Professional Documents
Culture Documents
e
ic
st
Ju
Abnormal Psychology Case Study
al
By Gavin
in
rim
C
2
Abstract
e
era Kraepelin, first described this condition and he called it dementia
praecox. Much more is known comparatively speaking since Emil
Kraepelin’s first comprehensive description of the condition now
ic
known as or called, Schizophrenia. Historical writings and records
allude to this disorder as far back as the Pharaoh’s of Egypt era.
Although there is no known cure at this time for schizophrenia, there
st
are treatments that can assist the patient in ameliorated living. Among
the newer treatments, psychotherapy and psychoeducation show
promising results. Presenting patient Shonda will be assessed in this
paper and a regimen of treatment extended specifically for her.
Ju
al
in
rim
C
3
Introduction:
(Barlow & Durand, p. 471). The cause of schizophrenia is not known at this time…exactly, but
e
researchers believe that genetics and environment contribute to the development of this
ic
disease—mental disorder. The case study selected for this paper is Abnormal Psychology
st
Continuous Schizophrenia: Paranoid Type. The subject, Shonda, for this case study, meets the
criteria for this diagnosis. Shonda hears voices, her speech pattern is disjointed and difficult to
Ju
follow, has delusions and hallucinations of being under surveillance by the FBI, CIA; she has
significant impairment in her ability to work. The subject has connection genetically to a relative
al
that was placed in a mental health care facility. Shonda was raised without emotional attachment
by both parents. Shonda has a brother but has little contact with her sibling. Shonda is currently
in
schizophrenia and medical treatments, the environmental impact/aspects cause (s) (causal)
contributions of/to the disorder; schizophrenia, diet contributions, and treatment approaches such
C
as medical, psychosocial, and others. “Despite much research, environmental influences that
can be said to cause a schizophrenic illness remain elusive” (Leask, pg.323). Psychosocial
treatments for Shonda’s schizophrenia will be examined, and a specific regimen will be proposed
Much is known comparatively speaking since Emil Kraepelin circa 1856-1926 CE. Peter
Williamson, Mind, Brain, and Schizophrenia introduces Kraepelin with these facts and
observations:
e
Kraepelin, who described a condition he called dementia praecox, around the end of the
ic
nineteenth century (circa 1887). These patients were differentiated from those with
st
manic-depressive insanity and paranoia by virtue of the fact that most of them never
recovered. His description of these patients (Kraepelin, 1919) is remarkable, even when
notice of what they may perceive quite well, nor do they try to understand it; they do not
in
follow what happens in their surroundings even though it may happen to be of great
rim
importance for them." Patients were found to be emotionally dull with a loss of interest
and singular indifference toward others. They had "no real joy in life," "no human
feelings"; to them "nothing matters," "everything is the same," and they feel "no grief and
C
However, symptoms of this disorder were recorded in ancient times. And the actual word
schizophrenia is only less than a hundred years old. Eugen Bleuler, Kraepelin’s contemporary,
introduced the word schizophrenia in 1908. Schizophrenia is derived from the Greek words for
split (skhizein) and mind (phren) meaning split-mind (Barlow & Durand, p. 472). The disease
5
itself was known in Ancient times. In his paper Notes on the History of Schizophrenia
Theocharis Chr. Kyziridis posits that the disorder now known as schizophrenia was known in the
ancient past with/by comparative symptoms. These symptoms can be compared to the modern
diagnosis starting with Kraepelin’s dementia praecox condition description. The disorder can be
traced back to written documents in Pharaonic Egypt and also to the second millennium before
Common Era (BCE). Details appeared in the Book of Hearts which was part of the Eber
e
papyrus. The Hindus description dates back to 1400 BCE. The Chinese text called The Yellow
ic
Emperor’s Classic, describes similar symptoms and was written 1000 BCE. Comparative
st
symptoms were known in ancient times according to manuscripts written and transitioned
through time.
Ju
“One of the problems with investigating disorders such as schizophrenia is that the
tools available in the past to evaluate subtle, small changes in the brain have been rather
al
crude. Thus most of the work done in the past century to investigate brain structural
abnormalities in schizophrenia was based on methods that were crude, prone to error, and it
in
therefore did not further our knowledge and understanding of brain abnormalities in
rim
schizophrenia and its historical evolution. Both of them are extremely helpful for the
Disorder Classification
characterized by odd or eccentric behavior and includes paranoid, schizoid, and schizotypal
personalities. This cluster tends to be the most treatment refractory and is probably the most
likely to have underlying biogenetic factors” (Magnavita, p. 7). In Durand and Barlow’s
Essentials of Abnormal Psychology they list Schizophrenia into four sub categories as follows.
(p. 479-80)
1. Paranoid Type
e
2. Disorganized Type
ic
3. Catatonic Type
st
4. Residual Type
The schizophrenia disorder criterion is listed with these features: (Id p. 475)
• Delusions
Ju
• Hallucinations
al
• Disorganized speech
• Neglected self-care
or being followed by the FBI, CIA and or; always seeing the same person on the street (Kring,
Studies on schizophrenia disorders include family, twin, adoption, and molecular which
includes Shotguns and Lasers. Family studies are/were used to indicate the risk of schizophrenia
within the family. Abnormal Psychology 10 Edition Ann M. Kring, Gerald C. Davison, John M.
Neale, Sheri L. Johnson posits (p. 360) that the results of family studies support the notion that a
e
Michael Foster Green says (p. 53) that schizophrenia does indeed run in families however, not
ic
with a certainty for any one person but with a rate higher than would be expected. Family
st
studies show 8 percent of siblings and 5 percent of parents of a schizophrenic individual will
monozygotic (MZ) and fraternal, dizygotic (DZ). The percentages are higher for MZ twins
al
because they share 100 percent of their genes (Green, p. 55) whereas DZ share 50 percent of
their genes, the same as any sibling. Kring et al chart them (pg. 360) at risk for schizophrenia
in
from people with the disorder at 12.08 percent for DZ twins and 44.3 percent for MZ twins.
rim
Green however, says “There are many twin studies in schizophrenia: the concordance rates vary
somewhat, but the rates for MZ twins are always higher than for DZ twins (p. 55). Green further
states that the percentages are 48 percent for MZ twins and 17 percent for DZ twins according to
C
a study by Irving Grottesman (1991). The nearly three-fold increase between the two can only
be explained genetically.
