PSY360: Abnormal Psychology-4th week
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Lecture10TreatmentsforSchizophrenia....pdf
Treatments for schizophrenia and other severe
mental disorders
Dr. Sumaira Khurshid Tahira
Associate prof
NNU,China
How is schizophrenia treated?
For much of human history, people with schizophrenia and other severe
mental disorders were considered beyond help
Though schizophrenia is still extremely difficult to treat, the discovery of
antipsychotic drugs has enabled people with the disorder to think clearly
and profit from psychotherapies
Each of the models offers treatments for schizophrenia, and all have been
influential at one time or another
Institutional care in the past
For more than half of the 20th century, people with schizophrenia were
institutionalized in public mental hospitals
Because patients failed to respond to traditional therapies, the primary
goals of the hospitals were to restrain them and give them food, shelter,
and clothing
Institutional care in the past
The move toward institutionalization began in 1793 with the practice of
“moral treatment”
Hospitals were located in isolated areas to protect patients from the
stresses of daily life and to offer them a healthful psychological
environment
Institutional care in the past
States throughout the U.S. were required by law to establish public mental institutions (state hospitals) for patients who could not afford private care
Unfortunately, problems with overcrowding, understaffing, and poor patient outcomes led to loss of individual care and the creation of “back wards”
Patients were transferred to back wards, or chronic wards, if they failed to improve quickly (Bloom, 1984). Most of the patients on these wards suffered from schizophrenia (Häfner & an der Heiden, 1988).
The back wards were human warehouses filled with hopelessness. Staff members relied on straitjackets and handcuffs to deal with difficult patients.
Institutional care in the past
Many patients not only failed to improve under these conditions but
developed additional symptoms, apparently as a result of the
institutionalization itself
The most common pattern of decline was called the social breakdown
syndrome, which involved:
Extreme withdrawal, anger, and physical aggressiveness
Loss of interest in personal appearance and functioning
Institutional care takes a turn for the better
In the 1950s, clinicians developed two institutional approaches that
brought some hope to chronic patients:
milieu therapy
Based on humanistic principles
Token economies
Based on behavioral principles
These approaches particularly helped improve the personal care and self-
image of patients, problem areas that were worsened by
institutionalization
Institutional care takes a turn for the better
Milieu therapy
• The premise is that institutions can help patients make clinical progress by creating a social climate (“milieu”) that promotes productive activity, self-respect, and individual responsibility
• Milieu-style programs have been set up in institutions throughout the Western world with moderate success
• Research has shown that patients with schizophrenia in milieu programs often leave the hospital at higher rates than patients receiving custodial care
Institutional care takes a turn for the better
The token economy
• Based on operant conditioning principles, token economies are used in institutions to change the behavior of patients with schizophrenia
• Patients are rewarded when they behave in socially acceptable ways and are not rewarded when they behave unacceptably
• Immediate rewards are tokens that can later be exchanged for food, cigarettes, privileges, and other desirable objects
• Acceptable behaviors likely to be targeted include care for oneself and one's possessions, going to a work program, speaking normally, following ward rules, and showing self-control
Institutional care takes a turn for the better
The token economy
• Researchers have found that token economies help reduce psychotic and related behavior
• However, questions have been raised about such programs:
• Many research studies have been uncontrolled; instead of patients being randomly assigned to groups, a whole ward will participate in the program
Institutional care takes a turn for the better
The token economy
• Questions have been raised about such programs:
• Are such programs truly effective? For example, patients may change overt behaviors but not underlying psychotic beliefs
• Transitioning from a token economy system to community living may be difficult for patients
Institutional care takes a turn for the better
Milieu therapy and token economies have helped improve the personal
care and self-image of patients, problem areas worsened by
institutionalization
They are still used in many mental hospitals, usually along with
medication
This approach has also been applied to other clinical problems
Antipsychotic drugs
While milieu therapy and token economies helped improve treatment
outcomes, it was the discovery of antipsychotic drugs in the 1950s that
revolutionized treatment for those suffering from schizophrenia
Antipsychotic drugs
The discovery of antipsychotic medications dates back to the 1940s,
when researchers developed antihistamine drugs for allergies
It was discovered that one group of antihistamines, phenothiazines, could
be used to calm patients about to undergo surgery
Psychiatrists tested one of the drugs, chlorpromazine, on 6 patients
with psychosis and observed a sharp reduction in their symptoms
In 1954, chlorpromazine (under the trade name Thorazine) was
approved for sale in the U.S. as an antipsychotic drug
Antipsychotic drugs
Since the discovery of the phenothiazines, other kinds of antipsychotic
drugs have been developed
Those developed throughout the 1960s, 1970s, and 1980s are now
referred to as “conventional” antipsychotic drugs
These drugs are also known as neuroleptic drugs, because they often
produce undesired movement effects similar to symptoms of
neurological diseases
Drugs developed in recent years are known as “ atypical ” or “second-generation” antipsychotics
How effective are antipsychotic drugs?
