SOPHIA F. DZ I E GI E L E W SK I
INTRODUCTION
This chapter provides information on children, adolescents, and adults suffering from the disor- ders that constitute schizophrenia spectrum and the other psychotic disorders. A brief overview of each disorder is provided, along with a case example that includes specific treatment plan- ning and an intervention-related application.
Although the definitions of what constitutes schizophrenia and the other spectrum related disorders continue to shift (Wong, 2013), these devastating illnesses can have far-reaching effects that go beyond the client. They can touch the very core of the individual, affecting the devel- opment of close relationships, talents, family relations, and economic independence. Further complicating the conditions, now referred to as the schizophrenia spectrum disorders, is that even with the best treatments known, repeated episodes of the illness will occur throughout a client’s life (Menezes, Arenovich, & Zipursky, 2006). Also, the symptoms can vary so much among individuals that no single treatment can be considered the intervention of choice. This varied and unpredictable course of the illness and the label placed can affect those seeking and receiving treatment (Rusch et al., 2013).
Because the psychotic disorders involve some level of psychosis that results in distorted perceptions and affects the way an individual perceives reality (Walker, Mitial, Tessner, &
Trotman, 2008), when experiencing these incorrect impressions, individuals often cannot function as others do. They can become lost in a world where they cannot communicate their basic needs. These types of communications are so basic to daily functioning and survival, and the variability of response and accomplishment has left many family members to question how this could happen. This lack of understanding of the symptoms related to the disease and the impaired communication further disturb family relationships and thereby alienate sup- port systems critical to enhanced functioning (Dziegielewski, 2007).
This chapter highlights the guidelines for using theDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-5) (American Psy- chiatric Association [APA], 2013) to better understand and assess these conditions. It is beyond the purpose of this chapter to explore in depth all of the diagnoses that constitute schizophrenia spectrum and the other psychotic disorders and the treatment options specific to each. Rather, the purpose of this chapter is to introduce the primary disorders as listed in DSM-5: schizotypal personality disorder (listed in this chapter but described in the chapter on
Special thanks to Shirleyann Amos and George Jacinto for contributions to the previous version of this chapter.
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personality disorders), delusional disorder, brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, substance/medication- induced psychotic disorder, and psychotic dis- order due to another medical condition. Of all the psychotic disorders, schizophrenia is the most common (Walker et al., 2008). Although this chapter presents a brief overview of this spectrum of disorders, the diagnosis and treatment of schizophrenia is the central focus.
The application section of this chapter pro- vides a case example of an individual suffering from schizophrenia with specific recommenda- tions for completing the diagnostic assessment and the subsequent treatment plan. The extent, importance, and the early predictors of problem behaviors and symptoms are explored. The vari- ous aspects of the disorder are presented with a case application that highlights the diagnostic assessment, treatment planning, and evidence- based treatment strategy. In addition, the latest practice methods and newest research andfind- ings are highlighted to further the understanding of these often-devastating illnesses.
TOWARD A BASIC UNDERSTANDING OF THE CONDITIONS
Reading about diverse ancient cultures (e.g., Egypt, India, Greece, and China), makes it clear that strange and bizarre behavior, often referred to as madness or lunacy, has existed for thou- sands of years (Woo & Keatinge, 2008, p. 470).
The term demence precoce, or early dementia (dementia praecox), was the general term for what we today call schizophrenia. Within the psychotic disorders, schizophrenia historically has always been the most clearly defined. Sev- eral subtypes that can occur within schizophre- nia were identified and described by Kraepelin in 1899. Emil Kraepelin (1856–1926), using the
earlier work of Morel, developed a formal diagnostic category in which he divided dementia praecox into different subtypes: dis- organized type (previously known as hebephre- nia), paranoid, and catatonic. This classification system lasted for many years. Not until a new generation of researchers voiced concerns with the consistency and uniformity of these earlier classification schemes was the DSM definition most similar to what we utilize today developed (Walker et al., 2008). InDSM-5,limited diag- nostic stability and problems with reliability and validity were the primary reasons for dropping thefive subtypes, resulting in the definition we use today (Tandon, 2012).
