PSYCHOTIC DISORDERS (Schizophrenia And Mood Disorder : Mania, Depression and Bipolar Disorders)
SCHIZOPHRENIA.
definition
Schizophrenia is a psychotic condition that affects the normal function of the brain, causing disturbances in a person’s thinking, emotion, and function. A person with schizophrenia experiences changes in behavior, perception, and thinking that can distance them from reality. When a person loses touch with reality, he experiences psychosis.
Impaired insight is a common feature of schizophrenia. The person who coined the term schizophrenia is Eugen Bleuler.
WHAT CAUSES OF SCHIZOPHRENIA
No specific cause of schizophrenia has been identified. But there are some factors that can develop schizophrenia. Which are as follows.
Genetics Factors
Schizophrenia can run in families, meaning that it can be passed from parents to their children. In the general population, children of parents with schizophrenia have a 10% chance of developing schizophrenia. Monozygotic twins are more likely to develop schizophrenia than dizygotic twins.
Biochemical Factor
Some people with schizophrenia may have a chemical imbalance. In the brain, they may be either very sensitive to or produce too much of a chemical called dopamine. An imbalance of dopamine affects the brain’s response to certain stimuli, such as sounds, smells, and sights, and hallucinations. And leads to delusion.
Brain Structure Abnormality
Abnormal structure and function of the brain have been observed in people with schizophrenia. Schizophrenia can be caused due to decrease blood flow, decrease metabolic activity and cerebral atrophy.
Psychological Factors
Schizophrenia can occur due to family relationship reasons like family tension, mother child relationship, dysfunctional family systems and double bind communication etc.
Pregnancy And Birth Complication
Abnormalities in the fetus related to trauma or infection are predisposing factors for schizophrenia.
Environmental Factors
Some environmental factors, such as viral infections, poor social interaction or more stressful situations can make people develop schizophrenia.
TYPES OF SCHIZOPHRENIA ACCORDING TO ICD 10 CLASSIFICATION (types of schizophrenia according to ICD-10)*
Paranoid Schizophrenia
This is the most common type. People of this type have delusions about being punished by other people. His thinking, speech
And emotions, however, remain quite normal. Their onset is gradual. Acute is also seen in some cases. There is a good prognosis. Persecution and grandeur disorder are seen.
Hebifhrenic Or Disorganized Schizophrenia
People with this type of schizophrenia are often confused and incoherent, and have jumbled speech. The worst prognosis. Their outward behavior is emotionless or inappropriate, stupid or childlike. Can’t perform their daily activities properly.Hallucinations are also seen.
Catatonic Schizophrenia
Onset is acute and sudden. The most striking symptoms of this type are physical. People with catatonic schizophrenia are usually immobile and unresponsive to the world around them. They often become very rigid and rigid, they do not move in one place. Their behavior is seen as bizzare. They may repeat the words spoken by another person. People with catatonic schizophrenia are at risk of malnutrition, and self-injury. They have the best prognosis. ECT and IV lorazepam are their best treatment.
(Undifferentiated Schizophrenia)
This subtype is diagnosed when a person’s symptoms do not clearly represent one of the other three subtypes.
Post Schizophrenic Depression
A depressive episode resulting from a schizophrenic illness where some low-level schizophrenic symptoms may also be present.
Residual Schizophrenia
This type of schizophrenia is chronic. Hallucinations, delusions and other symptoms may also be present but are significantly less than when schizophrenia is diagnosed. Symptoms such as eccentric behaviour, emotional blunting, excessive and illogical thinking are seen. .
Simple Schizophrenia
Prominent negative symptoms are observed. Hebephrenic schizophrenia has the worst prognosis.
Pfropf Schizophrenia
There are types associated with mental retardation. They are called grafted schizophrenia.
SIGN AND SYMPTOMS OF SCHIZOPHRENIA
Schizophrenia symptoms are divided into positive, negative and cognitive symptoms.
