Learning Objectives
- Describe psychopharmacological treatment options for schizophrenia spectrum and other psychotic disorders.
- Describe psychological treatment options for schizophrenia spectrum and other psychotic disorders.
- Describe family interventions for schizophrenia spectrum and other psychotic disorders.
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 still viewed as one that requires lifelong treatment and care.
12.5.1. Psychopharmacological
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 the organization of thoughts. Despite their effectiveness in managing psychotic symptoms, conventional antipsychotics (such as Thorazine and Chlorpromazine) also produced significant 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 the 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. If the management of psychotic symptoms cannot be resolved at this level, alternative medications are often added to produce a synergistic effect (Roh et al., 2014).
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 continues 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).
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 the use of antipsychotic drugs (Leucht, Heres, Kissling, & Davis, 2011). Because of this, it is also important to incorporate psychological interventions along with psychopharmacological treatment to both address medication adherence, as well as provide additional support for symptom management.
12.5.2. Psychological Interventions
12.5.2.1.Cognitive Behavioral Therapy (CBT). As discussed in previous chapters, the goal of treatment 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. For 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 and the course of their symptoms (i.e., ways to identify coming and going of delusions/hallucinations), challenging and replacing the negative thoughts/behaviors associated with their delusions/hallucinations to more positive thoughts/behaviors, 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.
12.5.3. Family Interventions
The diathesis-stress model of schizophrenia has primarily influenced family interventions. As previously discussed, the emergence of the disorder and 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 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 the onset of symptoms.
Unlike many other psychological interventions, there is not a specific outline for family-based interventions related to schizophrenia. However, the majority of 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 crucial component in the family intervention model. Seeing as family conflict can increase stress within the home, which in return can lead to worsening 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 mental illness and its direct effect on the family environment may also alleviate some friction 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).
12.5.3.1.Social skills training. Given the poor interpersonal functioning among individuals with schizophrenia, social skills training is another type of treatment 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 the 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 reduced 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 the exacerbation of symptoms. Learning how to interact with others appropriately (e.g., 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.
12.5.3.2.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. 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 enter outpatient care (Bales et al., 2014).
Key Takeaways
You should have learned the following in this section:
- Psychopharmacological treatment options for schizophrenia spectrum disorders include antipsychotic drugs such as Thorazine, Chlorpromazine, Clozaril, Risperdal, and Abilify.
- Psychological treatment options for schizophrenia spectrum disorders include CBT, the goal of which is to improve the interpretations and understandings of symptoms (and experiences) which will reduce associated distress.
- Family interventions for schizophrenia spectrum disorders include psychoeducation, problem-solving skills, cognitive-behavioral therapy (CBT), social skills training, and inpatient/partial hospitalizations.
Review Questions
- Define tardive dyskinesia.
- What pharmacological interventions have been effective in managing schizophrenia related disorder symptoms?
- What is the main goal of family interventions? How is this achieved?
Module Recap
In our first module of Part V – Block 4, we discussed the schizophrenia spectrum and other psychotic disorders to include schizophrenia, schizophreniform disorder, schizoaffective disorder, and delusional disorder. We started by describing their common features, such as delusions, hallucinations, disorganized thinking, disorganized/abnormal motor behavior, and negative symptoms. This led to a discussion of the epidemiology, comorbidity, etiology, and treatment options for the disorders.
