Psychiatric Nursing Schizophrenia 1 Concept of Schizophrenia Schizophrenia

Psychiatric Nursing Schizophrenia 1

Concept of Schizophrenia • Schizophrenia: devastating brain disease affecting thinking, language, emotions, social behavior, and reality perception – Psychotic disorder: refers to experiencing such phenomena as delusions, hallucinations, disorganized speech or behavior – Considered a severe mental illness (SMI) • Chronic condition; treatable but not curable 2

Features of Schizophrenia • Prevalence in U. S. is 1. 1%. • Average onset is late teens to early twenties, but can be as late as midfifties • Affects cognitive, emotional, and behavioral function • 30% to 40% relapse rate in the first year

Schizophrenias: Prevalence and Comorbidity • Prevalence – Lifetime prevalence worldwide is 1% – No differences in regard to race, social status, culture, gender, or environment 4

Schizophrenias: Prevalence and Comorbidity • Comorbidity – Substance abuse disorders: approximately 40%-50% of people with schizophrenia – Nicotine dependence: 75%-85% of people with schizophrenia – Depressive disorders, anxiety disorders and psychosis-induced polydipsia also common – Suicide 20 times more prevalent than general population 5

Schizophrenia • § • 1. 2. Schizophrenia 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. 6

Schizophrenia • Effective 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. 7

Definition of Schizophrenia • What 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. 8

Facts about Schizophrenia • Symptoms 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. 9

Features of Schizophrenia (cont'd) • Progression varies from one client to another – Exacerbations and remissions – Chronic but stable – Progressive deterioration

Features of Schizophrenia (cont'd) • DSM-IV-TR Diagnosis – Symptoms present at least 6 months – Active-phase symptoms present at least 1 month – Symptoms are defined as positive and negative

Features of Schizophrenia (cont'd) • Positive symptoms – Excess or distortion of normal functioning – Aberrant response • Negative symptoms – Deficit in functioning

Features of Schizophrenia (cont'd) • Positive Symptoms of Schizophrenia – Hallucination – Delusions – Disordered speech and behavior

Features of Schizophrenia (cont'd) • Negative Symptoms of Schizophrenia – Flat affect and apathy – Alogia – Avolition – Anhedonia

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Classifications of Schizophrenia • 1. 2. Ø Ø Two 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) 16

Phases of schizophrenia development 1. Phase 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. 17

Phases of schizophrenia development 2. 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). 18

Phases of schizophrenia development 3. 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: üDelusions üHallucinations üDisorganized speech (why does this happen? ) üCatatonic 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). 19

Phases of schizophrenia development ü Negative symptoms (affective flattening and alogia, lack of desire to form relationships (asociality), and lack of motivation (avolition)). 20

Phases of schizophrenia development • Social/occupational dysfunction ü It 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 markedly below the level achieved before the onset. • Duration ü This period should include at least 1 month of symptoms. 21

Phases of schizophrenia development • Schizoaffective & Mood disorder Exclusion ü Schizoaffective 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 Exclusion ü The disturbance is not due to the direct physiological effects of a substance or medical conditions. 22

Phases of schizophrenia development • Relationship to a pervasive developmental disorder ü If there is a history of pervasive development disorder (autistic disorder). ü the additional diagnosis of schizophrenia is made only if prominent hallucinations & delusions are there for 1 month. 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. 23

Phases of schizophrenia development • Several 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. 24

Biological Theories Related to Schizophrenia • Brain chemistry, brain activity different in a person with schizophrenia • Genetics – Twin and adoptive studies validate major role – Multiple genes believed to be involved 25

Etiological implications • The 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. 1. Genetics ü The 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 510% for siblings with the disease). ü How schizophrenia is inherited is still uncertain. No reliable biological markers have yet been found. 26

Etiological implications 1. Genetics (continued) ü 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. ü Adoption Studies: adoption studies found that children who were born of schizophrenic mothers were more likely to develop the illness. 27

Figure 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 implications 2. Biochemical influences ü oldest and most explored theory to explain schizophrenia attributes a pathogenic role to abnormal brain biochemistry. ü The Dopamine Hypothesis: 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). ü Pharmacological support for this hypothesis exists. Neuroleptics/antipsychotic (e. g. Haldol) lower brain level of dopamine by blocking dopamine receptors, thus reducing the symptoms. 29

• Neurobiological factors – Dopamine theory: derived from fact that antipsychotic drugs decrease dopamine and decrease symptoms of schizophrenia – Current research: other neurotransmitters involved 30

Etiological implications • Biochemical influences continued ü 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. 31

