In-Depth Overview of Schizophrenia - Essay Example

? Schizophrenia: An In-Depth Overview Tina West Kaplan Schizophrenia is listed among the most complicated and critical psychiatric disorders, causing an early onset of clinical features. It usually manifests in the age group of 15 and 30, and as it enters into a chronic phase it causes more serious disabling features for the patients. Apart from the serious signs and symptoms, this psychiatric disorder also has an immense impact on the close environment and relatives of the patients due to its severe nature. This paper provides an in-depth review of this disorder and other concepts associated with this condition. The studies have brought to light that schizophrenia has a neurodevelopment component in its etiology. This means that there are certain disturbances in the normal course of development and function of the brain which lead to the first episode of schizophrenia in a person. This occurs in the absence of any degenerative process in the brain. The symptoms of schizophrenia were caused by the excitatory and inhibitory actions of neurotransmitters such as dopamine, glutamate and serotonin. Other factors that may contribute to the etiology of schizophrenia are environmental factors, biological factors and genetics. The treatment modalities for disorder include antipsychotic medications, psychotherapy, electroshock therapy, control treatment and cognitive behavior therapy. Keywords: schizophrenia, biological factors, genetics, neurotransmitters, environmental factors, psychotherapy, electroshock therapy, control treatment PART I INTRODUCTION Schizophrenia is listed among the most complicated and critical psychiatric disorders, causing an early onset of clinical features. It usually manifests in the age group of 15 and 30, and as it enters into a chronic phase it causes more serious disabling features for the patients. Apart from the serious signs and symptoms, this psychiatric disorder also has an immense impact on the close environment and relatives of the patients due to its severe nature. The earliest description of schizophrenia is given by a French psychiatrist as a form of dementia and was termed “dementia praecox” (Mueser & Jeste, 2008). Prevalence of this psychotic disorder in the U.S. is recorded to fluctuate from 0.3 to 4.7 per 1000 people (Shean, 2004). A difference in prevalence is observed in the rural and urban areas as well. According to an estimate, a three-fold greater prevalence was observed in the urban areas of Baltimore within the U.S. rather than in rural areas. According to the WHO-Ten Country Study, the age at which schizophrenia manifests in any country depends directly to the degrees north to the equator (Weinberger & Harrison, 2011). Schizophrenia is termed as a heterogeneous disorder as it can neither be explained or defined by any particular clinical feature nor diagnosed by a specific test. After excluding all other psychotic disorder signs, an individual is diagnosed with schizophrenia if he presents with the symptoms of delusions, hallucination and thought disorder. However, there are certain individuals that will present with negative symptoms, for instance lack of energy, communication skills, emotions, and stress and speech disturbances. Such patients respond weakly to the conventional treatments of schizophrenia. Cognitive disturbances are another striking feature of this disorder. The patients have difficulty concentrating at work, speaking, understanding things, memorizing and performing various daily functions. These features have been established as a stable feature in schizophrenic patients in spite of manifesting either positive or negative symptoms (Ross et al., 2006). The studies have brought to light that schizophrenia has a neurodevelopment component in its etiology. This means that there are certain disturbances in the normal course of development and function of the brain which lead to the first episode of schizophrenia in a person. This occurs in the absence of any degenerative process in the brain. On the other hand, neurodegenerative etiological evidence has also been established where there is degradation of neurons due to various factors leading to the signs and symptoms of schizophrenia (Mueser & Jeste, 2008). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a handbook used widely in U.S. for classification of mental disorders, schizophrenia clinical features and diagnosis is described by the DSM fourth revision, DSM-1V. The DSM-1V describes the symptoms of schizophrenia as a disorganized behavior and speech, negative symptoms, hallucinations and delusion. DSM-1V provides a set of six guidelines to diagnose a schizophrenic individual which includes poor functioning, manifesting over a time period of six months and excluding any mood disorder. The symptoms should also not be caused by any substance abuse and should also not be a feature of autism (Eaton, 2006). DSM-1V describes positive symptoms as hyperactivity of the usual and normal cognitive functions while the negative symptom is a depression of the normal