Over the years, many theories about the causes of these mental health conditions evolved (Lehmann & Ban, 1997). Some of the more current theories of causation are oxygen defi- ciency, biological causes related to its similarity to epilepsy, and an imbalance of natural neuro- chemicals within the brain, such as serotonin or dopamine disturbance or both (Hong, Lee, Sim, & Hwu, 1997; Lehmann & Ban, 1997).
One reason defining the disorder may be so difficult is that when most researchers think of the psychotic disorders, they immediately think of schizophrenia; to complicate the matter fur- ther, many professionals agree that schizophrenia is an illness with a complex and heterogeneous nature (Glick, 2005; National Institute of Mental Health [NIMH], 2009c). Based on recent research, the conceptual definition of schizo- phrenia has broadened to include awareness that it is not one singular disease (Walker et al., 2008). Walker et al. (2008) acknowledge this research and agree that trying to make schizophrenia one disorder might confuse and complicate the diagnostic assessment process.
Rather, it might be easier to classify the disorder as a group or cluster of disorders that lack a single cause. According toDSM-5,what this complex group of psychotic disorders share is at least some
symptoms such as hallucinations, delusions, dis- organized or abnormal motor behavior, and a cadre of negative symptoms.
UNDERSTANDING INDIVIDUALS WHO SUFFER FROM THE PSYCHOTIC
DISORDERS
Receiving a diagnosis of schizophrenia or one of the psychotic disorders can be one of the most devastating experiences for an individual and his or her family. Unfortunately, no known preven- tion or cure exists for these disorders (Woo &
Keatinge, 2008). The behaviors and coping styles characteristic of psychotic disorders such as schiz- ophrenia, which include symptoms such as hal- lucinations, delusions, and disorganized or grossly disorganized, bizarre, or inappropriate behavior, can be problematic. The wordpsychotic can easily be misinterpreted. In the psychotic disorders, individual criteria must be met, and the definition and meaning of what constitutes a psychotic symptom can change, based on the diagnosis being considered. Further, the disor- ders in this category do not always stem from a common etiology. What diagnoses in this cate- gory share are problems with performing daily tasks, particularly those that involve interpersonal relationships. Symptoms related to the psychotic disorders often appear as a thought disorder, with poor reality testing, social isolation, poor self- image, problems in relating with family, and problems at work (Woo & Keatinge, 2008).
The individual who suffers from one of these disorders can experience states of terror that prevent daily interactions and create difficulty in distinguishing fantasy from reality. This result- ing separation from reality makes the symptoms that an individual client suffers extend far beyond personal discomfort. These symptoms also affect the support system and all of the people who come into contact with him or her. This disorder
has far-reaching effects; not only does it disrupt the life of the individual but also it can tear apart support systems and alienate the client from daily contacts with family and friends. These disorders are not static in symptomatology and presenta- tion, and having a client misinterpret the signs and symptoms may frustrate family and friends (Wong, 2013). A further complication is not knowing the actual cause of psychotic disorders.
This category of mental disorders, especially schizophrenia, has been documented as a leading worldwide public health problem.
The often-negative reaction by lay individ- uals, peers, family, and professionals toward individuals who suffer from schizophrenia and other psychotic disorders is extreme in compari- son to what might be experienced by those who suffer from depression. Once diagnosed, clients with these disorders often need extensive mon- itoring and support that most primary care phy- sicians and other practitioners are not able to provide or are not interested in providing (Dziegielewski, 2008). Furthermore, although they might not openly admit it, few professionals except in a mental health setting seek out this type of client to work with. Many professionals simply prefer not to work with clients suffering from a psychotic disorder because of the mon- itoring problems and the unpredictability of client responses, which makes it difficult to provide the support and supervision required in a nonspecialized treatment environment.
On the more optimistic side, it appears that practitioner views toward this population are changing somewhat, although the process is slow. In psychopharmacology, however, new medications have brought relief for many clients who have this chronic and debilitating condition (Dziegielewski, 2010).
