS trauma  Deafness  Fluid or electrolyte imbalances  Hepatic disease  Herpes encephalitis  Huntington’s disease  Hypoadrenocorticism  Hypo- or Hyperparathyroidism  Hypo- or Hyperthyroidism
  • 85.  Metabolic conditions (e.g., hypoxia, hypercarbia,  hypoglycemia)  Migraine headache  Neoplasms  Neurosyphilis  Normal pressure hydrocephalus  Renal disease  Systemic lupus erythematosus  Temporal lobe epilepsy  Vitamin deficiency (e.g., B12)  Wilson’s disease
  • 86. MANAGEMENT  Effective management=Patient effort + Family participation + staff commitment
  • 87.  Research studies shows 80% respond to drugs, 20% do not respond. There are mainly three types of management are done i.e. 1. Chemical Method 2. Physical methods 3. Psychosocial methods
  • 88. Chemical method  Mainstream treatment for Schizophrenia is – Antipsychotics.  Also referred as Major tranquilizers or Neuroleptics.  First Antipsychotic introduced for clinical application was Chlorpromazine.  Antipsychotic act on psychotic symptoms.  It may take any time between 1-15 days to show the effectiveness.  Drug should be continued in lower dose even after achievement of effectiveness.
  • 89. This dose must be continued for at least 2 years after asymptomatic period. Antipsychotics have calming effect due to adrenolytic and antihistaminic property. These types of drugs are useful for the violent patients.
  • 90.
  • 91. Treatment for acute Phase  Simultaneously chlorpromazinee/ Haloperdol and Antihistamine in IV.  Depending on improvement parenteral administration may be repeated in every 8 hours.  If patients becomes cooperative oral medication may be started.  Reduction in positive symptoms may take more than 2-4 weeks.
  • 92. Long Term Treatment  Once the symptoms are controlled patients have to review periodically.  Dosage are continued on maintainance level.  Clinical researcher told that patient should be treated prophylactically with antipsychotics 1-2 years after 1st episode 3-4 years after 2nd episode  Maintaince medication may be in the form of Oral only Depot only Oral+Depot
  • 93. Depot Neuroleptics The advantages of Depot injections A. Guaranteed drug delivery B. Improved compliance C. Prevalence of deliberate overdose D. Avoidance of first pass hepatic metabolism E. Maintainace of plasma level drug
  • 94. Fluphenazine Deconate  Fluphenazine Deconate has a half life of 22 days.  The dosage must be gradually increased in the acute phase and decreased in maintenance phase.  Dosage or maintenance therapy is 12.5-50mg once in 2-4 weeks.
  • 95. Side effects of antipsychotics 1. Dysphoria  It occurs at initial stage of antipsychotic medication.  Patient complains off uneasiness, pains and aches all over the body and being off colour.  Patient may discontinue medication because of this issues.  They should be persuaded to continue medication.
  • 96. 2. Dyskinesia  Most common symptom among the patient with high potency antipsychotics( except clozapine).  It is absent during sleep.  It occurs within hours of taking medications.
  • 97. Acute dystonia  This manifests as slow, involuntary contraction of one or more muscle group.  Commonest muscle which are involved are jaw, neck, tongue, shoulder, trunk.  May face difficulty in changing his position.  Occur within 12-48 hours of taking medication.
  • 98. Treatment  Anticholinergic drugs prophylactically.  Stopping antipsychotics.  Administration of Antihistanine+ Diazepam IV  Antipsychotic may started after symptoms subside with anticholinergics.  Dangerous types are pharyngeal and laryngeal dystonia.  These may treated with beztropine IV 2mg repeated ater 5-10 minutes.  If response is inadequate Lorazepam 1-2 mg IV.
  • 99. 3. Parkinsonism Results because blocking dopamine system in Nigrostriatal pathway. Characteristics are lack of motivation, restlessness, tremors of hands and rigidity of extremities. Treatments Antiparkinsonian agents.
  • 100. 4. Akathisia It is Neuroleptic induced movement Disorder. It has two components 1. Subjective 2. Objective
  • 101. Subjective is inability to remain still Objective are leg swinging, foot tapping, hand wringing, walking up and down. It varies between 5-50%. May be associated with parkinsonism.
