A Historical Perspective of Schizophrenia

schizophrenia1by Jen L’Insalata

Schizophrenia cannot be explained in its entirety by one particular theoretical model and the underlying neurobiological foundation for the disease is still relatively unknown.  Rather it is the descriptions and observations of the primary psychotic symptoms that have allowed several theories surrounding schizophrenia to evolve (Mishara, & Schwartz, 2013). Historically, schizophrenia was considered to be constructive in which anomalous experiences provide the construct of one self. Early clinical observations emphasized subjective self-experiences and altered self-awareness. The concept of self-experience is still referenced in modern work with schizophrenia. (Parnas, & Henriksen, 2014).

The earliest depictions of schizophrenia were recorded in France during the 12th century but were not linked to any particular disorder. Writing described individuals who deviated from what was considered to be normal self-perception; anomalous self-experiences. In many cases writing illustrate a disunity of consciousness in which a person’s thinking, perception, movement, and vision were disjointed and incongruent with presented stimuli (Parnas, & Henriksen, 2014).

The modern understanding of schizophrenia rose form the work of Emil Krapelin, an influential German psychiatrist working in the late 19th and early 20th century. Krapelin research surrounding the combination of symptoms and psychiatric illness from a biological origin highlighted two forms of psychosis; manic depression and dementia praecox (Ebert, & Bär, 2010). The disturbance known as Krapelin’s dementia praecox consisted of the phenomenon currently recognized as schizophrenia. During his research, Krapelin described the deterioration of what he believed to be perception and attention in combination with muscular tension (Mishara, & Schwartz, 2013).

Throughout the late 1800’s and early 1900’s core symptoms were studied by individuals from a psychodynamic perspective such as Carl Jung, Josef Berze, and Hans Walter Gruhle. Many of these theorists called attention to various cognitive and affective characteristics of the disorder. Jung in particular was fascinated by patients displaying confused speech which he described as a state of sleep-drunken-ness and confusion. Their theories critiqued by many other early psychotheorists and the phenomenon later was renamed schizophrenia in 1908 by Eugen Bleuler (Mishara, & Schwartz, 2013).

Bleuler theorized individuals with schizophrenia experienced a general loose association with a fissure personality which was highly influenced by Jung’s work. Bleuler believed that such loose associations allowed aspects of the unconscious to invade the consciousness and lead to an ego disorder. The unconscious invasion would erode the functioning of the ego to the level in which it exists in dreams. Gruhle added to Bleuler’s work and theorized that the primary symptoms of schizophrenia operated independently and observed a dysfunction between the cognitive and the affective components of the disorder (Mishara, & Schwartz, 2013).

Josef Berze criticized Jung’s work and theories believing that the symptoms were due to a reduction in mental activity rather than attention. He theorized that mental activity is more closely related to consciousness than affect and highlighted the concept of a disruption in self as the essences of schizophrenia. Berze also noted diminished mental activity in goal setting, linguistic coherence, and the ability to access the autobiographical self. Much of his work was inspired by emerging neurobiological research. He theorized that schizophrenia symptoms originated at a subcortical area, specifically the thalamus which gave rise primitive drives and motivations (Mishara, & Schwartz, 2013).

Jaspers integrated and critiqued his predecessors work in his book General Psychopathology published in 1913. (Mishara, & Schwartz, 2013). Highly influenced by the philosopher Descartes, he solidified the concept of self-experience pertaining to schizophrenia. Jaspers recognized that an individual may have and recognize experiences that are invalid and referred to positive symptoms as first person symptoms (Parnas, & Henriksen, 2014).

During the 1940s Freud’s psychoanalytic work continued to influence much of the theories surrounding schizophrenia and emphasized an etiological root stemming from early relationships. Psychoanalytic writers produces detailed descriptions of the schizophrenic experience including disruptions in interpersonal relationships and the self-experience due to the psychosis (Hamm, & Lysaker, 2016).

Writers such a Freud and Searles illustrate individuals that were detached from the world and redirected psychic energies inward during psychosis. Such writings provide the concept of an altered self-experience from which the schizophrenic individual is unable to integrate life experiences. Psychodynamic approaches took a pessimistic view of schizophrenia treatment which failed to produce empirically supported and measurable treatment modalities. Eventually, such treatment modalities fell out of favor and were replaced by psychosocial and cognitive behavioral perspectives (Hamm, & Lysaker, 2016).

