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Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
Abnorm psy pwrpt. lecture ch12
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Abnorm psy pwrpt. lecture ch12
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Abnorm psy pwrpt. lecture ch12

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  • 1. Schizophrenia Chapter 12
  • 2. Psychosis
    • Psychosis is a state defined by a loss of contact with reality
      • The ability to perceive and respond to the environment is significantly disturbed; functioning is impaired
      • Symptoms may include hallucinations (false sensory perceptions) and/or delusions (false beliefs)
    • Psychosis may be substance-induced or caused by brain injury, but most psychoses appear in the form of schizophrenia
  • 3. Schizophrenia
    • Schizophrenia appears to have been present in humans throughout history
    • Schizophrenia affects approximately 1 in 100 people in the world
      • An estimated 24 million people worldwide are afflicted, 2.5 million in the US
  • 4. Schizophrenia
    • The financial and emotional costs are enormous
      • Sufferers have an increased risk of suicide and physical – often fatal – illness
  • 5. Schizophrenia
    • Schizophrenia appears in all socioeconomic groups, but is found more frequently in the lower levels
      • Leading theorists argue that the stress of poverty causes the disorder
      • Other theorists argue that the disorder causes victims from higher social levels to fall to lower social levels and remain at lower levels
        • This is called the “downward drift” theory
  • 6. Schizophrenia
    • Equal numbers of men are women are diagnosed
      • In men, symptoms begin earlier and are more severe
    • Rates of diagnosis differ by marital status
      • 3% of divorced or separated people
      • 2% of single people
      • 1% of married people
        • It is unclear whether marital problems are a cause or a result
  • 7. The Clinical Picture of Schizophrenia
    • Schizophrenia produces many “clinical pictures”
      • The symptoms, triggers, and course of schizophrenia vary greatly
      • Some clinicians have argued that schizophrenia is actually a group of distinct disorders that share common features
  • 8. What Are the Symptoms of Schizophrenia?
    • Symptoms can be grouped into three categories:
      • Positive symptoms
      • Negative symptoms
      • Psychomotor symptoms
  • 9. What Are the Symptoms of Schizophrenia?
    • Positive symptoms
      • These “pathological excesses” are bizarre additions to a person’s behavior
      • Positive symptoms include:
        • Delusions – faulty interpretations of reality
          • Delusions may have a variety of bizarre content: being controlled by others; persecution; reference; grandeur; control
        • Disordered thinking and speech
          • May include loose associations, neologisms, perseverations, and clang
  • 10. What Are the Symptoms of Schizophrenia?
    • Examples of positive symptoms
      • Loose associations (derailment):
        • “ The problem is insects. My brother used to collect insects. He’s now a man 5 foot 10 inches. You know, 10 is my favorite number; I also like to dance, draw, and watch TV.”
      • Neologisms (made-up words):
        • “ This desk is a cramstile” “He’s an easterhorned head”
      • Perseveration
        • Patients repeat their words and statements again and again
      • Clang (rhymes):
        • How are you? “Well, hell, it’s well to tell”
        • How’s the weather? “So hot, you know it runs on a cot”
  • 11. What Are the Symptoms of Schizophrenia?
    • Examples of positive symptoms
      • Heightened perceptions
        • People may feel that their senses are being flooded by sights and sounds, making it impossible to attend to anything important
      • Hallucinations – sensory perceptions that occur in the absence of external stimuli
        • Most common are auditory
          • Seem to be spoken directly to, or overheard by, the hallucinator
        • Hallucinations and delusional ideas often occur together
      • Inappropriate affect – emotions that are unsuited to the situation
  • 12. What Are the Symptoms of Schizophrenia?
    • Negative symptoms
      • These “pathological deficits” are characteristics that are lacking in an individual
      • Negative symptoms include:
        • Poverty of speech (alogia)
          • Long lapses before responding to questions, or failure to answer
          • Reduction of quantity of speech or speech content
        • Blunted and flat affect – show less emotion than most people
  • 13. What Are the Symptoms of Schizophrenia?
