Clinical Brief-Schizophrenia Morgan Wachowski PSY 353-101 November 4th 2013

Schizophrenia is a mental health disorder which is characterized by symptoms that disturb thoughts, emotion, and behavior (Kring, Johnson, Davison, & Neale, 2013). These symptoms usually interfere with ones everyday life depending on the degree of the illness and whether or not it is being treated. This topic was chosen in order to get a better understanding of what is entailed with the diagnosis, etiology, and treatment of schizophrenia. In my own experience, the word schizophrenia has been exposed to me in a stigmatized manner so I want to change my perspective using a specific case study and other sources in order to obtain facts over opinions. Then I will discuss how the biological and cognitive perspectives are relevant to the etiology and treatments for the individual case study. In the case study, Changes in Persistent Delusions in Schizophrenia Using Guided SelfDetermination: A Single Case Study by authors (Jrgensen, Hansson, & Zoffmann, 2012), they discuss the diagnosis of a 55 year old man named John with paranoid schizophrenia. John was diagnosed thirty five years ago and has been suffering with ongoing symptoms ever since. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has a list of requirements in order to diagnose an individual with schizophrenia. John meets most of the criteria for this diagnosis and has struggled to get the right treatment. The first requirements of the DSM-5 include; Two of the following symptoms that are present for a significant amount of time in a one-month period and at least one from the first three listed, (1) Delusions. (2) Hallucinations. (3) Disorganized speech. (4) Grossly disorganized or catatonic behavior. (5) Negative symptoms. (Tandon, et al., 2013). Johns symptoms meet this criterion since he has had ongoing symptoms of delusions, hallucinations, disorganized thoughts, and negative symptoms for over thirty years. His delusions and hallucinations were persecutory in which he perceived that mental health care professionals were sneeringly talking to him or about him. He also started to believe that family 2

and friends had negative assumptions about him and were out to get him under all circumstances. This led him to move away and isolate himself from everyone except his son. He also reported grandiose delusions of being controlled by aliens and being Gods right hand (Jrgensen, Hansson, & Zoffmann, 2012). Although John has experienced various symptoms, he reports that each of them occured at different times of his life with some overlapping (Jrgensen, Hansson, & Zoffmann, 2012). The DSM-5 requirements also includes; B. Social/Occupational dysfunction that is markedly below the level achieved prior to onset. C. Duration of continuous signs of disturbance for 6 months with at least one month of active symptoms (Tandon, et al., 2013). Due to the long duration of his illness, John exceeds the time frame of suffering for at least 6 months with one month of active symptoms. As stated earlier, John isolated himself from family and friends based on his delusions which caused social dysfunction. Now that the nature of the case study and Johns symptoms are understood, I will discuss how the biological and cognitive perspectives explain the cause of his disorder. The biological perspective has a wide range of theories that pertain to the causes of schizophrenia. In this discussion, the brain structure and function will be the main focus based on Johns experience. Due to the lack of information about Johns early childhood and family history, it would be more reliable to analyze the way his brain is structured and how it functions. This can be done using his reports of different treatments that affected his schizophrenia in a positive or negative way. Researchers have recently found more information by using technological imaging sources that allow them to see what goes on in the brain. Since the cause of schizophrenia is still unknown, this type of research has developed more insight of possible contributors. By using brain imaging, different studies have found a correlation between enlarged ventricles and people diagnosed with schizophrenia. When the four ventricles in the brain are 3

enlarged that means they are filled with spinal fluid while other cells are being lost (Kring, Johnson, Davison, & Neale, 2013). Large ventricles also suggest that there is a correlation between poor performance on neuropsychological tests, poor functioning before onset of illness, and lack of response to drug treatment in people who are diagnosed with schizophrenia (Kring, Johnson, Davison, & Neale, 2013). A study was done using MRI brain imaging in which researchers examined 15 healthy patients versus 15 schizophrenic patients. Their results indicated that the schizophrenia patients total lateral ventricle volume, right ventricle volume, and left ventricle volume were all higher than the healthy patients (Meduri, et al., 2010).This is a significant finding because the lateral ventricles are the largest part of the ventricle system that also affect other brain functions which can have reasoning behind the dysfunctional thoughts that contribute to schizophrenia (Meduri, et al., 2010). Schizophrenic patients also differed from the healthy patients because less gray matter was presented in other areas of the brain (Meduri, et al., 2010). Although their results correlated, the researchers suggest that their findings are just a beginning and that there is more in depth solutions to be obtained regarding this theory (Meduri, et al., 2010). These studies relate to Johns experience because he reports of having no response to antipsychotic medications even with a dosage increase. This makes it reasonable to presume that there is a sign of abnormal brain structure and function that affects his lack of response to medication and other treatments. Brain imagining is also useful to view other activity in the brain which allows researchers to get more information on how it is affected during various tests that trigger emotion. Patients with schizophrenia have shown to have less gray matter in the prefrontal cortex (Kring, Johnson, Davison, & Neale, 2013). This is relevant since the prefrontal cortex involves activity with speech, decision making, emotion, and goal-directed behavior that become dysfunctional in 4

