Schizophrenia Introduction

• Schizophrenia is earlier known as Dementia Precox
• The word schizophrenia was discovered by Swiss psychiatrist Eugen bleuler in 1908.
• Schizophrenia is a psychological disorder.
• Schizophrenia is derived from a Greek word

QnA What is a simple definition of schizophrenia?

Ans. Schizo – means split

        Phrenic – means mind.

• Incidence – 1/1000 populations.

Definition of Schizophrenia

• Schizophrenia is a group of mental disorders in which disturbance of thinking, emotion and behaviour.
• Schizophrenia is referred to as a mental illness characterized by disturbance of mood, thinking and motor activity.
• Schizophrenia is characterized by the inability to separate reality from and a non-reality.

Incidence of Schizophrenia

• Schizophrenia is equally prevalent in men and women.
• Schizophrenia is most commonly present in lower socio-economic groups.
• Onset is 15 – 25 years for men and 25 – 35 years for women.

Cause and etiology of Schizophrenia

1. Biological cause of Schizophrenia –

• Increase the dopamine neurotransmitter level.
• Chromosome abnormality.
• 47% risk of the monozygotic child.
• 8% risk of any relative has a mental disorder.
• 12% risk in a dizygotic child.
• 70% of schizophrenia problems by genetic factors.

2. Psychological cause of Schizophrenia –

• maternal deprivation.
• Lack of love and affection with mother.
• Death of mother in childhood.
• Overprotection of children.
• Over strictness with children.
• Social isolation and broken family.
• The disorganisation of family.
• Overcrowding.
• Unhealthy relationship between parents and child.

3. Precipitation Cause of Schizophrenia– 

Sudden or acute onset when a person tries to control self-emotion after death of close relative but unable to succeed and Express abnormal behaviour.

4. Socio-cultural cause Schizophrenia –

domestic violence

• Technological change
• Financial crisis
• Family dispute.

5. Perinatal risk factors – maternal influenza

• Severe childhood abuse
• Birthday wearing winter session
• Immunological factors.

6. Other cause – poverty

• Head injury
• Accident.

Types of Schizophrenia

1. Typical Schizophrenia – intensity of symptoms is high.

• Recovery slow.

2. Atypical schizophrenia – the intensity of symptoms is low.

• Recovery fast.

1. Typical Schizophrenia 

1. Simple schizophrenia
2. Hebephrenic schizophrenia
3. Paranoid schizophrenia
4. Undifferentiated Schizophrenia
5. Catatonic schizophrenia.      

2.  Atypical Schizophrenia

1. Residual schizophrenia
2. Juvenile or childhood schizophrenia
3. Late schizophrenia
4. Latent schizophrenia.

1. A. Simple schizophrenia 

• Onset 15 – 20 year of age.
• Negative symptoms are present.
• Positive symptoms are absent.
• ECT is not effective in simple schizophrenia.
• Prognosis is very poor.
• More incidence in male.

B. Hebephrenic schizophrenia
 

• Also known as disorganised schizophrenia.
• Onset 20 – 25 year old.
• It is grossly disorganised behaviour, inappropriate expression flat or or inappropriate emotional reaction.

Patient behaves as child – eg.

• Finger biting
• Masturbation of sex organs
• Exhibition of sex organs
• Bizarre behaviour
• Irresponsible behaviour
• Lack of hygiene
• Urine and stool passing in clothes.
• Stuttering or odd speech.

• Positive symptoms of Schizophrenia the most commonly present.
• ECT is not effective.

C. Catatonic schizophrenia

• Catatonic schizophrenia is an acute onset disorder in which disturbance of psychomotor behaviours.
• On set 15 – 25 years.
• The word catatonic means = cata – disturbed
• Tonic – muscles tone.
• ECT is most effective in catatonic schizophrenia.
• Recovery is possible rapidly.

Catatonic schizophrenia types

1. Catatonic excitement –

• In these types, patients show manic patient-like symptoms.
• Example – increased psychomotor activity
• A patient injured to himself or others.
• Flight of ideas.
• Delusion of grandiosity.

2. Catatonic stupor –

In these types, patients or depression-like symptoms.

