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  1. 1. Schizophrenia Mohamed Mustafa Abdullah
  2. 2. definition ►It is a devastating brain disease that affecting a person's thinking, language, emotions, social behavior and ability to perceive reality accurately with fundamental symptoms known as Bleuler’s four A, s: 1- Autistic thinking 2- loosening Of Associations (LOA) 3- Ambivalence 4- disturbances of Affect
  3. 3. • A severe psychotic illness characterised by delusions, hallucinations (usually auditory), thought disorder and behavioural disturbance • Often deterioration in social, occupational and cognitive function • Occurs in Clear consciousness
  4. 4. Hitory • Kraeplin (1855 –1926) – dementia praecox • Bleuler (1857 – 1959) – schizophrenia • Kraeplin suggested that aud. Hallucinations, delusions, thought disorder, affective falttening and impaired insight were common to hebephrenia, paranoia, catatonia and dementia simplex – group of disorders which he called dementia praecox
  5. 5. History • Bleuler – the four As – abnormal thought association, affective abnormality, ambivalence, autism • Schneider (1887 – 1967) – first rank symptoms • Current classification – ICD 10/ DSM IV
  6. 6. Classification • Positive symptoms – hallucinations, delusions, bizarre behaviour, formal thought disorder, inappropriate affect • Negative symptoms – affective flattening, poverty of speech/thought, a volition (lacking motivation) – apathy, anhedonia (lacking pleasure or interest in enjoyable activities), social withdrawal, inattentiveness
  7. 7. ICD 10 • Paranoid schizophrenia – prominent delusions, and hallucinations. Usually not much thought disorder or negative symptoms • Hebephrenic (disorganised) SZP – affective abnormality, thought disorder, mannerisms. May have chronic course
  8. 8. ICD 10 contd. • Catatonic schizophrenia – psychomotor symptoms eg violent excitement, posturing, waxy flexibility, automatic obedience, perseveration, stupor • Residual SZP – “defect state” – positive symptoms give way to negative symptoms • Simple schizophrenia – insidious development of negative symptoms without positive symptoms
  9. 9. Epidemiology • Lifetime risk – 1% • Incidence – 20/100 000 per year • Equal prevalence in males and females • Males diagnosed earlier than women (males age 15-25 years, females age 25 – 35 years) • Winter birth excess – increase of 7 – 15%
  10. 10. Aetiological Theories • Biological: – biochemical: (Main theories are dopamine, serotonin and excitatory amino acid hypotheses). – genetic – Neurodevelopmental • psychological • social
  11. 11. Genetics • Greatest risk factor is having a relative with SZP • MZ twin – 48% risk; DZ twin 17% • Child of one parent with SZP – 13% • Child of two parents with SZP – 46%
  12. 12. DSM-IV schizophrenia • A. Characteristics of 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): • Delusions • Hallucinations • Disorganised speech • Grossly disorganised or catatonic behaviour • Negative symptoms (i.e. affective flattening, alogia (reduced speech), or avolition)
  13. 13. N.B. only one (A) symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behaviour or thoughts, or two more voices conversing with each other. • B. Social/occupational dysfunction • C. Duration: continuous signs of the disturbance persist for at least 6-months. This 6-month period must include at least one month of symptoms that meet criterion A.
  14. 14. Diagnosis and Investigation • Diagnosis – presence of typical symptoms • Exclusion of other disorder e.g. organic causes »CVA »Drug-induced e.g. cannabis, steroids »Alcoholic hallucinosis »dementia
  15. 15. Investigations • No diagnostic test • Screen for drugs of abuse (urine) • Bloods for CBC, biochemistry, blood glucose, TFT and VDRL • EEG, ECG, CT and MRI brain
  16. 16. Treatment • May require admission if acutely disturbed or present a risk to self or others • Admission may be useful in assessment • Essential to assess suicide risk as there is a mortality of about 10% from suicide in SZP
  17. 17. Treatment contd. • Antipsychotic drugs (typical and atypical). • May require depot injection • Atypicals have fewer extra-pyramidal side effects and tend to be better for negative symptoms than typicals • IM medication may be required in a very disturbed, involuntary patient
  18. 18. • Maintenance treatment – generally maintenance on one medication • Compliance may be a significant problem because of long-term nature of treatment and lack of insight.
  19. 19. Treatment contd. • Psychosocial treatment: • Education of patient and carers • Cognitive behavioural therapy • Rehabilitation • social skills training • family therapy • occupational therapy.
  20. 20. Prognosis • Good outcome is associated with: – Female – Older age of onset – Married – Living in a developing (as opposed to developed) country – Good premorbid personality – No previous psych history – Good education and employment record – Acute onset, affective symptoms, good compliance with meds
  21. 21. Nursing Management Assessment Assessment of clients who have schizophrenia occurs at individuals, family, and environmental levels. The nurse must be aware of the client' status and of changes in the client's personal life, Family situation and environment to planed care and intervene effectively.
  22. 22. The symptoms of schizophrenia are separated into:- 1-positive symptoms: which represent and excesses or distortion of normal functioning, 2- negative symptoms: which represent an deficit in functioning. 3- cognitive symptoms 4- Depressive symptoms
  23. 23. Assessing Positive Symptoms The positive symptoms appear early in the first phase of the illness, it is the symptoms that gets people's attention and often need hospitalization .They are , usually respond to antipsychotic and behavioral therapy . positive symptoms: ►Hallucinations ►Delusions ►Bizarre behavior ►Thought disorders
  24. 24. Assessing Negative Symptoms of Schizophrenia: ►aVolition; ►Poverty of content of speech. ►Poverty of speech. ►Thought blocking. ►A logia ►Apathy ►Anhedonia ►Attention deficits
  25. 25. Cognitive symptoms ►Difficulty with attention ►Difficulty with memory ►Difficulty with Executive functions (e.g. decision making and problem solving) ►Self care problems
  26. 26. Depressive symptoms ►Increase likelihood of substance abuse ►Increase likelihood of suicide ►Impaired functioning
  27. 27. Nursing Diagnosis: Nursing diagnoses are formulated from the information obtained during the assessment phase of the nursing process. ► The following is a listing of some of the more common diagnoses applicable to schizophrenia.
