Schizophrenia: A Review

This paper will undertake a general overview of the psychiatric disorder known as schizophrenia. It will be organized into the following seven sections. The second section will provide a general background for the pathology. Section three will review the diagnostic criteria for the disorder and related issues. Section four will examine the disorder's etiology. Section five will review the issues related to the onset of the disorder, including age and initial features. Section six will review treatments and the method of application. Section seven will discuss prognosis and related factors.

Background

Schizophrenia can be defined as a mental illness characterized by a number of different symptoms. It's said to affect about one percent of the population world-wide. Gejman, Sanders, & Duan (2010) report that US median lifetime prevalence is 4.0 per 1,000. The authors also report that the age at onset is usually during either adolescence or young adulthood. The onset of the disease during either early childhood or above the age of fifty is very rare. Schizophrenia prevalence follows similar patterns in males and females. However, the disturbance is noted to be more severe in males than in females. That is, males have higher rates of mortality than females. The main causes of mortality include suicide and cardiovascular failure (Gejman, Sanders, & Duan 2010). Schizophrenia symptoms are discussed in more detail in the next section.

Diagnostic Criteria

A diagnosis of schizophrenia is rendered based on a number of criteria. First, psychotic symptoms need to be present in an active phase based on one of three factors for a period of at least one week. The first of these factors includes several characteristics. These characteristics include delusions. There are also vivid hallucinations, which may be prominent throughout the day for a period of a week. The patient's hallucinatory event lasts for longer than a few brief moments. The patient demonstrates verbal incoherence or a significant loosening of associations. By loosening of associations is meant the individual's speech patterns display no logical unity of thought. The individual demonstrates a state of catatonia. This state can be characterized as a psychomotor disturbance involving stupor, meaningless excitability, and posturing in a manner that is bizarre or inappropriate. An effect of personality, which can be described as flat or highly inappropriate. An effect of personality means the individual displays no marked emotional response where it is appropriate to do so.

The second of three factors involves the individual experiencing bizarre delusions. An example of such delusions includes claims of being controlled by a deceased person or telepathy (Bentall 1990). Individuals with such an affliction may also make other bizarre and culturally inappropriate claims.

The third, and final factor, involves hallucinations manifest in a pronounced manner. These hallucinations include hearing voices in conversation with one another. It may also include hearing a voice that is commenting constantly on the individual's behavior or thinking (Bentall 1990). To review, a positive diagnosis is rendered if the individual exhibits one of the three factors noted above.

In addition, as the psychotic episode progresses, negative changes occur. These changes are evident in the individual's performance in such areas as work, school, personal relationships, and personal hygiene (Bentall 1990). However, when the disturbance occurs during adolescence, it may be characterized by a failure to achieve an appropriate level of personal development.

Also, in order to render a diagnosis, alternative explanations for the individual's behavior have been ruled out. These alternatives may include such psychotic disorders as schizoaffective disorder or a mood disorder with psychotic characteristics.

Finally, the psychotic disturbance lasts continuously for a period of six months or greater. This period of disturbance requires an active phase be present. This phase would be for a period of at least a week. If the individuals' symptoms were treated successfully, then the diagnosis would involve characteristic symptoms, as described above. The symptoms may be present coincident with prodromal or residual phases. It should be noted that a prodromal phase occurs prior to the onset of the active phase of the psychotic disturbance (Bentall 1990). It's important that the use of controlled substances also be ruled out as a factor in the changing mood. A residual phase occurs following the period of an active disturbance.

In addition, two or more symptoms are required for diagnosis during prodromal or residual phases. The symptoms are noted below (Bentell 1990):

1. The individual exhibits very noticeable social withdrawal or isolation

2. The individual's ability to normally function at work, school, student or parent becomes noticeably impaired.

3. Individual exhibits peculiar behavior (examples of which include garbage collecting, conversing with oneself publicly, or food hoarding).

4. Personal hygiene and grooming declines considerably

5. Affect becomes flat, blunt or inappropriate

6. Speech becomes overly elaborate, digressive or nonsensical.

7. Individual expresses beliefs in odd ideas (examples include people feeling each other's feelings, telepathy, seeing into the future, magical beliefs).

