(((I am currently studying for a licensure exam & completing an internship. This blog post is intended as a study exercise. In it, I review information from papers I’ve written on the subject of schizophrenia. It is not intended as a substitute for mental health counseling or diagnosis…)))
Schizophrenia is an illness associated with disabling symptoms & a distorted view of reality (Blaney & Millon, 2009). Symptoms associated with this diagnosis include, hallucinations, delusions, disorganized speech and thoughts as well as catatonic behaviors, and negative symptoms such as anhedonia (Beck & Rector, 2005).
Definition & Explanation
Positive symptoms of schizophrenia include issues most readily associated with psychotic disorders that are noticeably absent in the unaffected population (Morrison, 2014; Schizophrenia Symptoms, 2008). In contrast to negative symptoms, positive symptoms add vivid descriptive detail to the clinical picture of Schizophrenic and Psychotic Disorders (Morrison, 2014; Robinson, 2002). What follows is a list of positive symptoms of schizophrenia (Andraesen, 1984a; Morrison, 2014; Robinson, 2002; Schizophrenia Symptoms, 2008):
Disorganized & Bizarre Behavior
Formal Thought Disorder
Disorganized Mood & Affect
While negative symptoms contribute more to the functional outcome and quality of life for schizophrenia, positive symptoms receive significantly greater attention (Velligan & Alphs, 2014). The primary reason is that positive symptoms are easier to diagnose and recognize, for clinicians as well as suffers (Velligan & Alphs, 2014). As a result, there currently exists a wider array of treatment for positive symptoms (Velligan & Alphs, 2014). This week’s readings provide a great overview of how to assess positive symptoms in a MSE:
Appearance – Psychotic Disorders are commonly associated with an unkempt and disorganized appearance (Morrison, 2014; Robinson). Additionally, Morrison (2013) mentions a list of factors that can help differentiate between diagnoses in this category, including age, marital status, and age of onset (p214)
Behavior – Positive symptoms are most readily associated with the presentation of disorganized and bizarre behavior. Other positive behavioral symptoms can include psychomotor retardation, movement abnormalities and negative symptoms (Robinson, 2002).
Cooperation & Reliability – Morrison (2014) suggests that client reliability and cooperation may vary greatly within this diagnostic category. As a result, it is especially important to attain collateral information from family and the patient’s history.
Speech – Incoherent speech characterized by loose association and derailment, can also represent positive symptoms of paranoid disorders assessed in a MSE (Morrison, 2014)
Thought Form/Process/Content – Delusions can be found when assessing thought form and content in a MSE (Morrison, 2013; Robinson, 2002). Loose associations, and thought derailment can be found when assessing how thoughts are organized (Morrison, 2013; Robinson, 2002).
Mood & Affect – Incongruency between mood and affect is a positive symptom of psychotic disorders that can also be assessed in a mental status exam (Morrison, 2013)
Perception/Insight & Judgment – Hallucinations are a positive symptom of schizophrenia spectrum and psychotic disorders that can be assessed in a MSE (Morrison, 2013; Robinson, 2002). Additionally deficits in insight and judgment are also common in these disorders.
Definition & Examples
Negative symptoms refer to deficits in an individual’s clinical presentation when compared to the unaffected population (Morrison, 2014; Robinson, 2002). In other words, while positive symptoms refer to psychotic symptoms, negative symptoms refer to functional deficits (Morrison, 2014; Robins, 2002). Negative symptoms include primary and secondary subtypes (Velligan & Alphs, 2013). Primary negative symptoms are associated with “core pathology of schizophrenia” (Velligan & Alphs, 2013, p24) and are present from a disorder’s onset. Secondary negative symptoms occur later as a byproduct of issues, such as medication side effects, environmental factors, and disease processes (Velligan & Alphs, 2014). This differentiation is vital because it points at an underlying etiology. For example, social isolation resulting from paranoia is a primary negative symptom, whereas akinesia resulting from antipsychotic medication is a secondary negative symptom (Velligan & Alphs, 2014). As a collectivity, primary negative symptoms are referred to as a “Deficit Syndrome” (Velligan & Alphs, 2014). Examples of negative symptoms include the following (Andraesen, 1984b; Morrison, 2014; Robinson, 2002; Velligan & Alphs, 2014):
Decreased eye contact
Avolition, Apathy & Anhedondia
Alogia – Poverty of Speech
Inattentiveness, & Inactivity
Increase in Cognitive Deficits
Lack of Motivation
Negative symptoms contribute significantly to the morbidity and prognosis of schizophrenia and related psychotic disorders (American Psychiatric Association, 2013; Velligan & Alphs, 2014). Nonetheless, they are much less prominent and more difficult to diagnose (American Psychiatric Association, 2013; Velligan & Alphs, 2014). Sufferers are frequently unaware of the presence of negative symptoms and rarely report them (Velligan & Alphs, 2014). Additionally, negative symptoms frequently receive significantly less attention in treatment diagnosis and treatment (American Psychiatric Association, 2013). Morrison’s (2013) case study of Jeannie, an individual with a dual diagnosis of depression and schizophrenia, highlights the importance of addressing these issues. The biggest lesson from this story is the idea that we thoroughly address all symptoms in the diagnostic process.
