Kimberly Mei Q. Roxas Prof. Serafina Maxino
BSCP 4-3s Aug. 8, 2014
Overall Findings
A. Psychosis
Impaired over-all functioning
Abnormal content of thought
Illogical form of thought
Mood and affect
Impaired sense of self
Altered volition
Impaired interpersonal function
Change in psychomotor function
B. Depression
Depress
Guilt feelings
Hopeless and helpless
Feeling of inadequacy
Suicidal attempts
Anxious
Fear of death
Distorted perception
Withdrawal
Low self-esteem
Low function tolerance
Feeling of rejection
C. Schizophrenia
Auditory hallucination
Thought withdrawal
Thought insertion
Thought broadcasting
Suspiciousness
Poor interpersonal relation
Dependent
Regression
Feeling of inferiority
Mutism
Ideas of reference
D. 16 PF
Low intelligence
Emotionally stable
Ego-strength
Submissive
Lack assertiveness
Striving for autonomy
Summary of Findings with Psychodynamics
Evidence has been found in genetic high risk, cohort, and first-episode studies that moderately impaired social and role functioning are often early pre-illness characteristics of individuals who will later develop psychosis. Social difficulties appear to have particular potential to contribute to prediction of schizophrenia. Based on this early data, the neurodevelopmental model suggests that the widely acknowledged vulnerability for later psychosis involves deficits in at least 4 domains (Cognitive-Affective-Social-Isolation-School /work problems) which are labeled the ''CASIS'' cluster. It is proposed that in many cases, this vulnerability is the necessary but not sufficient precondition for development of major psychotic disorders, especially schizophrenia. According to this view, individuals at true risk have long-standing social difficulties and impaired age appropriate role functioning, including unsuccessful adaptation to school demands and later difficulties in becoming self-supporting. In this context, early school problems are considered the harbinger of later work difficulties and involve a broader set of skills than simply academic success. Emerging positive symptoms are considered developmentally independent processes that progress to chronic schizophrenia in the presence of some combination of CASIS deficits.
Many key formulations include the relationships between disorders in handling contextual material and thought disorder and between a weakened working memory and thought disorder. However, it is possible that some patients may have abnormal content of thought, impaired context processing, or both without having a working memory deficit. At present there is little direct empirical investigation to discern whether loss of context plays a significant role in thought disorder. Empirical studies of context and working memory in schizophrenia have often focused on potential impairment in performance tests and these tests may tap important deficits that need to be analyzed. Nevertheless, this is not the type of material where signs of positive thought disorder usually arise. A weakened working memory may be important in some major types of cognitive deficits without being central thought disorder or to all types of cognitive aberrations. On an empirical level, crucial for theoretical models about potential loss of context and thought disorder is whether schizophrenia patients with thought disorder fail to take in the context (e.g., they do not respond to the question). An alternate theoretical model is that schizophrenia patients with thought disorder take in the context, but" go astray" in processing contextual information (e.g., their responses are partly influenced by the external question and partly by other irrelevant personal or non personal material).
