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Shonda has a 12 year history diagnosis of continuous schizophrenia paranoid type. Shonda is
constantly preoccupied with delusions and frequent auditory hallucinations. Shonda is under the
occasional supervision of a caseworker from a local community health center. Shonda lives alone
and rarely sees family members. While growing up Shonda heard that an aunt suffered a
nervous breakdown but other than that her immediate family shows no sign of mental illness.
Shonda¶s medication and treatment has been reassessed multiple times due to the frequency of
hospitalization and number of different complaints which include auditory hallucinations and
many other delusions.

Shonda¶s suffers from a pattern of confused speech often lacking orderly continuity. After
interviewing Shonda for a period of more than an hour, her caseworker reports Shonda¶s
paranoia has her convinced that she is under the surveillance of the FBI and CIA. This topic of
conversation encourages further agitation by Shonda. Shonda has attempted to hide from audio
hallucinations as well without success.

Shonda has been hospitalized for many years and due to her recent escalation of symptoms she
will be recommended for reassessment and an increase in antipsychotic medication.

Durand (2007, p. 471) defines Schizophrenia as, ³Devastating psychotic disorder that may
involve characteristic disturbances in thinking (delusions), perception (hallucinations), speech,
emotions and behavior.´ Well, it is certain that schizophrenia is a curious disorder marred with a
mixture of signs and symptoms. Schizophrenia is complex and fastidious to diagnose due to the
different types, symptoms, cognitive and emotional dysfunctions, and the etiology (how the
disorder originates.) The complexity of the disorder combined with the mixture of signs and
symptoms, which may or may not be present, makes schizophrenia difficult to understand. At
some point of the disorder there is a psychotic phase. The psychotic phase must persist for at
least one month. The disorder is presented by delusions, hallucinations, disorganized speech and
behavior during the psychotic phase. Schizophrenia is usually found to present itself in early
adulthood, with some exceptions of adolescence. (Schizophrenia Symptoms, 2009)

The complexity of schizophrenia is further exacerbated by the complications exhibited by

individuals suffering from the disorder. The mood abnormalities such as significant loss of
impetus to continue with pleasurable activities, depression, anxiety, and anger, all contribute to
the patience¶s lack of awareness or concern they are suffering from a psychotic illness. Without
an understanding or a belief of illness, the patient is much more likely to avoid therapy.
(Symptoms and Treatment, 2009).

Withstanding over 100 years of classifying psychotic disorders into specific forms, and the fact
that psychotic disorders have been recognized throughout history, it is quite an accomplishment
that a definition by a German psychiatrist, Emil Kraepelin, who originally termed schizophrenia
as ³dementia praecox´ due to its chronic, rapid cognitive disintegration, still stands. The name,
³schizophrenia´ was later defined by Kraepelin and a team of psychiatrists. It was Eugen Bleuler
who suggested renaming it to ³schizophrenia´ due to the ³fragmented mind´ characteristic of the
disorder. Kraepelin attempted to identify the multiplicity of symptoms (catatonia, hebephrenia,
and paranoia) and further suggested that the term ³dementia praecox´ should be superseded
and that schizophrenia should be recognized as a ³group´ of disorders for which a fragmentation
of associations were the foundation of the symptoms. Kurt Schneider followed Bleuler¶s interest
in identifying and classifying the fundamental feature of the disorder. And so, he developed ³The
Schneiderian System´ of finding the correlations, or commonalities of patients¶ symptoms.
Schneider developed a set of ³First Rank Symptoms´ specific to diagnosis of schizophrenia¶s
psychotic phase. Again, the complexity of the disorder to this day and in the future will continue
to divide clinicians¶ diagnosis until specificities of schizophrenia¶s pathophysiology and etiology
are clearly uncovered and defined. (How was schizophrenia discovered?, 2005)

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard used by mental
health professionals in the United States to classify mental disorders. The Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), was published in 2004 and was
the last major revision of the DSM. According to the DSM-IV, schizophrenia is classified as a
mental disorder. There are several subtypes of schizophrenia, but because of the usefulness to
the DSM-IV, schizophrenia remains divided into three (aforementioned) major subtypes:
paranoid (delusions of grandeur or persecution), disorganized (or hebephrenic; silly and
immature emotionality), and catatonic (alternate immobility and exited agitation). There are two
additional schizophrenia subtypes; undifferential and residual types. These two subtypes are the
catch-all for which essentially all of the other disorders which symptoms are present but do not
fully met the criteria of the three major subtypes. (Durand, 2007)

