Chapter Seven Psychiatry Lecture Notes PDF

Lecturer: Dr Hussein Adam Omar Kismayo University Jubbaland, Somalia MBBS-KU Lecture: SEVEN  UNIT FOUR SCHIZOPHRENIA Learning objectives After studying the material in this unit, the student should be able to: 1. Define schizophrenia 2. Describe differ...

Lecturer: Dr Hussein Adam Omar Kismayo University Jubbaland, Somalia MBBS-KU Lecture: SEVEN  UNIT FOUR SCHIZOPHRENIA Learning objectives After studying the material in this unit, the student should be able to: 1. Define schizophrenia 2. Describe different types of schizophrenia 3. Recognize DSM-IV-R diagnostic criteria of schizophrenia 4. Describe differential diagnosis of schizophrenia 5. Explain possible management of Definition: The word schizophrenia is derived from a Greek word meaning Schizo - split } = meaning split mind Phrenia - mind} Generally schizophrenia is a serious psychiatric disorder characterized by impaired communication with loss of contact with reality and deterioration from a previous level of functioning in work, social relations or self-care. Clinical types of schizophrenia include disorganized, catatonic, paranoid, residual, and undifferentiated schizophrenia (Shives: 1990) Types of Schizophrenia A. Disorganized (hebephrenic type) Features include incoherence, lack of systematized delusions, and B. Catatonic type A type of schizophrenia which is dominated by one of the following: 1. Catatonic stupor: Morbid lack of reactivity to environment reduction in spontaneous movements and activity and/or mutism. 2. Catatonic negativism: Apparently motiveless resistance to all instructions or attempts to be moved. 3. Catatonic rigidity: Maintenance of a rigid position against efforts to be moved. 4. Catatonic excitement: Excited motor activity apparently purposeless and not influenced by external stimuli. 5. Catatonic positioning: Assumption of inappropriate or bizarre posture. C. Paranoid type Features of the paranoid type of schizophrenia include Associated features include anger, argumentative, violence, fearfulness, delusion of reference and sometimes loss of gender identity. - Onset is relatively late -Function remains more or less at constant level, and is not marked by deterioration. - D. Undifferentiated type Features include grossly disorganized behavior, hallucinations incoherence or prominent delusion. E. Residual type Features include current schizophrenic symptoms and definite experience of at least one schizophrenic episode in the past. There may be some delusion and hallucination but the person is burned out. F. Simple type The patient Experiences: - Paranoid disorders - Gradual insidious loss of drive, interest, ambition and initiative. - Withdrawal - Isolation -Gradual decrease of performance - Later the patient may show indifference to environment, slow personality deterioration and drift aimlessly through life. Usually hallucination and illusion are absent. DSM III diagnostic criteria for schizophrenic disorders The DSM III diagnostic criteria include the following: A At least one of the following at some point of the illness 1. Bizarre delusions, such as the delusion of being controlled, thought broadcasting, thought insertion and thought withdrawal, somatic, grandiose, religious, and nihilistic or other delusions without persecutory or jealous content. 3. Auditory hallucinations in which either a voice keeps up a running commentator on the individual’s behavior or thoughts, or two or more voices converse with each other. 4. Auditory hallucinations on several occasions with content of more than one or more words having no apparent relation to depression or elation. 5. Incoherence and marked loosing of association marked illogical thinking or marked poverty of content of speech, if associated at least with one of the following: -Blunted, flat or in appropriate affect - Delusion or hallucination - Catatonic or other grossly disorganized behavior. B. Deterioration Deterioration from a previous level of functioning in such area as work, social relations and self care. C. Duration: Continuous signs of the illness for at least six continuous months during the person’s life, with some signs of the illness at present. The six month period must include one active phase during which symptoms from criteria A (outlined above)are exhibited, D. symptoms of depression or manic syndrome The full depression or manic syndrome (major depression or manic episode) if developed after any psychiatric symptoms in criteria A (outlined) appear. E. Onset of pro-dromal or active phase of the illness before age of 45 years. F. Not due to any organic mental disorder or mental retardation. Bawleres symptoms ‘The 4 A's’ Of schizophrenia - Ambivalence - Association loosening (incoherence) - Affect disturbance Autism (turning towards self). Differential diagnosis - Organic mental disorder - Major affective disorder - Schizophreniform disorder - Paranoid disorder - Mental retardation - The developmental straggle of adolescent. Prognosis: Prognosis depends on onset, stress, pre morbid personality and social and economic status. Treatment (Rx) 1. Coma - Insulin coma is the ancient form of treatment. Nowadays it is not treatment modality of schizophrenia. 