Special Needs Pathway: Schizophrenia - Research Paper Example

Special Needs Pathway: Schizophrenia Introduction: Schizophrenia is a disease that frightens the household and society. One can imagine the "feeling of insects crawling" under the skin or the reaction when one hears God urging one to jump off the building to plan a suicide. These troublesome thoughts are terrifying or maybe just fantasy to the normal individuals, but to the sufferers, these are "real pieces of thoughts", which they transform into actions. In this work, an attempt will be made to understand the disease from the perspectives of prevalence, causes, the affected population, and difficulty with the disease and to critically evaluate the role of community-based psychiatric services in amelioration of the disease burden in the society. Description: Differing Views on Difficulty: Schizophrenia is a group of heterogeneous illness characterized by "perturbed language, perception, thinking, social activity, affect, and volition" that commonly begins in adolescence, progressing from social withdrawal and perceptual distortions to a "state of chronic delusions and hallucinations" with very poor outcome with interventions (Reus, V., 1998). The symptomatology of these patients are divided into positive and negative symptoms, such as, conceptual disorganizations, delusions and hallucinations, disorganized speech, severely disorganized behaviour, loss of functions, anhedonia, paucity of speech or emotional expressions, impaired concentration, diminished social engagement, affective flattening, alogia, or avolition and marked deterioration in work, social relations, and self care. This will mean disintegration in the process of thinking, of contact with reality, and of emotional responsiveness. The suffering with hallucinations and delusions can be extreme to the people surrounding the subject, but the patient thinks that his thoughts, sensations, and actions are controlled by or shared with others. Simply spoken, people with schizophrenia have their thoughts, feelings, and ability to plan and translate them into actions entirely bizarre right from their adolescence and suffers a downhill course leading to pose a danger of harming self, contrary to popular belief that they might harm others (A Dictionary of Nursing, 2003). Any individual is unique with respect to "thoughts, moods, actions, and perceptions". These higher level functions of brain are distorted and appear to establish no link with the reality and environment in schizophrenia. People with schizophrenia can hear voices that to them seem to come from outside but actually internally generated as reflections of their very own distorted thoughts and thought processes. Thought process may be affected and disorganized to becomes disjointed and difficult to follow. Since conversation is a function of thought process, there ceases to be any discernible connection between ideas, and conversation becomes incomprehensible (Colman, M.A., 2006). Schizophrenia can "diminish motivation, initiative, and emotional outlets". Over time, the patient and the family and friends lose contact with one another, the patients fails assignment in job or work, and his emotional status prefers isolation. In short, schizophrenia is a mental disorder that affects the "very fabric of the human mind, robbing it of the many facets of thought processes, abstract thinking, creativity, emotion, and skills of social interaction", which are innate in human beings (Gelder, M. G. et al, 2000). Statistics/Prevalence: As currently defined by the World Health Organization, just fewer that one (about 0.85%) in 100 people will suffer from schizophrenia in their lifetime, and it is the ninth greatest cause of disability in the world. Data will prove the exact load of the disease; if indirect costs are considered, the financial burden in England is about 2.6 billion per year, even without allowing for lost careers and lost lives. In addition, the health and social care costs for schizophrenia are considerable: about 810 million per year in England alone (American Psychiatric Association, 1994 and Oxford Dictionary of Psychology). Research has shown that schizophrenia occurs in equal rates in men and women and occurs in similar rates in all ethnic groups throughout the world. Studies have shown that it is more common in the urban than in rural areas and in migrant groups like "African-Caribbean people" living in UK. Psychotic symptoms, such as, hallucinations and delusions usually emerge in men in their late teens and early twenties, in women a little late, mid-20s or early 30s. Causes and Influencing Factors: The one popular hypothesis is interplay between environmental and genetic factors. Surveys identify that the principal risk factors are "genetic vulnerability, early developmental insults, and winter birth" (Selemon, L.D, 2001). The neurodevelopmental hypothesis postulates in schizophrenia, there is enlargement of lateral and third ventricles associated with cortical hypertrophy and sulcal enlargement; volumetric reduction of amygdala, hippocampus, right prefrontal cortex, and thalamus. This is hypothesized that there is localized hypoxia during critical stages of neuronal migration and maturation in the "neurodevelopmental phases" in the fetus in the schizophrenics (Benes, F., 2003). About 6.6% of all first-degree relatives of an affected proband will develop schizophrenia. If both the parents are affected, the risk for developing schizophrenia in an offspring is 40% (Hugh, M.D., 2006). Early environmental factors, such as, medical problems during early pregnancy or delivery have been implicated, and it has been suggested that environmental influences that might modulate a genetic factor like influenza in the mother may play a role. Indirect evidence in support of this comes from the curious fact that those who have schizophrenia are more likely to be born in late winter and early spring. All these can point to a "two-strike etiology" involving both environmental and genetic factors that might explain sporadic cases of schizophrenia (Theo, G. M. et al, 2002). Superficially seen, adverse life events like loss of a relationship or drug abuse with drugs that release dopamine in brain like amphetamine or cocaine have been observed findings in cases of schizophrenia. This translates into the question how schizophrenia evolves in the body. The acute symptoms of schizophrenia appears to result from excessive release of neurotransmitter, dopamine in the brain. Another causative hypothesis points to "hyperactivity of nigrostriatal and mesolimbic systems by event-related evoked potential" showing reduction in P300 amplitude to a novel stimulus implicating impairment in cognitive processing or information processing with relative decrease in the mesocortical tracts innervating the prefrontal cortex where information is processed. This action may be mediated by a combination of neurotransmitters like serotonin, acetylcholine, glutamine, and GABA (gamma amino butyric acid) (Winterer, G. et al, 2003). Critical Evaluation of Approaches: Antipsychotic medications remain the cornerstone of treatment of schizophrenia. Since these are inadequate till date despite advent of newer drugs, many different approaches are utilized for a successful outcome in treatment of this devastating disease, which psychiatrists are still trying to understand (Olfson, M. et al, 2006). We shall focus on the role of community-based psychiatric services to enable these patients to lead a normal life. Social and psychological interventions are as important as drugs and rehabilitation in the schizophrenics. Research has shown that "environment and social milieu" can significantly affect the course of the illness (Allardyce, J. and Boydell, J., 2006). The importance of this will be understood from the fact that the patients are often discharged from the hospital to the care of their family, so the family members should know as much as possible about the disease to prevent relapses. Family members should be aware of different kinds of treatment adherence programs and should learn coping strategies and problem-solving skills to effectively manage their relative (Pitschel-Walz, G., 2004). Even simple knowledge about resources to support schizophrenics and their caregivers would help a lot. Ensuring that people with schizophrenia continue to get treatment and take their medications after they leave the hospital is important since if they stop going to followup or stop taking medications, which is often the case, the disease will recur (AAP). The community-based psychiatric services may play a potential role in this care plan. The main objection to this kind of care plan is that it is funded by the state, hence as expected there would be "bureaucratic complexities and obstacles". If the community-based services are successful in achieving the goals of "integration of hospital care offered by state and aftercare offered by community"; despite the system of total care becomes integrated, there would remain always disparity between these two "historically different entities" (Brekke and Long, 2000). As proposed by Bachrach, the benefits of this system are immense. It has been observed that "increased aftercare compliance ensured by a customary appointment made by the social workers or psychologist" attached to the program will ensure continuity of treatment and utilization of emergency housing program will reduced the total number of hospital admissions, less overcrowding in the state psychiatric units as evidenced by lower census. One of the many reasons is that the patients can access and easily "traverse a comprehensive range of services" through the community-based psychiatric services that are in close communication with the patient and the family. This can be a useful alternative to hospitalization since this not only offers treatment, it also offers counseling, arrangement of specialty care, emergency housing in case of exacerbation, and most importantly, a "smoother integration into the community". As a result, though difficult to achieve, integration of community-based services and state services might have had a promising impact on the systemic indicators of continuity of care (Brekke and Long, 2000). Another aspect in the management of schizophrenia is rehabilitation. Community- based psychiatric services may assume a critical role in rehabilitating these patients. Most of these patients become ill during the most productive time of the life, that is, career- forming years and because the disease usually affect the cognitive skills, these patients are entirely untrained for skilled work (Talbott JA, 1979 and AAP). Community-based programs can institute rehabilitative programs like vocational counselling, job training, money management counselling, and provide opportunities to practice social and workplace communication skills. The community often fails to understand these patients since they are not trained to handle these individuals, as a result the community-based psychiatry can arrange for separate living arrangements for these patients. In fact, in the study made by Brekke and Long, the community-based psychosocial rehabilitative services are related to superior outcome for individuals with diagnosed schizophrenia. The main debate against this kind of approach is, although a variety of psychosocial interventions can reduce hospitalization rates and increase housing stability almost in all cases and can improve symptomatologic and psychosocial functioning picture and "social and independent living domains", it was almost futile in "humanitarian and subjective experience outcomes", such as, "self-esteem and life satisfaction". In these programmes great emphasis has been paid to the factors of increasing functional outcomes from psychosocial interventions with some attention to client satisfaction with services, but there was not much attention to the subjective experience of clients in terms of extensive psychosocial rehabilitation, or it was not even questioned whether changes in the functional status of the patient and subjective experience out of that are related. Another important variable that might be related to these outcomes can be the property of the disease itself. There are "intrapsychic deficits" which comprise "loss of motivation, pleasure, and purpose". These are related to a variety of potentially important rehabilitative outcomes, such as, "social competence, work, and independent living" (Brekke et al, 2007). The impact of intensive rehabilitation on the intrapsychic deficits of schizophrenia has been studied inadequately, and it remains to be determined whether "greater intensity" of rehabilitative actions by community-based psychiatric services would lead to betterment of those deficits. Studies have suggested that intensive rehabilitative services that produce increased functional outcome of the clients may also be related to improvement in "at least one aspect of the client subjective experience, self- esteem". It may be analyzed further to suggest that remaining in treatment was