    • Examples of negative symptoms
      • Blunted and flat affect
        • Avoidance of eye contact
        • Immobile, expressionless face
        • Monotonous voice, low and difficult to hear
        • Anhedonia – general lack of pleasure or enjoyment
  • 14. What Are the Symptoms of Schizophrenia?
    • Examples of negative symptoms
      • Loss of volition (motivation or directedness)
        • Feeling drained of energy and interest in normal goals
        • Inability to start or follow through on a course of action
        • Ambivalence – conflicted feelings about most things
      • Social withdrawal
        • May withdraw from social environment and attend only to their own ideas and fantasies
        • Seems to lead to a breakdown of social skills, including the ability to accurately recognize other people’s needs and emotions
  • 15. What Are the Symptoms of Schizophrenia?
    • Psychomotor symptoms
      • People with schizophrenia sometimes experience psychomotor symptoms
        • Awkward movements, repeated grimaces, odd gestures
        • The movements seem to have a magical quality
      • These symptoms may take extreme forms, collectively called catatonia
        • Includes stupor, rigidity, posturing, and excitement
  • 16. What Is the Course of Schizophrenia?
    • Schizophrenia usually first appears between the late teens and mid-30s
    • Many sufferers experience three phases:
      • Prodromal – beginning of deterioration; mild symptoms
      • Active – symptoms become increasingly apparent
      • Residual – a return to prodromal levels
        • One-quarter of patients fully recover; the majority continue to have residual problems
  • 17. What Is the Course of Schizophrenia?
    • Each phase of the disorder may last for days or years
    • A fuller recovery from the disorder is more likely in people:
      • With good premorbid functioning
      • Whose disorder was triggered by stress
      • With abrupt onset
      • With later onset (during middle age)
  • 18. Diagnosing Schizophrenia
    • The DSM-IV-TR calls for a diagnosis only after signs of the disorder continue for six months or more
    • People must also show a deterioration in their work, social relations, and ability to care for themselves
  • 19. Diagnosing Schizophrenia
    • The DSM-IV-TR distinguishes five subtypes:
      • Disorganized – characterized by confusion, incoherence, and flat or inappropriate affect
      • Catatonic – characterized by psychomotor disturbance of some sort
      • Paranoid – characterized by an organized system of delusions and auditory hallucinations
      • Undifferentiated – characterized by symptoms which fit no subtype; vague category
      • Residual – characterized by symptoms which have lessened in strength and number; person may continue to display blunted or inappropriate emotions, as well as social withdrawal, eccentric behavior, and some illogical thinking
  • 20. Diagnosing Schizophrenia
    • Apart from the DSM-IV-TR categories, many researchers believe that a distinction between Type I and Type II schizophrenia helps predict the course of the disorder
      • Type I schizophrenia is dominated by positive symptoms
        • Seem to have a greater likelihood of improvement
      • Type II schizophrenia is dominated by negative symptoms
  • 21. How Do Theorists Explain Schizophrenia?
