8.06.2011

Understanding Paranoid Schizophrenia: Shonda’s Case


by Elizabeth Hall 
Abstract
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Schizophrenia is one of the most misunderstood mental disorders that psychologist must treat today, however it is not a new disorder, and has been around for as long as there have been people.  The exact causes of the disease has not been pinpointed as of yet, however researchers have come far in discovering that it is both genetics and the environment that must be considered when researching the disease, as neither side alone seems to be the cause.  There are many subtypes of schizophrenia, paranoid, catatonic, undifferentiated, and disorganized schizophrenia, and no two people seem to present the exact symptoms and signs of the disease, not even when comparing quadruplets that were raised in the same house.  Antipsychotic medications and psychosocial programs are used to treat schizophrenia and the symptoms, although there is no cure, and most people that present the symptoms of the disorder can only hope for treatments to improve their quality of life and to minimize symptoms and relapses.



 Understanding Paranoid Schizophrenia: Shonda’s Case
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Schizophrenia is one of the most complex and misunderstood mental disorders that psychologists must treat as noted by the University of Texas Harris County Psychiatric Center at Houston (1997).  The audible and visual hallucinations, catatonia, and delusions that define this disorder make this disease particularly frightening for the patients, but also to society as well according to Barlow and Durand (2007).  Hallucinations and delusions seem to be the most prevalent symptom in all patients in one form or another however; the symptoms actually range from positive symptoms such as the delusions and hallucinations to negative ones such as avolition, alogia, anhedonia, and affective flattening.  There are also disorganized symptoms including disorganized speech, and catatonic immobility.  This wide range of symptoms is because there are several different subtypes of the disorder, and many different symptoms, which vary in degree and effect from subtype to subtype and present themselves differently in each patient (Barlow & Durand, 2007).
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These differences are a major factor in the public misconceptions of this disorder notes Barlow and Durand (2007).  The subtypes, paranoid schizophrenia, disorganized schizophrenia, undifferentiated schizophrenia, and catatonic schizophrenia all present differently, and contribute to the general misconception people have about the disease.  This paper will explore the science involved in the disorder including the biological and behavioral aspects, the known causes and neurotransmitters involved, what genetic factors influence the disorder, any brain abnormalities found to be consistent, and explore the subtype, paranoid schizophrenia through a particular case, along with treatments available to treat this frightening disease.  Through the discussion of the disorder, we hope to provide a better understanding of the science because it can only benefit the patients, and society, if we look deeper into what is really happening to the patient’s brain to clear up these misconceptions held by society (Barlow & Durand, 2007).
Behavioral and Biological Aspects of Schizophrenia
As the National Institute of Mental Health (NIMH) (2010) reports, schizophrenia is a very debilitating disorder.  This is true for the patient, the families of schizophrenics, and the public.  This stands to reason, as it contributes to the homeless population, families of those diagnosed are under duress because of the nature of the disorder, and the cost of treatment, and finally for the diseased, the symptoms of the disease itself are terrifying to experience.  People suffering from schizophrenia may see things that are not there, or hear things that are not there, and not be able to communicate well, along with feeling persecuted.  They even may be catatonic, or rather unable to move freely due to mental defects in the brain.  Three categories of symptoms identify with schizophrenia; however, they cover large ranges of symptoms, which are, positive symptoms, negative symptoms, and cognitive symptoms (NIMH, 2010).  
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Positive symptoms include delusions and hallucinations that are very real for the patient, who will be amazed that you cannot see, understand or hear them clearly, as they can (Barlow & Durand, 2007).  Delusions can come in many forms such as delusions of grandeur where the patient thinks that they alone can solve large global or local issues like world hunger for example, or persecution where they feel like they are being watched or that aluminum foil hats will stop the aliens from using their brains to communicate back and forth.  They are beliefs, which are not culturally associated with the person, but deemed untrue by the rest of society and often are perceived as bizarre.  Hallucinations are visual or audible disturbances in perception, causing the patient to see hear or smell things that are in reality not present.
 Hearing voices is very common in people diagnosed with schizophrenia, and they may be positive or negative in relation to what they say to the person.  Some may hear or see people telling them to hurt themselves or others, while other patients may see or hear things that coincide with delusions they have, such as that they work secretly for the FBI, have contact with aliens, etc.  In any case, these types of symptoms cause people suffering from schizophrenia to have trouble holding employment, which in turn also places a burden on society to provide welfare to these persons.  Another probability is that they will  become homeless and muttering to themselves animatedly as if they were talking to someone else, as they walk the streets because they simply have no place to go (Barlow & Durand, 2007).
