воскресенье, 21 июля 2013 г.

Psychiatry - Schizophrenia

Schizophrenia is a chronic severe psychosis usually occurs in young adults, clinically characterized by signs of dissociation, emotional dissonance and incoherent delirious activity, usually involving a loss of contact with the outside world and sometimes autistic withdrawal .

Schizophrenia comes from the Greek skizein: split and phren: thinking.

Epidemiology

Frequency

Schizophrenia occurs in all cultures, all races, all cultures.
Its frequency in the current population is 1%, which is considerable.
The disease occurs early in most cases between 15 and 35 years and is divided between the two sexes.

Aetiopathogenesis

At present, the etiology of schizophrenia remains unknown. The interaction of several factors may be taken into account.

Genetic factors

Higher risk of schizophrenia related to schizophrenia.
When a brother or sister is affected, the risk is 6 to 14%.
When a parent is affected, the risk is 7-16%.
When both parents are affected, the risk is 40 to 68%.
When it's two homozygous twins (identical twins), the risk is 50 to 75%.
Biological Factors

Many assumptions have been made, arguing in particular that it would be a biochemical disease with among others a disorder of the metabolism of dopamine.

Psychological Factors

According to psychoanalytic classification of mental diseases, roots of schizophrenia would be the earliest, at the oral stage in Freud or paranoid-schizoid stage in Melanie Klein, is schematically the first year of life. It is a preverbal period where interactions with the environment can be summarized in large part to the central role of the Mother.

But this meaning is often misunderstood as the Mother in the psychoanalytic sense not only or not at all correspond to the biological mother. It can also would be better to talk about mothering Winnicott. Winnicott defined the primary functions of the Mother by the holding (how the child is held, worn, supported), the handling (how it is handled, massaged, how he discovered his body sensations) and presenting the object ( how he was introduced to the objects of the external world, which also includes the first social contacts).

In psychoanalytic theory, schizophrenia is a disorder of the integration of the mind within the body. In this place of the mother is important because it is what makes discover his body to the child. But again it must be understood as the Mother as the protection zone, the buffer zone between the infant and the outside world.

The current psychoanalytic approach fully integrates the role of genetic predisposition that cause hypersensitivity psyche newborn to the mothering failures.
To explain this we can take a picture of a vase. A poorly constructed vessel will be more fragile and less shock resist a chaotic handling. On the other hand, a well-built vessel to better withstand these shocks. In the same vein, a poorly constructed vessel could break at the slightest touch, even if we pay attention or otherwise take a lifetime because no shock will hit weaknesses.

To go further on the relationship between the physical body and the loss of mental limits in schizophrenia, we recommend the book of D. Anzieu: "the self-skin".

Social factors

English antipsychiatrists widen the debate involving all the social environment close, a social genesis of schizophrenia. This was able to support each other Th. Szasz. Which considers that "any society to survive, needs to make scapegoats. The Middle Ages had its witches and heretics, we have our mentally ill ... "

Start and installation of schizophrenia

Sudden onset forms

Acute delirious episode (it does not sign every time an entry in schizophrenia) is the typical form of onset of the disease.
Other elements are feared an entry in schizophrenia as atypical depressive state associated with anorexia, asthenia, insomnia and mood disorders (dark thoughts, thoughts of death, sadness, disgust). This depression is not part of a neurotic and does not either in a manic-depressive psychosis.

Taking advantage of this input in schizophrenia way there:

1. schizoid traits of character:

Attitude of withdrawal, with a relative lack of interest in the outside world (introversion).
Drain social contacts (little or no friends).
Shy people and cleared.
Inability to express emotions - cold and distant contact.
Inability to experience pleasure.
Reduced interest in sex.
Imaginary life often intense but odd, with a great interest in abstract things.
Indifference to social norms and conventions.
Social adaptation is possible, but limited.
1.2 Swing the mood;
3.a great emotional vacuum.

Forms gradual onset

Disorders can be installed gradually over weeks, months, a year or two. It may begin with:

decreased intellectual performance;
an unusual failure in an examination;
abandonment of employment;
changing the character tendency to isolation, hostility to the family;
renunciation leisure activities without proof;
commitment to marginal things esoteric, occult;
the onset of neurotic disorders look: anxiety, anxiety blurred;
obsessive symptomatology doubts about besieged;
hysterical symptoms;
complaints;
a body dysmorphic disorder.
5. State period

Two essential elements are noted in the symptomatology of schizophrenia.

On the one hand a negative slope, which corresponds to personality disorders where dissociation dominate and autism. The subject is the World Cup.
On the other hand a positive slope with a delusional schizophrenic for reconstruction of the outside world and himself. This delusion is called paranoid delusions.
The paranoid delusions and dissociation can be found in a common element, the unconformity, a fundamental element of schizophrenia.

1. Mismatch

It is observed as a characteristic in schizophrenia considerable ambivalence by considering at the same time positive and negative emotions, feelings or thoughts they may have. Similarly, love and hate, affirmation and negation, desire and fear, are often entangled.
At the same time, the singularity and impenetrability often make it impossible to communicate with the schizophrenic who often seems airtight.
There is also a detachment from reality with a reversal of course, also known as autism.