With the publication of the ICD 8 and 9, Schizophrenia was recognized as a disturbance of personality and involved disorder concepts of individual uniqueness and self-direction. During that time the term personality referred to a subjective self rather than the personality descriptions used in contemporary psychology. Research surrounding a subjective self could be measured using systematic approached however lacked reliability in its methods. This notion soon fell out of favor and was replaced with an operational model following the publication of the DSM-III in 1980 (Parnas, & Henriksen, 2014).

The DSM-III emphasized behavioristic components of schizophrenia which stress observable features over the subjectivity and inference of previous theories. Biological concepts such as genetics in the etiology of schizophrenia were highlighted and lead to the emergence of a spectrum of observable features and predictors. Among the most noted were deficits in emotion, eccentricity, and thought disorder which caused interpersonal difficulties in social and occupational function. The inclusion of the diathesis stress model illustrated how core vulnerability combined with environmental stressors and produce cognitive changes observed in schizophrenia (Parnas, & Henriksen, 2014).

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References

Asenjo Lobos, C., Komossa, K., Rummel-Kluge, C., Hunger, H., Schmid, F., Schwarz, S., & Leucht, S. (2010). Clozapine versus other atypical antipsychotics for schizophrenia. The Cochrane Database of Systematic Reviews, (11), CD006633. Advance online publication. http://doi.org.library.capella.edu/10.1002/14651858.CD006633.pub2

Ebert, A., & Bär, K.-J. (2010). Emil Kraepelin: A pioneer of scientific understanding of psychiatry and psychopharmacology. Indian Journal of Psychiatry, 52(2), 191–192. http://doi.org/10.4103/0019-5545.64591

Hamm, J. A., & Lysaker, P. H. (2016). Psychoanalytic phenomenology of schizophrenia: Synthetic metacognition as a construct for guiding investigation. Psychoanalytic Psychology, 33(1), 147-160. doi:10.1037/a0038949

Mishara, A. L., & Schwartz, M. A. (2013). Jaspers’ critique of essentialist theories of schizophrenia and the phenomenological response. Psychopathology, 46(5), 309-19. doi:http://dx.doi.org.library.capella.edu/10.1159/000353355

Parnas, J., & Henriksen, M. G. (2014). Disordered Self in the Schizophrenia Spectrum: A Clinical and Research Perspective. Harvard Review of Psychiatry, 22(5), 251–265. http://doi.org.library.capella.edu/10.1097/HRP.0000000000000040

Spencer, E. K., & Campbell, M. (1994). Children with schizophrenia: Diagnosis, phenomenology, and pharmacotherapy. Schizophrenia Bulletin, 20(4), 713-725.

Psychotropic Medications and Children

childrenpills-e1463156827980by Jen L’Insalata

Historically children’s psychiatric treatment was comparable to those of adult populations. Diagnostic features were assumed to take on the same aspects of adult psychiatric features and therefore treatment was approached in the same manner. Contemporary views observe that emotional stress experienced by children and adolescents is due largely to situational experience. In these cases non-medication based treatment and psychotherapeutic interventions produce the best outcomes. However, research does take into consideration that many adult psychological and psychiatric disorders have their onset during childhood and can result in progressive neurobiological impairment. In the case of Bipolar disorder, Schizophrenia, and attention deficit/hyperactivity disorder (ADHD), pharmaceutical intervention is necessary to prevent neurological degradation (Preston, O’Neal, & Talaga, 2013).

Research surrounding the efficiency of two or more psychotropic medications is still limited and often time children are prescribed a combination of pharmaceutical agents to medicate disorders. The most common polypharmacy regimens include an antidepressant and a stimulant in combination with an antipsychotic and relate to the co-occurrence of a mood disorder and ADHD (Comer, Olfson, & Mojtabai, 2010).

Controversial Aspects

When medicating children there is no true informed consent and it is often the parents who facilitate the decision for medication treatment. In such instances, it becomes easier for parents to view the disorder as a chemical imbalance and ignore environmental components such as family dysfunction. Parents may rule out the need for psychological treatment in exchange for an easy chemical solution (Preston, O’Neal, & Talaga, 2013).

