Catatonic stupor syndrome in schizophrenic patients

Catatonic stupor syndrome in schizophrenic patients

Catatonic schizophrenia is also the same as catatonic stupor syndrome. So before we start with catatonic stupor, lets begin by understanding Schizophrenia 

SCHIZOPHRENIA

Introduction

Schizophrenia is one of the most severe forms of mental illnesses
which tend to run a downward trend. It affects 1% of the general
population.The term schizophrenia was coined in 1908 by Swish
Psychiatrist EugenBleuler. The word was derived from the Greek
word Schizo which means split and Phrenmind.

Definition

Schizophrenia is functional psychosis characterized by disturbance in thinking, emotion, volition and perception.
Schizophrenia is one of the major mental illnesses
characterized by disorder of thinking, perception and mood, deterioration of interpersonal relationship
Causes of Schizophrenia

The actual cause of schizophrenia is unknown (idiopathic) but some factors are associated with it.

  1.  Genes
    Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than does the general population.
    Twin studies indicated that the rate of schizophrenia among
    monozygotic (identical) twins is four times that of dizygotic
    (fraternal) twins.
  2.  Personality
    People who are withdrawn and having no friends and live solitary lives and those who prefer being isolated than in group are most likely to suffer from schizophrenia.
  3. Biochemical influences
    The theory stets that schizophrenia may be caused by an excess of dopamine dependent neuronal activity in the brain.
  4. Anatomical abnormalities
    Structural brain abnormalities have been observed in individuals with schizophrenia. For example: Ventricular enlargement is the most consistent finding. It is associated with cognitive impairment:
  5.  Physiological influences
    >   Viral infections.
    >   Birth injuries
    >   Alcohol abuse
    >   Cerebral vascular accidents
    >   Myxedema
    >   Parkinsonism
    >   Head at adulthood
    >   Cerebral tumour
  6. Psychological influences.
    >   Poor parent child relationships.
    >   Dysfunctional family systems
  7. Environmental influences
    Greater numbers of individuals from the lower socioeconomic
    classes experience symptoms of Schizophrenia than do the higher socioeconomic class or group. This explains:
    >   Poor living conditions
    >   Poverty
    >   Congested houses
    >   Inadequate nutrition
    >   Absence of prenatal care
    >   Feeling of hopelessness for changing ones life style.
    8. Stressful events
    Stress may contribute to the severity of and course of the illness

Types of Schizophrenia
1. Acute Schizophrenia
2. Chronic Schizophrenia

Subtypes of schizophrenia
  1.  Simple Schizophrenia
    >  gradual onset
    >   odd behaviours
    >   wandering tendency
    >   self absorbed
    >   idle and aimless activity are present
    >   solitary (isolated)
    >   usually occurs at late 20s or early 30s
  2.  Hebephrenic Schizophrenia (disorganized schizophrenia)
    This type of schizophrenia is marked by incoherence flat, incongruous or sill affect.
    >   onset is at age of 15 to 25 years
    >   insidious onset
    >   extreme social impairment
    >   poor premorbid personality
    >   runs a chronic course
    >   behaviour is regressive and primitive
    >   contact with reality is often lost or poor
    >   mood is often inappropriate
    >   silly laughter
    >   giggling
    >   facial grimaces
    >   bizarre mannerisms
    >   neglected hygiene
    >   social impairment is extreme
  3.  Paranoid Schizophrenia
    Is type of schizophrenia characterized by the presence of delusions of persecution or grandeur.
    >  Auditory hallucinations
    >  Individual is often suspicious
    >  Hostile
    >  Often tense
    >  Argumentative
    >  Aggressive
    >  Onset is mainly at 20s or 30s
    >  Less regression in mental faculties
    >  Emotional and behaviour is seen than in other subtypes
    4. Catatonic Schizophrenia
    Catatonic schizophrenia is characterized by marked abnormalities in motor behaviour and may manifest in form of stupor or excitement

Catatonic Stupor

Catatonia is characterized by an inability to move normally. The symptoms of catatonia can include:  Mutism, Negativism,  Waxy flexibility,  Bizarre positions may be assumed,  Patient is aware of what is taking place around him or her staying still i.e. the patient adapts to a rather uncomfortable positions and maintains it for long hours condition called waxy flexibility, lack of speech, abnormal movements

