The Impact and Management of Mental Health Comorbidity

Mrs. Bennett is a 72-years-old female with history of Parkinson’s disease that has been well controlled with medication for the last five years. Mrs. Bennett lives in a two-story home independently. Although her Parkinson’s disease has been managed well with medication, Mrs. Bennett has had multiple incidents of fall with one incident leading to broken wrist. Mrs. Bennett is at risk for fall related to hoarding disorder per her daughter’s report. The items that Mrs. Bennett’s accumulates in her house include newspapers, totting food and some other items not specified. The main purpose of this paper is to explore and to take into consideration the impact of comorbid Hoarding disorder in management of Parkinson’s disease and how to manage hoarding in an older adult with Parkinson’s.

Epidemiology of Hoarding Disorder

Adults 65 years and older have a mental disorder with estimated number of 8.6 million (Flood & Buckwalter, 2009). In an epidemiological study conducted in London using1698 participants 19 subjects screened positive for hoarding using DSM-V diagnosis criteria. The study concluded that the prevalence being 1.5%. This study also found that hoarding was correlated with old age and being unmarried (67%) and having comorbid physical health condition (Nordsletten et al., 2013). This evidence can be related to Mrs. Bennett who is older adult, unmarried with Parkinson’s and a comorbid hoarding disorder. Currently, hoarding disorder prevalence is 6% in American in older adults (Mathews, 2014). Some number of patients diagnosed with Parkinson’s disease who receives dopamine-replacement therapy also develop compulsive behaviors such as hoarding. This can lead to challenging therapeutic treatment and cause psychosocial impairment in patients (Ferrara & Stacy, 2008).

Assessment

Mostly hoarding disorder assessment is not easily revealed in family medicine. Patients with hoarding disorder present in primary care setting with an incident of fall (Frank & Misiaszek, 2012). This is true in Mrs. Bennett’s case; the hoarding disorder would have been hidden if her daughter fails to report to the physician. Hoarding include the compulsive urge and failure to discard huge amount of belongings that takes over the living area of the home and causes the individual a serious distress, health and safety risk (Frost & Hristova, 2011).

DSM-V Criteria

The symptoms of hoarding disorder has been under consideration in Diagnostic and Statistical Manual of Mental Disorder 5

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Edition (DSM-V) for a while (Frost & Hristova, 2011). Finally, in 2014, hoarding disorder was included in DSM-V as a mental disorder. The diagnostic criteria of hoarding disorder in DSM-V include: Difficulty in discarding or separating self from possessions as a result of urge to keep useless items. The accumulation of items clutters the active living area in different settings such home, office, car. The action of accumulation of possessions causes distress that is clinically significant and causes risk for unsafe environment for self and others. To make the diagnosis of hoarding disorder, medical and mental disorders, neurologic conditions that can cause the individual accumulate items need to be ruled out. Once it is confirmed that the disorder is not related to medical condition or mental disorder, hoarding disorder can be made (Mataix-Cols, 2014). In hoarding disorder, paperwork, newspapers, old clothing, books, and bags are some of the most commonly saved possessions. In Mrs. Bennet’s case newspapers seem to be the number one item she seems to have difficulty discarding.

Screening Measure

Several useful assessment questionnaires and interviews have been used to screen for hoarding disorder. These include: general obsessive compulsive disorder (OCD) measure with hoarding subscales such as Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which is an interview with two parts. The first one requires patients indicate OCD symptoms that are divided into compulsions and obsessions and participant is required to answer more than 50 being present. The list include hoarding as both a compulsion and obsession. The second part requires patients to list three obsessions and compulsion that is most frequent and rate them using things such as time, distress. Based on the addition of 10 ratings, the index of OCD severity such as hoarding can be assessed. Although this has been used a lot in early studies, the specificity of this tool is low and has serious problems. First, thoughts that associated with obsessive behavior and hoarding are not the same. Second the experience of hoarding and compulsion are different and may be recorded inaccurately. Third, the Y-BOCS hoarding questions do not correlate with the severity of hoarding behavior (Frost & Hristova, 2011).

Saving Inventory-Revised (SI-R) is another assessment tool composed of self-report questionnaire that is used mostly. SI-R is s elf-report that includes 23-item questionnaire with a score of 0 to 4 with total score range of 0 to 92 that includes three subscales to measure hoarding disorder main character. Based on evidence SI-R is a reliable and valid assessment tool for hoarding disorder (Frost & Hristova, 2011).

Hoarding Rating Scale –Interview (HRS-I) is one of the most valid and specific assessment used to screen hoarding disorder. HRS-I is composed of semi-structured interview of five-question that assess unique features of hoarding such as clutter, excessive accumulation of things, difficulty discarding, distress, and interference. The score ranges from 0 (not at all) to 8 (extreme). HRS-I has high sensitivity in measuring changes in hoarding treatment (Frost & Hristova, 2011).

Similarly, UCLA Hoarding Severity Scale (UHSS) is also semi-structured of 10-item questionnaire. On the other hand, UHSS includes slowness of task completion, procrastination, and indecisiveness, which makes the tool broader measure compare to HRS-I and other assessment tools. The validity and reliability of UHSS was not discussed but the interview correlates with treatment outcomes (Frost & Hristova, 2011).