8. Recurring odd perceptual experiences (examples include feeling the presence of an individual not present).

9. The individual's motivation, energy level and personal interests decline markedly

Etiology

Etiology refers to the causal factors involved in the disease. Schizophrenia is classified as one of number of number of psychopathologies that have been identified as complex genetic disorders (Gejman, Sanders, & Duan 2010). Nevertheless, there remains an ongoing discussion regarding the role of genetics or environment in the etiology of schizophrenia. There tends to be broad agreement that some interaction between these two factors is implicated. Gejman, Sanders, & Duan (2010) report that the disease's biological complexity is greater than researchers anticipated. They also report that additional research regarding the disease's molecular mechanisms is needed. The view that schizophrenia's genetic causation could be explained by means of a small number of major gene changes has not been supported by empirical tests. Still some research in both twin and adoption studies suggests that schizophrenia is heritable. Twin studies have yielded evidence of concordance in twins affected by the disorder (Gejman, Sanders, & Duan 2010). While adoption studies have yielded evidence that non-affected children, adopted by a schizophrenic foster parent, do not develop schizophrenia. These studies seem to further narrow down the causation to more likely genetic causes. Similarly, the disease is known to manifest itself during adolescence, when human physical and social development is still occurring. This seems to indicate that errors in brain development become apparent during these critical years (Gogtay, Vyas, Testa, Wood, & Pantelis 2013). Gejman, Sanders, & Duan (2010) report that head injuries, occurring during pregnancy or after birth, may be environmentally related risk factors. In sum, schizophrenia etiology remains a mix of genetic and environmental causal factors that interact in pertinent ways.

Treatment

Schizophrenia is treated with a combination of anti-psychotic medication and psychosocial rehabilitation. The anti-psychotic medication functions by changing the balance of certain brain chemicals called neurotransmitters (Knott & Kenny, 2013). These medicines perform best when reducing the effects of positive, rather than negative symptoms, of the pathology. They are also used to treat relapses and are usually taken for long periods of time. There are basically two types of such medication which are administered depending on the conditions particular to the patient. The first type of medication are the atypical anti-psychotic drugs (Knott & Kenny, 2013). They can also be called the newer or second-generation drugs. These medications are reserved mainly for first-time patients. Examples of such drugs include amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole. These medicines offer a good level efficacy with fewer side effects. The second type of medication are the first-generation anti-psychotics. These drugs are well-established in anti-psychotic treatment and examples include chlorpromazine, trifluoperazine, haloperidol, flupentixol, zuclopenthixol and sulpiride.

Anti-psychotic medication can be administered by means of an injection. This method is used to deliver medication that has a long-lasting and time release dose effect (Knott & Kenny, 2013). It's slowly absorbed by the body and can be administered once or twice per month. However, anti-psychotic medication is usually given in tablet form with water taking by the patient with a prescription. One concern with this approach is that patients may voluntarily chose to stop taking their medication. Whereas the injectable delivery allows verification that the treatment regimen is being observed.

Side effects are commonly discussed as part of the treatment regimen. It should be noted that individuals may experience side effects with certain medications and not others. Treatment has to strike the right balance between consideration for side effects and treatment. Some examples of side effects include dry mouth, blurring, flushing, constipation, drowsiness, and weight gain (Knott & Kenny, 2013). In addition, some movement disorders have been associated with treatment including parkinsonism, Akathisia or restlessness in legs, Dystonia or abnormal facial and body movements, and a condition called Tardive dyskinesia.

The psychosocial rehabilitation involves the use of cognitive behavior therapy (CBT). CBT is a type of psychotherapy that is used to treat patients experiencing anxiety and mood disorders. It is contrasted with other types of mental health intervention. That is, CBT is focused around patient involvement and participation in reaching a resolution to the causes of the mood or anxiety disorder. It's also contrasted with other therapies in that it's much more goal-oriented in its approach to problem resolution. CBT can be used to teach patients important skills that can be used long after the therapy has ended. CBT is designed to confront distortions in thinking patterns, modify self-destructive belief systems, relate to individuals in their lives in more fulfilling ways, and transform debilitating behaviors ("What is," n.d.).

Prognosis

Schizophrenia has an unfortunate long-term prognosis. According to Jobe & Harrow (2010), the treatment outcomes have been characterized as having poor long-term results. It's noted that existing treatment produces improvements that are limited in effect. At the same time, some patients experience full recovery from symptoms for certain periods of time. A review of the literature has produced some positive and some negative outcome and recovery features (Jobe, Thomas H. & Martin Harrow 2010). These features will be reviewed below.

