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INTRODUCTION MENTAL HEALTH According to WHO, it is a state of complete physical, mental, and social wellness, not merely the

e absence of disease or infirmity. MENTAL ILLNESS It is medical conditions that disrupt a person's thinking, feeling, mood, ability to relate to others and daily functioning. PSYCHOSIS It is a symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality. HISTORY 2000BC Thought disturbances are mentioned that are commonly seen in schizophrenia. At this time it was thought that these mental disturbances were caused by demons and evil spirits and could be cured by exorcising. 1700 It was during this time that more detailed and accurate descriptions of abnormal mental behavior were recorded. These included changes in a person's speech, gestures and emotions. 1878 Emil Kraepelin combined the various diseases of the mind and named it 'Dementia Praecox' - meaning early dementia and divided it into 4 categories. These included 'simple', 'paranoid', 'hebephrenic', and ' catatonic'. 1911 Eugen Bleuler gave the illness its current name 'schizophrenia' and split the symptoms into 'positive' and 'negative'. He coined the word from the Greek words 'schizo' meaning split, and 'phrene' meaning mind, and divided the illness into 4 categories - the 4 'A's' - blunted 'Affect', loosening of 'Associations', 'Ambivalence', and 'Autism'. Both Kraepelin and Bleuler kept studying the symptoms and effects of schizophrenia and subdividing the symptoms into categories. They finally came up with 5 subdivisions namely - 'disorganized', 'catatonic', 'paranoid', 'residual', and 'undifferentiated'. SCHIZOPHRENIA Comes from the Greek words Skhizo and phren meaning split mind by Eugene Blueler. It causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior. It cannot be defined as a single illness rather, schizophrenia is thought of as a syndrome or as a disease process with many different varieties and symptoms. Furthermore, it stems from a physiologic malfunctioning of the brain.

TYPES OF SCHIZOPHRENIA Type I Onset of positive symptoms is generally acute Symptoms generally respond to typical neuroleptic medication. Positive symptoms - Ambivalence - Flight of Ideas - Associative Looseness - Hallucinations - Delusions - Ideas of Reference - Echopraxia - Perseveration Type II Characterized by a slow onset of negative symptoms caused by viral infections and abnormalities in cholecystokinin. Intellectual decay occurs and enlarged ventricles are present. Negative symptoms respond to atypical antipsychotic medications. Negative symptoms - Alogia - Catatonia - Anhedonia - Flat affect - Apathy - Lack of Volition - Blunted Affect SUBTYPES OF SCHIZOPHRENIA 1. Paranoid Characterized mainly by the presence of delusions of persecution or grandeur and auditory hallucinations. The individual is often tense, suspicious, and guarded, and maybe argumentative, hostile and aggressive. Onset is in the late 20s or 30s. 2. Catatonic Characterized by marked abnormalities in motor behavior and may be manifested in the form of stupor or excitement. Catatonic Stupor Characterized by extreme psychomotor retardation. The individual exhibits a pronounced decrease in spontaneous movements and activity. Mutism is common and negativism may be evident. Waxy flexibility may be exhibited. Catatonic Excitement Manifested by a state of extreme psychomotor agitation. The movements are frenzied and purposeless, and are usually accompanied by continuous incoherent verbalizations and shouting. 3. Disorganized Previously was called hebephrenic schizophrenia. Onset of symptoms is usually before age 25 and the course is commonly chronic. Contact with reality is extremely poor. Affect is flat or grossly inappropriate, often with periods of silliness and incongruous giggling. Facial grimaces and bizarre mannerisms are common, and communication is consistently incoherent.

4. Residual Used when the individual has a history of at least one previous episode of schizophrenia with prominent psychotic symptoms. Symptoms may include social isolation, eccentric behavior, and impairment in personal hygiene, blunted or inappropriate affect and illogical thinking. 5. Undifferentiated Given when schizophrenic symptoms do not meet the criteria for any of the subtypes or they may meet the criteria for more than one subtype. The behavior is clearly psychotic; there is evidence of delusions, hallucinations, incoherence and bizarre behavior. FIVE PHASES OF SCHIZOPHRENIA I. II. Premorbid phase No clinical symptoms of schizophrenia are expressed Prodromal phase Gradual, subtle behavioral changes appear. These changes worsen and become recognizable as the symptoms that characterized schizophrenia. Onset phase Cognitive deficits proven to exist. Progressive phase Symptoms of schizophrenia manifest. Clients may recover from the first episode and experience repeated relapses. Chronic or Residual phase End stage of schizophrenia The client experienced repeated episodes and relapses for a number of years.