2. Dissociation

Dissociation is the breaking of the psychic unity causing a loosening of associative processes that would be based on mental functioning. Trouble relieved by:

dissociation at the behavioral level;
a sense of strangeness, incoherence;
stereotypy. Repetitive motion identical, unnecessary, which can affect the face (paramimie), gestural (swings);
a échomimie: the subject repeats the gesture he has seen. ;
mannerism gestures, attitudes (unnatural), it is a strange way to behave;
of unmotivated laughter;
the subject speaks for itself;
a clothing inconsistency (some form of eccentricity).
Disorders over the thought and language.
They reflect the dissociation at the intellectual level.

Disorders over the thought

The thought is blurred, chaotic, discontinuous (diffluence).
There is a disorder associations (the patient has difficulty moving from one idea to another). It has a depletion printing or pseudo-debility.
He answers to side because of the diffluence.
Dams sudden interruption in the middle of a sentence (a few seconds) and the subject will leave.
"Mental Fading" equivalent to minimum (less intense) of the dam, resulting in a slowdown in the verbal flow and then it's off again (thinking slows down).
Perseveration: they are parasites ideas that will hinder the normal sequence of ideas. This can also be actions that will be imposed on.
Morbid rationalism: it will streamline any cleavage between the mind and the emotions, logic reasoning becomes increasingly incoherent.
Memory problems: they are due to disorders of the course of thought with uncontrolled mobilization of memory.
Sometimes there are hypermnesia: have excessive recollections often affecting insignificant details.
Over time, there will be a deficit evolution, which will give a real memory disorder.
Impaired concentration and attention.
Language disorders

They reflect thought disorder at the word

Responses to side.
Dams.
"Fading mind."
Dumb or semi-dumb: this function is to cut contact with reality. There are sometimes verbal impulses will cut the silence.
Echolalie: the subject will repeat the last word or the last sentence heard.
Neologisms: invented words.
Impaired syntax: agrammatisme or paragrammatism.
Schizophasia: schizophrenic language (rare).
Disorders of affectivity

They will reflect the dissociation at an emotional level.
Emotional numbing or emotional anesthesia (athynormie). The subject loses his emotions.
He feels the lack of interest in almost everything. It fluctuates over time.
Emotional discord. Mismatch between a feeling and expression of the subject.
Emotional ambivalence. It is the fact that the subject has for a person, an object, a feeling of love and hate.
Sexuality. Purely masturbatory or sexual divested purely on an emotional level.
3. Paranoid delusions

Unstructured delirium, hermetic, fuzzy, weird.

Mechanisms

You can see all the mechanisms, especially auditory hallucinations sometimes preceded by intra-psychic hallucinations.

Themes

Topics influence (common).
Themes reference: when the subject is convinced that certain facts have meaning only for him.
Theme of persecution (common).
Schizophrenics, the themes are unclear, multiple and variable in time.

Structure of delirium

This is an unstructured delirium, disorganized, unclear and inconsistent.

Membership delirium

It is important to sometimes even acting out.

Anxiety

Delusions are often accompanied by anxiety.

Anxiety depersonalization. The subject has the feeling of having changed (physical and mental sign of the mirror: the patient spends long time to look to see if it has changed). This anxiety is also called fragmentation anxiety.
Anxiety derealization. The surrounding world is not recognized by the subject.
Mental automatism

Schizophrenia is often accompanied by mental automatism.
There are three degrees:

Small mental automatism. There is no hallucination. The patient has an automatic thought (ever scroll, rushed, uncontrollable, ideas, images in the head). The subject believes that people guess his ideas or thoughts fly. There is an echo of thought (thought that is repeated like an echo with comment).
Grand mental automatism. It is a small mental automatism + auditory hallucinations.
Triple mental automatism. This is when there is a syndrome of influence.
6. The clinical forms

Simple schizophrenia

There is rarely a delusion or it is very important. It is manifested by the dissociation is slow insidious. The subjects were a schizoid personality. They do not consult systematically.
This is the environment that encourages them.
Oddity, listlessness.
Emotional indifference.
Vagrancy, homeless, social disintegration but sometimes social integration.
Paranoid schizophrenia

The most common form.
Delirium is important and dissociation is attenuated in the background behind the madness. Delirium is unclear, inconsistent, no particular theme.
Alternating episodes of acute and remission (cyclical).
They are very sensitive to neuroleptics.
The hebephrenia

This is the form or dissociation is possible.
Insidious onset, absence of delirium, significant discrepancy, no emotion, purpose, project (deficit mental deterioration).
Neuroleptics work.
Catatonic form

It has become exceptional. The descriptions are historical.

