8.25.2011

Understanding the Environmental Influence on Paranoid Schizophrenia: Shonda’s Case




Abstract
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Schizophrenia is one of the most misunderstood mental disorders that psychologist must treat in the field today.  In this paper, we have extensively studied the environmental influences of the disorder, how they affect the development of schizophrenia, and what psychosocial treatments are currently available for patients suffering from this terrifying disease.  Although there is no cure for schizophrenia, researchers continue to study the disease because the symptoms of this mental illness require lifetime care and medicine.  Through the study of Shonda, who is diagnosed with paranoid schizophrenia and suffering a psychotic episode, we explore these treatments,  such as, the season a person is born, the geographical location they live in, the actual birthplace, which is often referred to as urbanisation, immigration status, and even substance abuse.  These are explained as external environmental influences.  Another consideration that has been researched is the environment that the person experienced in the womb, as we are in fact in the early stages of neural and physical development at this time. We found that in the treatment of this complex disorder, that it takes both pharmacological treatment, along with combined psychosocial treatments such as cognitive therapy, family therapy, individual therapy, vocational therapy, and social skill training to manage cases such as these. 

Understanding the Environmental Influence on Paranoid Schizophrenia: Shonda’s Case
Introduction
Schizophrenia is one of the most complex diseases of all of the mental disorders, and there is no cure for it, only treatments, which serve to alleviate the distress that the symptoms cause as reported by Barlow and Durand (2007).  Along with biological and genetic factors, there are some environmental factors associated with triggers to the onset of this disorder.  There have been numerous studies according to Leask (2004) that explore the environmental influences on the development of schizophrenia and the subtypes associated with the disease.  In this paper, we will explore the psychological studies conducted, what effect these influences have on the development of the disorder, how it affects patients, along with which one affects them the most, which influence, biological, genetic, or environmental plays the biggest role and how this affects our bodies.  Last, albeit certainly not least, we will explore the psychosocial treatment options available to these patients through the study of the etiology of schizophrenia itself and the case study of Shonda, a paranoid schizophrenic.
Psychological Studies of Environmental Influence on Schizophrenia
There have been many different types of environmental studies on the effects of environment on the development of schizophrenia reports Leask (2004).  These involve such environmental factors as the season a person is born, the geographical location they live in, the actual birthplace, which is often referred to as urbanisation, immigration status, and even substance abuse.  These are explained as external environmental influences.  Another consideration that has been researched is the environment that the person experienced in the womb, as we are in fact in the early stages of neural and physical development at this time.  Leask (2004) also discusses the nuclear environment as a cyclic factor in which environment influences genetic reactions and that genetic reactions influence behavior, which in turn also affects environmental reactions.    
How Environmental Influences on Schizophrenia Affect Patients
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Leask (2004) notes that studies have shown that people born in the winter and spring in the north hemisphere, and those born in the spring in the south hemisphere of the earth have an extra 5% - 8% chance of presenting with schizophrenia later in life.  Geographically, it has been found that the presence of schizophrenia is considerably higher in developing countries.  This, he goes on to say is based on the first-rank symptoms as defined by the IC-9, and the Present State Examination (PSE).  The World Health Organization (WHO), conducted this study involving ten countries, “Colombia, Czechoslovakia, Denmark, England, India, Ireland, Japan, Nigeria, the USA and the (then) USSR” reports Leask (2004), involving both rural and urban areas (Leask, 2004). 
Krabbendam and van Os (2005) hold, that the results of ten studies conclude that roughly one third of all schizophrenia cases can be attributed to the urbanisation factor.  The science behind this theory shows that urban conditions produce these numbers because of the overcrowded, poor conditions having adverse effects on the development of the neurological functions in developing young minds.  Statistics show that schizophrenia develops in urban areas in excess of two to one over the development of the disease in rural areas.  It is also noted that these studies showed a direct correlation with having a genetic predisposition to the disorder as well (Krabbendam and van Os, 2005). 
Immigrant status also plays a part in the environmental influence, although it is hard to maintain data on immigrant populations due to their migrant and sometimes undocumented nature says Leask (2004).  Studies that have been conducted do show however, that the origins of the immigrant population such as Norwegian, Danish, and African Caribbean cultures, and also makes note that it may be less diagnosed in some parts of the world due to cultural norms.  Another environmental influence is substance abuse, reports Leask (2004), however the studies on this factor are inconclusive as of yet. The main thing to consider is that patients with schizophrenia have larger rates of substance abuse than people not diagnosed with this disorder.
There are also prenatal influences on this disease as discussed by Leask (2004).  This theory is founded on the reflection that patients with this disorder are different from other people in the way they process thoughts, behaviors, brains structure, and their pathology histories.  Some of the influences that affect the neurological development of children are prenatal stress, prenatal famine, prenatal influenza, and obstetric complications while the child is in utero.  Other influences of this nature include low birth weight, pre-eclampsia, and Rhesus incompatibility as Leask (2004) reports.  This makes sense, when one considers the importance of our earliest neurological development.  One more thing that can influence this disease is some viral infections that can alter brain performance (Barlow and Durand, 2007).