individuals diagnosed with schizophrenia (Kring, Johnson, Davison, & Neale, 2013). Although gray matter in the prefrontal cortex is reduced, imaging shows that neurons in this area stay the same which affects nerve impulses or referred as dendrite spines (Kring, Johnson, Davison, & Neale, 2013). Researchers also use the term disconnection syndrome due to the interrupted communication that goes on between one neuron to the other which presents a correlation between disorganized speech and behavior in schizophrenia (Kring, Johnson, Davison, & Neale, 2013). Other parts of the brain such as the temporal cortex and the surrounding areas have also been emphasized in research regarding schizophrenic brain activity. The temporal cortex includes the temporal gyrus, hippocampus, amygdala, and anterior cingulate that all affect structural and functional aspects of the brain (Kring, Johnson, Davison, & Neale, 2013). A study supporting this information investigated the relationship between the matter of the prefrontal cortex (PFC) and Heschls gyrus (HG) and the duration of illness in schizophrenic patients to understand their cognitive impairments (Karabay, Oniz, Gokcay, Alptekin, HugdahlL, & Ozgoren, 2013). The study consisted of 29 schizophrenia patients that were observed from 20072012 using MRI tests. Their results found a relationship between less HG volume and longer illness duration but no correlation when viewing the PFC (Karabay, Oniz, Gokcay, Alptekin, HugdahlL, & Ozgoren, 2013). Researchers conduct these types of studies on the brain to obtain information as a starting point in understanding possible components that contribute to brain abnormalities in schizophrenia. Again, Johns symptoms can be explained in part by this information based on his reports of disorganized thoughts and impulsive behavior. The cognitive perspective is another theory that explains potential causes of schizophrenia. Thought processes of schizophrenic individuals deviate from normal processes which represent a cognitive dysfunction to the disorder. A great deal of information about Johns 5

thoughts and the way he perceives situations are reported which is why cognitive causes are reasonable to assess. His thought process is particularly different because he is able to understand his diagnosis of schizophrenia, yet he does not relate his hallucinations and delusions to the disorder. As discussed earlier, many of his symptoms meet the DSM-5 criterion which is why it would be illogical for him to separate those symptoms from his schizophrenia. His persecutory delusions also suggest a type of cognition that is affected by his disease because they affect his everyday choices and behaviors. A study that focuses on impairment in time perception included 22 schizophrenic patients and 22 controls of non-schizophrenic patients and investigated whether this type of cognitive process can contribute to symptoms that cause delusions and hallucinations (Peterburs, Nitsch, Miltner, & Straube, 2013). The results of the study indicated that schizophrenic patients underestimated time which suggests they have impairment in temporal processing and predictive timing (Peterburs, Nitsch, Miltner, & Straube, 2013). Although there was no evidence that suggests cause-related symptoms due to cognition, the study did find that cognitive dysfunction did occur during cognitive assessments (Peterburs, Nitsch, Miltner, & Straube, 2013). This study is important to consider when analyzing Johns symptoms because his thought process is clearly dysfunctional due to his delusions and lack of social interaction. Although the study focuses on time perception, it is important to see the results found on cognitive processes that affect schizophrenic patients similar to John. As mentioned earlier, John believes his delusions are not part of his diagnosis, yet he made significant life changes because of them which verify that his perceptions are part of his illness. John states that little success was made during psychotherapy and cognitive behavioral therapy because he felt as if the doctors were more concerned about his symptoms and diagnosis rather than his personal needs. This is also another factor indicating that Johns cognitive process 6

is significant to his illness especially due to the long time period he has suffered. In the case study focused on John, they discuss how an advanced cognitive therapy has been used to help schizophrenic patients to maintain their everyday life using the guided self-determinism method. Guided self-determinism (GSD) uses a number of psychological tools so that the patient can potentially gain new insight on their thoughts to improve life skills (Jrgensen, Hansson, & Zoffmann, 2012). John had the most success with GSD treatment because he felt more open to talk about his symptoms, he had more control of the topics discussed, and he also focused on his personal needs and wants so that he can potentially lead a normal life (Jrgensen, Hansson, & Zoffmann, 2012). During this therapy, his perception altered and he finally related his delusions to his schizophrenia. The cognitive remediation therapy is another therapy that could have been beneficial to Johns treatment even though he felt that cognitive-behavioral approaches were not useful. A randomized study of 67 diagnosed schizophrenic patients was designed to test how computer assisted cognitive remediation therapy affected the cognitive processes that contribute to ones everyday quality of life (Garrido, et al., 2013). The results conclude that there was improvement in mental processes such as processing skills, working memory, reasoning, and problem solving which are all simple yet important aspects for ones well-being and quality of life (Garrido, et al., 2013). John expresses his personal wants and needs that include living a normal life which can be improved through cognitive remediation therapy. Although there is significant evidence to support the biological and cognitive perspectives of schizophrenia, there is still more research and evidence to consider knowing that there is no specific cause to this brain disease. In conclusion, Johns experience of being diagnosed with schizophrenia is unique and has been useful in analyzing the complexity of what is involved in diagnosing, understanding the 7

