Schizophrenia, Psychosis, and Developmental Disorders - Term Paper Example

Schizophrenia, Psychosis, and Developmental Disorders Brain is the most complex and the most intriguing organ in the human body. Its diversity never ceases to amaze mankind, and so do its disorders. As perplexing that its development is, the disorders during the course of its development are also complex and demand a deep understanding. The disorders involving brain were initially considered to be due to an impaired mental state, until recently it was proved that they are associated with the underlying brain abnormalities. These psychological disorders in turn also affect the physical illnesses. The ancient view of psychological disorders may be justified on the basis of their presentation, as they manifest as disturbances in perception, memory, thinking and altered emotional state. However recent advances in research into the brain and its functioning have proved that there are established biologic basis behind these psychological disturbances. These pathologies of brain may be due to underlying structural abnormalities, altered ratios of gray and white matter in different areas of the brain, increase or decrease in the amounts of neurotransmitters, associated with factors like stress or substance abuse; or they can be due to organic lesions in the brain and the list goes on. Categorization of psychological disorders has thus been a challenge. It is due to the vast variety of underlying causes that give rise to these disturbances, and the need to standardize the terms defining these illnesses as there is considerable over lap in their modes of presentation. Two systems of categorization of psychiatric disorders are currently in use. In America, Diagnostic and Statistical Manual (4th edition) or DSM- IV, proposed by American psychiatric Association is used. The other classification given by World Health Organization is used more widely outside USA and is known as International Classification of Disease (10th edition), or ICD-10. Psychiatric disorders span a complete spectrum of moods of mankind, ranging from depression at one end to the manic psychosis on the other and the bipolar disorder alternating between the former two. Any part of brain can be affected and thus any aspect of life can be crippled by these psychoses. The person loses the ability to think clearly and respond appropriately, his learning abilities can suffer as his perception is impaired, his communication skills worsen and he becomes emotionally wretched. These people have trouble adjusting in society, coping up with their personal needs and building healthy relationships as they are often intimidating to the masses. Such people pose a challenge to the society. Therefore identifying the people with various types of psychoses and understanding their condition and appropriate management of their condition is important. Psychosis is defined as, ‘thought disorder in which reality testing is grossly impaired’. The attacks are accompanied by hallucinations and delusions. Hallucinations refer to the perceptions of the patient without any external sensory stimuli. They can involve any of the five basic human senses of perception, but most commonly involve visual or auditory pathways. Patient feels that he is hearing different sorts of voices when there may be no one present or he may perceive to see different faces or demonic figures. Type of hallucinations experienced by the patient may give a clue to the underlying disease. Auditory hallucinations generally accompany schizophrenia, while hallucinations involving other senses especially vision and taste point towards organic disease aetiology like delerium or temporal lobe epilepsy. Delusions refer to a person’s firm belief in something despite all obvious evidences against it. Patients have false beliefs and perceptions. It is hard to bring these patients back to the rational thinking by showing evidence because their delusions are unshakable. The delusions can be persecutory (patient feels like he is being tracked), hypochondriacal (despite being normal, patient believes that he is suffering from extreme physical ailment, like cancer), grandiose (patient believes that he has super powers). The most extreme delusions are nihilistic type in which the person feels that his body parts are missing or have been destroyed. The causes of psychological disorders are many and can be understood by studying as a combined effect of biological, behavioural and social factors. Psychosis can be functional and triggered due to factors like drug abuse (amphetamines cocaine, marijuana), alcohol, stress, sleep deprivation and depression. It can occur as a part of other psychiatric conditions including schizophrenia, bipolar disorder, epilepsy, schizoaffective disorder and others. Organic brain lesions like tumors or traumatic brain injuries can also lead to symptoms of psychosis. Biologic causes of psychiatric disorders can either be genetic or they can be due to abnormalities in brain structure and function. Schizophrenia, bipolar disorder and Huntington’s disease involve gene mutations. Schizophrenia is also associated with underlying structural brain abnormalities which include misdistribution of white and gray matter and enlargement of ventricles. Psychological and behavioural factors lead to the development of different psychiatric conditions. Excess alcohol intake, unpleasant childhood experiences, stressful events as well as neurotic type of personality leave the person prone to the development of psychiatric disturbances. Social events and