Adults with Schizoaffective Disorder in Cognitive Theories - Term Paper Example

Adults with Schizo-effective Disorder The literature on schizo-affective disorder suggests that it is part of a spectrum that includes schizophreniaand a mood disorder, which is usually depression. One of the interventions that has been shown to work with the schizophrenia spectrum is Cognitive Behavior Therapy (CBT). The literature describes schizo-affective disorder as one of several types of schizophrenia (Jarbin and Hansson, 2004; Felmet, Zisook and Kaschow, 2011; Kao and Liu, 2010). This research paper will describe schizo-effective disorder in adults and also give information about how it is tied to cognitive theories. The second and third aspects of the paper will also discuss how a family member saw this spectrum and how it is affects African-Americans. Research and Theoretical Orientation The theoretical orientation that has been chosen for this report is the cognitive theories. According to the Better Health Channel (2011) schizo-affective disorder is a combination of “schizophrenia and a mood disorder” (par. 1). There are two sub-types that have been identified: Schizo-affective bipolar type and schizo-affective depression type. The symptoms of schizo-affective disorder can include three types: Psychotic symptoms include losing touch with reality, chaotic speech, blank facial expression, hallucinations, disorganized thoughts and the inability to move. Manic symptoms can include rapid thoughts and/or speech, quick changes in mood, impulsive behaviors and exaggerated self-esteem. Depressive symptoms that can include low self-esteem, suicidal thoughts, loss of motivation and/or loss of interest, difficulty concentrating, insomnia and loss of appetite. Unfortunately, the causes of schizo-affective disorder is not known (Better Health Channel, 2011). Also, schizo-affective disorder is difficult to diagnose because clients are usually having the same challenges when they are diagnosed with schizophrenia or bipolar disorder. Generally, the diagnosis of schizo-affective disorder will be used if the individual has both schizophrenia and a mood disorder that is present for at least two weeks (Better Health Channel, 2011). This is one of the reasons that many researchers state that socio-affective disorder is part of a schizophrenia spectrum. Schizo-affective Disorder and Cognitive Theories The cognitive theories are important to this disorder because there are several areas of cognitive dysfunction. Green (2006) identified several key concepts in cognitive functioning. These concepts include: “speed of processing, attention/vigilance, working memory, visual learning and memory, reasoning and problem solving, and social cognition” (p. 3). Green further states that cognitive impairment is one of the key symptoms of these disorders. Bandura (1977) and his social learning theory suggests that an individual learn through their perceptions and thinking about the experiences they have in the world. Bandura presented two sets of expectations: Outcome expectations that suggest that when an individual acts in a certain way they will have a certain outcome and Efficacy expectations that suggest that an individual has the behavior that is necessary to have a certain outcome is obtainable by the individual (Using Theories in Social Work, n.d., slide #13). When applying this theory to schizophrenia disorders, the individual has difficulty with their perceptions and this may cause more challenges for them as they attempt to move through their lives in a positive way. Research and Schizo-affective Disorders The cognitive theories are reinforced as the literature is studied. Crisan, Bondor and MaCrea (2009) studied clients who were schizophrenic and how they perceived their illness. They called this “lack of insight” and it meant that those people with these disorders did not accept their diagnosis or they did not have a positive awareness of it. This lack of insight was a symptom in 98% of patients who have a schizophrenic disorder according to the authors. This lack of awareness brought about cognitive challenges that include hallucinations and delusions. Crisan, Bondor and MaCrea (2009) also stated that some patients accept that they are mentally ill but they do not understand the extent of their illness. In order to test this in their studies the authors used the Beck Cognitive Insight Scale (BCIS). This is a 15 item self-report instrument that has two subscales: Self-Reflectiveness and Self-Certainty. They used this study to provide insight into how clients see their illness and to suggest that clients who do not have the ability to understand their illness cannot heal. Kantrowitz and Citrome (2011) stated that the diagnosis of schizo-affective disorder was an extension of schizophrenia and they reviewed several themes inherent in the literature. Some researchers in their analysis showed that there was no clear definition between schizo-affective