related to maintaining gains in self-esteem. If it is true, then there is possibility that this can be applied to "multidimensional outcome assessments" as applied to schizophrenia symptoms (Rossi, A., 2002). Implicating finding that may influence psychosocial rehabilitation in terms of assessment and interventions is that clinical outcome is distinct from functional outcome. A change in both clinical and functional domains as a result of psychosocial rehabilitative approaches is just "modestly related" to change in subjective experiences. These findings in essence points at the assumption that functional changes in the patient will be closely associated with change in the humanitarian outcomes, such as, self-esteem or satisfaction in life issues, and these are very basic issues that are highlighted in a rehabilitative community care approach (Brekke et al, 2007). One very positive gain in this approach is that, there is "very high medication compliance" in the patients with schizophrenia that are treated by comprehensive psychosocial approaches, but the functional gains achieved during rehabilitation programs are lost once the intervention ends (Scott and Dixon 1995; Mueser et al. 1998); nevertheless, some functional gains do remain or maintained even after the "psychosocial intervention exits", but this may not be equally applicable to all the symptomatic parameters or functional variables (Brekke et al. 1997). However, it can be hypothesized that community-based psychiatric services do indeed boost the humanitarian experiences in a schizophrenic entering into a community-based rehabilitative service, and that can generate enough confidence in the subject and the family or community to ultimately lead to participation and hence to generation of positive outcomes as the parallel modalities of management develop and advance. Another aspect of community based care is close contact with the family and the patient. The usual hospital care fails to do so. In a study conducted by Swanson et al., they used atypical antipsychotic medications like clozapine, risperidone, or olanzapine over a two-year period. As opposed to the usual treatment, this has given rise to a striking outcome of significantly reduced violent behaviour. There were observations of "concurrent reductions in psychotic symptoms, substance abuse, and adverse medication side effects". The main reasons for this finding are not only the effects of atypical antipsychotics, but also adherence to the program. A great majority of patients with schizophrenia are not violent, but some patients may pose a big risk to the community by way of concurrent substance abuse; over and above it, they are noncompliant with the prescribed treatment (Geller, J., 1992). "Noncompliance is an independent risk factor for the outcome of schizophrenia", so are violent behaviour and uncontrolled substance abuse. If the patients are compliant, the risk of violent behaviour in the community dramatically reduces. "Medications compliance in the schizophrenics is a complex phenomenon, not only determined by unpleasant side effects" (Valenstein, M., 1998), but also guided by other factors, such as, insight, severity of symptoms, substance abuse, adverse social environments", availability of supportive caregivers, and the quality of "collaborative bond" between the patient on the one hand, and community, family, and clinician on the other hand (Olfson, M., 2000), which can all be delivered through community-based psychiatric services. In summary, the environments of care, treatment, and rehabilitation of patients with schizophrenia have taken many forms "ranging from sheltered and isolated mental asylums to mainstream community-based programmes". The hospital setting is bound by law to restrain the violent patients with schizophrenia against the civil rights. Authorities and specialists are now of the opinion that these people should better be treated in a setting outside mental institutions. This can take the form of residential long-term community-based program as an alternative to hospitalization with commitment to use evidence-based psychiatric rehabilitation techniques offered by a community psychiatry programme. The very fact that these patients have history of recurrent unsuccessful admissions to the hospitals and unsuccessful attempts to stay in the community or in the family may indicate an alternative. Many different approaches may be accepted, like rehabilitative training, community encounters, support, and all of these may happen under supervision of a psychiatrist who might take the charge of medical treatment (Guazzelli, M. et al, 2002). The facts of encouragement is that this approach reduces the cost, successfully creates a support group within the patients themselves, and reduces overall psychiatric symptoms. This kind of programme may impart the subjects a carefully "determined assistance and supervision" with an intent to enable them to acquire skills needed for independent living. This approach helps schizophrenic individuals take roles held by nondisabled people and will gradually uplift them to the status of a mainstream community member. Conclusion: Schizophrenia is a complicated and extremely variable disease condition, and treatment often requires sustained effort of a multidisciplinary care team that includes psychiatrists, nurses, social workers, occupational therapists, and psychologists. The role of family and community and psychosocial elements in making this tough target a success cannot be overruled. It is well-known that there is no 'cure' for schizophrenia, the rapidly increasing understanding of the psychological and neurobiological aspects of the illness is now translating into better treatments and a not- too-grim outlook. Unfortunately, in most countries the full range of appropriate pharmacological and psychosocial treatments is only available to a minority of sufferers, and in many countries, the facilities to establish a global and all-round care system that involves all the components including community psychiatric system is still lacking. Reference List .Alberto Rossi, Francesco Amaddeo, Giulia Bisoffi, Mirella Ruggeri, Graham Thornicroft, And Michele Tansella, Dropping out of care: inappropriate terminations of contact with community-based psychiatric services, Br. J. Psychiatry, Oct 2002; 181: 331 - 338. American Psychiatric Association: Diagnostic and Statistical Manual of Mental disorders, IV Ed, Washington DC, American Psychiatric Association, 1994. 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