Understanding Schizophrenia: A Comparison of Recent Studies - Essay Example

Understanding Schizophrenia: A Comparison of Recent Studies Chapter Introduction There had been a lot of developments in the study of treatment for schizophrenia since Kraepelin (Daniel, Harvey and Masand, 2006) conceptualised the illness with deteriorating course. There had been varying focus on the attributes of the illness such as on the traditional positive symptoms of delusions or hallucinations notably phenomenologic and treatment perspectives, while others on the negative symptoms. These were all presented as equally important as Daniel et al (2006) acknowledged “In recent years, researchers and clinicians have realized that understanding and treating the negative symptoms, the cognitive and the affective domains, are equally -- if not more -- important to improving the long-term outcome in patients with this illness.” Psychiatrists believe that their first duty to their psychotic patients is to control the positive symptoms of hallucinations, delusions and agitations, then meet the challenge of the illness in reintegrating their patients back to society (Daniel et al. 2006). This research shall present various schools of thought in order to integrate positive outcomes from each study which may be adaptable to practitioners and researchers. As the allopathic approach cannot be totally validated as effective and all-encompassing in addressing schizophrenia, other forms of medical treatment studies shall be considered. This researcher believes that a wider view may point out similar findings and approaches to treating or improving the condition of patients. With the premise that health or medical practitioners need data about these matters in order for them to gain insight and understanding of the illness, this study shall try to find out what have been the recent advances in the study of schizophrenia in various medical schools of thoughts in order. To present comparative analysis may open succeeding doors for more research and discovery in the advancement of professional health care provision for patients afflicted with the dreaded disease. Study Objective: This study aims to present various recent studies and findings about treatment and related data for the improvement and cure of the disease of schizophrenic patients. It will try to present various medical schools of thoughts approaches with the aim to integrate and compare findings that may aide health practitioners and professionals, as well as further research. It will try to answer the questions: What are the various medical schools of thoughts and their view on schizophrenia? How are the studies related to schizophrenia by these medical schools of thoughts impacted on subjects or patients? What are the similarities and contrasts on their findings regarding treatment or improvement of condition of schizophrenic patents? Methodology: This study, in consideration various research factors, employ secondary analysis approach to distinguish improvements of studies by various medical schools of thoughts regarding schizophrenia. Secondary analysis uses existing data which have already been collected for previous studies, but with a distinct purpose (Heaton, 2002). This has been chosen to come up with an additional in-depth analysis from previous studies. Some characteristic problems may arise such as that enumerated by Heaton (2002) in using secondary analysis as follows: “Secondary analysis involves the utilisation of existing data, collected for the purposes of a prior study, in order to pursue a research interest which is distinct from that of the original work; The approach has not been widely used in relation to qualitative data; Various methodological and ethical issues need to be considered and are more problematic if the secondary analyst was not part of the original research team; Further work to develop the approach is required in order to see if the potential benefits can actually be realised in practice.” Most of the above need not be addressed by this research as all sources of this material will be properly acknowledged. In using secondary analysis, this research will facilitate archiving of data from qualitative studies (Corti and Thompson 1998, Hammersley 1997, Corti et al 1995) with the advantage of maximizing use of previous studies, allow unnecessary recruitment of new subjects, and cutting down on cost and lengthy primary research process. Furthermore, this approach may generate new hypothesis or support previous theories which is the aim of this study; to collate previous study findings about schizophrenia which might prove useful and strengthened with the integration of various medical schools of thoughts. Ethical Consideration This study shall, for all its intention, acknowledge as properly as possible all sourced information and material so as not to aggravate primary researchers and their efforts. As much as possible, secondary data shall be interpreted the best understanding thios researcher could extend. Study of Related Literature