Research has shown that antipsychotic drugs reduce schizophrenia
symptoms in at least 65% of patients
In direct comparisons, drugs appear to be more effective than any other
approach used alone
In most cases, the drugs produce the maximum level of improvement
within the first six months of treatment
Symptoms may return if patients stop taking the drugs too soon
How effective are antipsychotic drugs?
Antipsychotic drugs, particularly the conventional ones, reduce the positive symptoms of schizophrenia more completely, or at least more quickly, than the negative symptoms
Correspondingly, people who display largely positive symptoms generally have better rates of recovery than those with primarily negative symptoms
Although the use of such drugs is now widely accepted, patients often dislike the powerful effects of the drugs, and some refuse to take them
Unwanted effects of conventional antipsychotic
drugs
In addition to reducing psychotic symptoms, conventional antipsychotic
drugs sometimes produce disturbing movement problems
These are called “extrapyramidal effects” because they appear to be caused by the drugs' impact on the extrapyramidal areas of the brain
Unwanted effects of conventional antipsychotic
drugs
The most common of these effects produce Parkinsonian symptoms,
reactions that closely resemble features of the neurological disorder
Parkinson's disease, including:
Muscle tremor and rigidity
Bizarre movements of the face, neck, tongue, and back
Great restlessness, agitation, and discomfort in the limbs
Unwanted effects of conventional antipsychotic
drugs
The Parkinsonian and related symptoms seem to be the result of
medication-induced reductions of dopamine activity in the basal ganglia
and substantia nigra, parts of the brain that coordinate movement and
posture
In most cases, the symptoms can be reversed if an anti-Parkinsonian drug
is taken along with the antipsychotic
Sometimes the dosage must be decreased or the medication must be
halted altogether
Unwanted effects of conventional antipsychotic
drugs
In as many as 1% of patients, particularly elderly ones, conventional
antipsychotic drugs produce neuroleptic malignant syndrome – a severe,
potentially fatal reaction
Symptoms include muscle rigidity, fever, altered consciousness, and
improper functioning of the autonomic nervous system
As soon as the syndrome is recognized, drug use is discontinued and each
symptom is treated medically
Individuals may also be given dopamine-enhancing drugs
Unwanted effects of conventional antipsychotic
drugs
A more difficult side effect of conventional antipsychotic drugs appears
up to 1 year after starting the medication
This reaction, called tardive dyskinesia, involves writhing or tic-like
involuntary movements, usually of the mouth, lips, tongue, legs, or body
It affects more than 10% of those taking the drugs
Tardive dyskinesia can be difficult, sometimes impossible, to eliminate
Unwanted effects of conventional antipsychotic
drugs
Since learning of the unwanted side effects of conventional antipsychotic
drugs, clinicians have become more careful in their prescription practices
They try to prescribe the lowest effective dose
They gradually reduce or stop medication weeks or months after the
patient begins functioning normally
Newer antipsychotic drugs
In recent years, new antipsychotic drugs have been developed
Examples: Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, and Abilify
Newer antipsychotic drugs
These new drugs are called “atypical” because their biological operation differs from that of conventional antipsychotics
They appear more effective than conventional antipsychotic drugs, especially for negative symptoms
They cause few extrapyramidal side effects and seem less likely to case tardive dyskinesia
They do, however, carry a risk of agranulocytosis, a life-threatening drop in white blood cells
They also may cause weight gain, dizziness, and significant elevations in blood sugar
Psychotherapy
Before the discovery of antipsychotic drugs, psychotherapy was not an
option for people with schizophrenia
Most were too far removed from reality to profit from psychotherapy
Psychotherapy
Today, psychotherapy is successful in many more cases of schizophrenia
The most helpful forms of psychotherapy include cognitive-behavioral
therapy and two broader sociocultural therapies: family therapy and
social therapy
These approaches are often combined
Psychotherapy
Cognitive-behavioral therapy
• An increasing number of clinicians employ techniques that seek to change how individuals view and react to their hallucinatory experiences, including:
• Provide education and evidence of the biological causes of hallucinations
• Help clients learn about the “comings and goings” of their own hallucinations and delusions
• Challenge clients' inaccurate ideas about the power of their hallucinations
Psychotherapy
Cognitive-behavioral therapy
• Teach clients to reattribute and more accurately interpret their hallucinations
• Teach techniques for coping with their unpleasant sensations
Psychotherapy
Cognitive-behavioral therapy
• New-wave cognitive-behavioral therapies also help clients to accept their streams of problematic thoughts
• These techniques help patients gain a greater sense of control, become more functional, and move forward in life
• Studies indicate that these various techniques are often very helpful
Psychotherapy
Family therapy
• Over 50% of persons recovering from schizophrenia and other severe disorder live with family members
• This creates significant family stress
• Those who live with relatives who display high levels of expressed emotion are at greater risk for relapse than those who live with more positive or supportive families
PSYCHOTHERAPY
Family therapy
• Family therapy attempts to address such issues, create more realistic expectations, and provide psycho-education about the disorder
• Families may also turn to family support groups and family psycho-education programs
• Although research has yet to determine the usefulness of these groups, the approach has become popular
Psychotherapy
Social Therapy
• Many clinicians believe that the treatment of people with schizophrenia should include techniques that address social and personal difficulties in the clients' lives
• These include: practical advice, problem solving, decision making, social skills training, medication management, employment counseling, financial assistance, and housing
• Research finds that this approach reduces rehospitalization
The community approach
The community approach is the broadest approach for the
treatment of schizophrenia and other severe mental disorders
In 1963, Congress passed the Community Mental Health Act,
which said that patients should be able to receive care within
their own communities, rather than being transported to
institutions far from home
This Act led to massive deinstitutionalization of patients with
schizophrenia
The community approach
Unfortunately, community care was (and is) inadequate for their care
The result is a “revolving door” syndrome
Revolving door syndrome refers to the tendency of clients to get better
for a while, and then end up relapsing
What are the features of effective community care?
