Download Paranoid schizophrenia cont.

Schizophrenia
Prepared by :
Hisham M. El Mudallal
Ibrahim H. Rabea
Mohamed Z. Aish
Supervised by :
Dr. Abd Al Kareem Radwan
Presentation Objectives:
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Introduction
Etiological Theories
Epidemiology
Classification
Clinical description and symptoms
Client assessment
Diagnostic criteria
Prognosis
Management and nursing diagnosis
Introduction
•
Schizophrenia describes psychotic that at
some time is characterized by apathy, a
volition.
• Schizophrenia is a mental disease that affects
brain works.
• This disease may change ad disturbance in
“thought – affect – and perception”.
• He become burden to his family and the
patient function deteriorates in all fields.
Etiological
1- Biologic Factor:
1- Heredity and generic:
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Children of schizophrenic parent are more liable to
develop schizophrenia.
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General population 1%.
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One schizophrenic parent 12%.
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Two schizophrenic parent 40%.
Etiological cont.
2- Neuroanatomics and neurochemicals:
Structure and function of nervous system
teratogenic drug exposure.
3- Neurotransmitter and the dopamine hypothesis:
The dopamine theory states that there
is
hyperactivity of the dopamine. System in the brains
of schizophrenics. Dopamine blocking agents are
effective in treating schizophrenic symptoms.
Etiological cont.
4- Immunological Factors:
Viral exposure in pregnancy.
5- High arousal levels from:
(stress, disease, trauma and drug)
Stress such as bombarded of stimuli from life event.
Disease such as prenatal virus exposure encephalitis
Trauma from obstetrical complication, head trauma.
Drugs such as cannabis.
Etiological cont.
2- Psychoanalytic and developmental Factor:
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Defect in ego organization.
The child is unable to separate and progress the
complete dependence on the mother.
3- Familiar Factor:
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Schizophrenic develops system due to family interaction
and communication.
 Double bind
 Destructive, express emotion communication patterns.
Etiological cont.
4- Culture and Environmental Theories:
 Low socioeconomic status.
 Less social support of family and community.
5- Learning Theory:
 The distorted thinking,
communication pattern.
and the deficient
Epidemiology
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New diagnostic of schizophrenia occur between 0.3%
and 0.6% per 1000 persons per years in the united
state.
 1.5% of the United State population has been
diagnosed with schizophrenia.
 Age of onset is greater females than in male.
 Paranoid-type schizophrenia occur earlies in male
than in female.
 Disorganized type schizophrenia occur earlies in
males than in females.
 50% of personal with schizophrenia attempt suicide.
Clinical Description:
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Schizophrenia according DSM-Iv has the following
criteria “continuous of symptoms more than six month”
include the symptoms at least two manifestation:"
hallucination – delusions - disorganized – catatonic
behavior disorganized speech.”
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There are five major subtype of schizophrenia and
several closely related disorder.
Clinical Description cont.
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The five subtype of schizophrenia are “paranoid –
disorganized- catatonic – undifferentiated- residual”
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The closely related disorders are:” schizophrenia
form- schizoaffective – delusional- brief psychotic
disorder- shorted psychotic disorder”
1-Paranoid schizophrenia
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Result in less neurological and cognitive impairment.
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According to the DSM-Iv criteria for schizophrenia
opposite, a diagnosis of paranoid schizophrenia must
meet
two
of
criteria
"presence
delusion
hallucinations“.
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Delusions to be perescutory or grandiose.
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Hallucination common auditory hallucination.
and
Paranoid schizophrenia cont.
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Paranoid schizophrenia usually has as sudden
onset.
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Prognosis: better prognosis for the individual.
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More hopeful than the courses of other subtype.
"pt's ego is stronger than other types"
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Is most responsive to proper treatment.
2-Disorganized schizophrenia
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Known as hebephrenic schizophrenia.
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Childish affect is characterized by server disintegration
of the personality.
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Speech is disorganized and may include word salad
"communication that includes both real and imaginary
words. No logical order"
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Speech incoherent.
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Behavior is odd, stereotyped behaviors.
Disorganized schizophrenia cont.
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The pt is withdrawal.
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Thinking is concrete.
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Poor personal grooming and unable to complete
activities of daily living because behavior is aimless
and without goals.
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Prognosis: is poor, stemming from an early pre-morbid
history of impaired adjustment.
3- Catatonic Schizophrenia
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Intense psychomotor disturbance " psychomotor
retardation" or excitement "psychomotor
excitement”.
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Manifestation immobility catalepsy wax flexibility,
mutism, and negativism "resistance to all
instruction”.
