Frequency of Mental Disorders - Case Study Example

Frequency of Mental Disorders The people affected by any means from mental disorders depend entirely on where we draw the cut-off. Most studies focus on the prevalence of disorders, which refers to the percentage of people in a population who meet the criteria for a specific disorder during a particular period of time. Prevalence can be defined across different time frames. For example, 12-month prevalence refers to cases of a disorder in the preceding year, while lifetime prevalence refers to the number of people who have met criteria for the disorder at any time in their life. Several different epidemiological studies conducted in various countries sample a large number of people and try hard to make sure that their sampling is representative of the particular country. Most commonly diagnosis are made on the basis of answers to structured interviews. Mental Disorder “Schizophrenia” “Schizophrenia” is the psychiatric classification of a group of severe and persistent mental disturbances characterized by the disruption of the processes of rational thinking and perceiving, which usually leads to delusional beliefs and hallucinatory perceptions in the auditory and visual field. The author’s view of schizophrenia is that although it is a highly complex and insufficiently understood phenomenon, it is essentially a reaction to life crises by individuals who are psychologically and biologically less well equipped to meet expectable developmental challenges, deprivations, and adversities than are non-psychotics. Study of the life history of such individuals provides evidence for the view that the root causes of this vulnerability are to be found in the psychological and social experiences of infancy and childhood. Whilst recognizing that everyone emerges into the world with differing biological equipment, the author makes clear his view that although the biological aspects are of undeniable relevance in research and treatment of schizophrenia, they are frequently given disproportionate emphasis, often at the expense of psychodynamic understanding. (Alanen, 1997) Despite common features, different forms of schizophrenia can appear quite dissimilar. One patient, for example, may be paranoid and hostile in certain circumstances but show good judgment and high functioning in many areas of life. Another may be bizarre in manner and appearance, preoccupied with delusions of bodily disorder, passive and withdrawn. So marked are these differences, in fact, that many psychiatrists believe that, when the underlying neuro physiological and biochemical mechanisms of schizophrenia are worked out, the illness will prove to be a set of different but related conditions which lead, via a final common pathway of biochemical interactions, to a similar series of consequences. (Warner, 1994) Amanda was a 19-year-old university student who lived with her parents and younger brother. Amanda had never been extremely outgoing, but over the past six months she had become more withdrawn and tense. She kept pretty much to herself, making little contact with her classmates, and at home spends most time alone in her room. When she did mix with the family she often had seemingly irrational outbursts, usually over relatively trivial incidents. In class, Amanda began to feel as though she was being singled out by the lecturers, one in particular. Amanda felt as though much of the class content was about her and her life and that many of the lecturer’s comments were specifically directed at her. One time the lecturer made a joke and the whole class laughed. Amanda felt as though the joke was about her and that they were all laughing and looking at her. She ran from the class and did not return to the university. As time went on, Amanda began to look after herself less and less and spent more time alone in her room. When she did leave the house, she felt as though everyone was whispering about her and she did not trust anyone except for her close family. Description Amanda knows many of the features of the group of disorders known as schizophrenia. Schizophrenia as described by some authors is actually referring to a group of related disorders and has several characteristic features. One of the major features is often referred to as “thought disorder”. Thought disorder is characterized by disturbances in the way in which thoughts and ideas are put together. It may involve losing one’s train of thought, jumping from idea to idea in seemingly unrelated ways and using meaningless words. In Amanda’s case she began to have trouble talking to people in a logical and coherent way and found that many of her thoughts were quite mixed up. Other common features of Schizophrenia are hallucinations and delusions. Hallucinations are perceptions that are not based in reality. The most common hallucinations in schizophrenia are auditory, such as hearing voices. At various times, Amanda heard the voices of people talking about her and mocking her shortcomings, but when she turned around, she could see no one there. Delusions are beliefs that are not based in reality. These can include delusions of grandeur, such as believing that one has incredible powers, delusions of reference, such as believing that irrelevant events are directed at oneself, or persecutory delusions, such as believing that certain people are plotting against oneself. Clearly Amanda had many delusions all surrounding the idea that people were plotting against her in some way. These symptoms where the person shows certain excesses, such as unusual thoughts and perceptions, are sometimes referred to as the positive symptoms of schizophrenia. People with