• Example – suicidal tendency
• Auditory hallucination.
• Loss of muscle tone.

D. Paranoid schizophrenia

• Paranoid schizophrenia is also known as chronic schizophrenia.
• Paranoid schizophrenia is a mostly common type of Schizophrenia.
• Delusional thinking abnormalities are mostly commonly present in these types of schizophrenia.
• Onset 30 year of age group.
• Patients are always suspected by others.
• ECT is less effective.

E. Undifferentiated schizophrenia  

• Undifferentiated schizophrenia is differ from other schizophrenia.

2.A. Residual schizophrenia

• Residual schizophrenia involves only one episode of Schizophrenia.
• Residual schizophrenia is when there are low level positive symptoms but psychotic symptoms are present.

B. Juvenile or childhood schizophrenia  

• Schizophrenia occurs before 14 year of age

C.Late Schizophrenia  

• Onset after 40 year of age.

D. Latent schizophrenia  

• Intensity of symptoms is very low.

Sign and symptoms of Schizophrenia

1. Primary and secondary symptoms.
2. Positive and negative symptoms.
3. First rank symptoms of schizophrenia.

1. Primary symptoms of schizophrenia

• Primary symptoms of schizophrenia are also known as – basic symptoms of schizophrenia.
• Fundamental symptoms of schizophrenia.
• “4 A” symptoms of schizophrenia.
• “4 A” symptoms are introduced by “Eugen bleuler”.

1. Ambivalence – It is an emotional related disorder and abnormality.

• Conflict feeling towards others.
• At the same time in the same person two opposite emotions occur.
• Eg. A girl told his father “I like you or I hate you.”

2. Affective disturbance

• Affective disturbance is also an emotional related disorder.
• Patient in ability to show appropriate emotion according to situation.
• Eg. – Patients start laughing, after the death of a loved one.

3. Association disturbance  

• Association disturbance is a thinking and thought-related disorder.
• Patients suddenly shift from one topic to another topic that are not associated with each other.

4. Autistic thinking  

• Autistic thinking abnormality is commonly present in toddlers (1 – 3 year).
• Autism is a social and communicable problem.

Secondary symptoms of schizophrenia

1. Disturbance of perception –

• Perceptual disorder involves abnormality in sense organ experience.
• Disturbance of perception is – hallucination.
• Illusion.
• Hallucination is a fast perception and misinterpretation in the absence of external stimuli.
• Illusion is a false perception and misinterpretation in the presence of external stimuli.

2. Disturbance of thinking

(1). Thought preservation –

• patients give some answers about different questions asked by doctors.
• Eg. – What is your name = Mohan
• What is your father’s name = Mohan
• Where are you live = Mohan

(2). Word salad – patient speak the irrelevant words.

(3). Neologism – patient formation of meaningless words, patients only understand them.

(4). Thought blocking – Patients give answers to questions asked by healthcare providers but patients suddenly stop and are unable to give the reason.

(5). Tangentially – Patients provide unnecessary information about the topic but are unable to reach on a topic at least.

(6). Circumstantiality – patient unnecessary travel around the topic but reach on topic at last.

Disturbance of motor activity

(1). Automatism – involuntary repetition of an activity.

• Echolalia – imitation of words spoken by others.
• Echopraxia – imitation of activity and posture of others.

(2). Waxy flexibility – maintaining position for a long time period.

(3). Ataxia – loss of balance.

(4). Dystonia – Unco-ordinate spastic movements of the body.

(5). Negativism – the opposite action and activity of others.

(6). Stereotype movement – needless, purposeless, repetitive same activity by the client.

(7). Tics – abnormal movements used by small amounts of muscles.

Eg. – Eye blinking.

3. Disturbance of emotions  

• Patients express the opposite emotion according to the demand of the situation.
• Eg. – Patient laughing after the death of a loved one.

4. Disturbance of attention  

• Patient unable to focus on a particular object.
• 3. Positive symptoms of schizophrenia
• Hallucination
• Delusion
• Delusion of grandiosity
• Magical thinking
• Agitated behaviour.
• 4. Negative symptoms of schizophrenia
• Anhedonia – a patient unable to express feelings of pleasure.
• A violation – lack of motivation.
• Apathy – lack of emotion.
• Flat affect – patients look blank or empty by the expression.
• Blunt affect – emotions are changed very slowly.