The psychosocial influences are stress, high expressed emotion, and reactions within families that contain schizophrenia states Barlow and Durand (2007).  Stressors such as loss from death, loss of a job, or combat situations, can trigger the onset of schizophrenia in people predisposed to the disease.  Often we find with these patients that families tend to criticize, treat with hostility, or even over involve themselves with the person.  This is called high expressed emotion and can often cause or contribute to the patient’s relapse. 
Which Environmental Influence Affects Patients the Most?
Schizophrenia seems to be most affected by the urbanization factor, which is involved with a geographic location and/or a birthplace according to the studies that have been performed in regards to this disorder.  However, given the studies involved within the research, it seems that we would have to say that the prenatal influences and stress/loss would be almost equal.  While the high expressed emotion can be very harmful, it doesn’t seem to fit the top of the list.  The other influences, viral, birth season, immigration status, seem to be important, yet still smaller in comparison to the others.  
Are Environmental, or Biological and Genetic
Influence More Prevalent on  Schizophrenics?
The answer to that as stated by Leask (2004), lies in the nuclear environment, which involves gene-environment interactions.  What this means is that genetic factors are influenced by the environment as much as the environment is influenced by choices derived from genetic factors.  In the schizophrenia disorder, it seems that genetic predispositions can trigger environmental reactions.  It has also been concluded that one’s genetic propensities also can affect their behavior, which has a direct effect on the environment that a person chooses (Leask, 2004). 
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Environmental Effect and Interaction with Biological Systems
Schizophrenia is a complex disorder on all fronts.  Barlow and Durand (2007), state that in this disorder, there are three neurotransmitter abnormalities are at work in the brains of these patients.  These would be, that the striatal dopamine D2 receptors, which are part of the basil ganglia disrupt the functional movements such as walking, balance, and movement, and also is responsible for deficiencies in the prefrontal D1 receptors. Along with the dopamine receptors in the prefrontal cortex, there has been research into the modification of the receptors that regulate glutamate communication.  This communication deals directly with N-methyl-d-aspartate (NMDA) (Barlow and Durand, 2007).
 The National Institute of Mental Health (NIMH) (2007) holds that recent studies have identified a fourth neurotransmitter, GABA that is also involved, and it is the reduction of enzymes such as the gene GAD1 that aid in the production of GABA.  This also plays an important role in schizophrenics’ development of the disorder.  Along with these changes in neurotransmitters, changes in the frontal lobes have also been noted which function to maintain less activity in people diagnosed with schizophrenia according to Barlow and Durand (2007).  This is also referenced as hypofrontality, particularly found in the dorsolateral prefrontal cortex in patients with schizophrenia, as researched by scientists from NIMH.  Barlow and Durand (2007), also hold that these cognitive dysfunctions begin to appear in patients before other symptoms and signs of the disease.
Available Psychosocial Treatments for Schizophrenia
Bustilo, Horan, Keith, & Lauriello (2001) completed the task of evaluating and updating the literature on the effectiveness of psychosocial treatments in schizophrenia, and evaluated eighteen studies for effectiveness.  Two of these studies were researching family studies, and they also selected two for the case management model.  Five each were selected for social skills training and cognitive behavior training.  They chose three studies involving employment programs, and even one to research individual therapy (Bustilo, Horan, Keith, & Lauriello, 2001).  These are good examples of current available programs available for these patients.
Effectiveness of Psychosocial Treatments on Schizophrenia
Bustilo, Horan, Keith, & Lauriello (2001) concluded that in the family studies the findings were in terms of high expressiveness and relapse.  What they found was in fact that in cases where high expression was involved, the theory that patients have a higher risk of relapse was empirically supported.  With this exception, it was found that relapse rates were down 40% in patients who received this form of therapy, from 64% to 24%. In addition, it was also noted that this form of treatment had longer lasting effects, lasting from nine months to a possible two years (Bustilo, Horan, Keith, & Lauriello, 2001).
In relation to the case study model Bustilo, Horan, Keith, & Lauriello (2001), reports that since it is hard for schizophrenics to have the cognitive reasoning it takes to manage their needs, case management provides a person a bridge between the patient and the different care providers.  They found one model that was different and a little more effective called the assertive community treatment model.  The premise of this model is that the care of patients was designated to one specific team of care providers consisting of the case manager, nurse, psychologist or psychologist and medical doctor that provide service 24 hours a day, every day, as needed.   The team has a fixed caseload in order to manage the patient needs effectively, and has proven to be an effective model for treatment, the only pitfall is the complexity of the model, but it has proven to be effective in the prevention of hospitalization.  It has not however shown to improve any other effects such as social skills, and employment reliability (Bustilo, Horan, Keith, & Lauriello, 2001).
