of the brain is in constant progress, therefore,
of aetiology, diagnostic criteria, prevalence, co-morbidities, and treatment optiINTRODUCTION
Schizophrenia appears severe and disabling of all brain disorders (Bernstein, Clark-Stewart, Penner, & Roy, 2012) which is expressed by means of atypical functioning and disturbing behavior (Lewis and Lieberman, 2000), thus, this essay reviews its nature in terms of its aetiology, diagnostic criteria, prevalence, co-morbidities, and treatment options. The subheadings are discussed in detail, with close attention paid to precision, for up to date ideas, statistics and developments. Examples from actual studies provide a support for many of the points mentioned throughout the essay, which offers a reliability of information.
The Aetiology of Schizophrenia
It is said that schizophrenia is one of the most intense disorders when it comes to searching for its causes. Diagnostic criteria, symptoms and fundamental clinical features result from different etiological factors. The influence of any factor may vary from patient to patient. The manner of development of schizophrenia depends on the relationship between three categories: biological, psychological and social factors (Tsoi, Hunter, & Woodruff, 2008).
Biological causes of schizophrenia mainly focus on numerous abnormalities in the structure, functioning and chemistry of the brain that appear in schizophrenic individuals. (Bernstein, Clark-Stewart, Penner, & Roy, 2012)
Genetic factors play a vital role in its aetiology; however, it doesn’t explain all cases. Usually, they combine with other nongenetic factors to cause schizophrenia (Bernstein et al., 2012; Meyer & MacCabe, 2016). From this, it is known that schizophrenia runs in families. Bernstein et al. (2012) continue to express that If children are adopted by families with no schizophrenia history, the children of biological schizophrenic parents are ten times likely to develop the disorder than adopted children with biologic non-schizophrenic parents. Thus, showing that Genetics ‘programmes’ the early development of the brain’s structure, like Tsoi et al. mention (2008). Although heritability is emphasized in schizophrenia, onset is associated with early life adversity also (Yang et al., 2014). Moreover, in early development, there are critical periods that can bring upon its onset.
As mentioned by Tsoi et al. (2008) and Bernstein et al. (2012), the prenatal and perinatal periods are important stages of brain development as the brain is in constant progress, therefore, disruptions during this can cause drastic problems. This is supported by Meyer and MacCabe in 2016, that roots of the illness lie in the previous stages of development, although evidence is noticed in adulthood. Studies show that viral infections as prenatal exposures, like rubella, can cause mental retardation (Rapoport, Giedd, & Gogtay, 2012). Also, perinatal variables like low birthweight, prematurity and prolonged labour which can also be caused by the environment all play a role in initiating schizophrenia. This is also supported by Bernstein et al. as they point out that physical traumas, viral infections and low birth-weight effect the prenatal period.
As stated previously, psychological factors have a role within schizophrenia’s aetiology also. As mentioned by Tsoi et al. (2008), schizophrenia is associated with cognitive impairments. This point is supported in 2012 by Keefe and Harvey, when they express that neurocognitive impairment is a core feature of the illness. Rapoport et al. (2012) say that there is a broad increase in childhood disorders such as attention deficit hyperactivity disorder and intellectual deficiency, which are risk factors of schizophrenia. They serve as restrictive aspects to social and occupational functioning (Goldstein and Kern, 1994). Ahmed et al. (2018) highlight domains in which there are chances of impairments. They include attention, memory, learning, reasoning and problem-solving. Thus, damage in these areas may give rise to symptoms in schizophrenic individuals, such as delusions (Tsoi et al., 2008). An example of cognitive impairment would be when an individual has the inability to filter attention to different stimuli within an environment, hence, causing instances of delusions, which is a symptom leading to schizophrenia (Meyer and MacCabe, 2016).
Harrison in 1990 also addresses the issue of immigration as a social cause of the disorder. From his study, there is a greater understanding that epidemiology has more to offer in the search for the causes of schizophrenia. He mentioned a high rate of Schizophrenia was found among afro-Caribbean migrants. This is verified by Meyer and MacCabe, explaining that schizophrenia is seen in first and second-generation immigrants compared with non-migrants. An additive factor that could be a consequence of immigration is isolation. Studies have shown that one being isolated from their own ethnic group and falling into a ‘minority position’ can cause social marginalization, which may have a degree of aetiological importance (2016).
The prevalence and incidence vary widely depending on the location and the diagnostic definition that is employed (Meyer & MacCabe, 2016). An example of this is seen in an English study where the incidence of schizophrenia in London was 20.1 cases per 100, 000 person-years, whereas Bristol had 7.2 cases, thus, providing evidence that there is geographical diversity in relation to prevalence. Likewise, Bhugra (2005) suggests that there are fewer cases in developing countries, which means that developed areas have high cases. Gejman et al. wrote that there is no evidence of a rapid change in the occurrence of schizophrenia like there is in other complex disorders, like obesity. In fact, they refer to an analysis in Denmark that has detected a possible trend of decreasing incidences of schizophrenia (2016). Bhugra (2005) supports this point with a study in China from 1979 to 2009, showing no trend in increasing incidences. Bernstein et al. themselves acknowledge that it affects 1 to 2 percent of the human population (2012), and often cited that 1 in 100 of the population will have schizophrenia in their life (Meyer & MacCabe, 2016).
Schizophrenia is prevalent in both men and women; however, it tends to “appear later in life in women, respond better to treatment and less severe” (Bernstein et al., 2012). The onset in males is slightly earlier than in women (Eranti, MacCabe, Bundy, & Murray, 2013; Meyer & MacCabe, 2016).
