Schizophrenia: Symptoms and Types

• Schizophrenia is a psychiatric syndrome marked by a split in personality, considered a major psychiatric disorder.

Types of Schizophrenia

• Schizo simplex includes social deviation (being a sycophant), irritability, proneness to drunkenness and prostitution, and difficulty functioning well.
• Hebephrenic schizophrenia is characterized by patients being frequently found in public places such as markets, post offices, and streets.
• Catatonic schizophrenia has two phases:
  • Excitement phase: patients are aggressive, physically and verbally overactive, and exhibit wandering tendencies.
  • Stuporous phase: patients display signs and symptoms similar to depression, appearing withdrawn and weak.
• Paranoid schizophrenia is mainly defined by paranoid delusions, where the patient attributes their misfortune to a specific person and firmly holds onto this belief.
  • Paraphemia and paranoid tendencies are features.
• Undifferentiated schizophrenia lacks specific features, making it hard to classify patients due to mixed signs and symptoms.

General Signs and Symptoms of Schizophrenia

• Disorders of perception, including illusions and hallucinations (auditory and somatic).
• Disorders of thought:
  • Delusions:
    • Delusion of persecution involves the belief that others are hostile or trying to harm the individual.
    • Delusion of reference involves the false belief that the public or specific people are directly related to the individual.
    • Somatic delusion involves the belief that one's body is altered from its normal structure or function.
    • Thought broadcasting involves the belief that unspoken thoughts can be heard by others.
    • Delusion of control involves the belief that one's actions or thoughts are controlled by an external person or force.
• Changes in communication:
  • Thought blocking: stopping mid-sentence as if stuck.
  • Tangential communication: clients wander from one topic to another.
  • Circumstantial communication: patients bring up irrelevant details.
• Disorder of emotion: Schizophrenia often involves inappropriate affect.
  • Incongruity of affect: displaying emotions that do not match the situation, like laughing while recounting abuse.
  • Burnt affect: a marked decrease in the variation of emotional expression intensity.
  • Flat affect: a total lack of emotional expression in verbal and nonverbal behavior.
  • Anhedonia: the inability to experience or imagine pleasurable emotions.
• Disorder of volition: decisional conflict due to biochemical alterations that impair information processing.
• Motor behavior disorder: aimless or disruptive motor behavior.
  • Waxy flexibility: maintaining postures into which they are placed by another person.
  • Stupor: holding the body still and being unresponsive to the environment.

Management of Schizophrenia

• Focus on physical and personal needs, conservation of energy, and social needs.
• Patients may recover enough to resume normal life with or without treatment.
• Physical needs:
  • Personal hygiene.
  • Adequate nutrition.
  • Weighing of patients.
  • Checking vital signs.
• Personal needs:
  • Addressing the patient by name.
  • Ensuring a sense of belonging and security.
• Social needs:
  • Encouraging participation in debates, singing, and recreational activities (diversional therapy).
• Chemotherapy:
  • Largactil.
  • Phenobarbitone.
  • Other drugs prescribed based on the doctor's assessment and the patient's condition.
• Physical therapy:
  • Electro-convulsive therapy (ECT) for selected cases as prescribed by a physician.

Sexual Abnormalities/Problems

• Definition: Sexual behavior not culturally accepted.
• Exhibitionism: Sexual satisfaction from genital exposure, typically by a man displaying his penis to women.
• Voyeurism: Gaining sexual pleasure from watching others during sexual intercourse or when naked.
• Transvestism: Sexual pleasure from dressing in the clothes of the opposite sex.
• Sadism: Sexual satisfaction from inflicting pain on a sexual partner.
• Paedophilia: Sexual interest in children.
• Fetishism: Sexual attraction to objects such as clothes or shoes.
• Bestiality: Sexual pleasure from an animal.
• Incest: Sexual satisfaction from a child, parent, brother, or sister.
• Promiscuity: Indiscriminate use of sexual organs.
• Necrophilia: Desire to satisfy oneself with a dead person.
• Nympho-Mania: A highly sexed woman who finds it difficult to satisfy her sexual appetite.
• Pimp: A man who lives on the immoral earnings of a woman.
• Rape: Sexual intercourse against a woman's will.
• Scopophilia: Satisfaction from looking at one's naked body.
• Causes:
  • Financial purposes.
  • Pleasure.
  • To achieve a status.
  • To prove one's virility.
• Complications:
  • Sexually transmitted diseases (STDs).
  • Lowering of moral.
  • Frigidity.
  • Future problems with the organs.
  • Unwanted pregnancy.