Since many sufferers of schizophrenia and other psychotic disorders are largely unaware of negative symptoms, it is important to specifically ask about them. For example, Velligan & Alphs, (2014) suggest starting with the following question: “Starting from the time you get up, could you tell me how you have spent a typical day?” (p25) Observing a client’s response to such a question, can aid in the assessment of negative symptoms in a MSE. Velligan & Alphs (2014) provide a great list of negative symptoms that can be observed in a MSE (p24). It is useful in contrast to the above description of positive symptoms also found in a MSE.
Communication – Negative symptoms are associated with the production of very little speech and require prodding and cueing throughout an interview (Velligan & Alphs, 2014).
Emotion/Affect – Negative symptoms also include blunted and flat affect. These symptoms can be seen in the form of a limited range of emotional response, alongside the expression of feelings of anhedonia (Velligan & Alphs, 2014).
Social Activity – Significantly limited interests, social isolation alongside a diminished interest in relationships are another negative symptom that can be assessed in a MSE (Velligan & Alphs, 2014).
Motivation – A lack of motivation can be associated with deficient grooming, and overall attitude disinterest (Velligan & Alphs, 2014).
Psychomotor Activity – The reduction and/or absence of psychomotor activity is also associated with negative symptoms of psychotic disorders (Velligan & Alphs, 2014).
Understanding the Cause: A Diathesis Stress Model
Lambert & Kinsley, (2011), briefly mention a diathesis stress model of schizophrenia which suggests that it a result of the interactive effects of a person’s makeup and environment stressors. In an article titled “Cognitive Approaches to Schizophrenia”, Aaron Beck and Neil Rector provide insight into the pathogenic development of this disorder (Beck & Rector, 2005). In some individual’s, pre-existing neurocognitive impairments cause them more prone to this disorder. When encounter problematic life events, “highly stressful conditions [can] lead to dysfunctional beliefs and, consequently, dysfunctional cognitive appraisals and maladaptive behaviors.” (Beck & Rector, 2005, p579). As time progresses the dysfunctional beliefs and cognitive distortions lead to more stressful life experiences and heightened pathophysiological stress in response to them. These stresses, then cause further neurological impairments in a feedback-loop fashion. “The repeated cycling of these psychological and physiological reactions lead to a cognitive decompensation and the clinical syndrome of schizophrenia” (Beck & Rector, 2005, p579).
Research has shown that early deficits can lead to later pathophysiological development, until schizophrenic symptoms finally arise (Preston, et al, 2013). The neurodevelopmental model of schizophrenia states that a series of abnormal processes are underway well before symptoms emerge. Longitudinal epidemiological studies show a strong familial component in support of a biological predisposition. Environmental factors include low birth weight, prenatal infection and risk, as well as abnormalities in placental development and function (Rapoport, et al, 2012). A history that includes childhood traumas, urban environments, also put individual at risk, indicating a stress-related factor in the development of schizophrenia (Rapoport, et al, 2012).
Neuroimaging studies indicate that gray mater loss is specific to individuals with early childhood onset schizophrenia (Rapoport, et al, 2012). In contrast adult-onset schizophrenia is associated with small thalamus volume and enlarged ventricles (Rapoport, et al, 2012). Individuals who are at highest risk for schizophrenia show a less white matter in the fronto-occipital area (Rapoport, et al, 2012).
In support of the pruning model of schizophrenia, several studies show that an effective growth and pruning process occurs in early brain development (Rapoport, et al, 2012). Additionally, brain abnormalities are noted in children that predate the onset of an illness such as brain cortical thinning (Rapoport, et al, 2012). Additionally, early onset schizophrenia is most strongly correlated with genetic error (Rapoport, et al, 2012).
Post-mortem studies appear to provide further support for the notion of ineffective pruning (Rapoport, et al, 2012). Additionally, post-mortem studies also indicate that ineffective DNA transcription may underlie the developing schizophrenic brain (Rapoport, et al, 2012). Finally, this article mentions several studies that point at defects GABA neurotransmission as highly correlated with schizophrenia (Rapoport, et al, 2012).
Medication & Stages of Schizophrenia
Schizophrenia has three stages: a prodromal phase, active phase, and residual phase (Lambert & Kinsley, 2011; Preston, et al, 2013). Symptoms vary greatly depending on the specific stage of the disorder. Treatment considerations vary greatly depending on the stage of schizophrenia, the client is exhibiting.
