Schizophrenia in the Social Environment Objectives Describe schizophrenia
Schizophrenia in the Social Environment
Objectives ØDescribe schizophrenia in the context of developmental stages ØDescribe how schizophrenia affects males and females differently, as well as African Americans ØDescribe the status of individuals with schizophrenia within the macro system ØImprove your overall understanding of schizophrenia
Outline ØWhat is schizophrenia? –Causes, symptoms, etc. ØOnset, course and prognosis ØShift in treatments (macro level information)
Schizophrenia
What is Schizophrenia? • Chronic, severe and disabling thought disorder – Break from reality (psychotic episode) – Illogical and irrational thoughts – Extreme emotional and social disregulation – NOT Dissociative Identity Disorder
Schizophrenia Demographics • Affects about 1 -2% of population (2 million) • More frequently seen in the lower socioeconomic classes • More frequently seen in large cities vs. rural • More frequently in divorced/separated families • 10 -15% may commit suicide • Affects men and women equally • Approximately 20% are homeless
Causes • No known single cause • Theoretical causes include genetics, environmental, and behavioral factors (drugs) • No cure
Symptoms • Positive Symptoms (delusions, hallucinations) – Pathological additions to normal behavior • Negative Symptoms (flat affect) – Characteristics that are lacking or reduced • Psychomotor Symptoms – Odd gestures – Excited Movement – Motionless stupor
Positive Symptoms • Delusions-beliefs contrary to reality – Persecution – Reference – Grandeur – Control • Disorganized Thinking/Speech – Loose Associations – Word Salad – Perseveration • Heightened Perceptions & Hallucinations – Sensory Flooding – Hallucinations
Negative Symptoms • Poverty of Speech • A decrease in speech or speech content (catatonia) • Blunted or Flat Affect – Flat-virtually no emotion – Ambivalence • Social Withdrawal – Conflicted feelings about many things
Psychosocial Factors • Disturbed Family Communication – Expressed Emotion • Family members express critical or overprotective emotions (e. g. flat affect, staring) • Predictive of relapse
Onset, Course and Prognosis
Childhood Precursors Some children who later develop SZ show (majority have normal childhoods): 1. Delayed developmental milestones (walking, etc) 2. More language and speech problems (predictor) 3. Poorer coordination (sports, phy ed class) 4. Poorer academic achievement 5. Poorer social functioning and fewer friends **Statistical associations not predictors** Source: Torrey, 2006 Surviving Schizophrenia
Onset • 75% of those who get SZ are between the ages of 17 and 25; Unusual to get before 14 or after 30 • Childhood SZ does occur but rare • Postpartum SZ happens but is usually eventually diagnosed as manic depressive illness or major depression with psychotic features • Late-onset SZ: Age 40 or over; more females than males and 1/3 go on to develop Alzheimer-type dementia
Questions Based on the article: • What aspects of an individual's life are affected by the development of schizophrenia during middle adulthood? • How does this affect their development, biologically, psychologically, and socially?
