Understanding Mental Health Illness
Mental health is a vital part of the well being of a person.The following definition of health by the World Health Organization (WHO) stresses mental health as an integral aspect of health- “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 2013). There is a wide array of mental disorders ranging from the less severe forms, such as eating disorders, anxiety disorders, and depression to more serious conditions, such as, schizophrenia, schizoaffective disorder, bipolar disorder, panic disorder etc (NAMI, 2013).
Mental illnesses, as are physical illnesses, are affected by a number of factors including genetic, socioeconomic and environmental factors. Mental illnesses have a high prevalence rate across the world and in most cases they are left undiagnosed and consequently untreated. A 2004 world mental health survey conducted by the WHO pointed out higher prevalence rates across Western countries while Asian countries had lower rates. Statistics from the survey also attested to the important fact that roughly 35 % to 50% and 76% to 85% of people were undiagnosed in the developed and developing countries of the world respectively, indicating the need for more awareness, evaluation and appropriate intervention for mental illnesses across the world (WHO, 2004). The focus of this essay will be on schizophrenia as one of the important mental disorders. Particularly, the paper will discuss the various aspects of schizophrenia and relate it to a case study of a 19 year old Mr John who experienced a sudden onset of psychotic symptoms. Such a case study based approach will allow for a better understanding of the sociological dimensions of schizophrenia.
Schizophrenia is a chronic mental disorder that is characterized by impairment in thought process leading to the patient having altered perception of reality and emotional response. In fact schizophrenia is now being understood as a collection of different mental disorders. Full blown psychosis is usually regarded as the late stage symptom of the disorder (Phillips et.al, 2005). The diagnostic and statistical manual of mental disorders (DSM IV) defines schizophrenia as a “mental disorder involving a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioural monitoring, affect, fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention” (APA, 2000). The DSMIV also specifies that the diagnosis of schizophrenia cannot be attributed to any single symptom but that a group of symptoms that impair functionality are usually involved. As per the US national statistics roughly 1 % of the population has schizophrenia and that the incidence rate is relatively standard across different countries and races. Among people with a genetic disposition, or a family member with a history of the disorder, there is a 10% incidence rate (NIH, 2013). The WHO statistics project the incidence rate at 3 per 10,000 people and a higher prevalence rate of 7 per 10,000 people in any population. The higher prevalence rate compared to the incidence rate is due to the chronicity of the disorder (WHO, 2013).
Symptoms of Schizophrenia
The symptoms of schizophrenia are generally classified into three types namely- positive symptoms, negative symptoms and cognitive symptoms (NIH, 2013). Positive symptoms refer to those that are observed among schizophrenia patients but are not present among the general population. For instance, symptoms such as auditory and visual hallucinations, disorganized thinking, delusions and catatonia or movement disorder are categorized as positive symptoms of schizophrenia. Hallucinations are the auditory or visual perceptions of the schizophrenia patient that are not felt by a healthy person (NIH, 2013).
The case study refers to a 19 year old teenager Mr. John who is experiencing auditory hallucinations where spirits are telling him to keep distance from others and that there is a future awaiting him. This is a clear example of the kind of auditory hallucination or the altered perceptions experienced by a schizophrenia patient. However, in the case study there is also the mention of Mr. John smoking cannabis recently. Though cannabis is generally accepted as safe for medicinal use, there is still considerable debate surrounding its potential psychiatric effects. An early British study, which was an extensive review of cannabis users, reported that the drug is potentially dangerous among people with pre-existing mental disorders. The study concluded that cannabis use triggers and aggravates psychotic episodes among schizophrenia patients (Johns, 2001). Other studies, such as Arendt et.al (2005) and Daniel et.al (2010), also conclude that cannabis use causes adverse psychotic effects among schizophrenia patients. From the case study, it can be inferred that cannabis usage could have possibly triggered the hallucinatory symptoms in John.
Other symptoms, such as avolition (lack of motivation), reduced social interaction, dull personality or what is called as ‘flat effect’ are the typical negative symptoms (NIH, 2013). In other words, negative symptoms are those social qualities and the drive that is usually found among normal people but are lacking among schizophrenia patients. With reference to the case study, Mr. John is also exhibiting some of these negative symptoms. John’s tendency to lock himself up in his bedroom and his refusal to come out to eat and interact with his mother and sister and his generally reduced social drive are suggestive symptoms of schizophrenia. Lastly, the cognitive symptoms refer to the various cognitive abilities that affect the day to day functioning of the patient including ‘poor memory’, ‘lack of focus’ and ‘poor executive functioning’ (NIH, 2013).
