TREATMENTS FOR SCHIZOPHRENIA Biological Treatments Shock and Psychosurgery Drug therapies Psychological Treatments Psychodynamic Therapy Family Therapy and Expressed Emotion EE) Behaviour Therapy Cognitive-Behavioural Therapy Milieu Therapy The notes here are a brief summary of the nature of the treatments available, their advantages, disadvantages and their effectiveness. For further detail refer to the loan file from Davison & Neale (1994) on therapies for schizophrenia. Reading from Gross (3 rd Ed.) is given for each therapeutic approach, from Chapter 31 - Treatments and Therapies. It is probably worth reiterating at the outset that there is no cure for schizophrenia, only treatments which help, in varying degrees, to alleviate the positive and or negative symptoms of schizophrenia and to help the patient to function more effectively. Biological treatments 1. Shock and Psychosurgery Insulin Coma Therapy - 1930 s - Coma induced by large doses of insulin. Early claims of success (Sakel, 1938), later findings less encouraging, serious health risks, even death. Gradually abandoned Prefrontal lobotomy - introduced 1935 - early claims of success (Moniz, 1938). Used extensively for 20 yrs. 1950 s also fell into disrepute due to side effects including serious losses in cognitive function, listlessness, even death. Main reason for abandonment - introduction of drugs. (See Gross p.822, Psychosurgery ). Electroconvulsive therapy (ECT) - introduced 1938 - induces seizure followed by unconsciousness. Ineffective for schizophrenia but remains effective for profound depression (See Gross, p. 820) 2. Drug Therapies 1
Neuroleptics/antipsychotics 1950 s - phenothiazine (chlorpromazine is a phenothiazine derivative), thought to block dopamine receptors. Other neuroleptics with similar effectiveness include the butyrophenones (e.g. haloperidol, Haldol), and the thioxanthenes (e.g. navane, Taractan). See Gross, p. 820 Major tranquillizers. Neuroleptics are effective for about 60 % of schizophrenics. These drugs are able to reduce positive symptoms (hallucination, delusion etc.) but have less effect on the negative symptoms of schizophrenia, such as social incompetence. Adjustment to the community may be marginal and readmission is frequent (revolving door pattern of admission, discharge and readmission). There is evidence that the combination of a maintenance programme of drugs combined with social skills training (see below) is effective at preventing relapse. Side effects of phenothiazines - dryness of mouth, blurred vision, grogginess constipation, low blood pressure, jaundice, - difficult to keep patients on medication particularly in the community. More serious side effects, which resemble symptoms of neurological disease include symptoms similar to Parkinson s Disease: tremors in the fingers, muscular rigidity tremors and spasms, shuffling gait and drooling, and tardive dyskinesia ( TD )which affects 25% of all patients who have taken phenothiazines for more than 7 years. TD is irreversible even if the patient stops taking the drugs. It is a movement disorder which involves involuntary facial ticks and grimacing More recent drug - clozapine (Clozaril) - does not appear to reduce symptoms by blocking dopamine receptors and does not produce the severe side effects above. It does however weaken the immune system and can produce seizures. It is very expensive due to the careful monitoring of the patient, GPs on the NHS are therefore reluctant to prescribe it. Conclusion: Despite their disadvantages the phenothiazines are preferable to straitjackets, and remain an indispensable part of treatment for schizophrenia. Drugs do not offer a cure for schizophrenia because symptoms typically recur once drugs are discontinued. Many clinicians believe that chemical imbalances in the brain are the result not the cause of abnormal functioning. If this is the case it can be claimed that drugs are treating the symptoms not the cause. In some cases side effects are so severe it is questionable whether the treatment outweighs the advantages. Overall they are preferred by clinicians because they are fast-acting and cheaper than talk therapies. Psychological Treatments 2
Psychodynamic therapy Freud believed that schizophrenics were unable to develop the close interpersonal relationship with the therapist necessary for analysis. Adaptations to psychodynamic therapy were made however, by Sullivan, who suggested that the schizophrenic has a very fragile ego and has regressed to early childhood forms of communication due to the extreme stress of interpersonal challenges. Therapy requires the patient to learn adult forms of communication and achieve insight in to role that the past has played in current problems. This has been referred to as an ego-analytical approach. Great success was claimed by Sullivan (from the 1920s) and Freida Fromm-Reichmann (1889-1957). However, analysis suggests that their patients were only mildly disturbed and may not have been diagnosed as schizophrenic using DSM IV criteria. More recent research showed little success - Long term, follow-up data from half the sample of more than 500 schizophrenic patients discharged after treatment between 1963 and 1976 in New York, showed that the patients were doing poorly (Stone, 1986). Stone suggests that psychoanalytic insight may worsen the condition. Family therapy and expressed emotion (EE) This approach attempts to reduce the likelihood of relapse after the patients have returned home. High levels of EE (critical comments, hostility, emotional over involvement), have been linked