disorder and schizophrenia or between “schizophrenia and major depressive disorder” (Kantrowitz and Citrome, 2011, p. 319). Other researchers studied genetics and suggested that testing of schizo-affective disorder could not be “useful as a clinical tool” (Kantrowitz and Citrome, 2011, p. 322). Neuro-cognition studies suggested that there is no difference between schizophrenia and schizo-affective disorder. As this author reviewed different studies for this research, it was found that studies either referred to schizo-affective disorder as part of the schizophrenic spectrum disorders or they interchanged the terms. Kao and Liu (2010) studied the age in which schizophrenia began. They studied 104 patients who had both schizophrenia and schizo-affective disorder. They diagnosed the patients through structured clinical interviews. They also did assessments for psychiatric symptoms and used the social and global function tool from the DSM-IV-TR instructions. From the sample of 104 patients, they found 52 with schizophrenia and 52 with schizo-affective disorder. The age group of the sample was 17 years to 52 years with 17 years as the onset age of the disorders. The authors did this study because of the implications that arise for adults with these disorders as they age. The authors stated that the timing of the onset of schizophrenia disorders determine the prognosis and clinical significance. What they found as a result of the study was that the patients who had an early onset for schizophrenia disorders had “higher levels of cognitive impairments and impulsivity traits” then those who had an onset of the disorders in adulthood (Kao and Liu, 2010, p. 6). The authors did a cross-sectional study and suggested that more research must be done in this area. Lysaker, Bond, Davis, Bryson and Bell (2005) presented a study regarding the use of cognitive-behavior therapy (CBT) with schizo-affective clients involved with vocational rehabilitation. They were particularly interested in addressing the effects of dysfunctional cognitions on vocational outcome. Their study was a 26 week program given through the Indianapolis Vocational Intervention Program (IVIP). The authors developed a program manual that was based on the work they were doing with 20 schizophrenic adults (including schizo-affective disorder). The actual study they did was a randomized controlled trial. They established a baseline of information for “symptoms, self-esteem and hope” (Lysaker et al., 2005, p. 674). The study participants were 52 males with schizophrenia or schizoaffective disorder who were attending outpatient psychiatry services at the Veterans Administration (VA). The authors measured the baseline factors in the beginning of the program and five months afterward. All participants received medication management. Twenty-eight of these men were African-American, 21 were Caucasian and one was Latino. All participants had been unemployed at least two years and they were referred to the program by the clinician in charge of the VA psychiatry program. Some of the participants had received different types of vocational rehabilitation services in the past. There were several assessments used with the patients to obtain the baseline assessment of hope, self-esteem and work behavior. The purpose of this study was to help these men receive employment and stay on the job by correcting any dysfunctional patters of work related thoughts and/or behaviors. Lysaker et al. (2005) found that those men who participated in the IVIP program were able to work more positively in their environments than those who did not participate. Those participants who had a long history of hospitalizations, or a history of dysfunction were able to make 66% of their counseling appointment in the IVIP as opposed to 42% of those in a standard support group. For the authors, this information supported the hypothesis that clients with schizophrenia disorders needed the extra coaching to keep them on track. This may mean that people within the schizophrenia spectrum will need extra assistance to maintain their goals. Gioia & Brekke (2009) also studied the issue of neurocognition as it related to how an individual with schizophrenia or schizo-affective disorder would act in various real life situations. Their study was a mixed method study that “combined quantitative NP [neuropsychological] test data and psychosocial functioning data with data on daily community living derived from an ethnographic observation method” (Gioia & Brekke, 2009, p. 96). The participants were 10 individuals diagnosed with schizophrenia disorders who had participated in another longitudinal study that Brekke had conducted. They used both qualitative and quantitative data in this study. The results showed the importance of using neuropsychological testing to predict community functioning and of a natural ethnographic method to study how individuals naturally behaved as predictors of how they would function in the