Adoption studies according to Green (p. 58) are probably the best way to separate and
examine genetic and environmental factors. The study of children, whose mother had
schizophrenia but were raised from infancy by adoptive parents without schizophrenia, provides
8
clearer confirmations of genetics role in schizophrenia (Kring et al, p. 361). Studies were done
in Nordic countries such as Finland, Denmark, Sweden and Norway that keeps/kept superb
national records for adoption and psychiatric hospitalizations, and this system of record keeping
made is easy to locate individuals with mental illnesses for research purposes. Green says;
“studies have shown that adoptees born to mothers with schizophrenia have higher rates of
schizophrenia themselves, even though they are not raised with their biological mothers” (p. 58).
e
“The risk for other disorders, such as schizoaffective, schozophreniform, and schizotypal
ic
personality disorder, was also greater among the adoptees with a biological parent with
st
schizophrenia than among the control adoptees” (Kring et al, 361). Therefore based on adoption
that the predisposition for schizophrenia is not transmitted by a single gene (Kring et al,). Green
al
says that it is technically incorrect to look for a “gene” because a schizophrenia-relevant gene
has many alleles (p. 60) (in genetics, either of a pair (or series) of alternative forms of a gene that
in
can occupy the same locus on a particular chromosome and that control the same character)
rim
(WordWeb Pro, V5.52) researchers are looking for a particular version of a gene (an allele) that
Linkage studies such as the “shotgun” approach look at the entire genome to look for links
C
between a certain region of a chromosome and the disorder. This type of research looks for a
“These studies collect DNA from a family that has several members with
schizophrenia, as well as many members who are not ill. Scientists compare the marker
alleles in the affected members to the unaffected members. Demonstrating that the affected
9
members have the same marker allele and the non-ill members no not, shows genetic
In contrast, association studies (Laser) have a narrow laser like focus. These types of
studies begin with a certain gene in mind, one that is relevant to the disorder. And the focus is
associated to the disorder by looking at what scientists posit could be attributed to some kind of
e
However, Green posits (p. 63) that “if we target a single substance that is important for
ic
schizophrenia, we will not be looking for a single gene. For years the substances of greatest
st
interest for schizophrenia have been neurotransmitters, the chemical messengers in the brain.”
However, this research may not yield the desired results. Other neurotransmitter systems are
Ju
being actively investigated such as serotonin, GABA, acetylcholine, and glutamate.
al
Case Comparison
The original case (Case Study 6: Shonda: Continuous Schizophrenia: Paranoid Type)
in
diagnosis aligns with the DSM-IV-TR criteria for paranoid schizophrenia. Shonda has a long
rim
history of mental illness and was somewhat functional as an employee of a local community
mental health center doing light cleaning and other chores. Shonda does not show up for work,
her caseworker becomes worried, and goes to Shonda’s home to pay her a visit. The caseworker
C
discovers that Shonda is exhibiting serious complications from her disorder. Shonda’s condition
has worsened and the caseworker is concerned and determines that Shonda might need a
medication adjustment and arranges for her to be checked into the clinic for assessment. Shonda
will undergo assessment on her condition and medications to see if any changes are necessary.
This case study ties in with the background of the disorder, however, what has been learned
10
through this case study can and does supersede standard conventional treatments based on earlier
studies and diagnosis of schizophrenia. Scientific studies have increased the understanding of
schizophrenia and newer treatments are proffered and should be seriously considered.
regimen perhaps even archaic by today’s improved treatment programs found in progressive
mental disorder health care facilities. Shonda is being treated according to the case study with
e
intervention by medicine/medication only as it appears. Her drug of selection by the attending
ic
Doctors is haloperidol (Haldol). Shonda has been taking the medication for years, and she has
st
taken other antipsychotic medicines previously. The problem with this regimen is that Shonda is
not showing any improvement and her treatment resides in either a change in medication (s) or
Ju
an increase/decrease in medication dosage. Although functional, (limited) Shonda is not
receiving other treatments that could or would assist her in improving her mental state and
al
functionality. Shonda should be included into the following treatment regimens.
Aside from drugs, there are several treatments that show progress and promise. Among
in
treatments; has the following recommendations. This treatment can be utilized once the
psychosis recedes. After psychosis recession a program like this can be integrated into Shonda’s
daily regimen. Psychosocial treatments focus on social training skills, family therapy, vocational
C
rehabilitation and obtaining gainful employment. Because Shonda has been already working
and has her own home, she would be a good candidate for psychosocial therapy.
psychoeducation and normalization techniques, will learn how to divert attention away from
11
hearing the voices. Shonda will be encouraged to watch TV, listen to music, make
conversations, read, and perhaps play a video game. With the correct medical and therapeutic
e
Roles of Neurotransmitters
ic
What neurotransmitter(s) have been linked to this disorder and how do they influence
st
behavior? See Appendix A for pictorial example of neurotransmitters.
Doctors in the fields of Psychology and Psychiatry have long said that the etiology of
Ju
schizophrenia was not completely known. According to an article by Sherrie Thomas, The
schizophrenia. While Durand and Barlow state that one of the major theories, although
in
controversial, involves dopamine as the cause of schizophrenia (p.488). Williamson lists some
rim
of the neurotransmitters involved in schizophrenia dopamine, glutamate, and serotonin (p. 15).
There seems to be a consensus that dopamine and serotonin play a major part in schizophrenia.
What are neurotransmitters? (See Figure 4.4) for a neurotransmitter transfer depiction.)
