A General Diagnostic Understanding: Schizophrenia and Related Psychotic Disorders

schizophreniaJen L’Insalata

Schizophrenia is a psychotic disorder characterized by the disruption of an individual’s sense of self and perception. Psychotic symptoms manifest in the form of auditory, visual, and sensational hallucinations, disordered or delusional thoughts, and disruptions in language and communication. An individual with schizophrenia is not always incoherent. Most individuals experience periods of active symptoms and symptom remission, while many experience at least one period of relapse (NIMH, 2009).

Schizophrenia is sometimes confused with having a split of multiple personality which are characteristic of another disorder. Diagnosing in an emergency room setting can be difficult as symptoms manifest differently in varying individuals. Involuntary hospitalization can only occur legally if a professional witnesses psychotic behavior which can take the form of the vocalization of delusional thoughts (NIMH, 2009).

295.90 (F20.9) Schizophrenia is characterized by delusions, hallucinations, disorganized speech that is easily derailed or incoherent, grossly disorganized or catatonic behavior, and negative symptoms including flat affect and diminished emotional expression. The symptoms must be severe enough to impact normal day to day function such as interpersonal relationships and self-care (APA, 2013). In an emergency room scenario it may be difficult to assess the impact of the symptoms on education and employment. It may be easier to visually assess the appearance of the individual to gather the extent of the symptoms on daily functionality. Schizophrenia can be distinguished from other psychotic disorders based on severity and length of duration of the symptoms. In schizophrenia the symptoms persist continuously for six months and meet the full diagnostic criteria for at least one month. If the duration and severity of the symptoms is less than the diagnostic criteria, a diagnosis of schizophrenipform disorder may be more appropriate. Additionally, if the active phase of psychosis includes depressive symptoms, a diagnosis of schizoaffective disorder may be warranted (APA, 2013).

Schizoaffective Disorder is similar to schizophrenia and symptoms include hallucinations, delusions, disorganized thought, and negative symptoms. In addition to the psychotic features present, individuals with schizoaffective disorder also exhibit features of depressive disorders and bipolar disorders. Coding for schizoaffective disorder is based on the mood episodes exhibited. 295.70 (F25.0) Schizoaffective Disorder, Bipolar type indicated there is a manic phase to the mood disturbances indicative of bipolar disorder. In 295.70 (F25.1) Schizoaffective Disorder, Depressive type, the individual experiences mood symptoms congruent with major depressive disorder (APA, 2013).

298.8 (F23) Brief Psychotic Disorder is characterized by the presence of delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. Symptoms last for at minimum, one day and at maximum, one month. Typically the onset is sudden and an individual goes from a non-psychotic to a psychotic state within two weeks. The differentiation between Brief psychotic disorder and other forms of psychotic disorder focuses on the length of time and onset of the symptoms. If the symptoms last longer that one month, the diagnosis of schizophrenipform disorder is more appropriate. Additionally, individuals who experience brief psychotic disorder do not meet the full DSM criteria for schizophrenia and show no disturbance in mood or affect. Individuals who experience brief psychotic disorder do not often show negative symptom that are common in schizophrenia. If mood congruent symptoms are present, schizoaffective disorder is a more appropriate diagnosis (APA, 2013).

The exact cause of schizophrenia is still unknown. It is believed that there is genetic, biological, and environmental links that correspond with the disorder and provide risk factors. Schizophrenia shows a genetic component and runs within families. Having a first degree relative with schizophrenia increases a person’s likelihood to develop the disorder themselves. Environmental factors such as exposure to prenatal viruses, malnutrition, and complications during birth also increase the risk of schizophrenia (NIMH, 2009). According to the diathesis stress model, individuals inherit a high or low genetic risk for schizophrenia. Varying psychosocial factors throughout the lifespan such as stressors and experiences influence the trajectory and development of the disorder (U.S. Department of Health and Human Services, 1999).

Several genes have been linked to schizophrenia and individuals with schizophrenia have a higher rate of gene mutation than healthy individuals. Brain physiology also differs in individuals with schizophrenia. Ventricles in the center of the brain are often larger in schizophrenic patients and individuals have decreased amounts of gray matter than healthy individuals. Genes that code for the chemicals associated with the development of higher brain function, neurotransmitters such as dopamine and glutamine are also effected which cause changes to the neuropathways that develop during puberty (NIMH, 2009).

