Abnormal Psychology: Case Study

The Case

Shonda has a 12 year history diagnosis of continuous schizophrenia paranoid type. Shonda is constantly preoccupied with delusions and frequent auditory hallucinations. Shonda is under the occasional supervision of a caseworker from a local community health center. Shonda lives alone and rarely sees family members. While growing up Shonda heard that an aunt suffered a nervous breakdown but other than that her immediate family shows no sign of mental illness. Shonda’s medication and treatment has been reassessed multiple times due to the frequency of hospitalization and number of different complaints which include auditory hallucinations and many other delusions.

Shonda’s suffers from a pattern of confused speech often lacking orderly continuity. After interviewing Shonda for a period of more than an hour, her caseworker reports Shonda’s paranoia has her convinced that she is under the surveillance of the FBI and CIA. This topic of conversation encourages further agitation by Shonda. Shonda has attempted to hide from audio hallucinations as well without success.

Shonda has been hospitalized for many years and due to her recent escalation of symptoms she will be recommended for reassessment and an increase in antipsychotic medication.

Durand (2007, p. 471) defines Schizophrenia as, “Devastating psychotic disorder that may involve characteristic disturbances in thinking (delusions), perception (hallucinations), speech, emotions and behavior.” Well, it is certain that schizophrenia is a curious disorder marred with a mixture of signs and symptoms. Schizophrenia is complex and fastidious to diagnose due to the different types, symptoms, cognitive and emotional dysfunctions, and the etiology (how the disorder originates.) The complexity of the disorder combined with the mixture of signs and symptoms, which may or may not be present, makes schizophrenia difficult to understand. At some point of the disorder there is a psychotic phase. The psychotic phase must persist for at least one month. The disorder is presented by delusions, hallucinations, disorganized speech and behavior during the psychotic phase. Schizophrenia is usually found to present itself in early adulthood, with some exceptions of adolescence. (Schizophrenia Symptoms, 2009)

The complexity of schizophrenia is further exacerbated by the complications exhibited by individuals suffering from the disorder. The mood abnormalities such as significant loss of impetus to continue with pleasurable activities, depression, anxiety, and anger, all contribute to the patience’s lack of awareness or concern they are suffering from a psychotic illness. Without an understanding or a belief of illness, the patient is much more likely to avoid therapy. (Symptoms and Treatment, 2009).

Withstanding over 100 years of classifying psychotic disorders into specific forms, and the fact that psychotic disorders have been recognized throughout history, it is quite an accomplishment that a definition by a German psychiatrist, Emil Kraepelin, who originally termed schizophrenia as “dementia praecox” due to its chronic, rapid cognitive disintegration, still stands. The name, “schizophrenia” was later defined by Kraepelin and a team of psychiatrists. It was Eugen Bleuler who suggested renaming it to “schizophrenia” due to the “fragmented mind” characteristic of the disorder. Kraepelin attempted to identify the multiplicity of symptoms (catatonia, hebephrenia, and paranoia) and further suggested that the term “dementia praecox” should be superseded and that schizophrenia should be recognized as a “group” of disorders for which a fragmentation of associations were the foundation of the symptoms. Kurt Schneider followed Bleuler’s interest in identifying and classifying the fundamental feature of the disorder. And so, he developed “The Schneiderian System” of finding the correlations, or commonalities of patients’ symptoms. Schneider developed a set of “First Rank Symptoms” specific to diagnosis of schizophrenia’s psychotic phase. Again, the complexity of the disorder to this day and in the future will continue to divide clinicians’ diagnosis until specificities of schizophrenia’s pathophysiology and etiology are clearly uncovered and defined. (How was schizophrenia discovered?, 2005)

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard used by mental health professionals in the United States to classify mental disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), was published in 2004 and was the last major revision of the DSM. According to the DSM-IV, schizophrenia is classified as a mental disorder. There are several subtypes of schizophrenia, but because of the usefulness to the DSM-IV, schizophrenia remains divided into three (aforementioned) major subtypes: paranoid (delusions of grandeur or persecution), disorganized (or hebephrenic; silly and immature emotionality), and catatonic (alternate immobility and exited agitation). There are two additional schizophrenia subtypes; undifferential and residual types. These two subtypes are the catch-all for which essentially all of the other disorders which symptoms are present but do not fully met the criteria of the three major subtypes. (Durand, 2007)