  • 102. Treatment Reduce antipsychotic doses. Administration of propranolol, 10-40mg t.i.d. Administration of amantadine, 100-300 mg. Anticholinergics. Clonidine,0.1mg t.i.d.
  • 103. TARDIVE DISKINESIA  It is characterized by choreo-athetoid or involuntary movements of mouth, lips, tongue, arms, legs.  Occurs when neuroleptics are given for long time.  Continuation of neuroleptic drugs may have these symptoms and discontinuation may reveal the same.  Dissappear about 2-3 years after discontinuation of medication.  Calcium channel blocker and vit .E may be useful.
  • 104.
  • 105. Hypotension  It occurs with chlorpromazine and can lead to giddiness, fatigue and fall.  This can occur sometimes even in low doses.
  • 106. Endocrine effects  It includes decreased erections, delayed or absent ejaculations, menstrual irregularities, weight gain and increased appetite.  Most common in Chlorpromazine, thioridazine, triflupromazine.  Side effects are distressing, especially to young patients and may result poor compliance.
  • 107. Anticholinergic Symptoms  These are common with high potency , low dosage drugs and antiparkinsonian agents.  Symptoms include dry mouth, blurred vision, constipation, nausea, urinary retention and memory disturbances.
  • 108. Neuroleptic Malignant Syndrome  It is uncommon but a dangerous and life threatening condition.  This syndrome is characterized by fever( upto 107F), tachycardia, labile blood pressure, impaired consciousness.  High dose or rapid increase in dose , high potency antipsychotics and malnourishment may be responsible.
  • 109. Treatment Stopping neuroleptics. Establishment of airway. Vigorous antipyretic therapy. Hydration IV fluids with vitamin. Intensive care may be needed. Recovery occurs about 7-15 days.
  • 110. Physical Methods Electroconvulsive therapy Convulsive therapy was introduced by VON MEDUNA. He induced convulsion in camphor oil. Cerleti and Binni used electricity to induce seizure.
  • 111.  ECT helps to control the excitement, violence, and aggression in acute schizophrenia.  There is evidence of clearing of all positive symptoms .  In acute phase ECT is better than neuroleptics.  ECT + Neuroleptics is better than ECT alone/ Neuroleptic alone.  ECT show faster effects and cheaper than neuroleptics
  • 112. Sargent and Slater and Kalinowsky suggest every schizophrenic patients must be given combination of ECT and Neuroleptic therapy.
  • 113. Psychosurgery  Target at Limbic function, fronto limbic or fronto limbic diencephalic neural tracts.  It was practiced in 30s for severe mental illness.
  • 114. Psychosocial Methods  Individual Psychotherapy  Reality oriented individual therapy is most suitable approach for Schizophrenia patients.  Decrease anxiety and Increase trust is main goal.  Patient respond to closeness with suspiciousness.  It become difficult to establish a relationship.
  • 115.  Once therapeutic IPR is established reality orientation is maintained through exploration with the client.  Client is educated to provide source of real or perceived danger.  Individual psychotherapy is a long term process .  Some times it may take years to give results .  So it should be clarified to the patient and family members.
  • 116. Group therapy  It is ineffective in inpatients.  It is useful for the long term course of illness.  Social interaction, sense of cohesiveness, and reality testing has been achieved within the group setting.  Supportive group are more helpful for the clients than confrontive groups.
  • 117. Behavior therapy  Behavioral modification has successfully changed the frequency of Bizarre, disturbing and deviant behaviors.  In treatment setting Health care provider can praise and use other positive reinforcement to reduce maladaptive behavior.
  • 118. Social skill training  Social skill training focuses on role play.  A series of scenarios are created which the client face in his/her daily life.  A healthcare provider may serve as a role model for some behavior.  Immediate feedback is provided regarding clients presentation.
  • 119. Milieu Therapy  Researcher believes that psychotropic medications with milieu therapy is more beneficial for the patient.  Milieu therapy programmes emphasize group and social interaction.  When patient viewed as responsible individual, the patient role becomes blurred .  Milieu therapy emphasizes interdisciplinary participation, goal oriented and clear communication.
  • 120. Family therapy  When family able to cope well there is notable impact in mental status of relatives.  The main aims of family therapy are:  Support the family system  Prevent or delay relapse  Help to maintain client in community.
