MH122.pdf

11/27/23, 3:40 AM Realizeit for Student Clinical Course Although the symptoms of schizophrenia are always severe, the long-term course does not always involve progressive deterioration. The clinical course varies among clients. Onset Onset may be abrupt or insidious, but most clients slowly and g...

11/27/23, 3:40 AM Realizeit for Student Clinical Course Although the symptoms of schizophrenia are always severe, the long-term course does not always involve progressive deterioration. The clinical course varies among clients. Onset Onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, loss of interest in school or at work, and neglected hygiene. The diagnosis of schizophrenia is usually made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disordered thinking (psychosis). Regardless of when and how the illness begins and the type of schizophrenia, consequences for most clients and their families are substantial and enduring. When and how the illness develops seems to affect the outcome. Age at onset appears to be an important factor in how well the client fares; those who develop the illness earlier show worse outcomes than those who develop it later. Younger clients display a poorer premorbid adjustment, more prominent negative signs, and greater cognitive impairment than do older clients. Those who experience a gradual onset of the disease (about 50%) tend to have a poorer immediate- and longterm course than those who experience an acute and sudden onset. Approximately one-third to onehalf of clients with schizophrenia relapse within 1 year of an acute episode. Higher relapse rates are associated with nonadherence to medication, persistent substance use, caregiver criticism, and negative attitude toward treatment (Wade, Tai, Awenot, & Haddock, 2017). Immediate-Term Course In the years immediately after the onset of psychotic symptoms, two typical clinical patterns emerge. In one pattern, the client experiences ongoing psychosis and never fully recovers, though symptoms may shift in severity over time. In another pattern, the client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recovery from the psychosis. Long-Term Course The intensity of psychosis tends to diminish with age. Many clients with long-term impairment regain some degree of social and occupational functioning. Over time, the disease becomes less disruptive to the person’s life and easier to manage but rarely can the client overcome the effects of many years of dysfunction. In later life, these clients may live independently or in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment. However, many clients with schizophrenia have difficulty functioning in the community, and few lead fully independent lives. This is primarily due to persistent negative symptoms, impaired cognition, or treatment-refractory positive symptoms (Jablensky, 2017). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1upt… 1/5 11/27/23, 3:40 AM Realizeit for Student Antipsychotic medications play a crucial role in the course of the disease and individual outcomes. They do not cure the disorder; however, they are crucial to its successful management. The more effective the client’s response and adherence to his or her medication regimen, the better the client’s outcome. Longer periods of untreated psychosis lead to poorer long-term outcomes. Therefore, early detection and aggressive treatment of the first psychotic episode with medication and psychosocial interventions are essential to promote improved outcomes, such as lower relapse rates and improved insight, quality of life, and social functioning (Jablensky, 2017). Etiology Whether schizophrenia is an organic disease with underlying physical brain pathology has been an important question for researchers and clinicians for as long as they have studied the illness. In the first half of the 20th century, studies focused on trying to find a particular pathologic structure associated with the disease, largely through autopsy. Such a site was not discovered. In the 1950s and 1960s, the emphasis shifted to examination of psychological and social causes. Interpersonal theorists suggested that schizophrenia resulted from dysfunctional relationships in early life and adolescence. None of the interpersonal theories has been proved, and newer scientific studies are finding more evidence to support neurologic/neurochemical causes. However, some therapists still believe that schizophrenia results from dysfunctional parenting or family dynamics. For parents or family members of persons diagnosed with schizophrenia, such beliefs cause agony over what they did “wrong” or what they could have done to help prevent it. Newer scientific studies began to demonstrate that schizophrenia results from a type of brain dysfunction. In the 1970s, studies began to focus on possible neurochemical causes, which remain the primary focus of research and theory today. These neurochemical/neurologic theories are supported by the effects of antipsychotic medications, which help control psychotic symptoms, and neuroimaging tools such as computed tomography, which have shown that the brains of people with schizophrenia differ in structure and function from those of control subjects. Biologic Theories The biologic theories of schizophrenia focus on genetic factors, neuroanatomic and neurochemical factors (structure and function of the brain), and immunovirology (the body’s response to exposure to a virus). Genetic Factors Most genetic studies have focused on immediate families (i.e., parents, siblings, and offspring) to examine whether schizophrenia is genetically transmitted or inherited. Few have focused on more distant relatives. The most important studies have centered on twins; these findings have demonstrated that identical twins have a 50% risk of schizophrenia; that is, if one twin has https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1upt… 2/5 11/27/23, 3:40 AM Realizeit for Student schizophrenia, the other has a 50% chance of developing it as well. Fraternal twins have only a 15% risk. This finding indicates a genetic vulnerability or risk of schizophrenia. Other important studies have shown that children with one biologic parent with schizophrenia have a 15% risk; the risk rises to 35% if both biologic parents have schizophrenia. Children adopted at birth into a family with no history of schizophrenia but whose biologic parents have a history of schizophrenia still reflect the genetic risk of their biologic parents. All these studies have indicated a genetic risk or tendency for schizophrenia, but Mendelian genetics cannot be the only factor; identical twins have only a 50% risk even though their genes are 100% identical. Rather, recent studies indicate that the genetic risk of schizophrenia is polygenic, meaning several genes contribute to the development (Kendall, Kirov, & Owen, 2017). Neuroanatomic and Neurochemical Factors With the development of noninvasive imaging techniques, such as computed tomography, magnetic resonance imaging, and positron emission tomography, in the past 25 years, scientists have been able to study the brain structure (neuroanatomy) and activity (neurochemistry) of people with schizophrenia. Findings have demonstrated that people with schizophrenia have relatively less brain tissue and cerebrospinal fluid than those who do not have schizophrenia; this could represent a