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In social skills training, patients use principals from learning theory to achieve a better balance in maintaining daily activities associated with functioning in life (Bustilo, Horan, Keith, & Lauriello, 2001).  Examples of these would be basic daily functions of living, maintaining employment, leisure activities, and personal relationships.  Since it seems that most schizophrenics have trouble with information processing, the social skills training breaks this down into manageable steps utilizing role-playing in naturalized settings.  Patients who received the cognitive remediation model of the skills training seemed to function better when paired with concentrated support therapy, seems to produce some positive results in living skills, but shows no improvement when considering social and employment areas but still was even more effective when coupled with the case management model (Bustilo, Horan, Keith, & Lauriello, 2001).
In cognitive therapy, the goals are to try and better manage and reduce the intensity of the hallucinations and delusions associated with the disorder, while at the same time involving them in the prevention of relapse and levels of social functioning states (Bustilo, Horan, Keith, & Lauriello, 2001).  This is intended for patients with drug resistive psychosis symptoms, and alone may not be able to effectively, reach the goals, however has shown some propensity when coupled with medications.  The results of these studies seem mixed when considered without medication.  Overall, however, Bustilo, Horan, Keith, & Lauriello (2001) do conclude that while the studies into this method are limited there is some propensity to alleviate some of the intensiveness of the hallucinations and delusions with optimal pharmacology. 
With employment programs, also called vocational rehabilitation the goal is to get these patients into the realm of competitive employment.  This treatment is so that we can get them out of programs that are typically overseen by rehabilitation agencies according to Bustilo, Horan, Keith, & Lauriello, (2001).  What they found was that while these programs, especially those involved in early placement, along with the continuation of vocational training and mental health services provided effectiveness with patients maintaining employment, they did not produce any other positive results in patients.  They did prove to be somewhat effective in programs associated with urbanized areas and areas with dissimilar ethnic groups as discussed in urbanization.  This area of studies they also noted were not fully researched as limited studies has been conducted (Bustilo, Horan, Keith, & Lauriello, 2001). 
Individual treatment programs also referred to as psychoanalytical treatments, as noted by Bustilo, Horan, Keith, & Lauriello, (2001) was the preferred method of treating this disorder until the 1960’s, but has since been replaced by a more effective model.  This model is more intensive, and seems to help with social functioning.  The method utilizes relaxation techniques and cognitive structure to reduce symptoms when the patient is stressed.  What they concluded is that there was a significant difference in the social skills areas of the patient’s lives.  Bustilo, Horan, Keith, & Lauriello, (2001), state that the only drawback to this form of therapy is the fact that 40% of patients treated with this method never did move on to the next levels of functioning after initial improvements.
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 Effectiveness of Combining Treatment Approaches
When considering how to treat this disorder, researchers have considered all options.  What they have concluded is that based on the research done on treatment options, it is obvious that the most effective means of treating schizophrenics is to combine treatments with several elements of psychosocial models along with pharmacological options.  This disorder is so complex that it seems that there is no single treatment option that is effective alone.  The particular course of treatment should be tailored to the patient and their symptoms in order to reach the most effective method for them based on the degree and frequency of the symptoms.
Shonda’s Case Information
Eastern State Hospital Behavioral Health Client Case File
Client: Wilson, Shonda            DOB: 8/15/1979     Client CIS ID# ES10854
Address: 3543 Sunnyvale Lane                                Client SSN: 401-85-7530
City: Lexington   State: KY   Zip: 40517                    Health Insurance Co: Anthem
Phone (859) 849-5298      E-mail docplocky405@yahoo.com  Health Plan: Access
Case Type: Patient File- Continuous Paranoid Schizophrenia
            Initial Patient Screening Date: 2/12/2004
           Extra Background Information: Employed at Eastern State, performs light janitorial     duties.  Supervisor- Zachary Brown Phone Number- (859)652-5305
            Medical History:  Has frequent, almost continual audible hallucinations, accompanied by delusions.  Has been on antipsychotics for almost 12 years, most recently prescribed haloperidol (Haldol)
            Family Background:  Older brother lives in Florida, parents live in Versailles, KY.  Patient has not seen any of her family members for years.  Parents have always been emotionally distant, with this worsening with diagnosis of schizophrenia.  Home life was volatile, with parents constantly bickering, and the father has a violent temper, often beating wife and children.  Father possibly an alcoholic.  One aunt on her father’s side was institutionalized for a nervous breakdown.  There is no other history of mental illness in the family history.
Date: 8/2/2011
           Current Issues: This morning I received a call from Zachary Brown advising that Shonda had not shown up for work today.  Upon visiting her at her residence, I found her anxious, fidgety, and very frightened of the voices she has been hearing in the past week.  Client has been hearing audible hallucinations since her first diagnosis of Paranoid Schizophrenia 12 years ago, but normally can function enough to work.  Client reports that voices are getting more intense, and frightening, critical, harsh, and louder. Shonda also states that she has been attempting to hide from the voices in closets and under beds but is having no success. She currently is delusional, and believes that she is under surveillance by the CIA and the FBI, and that they have planted cameras in her home and workplace.  Client is visibly agitated, and confused with disjointed speech patterns and alogia.
            Recommendations: I recommend immediate hospitalization, with adjustment of medicine.
        Figure 1