C
Neurotransmitters are “chemicals that cross the synaptic cleft between nerve cells to
transmit impulses from one neuron to the next. Their relative excess or deficiency is involved in
one neurotransmitter become too low, the balance can shift and other neurotransmitter
12
levels can become too high. Neurotransmitter-related disorders occur when the current
levels of neurotransmitters are unable to properly relay the electrical signal from one
nerve cell (neuron) to the next. A neurotransmitter imbalance can result from the levels
If for instance the dopamine levels were in excess the resultant could be one of the major factors
in schizophrenia. According to Peter Williamson in his book Mind, Brain, and Schizophrenia (p.
e
45) the original dopamine theory of schizophrenia was that hyperactivity of dopamine
ic
transmission was responsible for the symptoms of schizophrenia. If there is an excess or
st
depletion of neurotransmitters, the imbalances could cause disorders that influence behavior
patterns.
Ju
Genetic Research and Contributions
al
What is known about the genetic contributions to this disorder—what does the research
suggest?
in
Barlow and Durand Essentials of Abnormal Psychology posit (p. 485) that there is no
rim
other area of abnormal psychology that so clearly illustrates the intriguing mystery of genetic
influences on behavior as it does on schizophrenia. They further crystallize that they can safely
say in generalization “Genes are responsible for making some individuals vulnerable to
C
schizophrenia” (Id, p. 485). Peter Williamson Mind, Brain, and Schizophrenia (p. 9) says it is
known for some time that there is a strong genetic basis to schizophrenia. First-degree relatives
increase the risk 10-fold whereas identical twins increase the risk to 50-fold in comparison to the
general population. However, because of the 50% concordance in twins suggests that there are
other contributing factors such as brain development and obstetric complications. The risk of
13
Sherine Thomas in her article The Etiology of Schizophrenia says because there is not a
100% concordance rate among monozygotic twins (MZ) and people can apparently carry the
genotype for schizophrenia without ever developing the disease, therefore there is probably no
single dominant gene for schizophrenia (p. 2). And Williamson also makes a similar assessment
e
wherein he says
ic
”However, the marked heterogeneity of findings in schizophrenia indicates that
st
no single gene is likely to be the smoking gun…As time goes on, it is likely that a
number of genes will be weakly linked to schizophrenia. Some of these may convey
Ju
vulnerability stress. Others may result in the brain neurodevelopment anomalies…While
While genes may be a contributing factor, chemical imbalances in the neurotransmitters could be
rim
determinate. This coupled with “triggers” such as stress, could be the catalyst or main
psychological trigger that can cause episodic schizophrenia or complete DSM-IV Axis 2 criteria
Brain Abnormalities
Are brain abnormalities indicated in this disorder? Is so, what influence do they have on
this disorder?
14
“It is believed that there is something different about the workings of the brain in
tomography (PET scans), computer axial tomography (CT scans) and magnetic resonance
imaging (MRI), that the structure and function of the brain has been examined in detail.
A number of brain-imaging and post-mortem studies have shown that abnormal brain
e
(Thomas, p.3).
ic
This clearly indicates that brain abnormalities are existent in patients with schizophrenia.
st
However, to what levels can be determined with some applied testing assessment procedures.
Brain matter volume and loss can be found in the brains of schizophrenics as the following
attests:
Ju
“Significant Loss of Brain Gray Matter: Individuals with schizophrenia, including those
al
who have never been treated, have a reduced volume of gray matter in the brain,
especially in the temporal and frontal lobes. Recently neuroscientists have detected gray
in
matter loss of up to 25% (in some areas). The damage started in the parietal, or outer,
rim
regions of the brain but spread to the rest of the brain over a five year period. Patients
with the worst brain tissue loss also had the worst symptoms, which included
hallucinations, delusions, bizarre and psychotic thoughts, hearing voices, and depression”
C
There is good evidences with the added capabilities of the introduction of the positron
emission tomography (PET scans), the computer axial tomography (CT scans), plus the magnetic
resonance imaging (MRI) techniques, that brain abnormalities can now be seen via this
15
technology. This visual aid into the size and functioning of the brain can assist in diagnosis and
treatment for mental disorders such as schizophrenia. Also, the chemical actions and reactions
can be viewed. This assists in understanding the neurotransmissions taking place in the brain.
Will this be encouraging or discouraging? Does brain imaging provide an important tool in brain
“One could say that the findings from the neuropsychological studies are both
e
encouraging and discouraging. Discouraging because no finding differentiates all
ic
patients from controls, and what findings there are do not seem to be specific to
st
schizophrenia. However, a few themes are starting to emerge from the data that are
the abnormalities found are related to known functions of these areas-executive function,
al
verbal fluency, memory, and encoding, among others. Finally, none of these regions
could account for these abnormalities in isolation. They are linked in functional neuronal
in
circuits that appear to be damaged in some way. But what and where is the damage?
rim
Clearly, neuropsychological tests do not allow us to look into the brain, but brain imaging
Nature of Influences
16
substance misuse, prenatal influenza, famine and other stresses,” (Id) can possibly contribute to
this disorder. Schizophrenia however, is usually diagnosed using a “diagnostic system defined
Psychiatry remains the only branch of medicine where there is a lack of useful laboratory tests to
e
confirm the diagnosis” (Csernansky, p. 89). Can diagnosis of Schizophrenia become
ic
complicated because of conditions associated with drug-induced disorders? Many drugs present
st
symptoms that could lead the clinician to misdiagnose this disorder by masking. Drug abuse and
dependence present psychotic symptoms such as hallucinations, delusions, and thought disorder
Ju
(Id. p. 90). Can drugs, alcohol, stimulants, hallucinogenic drugs such as Phencyclidine (PCP),
lysergic acid diethylamide (LSD), and assorted Opioids present the same symptoms as
al
schizophrenia? (See Appendix A Table 1) Substance use or abuse can be an environmental
diagnosis that the clinician does not misdiagnose because of the physiological effects of these
rim
agents. Schizophrenia symptoms can parallel and be masked by the abuse and misuse of certain
drugs and alcohol. The clinician must conduct a multi-panel drug screen test to eliminate drugs
and or alcohol as the causal agency. However, drug abuse and misuse can be a contributing
C
factor. “Because chronic psychoses in the context of substance abuse may begin at an earlier
age than in the onset of schizophrenia in the absence of substance abuse, some authorities have
suggested that substance abuse precipitates the illness in the genetically predisposed”
(Csernansky, p. 65).