Safety Evaluation

For Mrs. Bennett safety evaluation should also be include using Tinetti balance and gait evaluation that assess balance in sitting, standing position, arising attempt, and coordination. Get up and go test for fall prevention also needs to be included by having Mrs. Bennett first to sit in a chair whit her back straight comfortably, stand up from chair, walk, turn around, and walk back to the chair at her normal pace and then finally sit down again (Mathias, Nayak, & Isaacs, 1986).

Evidence Based Treatment

A research reviews showed that treatment of hoarding disorder is best delivered by a multidisciplinary team approach including accessing local resources to manage hoarding disorder (Frank & Misiaszek, 2012). More than just using one treatment method is required to intervene in hoarding disorder; using local resources from multiple public agencies helps in improvement of services. For instance some communities have developed multiagency hoarding team (Chapin et al., 2010).

The treatment should start with evaluating the person and assessing the degree and risk of hoarding disorder. Assessment and evaluation will lead the clinician to provide appropriate management to each individual diagnosed with the hoarding disorder. Primary Care Nurse Practitioners can use the diagnostic interview to assists in evaluating the risk of hoarding such as risk for fall due to clutter, potential fire hazards, risk to health due to unsanitary living conditions, and risk of potential rodent or insect infection by directly interviewing the person (Mataix-Cols, 2014). In Mrs. Bennet’s case, the clutter is causing her to have unsafe environment, which leads to her to falling multiple times. Unfortunately, due to recent recognition of hoarding disorder, there is no evidence based professionally recognized management guideline for clinicians currently. The only evidence-based treatment is cognitive behavior incorporated with hoarding disorder education (Mataix-Cols, 2014).

Geriatric hoarding behavioral treatment in adults with average age of 66 was conducted. The treatment included 24 sessions with psychotherapy of cognitive rehabilitation focusing on discard exposure and executive functioning. The post treatment result was statistically and clinically significant for improved changes in hoarding symptoms. This treatment targets neurocognitive deficits of hoarding disorder (Ayers et al., 2014).

Pharmacotherapy treatment of hoarding disorder includes selective serotonin-reuptake inhibitors (SSRIs) and Serotonin-norepinephrine reuptake inhibitors (SNRIs). Evidence shows that patients with hoarding disorder had improve with use of paroxetine (Mataix-Cols, 2014). 70 % of patients diagnosed with hoarding disorder had significant symptom improvement using venlafaxine extended–release for 12 weeks (Saxena & Sumner, 2014).

Initial Plan of Care

The major concern of treatment of Hoarding for Mrs. Bennett is safety issue related to the seriousness of Parkinson’s disease and Hoarding. Parkinson’s disease is associated with postural instability, increased resting tremors, bradykinesia, and rigidity. Safety remains as the main issue due to hoarding disorder. Mrs. Bennett’s living arrangement is not suitable for someone with comorbid Parkinson’s disease. The plan of care for Mrs. Bennett should include treatment using pharmacology and non-pharmacology, education on hoarding disorder, and follow-up for monitoring and evaluating treatment response.

Pharmacological Treatments

Pharmacological treatment for Mrs. Bennett can be started with Paroxetine 20 mg by mouth every morning, increase dose by 10 mg per day every week, with maximum dose of 40 mg per day. Evidence shows that Patients with hoarding disorder who were treated with 40-60 mg of paroxetine showed symptom improvement after 12 weeks (Mathew, 2014). Since Mrs. Bennett is elderly, starting low and going slow with medication dose should be considered.

Non-pharmacological Treatment

Refer Mrs. Bennett to geriatric psychiatrist for cognitive behavioral therapy. Ayers et al. (2014) showed that cognitive and behavioral therapy treatment is effective for treating hoarding disorder in older adult. Looking at local resources of public agencies to clear the clutters in Mrs. Bennett’s house by involving a social worker or case manager is also necessary to help her navigate through her house while she is on pharmacological and/or non-pharmacological treatment for hoarding disorder. Hoarding in Parkinson’s disease can be attributed to multiple factors such as being physical unable to discard items. Evidence shows that inability to discard items correlates with obsessive-compulsive disorder in patients who have a comorbid hoarding disorder with Parkinson’s disease (O’Sullivan et al., 2010).

Monitoring Treatment Response

Improvement in hoarding severity will be measured using SI-R, UHSS and HRS-I before and after treatment for monitoring the effect of Paroxetine for Mrs. Bennett. Based on evidence treatment response takes 6-12 weeks. There fore, post treatment severity improvement should be assessed at 12 weeks (Mataix-Cols, 2014). Safety evaluation screening with Tinetti and get up and go will also be performed during pre and post treatment in order to evaluate safety due to Parkinson’s disease. If Mrs. Bennett does not respond to treatment management, placing her in assisted living or nursing home can also be used as a last resort. Every effort should me bade to keep Mrs. Bennett at her home.

