Schizophrenia

This is a major mental illness with a split in personality it is a psychotic disorder, which can affect any age group it is characterised by the onset of disturbances in personality, thinking emotional life interest, and relationship with other people. It is a malignant condition and very bad disease to cure.

Causes of schizophrenia

The cause of this disease is rather unknown but however there are pre- disposing and precipitating factors:

1. Predisposing factors

These are in relation with the constitutional predisposing of the individual and easily be trigged off with situation in ones environment

• Heredity incidence higher on relative and siblings
• Pre morbid personality is schizoid in nature i.e. withdrawn and solitary
• Physique – slim introvert orderly and hardworking

Precipitating factors

These factors are environmental and psychological in nature

1. Psychological stresses e.g.

• Loss of job
• Unhappy marriage
• Unwanted pregnancy
• Disappointment of all kinds

2. Physical stresses e.g.

• Major operation
• Chronic illness e.g. asthma puerperium
• Drug intoxication (e.g. Indian hemp, smoking, alcohol and amphetamine) and nutritional
• Deficiencies

Signs and symptoms

1. Disorder of thought, patents is confused
2. Disorder of emotion
3. Disorder of volition i.e. will power is lost and there is no drive
4. Delusion – false idea or belief
5. ambivalence – having two opposing feelings toward a person
6. there is echolalia and echophrasia
7. there is waxy flexibility when patient limbs are held in a peculiar way and in such a position for a long-time
8. hallucination usually auditory is very common
9. dirty physical appearance and amnesia
10. they eat rubbish
11. low resistance to infection they are impulsive, hustle and they go about naked without shame their ego is week and personality is unstable

Types of schizophrenia

There are five types schizophrenia, namely

1. schizophrenia simplest
2. hebephrenic schizophrenia or childhood schizophrenia
3. catatonic schizophrenia
4. paranoid schizophrenia
5. mixed/ un-differential schizophrenia

Schizophrenia simplest

It affects people from age 10-16 tears they are characterised by

• they are lazy and silly in action
• found of neglecting personal hygiene
• they leave their jobs other job in search of peace of mind because of their poor performance in the jobs
• they are eccentrics and work sly
• They find difficult to concentrate and have no insight, they have hallucinatory symptoms though not as common as other types schizophrenia kleptomania is compulsory and indicate exposure of the body is not uncommon. They are full of defective conduct however, with good environment and patients achievement in early life, he may be able to manage through without any admission into a psychiatric hospital

Hebephrenic schizophrenia

“Hebe” means youth. It affects people from 12-21 years. It is a disease of adolescent. The onset is insidious (without warning) the victims are found in odd place e.g. banks market place, post office etc. They of incoherent speeches hallucinations are still very common. They are in confused state; full of bad habit, manners. Prognosis is very poor. Condition goes into chronicity and relapses are very common

Catatonic schizophrenia

Effect ages 20-30 years this types have two phases: stuporous stage and excitement stage.

Stuporous stage: patient is semi conscious. He is mute or silent. Patient is full of negativism and highly irritated and confused. There is echophrasia (imitation). He is physically weak, fails to react to situation. At this stage patient can commit suicide

Excitement stage: in this phase there is psychomotor over activity i.e. the victims is wild and full purposeless active. Patient is impulsive and violent, he yells dances and sings anyhow. At this stage patient may commit homicide

NB: patient may be dangerous to the care providers therefore he has to be treated with care providers. Do no discuss his problem in his presence in either of the stages

Paranoid schizophnia

This type is very common in fairly old people, 25-40 and above and common among the Africans. Personality is retained or preserve. They are hostile and grandiose they are full of systematised reasoning. They are systematised reasoning. They are suspicious of everybody and feel unwanted in their community. They have persecutory

• Onset is very gradual
• Self mutilating (injuring themselves )
• Have auditory hallucinations that are insulting demanding, commanding and accusatory.

Undifferentiated schizophnia

The traits of simple, hebephrenic and catatonic schizophrenia are present

Management of schizophrenia

Try and meet the need of the patients thus:

1. Physical needs i.e. diet, hygiene, clothing etc.
2. Personal needs/ social needs

• Treat patient with respect but don’t allow too much dependency
• Allow freedom of speech and movements
• Provides occupational facilities where possible
• Allow patient to visits relations or relations to visit patient

3. Arrange for singing, dancing and debating section where possible
4. Chemotherapy- drugs of choice are (Oral Neuroleptics) largactil, phenobarb melleril and stellazine. They are mainly sedative. (DEPOT NEUROLEPTICS) modecate depixol, redeptin, to be given on monthly basis.
5. Physical therapy this is the use of ECT.( electro- convulsive therapy)

