SCHIZOPHRENIA

1911 - Swiss psychiatrist Eugene Bleuler. Greek words - schizein (to split) and phren (mind) complex neurobiological brain disease affecting ones ability to perceive and process information and involving a number of syndromes. causes distorted and bizzare thoughts, perceptions, emotions, movements and behavior. cant be defined as a single illness. CLINICAL COURSE Onset Abrupt or insidious, but most clients slowly & gradually develop s/sx such as social withdrawal, unusual behavior, loss of interest in school or work, & neglected hygiene. Dx-made when the person begins to display more active positive symptoms of delusions, hallucinations & disordered thinking. Those who develop the illness earlier show worse outcomes than those who develop it later. Immediate course: The client experiences ongoing psychosis and never fully recovers, although symptoms may shift in severity over time. The client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recovery from psychosis Long term course Tends to diminish with age. Regain some degree of social and occupational functioning. Over time, the disease becomes less disruptive to the persons life & easier to manage, but rarely can the client overcome the effects of many years of dysfunction. In later life, they may live independently or in a structured family-type setting & may succeed at jobs with stable expectations & a supportive work environment. Most clients have difficulty functioning in the community & a few lead fully independent lives. Etiology

Biological Factors a. Genetic b. Neuroanatomic c. Neurochemical d. Immunovirologic 2. Psychological Factors 3. Sociocultural and Environmental Factors Genetic: Identical twin 50% Fraternal twin 15% One parent 15% Both parents 35% Sibling 10% 2 relative 2 to 3% Adopted at birth Less brain tissue and cerebrospinal fluid. Failure in brain development or a subsequent loss of tissue. Changes within the brain affects language and memory. Neurochemical factor Alterations in the neurotransmitter systems. Dysregulation hypothesis of schizophrenia: a. Mesolimbic area (limbic system) has overactive dopamine pathways. Function-memory, smell and emotional behavior. b. Mesocortical area (frontal lobes) has hypoactive dopamine pathways. Function-insight, judgment, social consciousness, inhibition, and highest level of cognitive activities such reasoning, motivation, planning and decision making. c. An imbalance exists between dopamine and serotonin neurotransmitter systems. Immonovirologic factor Prenatal exposure to the influenza virus (second trimester) Psychological factor Poor care giving Failure to accomplish an early stage of psychosocial development

 Inability to cope with stress. Socio cultural factor Poverty Society Cultural disharmony Living in isolation

Echolalia-Imitation or repetition of what another person says. Flight of ideas-a constant flow of speech in which the individual jumps from one topic to another in rapid succession, there is a connection between topics, although it is sometimes difficult to identify. Hallucination-false sensory perceptions or perceptual experiences that do not exist in reality. Auditory Hallucinations involve hearing sounds, most often voices, talking to or about the client. Visual Hallucinations involve seeing images that do not exist at all or distortions. Olfactory Hallucinations involve smells or odors. Tactile Hallucinations involve feeling touch sensations in the absence of stimuli Gustatory Hallucinations involve experiencing taste in the absence of stimuli. Cenesthetic Hallucinations involve the clients report that he or she feels bodily functions that are usually undetectable. Kinesthetic Hallucinations occur when the client is motionless but reports the sensation of bodily movement. Perseveration-The persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, even when another person attempts to change the topic. Word salad-is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Negative Symptoms Diminution or loss of normal function. Usually unresponsive to traditional antipsychotics. More responsive to atypical antipsychotics. Mesocortical system. Alogia-Tendency to speak very little or to convey little substance of meaning (poverty of content)

Positive symtoms Exaggeration or distortion of normal function. Responsive to traditional antipsychotic drugs. Mesolimbic system. Looseness of association fragmented or poorly related thoughts and ideas Delusions fixed false beliefs that have no basis in reality Persecutory / Paranoid Delusions involve the clients belief that others are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Grandiose Delusions characterized by the clients claim to association with famous people or celebrities, or the clients belief that he or she is famous or capable of great feats. Religious Delusions often center around the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as part of the clients psychosis and are not part of his or her religious faith or that of others. Somatic Delusions are generally vague and unrealistic beliefs about the clients health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Referential Delusions / Ideas of Reference involve the clients belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Echopraxia -Imitation of the movements and gestures of another person whom the client is observing.

Anhedonia-feeling no joy or pleasure from life or any activities or relationships. Apathy-feelings of indifference toward people, activities, and events. Catatonia-psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless. Waxy flexibility-having ones arms or legs placed in a certain position and holding that same position for hours. Avolition-absence of will, ambition, or drive to take action or accomplish tasks. Flat affect-absence of any facial expression that would indicate emotions or mood. Blunted affect-restricted range of emotional feeling, tone, or mood. Unusual speech pattern Clang association-are ideas that are related to one another based on sound or rhyming rather than meaning. Neologism-are words invented by the client. Verbigeration-is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Stilted language-is the use of words or phrases that are flowery, excessive, and pompous. Perseveration-is the persistent adherence to a single idea or topic and a verbal repetition of a sentence phrase, or word, even when another person attempts to change the topic. Judgment is based on the ability to interpret the environment correctly. Lack of judgment is so severe that client cant meet their needs for safety & protection & place themselves in harms way.