There are many studies and infinite archives on the topic of schizophrenia. It is yet a great
conundrum to the brightest scientists, sociologist, pathopsychologists, and psychiatrists. Many
studies link marijuana and other drugs to schizophrenia. Other studies link a genetic mutation
(22q11) which hinders communication between the hippocampus and the prefrontal cortex to
schizophrenia. Similar genetic studies reveal ³undetectable genetic variations´ lead to
schizophrenia. The National Institute of Mental Health conducts a wide range of studies, one of
which examined the effects of D-cycloserine augmentation on cognitive remediation for patients
diagnosed with schizophrenia. Many institutes have focused on two studies on schizophrenia and
motion perception and the propensity to develop schizophrenia in individuals who have
difficulties tracking moving objects. The Genome News Network (2001) suggested that certain
individuals with two copies of the dopamine D3 receptor gene (DRD3) scored significantly low on
visual exams. Many epidemiological studies have observed an association between obstetric
complications during intrauterine life and schizophrenia. Quite often the studies that include
medication produce as many or more questions than the number of answers. There continues to
be countless ³new studies´ suggesting new theories and hypothesis on the topic of
schizophrenia. (Clinical Trials, Schizophrenia, Featured Studies, 2010)

Case Study, presented Shonda, a patient diagnosed with continuous paranoid schizophrenia. The
case study provided an intimate and detailed perspective into the life of someone with mental
illness and the people with whom they might associate. Shonda¶s description which included her
family history and current familial relationships provided a typical expectation for someone
diagnosed with schizophrenia based what I have learned about the background, DSM-IV criteria,
and the research that has been conducted on schizophrenia. After all of my research and
reading, I feel that this could be a hypothetical case study while it could very well be quite
legitimately a real-life case study.

There are neurotransmitters linked to schizophrenia. Both norepinephrine and dopamine appear
to be involved with schizophrenia. Dopamine receptors are thought to mediate both the transient
neurotransmitter functions as well as the neuromodulatory effects that alter cell metabolism. It is
suggested that dopamine controls the metabolism of the cell, or in other words, dopamine
affects the rate of synthesis of the neurotransmitter. Endorphins serve as neurotransmitters
which modulate the release of dopamine by acting as presynaptic receptors. The best results in
treating schizophrenia come from drugs that primarily block dopamine receptors. This further
suggests that schizophrenics have ³too many´ receptors. As it has often been said about the
human body preferring a state of homeostasis, so too do receptors and transmitters. When the
sequence of release and reception amongst transmitters and receivers is upset, a disease state
such as schizophrenia may occur. Human behavior is greatly influenced and the outcome is
altered thought patterns, hallucinations, agitation, delusions, and social withdrawal.

The medical approaches to schizophrenia usually include hospitalization, psychotherapy,

counseling, and drug treatment. I suspected that psychotherapy may have been the most
common treatment for schizophrenics. From my research it seems that chemotherapy has also
been used quite a bit to treat schizophrenics. Individual and family therapy seems to prove
helpful in reducing relapse. Family therapy is also suggested to be helpful in order to assist the
relatives with coping as well as educate. Becoming involved in community programs provides
beneficial support, encourages proper social skills and vocational rehabilitation. Hospitalization is
often preferred to ensure that the affected individual will receive the bare necessities; food, a
place to sleep, and hygiene. Drug treatment usually prescribes the antipsychotic drugs
risperidone, olanzapine, and closapine. There are many other psychopharmacological
antipsychotic drugs that may be prescribed; for example, chlorpromazine and the antipsychotic
drugs, phenothiazines, which are all powerful antagonists.

The impact of the antipsychotic medications on the treatment of schizophrenia has greatly
assisted the efforts to reduce agitation, hallucinations, delusions, and indeed most of the other
major symptoms of schizophrenia. The drugs also seem to greatly assist the prevention of
relapse. At the same time, of course, the use of antipsychotic drugs can be argued strongly
against prescription. There are debilitating side effects. Despite the side affects the strongest
argument may be the fact that antipsychotic drugs do not cure schizophrenia. In spite of the
arguments, continued use of drugs for treatment will continue. If the cause of schizophrenia is
unknown, surely the cure is likely to remain a mystery as well. Using antipsychotic drugs will
continue to relieve symptoms while researchers continue to search for the cause and the cure.