Catatonic Stupor is the lack of critical mental function and a level of consciousness where a patient is almost entirely unresponsive and only responds to base stimuli such as pain. Its occurrence in depression is called Depressive stupor

Catatonic Excitement:  Is manifested by a state of extreme psychomotor agitation. Excitement, Restlessness, Purposeless movement, Incoherent speech

Catatonic excitement
Symptoms of catatonic schizophrenia may include:
  •  Stupor (a state close to unconsciousness)
  • Catalepsy (trance seizure with rigid body)
  • Waxy flexibility (limbs stay in the position another person puts them in)
  • Mutism (lack of verbal response)
  • Negativism (lack of response stimuli or instruction)
  • Posturing (holding a posture that fights gravity)
  • Mannerism (odd and exaggerated movements)
  • Stereotypy (repetitive movements for no reason)
  • Agitation (not influenced by eternal stimuli)
  • Grimacing (contorted facial movements)
  • Echolalia (meaningless repetition of another person’s word)
  • Echopraxia (meaningless repetition of another person’s movements)
  • The catatonic state may be punctuated by times of polar opposite behaviors. For example, someone with catatonia may experience brief episodes of:
    >   Unexplained excitability
    >   Defiance

Causes of Catatonic Behavior
  •  Brain abnormalities: These include unusual activity in the brain including irregularities in neurotransmitter systems involving dopamine, glutamate, and gamma-aminobutyric acid
    (GABA).
  • Psychiatric conditions: Catatonia or catatonic behavior is a serious psychiatric condition that has historically been associated with schizophrenia, but it can be present in a variety of psychiatric conditions, including schizoaffective disorder, bipolar disorder, and major depressive disorder.
  • Substances and other medications: Catatonic behavior may also result from drugs, alcohol, and certain medications.
  • Medical conditions: Some other medical conditions can cause catatonic behavior or behaviors that can be mistaken for catatonia. Dystonia, encephalopathy, HIV, and renal failure are
    conditions that can potentially cause catatonia.
    Catatonic symptoms like facial contortions, strange limb movements, or unusual body positions can lead to a misdiagnosis of tardive dyskinesia or other movement disorders. Similarly, Tourette’s syndrome may be confused for catatonia due to some of the vocalizations that can be part of the syndrome.


Risk factors for catatonic schizophrenia
>   Family history is a risk factor for this condition.
>  However, a person’s own lifestyle and behavior may also be related i.e. catatonic schizophrenic
episodes have been linked to substance misuse.
Diagnosis of catatonic schizophrenia
There are no labs or tests to diagnose catatonic symptoms in schizophrenia. Catatonic behavior can also occur in other conditions such as autism and mood disorders, so a doctor will evaluate symptoms to determine what is causing them.
> EEG (electroencephalogram)
> MRI scan
> CT scan
> physical examination
> psychiatric examination (performed by a psychiatrist)
Catatonic schizophrenia treatment
Medication
Typically, the first step in treating catatonic schizophrenia is medication.
> Lorazepam
> Alprazolam (Xanax)
> Diazepam (Valium)
> Clorazepate (Tranxene)
Psychotherapy
Sometimes psychotherapy is combined with medication to teach coping skills and how to deal with stressful situations.
This treatment also aims to help people who have mental health issues associated with catatonia learn how to collaborate with their Health providers to manage their condition better.
ECT
ECT, formerly known as electroshock therapy, is increasingly used to effectively treat catatonia in schizophrenia and other psychiatric conditions.