Ethical Issues

The ethical issue in Mrs. Bennett’s case is that although she has a compulsive hoarding disorder that puts her at risk for fall and many other health conditions; the daughter was the one who reported Mrs. Bennett’s hoarding disorder. The ethical dilemma in this case would be autonomy, Mrs. Bennet’s decision to live at home versus safety risk, ethics of forcing her into nursing home. Despite Mr. Bennett’s hoarding disorder, assessment of elder abuse should also be considered.

Nursing Implications

As a Primary Care Nurse Practitioner (PCNP), one is expected to be able to address the issue of hoarding by using DSM-V screening criteria and using screening assessment tools to correctly diagnose and treat hoarding. The assumption with this Mrs. Bennett is that she probably wants to continue living at her house and getting her house free of clutter is very important. The house needs to be cleaned. With Mrs. Bennett’s Parkinson’s disease she will continue to have

fall incident and injure herself further therefore, safety is a major concern and issue for her.

PCNP can also incorporate teaching on hoarding disorder to Mrs. Bennett and her daughter. As it has been mentioned in evidence based treatment-involving family helps in managing hoarding. The burden for the daughter will be enormous, social support other than Mrs. Bennett’s daughter should also be considered. Evidence shows that the functional impairment involved in hoarding affects both the patient and their families with increasing level of burden associated with caring for individuals with hoarding disorder. Increasing support would benefit the family member in dealing with the individual with hoarding disorder. On the other hand, the study findings also showed that involving family members in treatment of hoarding disorder would be beneficial to the individual with hoarding disorder. This will help in understanding the severity and the etiology of hoarding disorder (Drury, Ajmi, Fernandez de la Cruz, Nordsletten, & Mataix-Cols, 2014). For maintaining ethical principles Nurse Practitioners must take into consideration elder abuse, Mrs. Bennett’s wish and safety risk in providing suggestion to the daughter for the living arrangement of Mrs. Bennett to avoid family influence in living arrangement.

Conclusion

In summary, hoarding disorder is one of the mental disorders that has been recognized recently and included in DSM-V recently. Review of research shows that evidence is limited on the management of hoarding disorder. Future research is needed on treatment management of hoarding disorder (Mataix-Cols, 2014). Hoarding disorder puts burden not only on the person who is being evaluated for hoarding or has been diagnosed with hoarding but also on families of the patient with hoarding disorder just like any other mental disorders. Mrs. Bennet’s hoarding disorder is causing her to fall and putting distress on her daughter.

Due to the rapid growth in Autism diagnoses, ABA clinics have dramatically increased in many states. Medical specialists are now treating ABA therapy as a treatment for obstacles individuals with Autism face. These treatments are intensive and parents are now seeing the importance of Early Intervention. With high demands for a solution, Autism has expanded outside a medical field to social and mental realms to address the issues individuals with Autism encounter in today’s society. As a result of this disorder, the lack of communication skills makes it extremely difficult for individuals with Autism to adapt and communicate with others in their surroundings, so ABA techniques and operants are desired.

“Autism Spectrum Disorder, also known as ASD, is a complex neurological developmental disability; signs typically appear during early childhood. Considering their neurological disabilities, it affects a person’s ability to communicate and interact with others and their environment” (Autism Society, 2016.) There is no known specific cause of Autism, yet increasing awareness for early diagnosis and intervention allows carriers to access the appropriate services and support needed to improve outcomes. Autism Spectrum Disorder is prevalent in all racial, ethnic, and socioeconomic groups, however, it’s about four times more common among boys than girls. According to the Center of Disease Control (2018), approximately “one in fifty-nine children are diagnosed with an Autism spectrum disorder. Commonly one in thirty-seven boys is diagnosed with Autism in comparison to one in every one hundred and fifty-one girls.” There is no cure for Autism but studies prove intervention during a child’s preschool years can help improve a child’s learning ability in social communication, functional and behavioral skills (Mayoclinic 2018.)

“Applied Behavioral Analysis also know as ABA is a method of autism treatment based on behavioral principles which, simply put, state that desired behaviors can be taught through a system of rewards and consequences” (Ruby 2019.) Majority of these therapy session are conducted by Registered Behavior Technicians or RBTs; these are paraprofessionals who are supervised under a Board Certified Behavior Analyst (BCBA), who implement treatment plans to assist Autistic individuals with their challenges. These therapeutic sessions are held at both in-home and center-based settings.  Home-based Applied Behavioral Analysis provides a great way to teach skills to children in a more holistic and familiar environment. For example, it may be more beneficial to teach daily skills such as bedtime routines, toileting, and bathing in a home-based environment. The therapist refers to this as a Natural Environment Teaching which allows the child to participate in an environment that is familiar while learning new skills. This method of teaching is less invasive for beginners. On the other hand, “Center-based ABA provides a child with a structured environment in which he or she learns a variety of important skills” (Trumpet Behavioral Health 2019 ). This method of teaching skills is implemented in very small steps inside a structured environment which is referred to as Discrete Trial Training allowing a child to follow the demands of someone in authority similar to a structured environment like school. ABA therapy allows us to understand the function of behaviors and what to do when undesired behaviors are present. The end goal is to increase socially appropriate behaviors while reducing undesired behaviors that are harmful or impair a child’s’ learning ability. Applied Behavioral Analysis aims to help increase language, communication between others, memory, and academics. Autism Speaks (2019) conducted research that proves using early intervention empowers the outcomes for many children with Autism Disorder, only if sessions are orchestrated using intensive and long time intervals approximately twenty to forty hours a week. Applied Behavioral Analysis is beneficial throughout any of the milestones, but early ABA interventions have a greater impact.