Etiological implications 3. Physiological Influences These are the possible factors although there mechanism is unclear: ü Viral infection: high incidence of schizophrenia after prenatal exposure to influenza. ü Anatomical abnormalities: structural brain abnormalities have been observed in individuals with schizophrenia. ü Physical conditions: link have been reported between schizophrenia and epilepsy, Huntington’s chorea (neurodegenerative genetic disorder), birth trauma, head injury in adulthood, alcohol abuse, cerebral tumor, CVA, Systemic lupus erythemastosus (SLE) and parkinsonians. 32

Biological Theories Related to Schizophrenia • Neuroanatomical factors – Brain-imaging techniques validate differences in structure of brain • • • Lower brain volume Larger lateral and third ventricles Atrophy in frontal lobe More cerebrospinal fluid Low rate of blood flow and glucose metabolism in frontal lobes of cerebral cortex 33

Etiological implications 4. Psychological influences ü Early conceptualization of schizophrenia focused on family relationships factors as major influences in the development of the illness. This probably occurred in the absence of information related to the biological connection. ü Poor parent-child relationships and dysfunctional family system may consider as risk factor for schizophrenia. ü Can family interaction cause schizophrenia? 34

Etiological implications 5. Environmental influences ü Sociocultural factors: o number of individuals from lower socioeconomic classes experience symptoms associated with schizophrenia more than individuals from higher classes. Lower social classes (living in poverty, congested accommodations, inadequate nutrition, absence of prenatal care and few resources of dealing with stress). o Downward drift hypothesis: It views poor social condition, isolation and segregation of self from others as a consequence to the disorder not a cause. 35

Etiological implications Environmental influences continued üStressful life events: although there is no scientific evidence, it is probable that stress may contribute to the severity and course of the illness. This depend also on severity of stress and degree of genetic vulnerability to schizophrenia. 6. Theoretical integration The etiology of schizophrenia remains unclear. no single cause/theory have given the clear-cut explanation for the disease. The more evidence is supporting the concept of multiple causation in the development of schizophrenia. The most current theory seems to be that schizophrenia is a biological based disease, the onset of which is influenced by factors in the environment (internal and external). 36

Famous people with Schizophrenia • John Nash (1928 - - Mathematician/Nobel Prize Winner 1994. • Dr. James Watson (discovered DNA and Nobel Prize winner 1962) 37

Types of schizophrenia and other psychotic disorders: Differential diagnosis according to the total symptoms. 1. Disorganized (hebephrenic) schizophrenia. * Onset of the symptoms usually before 25 years old & the course is commonly chronic. Poor contact with reality, inappropriate or flat affect, bizarre mannerisms are common, incoherent communication (hard to understand them), social impairment is extreme, & personal appearance in general is neglected with poor hygiene. 2. Catatonic schizophrenia. • Characterized by marked abnormalities in motor behavior manifested in two forms: ü catatonic stupor (psychomotor retardation) or ü catatonic excitement (extreme psychomotor agitation). 38

Types of schizophrenia and other psychotic disorders: 3. Paranoid Schizophrenia. • Manifested y the presence of delusion of persecution and grandeur and auditory hallucinations. Pt. is often tense, suspicious, guarded, hostile and aggressive. Symptoms late 20 s or 30 s. 4. Undifferentiated schizophrenia: • Symptoms of psychosis (delusions, hallucinations, incoherence, and bizarre behavior) are present, however, these symptoms cannot be easily classified in any kind of schizophrenia. 39

Types of schizophrenia and other psychotic disorders: 5. Residual schizophrenia: • Individual has a history of at least one previous episode of psychotic symptoms with prominent psychotic symptoms but no longer displays prominent symptoms. • Residual symptoms include: social isolation, impairment in personal hygiene and blunt effect. 6. Schizoaffective disorder: • Schizophrenic behaviors with strong elements of symptoms associated with mood disorder (mania or depression). Pt. appear depressed with psychomotor retardation, suicide ideation or symptoms may include euphoria and hyperactivity. 40

7. Brief Psychotic disorder: • Sudden onset of psychotic symptoms that may or may not be proceeded by a sever psychosocial stressor (last at least one day but less than one month). • Individuals with personality disorders are more susceptible to this type. 8. Schizophreniform disorder: • Duration of predormal, active, and residual stages is at least 1 month and less than 6 months. If more than 6 months, the diagnosis will be schizophrenia. 9. Delusional disorder • The essential features of this disorder is the presence of one or more of non-bizarre delusions that persist for at least 1 month. Behavior is not bizarre. 41