The major argument for the aforementioned dopamine hypothesis, which postulates that
schizophrenia is likely associated with the areas of the brain that use dopamine as a
neurotransmitter. This theory is heavily supported from the research on antipsychotic drugs.
These drugs are effective on symptoms of thought disorder, withdrawal and moderately effective
on hallucinations. The antipsychotic drugs effectively block the dopamine receptor sites. This
means that the affected areas have reduced activity of neural impulses. Slowing the dopamine
activity supports the hypothesis.

As previously mentioned it is thought that schizophrenia may be caused by an excess of

dopamine receptors. In contrast, Parkinsonism is a movement disorder which may be caused by
a deficiency of dopamine receptors. Two known facts worthy of further research are; Parkinson
disease sufferers rarely develop schizophrenia and drug treatments of schizophrenia oftentimes
produce irreversible Parkinson-like symptoms.

Psychological disorders are influenced in important ways genetically. In work with humans, twin,
family and adoption studies indicate that certain people may be genetically vulnerable, or
predisposed to psychological disorders. Among men, not as conclusive with women, alcoholism
research seems to suggest that genetics play a significant role. (Durand, Barlow, 2007).

It also seems likely that schizophrenia is genetically predisposed. A belief that is well-
established, or at least play a factor in schizophrenia, but as to the degree that genetics factor in
varies amongst researchers. Schizophrenia is likely due to a combination of genetic factors in
addition to social and environmental influences.
Many studies have been performed and much research conducted on family, twin, adoptee,
offspring and close relations like aunts, uncles and cousins. These studies show a strong
indication that schizophrenia is biological in nature. A person is more likely to develop
schizophrenia when this person shares more genes with a person already diagnosed with
schizophrenia. Studies have shown adopted children raised in an environment away from their
birth parents, who have the disorder, have a much higher chance of developing the disorder
themselves.

Since the 18th century there has been a belief in the theory that schizophrenia is likely passed
from parent to child. Until about 30 years ago, when higher technical research started becoming
possible scientists were not able to design studies that were sophisticated enough, similar to the
current genetic studies conducted on family, twin, and adoptive studies.

One key-note to make regarding family studies is that the family members all share a very
similar environment. This is support for the argument that environment plays a part in a person
developing the disorder. Twin studies are subject to a similar objection that they not only share
more similar genotype but also a more similar environment. The genotype similarity is obvious,
especially for monozygotic twins, for they developed from the same sperm and ovum, resulting
in 100% genetic similarity. Monozygotic twins are always the same-sex, so they tend to be
dressed alike during their younger years and may choose to continue this routine on into
adulthood. The study of monozygotic twins or identical twins is necessary, even to only establish
a baseline, for the argument of environment. They grow up in virtually the exact same
environment. However, the study may not be beneficial to the argument of genetics.

Another aspect of thought that most researchers are congruent is the genetic component
involved in developing schizophrenia. If there is a genetic component, few major genes are
responsible for transmitting the risk of developing schizophrenia. Many researchers believe that
schizophrenia is not caused by one gene alone, but a variety of genetic subtypes that produce a
range of similar disorders. Those disorders are grouped into a single category called
schizophrenia.

There have been brain abnormalities indicated in schizophrenia, mainly in chronic patients. It has
been noted, mostly in males but not all who suffer from the disorder a noticeable enlargement of
the ventricles of the brain. Chronic patients are the ones who tend to show large ventricles which
may indicate the cumulative effects of anti-psychotic drugs. However, all patients show
abnormalities in the basal ganglia. This could explain why so many patients have both positive
and negative symptoms.

Within the Shonda Case Study, her family history mentioned there is no indication of mental
illness occurring amongst her immediate family. However, a paternal aunt was noted as being
³locked away´ in a hospital after experiencing a ³nervous breakdown.´ Shonda reports that her
father never spoke about his sister and Shonda has never met her. Also mentioned within
Shonda¶s childhood background was a stressful environment. Shonda was exposed to constant
bickering between her mother and father. Shonda and her older brother were subjected to her
father¶s potent temper which took the form of his ³beating his two children and his wife.´
Another variable which may have added to Shonda¶s stressful environment is that her father
would often arrive home late, after stopping at the bar.