17
Primary Influences
According to Brown and Barlow a great deal of research has examined the aspects of the
person’s social and family influences on emergence or course of the symptoms of schizophrenia.
(p.238) Stuart J. Leask Environmental Influences in Schizophrenia: the Known and the Unknown
posits that one’s genes are the ultimate environmental influence because they affect both internal
e
and external environment profoundly—by defining the organism. (p. 327). Michael Foster
ic
Green, Schizophrenia Revealed (p. 53) says that:
st
“Schizophrenia does indeed run in families, not with certainty for any one person but
with a rate higher than would be expected. Family studies show that about 8 percent of
Ju
siblings and 5 percent of parents of a schizophrenic individual will have schizophrenia,
Family studies have consistently shown that schizophrenia runs in families. In Schizophrenia:
in
Cognitive Theory, Research, and Therapy (Beck, Rector, Stolar, & Grant) the genetic connection
rim
“Eighty years of behavior genetics research in the form of twin, family, and
adoption studies indicate that schizophrenia is highly heritable. Family studies have
C
consistently shown that schizophrenia runs in families and that the degree of genetic
the etiology of schizophrenia. Mary Cannon and colleagues, for example, have conducted
and abnormal fetal growth and development (e.g., low birth weight). The risk of
complications, a small effect that is comparable in magnitude to the risk associated with
e
The connection genetically and environmentally can be established in the early stages of
ic
pregnancy. Jonathan Picker, Ph.D. says in his article The Role of Genetic and Environmental
st
Factors in the Development of Schizophrenia that risk for schizophrenia appears to begin as early
These include maternal rubella and respiratory infections, low socioeconomic class,
al
maternal deprivation resulting from war or famine, urban birth, obstetric complications,
and birth in late winter/early spring (Dohrenwend et al., 1992; Lewis and Murray, 1987;
in
Marcelis et al., 1999; Susser et al., 1996; Torrey et al., 1997). A direct observation of
rim
genetic and environmental factors interacting in the perinatal period was demonstrated
when it was shown that fetal hypoxia, an environmental insult, was associated with
decreased grey matter and increased cerebrospinal fluid (CSF) in patients with
C
schizophrenia and their relatives but not in genetically low-risk individuals (Cannon et
The genetic connection can be seen graphically (See Appendix B) in Barlow and
as shown in Figure 12.3. The most striking feature of this graph is its orderly
demonstration that the risk of having schizophrenia varies according to how many genes
an individual shares with someone who has the disorder. For example, you have the
identical (monozygotic) twin, a person who shares 100% of your genetic information.
e
Your risk drops to about 17% with a fraternal (dizygotic) twin, who shares about 50% of
ic
your genetic information. And having any relative with schizophrenia makes you more
st
likely to have the disorder than someone in the general population without such a relative
(about 1%). Because family studies can't separate genetic influence from the impact of
Ju
the environment, we use twin and adoption studies to help us evaluate the role of shared
undoubtedly a genetic disorder and the estimated inheritability rates range from 74 percent to as
in
high as 90 percent. And, the most important factors for the development of schizophrenia are
rim
transmitted through the genetics (p. 51-52). Subsequently, the genetic link is known and
The risk increases in comparative environments such as rural and urban areas.
“Researchers have found a positive correlation between rural birth, and living conditions and
20
lower rates of schizophrenia. In fact, a number of studies have demonstrated that psychotic
illness is more prevalent in urban settings than in rural areas. Why this potential connection
exists is unclear, but higher rate in urban areas may be due to environmental toxins, the social
context that people live in, and viruses or influenza, including prenatal infections. Where you are
born and brought up is a larger contributing factor to risk than genetic predisposition”
( Schizophrenia.com). If one looks at the predilection that is found—more in urban areas than
e
rural areas—for disease susceptibility and mental psychosis based on environmental causes, one
ic
can correlate schizophrenia to diet and environment that is evident genetically (biologically)
st
imposed on each succeeding generation. People who live in an environment replete with toxins,
inadequate diet, and a constant bombardment of social diseases, such as flu strains et al, coupled
Ju
with pregnancy weaknesses because of biological and environmental pressures, it stands to
reason that the resultant would be offspring that are biologically/genetically damaged. The
al
biological effects are and can be enhanced by the environmental influences, and both are
treatments are existent or forthwith for schizophrenia? Can proper diet assist the schizophrenic
rim
Diet
Bad or incorrect diet can be detrimental to the schizophrenic patient. In Shonda’s case,
her diet requirements will enter the regimen when she achieves the ability to learn correct
choices and how to incorporate these correct choices into her daily therapeutic program. It is
21
recommended that Shonda be assigned a Dietician to assist her with correct food and vitamin
choice selections. Some problems that schizophrenics incur can, and does, include diabetes and
blood sugar complications. Sugar problems exacerbated with drug and stimulant excesses, can
Blood sugar problems are exacerbated by excessive stimulant, drug use, (Leask, p. 325)
and diet.
e
“It is well known that diet affects a person's physical health and can lead to
ic
conditions such as diabetes and coronary heart disease. But can your diet affect your
st
mental health as well? An article in the British Journal of Psychiatry suggests that it does.
The most consistent correlation found in this study, was that increased consumption of
Ju
refined sugar results in an overall worse outcome for schizophrenia, as measured by both
the number of days spent in the hospital and poor social functioning”
al
(schizophrenia.com).
Excessive intake of sugar, refined carbohydrates, caffeine, alcohol and cigarettes, (Leask, p.
in
325,) as well as stimulant drugs, (such as amphetamines and cocaine) (nimh.nih.gov) all affect
rim
one’s ability to keep their blood sugar level balanced. Antipsychotic medication may also
complicate blood sugar level control. The incidence of blood sugar problems and diabetes is
much higher in those with schizophrenia. Excessive smoking is also linked to an increased risk.