  28. 28. ►1. Altered thought processes. ►2. Sensory perceptual alterations. ► 3.. Impaired verbal communication. ►4. Social isolation. ►5. Ineffective individual coping. ►6. Self care deficit ( Bathing , hygiene, dressing, grooming, feeding, toileting). ► 7. Altered family processes. ►8. Risk for violence directed at others ►9. Risk for violence self- directed.
  29. 29. 1/ Altered thought process. Related factors: ► - Impaired ability to process and synthesize internal and external stimuli. ► - Biologic factors( neurophysiologic, genetic) ► - Sensory- perceptual alternations. ► - Psychosocial / environmental stressors.
  30. 30. Evidenced by : ►- Inability to distinguish internally stimulated irrational ideas leading to faulty conclusions (autistic). ► Perceives that others in the environment can hear his or her thoughts ( through broadcasting ). ►- Demonstrated neologisms, word salad, thought blocking ,thought insertion, thought withdrawal , poverty of speech, or mutisim.. ►- Believes that his or has thoughts are responsible for world events or disasters.
  31. 31. Goals: ► Demonstrate reality –based thinking in verbal and non-verbal behavior. ►- Demonstrate absence of psychosis ( delusions, incoherent, illogical speech , magical thinking, ideas of references , thought blocking, thought insertions, thought broadcasting).
  32. 32. Nursing Interventions: ►1/ Approach the client in a slow, calm matter of –fact manner ,to avoid distorting the client's sensory- perceptual field , which could foster altered thoughts and perceptions. ►2/ Maintain facial expressions and behaviors that are consistent with verbal statements. Patients are very sensitive to other's responses to their symptoms.
  33. 33. ►3/ Continue to assess the client's ability to think logically and to utilize realistic judgmental problem- solving abilities ►4/ Listen attentively to key themes and reality –oriented phrases or thoughts. Talk about real events of people. ِِ
  34. 34. ►5/ interpret the client's misconceptions and misperceived environmental events in a calm, matter-of fact manner, identifications of reality , by a trusted person is helpful. ►6/ Instruct the client to approach staff when frightening thoughts occur. A respectful , interested approach will enable the patient to discuss an usual and frightening thoughts.
  35. 35. ►7/ Refrain from touching client who is experiencing a delusion especially if it is persecutory type. Touch may be interpreted as a physical or sexual assault. ►8/ A void challenging the client's delusional system or arguing with challenging the belief , may force the client to adhere to it and defend it.
  36. 36. ►9/ Distract client from delusion by engaging him in a less threatening or more comforting topic or activity at the first sign of anxiety or discomfort. ►10/ Focus on the meaning, feeling or intent provoked by the delusion rater than on the delusional content. ►11/ A void seeking the details of the client's delusion so as not to reinforce the false belief and further distance client from reality.
  37. 37. ►12 / Offer praise as soon as the client begins to differentiate reality based on non- reality based thinking. ►13/ Respond to the Clint's delusions of persecution with calm, realistic statement. ►14/ Use simple declarative statements , when talking to the client who demonstrates fragmented ,disconnected , incoherent, or tangential speech patterns ,which reflect loose associations.
  38. 38. 2/ Sensory/ perceptual alteration. Related factors: ► - Psychosocial stressors, loneliness and isolation ( perceived or actual). ►- Withdrawal from environment. ►- Lack of adequate support persons. ►- Chronic illness and institutionalization. ►- Disorientation. ►- Ambivalence. ►- Biologic factors ( neurophysiologic, genetic).
  39. 39. Evidenced by: ► - attentive to surroundings ( preoccupied with hallucination). ►- Startles when approached and spoken to others. ►- Appears to be listening to voices or sounds when neither are present (cocks head to side as if concentrating on sounds tat are inaudible to others). ►- May act upon "voiced" commands ( may attempt mutilating gesture to self or others that could be injurious) ►- Describes hallucinatory experience: " it's my father's voce and he's telling me I'm not good".
  40. 40. Goals: ► - Able to hold conversation without hallucinating. ► - Remains in group activities. ► - Attends the task in hand (e.g. group process, recreational or occupational therapy activities. States that hallucinations are under control.
  41. 41. Nursing Interventions: ►1. Continuously orient patient to actual environmental events of activities. ►2/ Call the client and staff members by their names to reinforce reality. ►3/ Utilize clear, concrete statements. ►4/ utilize clear, direct verbal communication rather than unclear or nonverbal gestures.
  42. 42. ►5/ Focus on real events or activities to reinforce reality and divert client from the hallucinating experience. ►6/ Reassure the client ( frequently if necessary) that he or she is safe and won't be harmed: observe for verbal or nonverbal behaviors associated with hallucinations.
  43. 43. ►7/ Attempt to determine precipitants of the sensory alteration ( stressors that may trigger the hallucination): explore the content of the auditory hallucinations to determine the possibility of harm to self, others or the environment (auditory command and hallucinations) to prevent destructive behavior.
  44. 44. ►8/ When danger of violence is imminent , protect the client and others by following facility procedures and policies for seclusions or chemical or mechanical restrict to prevent harm or injury to client or others. ►9/ Teach the client techniques that will help stop hallucinations.