Tandon et al. (2016) wrote that the diagnostic criteria of schizophrenia progressed through 5 editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), however, DSM-5 is most suitable for the diagnostic criteria of schizophrenia, which provides valuable updated information (Reddy, Horan and green, 2014) and outlines a consistent approach to its diagnoses in the clinic (Owen, Sawa, & Mortensen, 2016).
Criteria for schizophrenia is made up of 6 sections, from A-F. These are Characteristic symptoms, Social/occupation dysfunction, Duration, Schizoaffective and mood disorder exclusion, Substance/general mood condition exclusion and relationship to Global Developmental Delay or Autism Spectrum Disorder respectively. Criteria are also known as ‘positive’ and ‘negative’ symptoms (Bernstein et al., 2012) and are said to have a fundamental position in its diagnosis (Dollfus & Lyne, 2017).
Psychosis is commonly presented in schizophrenia, as stated in the DSM-5 (Owen et al., 2016). Disorganized speech, delusions, and hallucinations (often hearing noises), bizarre behaviors and movement disorders are known as ‘positive’ symptoms which fall under criterion A. Negative symptoms or “diminished emotional expression or avolition” as highlighted by DSM-5, although written by Reddy et al. (2014) are also in criterion A.
To be diagnosed with schizophrenia, Reddy et al. wrote that the DSM-5 specifies one of the two required criteria A symptoms should include “delusions, hallucinations, or disorganized speech”, meaning that, a person cannot receive the diagnosis with only disorganized behaviour and negative symptoms. Tandon et al., (2013) give a detailed account of the DSM-5 diagnostic criteria. Regarding criterion B, one’s functioning in work, relationships or self-care must show a depression following previous results i.e. before commencement. This criterion is crucial as it distinguishes schizophrenia from other psychotic disorders (Heckers et al., 2013). Duration is also prominent in its diagnosis, as symptoms from criterion A must be constant for 6 consecutive months. The next criterion is whether a mood disorder, such a schizoaffective or bipolar is detected. They are excluded when identifying schizophrenia, as no key mood episodes have occurred with criterion A symptoms. Reddy et al. (2014) support this by saying that Schizophrenia is to be diagnosed if mood episodes are “brief” in comparison with the active-phase symptoms. Criterion E and F finish off by highlighting that symptoms mustn’t be caused by medication or substance abuse and that if hallucinations or delusions concurrently appear with an autism disorder, Schizophrenia may be distinguished.
Schizophrenia often occurs with and can be worsened by other psychiatric conditions (Tsai & Rosenheck, 2013) and studies have highlighted medical comorbidities present in schizophrenic individuals also (Sim et al., 2006). Tsai wrote that various reports have shown an increased occurrence of anxiety, depressive, and substance use disorders than the overall population (2006), and that these comorbidities can be evident at all phases of the illness (Buckley, Miller, Lehrer, & Castle, 2009). Substance abuse is remarkably common comorbidity according to Buckley et al. (2009). The “self-medication” theory can account for this, which suggests that it helps schizophrenic people relieve distress and emotions (Tsai & Rosenheck, 2013). Depression is very predominant also, at a rate of 50% of all schizophrenic people, according to Buckley et al. (2009). Furthermore, the depressive experience mostly overlapped during peak psychosis, providing solid evidence for its relationship with schizophrenia. In addition, Tsai and Rosenheck outline that comorbid depression makes people form a profound awareness of their mental illness (2013).
A study carried by Smith, Langan, McLean, Guthrie and Mercer (2013) discuss that physical-health comorbidities were very common in people with schizophrenia, of which include diabetes, cardiovascular diseases such as hypertension, and obesity, which are also known as metabolic syndromes. Sim et al. (2006) indicate a prevalence up to 57%. These may coincide with schizophrenia due to the use of antipsychotic drugs, which tend to develop the above illnesses (Lambert, Velakoulis, & Pantelis, 2003). Obesity appears usual as a comorbidity, accounting for 40% – 62% of schizophrenic individuals, thus, it is logical that schizophrenia is a ‘life-shortening disease’ (Lambert et al., 2003), as it’s comorbidities appear to be detrimental in society.
At present, the main treatment recommendations comprise medications with psychosocial interventions (Elis, Caponigro, & Kring, 2013), as this is said to help improve medication adherence (Patterson & Leeuwenkamp, 2008). Although, Lith (2016) discusses the use of art therapy treatment through occupational therapy as a valid possibility also. The article referenced studies which proved positive changes in patients within art therapy. Patients have grown to cognitively comprehend their disorder through artistic explorations., which has helped people control their psychosis, which aids the treatment process of the illness.
Family psychoeducation emerged as a treatment option for patients, with the involvement of the family (Meyer & MacCabe, 2016) in clinical settings, as family intervention is regarded as a significance in patient recovery, since these programs offer constant family supports, as written by MacFarlane, Dixon, Lukanes and Lucksted (2003).
Dixon, Adams and Lucksted notify that psychoeducation aids to support family well-being by ameliorating the burden of an ill family member. MacFarlane et al. reinforce this point in stating that this option enhances boundaries within the family, such as informing about strategies of effective communication (2003). Through this intervention, they also mention that numerous clinical trials have verified the reduction of the rate of relapses in patients and intensely helps decrease patient’s functional disability, thus, assisting people with a successful re-entry into community routines, such an employment (2000).
Similarly, medications like antipsychotics help minimize symptoms also, majorly focusing on positive rather than negative symptoms (Meyer & MacCabe, 2016), just as their name suggests. The therapeutic variant of using psychosocial and medication intervention has previously shown enhanced functional results (Valencia, Fresan, Juárez, Escamilla & Saracco, 2013), however, it is important to mention that antipsychotics come with the risk of causing neuroleptic malignant syndrome, which is associated with delirium and muscle rigidity (Meyer and MacCabe, 2016), consequently, its capacity as a treatment option remains questionable.