There is a strong and some believe undeniable genetic correlation to the development of
schizophrenia, but what is also being studied is the environmental element associated with
schizophrenia. In identical twin studies, studies of persons who share 100% of their genes, there
is only a 48% chance of developing schizophrenia. (Gottesman, 1991) This should suggest that
genetics alone may not predetermine whether a person develops schizophrenia, but rather
environment may also provide predetermining factors and influences. ³Environmental ± in this
definition ± includes everything from the nutritional environment or viruses that a baby is
subjected in the womb, to social environment growing up, to teen drug use or stress.´
(schizophrenia.com, 1996-2004)

³Schizophrenic individuals inherit genes that cause structural brain deviations which may be
compounded by early environmental insults. As a result some pre-schizophrenic children exhibit
subtle developmental delays, cognitive problems, or poor interpersonal relationships. ´
(International Journal of Neuropsychopharmacology, March Issue, 2004) There seems to be
strong empirical evidence of environmental influences determining whether a person may
develop schizophrenia. It is believed that certain individuals may be predisposed to the disorder
and environmental insults. Subtle changes in environmental stressors, which may occur at
various stages of a person¶s life, may activate or trigger the psychotic manifestations of
schizophrenia¶s signs and symptoms; hallucinations, delusions, disorganized speech and thought
patterns, as well as profound disruption in cognition and emotion. (schizoprhenia.com)

Stressors can precipitate development of schizophrenia. A stressful environment or prolonged

exposure to a stressful environment may lead to dysregulation (weak immune response) of
dopamine. This susceptibility may occur through early environmental damage or due to genetic
reasons. Drug abuse, social adversity, or prolonged stress may be the triggers necessary to
move a pre-schizophrenic condition into a full-blown schizophrenic disorder. (International
Journal of Neuropsychopharmacology, March Issue, 2004)

Schizophrenia occurs consistently amongst all groups of people worldwide. Differing perspectives
and opinions arise from varying scientific opinions; however, there is agreement on the fact that
schizophrenia does not arise from one specific cause. Much of the research performed studying
how a person might develop schizophrenia suggests a biological predisposition. There are a lot of
hypotheses about the nature and causes of schizophrenia in general. Environmental influences
continue to be investigated and challenged in an effort to determine if a person¶s biological
predisposition to the disorder is triggered by environmental influences.

Many studies have been conducted on the environmental and biological interactions which may
influence the development of schizophrenia. The following are amongst those researched;
cultural factors, genetic influences, twin studies, adoption studies, offspring of twins, genetic
linkage studies, evidence of multiple genes, neurobiological influences, brain structure, viral
infections, psychological and social interactions, and the influence of stressors.

Pregnancy is a volatile period for mother and child. The mother¶s well being and health directly
affect the child¶s overall development from conception, cell differentiation, and birth. This is an
environmental influence that some research suggests may increase the chance of schizotypal
personality disorder; a phenotype of schizophrenia genotype. The suggestion is primarily based
on potential damage to the left hemisphere of the brain of the fetus. The left hemisphere is
thought to be primarily responsible for the semantic and computational aspects of language. This
is a possible cause of Shonda¶s disconnected fragments of thought, and disjointed speech
patterns. When damaged, the interactive ability between the right and left hemispheres of the
brain is compromised (Scheibel, Arnold, 1997). This leads to decrements in their ability to
perform on memory and learning tests. Concerning the developing fetus¶ environment, the
mother¶s exposure to influenza, or other viruses, and a variety of influences, biological or
environmental, the severity of the development of schizotypal characteristics, like paranoia or
illusions, will vary from mild to moderate. (Durand & Barlow, 2007, ch 11)