Many psychotropic medications have adverse side effects including addiction, which at an early age can lead to lifelong struggles with prescription abuse.  Stimulants such as Ritalin used to treat ADHD and benzodiazepines such as Xanax used to treat anxiety (Preston, O’Neal,  & Talaga, 2013) are among the most commonly abused prescription drugs among children and adolescents.

Pre-pubescent children have a higher hepatic rate then children who have entered puberty. Medication dosages prior to puberty are often metabolized faster and require a higher dose. Once a child enters puberty the dosage must continue to be monitored closely for toleration and side effects (Preston, O’Neal, & Talaga, 2013).

Parents often ignore the child’s beliefs and views surrounding medication and may have private consultations regarding treatment with doctors. When working with children it is important to address the child’s concerns surrounding psychotropic medication and mental health stigma (Preston, O’Neal, & Talaga, 2013). Doing so no only ensures that the child will comply with medication treatment, but also provide education and awareness to the outcome of their disorder.

Integrated treatment

The use of psychotropic medication in children is on the rise and in conjunction, doctors are moving toward a polypharmaceutical regime to manage childhood psychological distress. This is largely due to an emphasis of symptom reduction and the increasing number of psychiatrists specializing in pharmacotherapy. Emphasis and access to psychosocial interventions is sometimes limited, expensive (Comer, Olfson, & Mojtabai, 2010), and time consuming.

The Affordable Care Act of 2010 established the health home program for children with emotional disorders aimed at helping children meet both health and developmental goals. Aspects focus on behavioral health, education, child-welfare, and juvenile justice to create a continuum of care that care child and family focused. Policies aim at prevention and continued care while also controlling the cost of child psychiatric care. Aspects emphasize substance abuse and mental health issues that are common among children and adolescents and aim to prevent complications leading to behavioral health problems as adults (de Voursney, & Huang, 2016).

It is estimated that childhood mental health problems cost aproxamiatly 12.2 billion dollars annually and are some of the most prevalent concerns surrounding health, productivity, and crime. Conditions such as oppositional defiant and conduct disorder, substance abuse, post-traumatic stress disorder, anxiety and depression, and bipolar disorder (de Voursney, & Huang, 2016) lead to involvement in criminal and illegal activity, as well as social and societal dysfunction.

Stigmas surrounding the diagnosis of childhood mental health concerns inhibit the identification of children who may be at higher risk and the improper or inadequate treatment. The goal of the Affordable Care Act is to ensure continuity between a child’s home and school life to ensure therapeutic intervention as well as medical intervention (de Voursney, & Huang, 2016).

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References

Comer, J. S., Olfson, M., & Mojtabai, R. (2010). National Trends in Child and Adolescent Psychotropic Polypharmacy in Office-Based Practice, 1996–2007.Journal of the American Academy of Child and Adolescent Psychiatry, 49(10), 1001–1010. http://doi.org.library.capella.edu/10.1016/j.jaac.2010.07.007

de Voursney, D., & Huang, L. N. (2016). Meeting the mental health needs of children and youth through integrated care: A systems and policy perspective. Psychological Services, 13(1), 77-91. doi:10.1037/ser0000045

Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2013). Handbook of clinical psychopharmacology for therapists (7th ed.). Oakland, CA: New Harbinger. ISBN: 9781608826643.

CBT: Cognitive Behavioral Therapy

woodbrainby Jen L’Insalata

In most psychotherapeutic environments the term CBT is tossed around all the time. CBT in research; my insurance providers prefer CBT; CBT; CBT; CBT. So what is this CBT stuff? CBT is short for cognitive behavioral therapy and essentially addresses both thoughts and the underlying emotions that influence behavior. This is achieved by bringing together components of both cognitive therapy and behavioral therapy is a direct and effective manner.

Behavior Therapy

Behavior therapy is centered on the concept that human behavior serves a function and results from stimuli within the individual’s environment. Behaviors result in response to environmental stimuli and behavioral patterns result from the reinforcement or punishment received from the interaction between the individual and their particular environment. The psychosociocultural viewpoint encompasses a wide range of therapeutic strategies that aim to change the environmental factors that stimulate maladaptive behaviors (Wedding, & Corsini, 2014).

