Treatment and Therapies for Schizophrenia

Common Treatments for Schizophrenia

Common treatments for schizophrenia vary but typically fall into two categories; a biological approach to treatment and a psychological approach to treatment.

Modern Treatments for Schizophrenia

Modern forms of treatment tend to integrate the two approaches to address biological causes of schizophrenia and psychological causes of schizophrenia.

Biological Treatments for Schizophrenia

Biological therapies and treatment plans focus on drugs and medications to treat schizophrenia. Antipsychotic drugs are used in the cases of schizophrenia primarily.

Typical Antipsychotics

Typical antipsychotics are the first generation of antipsychotic drug therapy. Developed in the 1950s, they are known for treating positive symptoms. Since the advent of atypical antipsychotics, they have lost favour, as they have side effects some patients consider too severe to continue treatment consistently. Whether or not they are an outdated treatment or the more modern atypical antipsychotic drugs are better is still up for debate, however.

Typical antipsychotic drugs include:

• Chlorpromazine

• Haloperidol

They work by affecting the dopamine receptors (D2) in the mesolimbic pathway in the brain primarily (this is the reward centre) but also affect the rest of the brain unintentionally. They’re known as dopamine antagonists, as they block D2 receptors and calm the dopamine system in the brain.

Positive symptoms of schizophrenia result from the increased subcortical dopamine release in the brain, possibly due to a defect in the cortical pathway through the nucleus accumbens (Brisch et al., 2014).

By targeting the dopamine system in the brain (the dopamine hypothesis) and blocking the receptors, typical antipsychotics reduce the stimulation that would be caused by any initial dopamine release, reducing positive symptom occurrence.

Fig. 2 - Typical and atypical antipsychotic drugs target the main dopaminergic pathways of the human brain¹.

Side effects of typical antipsychotics include:

• Tardive Dyskinesia (uncontrollable muscle movements usually affecting the face).

• Akathisia (uncomfortable restlessness).

• Dry mouth.

• Constipation.

Atypical Antipsychotics

Atypical antipsychotics were developed in an attempt to address the side effects of typical antipsychotics.

Examples of atypical antipsychotic drugs include:

• Clozapine.

• Olanzapine.

Atypical antipsychotics affect dopamine receptors in the limbic system. However, they do not affect the rest of the brain as typical antipsychotics do. They also work on:

• Acetylcholine.

• Glutamate.

• Serotonin.

These neurotransmitters are associated with negative symptoms in schizophrenia. This is where atypical drugs differ, as dopamine affects the positive symptoms, and these neurotransmitters affect the negative symptoms.

Side effects include:

• Diabetes (long term).

• Tardive Dyskinesia (uncontrollable muscle movements usually affecting the face), although it is less likely to happen with atypical antipsychotics.

• Cardiovascular problems.

• Weight gain.

Psychological Treatment for Schizophrenia

As schizophrenia is a somewhat complex mental health disorder, there are multiple avenues of treatment. Psychological treatments for schizophrenia wors through the disorder with an appointed psychiatrist, clinician, or therapist.

There are multiple forms of psychological treatment, including CBT, family therapies, and token economies.

Cognitive Behavioural Therapy (CBT)

Developed in the 1960s by Beck, cognitive behavioural therapy (CBT) focuses on addressing dysfunctional thought processes and behaviours. It encourages patients to work through symptoms such as delusions, hallucinations, and depression by evaluating these symptoms logically.

CBT lasts around 6 to 12 weeks, although this can vary depending on a patient’s needs. Patients work closely with an appointed therapist to build trust.

CBT addresses other issues, such as:

• General, irrational beliefs, e.g., hearing people who are not there talking about you or hearing a voice narrate your daily life.

• Self-image issues.

• Beliefs about people’s perception of the patient (Do they hate the patient? Do people think they’re ugly? Do people think they’re a bad person?).

A process is identified and followed, whereby patients are:

1. Assessed: Patients explain their issues to a therapist. These are identified, and patients are encouraged to reflect during this stage to understand better where these symptoms originate.

2. Engaged with: After being assessed, the therapist then begins to logically work through the issues, such as identifying a delusion (for example, believing a neighbour is trying to kill the patient) and explaining why this isn’t the case; the neighbour has no ill intent towards the patient, they are friendly, and it would result in the neighbour being tried and imprisoned.

CBT adopts the ‘ABC’ method to work through this process.

This is known as:

• Activating Event: What is causing the problem?

• Behaviour and Beliefs: How does the patient react in these situations?

