Chapter 12 - "Schizophrenia" - Review for Final

"There are _______ kinds of dopamine receptors that have been identified throughout the brain."

B, "Five."

"Summarize institutional care of the past, milieu therapy and token economy programs."

"In terms of talking about the institutional care of the past, looking back into many decades within the twentieth century, Comer made it clear that there were many individuals who have schizophrenia during this time who ; "Were institutionalized in a public mental hospital. Because many patients with schizophrenia did not respond to traditional therapies, the primary goals of these hospitals were to restrain them and give them food, shelter, and clothing. Patients rarely saw therapists and generally were neglected. Many were abused. Oddly enough, this state of affairs unfolded in an atmosphere of good intentions. The move toward institutionalization in hospitals began in 1793 when French physician Philippe Pinel "Unchained the insane," at La Bicetre asylum and began the practice of "moral treatment." For the first time in centuries, patients with severe disturbances were viewed as human beings who should be cared for with sympathy and kindness. As Pinel's ideas spread throughout Europe and the United States, they led to the creation of large mental hospitals rather than asylums to care for those with severe mental disorders." Moreover, the "New mental hospitals" were known to reside in areas that were isolated in nature. They were in isolated locations due to the fact that both the land and labor were inexpensive. Not only that, the patients residing in these hospitals were shielded from the consistent stresses they would have encountered on a daily basis. It is also true that they wanted all the patients to be a part of an atmosphere that was healthy from a psychological standpoint, to the point that they could have the opportunity to work with a therapist more so closely. Within the United States, there was a law in place that essentially required many states to create state hospitals (also known as mental institutions that are public). The purpose of it to come into fruition in the first place is to private mentally ill patients a place that was more affordable. Statistic wise, it is true that, "Eventually, however, the state hospital system encountered serious problems. Between 1845 and 1955, nearly 300 state hospitals opened up in the United States opened in the United States, and the number of hospitalized patients on any given day rose from 2,000 in 1845 to nearly 600,000 in 1955. During this expansion, wards became overcrowded, admissions kept rising, and state funding was unable to keep up. The priorities of the public mental hospitals, and the quality of care they provided, changed over those 110 years. When talking about institutions, it is also critical to note that, "In the face of overcrowding and under-staffing, the emphasis shifted from giving humanitarian care to keeping order. In a throwback to the asylum period, difficult patients were restrained, isolated, and punished; individual attention disappeared. Patients were transferred to back wards, or chronic wards, if they failed to improve quickly. Most of the patients on these wards suffered from schizophrenia. The back wards were human warehouses filled will hopelessness. Staff members relied on straitjackets ("A piece of clothing like a jacket with long arms which are tied to prevent the person wearing it from behaving violently. Straitjackets are sometimes used to control people who are mentally ill," - OALD) included medical approaches such as lobotomy. Many patients not only failed to improve under these conditions but also developed additional symptoms, apparently as a result of institutionalization itself." **It is said that during the 1950's, there were two methods of institutionalization that came into fruition called milieu therapy and token economic programs. "Milieu therapy is based on humanistic principles and the token economy program is based on behavioral principles. These approaches particularly helped improve the personal care and self image of patients, problem areas that had been worsened by institutionalization. The approaches were soon adapted by many institutions and are now standard features of institutional care." According to pg. 404, "In 1953, Maxwell Jones, a London psychiatrist, converted a ward of patients with various psychological disorders into a therapeutic community - the first application of milieu therapy in a hospital setting. The premise of milieu therapy is that institutions can help patients by creating a social climate, or milieu, that promotes productive activity, self - respect, and individual responsibility. In such settings, patients are often given the right to run their own lives and make their own decisions. They may participate in community government, working with staff members to set up rules and decide penalties. Patients may also take on special projects, jobs, and recreational activities. In short, their daily schedule is designed to resemble life outside the hospital." It is true that after Mr. Jones brought this therapeutic approach to life, there have been new programs that were established after this therapy called "Milieu - Style Programs." Moreover, they are available worldwide, more specifically in institutions. The text makes it clear that, "The programs vary from setting to setting, but at a minimum, staff members try to encourage interactions (especially group interactions) between patients and staff, to keep patients active, and to raise their expectations about what they can accomplish." What are Token Economy Programs? It is true that programs who incorporate operant conditioning methodologies is essentially what they are. Furthermore, "In the 1950's, behaviorists discovered that the systematic use of operant conditioning techniques on hospital wards could help change the behaviors of patients." Comer makes it clear that those who use this are known to get an reward, but only when they are behaving in an acceptable manner. Obviously, if the patients do not act appropriately, they do not get any reward. "The immediate rewards for acceptable behavior are often tokens that can be later exchanged for food, cigarettes, hospital privileges, and other desirable items, all of which compose a "token economy." Acceptable behaviors likely to be included are caring for oneself and for one's possessions (making the bed, getting dressed), going to a work program, speaking normally, following ward rules and showing self-control. Are behaviorists changing a patient's psychotic thoughts and perceptions or simply improving the patient's ability to imitate normal behavior? Critics of the behavioral approach would argue that John was still delusional and therefore as psychotic as before. Behaviorists, however, would argue that at the very least, John's judgment about the consequences of his behavior had improved. Token economy programs are no longer as popular as they once were, but they are still used in many mental hospitals, usually along with medication, and in many community residences as well. The approach has also been applied to other clinical problems, including intellectual disability, delinquency, and hyperactivity, as well as in other fields, such as education and business."