functions. The positive symptoms have a “psychotic dimension” and a “disorganization dimension” (Mueser & Jeste, 2008). The subject of the case, Shonda, exhibits a history of 12 years since she was first diagnosed with schizophrenia. Her major symptoms include auditory hallucinations and delusions that she might be under surveillance. However, recently she has showed an increase in the hallucinations and she is experiencing disturbed speech and thought process. She also shows a family history of an undiagnosed psychiatric disorder in her family. The case exhibited psychotic symptoms of hallucination and delirium, and they were suppressed by the usage of anti-psychotic drugs. PART II BIOLOGICAL ASPECTS The symptoms of schizophrenia were caused by the excitatory and inhibitory actions of neurotransmitters. The role of neurotransmitters in the pathophysiology of schizophrenia was understood through the concepts of pharmacological studies. It was observed that if stimulants of dopamine were given to normal people, it induced symptoms of psychosis in them. Similarly, in the schizophrenic patients it exaggerated the signs and symptoms. This was termed as the “dopamine hypothesis” and gave evidence about the involvement of dopamine in causing the schizophrenic symptoms. Glutamate is another neurotransmitter of important role in this disorder (Ross et al., 2006). In 1943, Albert Hoffman experimented with LSD which induced psychotic symptoms and it was discovered that this chemical compound enhanced the action of serotonin in the brain. Hence, this led to the discovery that serotonin is another neurotransmitter whose hyperactivity causes schizophrenic symptoms. However, the importance of serotonin in the patho-physiology is yet to be established. Glutamate has an excitatory action on the brain’s activity. Evidence about this neurotransmitter was found when antipsychotic drugs blocked the NMDA receptors and inhibited the action of glutamate. Other neurons found to be involved in schizophrenia are aspartate, glycine and GABA (Mueser & Jeste, 2008). Shonda shows a family history of an aunt who had a “nervous breakdown” and was not treated by any doctor. This observation points towards a positive family history of similar cases. Studies have shown that schizophrenia has a familial trait and familial factors that lead toward the occurrence of schizophrenia or even other psychotic disorders. Carrier forms can be present and susceptibility genes can be present in families who may or may not present the manifestations (Kendler & Diehl, 1993). Many genetic risk factors have been established that can result in the causation of schizophrenia. Neuregulin 1 is one gene located on chromosome 8p locus that is associated with schizophrenia. Recent studies have pointed out that the activity of this gene signaling is exacerbated in schizophrenic patients. Dysbindin located on chromosome 6p is another gene, which performs the function of glutamate neurotransmission. Mutations in this gene are related with schizophrenia. There is a reduction in the expression of the Dysbindin gene and this results in the reduced function of glutamate as a consequence. D amino acid oxidase activator (DAOA) is present on the 13 chromosome locus. This gene has the function of activating the D amino acid oxidase which acts as a co-agonist with the NMDA receptors for glutamate. COMT and chromosome 22 deletion is strongly associated with schizophrenia. COMT gene produces a protein that clears the excess dopamine from the synaptic regions of the neurons and mutations lead to increased dopamine levels. Some genetic abnormalities occur due to gene translocations; however they are not major causes of schizophrenia (Ross et al., 2006). The major brain abnormalities found in the schizophrenic patients are divided according to their anatomic site and these include the global region, cortical, sub cortical and white matter of the brain. These abnormalities are described under the neurodevelopment model of the brain of the schizophrenic person. The global brain findings include reduced brain volume and ventricular enlargement. This increase in the ventricular size measured by ventricular-brain ratio affects the presentation of the disease. Prefrontal region of the brain cortex is involved with the normal cognitive and behavioral functions. An important finding in neuro-imaging studies was an increased neuronal packing which was specifically increased in the dorso-lateral part of the cortex. This area is specifically associated with the diminished cognitive functions in the patients. Reduced volume of the medial temporal lobe is seen and the regions of the brain which are affected by this include amygdala, hippocampus and parahypocampal gyrus. Variations in neuron pack density and reduced superior temporal gyrus volume has been associated with audio hallucinations and thought disturbances. Abnormalities in cerebellum cause a disturbance in higher cognitive functions. A theory of disconnectivity describes that different parts of the brain do not connect and communicate normally with