schizophrenia may also show several psychomotor signs, such as unusual grimaces, odd movements and odd postures. It is often difficult to know whether these signs are part of the schizophrenia or a result of the medication that people with schizophrenia are on. Finally people with schizophrenia may also report several other symptoms, such as withdrawal from other people, difficulty in maintaining interpersonal relationships, poor social skills and impairments in self-care and grooming. Such apparent deficits in behaviour are usually referred to as negative symptoms of schizophrenia. All the above-mentioned symptoms began to emerge in Amanda and made her difficult to live with and appear unusual to others. According to DSM-IV, for a person to be diagnosed with schizophrenia, they must show two or more of the following symptoms: Delusions Hallucinations Disorganized speech Grossly disorganized behaviour Negative symptoms, such as flat mood, lack of motivation. Demographic Features People with schizophrenia usually go through an episode called an acute psychotic phase, which involves a marked deterioration in functioning, usually involving thought disorder, hallucinations and delusions. Prior to the first psychotic episode, there is usually a prodromal phase, consisting of vague, non-specific symptoms. Between acute psychotic episodes, they may return to these non-specific symptoms, which are referred to as the residual phase. The first acute psychotic episode most commonly begins between 15 and 25 years of age and the average age of onset is around 19 years. Interestingly males seem to have a generally earlier age of onset than females. Researchers applying the scientific method to describe, explain, and enhance the status of children and youth at risk for or suffering from mental disorders are encountering ethical dilemmas to which current federal and institutional guidelines offer incomplete answers. The scientific and ethical dimensions of such work often appear to have contradictory goals. Scientific responsibility requires validation of knowledge through experimental controls, whereas ethical responsibility requires the protection of participant welfare and rights that may appear to jeopardize controls (Fisher, 1993). Researchers must confront such questions as: “How is an appropriate balance between research risks and benefits achieved?” Balancing research risks and benefits. Protecting participant welfare in research designs requiring the withholding of treatment. Protecting participant rights during identification and recruitment of subjects. Developing adequate informed consent procedures. Developing adequate child assent procedures when guardian consent is unavailable or inappropriate. Protecting participant rights when designing and conducting deceptive research. Protecting participant confidentiality. Modifying research procedures in response to participant needs. Offering services beyond those required by the research protocol. Debriefing participants and disseminating research findings. Ethical decision making in research with children and youth with mental disorders is enhanced by empirical data on participant and guardian responses to recruitment practices, random assignment, informed consent procedures, experimental methods, and debriefing procedures. (Fisher, 1996) Although relevant federal guidelines are highlighted in the introductions to each section, the cases themselves are not meant to provide definitive rules or guidelines for ethical practice. The ethical demands of a situation are best understood when seen within the context or the culture of a given study. As such, ethical decision-making is a process of constructing the best procedures possible within a given situation rather than discovering rules that can be universally applied across situations. Thus, the value of the cases lies in providing models of ethical decision making that focus on the scientist as a moral agent rather than a moral judge. It is not always easy to share the deliberations that are involved in one's ethical decision making. It requires self-reflection and the courage to analyze and reveal one's values. We are fortunate that our case contributors and consultants have so generously shared their experiences and concerns with us. Their dedication to promoting the science and ethics of research on child and adolescent mental disorders has and continues to help investigators achieve the highest standards of scientific integrity and humanitarian concern. Relationship between social class and schizophrenia The link between social class and mental disorders such as schizophrenia, interestingly, has been conclusively demonstrated only for city dwellers. Strongest in large cities, it becomes weaker in smaller cities and most rural areas. In the small town of Hagerstown, Maryland, for example, the prevalence of schizophrenia was not related to social class. Dorothea Leighton and her co-workers did detect a social-class gradient for mental disorder in rural Nova Scotia, but not in rural Sweden. In two British studies, one comparing London women with women in the crafting and fishing community of North in the Outer Hebrides and another comparing women in London with women living in the rural Isle of Wight, the prevalence of mental disorder was found to be highly influenced by class in the urban setting but not at all in the rural communities. On the rural Danish island of Samso, although mental disorder in general was more frequent among the lower social classes, the prevalence of psychosis in particular was unrelated to class (Warner, 1994) The absence of a social-class gradient for schizophrenia for most rural areas can be