Many subtypes is based on the delusional theme: – Erotomanic: individuals believes that someone, usually of higher status, is in love with him or her. – Grandiose: individual have irrational ideas regarding their own worth, talent, knowledge, or power. – Jealous: content delusion centers on the idea that person’s sexual partner is unfaithful (irrational and without cause but the patient tries to justify it). – Persecutory: individuals believe they are being malevolently treated in some way (cheated, spied on, poisoned, drugged, etc. ). – Somatic: individuals believe they have some physical defect, disorder, or disease (foul oder, insects on the skin, internal parasite, ugly body parts, dysfunctional body parts). 42

10. Shared psychotic disorder * Delusional system that develops in a second person as a result of a strong relationship with another person who already has a psychotic disorder with prominent delusions. The primary person with the disorder is usually the dominant person in the relationship. 11. Psychotic disorder due to medical condition * Hallucination and delusion directly attributed to a medical condition such as Neurologic conditions (CNS infection), Endocrine conditions, Metabolic conditions (hypoxia), Autoimmune conditions (SLE), & others (fluid imbalance). 12. Substance-induced psychotic disorder * Presence of hallucinations and delusions due to physiological effect of substance. Such as drug of abuse (cocaine, opioids, alcohol), medications (anesthetics, analgesics, anticonvulsants) & Toxins (organophsphorate insecticides, carbon dioxide, carbon monoxide). 43

Nursing Process: Assessment Guidelines • Review medical workup to rule out medical cause and use of abusive substances • Assess for command hallucinations (voices telling patient to harm self or others) • Determine patient’s belief system (delusions, paranoid beliefs) 44

Nursing Process: Assessment Guidelines • Determine any psychiatric comorbidity • Determine medication use/compliance • Determine family response to patient/symptoms • Determine social support system • Use Global Assessment of Functioning (GAF) scale 45

Nursing Process: Diagnosis and Outcomes Identification • Common nursing diagnoses – Disturbed sensory perception, Disturbed thought processes, Impaired verbal communication, Social isolation, Ineffective coping, Compromised family coping 46

Nursing Process: Diagnosis and Outcomes Identification • Outcome identification: dependent on particular phase of illness – Overall goal: patient safety and medical stabilization – Other goals: help patient adhere to medication regimens, understand disease, participate in psychoeducational programs, prevent relapse 47

Nursing Process: Planning and Implementation • Planning: dependent on particular phase of illness – Acute phase: planning strategies to ensure patient safety and stabilize symptoms – Maintenance phase: planning strategies to provide patient and family education – Stabilization phase: planning strategies to prevent relapse 48

Nursing Process: Planning and Implementation • Implementation: need to be geared toward patient’s strengths and healthy functioning as well as weaknesses/symptoms 49

Communication Guidelines for the Patient with Schizophrenia • Dealing with hallucinations and delusions – Approach patient in nonthreatening and nonjudgmental manner – Identify feelings patient is experiencing – Clarify reality of patient’s experience – Avoid arguing/attempt to reason with patient who is delusional – Interact with patient about concrete reality – Distract patient’s attention from hallucination/delusional belief 50

Communication Guidelines for the Patient with Schizophrenia • Dealing with the patient who is paranoid – Be honest and consistent – Avoid talking, laughing, whispering when patient cannot hear what is being said 51

Communication Guidelines for the Patient with Schizophrenia • Dealing with associative looseness – Do not pretend to understand patient’s communications when you do not – Tell patient you are having difficulty understanding – Look for recurring topics or themes – Emphasize what is going on in the “here and now” 52

Guidelines for Health Teaching and Promotion • Include patient and family in teaching • Topics to include – Disease process – Medications and side effects – Prevention of relapse – Stress management – Sources of ongoing support for patient and family 53

Treatment for Schizophrenia: Milieu Therapy • Therapeutic milieu can be in hospital, partial hospitalization program, halfway house or day treatment program • Aspects of milieu therapy – Safety: protect patient and others – Structured routine – Use of group therapy, supervised activities, individual counseling, specialized training, and rehabilitation 54

Treatment of Schizophrenia: Psychotherapy • Program for Assertive Community Treatment (PACT) – Prevent relapse, maximize social and vocational functioning and keep individual in community • Family therapy – Support family and use psychoeducation to help establish improved communication and functioning 55

Treatment of Schizophrenia: Psychotherapy • Cognitive-behavioral therapy – Helps reduce frequency and intensity of delusions and hallucinations • Social skills training – Helps improve level of social activity, foster new social contacts, improve quality of life 56

Treatment for Schizophrenia: Antipsychotic Medications • Used to alleviate symptoms, not curative – When patients discontinue medication, psychotic symptoms/relapse occurs • Each relapse leads to longer recovery time and possibility that patient will become unresponsive to medications • Types of antipsychotic medications – Conventional (first-generation) – Atypical (second-generation) 57