Labile affect – emotional change is faster than normal change.

First rank symptoms of schizophrenia

1. Through broadcasting – the patient believes that other people know about his thoughts without sharing them with others.

2. Delusion of perception – normal perception is converted into delusion thought or patient belief someone brings a secret message of God or other for him.

3. The hallucination of voice – patient believes he is discussed by others and discussion heard by him.

4. Thought insertion

5. Thought withdrawal.

• Management of schizophrenia
• Nurses maintain a trusting relationship with patients.
• Avoid the arguments with the patients.
• Nurses provide protection from injury.
• Nurses encourage patients to face reality.
• Do not share false information.

Pharmacotherapy –

• antipsychotics – chlorpromazine
• Haloperidol
• Trifluoperazine.
• Commonly use atypical antipsychotics are
• Clozapine, Risperidone
• Olanzapine, Quetiapine.

ECT therapy –

• ECT is effective for – catatonic stupor
• Catatonic excitement
• Drugs side effects.
• Psychological therapies –
• group therapy
• Cognitive behaviour therapy
• Social skill training
• Family therapy
• Adjuvant therapy.
• Note-  
• Schizophrenia patients use rationalization, projection and denial defence mechanism.
• Key Points of Schizophrenia
• Schizophrenia was discovered by the – Eugen bleuler in 1908
• Group of mental disorders in which disturbance of thinking, emotion and behaviour is called – Schizophrenia disorder
• Schizophrenia most commonly affects the – Low socio economic group
• Simple schizophrenia affects the age group peoples – 15 – 20 year
•  Disorganised schizophrenia is known as – Hebephrenic schizophrenia
• Patients behave as children in which schizophrenia – Hebephrenic schizophrenia
• ECTis most effective in which type Schizophrenia – Catatonic schizophrenia
• Which type of Schizophrenia involved disturbance of psychomotor behaviour – Catatonic schizophrenia
• Catatonic excitement Schizophrenia patient show – Manic patient like symptoms
• Catatonic stupor Schizophrenia patient show – Depression patient like symptoms
• Most common type of Schizophrenia is – Paranoid schizophrenia
• Another name of paranoid schizophrenia is – Chronic schizophrenia
• Fundamental symptoms of schizophrenia are – “4A” symptoms
• At same time, in the same person two opposite emotions occur is known – Ambivalence
• In which disorder patients show appropriate emotion according to situation demand – Affective disturbance
• In which disorder patients give some answer about all questions – Thought preservation
• Patient imitation of words spoken by others is known – Echolalia
• Patient imitation of the activity and posture of another person is known – Echopraxia
• Patient loss of balance and movement in which disorder – Ataxia
• Patients provide unnecessary travel around the topic but reach on topic at least – Tangentially
• Most common positive symptoms of schizophrenia is – Hallucination and delusion
• What is the meaning of anhedonia – Patient unable to express feeling or pleasure (lack of pleasure)
• What type of therapy is used in the management of autism – Play therapy
• Early indicator sign of schizophrenia is – Auditory hallucination
• Most common form of delusion is – Delusion of persecution
• Which type of delusion disorder in which a patient believes his life partner is not faithful to him / her is – Delusion of jealousy

• ECT is also known as electroshock therapy.
• ECT is a physical therapy in which artificial or grand mal seizure is produced in patients by applying the electrode on the temporal region between the hemispheres of the brain.
• ECT is the main and most common treatment for severe depression patients.

History of ECT

• ECT was introduced by the cerletti and Bini in 1938.
• American psychiatric association provides rights for ECT.
• In 1976, consent started before ECT.
• Consent for ECT should be collected by the patient.
• In 2005, WHO also recommended consent before ECT.
• In 2010, the Parliament of India passed the act to collect consent before ECT.

Indication of ECT   

• Major Severe depression of suicidal ideas.
• Schizophrenia types – catatonic schizophrenia

• Paranoid schizophrenia
• Unresponsive schizophrenia.
• Bipolar disorder.
• Organic brain syndrome.
• Delirium and profound mania.
• Medical condition seizures.