Individuals with schizophrenia demonstrate impaired emotion perception, particularly, in the areas of facial affect recognition and emotional prosody identification. Similarly, individuals with schizotypy have demonstrated reduced ability to perceive affect in prosody and reduced perception of affect in body posture. Findings are mixed as to whether individuals with schizotypy demonstrate facial affect recognition impairments. Individuals in the premorbid phase of schizophrenia may be vulnerable through a combination of emotion processing abnormalities. Individuals at familial high-risk reportan increased stress response to events labeled as everyday activities. In addition, in the premorbid phase, anhedonia is likely to be present as it is consistently described inat-risk groups. This reduced sense of positivity may make one more vulnerable through a reduction in remembered or salient positive experience, which might otherwise be a buffer against stress. Further, poor perception of subtle emotional and social nuances may lead to misinterpretation. This, in turn, may be associated with a heightened stress response and a reduced capacity for social relationships and lead to social withdrawal. In subgroups of persons at risk, such as males, increased difficulty understanding and reporting their emotions may be present. Finally, reduced amygdala-hippocampal volumes and abnormal functional activity in some brain areas pertinent to emotion may add increased vulnerability through impaired emotion regulation. The transition from the premorbid to the prodromal phase may involve increased negative affect and reduced positive affect. This negative affect may evolve to take the form of a growing anxiety or mood disorder. Abnormal thinking, in the form of magical thinking, unusual beliefs, or subtle paranoia, may lead to social isolation and increased negative affect and stress. Increasingly abnormal emotion perception and expression may compound social difficulties. In addition, continued insufficient compensatory brain activity, particularly in prefrontal cortex, may contribute to vulnerability. Of course, these proposed emotional difficulties are likely to be only one component of a growing social disorder, also marked by neurocognitive difficulties. The mechanisms of transition from a risk state to acute psychosis is as yet not well understood but is under active investigation in studies of the prodrome. In the domain of experience, heightened negative affect in schizophrenia has been proposed to occur as a result of disconnected or dysregulated activity between cortical and subcortical structures. Specifically, reductions in amygdala and medial prefrontal activity are associated with increased autonomic response to fearful information. As a result, inappropriate appraisal of this excessive somatic response to fear may occur. A similar theory proposes that there is a disruption of cortical regulation of subcortical dopamine systems, which leads to an exaggerated influence of the amygdala. Instead of being guided by a balance between the hippocampus and the amygdala, an overactive amygdala signals a threat where it does not exist, and increased negative affect ensues. Other theories propose an underactive amygdala coupled with an underactive prefrontal cortex, leading to the processing of social information without regulation by the prefrontal areas. Finally, in the area of expression, patients exhibit facial muscle expressiveness that is overtly unobservable but which occurs in the expected directions.
2 major dysfunctions, specifically in hyperreflexivity and reduced self-affection lead to the impairment of sense of self. Diminished self-affection is a loss of sense of inhabiting one's own actions, thoughts, feelings, impulses, bodily sensations or perceptions, often to the point of feeling that these are actually in the possession or under control of some alien being or force. Hyperreflexivity on the other hand is an exaggerated form of attention being paid to self features as if they were external objects. The patient started to have exaggerated self-consciousness up to the extent that he thinks that every people around him are conspiring against his actions. Hence, results from a breakdown of some form of inhibition to prevent the unexpected awareness of these self features from breaking into consciousness.
Impairments of self-awareness and self-regulation in schizophrenia are part of the deficit in executive control. A defect in volition was central to the idea of dementia praecox, which was being ultimately linked to a loss of will. It is now known that executive function is subserved at least in part by the prefrontal cortex and that there is prefrontal cortical dysfunction in schizophrenia. Impairment of volitional control is now known to be associated with specific neuropathology. For instance, researchers reported an 11% reduction in the volume of prefrontal cortical grey matter and reduced autonomic activity in 21 people with antisocial personality disorder, compared with controls. This means that such people may differ from others in the part of the brain dealing with executive functions including volition and will, although psychiatrists are unlikely to agree whether this removes personal responsibility. Molecular genetics is producing evidence about heritable vulnerability to some personality traits and psychiatric syndromes. There are now a number of studies, all unconfirmed, reporting associations between neurotransmitter polymorphisms and personality traits such as novelty seeking, violence, gambling and alcohol dependency. Alper, however, argues that 'even if human beings are genetically deterministic systems, their behavior may still be unpredictable and they may still possess free will'. He adds, 'behavior influenced by genes is no more deterministic than is behavior influenced by the environment'. These scientific advances are prompting the wider community to be concerned about the extent to which free will really exists, in contrast to behaviour that is biologically determined.
One factor that impacts on risk for psychosis is social/interpersonal functioning. Deviations in social functioning are a common feature in patients with schizophrenia, those experiencing a first episode of psychotic illness, and inhelp-seeking individuals at ultra-high risk for psychotic disorder. This is consistent with evidence of deficits in premorbid social development in childhood and adolescence in individuals destined to develop non-affective psychotic disorder. Individuals at ultra-high risk who transition to psychotic disorder also show poorer social functioning compared with those who do not make the transition. At the general population level, persistence of subclinical psychotic experiences is similarly associated with poorer social functioning. A recent prospective study of a general population sample from Israel showed that transition from subclinical psychotic experiences to hospital admission for psychotic disorder occurred almost exclusively in the group with psychotic experiences who also showed deviant premorbid social functioning.
