Daily Archives: September 2, 2010

Schizophrenia Information Grab-bag

“Schizophrenia is the most crippling of the psychiatric disorders.”  (Blaney & Millon, 2009, p. 298)  That’s a bold first statement.  I was curious as to the reason why typical onset times are younger (sooner) for males as compared to females.  The developmental perception I am accustomed to generally indicate that females “grow up” sooner than males… I am the slightest bit curious what could cause this phenomenon to flip-flop.  Any insight there readers?

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Although I was alive during the 1980’s, I was so young that I was wholly unaware of the de-institutionalization that took place during that era.  The statement that prisons have become the de factor health care provider reaffirms my belief that working with that population is absolutely critical to our success as a society.

Typical schizophrenia characteristics include hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, and/or negative affective symptoms.  The text states that the most common types of hallucination consist of hearing voices, one or several, typically making commentaries about the individual or conversing with each other.  One word… WOW.  Persecutory, grandiose, or somatic delusions are most common.  The first person accounts depict individuals who are very disturbed to say the least.  In particular, an individual who believed that they were controlled by someone (the “controller”) and the persistent belief that other people have external controllers was beyond comprehension.

Regarding the etiology of the disorder, it is increasingly evident that there is some kind of genetic link involved in schizophrenia.  The diathesis-stress theory of illness is the predominant theory, suggesting that a predisposition may not be sufficient in itself to cause schizophrenia, but probably requires some kind of “trigger” such as exposure to prenatal insults.  (Blaney & Millon, 2009, p. 302)

This is my first exposure to “genotype” and “phenotype.”  Genotype represents the underlying genetic constitution of the individual (genetic predisposition?).  Phenotype refers to the observable traits, characteristics, or behaviors of an individual.  It is entirely possible to have a genotype that suggests a predisposition to a disorder like schizophrenia, but the disorder will not be expressed behaviorally by the phenotype.  “In other words, what the individual inherits is a liability or predisposition for developing the disease, not the disease itself.”  (Blaney & Millon, 2009, p. 305)

With regard to prenatal and perinatal insult, the critical period of exposure appears to be the 2nd trimester (4th-6th month of pregnancy).  Examples might include toxemia, preeclampsia, or labor delivery complications.  Fetal hypoxia (oxygen deprivation) was strongly linked with later schizophrenia.  Prenatal stress, inclining losing a spouse or being exposed to a military invasion, has been implicated in the predisposition of schizophrenia.  Maternal viral infection, including influenza, was also implicated.  Unlike influenza studies, increased risk for offspring exposed to prenatal nutritional deficiencies was primarily attributed to growth and development during the 1st trimester, not the second.

Cognitive impairments are considered to be central, or primary, in schizophrenia.  Typically, they predate the more typical outward signs of the illness (hallucinations, delusions, etc.).  The cognitive impairments can occur in the absence of the other clinical symptoms.  “It is estimated that 90% of patients have clinically meaningful deficits in at least one cognitive domain and that 75% have deficits in at least two.”  (Blaney & Millon, 2009, p. 309)

Neurocognitive assessment is used in contemporary practices to quantify the severity of impairment in clinically relevant domains of cognitive functioning.  Relevant domains are speed of processing, attention/vigilance, working memory, verbal learning, visual learning, reasoning and problem solving, and social cognition.  Typically, a patient with schizophrenia will struggle with verbal learning and vigilance, and have lesser impairments in visual organization and vocabulary.

A neuro-developmental view of schizophrenia is the foundation of high-risk research.  “The majority of individuals who succumb to schizophrenia and other psychotic disorders manifest prodromal signs of behavioral disturbance” in adolescence, and they get progressively worse as they approach young adulthood.  (Blaney & Millon, 2009, p. 321)  The prodromal period represents a clinically significant opportunity for intervention, with high potential to shed light on the etiological origins of schizophrenia.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Pick 4 Psychoanalysis Theories! Which do you favor, and why?