Suicide

• Suicide is an intentional self-destruction.
• Attempted suicide involves self-damage with destructive intent.
• Methods of suicide:
  • Hanging.
  • Poisoning by drugs/antiseptics/acids.
  • Drowning.
  • Stabbing.
  • Use of firearms.
  • Jumping from trees.
  • Hunger strike.
• Causes and predisposing factors:
  • Depression.
  • Schizophrenia.
  • Loneliness.
  • Constant failure.
  • Broken homes.
• Prevention:
  • Provision of basic needs: food, sleep, shelter, clothing, affection.
  • Addressing Maslow's hierarchy of needs:
    • Basic physiological needs: housing, food, clothing, sleep.
    • Safety/Security: protection from physical and social harm, immunization.
    • Affection: need to belong to special people, places, and associations.
    • Ego and self-esteem: need for independence and social recognition.
    • Self-actualization: need to be free and make distinguished contributions.
  • Establishment and maintenance of a social welfare department.
• Management:
  • Careful supervision in the hospital, clinic, or home.
  • Treatment according to cause.
  • Referral.

Depression

• Depression is an affective disorder with loss of interest, happiness, lack of energy, and pessimism.
• Depressive illness involves extreme psychomotor retardation characterized by sadness, withdrawal, and suicidal thoughts.

Types of Depression

• Exogenous or reactive depression: caused by catastrophic events such as failure in exams, loss of employment, or disappointment by a spouse.
  • Characterized by neurotic symptoms and is less severe.
  • May respond temporarily to reassurance and change of environment.
  • Common in people with low self-esteem.
• Endogenous or primary depression: develops spontaneously due to idiopathic causes, constitutional predisposition, hereditary factors, or biochemical changes.
  • Characterized by early morning waking, loss of weight and appetite, delusions, and hallucinations.
• Others type of endogenous depression:
  • Involutional melancholia: occurs in middle age and later life, caused by hormonal changes (e.g., menopause).
  • Senile depression: occurs in old age due to degenerative changes in the brain, leading to loss of intellectual powers, concentration, memory, and appetite.
  • Manic depressive illness (bipolar depression): symptoms of mania and depression with separation from reality, delusions, and hallucinations.
• Secondary depression: linked with physiological changes such as old age or menopausal syndrome.
• Causes
  • Hereditary factors (genetic).
  • Biochemical factors (depletion of amines in the brain, electrolyte imbalances, excessive cortisone production).
  • Psychosocial factors (failure, loss of loved ones, divorce, disappointment).
  • Age (menopause and old age).
  • Premorbid personality.
  • Drugs (methyldopa, contraceptives).
• Clinical manifestation:
  • Patient looks sad and lacks interest.
  • Lacks initiative.
  • Impaired concentration and memory.
  • Delusion of guilt and unworthiness.
  • Hypochondrias.
  • Insomnia, loss of appetite and weight.
  • Suicidal tendencies.
  • Loss of libido.
  • Amenorrhea in women.
  • Monotonous and slow speech.
  • Symptoms worsen in the day and improve as the day goes by.

Treatment for Depression

• Drugs:
  • Antidepressants such as amitriptyline (tryptizole) 50-30mg in divided doses of Imipramine (tofranil) 50-150mg is divided doses.
• ECT (Electroconvulsive Therapy): useful for this type of patient.
• Psychotherapy: to vitalize the patient and arouse interest.
• Occupational therapy: to encourage and stimulate patients' interest.

