1. Schizophrenia Prepared by : Hisham M. El Mudallal Ibrahim H. Rabea Mohamed Z. Aish Supervised by : Dr. Abd Al Kareem Radwan

2. Presentation Objectives: Introduction Etiological Theories Epidemiology Classification Clinical description and symptoms Client assessment Diagnostic criteria Prognosis Management and nursing diagnosis

3. 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.

4. Etiological 1- Biologic Factor: 1- Heredity and generic: Children of schizophrenic parent are more liable to develop schizophrenia. General population 1%. One schizophrenic parent 12%. Two schizophrenic parent 40%.

5. 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.

6. 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.

7. 2- Psychoanalytic and developmental Factor: Defect in ego organization. The child is unable to separate and progress the complete dependence on the mother. 3- Familiar Factor: Schizophrenic develops system due to family interaction and communication. Double bind Destructive, express emotion communication patterns. Etiological cont.

8. 4- Culture and Environmental Theories: Low socioeconomic status. Less social support of family and community. 5- Learning Theory: The distorted thinking, and the deficient communication pattern. Etiological cont.

9. Epidemiology 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.

10. Clinical Description: 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.” There are five major subtype of schizophrenia and several closely related disorder.

11. Clinical Description cont. The five subtype of schizophrenia are “paranoid – disorganized- catatonic – undifferentiated- residual” The closely related disorders are:” schizophrenia form- schizoaffective – delusional- brief psychotic disorder- shorted psychotic disorder”

12. 1-Paranoid schizophrenia Result in less neurological and cognitive impairment. According to the DSM-Iv criteria for schizophrenia opposite, a diagnosis of paranoid schizophrenia must meet two of criteria "presence delusion and hallucinations“. Delusions to be perescutory or grandiose. Hallucination common auditory hallucination.

13. Paranoid schizophrenia cont. Paranoid schizophrenia usually has as sudden onset. Prognosis: better prognosis for the individual. More hopeful than the courses of other subtype. "pt's ego is stronger than other types" Is most responsive to proper treatment.

14. 2-Disorganized schizophrenia Known as hebephrenic schizophrenia. Childish affect is characterized by server disintegration of the personality. Speech is disorganized and may include word salad "communication that includes both real and imaginary words. No logical order" Speech incoherent. Behavior is odd, stereotyped behaviors.

15. Disorganized schizophrenia cont. The pt is withdrawal. Thinking is concrete. Poor personal grooming and unable to complete activities of daily living because behavior is aimless and without goals. Prognosis: is poor, stemming from an early pre-morbid history of impaired adjustment.

16. 3- Catatonic Schizophrenia Intense psychomotor disturbance " psychomotor retardation" or excitement "psychomotor excitement”. Manifestation immobility catalepsy wax flexibility, mutism, and negativism "resistance to all instruction”. Echopraxia" imitating the movement of other”.

17. Catatonic Schizophrenia cont. Echolalia “repeating what was said by another”. Stereotyped movement. Catatonic stupor: withdraw. When stuporous: that can threatening of life because not eat, danger of malnutrition, constipation. Prognosis: depend on the age of onset which is often in early 20s to 30s.

18. 4- Undifferentiated Schizophrenia Doesn’t clearly meet the criteria necessary for diagnosis in other types of schizophrenia "paranoid- disorganized catatonic“. Manifestation fragmented delusion- vogue hallucination bizarre- careless- incoherence. Growth and development milestones may have been delayed. The most common symptoms bored. Sleep disturbed by nightmares and early morning Prognosis: generally poor.

19. 5- Residual Schizophrenia 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. This pattern may persist for years, with or without exacerbation. Diagnostic criteria: absence of delusions – hallucination disorganized speech- catatonic behavior.

20. Residual Schizophrenia cont. Continue negative and positive symptoms. Positive symptoms: delusion – hallucination – bizzar dress – agitation behavior – pressured speech. Negative symptoms: flat or inappropriate affect poor eye contact – withdrawal - poor hygiene - apathy - inattentiveness.

21. 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: Cognitive Symptoms: Not able to make decisions. Memory problem. Poor ability to understand information. Poor problem solving skills.

22. 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. Syptoms cont.

23. 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 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"

24. 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.

25. Other Psychotic Disorder cont. 6- Delusional Disorder “Paraphrenia” It is disorder in which the organized delusions dominate without physical causes and the symptoms of mood disorder or schizophrenia are not present. 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

26. 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”

27. 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. - The following must also be true for you to be diagnosis with schizophrenia your must symptoms last at least six months.

28. 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.

29. 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.

30. 3- Perception 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. Management of Schizophrenia 1- Hospitalization: In acute stage of the disorder, because pt may be aggressive- diagnosis- care. 2- Medication: Neuroleptics: do not treat schizophrenia they treat schizophrenic symptoms. A. Chlorpromazine “largactil” used in acute stage. B. Haloperidol “ haldol” used in chronic stage. 3- Electro convulsive therapy “ECT” used in catatonic or pt not taken medication.

37. Management of Schizophrenia cont. 4- Psychosocial Treatment:  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.

38. 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.

39. NursingDiagnosis 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.

40. References:  Katherine M. Fortinasl and Patricia A. Holoday- worret (1996) psychiatric Mental Health Nursing, Newyork, Tornto, 1st edition.  Rob Newell and Kevin Gournay. (2009) Mental Health Nursing, New York, Tornto, 2nd edition.