each other that leads to different signs and symptoms. This can be explained by dysfunctional neurotransmission. Abnormal distribution and increased cell density of oligodendrocytes and myelin, a part of the white matter has also been detected in prefrontal cortex of the schizophrenic patients (Mueser & Jeste, 2008). According to the case-study, Shonda experiences auditory hallucinations and delusions which point towards the fact that the major brain abnormality might be in the amygdala-hippocampal-paraphypocampal gyrus complex and the superior temporal gyrus as they are strongly associated with these symptoms. PART III ENVIRONMENTAL ASPECTS There are several environmental factors which influence schizophrenia such as viruses, malnutrition of a fetus, family and drugs among other environmental factors (Lenzenweger, 2010). The drugs affect those with the disorder by aggravating the symptoms and also may cause the development of the disorder to those who are abusers of the drugs and substances. The other environmental factor is urban living. This is attributed to cause the disorder due to the social life in the urban areas and there is also a lot of peer pressure and interpersonal relations due to the technological advancement and education levels in such places. Malnutrition which is regarded as an environmental factor is the type present in fetuses and not in fully grown individuals. Hence it is the responsibility of pregnant women to ensure their unborn children receive all the nutrition needed while in the womb (Durand and Barlow 2009). During pregnancy, the fetus is supposed to receive nutrition from the mother in order to develop its brain properly and maturely. Failure of the brain to receive proper nutrition or to be malnourished makes it not develop fully and hence higher chances of developing schizophrenia. The viruses mentioned are those that mostly affect children when they are young where their immune system is still weak; hence, making them vulnerable. The viruses affect the chemicals of the brain and therefore may lead to the disorder. The use and abuse of drugs and alcohol may cause schizophrenia and may also aggravate the disorder in those who already have it. Drugs have chemical substances like dopamine which negatively affects proper brain functioning (Sigelman & Rider, 2011). Schizophrenia is a brain disorder and hence if the brain is not normally functioning or is tampered with, the chances of developing the disorders are very high. When a woman is pregnant and is abusing drugs, the chemicals of the drugs affect the brain of the unborn child causing the disorder. The child is then born with the disorder even though none of his parents possess the disorder. When the child grows and decides to have a family, he or she may pass the disorder to their children through genes; hence, schizophrenia becomes a genetic disorder in the next generations of that family. Malnutrition and substance abuse are what most schizophrenia researchers feel are important in the cause and even treatment of the disorder. The use and abuse of drugs and other substances has become rampant has increased especially among the individuals between 15-35 years old. This can be attributed to social influences like living in the urban areas and also because of peer pressure. These drugs as mentioned earlier have chemicals which affect the chemical balance and normal functioning of the brain; thus, causing the development of schizophrenia leading to the administration of psych medications to individuals suffering from this disorder. The aforementioned age group is also considered as the reproductive age in the society. This means that the children they will be giving birth to will already be having the symptoms of the disorder due to the under nourishment when in the womb. The malnutrition comes about as a result of the parents spending all their money in trying to obtain the drugs and not enough money to buy nutritional supplements required for fetal development. Genetics and biological influences limit the causes of this disorder unlike the environmental factors which are diverse and can cause the disorder to any individual. The biological influences and genetics are only concerned with the cause of schizophrenia whereas environmental influences cause the disorder, aggravate the condition of those already suffering from the disorder and also tamper with the treatment of the disorder. Environmental influences can therefore be concluded to have a greater impact in comparison with biological influences or genetics. PART IV TREATMENT APPROACHES There are several types of treatment for this disorder. They include; antipsychotic medication (use of medication as a treatment) and psychosocial (use of therapy). The psychosocial treatment is however employed on individuals who have already been stabilized by the medication. They include therapies on illness management skills (to cope with the symptoms on their own); rehabilitation (to help them function better through training and communication skills) and cognitive behavior therapy which help them