Schizophrenia -Age of Onset and Aetiology
The onset of schizophrenia is predominantly during the late adolescent and early adult years. Though early onset schizophrenia among children as well as late stage schizophrenia has been known it is only during the late teen and early adult years that the symptoms of schizophrenia begin to show up predominantly (NIH, 2013). This is baffling as researchers were thus far prescribed to the notion that human brain development assumes maturation at a very early stage in life. However, recent studies of the human brain have shown that the brain continues to grow and undergo structural adaptations during the stage of puberty (Bruer, 1999). In fact, studies have pointed out significant levels of grey matter changes during the late adolescent and early adult years (Blakemore et.al, 2010).
There is also significant transition in terms of the structural composition and the synaptic connections of the brain cells that control the emotions, motivations and behavioural maturation occurring during the early adulthood period (NIH, 2011). In other words, puberty related brain changes are thought to have a direct impact on the onset of schizophrenia symptoms during early adulthood. Several studies have hypothesized that faulty neuronal development with a tendency towards reduced neuronal density during puberty related brain changes, might actually be responsible for the onset of schizophrenia during early adulthood (Bruer, 1999). For instance, one of the early studies to emphasize defective neuronal pruning, and consequent loss of synaptic connections, was Feinberg (1983). More recent studies have also hypothesized excessive synaptic pruning as the potential cause of schizophrenia. Faludi and Mirnics (2011) confirmed this hypothesis by conducting neuroimaging studies of various brain regions of schizophrenia patients. Their study revealed that schizophrenia patients indeed had reduced synaptic connections in the different brain regions that were studied compared to health human subjects. More recently, research has also pointed to the role of microglia in synaptic pruning and therefore its potential role in schizophrenia (Paolicelli et.al., 2011). Several other hypotheses have also been pursued in studies including exposure to adverse factors, maternal stress and malnutrition and adult immunocompetence, early exposure to infectious neurotropic agents and vulnerability to immune disorders that are subsequently aroused due to thymus involution during puberty and early adulthood (Kinney et.al, 2009).
Although several environmental factors including maternal uterine environment, obstetric complications, substance abuse for example, are attributed in schizophrenia, one of the important environmental factors is that of parental separation. The early exposure to stress induced by parental separation either due to parental divorce or loss of parent due to death has been associated with a heightened risk for the onset of schizophrenia symptoms among young adults. Janice et.al (2012) was one study that specifically focused on the effects of a variety of environmental factors on schizophrenia among subjects with a genetic predisposition to schizophrenia. The study found that maternal mental illness was the most significant childhood adversity (44.6%) while disruption in the family setting was identified as the next significant childhood adversity (40.0%). Cannabis smoking was also identified as an important risk factor at 24.5%. Overall the study reported significant association between these cumulative risk factors and the onset of schizophrenia. Galletly et.al (2011) also contributed with the findings that childhood exposure to familial adversities and cannabis smoking carry a high risk for psychosis.In our case study it is important to notice that Mr. John has experienced some of these childhood adversities that carry a high risk factor for schizophrenia. John’s parents separated 12 years ago when John was just a young 7 year old boy. The disruption in the family setting and consequently the rearing environment must have caused significant stress for John. Compounding this stress is the fact that John has witnessed violent attacks on his mother by his father and even now continues to witness heated arguments between his mother and his elder sister. It transpires that the cumulative effect of these multiple environmental stressors might have triggered the onset of schizophrenia symptoms in John who has just completed puberty, which is a vulnerable stage as discussed in the previous sections.
Treatment for Schizophrenia
Effective diagnosis constitutes the first step in the treatment of schizophrenia. Though pharmaceutical therapy is available in the treatment of schizophrenia, currently they do not promise a cure for the disorder but help a lot in alleviating the psychotic symptoms.Antipsychotic drugs are the main pharmaceutical intervention used in the treatment of schizophrenia. Thorazine, Haldol and Prolixin are some of the earlier antipsychotic medicines used in treating schizophrenia. However, these drugs had adverse effects including tremors, and cognitive dulling for instances (University of Maryland, 2013). Over the last two decades another class of antipsychotics with limited side effects such as Risperdol, Zyprexa are used particularly in the treatment of the acute phase of schizophrenia when the symptoms flare up (Harvard Medical School 2006).More recently however, a new class of antipsychotics namely injectable long acting antipsychotics are available. These drugs are particularly effective among schizophrenia patients who are not medically compliant (Manchanda et.al, 2013). The key to effective management of schizophrenia is to adhere to the treatment plan. It must be noted, however, that though antipsychotic medications are effective against psychotic symptoms they are not useful in the treatment of the so called negative symptoms of schizophrenia. Other forms of therapies, such as psychotherapy should be utilized. One of the important psychotherapies is cognitive-behavioural therapy (CBT).
