HPS308 Psychopathology

Introduction

Schizophrenia is chronic and a cognitive disorder that is characterised by hallucinations, delusions , thought disorders, avolition, poor expression of the emotions, social withdrawal, suicidal tendency and other cognitive difficulties that significantly affects the way a person behaves and believes. It usually appears in the early adulthood or the late adolescent period.  There are generally five types of schizophrenia- paranoid schizophrenia, disorganized, or hebephrenic schizophrenia, catatonic schizophrenia, childhood schizophrenia and schizoaffective disorder. In Australia, Schizophrenia affects about 1.5 % of the population. The prevalence of the disease is more in the migrants than the native born people (Australian government, Department of health, 2018). 15 % of the people suffering from schizophrenia have had suicidal ideation frequently (Australian government, Department of health, 2018). Furthermore, there is also a strong public perception about schizophrenia, that all the schizophrenic patients are violent and can pose harm to the society.

The most effective available treatment for the schizophrenia involves both medication and psychological therapy yet there had been recurrent symptoms of schizophrenic episodes. In order to incorporate appropriate treatment strategies, it is necessary to have an in depth understanding of the biological, psychological and the social factors responsible for the symptoms. This literature review aims to explore the above mentioned factors behind the etiology of the disease.

Biological factors

Brain structure discoveries in case of Schizophreniua have been noticed with the help of magnetic resonance imaging (MRI). Volumetric differences in the brain of the schizophrenic patients have been observed. The volume of the superior temporal gyrus has been noticed in Schizophrenia and a correlation can be found between the changes in the volume and the characteristics of the illness (Rees et al., 2016). The medial temporal cortex, including the entorhinal, hippocampal cortex, parahippocampal and the hippocampal cortex have also shown reduction in size and the results has been consistent across different laboratories. Karlsgodt et al., (2010), have noted that there is a reduced blood flow in the prefrontal cortex in the brain in schizophrenia and this information served a great deal to develop the future ideas. Recently, the laboratories have focused on the abnormalities on the anterior cingulated cortex and the hippocampus of a schizophrenic brain. It is known that a normal brain involves a complexly interacting neuronal system. There is a long tract pathway between the sub cortical are and the frontal cortex, through which the basal ganglia affects the functioning of the frontal cortex (Rees et al., 2016). Since basal ganglia involve a diversity of modulators and neurotransmitters, any abnormality in the neurotransmitter functioning in the basal ganglia might lead to schizoaffective disorder. Furthermore, a study examined brain surface contraction in the schizophrenic patients (Sun et al., 2009). Surface contraction in the prefrontal and a reduction in the grey matter have been found to be higher in patients than the control group. Apart from the neurological factor, there are several genetic variants that make substantial contributions to thee this disorder.

A direct observation of the environmental and the genetic factors was demonstrated when it was observed that fetal hypoxia can be associated with the reduction in the grey matter and increased cerebrospinal fluid in patients suffering from Schizophrenia. Other free-natal factors associated with schizophrenic disorders are low folate, which can lead to the an increased plasma homocysteine (Rees et al., 2016) . An increased homocystiene imparts a modulatory effect on N-methyl- D-aspartate (NMDA) receptor, the key component of the gluitamatergic theory of schizophrenia.

Psychological factors

Certain environmental triggers and discrete events can trigger schizophrenia. Stresses like loss of parents, partners, disrupted family patterns, rejection, criticism, over involvement,  high anxiety and conflicts at home or with partners might lead to extreme stresses.

Factors like social isolation and high expressed emotions are one of the main cause of Schizophrenia. Expressed emotions have been found to be a significant predictor of the relapse of schizophrenia. However, there are very few papers in precipitating the first break in the psychosis. Jiang et al., (2013), had studied the impact of the environment of the family in the in the development of schizophrenia and found that lower levels of caregivers emotional attachment, warmth and remarks is associated with disruptive behavioral pattern in children. A study conducted by Li et al., (2017), have proved that social isolation leads to a series of schizophrenic deficit problems such as social withdrawal, cognitive impairment, anxiety disorder, sensorimotor gating disturbances, Surprisingly, Social isolation has also been linked with the potential interactions between histidine triad nucleotide binding protein 1 (HINT1), the NRI subunit of N-methyl-d-aspartate acid receptor, and D2R (dopamine type 2 receptor) (Mumtaz,  Khan, Zubair & Dehpour, 2018). Similarly, a study by Jiang et al., (2013), has reported that deletion of  the  N-methyl-D-aspartate receptor (NMDAR) from a subset of corticolimbic interneurons present in the mouse brain at the time of  early postnatal development is responsible for triggering several pathophysiological and behavioral features resembling the symptoms of human schizophrenia and many of the behavioral phenotypes have been found to be increased due to social isolation (Zhou et al., 2018). Again, Amaresha & Venkatasubramanian,  (2012), have explained the components of expressed emotions like hostility, critical comments, EOI, warmth and positive remarks that guides one’s behavioural patterns. A cross-sectional study involving 400 participants had demonstrated that anger, rejection, ignorance, blaming, irritability and negligence to be the main in house factors for the development of schizophrenic symptoms.