ABA Therapy uses many verbal operants to increase the vocabulary of children with autism. These strategies are based on intense scientific research studies that have proven successful outcome rate, such as:

●       Manding: This strategy is used to provoke a request for a desired behavior or item. For example, the therapist will have a child’s preferred toy in sight yet not close enough for him/her to gain it independently, so the child would ask verbally or manually gesture towards the preferred item. This will be reinforced by giving him/her the toy. Again, this teaches a child to ask for the item rather than tantrum for what he/she wants.

●       Echoic: The therapist delivers a discriminative stimulus (SD) or commands like “say cup” and the child says “cup.” These commands are delivered with the hopes a child would imitate sound or word. This is used for both non-verbal and verbal children to increase their vocabulary and work towards communication skills. Therapists highly recommend these strategies to be used in a clinical setting and conversation with parents to ensure the child’s pronunciation is generalized outside a clinical setting.

●       Tact: The therapists use a verbal label to familiarize clients with what’s being presented. For example, a therapist shows a picture of a car and asks “what is this?” and the child responds “car.” This technique is used to provoke words with the association of an object. The therapist encourages parents to label objects at home such as the kitchen sink, toilet, and bed then reinforce the child when he/she answers correctly. Allowing the child to gain a better understanding of tangible objects rather than only seeing pictures in a clinical setting.

●       Intraverbal: The therapist and clients practice the correct response when engaging in a conversation. For example, a therapist asks “what’s your name?” and the child replies “John.” This is one of the most empowering techniques to advance interaction with peers, parents, and others in society.

ABA treatment goals are based on the age and ability level of the person with Autism Disorder. Goals can include many different skill areas, such as: “social skills, self-care, motor skills, learning and academic skills” (Autism speaks 2019.) Most importantly communication and language are a prioritized targets when teaching children with Autism. Communication is the foundation of learning so the above operants are practice during many sessions within the home and clinical environment to provide a child with greater social skills.

Applied Behavioral Analysis includes techniques as well. Applied Behavioral Analysis includes Discrete Trial Training, Natural Environmental Teaching, Chaining, and  Extinction and many other teaching methods. Techniques differ from operants. Operants rely on reinforcers or prompts to increase the response of a child. Additionally, Techniques are teaching methods that rely on an ABCs method to understand the antecedent and consequences of behavior and/or response. ABC is broken down into three sections to understand targeted behavior. For example, “A” stands for antecedent which could be described as the action that occurs before a target behavior. “B” is defined as the behavior that occurs after the antecedent occurs. Lastly, “C,” defined as the consequence of the behavior. Many times the ABC methods result in a Behavior plan because Board Certified Behavior Analyst use this majority to properly handle undesired behaviors at large. Applied Behavioral Analysis techniques include Discrete Trial Training, Natural Environmental Teaching, Chaining, and Extinction.  As stated before, Discrete Trial Training allows a child to follow the demands of someone in authority similar to a structured environment like school this is similar to Errorless learning, in which the children can not make any mistake forcing a correct response or reaction. Natural Environment Teaching is conducted in generalized areas such as home, kitchen, and bathroom to prompt behavior or action that is essential to daily life. In addition to Chaining and Exctition all techniques play a role in teaching individuals with Autism. Channing is implemented through very small steps. Once small steps are mastered the next step is followed. Therapist utilized this in a backward and forward procedure. Backward Chaining is implemented by teaching the last step first. For example, a child gets a taste of a peanut and butter sandwich then the therapist and child reconstruct another sandwich step by step starting from the beginning. Forwards chaining is the opposite. Forward chaining is implemented by teaching the first stop then guide a child step by step to reach the finalized goal. Each technique is utilized based on a child’s abilities and skills. Both operations and techniques were taken advantage of to implement studies and justify the results of Early ABA intervention.