C
Your daily intake of sugar, refined carbohydrates, nicotine, caffeine, and stimulant drugs
should be regulated by a psychiatrist and a dietician. “Previous studies have shown that insulin
resistance and diabetes as well as heart disease occur with greater frequency in people with
schizophrenia. Insulin resistance is increased by regularly high intake of sugar and saturated fats”
• Excessive oxidant intake and not enough antioxidants (Ester C is useful here as an
antioxidant)
Diet and substance usage must be considered in the patient’s diagnosis. And for the long
term prognosis, a dietary regimen should be prescribed according to mental and physical
e
condition, and overall patient system demand. This should be correlated with the results of the
ic
lab panels of the patient.
st
IV. Treatment Approaches
Medical Treatments:
Ju
Medical Approaches to Treatment
al
What types of medical approaches (ECT, prescription medications, psychosurgery) are
Treatment (s) begins with initial work-ups, (medscape.com) to rule out any conditions
rim
that may mimic schizophrenia, identify any comorbid conditions, and establish a baseline for
monitoring the treatment course and response to treatment. Medical examinations begin with
thorough physical and mental examinations. “The physical exam should include a thorough
C
neurologic exam, plus urine and serum screening for alcohol, other drugs that may be abused,
and level of antipsychotic medications if currently prescribed. In addition, such basic lab tests as
CBC; serum electrolytes; glucose, liver, renal, and thyroid function; and HIV and syphilis
testing” (medscape.com). The possible medical approaches to treatment include the following.
23
electroconvulsive therapy (ECT), that may be used when someone does not respond to
medication, Barlow and Durand (pg. 243). Used early in the 20th century, and subsequently
abused as a therapy, the treatment has since evolved into a safe and reasonably effective
treatment for severe cases that do not respond to medications, found useful in cases of severe
e
“While prescription of an antipsychotic medication for schizophrenia is the first
ic
step of treatment and for the resolution of an acute episode of psychosis, it is increasingly
st
recognized that comprehensive care requires the integration of adjunctive therapies and
directed at functional rehabilitation and improved quality of life” (Mahgerefteh, Pierre, &
rim
Medications such as antipsychotic are listed in Barlow and Durand (p. 429) Barlow and Durand
(p. 496) et al. See Appendix C for a table that describes many of these medications. Taken from
C
(uspharmacist.com).
medications a real breakthrough in the 1950s with the advent of drugs called neuroleptics,
(meaning “taking hold of the nerves”) and these drugs provided the first real help and hope for
24
patients diagnosed with schizophrenia. (p.495) However they go on to say that these drugs are
effective with some and not with others (Id). There are also intrusive therapies such as
psychosurgery (aka frontal lobotomy) that can be considered as a treatment for schizophrenia.
Although considered by many to be a barbaric procedure the operation is still used in some
e
introduced in the United States by Walter Freeman in 1936 were proposed as a way of
ic
isolating the diseased frontal lobe from the rest of the brain. Unfortunately, they lead to
st
emotional flatness, euphoria, and a lack of judgment. With the introduction of better
in medical refractory Parkinson disease, a treatment that has been associated with lasting
al
benefits in many patients (Krause et al, & Romito et al.). The precise mechanism of
effectiveness is not known, but it is likely that the stimulation leads to diminished
in
inhibitory outflow of the internal segment of the globus pallidus onto the motor thalamus,
rim
resulting in improvement in the motor symptoms of the disease. Is it possible that deep
patients face a lifetime in seclusion. I would not doubt that many would choose to take
C
the risks of surgery if one were available. Unfortunately, no procedures are available, but
Psychosurgery probably should be considered as a last resort treatment option. Other treatments
What are the effects these medications have on the brain chemistry or neurotransmitter
activity?
"Given the relative safety of most antipsychotic medications," the APA Guideline
recommends that the psychiatrist "begin treatment with an appropriate medication, even in states
where involuntary use of medication must be approved by a court, and perform the necessary
e
evaluations as they become possible" (medscape.com). Mayo Clinic in the article Schizophrenia
ic
by Mayo Clinic Staff explains the medical concept of antipsychotics used to control
st
schizophrenia.
given injections instead of taking a pill. Someone who is agitated may need to be calmed
in
initially with benzodiazapine such as lorazepam (Ativan), which may be combined with
rim
The drugs used to control schizophrenia can effectively block and regulate the production or
schizophrenia as neurotransmitters.
Contraindications
What, if any, side effects are associated with the medical treatments?
26
schizophrenia can be found in drugs such as cocaine, marijuana, and amphetamines. These
drugs may worsen the existing condition. Schizophrenia nimh.nih.gov also says:
with schizophrenia. They are addicted to nicotine at three times the rate of the general
e
The relationship between smoking and schizophrenia is complex. People with
ic
schizophrenia seem to be driven to smoke, and researchers are exploring whether there is
st
a biological basis for this need. In addition to its known health hazards, several studies
have found that smoking may make antipsychotic drugs less effective.
Ju
Quitting smoking may be very difficult for people with schizophrenia because
nicotine withdrawal may cause their psychotic symptoms to get worse for a while.
al
Quitting strategies that include nicotine replacement methods may be easier for patients
to handle. Doctors who treat people with schizophrenia should watch their patients'
in
“The most common side effects associated with conventional antipsychotics are
C
sedation, anticholinergic and antiadrenergic effects, and neurological side effects. Nearly
all patients experience sedation early in treatment with conventional antipsychotics, but
the symptom can often be managed by lowering the dose, consolidating divided doses
antiadrenergic side effects. In some cases, patients have mild and tolerable side effects
such as transient dry mouth, blurred vision, or constipation. More serious anticholinergic
side effects can include central anticholinergic toxicity leading to impaired cognition,
Promising Treatments
e
Which of these medical treatments are most successful according to research that has
ic
been conducted?