  • 121. Nursing Management  Disturbed thought process related to inability to trust, panic anxiety, possible hereditary or biochemical factors as evidenced by inability to solving problem, abstract, conceptualize, extreme suspiciousness to others.  Disturbed sensory perception : auditory/ visual related to panic anxiety extreme loneliness and withdrawl into the self as evidenced by withdrawl, sad or dull affect, need fear dilemma preoccupation with own thoughts.
  • 122.  Social isolation related to Inability to trust/panic anxiety/weak ego development/delusional thinking as evidenced by expression of feeling rejection/ withdrawl sad or dull affect/ loneliness.  Risk for violence: self directed/ other directed related to Extreme suspiciousness/panic anxiety/catatonic excitement/command hallucination as evidenced by overt and aggressive acts/ goal directed destruction of a object in the environment.
  • 123.  Impaired verbal communication related to panic anxiety/regression/withdrawl and disordered/unrealistic thinking As evidenced by loose association of ideas/neologisms/word salad/clang association/echolalia/poor eye contact.  Self care deficit related to withdrwal/ regression/panic anxiety/perceptual and cognitive impairement evidenced by Difficulty carrying out tasks associated with hygiene dressing, grooming, eating and toileting.
  • 124. Major nursing Interventions Promoting safety of client and others. Maintain right to privacy and dignity. Use therapeutic communication techniques.
  • 125. Intervention for delusion  Don’t openly confront the delusions or argue with the client.  Establish and maintain reality of the client.  Use distracting techniques.  Teach the client positive self talk, positive thinking and delusional beliefs.
  • 126. Hallucination  Help present and maintain reality by frequent contact and communication with the client.  Elicit description of hallucination to protect client and others.  Engage client inn reality based activities such as card playing.  Occupational therapy or listening music.
  • 127. Coping with socially inappropriate behavior  Redirect client away from the problematic situation  Deal with inappropriate behavior in non judgmental way .  Reassure others that clients behavior or comments are not his/her fault.  Don’t make the client feel punished or stunned for inappropriate behaviors.  Teach social skills through education, role modelling and practice.  Establish community support system and care.
  • 128. Health education regarding medication  Drink sugar free fluids and eat sugar free hard candy to ease to ease the anticholinergic effect of dry mouth.  Drink more amount of water and exercise to prevent constipation.  Use sun screen and wear protective clothes to prevent burning.  Change position slowly from orthostatic hypotension.  Avoid potentially hazardous works.  Self care and proper nutrition.

Editor's Notes

  1. Ebers Papyrus 32BC-332BC –pharaonic egypt
  2. Interpolations-the insertion of something of a different nature into something else.
  3. ECCENTRIC-unconventional and slightly strange
  4. Emotion-a strong feeling deriving from one's circumstances Affect-
  5. Inhibition-a voluntary or involuntary restraint on the direct expression of an instinct.
  6. Deception- an act that made a person to believe on something
  7. Dopamine (DA, a contraction of 3,4-dihydroxyphenethylamine) is an organic chemical of the catecholamineand phenethylamine families that plays several important roles in the brain and body.
  8. serotonin increased and production of oxytocin, a hormone that reduces pain perception and increases the emotional connection.
  9. The thalamus also plays an important role in regulating states of sleep and wakefulness.[17] Thalamic nuclei have strong reciprocal connections with the cerebral cortex, forming thalamo-cortico-thalamic circuits that are believed to be involved with consciousness.[18] The thalamus plays a major role in regulating arousal, the level of awareness, and activity. Damage to the thalamus can lead to permanent coma
  10. More N-acetyl aspartate more active is your brain.
  11. Paranoia- Mistrust to the people
  12. Exalted- noble birth
  13. Incongruity mood- Smiling while anxious
  14. Volition- will power
  15. Brooding-engaged in or showing deep thought about something that makes one sad, angry, or worried.
  16.  Diagnostic criteria for schizophrenia: A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence (4) grossly disorganized or catatonic behaviour (5) negative symptoms, 
  17. Time is taken depending upon age sex, weight, physical condition, and duration of illness.
  18. off colour- slightly unwell
  19. Diskinesia-abnormality or impairment of voluntary movement.
  20. Amantadine- antiviral and antiparkinsonian.