III. IV.

V.

CAUSE: Unknown Theories Biochemical or Neurostructural Theory Organic or Phatophysiologic Environmental or Cultural Psychoanalytic Theory Psychological or Experimental RISK FACTORS: Low socioeconomic status Genetics Fetal exposure to influenza virus Maternal malnutrition and perinatal complications CNS infection during childhood Substance Abuse

CLINICAL SYMPTOMS: Positive symptoms

Ambivalence Associative Looseness Neologism Concrete thinking Clang association Word salad Circumstantiality Tangentiality Mutism Perseveration Delusions Persecutory Grandiose Religious Somatic Referential Echopraxia

- Flight of Ideas - Hallucinations Auditory Visual Tactile Gustatory Olfactory

- Perseveration

Negative symptoms - Alogia - Anhedonia - Apathy - Blunted Affect COMPLICATIONS: Suicide Homelessness Self-injury DIAGNOSTIC TESTS:

- Catatonia - Flat affect - Lack of Volition

1. Magnetic Resonance Imaging (MRI) An energy field is created with a huge magnet and radio waves. The energy field is converted to a visual image or scan Produces more tissue detail and contrast It also can be used to measure the size and thickness of brain structures The person undergoing an MRI must lie in a small, closed chamber and remain motionless during the procedure, which takes about 45 minutes Those who feel claustrophobic or have increased anxiety may require sedation before the procedure. Clients with pacemakers or metal implants, such as heart valves or orthopedic devices, cannot undergo MRI. Nursing Responsibilities: a. Secure consent b. Instruct patient to wear a gown during the exam or loose-fitting and has no metal fasteners. c. Instruct patient not to eat and drink for several hours before the procedure d. If the patient is female ask if she is pregnant e. Ask the patient if she has claustrophobia

f. Explain the procedure g. Provide patients privacy Result: Increased cerebral ventricles 2. Positron Emission Tomography Used to examine the function of the brain Radioactive substances are injected into the blood The flow of those substances in the brain is monitored as the client performs cognitive activities as instructed by the operator PET uses two photons simultaneously PET provides better resolution with sharper and clearer pictures PET is used primarily for research not for the diagnosis and treatment of clients with mental disorders. Nursing Responsibilities: a. b. c. d. e. NPO 4 hours before test. Provide for clients privacy. Explain the procedure. May return to normal activity after the procedure The test will only take 2-3 hours.

Result: Glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain.

3. Computed Tomography Scan It is a procedure in which a precise x-ray beam takes cross-sectional images (slices) layer by layer. Can visualize the brains soft tissues Used to diagnose primary tumors, metastases, and effusions and to determine the size of the ventricles of the brain The person undergoing a CT scan must lie motionless on a stretcher-like table for about 20 to 40 minutes as the stretcher passes through a ring while the serial x-rays are taken. Nursing Responsibilities: a. b. c. d. e. Ensure for clients cooperation. Provide for clients privacy. Instruct client to remain motionless. NPO 24 hours before the test. Instruct client to void unless CT scan is on the pelvic area.

Result: Show enlarged ventricles in the brain and cortical atrophy. 4. Physical Examination

It is a process by which a doctor investigates the body of a patient for signs of disease. Nursing Responsibilities: a. Explain the procedure to the patient. b. Provide for patients privacy. c. Ask the client to void into a urine specimen cup to empty the bladder and for urinalysis. d. Instruct the patient to put on hospital gown. e. Assist the patient to assume proper position for the examination. Normal Results: Normal results of a physical examination correspond to the healthy appearance and normal functioning of the body. Abnormal Results Nonspecific abnormalities in reflexes, coordination, graphesthesia and stereognosis Odd or awkward movement Alterations in muscle tone Increased blink rate Abnormal papillary response Voluntary saccadic eye movement

