30 Treatment of Schizophrenia
The currently available treatments for schizophrenia leave much to be desired, and the search for more effective treatments for both the psychotic symptoms of schizophrenia (e.g., hallucinations and delusions) as well as cognitive deficits and negative symptoms is a highly active area of research. The first line of treatment for schizophrenia and other psychotic disorders is the use of antipsychotic medications. There are two primary types of antipsychotic medications, referred to as “typical” and “atypical.” The fact that “typical” antipsychotics helped some symptoms of schizophrenia was discovered serendipitously more than 60 years ago (Carpenter & Davis, 2012; Lopez-Munoz et al., 2005). These are drugs that all share a common feature of being a strong block of the D2 type dopamine receptor. Although these drugs can help reduce hallucinations, delusions, and disorganized speech, they do little to improve cognitive deficits or negative symptoms and can be associated with distressing motor side effects. The newer generation of antipsychotics is referred to as “atypical” antipsychotics. These drugs have more mixed mechanisms of action in terms of the receptor types that they influence, though most of them also influence D2 receptors. These newer antipsychotics are not necessarily more helpful for schizophrenia but have fewer motor side effects. However, many of the atypical antipsychotics are associated with side effects referred to as the “metabolic syndrome,” which includes weight gain and increased risk for cardiovascular illness, Type-2 diabetes, and mortality (Lieberman et al., 2005).
The evidence that cognitive deficits also contribute to functional impairment in schizophrenia has led to an increased search for treatments that might enhance cognitive function in schizophrenia. Unfortunately, as of yet, there are no pharmacological treatments that work consistently to improve cognition in schizophrenia, though many new types of drugs are currently under exploration. However, there is a type of psychological intervention, referred to as cognitive remediation, which has shown some evidence of helping cognition and function in schizophrenia. In particular, a version of this treatment called Cognitive Enhancement Therapy (CET) has been shown to improve cognition, functional outcome, social cognition, and to protect against gray matter loss (Eack et al., 2009; Eack, Greenwald, Hogarty, & Keshavan, 2010; Eack et al., 2010; Eack, Pogue-Geile, Greenwald, Hogarty, & Keshavan, 2010; Hogarty, Greenwald, & Eack, 2006) in young individuals with schizophrenia. The development of new treatments such as Cognitive Enhancement Therapy provides some hope that we will be able to develop new and better approaches to improving the lives of individuals with this serious mental health condition and potentially even prevent it some day.
Cognitive remediation is usually used in combination with pharmacotherapy. Also, if combined with vocational rehabilitation, the effects can be enhanced. For each patient, an interdisciplinary team must define a structured plan. It’s utterly important that the rehabilitation program is adapted to the individual.
While a combination of psychopharmacological, psychological, and family interventions is the most effective treatment in managing schizophrenia symptoms, rarely do these treatments restore a patient to premorbid levels of functioning (Kurtz, 2015; Penn et al., 2004). Although more recent advancements in treatment for schizophrenia appear promising, the disease itself is continued to be viewed as one that requires lifelong treatment and care.
Psychopharmacological Treatments
Among the first antipsychotic medications used for the treatment of schizophrenia was Thorazine. Developed as a derivative of antihistamines, Thorazine was the first line of treatment that produced a calming effect on even the most severely agitated patients, and allowed for organization of thoughts. Despite their effectiveness in managing psychotic symptoms, conventional antipsychotics (such as Thorazine and Chlorpromazine) also produced significant negative side effects similar to that of neurological disorders. Therefore, psychotic symptoms were replaced with muscle tremors, involuntary movements, and muscle rigidity. Additionally, these conventional antipsychotics also produced tardive dyskinesia in patients, which included involuntary movements isolated to the tongue, mouth, and face (Tenback et al., 2006). While only 10% of patients reported development of tardive dyskinesia, this percentage increased the longer patients were on the medication, as well as the higher the dose (Achalia, Chaturvedi, Desai, Rao, & Prakash, 2014). In efforts to avoid these symptoms, clinicians have been cognizant of not exceeding the clinically effective dose of conventional antipsychotic medications. Should management of psychotic symptoms not be resolved at this level, alternative medications are often added to produce a synergistic effect (Roh et al., 2014).
Risperidone (trade name Risperdal) is a common atypical antipsychotic medication.
Due to the harsh side effects of conventional antipsychotic drugs, newer, arguably more effective second generation or atypical antipsychotic drugs have been developed. The atypical antipsychotic drugs appear to act on both dopamine and serotonin receptors, as opposed to only dopamine receptors in the conventional antipsychotics. Because of this, common medications such as clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (abilify), appear to be more effective in managing both positive and negative symptoms. While there does continue to be a risk of developing side effects such as tardive dyskinesia, recent studies suggest it is much lower than that of the conventional antipsychotics (Leucht, Heres, Kissling, & Davis, 2011). Thus, due to their effectiveness and minimal side effects, atypical antipsychotic medications are typically the first line of treatment for schizophrenia (Barnes & Marder, 2011).
Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that antagonize dopamine D2 receptors. The most common typical antipsychotics associated with EPS are haloperidol and fluphenazine. Atypical antipsychotics have lower D2 receptor affinity or higher serotonin 5-HT2A receptor affinity which lead to lower rates of EPS. Extrapyramidal symptoms (EPS), also known as extrapyramidal side effects (EPSE) if drug-induced, are movement disorders, which include acute and long term symptoms. These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (may manifest as motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements).
It should be noted that because of the harsh side effects of antipsychotic medications in general, many individuals, nearly one half to three quarters of patients, discontinue use of antipsychotic medications (Leucht, Heres, Kissling, & Davis, 2011). Because of this, it is also important to incorporate psychological treatment along with psychopharmacological treatment to both address medication adherence, as well as provide additional support for symptom management.