In acute evolutionary periods.
In very ancient forms.
It also reflects the behavioral dissociation.
They may stop at any time.
Negativity: it is the expression of negative attitude (stay in bed all day (clinophilia), contracture of the jaw, refusing the outstretched hand, refusal of any negativity and sometimes it can be aggressive.
Catalepsy. The subject is completely still and when we mobilize the subject it will keep the position.
Hyperkinesis: these are impulses that come suddenly.
Vegetative disorders: odèmes, vasomotor disorders.
7. The differential diagnosis

The crisis of adolescence

There is a contrast, sometimes a failure at school, marginal behavior, social withdrawal, an ideological claim.

Childhood psychoses set

It affects young children (mental retardation without evolution).
Severe personality disorders.
Slightly dissociated.
The acute delirious.
They may be isolated or the onset of schizophrenia.

Neurotic disorders

Same with severe personality disorders.
Bipolar disorder with delusions.
There are delirious mania and melancholy delusional.

Non-schizophrenic delusions

There are elements that show the difference.

No dissociation.
Later age of onset (40 years).
No change in deficit.
Organic pathologies

They can simulate schizophrenia:

Brain tumor.
Cerebral syphilis.
Cerebral venous thrombosis.
Epilepsy.
Toxic (L.S.D., cannabis, amphetamines, etc..).
8. Evolution and prognosis

Favorable prognostic factors

Late start.
Existence of a triggering stress.
Associated mood disorders.
No previous schizoid personality.
Presence of complete remission at a time of evolution.
Major complications

Depression.
Suicide. Common among schizophrenics.
Self-harm in the great moments of anguish.
Switching to the straight aggressive act: rare.
Family and social disintegration frequent.
9. Treatment

Treatment principle

Early detection.
No etiological treatment (there is no cure for schizophrenia).
Chronic disease: understanding the family.
Aim of treatment

Reduce the frequency of access of crisis.
Avoid loss evolution.
To accept the need for treatment.
Followed by sector teams (C.M.P.).
Neuroleptics

The choice of antipsychotic according to symptoms.

In the case of a very important delirium neuroleptic anti-delusional (haldol, largactil, Loxapac, solian).
In the case of a psychotic anxiety or agitation sedative neuroleptics (Tercian, Loxapac, Nozinan).
In a hébéphrène: disinhibiting low dose neuroleptics (haldol, solian).
Delay treatment (depot injection) intramuscularly every 2 3.4 weeks.
Psychotherapies

Psychoanalysis

Psychoanalysis adapts to the specific conditions of the treatment by applying some very different from those which are reserved for neurotic patients rules. Schizophrenic patient is made to support rather than trying to find her unconscious, do not push in-depth investigations, seek to strengthen defenses, neither confirm nor deny the delusions, help the patient to solve interpersonal problems.

Supportive psychotherapy

Gaining the trust of the patient.
Achieve a minimum agreement on drug plane (at worst provide a delay treatment).
Speaking of side effects and dramatize.
Be stable and available therapist.
Gain the confidence of the patient's relatives.
Institutional psychotherapy

In institutions: hospital, day hospital, home.
Purpose: to help the patient cope better with the hospital stay. We can help therapeutic workshops.

Family therapy

Meet all the patient and family.
Goal: Better acceptance by the family of schizophrenic.
Social Therapy

These are the measures that will facilitate the social reintegration. They complete the first two parts that are chemotherapy and psychotherapy.
Use

Patients can work under treatment.
The patient can take a secure job.
Earnings

Those who work obviously have a salary.
A request for Disabled Adult Allowance (AAH) can be made to the COTOREP
A disability pension may be granted for a schizophrenic who has worked.
Support 100%.
Protection of property

It is often called a guardianship or curatorship to help the patient to manage his property.

Housing

Is the subject works and housing, or accommodation is provided by the family. There is also the:

Transient structures: Therapeutic apartments, nursing homes.
Structures definitive host: host families, specialized shelters.
10. Role of the nurse

The team concept is paramount in the management of schizophrenia. Decisions must be taken together and implemented open consistently. The difference is the wealth of a team and do not be afraid of conflict. The confrontation is useless against. We must be able to question yourself, this is a critical requirement.

Do not go too fast with patients with schizophrenia. They are sick for several years for most, then return at once to reality will only disturb more. It is therefore in their interest to take the time.

As nurses, we are never alone. A project to build a team and nurses have a specific role to play. It should hold its own, arguing ideas, and refer to the doctor. We must of course mention the sick but do not forget to talk about our own difficulties in these absorptions. The internal consistency of the team prevents the patient to repeat his conflicts with caregivers, to induce similar to those that have known the family environment with such conflicts.

At times, the nurse can be alone with the patient. It should address the patient without fear or aggression. The patient needs to have before him a caregiver inscribed in reality and serene. Do not put in doubt his word is his reality. The patient also invest differently caregivers who understand and those who do not understand. The nurse may also be there, within its competence to teach the patient to speak. This is obviously not the psychotherapy but a preparation for the latter.

Finally, it is necessary to make an alliance with the family should be aware of and care project stakeholder. The health care team plays a very important role as a mediator between the patient and his family. The family must be accompanied to the end.