Change in psychomotor function is a cluster of symptoms that was already recognized in schizophrenia by its earliest investigators. Nevertheless, few studies have been dedicated to the clarification of the nature and the role of the phenomenon in this illness. Moreover, slowed psychomotor functioning is often not clearly delineated from reduced processing speed. The current, first review of all existing literature on the subject discusses the key findings. Firstly, Psychomotor Slowing is a clinically observable feature that is most frequently established by neuropsychological measures assessing speed of fine movements such as writing or tasks that require rapid fingertip manipulations or the maintenance of maximal speed over brief periods of time in manual activities. Moreover, the slowed performance on the various psychomotor measures has been demonstrated independent of medication and has also been found to be associated with negative symptoms and, to a lesser extent, with positive and depressive symptoms. Importantly, performance on the psychomotor tasks proved related to the patients' social, clinical, and functional outcomes. Several imaging studies showed slowed performance to coincide with dopaminergic striatal activity. Finally, conventional neuroleptics do not improve the patients' psychomotor symptoms, in contrast to the atypical agents that do seem to produce modestly improving effects.
The sudden misfortunes on the patient's life provoked the development of hostility. When an individual failed to express these feelings it becomes buried deep down the unconscious level. As an individual learned to internalize the values and standards of the society, the anger and hostility could not be expressed overtly thus, the feelings become an anger turned inward. Individuals who take it out on themselves experience depressed feelings for they have nothing but themselves to help them release their rage.
In order to ward-off the anxiety which was brought about the patient's past and present situations, he adopted a safeguarding tendency in order to hide his inflated image and to maintain his current state of life. Self-accusation is marked by self-torture and guilt. He continuously prosecuted his life regarding his misdeeds and unknowingly, it became his own way to fend off his suffering and also to protect his own self-esteem. By doing this, he had thought that he can bring his old life back and without traces.
Hostile impulses which have been repressed on the unconscious level can promulgate basic anxiety. This basic anxiety is a feeling of isolation, helplessness and hopelessness in a world conceived as a potentially hostile. In the subject's case, he perceives those people around his as threats because of his paranoid ideations. As a result, he develops reactive hostility in order to defense the threat but he could not express it overtly due o the moral standards emphasized by his superego thus, the patient ends up guilty towards himself.
Exaggerated physical deficiencies, whether congenital or the result of injury or disease, are not sufficient to lead to maladjustment. They must be accompanied by accentuated feelings of inferiority. These subjective feelings may be greatly encouraged by a defective body, but they are the progeny of the creative power. Each person comes into the world "blessed" with physical deficiencies, and these deficiencies lead to feelings of inferiority. People with exaggerated physical deficiencies sometimes develop exaggerated feelings of inferiority because they overcompensate for their inadequacy. They tend to be overly concerned with themselves and lack consideration for others. They feel as if they are living in enemy country, fear defeat more than they desire success, and are convinced that life's major problems can be solved only in a selfish manner
Self-hatred may result in relentless demand on the self, which are exemplified by the tyranny of the should. These people make demands upon themselves that will not stop even when they achieve a measure of success. As a result, the individual engages himself in self-destructive actions and impulses. It may be either physical r psychological, conscious or unconscious, acute or chronic, carried out in action or enacted only in the imagination. In the subject's case, due to his constant life disappointments, he carried out his self-hatred through multiple suicidal attempts.
The subject started to apprehend an unknown danger whenever he happens to come across people. He always thinks that these people are talking about him because he previously experienced unconscious feelings of destruction against his father. During childhood, these feelings of hostility are often accompanied by fear of punishment, and as this fear becomes generalized, it'll make him anxious during social situations.