Positive symptoms
Delusions (false beliefs)
Hallucinations
•Disorganized speech
•Disorganized thought
Catatonic behavior (lack of movement and response)
Suspicious (suspicious)
•Agitation
Negative symptoms
•Alogia (Inability to speak properly is also called poverty of speech.)”
Anhedonia (absence of pleasure from any activity)
•Mood and thinking do not fit the situation (eg starts crying during jokes.)
Cognitive symptoms
Blueler 4A’s
Example In this the person says “I like to dance, all people have hands.” “I like to play sports because the river flows under the mountain.”
This is a type of thought problem, in which the person daydreams, which have little or no relation to reality. There is no awareness of the surrounding environment.
Showing an opposite feeling or attitude and emotion towards the same person, thing or situation.
Other symptoms
Audible thought
Thought withdrawal
TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA
*Pharmacological management
•Antipsychotic medication
Typical antipsychotics: chlorpromazine, haloperidol, trifluperazine, droperidol, pimozide.
Atypical antipsychotic: olanzapine, rasperidone, zipra sidon, amisulpride, aripiprazole.
*Non-pharmacological management
•Electroconvulsive therapy (ECT)
ECT is used in acute schizophrenia and when medication does not respond. It is effective in reducing the depressive and catatonic symptoms of schizophrenia.
*Other treatment
•Promotion program
•Rehabilitation
•Supportive psychotherapy
**Psychosocial management
•Psycho education
•CBT (Cognitive Behavioral Therapy)
NURSING MANAGEMENT OF SCHIZOPHRENIA
★Common Nursing Diagnoses of Schizophrenia.
9.Sleep disturbance
*Objectives: To reduce disturbing thoughts and reduce anxiety levels, also reduce delusions.
Nursing Interventions
•Careful monitoring of the patient so that he does not harm himself due to delusions.
•Initially, do not argue with the client or try to convince the client that the delusions are false or unrealistic.
•Recognizing and supporting client achievements.
•Should deal with the patient honestly and have a simple conversation and give appropriate feedback about the patient’s condition.
.2 Disturb Sensory Perception
*Objectives: reduce hallucinations, provide greater opportunities to interact with others, administer medication.
Nursing Interventions
•Assessing the types of hallucinations.
•Hallucinating behavior of the patient like laughing at himself or talking to himself should be observed.
•Concerns other than hallucinations should be discussed with the patient.
•Encourage the patient to express any feelings or keep the patient busy with other things or activities to distract him from the hallucinations.
*Objectives: At the time of discharge the patient can communicate properly.
Nursing Interventions
•Provide a separate space for the patient to express his feelings, talk and talk.
•The patient should be taught social skills
•Talking to the patient briefly and in simple language.
*Objectives: To improve the patient’s own identity.
Nursing Interventions
•Inform the patient about himself and all staff members and reduce excessive stimuli in the environment
•Spending time with the patient and informing the patient about the person, place and time.
•Simply talk about things with the patient and talk simply and directly with the patient.
DEPRESSION
*DEFINITION
Depression is a mood disorder characterized by feelings of sadness and hopelessness and loss of interest and pleasure in activities and social and occupational function is impaired. Sleep patterns and appetite also change. Which affects mood, thought, behavior and overall health.
ETIOLOGY OF DEPRESSION
•Genetic abnormality
•Environmental factor
•Biochemical factor (Biochemical theory: Deficiency of neurotransmitters like (serotonin, norepinephrine and dopamine) in the brain area also causes depression.
•Cognitive theory: According to this theory, depression occurs as a result of impaired cognition, a person feels pessimistic and sees himself as inadequate and worthless and life as hopeless.
•Learning Hopelessness: (Depressive illness is caused by a person’s numerous failures.)
•Object loss theory suggests that depression occurs if a person is separated or abandoned from a close person during some months of life.
•Endocrine factor : Hypothyroidism, Cushing’s syndrome
•Alcohol and drug abuse
•Hormones level changes
•Side effects of medication (medication like analgesic, antipsychotic, antidepressant, anticonvulsant etc.)
