Schizophrenia Peculiarities Analysis - Case Study Example

SCHIZOPHRENIA- AN INTRODUCTION: Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect, and sense of self. The array of symptoms, while wide ranging, frequently includes psychotic manifestations, such as hearing internal voices or experiencing other sensations not connected to an obvious source (hallucinations) and assigning unusual significance or meaning to normal events or holding fixed false personal beliefs (delusions). No single symptom is definitive for diagnosis; rather, the diagnosis encompasses a pattern of signs and symptoms, in conjunction with impaired occupational or social functioning (DSM-IV). CASE STUDY: Jim is twenty year old man with a recent history of unusual and disturbed behavior .Jims parents are becoming concerned about him and his doctor has made a referral to the crisis assessment treatment team (CATT). Recent History: Jim had spent first semester at university and had lived at home for the past two months At home his activities had been lounging around, listening to music, sleeping, eating from refrigerator at night .Jims appearance had started becoming untidy and he had become defensive and verbally abusive at one stage threatened physical violence. Psychiatric interview: A psychiatrist and a mental nurse interviewed Jim who was in a poor state of personal hygiene. Although he was cooperative, he appeared to be restless when questioned. In conversation Jim appeared monosyllabic, slow in speech and lacked energy. His expression was flat and he couldn't concentrate. Jim had also been hearing voices. He enquired if the room had video surveillance equipment as he could feel the radiation. As the level of risk appeared low and Jim is cooperative it was felt that twice daily visit by the CATT were appropriate. The psychiatrist made a diagnosis of acute paranoid schizophrenia Jim was commenced on Zuclopenthixol, Olanzapine and Benztropine following which Jim had a plethora of side effects. Jim's psychiatrist advised his parents to remove him from his current strenuous surroundings and provide him with individual care in a positive, constructive environment. Specifically, he recommended a place with a clean atmosphere, in plenty of sunshine and out-of-door activity. As part of a clinical trial Jim was provided with a companion constantly that would make for those engagements mentally and physically in activities that are constructive and yet, with patience and persistence, have those activities carried on in such a way as to make for constructive thinking, constructive activity, both as to the association and as to the speech, and as to the environment. Jim's was now experiencing a slow but definite improvement in his condition. Many contemporary psychosocial rehabilitation models use a similar approach and companions may be include professional caretakers, a patient friend or member of the family or even teachers. As the individual responds to treatment, more self-responsibility is expected. Because some psychiatric patients develop manipulative techniques for avoiding responsibility, the question of how much self-responsibility is appropriate must always be addressed. This essay focuses on some of the psychosocial factors that play an important role in the onset, course and treatment of schizophrenia. Most researchers believe there is an interaction between genetic/biological predispositions and environmental stresses. 1. Vulnerability Factors: Vulnerability of an individual depends on personal attributes of the person and social/environmental conditions which predispose the person to schizophrenia. Hence, it is necessary to examine the person and his/her environment prior to the development of the disorder. 2. Social Factors: one of the most consistent social factors associated with adult onset of schizophrenia is marked social withdrawal and generally poor interpersonal relationships (Goldstein, 1987, Parnas, Schulsinger, Schulsinger, et al., 1982). These social difficulties become particularly noticeable during later childhood and adolescence. Nevertheless, the nonspecific nature of these vulnerability factors (ie: schizophrenic persons are not the only ones to experience them) makes it impossible to use these factors to reliably identify those children who are "at risk". 3. Psychosocial Stress Factors: these are more appropriately referred to as "provoking" factors due to their nonspecificity and can be divided into sub-components.The family environment as a source of chronic stress has been hypothesized to be a critical provoking factor in schizophrenic disorders. A. Communication: During the 1950's there was a growing interest in the role disturbed family interactions might play in the development of schizophrenia in a family member. Of particular interest were disturbed communication patterns. 1. Double binds: Bateson and his colleagues (eg: Bateson,Jackson, Haley & Weakland, 1956) identified a particularly insidious communication pattern that they hypothesized could play a causal role in schizophrenia. They first noted that communication occurs on multiple levels: verbal, facial, voice, tone, posture. In the double bind situation, a parent gives the child simultaneous messages on more than one level which contradict each other: he/she says one thing but acts differently. Example: A schizophrenic patient, glad to see his mother "impulsively put his arm around her shoulders, whereupon she stiffened. He withdrew his arm and she asked, "Don't you love me anymore" He blushed, and she said, "Dear, you must not be so easily embarrassed and afraid of your feelings." (Bateson, et al., 1956, p.251). 