My plan is to specialize in Applied Behavior Analysis (ABA).  I like the concept of direct and frequent measurement of variables that can me quantitatively or qualitatively measured.  I like the transparency of the ABA discipline.  “Everything about ABA is visible and public, explicit and straightforward… ABA entails no ephemeral, mystical, or metaphysical explanations; there are no hidden treatments; there is no magic.”  (Cooper, Heron, & Heward, 2007, p. 18-19)  ABA is committed to resolving real world issues not theoretical quandaries.  It’s sensible, it’s practical, and it’s in demand.  ABA focuses on the behavior that needs improvement, not just any behavior. Good results are measurable, conceptually systematic, and able to be replicated.  Finally, a good theory must possess generality of the in the respect that it lasts over time and it appears in environments other than the one in which it was observed.  ABA relies on operant conditioning with the fundamental assumption being that behavior is a function of its consequences.  I intend to make use of positive and negative reinforcement, token economies, extinction, and stimulus control.  I’m not ready to rule out cognitive processed entirely because I want to keep an open stance, but right now, I am “all in” with ABA (more specifically, Dialectical Behavior Therapy (DBT), role-playing, behavioral observation, guided imagery.  If there’s anything I don’t like about ABA, it’s the measure of control that is required to do it right… I would like to soften that requirement a bit and do observation in a more natural setting… the inpatient clinical environment is too artificial to get good measurements or results that can be generalized.

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I really enjoy reading Carl Jung despite the fact that he has fallen out of favor with many of the movers and shakers in psychology.  Conceptually speaking it is a lot different than ABA, but I see some synergy there that is untapped.  Specifically, I really buy the concept of Enantiodromia.  “This word refers to Heraclitus’ law that everything sooner or later turns into its opposite.”  (Corsini & Wedding, 2011, p. 123)  Please forgive the lack of a citation because it comes from memory… but Carl Jung said “the word happiness would lose its meaning if it were not balanced by sadness.”  It’s a concept I will never forget, so, I’d like to learn more about Carl Jung and Analytical Psychotherapy.  The only part I don’t like about Analytical Psychotherapy that is it’s not as practical as “brief therapy” techniques that are more pragmatic.  Realistically, how often am I going to get the opportunity to go 20 sessions + with someone with EAP and managed care looming around the corner?  Not often, I suppose.  It’s more likely to be the croutons on my metaphorical presentation salad, there’s too much meat and too many vegetarians to serve Analytical Psychotherapy as the main course in 22nd Century counseling.  It’s still an intriguing option nonetheless, one that I will definitely continue to read whether it’s assigned or not… it interests me.

I would have put existential therapy at the top of the list if it were a legitimate “stand alone” school of therapy.  I really enjoy the duality and the conflict involved in relativism.  I like shooting for the moon… talking about the BIG PROBLEMS (Death, The Meaning of Life, etc).  I really like that it is more person centered and holistic, as compared to reductionist (like ABA).  I like the idea of creating meaning for people… love, marriage, family, religion, etc.  (Corsini & Wedding, 2011, p. 340)  I would, however, like to bring it back down to earth, if you will… it’s a bit “out there” sometimes.

My last choice would have to be Cognitive Therapy for no other reason that it is so dominant in the field right now.  It seems to be the tool of choice for most people, I don’t suspect we will have any difficulty finding someone to write on this one.  I like the concept of guided discovery, and I am particularly drawn to cognitive restructuring as it relates to phobias, OCD, and eating disorders.  If I had a problem with cognitive therapy at all, it’s that everyone is doing it… and while I can hardly afford to neglect it, CBT just doesn’t “excite me” like the opportunity to measure behavior.  Mostly a personal preference I suppose.

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Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Corsini, R. J., & Wedding, D. (2011). Current psychotherapies (9th ed.). Belmont, CA: Brooks/Cole.