Prior research indicated that early ABA intervention increase the IQ by twenty points, increasing the scores of standardized testing and minimizing the aid needed for individuals with Autism in school settings. The results was colledcted with hopes that Early Intervection will “normalizie” children with Autistic disorder. Due to previous studies, early ABA interventions is in high demand for parents’ with autistic children today, yet the aid and resources needed to conduct these sessions are limited. Registered Behavior Technicians and Board Certified Behavior Analysts are numbered. Behavior technicians did not have adequate training and credentials to provide services to children as well as Behavior Analyst to individualize the plans need to increase a child’s social skills and appropriate behavior at this time. So, The University of California in Los Angeles famously known as UCLA studied the results of early intervention and transformed the dream of early intervention into reality as a pilot study. This pilot study was condomed after UCLA students saw the need for Early ABA and decided to execute the plan and study the impact early interventions have on children with autism and their providers. The study aimed to address three aspects of their study which included the progress of six children with a mental disorder, quality of treatment and the review of parents associated with this study. This research required intensive background knowledge and tracking of the kid’s activity for years. It was achieved by gaining the proper training from professionals and building a trustworthy relationship with parents and children. They realized that previous psychologists in the 1980s tested a child’s’ IQ and other standardized testing before conducted experiments. Despite the common gender denominator, undergraduates also investigated the families’ socioeconomic data. To qualify for this longing study, participants must have been diagnosed by a professional with Autism or PDD. After further investigation, researchers found all six participants were boys and shared more than a diagnosis. “They all lack of imaginary play and peer play, as well as high rates of stereotyped or ritualistic behaviors according to their parents” (Smith, T, et al. 2000:299) Although the children shared many similarities the parental background differed. All parents received a high school diploma or a form of equal education yet more than half of the mothers were married providing some of the children with more support while other parents were single parents, dominantly single-mothers,  altering the amount of support and time need to implement fair trials. We know socioeconomic backgrounds does not play a factor in the progress of an individual, but it was important to state all aspects of this study. All contributors, including students, were new to early intervention training so data was collected from professionals and training was contributed from paraprofessionals also. To begin the experiment Baseline data was collected. Baseline data is “collected to determine the needs and identify targeted behavior. Behaviors are collected under baseline when procedures have not been developed” (Brousseau, A, et al. n.d.) Behavior Analyst uses this information to implement a child’s intervention plan. For this study, the intervention plan included: “40 unmastered tasks, including 10 receptive actions, 10 nonverbal imitation tasks, 10 verbal imitation tasks, and 10 expressive object labels.” (Smith, T, et al. 2000:301). They also included an IQ and standardized test before implementing procedures and recording baseline data to created individualize assessment plans.  Individualized assesments were client based, but assessments involved all parents, students, and children. Therefore training for all of the above was fairly important. Licesended Psychologist, who was not associated with this study, conducted a “blind” study to prevent any bias results and ensure the reliability of the research. This was done by testing children not associated with the study with children associated with the study and their IQ ranking was surprisingly the same. After the research began, parents became significantly involved. Parents and students were able to provide quality treatments due to the professionals of UCLA that provided them with sampling videos to model and provide quality treatment. Parents were instructed to measure the number of therapy hours a child receives over the course of the years and undergraduated students proceed to track follow up for one year after initial start date. The therapy session was timely measuring thirty-five hours per week for one year. The results concluded “5 of the 6 children substantially increased their correct responding to receptive actions, nonverbal imitation, and verbal imitation,” and “ all attending first or second-grade classes for typically developing children and were all assisted in the classroom by an aide” (Smith, T, et al. 2000:303). This proved children who received early intervention resuted in the likelihood of living in today’s social environment is astonishing higher.

Thanks to all of the incredible research of psychologist, students, and medical professionals their has been great progress in Autism treatment, yet there is still much more to discovered. Experiments are now working towards a more progressive plan that will detect Autism earlier than 13 month to 3 years in age to improve the lives of autistic children more dramatically. If Autism is detected earlier, around infantry age, parents can begin therapy and working towards skills that will improve the outcome of early intervention therapy. Formal articles and blogs encourage parents to pay attention to their children’s actions and not fear autism testing. A call for action and findings are important! In spite of that, there is limited funding to support these studies and the families of Autistic kids. Dr. Bryna Siegel, a professor of child and adolescent psychology at the University of California at San Francisco, states “single most heavily funded area of autism research across the last 20-30 years has been autism genetics. Brain science also receives a significant portion of funds” (Valerie 2018.)  Throughout previous studies, there has been no proven statistics that Autism is a genetic mutation yet majority of  all funding is aimed towards the electrical wiring of children’s brains. These funds should be aimed to increase therapy awareness, parent training and providing Registered Behavior Technicians in public school setting to ensure challenged children are receiving the proper assistance in order to be a productive citizen in society. It is important for us to volunteer in community activities involving autism and join awareness groups to spread knowledge and educate everyone of the characteristics of autism. Again, there is no specific race or socioeconomic background dominantly affected with this disorder so testing is extremely important especially in young men. Remember early intervention and detection is the best method utilized to shape a young autisc individuals in a social environment.

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Abstract

Schizophrenia affects a quarter of a million people in the UK. Schizophrenia is a psychotic disorder which unmediated patients find difficulties to sustain relationships and can become unable to represent themselves appropriately, this can lead to difficulties with employment, cause hallucinations, delusions, loss of sense of pleasure, loss of concentration, unnecessary behaviour outside of the social norm and social withdrawal. This essay highlights the environmental factors and genetic factors which can influence the role of an individual developing schizophrenia, the symptoms, how schizophrenia is diagnosed and the treatment in controlling the illness.

Studies however, are difficult to replicate and greater work needs to be complete in all areas of the development of schizophrenia. Inheritance is important in schizophrenia although it is not 100 percent based on the genetic of the individual. Dizygotic twins have a 17 percent risk factor to developing schizophrenia whereas monozygotic twins have a staggering 48percentrisk of developing the disease. There has been 27 genes which have been identified with schizophrenia to date although interestingly dopamine was not among them although the dopamine receptor is.