• Consequences: What impact does this have on the patient’s life and relationships with others?

Disputing irrational beliefs can be addressed using these methods:

• Reality testing.

• Normalisation.

• Critical analysis of ideas together (therapist and patient).

Family Therapy

Whilst providing therapy for the patient is a good start, when factors such as expressed emotions and dysfunctional family issues are taken into account, family therapy is a form of treatment that should be considered in schizophrenia.

It focuses on reducing expressed emotion (EE), associated with relapse issues, alongside stress and guilt among family members who live with the patient. Usually, it is given through group sessions involving the patient and their family.

Like CBT, family therapy involves assessing the patient and the family and providing the appropriate treatment. It does so by focusing on educating family members about the disorder, reducing stress levels, and providing opportunities to learn about problem-solving associated with schizophrenia issues². Family therapy teaches family members and patients how to deal with schizophrenia at home to avoid relapses, and often educates family members while patients may have been hospitalised.

Family therapy will interview and, in some cases, observe the family and the patient interacting.

Teaching family members communication training can be done in the following ways:

• Compromise and negotiation involve weekly meetings to air out issues.

• Being family-centred: the whole family is the focus, not just the patient.

These methods should improve problem-solving skills for the family involved, rather than resorting to negative behaviours that worsen schizophrenic symptoms in the patient and dismantle relationships.

Fig. 3 - Family therapy in schizophrenia aims to educate the family and reduce relapse rates.

Token Economy Systems (TES)

Although not as highly used with the reduced need to hospitalise patients with schizophrenia, token economies are a form of psychological treatment that aims to address the disorder through operant conditioning.

It involves a system introduced when the patient is first hospitalised, as TES were particularly popular when institutionalisation was common for schizophrenic patients.

Tokens, such as physical items (chips or plastic coins) or a tally system, are used as a secondary reinforcer earned through good behaviour. This can include:

• Getting up on time.

• Getting washed and dressed.

• Brushing teeth.

Once patients earn enough tokens, a patient can trade them in for a reward, known as the primary reinforcer. Secondary reinforcers gain power by being associated with the primary reinforcer.

Three examples, established by Matson et al. (2016), are good instances of behaviours tackled by token economy systems:

• Personal care (issues with hygiene such as showering, changing clothes, and brushing teeth).

• Condition-related behaviour (issues with positive and negative symptoms).

• Social behaviour (issues with socialising with other people)

It is a motivational therapy but has underlying issues. Mainly, patients have to want to do the above behaviours. TES works by being specific to patients, using their favourite things to encourage desirable behaviours.

Interactionist Approach: The Diathesis-Stress Model

The interactionist approach differs from the biological or psychological approach to schizophrenia.

It is holistic in that it considers the patient as a whole person, rather than identifying them through their mental health disorder alone (a reductionist issue).

A well known interactionist approach is the diathesis-stress model.

The Diathesis-Stress Model

The diathesis-stress model combines the biological factors of schizophrenia and the psychological factors of schizophrenia, in an attempt to address

We now understand that schizophrenia is a polygenetic disorder and results from dopamine imbalances in the brain.

Studies have found that early childhood trauma can act as a trigger for schizophrenia to develop. Issues such as:

• Birthing complications,

• General pregnancy complications.

• Negative life experiences (such as academic pressures or emotional breakups).

• Childhood traumas (expressed emotion, family dysfunction) altering neurological development - Read (2001).

Drug abuse has also been linked to the development of schizophrenia, such as using cannabis (increasing levels of paranoia, a positive symptom in schizophrenia).

Two prominent cases involving the diathesis-stress model are:

1. Gottesman (1991): twin study, where they compared identical twins with non-identical twins. Only 48% of identical twins developed schizophrenia, despite sharing 100% of their DNA - this suggests that both of these twins have a genetic vulnerability to schizophrenia. However, psychological factors such as experiences in the environment help trigger the disorder, as otherwise identical twins (MZ twins) would have a 100% concordance rate.

2. Tienari (2004): This study investigated adopted biological children of schizophrenic mothers. 36.8% of the children developed schizophrenia in dysfunctional households, compared to just 5.8% of children in healthy households. There is genetic vulnerability, and the family household acted as a stressor to trigger schizophrenia.

The interactionist approach understandably encourages a combination of biological and psychological therapies to treat schizophrenia. It is supported by studies that show combining antipsychotic treatment with a form of therapy reduces symptoms and rehospitalisation.

Antipsychotics, in a lot of cases, reduce symptoms to allow patients to undergo therapy.