community. Another theme that was seen in the literature was that of quality of life. Jarbin and Hansson (2004) studied the quality of life and the associated factors in adolescence at the onset of schizophrenia. The study involved 53 patients who were 25 years of age but who had the onset of schizophrenia in adolescence. The patients were assessed via several assessments for psychopathology, psychosocial function and quality of life. There were 25 males and 28 females who had experienced their first psychotic episodes between the ages of 15.8 years and 16 years. They compared patients with schizophrenia and those with schizo-affective disorder against those with psychotic mood disorders. The participants also were not living independently at the time of the study, they lived on disability and they had lower scales on the GAF. The results of the study showed that patients with schizophrenia disorders were more able to relate to the domains of safety and religion than they were to social relations and living conditions. The issue of depressed mood overshadowed quality of life in many of these patients. The authors suggested that further studies should be done on the relationship between quality of life and depression and how this relates to participation and adjustment in work. There is other research that has studied the link between depression and people with schizophrenia disorders. Mausbach, Cardenas, Goldman and Patterson (2007) studied depression in patients with schizophrenia who were middle aged and older. Depression is a mood disorder that challenges the individual’s cognitive functioning. These authors studied 210 middle aged and older clients who were enrolled in another study that examined the effects of a “behavioral skills intervention” (Mausbach et al., 2007, p. 340). The intervention was created to improve functional skills among those who were seen as severely mentally ill. Several assessment were used to determine depression, quality of life, satisfaction and activities, positive and negative symptoms and insight (to test their own recognition of their mental illness), need for treatment and their ability to re-label any psychotic symptoms (Mausbach, et al., 2007). The authors found that although clients with schizophrenia disorders often had increased symptoms of depression and a reduced quality of well-being, some patients stayed well-adapted to their illnesses. The authors further found that schizophrenic patients only had problems with well-being when they were unable to engage in social activities on a daily basis that were satisfying to them. those who had less satisfying activities were more prone to depression and a reduced quality of well-being. This research suggested that cognitive development in clients with schizophrenia disorders was compromised when they lacked an understanding of their symptoms and how these symptoms affected their quality of life. Mausbach et al. (2007) also stated that cognitive-behavior therapy (CBT) was the therapy most often used for managing both positive and negative symptoms of schizophrenia. The authors suggested that there should be a behavioral component in addition to CBT in order to assist with the negative symptoms. The authors stressed that CBT worked for positive symptoms but it was not effective for negative symptoms. Schizophrenia and schizo-affective disorder happens in adults of all ages. Felmet, Zizook and Kasckow (2011) reviewed treatment modalities for elderly patients with schizophrenia disorders. Their study provided insight into these disorders and depression. The authors studied the research on depression and older adults with schizophrenia. There were several themes that were present in the research. Several studies showed that depression increased the challenges that schizophrenics experienced. Depression could also add to severe negative consequences when the individual also had depression. This could also influence the overall global functioning score and the individual’s quality of life, depending on the severity of the depression symptoms. The authors stated that “a substantive portion” of patients can have at least “one full episode of major depression” (Felmet, Zisook and Kaschow, 2011, p. 242). This episode of depression would change the patient’s diagnosis from only schizophrenia to schizophrenia with major depression as a co-occurring disorder, but it would not be seen as schizo-affective disorder. This research showed that schizophrenia in adults is a complex diagnosis when the patient experiences more than one disorder. Bradshaw, Lovell and Harris (2004) conducted a systematic review of the literature on healthy living interventions in working with patients with schizophrenia. Their review was designed to use several databases and was conducted using the guidelines form the United Kingdom National Health Service Centre for Reviews and Dissemination. The review involved patients with schizophrenia or schizo-affective disorder. The