There are many studies and infinite archives on the topic of schizophrenia. It is yet a great conundrum to the brightest scientists, sociologist, pathopsychologists, and psychiatrists. Many studies link marijuana and other drugs to schizophrenia. Other studies link a genetic mutation (22q11) which hinders communication between the hippocampus and the prefrontal cortex to schizophrenia. Similar genetic studies reveal “undetectable genetic variations” lead to schizophrenia. The National Institute of Mental Health conducts a wide range of studies, one of which examined the effects of D-cycloserine augmentation on cognitive remediation for patients diagnosed with schizophrenia. Many institutes have focused on two studies on schizophrenia and motion perception and the propensity to develop schizophrenia in individuals who have difficulties tracking moving objects. The Genome News Network (2001) suggested that certain individuals with two copies of the dopamine D3 receptor gene (DRD3) scored significantly low on visual exams. Many epidemiological studies have observed an association between obstetric complications during intrauterine life and schizophrenia. Quite often the studies that include medication produce as many or more questions than the number of answers. There continues to be countless “new studies” suggesting new theories and hypothesis on the topic of schizophrenia. (Clinical Trials, Schizophrenia, Featured Studies, 2010)

Case Study, presented Shonda, a patient diagnosed with continuous paranoid schizophrenia. The case study provided an intimate and detailed perspective into the life of someone with mental illness and the people with whom they might associate. Shonda’s description which included her family history and current familial relationships provided a typical expectation for someone diagnosed with schizophrenia based what I have learned about the background, DSM-IV criteria, and the research that has been conducted on schizophrenia. After all of my research and reading, I feel that this could be a hypothetical case study while it could very well be quite legitimately a real-life case study.

There are neurotransmitters linked to schizophrenia. Both norepinephrine and dopamine appear to be involved with schizophrenia. Dopamine receptors are thought to mediate both the transient neurotransmitter functions as well as the neuromodulatory effects that alter cell metabolism. It is suggested that dopamine controls the metabolism of the cell, or in other words, dopamine affects the rate of synthesis of the neurotransmitter. Endorphins serve as neurotransmitters which modulate the release of dopamine by acting as presynaptic receptors. The best results in treating schizophrenia come from drugs that primarily block dopamine receptors. This further suggests that schizophrenics have “too many” receptors. As it has often been said about the human body preferring a state of homeostasis, so too do receptors and transmitters. When the sequence of release and reception amongst transmitters and receivers is upset, a disease state such as schizophrenia may occur. Human behavior is greatly influenced and the outcome is altered thought patterns, hallucinations, agitation, delusions, and social withdrawal.

The medical approaches to schizophrenia usually include hospitalization, psychotherapy, counseling, and drug treatment. I suspected that psychotherapy may have been the most common treatment for schizophrenics. From my research it seems that chemotherapy has also been used quite a bit to treat schizophrenics. Individual and family therapy seems to prove helpful in reducing relapse. Family therapy is also suggested to be helpful in order to assist the relatives with coping as well as educate. Becoming involved in community programs provides beneficial support, encourages proper social skills and vocational rehabilitation. Hospitalization is often preferred to ensure that the affected individual will receive the bare necessities; food, a place to sleep, and hygiene. Drug treatment usually prescribes the antipsychotic drugs risperidone, olanzapine, and closapine. There are many other psychopharmacological antipsychotic drugs that may be prescribed; for example, chlorpromazine and the antipsychotic drugs, phenothiazines, which are all powerful antagonists.

The impact of the antipsychotic medications on the treatment of schizophrenia has greatly assisted the efforts to reduce agitation, hallucinations, delusions, and indeed most of the other major symptoms of schizophrenia. The drugs also seem to greatly assist the prevention of relapse. At the same time, of course, the use of antipsychotic drugs can be argued strongly against prescription. There are debilitating side effects. Despite the side affects the strongest argument may be the fact that antipsychotic drugs do not cure schizophrenia. In spite of the arguments, continued use of drugs for treatment will continue. If the cause of schizophrenia is unknown, surely the cure is likely to remain a mystery as well. Using antipsychotic drugs will continue to relieve symptoms while researchers continue to search for the cause and the cure.