Cognitive Therapy

Cognitive theory is a theory of personality in which individuals respond to life events cognitively, motivationally, and behaviorally. An individual perceives, interoperates, and assigns meaning to particular life events. Maladaptive behaviors and affects are caused due to the misinterpretation of stimuli, situations, and events. Cognitive therapy aims to adjust the way the individual processes incoming information by examining the individual’s belief about their self, the world, and others (Wedding, & Corsini, 2014).

Five Concepts That Add Dimension

Both behavior and cognitive therapy recognize that personality is consistent and an individual’s response to environmental stimuli can be predicted. Behavior therapy acknowledges five core domains from which personality can be assessed. Behavior therapy teaches flexibility within an individual’s personality domains and introduces healthy coping mechanisms and responses for environmental stimuli (Wedding, & Corsini, 2014).

Cognitive therapy recognizes schemas to explain and predict responses to environmental stimuli and situational cues.  A network of affective, motivational, and behavioral schemas known as modes asses and interoperate situations. Some modes are rooted in instinct and are referred to as primal modes. Primal modes are often ridged, automatic, and absolute. Primal thinking leads to maladaptive behavior. Cognitive therapy teaches a client to consciously override primal modes through means of deliberate thinking and problem solving (Wedding, & Corsini, 2014).

Behavior therapy focuses on the behaviors and actions that are conditioned responses to external stimuli. Cognitive therapy focuses on the affect and mental interpretation of a particular stimuli (Zaretsky, Segal, & Fefergrad, 2007). Due to similarities, behavior therapy and cognitive therapy are often combined in a treatment known as cognitive behavioral therapy. CBT targets the bias mental interpretations acknowledged in cognitive therapy and teaches the client to regulate emotions causing maladaptive behaviors (Harvey, Bélanger, Talbot, Eidelman, Beaulieu-Bonneau, Fortier-Brochu, & … Morin, 2014).

CBT is often used as a primary treatment for depression and mood disorders.  By leveraging a client’s awareness of the changes in their cognition, (Zaretsky, Segal, & Fefergrad, 2007) treatment techniques encompassing mindfulness, relaxation, meditation, exposure, (Wedding, & Corsini, 2014) and modeling teach the client ways to regulate their affect and reduce symptoms (Zaretsky, Segal, & Fefergrad, 2007).

When addressing depression, cognitive therapy addresses the client’s negative views of one’s self, their experiences, and future. A client’s interpretation of their environment is often bleak and the client maintains a pessimistic bias toward themselves and their future. Motivational symptoms appear such as a lack of energy and sometimes paralysis that inhibits the completion of everyday life tasks. Increasing activity and social exposure combined with combating negative interpretations of situations are used to alleviate the cognitive components of depression (Wedding, & Corsini, 2014).

Behavior therapy addresses the conditioned response to stimuli. Behaviors increase due to reinforcement (Wedding, & Corsini, 2014). Maladaptive coping strategies and behaviors continue to reinforce depressive behaviors. Treatments focused on positive social exposure and activity work to reinforce positive experiences for the depressed individual and reduce exposure to negative experiences such as isolation. Exposure to positive stimuli aids in reinforcing non-depressive behaviors (Ryba, Lejuez, & Hopko, 2014).

Modeling behaviors occurs when an individual observers others in a sociocultural environment. Anxiety or phobias are maladaptive behaviors that can be learned through modeling abuse (Wedding, & Corsini, 2014). If an individual observes a social fear or anxiety about a particular situation, it is likely to be interoperated as a truth. An individual may model the anxious or phobic behavior learned from observation.

Behavior therapy addresses the hyperarousal brought on by anxiety and phobia by combining exposure and relaxation training. Practicing relaxation techniques while exposed to environmental stimuli helps alleviate the physical stress and tension associated with phobia and anxiety. Cognitive therapy teaches an individual to reevaluate the particular stimuli and interoperate it as less threatening (Wedding, & Corsini, 2014).