Contraindication of ECT

• Pregnancy, fracture patient.
• Old age patient.
• Myocardial infarction patient.
• Retinal detachment.
• Brain tumor.
• Increased ICP (1st priority option).
• Renal and lungs disorder.
• Hypertension.

• Note – ECT is contraindicated in pregnancy only in 1st trimester.

Amount of current in ECT

• 70 – 130 volt.
• If seizures are not produced or patients take lithium therapy, it can be extended up to 150 volt.
• Time duration of ECT = 0.6 – 1 second.

• Extended up to 1.2 seconds.

Method and techniques of ECT

1. Direct method – 

• The direct method applies without sedation or anesthesia.
• Only use the atropine sulfate.

2. Indirect method – 

• the indirect method also known as – modified ECT.
• The indirect method is the commonest in clinical practice.
• Anesthesia and sedation used during ECT with other associated drugs are –
• Atropine sulfate
• Thiopentane sodium
• Succinylcholine
• O2 inhalation.

Drugs during ECT

1. Atropine sulfate – Administer 30 minutes from ECT.

• Atropine sulfate is used in ECT to prevent bradycardia.

2. Thiopentone sodium – Thiopentane sodium used to provide the anaesthesia during ECT.

• Control the intensity of seizure.

3. Succinylcholine – Used as a muscle relaxant.

• During ECT succinylcholine prevents the risk of fracture.

Learning trick for – sequence of drug administration during ECT

आज तुम सब को हवा में उड़ा दूँगा ।

आज     = atropine sulfate

तुम       =  thiopentone sodium

सबको   = succinylcholine

हवा      =  O2 administer.

Types of ECT

1. Unilateral ECT –

• In unilateral ECT, electrodes are placed on a single side.

Eg. – Right side is for a right-handed person and the left side for a left-handed person.

• Unilateral ECT is less effective and less confusing and less complicated.

2. Bilateral ECT – 

• Bilateral ECT is most commonly used in clinical practice.
• Electrodes are placed on both sides of the temporal region.
• Side of bilateral ECT – Bi frontal

•  Bi temporal region

• Bilateral ECT is most effective but more confusing or more complicated.

Note – Position, where electrodes are placed unilateral.

ECT = D-Elias position.

Frequency of ECT –

In depression = Total ECT is 6 – 8 times.

In schizophrenia = Total ECT is 8 – 12 times.

In chronic schizophrenia = Total ECT 20 – 25 times.

Note – 3 times alternative days in a week.

(Only 3 ECT in a week)

Nursing role in preparation ECT

• Nurses collect lab investigations and reports. Eg. – X-ray, ECG, and blood reports.
• Select the consent of the patient.
• Physical examination of the patient before the ECT.
• The empty bowel and bladder of the patient are done.
• Inform the family member of the procedure.
• Remove all artificial dentures, metallic jewelry, and articles of lipstick and nail paints.
• Loose cloth provided to patients.
• Vital sign examination.
• Shampoo to the hair, tie to the women’s hair.
• A nurse administered pre- ECT medication.

Nursing role during ECT

• Nurses provide the supine position and apply pillows under the lumbar curve to prevent the risk of fracture in the 3rd, 4th, and 5th lumbar vertebra.
• Anaesthetic medication is to be administered.
• Restrain both legs, to prevent the risk of femur fracture.
• Provide mouth gag to prevent tongue bites.
• Hyperextension of the head with support to the chin is to be done.
• Vital sign examination and maintaining an airway.
• Observe tonic and clonic phases during ECT.
• Observe the intensity of seizures.

Nursing role after ECT

• A nurse opened the restrain.
• Place the patient in a lateral or side-lying position.
• Assess the vital sign.
• Nurses physically observe the patient for injury or any complications.
• Give a sip of water to check the gag reflex.
• Ambulation to the patient to observe the injury of fracture.

Complications of ECT

• Retrograde amnesia – unable to recall past memory.
• Most common complication.
• Respiratory distress.
• Aspiration.
• Mandible/jaw fracture (most common fracture after ECT).

Read also.