General Clinical features of Schizophrenia

  •  Neglected personal hygiene
  • Patient is withdrawn into world of his own
  • Pack of interest in the environment
  • Hallucinations are common
  • Illusions are also present
  • Lack of drive or will power
  • Delusions of persecutory
  • Passivity thoughts are also common
  • Disturbed thoughts for example insertion, broadcasting and
    withdrawal
  • Disturbed behaviour
  • Disturbed mood
  • Disturbed speech: echolalia, neologism, ward salad, Incoherency
  • Flexibilitas Cerea (is the capacity (as in catalepsy) to maintain the limbs or other bodily parts in whatever position they have been placed.)
  • Catalepsy
  • Echopraxia
  • Anergia- deficiency in energy
  • Anhedonia- inability to express or experience pleasure.
  • Regression
Positive symptoms of schizophrenia

Positive signs and symptoms of schizophrenia refers to mental disturbances in the patient’s perception of reality that do not exist objectively. Positive symptoms make treatment seem  more urgent, and they can often be effectively treated with antipsychotic drugs. They include:

  • Delusions: These firmly held erroneous beliefs due to distortions or exaggerations of reasoning and/or misinterpretations of perceptions or experiences. Delusions of being followed or
    watched are common, as are beliefs that comments, radio or TV programs, etc., are directing special messages directly to him/her.
  • Hallucinations: These are distortions or exaggerations of perception in any of the senses, although auditory hallucinations (“hearing voices” within, distinct from one’s own thoughts) are the most common, followed by visual hallucinations.
  • Disorganized speech/thinking, also described as “thought
    disorder” or “loosening of associations,” is a key aspect of
    schizophrenia. Disorganized thinking is usually assessed primarily
    based on the person’s speech such as loosely associated, or
    incoherent speech, neologisms
  • Grossly disorganized behavior which includes difficulty in goal-directed behavior (leading to difficulties in activities of daily living), unpredictable agitation or silliness, social disinhibition, or behaviors that are bizarre to onlookers. Their purposelessness
    distinguishes them from unusual behavior prompted by delusional beliefs.
  • Catatonic behaviors are characterized by a marked decrease in reaction to the immediate surrounding environment, sometimes
    taking the form of motionless and apparent unawareness, rigid or
    bizarre postures, or aimless excess motor activity.
  • Other symptoms sometimes present in schizophrenia but not
    often enough to be definitional alone include affect inappropriate
    to the situation or stimuli, unusual motor behavior (pacing, rocking), depersonalization, derealization, and somatic
    preoccupations.
Negative symptoms of schizophrenia are;

Negative symptoms are the main reason patients with schizophrenia cannot live independently, hold jobs, establish
personal relationships, and manage everyday social situations.
These symptoms are also the ones that trouble them most

  • Affective flattening is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye
    contact, and body language.
  • Alogia, or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts,
    and often manifested as short, empty replies to questions.
  • Avolition(will power) is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest. (examples of avolition include: no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing.)
  • Anhedonia: absence of pleasure in social activities.
  • Social withdrawal: Patient becomes socially isolated, loses
    interests in friends.


Good prognosis of Schizophrenia
>  Acute and later onset
>  Obvious precipitating factor
>  Good premorbid personality
>  Affective symptoms are present
>  Married
>  Family history of mood disorder
>  Good support system
>  Positive symptoms are present


Poor prognosis
>  Insidious and younger onset
>  No precipitating factors
>  Poor premorbid social and work history
>  Withdrawn
>  Single, divorced or widowed
>  Family history of schizophrenia
>  Poor support system
>  Negative symptoms.

Schneider’s first-rank symptoms of schizophrenia

are symptoms which, if present, are strongly suggestive of schizophrenia. They include:

  •  Auditory hallucinations:
    >  hearing thoughts spoken aloud
    >  hearing voices referring to himself / herself, made
    in the third person
    >  auditory hallucinations in the form of a
    commentary
  • Thought withdrawal, insertion and interruption
  • Thought broadcasting
  • Somatic hallucinations
  • Delusional perception
  • Feelings or actions experienced as made or influenced by
    external agents
Nursing diagnoses of patient suffering from schizophrenic
illness.


1. Altered sensory-perception (auditory hallucination) related to
schizophrenia as evidenced by patient seen communicating to
people other people do not see, hearing voices.


2. Altered thought process (delusions) related to schizophrenia
as evidenced by patient believing that people are against him.


3. Impaired communication (neologisms) related to the disorder as evidenced by patient talking language which other people do not understand.

4. Impaired social interaction related to the disorder as
evidenced by patient becoming isolated and been suspicious
of the next of kin.