5. Mental Status Examination It is an assessment of a patients level of cognitive ability, appearance, emotional mood and speech and thought patterns at the time of evaluation. Nursing Responsibilities: a. Explain the procedure to the patient. b. Provide for patients privacy. Normal Results: Normal results for a mental status examination depend to some extent on the patient's history, level of education, and recent life events. Abnormal Results: Evidence of thought disorders. A mood or affect that is clearly inappropriate to its context. Thoughts of suicide. Disturbed speech patterns. Dissociative symptoms. Delusions or hallucinations 6. Diagnostic and Statistical Manual of Mental Disorders IV - TR

It provides a common language and standard criteria for the classification of mental disorders. Criteria: A. Characteristic Symptoms: Two or more of the following, each present for a significant portion of time during a 1 month period: Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms B. Social/Occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relationships, or self-care are markedly below the level achieved prior to the onset. C. Duration: Continuous signs of the disturbance persist for at least 6 months. D. Schizoaffective and mood disorder exclusion: 1. No major depressive, manic or mixed episodes have occurred concurrently with the active-phase symptoms. 2. If mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological of a substance or a general medical condition. F. Relationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month. TREATMENT: Psychopharmacology Antipsychotic medications are very effective in treating the symptoms of schizophrenia. The efficacy of antipsychotic medications is enhanced by adjunct psychosocial therapy. Because the psychotic manifestations of the illness subside with use of the drugs, clients are generally more cooperative with the psychosocial therapies. Antipsychotic drugs or neuroleptics or major tranquilizers, are effective in the treatment of acute and chronic manifestations of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms. However, because of a number of unpleasant and even dangerous side effects, the advisability of long term use may be questionable. Antiparkinsonian agents may be prescribed to counteract the extrapyramidal symptoms associated with antipsychotic medications. These drugs are cholinergic blockers, producing the same anticholinergic side effects as the antipsychotic medications.

For those clients with schizophrenia who do not respond to antipsychotic medications, a number of other pharmacological options have been tried, with various degrees of success. RESERPINE a dopamine receptor antagonist has been used as an antihypertensive agent and as an antipsychotic. It has produce severe depression in humans for this reason is now rarely used for either purpose. LITHIUM CARBONATE can ameliorate schizophrenic symptoms or suppress episodic violence in clients with schizophrenia but is seldom an adequate drug therapy alone. CARBAMAZEPINE ameliorates symptoms in some treatment resistant psychotic clients, but it alone is not an adequate therapy for schizophrenia. VALIUM in high dosages, was shown to control psychotic symptoms of schizophrenia, such as agitation, thought disorder, delusions, and hallucinations. It has been also used to relieve akathisia associated with some antipsychotic medication. PROPANOLOL may be useful in controlling temper outbursts in aggressive or violent psychotic clients. Psychosocial 1. Individual Therapy Reality oriented individual therapy is the most suitable approach to individual psychotherapy for schizophrenia. Decrease anxiety and increase trust. 2. Group Therapy It is generally focuses on real life plans, problems, and relationships. It is effective in reducing social isolation, increasing the sense of cohesiveness, and improving reality testing for patients with schizophrenia. It has been most useful over the long term course of the illness. The social interaction, sense of cohesiveness, identification, and reality testing achieved within the group setting have proven to be highly therapeutic processes for these clients.

3. Behavioral Therapy It has a history of qualified success in reducing the frequency of bizarre, disturbing, and deviant behaviors and increasing appropriate behaviors. Can be a powerful treatment tool for helping clients change undesirable behaviors. The therapist can use praise and other positive reinforcements to help the schizophrenic person reduce the frequency of maladaptive or deviant behaviors. 4. Social Skills training

Can improve their social competence, which translates into more effective functioning in the community. 5. Cognitive adaptation training Using environmental support. It is designed to improve adaptive functioning in the home setting. 6. Cognitive Enhancement Therapy (CET) Combines computer-based cognitive training with group sessions that allow clients to practice and develop social skills. 7. Family Education and Therapy Are known to diminish the negative effects of schizophrenia and reduce the relapse rate. Is typically consists of a brief program of family education about schizophrenia, and more extended program of family contact designed to reduce overt manifestations of conflict and to alter patterns of family communication and problem solving. PROGNOSIS: Individuals with schizophrenia have more than twice the rate of death than those without the disorder. Almost half of people with schizophrenia will suffer from a substance-use disorder during their lifetime. Research shows that people with schizophrenia or schizoaffective disorder have a better quality of life if their family members tend to be more supportive and less critical of them. PREVENTION: Schizophrenia cannot be prevented.

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