Schizophrenia Schizophrenia is a group of heterogeneous disorders characterized by severe disturbances of thought, speech, perception, altered social functioning and volition (Areiti, 1974), disorganisation and dysfunction that afflicts both males and females with lifetime morbid rate of 1 % consuming a great deal of long term medical and social care. First recognized by Belgian psychiatrist Morel, the onset is usually between 15-30 yrs of age, which is insidious and has a poor outcome. It is earlier in a state of perceptual distortion and social withdrawal progressing to a state of chronic delusions and hallucinations. Symptoms vary from conceptual disorganization, delusions and hallucinations (positive symptoms) to negative symptoms like anhedonia, lowered emotional expression decreased social activity, impaired concentration and lack of function (Hamilton, 1986). At least one third of schizophrenics have predominantly negative symptoms (Chapman, 1966), which has poor outcome and drug response, most of them (10%) committing suicide (Siris, 2001). Diagnosis is only clinical and should have any of these two symptoms for a one-month period and continuous signs for at least 6 months. Response to anti-psychotics confers the prognosis and not the severity of symptoms. Genetic viability, winter birth, early birth insults are the major identified risk factors (Hamilton, 1986). Cortical-striatal-thalamic circuit is disturbed as evidenced by cortical atrophy, ventricular enlargement, specific volume losses in amygdala, hippocampus and thalamus, decreased metabolism in thalamus and prefrontal cortex, which is associated with progressive reduction of cortical volume over time (Kasper, 2005). Anti-psychotics remain the mainstay of treatment to date. Traditional Chinese medicine, which was used for more than 2000 years for the treatment of mental illness, was the mainstay of treatment in China before anti-psychotics were discovered. The Chinese considered the body (xing) and mind (shen) to be inseparable “when there is a body, there can be a mind” (Xunzi) in contrast to the western medicine which separates organic from other mental illnesses (Flaws and Lake, 2001). Similarly homeopathy considers that body and mind are not independent but are in a state of dynamic equilibrium and effect to one may lead to disturbances in other . As the Chinese medicine affects the various routes or channels in the body, similarly homeopathy tunes the body and supplies energy to the body in the form of medicine (Vithoulkas, 1979). Orthomolecular psychiatry considers schizophrenia to be due to distortion in the components of the body such as vitamins, minerals, amino acids etc. (Autry, 1975). And treatment is with substances that are normally present in the body like vitamins in very high doses creating a biochemical environment (Hoffer, 1996). Clinical Types of Schizophrenia Different schools of medicine have classified schizophrenia into different clinical types. In Allopathy and Homeopathy schizophrenia has been differentiated into the following clinical varieties (DSM IV, 1994)18. 1. Paranoid schizophrenia: it is characterized by the following features Delusion of persecution, reference, grandeur, control or infidelity or jealousy. Delusions are well systematized. Hallucinations have a persecutory or grandiose content. Disturbances of affect, volition, speech and motor behavior. Personality deterioration is much less than in other types. Patients may be apprehensive and evasive. Onset is insidious, occurs later in life (late 3rd and early 4th decades) Course is usually progressive and complete recovery usually does not occur. 2. Disorganized (hebephrenic) schizophrenia: characterized by Marked thought disorder, incoherence and severe loosening of associations. Delusions and hallucinations are fragmentary and changeable. Emotional disturbances (inappropriate and blunted affect) mannerisms, mirror gazing for long periods of time, poor self-care and hygiene, impaired social activities, lack of function. Onset is insidious, usual in early second decade. Worst prognosis among the sub-types. Course is progressive and down hill. Recovery never occurs. 3. Catatonic schizophrenia: it is characterized by marked disturbance of motor behaviour. It can present in three clinical forms. Exited catatonia: increase in psychomotor activity, ranging from restlessness, agitation, excitement, aggressiveness and violent behavior (furor). There is increase in speech production, with increased spontaneity, pressure of speech and incoherence. Stuporous (retarded) catatonia: there is extreme retardation of psychomotor function. Catatonia alternating between excitement and stupor: the features of both excited and stupurous catatonia is present alternately. The onset of catatonic schizophrenia is usually acute, usually in the late 2nd and early 3rd decade. Recovery from the episode is usually complete. 