Individuals with schizophrenia who receive treatment have a better outcome than individuals who do not. One halt to two thirds of individuals who receive treatment recover or show significant improvement over time (U.S. Department of Health and Human Services, 1999). Treatment for schizophrenia includes both psycho-pharmisudical and psychotherapeutic interventions that focus on eliminating the symptoms and developing coping strategies.

During the 1950’s antipsychotics were developed to treat schizophrenic symptoms. This first generation of antipsychotics consisted of medications including Chlorpromazine (Thorazine), Haloperidol (Haldol), Perphenazine (Etrafon, Trilafon), Fluphenazine (Prolixin), and Clozapine (Clozaril). Each individual responds to treatment differently, however Clozapine appeared to be most effective in the most varied cases. Clozapine also had a side effect that reduced white blood cell count requiring patients using the medication to receive blood screening every two weeks (NIMH, 2009).

During the 1990’s a second generation of antipsychotics were developed that had reduces side-effects. These include Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripiprazole (Abilify), Paliperidone (Invega); which are more commonly prescribed today. Side effects to antipsychotics may include drowsiness, dizziness, blurred vision, rapid heartbeat, sensitivity to the sun, and skin rashes. In women, menstrual problems may occur. Additional side effects may be physical in nature and long term use of antipsychotics may cause loss of neuromuscular control. Once a compatible antipsychotic is found patients may see improvements in as little a few days, with an overall reduction in psychotic symptoms in as little as six weeks (NIMH, 2009).

In addition to pharmisudical treatment, psychotherapy is important to an individual’s recovery.  Therapy provides prosocial, interpersonal, vocational skills, and education that helps prevent relapse of symptoms. Family and community based therapy helps to build a support system that also helps improve the individual’s prognosis. Psychosocial and Cognitive Behavioral Therapy address the disruptive thoughts and perceptions that are symptomatic of schizophrenia. CBT helps develop coping skills that allow the individual to test the legitimacy of their delusions or hallucinations and implement healthy behavioral alternative to actin on such thoughts. Prosocial components address areas of daily self-care, occupational, and educational skills that help schizophrenic patients live healthy and functioning lives (U.S. Department of Health and Human Services, 1999, & NIMH, 2009).

Schizophrenia effects men and woman and displays cultural equality, however not all symptoms manifest the same. Misdiagnosis can occur if the culture to which a patient differs from that of the diagnosing clinician.  Many cultural sub groups participate in religious experiences where hearing voices or seeing vision is acceptable. In other cultures, affect and avoidance can be misinterpreted as paranoia or other negative symptoms. It is important to understand the culture from which an individual comes from to determine if the symptoms are due to psychosis or cultural misinterpretation (U.S. Department of Health and Human Services, 1999, & NIMH, 2009).

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. ISBN: 9780890425558.

National Institute of Mental Health. (2009). Schizophrenia. Retrieved from http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from http://profiles.nlm.nih.gov/ps/access/NNBBHS.pdf

Theories of Moral Development

moral
Jen L’Insalata

Morality is often defined as an individual’s ability to judge and understand what is right and wrong and then to act in accordance to what they judge to be right. An individual’s moral and belief system influence their behaviors. Behaviors aligned with personal beliefs and morals help to build self-concept and self-esteem (Broderick, & Blewitt, 2010).

A child’s early sense of morals are influenced by a system of rewards and punishment established by the caregiver. Young children will act in accordance of with the egocentric self to meet the standards of their primary caregiver and avoid punishment. Perspective-taking improves and parental established morals give way to a conscience that intertwines emotions, cognition, and behavior (Broderick, & Blewitt, 2010).

Despite cultural and religious influences on morality, there are several universal component that establish good morals. Generally speaking, morality take into account the concern for others, a sense of justice and fairness, honesty and trustworthiness, and self-control (Broderick, & Blewitt, 2010). Feelings of morality and actions are often at a conflict and moral conduct appears to be determined more by situational assessment then by moral reasoning (Broderick, & Blewitt, 2010).

Several theories surrounding moral development exist. Freud discussed in his Psychoanalytic Theory that infants and young children are driven by the impulses of the self-serving id. The superego emerges and establishes a source of morals around preschool age (Broderick, & Blewitt, 2010). Freud believed these morals stemmed from an internalized system of rewards and punishments driven by parental conflict. Around the age of three, vague sexual desires toward the parent of the opposite sex and leads to an internal conflict and competition with the parent of the same sex. The solution to this conflict is to identify with the dominant same sex parent in order to be like them and satisfy this sexual longing (Broderick, & Blewitt, 2010). Morals are established by imitating the same sex parent’s actions.

