Psychology

Schizophrenia as a neuropsychological condition has been linked to various abnormalities of the brain. The understanding of the disease presentation and prognosis is an important means of unearthing these brain abnormalities. This paper presents the case of a 26-years-old schizophrenic woman named Carol. The development of the schizophrenia when Carol is in late adolescence and the presentation of various signs such as stress are utilized to help understand the impaired brain parts. This case study identifies that schizophrenia is a brain developmental disorder mainly associated with developmental anomalies in the cerebrum. Introduction

Schizophrenia is a psychological process that results from various impairments in brain structure and hence their functions. The disease is characterized by hallucinations, delusions, apathy, social withdrawal and anxiety. Case studies on the presentation and treatment of schizophrenia can be very beneficial in understanding the likely relationship between impaired brain structure and function and disease presentation. This paper presents a case study of a woman (named Carol) with schizophrenia with the signs and prognosis of the disease forming a basis for brain involvement.

Carols background
Bradshaw (1998) presents a case of a 26 years old Carol who is not married. Carol is a White who in addition to completing high school, she has also been in college for one year. Carol was brought up in a family where among the most emphasized things were academics, career as well as a conservative Christian faith. She was a third born in an upper-middle class family of five children. In school, Carol was a hard working student with good conduct but she was self-critical to some extent. Although she was shy, Carol had a number of friends and she dated sporadically. After completing high school, Carol joined college in a different state where her first year was successful as she was performing excellently. Upon completing her first year her status changed with auditory hallucinations and delusions taking over her life. Carol also became socially withdrawn and when she was 18 years old, she was hospitalized for one month. Eventually, she dropped out of college and since then, Carol has been hospitalized for twelve times with working being impossible for her. As such, SSI stepped in to support her.  Financial support was always available from her family. Although Carol was presenting with these symptoms, there was no known family history of a psychiatric disorder.

Case description
As Bradshaw (1998), was carrying out this study, Carol had just been released from a two months hospitalization where she had been receiving the services of a psychiatrist. She was diagnosed with undifferentiated chronic schizophrenia and during her time of discharge, she had a Global Assessment of Functioning (GAP) of 30. After being discharged, Carol went to live with her parents and continued to get SSI support in addition to compliantly taking 500 mg of thorazone once per day. Carol was not just discharged and left to take the medication but she maintained contact with a psychiatrist who was to help her in assimilating into the community and adapt to the challenges of the illness.  Some of the cognitive impairments that she experienced include auditory hallucinations with persecution thoughts, delusions with a low self image. In addition to the cognitive problems, Carol also experienced flat feelings accompanied with anxiety. The anxiety was mainly as a result of her impaired interpersonal relationships in addition to the contribution of hallucinations and delusions. Carols coping methods included avoiding other people and tasks. She also had negative symptoms such as apathy which she developed in an attempt to cope with stress. These however seemed to worsen anxiety and psychosis presentation. From the above coping strategies, Carol experienced considerable psychosocial dysfunction.

There were several assessment measures used by Bradshaw (1998) in Carols case. These measures were addressing presentation of symptoms in Carols case, the psychosocial function in this condition, whether the treatment goals were achieved and frequency of hospitalization. To measure symptomatology, Bradshaw (1998) used the Global Pathology Index (GPI) of the Hopkins Psychiatric Rating Scale which has eight points that help in assessing how severe the symptoms are. The psychological functioning measure was carried out using the Role Functioning Scale (RFS) which contains four other scales that address work functioning, social functionality, family as well as how independent the individual can manage life. These subscales are each made of seven points which address behavior. To measure the hospitalization variable, the number of times in which Carol was hospitalized as well as the total number of days she spent in hospital. To measure how well the treatment goals were attained, Bradshaw (1998) used the Goal Attainment Scaling (GAS) which provides attaches various scores of according to how the client responds to various measures of goal achievement. In this case, scores ranging from -2 to 0 showed a progression from low goal attainment to attainment of the goal. If the score ranged from 0 to 2, then the attainment of the goal was considered to have exceeded the standards for the particular goal. A case manager who was assigned to Carol obtained data on GPI, RFS and hospitalization after every nine months for a period of three years through which Carol was receiving treatment. The same data was obtained later during a one year follow up at intervals of six months.

