Schizophrenia is a severe mental disorder, characterised by profound disruptions in thinking, affecting language, perception, and the sense of self. It often includes psychotic experiences, including audio and visual hallucinations or delusions. It can impair functions through loss of an acquired capability to earn a living. Typically, it begins in late adolescence or early childhood ("WHO | Schizophrenia", 2018). There needs to be two or more of the following presentations for a period over more than six months to qualify for diagnosis, delusions, hallucinations, disorganised speech, being grossly disorganised and negative symptoms, which include diminished emotional expression or avolition. However at least one of delusions, hallucinations or disorganised speech must be present for diagnosis (American Psychiatric Association, 2013). This blog will outline the prevalence and potential causes of schizophrenia, utilising the diathesis-stress model as a framework to explain how environmental factors may impact those with a vulnerability to schizophrenia. This blog will review treatment, intervention and therapies whilst acknowledging the implications on the therapeutic process, furthermore, it will outline best practice and potentials risks for and of therapeutic intervention.Prevalence and causes
Schizophrenia impacts less than 1% of society, however globally this equates to over twenty-three million people. It is more prevalent in males (fifty-two percent) than females (forty-eight percent) however it commonly starts earlier in the life of males and later in that of females (Silverstein, 2014). Research has not identified one single factor that causes schizophrenia, its aetiology may be a result of the complex interactions between a person’s life experience, development of self, chronic stress, the quality of interpersonal environment, genetic and other biological factors. It is noted that stress, anxiety and depression can trigger the emergence of a psychotic instance (Silverstein, 2014; American Psychiatric Association, 2013). Triggers to psychotic episodes for clients can be experiences of sleep deprivation, trauma, abuse and confinement (Harris and Williams 2002, Turkington & Kingdon 1997).
People with schizophrenia are two to three times more likely to die early than the general population, this is often due to preventable physical diseases including cardiovascular disease, metabolic disease and ill health due to poor lifestyle. It is noted that over fifty percent of people with schizophrenia are not receiving the appropriate care and that financial implications mean that ninety percent of people with untreated schizophrenia live in low- and middle-income countries ("WHO | Schizophrenia", 2018).
Research has looked to prove and disprove the impact of drugs, such as heroin and cannabis on schizophrenia. Currently alternate research has demonstrated both that cannabis can cause schizophrenia and drug addiction can predispose people to schizophrenia (Frisher, 2010). In the UK between 1996 and 2005 it was proven that the prevalence of schizophrenia was declining, however in 2004 it was also reported that some institutions were admitting up to 80% of new cases of clients with schizophrenia involving cannabis use (Frisher, Crome, Martino and Croft, 2009). A UK government drug website stated that regular use of cannabis is associated with a greater risk of developing psychotic illness, including schizophrenia, for people with an existing diagnosis it can cause a serious relapse ("Cannabis | FRANK", 2018).Genetics and Environment
There has been significant research in the area of genetics, it is still unclear if there is one definitive cause, however genetic factors have accounted for approximately eighty-five percent of the variance in a liability to develop schizophrenia, ergo, people with schizophrenia in their family are more likely to suffer from the same disorder (Cardno and Gottesman, 2000). Pre and post-natal factors that cause schizophrenia have also been studied, however it is agreed that the presence of an effected family member is an important risk factor in schizophrenia (Fowles, 1992). It has been postulated that this is may be due to Mosaic X chromosome aneuploidies, however there is more research needed before confirmation of this. (Koc, Yirmibes Karaoguz, Cosar, Ferda Percin, Sahin, Baysak and Kardem, 2010). There has also been a correlation between potential physical similarities of those with schizophrenia, namely, malformed ears, high arched palate, slanted palpebral fissures and syndactyly of toes which some are arguing is proof of a more biological cause for schizophrenia (Nicolson, 2000). Several twin studies have been a part of this research, whilst it has been found there is an increase in heritability of schizophrenia liability and a corresponding decline in the degree to which this variance can be attributed to environmental factors there is still no conclusive cause yet confirmed (Koç et al. 2010). The diathesis-stress model of schizophrenia postulates that stress, through its effect on cortisol production may exacerbate symptoms of schizophrenia if there is a pre-existing vulnerability (Jones and Fernyhough, 2007). There is current research which is focusing on neurotransmitter pathways for serotonin, Dopamine and glutamate and their receptors which are hoping to demonstrate the excessive stimulation of these may result in psychotic symptoms (Koç et al. 2010).Treatment intervention and therapy
Schizophrenia is treatable with medicine and psychosocial support however many that are diagnosed with chronic schizophrenia lack access to treatment ("WHO | Schizophrenia", 2018). The schizophrenia commission (2012) report that stated that forty-five percent of people with schizophrenia recover. Twenty percent of people have chronic symptoms. Thirty-five percent have changeable patterns of remission and deterioration. When working with clients that have schizophrenia it is imperative to understand that this impact is not only psychological, it is also, social, recreational and vocational as are many mental health disorders (Brooker & Brabban, 2004; Walker 2014; Jones et al., 2012)