studies they reviewed identified the following interventions: Smoking cessation, weight management, exercise and nutritional education. The authors found that smoking cessation, weight management and exercise showed positive outcomes but the authors admit that the studies were not of high quality. The authors suggested that more research was needed in the area of interventions to assist clients in adopting and maintaining healthier lifestyles. Lommen and Restifo (2009) add to this discussion with their study on trauma and post traumatic stress in schizophrenia disorders. the authors state that psychosis can cause PTSD and that it can happen as the result of an individual’s ability to threaten their own life or someone else’s life. Although the traditional view states that there must be a traumatic even that include an actual “threat, death, serious injury, or threat to physical integrity” (Lommen and Restifo, 2009, p. 436), with an individual who experiences a schizophrenic disorder, the threat can be an aspect of the psychosis. The authors also showed that psychosis and PTSD could be the way that an individual with a schizophrenic disorder could experience a traumatic event. Trauma and PTSD are more prevalent in individuals with a psychotic disorder, but PTSD is often overlooked in this population. The cognitive model of CBT suggests that PTSD is a normal reaction to a traumatic event for a person with a psychotic disorder. The cognitive aspect of PTSD for an individual with schizo-affective disorder has to do with the way the individual processes the trauma that moves the trauma into a “sense of current threat” (Lommen and Restifo, 2009, p. 486). This sense of threat happens because of “excessively negative appraisals of the trauma and/or its sequelae … and a disturbance of autobiographical memory …” (p. 486) and other cognitive issues. The negative appraisals will also maintain PTSD because they produce negative emotions and the negative appraisals encourage the individuals to use “dysfunctional coping strategies” that also enhance PTSD. In other words, the individual with schizo-affective disorder, by nature of their symptoms, will enhance and maintain PTSD. The authors also conducted their own research to determine whether PTSD was under-reported in a population of patients diagnosed as psychotic. Their study consisted of 33 patients (23 men and 10 women) who were diagnosed with schizophrenia or schizo-affective disorder and were between the ages of 21 and 63. The study found that 97% of the patients reported at least one traumatic even that happened in their lifetime. Lommen and Restifo (2009) stated that this was proof that PTSD can be overshadowed by other symptoms in schizophrenia disorders. Part 2: Discussion of Differential Application with Individuals, Family and Small Groups Cognitive theory has been used to assist a variety of individuals in doing many things that they may not otherwise do. Generally, this theory is based in the concept that how an individual perceives the world around them is how they will react to the world. As an example, an individual that perceives the world as a negative place will always look at the negative aspects of the world. They will find it very difficult to find the positive views of life. When talking with friends and family it was interesting because many of my friends believe that we how we perceive the world is our own perception and that we have a right to it. As I explained the theory, many of my friends thought that it was ridiculous because they did not feel that someone could predict how their life would turn out based on their perception of what the world looked like to them. Cognitive Behavior Therapy (CBT) would be the intervention that I would use with all these groups. Individuals could benefit from this process because those who are negative could find a way to feel more positive through CBT. Assessment Using CBT CBT allows the individual to look at themselves and their perception of the world. To work with individuals who had depression, the Beck Depression Scale (BDS) could be a starting point so that they could understand how depression looked. This scale is a self-report scale and in many of the articles that were read for this research, this was the assessment used for depression. There are many assessments that deal with an individual, group or family population that assess how an individual perceives quality of life, self-esteem, behavior and personality that would fit all three of these populations. In assessment, it would be necessary to address cognitive and behavioral factors separately. CBT as an Intervention CBT as an intervention works for all groups. According to Huston (2008) individual and group therapy works well for “social phobia, anxiety disorder, bulimia nervosa, and obsessive-compulsive disorder” (p. 4). These categories each have a perception of the individual that they must undergo a change within so that they can move forward. As an