Carols treatment began with a therapist-client joining phase whereby a rapport was created over a period of almost three months. This was done by having the case management worker familiarize with Carols situation and genuineness as well as self disclosure. The relatively long period of about three months was taken as consistency had to be maintained for Carol to cope effectively. After establishing a relationship between Carol and the social worker, a socialization phase was started which was aimed at helping Carol understand cognitive-behavioral treatment. During the phase of almost two months, treatment goals were also clearly made known to Carol. This phase was like an educational for phase enlightening Carol on schizophrenia in terms of its presentation and the associated complications thus preparing her to cope with complications such as stress (Bradshaw, 1998).

In the initial phase of treatment which took around twelve months, addressed Carols difficulties of dealing with stress and anxiety. Her poor stress management strategy of social withdrawal and apathy were addressed. At the same time, she was also helped to integrate into the home environment which was different from the hospital condition where she came from. She was also helped in getting involved in activities starting with daily living skills and then progressed to a number of other activities. Carol was helped through stress by being taught meditation which addressed prevailing stress as well as anticipated stress. To deal with low self efficacy graded task assignments were used and with time, Carols status of self independence improved to a point where she stayed in her own apartment with her self efficacy also improving (Bradshaw, 1998).

The cognitive-behavioral treatment entered the middle phase which spanned about sixteen months. This stage focused on helping Carol cope with habitual stress through cognitive strategies. Her interpersonal abilities were enhanced by encouraging her to get involved in social activities. She was specifically encouraged to stop generalizing views about others and to collaborate with others as a means of coping effectively. Carol progressed to appoint where she went back to school in a community college as she also appreciated outings with friends and volunteer roles. As Carol was progressing positively, she would develop fears of relapse. These were effectively addressed making her understand that anxiety and stress were a normal part of her sickness. In addition, she was also helped in coping with these by reviewing her cognitive strategies with the things she feared most being addressed through effectively answering her questions. By this far, Carol had improved tremendously even in her self esteem. Since ending the treatment was thought to lead to stress due to fears of relapse, the worker provided Carol with guidelines on how to address the fears including ways of handling emergencies (Bradshaw, 1998).

On measuring the various outcomes regarding the cognitive-behavioral treatment that Carol went through, the results were encouraging in all the variables that were being assessed. On psychological functioning by the end of the therapy, Carols RFS score was 27 indicating that she improved in all areas including in her work, her independent living and being involved in social and family activities. Carol could also reliably continue with education successfully. On the area of symptomatology, Carol had moved from severe symptoms at the beginning of the study with a baseline score of 7 and progressed to a baseline score of 1 where only a few symptoms presented. Even the few that presented, she was able to successfully handle them. Regarding attainment of treatment goals, Carol showed a tremendous improvement as she started with a GAS score value of 19.85 and by the end of the treatment, her GAS score value was 80.15. This was way beyond the expected level of the measure (50.00).  In specific, Carol was able to get on with daily living successfully to a point where she became independent and eventually went back to school. She also successfully secured employment showing successful goal attainment. On the last measure regarding rehospitalization, there was no psychiatrist rehospitalization in a period of four years which was a major improvement considering the many rehospitalizations she had prior to treatment (Bradshaw, 1998).

The role of brain anatomy and physiology in Carols case
It is important to look at how Carols schizophrenic presentation is a determinant of abnormalities in the structure of the brain and hence its function. According to images of the brain as per magnetic resonance imaging (MRI) studies and computerized tomography (CT) studies, schizophrenia is associated with a wide range of brain abnormalities among them being decreased cerebral volume, and an increase in the brain ventricles. (Lawrie and Abukmeil (1998) identified that in schizophrenic individuals, overall brain volume reduces by 3 with the amygdala and the hippocampus reduced by an average of 6.on the other hand, the lateral ventricles were observed to increase by 36 to 44 percent.