Drugs and psychiatric therapies have been found effective in some cases although the drugs do have a few side effects and the talking therapies cannot be guaranteed to always work. Environmental factors can also be important with the treatment and family members need to support individuals correctly.

Schizophrenia is a major illness within the UK. Current statistics have shown that a staggering 220,000 people, both male and female, are being treated for the illness by the NHS according to (living with schizophrenia, 2017). Schizophrenia has been found to have no definite answer in the causes of the illness but several different factors which combine to create the illness. Schizophrenia can be an important issue to cover due to the staggering amount of individuals being treated in the UK each year. But what are the causes of the illness and how can it affect daily lives of the individuals who suffer from it. This essay will analyse what factors can influence an individuals likelihood of developing the disorder, the symptoms associated with the disorder and what treatments are available to ensure individuals with the disorder can live a happy and normal life.

Bressert (2018) suggests that symptoms regarding schizophrenia are both psychological and physical leading from delusions, hallucinations, catatonic behaviour and disorganised speech, Silber (2014) also back up these symptoms. Doctors describes there being two types of symptoms in individuals who suffer with schizophrenia, positive symptoms and negative symptoms.

Tracy (2016) along with Silber (2014) states that positive symptoms refer to excess or distortion of normal functions. Positive symptoms are most commonly associated with schizophrenia due to the individuals confusion and beliefs of reality. Dr Knott (2016) states that a primary symptom of schizophrenia would be delusions and hallucinations. Knott explains delusions as a false belief which is ongoing and based on incorrect reasoning. He argues that there are criteria which are required for a delusion. One being the certainty of a situation, this meaning that the individual believes the delusion unconditionally. Secondly, incorrigibility leading to the belief not being diminished in any way. Thirdly, impossibility which is positively fabricated. In an individual with schizophrenia delusions will be classified as primary, this means that it will occur within the mind and will be fully formed with no proceedings and will be showing a range of delusional topics, polythematic. Hallucinations are described as a sensory perception being experienced regardless of there being no external stimulus. Hallucinations can range from being visual, auditory, olfactory or tactile. Visual hallucinations have been reported in 72% of patients with schizophrenia although auditory characteristics are seen in most patients which relates to one or more taking voices.

Other positives symptoms of schizophrenia will also include movement disorder, where individual becomes agitated or catatonia. Disorganised behaviour, showing signs of unusual and inappropriate behaviour which could be childlike. Another would be thought disorder, difficulty organising or expressing thoughts resulting in patients stopping mid-sentence, making up words or speaking of nonsense.

Whereas negative in schizophrenia will be a decrease or the absence of normal day to day functions. These may exist many years before positive symptoms occur in schizophrenia due to negative symptoms being much harder to diagnose. Negative symptoms in schizophrenia include apparent lack of emotion (small emotional range), neglect of personal hygiene, loss of motivation, decreased ability to complete activities and neglect social interaction. Individuals suffering from negative symptoms are more prone to require help with everyday tasks including taking care of themselves. Due to the negative symptoms an individual may show traits of not wanting help or that they are frustrated and not trying while this is just an exhibition of the symptoms.

Moving on, NHS UK (2016) suggests that there is no sole test for diagnosing schizophrenia and it is typically diagnosed after crucial assessments undergone by a specialist within the mental health field. It states that individuals who may sense a change in their mood or behaviour to seek help from their doctor. During an appointment with the doctor, if schizophrenia is suspected the individual will be referred promptly to the local community mental health team (CMHT). The CMHT consists of different professionals to support individuals with complex conditions. Usually a psychiatric will carry out a more thorough assessment of the symptoms. Alternatively, due to their delusional thoughts, individuals showing signs of schizophrenia may believe that there is nothing wrong with them and refuse help. At this stage of diagnoses a mental health professional will undertake a diagnostic checklist. Usually if the individual has experienced one or more of the above symptoms for most of the time of a month, symptoms has shown significant impact on performance in work or studies and that all alternative illnesses has been ruled out such as alcohol intake drug misuse and other possible disorders a positive diagnosis of schizophrenia could be expected.

Grohol (2019) explains that schizophrenia will require lifelong treatment due to the illness being a chronic condition which exist in on a wide spectrum. He states that although schizophrenia can be devastating and sever that there are treatments which have been found to be effective. Medication can help with controlling symptoms such as psychosis and is the main treatment for schizophrenia along with psychotherapy including cognitive behavioural therapy, arts therapies and family interventions which is done alone side a professional within this field of treatment.

There are two classes of medications used in the treatment of schizophrenia, one being antipsychotics. This medication has been found to block dopamine receptors in the body and are effective in controlling the hallucinations, delusions and confusions which has been caused by the illness. Antipsychotics such as chlorpromazine, haloperidol and fluphenazine have all been a manageable medication used. Another being atypical antipsychotics, these include quetiapine, risperidone and olanzapine. This medication was first introduced in the 1990 and have been found in some cases to have a positive effect on both positive and also negative symptoms of schizophrenia.

