Schizophrenia: Drug Therapy

Drug Therapy

Antipsychotic drugs (drugs used to reduce the intensity of the symptoms) are the most common treatment for schizophrenia. They involve modifying/interfering with the action of neurotransmitters, in order to increase (agonists) or decrease (antagonists) their activity. Medication can be taken as pills, syrups or injections, and may be taken over a short or long-term.

Typical antipsychotics: Developed in the 1950s, for example Chlorpromazine. They act as dopamine antagonists, attempting to reduce dopamine activity. They block dopamine receptors on post-synaptic neurons, meaning that less dopamine is transmitted across the synapse. This has the effect of reducing dopamine production, and reduces positive symptoms such as hallucinations. Drugs such as Chlorpromazine also have a sedative effect, meaning that they calm patients down and reduce anxiety. As the drugs block dopamine activity, they tend to have (sometime severe) side-effects.

Atypical antipsychotics: Developed in the 1970s, as an attempt to find drugs with fewer severe side-effects than typical antipsychotics. An example is Clozapine which is used when other drugs have failed, due to the risk of agranulocytosis (a potentially fatal blood condition). Clozapine acts in a similar way to Chlorpromazine, but also acts on serotonin and glutamate receptors. The effect of this is, as well as reducing positive symptoms, the reduction of depression and anxiety, and the enhancement of mood. It is therefore prescribed when the patient is at risk of suicide.

Risperidone is another atypical antipsychotic, and is designed to be as effective as Clozapine without the risky side-effects. It binds to dopamine receptors more strongly than Clozapine, and there is some evidence that it produces fewer side-effects.

Evaluation:

• Thornley et al (2003) found in a meta-analysis that Chlorpromazine was associated with better functioning and reduced symptom severity than placebos, supporting that the drug does have a positive effect on schizophrenia patients.
• Melzer (2012) concluded that Clozapine is effective in 30-50% of cases where other drugs have failed, supporting its use in schizophrenia treatment.
• Antipsychotic drugs are weakened by the fact that they have severe side-effects. For example, some patients on typical antipsychotics develop tardive dyskinesia- a condition where there are uncontrollable facial tics. Even after stopping the use of the drug, this condition can persist. Other side effects are potentially fatal, for example agranulocytosis and neuroleptic malignant syndrome (NMS). Side effects are less severe where patients are taking a reduced dose, as many do today, but this can reduce the effectiveness of the drug as well. The severity of the side-effects is a weakness as patients will be reluctant to take them, or may even die as a result of the effect.

Cognitive Behaviour Therapy

The basic assumption of CBT is that people often have distorted beliefs which influence their behaviour in maladaptive ways. In CBT, schizophrenia patients are encouraged to trace back the origins of their symptoms in order to get a better idea of how the symptoms might have developed. They are also encouraged to evaluate the content of their delusions or of any internal voices they hear and to consider ways in which they might test the validity of their faulty beliefs. Therapists may use logical (does it make sense?), empirical (where is the evidence?) and pragmatic (how is the belief helpful?) disputing techniques. Having attempted to dispute faulty beliefs, patients may also be set behavioural assignments with the aim of improving their general level of functioning. During CBT, the therapist lets the patient develop their own alternatives to previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in the patient’s mind. Once the patient has had several sessions (often between 5 and 20), they should be able to recognise the fact that their beliefs are not based on reality.

Evaluation:

• Jauhar et al (2014) found in a meta-analysis that CBT had an effect on positive and negative symptoms. This effect was significant, but quite small. This is therefore moderate support for the effectiveness of CBT in treating schizophrenia.
• CBT may involve challenging the validity of beliefs, which may interfere with freedom of thought. For example, trying to persuade an individual that the government is not watching or monitoring them in any way may interfere with their (possibly justifiable) fear of an over-controlling government. Therefore, CBT has potential ethical issues
• Just challenging the dysfunctional thoughts through disputing may not be enough to change them if the thoughts have a biological basis. CBT is rarely used without drug therapy, suggesting it is not enough on its own to treat schizophrenia.

Family Therapy

Family therapy is based on the theory that schizophrenia is associated with schizophrenogenic mothers, double bind communication, expressed emotion, or other dysfunction in the family. The aim in modern forms of this therapy is to reduce the stress in the family environment so preventing relapse. Pharoah et al (2010) suggest that the following techniques, in which all of the family are involved, are used:

• A co-operative, trusting relationship with the family is established
• Therapist provides information about schizophrenia
• Family members contribute, all contributions valued
• Reducing anger and guilt
• Family is provided with practical coping skills to help deal with the disorder (to anticipate and solve problems)
• More constructive ways of interaction and communication encouraged (to avoid expressed emotion)
• Training to detect any signs of relapse in the patient

Evaluation:

• Pharoah et al (2010) found that there is moderate evidence to show that family therapy reduces relapse rates and hospital readmissions in schizophrenia patients, but there were variances in the quality of research studies used. Therefore, there is (weak) research support for family therapy.
• Family therapies may improve the quality of life for schizophrenia patients and their families, but do not provide a cure for schizophrenia, rather a management of the effects. This means it cannot be used to treat schizophrenia by itself.
• Family therapy is based on the premise that nurture (upbringing) is a significant factor in schizophrenia. The biological basis for schizophrenia is therefore not addressed at all in the therapy, limiting its use.

