Schizophrenia: Treatments

Biological; Behavioral; Cognitive-Behavioral

Biological1. First-generation Antipsychotics

2. Second-generation Antipsychotics (Also called Atypical)

3. Electroconvulsive Therapy

Conventional Antipsychotic Medication1. Discovered in 1951 in France while attempting to find a

powerful antihistamine2. They bind to dopamine receptors (especially D2

receptors) and block dopamine from entering. Thus, dopaminergic signals are decreased and neurons in the dopamine pathways fire less often.

Conventional Antipsychotics They reduce symptoms of schizophrenic psychosis, especially positive symptoms :

1. delusions, 2. hallucinations, 3. disorganized speech

Thousands of studies have shown that 65-75% of those with schizophrenia are much improved with antipsychotic treatment.

Conventional Antipsychotics: Side Effects

1. “Extrapyramidal Effects” Movement/muscle problems1. Parkinsonian Symptoms: 50% of those taking first generation side

effects experience these: 1. Rigid muscles2. Muscle tremors3. Move slowly, shuffle feet, little facial movement

These symptoms can be treated with L-dopa or by reducing the dose of the antipsychotic medications.

First Generation Antipsychotics: Side Effects

1. Tardive Dyskinesia: 1. Muscle twitches, especially around the mouth and tongue.

2. Involuntary sucking, chewing, lip smacking

3. Sometimes in whole body—arm, leg jerking

4. Symptoms don’t appear until after taking the medication for a year.

5. Sometimes is permanent, even when drug is stopped.

Conventional Antipsychotics Most Commonly Prescribed:

1. Haloperidol

2. Chlorpromazine

Second Generation or Atypical Antipsychotics

The new generation of antipsychotics work differently than the conventional antipsychotics:

Conventional bind to D2 dopamine receptors Atypicals have less affinity to D2 and predominantly bind to D1 and D4 (both dopamine) and serotonin receptors.

Atypical Antipsychotics1. 85% of schizophrenics treated with atypicals show much

improvement. Thus they are more effective than conventionals.

2. Also atypical reduce both positive and negative symptoms of schizophrenia.

3. Also, they are much less likely to produce extrapyramidal effects and tardive dyskenia.

4. BUT….

Atypical Antipsychotics …They can cause major side effects including:

1. Dangerous drop in white blood cells (agranulocytosis)

2. Type II Diabetes

3. Heart attack

4. Stroke

5. Cataract

6. Weight gain

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy is perhaps the most effective treatment for severe depression that is resistant to other treatments.

It is occasionally used for schizophrenic patients who are resistant to treatment.

Not surprisingly, it is also used for cases of schizophrenia which are comorbid (combined with) mood issues such as depression, but also mania.

Finally, it is sometimes used in cases with severe catatonic symptoms. It is used in conjunction (with) antipsychotic drugs)

ECT continued Very short-acting drugs (fifteen minutes) are given to cause a short, drug-induced coma. Then several very short bursts (less than a second) of electric current are sent through electrodes that are attached either to the two temples (bilateral ECT) or to one temple and the forehead (unilateral ECT). This causes seizures.

Usually several treatments will be given over the course of a month or so.

It has proven effective in reducing both mood and psychotic symptoms. However, the results do not seem to last long term and so treatment must be repeated.

ECT continued Side effects. Surprisingly, side effects are not that severe. People may feel confused, dizzy and/or sick when awakening but these side-effects usually disappear within an hor.

Verbal memory is impaired Visual memory may be impaired, though results are not conclusive.

Behavioral Treatment: Token Economy

Token Economy Systems are based on Operant Conditioning (altering behavior with positive and negative consequences; specifically positive and negative reinforcement as well as positive and negative punishments).

It is used in mental hospitals

Token Economy The idea is simple: Do well and get tokens (fake coins) which can be exchanged for privileges such as cigarettes, extra or special food, extra free time or other privileges. Don’t do well and don’t receive tokens.

Behavioral Therapy: Token Economy

What kind of behaviors are rewarded?

1. Speaking coherently

2. Basic hygiene

3. Keeping room and belongings tidy

4. Doing chores

5. Participating in hospital activities

Token Economy: Effectiveness It has been proven effective in reducing psychotic behaviors In some cases, it has proven very effective. Paul and Lentz (1977) ran a token economy in a mental hospital ward with chronic, treatment resistant schizophrenia.

98% if patients improved so much that they could leave the hospital. (With basic hospital care, the percentage is only 45% discharge)

Token Economies: Problems Some say that most studies, including the Paul and Lentz’ study are not controlled. They are therefore not scientific and so the data not reliable.

In the past, some token economies have involved having to earn even basic rights such as food, belongings and a comfortable place to sleep. This has since been deemed unethical and laws have been passed to ensure token economies are based on other privileges than basic rights.

CBT: Sensky et al. (2000) Sensky et al. conducted a trial of CBT on chronic schizophrenic patients who were resistant (did not respond well) to medication. The control group received “befriending” which meant the patients received the same amount of friendly attention from therapists as did the treatment group who received CBT Why was this important?

CBT 90 patients in total Some in control, some in treatment group. 19 sessions of CBT/befriending (BF) given over the course of 9 months.

Both CBT and resulted in significant decrease in positive and negative symptoms of schizophrenia

However, nine months after the end of treatment, the patients were again assessed. Those who had CBT showed sustained improvement while those with befriending lost improvement.

What did the CBT Treatment Include?

There were two basic stages:

1. Creating a foundation for the CBT

2. The actual CBT

CBT Laying the Foundation:

1. Find out how and when symptoms began

2. Helping reduce anxiety and stress about having symptoms

3. Finding typical antecedents of the symptoms (e.g. stress triggers delusions; seeing the camera causes paranoia)

4. Helping patients understand symptoms to be symptoms, not reality.

5. Normalizing (helping patients understand that many others also have schizophrenia). This reduces feelings of hopelessness and isolation

6. Treating anxiety and depression (Probably with medication)

CBT Main Therapy Elements: FOR HALLUCINATIONS

1. Voice Diary (why would this be helpful?)

2. Training to focus on the fact that voices are just hallucinations, not real

3. Teaching patients how to cope with voices, e.g. ignore or talk to others about what they hear.

CBT Main Treatment: FOR DELUSIONS:

1. Using Socratic questioning/reasoning to verify the validity of delusions. “OK, so explain the evidence for believing the CIA has a satellite tracking you.

2. For grandiose delusions, looking for any belief that may lead to the delusion. For example, belief in God, may lead to believing one is a prophet. Point out the difference between believing in God and then deciding one is a prophet.

CBT MAIN TREATMENT FOR DISORGANIZED SPEECH

1. Make patients explain themselves when they don’t make sense

2. Have patients focus on and talk about specific topics and keep prompting them to refocus on the right topic.

CBT MAIN TREATMENT For Disorganized Behavior:

1. Give specific tasks to the patients. For example, they may have to mop the floor

2. For anhedonia (Disinterest in pleasure) and avolition (no motivation) have the patients keep a diary about what gave some level of enjoyment during the day.