explained in two ways. Schizophrenic people may migrate away from rural areas and become part of the urban underclass. This explanation is a variation of the social-drift hypothesis. Alternatively, the conditions of rural working-class life may be less likely to create a vulnerability to schizophrenia than urban lower-class existence. When we look at the effects of the business cycle, we see that there is also a rural-urban difference in the effect of fluctuations in the economy on symptoms of mental disorder, just as there is a rural-urban variation in the influence of social class. The rural-urban difference in the effect of economic change cannot be explained by social drift, and if the differential is the result of similar factors in each case (which is possible), then we should look for real differences in the impact of economic and class-related stress between cities and country towns. The cultural bias, perhaps, prevents a more vigorous attempt to look for social causes of, and solutions to, substance use by people with mental illness. We should try to overcome this bias, however, and examine, in each case, to what extent alienation, unemployment and boredom, for example, are factors increasing the use of drugs and alcohol by people with mental illness. If we are to decrease the harmful and expensive consequences of substance use by people with schizophrenia-deterioration of health, failure to care for one’s basic needs and hospital admission-we may need to invest more in those programs that can help a person find a place in the world, that help people make friends and fulfill useful social roles-such programs as supported employment, psychosocial clubhouses, and consumer-run businesses. The research reveals that stress can trigger episodes of schizophrenia. People with schizophrenia are more likely to report a stressful life event preceding an episode of illness than during a period of remission. Similarly, stressful events are more likely to occur prior to an episode of schizophrenia than in the same time period for people drawn from the general population (Warner, 2000). For example, in a study from London, 46 percent of a group of people with schizophrenia experienced a life event that was independent of their own actions in the three weeks before an episode of illness, compared to only 12 per cent of healthy population controls (Warner, 2000). It appears that stress can precipitate episodes of illness in people who suffer from schizophrenia and that, although stress does not cause the illness, it can influence the timing of the first episode of schizophrenia. The research also indicates that the life events occurring before episodes of schizophrenia are milder and less objectively troublesome than those before episodes of other disorders such as depression (Warner, 2000). This sensitivity to mild stress may explain why some studies do not show big differences in the response of people with schizophrenia to stress; the cut-off level of stress in the research may be set too high to show an effect. Ironically, given the exquisite sensitivity of people with schizophrenia to stress, the research shows that the chronic stress level is inflated above normal for many people who suffer from this illness, adding to their vulnerability to relapse. These findings make sense when we recall that in schizophrenia there is a deficit in the regulation of brain activity so that the brain over-responds to environmental stimuli, reducing the person’s ability to regulate his or her response to new stresses. Anti psychotic drugs appear to be more important in preventing relapse in schizophrenia for people living under stressful conditions, and of less importance for those in settings where stress is milder. As British social psychiatrist John Wing put it: “Drug treatment and social treatments are not alternatives but must be used to complement each other. The better the environmental conditions, the less the need for medication: the poorer the social milieu, the greater the need (or at least the use) of drugs”. (Wing, 1978, p. 1335) Several pieces of research support this view. A series of studies has shown that the relapse rate is higher for people with schizophrenia who live with critical or over-involved relatives than for those whose relatives are more supportive and less smothering. In the earliest of these studies, conducted in London, it was found that the relapse rate for patients living in more stressful households could be reduced either by limiting contact between the patient and his or her relatives or by using anti psychotic medication. For patients living in low-stress families, however, the relapse rate was low regardless of whether they were taking medicine or not. With longer follow-up, it emerged that anti psychotic medication was of some benefit to the patients in low-stress homes. Relapse in patients in low-stress homes was only likely to occur if they were subjected to additional independent stressful events, such as job loss, and medication appeared to be of value in protecting patients against the effect of such acute stresses (Warner, 1994) The stress-reducing effect of a supportive human environment has been demonstrated in other British studies. Heart rate and skin-conductance tests have shown that people with schizophrenia have a higher level of arousal than normal individuals, irrespective of whether they are living in high- or low-stress households. This heightened level of arousal drops to normal when the person with schizophrenia is in the company of a non stressful relative but continues at an elevated rate when he or she is in the company of a critical or over-involved relative. The finding holds