People recovering from schizophrenia and other severe disorders need
medication, psychotherapy, help in handling daily pressures and
responsibilities, guidance in making decisions, training in social skills,
residential supervision, and vocational counseling
This combination of services sometimes is called assertive community
treatment
What are the features of effective community care?
Coordinated services
Community mental health centers provide medications, psychotherapy, and inpatient
emergency care
Coordination of services is especially important for mentally ill chemical abusers
(MICAs) mentally ill chemical abusers
Short-term hospitalization
If treatment on an outpatient basis is unsuccessful, patients may be transferred to short-
term hospital programs
After being hospitalized for up to a few weeks, patients are released to aftercare programs
for follow-up in the community
What are the features of effective community care?
Partial hospitalization
If patient needs fall between full hospitalization and outpatient care, day
center programs may be effective
These programs provide daily supervised activities and programs to
improve social skills
Another kind of institution that has become popular is the semihospital,
or residential crisis center – houses or other structures in the community
that provide 24-hour nursing care for those with severe mental disorders
What are the features of effective community care?
Supervised residences
Halfway houses (or group homes) provide shelter and supervision for
those patients who are unable to live alone or with their families, but who
do not require hospitalization
Staff are usually paraprofessionals (lay people who receive training and
ongoing supervision from outside mental health professionals)
Houses are run with a milieu therapy philosophy
These programs help those with schizophrenia adjust to community life
and avoid rehospitalization
What are the features of effective community care?
Occupational training and support
Paid employment provides income, independence, self-respect, and the
stimulation of working with others
Many people recovering from schizophrenia receive occupational training
in a sheltered workshop – a supervised workplace for employees who are
not ready for competitive or complicated jobs
An alternative work opportunity for individuals with severe disorders is
supported employment
How has community treatment failed?
There is no doubt that effective community programs can help people
with schizophrenia and other severe mental disorders recover
However, fewer than half of all people who need them receive
appropriate community mental health services
In any given year, 40% to 60% of all people with schizophrenia receive
no treatment at all
Two factors are primarily responsible:
Poor coordination of services
Shortage of services
How has community treatment failed?
Poor coordination of services
Mental health agencies in a community often fail to communicate with
one another
To combat this problem, a growing number of community therapists have
become case managers for people suffering from schizophrenia
Case managers offer therapy and advice, teach problem-solving and
social skills, and ensure compliance with medications
Case managers also try to coordinate available community services for
their clients, guide them through the system and protect their legal rights
How has community treatment failed?
Shortage of services
The number of community programs available to people with
schizophrenia falls woefully short
The centers that do exist generally fail to provide adequate services for
people with severe disorders
While there are various reasons for these shortages, the primary one is
economic
What are the consequences of inadequate
community treatment?
When community treatment fails, many people suffering from
schizophrenia and other severe mental disorders receive no treatment at
all
Many return to their families and receive medication and perhaps
emotional and financial support, but little else in the way of treatment
What are the consequences of inadequate
community treatment?
Around 8% of patients enter an alternative care facility (such as a nursing
home), where they receive custodial care and medication
As many as 18% are placed in privately run residences where supervision
is provided by untrained individuals
Another 34% of patients are placed in single-room occupancy hotels,
generally in rundown environments, where they survive on government
disability payments
What are the consequences of inadequate
community treatment?
Finally, a great number of people suffering from schizophrenia become
homeless
Approximately one-third of the homeless people in America have a
severe mental disorder, commonly schizophrenia
The promise of community treatment
Despite these very serious problems, proper community care has shown
great potential for assisting in recovery from schizophrenia
In addition, a number of national interest groups, including the National
Alliance on Mental Illness (NAMI), have formed to push for better
community treatment
The promise of community treatment
Today, community care is a major feature of treatment for people
recovering from severe mental disorders in countries around the world
Both in the U.S. and abroad, varied and wellcoordinated community
treatment is seen as an important part of the solution to the problem of
schizophrenia
“Alternative” mental health care
Experts say U.S. prisons and jails have become the country’s largest
mental health institutions, its new asylums.
Nearly four times more Californians with serious mental illnesses
are housed in jails and prisons than in hospitals
16 to 20 percent of prisoners are mentally ill
