psychology

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Symptoms of schizoaffective disorder

Background:

In the film Shine, protagonist David Helfgott is an authentic example of someone who suffers from schizoaffective disorder. From the start of the film we are able to see the accuracy of this diagnosis through David's childhood upbringing and his relationship with his abusive father. This will further be addressed throughout this paper and adequate examples will be mentioned to further show the precision of the diagnosis.

Symptoms:

Symptoms of Schizoaffective Disorder which can be observed in David include that of onset. According to William H. Murray, "the time period between late adolescence and early adulthood are the peak years for the onset of the schizoaffective disorder" (21), and that it is very rarely diagnosed in childhood. David exhibited no signs of mental illness during his young childhood and had a severe mental break around age 14 or 15. He was later hospitalized at a psychiatric ward during his early adulthood years. Obviously, these periods are often the most critical in a person's social development and can be severely disrupted by disease onset.

Schizoaffective disorder is a mental disorder characterized by recurring episodes of mood disorder and psychosis (Murray, 8). David does exhibit a few periods of depression in the film, especially when he lets his father down by losing several piano competitions. David's father, Peter, reveals that his father never allowed him to play any instruments and places all of his own personal lifelong dreams on the shoulders of his son. Anytime David loses, his father is sure to let him know how displeased he is and hounds him to "Win!" "Win!" "Win!" next time. Having such constant pressure from his father, David begins experiencing sadness during childhood.

David's depression continues to nurture itself as he struggles to live out the prodigy son career his dad has in mind for him. Around age 14, David wins a competition and gets invited by musician Isaac Stern to study music in America. David's father forbids him to go for personal selfish reasons and this becomes the turning point in both the film and the relationship of both father and son characters. David has a mental breakdown that occurred from agitation, guilt, anxiety, fatigue, panic, rage, pressured speech, suicidal ideation, rage, among other things. These feelings were stirred up by not only the abusive and immense pressure exerted by David's father, but also by the lack of love he showed to David. David was constantly striving to please his father and solely concerned himself with Pete's happiness and ambitions, ignoring his own. This created a great let down when David won the competition and the prize, yet still his father was not satisfied in the manner or degree David had anticipated. All of those emotions caused David's break down.

David's mania, states of abnormally elevated or irritable mood, arousal, and/or energy levels (Murray, 41) further added to the symptoms he possessed for schizoaffective disorder. In his college years, David began having hallucinations about performing in front of crowds where he would either faint or nearly die. His father had expressed that David play Rachmaninoff which is the hardest piano piece to play and very rare that a pianist can play the piece well. While extensively practicing the piece, David displays extreme paranoia and irrationality because of the expectation to play the piece perfectly. David displays symptoms of mania such as increased activity with little need for sleep, racing thoughts, rapid talking and inflated self-esteem at times. David exhibits excessive restlessness when practicing pieces for performances and during the entire film he exhibits guilt or self-blame by verbally reassuring himself aloud: "We played well tonight. Very well. Very well."

David has the symptom of disorganized speech. He is constantly repeating fragments throughout the film and this exhibits his disordered thinking. David even appears incoherent at times, when he gets lost and stumbles across strangers at a bar. David also posses the grossly disorganized behavior symptom; he cannot dress himself and his family members have to button his shirt and put on his shoes for his big performances. David does cry frequently throughout his struggle to prove himself to his father and also later on to overcome his own struggles with learning music notes, being disowned by his father, and also overcome his disorder, so that he can marry and re-start his musical career.

Many rule outs were encountered in the diagnosis of David. In schizophrenia for example, mood episodes have been thought to be absent or less prominent than in schizoaffective disorder (Akiskal, 76). David was not controlled by an outside force that drove him to have excessive delusions and hallucinations. His mental standing was caused by the neglect of receiving his father's love and also by his neurotic and perfectionist drive to be the best and practice excessively.

Agoraphobia was eliminated because David did not avoid the public and was able to play in front of large crowds and in open spaces. He did not have that personal "safe place" that agoraphobics have a problem escaping from. Autism was also ruled out because David did not have severe impaired social interaction and there were no signs of a disorder present during his childhood, as is often the case with Autism (Saddock, 54). Clinical depression was ruled out as the sole source because although David did experience depressive episodes, his self-esteem was almost always exceptionally high during the film.