Early intervention using both pharmaceutical as well as behavioural therapies provides the optimum treatment plan for schizophrenia patients. Since providing optimal intervention at the earliest is considered the best for achieving better outcome, it is necessary to include concomitant behavioural therapies. Several studies have proven the efficacy of CBT in the management of the symptoms of schizophrenia (University of Maryland, 2013). Coupled with family therapy, CBT is found to be very effective in the management of schizophrenia. The underlying idea in cognitive therapy is to change the thoughts and then the behaviour of the patient. CBT focuses on normalizing the psychotic experience of the patient (Turkington et.al, 2006). CBT provides an action plan for the patient so the next time symptoms appear they are better able to manage them (Turkington et.al, 2006). In the context of the present case study CBT offers an excellent therapy as it is known that CBT is more effective in early stages of psychosis. One significant advantage of CBT is that it has no known side effects (Addington & Lecomte, 2012).
Diagnosis and management of schizophrenia is very important since suicide presents as a prominent risk for schizophrenia patients. Palmer et.al (2005) pointed out close to 5% risk for suicide among schizophrenia patients. Erlangsen (2012) was a recent study that reported a heightened risk for suicide among elderly schizophrenia patients. CBT is a very effective therapeutic tool in aiding self monitoring of thoughts and in developing coping strategies among schizophrenia patients. As such, John must be provided with CBT.
Schizophrenia Support Services
Despite the significant improvements in our understanding of the cause of mental illnesses there is very little improvement in terms of the quality of services offered to schizophrenia patients and their families (Schizophrenia Commission, 2012). In the UK, the recent report by the schizophrenia commission confirms this dismal picture. The report highlighted that there is only “a broken and demoralized system that does not deliver the quality of treatment needed for recovery” (Kelland, 2012). There have been funding cuts for early intervention services despite the fact that research evidence point to the effectiveness of these programs in preventing relapse of psychotic episodes and in improving the overall outcome for the patient. Another highlight of the report is the poor plight of the psychiatric wards and the lack of treatment plan. It is reported that only 1 in 10 patients are provided with CBT and other forms of beneficial psychological interventions while in the majority of cases drugs are the only treatment. “Some wards are so anti-therapeutic that when people relapse and are in need of a period of care and respite, they are unwilling to be admitted voluntarily; so compulsion rates rise.”(Kelland, 2012)There is also a distinct lack of employment support services with only 8% of schizophrenia patients still working. There is also widespread stigma associated with schizophrenia and other mental illnesses which causes additional burden on the caregivers. There is also increasing coercion in the UK with patients being forced into secure care. As Robin Murray, a psychiatric professor with the British institute of psychiatry puts it, “If you develop psychosis and your mind is disturbed … and you think people are against you, you’d want to be admitted for a period of care and respite and calm and some gentle pharmacological and psychological treatments. But in fact that doesn’t happen. Here, you get admitted to a mad house. And some of these places are very anti-therapeutic – not only for patients but also for staff. No sensible person would want to be admitted to one of these places.” (Kelland, 2012).
However many private charities and voluntary groups have emerged across Britain that offer useful service to the patient and the carer. For instance, ‘Carers trust’ is a charity group operating across the UK that provides useful respite services for schizophrenia carers and thereby reduces their burden and carer burnout. Similarly the government led ‘meals on wheels’ scheme would be very useful for carers of patients who live alone to ensure that their loved ones are served with hot meals every day. The government also provides the ‘Independent living fund’ (ILF) that could be utilized to pay for personal assistants to help the schizophrenia patients in managing their day to day tasks (NHS, 2012).
Schizophrenia is a chronic debilitating mental disorder that impairs social functioning and the autonomy of the patient. As yet, the aetiology remains rather obscure with a myriad of contributing symptoms making diagnosis a lot complicated. Since schizophrenia is a heterogeneous disorder carrying an array of symptoms, an interdisciplinary approach including research based on both biological and behavioural models is necessary to gain valuable insights into its aetiology. Early adulthood is a particularly vulnerable phase with the onset of symptoms. In view of the symptoms and the risk factors that were discussed in the paper it is clear that Mr John, the 19 year old young adult, is clearly experiencing the various symptoms of schizophrenia. Early parental separation, witnessing family violence, smoking cannabis are all high risk factors. These environmental factors are the triggers for the onset of schizophrenia symptoms.
It is clear that in majority of the cases, such as John’s, there is an undue delay in the diagnosis as there is hesitance in approaching a psychiatrist due to the stigma associated with mental illnesses. Interventions during this early phase of the disorder are critical and offer the best opportunity for delivering optimal care. In John’s case, immediate consultation with the psychiatrist followed by adherence to medication along with psychological therapies like CBT should ensure control of the psychotic symptoms. This would enable John to continue his life with minimal hindrance. The main point is the emphasis that though schizophrenia and some other forms of mental illnesses do not have a cure as of yet, they could be effectively managed with drugs and other behavioural therapies that would drastically improve the quality of life for the patient.
Another important and largely ignored fact is that deinstitutionalisation of mental health care also implies a growing burden on the family members as caregivers. Caregiver burden should also be the focus of mental health policies. Respite services must be improved. There is also a need to increase awareness to destigmatise schizophrenia and other mental disorders. Stigma effectively prevents the utilisation of support services. Much work needs to be done.
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