Social factors

One of the important social factors behind the cause and the maintenance of schizophrenia is the social stigma, which can cause antipsychotic non-adherence.  Despite of the recent advancements in the treatment of the schizophrenia, those people suffering from schizophrenia suffers from considerable stigma. Schizophrenic patients often suffer from self-stigma due to the process of internalization of the stigma. According to Higashi et al., (2016), people hallucinating with voices and visions often do not want to adhere to antipsychotics as they want the moments of fantasies to remain forever, or they love to stay in the world of fantasies. The urge of doing unusual and the exciting things makes them to live in the world of fantasies, which normally starts fading as the patient starts responding to the treatment. Some schizophrenic patients might not want to live in the reality and thus do not comply with the treatment regimen. A study by Read & Dillon, (2013), compared the adherence to medication between the patients with one mental illness and one somatic illness. Non adherence to medications was more found in patients with schizophrenic patients. The researchers have found out the stigmatization, shame and fear of being marginalized prevented them from taking the antipsychotics. Many people suffering from schizophrenic symptoms do not stick to the treatment regimen as most of them wants to conceal it from the society or workplace. This is due to the fact that in most of the cases people suffering from mental health illness are being discriminated in terms of terms of job role or remuneration.  Higashi et al., (2016), on the other hand have opined that society pays a great role other than self stigmatization and it is the emotional responses of the family that decides the antipsychotic adherence.

Effect of all the three integrated factors

As per the literary evidences discussed above, it can be easily perceived that there is a lack of concrete data or evidences regarding the actual reason behind the symptoms of Schizophrenia. A large gap can be noticed in the researches associated with the biological factors. A wide number of researches are still going on to identify the genes associated or the lobes of the brain involved. However Read& Dillon, (2013) , have opined that unmet needs during childhood such as the psychological needs might lead to the development of maladaptive schemas, which in turn designs neurological development in early childhood period. According to Gejman, Sanders & Duan, (2010), genetic factors like deletion of certain genes are not related to any king of preformed schema and are solely due to genetic mutations. It has already been mentioned that folate deficiencies at the time of pregnancy might lead to insufficient neuronal development causing the cognitive symptoms of schizophrenia. Folate deficiencies can again be related to lack of proper nutrition at the time of pregnancy, which indicates largely towards poor socio- economic status (Kirkbride et al., 2012). In relation to this Topor et al., (2014), have demonstrated that poverty is an important predicting factor of schizophrenia. Poverty has also been identified as one of the determinants of medical non-adherence. Hence, it is evident, that Schizophrenia can be multifactorial depending upon the type of exposure the patient is subjected to.

Conclusion

The literature review has portrayed a range of biological, psychological and the social factors behind the progression and the maintenance of the schizophrenic symptoms. Considering a large number of factors responsible for this condition, this review indicates towards the adoption of multidirectional approach for treating the symptoms. It can also be understood from this review that there are still some gaps left in the assessing the actual factors behind the disease and hence requires larger scopes of further researches.  However, proper screening, pharmacological treatment in collaboration with some strength based alternative approach can bring about positive patient outcomes.

The film that has been chosen for this assignment is “The voices” directed by Marjane Satrapi. It is a black comedy horror, where Jerry is a schizophrenic patient, who works at a bathtub factory and lives alone with his pet dog and cat. Jerry does not adhere to his medications as enjoys the hallucinations where, his pet dog and cat engages in conversation with him and encourages him to do obnoxious and violent activities. Jerry had a romantic interest for his colleague, but things turned bad when they were up for a date. Guided by the suggestions of the talking cat, Jerry ended up murdering his girlfriend. This main story is guided by several moments of fun and horror.

It should be mentioned that schizophrenic patients are subjected to delusional thoughts and hallucinations hence the clinical manifestations shown by Jerry in this film matches with the general signs and symptoms of schizophrenia.