The major argument for the aforementioned dopamine hypothesis, which postulates that schizophrenia is likely associated with the areas of the brain that use dopamine as a neurotransmitter. This theory is heavily supported from the research on antipsychotic drugs. These drugs are effective on symptoms of thought disorder, withdrawal and moderately effective on hallucinations. The antipsychotic drugs effectively block the dopamine receptor sites. This means that the affected areas have reduced activity of neural impulses. Slowing the dopamine activity supports the hypothesis.

As previously mentioned it is thought that schizophrenia may be caused by an excess of dopamine receptors. In contrast, Parkinsonism is a movement disorder which may be caused by a deficiency of dopamine receptors. Two known facts worthy of further research are; Parkinson disease sufferers rarely develop schizophrenia and drug treatments of schizophrenia oftentimes produce irreversible Parkinson-like symptoms.

Psychological disorders are influenced in important ways genetically. In work with humans, twin, family and adoption studies indicate that certain people may be genetically vulnerable, or predisposed to psychological disorders. Among men, not as conclusive with women, alcoholism research seems to suggest that genetics play a significant role. (Durand, Barlow, 2007).

It also seems likely that schizophrenia is genetically predisposed. A belief that is well-established, or at least play a factor in schizophrenia, but as to the degree that genetics factor in varies amongst researchers. Schizophrenia is likely due to a combination of genetic factors in addition to social and environmental influences.

Many studies have been performed and much research conducted on family, twin, adoptee, offspring and close relations like aunts, uncles and cousins. These studies show a strong indication that schizophrenia is biological in nature. A person is more likely to develop schizophrenia when this person shares more genes with a person already diagnosed with schizophrenia. Studies have shown adopted children raised in an environment away from their birth parents, who have the disorder, have a much higher chance of developing the disorder themselves.

Since the 18th century there has been a belief in the theory that schizophrenia is likely passed from parent to child. Until about 30 years ago, when higher technical research started becoming possible scientists were not able to design studies that were sophisticated enough, similar to the current genetic studies conducted on family, twin, and adoptive studies.

One key-note to make regarding family studies is that the family members all share a very similar environment. This is support for the argument that environment plays a part in a person developing the disorder. Twin studies are subject to a similar objection that they not only share more similar genotype but also a more similar environment. The genotype similarity is obvious, especially for monozygotic twins, for they developed from the same sperm and ovum, resulting in 100% genetic similarity. Monozygotic twins are always the same-sex, so they tend to be dressed alike during their younger years and may choose to continue this routine on into adulthood. The study of monozygotic twins or identical twins is necessary, even to only establish a baseline, for the argument of environment. They grow up in virtually the exact same environment. However, the study may not be beneficial to the argument of genetics.

Another aspect of thought that most researchers are congruent is the genetic component involved in developing schizophrenia. If there is a genetic component, few major genes are responsible for transmitting the risk of developing schizophrenia. Many researchers believe that schizophrenia is not caused by one gene alone, but a variety of genetic subtypes that produce a range of similar disorders. Those disorders are grouped into a single category called schizophrenia.

There have been brain abnormalities indicated in schizophrenia, mainly in chronic patients. It has been noted, mostly in males but not all who suffer from the disorder a noticeable enlargement of the ventricles of the brain. Chronic patients are the ones who tend to show large ventricles which may indicate the cumulative effects of anti-psychotic drugs. However, all patients show abnormalities in the basal ganglia. This could explain why so many patients have both positive and negative symptoms.

Within the Shonda Case Study, her family history mentioned there is no indication of mental illness occurring amongst her immediate family. However, a paternal aunt was noted as being “locked away” in a hospital after experiencing a “nervous breakdown.” Shonda reports that her father never spoke about his sister and Shonda has never met her. Also mentioned within Shonda’s childhood background was a stressful environment. Shonda was exposed to constant bickering between her mother and father. Shonda and her older brother were subjected to her father’s potent temper which took the form of his “beating his two children and his wife.” Another variable which may have added to Shonda’s stressful environment is that her father would often arrive home late, after stopping at the bar.

