critical analyses on paranoid schizophrenia

Name of the Student
Professor’s Name
Medicine
6th January, 2016.
A Critical Analysis on Paranoid Schizophrenia
Introduction
Mental health and illness refer to the issue of cognitive and emotional health status of an individual. It is defined as a state of psychological well-being and an absence of any cognitive or emotional dysfunction. A person is said to exhibit appropriate mental, when the individual functions at a satisfactory level concerning emotional and behavioral aspects. The World Health Organization (WHO) has defined mental health as a state of subjective well-being, perceived self-efficacy, adequate competence, autonomy and self-actualization in a person. If any of the aspects above are compromised in an individual, he or she is referred to be a patient of mental illness. Appropriate mental health is important from the perspective of social and clinical well-being. However, the WHO suggests that approximately 50% of individuals across the globe are affected by some mental disorder (Anthony et al. 353-358). Emotional abilities and behavioral adjustments are essential in combating stress and physical hazards. Studies have also indicated that inadequate emotional abilities and behavioral adjustments may lead to anti-social behaviors and also increases the chances of self-harm. Hence, maintaining appropriate mental health is important for maintaining a healthy life and lifestyle. There are various forms of mental disorders that include depression, anxiety, panic disorder, obsessive-compulsive disorder, and schizophrenia.

Apart from purely psychological or mental disorders some disorders are associated with social or environmental aspects and such disorders are also classified as mental disorders. Psychological disorders are often co morbid in nature. This means the presence of one form of the psychological disorder may be associated with other forms of psychological disorders. For example, major depressive disorder is often associated with the panic disorder or obsessive –compulsive disorder. This leads to the poor prognosis of the affected individual. However, early diagnosis and appropriate pharmacological and non-pharmacological management may improve health care outcomes in such individuals.
Brief of the Case Study
The case study is about Martin, who is a 19-year male student. He is away from his home to pursue a degree in medicine. However, over the past few weeks, Martin has developed certain unusual behaviors as reported by his friends. On numerous occasions, they have overheard him, where Martin was seemed to be whispering alone in an agitated voice. Moreover, he refuses to use his mobile phone to speak to somebody as he apprehends that some Chinese spies will implant a deadly device (a chip) in his brain. In fact, Martin’s parents have tried to get him to a psychiatrist, but he refused such interventions. Further, Martin also believes that his parents are conspiring with the Chinese spies to get him killed. He apprehends that these spies will take his anatomical organs for the purpose of transplants. Due to such problems, Martin has stopped attending his regular classes and is at the risk of failing in the semester. The family history of Martin suggested that one of his aunt’s suffers from psychiatric ailments and often has to be admitted for her mental conditions. Martin does not indicate any habits of drug or alcohol abuse.
Probable Diagnosis
Martin may be considered to be suffering from Paranoid Schizophrenia. Schizophrenia is a type of psychiatric disorder when an individual loses his connection with reality and suffers from a condition called fear psychosis. There are various subtypes of Schizophrenia based on the symptoms presented by the individual patients. The common symptoms of Schizophrenia include hallucinations, delusions, auditory dilemmas (hearing a voice when there are no such voices) and disturbances in perceptions. Paranoid Schizophrenia is designated as a sub-type of schizophrenia as per the Diagnostic and Statistical Manual of Psychiatric disorder guidelines (DSM-IV guidelines). Paranoid Schizophrenia is debilitating and impacts the well-being of an individual significantly. Usually, a person is considered to suffering from Paranoid Schizophrenia, when an individual suffers from very first episode of Schizophrenia. However typical Schizophrenia is associated with disorganized speech and catatonic behavior. Since, Martin is suffering from the very first episodes of Schizophrenia and that too over a period ranging beyond a month, along with the symptoms of hallucinations, fear psychosis and the absence of symptoms like disorganized speech and catatonic behavior; he could be designated as a patient of Paranoid Schizophrenia (Ciompi 413-420). Further, the case study also reflects that he is suffering from anxiety and panic, and hence it may be assumed, that he is suffering from psychiatric co morbid disorders.
