Professional Documents
Culture Documents
TUPPAD
Lecturer Department of psychiatry
SIONS Bagalkot
HISTORICAL BACKGROUND
ë Ayurveda --- aorel described schizophrenia
as r
Oahlbaum described schizophrenia
as
ecker described schizophrenia as
2 2
The scientific study of schizophrenia began with
the description of r
by Emil
Oraepelin
Dementia= deterioration;
precox=earlyonset
§ IL KRA§§LIN
ë In 1986 he differentiated the major psychiatric
illnesses into two clinical types
1. Dementia precox (delusions,
hallucinations, disturbances of affect, &
motor disturbances)
2. D
§UG§N BL§UL§R(1911)
ë Renamed dementia precox as 2
2
(splitting of
mind) (1908) group of disorders rather than distinct entity
so, he used the word group of schizophrenias.
ë Described characteristic symptoms as
ë Affect disturbance,
ë Association disturbance
ë Negativism
KURT SCHN§ID§R (1959)
ë Described symptoms which though not specific of
schizophrenia, were of great importance in
making a clinical diagnosis
O Schneider First rank symptoms (SFRS)
A.
allucinations
1. Audible thoughts(thought echo)
2. Voices heard arguing
3. Voices commenting on one·s action
B. Thought Alienation phenomena
º. Thought withdrawal
5. Thought insertion
6. Thought diffusion or broadcasting
C. Passivity phenomena
7. ade feeling or affect
8. ade impulses
9. ade volition or acts (robot like)
10. Somatic passivity
D. Delusional perception
11. Delusional perception
SCHIZOHR§NIA
ë The word schizophrenia is derived from Greek
word 2
2
r
ë Term was coined by Swiss psychiatrist §ugen
Bleuler
ë ajor mental disorder characterized by Group of
disturbances which sometimes occur in different
combinations and intensities. Hence it is
2 in nature
D§INITION O SCHIZOHR§NIA
´Schizophrenia is defined as functional
psychotic condition characterized by disturbances
in thinking, emotion, volition and perception in
presence of clear consciousness, which usually
leads to social withdrawalµ.
§ID§ IOLOGY
ë ost common of the psychotic disorders
ë 50% 0f beds in psychiatric hospitals are occupied
I. BIOLOGICAL T
EORIES
1. Genetic hypothesis
ë 8-10% of first degree relatives 3% of second degree
relatives and 2% of third degree relatives of patients with
schizophrenia can have schizophrenia as compared with
0.5-1% prevalence rate in the general population
OULATION INCID§NC§(%)
General population 1.0
Sibling of schizophrenic patient 8.0
Child with one schizophrenic parent 12.0
Child with two schizophrenic parent º0.0
Dizygotic twin of schizophrenic pt 1º.0
onozygotic twin of schizophrenic pt º6.0
£. Biochemical theories
ë unctional increase in dopamine level at post synaptic
receptor
ë Other NT·s like 5-HT, GABA, Acetyl choline
D. Brain imaging
ë Cranial CT Scan, RI Scan, and post mortem studies show
enlarged ventricles and mild cortical atrophy
ë §T Scan shows hypofrontality and decreased glucose
utilization in the dominant temporal lobe
ë Attempts are being made to localize symptoms of
schizophrenia to the various brain regions by §T
º. Other theories
Biological basis of schizophrenia
O Antipsychotics block the D2 receptor, cause improvement, and
relapse occurs on stopping antipsychotic medication
O Newer atypical antipsychotics are D2-5-HT2 antagonists
O Drugs like LSD, amphetamines, and mescaline, can cause
schizophrenia like symptoms in normal subjects.
O Organic mental disorders with schizophrenia like symptoms
may be seen in Huntington·s chorea, homocystinuria, acute
intermittent porphyria, Wilson·s disease and hemachromatosis.
O Soft neurological signs (SNS), minor physical anomalies, and
impaired eye tracking (smooth pursuit eye movements) are more
oftenly seen
O Viral and auto-immune factors have also been implicated by
some, while others (Wein berger) have suggested a
neurodevelopmental hypothesis for schizophrenia.
II.PSYC
OLOGICAL T
EORIES
1. Stress ²Diathesis model
ë Stressful life events
ë Stress-Vulnerability Hypothesis
ë Double-bind theory
ë Communication deviance
ë seudo mutuality
D. Information processing hypothesis
ë Disturbance in attention, inability to maintain a set, and
inability to assimilate and integrate percepts are common
findings
ë The patients may at first be overly attentive to stimuli
but later may reduce attention to stimuli
ë Breakdown in the internal representation of mental
events.
º. Psychoanalytical theories
ë Acc to reud regression to pre oral (and oral) stage of
psychosexual development, with the use of defense
mechanism of denial, projection and reaction formation
ë Acc to edern Loss of ego boundaries, with loss of touch
with reality.