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Negative symptoms include avolition, alogia, anhedonia, and affective flattening (Barlow & Durand, 2007).  Avolition refers to the patient being unable to start or finish activities and people often see this as apathy because they just have no desire to do either.  Often this affects patients’ hygiene and other basic daily functions which also affects how society views people who suffer from this disorder.  Alogia is what is used to describe the lack of speech that is seen markedly in schizophrenia patients, and is defined as  short brief replies coupled with a seemed lack of interest in conversation at all (Barlow & Durand, 2007). 
A third negative symptom is anhedonia which NIMH (2010), defines as a marked “lack of pleasure in everyday life”, and results in the patient experiencing no interest in pleasurable activities such as eating, social situations, and sex (Barlow & Durand, 2007).  This, combined with affective flattening, which is another symptom of schizophrenia, makes this a particularly debilitating disease.  Affective flattening, which affects facial expressions and emotional responses, causes the patient to have monotone speech and no reaction to the immediate world around them when it would be a normal response to react.
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Cognitive symptoms according to NIMH (2010) are symptoms that affect the schizophrenic’s ability to focus, pay attention, process information, even right after learning it, and to make sound decisions.  This can affect their ability to regulate and take their medicine, and function on their own in daily life.  Schizophrenics often have symptom relapses when they skip, or stop taking their medications.  During these incidents of symptoms, there are actions happening in the brain between the synaptic clefts using neurotransmitters, which are chemicals in the brain that cross the synaptic cleft allowing the neurons to communicate and pass messages between one another (Barlow & Durand, 2007). 
Neurotransmitters Involved
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As reported by Yale University School of Medicine, Psychiatry (2005), one of the major neurotransmitters involved with schizophrenia is dopamine.  The NIHM (2004) also concurs with this, but goes on to note that dopamine is not the only neurotransmitter that is related to schizophrenia, and names glutamate as a big player that has been linked to the disease for a long time.  This study relates the glutamate receptor GR3, which regulates the amount of glutamate present in the synaptic clefts, to possible negative impacts on cognitive functions.  Researchers are also now aware that this disorder affects the regions in the forefront of the brain, which take part in the higher thinking functions and the decision-making processes for people.  According to NIMH (2007), recently  they have also found that GABA is also involved, and it is the reduction of enzymes such as  the gene GAD1 that aid in the production of GABA that play an important role in schizophrenics’ development of the disorder.  When you discuss the neurotransmitters, however this activity is also closely related to genetics.
Genetic Contributions to Schizophrenia
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Schizophrenia is the disorder with the clearest distinction between genetics and behavior, as it is found to clearly run through families, Barlow and Durand (2007) make the connection in the direct statement, “we can safely make one generalization: Genes are responsible for making some individuals vulnerable to schizophrenia”. There have been several different types of studies to show this connection as well.  These include twin studies, family studies, adoptee studies, offspring of twin studies, and linkage studies.  Unfortunately, the studies’ findings show that no one gene causes people to become more susceptible to schizophrenia, but instead combinations of numerous genes cause it to affect people (Durand & Barlow, 2007). 
There was a family study done in 1938 by a man named Frank Kallmann that confirmed the correlation of the severity to which the parents were affected by the disease, with the chances that their offspring would follow suit and develop schizophrenia states Barlow and Durand, (2007).  He made another valuable discovery during this study, finding that the type of schizophrenia that your relatives have really has no bearing on what subtype (paranoid, disorganized, etc.) of schizophrenia you may inherit.  Instead, he believes that what you really inherit is just a genetic predisposition for schizophrenia, as all of the types ran through the individual families at random. Another fact from Barlow and Durand (2007), is that current research holds that if your family has a member that has been diagnosed with schizophrenia, this will put your family as risk candidates for multiple psychotic disorders all related to schizophrenia in some way. A summary of approximately forty different research projects concerning schizophrenia, were also studied by another group, and concluded that the likelihood of a person developing schizophrenia in their lifetime is directly correlated to the number of genes that person shares with someone already presenting the disorder (Barlow and Durand, 2007).
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Twin studies prove that environment alone is not responsible for the development of schizophrenia, but that genetics must play a part in the equation (Barlow & Durand, 2007).  This is because if they are not separated, but in fact, raised together, they share the full one hundred percent of their environments.  If they are identical twins, then they also share one hundred percent of their genetic material as well.  Even with fraternal twins, they still share half of their genes, however, when David Rosenthal and the NIMH studied a group of quadruplets who had grown up together in less than desirable conditions they found that the disease presented itself differently in all four.  This held true for the entire course of the disease from the age of initial onset to the results that came from the disorder. This is particularly important because it shows that even with identical genes and environments; individualism still applies when it comes to the genetics of schizophrenia (Barlow & Durand, 2007).
Europe seems to be where studies of adoption in relation to schizophrenia are mostly carried out.  This is because of the socialized medicine system practiced there.  Apparently, notes Barlow and Durand (2007), a bonus for researchers is that socialized medicine requires that very precise records be kept.  Key findings from these studies show that even when completely removed from the environment, children of parents with schizophrenia are more likely to develop the disease anyway.  This strongly suggests that the environment cannot be the sole cause of schizophrenia (Barlow & Durand, 2007).