intervention, CBT would address these different perceptions and help the individual or group move to a different perception. As an example, in a family, the family members may have specific perceptions of each other which would have to be addressed individually and as a group. Outcome Measures Outcome measures for individuals would be different than for the group. As an example, individual outcome measures would be more specific to the individual and help them understand how their perception of the world was making their lives more difficult. In a group, the outcome measures would be more general because the group would have to decide what goals they wanted to accomplish by the end of the group. In a family, the outcome measures might be general and specific in that as a group, the family may want to come together and connect more easily. Each individual may have to have personal outcome measures so they could be a more effective part of the family. Part 3: Diversity and Socio-Affective Disorder Schizo-affective disorder is different in different cultures because of cultural values. There are many issues to consider in all aspects of the diagnosis of this disorder. The group that this research has chosen is African-Americans. One of the reasons this group was chosen is because in this researcher’s experience, this group is under-represented in therapy because they tend to go to their church or to friends and family instead of going to a therapist. Generally, when people of color are diagnosed it seems to happen after they have become very difficult to manage. The literature pointed out that there is another issue that happens for African-Americans and this is that their can be bias in their diagnosis. As an example, Whaley (2002) suggested that African-Americans were most likely to be diagnosed with schizophrenia than whites and whites with the same symptoms were more likely to be diagnosed as bipolar. The author found that there was a difference in the diagnostic categories for whites and African-Americans even when there were no differences in their symptoms. This meant to the author that this diagnosis may not only be attributed to race. Neighbors, Trierweiler, Ford and Muroff (2003) add to this discussion as they studied the diagnosis of schizo-affective disorder. In their study they used a semi-structured instrument to test whether there was a difference between how whites and African-Americans were diagnosed. Although the authors found that African-Americans were more often to be diagnosed with schizo-affective disorder than whites, they found that whites were more often diagnosed as bipolar. The authors also stated that diagnostic categories had to be considered when describing bipolar disorder or schizo-affective disorder because each group would have different way of reacting inside their culture. Conclusion There are many factors that are present in schizophrenia disorders that need to be taken into account when dealing with this type of disorder. The way that people perceive themselves may be different because of culture or because of other factors. The research suggests that schizo-affective disorder is only another aspect of the schizophrenic spectrum and should not be treated as a separate issue. Some researchers see this as a separate issue especially when it is coupled with depression. There can also be a difference in how different cultures perceive themselves that may not have anything to do with a psychotic disorder. References Better Health. (2011). Schizoaffective disorder. Retrieved from http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Schizoaffective_disorder Bradshaw, T., Lovell, K., & Harris, N. (2005). Healthy living interventions and schizophrenia: a systematic review. Journal of Advanced Nursing, 49(6), 634-654. doi:10.1111/j.1365- 2648.2004.03338.x Calkins, M.E., Tepper, P., Gur, R.C., Ragland, J.D., Klei, L. ,Wiener, H.W., …Gur, R.E. (2010). 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Community Mental Health Journal, 45(6), 485-496. doi:10.1007/s10597-009-9248-x Lysaker, P., Bond, G., Davis, L., Bryson, G., & Bell, M. (2005). Enhanced cognitive-behavioral therapy for vocational rehabilitation in schizophrenia: effects on hope and work. Journal of Rehabilitation Research & Development, 42(5), 673-681. Retrieved from EBSCOhost. Mausbach, B. T., Cardenas, V., Goldman, S. R., & Patterson, T. L. (2007). Symptoms of psychosis and depression in middle-aged and older adults with psychotic disorders: The role of activity satisfaction. Aging & Mental Health, 11(3), 339-345. doi:10.1080/13607860600963729 Mental Help Net. (2011). Cognitive theories. http://www.mentalhelp.net/poc/view_doc.php?id=439&type=book&cn=7 Neighbors, H.W., Trierweiler, S.J., Ford, B.C., and Muroff, J.R. (2003). Racial differences in DSM diagnosis using a semi-structured instrument: The importance of clinical judgment in the diagnosis of African-Americans. 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