Predictors of Outcome Good vs. Worse Prognosis • • Consider “normal” prior to SZ Female No hx or relatives with SZ Family hx depression or bipolar disorder Sudden onset More positive symptoms Quick response to initial dose meds Good illness awareness • Family hx of SZ • Male • Younger the age when SZ developed (15 vs. 25) • Slower, gradual onset • Have more negative symptoms (flattened affect) • Poor illness awareness • Poor initial response to meds
Illness awareness… or lack thereof
Two theories on lack of insight (1) Anosognosia – – Neurological term Limited or no awareness Strokes or brain tumors in the right side of the brain Frontal lobe damage (2) Psychological defense mechanism – Blocking – Do not want to talk about illness episodes when better
Men and Schizophrenia • Males earlier onset than females • More severe in males • Males do not respond well to antipsychotic meds-require higher doses than women (metabolic issue? ) • Higher relapse rate than women • More trouble with long-term adjustment (e. g. marriage, work, level of function) when compared to women
African Americans and SZ • Recent study shows African Americans has 3 fold increase in SZ when compared to whites • Past studies show same • Researchers not sure why
Long-term Prognosis Studies that follow individuals long-term generally show that the course of outcome is better after 30 years than after 10 years • Illness seems to “die down” after many years • Gets worse before it gets better
Schizophrenia and Life Expectancy • • • People with SZ tend to die younger WHY? Suicide (12 x times higher than gen pop) Diseases (diabetes type II, heart disease, etc) Unhealthy lifestyles (smoking) Inadequate medical care and lack of access Homelessness
Schizophrenia & Violence • Violence is NOT a symptom • Risk Factors – History of violence – Substance abuse – Off medication and actively psychotic -Lack of illness insight Most violent crimes are not committed by persons with schizophrenia, and most persons with schizophrenia do not commit violent crimes. -NIMH
SZ Treatment – Cognitive techniques – Behavioral strategies – Family & Group therapy *Often combined with medication
SZ can be very difficult to treat • Nearly half of those diagnosed do not know that they are sick • Co-occurring disorders • Medication side effects • Laws and Insurance Companies** • Lack of social and familial support • Stigma and discrimination • SZ Difficult to understand
SZ and Macro Systems
Question Psychiatric hospitals across the country are down-sizing and closing…Less help and fewer beds…No observable decrease in the # of people needing help… Does anyone know where many of these individuals who are still in need of help are winding up?
Big Shift Mental health system to the…
Current Conditions • By the end of 2006, there were 2. 3 million confined individuals. • 16 to 37. 5% of those individuals are diagnosed with an SMI (bipolar, SZA) • 2 to 4 times higher than found in the general public • HRW estimates 200, 000 to 400, 000 SMI
Not a New Problem • century • Dorothea Dix • Hospitals remained the primary treatment of SMI for next 150 years th 19
Trend of Incarcerating SMI • Began to notice increase in the number of SMI being jailed beginning in the 1970’s – Teplin and Colleagues and Cook County, Illinois • Failure of the mental health system
Possible causes of incarceration of those with SMI • Deinstitutionalization beginning in 1950’s • Lack of community mental health centers and services-did not want to treat SMI • Lack of housing – Led to Homelessness (1/3 have SMI) • Social welfare policies (Medicare/Medicaid)
Possible Causes…continued • Changes in drug laws • Strict inpatient laws • Inability to recognize illness – 50% of people with schizophrenia and bipolar disorder do not recognize they are ill • Penrose's theory
Mental Health Courts and Federal Laws • Congress saw increasing levels of SMI as a problem • 2000 America’s Law Enforcement and Mental Health Project Act (ALEMHP) (S. 1865), P. L. 106 -515. President Clinton • 2004 Mentally Ill Offender Treatment and Crime Reduction Act of 2004 (MIOTCRA) P. L. 108 -414. President Bush
What is a Mental Health Court? • Similar to drug courts • Forensic courts that manage the cases of those with mental illness charged with committing misdemeanors and/or felony crimes. • Approximately 130 in operation-growing • Based on “therapeutic jurisprudence” • Problem: Treatment after crime committed
NAMI Mental Health in Pennsylvania Report Card • NAMI D+ (Nationally D+) – Infrastructure: C– Information: D– Access: D– Services: C– Recovery Supports: C-
Mental Health and Pittsburgh • State inmate re-entry program in Allegheny County (MHC program) – 2001: 3 rd largest mental health facility in PA – 20 -25% inmates mentally ill • RAND study – 1 st study to examine cost of program – Cost effectiveness took effect after 2 years – Received more mental health services and spent fewer days in jail (criminal court)
Mental Health Laws and SZ in Pittsburgh Most restrictive laws in the nation
Troy Hill Jr.
Consequences of Strict Laws • Fatally attacked one brother and hurt another • Diagnosed as having paranoid SZ • Tried to seek help but was turned away
Powerful Letter “I have made thousands of mistakes in my life, but my worst mistake, the one I lament almost daily, [was] working … to pass the state's Mental Health Procedures Act” -Bill Shane-Former PA Legislator Thursday Sept 13, 2007 Pittsburgh Post Gazette
Summary • Most people who develop SZ do so at late adolescence/early adulthood • Schizophrenia is still a very misunderstood disease • Many people with SZ do not receive or accept treatment • Many are now involved in the criminal justice system
Questions or Comments?
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