Finally dissociative disorder was ruled out because David did not struggle with 2 personalities, but more of 2 selves within: one whom wanted to give everything to please his father and the other who wanted to live his own life independent of his father's opinions. Obsessive compulsive disorder was also ruled out because David did not have any rituals or repetitive behaviors (other than verbal) and was not paranoid of his verbal repetitiveness.

Epidemiology:

Estimates of the prevalence of schizoaffective disorder vary widely, but schizoaffective patients appear to comprise 3-5% of psychiatric admissions to typical clinical centers. At one point it was widely believed that schizoaffective disorder was associated with increased risk of mood disorders in relatives. This may have been because of the number of patients with psychotic mood disorders who were included in schizoaffective study populations. The current diagnostic criteria define a group of individuals with a mixed genetic picture. They are more likely to have schizophrenic relatives than individuals with mood disorders, but more likely to have relatives with mood disorders than individuals with schizophrenia. (Saddock, 502).

Co-occurring anxiety disorders are comorbid with schizoaffective disorder. Anxiety may also play a role in the subjective experience and thus shape the individual's delusional thought content (Murray, 23). This is evident in David's behavior when he begins to feel anxious about a performance and believes that someone else will win over him. His anxiety is so severe at some points that he is covered in sweat and sweat is almost 'pouring' off him, all over his hands and the piano keys.

Lifetime prevalence is estimated at 0.5% to 0.8%. Age of onset is similar to schizophrenia (late teens to early 20s) and schizoaffective patients are more likely than schizophrenics, but less likely than mood-disordered patients to have a remission after treatment (Podosyan, 2007).

When David was untreated, he would sleep too little because he was unable to fall asleep and was frantically scanning the newspaper or chain smoking. David had a difficult paying attention and concentrating on what was not his music. At times he showed difficulties with logical reasoning (he would not wear pants in public) and impulse control (he grabbed a woman's breast and kissed her, having only just been introduced to her). These difficulties with thinking are what known as cognitive deficits and deal with our executive functions (Murray, 24).

Without treatment, individuals with the disorder may further worsen in the delusional thought processes and become further alienated from people and society (Murray, 24), With comprehensive treatment, many individuals with schizoaffective disorder may recover much, most or even all of their functionality (Akiskal, 8).

In the film, it appeared that the cultural difference in Europe was that there was more of a stigma associated with David's disorder. This was evident in the lack of knowledge and understanding people had about his disorder and after he returned from treatment, people seemed reluctant that he still possessed the same playing abilities and talents from his younger, pre-treatment days.

Etiology:

It is suspected that the diagnosis represents a heterogeneous group of individuals, some with aberrant forms of schizophrenia and some with very serious forms of mood disorders (Saddock, 502). There is little evidence that schizoaffective disorder is a distinct variety of psychotic illness. Consequently, the disorder appears to exist on a continuum in-between schizophrenia and bipolar disorder and severe recurrent unipolar depression. It follows then that the etiology is probably more similar to that of schizophrenia in some cases and more similar to severe mood disorders in other cases (Murray, 213).

In the movie, David's family (specifically father) contributed greatly to the onset of his disorder, although he himself only displayed minor forms of neuroses and perfectionism and not schizophrenia or schizoaffective disorder. Many different genes may be contributing to the genetic risk of acquiring this illness (Podosyan 2007).

The NOTCH4 gene is located at 6p21.3, a site which several studies have shown an exceptionally strong association between this gene polymorphisms and schizophrenia patients (Ujike, 2001). In addition, many different biological and environmental factors are believed to interact with the person's genes in way which can increase or decrease the person's risk for developing schizoaffective disorder. Schizophrenia spectrum disorders have been marginally linked to advanced paternal age at the time of conception, a common cause of mutations (Brown, 159).

Many psychological factors may have played into David's disorder. His emotional states were constantly changing from bad to worse and it seemed as if he could not get an emotional break from his father's constant pressure. David was almost always anxious about performing flawless on stage and he was so driven to win that when he did lose, it was more of a blow to his esteem because he was not prepared for a loss.

David's sociocultural factors included the stigma from his peers in college. He was socially awkward at times and it was difficult for him to take to girl before his diagnosis and afterwards he seemed to overcompensate for his shyness by acting inappropriately to stranger by either kissing them or grabbing their breast. David also faced peer jealousy because his professors adored him and saw the immense potential inside him and this may have affected the other student's attitudes towards him. Going away to college to study music did help him experience what it was like to be a young man out on his own, away from his father. It is possible this may have created more anger and resentment towards his father.