TYPES OF DEPRESSION
•Psychotic depression
Seasonal Affective Disorder (Winter Depression)
•Persistent depressive disorder
SIGN AND SYMPTOMS OF DEPRESSION
•Helplessness
•Worthlessness
•Depressed mood
•Suicidal thought
•Poor memory
•Poor concentration
•Decreases appetite
•Psychomotor agitation.
•Decreases libido (decrease in sex drive.)
TREATMENT AND MANAGEMENT OF DEPRESSION
Depression can be treated. Depression symptoms can be managed with support, psychotherapy and medication.
Practical solutions and possible causes should be discussed and family members should be educated.
Antidepressant medications are useful for treating moderate to severe depression.
Many classes of antidepressant medications are available.
Each class of medication works on a different neurotransmitter or a combination of neurotransmitters.
Atypical Antidepressants: Mirtazapine, Bupropion, Terazodone…
•TCAs (Tricyclic Antidepressants) : Imipramine Amitriptyline, Clomipramine, Desipramine etc.
•SSRIs(Selective Serotonin Reuptake Inhibitors): Vilazodone, Fluoxetine, Acetalopram, Shertraline medicines are SSRI antidepressants.
•SNRIs (Selective Nor Epinephrine Reuptake Inhibitors): Duloxetine, Desvenlafaxine, etc. Medicines are SNRIs inhibitors.
•MAOIs (Mono Amine Oxidase Inhibitors) : Nardyl Phenelzine, Isocarboxazid etc…
Psychotherapy is also called talking therapy.
•CBT (Cognitive Behavioral Therapy) and one to one counselling.
•Interpersonal therapy
•Family therapy and marital therapy
•Supportive psychotherapy
•Psychoanalytic psychotherapy
ECT (Electro Convulsive Therapy)
ECT is helpful when medication and other psychotherapies do not work. ECT is a more effective treatment for depression and works faster than drugs. ECT is the drug of choice for major depression. ECT is also given when drugs do not work in depression.
NURSING MANAGEMENT OF DEPRESSION
•Suicidal ideation and attempt
•Loss of interest
•Increased weight loss
•Impaired socialization
•Self-care deficit
*Objectives: To prevent patients from suicidal ideation and attempt.
*Nursing intervention
*Do not leave the patient alone, stay with them.
*Observe for passive suicide – patient may starve to death or sleep in bathtub/sink.
*Monitor closely when the patient is recovering from depression, as he may have the energy and opportunity to kill himself.
*Making a big weight to express the patient’s own feelings and emotions.
*Help the patient find meaning in real-life situations and teach coping mechanisms.
Objectives: The patient has optimum cognitive abilities and his thought process improves.
Nursing Interventions
•Patient should be encouraged to participate in creative activities.
Objectives: To improve patient’s communication and interaction with people.
Nursing Interventions
•Must have a friendly approach with the patient and proper communication with the patient.
•Giving them opportunities for social interaction and providing a friendly environment.
Objectives: The client will be able to perform activities of daily living independently and maintain personal hygiene.
intervention
•Assess the patient’s daily life activities including bath, diet intake, cloth and hair care etc.
Objectives: Improve sleep pattern and balance rest and activity.
Nursing Interventions
*Assessing sleep patterns and providing clean and comfortable bed.
*Giving medicine as per prescription and maintaining patient hygiene.
MANIA
*DEFINITION
Mania is a psychiatric illness characterized by persistent, abnormal and extreme changes in mood, characterized by excessive excitement, agitation, hyperactivity and irritability. Symptoms of mania include elevated mood, disconnected thoughts, increased sexual desire, increased energy and activity levels, and abnormal social behavior.
VARIOUS TYPES OF MANIA
Three types of mania are given according to the symptoms.
Hypomania
Acute mania
•Delirious mania
Hypomania
*Disturbance in this stage is not severe enough to impair social or occupational function or require hospitalization.