Paranoid Schizophrenia Subtype Psychosocial Treatment and Environmental Influence
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According to Medline Plus (2011), people suffering from the paranoid schizophrenia subtype have delusions, often of people plotting against them, and audible hallucinations are common as well.  The environmental issues most associated with this subtype are the ones involving urbanization, prenatal environments, and environmental stress.  These influences seem to bring on the onset of the disorder, and cause paranoid schizophrenics to begin to  isolate themselves socially, and have feelings that they need to protect themselves at all times from the people plotting against them, in other words, bringing on the delusions and hallucinations, as noted by Leask (2004).  You can clearly see this in the psychotic episode that Shonda is experiencing.

Best Course of Combined Treatment for Positive Outcome
Based on the research covered, most of the studies agreed that a combined treatment plan has the best effect on this disorder.  This means that a paranoid schizophrenic like Shonda should be receiving case management, cognitive therapies, and family treatments, however, in her specific case, she has no family so that may be excluded.  These therapies should be in conjunction with pharmacological treatments.
The antipsychotic drugs available to treat schizophrenia fall into four classes, Phenothiazines (Chloropromazine/Thorazine, or Fluphenazine/Proloxin for example), Butyrophenones (Haldol), Others (Loxapine/Loxitane for example), and Second Generation Agents (Ariprazole/Abilify, Clozapine/Clozaril, or Quetiapine/Seroquel for examples of these) (Barlow ad Durand, 2007).  These medications seem to be effective, and usually are prescribed mostly to work on the dopamine system, in an effort to regulate the neurotransmitters in our brains (NIMH, 2004).  Since Shonda has been on antipsychotic medicines for the better part of twelve years already, and had recently been prescribed haloperidol (Haldol), with which, she had shown some improvements previously until this psychotic episode, an adjustment in her medication is needed.  For the immediate future, it should be recommended that Shonda be immediately hospitalized for stabilization.  While she is hospitalized careful adjustments of her medicine should be explored, as she will be monitored in this setting.  She already has a case management program, however while she is hospitalized she needs to be introduced to cognitive therapies, to aid in the reduction of the hallucinations and delusions, along with an independent treatment to serve in the place of the family therapy.  When she is stabilized, and released, this course of treatment should continue for a minimum of one year and longer if needed.
Conclusion
We have explored the psychological studies conducted in attempt to find either a cause for schizophrenia or the best effective treatment course for Shonda, who is diagnosed with paranoid schizophrenia.  We have studied what effect these influences have on the development of the disorder, and, how it affects patients, along with which one affects them the most, which influence, biological, genetic, or environmental plays the biggest role and how this affects our bodies.  In exploring the etiology of schizophrenia, we have looked at the psychosocial treatments available to these patients, particularly Shonda, our paranoid schizophrenic case study.  What we found is that the best known research points to the fact that it is biological, genetic, and environmental influencers are comorbid, considered to interact together throughout our lifetime, and that, it is a combination of all three that designate a person’s risk to the development of the disorder. 
