put their perceptions and thoughts into reality (Shean, 2004). According to researchers, the most effective treatment modality is the cognitive behavior therapy. This is because the most prevalent and decapitating symptom of the disorder are hallucinations (Shean, 2004). CBT helps schizophrenics to cope and manage such symptoms and hence, to be able to finally live well with other members of the society and to be able to communicate effectively with them. This however does not mean that the other treatments are ineffective. Shonda has been given a variation of antipsychotics but currently she is being given a neuroleptic called Haloperidol. The recommended dosage of the drug is 6-12 mg. It is a chemical structure of the butyrophenones which is a type of FGAs (Aronson, 2009). Currently 11 different classes of anti-psychotic drugs are used for treatment in the U.S. The first generation antipsychotics (FGAs) include phenothiazines, butyrophenones and thioxanthenes. The second generation anti-psychotics (SGAs) include clozapine, risperidone, olanzipine, quietiapine, ziprasidone, sertindole and zotepine. These are also called the atypical drugs. Aripiprazole is considered as a “next-generation antipsychotic” and has a partial dopamine agonist mechanism of action (Miyamoto, 2005). The use of ECT in the U.S. is quite limited that only about 1% patients receive this therapy. This therapy is only recommended for those patients who fail to respond to medications and psychotherapy. With only 0.0002% rate of mortality, this treatment is mainly safe and free of any severe harm (Mueser & Jeste, 2008). There is no history of any other treatment given to Shonda other than anti-psychotic drugs, which has been proven through various researches as an effective strategy. According to research carried out on five different treatment methods of schizophrenia in 2011 by Philip R. A. Mary and A. Hussain Tuma, it was concluded that patients who were treated with medications alone or with psychotherapy exhibited the best therapeutic results. The five types of treatment strategies that were experimented included; drugs alone, drugs with psychotherapy, only psychotherapy, electroshock therapy and control treatment devoid of any above mentioned strategies. The patients with ECT and only psychotherapy showed poor results as compared to those treated with drugs and psychotherapy together (May & Tuma, 1965). Out of the three types of drugs available for the treatment for schizophrenia, the second generation anti-psychotics have proved to be better and more beneficial than the first generation drugs (Miyamoto, 2005). They have a lesser tendency for the dopamine receptors in the basal ganglia of the brain and hence they cause lesser adverse effects as compared to the FGAs (Aronson, 2009). Haloperidol, which is the current treatment of the subject, is a typical neuroleptic and is associated with extrapyramidal symptoms. FGAs are effective in curing the positive symptoms of schizophrenia but some patients show no or little response to this treatment. They are comparatively less effective against the negative symptoms and may cause exacerbations or no effect at all. FGAs have the potency to cause Parkinson-like symptoms, dystonia, akathisia and tardive dyskinesia and can also lead to hyperprolactemia. The SGAs are superior to the FGAs in their safety levels as they do not cause tardive dyskinesia and extrapyramidal symptoms like dystonia. However, they are associated with a different set of adverse effects which include increase in weight, diabetes mellitus, cardiovascular problems and prolonged QTc interval. Clozapine is one SGA that has given evidence of least cases of hyper-prolactemia and EPS (Miyamoto, 2005). When compared with clozapine, haloperidol shows fewer improvements in occupational and daily work activities. It has also been associated with dry mouth and less improvement in negative symptoms. Through studies it has been showed that quality of life improves more significantly with atypical drugs (Aronson, 2009). Treating the disorder with only one approach will not be effective. This is because there are different levels of the disorder and each approach offers a different treatment that the other does not. This is true for example when comparing antipsychotic medication and psychosocial treatment. The therapy does not offer immediate relief of the symptoms like the medication, on the other hand, the medication does not offer long term survival skills to the patient like the way the therapies do. It is therefore advisable to combine the approaches. If the author of this paper will be deemed to choose a treatment regimen for Shonda, the treatment that will be utilized is the combination of the medical treatment which involves medication and the psychosocial treatment. The reason behind the chosen modality is to ensure that the severe symptoms of the disorder are managed as well as to enable the patient to become self-dependent for she will be given the opportunity to be involved in the treatment by means of communication between the patient