And irritability will be seen due to unfulfilled desire.
Acute Mania
*In acute mania, function is impaired and the person needs to be admitted to a hospital.
Elation (Patient feels overjoyed).
*Mood changes and turns into anger and sadness.
•Delirious mania
This is a more severe form of mania and involves clouding of consciousness and intensification of symptoms associated with acute mania, increasing the severity of symptoms.
In these types, the patient is labile (unstable) and
Shows feelings of despair. Patient feels grandiosity.
CAUSES OF MANIA
A. Genetics
*If there is a person in the family who has suffered from dementia, someone in the family can get dementia.
*Manic disorder occurs in twins. Identical twins are more likely to develop mania than fraternal twins.
B. Brain Chemistry
Levels of neurotransmitters such as dopamine and nor epinephrine are imbalanced.
C. Substance Abuse
Drug and alcohol abuse can lead to manic episodes.
*D.Stressful life event
Traumatic experiences and some life triggers can lead to manic episodes.
E. Medication
Mania can also occur due to the side effects of some medicines like antidepressants, stimulants, steroids.
F. Sleep disturbance
Changes in sleep patterns can also cause mania.
G. Medical condition
Thyroid disorders and neurological conditions have been linked to mania symptoms.
H. Brain lesion
Right fronto-temporal or left-pareito occipital lesions are associated with mania.
*I.Psychological Factor
Personality traits and coping mechanisms are also responsible for causing mania.
CLINICAL FEATURES OF MANIA
•Mania has four stages.
3.Exaltation: Severe elevation in mood and delusions of grandiosity are seen.
•Psychomotor activity
*Psychomotor activity increases.
•Speech and thought disturbances
*Flight of ideas (immediately jumping from one thing to another)
*Pressure of speech (speaks more loudly and continuously.
Delusion of Grandiosity
*Distractibility (lack of proper attention)
*Poverty of thought (The number and variety of thoughts are less and they pass through the mind very slowly.)
Other Features of MANIA
*Impulsive behavior
*Action Oriented Wishes
*Positive self image
*Exhibit poor judgment
*Tendency to blame others
*Hyperactivity
*Productivity
*Increased libido (increased sexual desire)
*Insomnia
*Poor judgment
TREATMENT AND MANAGEMENT OF MANIA
A. Pharmacotherapy
•Lithium Carbonate :- Lithium is the first line treatment of mania. 900-2100mg/day is the drug of choice for mania. Lithium is a mood stabilizer.
•Anticonvulsants :- Anticonvulsants were introduced in the treatment of mania when their therapeutic value was noted through mood stability in people with epilepsy. Sodium valporate (15-60mg/kg/day) is given.
•Calcium channel blockers:-They are used to manage minor degree symptoms of mania. Nifedipine, diltiazem, verapamil etc. are used.
•Antipsychotic :-This medicine is used for the treatment of acute episodes of mania with psychosis.Olanzepines, rasperidone etc.
B.ECT (Electro-Convulsive Therapy)
ECT is used when the client is unresponsive to antipsychotics and mood stabilizers or is given early in pregnancy to avoid risks.
C. Psychotherapy
•Family therapy
•CBT (Cognitive Behavior Therapy)
NURSING MANAGEMENT OF MANIA
Common Nursing Diagnoses of Manic Disorder
•Imbalance nutrition
•Alteration in thought process
•Non compliance to treatment
*Objectives: To keep the patient safe and prevent injury.
Nursing Interventions
•Providing a safe and peaceful environment without external stimuli.
Asking the patient to do writing, drawing and physical exercise.
•The patient should never be left alone and provide diversional help to divert the mind.
Objectives: To change violent behavior of patients and prevent suicide.
Nursing Interventions
Assessing suicidal thinking, including frequency, plan, opportunity, past suicide attempt etc.
•The patient’s behavior should be observed for 15 minutes.
Objectives: Patient should recover from perceptual and thought disturbances.
Nursing Interventions
•Assess the patient’s thought process and reorient the patient from the present situation.