etiology, and what type of treatments are available for individuals with schizophrenia. With limited information provided from Johns history and daily life, I used the information given in order to assess potential causes of his illness using the help of other case studies and class resources to validate my research. It would be interesting to gain more knowledge on Johns history which would entail more information on his family medical history, social support, and environment that may have affected the onset of his schizophrenia. Another biological aspect provided by (Kring, Johnson, Davison, & Neale, 2013) suggest that environmental influences also affect the brain development which shows the importance of obtaining as much information as possible for an in depth analysis. During my research, the prevalence of medicine has been a role in treatment for schizophrenic patients while also using the help of therapy to maintain ones stability. Since Johns case is unique and the use of medicine and various therapies were not useful, it would be helpful to know the specific treatments and how long he attempted to use each one. This would make it clearer to understand why most of the treatments were unsuccessful due to either the severity of his disorder or the lack of effort given to each therapy. I believe family support and therapy would be helpful so that he can make an effort to build relationships with people he already knows which can improve his skills with strangers. John mentions he always wanted a significant other but because of his symptoms, he was never married and was unable to manage an intimate relationship (Jrgensen, Hansson, & Zoffmann, 2012). Family therapy can improve his skills similar to other therapies for schizophrenia which are designed to help patients manage their disorder while leading a normal life. It involves educating the family, discussing individual treatment options, blame avoidance and reduction, communication and problem-solving skills, social network expansion, and hopes which are all components that help everyone be supportive members, including the patient (Kring, Johnson,

Davison, & Neale, 2013). Johns lack of social support can also be a reason why medications and treatments were not useful because based on his delusions, everyone was against him and there seemed to be a lack of support from family and friends when John lived close by. He reports keeping in contact with his son but there is no evidence to show that his son is being supportive or even talks to his father about his schizophrenia. This is another detail that will build Johns treatment success in order to give him the most satisfying results. Overall, the analysis of John and his schizophrenia was helpful in clarifying stigmatizations that had molded my imagination of how a schizophrenic person behaves, and gave insight to the struggles they go through in order to be a part of society and manage everyday life. Johns case along with others from class readings and discussion were also informative in trying to explain the complexity of diagnosing and dealing with a disorder that is very difficult to treat because the cause remains unknown. That is why the biological and cognitive perspective was chosen for discussion about the etiology of Johns schizophrenia. Each perspective has a lot of data to support each side which shows some potential causes in explaining the onset of schizophrenia. Even though the prevalence of schizophrenia is less than 1% and the cost of treatment can be extremely expensive (Torres, 2013), I think it is worth the time and effort to discover more information to help those who suffer from such a deviant disorder.

Garrido, G., Barrios, M., Penads, R., Enrquez, M., Garolera, M., Aragay, N., et al. (2013). Computer-assisted cognitive remediation therapy: Cognition, self-esteem and quality of life in schizophrenia. Schizophrenia Research , 563-569. Jrgensen, R., Hansson, L., & Zoffmann, V. (2012). Changes in Persistent Delusions in Schizophrenia Using Guided Self-Determination: A Single Case Study. Issues in Mental Health Nursing , 293-300. Karabay, N., Oniz, A., Gokcay, D., Alptekin, K., HugdahlL, K., & Ozgoren, M. (2013). The Relationship Between Illness Duration And Brain Morphometry in Schizophrenia: Heschl's Gyrus and Prefrontal Cortex Volumetry. Journal of Neurological Sciences , 153-167. Kring, A. M., Johnson, S. L., Davison, G., & Neale, J. (2013). Abnormal Psychology 12th Edition DSM-5 Update. New York: John Wiley & Sons. Meduri, M., Bramanti, P., Ielitro, G., Favaloro, A., Milardi, D., Cutroneo, G., et al. (2010). Morphometrical and morphological analysis of lateral ventricles in schizophrenia patients versus healthy controls. Psychiatry Research: Neuroimaging , 52-58. Peterburs, J., Nitsch, A. M., Miltner, W. H., & Straube, T. (2013). Impaired Representation of Time in Schizophrenia Is Linked to Positive Symptoms and Cognitive Demand. PLoS ONE , 1-7. Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., et al. (2013). Definition and description of schizophrenia in the dsm-5. Schizophrenia Research . Torres, R. S. (2013). Schizophrenia. Lecture .

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