When an individual starts to be dreaded of nonbeing or fear of death, he is now starting to become less of a person. In addition, people usually start to engage themselves to alcohol, smoking and other compulsive behavior when refused to confront our nonbeing by contemplating death. Furthermore, these types of individuals usually end up isolated and alienated. On the other hand, if the patient continuously avoided the dread of death by dimming his self-awareness and deny his individuality, it'll only cause to have feelings of despair and loneliness.
In order to avoid or circumscribe the conflicts that were encountered in his relationship with the external world, the patient had tried to reshape his own perception of reality. Through this, the subject may be able to distort his perception in order to meet his external needs. Moreover, distortion is a type of defense mechanism usually overt in psychosis. Mentally disordered individuals dissociate many of their experiences from their self-system. As it becomes persistent, the individual begins to increasingly operate in his own private world, with increasing parataxic distortions and decreasing consensually validated experiences.
Personality development can be halted when people runaway from difficulties. Although this safeguarding tendency can promulgate relief toward a maladjusted individual, he unconsciously sets his own way how to set a distance between himself and those problems therefore, could possibly elicit a withdrawal tendency in his environment. As a result of this psychological distance, the individual chooses to stand still to avoid all responsibilities by ensuring himself against any threat of failure. The individual thinks that by engaging to this safeguarding tendency, he can guard his self-esteem and protect himself against failure.
As a person continuously displease the people round him, he also persistently perceives negative feedbacks from those he holds on for emotional support. The patient then started to feel bad about himself and therefore resulted in declined self-worth. Devaluing one's self could result in low self-esteem. When an individual starts to devalue himself, he will soon develop a low motivation that could lead to stagnation. This stagnation will prevent him from promoting his well-being hence, in the forthcoming setbacks in his life he'll no longer strive to overcome it.
Typically, depressed individuals usually have failed to develop a good sense of self-worth and for this reason the patient could not accept his own faults and weaknesses. Usually, these types of individuals seldom engage themselves in such activities because of the fear of revealing their incompetence. Aside from this fear, absence of motivators could also lead to low function tolerance. Motivators help and individual cope with failures hence, any sort of its absence could potentially lead to social stagnation and withdrawal.
The parent-child avoidant relationship between the patient and his father had become the immediate cause of his inadequate sense of belongingness in the family. When his parents were unable to satisfy the patient's needs, he soon develops basic hostility toward his parents. But as a child who cannot overtly express such rage, the child therefore tends to repress this hostility out of his awareness. The repression of anger and hostility often leads to the development of basic anxiety. As the individual experiences this anxiety, he now feels rejected, isolated and helpless in a world where hostility is dominant.
The pathophysiological basis of auditory verbal hallucinations, experienced by 60–80% of people with schizophrenia, remains uncertain. Functional neuroimaging studies have associated these hallucinations with haemodynamic activity in diverse brain regions, including the left inferior frontal gyrus, right inferior frontal gyrus, middle and superior temporal gyri, primary and association auditory cortex, hippocampal and parahippocampal regions, and the thalamus, with much variation between patients and across studies. It is uncertain, moreover, which of these findings reflect core mechanistic processes producing auditory verbal hallucinations or are downstream consequences, such as registration of hallucinated content in verbal memory or propagated activity to non-essential areas.
In high dopamine states, a small proportion of striatal neurons undergo increases in impulse activity. The overactivity of these few neurons could apply to neurons of origin of either the direct or the indirect pathway. One would anticipate that the former would lead to "positive symptoms", and representing abnormal exaggeration of normal function and experience. These inherently more likely to attract attention of clinicians than those arising from overactivity in the neurons of origin of the indirect pathway. For the latter, one would expect that abnormal suppression of normal functions would occur. This could consist of sudden cassation of a train of thought. Something like this does occur in schizophrenia, but a distinction needs to be made between true cessation of a train of thought and derailment of thought by other competing trains of thought. If this occurs in the manner suggested, it should not be a result of competition from other concurrent foci of mental activity. Such a description fits one of the symptoms of schizophrenia, referred to as thought withdrawal. There has, however, been detailed examination of this symptom.