In summary, since first introduced in the earliest version of the DSM (APA, 1952), the diagnostic category of the psychotic disorders, especially schizophrenia, continues to raise many
questions for practitioners. Concerns center on validity and application of criteria, as well as the detrimental and negative impact that this diag- nosis or others in the schizophrenia spectrum can have on the future life of the individual. With all the information available to people on the Inter- net, self-labeling has become a practice reality; in schizophrenia and the bipolar disorders, how- ever, it can have particularly problematic effects.
Individuals may increase their use of mental health services because of their fear of psychosis or be stigmatized by an inaccurately placed label (Rusch et al., 2013). For many individuals who suffer from this disorder, complete or total remis- sion is rare, and a chronic yet variable course of the illness is to be expected. Furthermore, schiz- ophrenia spectrum and the other psychotic dis- orders appear to be an equal opportunity illness that affects rich and poor alike.
Biology and Etiology of Schizophrenia Spectrum and the Psychotic Disorders Support for a biological component to schizo- phrenia spectrum disorders increased substan- tially when psychotropic medications showed a decrease in symptoms related to the disorder (Dziegielewski, 2010; Lehmann & Ban, 1997).
Subsequently, the medications that had an effect on these symptoms also opened a window to further understanding the biological dynamics of disorders such as schizophrenia (Lehmann &
Ban, 1997). Researchers took great interest in the role that neurotransmitters such as serotonin and dopamine, as well as noradrenaline, acetyl- choline, and glutamate, had in establishing a biological basis for schizophrenia (Bishara &
Taylor, 2009). For example, the autopsied brains of individuals who suffered from schizophrenia showed that the D-4 (dopamine) receptors (members of the G-protein family that bind with antipsychotic medications) were six times denser than in others’brains (Hong et al., 1997).
In turn, this discovery led to the biological or dopamine D-4 hypothesis of schizophrenia (Lehmann & Ban, 1997).
Regardless of the exact relationship, a con- nection between schizophrenia and the neuro- chemical dopamine is clear. This connection remains ambiguous because many of the medi- cations to treat the disorder can also increase dopamine receptor density. However, even never-medicated patients with schizophrenia, in particular, still show elevations in the dopa- mine receptors (Walker et al., 2008). Studies on the structure and function of the amygdala and anterior segment of the hippocampus, basal gan- glia, and thalamus have noted differences in individuals with schizophrenia and their siblings versus the control group (Qiu et al., 2009). Qiu and colleagues concluded that there may be a schizophrenia-related endophenotype. Neuro- endocrinology studies have offered another per- spective on the etiology of schizophrenia. These studies focus on the workings of the pituitary gland as related to the hypothalamus and the central nervous system (CNS). These studies have looked at growth hormone (GH) and thyroid-releasing hormone (TRH), but results linked directly to a causal interpretation have been mixed (Keshavan, Marshall, Shazly, & Paki, 1988; Lieberman et al., 1992).
Neuroimaging studies,first introduced in the 1970s, have been helpful in identifying possible causative factors for schizophrenia (Raz & Raz, 1990). These studies are helpful in exploring both the functional and the structural changes in the brains of individuals who suffer from schizophre- nia. Through these studies (e.g., magnetic reso- nance imaging [MRI] or cerebral blood flow [CBF]), specific areas of the brain can be identified and studied (Gur & Pearlson, 1993; Keshavan et al., 1997). For example, MRIs used to look specifically at individuals who suffer from schizo- phrenia revealed decreased frontal, temporal, and whole-brain volume (Lawrie & Abukmeil, 1998).
The hippocampus has consistently been identified as where people with schizophrenia can be dif- ferentiating from people without it (Crow, Chance, Priddle, Radua, & James, 2013). Some researchers believe that a genetic link contributes to the subsequent risk of developing schizophre- nia (Brzustowicz, Hodgkinson, Chow, Honer, &
Bassett, 2000; Kendler & Diehl, 1993; Nauert, 2007; Tsuang, 2004). Researchers conducting studies in the United States, Germany, Greece, and Ireland affirm findings that schizophrenia strongly runs in families (Baron et al., 1985;
Kendler et al., 1993; Kendler, Gruenberg, &
Tsuang, 1985; Maier, Hallmayer, Minges, &
Lichtermann, 1990; Tsuang, 2004).