with relapse and reinstitutionalisation (Brown et al., 1966;Koenisberg & Hadley, 1986). Family treatments aim to calm the home life of the family, reducing turmoil in the home. Sessions may take place in the family home. Family members are instructed in ways to express both negative and positive feelings in a constructive, empathic manner and to defuse tense personal conflicts through collaborative problem solving.. (Davison and Neale, 1994) Fallon et al (1982, 1985), attempted to lower EE in households to which schizophrenics were discharged, through cognitive and behavioural means (see handout for details) The family therapy group fared much better than the control group. Far fewer relapsed and far fewer had to be rehospitalised. Hogarty et al (1986), carried out a larger study and found that teaching the patient social skills e.g. handling conflict and abstaining from behaviour which might increase high EE reactions in their family, resulted in low relapse after one year, similar to the Fallon study. But after 2 years relapse rates were the same between groups. There were no real improvements in the patients ability to adjust to real-life and become fully functioning members of society. In conclusion, the family approach to therapy does appear to be effective in reducing the rate of relapse, although these gains are not sustained. 3
Behaviour Therapy and Behaviour Modification (See Gross p.826 for the distinction between the two!) Social skills training A2 Module 4-13.7.2 Schizophrenia Social Skills training as a means of reducing EE is generally viewed as a form of behavioural therapy. Social Skills Training (SST), originates from Dollard and Millers Social Learning Theory. Clients are exposed to models upon which to base their own behaviour (e.g. assertiveness training). They are encouraged to role play potentially difficult situations and receive feedback (reinforcement) on their performance. Token Economies Token economies are behaviour modification programmes based on Skinner s ideas about operant conditioning. In therapeutic settings patients are given tokens for positive behaviours which can then be exchanged for privileges such as cigarettes, days out or watching TV. The tokens act as secondary reinforcers. (See Gross p831-833, incl. p. 832, Box 31.3) Milieu Therapy A residential treatment programme in which the entire hospital becomes a therapeutic community (Jones, 1953), which enables the patient to cope with life outside the institution. Also provides a better quality of life while remaining hospitalised. Patients are given responsibilities and kept active, encouraged to make decisions and to take part in hospital life rather than the passive role traditionally associated with institutional living (See Gross, p.832, Box 31.3). KEY STUDY: Paul and Lentz (1977) (see Gross p.832, Box 31.3), conducted a study of 84 patients who were randomly assigned to either: 1. Social learning/token economy(te); 2. Milieu therapy; or 3. Custodial care (routine hospital management). Results: Social learning/token economy and Milieu therapy: Both reduced some symptoms with better results for TE on several measures such as bizarre motor behaviours such as rocking and blank staring. Both successful with interpersonal skills, instrumental role performance (vocational and housekeeping) and self-care skills. Neither were effective for cognitive symptoms such as delusions and hallucinations, nor hostile behaviour such as screaming and cursing. 4
Percentage of those released to live independently from each treatment group (Paul; and Lentz, 1977) TE Milieu Custodial care over 10% 7% 0 % About 90 % of all the patients in all the groups were receiving neuroleptics at the beginning of treatment. This figure reduced to 11 % for TE and 18 % for Milieu therapy, whilst the figure for custodial care increased to 100%. For further discussion and evaluation of this study and token economies etc., see Gross 3 rd Ed p 832-834. See also handout from Davison and Neale - The Mental Hospital Today Evaluation cont. Although social skills training has little influence on the primary symptoms of schizophrenia, it is effective in developing abilities such as improved communication and self-help skills. As with social skills training, no impact on the primary symptoms, although it can be effective in improving personal hygiene etc. Unfortunately it is difficult to sustain positive behaviours outside the therapeutic setting and there is a high re-hospitalisation rate for these patients. Milieu therapies can be harmful if the environment is overstimulating e.g. lively group discussions encouraging emotional exploration of self and others (Davison and Neale, 1994). At present it is generally accepted that therapy programmes with a learning framework are the most effective for helping schizophrenics to function better. Such programmes do not attempt to cure but to help patients to fit in with the social world better, and to reduce inappropriate behaviours (e.g. hoarding towels). They seem to be quite effective at this although it is questionable whether this is to do with the actual programme or the increase contact and involvement with clinical staff which results from it. They help to reverse the effects of institutionalisation and fostering social skills such as assertiveness in people who have been reinforced by hospital staff for passiveness and compliance (Davison and Neale, 1994) There is also the possibility that token economies are there for the benefit of the staff (making the patients more manageable) rather than the patients, which begs a few questions about therapeutic goals. Cognitive-Behavioural Therapy 5