Mind (2017) recommends cognitive behavioural therapy to be used alongside medication to help the individual cope with symptoms of psychosis, to reduce stress, handle other problems that could arias due to the condition and also manage side effects caused from medication. Cognitive behavioural therapy is a treated as a talking therapy for patients and helps to ease the individuals patterns of thinking or behaviour. This type of treatment will focus of helping the individuals cope with symptoms of schizophrenia instead of convincing the individual that their experiences and beliefs are incorrect. Family interventions can help relative or carers find a way which is best suited to support the needs of the patient and support families in finding necessary ways of coping and solving problems together. Family intervention is a type of treatment regarding relatives, carers and families of the patient who is diagnosed with schizophrenia. All treatments go hand in hand and together can help the individual diagnosed with the condition in finding a way to get their lives as close to normal as possible (Tse, 2013).

Moving on to different causes of schizophrenia. According to Silber (2014) there have been numerous evidence and studies found to have shown the different causes of schizophrenia, although no one cause has been constructed. Mind (2017) suggests that schizophrenia has been generally agreed to have a combination of causes rather than one. Environmental factors and genetic factors have a strong link within the cause of schizophrenia.

According to Schoenstadt (2017) genetic factors are not the exact cause of schizophrenia although genes do have a reflection on a person’s risk of developing the condition. Schoenstadt suggests that schizophrenia will occur in only 1% of the general population despite the fact schizophrenia is also seen in 10% of people who has a parent of biological sibling who suffers from schizophrenia. Twin studies have also been produced to potentially helping identify the genes responsible for the symptoms of schizophrenia.

Scientists from the University of Copenhagen in Denmark collectively gathered information through their Danish Twin Register and collaborated that information with the data collected from the Danish Psychiatric Central Research Register. This research found that a staggering sample of 31,524 twins born between 1951 and 2000 had realistically required psychiatric support. Due to monozygotic twins inheriting the same sets of genes from the parents it is possible to compare them with those of dizygotic twin pairs and can provide a powerful indication whether schizophrenia was caused by the genes a person inherits or as a result of environmental factors.

However, John (2014) states that research into the neurodevelopment of schizophrenia has also been undergone by an international collaborative group of researchers, studying the brain development during childhood and adolescence in people with and without schizophrenia. The researchers have now been able to describe brain development outlines to supplement the development of schizophrenia. This has been able due to the new statistical approaches and long term follow up with individuals. Research investigating the path of cortical thickness growth curves was conducted on 106 individuals with childhood onset schizophrenia and a comparison group of 102healthy individuals. Each individual ranging for ages 7-32 had repetitive imaging scans over the course of a number of years. Using above 80,000 vertices through the cortex, the research were able to fashion the effect of schizophrenia on the growth curve of the cortical cortex. This research discovered transformations which occur with a specific group of vastly connected brain regions which mature in association during distinctive development, although, follow changed trajectories of growth within schizophrenia. These finding show a relationship that the theorem that schizophrenia is a neurodevelopmental illness and the hypothesis that schizophrenia is a disease of altered connectivity amongst different sections of the brain.

Scientist have also found that individuals who have the disorder may well be more likely to have glitches within their genes which could contribute to disruptive brain development. Studies show that certain chemicals of the brain can control thinking, emotions and behaviour can be too active or not active enough within individuals with schizophrenia. They believe that brain loses tissue over time which PET scans and MRI scans for instance have shown individuals with schizophrenia have shown less gay matter which is the area of the brain which contains nerve cells.

Two chemicals within the brain dopamine and glutamate carry messages to cells along brain pathways, this is where professionals believe can control thinking, motivation and perception. Dopamine is well researched due to it linked characteristics to addiction, psychiatric and movement disorders. Dopamine in individuals with schizophrenia has been linked closely to hallucinations and delusions, this is due to the areas of the brain which drive off dopamine may well become overactive.

Karlsgodt (2014) Claims there are many theories have also justifies schizophrenia being a disorder of reduced or disturbed neural connectivity which impaired communication between brain areas leads to associated symptoms and cognitive changes in individuals with schizophrenia. White matter changes has also been connected to schizophrenia. Supporting evidence of this includes the neuroimaging studies of the first-episode and chronic patients that find white matter volume reductions and structural abnormalities (Write et al, 2000).

There have also been research produced in finding variations in many genes which are likely to contribute to the risk of developing schizophrenia. In a high number of cases multiple genetic changes along with a small effect combine to increase an individuals risk of developing schizophrenia. Although genetic changes are still an active field of research scientists are convinced genes have a higher risk factor leading to schizophrenia that environmental factors alone. Genetics Home Reference (2018) states that deletions and duplications of genetic material in any numerous chromosomes, which have the strength to affect multiple genes, are also known to increase an individuals risk of developing schizophrenia. A small deletion (microdeletion) in an area of chromosome 22 known as 22q11 may be involved within a small percentage of schizophrenia cases. Individuals who show this deletion have also shown other features in addition to schizophrenia for instance heart abnormalities, opening in the roof of the mouth (cleft palate) and problems with immune system and are diagnosed with an illness called 22q11.2 deletion syndrome.