Substance abuse is often coupled with depression and anxiety. The recognition of psychosocial factors maintain the maladaptive belief and subsequent behaviors are addressed by combining cognitive and behavioral therapies (Harvey, Bélanger, Talbot, Eidelman, Beaulieu-Bonneau, Fortier-Brochu, & … Morin, 2014). Substance abuse may begin as a molded socioenvironmental behavior and become reinforced through positive social experiences. Reinforcement of addictive behaviors may be reinforced when a client engages in self-medication to alleviate depression and anxiety symptoms.

Stimulus control is a behavioral technique that can be used to help individuals with substance abuse issues and addiction. Principles of classical conditioning state that conditioned cues illicit behavioral responses.  Stimulus control aims to correct the problems associated with a particular stimuli (Wedding, & Corsini, 2014). For example, a client may associate a place or event with the acquisition and consumption of substances. Clients are encouraged to avoid places and situations which are cues for their addiction.

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References

Wedding, D., & Corsini, R. J. (Eds.). (2014). Current psychotherapies (10th ed.). Belmont, CA: Brooks/Cole. ISBN: 9781285083711.

Zaretsky, A., Segal, Z., & Fefergrad, M. (2007). New developments in cognitive-behavioural therapy for mood disorders.Canadian Journal of Psychiatry, 52(1), 3-4. Retrieved from http://search.proquest.com.library.capella.edu/docview/222807541?accountid=27965

Harvey, A. G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., & … Morin, C. M. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal Of Consulting And Clinical Psychology, 82(4), 670-683. doi:10.1037/a0036606

Ryba, M. M., Lejuez, C. W., & Hopko, D. R. (2014). Behavioral activation for depressed breast cancer patients: The impact of therapeutic compliance and quantity of activities completed on symptom reduction. Journal Of Consulting And Clinical Psychology, 82(2), 325-335. doi:10.1037/a0035363

Freud and Attachment

boy and gearsJen L’Insalata

Freudian psychoanalytic theory presents concepts which have shaped and influenced many aspects of the field of psychology. Much of Freud’s theory was developed from observations and case studies of many of his own patients. He is often criticized for a lack of experimental investigation and hypothesis testing throughout his theory and an over emphasis placed on psychosexual components (Feist, Feist, & Roberts, 2013). Yet despite the criticism, Freudian psychoanalysis explores ways in which unconscious motivations influence personality and behavior and still maintains relevancy in psychological practice today.

Freud explored how unconscious motivations influence emotional states, personality and outward manifestations of behavior. According to Freud, such motivation have root in past experience (Feist, Feist, & Roberts, 2013). In essence behavior is shaped by an unconscious struggle to reduce emotional tensions caused by our past traumas.

A core component of psychoanalytic theory emphasizes maladaptive coping mechanisms such as defense mechanisms and repression (Feist, Feist, & Roberts, 2013). Individuals who experience trauma often utilizes maladaptive defense mechanisms to reduce psychological tension. Often, individuals suffering from severe PTSD repress memories of the traumatic event. This is a temporary solution which allows the individual to function in immediate aftermath. According to Freud, manifestations of the unconscious repression manifest in recurrent dreams commonly experienced by individuals suffering from PTSD (Feist, Feist, & Roberts, 2013). Psychoanalytic theory can be applied in the treatment of severe trauma as the individual begins to bring the unconscious to light and acknowledge their past experiences.

Attachment theory places emphasis on the earliest of childhood experiences and emphasizes ways in which infants form bonds with their caregivers. As much of Feud’s theory relies heavily on early childhood and past experiences, concepts of personality and behavior manifestations focus heavily on such bonds. Freud believed that attachment centered on a child’s identification with the same sex parent and their desire to be with the opposite sex parent. Freud theorized that these unconscious sexual desires manifested in overcoming what he called the Oedipus and Electra complex (Feist, Feist, & Roberts, 2013). Successful resolution of the unconscious sexual motivators in such complexes allow for secure attachment bonds to parents and healthy interpersonal relationships in the future.

Although the Oedipus and Electra complex are highly discredited, Freud’s theory paved the way for his contemporaries to explore the relationship between healthy and secure attachments to caregivers. Early childhood attachments are viewed as an underlying component in many theories on healthy human functioning and interpersonal behavior. Attachment theory serves as a heavily emphasized component in developmental and behavioral psychology.

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References

Feist, J., Feist, G. J., & Roberts, T. (2013). Theories of personality (8th ed.). New York, NY: McGraw-Hill.