Schizophrenia

Presented by:- Suresh Kumar Prajapati M Sc Nursing Final yr P. G. College of Nursing

Definition :-

“it is type of functional psychosis characterized mainly by disturbance in thinking and associated disturbances in psychomotor activity, affect, perception, and behaviour.

History :-Emil Kraepelin: This illness develops relatively

early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia („Dementia praecox“), but was not followed by any organic changes of the brain, detectable at that time.

Eugen Bleuler: He renamed Kraepelin’s dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a „splitting“ of mind.

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

cont. Bleuler maintained, that for the diagnosis of

schizophrenia are most important the following four fundamental symptoms:

◦ affective blunting◦ Loosing of association (fragmented thinking)◦ Autism(Social withdrawal)◦ ambivalence (conflicting attitude )

These groups of symptoms, are called „four A’ s” and Bleuler thought, that they are „primary” for this diagnosis.

Phases of schizophrenia

1. Pre-morbid phase.(normal functioning)

2. Prodromal phase.(certain sign and symptoms )

3. Schizophrenia.(psychotic symptoms prominent)

4. Residual phase.(negative symptoms)

PREDISPOSING FACTORThe cause of schizophrenia is still uncertain. No

single factor can be implicated in the etiology that include biological, psychological and environmental factors

Biological factors:-

- Genetic, biochemical influences (dopamine, neurotransmitters, serotonin, acetylcholine etc.) viral infection, anatomical abnormilties and physical conditions (head injuries, birth trauma, pakinsonism, huntington disease).

PREDISPOSING FACTOR Psychological influences :-

- Poor parent-child relationship.

- Dysfunctional family systems.Environmental influences :-

-Sociocultural factors (lower socioeconomic classes)

- Stressful life events.

Types of schizophreniaSimple schizophrenia.Disorganized / hebephrenic

schizophrenia.Catatonic schizophrenia.Paranoid schizophrenia.Undifferentiated schizophrenia.Residual schizophrenia.Schizoaffective disorder.

Types..Simple schizophrenia.

- Insidious and gradual course.

- Onset is age of 15-20 yrs.

- More incidence in males.

- Disturbance in affect.

- Disturbance in thinking.

- Delusion & hallucination.

Types..Disorganized / hebephrenic schizophrenia

- Early & insidious onset before age of 25yr.

- Contact with reality extremely poor.

- Affect is flat & inappropriate.

- Communication is consistently incoherent.

- Facial grimaces & bizzare mannerism.

- Personal appearance is generally neglected.

- Social impairment is extreme.

Types..Catatonic schizophrenia.

Marked abnormalities in motar behaviour & may be manifested in the form of stupor & excitement.

Catatonic stupor :- - Extreme psychomotor retardation.

- Mutism (absence of speech).

- Negativism.

- Waxy flexibility

- Echolalia & Echopraxia.

Types..Catatonic excitement:-

-Extreme psychomotar agitation.

- Movements are purposeless.

- Incoherent verbalization.

- Urgently require physical & medical control.

Types..Paranoid schizophrenia:- - onset in late 20s & 30s.

- presence of delusion of persecution, grandeur.

- auditory hallucination.

- individual often tense, suspicious.

- argumentative , hostile & aggressive.

- social impairment minimal.

- negative symptoms like flat affect, poverty of speech & poor activity.

Types..Undifferentiated schizophrenia:- Schizophrenia symptom do not meet the

criteria for any of the subtype or they may meet the criteria for more than one subtype.

- Psychotic symptoms

- Delusion & hallucination.

- Onset late after 40yr of age.

- Incoherent.

- Bizzarre behaviour.

Types..Residual schizophrenia:- There is continuing evidence of the illness,

although there are no prominent psychotic symptoms.

- Residual symptoms

Social isolation , impairment in personal hygiene & grooming, eccentric behaviour , blunted & inappropriate affect, illogical thinking, poverty or elaborate speech.

Types..Schizoaffective disorder:-

This disorder is manifested by schizophrenic behaviour with a strong element of symptomatology associated with the mood disorder (Depression & mania).

The Criteria of DiagnosisFor the diagnosis of schizophrenia is necessary presence of one very clear symptom - from point a) to d) or the presence of the symptoms from at least two groups - from point

e) to h)for one month or more:

a) the hearing of own thoughts, the feelings of thought withdrawal, thought insertion, or thought broadcasting

b) the delusions of control, outside manipulation and influence, or the feelings of passivity, which are connected with the movements of the body or extremities, specific thoughts, acting or feelings, delusional perception

c) hallucinated voices, which are commenting permanently the behavior of the patient or they talk about him between themselves, or the other types of hallucinatory voices, coming from different parts of body

d) permanent delusions of different kind, which are inappropriate and unacceptable in given culture

The Criteria of Diagnosise) the lasting hallucination of every formf) blocks or intrusion of thoughts into the flow of

thinking and resulting incoherence and irrelevance of speach, or neologisms

g) catatonic behaviorh) „the negative symptoms”, for instance the expressed

apathy, poor speech, blunting and inappropriatness of emotional reactions

i) expressed and conspicuous qualitative changes in patient’s behavior, the loss of interests, hobbies, aimlesness, inactivity, the loss of relations to others and social withdrawal

CLINICAL MANIFESTATION

POSITIVE SYMPTOMS.. Content of thought:- Delusion(Persecution, Grandeur, reference, control, nihilistic,

somatic paranoia ), Magical thinking.

form of thought:- Associative looseness, neologism, concrete thinking, clang

association, word salad, circumstantiality, tangentiality, Mutism.

Perception:- Hallucination(auditory, visual, tactile, gustatory, olfactory), illusion.

Sense of self:- Echolalia, echopraxia & depersonalization.

CLINICAL MANIFESTATION Negative symptoms.. Affect:- inappropriate, flat .

volition:- inability to initiate goal directed activity.

Emotional ambivalence impaired interpersonal functioning & relationship with

the external world – autism, deteriorated appearance. Psychomotar behaviour:- anergia(deficiency of energy),

waxy flexibility. Associated feature:-

Anhedonia( inability to experience pleasure).

Management of Schizophrenia

The treatment of schizophrenia can be discussed under the following headings.

Pharmacological treatment. Electro-convulsive therapy. Psychosocial treatment & Rehabilitation.

Pharmacological treatment. Typical (Traditional) Antipsychotics – target the

positive symptoms. Atypical (Novel) Antipsychotics – diminish the

positive and negative symptoms.

Typical Antipsychotics Atypical Antipsychotics Chlorpromazine (CPZ) Clozapine

Haloperidol Risperidone

Loxapine Olanzapine

Trifluoperazine AmisulpridePerphenazine ZiprasidoneMesoridazine QuetiapineFluphenazine AriprazoleThiothixene

Electro-convulsive therapyIt's extremely rare for patients with

schizophrenia to be offered ECT,“.Most people are given ECT every two to

five days for a total of 6 to 12 sessions.

Psychosocial treatment & Rehabilitation Psychosocial treatment is an extremely important

component of the comprehensive management o schizophrenia which involve a various type of psychotherapy..

Psychoeducation. Individual psychotherapy. Group therapy family therapy Milieu therapy. Psychosocial rehabilitation(social skills,

occupational & vocational guidance)