Sekar (2016) explains that researchers feel they have found a new schizophrenia risk factor within genetics. A gene called C4 appears to be involved in the elimination of the connections of the neurons, this is a process called synaptic pruning and occurs naturally in the teen years. Researchers speculate that it is possible that excessive or inappropriate pruning of the neural connections could lead to schizophrenia being developed, which is why schizophrenia symptoms often start or appear during the teen years. This hypothesis was also confirmed during the rodent model (Sekar, A. et al. 2016.) Crew (2016) agrees with this statement and continues to say that in 2014 a tat of researchers from Harvard Medical School performed a genetic study based on 36,989 schizophrenia cases and 113,075 controls. They identified 108 regions of DNA where genetic variants increased an individuals risk of schizophrenia. They continued with their research and combined data from a genetic analysis of approximately 100,000 DNA samples from 30 countries, post-mortem brain samples from 700 patients and animal models. This was created to identify one gene which is associated with the highest risk of developing schizophrenia. Researchers then found the compliment component 4 gene known as C4. This specific gene is associated with the immune system and the development if the brain which also varies is structure significantly across individuals. A genetic investigation of more than65, 000 individuals with and without schizophrenia found that those who carried the specific variant of the gene had a greater risk of schizophrenia in their youth.

Harrison (2019) suggests that if a sibling or one parent has schizophrenia then the chances of an individual developing the disorder is around 10%, if an identical twin has the illness the chances are 50%, although, if both parents suffer with schizophrenia then an individual has 35% chance of developing it themselves.

Environmental Factors have also been studied to analyse the effects on the development of schizophrenia. Environment risk factors include obstetric complications such as prenatal infections, prenatal maternal malnutrition, foetal hypoxia, maternal life stressors birth season and location.  There have also been links found with later candidate environmental factors which can consist of psychological stress factors, substance abuse and individuals personality trait that can contribute to the causes of schizophrenia.

Kraepelin, a leading researcher into schizophrenia suggested that following the 1918 influenza epidemic there were increased numbers of “dementia praecox” now known as schizophrenia, this has since lead Kraepelin to the belief that such infection may be a factor in the development of schizophrenia. Recently, an increasing number of researchers have documented that an infectious hypothesis for schizophrenia is both biological plausible and testable. Investigators from various areas of research such as infectious disease, paediatrics, neonatology, obstetrics and paediatrics have known for some time that infections during prenatal life have many neuropsychiatric development, including behavioural issues, mental retardation, mood alterations and learning disabilities. Additional evidence to this hypothesis was the well replicated excess of births of schizophrenic individuals during the winter and mid spring. This was an era distinct by the increase in the occurrence of infections such as the influenza virus (brown, 2008, p. 7-10).

Substance exploitation has also been found to have been a co-occurring issue among those diagnosed with schizophrenia. In the region of 50 percent of individuals suffering with schizophrenia struggle with drug abuse. Though Substance abuse does not cause schizophrenia it will act as an environmental trigger. Using substances such as amphetamines, marijuana and cocaine can increase the symptoms associated with schizophrenia dramatically and can also cause symptoms to worsen in severity over time. Some researchers believe that individuals who are more at risk of developing schizophrenia are also more at risk for substance use. There is also evidence which shows that environmental factors can also play a role due to most individuals with schizophrenia and substance abuse also experiencing significant trauma early on in life.

Nutritional factors have also clearly been hypothesised to play a role in the cause of schizophrenia. A lack of specific micronutrients and the general nutritional deprivation have both been previously concerned as risk factors of the development of schizophrenia. In one landmark study of prenatal nutritional deprivation known as the Dutch Famine Study (Susser et al 1998), neurodevelopmental conclusions were measured after severe intake of calories where decreased. The rates of schizophrenia doubled for individuals who were conceived under circumstances of nutrient deprivation throughout premature foetal development, whereas, late gestational exposure did not. Later studies lengthened theses finding to schizophrenia showed a 2 fold growth in risk for early gestational exposure to famine (Hoek et al. 1998). Two further studies found evidence that low maternal body mass index or low birth weight can also be associated with schizophrenia (Done et at. 1991: Wahlbeck et al 2001).

Stress also has a partial influence to the glutamate and dopamine which provides with an environmental factor toward schizophrenia and appears to control neurotransmitter function. Furthermore, dopamine dysregulation may also ascend through a process called sensitisation. Varied individuals can be particularly sensitive to the effects of certain drugs for either genetic factors or due to a result of pre-environmental damage. Leading to the reason stress, such as drug use in adolescence may propel the neurodevelopmental impaired individual over the limit for schizophrenia (Picker, 2005).

In conclusion to this essay it can be seen that the genetic factors of schizophrenia has a greater relationship to the individuals chances of developing the illness, it has received further research than the contrasting environmental factors, and have shown that various genetic mechanisms of schizophrenia are only recently being identified. As evidence suggests that genetic vulnerability along with environmental factors can be combined in the development of schizophrenia although without the genetic factors already in place it is of a low certainty the schizophrenia will develop in the individual.

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