8.4 Treatment

Section 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.

8.4.1 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 people and aided in the organization of thoughts. Despite their effectiveness in managing psychotic symptoms, conventional or first-generation antipsychotics (such as Thorazine and Chlorpromazine) also produced significant negative side effects similar to symptoms of neurological disorders. Therefore, psychotic symptoms were replaced with muscle tremors, involuntary movements, and muscle rigidity. Additionally, these conventional antipsychotics also produced tardive dyskinesia, which includes involuntary movements isolated to the tongue, mouth, and face (Tenback et al., 2006). While only 10% of clients reported the development of tardive dyskinesia, this percentage increased the longer they were on these medications, 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 the management of psychotic symptoms not 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 were developed. The atypical antipsychotic drugs appear to act on both dopamine and serotonin receptors, as opposed to only dopamine receptors targeted by conventional antipsychotics. Because of this, common atypical antipsychotic medications such as clozapine (Clozaril), risperidone (Risperdal), and aripiprazole (Abilify), appear to be more effective in managing both the 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 the risk associated with conventional antipsychotics (Leucht, Heres, Kissling, & Davis, 2011). Due to their effectiveness and diminished 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, discontinue 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.

8.4.2 Psychological Interventions

8.4.2.1 Cognitive Behavioral Therapy (CBT)

CBT has been thoroughly discussed in previous chapters and it should be clear that the goal of this 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 their associated behaviors. When used in the context of a schizophrenia spectrum and other psychotic disorders, CBT focuses on the maladaptive emotional and behavioral responses to psychotic experiences, which are 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 in this context include psychoeducation about the disorder, the course of the symptoms (e.g., ways to identify the onset of delusions/hallucinations), challenging and replacing the negative thoughts/behaviors with more positive thoughts/behaviors associated with delusions/hallucinations, and finally, learning positive coping strategies to deal with other 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, 2012) found that recovery-oriented CBT produced a marked improvement in overall functioning as well as symptom reduction in clients diagnosed with schizophrenia. This study suggests that by focusing on targeted goals such as independent living, securing employment, and improving social relationships, individuals 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.

8.4.2.2 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 the relapse 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 three components: psychoeducation, problem-solving skills, and cognitive-behavioral therapy.

Psychoeducation is important for both the client 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 the onset of psychotic symptoms is important to ensure optimal recovery.
Problem-solving is a very important component of the family intervention model. Family conflict can increase stress within the home, which in turn can lead to exacerbation and relapse of psychotic symptoms. As such, family members can benefit from learning effective methods of problem-solving to address family conflicts. Additionally, teaching positive coping strategies for dealing with the symptoms and their direct effects on the family environment may also alleviate some conflict within the home
CBT is similar to that described above. The goal of family-based CBT is to reduce negativity (e.g., expressed emotion) 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).

8.4.2.3 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 pre-date the onset of the disorder but also remain significant even with the management of symptoms via antipsychotic medications. The impaired ability to interact with individuals in social, occupational, or recreational settings 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 against symptom exacerbation, as it buffers psychosocial stressors that are often responsible for the 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.

8.4.2.4 Inpatient Hospitalizations

More commonly viewed as community-based treatments, inpatient hospitalization programs can be essential in stabilizing individuals experiencing acute psychotic episodes. Generally speaking, individuals will be treated on an outpatient basis, however, there are times when their symptoms exceed the needs of outpatient services. Short-term hospitalizations are used to modify antipsychotic medications and implement additional psychological treatments so that the individual can safely return 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. 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).

While a combination of psychopharmacological, psychological, and family interventions is the most effective treatment in managing symptoms of schizophrenia spectrum and other psychotic disorders, rarely do these treatments restore the individual to premorbid levels of functioning (Kurtz, 2015; Penn et al., 2004). Although more recent advancements in treatment for schizophrenia spectrum and other psychotic disorders appear promising, schizophrenia is typically viewed as a disorder that requires lifelong treatment and care.

Chapter Recap

In Chapter 8, we discussed the schizophrenia spectrum and other psychotic disorders including schizophrenia, schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, and delusional disorder. We started by describing the common symptoms of such disorders including delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms. We then identified how the various schizophrenia spectrum and other psychotic disorders are distinguished from one another. This led to our normal discussion of the epidemiology, comorbidity, etiology, and treatment options for these disorders. In our final chapter, we will discuss personality disorders.