st
Aside from drugs, there are several treatments that show progress and promise. Among
recedes then a program like this can be integrated into the patient’s daily regimen. Psychosocial
al
treatments focus on social training skills, family therapy, vocational rehabilitation and obtaining
gainful employment. And this therapy includes teaching the patient how to cope with the stress
in
related problems, and how to collectively manage their illness. Williamson offers the following
rim
under the chapter subtitle: Is There Any Reason to Be Hopeful: (p. 180)
“Over the last 50 years, the only option in the treatment of schizophrenia has been
drugs that block D2 receptors. As models of schizophrenia have developed, some other
C
possibilities have started to emerge. The early attempts to find drugs that decrease
disappointing, but there are now some other approaches targeting glutamate, GABA, and
other neurotransmitters. Of these, drugs that affect the glycine receptor and lamotrigine
look promising, but many more are in development (Miyamoto et al,). One of the
28
limitations of the glutamatergic drugs is that ionotropic receptors are ubiquitous in the
brain. Metabotropic receptors may be more regionally specific but we do not as yet know
Probably the most hopeful sign in treatment is that we are now starting to think
about ways of preventing deterioration in patients, not just providing acute treatment of
their symptoms. Many of the drugs already available such as lamotrigine have the
e
potential to prevent deterioration by virtue of their neuroprotective properties. However,
ic
long-term studies are required to demonstrate these benefits. This research is not
st
something that the drug companies are eager to do, but it is essential if we hope to change
Common Treatments
and treatment interventions that are intended to provide knowledge and teach skills and
C
behaviors for "living in the world," This includes work and social skills, education about
the disease, medications, symptom management, and relapse prevention. The notion that
patients with schizophrenia can significantly improve their level of functioning is crucial
program after being discharged from a state hospital in the late 1950s showed that, 30
years later, those who had been in the rehabilitation program had far fewer symptoms of
schizophrenia, had a greater percentage in the workforce, and had better community
With this in mind, it will benefit the patient, in this case Shonda, to participate in
psychosocial therapeutic programs as necessary. The schizophrenic patient will need several
e
psychosocial skill sets to basically survive with their disease in a real world setting. Also, the
ic
caretakers whether they are immediate family, or others, also need training on how to facilitate
st
that care for their loved one or patient. Schizophrenia is not an easy disease to comprehend or
treat without specific skills. The following list the major psychosocial treatment programs as
This usually focuses on helping people with schizophrenia to find and then keep jobs.
rim
3. Family interventions.
The education of the family in how to support the individual afflicted with schizophrenia.
4. Individual therapy.
C
This will instruct the person with schizophrenia how to cope with their illness and how to
The most effective of these psychosocial treatments can be realized in the rehabilitation
sector of this treatment regimen. Schizophrenia patients must learn how to function within
society while learning how to cope with their disease. Social skills such as shopping at a store,
initiating conversations in general, making friends, finding and then keeping a job are all
necessary for the schizophrenic patient if they are going to function outside of a medical care
facility. Coupled with their medicines, the patient must learn how to adapt to social settings
e
while living with their disorder. They must learn self-help skills such as personal hygiene,
ic
money management, and proper nutrition. The most effective treatments as previously
st
mentioned by Csernansky were those who followed a “rehabilitation program after being
discharged from a state hospital in the late 1950s showed that, 30 years later, those who had been
Ju
in the rehabilitation program had far fewer symptoms of schizophrenia, had a greater percentage
in the workforce, and had better community adjustment.” The rehabilitation program (s) with the
al
medication applications can be effective in schizophrenia management.
in
rim
will continue to take the neuroleptic haloperidol (Haldol) because of her increase in auditory
hallucinations and other conditions that she exhibits. Shonda will be reassessed by the
psychiatric team, in accordance with her treatment plan, to see if she will continue to take this
dosage that will allow Shonda more functionality. Shonda will be placed into a psychosocial
31
management program that will allow her to once again return to the work force. Shonda as of
late has been unable to function at her job. Once the delusions and auditory hallucinations are
Turkington (1991), patients vary in the degree to which they want an explanation for the
e
occurrence of their voices. Some patients explain the voices as a function of having
ic
schizophrenia. As part of the early psychoeducation process, patients are socialized to the
st
stress-vulnerability view of psychosis and hallucinatory activity, in particular. As such,
experiences), and social (e.g., isolation and marginalization) variables that make sense to
al
the patient in terms of comprehension and experience…The provision of
evidence to fuel alternative explanations of the voices, which will be the key component
rim
The patient Shonda, using psychoeducation and normalization techniques, will learn how
C
to divert attention away from hearing the voices. Shonda will be encouraged to watch TV, listen
to music, make conversations, read, and perhaps play a video game. Shonda will be encouraged
to engage in effortful activities such as playing sports, working out at a health spa, going for a
walk or jog. These activities can become diversions to voices and act as a suppression or
suppressors. Many cases of voice noise acceleration occur during anxious arousal moments, so
32
Shonda will be encouraged through therapy to utilize relaxation methods, and meditation
techniques.
With the modern treatment medications and therapies, Shonda’s prognosis is positive.
Shonda has already functioned at a job in the past and has had her own apartment. Shonda will
be encouraged to be retrained as needed because of her relapse and once again she will occupy
her own apartment and have a job. Because Shonda’s schizophrenia is complicated with
e
paranoia, the therapist must gain her trust. With the right therapy and therapist team, Shonda
ic
should show improvement if the sessions are coupled with good communications, positive
st
reinforcement, a warm working relationship between Shonda and the therapy team. Because of
her paranoid suspicions, Shonda will need reassurance that everyone on the therapy team is on
her side.