Later research has failed to support Freud’s Psychoanalytic predictions. Finding show that children as young as eighteen to twenty-four months are capable of understanding empathy. This is inconsistent with Freud’s timeline for the emergence of the id ego and superego (Broderick, & Blewitt, 2010). Toddlers do however preform pro-social actions as a willingness to comply with the authority of their parents. The Psychoanalytic Theory associates this compliance with a fear of the same sex parental conflict. This concept contradicts research establishing that secure attachment and warm affectionate parental styles forester pro-social behavior and moral development (Broderick, & Blewitt, 2010).

Cognitive Theories of moral development center on the works of Piaget, Kohlberg, and Gilligan and emphasize changes in logical thinking at the core of moral development. Piaget theorized that there are three stages to moral development, premoral, heteronomous, and autonomous (Broderick, & Blewitt, 2010). In studies, Piaget presented children with moral dilemmas and asked them to assess the behavior of the protagonist or the rules of a game. During the premoral stage, infants have no concern for rules and often make up their own rules to serve an egocentric purpose. Around age five, children enter the heteronomous stage and view morals and rules through a realist perspective. They view rules at concrete and never to be broken. Violation of rules requires immediate justice and punishment. During middle childhood socialization and perspective-taking abilities become more refined. The child transitions into the autonomous stage and views morals as a social agreement to promote fairness. Rules can be modified and amended to serve a higher social purpose (Broderick, & Blewitt, 2010).

Kohlberg expanded on Piaget’s theory and assessed moral development beyond childhood into adulthood. Kohlberg based much of his work off philosophical concepts of morality referenced in Plato’s The Republic (Jorgensen, 2006) which morality is centered on justice. Utilizing unconventional philosophical scenarios, Kohlberg established three levels of moral reasoning each broken into stages. The preconventional level corresponds with Piaget’s heteronomous stage and established that children follow rules to avoid punishment and judgment from a superior authority during stage one. During stage two, children follow rules to serve their own interest, however may include the interests of others (Broderick, & Blewitt, 2010).  The conventional level is reached during adolescence and young adulthood. In stage three, social relationships become moral motivators and shared interests trump personal interest. Stage four focuses on social and societal order. Morals and behaviors at this stage are motivated by contributions to society, responsibility, and laws (Broderick, & Blewitt, 2010).  The postconvetional levels focus on universal standards of justice, democratic principles, and individual rights. Stage five establishes a moral social contract and is reached around adulthood. Stage six takes a more theoretical approach and addresses abstract concepts of social justice (Broderick, & Blewitt, 2010).

Research supports both Piaget and Kohlberg and shows that children indeed pay attention to the consequences and punishments surrounding moral violations and older children pay more attention to the intent of the protagonist to establish moral basis (Broderick, & Blewitt, 2010).  However finding show that children have a greater capacity for focusing on intentions and moral reasoning then given credit in the theories of Piaget and Kohlberg. Studies also show that preschoolers are able to differentiate between an intentional lie and a mistake and judge the liar more harshly (Broderick, & Blewitt, 2010).  Piaget believed that children believed all rules to be handed down from a superior authority. Children do however show a philosophical understanding of the difference between moral rules, conventional rules, and cultural rules. Children have the capacity to view cultural rules as arbitrary, but adhere more strictly to personal self-governed rules (Broderick, & Blewitt, 2010). Thus demonstrating that children have the understanding moral context.

Gilligan often criticized Kohlberg stating that his description of moral reasoning focused primarily on cerebral components of justice, ignoring the care and concern involved in moral reasoning (Jorgensen, 2006). Gilligan argued that morals developed on different trajectories for males and female. Women are more inclined to introduce sympathy, empathy and compassion into moral reasoning, whereas males utilize justice as an emphasis for moral reasoning (Broderick, & Blewitt, 2010).  This feminine viewpoint has earned Gilligan criticism question her bias in her approach to moral reasoning (Jorgensen, 2006).

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References:

Jorgensen, G. (2006). Kohlberg and Gilligan: duet or duel?. Journal Of Moral Education, 35(2), 179-196. doi:10.1080/03057240600681710

Broderick, P. C., & Blewitt, P. (2010). The life span: Human development for helping professionals (3rd ed.). Boston, MA: Allyn & Bacon. ISBN: 9780137152476