Psychological Interventions
Cognitive Behavioral Therapy (CBT)
The goal of CBT is to identify the negative biases and attributions that influence an individual’s interpretations of events and the subsequent consequences of these thoughts and behaviors. With respect to schizophrenia, CBT focuses on the maladaptive emotional and behavioral responses to psychotic experiences, which is directly related to distress and disability. Therefore, the goal of CBT is not on symptom reduction, but rather to improve the interpretations and understandings of these symptoms (and experiences) which will reduce associated distress (Kurtz, 2015). Common features of CBT for schizophrenia patients include: psychoeducation about their disease, the course of their symptoms (i.e. ways to identify coming and going of delusions/hallucinations), challenging and replacing the negative thoughts/behaviors to more positive thoughts/behaviors associated with their delusions/hallucinations, and finally, learning positive coping strategies to deal with their unpleasant symptoms (Veiga-Martinez, Perez-Alvarez, & Garcia-Montes, 2008).
Findings from studies exploring CBT as a supportive treatment have been promising. One study conducted by Aaron Beck (the founder of CBT) and colleagues (Grant, Huh, Perivoliotis, Stolar, & Beck, 2011) found that recovery-oriented CBT produced a marked improvement in overall functioning as well as symptom reduction in patients diagnosed with schizophrenia. This study suggests that by focusing on targeted goals such as independent living, securing employment, and improving social relationships, patients were able to slowly move closer to these targeted goals. By also including a variety of CBT strategies such as role-playing, scheduling community outings, and addressing negative cognitions, individuals were also able to address cognitive and social skill deficits.
Family Interventions
Family interventions have been largely influenced by the diathesis-stress model of schizophrenia. As previously discussed, the emergence of the disorder and/or exacerbation of symptoms is likely related to environmental stressors and psychological factors. While the degree in which environmental stress stimulates an exacerbation of symptoms varies among individuals, there is significant evidence to conclude that overall stress does impact illness presentation (Haddock & Spaulding, 2011). Therefore, the overall goal of family interventions is to reduce the stress on the individual that is likely to elicit onset of symptoms.
Unlike many other psychological interventions, there is not a specific outline for family based interventions related to schizophrenia. However, a majority of the programs include the following components: psychoeducation, problem-solving skills, and cognitive-behavioral therapy.
Psychoeducation is important for both the patient and family members as it is reported that more than half of those recovering from a psychotic episode reside with their family (Haddock & Spaulding, 2011). Therefore, educating families on the course of the illness, as well as ways to recognize onset of psychotic symptoms is important to ensure optimal recovery.
Problem-solving is a very important component in the family intervention model. Seeing as family conflict can increase stress within the home, which in return can lead to exacerbation of psychotic symptoms, family members benefit from learning effective methods of problem-solving to address family conflicts. Additionally, teaching positive coping strategies for dealing with the symptoms of a mental illness and its direct effect on the family environment may also alleviate some conflict within the home
The third component, CBT, is similar to that described above. The goal of family based CBT is to reduce negativity among family member interactions, as well as help family members adjust to living with someone with psychotic symptoms. These three components within the family intervention program have been shown to reduce re-hospitalization rates, as well as slow the worsening of schizophrenia related symptoms (Pitschel-Walz, Leucht, Baumi, Kissling, & Engel, 2001).
Social Skills Training
Given the poor interpersonal functioning among individuals with schizophrenia, social skills training is another type of treatment that is commonly suggested to improve psychosocial functioning. Research has indicated that poor interpersonal skills not only predate the onset of the disorder, but also remain significant even with management of symptoms via antipsychotic medications. Impaired ability to interact with individuals in a social, occupational, or recreational setting is related to poorer psychological adjustment (Bellack, Morrison, Wixted, & Mueser, 1990). This can lead to greater isolation and poorer social support among individuals with schizophrenia. As previously discussed, social support has been identified as a protective factor of symptom exacerbation, as it buffers psychosocial stressors that are often responsible for exacerbation of symptoms. Learning how to appropriately interact with others (i.e. establish eye contact, engage in reciprocal conversations, etc.) through role play in a group therapy setting is one effective way to teach positive social skills.
Inpatient Hospitalizations
More commonly viewed as community based treatments, inpatient hospitalization programs are essential in stabilizing patients in psychotic episodes. Generally speaking, patients will be treated on an outpatient basis, however, there are times when their symptoms exceed the needs of an outpatient service. Short-term hospitalizations are used to modify antipsychotic medications and implement additional psychological treatments so that a patient can safely return to their home. These hospitalizations generally last for a few weeks as opposed to a long-term treatment option that would last months or years (Craig & Power, 2010).
In addition to short-term hospitalizations, there are also partial hospitalizations where an individual enrolls in a full-day program but returns home for the evening/night. These programs provide individuals with intensive therapy, organized activities, and group therapy programs that enhance social skills training. Research supports the use of partial hospitalizations as individuals enrolled in these programs tend to do better than those who enroll in outpatient care (Bales et al., 2014).
KEY TAKEAWAYS
Cognitive Remediation Therapy (CRT)
A behavioral-training based intervention that aims to improve cognitive processes and psychosocial functioning.
Dopamine
A neurotransmitter in the brain that is thought to play an important role in regulating the function of other neurotransmitters.
Extrapyramidal symptoms (EPS), also known as extrapyramidal side effects (EPSE)
Movement disorders, which include acute and long term symptoms.
Tardive dyskinesia (TD)
Characterized by involuntary, repetitive, and purposeless movements, which may involve chewing motions, cheek puffing, tongue protrusion, and lip pursing.
“Treatment of Schizophrenia” is adapted from Abnormal Psychology by Coursehero, used under CC BY-SA: Attribution-ShareAlike.
