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Psychiatric Nursing Schizophrenia 1. Features of Schizophrenia Prevalence in U.S. is 1.1%. Average onset is late teens to early twenties, but can be as

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Psychiatric NursingSchizophrenia1Features of SchizophreniaPrevalence in U.S. is 1.1%.Average onset is late teens to early twenties, but can be as late as mid-fiftiesAffects cognitive, emotional, and behavioral function30% to 40% relapse rate in the first year2LO 16-1: Describe the central features of schizophrenia.CFL 16-1-1SchizophreniaSchizophrenia was derived from Greek=Schizo (split) and Phren (mind) Much debates has surrounded the concept of schizophrenia; various definitions, numerous treatment strategies, but non have proved to be completely effective.Although wide controversy around schizophrenia, most clinicians agreed on two factors:Schizophrenia is not a homogenous disease entity of a single cause BUT results from a variable combination of genetic predisposition, biochemical dysfunction, physiological factors, & psychosocial stress.Yet, and probably never will be a single treatment that cures the disorder.

3SchizophreniaEffective treatment requires a comprehensive, multidisciplinary effort, including pharmacotherapy & various forms of psychosocial care, such as living skills & social skills training, rehabilitation, & family therapy.

Of all the mental illnesses, schizophrenia cause more lengthy hospitalization, more chaos in family life, cost more to individual and government.

4What is Schizophrenia? Is it Dual personality?Schizophrenia: is a severe psychotic disorder characterized by a breakdown of thought processes and by poor emotional responsiveness. It affects the mood, regulation of emotions, thought processes, behavior, perception, affect, & total personality integrity.It most commonly associated with auditory hallucinations, paranoid or bizarre delusions, or disorganized speech or thoughts. These disturbances result in a severe deterioration of social & occupational functioning.

Definition of Schizophrenia5Facts about SchizophreniaSymptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life (APA, 2000). They occur earlier in men than in women. Approximately 1.7 million American adults have schizophrenia.They make up more than 50% of the long-term residents of mental hospitals.Between 10%-15% of them commit suicide, usually before age 40.6Features of Schizophrenia (cont'd)Progression varies from one client to anotherExacerbations and remissionsChronic but stableProgressive deterioration7LO 16-1: Describe the central features of schizophrenia.CFL 16-1-2

Features of Schizophrenia (cont'd)DSM-IV-TR DiagnosisSymptoms present at least 6 monthsActive-phase symptoms present at least 1 monthSymptoms are defined as positive and negative8LO 16-1: Describe the central features of schizophrenia.CFL 16-1-3

Features of Schizophrenia (cont'd)Positive symptoms Excess or distortion of normal functioningAberrant responseNegative symptomsDeficit in functioning9LO 16-1: Describe the central features of schizophrenia.CFL 16-1-4

Features of Schizophrenia (cont'd)Positive Symptoms of Schizophrenia HallucinationDelusionsDisordered speech and behavior10LO 16-1: Describe the central features of schizophrenia.CFL 16-1-5

Features of Schizophrenia (cont'd)Negative Symptoms of SchizophreniaFlat affect and apathyAlogiaAvolitionAnhedonia11LO 16-1: Describe the central features of schizophrenia.CFL 16-1-6


Classifications of SchizophreniaTwo major groupings can be seen in schizophrenia:Chronic: long-term illness with poor prognosis. Acute: have good prognosis. 1% of population will develop schizophrenia over the course of life time.There is a premorbid behavior that proceeds schizophrenia (the development of the disease occurs in phases) 13Phases of schizophrenia developmentPhase I Schizoid personality: indifferent (unresponsive) to social relationships, limited range of emotional experience and expression. They do not enjoy close relationships and prefer to be loners & described as being cold and aloof (not interested).

Not all individuals with schizoid personality will progress to schizophrenia, but most with schizophrenia show evidence of having these characteristics in the premorbid condition.14Phases of schizophrenia development2. Phase II Prodromal phase: social withdrawal, role functioning impairment, poor hygiene, self neglect, bizarre ideas, unusual perceptual experiences, lack of energy & initiatives.The length of this stage is highly variable (many years before deteriorating to schizophrenic state).