Ju
al
in
V. Conclusion
rim
disorder. The family inheritance rate varies, but is significantly higher than the general
populace. Environmental contributions such as drug and alcohol use (and abuse) are also
C
contributing factors. The geography of birth, urbanization, and influenzas transferred to the fetus
can impact the predisposed recipient also. This seems to affect those living in an urban setting
more so when compared to those who live in rural areas. The lack of prenatal care, diet, famine
and stresses all complicate and are participatory in generating weaknesses in the predisposed for
the schizophrenic disorder. However, the genes are the ultimate environmental influence
33
because they affect both the internal and external environment profoundly. Nonetheless, current
treatment plans are having an effect on schizophrenia and this can be seen in positive
Psychological Models
e
disorder—schizophrenia are found in psychodynamic, behavioral, humanistic, cognitive and
ic
biological models. Which psychological model (s) affords the best treatment and control
st
regimens for the paranoid schizophrenic patient? The Psychodynamic approach and treatment
with its origin in the psychoanalysis of Dr. Sigmund Freud, is still practiced by psychotherapists
Ju
in larger cities (Barlow & Durand, p. 23), the insurance companies have reduced the therapy
sessions to around 25 per year, most courses of therapy only last fewer than 10 sessions (Kring,
al
Davison, Neale, & Johnson, p. 45-46). This treatment is based on the three parts as defined by
Freud, The Id, Ego, and Superego. Freud believed that people are “stuck” in any one of these
in
stages and have not progressed beyond that particular stage. Would this therapy prove beneficial
rim
to the schizophrenia disorder? As a therapy that involves talking and listening, it could be useful
in conjunction with medication during initial case presentation and discovery of patient’s
Behavioral models are based on operant conditioning by Pavlov, Watson, and B.F.
psychiatrist about medication side effects requires psychosocial skills that many patients
are lacking. Some patients had the skills before they became ill, others never really had
34
them. How does one train patients in the use of such skills? If you are a behaviorist, you
would use behavioral principals such as reinforcing desired behaviors and ignoring non-
The response solicited and used in operant conditioning behaviorism was a reward based system.
To reinforce the desired behavior patients were rewarded for correct actions and responses. “In
social skills training, a particular group of skills is selected; these could include skills necessary
e
for managing symptoms, for community re-entry, or for starting and maintaining conversations.
ic
The trainers use a range of techniques, including teaching, demonstrating the desired behavior,
st
coaching the patient during role-plays of desired behavior, giving strong verbal encouragement,
and assigning homework” (Id, p. 139). Would this therapeutic approach be one that would assist
Ju
and improve the patient with schizophrenia? Yes it would!
Humanistic approaches offer an approach that seeks the good and potential of every
al
individual. The Humanistic Theory posits:
“Jung and Adler broke sharply with Freud. Their Fundamental disagreement concerned
in
the very nature of humanity. Freud portrayed life as a battleground where we are
rim
continually in danger of being overwhelmed by our darkest forces. Jung and Adler, by
contrast, emphasized the positive, optimistic side of human nature. Jung talked about
setting goals, looking toward the future, and realizing one's fullest potential… The
C
underlying assumption is that all of us could reach our highest potential, in all areas of
functioning, if only we had the freedom to grow. Inevitably, a variety of conditions may
block our actualization. Because every person is basically good and whole, most blocks
Can this positive approach find usefulness in schizophrenia therapy? Yes because, the
patient already has problems with their disorder that separates them from the general population
and they usually have problems with confidence (self) and self-assurance. Making the patient
see their potential, orienting them to something that accentuates the positive, followed by giving
them the training and freedom to grow and improve is essential for their overall wellbeing.
Other possible models are cognitive and biological. Cognitive behavior therapy for
e
schizophrenia uses a psychotherapeutic approach to treat the symptoms of schizophrenia. The
ic
cognitive approach has the patient alter their beliefs, views, and assumptions and to shift their
st
views about their symptoms (Green p. 136). This treatment model compliments other models of
treatment.
Ju
“Although medications are crucial in the management of schizophrenia, many
people with the disorder are not compliant with taking the medications, and even if they
al
are compliant, over 50% of people with schizophrenia will continue to have distressing
symptoms. Thus, complementary and additional treatments are needed. Cognitive and
in
disorders, OCD, insomnia, phobias, and other disorders. Cognitive Therapy has also been
symptoms. Outcome studies suggest that patients who receive CT have fewer and less
C
intense hallucinations and delusions, and recover their functioning to a greater extent than
This treatment regimen shows effectiveness in schizophrenia management by patients using this
therapy model.
36
The model (s) of choice for Shonda would be found in the behavioral, humanistic, and
cognitive models. Because Shonda needs to continue her medications she will also need to learn
or relearn some behavioral concepts. And Shonda needs positive reinforcement, so humanistic
treatment would also be conducive to her treatment regimen. For Shonda, one model exclusively
would not achieve the best results. Therefore a composite of therapy models would produce the
e
best results. Cognitive therapy would prove beneficial to Shonda. She would learn how to
ic
ameliorate her condition, be able to foresee a relapse before it comes. And before she becomes
st
incapable of doing her job or taking care of herself again, Shonda will have the knowledge and
experience to handle this problem, whereas in the past, she did not. She would learn how to
Ju
better control her symptoms pre-relapse and recognize any signs of emergent onset. The
biological model would be inappropriate for Shonda as she has had little contact with her sibling
al
and her parents were aloof from her during upbringing. Her history already reveals a biological
Schizophrenia’s Future
by a number of different risk factors. While substantial efforts have been made to identify
C
the underlying susceptibility alleles over the past 2 decades, they have been of only
limited success. Each year, the field is enriched with nearly 150 additional genetic
association studies, each of which either proposes or refutes the existence of certain
highlight not only over 20 different potential schizophrenia genes, many of which
represent the ‘‘usual suspects’’ (e.g. various dopamine receptors and neuregulin 1), but
also several that were never meta-analyzed previously… Eventually, only the concerted
efforts of genetics, genomics, proteomics and clinical disciplines will give rise to new
diagnostic and therapeutic targets that, hopefully in the not too distant future, will benefit
e
the millions of patients afflicted with this debilitating disorder.” (Bertram, p. 806 & 811).
ic
The future for people with schizophrenia continues to improve. Research studies are
st
advancing. Medical advancements will continue to produce medications that will help control
the symptoms of schizophrenia. Although there is no cure, treatments that work well are and will
Ju
continue to be available. The science of neurotransmitter function is advancing every year. At
the onset of understanding this disorder, there was little that could be done. Now however,
al
treatment regimens are replete and patients are receiving adequate treatment for their disorder
with medications and therapies. Today many people with schizophrenia are improving enough
in
to lead independent, comfortable lives. They are able to work and live in their own homes
rim
whereas, in times past they would likely end up in a mental care facility for the rest of their lives.