III. SOCIO-CULTURAL T
EORIES
ë Although revalence is uniform across cultures, it was
found more common in low S§S which is now explained
due to a downward social drift which is a result of having
developed schizophrenia rather than causing it
ë igration
ë Disorganization
HAS§S O SCHIZOHR§NIA
ë RODRO AL HAS§
O DS -IV characterizes the prodromal phase as clear deterioration
in functioning before the active phase of the disturbance that is
not due to a disturbance in mood or to a psychoactive substance
use disorder and that involves at least two of the following s/s
ë Social isolation/ withdrawal
ë Impairment in role functioning
ë eculiar behavior
ë Delusions of grandeur
ë Delusions of control
ë Somatic Delusions
ë Overinclusion
ë Impaired abstraction
ë Concreteness
ë erplexity
ë Ambivalence
ë Disorders of perception
O Hallucination
ë Disorders of affect
O Apathy
O §motional blunting
O §motional shallowness
O Anhedonia
O Inappropriate §motional response
O Lack of rapport (due to lack of §motional contact)
ë Disorders of motor behavior
O Decreases (inertia, stupor) or
O increase in psychomotor activities (excitement, aggression,
restlessness, agitation)
O annerisms
O Stereotypies
O Decreased self care
O oor grooming
O Catatonic features
ë ositive symptoms
O Delusions
O Hallucinations
O Bizarre behavior
O Aggression
O Agitation
O Suspiciousness
O Hostility
O §xcitement
O Grandiosity
ë Negative symptoms
O Affective flattening or blunting
O Attentional impairment
O Avolition-apathy (lack of initiative)
O Anhedonia
O Asociality
O Alogia
O Diminished emotional responsiveness
O Stereotyped thinking
O sychomotor slowing, under activity
O assivity and lack of initiative
ë Other features
O Decreased functioning in work, social relations and self care
O Loss of ego boundaries
O ultiple somatic symptoms
O Insight will be absent
O Social judgment will poor
O No disturbance with consciousness, orientation, attention,
memory, intelligence.
O Variability in symptoms over time
O No underlying organic cause
O No prominent mood disorder of depressive or manic type
ë Suicide
ë DIAGNOSIS
O Acc to ICD-10 a minimum of 1 very clear symptom ( and usually
2 or more if less clear cut) belonging to any one of the groups of
referred to as (a) to (d) below, or symptoms from at least 2 of the
groups referred to as (e) to (h), should have been clearly present
for most of the time during a period of 1 month or more (DS -
IV-TR on the other hand requires a minimum period of 6
months)
O If the duration of illness is less than 1 month then a diagnosis of
acute schizophrenia like psychotic disorder should be made.
a. Thought echo, Thought insertion, or withdrawal, or Thought
broadcasting;
b. Delusions of control, influence, or passivity, clearly referred to
body or limb movements or specific thoughts, actions, or
sensation; delusional perception;
c. Hallucinatory voices giving a running commentary on the
patient·s behavior or discussing the patient among
themselves, or other types of hallucinatory voices coming from
some part of the body;
d. ersistent delusions of other kinds that are culturally
inappropriate and completely impossible (e.g. being able to
control the weather, or being in communication with aliens
from another world);
e. persistent hallucinations occurring every day for weeks or
months or months
f. breaks or interpolations in the train of thought resulting in
incoherent or irrelevant speech or neologism;
g. Catatonic behavior
h. Negative symptoms
i. A significant and consistent change in the overall quality of
some aspects of personal behavior, (loss of interest,
aimlessness, idleness, a self absorbed attitude, and social
withdrawal)
ë CLINICAL TYPES
F£ -F£ Schizophrenia
20- Schizophrenia
20.0-aranoid Schizophrenia
20.1-Hebephrenic Schizophrenia
20.2-Catatonic Schizophrenia
20.3-Undifferentiated Schizophrenia
20.º-ost- Schizophrenia depression
20.5-Residual Schizophrenia
20.6-Simple Schizophrenia
ë F£ . -Paranoid Schizophrenia
O Delusions of ersecutory, Grandeur, control, infidelity (Jealousy)
O Hallucinations have ersecutory, Grandiose content
O Unfocussed anxiety
O Anger
O Argumentativeness
O Violence
O Doubts about gender identity
O Disturbances of affect, volition, speech, and motor behavior
O ersonality deterioration is less
O atients may be apprehensive (intelligent, fearful), evasive
(escaping)
O Onset is insidious, occurs later in life, progressive and complete
recovery may not occur
O requent remissions and relapses are seen
O Slight impairment with functional capability
ëF£ .1-
ebephrenic Schizophrenia
O In other classification this type is termed as Disorganized schizophrenia
O arked thought disorder, incoherence and severe loosening of
associations.