Treatment of Schizophrenia: Atypical Antipsychotics • Action: serotonin and dopamine antagonist • First atypical introduced: clozapine (Clozaril) – Problem: causes agranulocytosis (up to 1% of patients) 58

Treatment of Schizophrenia: Atypical Antipsychotics • Advantage of atypicals – Alleviate positive and negative symptoms – Produce minimal extrapyramidal symptoms – Help improve cognitive deficits and decrease anxiety and depression 59

Treatment of Schizophrenia: Atypical Antipsychotics • Disadvantage of atypicals – Tend to cause weight gain associated with additional metabolic side effects increasing risk for diabetes, cardiovascular disease, and hypertension – More expensive than conventional antipsychotics 60

Treatment of Schizophrenia: Conventional Antipsychotics • Action: dopamine antagonist at D 2 receptor sites in both limbic and motor areas of brain • Disadvantage: side effect profile is severe 61

Treatment of Schizophrenia: Conventional Antipsychotics • Major side effects: extrapyramidal symptoms – Tardive dyskinesia (TD): tongue movements, lip smacking with uncontrollable biting, chewing, or sucking movements – Acute dystonia: muscle cramps of head and neck – Akathisia: internal and external restlessness – Pseudoparkinsonism: stiffened extremities, fine motor tremors 62

Treatment of Schizophrenia: Conventional Antipsychotics • Other side effects – Neuroleptic malignant syndrome (NMS): occurs from dopamine blockage • Produces decreased level of consciousness, increased muscle tone, high fever, hypertension, sweating, tachycardia, drooling • Discontinue antipsychotic drug, treat symptomatically in intensive care environment • Dopaminergic medications bromocriptine (Parlodel) and dantrolene (Dantrium) – Agranulocytosis 63

Implementations for Antipsychotic Medications • Use Abnormal Involuntary Movement Scale (AIMS) for early recognition of EPS • Use anticholinergic medications as treatment for EPS • Monitor patient for symptoms of agranulocytosis • Monitor patient for symptoms of NMS and intervene early 64

Nursing Process: Evaluation • Recognize that process of improvement may take long time • Consider questions such as: – Are patient strengths being used to achieve outcomes? – Are more appropriate interventions available? – Are medications effectively reducing symptoms? – Are family members involved and supportive? – Are community resources appropriately used? 65

Nursing care for schizophrenia • Assessment: Assessment of the client with schizophrenia may be a complex process, therefore , data may be obtained from different recourses: Family members, old records, other individuals. • Behavioral disturbances in eight areas of functioning are affected: 1. Content of thought v. Delusions: false personal beliefs that are inconsistent with the person’s intelligence or background. Delusions are subdivided into: • Persecutory: individual feels threatened and believes others intend to harm him/her. • Grandiosity: individual has an exaggerated feeling of power • Reference: all events within environment referred by psychotic person to him/her self. 66

Nursing care for schizophrenia v. Delusions (continued) • Control or influence: certain objects or person have control over psychotic person. • Somatic delusions: the individual has a false ideas about the functioning of his or her body. • Nihilistic delusions: the individual has a false idea that the self, a part of the self, others, or the world is nonexistent. v. Religiosity: is an excessive demonstration of or obsession with religious ideas and behavior. v Paranoia: individuals have extreme suspiciousness of others and of their actions or perceived intentions. v Magical thinking: individuals believe that their thoughts 67 or behaviors have control over specific situations or people.

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Nursing care for schizophrenia 2. Form of thought – Associative looseness: ideas shift from one unrelated subject to another. – Neologism: psychotic person invents new words that are meaningless to others. – Concrete thinking: regression to an earlier level of cognitive development. – Clang association: choice of words is governed by sounds 69

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Nursing care for schizophrenia – World salad: group of words without logical connection. – Circumstantiality: delayed in reaching point of communication because of unnecessary details. – Tangentiality: the person never gets to the point of communication. – Mutism: individuals inability or refusal to speech – Perseveration: repeating the same ideas or words in response to different questions. 71

Assessment of schizophrenia 3. Perception • Hallucinations: Auditory, visual, tactile, gustatory, olfactory • Illusion: misperceptions of real external stimuli. 4. Affect • Inappropriate affect: emotional tone is incongruent with circumstances • Bland of flat affect: emotional tone is weak. • Apathy: disinterest in environment. 5. Sense of self: – Echolalia: repeat words – Echopraxia: imitate movements – Identification and imitation: self-identity confusion – Depersonalization: feeling unreality 72