2. ECT is also seldom used today 3. Contemporary treatment: a, Supportive psychotherapy b, Drug therapy: The choice of drug depends upon availability, cost and side effects - Chlorpromazine(CPZ) 100 - 600 mg/day in divided dose -Thioridazine (mellaril) 100 - 1000 mg/day - Nursing interventions Nursing interventions focus on assisting the patient to meet the following goals: 1. Establish a trusting relationship; 2. Alleviate anxiety; 3. Maintain biological integrity; and 4. Establish clear, consistent, and open communication. The nurse must establish a therapeutic relationship so that effective communication with the patient can take place. The nurse must remember that all behavior is meaningful to the patient, if not to anyone else. Reality should be presented when caring for the patient who is disoriented. The nurse can do this by pointing out what would be appropriate behavior, for instance, ‘I’d like you to put your shoes on now’ Recognizing the presence of hallucinations and delusion, but not reinforcing such behavior or thoughts is an appropriate response when interacting with patients. The nurse should look for factors causing hallucinations and attempt to intervene before they occur. Safety measures may need to be incorporated to protect the patient who displays poor judgment, disorientation, destructive behavior, suicidal ideation, or agitation. Limit setting, acknowledging spatial patient must be protected from her or himself because she or he may injure her or himself accidentally, or may try to destroy her or himself or attack other patients as a result of auditory hallucinations or paranoid ideations. Efforts should be made to plan activates to increase the patient’s self concept. Sincere compliments should be given as often as possible, focusing on positive aspects of the person’s personality or capabilities. Encourage participation in activates. The nurse must observe for extra pyramidal side effects of psychotropic drugs and monitor the patient’s willingness to take the drugs. Patients may refuse to take medication, pretend to take medication by palming it, or pretend to swallow the medication while retaining the pill in the mouth (only to get rid of it at the first possible moment). Table 6: Nursing diagnoses and interventions for patients with schizophrenic disorders. Nursing diagnoses Nursing Interventions Sensory-perceptual Call the patient by name. Present alteration: reality when talking to or working Disoriented to place with the patient. Keep a calendar and person, in clear view to orient the patient disoriented in time. daily. Provide a protective, safe environment. Social isolation: Assign one member of the health Withdrawal care team to establish a one-to- one relationship. Provide a structured list of activities such as times to awaken, shower, and eat. Spend a specific amount of time daily with the patient. Set limits regarding amount of times spent alone in room. Alteration in Present reality when talking to or thought process: working with the patient. Ignore Alteration in Decrease environmental though process: stimuli such as loud music Hallucinations or television shows, extremely bright colors, or flashing lights. Present reality, for example: “The voices may be real to you but I don’t hear anything.” Attempt to identify precipitating factors by asking the patient what happened before the onset of the hallucination. Ineffective Assess the patient’s individual coping: present developmental Regression level. State expected behavior Dysrhythmia of Recognize signs of increasing sleep-rest activity: agitation. Agitation and Decrease environmental stimuli unpredictable that could be upsetting to the behavior patient. Sensory-perceptual Be sincere and honest when alteration: talking with the patient. Avoid Suspiciousness making promises that can not be fulfilled. Face the patient while talking. Avoid whispering or any other behavior that may cause the patient to feel that you are talking about him. Give detailed explanations of tests, procedures, and so forth to the patient. Allow the patient to help to  End Thanks 15