occurrences can precipitate psychological disturbances, like loss of a loved one might lead to depression whereas threats lead to anxiety. Schizophrenia is a psychiatric disorder characterized by hallucinations, delusions and lack of insight (Boon and Davidson 2006). It is a progressive disorder and mostly presents as an acute condition, or may become chronic. The acute attacks are characterized by extreme forms of hallucinations and delusions and impaired thinking. While the chronic form, it is associated with social withdrawal and subtle hallucinations and delusions. It affects men and women at a similar rate and the prevalence is nearly same across the globe affecting about 1% population. The onset of disease is mostly at a young adult age, although it can present at any age. The past concept, that schizophrenia is a functional disorder as there are no structural abnormalities is now obsolete. The latest diagnostic modalities have allowed a peek into the human brain and revealed that there are certain changes in the brain structure that lead to the psychosis in schizophrenia. There is generalized reduction in brain volume and increase in the size of lateral ventricles. The brain volume in the temporal lobe is particularly reduced. Imaging studies have shown altered amounts of gray and white matter in the brain substance. Schizophrenia is a classic example of a disease having multifactorial aetiology, with the interplay between biological, behavioural and social factors controlling the cause and severity of the condition. The genetic bases of inheritance of schizophrenia are evident from the fact that if one parent is affected, the child has 10% risk of developing the same condition. This risk rises to 50% if both parents are schizophrenics (Boon and Davidson 2006). Not one particular gene has been isolated to be affected in schizophrenia; rather it involves multiple susceptibility genes, each adding up to the personality defect. The environmental factors like urban birth, low socio-economic status and obstetric complication have adverse effects on brain during the early course of development. On the background of these conditions, acute stress can precipitate an attack of schizophrenia. Schizophrenia is thus defined as a neurodevelopmental disorder due to abnormal brain development in genetically predisposed individuals, conditioned by early environmental insults and triggered by stress. Acute attacks of psychoses, accompanied by auditory hallucinations (most common), emotional instability and bizarre behaviour should raise the suspicion of schizophrenia, after organic disease and substance abuse have been ruled out. Schneider proposed the set of symptoms to diagnose acute schizophrenia (and Davidson 2006). These symptoms, known as ‘first-rank symptoms’ are: A= Auditory hallucinations (voices heard outside the head, talking to or bout the person) B= Broadcasting, insertion/ withdrawal of thoughts (patients become alienated to their own thoughts as they believe their thoughts are being broadcasted to others; or being inserted or withdrawn from their mind) C= Controlled feelings, impulses or acts (believing that one’s thoughts and emotions are not in their control) D= Delusional perception (bizarre interpretation of experiences) These symptoms are commonly known as positive symptoms. Chronic schizophrenia, on the other hand presents with negative symptoms. Negative symptoms include emotional apathy and flattened (blunted) effect, loss of drive, social isolation, poverty of speech and poor self care. The cognitive impairment that accompanies schizophrenia results in decline in memory, decrease in the ability of staying focused and paying attention and difficulty in execution of daily life activities. As compared to adults, the cognitive impairment is more severe in childhood onset schizophrenia or in adolescents considering these are the years during which brain acquires its learning and intellectual strength. Depending upon the predominant features present, schizophrenic psychosis can be divided into four types. The paranoid type is the most common type. It is characterized by the first-rank symptoms described above, along with feelings of jealousy, anger and violence. In catatonic type of schizophrenia patients adopt awkward postures and remain immobile for prolonged periods of time (Boon and Davidson 2006). Disorganized or hebephrenic schizophrenics exhibit more negative symptoms with flat mundane expressions and incoherence. Most of the patients who do not fit the paranoid criteria fall into the fourth category which is the largest and is referred to as undifferentiated schizophrenia. Schizophrenics whose symptoms are not particularly characteristic of any of the above three categories are placed in this category. In 1917, The American Psychiatric Association first proposed the manual for categorization of psychiatric disorders known as ‘Diagnostic and Statistical Manual of Mental Disorders (DSM). Currently its 4th edition, DSM- IV is in use all over the USA. According to DSM-IV, a patient’s personality is assessed on five different axes. These axes combine different aspects of a the patient’s perception, emotion and over all mental health as well as physical health and paint an over all picture as to where the he fits the criteria for placement in a particular disease category. It is thus a multi-axial system that analyzes the overall mental health. Axis I includes majority of the mental disorders, including the ones diagnosed in infancy or childhood (mental retardation, learning deficits, ADHD), delirium, dementia, cognitive