Nursing Considerations When Giving Drugs

• Administer with food or milk to reduce gastrointestinal effects.
• Crush drugs if the patient cannot swallow.
• Increase fluids and bulky diet if constipation occurs.
• Give full dose at bedtime if daytime sedation is an issue.
• Warn about orthostatic hypotension.
• Assist with ambulation.
• Relieve dry mouth with sips of water or sugarless gum.
• Advise against abruptly discontinuing the drug.
• Caution about activities requiring alertness (may cause drowsiness, dizziness, blurred vision).
• Advise changing position slowly to avoid fainting.
• Inform about potential delayed drug effect.
• Advise avoiding alcohol and other CNS depressants.

Nursing Management for Depression:

• Adequate observation to prevent injury to self and others.
• Adequate nourishment to maintain good health.
• Improve personal and environmental hygiene.
• Adequate rest and stimulation through occupational therapy.
• Prevention of suicide through observation and identification of potential suicidal patients.
• Accurate reporting of patient behaviors and symptoms.
• Ensure patients take and swallow medications.
• Utilise suicidal caution card (SCC) for strict observation without making the patient aware.

Involutional Melancholia

• Definition: depression occurring during or after menopause in women or when sexual power declines in men.
• Clinical features:
  • Marked agitation.
  • Delusions of persecution.
  • Suicide attempts.
  • Feeling insulted.
  • Conservatism.
  • Early tears.
• Treatment:
  • Supervision by responsible relatives.
  • In-patient care.
  • Hydration and nutrition.
  • Precautions to prevent suicide.
  • Refer if the condition deteriorates.

General Factors of Psychotic Disorders

• Sphere of the mind.
  • Consciousness: a state of awareness.
    • Changes as a disturbance of consciousness,attention,or suggestibility.
    • Symptoms include folie a deux and hypnosis.
  • Affect: emotional feeling tone (pleasurable or unpleasurable).
    • Inappropriate affect: incongruity of emotion.
    • Unpleasureable affect: depression, grief, mourning.
    • Pleasureable affect: euphoria, elation, ecstasy.
      • Anxiety, fear, agitation, tension, panic, apathy, ambivalence, depersonalization, derealization aggression, and mood swing.
  • Behaviour: includes echolalia, echopraxia, wax flexibility, catalepsy, command automatism negamasim manarism, hyperactivity, somnambulism (sleepwalking).
  • Thinking: problems include neologism words aled mixing of word circumstantially beating about the bush etc.
  • Perception: disturbance includes hallucination, illusion delusion (false interpretation of stimulus).

Puerperal Psychosis

• Definition: mental illness altering the whole personality after childbirth.
• Causes:
  • Febrile illness after delivery.
  • Postpartum hemorrhage.
  • Toxemia of pregnancy.
  • Hypertension.
  • Epilepsy.
  • Previous mental illness.
• Signs and symptoms:
  • Hallucinations.
  • Delusions.
  • Mood disturbances.
  • Withdrawal.
  • Neglect of the infant.
• Treatment:
  • Special attention to infant care.
  • Minimize separation period.
  • Ensure hydration and nutrition.
  • Maintain milk flow.
  • Show sympathy.
  • Give tranquilizers (e.g., diazepam).
  • Refer if no response in two weeks.

Acute Confusional State (Delirium)