When considering the offspring of twins, research done in this field discovered another important detail.  It is possible to be a carrier of schizophrenia and pass the genes on, even though you may have not presented with any symptoms or signs of the disorder, asserts Barlow and Durand (2007).  The offspring of twins’ research did find that there is about a 17% chance of developing the disease even if your parent did not show the disorder, meaning that other factors must have to be involved to develop the disease.  Barlow and Durand (2007) go on to state that this is the most important evidence that genetics play a role in the development of schizophrenia.
One final type of study called Linkage and Association Studies, have been able to use traits (blood types for example), to use the fact that they already know the location on the chromosome, to study the genetic disposition of traits that are known to be inherited with the disorder you are studying.  These are known as marker genes, and by studying them, we can estimate the location of the disease genes we are looking for.  What was found in relation to schizophrenia was that the easiest way to study these genes was to study the dopamine genes to establish whether there is a link to schizophrenia, and if so, what that link is (Barlow & Durand, 2007). 
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In relation to schizophrenia there have been several different genetic markers studied, because it seems that researchers have come to the realization that it may be easier to study the common traits of the disorder rather than symptoms of the disease.  This is because of the varied presentation and degree of symptoms found within patients with this disorder, states Barlow and Durand (2007).  One of these was about the movement of the eyes, and it concludes that it is hard for schizophrenics to track an object across their visual field in a smooth manner. Just as importantly, it also studied relatives, and they have shown a lack of ability to follow objects with their eyes alone smoothly (Barlow and Durand, 2007).  Genetically, researchers have now seen that it is multiple genes responsible for the development of schizophrenia. This observation, called quantitative trait, loci represents an explanation into the variances of the disease, including why we have gradations of severity, and that these studies show the correlation between the number of family members with the disease and the chances of developing it increasing with the addition of each new family member diagnosed (Barlow and Durand, 2007).
Brain Abnormalities in Schizophrenics
The Journal of Psychiatry and Neuroscience (2002) considers schizophrenia as a disease of the brain.  It always has been thought of in this classification area for as long as people have been studying it.  In recent decades with the invention of the MRI, and Computed Tomography (CT), researchers have been able to study physical defects that are present in the brains of schizophrenics.   They have found several brain abnormalities such as lateral ventricles appear larger than normal while cortical grey matter and hippocampal masses appear to be smaller than normal.
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 Barlow and Durand (2007, p490 par3-4) go on to say that there is very good evidence that schizophrenia is partially caused by “excessive stimulation of striatal dopamine D2 receptors” and by the “deficiency in the stimulation of prefrontal D, receptors”.  These regions are located in the basil ganglia and the prefrontal cortex. They also go into another newer area that has been researched that looks at modifications in the prefrontal cortex action that regulates glutamate communication.  This communication deals directly with N-methyl-d-aspartate (NMDA) receptors in the brain, and was discovered by studying effects of certain drugs on the brain (Barlow and Durand, 2007).
The frontal lobes have also been noted 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.  This, also like other symptoms and causes of schizophrenia react differently to each individual.
Paranoid Schizophrenia Subtype
Schizophrenia is such a complex disease because of these different reactions in individuals.  In this paper, we are going to review one case in particular, in which the patient suffers from continuous paranoid schizophrenia.  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.  They also tend to isolate themselves socially, and have feelings that they need to protect themselves at all times from the people plotting against them as noted by Medline Plus (2011).
Available Treatments for Schizophrenia
Although there is no cure for schizophrenia, it is very rare that anyone completely recovers, as told by Barlow and Durand (2007); however, there are treatments that can help to minimize the symptoms associated with the disease.  Usually this is accomplished by a combination of antipsychotic drugs and psychosocial therapy designed to minimize relapses and develop cognitive and physical skills in areas that the patient shows a deficit in performing.  These programs are also designed to help patients comply with taking their medicines regularly.  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 most work on the dopamine system, in an effort to regulate the neurotransmitters in our brains, but produce almost as annoying side effects such as drowsiness, rapid heartbeat, dizziness, sensitivity to the sun, and lowered libido (NIMH, 2004)
 Examples of psychosocial therapies include several types of therapy to improve patient quality of life.  One involves using a token economy with patients where they can receive rewards through tokens they receive for acting appropriately.  Another is behavioral family therapy where family members of schizophrenics are taught skills on how to deal with the family member affected.  A third program type is Independent Living Skills programs for the patients to assist them in acquiring skills needed to function better in society and to achieve a higher quality of living (Barlow and Durand, 2007).