15Phases of schizophrenia development3. Phase III Schizophrenia: the active phase of the disorder. Psychotic symptoms are prominent. Diagnostic criteria for schizophrenia:Characteristics symptoms: include two or more of the following:DelusionsHallucinationsDisorganized speech (why does this happen?)Catatonic behavior (Behavior characterized by muscular tightness or rigidity and lack of response to the environment. In some patients rigidity alternates with excited or hyperactive behavior).1616Phases of schizophrenia developmentNegative symptoms (affective flattening and alogia, lack of desire to form relationships (asociality), and lack of motivation (avolition)).17Phases of schizophrenia developmentSocial/occupational dysfunctionIt happen for a significant portion of the time since the onset of the disturbance, one or more major areas of functioning-such as work, interpersonal relations, or self-care are markedly below the level achieved before the onset.DurationThis period should include at least 1 month of symptoms.

18Phases of schizophrenia developmentSchizoaffective & Mood disorder ExclusionSchizoaffective disorder and Mood disorder with psychotic features have been ruled out because no major depressive, manic or mixed episode have occurred during the active-phase symptoms.

Substance /General medical conditions ExclusionThe disturbance is not due to the direct physiological effects of a substance or medical conditions.19Phases of schizophrenia developmentRelationship to a pervasive developmental disorderIf there is a history of pervasive development disorder (autistic disorder).the additional diagnosis of schizophrenia is made only if prominent hallucinations & delusions are there for 1month.4. Phase IV Residual phase: this stage usually follows the active phase of schizophrenia. Symptoms are similar to those of the prodromal phase, with flat affect and impairment in role functioning are prominent. Residual impairment often increases between episodes of active psychosis.

20Several factors result in positive prognosis: later age at onset, being female, abrupt onset of symptoms, precipitated by a stressful event, associated mood disturbance, brief duration of active-phase, absence of structural brain abnormalities, normal neurological functioning, a family history of mood disorder, & no family history of schizophrenia.Phases of schizophrenia development21Etiological implicationsThe cause of Schizophrenia is still uncertain. No single factor can be implicated in the etiology; rather, the disease probably results from a combinations of influences including biological, psychological, and environmental.GeneticsThe evidence for genetic vulnerability to schizophrenia is growing. Relatives of individuals with schizophrenia have a higher probability of developing the disease than does the general population (1% for normal population and 5-10% for siblings with the disease).How schizophrenia is inherited is still uncertain. No reliable biological markers have yet been found.

22Etiological implicationsGenetics (continued)Twin Studies: rate of schizophrenia among monozygotic (identical) twins is 4 time that of dizygotic (fraternal) twins & almost 50 times that of general population.Rearing? Studies found that identical twins reared apart have the same rate of development of the illness as do those reared together. Because in about 50% of the cases only one of a pair of monozygotic twins develops schizophrenia, some investigators believe that environmental factors interact with genetic ones.Adoption Studies: adoption studies found that children who were born of schizophrenic mothers were more likely to develop the illness.

23Figure 16-2 PET (positron emission tomography) scans measuring regional cerebral blood flow. (a) Areas of lower blood flow and brain activity are seen in the individual with schizophrenia. (b) Areas of normal blood flow and brain activity are visible in the unaffected individual. Photo courtesy of R. Haier/Photolibrary.

Etiological implications2. Biochemical influences oldest and most explored theory to explain schizophrenia attributes a pathogenic role to abnormal brain biochemistry.The Dopamine Hypothesis: the theory suggest that schizophrenia (or schizophrenia-like symptoms) is caused by an excess of dopamine activity (increase production of dopamine, increase the number of dopamine receptors, and reduce activity of dopamine antagonists).Pharmacological support for this hypothesis exists. Neuroleptics/antipsychotic (e.g. Haldol) lower brain level of dopamine by blocking dopamine receptors, thus reducing the symptoms.25Etiological implicationsBiochemical influences continued Other Biochemical Hypotheses: Abnormalities in the neurotransmitters norepinephrine, serotonin, acetylcholine and gamma-aminobutyric acid and in the neuroregulators such as prostaglandins and endorphins, have been suggested.26Etiological implicationsPhysiological InfluencesThese are the possible factors although there mechanism is unclear:Viral infection: high incidence of schizophrenia after prenatal exposure to influenza.Anatomical abnormalities: structural brain abnormalities have been observed in individuals with schizophrenia.Physical conditions: link have been reported between schizophrenia and epilepsy, Huntingtons chorea (neurodegenerative genetic

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