CBT has largely been developed and employed to treat depression and has largely been seen as inappropriate for schizophrenia. In combination with neuroleptic drugs however, some benefits may be found. The major assumptions of cognitive therapists is that when thoughts are persistently negative and irrational they can develop into emotional and behavioural disturbance. CBT is active and directive, aiming to identify and correct the negative and irrational thoughts leading to emotional and behavioural problems. Each session contains a cognitive and behavioural element Cognitive - therapist encourages the client to become aware of their own irrational thought processes and the way in which these lead to problems in living. The clients beliefs about the world are not challenged directly but treated as hypotheses about the world which can be tested empirically. Behavioural - therapist and client decide ways in which these hypotheses can be tested out through experimentation. This can be done through role-playing during the session or through homework assignments between sessions. The aim is that the client will test out their assumptions about the world and come to recognise their irrational beliefs by looking at the consequences of behaving in particular ways. Progress is gradual and clear goals are set so that therapeutic progress can be easily assessed. For further detail about CBT see Gross p. 834-835 CBT is very effective for patients who find insight/emotion based therapies threatening. They are subject to criticism that they treat symptoms not causes but are good in that they attempt to empower the client to correct their own behaviour. It is clearly structured and has clear goals, making progress easy to evaluate. It seems to be most effective with clients who have reasonable insight and good problem solving skills. For this reason it has not been seen as appropriate for psychotic patients (Ellis, 1980). However recent studies (e.g. Haddock and Slade, 1996; Kingdon and Turkingdon, 1994) suggest that in combination with anti-psychotic drugs it can reduce the pervasive nature of delusions (through reality testing) and reduce the disturbing nature of auditory hallucinations (through reattribution and normalising strategies). Thus CBT does not represent a cure for schizophrenia but can be used to provide a set of coping strategies which make it easier to live with. Institutionalisation and care in the community These are not really treatments or therapies as such, but strategies or approaches to the care and management of patients. The issues are highly emotive, topical, controversial and political in nature. The examination board expects you to have an awareness of these issues and the main evaluative points for both approaches. Reading on Institutionalisation and Community Care - Handouts Focus 1.2 The Mental Hospital Today from Abnormal Psychology by Davison and Neale (1994) - focuses on American institutions. News Articles relevant to care in the community and institutional care, incl. Positive Thoughts for Negative Minds, and Doing it by halves from the Guardian. SAQs 6
June 2005 A2 Module 4-13.7.2 Schizophrenia 7 (a) Archie spends hours in the same position, apparently unaware of what is going on around him. Occasionally, he will become extremely agitated and have brief periods of excitable and exaggerated movement before returning to his immobile state. Viv is convinced that there are people under the floorboards in her house and that they are listening to everything she says and does. Sometimes she can hear them talking about her and how they will hurt her when she is asleep at night. With reference to the two cases above, outline what is meant by classification of schizophrenia. (4 marks) (b) (c) Briefly discuss the family dysfunction explanation of schizophrenia (4 marks) Describe and discuss at least one biological explanation of schizophrenia. Refer to empirical evidence in your answer. (12 marks) January 2005 7 (a) From the point of view of patients suffering from schizophrenia, outline one advantage and one limitation of community care. (4 marks) (b) Briefly discuss one problem with the psychodynamic approach to schizophrenia (4 marks) January 2004 7 (c) Discuss one biological treatment for schizophrenia, such as drug therapy. (12 marks) June 2003 7 (c) Describe and discuss one socio-cultural explanation for schizophrenia. Refer to empirical evidence in your answer. (12 marks) January 2003 7 (a) Identify three symptoms used in the diagnosis of schizophrenia. (3 marks) (b) Outline and briefly discuss one socio-cultural explanation of schizophrenia. (5 marks) June 2002 7 (b) Outline and explain one problem involved in the classification of schizophrenia. Refer to psychological evidence in your answer. (4 marks) (c) Discuss one explanation for schizophrenia. Refer to psychological evidence in your answer. (12 marks) 7
Further Reading A2 Module 4-13.7.2 Schizophrenia. Brewer, K. (2001) Clinical Psychology. Oxford, Heinemann. Chapter 3, p.53 Gross, R (various editions) Psychology: The Science of Mind and Behaviour. London, Hodder & Stoughton. Chapter on Psychopathology. Turner, L. (2003) Advanced Psychology: Atypical Behaviour. London, Hodder and Stoughton. Chapter 3, p.70. Useful Websites http://www.mentalhealth.org.uk http://www.sane.org.uk http://www.rcpsych.ac.uk http://www.rethink.org The Mental Health Foundation SANE The Royal College of Psychiatrists Rethink mental illness (formerly known as The National Schizophrenia Foundation) 8