failure in the development or a subsequent loss of tissue. Computed tomography scans have shown enlarged ventricles in the brain and cortical atrophy. Positron emission tomography studies suggest that glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain. The research consistently shows decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia. This pathology correlates with the positive signs of schizophrenia (temporal lobe), such as psychosis, and the negative signs of schizophrenia (frontal lobe), such as lack of volition or motivation and anhedonia. It is unknown whether these changes in the frontal and temporal lobes are the result of a failure of these areas to develop properly or whether a virus, trauma, or immune response has damaged them. Intrauterine influences, such as poor nutrition, tobacco, alcohol, and other drugs, and stress are also being studied as possible causes of the brain pathology found in people with schizophrenia (Kendall et al., 2017). Neurochemical studies have consistently demonstrated alterations in the neurotransmitter systems of the brain in people with schizophrenia. The neuronal networks that transmit information by electrical signals from a nerve cell through its axon and across synapses to postsynaptic receptors on other nerve cells seem to malfunction. The transmission of the signal across the synapse requires a complex series of biochemical events. Studies have implicated the actions of dopamine, serotonin, norepinephrine, acetylcholine, glutamate, and several neuromodulary peptides. Currently, the most prominent neurochemical theories involve dopamine and serotonin. One prominent theory suggests excess dopamine as a cause. This theory was developed on the basis of https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1upt… 3/5 11/27/23, 3:40 AM Realizeit for Student two observations: First, drugs that increase activity in the dopaminergic system, such as amphetamine and levodopa, sometimes induce a paranoid psychotic reaction similar to schizophrenia. Second, drugs blocking postsynaptic dopamine receptors reduce psychotic symptoms; in fact, the greater the ability of the drug to block dopamine receptors, the more effective it is in decreasing symptoms of schizophrenia (Perez & Ghose, 2017). More recently, serotonin has been included among the leading neurochemical factors affecting schizophrenia. The theory regarding serotonin suggests that serotonin modulates and helps to control excess dopamine. Some believe that excess serotonin itself contributes to the development of schizophrenia. Newer atypical antipsychotics, such as clozapine (Clozaril), are both dopamine and serotonin antagonists. Drug studies have shown that clozapine can dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia (Kane & Correll, 2017). Immunovirologic Factors Popular theories have emerged, stating that exposure to a virus or the body’s immune response to a virus could alter the brain physiology of people with schizophrenia. Although scientists continue to study these possibilities, few findings have validated them. Cytokines are chemical messengers between immune cells, mediating inflammatory and immune responses. Specific cytokines also play a role in signaling the brain to produce behavioral and neurochemical changes needed in the face of physical or psychological stress to maintain homeostasis. It is believed that cytokines may have a role in the development of major psychiatric disorders such as schizophrenia (Dahan et al., 2018). Recently, researchers have been focusing on infections in pregnant women as a possible origin for schizophrenia. Waves of schizophrenia in England, Wales, Denmark, Finland, and other countries have occurred a generation after influenza epidemics. Also, there are higher rates of schizophrenia among children born in crowded areas in cold weather, conditions that are hospitable to respiratory ailments (Kendall et al., 2017). CULTURAL CONSIDERATIONS Awareness of cultural differences is important when assessing for symptoms of schizophrenia. Ideas that are considered delusional in one culture, such as beliefs in sorcery or witchcraft, may be commonly accepted by other cultures. Also, auditory or visual hallucinations, such as seeing the Virgin Mary or hearing God’s voice, may be a normal part of religious experiences in some cultures. The assessment of affect requires sensitivity to differences in eye contact, body language, and acceptable emotional expression; these vary across cultures. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1upt… 4/5 11/27/23, 3:40 AM Realizeit for Student Psychotic behavior observed in countries other than the United States or among particular ethnic groups has been identified as a “culture-bound” syndrome. Although these episodes exist primarily in certain countries, they may be seen in other places as people visit or immigrate to other countries or areas. Some examples of culture-bound syndromes are as follows: Bouffée délirante is a syndrome found in West Africa and Haiti, characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. It is sometimes accompanied by visual and auditory hallucinations or paranoid ideation (Mojtabai et al., 2017). Ghost sickness is preoccupation with death and the deceased frequently observed among members of some Native American tribes. Symptoms include bad dreams, weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, and a sense of suffocation. Jikoshu-kyofu is a condition characterized by a fear of offending others by emitting foul body odor. This was first described in Japan in the 1960s and has two subtypes, either with or without delusions (Greenberg, Shaw, Reuman, Schwartz, & Wilhelm, 2016). Locura refers to a chronic psychosis experienced by Latinos in the United States and Latin America. Symptoms include incoherence, agitation, visual and auditory hallucinations, inability to follow social rules, unpredictability, and, possibly, violent behavior. Qi-gong psychotic reaction is an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic symptoms that occur after participating in the Chinese folk healthenhancing practice of qi-gong. Especially vulnerable are those who become overly involved in the practice. Zar, an experience of spirits possessing a person, is seen in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies. The afflicted person may laugh, shout, wail, bang his or her head on a wall, or be apathetic and withdrawn, refusing to eat or carry out daily tasks. Locally, such behavior is not considered pathologic. Ethnicity may also be a factor in the way a person responds to psychotropic medications. This difference in response is probably the result of the person’s genetic makeup. Some people metabolize certain drugs more slowly, so the drug level in the bloodstream is higher than desired. In a study on poor treatment response, researchers found subtherapeutic plasma levels in some individuals despite having been administered therapeutic doses of the medication (McCutcheon et al., 2018). Black ethnicity was a factor associated with low plasma levels, causing the researchers to postulate that standard drug doses were not leading to therapeutic levels. Changing doses or changing the antipsychotic medication may be indicated in people with subtherapeutic plasma levels who have a poor response to treatment. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1upt… 5/5