"Describe effective community care of patients with schizophrenia; what are the features of effective community care and how has community treatment failed?"

"When it comes to effective community care, "People recover from schizophrenia and other severe disorders need medication, psychotherapy, help in handling daily pressures and responsibilities, guidance in making decisions, social skills training, residential supervision, and vocational counseling - a combination of services sometimes called assertive community treatment. Those whose communities help them meet these needs make more progress than those living in other communities. Some of the key features of effective community care programs are (1) coordination of patient services, (2) short - term hospitalization, (3) partial hospitalization, (4) supervised residencies, and (5) occupational training." # 1: Coordinated Services - "It is true that community mental health centers were known as the facilities that implemented community care and was something these facilities were expected to pursue there. This was put into fruition by the well-known Community Mental Health Act. But, what is a Community Mental Health Center? Comer makes it clear that they are facilities that focus on treatment for those who experience with psychological issues. There, it is the staff's responsibility to provide patients with their medicine. Not only that, they have psychotherapy services available. On top of that, there is emergency inpatient care for those who are known to have "Severe Disturbances." It is also important to mention that these centers work with their patients to be involved with other agencies, which they essentially put together. It is said that the individuals who use these services benefit greatly from them. In terms of other diagnoses that are in need of them is referred to as "Dual - Diagnosis Patients" also known as "Mentally - Ill Chemical Abusers." # 2: Short - Term Hospitalization - "When people are in this situation, they tend to, "Develop severe psychotic symptoms." Furthermore, the clinicians that are working with these clients have their first option to be "To treat them on an outpatient basis, usually with a combination of anti-psychotic medication and psychotherapy." It is true that when this first plan does not work out in the patient's best interest, then it suggested that the individual then pursues short - term hospitalization. Comer makes it clear that this usually is common within one of the following places: a psychiatric unit in a hospital or within a mental hospital. It is said that their stay lasts for approximately several weeks. Once they improve, they then go to after-care. Aftercare is, "A general term for follow-up care and treatment in the community." In addition, it is, "A program of post-hospitalization care and treatment in the community." # 3: Partial Hospitalization - "Others in this situation may need partial hospitalization, which requires them to go to a "Day Center" also known as a "Day Hospital." Essentially, it is known as a program that individuals do during the day, hence the name, where they go home after treatment. "Such programs provide patients with daily supervised activities, therapy, and programs to improve social skills." It is said that, "People recovering from severe disorders in day centers often do better than those who spend extended periods in a hospital or in traditional outpatient therapy." Furthermore, Comer points out that Residential Crisis Centers or Semi-hospitals is known as another institution available for this population. According to pg. 413, "Semi-hospitals are houses or other structures in the community that provide 24 - hour nursing care for people with severe mental disorders." # 4: Supervised Residences - "To add, there are others in this particular situation in this particular population that are not in need of hospitalization or is not able to live independently or in the same residence as their loved ones. However, there is an option that solves that problem, and that is Halfway Houses. They also go by Crisis Houses, and/or Group Homes. It is true that residents do well there also. It is said that approximately 12 - 24 individuals live in a Halfway House at a time. "Live-in staff members usually are paraprofessionals - lay people who receive training and ongoing supervision from outside mental health professionals. The houses are usually run with a milieu therapy philosophy that emphasizes mutual support, resident responsibility, and self- government. Research indicates that halfway houses help many people recovering from schizophrenia and other severe disorders adjust to community life and avoid re-hospitalization." # 5: Occupational Training and Support - "It is true that occupational training and