Neuropsychology:

David had exceptional memory skills because he was clearly able to memorize lengthy pieces of music and play them for large crowds with ease. During his younger days, he paid attention to what his father wanted; his music instructors and professors asked of him and of course his music. It was not until after treatment that David began noticing what he wanted and decided to get married and pick up playing the piano again.

David's sensitivity was very high throughout parts of the entire film. He was sensitive to his competition and wished them luck; he was sensitive of what the audience thought of his playing and most of all he was extremely sensitive of his father's wants all the time. This created an obsession to please him when in reality that was simply not possibly.

Treatment:

Treatment for schizoaffective disorder consists of a combination of medication, psychotherapy and psychosocial rehabilitation focused on recovery (Saddock, 97).

A psychiatrist will prescribe medicine for the individual. Each person responds differently to medication and sometimes a combination of medicines may be prescribed.

For psychotic symptoms, preferably one, but sometimes neuroleptic medications are prescribed (Brannon). Examples of neuroleptic medications include Olanzapine, Risperidone, Quetiapine, Aripiprazole, and Ziprasidone (Saddock, 143). For manic symptoms, mood stabilizer medications may be prescribed along with a neuroleptic (lithium salt or carbamazepine) and for depression, antidepressant medications (SSRI or a mood stabilizer like Lamictal) may be prescribed along with a neuroleptic (Saddock, 145).

If patients are suicidal, homicidal, or gravely disabled, admit them to an inpatient psychiatric unit...patients who have schizoaffective disorder can greatly benefit from psychotherapy as well as psycho educational programs (Brannon). Patients should receive therapy that involves their families, develops their social skills and focuses on cognitive rehabilitation.....psychotherapies should include supportive therapy and assertive community therapy in addition to individual and group forms of therapy and rehabilitation programs (Brannon).

Family involvement is needed and very effective in the treatment of this specific disorder. Treatment includes education about the disorder and its treatment, family assistance in compliance with medications and appointments, and maintenance of structured daily activities (i.e., schedule of daily events) for the patient (Saddock 147).

Early treatment with medication, along with good premorbid function often improves outcomes (Brannon). As with every disorder, the earlier the detection, the better chances for prevention. If patients are not a danger to themselves or to others, they are encouraged to continue their normal routines and strengthen their social skills whenever possible (Brannon).

In the film David is not shown taking any medications but is highly likely is on medication during his psychiatric therapy. During psychiatric therapy, his family visits him regularly for support and he is later allowed to go live with his sister after he is released. It is at this point we are able to see how effective medication and psychotherapy have been for David over the last 20 years or so. Once he enters the real world, his social skills have changed so much that his is able to meet a woman, have a relationship with her and eventually marry. He also begins to play the piano again, and plays regularly for patrons of a local restaurant, and years later returns to play at concerts for the public. David does mention at one point of the movie that he received electroshock therapy and was also forbidden to go near any pianos to avoid playing and relapsing all of his hallucinations and anxiety. David's recovery really shows how successful someone with schizoaffective disorder can be after treatment. It is really amazing to watch this man come full circle to where he started as a young child (playing in concert halls) and be happy with his life.

Works Cited:

  • Akiskal, Maneros. The Overlap of Schizophrenic and Affective Spectra. New York: Cambridge University Press. (2007)
  • Brannon, Guy, M.D. Schizoaffective Disorder: Treatment and Medication. http://emedicine.medscape.com/article/294763-treatment (June 3 2009)
  • Hicks, S. (Producer & Director). (1996) Shine [Film]. Australia: New Line Home Cinema.
  • Murray, William. Schizoaffective Disorders: New Research. New York: Nova Science Publishers, Inc. (2006)
  • Podosyan, Gevetg. Schizoaffective Disorder. www.health.am/psy/more/schizoaffective_disorder/ (Dec. 7, 2007)
  • Saddock, VA. Synopsis of Psychiatry. New York: Lippincott, Williams &Wilkins. (2007).
  • Ujike, Hiroshi, et al. NOTCH 4 Gene Polymorphism and Susceptibility to Schizophrenia and Schizoaffective Disorder. www.Scinecedirect.com (2001)

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