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Echopraxia" imitating the movement of other”.
Catatonic Schizophrenia cont.
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Echolalia “repeating what was said by another”.
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Stereotyped movement.
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Catatonic stupor: withdraw.
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When stuporous: that can threatening of life because
not eat, danger of malnutrition, constipation.
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Prognosis: depend on the age of onset which is often
in early 20s to 30s.
4- Undifferentiated Schizophrenia
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Doesn’t clearly meet the criteria necessary for
diagnosis in other types of schizophrenia
"paranoid- disorganized catatonic“.
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Manifestation
fragmented
delusionvogue
hallucination bizarre- careless- incoherence.
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Growth and development milestones may have
been delayed.
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The most common symptoms bored.
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Sleep disturbed by nightmares and early morning
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Prognosis: generally poor.
5- Residual Schizophrenia
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In an individual had at least one acute episode of
schizophrenia and in how free of prominent positive
symptoms but has some negative symptoms he is
diagnostic suffering from residual schizophrenia.
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This pattern may persist for years, with or without
exacerbation.
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Diagnostic
criteria:
absence
of
delusions
–
hallucination disorganized speech- catatonic behavior.
Residual Schizophrenia cont.
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Continue negative and positive symptoms.
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Positive symptoms: delusion – hallucination – bizzar
dress – agitation behavior – pressured speech.
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Negative symptoms: flat or inappropriate affect poor
eye contact – withdrawal - poor hygiene - apathy inattentiveness.
Syptoms
1- Perceptual Disturbance:
Hallucination can occur in any of the five receptive senses
" Auditory – visual – tactile – olfactory – taste: but the most
common are auditory.
2- Cognitive disturbances:
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Cognitive Symptoms:
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Not able to make decisions.
Memory problem.
Poor ability to understand information.
Poor problem solving skills.
Syptoms cont.
3- Emotion Disturbance:
Emotion disturbance is a primary sign of all forms of
schizophrenia affect flat and poor eye contact. Cannot
adapt.
4- Behavioral Disturbance:
Is the possibility of violence the incidence and type of
violence depend on certain factor type of schizophrenia.
5- Social Disturbance:
Poor social competence may be important development
schizophrenia.
Other Psychotic Disorder
1- Schizophreniform disorder:
Similar to Schizophrenia in the symptoms but differs in the
period in which disorder stage don’t excess 6 months.
2- Schizo affective disorder:
Symptoms of Schizophrenia are mixed
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If the symptoms of depression are present disorder culled "
Schizo – depressive disorder
If the symptoms of mania are present the disorder will be culled
"schizo p manic disorder"
Other Psychotic Disorder cont.
3- Brief psychotic disorder.
Psychotic symptoms with acute onset for few hour and not
exceeding one month. Then person back to his normal
vocational and social.
4- Shared psychotic disorder.
Delusional disorder occur to the pt as a result of his strong
relation with another person who is the original owner of
these delusions. treatment –> separate them.
5- Post – partum psychoses.
Usually the symptoms appear at the third day of delivery
starting with insomnia irritability, crying, in late symptoms
she thought is not married and she is still virgin.
Other Psychotic Disorder cont.
6- Delusional Disorder “Paraphrenia”
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It is disorder in which the organized delusions dominate
without physical causes and the symptoms of mood
disorder or schizophrenia are not present.
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Types:
1.
Erotomanian: that dominates on the pt that he is loved
another love. Usually the pt is female.
2.
Grandiose: The pt believes that he is great but unknown or
he discovered important discoveries
3.
Jealously: the pt is convinced that his wife is unfaithful
and he is collecting even weak evidence to prove her
unfaithfulness.
4.
Persecutory: Most common the pt believes that the
other observing him following him and trying to put
poison for him to prevent from achieving his goals.
5.
Somatic Type: is that the pt is convinced that a bad
order is coming out from his skin; or part of his body is
not working “kidney”
How Is Schizophrenia Diagnosis?
You must have two or more of the following symptoms
during a one-month period:
 Delusion.
 Hallucinations.
 Disorder thinking or speech.
 Negative symptoms.
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The following must also be true for you to be diagnosis
with schizophrenia your must symptoms last at least
six months.
Mental Status Examination
1- Appearance and Behavior:
The patient’s behavior may be very strange. He may be
talkative and hyperactive or mute and very quiet. Catatonic
excitement is used to describe a state of intense
disorganized hyperactivity. In catatonic stupor, on the other
hand, the patient seems completely lifeless and may show
signs of negativism, muteness and automatic obedience. The
patient is withdrawn and shows lack of self-care and hygiene.