4. Residual and latent schizophrenia: Prominent negative schizophrenic symptoms, i.e. psychomotor slowing, under reactivity, blunting of affects, passivity and lack of initiative, poverty of quantity or content of speech, poor nonverbal communication by facial expressions, eye contact, voice modulation, and posture, poor self care and social performance: Evidence in the past of at least one clear-cut psychotic episode. A period of at least one year during which the intensity and frequency of florid symptoms such as delusions and hallucinations have been minimal and the negative schizophrenic syndrome has been present. Absence of dementia or other organic brain disorder. 5. Undifferentiated schizophrenia: diagnosed either when features of no subtype are fully present or features of more that one subtype are exhibited. 6. Simple schizophrenia: early onset (2nd decade), insidious and progressive course, and presence of characteristic negative symptoms of residual schizophrenia, vague hypochondriacal features, a drift down the social ladder, and living shaggily and wandering aimlessly. Delusions and hallucinations are usually absent. The prognosis is usually very poor (APA, 1994). Historical Background Western records of schizophrenia can be gathered from Morel’s description of demence precoce; Kahlbaum’s description of catatonia; Hecker’s description of hebephrenia. The scientific study of the disorder began with Emil Kraepelin who differentiated psychiatric illnesses into dementia precox and manic-depressive psychosis (Kraepelin, 1971). Later Eugen Bleuler(1950) renamed dementia precox as schizophrenia (meaning mental splitting) and recognized schizophrenia as a group of disorders rather than being a distinct entity(Bleuler, 1950). Kurt Schneider (1959) described first rank symptoms and second rank symptoms of schizophrenia. 19th century saw the rising of homeopathy with physicians like Hahnemann(1842), Jahr, Worcestor and Talcott .In olden days schizophrenics were socially unacceptable and were chained and put in jails and asylums. This practice was first opposed by Hahnemann who revolutionalised the treatment of schizophrenics (Hahnemann, 1842). Later the works of Hahnemann and Talcott were reinforced by eminent works of Thatcher, Cook, Andre Saine, Vithoulkas etc. From the past twenty centuries Chinese medicine has been researching and treating various forms of schizophrenia with a traditional way based on Qi (acupuncture and Qigong), which were gradually replaced by herbal medicines in the 19th century, when Wang Qingren (blood moving school) based on “blood stasis” formula made “Dian kang meng xing tang” (Awaken from the dream of madness decoctions). Another contribution to the classical Chinese medicine was by the famous Zhang Xichun who based on the phlegm theory made “Dang tan tang” (Flaws B, Lake, 2001). The earlier descriptions of schizophrenia like illnesses are recorded in ayurveda, which describes psychiatry as “bhuta vidya” (study of devil). The renowned sage Charaka Samhita described schizophrenia as “Bhuta yogika” (devils handy work) and used “jadi booti” (medicinal herbs) and meditation as treatment (Agnivesha, 1941). In 1222 AD, Najabuddin described a condition (sauda-e-tabee) with charachterstics resembling schizophrenia, which is a hallmark of “Ilaj-I-Nafsani” in Unani medicine (handbook of Unani medicine, 2004). Conventional Genetic Findings Mental disorders are considered as one of the leading causes of deaths that is universal in nature, or affecting the general world population (McGrath et al, 2004). In a 2004 study (Riley and Kindler), it was pointed out that genetic factors play an important role in influencing susceptibility to many of the most common disorders such as schizophrenia and bipolar disorder. Numerous family, twin and adoption studies have shown that risk of illness is higher among relatives of affected individuals. This, as pointed out by McGuffin et al (1994) and Kendler (2001), is the result of genes rather than shared environment. Five ascertained studies using modern diagnostic criteria report monozygotic (MZ) concordances estimated at 41-65% as compared with dizygotic concordances of 0-28% translating to broad heritability at 85% (Cardno and Gottesman, 2000) making genetic epidemiology a complex mode of transmission (Gottesman and Shields, 1967). The heritability of schizophrenia has been compared to that of type 1 diabetes at 72% to 88% and it has been considered that so much like environmental factors, many genes or polygenes distributed on different loci, influence predisposition to the diseases as claimed by Frota-Pessoa (1989) that “the determinants of schizophrenia are multifactorial and polygenic.” The following table shows the percentage of risk of illness: Table 1 Source: American Society for Clinical Investigation, 2006. Expressed Emotion. One of the most important findings in the field of treatment of schizophrenia is the concept of “Expressed Emotion” or EE. Kravanagh (1992, p. 616) claimed, EE “may prove to be the most significant treatment breakthrough in schizophrenia since the discovery of neuroleptic medication.” Psychoanalytic or “insight-oriented” psychotherapy