The inability to express appropriate emotional feelings towards his parents and appropriate cognitive behavior in pursuing his studies, the overall symptoms clearly defines that Martin is suffering from mental illness as per the defining criteria of WHO and DSM-IV guidelines. The typical symptoms associated with the diagnosis of Martin include the presence of auditory hallucinations (where an individual hears voices, which is not present in reality) and the presence of delusions. Delusions are feelings where an individual always feel that somebody is going to harm him or her and may even think that it will lead to his or her death. The specific symptoms of hallucinations and delusions differentiate paranoid schizophrenia from other forms of schizophrenia. The DSM-IV guidelines recommend that an individual should be diagnosed as a patient of paranoid schizophrenia, based on the following criteria:
Typical Symptoms: if he or she exhibits two of the following symptoms(Carpenter 681-690):
Auditory hallucinations: an individual hears voices, which is not present in reality
Paranoid Delusions: feeling that somebody is going to harm him or her
Disorganized Speech: Speech may get disoriented, and the individual cannot express his or her communication.
Exhibition of catatonic or disorganized behavior where the motor skills are compromised (Pataki, Zervas, & Jandorf 163-173)
Negative symptoms like flattening ( where an individual exhibits restricted sense of emotional expression)
The above symptoms must be present for at least one month if it is the first episode of schizophrenia in an individual and should continue over a period of six months.
Functional and Social Challenges
Constrained interpersonal relationship, either with their family members or friends
Significant impairment in work that leads to disturbance in professional life
Lack of self-care and self-management.
Failure in academic achievement
Exclusion of Mood Disorders
The person suffering from paranoid schizophrenia will not exhibit symptoms of major depressive disorder or mania.
Excluding effects of medication
The person suffering from paranoid schizophrenia will not exhibit symptoms under the effects of any drug, and the symptoms should not have a pharmacological intervention origin.
Segregation from other disorders when to present under co morbid symptoms:
If an individual suffers from other psychological or psychosocial disorders like autism, paranoid schizophrenia should only be confirmed if the subject expresses catatonic or disorganized behavior, paranoid Delusions, and auditory hallucinations
Chronic Symptoms
A person may be classified to carry on the episodes of paranoid schizophrenia, usually over longer period (>one year):
If there are episodic symptoms of paranoid depression, along with residual symptoms
Episodic symptoms without any residual symptoms in between.
The single episode even after full remission (especially exhibition of negative symptoms rather than classical symptoms) (Carpenter 681-690).
From the above criteria, it may be concluded that Martin Exhibits auditory hallucinations, paranoid delusions, negative symptoms, poor academic concentration and disturbed interpersonal relationship. Moreover, such episodes are neither due to pharmacological therapy or drug abuse. Martin also does not exhibit episodes of major depressive disorder or mania. All such findings indicate that Martin suffers from Paranoid Schizophrenia.
Functional Difficulties and Causes Associated with Paranoid Depression
Progression and Genesis
The genesis of Paranoid Depression occurs in 3 phases. These phases are premorbid, prodromal and psychotic (Carpenter 681-690). The phases are explained as follows:
Premorbid Phase: In this phase a subject expresses a normative and near normative behavior, motor, and psychological functioning. However, during this period a person who is destined to have paranoid schizophrenia at later stages are exposed to family stress, acute or chronic illness in the prenatal or post natal period, trauma or shock. Although the impact of such challenges is not evident in this phase.
Prodromal Phase: It is during this phase that the functional and behavioral features of an individual starts to differ from his or her functional and behavioral features during the premorbid phase. This phase extends from the end of the premorbid phase to the initiation of the Psychotic phase where the typical symptoms (hallucinations, delusions, disorganized behavior) start to appear. Such phases may last from a month to years and the typical time frame is 2 to 5 years after which the Psychotic phase appears. The individual exhibits typical symptoms in the Prodromal Phase. Such symptoms include disturbance in sleep, anxiety and depressed mood, signs of fatigue, lack of concentration, irritation and initial signs of behavioral and cognitive deficits.
Psychotic phase: This phase is marked by an abrupt and sudden appearance of typical and classical symptoms of paranoid schizophrenia (hallucinations, delusions, disorganized behavior). The progression of Psychotic phase occurs through three sub-phases:
Acute Phase: On this period there is a sudden appearance of typical and classical symptoms of paranoid schizophrenia-like hallucinations, delusions, disorganized behavior and negative symptoms. Moreover, during this phase an individual fails to correlate his thoughts. The negative symptoms in this phase are more prominent than the classical symptoms of paranoid schizophrenia-like hallucinations and delusions.