2- Mood and Affect
Affect is abnormal.
Restricted affective response: the patient shows very little
affect, his face may show little change when talking about
different topic. Blunting and flat of affect means absence of
any affective response in the facial expression, tone of
voice or movements.
Inappropriate affect: the patient’s affective response is not
going with hi experience.
Ambivalence: some patients show contradicting affects to
same experience, like feeling love and hate to the same
person at the same time.
3- Perception
Hallucination: Auditory hallucination are the most common
perceptual disturbance in schizophrenia. Usually they are
voices that talk to the patient or comment on his actions or
thoughts.
Visual hallucinations may occur in schizophrenia, but this
should alert to the possibility of organic cause. Tactile and
other somatic hallucination occur rarely, they require
investigation for possible organic cause.
Illusions: illusions also occur in schizophrenia.
4- Thought disturbance
This may be divided into disturbance in content, from and
process of thinking.
Delusion: they can be persecutory ,grandiose, religious, or
somatic delusions.
In persecutory delusions the patient may believe that other
people are trying to harm him or kill him , he may think that his
family is putting poison in his food and refuse to eat with them.
Delusions of reference: are beliefs that others talk about the
patient e.g. TV news about him or hearing his name in the
radio .
4- Thought disturbance cont.
Grandiose delusions: the beliefs of great abilities or wealth.
The patient may think that he is a president or prophet.
Passivity delusions: the belief being influenced by other, e g.
other can read his thoughts or a computer is directing his
actions.
Lack of boundary: the patient does not have a clear sense
of where his body and internal hallucination from external
perception . his control over his thought process may show
thought insertion or thought withdrawal , the patient feels
that others can put thoughts into his head (or take) or read
his thoughts.
Disorders in the form of thought
Thought process is the way ideas and language are formulated.
Flight of ideas: rapid and continuous flow of ideas, with plays on
words, and constant shifting from one idea to another.
Thought blocking: sudden stop in the process of thinking
experienced by the patient as if the thoughts were withdrawn
from his head. The patient may stop talking and does not return
to the subject.
Abstract thinking : is abnormal, the patient can not think in
abstract terms.
It is difficult for him to interpret proverb, or find similarities
between objects.
Mental Status Examination cont.
5- Impulse Control:
The patient may have poor control over his actions may
be aggressive or intrusive . some patients may commit
homicide (kill others)driven by their delusions. Others
may commit suicide.
6- Orlentaion:
usually the patient is oriented to place, time and person.
This may be difficult to assess because of poor
cooperation from patient.
Mental Status Examination cont.
7- Memory:
It is usually normal, but can be distorted by delusional
thinking, e.g. the patient remembers clearly that he was
dispelled from school, but may attribute that to the
teacher being against him.
8 Judgment and insight:
Schizophrenia pt have little or no insight into their
condition. Judgment is best assessed by observing the pt
in the interview or from external sources.
Management of Schizophrenia
1- Hospitalization:
In acute stage of the disorder, because pt may be aggressivediagnosis- care.
2- Medication:
Neuroleptics: do not treat schizophrenia they treat
schizophrenic symptoms.
A.
B.
Chlorpromazine “largactil” used in acute stage.
Haloperidol “ haldol” used in chronic stage.
3- Electro convulsive therapy “ECT” used in catatonic or pt not
taken medication.
Management of Schizophrenia cont.
4- Psychosocial Treatment:
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Behavior therapy.
Occupational therapy.
Group therapy.
Assertive community treatment: a team of caregiver and support
group.
Cognitive behavior therapy: helps to change behavior.
Family psychoeducation.
Social skills training
Supported employment: it will help give you independence and
self-confidence.
Teaching illness-management skills
Therapist must be flexible and take into account the pt fear.
Management of Schizophrenia cont.
5- Community care for schizophrenic
patients:
•
In community care the services are provided to the pt
and his family on local basis.
• Services provided by team of professional working.
• Family is involved management plan and care for pt.
Nursing Diagnosis
1.
High risk for violence. Self directed or directed at
other related to hallucination.
2.
Altered thought process related to anxiety.
3.
Sensory perceptual alteration “Auditory” related to
poor concentration.
4.
Altered though process related to inability to trust.
5.
Impaired verbal communication related to withdrawal
into the self.
References:
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Katherine M. Fortinasl and Patricia A. Holodayworret (1996) psychiatric Mental Health Nursing,
Newyork, Tornto, 1st edition.
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Rob Newell and Kevin Gournay. (2009) Mental
Health Nursing, New York, Tornto, 2nd edition.