Thought insertion as a problem of 'agency', which defined as 'consisting in regarding one's mental episodes or thoughts as expressions of one's own active doing: as things one does rather than things that happen to one'. Hence, they differentiate 'influenced' thinking from thought insertion on the basis of whether or not the alien performs the thinking. 'The merely influenced subject believes that someone else has caused him to think the thought. . . In thought insertion, by contrast, the subject believes that someone else has actually done the thinking for him. He has not been manipulated into thinking something; rather his agency has been bypassed completely. Hence, the concept of agency helps us to disambiguate thought insertion from influenced/made thinking. An 'influenced' thought emerges when the alien 'other' interferes with the subject's agency but the subject owns the ensuing thought. In thought insertion the subject's own agency is absent and an alien thought is 'inserted'. In this account, patients retain ownership of a 'made' thought whereas thought insertion thoughts are experienced as 'alien'.
Thought broadcast, the psychoanalytic interpretation is that the boundary between the ego and the surrounding world has broken down, so it is not altogether surprising that these symproms were prevously considered to be diagnostic of schizophrenia. This phenomena can be approached through the prism of egosyntonicity/ego-dystonicity. An experience is descibed as ego-syntonic if it is consistent with the goals and needs of the ego and/or consistent with the individual's ideal self-image; the reverse is the case for ego-dystonicity. The division between ego-syntpni and ego-dystonic phenomena is not, however, absolute, and the clinical picture may be complicated by primary of secondary delusions, as well as changing mood states. In general, however, as an individual with psychosis develops insight into their symptoms, the experience of thought alienation may seem increasingly ego-dystonic and distressing them.
Individuals who did not learn the basic trust during infancy develops a sense of basic mistrust. In the patient's case, the father-child relationship is too cold that they never had a chance to bond with each other. As an infant tries to sense his caregivers' emotional presence, he can feel that there's one lacking in his emotional well-being thus, will come up to the realization that his overall needs are not fully met. During this instance, the child is having a hard time in choosing people whom he will trust and as a consequence, the individual begins a lifelong pattern of suspicion about people.
The brain circuits involved in emotion are complex and are believed to include multiple highly intertwined structures. Two neural systems, a ventral and a dorsal, are integral to emotion processing. The ventral system is involved in identification of the emotional significance of a stimulus, production of affective states, and automatic regulation of an emotional response. Its component structures that are relevant to this review are the amygdala, anterior insula, ventral anterior cingulate cortex, orbital prefrontal cortex, and ventrolateral prefrontal cortex. The dorsal system is thought to be involved in the effortful regulation of affective states and related behaviors. Relevant structures include the hippocampus, dorsal anterior cingulate gyrus, and the dorsolateral prefrontal cortex. Abnormalities in the connections between these 2 systems are associated with abnormalities in emotion perception and identification, emotion experience, and emotion expression. Furthermore, if the individual happens to have abnormalities on these vital systems, it'll result in poor emotion expression that could cause him to elicit poor interpersonal relation.
Typically, last born children are prone to experience excessive feelings of inferiority. As he began to identify his immediate family, he likewise starts to recognize them as individuals who were stronger than him. And for this reason, he chose to move toward these people in order to gain esteem and to regain his gravitated feelings toward himself. Individuals who rather chose to move toward other people around them actually become dependent. They feel powerless when they're alone so when they had the chance to cling unto others, they'll do everything just to keep the parasitic relationship even if it'll cause painful consequences.
Psychotic processes reflected some regression to an earlier and more "primitive" level of organization found in children. Freud used the term 'primary process' to describe a child's first mode of thinking. He contrasted this with 'secondary process' which he thought was an adult way of thinking. Individuals who were acting in a regressed manner may have a primitive organization which are actually found in children and could have a possible tendency to act them out during the course of schizophrenia. These types of behaviors do not consider the situations in their reality hence, it might be a desire promulgated by the id which was buried deep down the individual's unconscious.
The superego is not concerned with the happiness of the ego. It strives blindly and unrealistically toward perfection. After the repressed demands of the superego had dominated the patient's mind, his superego started to create inapprehensible conscience in which he could no longer deal with. As a repercussion, the persistent failure of the ego to satisfy the moral standards demanded by the superego, the patient started to promulgate his feelings of inferiority. In spite of the difficulties and impossibilities of carrying out the orders given by the superego, it doesn't consider the setbacks that the ego could possibly encounter in dealing with reality.