• Definition: an organic psychosis with rapid onset and reversible condition in which a patient unable is unable to perceive his environment.
• Clinical manifestation:
  • Disturbance of consciousness.
  • Disorientation.
  • Anxiety, aggressiveness, and insomnia.
  • Short attention and concentration span.
  • Loss of memory.
  • Restlessness.
  • Mood fluctuations.
  • Terrifying dreams.
  • Delusions and hallucinations.
  • Incoherent speech, irritability, and confusion.
  • May present with headache, aches, pains, flushed face, and malaise.
• Aetiology: can occur in various conditions.
  • Infection (e.g., encephalitis, meningitis, influenza, pneumonia).
  • Metabolic disorder (e.g., hypoglycemia, hyperglycemia, hepatic failure, uremia, electrolyte imbalance).
  • Nutritional deficiencies (e.g., vitamins B1, B6, B3, B12).
  • Intoxication (e.g., anfitalin, barbiturates, alcohol).
  • Diseases (e.g., congestive heart failure).
  • Trauma (e.g., head injury).
  • Tumors (e.g., cerebral tumors).
  • Selile/insenile dementia.
  • Cerebral malaria/abscess.
  • Puerperal psychosis.
  • Hypoxia.
  • Poisoning (e.g., carbon monoxide).
  • Drug withdrawal (e.g., alcoholism, barbiturates, narcotics).
  • Cerebro vascular accident.
• Management:
  • Remove primary causes and provide symptomatic treatment.
  • Admit to a quiet corner of the ward.
  • Close observation for protection.
  • Keep patient's belongings at familiar positions.
  • General nursing care (hygiene, pressure areas, bladder and bowel).
  • Nutritious diet and adequate fluids.
  • Introduce medical staff to aid orientation.
    • Treat specific causes with the use of antibiotics, anticonvulsants..
  • Drugs.
    • Chlorpromazine 25-100mg may be prescribed 3-4 times daily.
    • Haloperidol 15-20mg in divided doses.
    • Anxiolethic (e.g., diazepan 15-40mg daily in divided doses.
    • Vitamin B complex IV.
  • Night care and observation vital signs, response to medication etc.
  • Psychotherapy, Occupational Therapy,Recreational Therapy when condition permits.
  • Family/spiritual care.
  • Rehabilitation and discharge.

Old Age

• Old age is defined as an age over 60 years in developing countries.
• Social changes include: retirement, reduced income, bereavemente and widowhood.
• Biological changes: degenerative changes e.g. loss of hearing,vision and muscle tone.
• Cognitive changes: intellectual capacity decline, for gets something depends on past ideas.
• Mental disorders of old age include:
  • Dementia: arises due to cerebral disease.
  • Depression: especially after bereavement.
  • Confusional states: paranoid disorders, delirium etc.

Dissociative Type/Hysteria

• Narrowing of field of consciousness and acting in an automatic fashion.
• Wandering away from home, due to loss of memory.
• Somnambulism (sleep walking).
• Amnesia: loss of identity.
• Gansar syndrome (prisons psychosis) gives approximate answers to simplequestions.
• Management:
  • Eliminate factors that reinforce symptoms and encourage normal behaviour.
  • Psychotherapy. -Discussion and negotiation..
  • Recreational therapy.
  • General nursing care and observation of vital sign behaviour.
  • Drugs (1) minor tranquilizers (2) antidepressants (3) ECT.
  • Suggestion and counseling by psychiatric social workers.
  • Family therapy.

Types of Phobia

• Acrophobia: Heights
• Aerophobia: Flying
• Agoraphobia: Open spaces, public spaces
• Aichmophobia: Sharp pointed objects
• Amaxophobia: Vehicles, driving
• Anthropephobia: People
• Aquaphobia: Water
• Arachnephobia: Spiders
• Astraphobia: Lightning
• Blennophobia: Frogs, amphibians
• Brontophobia: Thunder
• Carcinophobia: Cancer
• Claustrophobia: Closed spaces, confinement
• Clinophobia: Going to bed
• Dementophobia: Dogs
• Dromophobia: Insanity
• Emetophobia: Vomiting
• Entomophobia: Insects
• Gephyrophobia: Sex
• Hematophobia: Crossing bridges
• Heipetophobia: Blood
• Homilophobia: Reptiles
• Linonopbobia: Sermons
• Monophobia: String
• Musophobia: Being alone
• Mysophobia: Mice
• Nudophobia; Dirt and germs
• Numerophobia: Nudity
• Nyctophobia: Numbers
• Ochlophobia: Darkness, night
• Ophidiophobia: Snakes
• Omithophobia: Birds
• Phasmopbobia: Ghosts
• Phobophobia: Phobias
• Pnigophobia: Choking
• Pogonophobia: Beards
• Pyrophobia: Fire
• Siderodromophobia: Trains
• Taphephobia: Being bured alive
• Thanatophobia: Death
• Trichophobia: Hair
• Triskaidekaphobia: The number 13
• Trypanophobia: Injections
• Xenophobia: Strangers

Affective Psychosis

• Affective mania is a functional psychosis occurring without physical brain diseases or impairment.
• Believed to be caused by biochemical disturbances in the brain.
• Psychotic disorders affect every aspect of the patient's life.
• Mania definition: an affective mental disorder characterized by elation of mood, rapid thoughts and speech, extreme over activity.
• Incidence: occur in early adulthood between 20-25 years.