Insight is also impared, especially when family & relatives dont understand what is happening. Lack of a clear sense of where his or her own body, mind, & influence end & where those aspects of other animate & inanimate objects begin . Clients believe they are fused with another person or object, may not recognized body parts as their own, or may fail to know whether they are male or female. Inattention to hygiene & grooming needs is common, especially during psychotic episodes . Preoccupied with delusions or hallucinations leading to nonperforming of basic daily living activities. Failure to recognized sensations such as hunger or thirst, food or fluid intake may be inadequate. Sleep problems are common. TYPES: Paranoid type Persecutory or grandiose delusions, hallucinations, and occasionally, excessive religiosity or hostile and aggressive behavior. Disorganized type Grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Catatonic type Marked psychomotor disturbance (motionless or excessive motor activity), extreme negativism, mutism, pecularities of voluntary movement, echolalia, and echopraxia. Undifferentiated type Mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. Residual type

 At least one previous, though not a current episode; social withdrawal; flat affect; and looseness of associations. Related disorder Schizophreniform-The client exhibits the symptoms of schizophrenia but less than 6 months. Social or occupational functioning may or may not be impaired. Schizoaffective-The client exhibits the symptoms of pychosis and all the features of a mood disorder, either depression or mania. Delutional-The client has one or more nonbizarre delusions-the focus of delusion is believable. Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre. Brief psychotic-The client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which last from 1day to 1 month. The episode may or may not have an identifiable stressor or may follow childbirth Shared Psychotic-Two people share a similar delusion. The person with this diagnosis develop this delusion in the context of a close relationship with someone who has psychotic delusions . Management Build trust Basic needs Reality Self-esteem Independence Medical Intervention Treatment Psychopharmacology Psychosocial Treatment Antipsychotic medications / Neuroleptics: 1. The conventional antipsychotic medications

ex. Chlorpromazine dopamine antagonists target positive signs but have no observable effect on the negative signs. 2. The atypical antipsychotic medications ex. Clozapine both dopamine and serotonin antagonists target both positive and negative signs. Psychosocial treatment 1.Individual and group therapy - social contact and meaningful relationships with other people. 2. Social skills training - improve social competence. 3. Family therapy and education - make family members part of the treatment team.

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*Norepineprine increase - mania *Norepinephrine decrease - depression Object Loss Theory Loss of parent before age 11 increases risk Personality Organization Theory Obsessive-Compulsive Dependent personality Hyterical personality Aggression turned inward Theory Over-developed superego leads depression Learned Helplessness Theory one has no control over his environment helplessness and hopelessness Cognitive Theory (-) view of self (-) view of future (-) interpretation of Experience Environmental Theory Financial hardship, physical illness, perceived or real failure, midlife crises Poor, single persons, working mothers with young children Divorce, relocation, loss or change of employment, retirement TYPES: I. UNIPOLAR - with history of depression without any history of elation 1. MAJOR DEPRESSIVE DISORDER 2. DYSTHYMIC DISORDER 3. Depressive Disorder Not Otherwise Specified (DDNOS) II. BIPOLAR - with history of elation with or without depression DEPRESSION/UNIPOLAR DISORDER persistent sad or depressed mood, loss of interest on things that were to

MOOD DISORDER
Mood- Pervasive and sustained emotions that influences how a person perceives the world. Affect-Indicates emotional state. a persons current

TYPES OF MOOD 1. Euthymic mood 2. Elated mood 3. Dysphoric mood 4. Irritable mood Mood Disorder-pervasive alterations in emotions that are manifested by mania, depression or both. Etiology 1. Genetic/Hereditary Theory 2. Biochemical Theory 3. Object Loss Theory 4. Personality Organization Theory 5. Aggression turned inward Theory 6. Learned Helplessness Theory 7. Cognitive Theory 8. Environmental Theory Genetic/hereditary Twin 70% Parents 15% Sibling 15% 2 relative 7% Biochemical Theory Norepinephrine and Serotonin *Deficit serotonin in Depression