of schizophrenia was shown to be ineffective in some studies (Gunderson et al, 1984, McGlashan, 1984, and Stone, 1986), EE studies proved that structured form of family psychotherapy influence the course of schizophrenia. This has opened the way for further studies of these psychological interventions and to a framework of general understanding (Migone, 1993). Some authors have relied on the concept of vulnerability which is the stress-diathesis model (Zubin and Spring, 1977) where EE in this concept is conceived as stressor that provoke relapse by increasing patients’ arousal beyond optimal level (Migone, 1993). Nevertheless, little is known precisely on why the emotions related to high EE trigger relapse of schizophrenia. Migone (1993) applied the psychoanalytic concept of projective identification to fill the gap in this area between psychiatric and psychoanalytic research in view of its use in general psychiatry (Jureidini, 1990). Since 1958, it has been found that discharged psychiatric patients have different outcome depending on their living arrangements with parents, spouse, in hostels so that those who lived alone or with siblings had a relapse of 17%, 32% for those who lived with their parents, and 50% for those who stayed with their spouses (Brown). EE has been found a fundamental variable in a succeeding study (Brown, 1962) where 128 families of psychiatric patients were divided into two groups of high and low emotional involvement. After one year, those with high involvement group showed worsening of symptoms and social behaviour at 76% with 56% readmitted as compared to the 28% of patients that lived in families with low emotional involvement. Brown et al (1962) pointed out that the higher the level of emotion and hostility in the family, the higher the likelihood for the patient to have a relapse within the following year. Vaughn and Leff (1976) modified an original scale formulated by Brown et al (1972) with the final version that includes the following: Criticism – frequency of comments through expressions of disapproval, resentment or rejection and specific vocal characteristics of rate, tone of speech and volume. Hostility – reflects global or generalised criticism or rejection of patient. Emotional Over-Involvement – basis of both the past behaviour as exaggerated emotional response, excessive attitude of devotion or self-sacrifice or over-protectiveness. Warmth – based on voice tone, spontaneity, sympathy, empathy, interest in or concern for the person. Positive Remarks – are expressions of praise and approval of the patient’s personality measured in frequency. All four but Positive Remarks have been directly correlated with the course of schizophrenia with Warmth regarded as associated with better course more effective in a low EE families (Migone, 1993). Criticism presented 30-70% relapse, while Emotional Involvement relapse rate is at 8-30%.. Empirically, the threshold levels of high EE predicts schizophrenia relapses in nine months after discharge (Brown et al, 1972; Vaughn & Leff, 1976; Vaughn et al, 1984; Leff and Vaughn; 1985 Moline et al, 1985; Jenkins et al, 1986; Nuechaterlein et al, 1986; Tarrier et al, 1989; etc.). High EE in the patent’s family showed greater risk of relapse at three-to-fourfold in the next 9-12 months after discharge. Three factors have been identified to interact with EE and each other: Medication – helps protect patients in low EE families from stressful events but less effective in high EE and stressful life events (Hogarty, 1988) Time of face-to-face interaction with relatives at high EE exceeding 35 hours per week marks increase of relapse Life events such as death of a relative, major changes in work or life situation increases possibility of relapse although it has been found that to be less effective in high EE (Birley and brown, 1970; Leff & Vaughn, 1980). Effect of high EE, nevertheless, is not confined to schizophrenia or mental disorders but also indicative in patients with depression, anorexia nervosa, obesity (Vaughn and Leff, 1976, Miklowitz et al, 1988; Hodes & LeGrange, 1993) and patients with epilepsy, diabetes, Parkinson’s disease, ulcerative colitis, and Crohn’s disease. Skin Conductance (SC) response has been found higher in patients who expect to interact with a high EE relative or just being in the same room, than that of a low EE relative (Turpin et al, 1988 and Tarrier, 1989). Affective Style (AS) based on harsh or benevolent criticism, intrusiveness and induction of guilt feelings also predicts relapses as EE (Valone et al, 1983 and Miklowitz et al, 1984). Another factor, Communication Deviance that measures parent’s inability to establish or maintain shared focus of attention, negative AS, as high EE predicts the onset of schizophrenic symptoms up to four times (Goldstein, 1987). Psycho-educational Approach In consideration of the previous findings already mentioned, some studies probed into modifying EE levels and found that his helped lower the relapse rate. This has been called Psychoeducational by Anderson