Twin studies also appear to support genetic transmission of schizophrenia; however, not all individuals with a genetic predisposition will experience symptoms of schizophrenia (Ken- dler & Diehl, 1993). Several accounts for this discrepancy have been posited, including the interplay of genetic and environmental consid- erations, where a biological child of an individual with schizophrenia has a similar risk for devel- oping the disorder whether the child grows up in a home with that parent or not (Altschule et al., 1976; Gottesman, 1991). Brzustowicz et al.
(2000) found a susceptibility point on a particular gene for schizophrenia, which lends support to the theory that schizophrenia is related to genetic as well as environmental factors.
Environmental issues are highlighted by fam- ily response to a person diagnosed with schizo- phrenia and how soon the person relapses following hospitalization. It appears that relapse occurs most quickly if there is a hostile family environment that is nonsupportive or overcon- trolling (Weisman, 1997). Research on the brain supports neurodevelopmental damage during childhood as a possible antecedent to the diagnosis of schizophrenia in children, adolescents, and adults (Dutta et al., 2007; Hollis, 1995; Mental Health America, 2009). These environmental
events associated with developmental delays or permanent neurological damage can increase the occurrence of schizophrenia, as well as the possi- bility of an individual being most susceptible to developing other mental illnesses.
Nonetheless, it is fairly well accepted that genetics may be a necessary, but not a sufficient, cause for schizophrenia (Kendler & Diehl, 1993).
To acknowledge this link between the individual and the family, the termschizophrenia spectrumwas added to theDSM-IV-TR(APA, 2000) under the familial pattern section. Schizophrenia spectrum represented the range of mental disorders that are more likely to occur in family members of indi- viduals with schizophrenia, such as schizoaffective disorder and schizotypal personality disorder. In DSM-5,this term was expanded to include the types of disorders that fall into this category that often have a genetic component linking them.
IMPORTANT FEATURES RELATED TO THE PSYCHOTIC DISORDERS When preparing for the diagnostic assessment and the appropriate diagnosis, the practitioner mustfirst be aware of the key features prevalent in the psychotic disorders that are used to con- stitute the diagnosis. Creating any diagnostic impression and the treatment plan to follow always requires a delicate balance of ground- breaking research and the practitioner’s judg- ment and experience (Schore, 2014). Starting this process requires familiarity with applying the five primary characteristics of each of the disor- ders listed in this chapter: delusions, hallucina- tions, disorganized thinking and speech, grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms.
Delusions
A primary feature of many of the diagnoses in this area is delusions. Simply stated, adelusionis a
belief held with extreme conviction, although others do not believe it; when compared with evidence to the contrary, the belief is clearly incorrect or unfounded. The individual suffering from delusions often becomes anxious or angry when the delusion is challenged. The individual often holds on to the false belief with what is sometimes referred to as delusional conviction.
Whether delusions can be addressed when chal- lenged is debatable, and more research in this area is needed (Wong, 2013). What is most evident is the frustration and sense of hopeless- ness that many clients feel.
In the glossary section, DSM-5 identifies several types of delusions (APA, 2013). (See
Quick Reference 5.1.) This chapter further defines the most common types of delusions and gives examples of each. The most common fixed delusions are persecutory, referential, gran- diose, erotomanic, nihilistic, and somatic. In completing the diagnostic assessment, establish- ing the difference between a delusion and strong culturally held belief can be difficult. The easiest way to differentiate between them is to break the thought patterns into two classes: fixed and bizarre. In fixed delusions, the person is con- vinced, no matter how contrary the evidence, that what he or she believes is accurate. In the bizarre type, even when compared with indi- viduals of the same cultural group, their thoughts
QUICK REFERENCE 5.1 TYPES OF DELUSIONS
Fixed Belief Delusions
■ Persecutory delusions:The self or someone close is being conspired against.