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

Best Course of Treatment for Positive Outcome
Generally, the best course of treatment for a positive outcome in case of schizophrenia involves antipsychotic medicines and psychosocial treatments, but as stated by NIMH (2011) these are designed to minimize the symptoms of the disorder not cure it.  In order to have a positive outcome with a disease such as this in which no two individuals present the exact same symptoms or levels of impairment often, patients must try several different antipsychotics and treatment courses to figure out which works best for them individually.  Remember, what a positive outcome means for these patients is that they have managed symptoms and have gained enough skills to live out on their own (Barlow and Durand, 2007).  In our case study, Shonda Wilson had managed to do that, but the disorder pressed on, and she ended up in a relapse.
In a case such as Shonda Wilson’s disease progression, the best course of treatment for her would be to hospitalize her and adjust her medicine immediately.  She then must be watched for positive changes, and possible negative changes that occur after adjusting the medicine.  This is because antipsychotic drugs are very powerful, and any change in medicine whether up, down, or stopping them altogether can have very serious psychological effects on brain chemistry, and our physical health.  Because she has responded well to the haloperidol (Haldol), and has been on various antipsychotic drugs for the past 12 years, it would seem that the best choice for the psychologist to adjust her dosage up in small levels until they once again control her delusional and hallucination symptoms.

Conclusion
In this paper we have explored the science involved in the disorder known as schizophrenia including the biological and behavioral aspects, the known causes and neurotransmitters involved, what genetic factors influence the disorder, any brain abnormalities found to be consistent, and have explored the subtype, paranoid schizophrenia through a particular case, along with treatments available to treat this disease.  Schizophrenia remains one of the most widely misunderstood mental disorders that someone can suffer.  Everything about this disease from the symptoms to the side effects of the medicines is frightening to the patients, family, and friends of patients, and even to society itself, when we come across someone muttering and talking to themselves on the street.  Through the discussion of the disease, patients and society alike can only benefit, if we look deeper into what is really happening to the patient’s brain to clear up these misconceptions held by society (Barlow & Durand, 2007). 

References:
Barlow, Durand, (2007).  Essentials of Abnormal Psychology.  Mason, Ohio.  Cengage Learning
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/
Medline Plus, (2011) Schizophrenia- paranoid type.  Retreived From: http://www.nlm.nih.gov/medlineplus/ency/article/000936.htm
National Institute of Mental Health (NIMH), (2010).  Schizophrenia.  Retrieved From: http://www.nimh.nih.gov/health/publications/schizophrenia/complete-index.shtml
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
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
National Institute of Mental Health (NIMH), (2004).  Schizophrenia Gene Variant Linked to Risk Traits.  Retrieved From: http://www.nimh.nih.gov/science-news/2004/schizophrenia-gene-variant-linked-to-risk-traits.shtml
The University of Texas Harris County Psychiatric Center at Houston, (1997).  Understanding Schizophrenia.  Retrieved From:  http://www.uth.tmc.edu/uth_orgs/hcpc/schizophrenia.htm
Yale University School of Medicine, Psychiatry, (2005).  Research Clinics: What Causes Schizophrenia.  Retrieved From: http://www.med.yale.edu/psych/clinics/schizophrenia.html


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