support is a service for this population because, "Paid employment provides income, independence, self-respect, and the stimulation of working with others. It also brings companionship and order to one's daily life. For these reasons, occupational training and placement are important services for people with schizophrenia and other severe mental disorders. To add, a sheltered workshop is another option available for those who are recovering from illnesses such as Schizophrenia. What makes a sheltered workshop different is that it is a work environment that supervises all of the employees. This is done because some are, "Not ready for competitive or complicated jobs." "For some, the sheltered workshop becomes a permanent workplace. For others, it is an important step toward better - paying and more demanding employment or a return to a previous job in the United States, however occupational training is not consistently available to people with severe mental disorders." The text makes it clear that, "An alternative work opportunity for people with severe psychological disorders is supported employment, in which vocational agencies and counselors help clients find competitive jobs in the community and provide psychological support while the clients are employed. Like sheltered workshops, supported employment opportunities are often in short supply." "When it comes to how Community Treatment has failed, "Fewer than half of all the people who need them receive appropriate community mental health services. In fact, in any given year, 40 to 60 percent of all people with schizophrenia and other severe mental disorders receive no treatment at all. Two factors are primarily responsible: poor coordination of services and a shortage of services." # 1: Poor Coordination of Services - "It is true that there is a lack of communication between mental health facilities. "There may be an opening at a nearby halfway house, for example, and the therapist at the community mental health center may not know about it. In addition, even within a community agency a patient may not have continuing contacts with the same staff members and may fail to receive consistent services." Furthermore, community mental health centers and state hospitals do not speak with one another as much as they should either. When this occurs, Case Managers step in. A Case Manager is, "A community therapist who offers a full range of services for people with schizophrenia or other severe disorders, including therapy, advice, medication, guidance, and protection of patient's rights." "They try to coordinate available community services, guide clients through the community system, and help protect clients' legal rights. Like the social therapists described earlier, they also offer therapy and advice, teach problem - solving and social skills, ensure that clients are taking their medications properly, and keep an eye on possible health care needs. Many professionals now believe that effective case - management is the key to success for a community program." # 2: Shortage of Services - "The numbers of community programs - community mental health centers, halfway houses, sheltered workshops ---- available to people with severe mental disorders fall woefully short. Moreover, the community mental health centers that do exist generally fail to provide adequate services for people with severe disorders. They tend to devote their efforts and money to people with less disabling problems, such as anxiety disorders or problems in social adjustment. Only a fraction of the patients treated by community mental health centers suffer from schizophrenia or other disorders marked by psychosis. There are various reasons for this shortage of services. The primary one is economic. On the other hand, more public funds are available for people with psychological disorders now than in the past. In 1963, a total of $ 1 billion was spent in this area, whereas today approximately $ 171 billion in public funding is devoted to each year to people with mental disorders. This represents a significant increase even when inflation and so-called real dollars are factored in. On the other hand, rather little of the additional money is going to community treatment programs for people with severe disorders. Much of it goes instead to prescription drugs, monthly income payments such as social security disability income, services for people with mental disorders in nursing homes and general hospitals, and community services for people who are less disturbed. Today, the financial burden of providing community treatments for people with long-term severe disorders often falls on local governments and non-profit organizations rather than the federal or state government, and local resources cannot always meet this challenge."