■ Referential delusions:Related to an event or an object in the person’s life situation that holds what others in a similar situation would term as having an incorrect or unusual meaning.
■ Grandiose delusions:Places extreme self-importance on their own existence and what is forthcoming from their contributions.
■ Erotomanic delusions:The individual believes falsely another person loves him or her.
■ Nihilistic delusions:Belief a major catastrophe will occur.
■ Somatic delusions:Related directly to bodily concerns or images.
Bizarre Thoughts
■ Thought withdrawal:The individual becomes convinced that someone or some- thing is removing ideas from their head that he or she cannot stop from happening.
■ Thought insertion:The individual becomes convinced that someone or something is planting ideas in his or her head from which he or she cannot escape.
■ Thought broadcasting: The individual feels his or her own thoughts are being revealed and others can hear their most personal and private thoughts.
Bizarre Thoughts That Lead to Dysfunctional Behaviors
■ Delusions of control:The individual believes someone or something has mental control that is so strong it can affect the individual’s daily functioning and the resulting social or occupational behaviors.
and behaviors still are reportedly outside the norm.
The most common of thefixed delusions is termed persecutory. In persecutory delusions, the individual or someone close to the individual is being conspired against. As in most delusional thinking, the frustration level increases, as the individual really believes this is happening. To avoid potential harm, the individual will try almost anything because he or she feels so powerless to do anything to prevent it. The thoughts are so over- whelming that the individual cannot escape from them; when the problem is discussed with others, the person is often not believed. Frustration builds;
there appears to be no way to improve or stop the situation. The person is often desperate and over- whelmed with feelings of impending doom from which no escape seems possible.
In referential delusions, the false belief held with delusional conviction is related to an event or an object in the person’s life situation that holds what others in a similar situation would term as having an incorrect or unusual meaning. In delu- sions of reference, an individual may fear that everyone is out to get him or her and so interpret normal everyday events as tied to his or her own life. These types of delusions are linked to impor- tant aspects or objects in a person’s life, and it is difficult to escape from its influence. Referential delusions can become so severe that they stop an individual from performing daily activities and basic functioning; the individual applies special meaning to objects or events recurring in his or her life, thereby creating an inescapable cumula- tive effect directed personally.
Grandiose delusions are often related to inflated self-worth or self-esteem. The person may see himself or herself as a famous person or connected to a deity. In grandiose delusions, the individual places extreme self-importance on his or her own existence and contributions.
Inerotomanicdelusions, the individual is con- vinced that another person loves him or her. This
belief is not reciprocated, and the individual with the delusional belief can become completely engrossed in a fantasy relationship. The belief is so strong that it becomes difficult for the person to see what is real and what is not.
Innihilisticdelusions, there is a belief that a horrible catastrophe is about to come. The indi- vidual continually talks about it and prepares for the worst, and this preoccupation may prevent completing current requirements needed to maintain his or her current situation.
Somaticdelusions relate directly to the body or concerns with bodily function. The individual may focus on an imagined bodyflaw and not be able to see himself or herself positively because of it.
The second classification of delusions is bizarre. Delusions that fall into this category and involve thought content seem strange to everyone, including those with similar beliefs in a similar cultural group. Delusions of this type include problems with basic cognitive pro- cesses: thought insertion, thought withdrawal, and thought broadcasting. In thought insertion, the individual becomes convinced that some- one or something is planting ideas in his or her head from which he or she cannot escape.
There is a constant nagging feeling that the thoughts are really not of the person’s thinking them, but rather put there and influenced by somebody or something else. This thought is so powerful the individual cannot function with- out taking it into account. Inthought withdrawal, the individual becomes convinced that some- one or something is removing ideas from his or her head that the person cannot stop from happening. In thought broadcasting, the individ- ual feels his or her own thoughts are being revealed, and others can hear the most personal and private thoughts. To the person experienc- ing thought broadcasting, his or her general and most intimate thoughts cannot be pro- tected from others’ knowledge. This causes