Puerperal psychosis

When one considers that childbirth involves relatively sudden and far- reaching changes in metabolism and endocrine balance and their frequent complication by physical exhaustion a much grater incidence of psychiatric disorder of pregnancy and the puerperium might be excepted than is actually found. Puerperal psychosis in its fully developed from is not a very frequent complication during and after delivery; but mild symptoms of mental stress and slight disturbances are frequent since the mild condition may develop into a psychosis at any time, which be dangerous to the patient and infant. Healthy worker needs the knowledge and experience to handle such cases. The definition of psychosis by different experts varies mainly in respect of length of time, from six weeks to one year including before and after delivery, some restrict puerperal psychosis to its occurrences within six weeks of delivery. The incidences of puerperal psychosis is reported to be one in 700 maternity cases; one in cases complicated by eclamsia and one in 100 of all admission to maternity hospital. As regards its onset 14 percent started during pregnancy:54 percent in the first fornight post- partum 32 percent later after delivered that the symptoms of puerperal psychosis may resemble those of any other form of mental disorder for example. some show evidence of a typical acute organic brain syndrome with disturbance of consciousness a prominent symptoms accompanied by anxiety and visual hallucination, sometimes resulting in extreme excitement. In other, the psychosis may resemble severe depressive disease or a schizophrenic disorder in any case the differentiation is possible only according to the time of onset, the course and the outcome. The first types may develop into the later one, although in practice patient often show a mixture of both

Causes

The causes of puerperal psychosis are many and the most important contributory factors are

1. The physical strain of delivery, maternal exhaustion, which may be made worse by surgical intervention
2. Any infection causing high fever and additional strain
3. Loss of blood (ante- partum haemorrhage or post partum haemorrhage)
4. Reabsorption of haematoma or post partum containing fluids; allergic reaction
5. Endocrinological disturbances following delivery
6. Psychological stresses of pregnancy and labour including emotional stresses of pregnancy and motherhood.
7. Possibility, hereditary factors

Clinical course

It is necessary for community health worker to know different stages of puerperal psychosis and therefore be in a better position to assist in the diagnosis and early of the condition.

First stage

1. Irritability
2. sensitivity to light and noise
3. headache
4. restlessness
5. insomnia
6. Disturbing dreams

Second stage

• Dream- like state, (b) illusion, (c) hallucinations mostly visual (d) the patient can be aroused and can be misleading, (e) in between times the patient may bear a stage the patient may develop panic, try to run away and behave unreasonable.

Third stage

The typically delirium: motor disturbances excitement, extreme fear; and clouded consciousness excitement extreme fear; and clouded consciousness without lucid intervals

Fourth stage

State of consciousness ataxic movements, come death follows if the patient does not receive treatment.

Treatment

This is started as early as the first visit so the primary health centres for booking in the ante natal clinic. Patient with a history of the following should be noted for doctors / hospital care:

• Mental disturbances in the family
• Previous history of illness during menstruation and early pregnancy.
• Patient with an aversion to pregnancy and motherhood.
• Previous history of puerperal psychosis.
• Neurotic attitude toward motherhood based on experience in the parental home
• Unsatisfactory married life pregnancy and childbirth.

1. the health worker should in a pleasant manner introduce the patient to the doctor, and later to the hospital almoner for all the help she may need.
2. The patient should be made familiar with her surrounding, and acquainted with the members of staff of maternity hospital
3. The patient should be given good ante-natal care to prevent any complication during childbirth mothercarft talks are necessary for mental hygiene and the patient should be encouraged to ask as many importance to her.
4. Early detection of puerperal psychosis and seeking appropriate treatment, for example seeking appropriate treatment, for example antibiotic, anti malarial drug and the specialist in a mental hospital gives sedatives.
5. Prevent the patient from harming herself, by removing sharp instruments, glasses, and antiseptic fluids, and by preventing her from throwing herself or her child through the window. Once psychosis has developed hypnotic and tranquillisers are used by the doctor, for example chlorpromazine (largactil)100mg intramuscularly with paraldehyde 10ml intramuscularly state followed by largactil 100mg alone intramuscularly, three times daily once the patient has quietened down, the doctor may change to oral medication, the dose being increased to 150 mg three times daily until the psychosis has subsided. in some causes to control the hyperactivity, the psychiatrist may recommend admission to a mental hospital during pregnancy. The following drugs are given (a) 5 to 10 ml of paraldehyde by mouth or, if she refuse, (b) 10ml by the parenteral route initially, and repeated every four. (c) as soon as the period of excitement is over, promazine (sparine) 50 mg thrice daily or (d) chlorpromazine 50 mg thrice daily

Delirium

During the puerperium where delirium has supervened, need to give the patient specialised care and attention, talking turns throughout the 24 hours, and bearing in mind the possibility of aggressive outbursts, suicidal and homicidal tendencies.

Treatment intramuscular chlorpromazine (largactil 100 gm twice is believed to reduce the excitement within 72 hours 2 later the patient is given a 100 mg tablet thrice daily.

3. Massive doses of antibiotic and vitamin of the B group will be given 4 intramuscular stilboestrol 2mg daily for five days, or necessary will be ordered 5 the infant is cared for in the nursing by midwife. In a few instances electro – convulsive therapy is considered. The question of termination of pregnancy in cases where attack of puerperal psychosis have cases where attacks of pregnancy have to be considered; the psychiatrist and obstetrian will consider each case on its own merits.