References:
Barlow, Durand, (2007).  Essentials of Abnormal Psychology.  Mason, Ohio.  Cengage Learning
Bustilo, J.R., M.D., Horan, W.P., M.S., Keith, S.J. M.D., & Lauriello J., M.D., (2001).  The Psychosocial Treatment of Schizophrenia: An Update.  Am J Psychiatry 158:163-175, February 2001.
Journal of Psychiatry and Neuroscience, (2002).  The Neuropathology of Schizophrenia: Progress and Interpretation.  Vol. 27 May 2002, (3): 193-194.  Retrieved From: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC161649/
Krabbendam, L., and van Os, J. (2005).  Schizophrenia and Urbanicity: A Major Environmental Influence-Conditional on Genetic Risk.  Schizophrenia Bulletin, vol. 31, no. 4, pp.795-799, 2005.
Leask, S.J., (2004).  Environmental Influences in Schizophrenia: The Known and the Unknown.  Advances in Psychiatric Treatment, Journal of Professional Development, (2004), vol. 10, 323-330
Medline Plus, (2011) Schizophrenia- paranoid type.  Retreived From: http://www.nlm.nih.gov/medlineplus/ency/article/000936.htm
National Institute of Mental Health (NIMH), (2007).  How Schizophrenia Develops: Major Clues Uncovered.  Retrieved From: http://www.nimh.nih.gov/science-news/2007/how-schizophrenia-develops-major-clues-discovered.shtml
U.S. Department of Health and Human Services (Surgeon General), (1999).  Mental Health: A Report of the Surgeon General—Etiology of Schizophrenia.  Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health,



National Institute of Mental Health, 1999.  .  Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.  Retrieved From:  http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec4_1.html#etiology


Other References:

McFarr, L.M., Ph.D. (2010).  Academy of Cognitive Therapy.  Schizophrenia and Cognitive Therapy.  Retrieved From:      http://www.academyofct.org/Library/InfoManage/Guide.asp?FolderID=1097&SessionID=
National Institute of Mental Health (NIMH), (2011).  How is Schizophrenia Treated?  Retrieved From: http://www.nimh.nih.gov/health/publications/schizophrenia/how-is-schizophrenia-treated.shtml

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