It has been debated that people with early episodes of schizophrenia seem to respond differently that those with several prior episodes, this has implications on the prescription of medication as psychological history may have an impact on dosage, drug choice and administration in patients with schizophrenia (Bola, Kao, Soydan, 2011). (Zhu et al 2017) concluded that patients successfully treated for first episode psychosis with anti-psychotic medication, with compliance for at least three years, decrease the incidences of relapse and had better long-term outcomes. There is also no ‘best’ medication for those diagnosed with schizophrenia, this is due to the high attrition for those attending randomised trials and the quick change in medication if adverse side-effects are being experienced (Komossa et al., 2011). It is also important to note that anything between five percent to twenty-five percent of people continue to experience symptoms despite medication (Jones et al., 2012).Alternate therapies
A study on prison inmates in china looked at the effect of an art brut therapy program called ‘go beyond the schizophrenia’. It was reported that there was a decrease in anxiety, depression, anger and negative psychiatric symptoms which are synonymous with a schizophrenia diagnosis (Qiu et al., 2017). Art therapy allows for the clients to achieve greater cognitive understanding of their disorder, impact their self-esteem and personal perception, and allow them to express their sufferings, anger and despair in a creative way with an aim to improve their quality of life and sense of value all of which are impacted in those that have schizophrenia (Qiu et al., 2017).Family Therapy
Treatment for schizophrenia has been primarily focused on pharmacotherapy with an emphasis on respite for the family. However, family dynamics and relationship distress have been attributed to a cause for schizophrenic symptoms in a client and can also negatively impact those working towards remission. Family oriented interventions seek to reduce and managing disabling symptoms and facilitate patients in adapting to society. Clinical trials have demonstrated that family-oriented interventions produce superior outcomes, including increased medication compliance and reduced symptom severity with a reduced likelihood of relapse. The stress-diathesis model, which looks at genetic vulnerability and its exacerbation of the development of schizophrenia, goes some way to explain why only one child in a family may show symptoms despite all experiencing similar stressors (Park, Park and Park, 2017).Integrative approach
An integrative approach offering a diverse and varied strategic approach is the most efficient and holistic way to work with a client with schizophrenia, that said, there is a distinct lack of evidence-based treatments to create a complete strategy (Lanfredi et al., 2017; Lysaker and Roe, 2016). There are efforts currently to develop further psychotherapies to assist with schizophrenia, some based in psychoanalytical models and others more focused on CBT, all of which rely on psychopharmacology, psychotherapeutic interventions and cognitive therapies to assist in the reduction of psychosis and disturbances (Silverstein, 2014). However, neither medication nor CBT are identified as the best psychological treatments for clients as medication is limited to dampening experiences while CBT assumes there is underlying cognitional dysfunctions which may see it as counter productive as it may exacerbate hyper-reflectivity in clients (Pérez-Álvarez, García-Montes, Vallina-Fernández, Perona-Garcelán & Cuevas-Yust, 2010). Co-morbidity is also high with clients who have schizophrenia, over fifty percent of whom have tobacco use disorder. There is an increase with anxiety disorders and higher rates of obsessive-compulsive disorder are also elevated, this will need to be taken into consideration before a robust and appropriate set of interventions are sought (Silverstein, 2014; American Psychiatric Association, 2013)Therapeutic implications
Jung was one of the initial psychiatrists to utilise psychotherapy as an intervention for schizophrenia, he maintained, throughout his career that schizophrenia could be cured by psychological means, however he alternatively notes that, under certain conditions, forms of psychotherapy could lead to symptom exacerbation (Silverstein, 2014). Regardless of the importance of utilising specific interventions, Jung recognised that the relationship between the client and therapist were critical factor in treatment response (Silverstein, 2014; Hamm and Leonhardt, 2016). The relationship between the psychotherapist and client is of utmost importance, and with empathy the client is lead to be accepted and appreciated in spite of their disorder, there is healing in this process which provides a space for the client to evolve a more robust pre-reflective self-awareness (Pérez-Álvarez, García-Montes, Vallina-Fernández, Perona-Garcelán & Cuevas-Yust, 2010; Hamm and Leonhardt, 2016). Jung goes further to note that improvements can be made but it is up to the constitution and resilience of the therapist to be comfortable in this space (Jung, 1940). Case studies have demonstrated that the therapist’s willingness to be vulnerable, and ability to lean into the discomfort of not knowing how to immediately respond to clients will facilitate their own growth while assisting in the therapeutic process with their client (Lysaker and Roe, 2016).Presentation and risk