Biological interventions are the oldest acceptable method of treatment. Even as late as 1930
insulin dosing was used to induce comas at the risk of serious illness or death. At the same time,
psychosurgery (lobotomies), and electroconvulsive therapy (ECT) gained popularity. It was found
that all three were not beneficial for most people with schizophrenia. Soon after followed
antipsychotic medications. The 1950s brought with it a plethora of several neuroleptics. These
medications were found to be effective at reducing or eliminating hallucinations and delusions as
well as social deficits. However, clinicians and patients must be willing to run through the gamut
of available medications available, because as with most schizophrenic treatment attempts, it
works to varying degrees and not at all with others. (Durand & Barlow, 2007, p. 494-500)

The common treatment of schizophrenia and treatment delivery varies quite considerably across
different cultures. For example, Hispanic families are most likely to take in a relative instead of
sending a loved one to long-term care. Chinese medicine is relied upon among the Chinese. It
could be a choice for the Chinese to use holistic remedies, herbs, acupuncture and acupressure
for tradition or for the reason of expense. Sufferers are not so lucky in Africa. Most countries in
Africa choose to send their schizophrenia sufferers to jails due to lack of appropriate facilities.
(Durand & Barlow, 2007, p. 500)

There has been much research and work conducted in an attempt to determine which type of
psychosocial treatment is most effective in treating schizophrenia. The recent work in the area of
psychosocial intervention has suggested that there is high value of an approach consisting of
both drug treatment and psychological methods (Tarrier et al., 1999).

It seems no matter the treatment chosen to address schizophrenia; it is a rarity that the
treatment is successful enough to claim full recovery. However, the easement of the disorder
may be achieved through a combination of efforts and treatments. The quality of life for
schizophrenic patients can be meaningfully affected by combining antipsychotic medications with
psychosocial approaches, employment support, and community-based and family interventions.
(Durand & Barlow, 2007, p 500)

The effectiveness of any chosen treatment for schizophrenia is quite limited. Until recently
methods of psychotherapy did not seem to be helpful. But specific types of psychotherapy,
sometimes combined with drug therapy, have been starting to show signs of alleviating the
personality disorder. It¶s just a plain hard fact that schizophrenia is chronic and by nature it is
always quite a chore to experience any relief, let alone successful recovery for any chronic
disorder. Drug treatment is currently designed to temporarily affect the patient¶s behavior.
Psychotherapy makes attempts to help people recognize their problem and change their social
behavior.

Although typical treatment may involve antipsychotic drugs and psychosocial treatments, I think
I would plan a heavy psycho-social treatment with medical interventions at different or
alternating intervals. This might be radical but I think that the irregularity of the medications
would inhibit the body¶s ability to adjust to the medications while the regularity of the
psychosocial treatments builds a solid dependable foundation for the mind.

I also believe through regular conditioning or reconditioning of the social and moral aspects of
human relationships, I think any person can benefit and learn from social learning. The essence
of normality in our lives is self-care, calm and safe social interactions, and of course most
everyone learns a vocational skill or two. Experiencing noticeable results would take more or less
effort depending on the patient and more or less time as well. As with all healthy regimes,
maintenance is required. I would suggest that a major stipulation of this plan would be regular
practice of skills learned. This would help maintain the effects for a longer period of time,
perhaps if followed diligently, without degradation in displayed skills.
Ãike schizophrenia itself, any psychological model applied to understanding and treating
schizophrenia will be complex due to the multiple factors incorporated. The cognitive model
introduced by David Hemsley suggests the summary of the formation of a persecutory delusion.
In short, the precipitant is affected by the emotion or beliefs a person has about oneself, others
and the world and anomalous experiences and finally cognitive biases. The search for meaning
ensues and the selection of an explanation develops based on one¶s belief about illness, social
factors, and belief flexibility. Ultimately all of these factors conspire to create ³The Threat Belief.´
The model indicates exploration into newer directions. The empirical determination of internal
and external events still remains. The flexible nature of the model allows for events which may
be positive, negative or neutral. (Hemsley, D., 2005)

The future of schizophrenia is bleak for the mind is a vast and curious entity and will likely
always remain so. Shonda will likely live her life in the mental institution heavily drugged with
that same bleak prognosis. Perhaps studies will advance, or researchers will finally win a break-
through and schizophrenia will finally become less convoluted to follow intelligently. Our world is
changing and many developments occur daily which perpetuate the existence of our species. A
strength of a world producing such research and studies is that it facilitates investigation as to
the interaction of psychotic processes, non-psychotic processes, the environment, genetic
predisposition, and how each affects the other.

'
 

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