et al (1986) which involves education of the family regarding the nature of the mental disorder in a way that they are reassured of its biological nature resulting to less guilt and decreased pressure on the patient to change his behaviour. Projective Identification Formulated by Melanie Klein in 1946, this is the projection of the part of the subject onto the object with whom the subject is closely associating with, of which control is exerted. It has been regarded as a “bridge concept” and Ogden (1979, 1982) divided it into three phases: projection, interpersonal pressure, and reinternalisation. Interpersonal pressure is identifiable in projective identification as a term most widely used (Migone, 1993). As early, Heiman (1950) clinical intuitions such as use of the analyst’s own feelings to know and understand the patient’s unconscious, concept of evocation of a proxy (Wangh, 1962), externalisation (Brodey, 1965) role actualisation and role responsiveness (Sandler, 1976) supervise and interpret patient’s feelings (Searles, 1975 and Hoffman, 1983). The non-metapsychological explanation is that in the course of interaction with therapist, the patient learns new skills of adoptive behaviours he can use to cope with emotional stressors. If an analyst shows that it is possible to tolerate stressful feelings of anxiety, fears, depression, etc., and to survive through the analyst’s own behaviour, then, improvement occurs because the therapist does not discharge back onto the patient the projected feeling and keeps it to himself through silence and non-defensive attitude. Notably, discharge brings to mind the old metapsychological terminology of Freudian drive theory (Migone, 1993). In relating back to EE, high EE relatives are seen to be struggling to control the uncontrollable (Hooley, 1985 and Brewin et al, 1991) and seem to be unable to accept the loss of the idealised individual; or what the patient might have been. With low EE relatives, they may be sad about the loss but are more progressive and are able to acknowledge the loss as permanent so that they have a lower sense of guilt and no longer project it to the patient (McCarthy, 1993). Projective identification in this instance may complement psychoeducation and help relatives understand some aspects of their distress (Migone, 1993). When the therapist was able to teach relatives to contain the disturbing feelings they get from the patient and lower their EE, this may break the vicious cycle of anxieties and fears thereby relieving the patient. They learn that the patient is not to blame for his biological illness, their guilt lessened, and expectations lowered thus preventing frustration (Migone, 1993). Homeopathy and Schizophrenia As integrated approach is targeted in this study to reveal commonalities between various medical schools of thoughts, homeopathy or the “Law of Similars” postulated by German physician Samuel Hahnemann is considered in this research. It is based on the “similar suffering” popular in Europe and India with the premise of treating sick persons with extremely diluted agents that when undiluted, produce the same symptoms as that of the disease being treated. It views a sickness as “morbid derangements of the organism” (Morell, 1997) and that a sick person have dynamic disturbance rejecting the standard medical diagnoses of named diseases (Verspoor, 2006). Pataracchia (2002) cited several studies that have associated homeopathic medicine for mental illnesses that include schizophrenia but a study from India stood out with the report that 70 schizophrenics were managed in a 1-to 8 week trial using psycho-tropic action administered in low dose (Pataracchia, 2002). The patients were treated in a clinical hospital setting at the Regional Research Institute between 972 and 1974 in Kottayam, India. “Homeopathic medicine works by a mechanism of action that is said to tune the patient’s vital force witch has become mis-tuned as a result of disease,” Pataracchia (2002) explained, adding that “Therapy is not always a smooth process as patients may relapse and remise over the course of a treatment witch may last 2 or more years.” Although it was suggested that homeopathic medicines are reportedly “suitable adjuncts to neuroleptic therapy due to their relative safety and absence of side-effects,” (Pataracchia, 2002), aggravation of symptom that includes psychotic features occur, the report added, “Theoretically, in severe cases of aggravation and in extraordinarily rare cases, the aggravation could be permanent and perhaps lethal. Aggravations can proceed in a suppressive manner. Anti-doting a homeopathic medicine is not always successful,” with the disclaimer that “Aggravations are thought to foreshadow the disease presentation as it would have occurred without the homeopathic medicine. Aggravating symptoms are not new symptoms but rather, they are existing symptoms or a re-emergence of previously existing symptoms in the course of the patients’ lifetime. True aggravations, according to homeopathic philosophy, after lasting