Stabilization or Recovery Phase: This period refers to the period of six months to a period of eighteen months after the initiation of treatment for the acute phase of paranoid schizophrenia. In this phase the residual and negative symptoms like disorganized and appropriate emotional feelings remains compromised and may occur with higher intensities compared to the acute phase.
Stable Phase: During this phase both negative symptoms and classical symptoms of paranoid schizophrenia becomes stabilized or becomes consistent, without any flare-ups. Usually, the negative symptoms although consistent and compromised, remain lesser in intensity compared to the acute phase. In most instances the patients may not exhibit such negative symptoms or classical symptoms of paranoid schizophrenia and remains asymptomatic during this period (Carpenter 681-690).
Functional Features
Significant impairment in work that leads to disturbance in professional life
Lack of self-care and self-management.
Failure in academic achievement
Development of meaningful thought
Disorganized motor skills exhibited by catatonic behavior
Loss of self-control
Severe constrained interpersonal relationship
Decreased social interaction or inappropriate social interaction
Impaired performance in academic or professional life
Suspecting others for harmful behavior and exhibition of harsh behavior towards such individuals (Carpenter 681-690).
Causes of Paranoid Schizophrenia
Research is being carried out to understand the causes of paranoid schizophrenia. However, no concrete cause or causes could be correlated towards the development of paranoid schizophrenia in an individual. On the other hand, various researchers have speculated certain causes based on scientific findings. Experts are of the opinion that brain dysfunction may lead to episodes of paranoid schizophrenia and may act as the causative factor for the onset of the disease. Certain experts also believe that genetics and environmental condition around an individual trigger the onset of the disease either independently or in an association of each other. These researchers believe that environmental triggers sensitize the genetic predisposition of an individual towards paranoid schizophrenia. The risk factors or triggers that may sensitize the genetic predisposition of an individual towards paranoid schizophrenia include (Carpenter 681-690):
The family history of schizophrenia or other psychotic disorders that may have been prevalent in the past or is prevalent in the present. This is true for Martin, as his aunt is suffering from some psychotic disorders, for which she often have to get admitted in mental care set-ups.
Exposure of an individual to life-threatening infections during the prenatal or post natal period (suffering from a viral infection during the prenatal period or suffering from meningitis during post natal period). Such infections may cause permanent debility on the normal functioning of the brain.
Malnutrition during fetal life that leads to inappropriate brain development.
Exposure to stress during early childhood from family constraints or suffering from chronic disease or academic failures.
Sexual and Physical abuse that occurs suddenly or over a period.
Delayed birth due to an age of parents.
Substance abuse (alcohol abuse) or drug abuse (pharmacological agents or usage of psychoactive agents).
Family Care
Since, paranoid schizophrenia cannot be cured, support from family members is extremely essential for the individual affected by such diseases (Brenner et al. 551-561). The family members must ensure that the individual affected by paranoid schizophrenia must comply with pharmacological and non-pharmacological interventions. Hence, the role of Martin’s parents in alleviating his agony is very significant. In fact, a guiding principle for treatment of paranoid schizophrenia is that the family members of such patients should be engaged actively and works in collaboration during the treatment phase. Martin’s parents will contribute to his care, and hence would require adequate education, knowledge, guidance, support and training to extend care provisions to Martin. Moreover, Martin’s parents should also ensure their own well being which is essential for extending appropriate and effective care to Martin. Therefore, physicians must understand that the family of a person who suffers from paranoid schizophrenia is under considerable stress and should ensure their well being, along with the care for the affected individual (Simpson & House 1265).
Martin’s parents should ensure the prevention of relapse of symptoms of paranoid schizophrenia. They should identify the probable risk factors and causative factors that may precipitate paranoid schizophrenia in Martin. After identification of such risk factors and causative factors, the must take each and every measure to avert such factors. Hence, they must not engage in violent behavior, or should not exhibit constrained family relationship. They must ensure and keep a strict vigil on Martin regarding the threats of substance abuse or drug abuse. Martin’s parents must also ensure that he does not exhibit any suicidal tendency or shows a tendency of self-harm. They must be compassionate towards Martin, irrespective of Martin’s attitude towards them. Martin’s parents must attend psycho education session with psycho counselors and psychiatrists to understand the coping requirements for Martin and themselves. They should also understand the educational needs for improving the functioning in patients, knowledge about the illness and course of the disease with identification of classical symptoms and residual symptoms, problem –solving skills, improved and appropriate communication amongst themselves and towards Martin and finally, they should be aware of stress reduction techniques (Klein , Cnaan , & Whitecraft 529-551).