O Delusions and Hallucinations
O §motional disturbances
ë Inappropriate affect
ë Blunted affect
ë Senseless giggling
O mannerisms
O irror gazing (for long periods of time)
O oor self care and hygiene
O Impaired social and occupational ----social withdrawal
O ICD-10 recommends 2-3 months of continuous observation for confident
diagnosis
O Onset is insidious in early 2nd decade(15-25 years)
O Course is progressive and downhill
O Recovery never occurs, severe deterioration without remissions
O Has one of the worst prognosis among the subtypes of schizophrenia
ë F£ .£-Catatonic Schizophrenia
ë Catatonia ² marked disturbance in the motor behavior
r
r
ë Onset is acute in late 2nd and early 3rd decade
ë Negativism
ë osturing
ë Stupor
ë §cholalia
ë §chopraxia
ë Waxy flexibility
ë Ambitendency
verbigeration
ë Delusions and hallucinations may present but not prominent
ë
ë
ë
O Schizophreniform disorder
ë This is diagnostic category in DS -IV-TR with features of
schizophrenia. Only difference is duration is less than 6 months and
prognosis is better than schizophrenia
ë This term was introduced by Langfeldt (161)
ë §pisode- brief
illness
O Late Paraphrenia
ë Described by Sir artin Roth
ë Occurs late in life (6
th decade)
room
ë Hallucinations of all kinds are present
O Pfropf schizophrenia
ë Schizophrenia occurring in the presence of R
ë Behavioral disturbances are more prominent than thought disorder
O Type I and Type II Schizophrenia
ë T. J. Crow has divided schizophrenia in to two subtypes as
ë Type I and Type II Schizophrenia
ë NEEDING
OSPITALIZATION
COURS§ AND OUTCO §
ë A study of factors associated with course and
outcome of schizophrenia (SOACOS) conducted
by IC R (Indian Council of edical Research )
at 3 centers in India (Vellore, adras, and
Luknow)
O 386 patients were followed up for 5 years (1981
to1986) the out come was
ë Very favorable outcome (27%)
ë avorable out come (º0%)
ë sychosurgery
O rarely used
O when used limbic leucotomy (small subcaudate lesion with
cingulate lesion) in severe and prominent depression, anxiety
or obsessional symptoms
O Antipsychotics are far better
ë ind a nurse who is having stable and consistent nature and who
is having patience
O Accept him as he is. Accept the pt whole heartedly
O Nurse should not expect the impossible from the pt.
O Assign small responsibilities
O §ngage and support
O Supervise him
O Appreciate for every achievements
O Do not -------- Ignore
Criticize
§xert social behavior
Refrain from over involvement
ë II
ë Careful assessment--------diagnosis----------formulating
a treatment plan
ë Nsg management depends on
O Defining reality
O Handling pt control
O Strengthening the patient·s self image and Strengthening
the IR
O Giving emotional support
ë Nsg diagnosis I
Alteration in thought process r/t inability to trust,
panic anxiety, evidenced by delusional thinking,
inability to concentrate, impaired volition, extreme
suspiciousness of others
O Objective pt will eliminate patterns of delusional thinking
and demonstrate trust in others
ë Nsg diagnosis II
Sensory-perceptual alteration Auditory, visual,
r/t panic anxiety, withdrawal into self, as evidenced by
inappropriate responses, disordered thought process,
poor concentration and disorientation.
O Objective pt will be able to define and test reality,
eliminating the occurrence of hallucinations
ë Nsg diagnosis III
Social isolation r/t inability to trust, panic anxiety,
delusional thinking, evidenced by withdrawal, sad,
dull affect, preoccupation with own thoughts,
expression of feelings of rejection of aloneness imposed
by others.
O Objective pt will voluntarily spend time with other pts and
staff members in group activities on the units
ë Nsg diagnosis IV
otential for violence, self directed or directed to
others, r/t extreme suspiciousness, panic anxiety,
catatonic excitement, rage reactions, command
hallucinations, as evidenced by physical violence,
destruction of objects in the environment, self
destructive behavior or active aggressive suicidal acts.
O Objective pt will not harm self or others
ë Nsg diagnosis V
Impaired verbal communication r/t panic anxiety,
disordered, unrealistic thinking as evidenced by
loosening of associations, echolalia, verbalizations that
reflect concrete thinking and poor eye contact
Objective pt will be able to communicate appropriately and
comprehensibly by the time of discharge
ë Nsg diagnosis VI
Self care deficit r/t withdrawal, panic
anxiety, perceptual or cognitive impairment as
evidenced by difficulty in carrying out tasks associated
with hygiene, dressing, grooming, eating, and toileting.
O Objective patient will demonstrate ability to meet self care
needs independently
DTHµL;;
¶;. Nsg diagnosis VII
ë
´ ineffective family coping r/t highly
ambivalent family relationships, impaired family
communications, as evidenced by neglectful care of the
client, extreme denial or prolonged over concern
regarding his illness
O Objective family will identify more adaptive coping
strategies for dealing with patients illness and treatment
regimen.
§VALUATION
ë Has the pt established trust with at least one
staff member?
ë Is delusional thinking still prevalent?
ë hysical needs
O Nutrition
O ersonal hygiene
O §limination
ë §motional needs
O To improve Social contacts, communication, and IR
O Give importance to personal identity
ë Therapeutic needs
O Accept the pt as human being
O Give responsibility about ward routine works
O atiently and positively hear the suggestions from the pt
himself in implementing routine ward work
O Chronic patients need stimulation, occupational and
recreational therapies
O Nursing care of Chronic patients emphasis should be placed on
the 5 R·s
ë Reassurance
ë Readjustment
ë Reeducation
ë Rehabilitation
ë Recreation