“During the prodromal phase, patients show a deterioration in their level of functioning” (Preston, et al, 2013, p130). During this phase, no positive symptoms of psychosis appear: including delusions, hallucinations, bizarre behavior (Lambert & Kinsley, 2011; Preston, et al, 2013). If these symptoms occur at all, they are much less intense like “misperceptions and…subdelusional changes” (Lieberman, et al, 2012, p58). Instead, prodromal phase symptoms involve distractibility, loss of motivation, depression, blunted affect, and declining functionality (Lieberman, et al, 2012; Preston, et al, 2013). Currently antipsychotic medications are geared toward active phase symptoms, and no treatment regimen exists to prevent psychosis. However, research shows a kindling effect at hand with each successive psychotic episode, as noted by brain changes and declining function (Lambert & Kinsley, et al; Preston, et al, 2013).
Treatment during the prodromal phase requires family education and management of negative symptoms. This family education can involve helping with the recognition of symptoms, such as “subdelusional changes….attenuated hallucinations” (Lieberman, et al, 2012, p59) that indicate a risk for an upcoming psychotic phase. Velligan & Alphs, (2013), mention that while negative symptoms contribute more to a person’s overall functioning and quality of life, few treatments exists. An adjustment in the client’s antipsychotics may be in order, where they produce negative symptoms. Antidepressants are useful in addressing a client’s negative mood and amotivational state. Finally, addressing other side effects of antipsychotics may require the use of antiparkinson medications, and propranolol (Preston, et al, 2013).
During the active phase of schizophrenia, all the classic symptoms of psychosis are present, including delusions, hallucinations, bizarre thoughts and behaviors (American Psychiatric Association 2013). Antipsychotic medications are useful in the treatment of active phase symptoms. First generation psychotics such as Thorazine are designed to address these positive symptoms by blocking the reuptake of Dopamine (Preston, et al, 2013). However, these medications produce a wide array of neurochemical effects throughout the brain and cause an array unpleasant side effects. These side effects include akathisia, depressive symptoms, and extrapyramidal side effects. Addressing these side effects with medication will also be required.
As an alternative, second generation antipsychotics, may be a better choice for clients due to their ability to address both positive and negative symptoms (Preston, et al, 2013). These medication block the reuptake of serotonin, and have fewer unpleasant side effects. Finally, it is important to note that often patients, over time, will require proper psychoeducation to better understand and recognize psychosis when it happens. This can, in time, allow them to better appreciate the actual extent of how these symptoms may hamper their overall functioning.
In the residual phase of schizophrenia, a patient’s positive symptoms of psychosis are in remission (Lieberman, et al, 2012). Nonetheless, in order to prevent relapse, it is likely the patient will be required to take antipsychotics. “In the residual phase, the patient continues to be impaired but without psychotic symptoms. Social isolation and peculiar affect…may persist” (Preston, et al, 2013, p130). Preventing relapse and addressing negative symptoms are two key priorities during the relapse phase. Lieberman, et al, (2012) state that recovery is increasingly problematic with each successive psychotic phase, and neurodegneration is often the result. In addition to the antipsychotics, as mentioned in the active phase, it will be important to address both side effects and negative symptoms. This can be addressed with medications such as: antidepressants, antiparkinson drugs, benzodizapenes, lithium, and propaolol (Preston et al, 2013).
Other Treatment Considerations….
Advocacy – Addressing the Treatment Gap
In an article titled “The Treatment Gap in Mental Health Care”, by Richard Kohn, is the introduction of an intriguing concept relevant to the discussion:
“If (mental) disability is to be reduced, a bridging of the ‘treatment gap’ must occur. The treatment represents the absolute difference between the true prevalence of a disorder and the treated proportion of individuals affected by the disorder. Alternatively, the treatment gap may be expressed as the percentage of individuals who require but do not receive treatment.” (Kohn, et al, 2004, p859).
This notion, adds to a relevant insight from the assigned videos this week that illuminates the fact that a majority of schizophrenia patients don’t receive the care they need. (Film Media Group, 1998; Film Media Group, 2003). Proposed causes for this gap in treatment are associated with an array of factors, including (1) a limited availability of services; (2) cost-prohibitive barriers; (3) delays in seeking treatment; (4) social stigma and lack of knowledge. When taking all these factors, alongside the nature of schizophrenia, it is clear that this population has difficulty advocating for its own needs. It is therefore of primary importance that mental health professionals, caring for this population, do so.
Mind you, these advocacy efforts would ideally occur at multiple levels. Firstly, this advocacy can involve assisting patients who are seeking outpatient and community based services. Knowing the available services for these clients, and helping them attain access to these services will be important. Secondly, other suggested advocacy efforts could involve community-based work. This might mean, educating the public on the nature of the disorder as well as campaigning for the availability of funds and services.
Family-Based Psychosocial Education.