"Describe and list the positive and negative symptoms of schizophrenia."

**According to pg. 387, it is; "A psychotic disorder in which personal, social, and occupational functioning deteriorate as a result of unusual perceptions, odd thoughts, disturbed emotions, and motor abnormalities." It is true that, "People with schizophrenia, though they previously functioned well or at least acceptably, deteriorate into an isolated wilderness of unusual perceptions, odd thoughts, disturbed emotions, and motor abnormalities. People with schizophrenia experience psychosis, a loss of contact with reality. Their ability to perceive and respond to the environment becomes so disturbed that they may not be able to function at home, with friends, in school, or at work. They may have hallucinations (also known as false sensory perceptions,) or delusions (false beliefs), or they may withdraw into a private world. DSM - 5 calls for a diagnosis of schizophrenia only after the symptoms of psychosis continue for six months or more." **In terms of the DSM - 5 symptoms list of Schizophrenia, they consist of: # 1: People showcases two or more of the following symptoms within a month (1. Delusions, 2. Hallucinations, 3. Speech that is very disorganized, 4. Motor activity that is extremely abnormal, 5. Negative symptoms.) # 2: Individuals must experience one of the following (1. Delusions, 2. Hallucination or 3. Speech that is very disorganized.) # 3: Those with this condition functions in society in a extremely poor manner when it comes to several things to their life that played a role before they were diagnosed. # 4: Individuals experience these symptoms intensely for five more months on top of the first one. Positive Symptoms: According to pg. 387, "Positive symptoms are "pathological excesses," or bizarre additions, to a person's behavior. Delusions, disorganized speech and thinking, heightened perceptions and hallucinations, and inappropriate affect are the ones most often found in schizophrenia. Many people with schizophrenia develop delusions, ideas that they believe wholeheartedly but have no basis in fact. Some people hold a single delusion that dominates their lives and behavior; others have many delusions. Delusions of persecution are the most common in schizophrenia. People with such delusions believe that they are being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized. People with schizophrenia may also have delusions of reference: they attach special and personal meaning to the actions of others or to various objects or events. People with delusions of grandeur believe themselves to be great inventors, religious saviors, or other specifically empowered persons. And those with delusions of control believe their feelings, thoughts and actions are being controlled by other people." Not only that, they have much difficulty thinking from a logical perspective. Furthermore, this is true because they also speak with others in some cases in ways that are peculiar in nature. It is critical to add that individuals who encounter this is known to have something called formal thought disorders, which in essence makes the Schizophrenic person to have a high level of confusion. Moreover, they encounter severe challenges when communicating. Comer also makes it clear that the positive symptoms for this disorder are, "Loose associations (which is also known as derailment), which means, "Thoughts that lose almost all connections with one another and become disconnected and disjointed) (i.e. "I always liked geography. My last teacher in that subject was Professor August, A. He was a man with black eyes. I also like black eyes. There are also blue and grey eyes and other sorts, too" verywellmind.com) , neologisms ("made up words" - verywellmind.com) , along with clang ("When the individual chooses words based on sound (rhyming) rather than meaning - verywellmind.com) (i.e. "I got so angry I picked up a dish and threw it at the geshinker," -verywellmind.com) . In addition, someone has perseveration ('Patients repeat their words and statements over and over again," Slide 5.) "Heightened perceptions" is another positive symptom, which is when, "The perceptions and attention of some people with schizophrenia seem to intensify. The person may feel that their senses are being flooded by all the sights and sounds that surround them. This makes it almost impossible for them to attend to any important. The last positive symptom is inappropriate effect, which is, "Emotions that are unsuited to the situation." Negative Symptoms: In contrast, negative symptoms are signs also known as "Pathological Deficits." Furthermore, "Pathological Deficits" are known as characteristics that people with Schizophrenia have that are not that apparent within them. One of them is known as alogia. Alogia is simply when someone has, "A decrease with their speech content ("When someone is repetitive and vague all at the same time" -American Psychological Association), (What they are saying also has, "Little meaning," pg. 391.) Not only that, it takes them a little extra time before they come up or think about their answer to the question being asked of them. Moreover, "Many people with schizophrenia have a blunted affect - they show less anger, sadness, joy, and other feelings than most people. And some show almost no emotions at all, a condition known as flat affect. Their faces are still, their eye contact is poor, and their voices are monotonous. In some cases, people with these problems may have anhedonia, a general lack of pleasure or enjoyment. In other cases, however, the restricted affect may reflect an inability to express emotions as others do." Loss of volition is another negative sign. This, in contrast is when, "Many people with schizophrenia experience avolition, or apathy, feeling drained of energy and of interest in normal goals and unable to start or follow through on a course of action. This problem is particularly common in people who have had schizophrenia for many years, as if they have been worn down by it. Similarly, people with schizophrenia may feel ambivalence, or conflicting feelings, about most things." It is also true social withdrawal plays a role as well. When talking about social withdrawal, it is critical to add that, "People with schizophrenia may withdraw from their social environment and attend only to their own ideas and fantasies." Furthermore, "Because their ideas are illogical ("Not sensible or thought out in a local way," -OALD) and confused, the withdrawal has the effect of distancing them still further from reality. The social withdrawal seems also to lead to a breakdown of social skills, including the ability to recognize other people's needs and emotions accurately." ** In terms of symptoms, individuals, according to pg. 391, "With Schizophrenia sometimes experience psychomotor symptoms, for example, awkward movements or repeated grimaces ("To make an ugly expression with your face to show pain, disgust, etc." - OALD) and odd gestures that seem to have a private purpose - perhaps ritualistic or magical. The psychomotor symptoms of schizophrenia may take certain extreme forms, collectively called Catatonia." It is true that another definition of catatonia is, "A pattern of psychomotor symptoms, found in some forms of schizophrenia, which may include catatonic stupor, rigidity or posturing."