and the healthcare provider. As a result, she will be oriented to reality and hence will be capable to contain her hallucinations. This will enable her to gain optimum functioning at the same time, to be able to work with others (Mueser & Jeste, 2008). PART V CONCLUSION A variety of issues have resulted to a rational case for considering the application of psychological treatment approaches for psychotic symptoms in the emergent phase of psychotic disorders as emphasized by Weinberger and Harrison (2011). It was suggested that the evaluation of psychological treatment approaches in the early phase of psychotic disorders would be a more acceptable and safer first step in the development of preventive interventions, which may aid in declining or forestalling the option for drug treatment (Weinberger & Harrison, 2011). Moreover, since these patients are usually looking for someone or a method that may provide them with a sense of hope, though at times such interventions may give false positive outcomes (Weinberger & Harrison, 2011). There are diverse psychological models that can be relevant in understanding and managing schizophrenia. The models that may be utilized for the treatment of the aforementioned disorder are psychodynamic, behavioral, humanistic or cognitive approach. Three of the traditional group therapeutic approaches for patients with schizophrenia include the educative, the psychodynamic and the interpersonal (Martindale et al., 2002). The educative approach highlights the biological elements of schizophrenia. The therapy groups employing the use of this treatment regimen attempt to aid the members to gain knowledge and skills in dealing with the manifestations of the illness and to deal with the actual problems that these symptoms produce (Martindale et al., 2002). The usual techniques encompass lectures, question and answer periods, problem-solving, advice-giving, role-playing and homework assignments between the sessions as cited by Martindale et al. (2002). On the other hand, the psychodynamic approach accentuates the psychological features of schizophrenia. In this modality, the groups endeavor to facilitate understanding and discernment of the members regarding long-term, intra-psychic problems and maladaptive behaviors and its influence to their lives, with the expectation of reducing the impact of possible intricacies and enhancing ego functions (Martindale et al., 2002). The techniques involved in this regimen are the encouragement of open discussions initiated by the patients, uncovering of significant unconscious issues and interpretations of transference (Martindale et al., 2002). Conversely, the interpersonal approach identifies immense significance on the relationship elements of schizophrenia and struggles to help the group members become less socially isolated and develop their ability to interact with other people (Martindale et al., 2002). The techniques in this modality encompass the following: facilitating discussions of interpersonal problems, encouraging patients to relate to each other during the sessions using structured exercises and other interaction-oriented techniques and interpreting maladaptive interactions that are evident in the group (Martindale et al., 2002). The author of this paper believes that cognitive behavioral therapy is a beneficial psychological intervention for patients with schizophrenia for a variety of reasons as supported by Weinberger and Harrison (2011). First, the aforementioned approach is likely to help with both the attenuated and brief intermittent psychotic symptoms; moreover, it has demonstrated effectiveness for those with schizophrenia to cope with psychotic symptoms and to decrease associated distress and the possibility of relapse (Weinberger & Harrison, 2011). Second, the said approach is a valuable intervention for the non-specific emotional problems that are usually evident during the at-risk mental state; furthermore, it has been proven effective for both depression and anxiety which are common in schizophrenia and in its prodromal stage (Weinberger & Harrison, 2011). Third, CBT interventions fit very well in a stress-vulnerability model and may be an invaluable therapy to teach the types of coping strategies that may provide protection against environmental stresses that lead to conversion (Weinberger & Harrison, 2011). It is apparent that with the following reason cited, CBT is indeed an effective strategy in managing schizophrenia. Continuous studies are being conducted to improve the treatment for schizophrenia as cited by Weinberger & Harrison (2011). These include advancements in pharmacological therapy and even modifications in psychological therapies. The said improvements are aimed in providing better management of schizophrenia and preventing unpleasant side effects. The author of this paper deems that if the subject, Shonda complies with her treatment regimen accompanied by psychological model which will work for her, and the chances of being treated from the symptoms may increase. 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