Families of individuals with mutism has been described as conflictual, isolated, and refraining from social contact with parent-child relationships described as overprotective, especially between mother and child. The patient had experienced emotional coldness from his father throughout his childhood and for this reason, he wasn't able to express his affection toward his paternal parent. Family problem inflicts a negative impact on the developing cognition of individual. As he continuously experience this type of avoidant relationship, he then becomes aloof as he grows older thus, making him verbally inhibited.
Ideas of reference illuminated the concept of the superego. After the patient had experienced paranoid symptoms, his regressed form of the superego had been manifested again through the idea of reference. In this case, the patient's evolution of the conscience caused him to believe and promulgate irrational thoughts. Moreover, these thoughts that occupied him had backfired through the form of unwarrantable conscience. This state of mind typically occurs when the patient had perceived a description of his parents' behavior toward him thus, mad e him believe that his notions are true.
Education on the other hand is the knowledge acquired by learning and instruction over a period of time. It enables one with some fundamental cognition so as to impart an all round grooming. Holistic education is a tool which prepares one for life. On one hand there is education which is a skill set which has to be acquired or gained, while IQ is believed to be an innate quality, present from birth. IQ scores have been shown to be associated with such factors as morbidity and mortality, parental social status, and to a substantial degree, parental IQ. Its inheritance has been investigated for nearly a century; the mechanisms of inheritance remain debatable. In contrast, skipping school has a long term detrimental effect on an individual's intelligence. Common reasons of skipping class are peer pressure, and family problems. The more he skips his class, the less he becomes intelligent. Thus, as this pervasive pattern then continues, the individual will then soon have a low intelligence.
Individuals who are emotionally stable typically possess a great emotional resiliency. The patient's adaptive ability had helped him adjust despite of the different setbacks in life. And for the reason that he was having a hard time relating his problem to his family, he just chose to repress it and live a normal life. Moreover, an individual who has a sufficient amount of emotional stability has the capacity to resist a neurotic disorder even in periods of extreme stress and therefore, this individual are less likely to become neurotic.
In situations involving psychological disorders, ego strength is often used so that the patient's identity and sense of self are maintained despite of pain, distress, and conflict. Typically, individuals who have developed a good sense of ego strength have a good coping and defense mechanisms. By doing this, they are now able to defend on their ego against anxiety and cope up with life's setbacks. Moreover, the patient had a fully developed basic strength during his infancy and for this reason, the conflict between his dystonic and syntonic elements had produced an ego strength or ego quality.
All individuals have inherent feelings of basic anxiety. It is very common that an infant had an established dependence toward her caregivers. If the applications of the parenting strategies are inefficient or overly employed, his inherent anxiety could later on lead to the development of deeper psychological conflicts that could affect throughout his life span. In order to evade the development of a severe anxiety, the patient had become submissive – which served as his protective device against anxiety. He may submit herself to either to people or to institutions such as organizations or a religion.
Low freedom means low expectancies. Individuals who lack the motive to move forward a goal-oriented behavior may have developed a low freedom of movement. As the patient develops toward his adulthood, he displayed a lack of assertiveness toward his family and colleagues. This was caused by his aggravated fear of being punished by his father in every action that he makes. In addition, this had also caused him to be reluctant in terms of initiating actions thus, eliciting an inhibited action.
The patient had established a strong bond with his mother who had become his caregiver up to this present. Individuals who failed to separate from the beginning of his psychological birth, (for the next 5 years or so) may fail to develop his sense of identity. This failure of obtaining his own identity could lead him from becoming a social loafer and an indecisive individual. During this time, children who have not achieved the psychological separation from their mother may strive for autonomy in order to achieve individuation and develop feelings of identity. When the individual no longer experience a dual unity with their mother, that is the time that they must surrender his decision of omnipotence and face his vulnerability to external threats. In contrast, failure to do such could lead him to a lifelong struggle in achieving his independence and identity.