Acute or mania Proper

• Example (ECT)-electro-convulsive therapy.
• Psychological stress-frustration death of loved ones and threats to self esteemdrug intoxication like poison,alcohol drugs like antidepressants.
• Main cause of mania remains obscure and controversial.
• Three types of mania acute or mania proper-hypomania-manic depressive psychosis.

Acute Mania Proper

• This type has acute or sudden onset and is characterized by excessive cheerfulness-,elation of mode and over activity-Hignly iritable and intolerant-High ranking officials e.g.head of states,govemors and so on-Suffers from invariably loss of weight-Impulsive sexually and can attack ladies and rape openly-Speech and thought-Very rapid indeed.
• Hallucination
• Grandeur.
• No insight therefore does not agree or believe he is sick

Management

• Management of Physical needs include daily weighing
• Psychological needs should be engaged in meaningful activities and communication
• Chemotherapy drugs like largactil, melleril or stela zinc

Drugs management

• Largactil: Dose:adult 25mg 3 times daily adjusted according to response to usual maintenance, dose 100-300mg daily (but to 1.2g daily may be required in psychosis).

Dose

• Adult initially 5mg twice daily or 10mg daily in slow released from: increased by 5mg after / week dependent on the response.

Meileril

• Adult 25-600mg daily depending on the indication child (1 year and above). dose -14mg/kg body daily

Hypomania

• This a mild form of mania with all its symptoms in lesser degree.
• The patient can be nursed in the ward with other patient.
• At first others are amused by him his drive and energy makes him to bechosen as a spokesman and to organize activities for the rest.
• They dressed outstandingly manner using all scraps of colourful material.
• The management deepens on the patient's behaviors.
• In acute minia the patient is to disturb to be nursed with other.
  • Admission: admission into the hospital is often necessary the environmentshould be quiet to provide adequate rest.
  • Personal hygiene supervised bathroom take care for the nails
  • Encourage oral toilet and dressing.
  • Nutrition: give nutritious diet and cupious fluid to correct dehydration and nutritional states
  • Physical: exhaustion and protect patient from possible dangers.
  • Sleep and rest-ensure enough sleep and rest in noises-free environment.
  • Remove the things that would cause distraction.
• The patient and socials therapy should avoid exposing patient to competition because if, defeated may display aggressiveness.
• Acute depressive psychosis:1)Is Often characterised.

Chemotherapy

Specific drugs: haloperidol 5.16mg often it is to prevent takinsonism.

• Supportive drugs antioliinergis: Benzhexol Congentine
• No visitor/limited visitor in early stage of admission
• ECT: It is given weekiy and 5 weeks trial leave and discharge.
• When the condition improves the patient is placed on trial leave for assessment to this tome condition.
• Relative are also advised-give the love and attention etc.
• Advice follow 1:Keep appt date 2:Take has take home Drugs 3 :Refrain from things that may cause him Relapase4:Report any physical ill health to his doctor 5:Keep appt due Visitation:

Advice on Discharge

• Keep appointments.
• Take medications.
• Refrain from things that may cause relapse.
• Report any physical ill health to his doctor.
• Relatives should provide home proper care, love and attention.
• Follow up check patient condition at home.

Clinical features1.Mood:acute and sudden onset-feels he can do everything withoutassistanceEuphoria orelation Grandiose-Infectiousjollity Arrogance is impaired but he has insight he plans sometimes of child which do not possess bank. psychomotor or over activity very restless,moves especially it carrying out is 806 so as to attack people and object functions. with from his or 4)thought and speech 7)8078 be and impulsiveness came. emaciated. protacted

Comparison Depressive and Manic phases PHASE a)1.Total1Phase7.4-5-Total