It has been noted by attending psychotherapists that in presentation, the client may demonstrate significant reductions of attention (Silverstein, 2014; Reichenberg, 2010). Cognitive deficits are highly prevalent in schizophrenia and are detected in the early stages of the disturbance. This will impact how the client is presenting and their own self-awareness around their illness. Cognitive remediation therapy has been reported to affect neurocognitive process among client with schizophrenia (Lanfredi et al., 2017). It is estimated that twenty percent of people with schizophrenia will attempt suicide, far more than this have suicidal ideation, approximately five to six percent of individuals with schizophrenia die by suicide, it is important to note that this risk remains high throughout the life span of those with schizophrenia (American Psychiatric Association, 2013)
Clients who are heavily medicated may present with different side effects of their medication. There is a vast realm of research on the different impact certain medications may have on a client’s demeanour. Whist reviewing just one study on medication it was shown that cilistazol and risperidone cause dizziness in twenty three percent of users, headaches in eighteen percent and insomnia fourteen percent (Rezaei, Mesgarpour, Jeddian, Zeionoddini, Mohammadinejad, Salardini, Akhondzadeh, 2017). Its important, when working with clients with schizophrenia to gain understanding on the medication, and side effects that they are experiencing, this will allow full exploration of what is psychosis and what is a side effect to medication. Co-morbidity is also high with clients who have schizophrenia, over fifty percent of whom have tobacco use disorder. There is an increase with anxiety disorders and higher rates of obsessive-compulsive disorder are also elevated (American Psychiatric Association, 2013). This also must be taken into consideration as the client may be working through more than one disorder.Societal implications
Through several studies is has been ascertained that there is still a large stigma surrounding any mental illness, this is more so in the case of psychosis, namely schizophrenia (Mannarini and Boffo, 2015). This has a negative impact on the availability of rehabilitative social interventions. This may be down to the perceived unpredictability of clients with schizophrenia and the assumption of underlying violence. There needs to be greater awareness surrounding the behaviours of those with schizophrenia, campaigns with aims to reduce discrimination towards those with the illness and a more explorative process when reviewing dual-diagnosis for people with schizophrenia to potentially include substance misuse and personality disorders. Finally, a more integrated approach, utilising a full multi-disciplinary team will also assist in the rehabilitation and re-integration of a client that has schizophrenia, each layer of this is important to explore in the therapeutic setting (Magliano, De Rosa, Fiorillo, Malangone and Maj, 2004).Best practice
It is generally accepted that, with the introduction of anti-psychotics, there is a reduction in the cortical volume of clients with schizophrenia, which leads to neuro inflammation, the impact of this is not yet known but it is acknowledged that it is functionally significant and may exacerbate manifestations of said disorder (Zhang, Catts, Sheedy, McCrossin, Kril, Shannon Weickert, 2016). It has also been postulated that patients will experience unpleasant side effects and become increasingly resistant to long term use of antipsychotic medication and as such a more integrative approach may be best practice when working with clients with schizophrenia (Qiu et al., 2017).
Guidelines for service users suffering schizophrenia were published by national institute for health and care excellence (NICE) in 2014. These strategies recognised the efficiency of psychosocial interventions and noted cognitive behaviour therapy and family therapy will assist in the rehabilitation of clients. It proposes that the integration of a multi-interventional approach, incorporating medical, social and psychological offers a best-practice delivery of care (Brooker & Brabber 2004; NICE 2014; Gamble & Hart 2003). The aim of using CBT working with client’s with schizophrenia symptoms is to “normalise” them by educating the client on how they can be understood (Silverstein, 2014; Jones et al., 2012). Benefits have been seen with optimum medication management and psychosocial interventions for psychosis (Norman et al 2017, NICE 2014).
In the psychotherapeutic setting the therapist acts as the referee, catalyst and reference for common sense in suggested and significant narratives. Through detailed descriptive exploration the therapist and client can build a dialogical prostheses and shared vocabulary which will be instrumental in understanding and will better both parties be understanding of nuances in communication with each other (Pérez-Álvarez, García-Montes, Vallina-Fernández, Perona-Garcelán & Cuevas-Yust, 2010).Conclusion
Whilst the prevalence rates of schizophrenia are low it does impact a high number of people worldwide, its impacts are detrimental not only to mental, but also physical health, this brings a new dimension and vulnerability to the client presenting before us. Thus far an exact cause of schizophrenia has not been pin pointed so further research is necessary before a robust rehabilitation can be cemented for those diagnosed. This blog has broadly outlined the diagnostic features of schizophrenia and the manifestations of the disorder while noting etiological factors and current understanding of the illness. Whilst reviewing the current interventions utilised when working with schizophrenia there has been a distinct focus on mixed therapy with a psychopharmacological and psychotherapeutic underpinning. In the Best Practice segment of this blog alternative and integrative treatments have been explored, this however is subject to change due to the limited evidence-based practice, confirming that more research is needed. Once again however, there is vast literature that outlines the importance of the therapeutic relationship which offers some solace to this trainee therapist, before any interventions, the process of just being present and creating that space for the client, psychosis or not, is enough to start the healing.References
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