Management of Schizophrenia

 Nursing Management

  1.  Build positive nurse patient relationship which is difficult in
    schizophrenia
  2. Let patient and relatives know about the nature of the illness.
  3. Reality orientation is maintained through out the illness or period.
  4. Ensure that patient’s basic needs are met
  5. Minimize risks resulting from psychotic symptoms ie hallucinations and delusions.
  6. Employ reality orientation approaches
  7. Avoid highly expressed emotions.
  8. Avoid criticisms
  9. Do not argue with a patient in case of delusions. This may aggravate the condition

 

 Collaborative care

  •  Nurse identifies problems which need collective team
    interventions for example administering psychotic drugs in case the patient is aggressive.
  • Care to ensure that the patient gets the treatment.
  • Drugs should be prescribed and monitor side effects. They
    may poor drug compliance
  • Plan care for over coming side effects of the drugs.


 Psychological management

  •  Occupational therapy
    Care offered by specialists such as occupational therapist. Teach
    social skills in ADL(Activities of daily living e.g brushing his teeth, using places of inconvenience, e.t.c ). This is the hall mark of schizophrenia.
  •  Psychotherapy
    Reassurance and counseling about the disorder. This requires
    patience on the side of the nurse.
  •  Group therapy
    Has been effective especially with out patients. It is less
    productive with in-patients.
  •  Behaviour therapy
    Modification reduces the frequency of bizarre disturbing deviant
    behaviour.
  •  Family and involvement of other parties (family and supportive
    therapy),  Involve the family, religious leaders, organizations and friends in the care of the patient especially in giving support to such patients.


 Electroconvulsive therapy: can be prescribed incase drugs
have not worked.


 Medical management
The common drugs used are:

  •  Chlorpromazine both tablet and injection: 75mgs-1500mg
    daily in divided doses
  •  Haloperidol both tablets and injection: short and long acting
  •  Trifluoperazine: 5-30 mg
  •  Thioridazine: 100-300mg preferably in old age because it is less sedating.
  •  Artane 2-5mg orally PRN to treat the side effects.


 Rehabilitation and social therapy
Social skills training- patient be engaged in activities that make
him work with others and socialize.
Habit training for correcting deteriorated habits especially for
patients with hebephrenic schizophrenia.


 Advice on discharge

  •  Support be given to the patient and family
  •  Take treatment as prescribed
  •  Avoid stigma or labeling the patient.
  •  Advice to take drugs to treat side effects of drugs
  •  In case of any problem should always report to the hospital.
  •  Use skills to generate income and to avoid being idle.
  •  Link the patient other organizations for any support for
    example schizophrenia fellowship.

Effects of schizophrenia

When the signs and symptoms of schizophrenia are ignored or
improperly treated, the effects can be devastating both to the
individual with the disorder and those around him or her. Some
of the possible effects of schizophrenia are:

  1.  Relationship problems. Relationships suffer because people
    with schizophrenia often withdraw and isolate themselves.
    Paranoia can also cause a person with schizophrenia to be suspicious of friends and family.
  2.  Disruption to normal daily activities. Schizophrenia causes
    significant disruptions to daily functioning, both because of social difficulties and because everyday tasks become hard, if not impossible to do. A schizophrenic person’s delusions,
    hallucinations, and disorganized thoughts typically prevent
    him or her from doing normal things like bathing, eating, or
    running errands.
  3.  Alcohol and drug abuse. People with schizophrenia frequently develop problems with alcohol or drugs, which are often used in an attempt to self-medicate, or relieve symptoms. In
    addition, they may also be heavy smokers, a complicating
    situation as cigarette smoke can interfere with the
    effectiveness of medications prescribed for the disorder.
  4.  Increased suicide risk. People with schizophrenia have a high
    risk of attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously. People with
    schizophrenia are especially likely to commit suicide during
    psychotic episodes, during periods of depression, and in the first six months after they’ve started treatment.
  5.  Increased expenses to the family since they may need to take
    medication for the rest of their lives.
  6.  Stigmatization: The patient of family may be stigmatized.
  7.  Social embarrassment: family or community may feel ashamed because of abnormal behaviour of the patients.
  8.  Crimes committed: sometimes they commit crimes because of their poor thinking and judgment.
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