Specific Challenges that Martin may impose
Martin may be extremely apprehensive regarding the care extended towards him. He might show resistance in getting admitted or receiving pharmacological or non-pharmacological interventions. He might also exhibit signs of suspicion towards his parents and his care givers in anticipation of a harming behavior. At times, Martin may show inappropriate emotional expression and may exhibit harsh behavior towards his parents or the care providers (Perkins 1121-1128). He might also refuse to take any medication and may not listen to the communications of his parents or his care providers.
Reflection on an Individual Suffering from Mental Illness
A person, who suffers from mental disorder, actually suffers from tremendous mental agony. Although the external world and the social surroundings think and believe him as a patient, he might be sensitive towards some issues that lead to this situation. A person suffering from mental disorder often cannot express themselves regarding such states, but there is a cause that causes such symptoms or such behavior in them. It is very easy to define a disease and formulate an action plan based on pharmacological or non-pharmacological interventions, but rarely the causative factors for such mental disorders are screened or are asked form the affected persons. I strongly believe that treatment of psychiatric illness should be associated with eradicating the cause for such diseases and should just not be a treatment plan with pharmacological or non-pharmacological interventions. The person who suffers from a mental disease often feels insecure, solitary and is prone to suicidal attempts. More than pharmacological interventions, they require the support and compassion from their near and dear ones. They feel that people around them should understand the reasons for such behavior and must act in a way, which helps to reduce their agony. However, in various instances, it is noted that the near and dear ones are ignorant towards their need. Such issues may aggravate their disease condition and lead them to more miserable condition both functionally and socially.
Martin, who is suffering from paranoid depression, may also feel the same type of insecurity and require a compassionate behavior from his parents, friends and care providers. It might also be possible that Martin is sorry from within for exhibiting such unnatural behavior towards his parents or towards self, but he becomes compelled and cannot resist such actions. Such actions may bother him from within, and he might suffer from mental agony. There might be some definite cause that imposes such behavior in Martin. If such causes have already occurred, then his parents or dear ones should try to understand such causes. I strongly believe if such causes could be identified, it will be possible to orient and rehabilitate Martin, even understanding the etiology and the course of the disease.
Appropriate Support Plan and Treatment for Martin’s Condition
Martin should be managed by pharmacological and non-pharmacological interventions for symptomatic relief for his condition (Hogarty 27-35). He should be advocated traditional and atypical psychotic medications. These medications could be of two categories, first generation, and second generation. The first generation antipsychotic agents act on the extra pyramidal systems and block the dopamine receptor in the nigrostriatal and mesolimbic areas of the brain. Such medications immediately decrease the classical symptoms like hallucinations and delusions associated with paranoid schizophrenia. Second generation anti-psychotics like clonazepine also reduces the symptoms like hallucinations and delusions associated with paranoid schizophrenia but do not cause extra pyramidal side effects in an individual. These agents also block the dopamine receptor or the serotonergic receptors in the nigrostriatal and mesolimbic areas of the brain. However, their binding kinetics reflects that they are loosely bound to such receptors compared to the first generation agents and hence the side effects are less. The common side effects associated with the anti-psychotics used to treat paranoid depression included dry mouth, interaction with other anti-psychotic agents like selective serotonin re-uptake inhibitors, hypersensitivity and allergic reactions, weight gain and increased sleep (Davis, Chen & Glick 553-564).
The non-pharmacological interventions include electroconvulsive therapy, repetitive transcranial magnetic stimulation and other psychosocial interventions like psycho counseling. Electroconvulsive therapy is thought to be beneficial for the treatment of positive and classical symptoms of paranoid schizophrenia. It is also beneficial when the episodes of paranoid schizophrenia are of shorter duration and occurs with lesser intensity. However, electroconvulsive therapy is associated with cardiovascular ailments and increases the chances of epileptic seizures. Hence, repetitive transcranial magnetic stimulation is used currently to avoid such side effects. Moreover, this form of therapy may be extended towards the patients with paranoid schizophrenia over a chronic duration, due to the decreased chances of adverse events (Kales, Dequardo, &Tandon 547-556). Psycho-counseling and community development programs are also helpful in managing symptoms of paranoid schizophrenia (Retor & Bect 278-287).
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