disorders, substance- related disorders (alcohol, amphetamine, cocaine, nicotine, opiods), Schizophrenia and other psychotic disorders, disorders associated with mood (depression, bipolar disorder), anxiety disorders (somatoform, factitious, dissociative), sexual and gender identity disorders, Eating disorders (anorexia nervosa, bulimia nervosa), sleep disorders (primary, secondary), mental disorders due to other medical conditions, Impulse- control disorders that cannot be classified anywhere else, adjustment disorders and personality disorders. Axis II of DSM- IV is used to identify personality disorders. It differentiates among various negative personality traits (narcissistic, dependant, antisocial) on the basis of person’s life long behavioural patterns. It also takes into account various developmental disorders of children (mental retardation). Axis III takes into account organic medical conditions (somatic problems). Whereas the effects of social and environmental factors (loss of loved one or poverty, abuse) on a person’s mental health are taken into account under axis IV of DSM. Axis V assesses the global functioning of the brain. It takes into account the patient’s over all performance in different areas of life (social, psychological) within the past one year and scores on the scale of 1 to 100. It is vital to differentiate and categorize the psychotic disorders as there is considerable over lap in presenting symptoms. This often gives rise to difficulty in identifying them. Schizophrenia may give a mixed picture with combined psychotic and affective symptoms. In this case the disorder is not diagnosed as schizophrenia, but as schizoaffective disorder (Boon and Davidson 2006). Similarly, it can be differentiated from other functional psychosis like psychotic depression, manic episodes, puerperal psychosis, and delusional psychosis by the presence or absence of particular distinguishing features. Differentiation from organic psychoses is accomplished by identifying and isolating the triggering factors like a drug or abused substance, focal brain lesions, looking for other signs of seizures in case of epilepsy, patient’s age in dementia, family history and choreiform movements in Huntington’s disease and so on. Thus the differentiating symptoms of different psychotic disorders have to be looked for with an eagle eye to accurately diagnose the condition. At times when the patients present with mixed symptoms, it can actually be these mixed symptoms that guide the diagnosis. This is known a congruence of symptoms (Boon and Davidson 2006). Congruence of symptoms is analyzed in different areas like impulse, perception, mood and belief. The final diagnosis rests on the combined effect, for example mixed symptoms involving hallucinations and delusion along with emotional disturbances point towards the diagnosis of schizophrenia. On the other hand, if hallucinations and delusions are accompanied by disturbed consciousness, then these symptoms point towards a disease with organic aetiology like dementia or delirium. People affected by psychotic disorders present a great challenge to the society. The first and foremost realization comes from knowing the fact that the people suffering from psychiatric disturbances are not ‘mad’ but that they are ill. Dealing with these patients should be similar to the way other sick people are dealt with. Considering from sickness point of view, these patients can be particularly challenging as they don’t have any realization of their sickness. A sick person suffering from any other ailment would take medication because he knows that he is unfit and needs to become healthy again. Psychoses especially the ones involving personality disorders or black outs are particularly difficult to manage because of the patients altered state of mind and the ‘lost’ period in which they do not know what had happened. Psychotic patients refuse to take medications and are at increased risk of harming others or themselves. Therefore they need to be hospitalized during the acute phase. Chronic forms of psychoses do not need hospitalization. On the contrary, they benefit from long term support programmes. General or supportive psychotherapy builds a healthy relationship between the patient and the doctor. The patient confides in the doctor and this aids the treatment as doctor gets to know more about the patient’s condition. Psychiatric patients especially those suffering from depression, bulimia and anxiety often think negative about their own selves and have a negative perspective about other things in life as well. Cognitive therapy helps them challenge this negativity. Behaviour therapy helps patients realize their illness and change their behaviour to take charge and play a positive role in their therapy. The most widely used method to treat psychiatric illnesses is the cognitive behaviour therapy (CBT). It combines the cognitive and behaviour therapy for the optimum improvement in patients’ condition. Thus, when dealing with psychiatric disorders the underlying causes should always be identified as they are the targets for treatment interventions. Dealing with the psychiatric patients is a difficult task and requires proper understanding between the patient and the diagnostician, and patience on the part of the society. References: 1. Boon, N. A., & Davidson, S. (2006). Davidson's principles & practice of medicine. Edinburgh: Elsevier/Churchill Livingstone. 2. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) - CLASSIFICATION OF MENTAL DISORDERS, MULTIAXIAL CLASSIFICATION SYSTEM Read More