Psychotherapy Definition

Key points

• Which type of therapy is used in the ECT – Physical Therapy?
•  Electroshock therapy was introduced by – Carletti and Bini in 1938.
• WHO recommended consent before ECT – in 2005.
• ECT Consent was taken from the – Patient.
• ECT Consent act was passed by the Parliament of India in – 2010.
• ECT is the most effective management in which disease conditions – Severe depression and suicidal ideas.
• Which type of Schizophrenia where ECT is less effective – Paranoid Schizophrenia.
• Which type of Schizophrenia, where ECT is more effective – Catatonic Schizophrenia.
• what is ect power?- 70 – 130 volt.
• The most common ECT method used in clinical practice? – indirect Method.
• Another name for indirect ECT methods? – Modified ECT.
• Which drug to use to prevent bradycardia in ECT? – Atropine Sulphate.
• Which drug can cause respiratory problems during ECT? – Succinylcholine.
• The most common type of ECT in clinical practice? – Bilateral ECT.
• Advantages of unilateral ECT? – Less complication and Less confusion.
• Do nurses provide which position during ECT electrodes are placed in unilateral ECT? – D-Elias position.
• Depression patients require a total ECT ?- of 6 – 8 times.
• ECT Consent should be collected by? – Patient.
• Position of a patient, during ECT therapy? – Supine Position.
• What is the important nursing action during ECT? – Observe the intensity of seizures.
• Control the intensity of seizures during ECT by the – Thiopentane sodium.
• The most common complication occurs after ECT therapy. – Retrograde amnesia.
• Most common fractures occur after the ECT therapy. – Mandible/jaw fracture.
• What is the complication of ECT attained by nurses according to priority? – Respiratory distress.

psychotherapy definition

• Psychotherapy is a relationship between the patient and the therapist. The therapist may be a psychiatrist, Nurse psychologist, etc.
• Psychotherapy’s objective is personality growth in the direction of maturity, competence and self-actualization.
• Psychotherapy is a treatment of mental illness by the psychological rather than medical treatment.

Purpose of psychotherapy

• Psychotherapy helps in identifying the cause of abnormal behavior
• Modified the patient’s abnormal behavior.
• Reduce and stop abnormal thinking thoughts.
• Improve the social functions.
• Rehabilitation.
• Helping the patient to resolve inner conflict and overcome feelings of handicap.
• Psychotherapy promotes to development of self-esteem.
• Psychotherapy helps to improve interpersonal relationships and communication skills.

Indication of Psychotherapy  

• Neurotic disorder – Eg Anxiety, Depression, OCD, etc.
• Psychosis disorder
• Alcohol and drug substance abuse.
• Eating behavior disorder
• Sexual behavior and personality disorder
• Psychosomatic and behavioral disorder
• Child psychiatric disorder

Contraindication of Psychotherapy

• Unresponsive patient
• Patient with excitement
• Violence patient
• Acute organic mental disorder (Delirium and dementia)
• Manic patient
• Unmotivated and unwilling patients.
• Group psychotherapy is contraindicated in Hysteria, Hypochondriasis etc.
• Psychotherapy is less effective in mental retardation.

Types of psychotherapy

1. Individual Psychotherapy 

a). Psychoanalysis

b). Hypnosis

c). Abreaction

d). Supportive therapy

1. • • • Ventilation
       • Persuasion
       • Re-education
       • Environment
       • Modification
       • Suggestion.

2. Group psychotherapy

   • Group psychotherapy is provided for 2 or more clients once a time.
   • Group psychotherapy is the treatment of psychological problems in which a group of patients and a group of psychiatrists discuss with each other and help in problem-solving.
   • Group therapy was introduced by – Joseph Pratt
   • A number of patients – 8-10 clients.
   • Group therapy time – 1 hour every session.
   • Frequency of group therapy – Once a week.

3. Behavior therapy  

a). Systemic desensitization

b). Aversion therapy

c). Flooding

d). Reinforcement

e). Assertiveness training

f). Cognitive behavior therapy

4. Other Psychotherapy therapy 

a). Milieu therapy

b). Biblio therapy

c). Occupational therapy

d). Recreational therapy

e). Community therapy

f). Activity therapy

Read also.

Electro Convulsive Therapy(ECT)