There is a strong and some believe undeniable genetic correlation to the development of schizophrenia, but what is also being studied is the environmental element associated with schizophrenia. In identical twin studies, studies of persons who share 100% of their genes, there is only a 48% chance of developing schizophrenia. (Gottesman, 1991) This should suggest that genetics alone may not predetermine whether a person develops schizophrenia, but rather environment may also provide predetermining factors and influences. “Environmental – in this definition – includes everything from the nutritional environment or viruses that a baby is subjected in the womb, to social environment growing up, to teen drug use or stress.” (schizophrenia.com, 1996-2004)

“Schizophrenic individuals inherit genes that cause structural brain deviations which may be compounded by early environmental insults. As a result some pre-schizophrenic children exhibit subtle developmental delays, cognitive problems, or poor interpersonal relationships. ” (International Journal of Neuropsychopharmacology, March Issue, 2004) There seems to be strong empirical evidence of environmental influences determining whether a person may develop schizophrenia. It is believed that certain individuals may be predisposed to the disorder and environmental insults. Subtle changes in environmental stressors, which may occur at various stages of a person’s life, may activate or trigger the psychotic manifestations of schizophrenia’s signs and symptoms; hallucinations, delusions, disorganized speech and thought patterns, as well as profound disruption in cognition and emotion. (schizoprhenia.com)

Stressors can precipitate development of schizophrenia. A stressful environment or prolonged exposure to a stressful environment may lead to dysregulation (weak immune response) of dopamine. This susceptibility may occur through early environmental damage or due to genetic reasons. Drug abuse, social adversity, or prolonged stress may be the triggers necessary to move a pre-schizophrenic condition into a full-blown schizophrenic disorder. (International Journal of Neuropsychopharmacology, March Issue, 2004)

Schizophrenia occurs consistently amongst all groups of people worldwide. Differing perspectives and opinions arise from varying scientific opinions; however, there is agreement on the fact that schizophrenia does not arise from one specific cause. Much of the research performed studying how a person might develop schizophrenia suggests a biological predisposition. There are a lot of hypotheses about the nature and causes of schizophrenia in general. Environmental influences continue to be investigated and challenged in an effort to determine if a person’s biological predisposition to the disorder is triggered by environmental influences.

Many studies have been conducted on the environmental and biological interactions which may influence the development of schizophrenia. The following are amongst those researched; cultural factors, genetic influences, twin studies, adoption studies, offspring of twins, genetic linkage studies, evidence of multiple genes, neurobiological influences, brain structure, viral infections, psychological and social interactions, and the influence of stressors.

Pregnancy is a volatile period for mother and child. The mother’s well being and health directly affect the child’s overall development from conception, cell differentiation, and birth. This is an environmental influence that some research suggests may increase the chance of schizotypal personality disorder; a phenotype of schizophrenia genotype. The suggestion is primarily based on potential damage to the left hemisphere of the brain of the fetus. The left hemisphere is thought to be primarily responsible for the semantic and computational aspects of language. This is a possible cause of Shonda’s disconnected fragments of thought, and disjointed speech patterns. When damaged, the interactive ability between the right and left hemispheres of the brain is compromised (Scheibel, Arnold, 1997). This leads to decrements in their ability to perform on memory and learning tests. Concerning the developing fetus’ environment, the mother’s exposure to influenza, or other viruses, and a variety of influences, biological or environmental, the severity of the development of schizotypal characteristics, like paranoia or illusions, will vary from mild to moderate. (Durand & Barlow, 2007, ch 11)