Token Economies

This is a behavioural treatment for schizophrenia, based on operant conditioning (learning through reinforcement). In a token economy, tokens are given to reward people in psychiatric institutions for performing socially desirable behaviours, the aim being to encourage self-care.

Tokens are secondary reinforcers, which are exchanged for rewards (primary reinforcers), for example food, being allowed to watch a film, and so on. Ayllon and Azrin (1968) set up a token economy with schizophrenic patients in a psychiatric institution. Patients went from performing 5 chores a day to around 40. This helps improve the quality of life for schizophrenia sufferers.

Evaluation:

• McMonagle and Sultana (2009) found in a meta-analysis of 110 studies, that only 3 had used random allocation (where a true comparison was available with an experimental and control group). Of these, only 1 study showed improvement in symptoms and behavioural change in patients. Therefore, the evidence supporting token economies is very weak.
• Token economies raise ethical issues. The patients with the most severe symptoms are unable to access the tokens, as they are unable to perform the desirable behaviours. They are effectively discriminated against (in this case, denied rewards) for being more severely ill. The legality of this has been challenged, and the use of token economies has declined as a result.
• Token economies are only likely to work in a clinical setting, where patients can be constantly monitored and the system of rewards is closely controlled. This limits the usefulness of token economies in treating schizophrenia.

Brandon has recently been diagnosed with schizophrenia due to very severe symptoms of hallucinations and delusions. His psychiatrist suggests that he be given drug therapy to treat the condition. Brandon is nervous about taking drugs and asks about what other treatments are available. What advice should Brandon’s psychiatrist give him about possible treatments for his schizophrenia? (6 marks - 2-3 paragraphs)

Your answer should include: Severity / Symptoms / Side / Effects / Monitored / Therapy

The Interactionist Approach to Schizophrenia

Interactionist approaches attempt to explain schizophrenia as a combination of nature (biological) and nurture (environmental) factors.

Diathesis-stress model: Meehl (1962) originally proposed that both a vulnerability to schizophrenia and a stress-trigger are necessary in order to develop the condition. Meehl suggested that the vulnerability is genetic (the result of a ‘schizogene’), causing a sensitive personality. Chronic environmental stress, for example having a schizophrenogenic mother, results in the onset of schizophrenia. Those who do not have the ‘schizogene’ would not develop schizophrenia, even if they experienced a chronically stressful upbringing. Both aspect of diathesis-stress must be present to develop the disorder.

The modern understanding of diathesis-stress is slightly different. It is now recognised that the vulnerability could be genetic or __environmental (for example, a traumatic event in early childhood). The stress-trigger could be environmental __or biological (for example, smoking cannabis is linked with schizophrenia).

Treatment: In an interactionist approach, treatments will take more than one form. Antipsychotic medication will often be used alongside CBT, acknowledging the role that biological and psychological factors play in the disorder. Combining treatments is most common in the UK, although it is also sometimes used in the USA. Psychological therapies are very rarely used alone, but sometimes patients may just take drugs without any other therapy.

Evaluation:

• Tienari et al (2004) found that children from adopted families who had mothers with schizophrenia were more likely to develop schizophrenia themselves, but only in those whose adopted families were assessed as having a child-rearing style which was critical and lacking in empathy. This supports the diathesis-stress model, as the genetic vulnerability only led to the disorder when combined with an environmental stressor (critical family).
• Tarrier et al (2004) found that patients who were treated with drug therapy and CBT showed lower symptom levels than those only taking drugs, supporting the interactionist approach in explaining schizophrenia.
• There is a lack of understanding and explanation of how the diathesis-stress model works- it is known that both have to be present to lead to schizophrenia, but not how the mechanisms of schizophrenia symptoms develop. This weakens the interactionist explanation.

Approximately what percentage of the world population have schizophrenia?

1%

This is the inability to persist with goal-directed behaviour.

Avolition

The phenomenon of two or more conditions occurring together.

Co-morbidity

These are unusual sensory experiences.

Hallucinations

Gottesman found what concordance rate for schizophrenia in identical twins?

48%

Which brain area is correlated with negative symptoms of schizophrenia?

Your answer should include: Ventral / Striatum

Which psychological explanation of schizophrenia did Fromm-Reichmann propose?

Your answer should include: Schizophrenogenic / Mother

What is an example of a conventional (typical) antipsychotic drug?

Chlorpromazine

What approach is the token economy treatment based on?

Behavioural

Who identified a range of strategies that could be used in family therapy?

Pharoah