2. General Communication Patterns: Other lines of research have looked at general patterns of communication within the family as a whole. Families of schizophrenics tend to have deviant communication patterns. For example, parents are unable to establish a focus of attention and instead communicate with each other and other family members in an incoherent manner (Wynne, Singer, Bartko & Toohey, 1975). Verbal exchanges are often confused, vague, or incomplete. For example: Daughter (presenting patient), complainingly: Nobody will listen to me. Everybody is trying to still me. Mother: Nobody wants to kill you. Father: If you're going to associate with intellectual people, you're going to have to remember that still is a noun and not a verb. (Wynne & Singer, 1963, quoted in Neale & Oltmanns,1980, p.315) B. Expressed Emotion: Another family variable associated with schizophrenia is a negative emotional climate, or more generally, a high degree of expressed emotion (EE). Of particular interest are things like critical comments, hostility and emotional over involvement (high levels of tension and emotion). It has been claimed by some that families with high EE seem more likely to have a member who develops a schizophrenic disorder(Goldstein, 1987). The chance of relapse in patients with schizophrenia living at home depends heavily on the emotional environment provided by the family. The concept of expressed emotion has evolved as an index of the quality of this environment. Expressed emotion covers many of the emotional responses by a key relative, usually the spouse or parent, towards the patient. The key relative's level of expressed emotion is classed as high or low on the basis of the frequency of critical comments and the intensity of hostility and emotional over involvement elicited. Patients with schizophrenia in families with high expressed emotion are more likely to relapse despite receiving maintenance neuroleptic medication, and to relapse more often, than those whose key relatives show low expressed emotion. This general relation between expressed emotion and relapse seems true in most cultures but with some variations. The proportion of families showing high expressed emotion is smaller in developing countries and rural communities than in Western countries. C. Abuse: Martin Willick (J. Amer. Psychoanal. Assn. 49/1) suggests a clearly biological contribution to the etiology of schizophrenia, there is growing evidence that psychosocial factors-particularly childhood physical and sexual abuse which play an extremely important role in its etiology. Traumatic experiences like these might not be a contributing factor in all people diagnosed with schizophrenia, but approximately 60 percent of schizophrenic patients report having experienced some form of childhood abuse .Neurological data strongly suggest that traumatic experiences like these have an untoward impact on the developing brain, which, it has been hypothesized, might create the vulnerability to developing schizophrenia It should be clear by now that child abuse does not necessarily implicate families as its perpetrators. Families are not the only possible source of such abuse: childhood traumas can occur under a variety of circumstances with many different people. A child born to a warm, loving family can suffer abuse at the hands of neighbors, relatives, or anyone else, for that matter. It is the trauma that is important in this model, not necessarily who perpetrated it. D. Social defeat: A recent study done in Sweden examined the role of psychosocial factors in the development of psychotic disorders. First-generation immigrants four times more likely to develop a schizophrenic disorder whereas second-generation immigrants were at a much lower risk than native Swedes to develop such disorders. There was a significant difference between light and darker skin as well, "Moreover, the team found that the highest risks of developing psychotic disorder were seen among first-generation immigrants who had "black" skin and those who had come from a developing country, with relative risks of 5.8 and 3.3, respectively" (Psychiatry Source, 2005). This may be due to the fact that they felt even more "different" than the first-generation immigrants who looked like Swedes due to their paler skin or lighter hair. It is hypothesized that the stress eminating from high social stress or "social defeat" could elicate extra dopamine release or "dopaminergic hyperactivity in mesocorticolimbic circuits". Schizophrenia has been linked to high dopamine levels in those who suffer from the disease. The study gives us a better look at the potential affects that environment and psychosocial factors can have on the individual although it is not very definitive ( Psychol Med 2005; 35: 1155-1163) Family based therapies, already shown to be particularly effective in reducing relapse rates, also typically decrease (Doane, Goldstein, Miklowitz & Falloon, 1986). In fact, whatever the therapy method when family members shift to low EE patterns, relapse rates are as low as 0%;if EE stays high, relapse rates stay high (Hogarty, Anderson,Reiss, et al., 1986). Psychosocial factors are important in the etiology of schizophrenia: developmental dysfunctions, social factors, communication deviance, and expressed emotion. Yet, it is difficult to specify the direction of causality in these findings. A purely psychosocial explanation of schizophrenia, however, is probably unlikely. A focus on rehabilitation in shaping patient outcome was supported by one of the only direct comparisons between patient cohorts. Patients' degree of recovery at follow-up after three decades was measured by global functional improvement and other functional measures. In any event, the communication variables that are hypothesized to be stressful and