Assessment of schizophrenia 6. Volition: impairment in ability to initiate goal-directed activity. – Emotional ambivalence: opposite emotion to same situation. – Impaired interpersonal functioning: intrude others personal space – Autism: focuses on a fantasy world. – Deteriorated appearance 7. Psychomotor behavior: – Anergia: deficiency of energy – Waxy flexibility: body parts placed in bizarre positions. 73

Assessment of schizophrenia – Posturing: bizarre postures – Pacing or rocking: back and forth rocking 8. Associated Features • Anhedonia: inability to experience pleasure • Regression: to retreat to an earlier level of development. 9. Positive & Negative Symptoms • +ve: reflect an excess or distortion of normal functions. • -ve: loss of normal functions. 74

Nursing Implications (cont'd) • Nursing Diagnoses – Altered thought process – Social isolation – Risk for violence – Self-care deficits – Altered health maintenance – Ineffective family coping

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Nursing Implications: Supporting Families • Family needs vary with degree of illness and involvement in client’s care – Education – Financial support – Psychosocial support – Advocacy

Nursing Implications: Supporting Families (cont'd) • Schizophrenia is a “family illness. ” • Family members need to be involved. • Educate family about – Medication – Illness – Relapse prevention

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Nursing Implications: Supporting Families (cont'd) • Nurse assists family by – Identifying community agencies/groups for family members – Advocating for rights

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Measures to Prevent Relapse • Ensure client takes medication • Educate family about signs and symptoms of relapse • Client and family to participate in relapse prevention program

Measures to Prevent Relapse (cont'd) • Relapse prevention programs work best when: – Psychosocial treatment and social skills training are combined with antipsychotic medication – Behavior patterns are monitored – Family members understand triggers

Measures to Prevent Relapse (cont'd) • Relapse prevention programs provide education and support regarding: – Individual triggers, symptoms of relapse – Managing side effects of medications – Interventions to reduce or eliminate triggers – Strategies to facilitate early intervention – Cognitive therapy – Community resources

Challenges to Adherence • Side effects • Level of symptomatology • Cognitive, motivational, financial, and cultural issues • Issues with caregivers • Insufficient medication teaching

Increasing Adherence • Involve clients in treatment • Instruct client about reducing discomfort • Provide peer support • Provide reminders and positive feedback • Recognize accomplishments

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Personal Awareness • Identify personal feelings. • Recognize personal perceptions. • What behaviors do you expect to see? • How will you respond to these behaviors? • What is the meaning of the behaviors?

Personal Awareness (cont'd) • What defines “normal” behavior? • What are my fears associated with mental illness?

Personal Awareness (cont'd) • Be honest with your feelings. • Identify what strengths you bring to the situation. • Remember that clients are human beings with a mental disorder and do not choose to be this way.

Treatment modalities for Schizophrenia • Individual psychotherapy – Problem solving, reality testing, psychoeducation, and supportive & cognitive-behavioral techniques. – Reality-oriented individual therapy is the most suitable approach. – Effort should focus on decreasing anxiety and increase trust. – Because it is difficult to establish relationship with pt. the successful intervention may be achieved with honest, simple directness, and respecting the client privacy and dignity. 98

Treatment modalities for Schizophrenia • Group therapy – It is less productive in inpatient settings. – It is the most useful over the long-term course of the illness. • Behavior therapy – It help in reducing the frequency of bizarre, disturbing, and deviant behaviors and increase appropriate behaviors. Features led to positive results include: – Clearly defined goals. – Attaching +ve, -ve, & aversive reinforcements to adaptive and maladaptive behavior. – Using simple, concrete instructions and prompts to elicit the desired behavior. 99

Treatment modalities for Schizophrenia • Social skill training – One of the most widely used psychosocial interventions. – The educational procedure focus on role-play, like using scenarios. – Progress is directed toward the client’s need and limitations. 100

Treatment modalities for Schizophrenia • Milieu therapy – More successful if used in conjunction with psychotropic medications. • Family therapy – Designed to support the family system, prevent or delay relapse, and help maintain the client in the community. • Antipsychotic drugs – Antipsychotic medications – Reserpine: a dopamine receptor antagonist used as antihypertensive and antipsychotic. It is now rarely used because it produced severe depression 101

Treatment modalities for Schizophrenia • Antipsychotic drugs (continued) – Lithium carbonate: used to suppress episodic violence. – Carbamazepine: ameliorates symptoms in some treatment-resistant psychotic client. – Valium: control agitation, thought disorder, delusions, and hallucinations. – Propranolol: useful in controlling temper outbursts in aggressive or violent psychotic clients. 102

THANK YOU 103