true for people with schizophrenia in an acute psychotic episode and for those in remission. The level of arousal in people with schizophrenia in residential treatment can be controlled by creating an environment that is optimally stimulating and supportive. In such settings drug dosage need not be as high. Drug doses for people with schizophrenia were consistently lower in such progressive psychosocial treatment programs as Gordon Paul’s unit at Illinois State Hospital, William Carpenter’s program at the National Institute of Mental Health (NIMH) (Carpenter et al., 1977), Loren Mosher’s two Soteria House projects in California (Mosher, 1995), and Luc Ciompi's Soteria Berne in Switzerland. All of these programs developed individualized treatment interventions in low-stress environments in which the alienating aspects of the institution were reduced to a minimum. Overly stimulating treatment, on the other hand, can increase stress, arousal and relapse in schizophrenia. In a study conducted by Solomon Goldberg and associates at NIMH, outpatients suffering from schizophrenia were randomly allocated to either routine outpatient care or a more intensive program of “major role therapy,” a combination of social casework and vocational counseling. The more severely ill patients relapsed sooner if they were receiving the intensive social therapy. The main thrust of the therapy was to urge “the patient to become more responsible and to expand his horizons” (Goldberg et al., 1977, p. 171). The authors concluded that the therapy was too intrusive and stressful and had a toxic effect similar to that of critical and over-involved relatives. We may conclude that when people with schizophrenia are in an environment which is protective but not regressive, stimulating but not stressful, and warm but not intrusive (whether it be a family home, their own apartment or a residential treatment setting), many will need less anti psychotic medication. On the other hand, people with schizophrenia that are exposed to significant stress (whether it be intrusive relatives, over-enthusiastic psychotherapy or homelessness, hunger, or poverty) will have a higher relapse rate and will have to rely on higher doses of medication to achieve adequate functioning. We should invest in helping people with schizophrenia develop coping strategies designed to minimize stress and psychotic symptoms, and which may, as a result, eventually allow treatment with lower doses of medication. Despite the long-held belief that it is a pointless exercise to try and dissuade people from tenacious delusional beliefs, recent research reveals that talking to people about their psychotic symptoms, and about their meaning to the individual, can lead to an improvement in symptoms. It emerges that the gentle challenge of evidence used by people with psychotic disorders to support their delusions-for example, presenting alternative viewpoints, reality-testing and enhancing coping strategies-can be helpful. In a British study conducted by Nicholas Tarrier and associates (Tarrier et al., 1993), people with schizophrenia who continued to experience positive symptoms of psychosis, despite optimal drug treatment, improved when they received a cognitive-behavioral treatment called coping strategy enhancement. In this approach, patients were helped to identify coping strategies that could be used to reduce both the cues and reactions to symptoms like hallucinations or delusions. For one person, for example, being alone or bored may be a cue to an increase in hallucinations; he or she can be taught to adopt strategies to reduce isolation or boredom. Others can learn to reduce auditory hallucinations by humming, conversing with others, or even reasoning with the voices and telling them to go away and come back later. Similarly, a person might be taught to test the reality of delusional beliefs against the therapist's interpretation of events and, for example, return to a church social group about which he or she had harbored paranoid fears. After six months, the patients who received this type of coping strategy treatment had lower levels of delusions and anxiety, compared to those who received a less specific form of cognitive therapy called problem-solving training. Cognitive strategies such as those described here can lead to a reduction in stress levels for people with schizophrenia, by helping them cope better with the stress of the external environment and with the provocations of internal hallucinations and delusional beliefs. The primary cost in providing this type of treatment is in training staff in the methods used; beyond that, additional costs will be low as current staff time can be re-channeled into providing this approach to care. In the US, where cognitive therapy is moderately well diffused and understood for the treatment of non-psychotic disorders, the approach has scarcely been used with people with psychotic disorders. The opportunity for change and benefit, in enhancing the capacity of people with serious mental illness to improve their ability to cope with their illness, is very great. References Alanen, Yrjo. 1997. “Schizophrenia: Its Origins and Need-Adapted Treatment: Karnac Books: London. Bond & McKonkey. 2001. “Psychological Science, An Introduction”. Fisher B. Celia & Hoagwood Kimberly. 1996. “Ethical Issues in Mental Health Research with Children and Adolescents”: Lawrence Erlbaum Associates: Mahwah, NJ. Warner Richard. 2000. “The Environment of Schizophrenia: Innovations in Practice, Policy, and Communications”: Brunner-Routledge: London. Warner Richard. 1994. “Recovery from Schizophrenia: Psychiatry and Political Economy”: Routledge: New York. Read More