pleasurable and disturbance in sleep, appetite, energy and concentration. RISK FACTORS FOR DEPRESSION 1. Prior episodes of depression. 2. Family history of depressive disorder 3. Prior suicide attempts. 4. Gender: female 5. Age: younger than 40 years 6. Postpartum period 7. Chronic general medical condition 8. Lack of social support 9. Stressful life events. 10. Substance abuse or dependency 11. Other psychiatric conditions. 9 CLINICAL SIGNS D-ecrease ability to concentrate E-ating disturbance P-hysical signs (agitation or retardation) R-eccurent thought of death E-xcessive feeling of unworthiness S-leep disturbance (insomnia/hypersomnia) S-adness/dysphoria E-nergy diminished D-iminished pleasure (anhedonia) MAJOR DEPRESSIVE EPISODE At least 2weeks period of maladaptive functioning that is a clear change from previous levels of functioning. The mood disturbance causes marked distress and / or significant impairment in social or occupational functioning. There is no evidence of a physical or substance etiology for the patients symptoms or of the presence of another major mental disorder that accounts for the patients depressive symptoms. At least 1 or 2 of the following symptoms must be present during that 2-week period: 1. Depressed mood 2. Inability to experience pleasure or markedly diminished interest in pleasurable activities 3. Appetite disturbance with weight change 4. Sleep disturbance 5. Psychomotor disturbance 6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to concentrate or indecisiveness 9. Recurrent thoughts of death or suicidal ideations Categories of MDD according to specifiers (population, time frame, and/or symptoms) 1. Atypical depression 2. Melancholic depression 3. Postpartum depression 4. Psychotic depression 5. Seasonal affective disorder (SAD) Characteristics of Major Depressive Episode Mood depressed; Memory problems Anxious; Apathetic; Appetite changes Just no fun Occupational impairment Restlessness Doubts self; Difficulty making decisions Empty feeling Persistent sadness; Psychomotor retardation Report vague pains Energy gone Suicidal thoughts and impulses Sleep disturbances Irritability; Inability to concentrate Oppressive guilt Nothing can help (Hopelessness) 2. Dysthymic Disorder Exhibit 2 or more of six clinical symptoms with depression. Clinical symptoms usually persist for 2 years or more and may be continual or may occur intermittently with normal mood swings for a few days or weeks. Clinical symptoms interfere with functioning and are not due to a medical condition or the physiologic effects of a substance. Not as severe and do not include symptoms such as delusions, hallucinations, impaired communication, or incoherence. 3. Depressive Disorder Not Otherwise Specified Disorders with depressive features that do not meet the criteria for major depressive

disorder, dysthymic disorder and other related disorder. BIPOLAR DISORDER Also called manic-depressive disorder both poles of mood TYPES 1. Manic episode or Mania 2. Hypomanic episode or Hypomania 3. Bipolar I 4. Bipolar II 5. Cyclothymic Disorder or Cyclothymia Manic/Mania Episode A. A distinct period of abnormal and persistent elevated, expansive, or irritable mood that lasts at least 1 week (or less if hospitalization is required). B. At least 3 of the following symptoms must occur during the episode (or 4 if the patient is only irritable). 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. Very talkative 4. Flight of ideas 5. Distractibility 6. Psychomotor agitation 7. Excessive involvement in apleasurable activities that have a high potential for personal problems. C. Mood disturbance severe enough to cause problems socially, interpersonally, or at work, or the person has to be hospitalized to prevent harm to self or others. D. The symptoms are not due to the direct physiological effects of a substance or a general medical condition. Characteristics of Manic Episodes Endless energy Decreased need for sleep Omnipotent feelings Substance abuse Increased sexual interest Poor judgment; Provocative behavior Euphoric mood

Cant sit still Irritable, impulsive, intrusive behavior Nothing is wrong Active; Aggressive Mood swings Hypomanic/Hypomania Meets most of the criteria for manic episode, with 2 major exceptions: 1. The symptoms must last at least 4 days 2. The person must manifest an unequivocal change in functioning that is observable by others. Bipolar I The patient must have a history of a manic episode Six categories: 1. Bipolar I disorder, single episode 2. Bipolar I disorder, most recent episode manic 3. Bipolar I disorder, most recent episode hypomanic 4. Bipolar I disorder, most recent episode mixed 5. Bipolar I disorder, most recent episode depressed 6. Bipolar I disorder, most recent episode unspecified Bipolar II The patient has experienced major depression and a hypomanic episode but not a manic episode Cyclothymic/Cyclothymia 1. For a period of 2 years, the patient has had numerous periods of hypomanic symptoms and numerous periods of a depressed mood. 2. The patient is never symptom-free for more than 2 months at a time. 3. The patient has never experienced major depression. PSYCHOTHERAPEUTIC MANAGEMENT 1. Therapeutic Nurse-Patient Relationship 2. Milieu Management 3. Psychopharmacology Therapeutic nurse-patient relationship Matter of fact tone

Clear, concise directions and comments Limit setting Reinforcement of reality Respond to legitimate complaints Redirect patients into more healthy activity Safety Consistency among staff Reduction of environmental stimuli Dealing with patients who are escalating Reinforcement of appropriate hygiene & dress Nutrition and Sleep issues

Bipolar patients who are too busy to eat: 1. Provide finger foods 2. Provide high-protein, high-calorie snacks 3. Weigh regularly Bipolar patients who cannot sleep: 1. Provide a quiet place to sleep 2. Structure and plan activities 3. Do not allow caffeinated drinks before Bedtime Psychopharmacology Antimanic: Lithium (900-1200mg/day) Mood Stabilizers: Anticonvulsants Carbamazepine (Tegretol) Valproic acid (Depakote) Gabapentin (Neurontin) Lamotrigine (Lamictal) Topiramate (Topamax)

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