Shonda’s Future
C
Shona’s future is optimistically bright but contingent on her treatment regimen and
response to this program. With the newer models and modalities of treatment programs
available today, Shonda can function very well in society. However, her assessment should
determine employment options accordingly. She should be advanced slowly and encouraged to
learn more and do more on the job and for herself as well. If Shonda utilizes the
38
psychoeducation and normalization treatments, she can really improve because these therapies
will offer an alternative to her symptoms and a distraction that she will find to be positive and
enjoyable. Based on what has been covered and discovered in this project, Shonda has a bright
Final Thoughts
e
Evidence abounds that connects schizophrenia to families predisposed genetically to this
ic
disorder. The family inheritance rate varies, but is significantly higher than the general
st
populace. Environmental contributions such as drug and alcohol use (and abuse) are also
contributing factors. The geography of birth, urbanization, and influenzas transferred to the fetus
Ju
can impact the predisposed recipient also. This seems to affect those living in an urban setting
more so when compared to those who live in rural areas. The lack of prenatal care, correct diet,
al
famine and stresses all complicate and are participatory in generating weaknesses in the
predisposed for the schizophrenic disorder. However, the genes are the ultimate environmental
in
influence because they affect both the internal and external environment profoundly.
rim
Nonetheless, current treatment plans are having an effect on schizophrenia and this can be seen
References
APA guideline for treating adults with schizophrenia: Treatment strategy in the acute phase.
http://www.medscape.com/viewarticle/431253_3
Barlow, David H. & Durand, V. Mark Abnormal psychology an integrative approach (2nd ed.,
Barlow, David H. & Durand, V. Mark Abnormal psychology: Media edition (2nd ed., Vol. 1).
e
Belmont, CA, USA : Wadsworth/Thomson Learning
ic
Barlow, David H., Durand, V. Mark, Essentials of abnormal psychology. Centage Learning:
st
Mason, OH
Beck, A.T., Rector, Neal A., Stolar, Neal M., Grant, Paul M. Schizophrenia:
Ju
Cognitivetheory, research and therapy. New York, NY: Guilford Press
Bertram, Lars, Genetic research in schizophrenia: New tools and future perspectives
al
http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/sbn079
Csernansky, John G., (1st ed.) Schizophrenia: A new guide for clinicians. NY: Marcel
in
Dekker, Inc.
rim
Country and Rural life (vs. city living) before age 15 is associated with lower rates of
schizophrenia http://www.schizophrenia.com/prevention/country.html
http://www.schizophrenia.com/sznews/archives/002546.html
Green, Michael F., Ph.D., Schizophrenia revealed: From neurons to social interactions. New
Kring, Ann M., Davison, Gerald C., Neale, John M., & Johnson, Sheri L., Abnormal psychology
Leask, Stuart J., Environmental influences in schizophrenia: The known and the unknown
http://apt.rcpsych.org/cgi/reprint/10/5/323.pdf
http://www.academyofct.org/Library/InfoManage/Guide.asp?FolderID=1097&SessionID
e
Magnavita, Jeffrey J., Etiology, theory, psychopathology, and assessment
ic
http://media.wiley.com/product_data/excerpt/62/04712011/0471201162.pdf
st
Mahgerefteh, Shirly., Pierre, Joseph M., MD, and Wirshing, Donna A., MD Treatment
Neurotransmitters: Testing/Treating
al
http://www.nhnatural.com/services/neurotransmitterbalance.html
Picker, Jonathan, Ph.D. The role of genetic and environmental factors in the development of
in
schizophrenia.
rim
http://www.psychiatrictimes.com/display/article/10168/52516?pageNumber=3
http://www.schizophrenia.com/disease.htm
http://www.nimh.nih.gov/health/publications/schizophrenia/
Williamson, Peter, Mind, brain, and schizophrenia. New York, NY: Oxford University Press
Web Pro 5.52 World Net Database. Princeton University. Installed Software Program
e
ic
st
Ju
al
in
rim
C
42
Appendix A
e
ic
st
Ju
al
Figure 4.4 This computer graphic of a synapse shows the release of neurotransmitters (pink
spheres at lower center) by vesicles inside the synaptic knob (upper center). The
in
neurotransmitters will cross the gap and bond to the receptors of the adjacent cell, which is how
rim
information is transmitted along the nervous system. © Alfred Pasieka/Photo Researchers, Inc.
C
43
e
ic
st
Ju
Figure 4.1 The Image Source is: Laboratory of Neuro Imaging, UCLA, Derived from
high-resolution magnetic resonance images (MRI scans), the above images were created after
repeatedly scanning 12 schizophrenia subjects over five years, and comparing them with
al
matched 12 healthy controls, scanned at the same ages and intervals. Severe loss of gray matter
in
is indicated by red and pink colors, while stable regions are in blue. STG denotes the superior
temporal gyrus, and DLPFC denotes the dorsolateral prefrontal cortex. Note: This study was of
rim
Childhood onset schizophrenia which occurs in 1 of every 40,000 people and is frequently a
significantly more aggressive form of schizophrenia (than later onset schizophrenia which
C
e
ic
st
Ju
al
in
rim
Cephalosporins Cimetidine
Corticosteroids Ethambutol
45
Cycloserine 5-Flucytosine
Ethosuximide Isoniazid
Methylphenidate Phenytoin
Theophylline Vincristine
e
Aminoglycosides Sympathomimetics
ic
Beta-blockers Tocainide
st
Bumetanide Trimethoprim
Cyclobenzaprine Vinblastine
Gancyclovir
Ju Zidovudine (AZT)
Hydralazine
al
Lidocaine
in
rim
C
C
rim
in
Appendix B
al
Ju
st
ic
e
46