    • While there is no known cause, research has focused on:
      • Biological factors (most promising)
      • Psychological factors
      • Sociocultural factors
    • A diathesis-stress relationship may be at work
      • People with a biological predisposition will develop schizophrenia only if certain kinds of stressors or events are also present
  • 22. Biological Views
    • Genetic and biological studies of schizophrenia have dominated clinical research in the last several decades
      • These studies have revealed the key roles of inheritance and brain activity and have opened the door to important changes in treatment
  • 23. Biological Views
    • Genetic factors
      • Following the principles of a diathesis-stress approach, genetic researchers believe that some people inherit a biological predisposition to schizophrenia
        • This disposition (and disorder) are triggered by later exposure to extreme stress
        • This theory has been supported by studies of relatives, twins, and adoptees, and by genetic linkage studies
  • 24. Biological Views
    • Genetic factors
      • Family pedigree studies have repeatedly shown that schizophrenia is more common among relatives of people with the disorder
        • The more closely related they are to the person with schizophrenia, the greater their likelihood for developing the disorder
  • 25. Biological Views
    • Genetic factors
      • Twins have received particular research study
        • Studies of identical twins have found that if one twin develops the disorder, there is a 48% chance that the other twin will do so as well
        • If the twins are fraternal, the second twin has a 17% chance of developing the disorder
  • 26. Biological Views
    • Genetic factors
      • Adoption studies have compared adults with schizophrenia, who were adopted as infants, with both their biological and adoptive relatives
        • Because they were reared apart from their biological relatives, similar symptoms in those relatives would indicate genetic influences; similarities to their adoptive relatives would suggest environmental influences
      • Researchers have found that the biological relatives of adoptees with schizophrenia are more likely to display schizophrenic symptoms than are their adoptive relatives
  • 27. Biological Views
    • Genetic factors
      • Genetic linkage and molecular biology studies indicate that possible gene defects on numerous chromosomes may predispose individuals to develop schizophrenia
        • These varied findings may indicate:
          • A case of “mistaken identity” – that is, some of these gene sites do not contribute to the disorder;
          • Various types of schizophrenia are linked to different genes; or
          • Schizophrenia, like many disorders, is a polygenic disorder, caused by a combination of gene defects
  • 28. Biological Views
    • Genetic factors
      • Genetic factors may lead to the development of schizophrenia through two kinds of (potentially inherited) biological abnormalities:
        • Biochemical abnormalities
        • Abnormal brain structure
  • 29. Biological Views
    • Biochemical abnormalities
      • One promising theory is the dopamine hypothesis:
        • Certain neurons using dopamine fire too often, producing symptoms of schizophrenia
      • This theory is based on the effectiveness of antipsychotic medications (dopamine antagonists)
  • 30. Biological Views
    • Biochemical abnormalities
      • Originally developed for treatment of allergies, antipsychotic drugs were found to cause a Parkinson’s disease-like tremor response in patients
      • Scientists knew that Parkinson’s patients had abnormally low levels of dopamine, which caused their shaking
      • This relationship between symptoms suggested that symptoms of schizophrenia were related to excess dopamine
  • 31. Biological Views
    • Biochemical abnormalities
      • Research since the 1960s has supported and clarified this hypothesis
        • Example: patients with Parkinson’s develop schizophrenia-like symptoms if they take too much L-dopa, a medication that raises dopamine levels
        • Example: people who take high doses of amphetamines, which increase dopamine activity in the brain, may develop amphetamine psychosis – a syndrome similar to schizophrenia
  • 32. Biological Views
    • Biochemical abnormalities
      • Investigators have also located the dopamine receptors to which antipsychotic drugs bind
        • The drugs are apparently dopamine antagonists that bind to the receptors, preventing further dopamine binding and neuron firing
      • These findings suggest that, in schizophrenia, messages traveling from dopamine-sending neurons to dopamine-receptors (particularly D-2) may be transmitted too easily or too often
        • An appealing theory, because certain dopamine receptors are known to play a role in guiding attention
  • 33. Biological Views
    • Biochemical abnormalities
      • Though enlightening, the dopamine hypothesis has certain problems
        • It has been challenged by the discovery of a new type of antipsychotic drug (“atypical” antipsychotics), which are more effective than traditional antipsychotics and also bind to D-1 receptors and to serotonin receptors
      • Thus, it may be that schizophrenia is related to abnormal activity or interactions of both dopamine and serotonin and perhaps other NTs as well, rather than to abnormal dopamine activity alone
  • 34. Biological Views
    • Abnormal brain structure