As is clear, from the assigned videos this week, schizophrenia doesn’t appear to just affect the individual, but everyone in their lives as well (Film Media Group, 1998; Film Media Group, 2003). Additionally, it seems the ability to function effectively in the real world is determined to a great degree by the nature of the home environment, interpersonal relationships (Film Media Group, 1998; Film Media Group, 2003). With this in mind, it is clear that psychosocial education for the individual as well as their family is an essential component in the treatment and care of this group. What follows is a brief listing of suggestions to help provide family-based psychosocial education for schizophrenia patients.
Assessing The Situation.
Assessing the quality of a client’s relationship with loved one’s is important, as is the level emotional dynamics of the home environment. Additionally, alongside an assessment of the patient’s current level of functioning, it would be useful to examine how this affects family members. How have the coped, and what is their understanding regarding the client’s illness?
With this assessment in place it will be vital to begin developing a collaborative relationship with family members. This can involve communicating with them the nature of the illness and how it is influenced by family dynamics and relationships (McFarlane, et al, 2003, 224). Working with the family over the long term to address these factors would ideally mean helping them understand the disorder, and how specific interactions can influences symptoms. Getting the family involved in the process of psychosocial rehabilitation for the sake of the client will be essential (McFarlane, et al, 2003, 224).
Family Based Education.
Helping the family understand the nature of the disorder is a related issue that also appears crucial. As was clear in the videos assigned for this week showed, outcomes appeared to be correlated with the family’s awareness and understanding of the disorder.
Access to Community Support Networks.
Addressing the family’s coping with the patient’s illness is a vital component of the treatment process. In addition to participating in therapy, helping family members access community social support networks is helpful. It can provide them with another useful outlet, if for no other reason than helping them understand they aren’t alone.
Cognitive Behavioral Interventions.
In an article titled “Cognitive Approaches to Schizophrenia” by Aaron Beck is important interventional strategies to help those with this disorder. From the standpoint of Cognitive Behavioral Therapy, a few key issues appear to stand out for Beck. Firstly, he makes a point to note the deficits in “reality testing” that come with notions and ideas that have a highly emotionally charged component (Beck & Rector, 2005, p581). This unwillingness to test reality appears to prevent them from being able to consider wrongness in their notions or beliefs. Secondly, of note to Beck is the idea that delusions may be characterized as a unique and problematic cognitive pattern (Beck & Rector, 2005 p583). From the standpoint of Beck’s explanation, these delusions appear to be based on “idiosyncratic beliefs” (Beck & Rector, 2005 p583). With these idiosyncratic beliefs in place, impervious to reality testing, it appears their perceptions and personal world is defined largely by their nature. With this in mind, what brief listing of interventional techniques might Beck suggest?
As a structured and time-limited approach, Beck’s approach appears to be aimed at first developing a trusting relationship upon which guided discovery can take place (Beck & Rector, 2005 p598). Alongside a formal assessment of client’s symptoms, an educational process about the nature of their illness will be vital. With a trusting relationship in place, a normalization process occurs, in which a client’s sharing of symptoms are explained in terms of relevant diagnosis (Beck & Rector, 2005 p598). The goal of this, according to Beck, is a reducing in Stigma, and further building of trust in the therapeutic relationship. Later in the therapeutic process, the guided discovery process may occur in which therapists help clients understand relationship between feelings, thoughts and behaviors. With a gradual development in understanding of this from the client’s point of view, a Socratic dialogue may take place.
“Therapists questioning mode provides the context for patients to generate a range of alternative explanations for their experiences. With repeated practice in generating alternative explanations in the therapists’ office and then routinely in homework sessions, the patient can begin to respond to life events ore flexibly and thus reduce the delusional beliefs. In addition to verbal strategies, the cognitive therapist aims to institute change in delusional thinking by setting up behavioral experiments to test the accuracy of different interpretations. “ (Beck & Rector, 2005, p599)
Skillful Pharmacological Management.
While outside the scope of a therapists practice, it warrants mention that several resources of this article pointed towards inadequate pharmacological management as a key issue (Razali, et al, 2000; Ryu, et al, 2006). There are several reasons cited for this. Firstly, mention was made to the poor coordination of services that exists as one underlying cause. Secondly, other reasons for this include, a lack of attentive care to the responsiveness to therapies. Failing to carefully examine a clients responses to medication and assessing this is another problem.
Again, while this isn’t something a therapist may be involved in, it might be useful to note again the therapist’s role as an advocate for the patient. Helping to coordinate the many services and providers the client sees, is vital. Additionally, observing a client’s reaction, presenting symptoms, and communicating this to the psychiatrist may be useful. Working to create a coordinated treatment effort, can be yet another vital role for the therapist in these cases.
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Andreasen, N. C. (1984b). Scale for the assessment of negative symptoms. Iowa City: University of Iowa.
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