Biological interventions are the oldest acceptable method of treatment. Even as late as 1930 insulin dosing was used to induce comas at the risk of serious illness or death. At the same time, psychosurgery (lobotomies), and electroconvulsive therapy (ECT) gained popularity. It was found that all three were not beneficial for most people with schizophrenia. Soon after followed antipsychotic medications. The 1950s brought with it a plethora of several neuroleptics. These medications were found to be effective at reducing or eliminating hallucinations and delusions as well as social deficits. However, clinicians and patients must be willing to run through the gamut of available medications available, because as with most schizophrenic treatment attempts, it works to varying degrees and not at all with others. (Durand & Barlow, 2007, p. 494-500)

The common treatment of schizophrenia and treatment delivery varies quite considerably across different cultures. For example, Hispanic families are most likely to take in a relative instead of sending a loved one to long-term care. Chinese medicine is relied upon among the Chinese. It could be a choice for the Chinese to use holistic remedies, herbs, acupuncture and acupressure for tradition or for the reason of expense. Sufferers are not so lucky in Africa. Most countries in Africa choose to send their schizophrenia sufferers to jails due to lack of appropriate facilities. (Durand & Barlow, 2007, p. 500)

There has been much research and work conducted in an attempt to determine which type of psychosocial treatment is most effective in treating schizophrenia. The recent work in the area of psychosocial intervention has suggested that there is high value of an approach consisting of both drug treatment and psychological methods (Tarrier et al., 1999).

It seems no matter the treatment chosen to address schizophrenia; it is a rarity that the treatment is successful enough to claim full recovery. However, the easement of the disorder may be achieved through a combination of efforts and treatments. The quality of life for schizophrenic patients can be meaningfully affected by combining antipsychotic medications with psychosocial approaches, employment support, and community-based and family interventions. (Durand & Barlow, 2007, p 500)

The effectiveness of any chosen treatment for schizophrenia is quite limited. Until recently methods of psychotherapy did not seem to be helpful. But specific types of psychotherapy, sometimes combined with drug therapy, have been starting to show signs of alleviating the personality disorder. It’s just a plain hard fact that schizophrenia is chronic and by nature it is always quite a chore to experience any relief, let alone successful recovery for any chronic disorder. Drug treatment is currently designed to temporarily affect the patient’s behavior. Psychotherapy makes attempts to help people recognize their problem and change their social behavior.

Although typical treatment may involve antipsychotic drugs and psychosocial treatments, I think I would plan a heavy psycho-social treatment with medical interventions at different or alternating intervals. This might be radical but I think that the irregularity of the medications would inhibit the body’s ability to adjust to the medications while the regularity of the psychosocial treatments builds a solid dependable foundation for the mind.

I also believe through regular conditioning or reconditioning of the social and moral aspects of human relationships, I think any person can benefit and learn from social learning. The essence of normality in our lives is self-care, calm and safe social interactions, and of course most everyone learns a vocational skill or two. Experiencing noticeable results would take more or less effort depending on the patient and more or less time as well. As with all healthy regimes, maintenance is required. I would suggest that a major stipulation of this plan would be regular practice of skills learned. This would help maintain the effects for a longer period of time, perhaps if followed diligently, without degradation in displayed skills.

Like schizophrenia itself, any psychological model applied to understanding and treating schizophrenia will be complex due to the multiple factors incorporated. The cognitive model introduced by David Hemsley suggests the summary of the formation of a persecutory delusion. In short, the precipitant is affected by the emotion or beliefs a person has about oneself, others and the world and anomalous experiences and finally cognitive biases. The search for meaning ensues and the selection of an explanation develops based on one’s belief about illness, social factors, and belief flexibility. Ultimately all of these factors conspire to create “The Threat Belief.” The model indicates exploration into newer directions. The empirical determination of internal and external events still remains. The flexible nature of the model allows for events which may be positive, negative or neutral. (Hemsley, D., 2005)

The future of schizophrenia is bleak for the mind is a vast and curious entity and will likely always remain so. Shonda will likely live her life in the mental institution heavily drugged with that same bleak prognosis. Perhaps studies will advance, or researchers will finally win a break-through and schizophrenia will finally become less convoluted to follow intelligently. Our world is changing and many developments occur daily which perpetuate the existence of our species. A strength of a world producing such research and studies is that it facilitates investigation as to the interaction of psychotic processes, non-psychotic processes, the environment, genetic predisposition, and how each affects the other.

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