thus provoke a schizophrenic episode also appear to contribute to its exacerbation. Interventions that teach family members more adaptive Communication methods have lead to substantial reductions in relapse rates. Indeed, family based communication skills training appears more effective than individual psychotherapy or drug treatment in reducing relapse rates over a 1 year period (Goldstein, 1987).In summary, schizophrenia does not follow a single pathway. Rather, like other mental and somatic disorders, course and recovery are determined by a constellation of biological, psychological, and sociocultural factors. That different degrees of recovery are attainable has offered hope to consumers and families. References: Primary source: Abnormal Psychology- lecture notes http://ubcounseling.buffalo.edu/Abpsy/lecture13.html 'Social defeat' linked to psychotic disorder development. Psychiatry Source. August 2, 2005: Psychol Med 2005; 35: 1155-1163 Andreasen, N.C. (1985). Positive vs. negative schizophrenia: A critical evaluation. Schizophrenia Bulletin, 11, 380-389. Andreasen, N.C. (1987a). The diagnosis of schizophrenia. Schizophrenia Bulletin, 13 (1), 9-22. Bateson, G., Jackson, D.D., Haley, J., & Weakland, J. (1956). Toward a theory of schizophrenia. Behavioral Science, 1, 251-264. Brown, G.W., Monck, E.M., Carstairs, G.M., & Wing, J.K. (1962). Influence of family life on the course of schizophrenic illness. British Journal of Preventive and Social Medicine, 16, 55-68. Brown, G.W., Birley, J.L.T., & Wing, J.K. (1972). Influence of family life on the course of schizophrenic disorders: replication. British Journal of Psychiatry, 121, 241-258. Browne, A. & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the literature. Psychological Bulletin, 99, 66-77. Cantwell, N. (1982). Crossing the cultural barriers. In K. Oates (Ed.),Child abuse: A community concern. Secaucus, N.J.: Citadel Press. Carpenter, W.T. (1987). Approaches to knowledge and understanding of schizophrenia. Schizophrenia Bulletin, 13 (1), 1-8. Doane, J.A., Goldstein, M.J., Miklowitz, D.J., & Falloon, I.R.H. (1986). The impact of individual and family treatment on the affective climate of families of schizophrenics. British Journal of Psychiatry, 148, 279-287. Dohrenwend, B.P. & Dohrenwend, B.S. (Eds.) (1974). Stressful life events: Their nature and effects. N.Y.: Wiley. Erlenmeyer-Kimling, L. (1968). Studies on the offspring of two schizophrenic parents. In D. Rosenthal & S.S. Kety (Eds.), The transmission of schizophrenia. New York: Pergamon. Falloon, I.R.H. (1988). Expressed emotion: Current status. Psychological Medicine, 18, 269-274. Freud, S. (1943). A general introduction to psychoanalysis. N.Y.: Garden City. Goldstein, M.J. (1987). Psychosocial issues.Schizophrenia Bulletin, 13, 157-171. Gordon, S.B. & Davidson, N. (1981). Behavioral parent training. In A.Gurman & D. Kniskern (Eds). Handbook of family therapy. N.Y.: Brunner/Mazel. Gorenstein, E.E. (1984). Debating mental illness: Implications for science, medicine, and social policy. American Psychologist, 39(1), 50-56. Harris, S.L. (1979). DSM-III - Its implications for children. Child Behavior Therapy, 1 (1), 37-46. Holzman, P.S., Proctor, L.R., Levy, D.L., et al. (1974). Eye-tracking dysfunctions and schizophrenic patients and their relatives.Archives of General Psychiatry, 31, 143-151. Liem, J.H. (1974). Effects of verbal communications of parents and children: A comparison of normal and schizophrenic families.Journal of Consulting and Clinical Psychology, 42, 438-450. Crease, I., & Snyder, S.H. (1982). Increased brain dopamine and dopamine receptors in schizophrenia. Archives of General Psychiatry, 39, 991-997. Martin, H.P. (1982). Abused children -- What happens eventually. In K.Oates (Ed.), Child abuse: A community concern. Secaucus, N.J.:Citadel Press. Meltzer, H.Y. (1987). Biological studies in schizophrenia. Schizophrenia Bulletin, 13 (1), 77-111. Neale, J.M. & Oltmanns, T.F. (1980). Schizophrenia. N.Y.: John Wiley & Sons. Parnas, J., Schulsinger, F., Schulsinger, H., Mednick, S., & Teasdale, T. (1982). Behavioral precursors of schizophrenia spectrum.Archives of General Psychiatry, 39, 658-664. Patterson, G.R. & Reid, J. (1970). Reciprocity and coercion: Two facets of social systems. In C. Neuringer & J. Michael (Eds.), Behavior modification in clinical psychology. N.Y.:Appleton-Century-Crofts. Kaufman, C.F. & Harrow, M. (1983). Associative disturbances in schizophrenia, schizoaffective disorders, and major affective disorders:Comparisons between hospitalization and 1 year follow-up. Journal of Consulting and Clinical Psychology, 51 (4), 621-623. Reiss, B. (1974). Competing hypotheses and warring factions: Applying knowledge of schizophrenia. Schizophrenia Bulletin, 8, 7-11. Sarbin, T.R. & Mancuso, J.C. (1980). Schizophrenia: Medical diagnosis or moral verdict. N.Y.: Pergamon. Weiner, I.B. (1982). Child and adolescent psychopathology. N.Y.: John Wiley and Sons. Wolfe. D.A. (1987). Child abuse: Implications for child development and psychopathology. Newbury Park, Calif.: Sage. Wolpe, J. (1982). The practice of behavior therapy, 3rd ed. N.Y.: Pergamon Press. Wong, N. (1987). Overview. In G.L. Tischler (Ed.), Diagnosis and Classification in psychiatry: A critical appraisal of DSM-III.New York: Cambridge University Press. Wynne, L.C., & Singer, M.T. (1963). Thought disorder and family relations of schizophrenics: I. A research strategy. Archives of General Psychiatry, 9, 191-198. Wynne, L.C., Singer, M.T., Bartko, J., & Toohey, M.L. (1975).Schizophrenics and their families: Recent research on parental communication. In J.M. Tanner (Ed.), Psychiatric research: The widening perspective. New York: International Universities Press. Read More