A number of longitudinal research studies have found disappointing treatment results. Jobe & Harrow (2010) report that even with modern treatment methods, schizophrenia patients experience poorer outcomes than patients afflicted with other types of psychotic and non-psychotic conditions. One common characteristic of the early phases of the disease, during its first ten to fifteen years, is that psychopathology recurs for many patients (Jobe, Thomas H. & Martin Harrow 2010). Most schizophrenia patients remain vulnerable to recurrence of the disorder's positive symptoms (such as disorganized speech) and negative symptoms (such as flat affect, poverty of speech, and reduced motor function). Also, functional impairment is more persistent over time than with other disorders. This impairment extends to the ability to retain gainful employment and maintain stable social relationships.

However, there is some promising information to report as well. An estimated 40 percent of patients undergoing treatment will experience at least one period of global recovery (Jobe, Thomas H. & Martin Harrow 2010). Global recovery is defined as a recovery period lasting at least one year. The patient is in recovery if they have not experienced any of the associated symptoms, avoided hospitalization due to psychiatric related treatment, is at least adequately socialized, and has returned to gainful employment for at least half-time. Still recovery can best be conceptualized as having intermittent periods, rather than as one single conclusive and easily definable event (Jobe, Thomas H. & Martin Harrow 2010). However, each patient is different and factors influencing recovery are very individualized. Nevertheless, intermittent recovery may last for at least as long as a decade.

Some schizophrenia patients are more resilient than others. Jobe & Harrow (2010) argue that poor recovery outcomes are due to certain factors inherent to the sufferers of the disease. In the main, schizophrenia patients suffer from a susceptibility to psychosis, negative symptoms, and deficient outcomes that has a biological basis. Also, disease susceptibility is exacerbated by an array of both inherent and environmental risk factors. These factors include a heightened anxiety vulnerability, an external locus of control, and low self-esteem (Jobe, Thomas H. & Martin Harrow 2010). In the afflicted individual, these factors work in concert with other negative biases (such as misreading intentions) to significantly increase the likelihood of an overt expression of the psychosis.

The locus of control is the extent to which an individual perceives their personal success or failure is due to their own initiative taking (Bonnett & Furnham 1991). Thus, an individual with an internal locus of control believes that studying for an exam will produce good grades. In turn, if the individual achieves good grades, he or she will attain a strong chance of graduation. An individual with an external locus of control believes that no action they could perform will change their circumstances to any worthwhile degree.

One other aspect of schizophrenia treatment prognosis is worth reviewing. According to studies reported by Jobe & Harrow (2010), there is evidence of a sub-population of schizophrenia patients who respond to treatment and then are taken off anti-psychotic medication. This cohort is believed to comprise about 20 percent to 35 percent of patients in treatment. Patients of this type have been followed in longitudinal studies for a number of years to confirm their ability to function without medication. Bentall (1990) similarly notes, that not all schizophrenia patients should be on anti-psychotic medication, owing to the side effects. While at the same, the majority of patients likely should remain on treatment for as long as needed.

References

Bentall, Richard. (1990). Preface. In Reconstructing Schizophrenia, ed. Richard Bentall. New York, NY: Routledge.

Bonnett C. & Furnham A. (1991). Who wants to be an entrepreneur? A study of adolescents interested in a Young Enterprise scheme. Journal of Economic Psychology, 12, 465-478.

Gejman, P.V., A.R. Sanders, & J. Duan. (2010, Mar.). The role of genetics in the etiology of schizophrenia. Psychiatr Clin North Am, 33(1), 35-66.

Gogtay, Nitin, Nora S. Vyas, Renee Testa, Stephen J. Wood, & Christos Pantelis. (2013, Nov.). Age of onset of schizophrenia: Perspectives from structural neuroimaging studies. Schizophrenia Bulletin, 39(6), 504-513.

Jobe, Thomas H. & Martin Harrow. (2010). Schizophrenia course, long-term outcome, recovery, and prognosis. Current Directions in Psychological Science, 19(4), 220-225.

Knott, Laurence & Tim Kenny. (2013, May). Schizophrenia. Patient.co.uk. Retrieved from http://www.patient.co.uk/health/schizophrenia-leaflet.

What is CBT? (n.d.). Beckinstitute.org. Retrieved from http://www.beckinstitute.org/cognitive-behavioral-therapy.