A decrease in the cerebral volume is due to the increased brain ventricles. Since the cerebrum is responsible for various functions including regulating emotions, the above case study affirms a dysfunction in this brain region. This is more so with the Carols dominant symptom i.e. stress which is regulated by the amygdala in the frontal lobe. Carols reasoning and planning abilities are poor as se is unable to work or even continue schooling. This also shows impairment in the structures of the frontal lobe. Carols state was characterized by inability to plan poor attention and dysfunctional memory such that she had to drop out of college are in line with findings that schizophrenic patients have reduced frontal lobe which executes these functions. Carol was also not motivated as characterized by her apathy state a situation resulting from impaired frontal lobe.

In schizophrenic individuals, the brain amygdala is usually reduced while hippocampal fissures are enlarged. The hippocampal fissures are thought to be enlarged as a result of failed fusion of the anterior and posterior hippocampus. This is thought to happen during developmental stages of the neurons. The corpus collosum of schizophrenic persons is also found to have abnormalities such that interhemispheric integration is compromised. The reduction in corpus collosum and the subsequent of interhemispheric communication means that the patient cannot effectively shift the functions to either side of the brain. The posterior temporal gyrus is reduced in volume on the right side with a further decrease in this volume resulting to severe psychotic conditions as in Carols case.

Carol seemed to have developed schizophrenia at late adolescence (18 years) a finding that is consistent with speculations that schizophrenia is usually dormant until during adolescence (Rajarethinam, Prasad and Keshavan, 2005). It is speculated that individuals are born with the brain abnormalities but these explode during adolescence since the brain undergoes major structural changes at this stage of life. As such, the impaired brain structure translates to the poor functioning of the brain parts. Lack of a psychiatric illness history in Carols family signifies that Carol is less likely to have inherited the condition hence leaving abnormal development of the brain during adolescence as the only likely possibility.

By applying cognitive-behavioral therapy, the biological causes of Carols schizophrenic condition were not addressed. It is for this reason that Carol would experience relapses of schizophrenic symptoms. This finding asserts that schizophrenia can possibly be addressed through addressing the biological cause and not merely addressing the presentation of symptoms. The understanding the above brain dysfunctions interfere with two main neurotransmitters (glutamate and dopamine) has been utilized in the past to treat schizophrenia (Seeman, 2009). This gives more weight to brain involvement in the development of schizophrenia.

During the early phase of treatment, Carol was noted to have difficulties in coping with stress and anxiety. As such, she would get into smoking most of the times in addition to watching TV for long hours. Carols smoking condition is in line with the finding that mental illness patients are more likely to indulge in smoking compared to people who have no mental illness (Forchuk et al, 2002). Forchuk and colleagues found out that most schizophrenic patients smoked with the aim of getting sedated and eventually control the negative symptoms associated with schizophrenia. Carols case therefore affirms a deficiency in important neurotransmitters such as dopamine that are supposed to provide a sedative effect to the brain.

Although Carols case is presented in form of how cognitive-behavioral therapy can be effective in treating schizophrenia, it also helps in understanding the neuropathological basis of schizophrenia. The presentation of symptoms and prognosis is in tandem with deficiencies in the brain anatomy which then affect its physiology.  Relapses even after cognitive-behavioral therapy particularly show that there is a likely biological process in this disease which must be addressed.

Conclusion
Carols case study highlights important signs and symptoms in schizophrenia which are linked to brain abnormalities. MRI images indicate reduced brain volume specifically in the frontal cortex. Since Carol presents with poor reasoning and emotional instability, it is no doubt that her frontal cortex has some abnormities. In addition, Carols development of schizophrenia in a family that has no psychiatric illness history rules out the possibility of inheriting the disease leaving brain developmental abnormalities as the only possible cause. This case is therefore an enlightening work in the understanding of the neurological basis of schizophrenia.