"Approximately __________ or more people with severe mental disorders end up in prisons because their disorders have led them to break the law."

A, "135,000."

"Which are the key features of delusional disorder?"

A, "Persistent delusions that are not bizarre and not due to Schizophrenia," pg. 386.

"During which phase do symptoms of Schizophrenia lessen, but the negative symptoms may remain?"

A, "Residual Phase."

"Ron attended the funeral of a family member and began laughing during the service. This is BEST characterized as ________________ affect."

C, "Inappropriate," pg. 389.

"If we were to administer _____ - dopa to you, we would raise your dopamine activity so much that you would experience psychosis."

C, "L."

"Which of the following is a humanistic approach to institutional treatment based on the belief that institutions can help patients recover by creating a climate that promotes self - respect, individual responsibility and productive activity?"

C, "Milieu Therapy."

"Second - Generation Antipsychotic Drugs bind to dopamine receptors and _________________________ receptors."

C, "Serotonin," pg. 397.

"An estimated ______ million people worldwide are afflicted with Schizophrenia."

D, "26," pg. 386.

"Avolition is:"

D, "An ability to start or complete a course of action," pg. 391.

"In 1954, this antipsychotic was approved for sale in the United States."

D, "Chlorpromazine."

"Which are the key features shared by Schizophrenia, Schizophreniform Disorder and Brief Psychotic Disorder?"

D, "Various psychotic symptoms such as delusions, hallucinations, disorganized speech, flat or inappropriate affect, and catatonia," pg. 386.