Some of the tasks related to the depiction of the schizophrenia are discussing the stigma. It has to be noted, that patients suffering from schizophrenia are often marginalized due to the predetermined notion of violence due to some past experiences (Read & Dillon, 2013). Another task of depicting the mental illness is to understand the predisposing factors and the precipitating factors behind the clinical conditions. A range of biological, social and the psychosocial factors are responsible for this disease.

References

Amaresha, A. C., & Venkatasubramanian, G. (2012). Expressed emotion in schizophrenia: an overview. Indian journal of psychological medicine, 34(1), 12-20. doi:  [10.4103/0253-7176.96149]

Australian government, Department of health., (2018). Schizophrenia fact sheets, Australia. Access date: 4.12,2018. Retrieved from: https://www.health.gov.au

Gejman, P. V., Sanders, A. R., & Duan, J. (2010). The role of genetics in the etiology of schizophrenia. The Psychiatric clinics of North America, 33(1), 35-66. [10.1016/j.psc.2009.12.003]

Higashi, K., Medic, G., Littlewood, K. J., Diez, T., Granström, O., & De Hert, M. (2013). Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review. Therapeutic advances in psychopharmacology, 3(4), 200-218.

Jiang, Z., Rompala, G. R., Zhang, S., Cowell, R. M., & Nakazawa, K. (2013). Social isolation exacerbates schizophrenia-like phenotypes via oxidative stress in cortical interneurons. Biological psychiatry, 73(10), 1024-1034. https://doi.org/10.1016/j.biopsych.2012.12.00

Karlsgodt, K. H., Sun, D., & Cannon, T. D. (2010). Structural and Functional Brain Abnormalities in Schizophrenia. Current directions in psychological science, 19(4), 226-231. doi:  [10.1177/0963721410377601]

Kirkbride, J. B., Susser, E., Kundakovic, M., Kresovich, J. K., Davey Smith, G., & Relton, C. L. (2012). Prenatal nutrition, epigenetics and schizophrenia risk: can we test causal effects?. Epigenomics, 4(3), 303-315. https://doi.org/10.2217/epi.12.20

Li, B. J., Liu, P., Chu, Z., Shang, Y., Huan, M. X., Dang, Y. H., & Gao, C. G. (2017). Social isolation induces schizophrenia-like behavior potentially associated with HINT1, NMDA receptor 1, and dopamine receptor 2. Neuroreport, 28(8), 462-469. doi:  [10.1097/WNR.0000000000000775]

Mumtaz, F., Khan, M. I., Zubair, M., & Dehpour, A. R. (2018). Neurobiology and consequences of social isolation stress in animal model—A comprehensive review. Biomedicine & Pharmacotherapy, 105, 1205-1222. https://doi.org/10.1016/j.biopha.2018.05.086

Read, J., & Dillon, J. (Eds.). (2013). Models of madness: Psychological, social and biological approaches to psychosis. Routledge.

Rees, E., Carrera, N., Morgan, J., Hambridge, K., Escott-Price, V., Pocklington, A. J., … & Morris, D. W. (2018). Targeted sequencing of 10,198 samples confirms abnormalities in neuronal activity and implicates voltage-gated sodium channels in schizophrenia pathogenesis. Biological psychiatry. https://doi.org/10.1016/j.biopsych.2018.08.022

Shrivastava, A., Johnston, M., & Bureau, Y. (2012). Stigma of Mental Illness-1: Clinical reflections. Mens sana monographs, 10(1), 70-84. doi:  [10.4103/0973-1229.90181]

Sun D, Stuart GW, Jenkinson M, Wood SJ, McGorry PD, Velakoulis D, et al. Brain surface contraction mapped in first-episode schizophrenia—A longitudinal magnetic resonance imaging study. Molecular Psychiatry. 2009;14:976–986

Topor, A., Andersson, G., Denhov, A., Holmqvist, S., Mattsson, M., Stefansson, C. G., & Bülow, P. (2014). Psychosis and poverty: coping with poverty and severe mental illness in everyday life. Psychosis, 6(2), 117-127. https://doi.org/10.1080/17522439.2013.790070

Zhou, H. Y., Li, Z., Xie, D. J., Xu, T., Cheung, E. E., Li, H., & Chan, R. C. (2018). Heritability estimates of spatial working memory and set?shifting in a healthy Chinese twin sample: A preliminary study. PsyCh journal, 7(3), 144-151. doi:  [10.4103/0973-1229.90181]