from a few hours to a few weeks, are followed by general amelioration. True aggravations are not unbearable.” Allopathic Medicine Coined by Hahnemann for the methods of his medical foes, allopathy is generally defined nowadays as the conventional, present or prevailing system of medicine. It was also defined as “therapeutic system in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first,” (Steadman’s Medical Dictionary, 2005). Originally, allopathy uses bleeding, leeching, cupping, blisteringm purging, puking, rubbing with toxic ointments to treat patients as these were thought to cleanse, purify or balance the harmony of the four humours (Shelton, 1968). The Four Humours Theory attribute disease with the imbalance of four humours” which are the blood, plegm, black and yellow bile and the four body conditions of hot, cold, wet and dry. These are also corresponding to the four elements earth, air, water and fire. So that those who follow the Hippocratic tradition balance sysmptoms with the opposite. Example cited was fever which is hot, and believed to mean excessive blood, and the petient was treated by blood-letting to cool the aptient, (Jarvis, 2000.) Complementray Medicines Zollman and Vickers (1999) defined complementary medicine as “to a group of therapeutic and diagnostic disciplines that exist largely outside the institutions where conventional health care is taught and provided.” These served as alternative for conventional and prevailing medicine in the 1970s to 1980s but have been in practice for centuries in eastern and western civilisations. Below is a table of existing complementary therapies: Table 2    Acupressure   Chiropractic*   Naturopathy    Acupuncture*   Cranial osteopathy   Nutritional therapy*    Alexander technique   Environmental   Osteopathy* medicine   Reflexology*    Applied kinesiology   Healing   Reiki    Anthroposophic medicine   Herbal medicine*   Relaxation and    Aromatherapy*   Homoeopathy* visualisation*    Autogenic training   Hypnosis*   Shiatsu    Ayurveda   Massage*   Therapeutic touch   Meditation*   Yoga* Source: Zollman and Vickers, 1999. Most complementary medicine practice holistic approach in consideration that: “Each individual is unique Scientific, artistic, and spiritual insights may need to be applied together to restore health Life has meaning and purpose the loss of this sense may lead to a deterioration in health Illness may provide opportunities for positive change and a new balance in our lives,” (Zollman and Vickers, 2002). Discussion The conventional method (which may or may not be alluded to allopathic medicine) in the treatment of schizophrenia combines medicines and therapy as well as psychoeducation as promoted and supported by clinical and research findings as discussed extensively in this research. Since conventional method previously had been categorical in their approach to treat each disease such as schizophrenia as “mental”, thereby purely physical in nature, use of analysts and therapists introduced as well as supported Sigmund Freud’s psychoanalysis method. Complementary, and previously “alternative” medicine has for centuries alluded to an all embracing approach of treating a disease, whether it be apparently physical in nature. Forces include social, emotional and relational factors of an individual who is sick. With the extensive and consistent findings of the studies particularly in relation to Expressed Emotion and all other factors that come with it, emotional and social factors indeed poses great implications to the schizophrenic patient. Surprisingly, benefits derived from positive approaches of therapy benefit both the patient and the family, thereby indicating, after all, that although the cause of schizophrenia may be basically hereditary, environment, which is the family or relatives where patient lives, may ultimately influence source of positive treatment. This is supported by the views of other medical schools of thought such as homeopathy and complementary therapies. Conclusion: This research concludes that although there had been huge gaps and differences when it comes to practice and theories between conventional medicine and complementary medicine, there is an overlapping factor when it comes to the treatment of schizophrenia, and this refers to the social and emotional consideration of the patient, family members and even the therapists involved in the treatment. As complementary medicine and therapies are slowly being embraced mainstream, not basically by conventional medicine professionals but by users, patients and their families, it is therefore a progression that leads for the betterment of the schizophrenic patients and their families. It is therefore recommended that integrated studies must be considered in these fields in order to obtain empirical as well as phenomenologic data towards a better mental world. Reference: Anderson C.M. et al. (1986). Schizophrenia and the Family. A Practictioners Guide to Psychoeducation and Management. 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