•Reducing external stimuli in the client’s environment.
Recognizing and supporting client achievements.
•Should deal with the patient honestly and have a simple conversation and give appropriate feedback about the patient’s condition.
•Provide support and encourage the patient to express his feelings and emotions.
Objectives :- Client’s communication will improve and participation in group interaction will be done.
Nursing Interventions
•Assess the patient’s level of communication and social interaction.
•Must have a friendly approach with the patient and proper communication with the patient.
•Maintaining good, realistic and therapeutic relationship with clients.
•Spending time with patients and communicating with them in simple and understandable language.
•Giving them opportunities for social interaction and providing a friendly environment.
BIPOLAR DISORDER (Manic-Depressive Disorder (MDP)) Bipolar Disorder (Manic Depressive Disorder)
Manic-depressive disorder is a cycling mood disorder in which the patient’s mood swings from manic episodes to depressive episodes at different times. There are extreme shifts in mood, energy and function. This condition is called bipolar disorder because it has alternating periods of depression and mania. Bipolar disorder is the most common, severe and persistent mental illness.
WHAT CAUSES OF BIPOLAR DISORDER
The Genetic Hypothesis
If parents have bipolar, children can get bipolar.
Biochemical factor
•Hormonal imbalance and stress response can lead to bipolar.
A stressful life event
Bipolar is caused by traumatic experiences and certain life events.
Medication
Bipolar can also occur due to the side effects of some medicines like antidepressants, stimulants, steroids.
Sleep disturbance
Bipolar disorder is also seen due to changes in sleep patterns.
Other Factor
•Pregnancy
•Treatment with depression
CLINICAL FEATURES OF BIPOLAR DISORDER
*Manic episodes
•High energy level
•Increased self confidence
•Loss of appetite
Hyperactivity (increased activity)
*Depressive episodes
•Helplessness
•Worthlessness
•Suicidal thought
•Poor memory
•Poor concentration
•Decreases appetite
•Psychomotor agitation.
•Decreases libido (decrease in sex drive.)
•Anger
•Crying spells
TREATMENT OF BIPOLAR DISORDER
A. Pharmacotherapy
*Lithium Carbonate: Lithium and other mood stabilizers are used to treat bipolar disorder.
*Anticonvulsant: Anticonvulsant medication is used to treat bipolar.
*Antidepressants: Antidepressant medications like MAOIs (monoamine oxidase inhibitors) and SSRIs (selective serotonin reuptake inhibitors) are used.
*Antipsychotic: Antipsychotic medication is effective in reducing the symptoms of bipolar.
*Omega 3 fatty acids: These acids are found in fish oil and flax seed oil.
B.ECT (Electro-Convulsive Therapy)
B. Psychotherapy
•Family therapy
•Interpersonal therapy
•Group therapy
NURSING MANAGEMENT OF BIPOLAR DISORDER
Nursing Diagnosis
•Chronic low self-esteem
•Self-care deficit
*Objectives: To keep the patient safe and prevent injury.
Nursing Interventions
•Providing a safe and peaceful environment without external stimuli.
Asking the patient to do writing, drawing and physical exercise.
•The patient should never be left alone and provide diversional help to divert the mind.
Objectives: Patient should recover from perceptual and thought disturbance.
Nursing Interventions
•Assess the patient’s thought process and reorient the patient from the present situation.
•Reducing external stimuli in the client’s environment.
Recognizing and supporting client achievements.
•Should deal with the patient honestly and have a simple conversation and give appropriate feedback about the patient’s condition.
Objectives :- The patient’s self-concept should be improved.
Nursing Interventions
•Giving a brief explanation for the activity and helping the patient identify his positive points.
•Anchor the client for positive physical habits.
Teach the patient esteem-building exercises.
Objectives: The client will be able to perform activities of daily living independently and maintain personal hygiene.
Nursing Interventions
•Assess the patient’s daily life activities including bath, diet intake, cloth and hair care etc.