      • During the past decade, researchers have also linked schizophrenia (particularly cases dominated by negative symptoms) to abnormalities in brain structure
        • For example, brain scans have found that many people with schizophrenia have enlarged ventricles – the brain cavities that contain cerebrospinal fluid
          • This enlargement may be a sign of poor development or damage in related brain regions
        • People with schizophrenia have also been found to have smaller temporal and frontal lobes, and abnormal blood flow to certain brain areas
  • 35. Biological Views
    • Viral problems
      • A growing number of researchers suggest that the biochemical and structural brain abnormalities seen in schizophrenia result from exposure to viruses before birth
        • Some of the evidence comes from animal model investigations
  • 36. Biological Views
    • Viral problems
      • Circumstantial evidence for this theory comes from the unusually large number of people with schizophrenia who were born in winter months
      • More direct evidence comes from studies showing that mothers of children with schizophrenia were more often exposed to the influenza virus during pregnancy than mothers of children without schizophrenia
      • Other studies have found a link between schizophrenia and a particular group of viruses found in animals, suggesting that people had at some point been exposed to those particular viruses
  • 37. Biological Views
    • While the biochemical, brain structure, and viral findings are beginning to shed much light on the mysteries of schizophrenia, they offer only a partial explanation
      • Some people who have these biological problems never develop schizophrenia
        • Might be because biology sets the stage for the disorder, but psychological and sociocultural factors must be present for it to appear
  • 38. Psychological Views
    • As schizophrenia investigators began to identify genetic and biological factors linked to schizophrenia, clinicians largely abandoned psychological theories
      • In the past decade, however, psychological factors are again being considered important
        • Leading psychological explanations come from the psychodynamic, behavioral, and cognitive perspectives
  • 39. Psychological Views
    • The psychodynamic explanation
      • Freud believed that schizophrenia developed from two processes:
        • Regression to a pre-ego stage
        • Efforts to re-establish ego control
      • He proposed that when their world is extremely harsh, people who develop schizophrenia regress to the earliest points in their development (primary narcissism), in which they recognize and meet only their own needs
        • This regression leads to self-centered symptoms such as neologisms, loose associations, and delusions of grandeur
  • 40. Psychological Views
    • The psychodynamic explanation
      • Freud’s theory posits that attempts to reestablish ego control from such a state fail and lead to further schizophrenic symptoms
      • Years later, another psychodynamic theorist elaborated on Freud’s idea of harsh parents
        • The theory of schizophrenogenic mothers proposed that mothers of people with schizophrenia were cold, domineering, and uninterested in their children’s needs
      • Both of these theories have received little research support and have been rejected by most psychodynamic theorists
  • 41. Psychological Views
    • The cognitive view
      • Leading cognitive explanations agree that biological factors produce symptoms
      • They argue that further features of the disorder emerge because of faulty interpretation and a misunderstanding of symptoms
        • Example: a man experiences auditory hallucinations and approaches his friends for help; they deny the reality of his sensations; he concludes that they are trying to hide the truth from him; he begins to reject all feedback and starts feeling persecuted
      • There is little direct research support for this view
  • 42. Sociocultural Views
    • Sociocultural theorists believe that three main social forces contribute to schizophrenia:
      • Multicultural factors
      • Social labeling
      • Family dysfunction
    • Although these forces are considered important in the development of schizophrenia, research has not yet clarified what their precise relationships might be
  • 43. Sociocultural Views
    • Multicultural Factors
      • Rates of the disorder differ by ethnicity and race
        • About 2% of African Americans are diagnosed, compared with 1.4% of Caucasians
          • It is not clear why this difference exists but one explanation is economic
            • On average, African Americans are more likely to be poor and, when that factor is controlled for, rates of schizophrenia become closer between the two racial groups
            • Also consistent with the economic explanation, Hispanic Americans who also are, on average, economically disadvantaged, appear to have a much higher likelihood of being diagnosed than White Americans
  • 44. Sociocultural Factors
    • Multicultural Factors
      • Rates also differ between countries, as do the course and outcome of the disorder
        • Some theorists believe the differences partly reflect genetic differences from population to population
        • Others argue that the psychosocial environments of developing countries tend to be more supportive than developed countries, leading to more favorable outcomes for people with schizophrenia
  • 45. Sociocultural Views
    • Social labeling
      • Many sociocultural theorists believe that the features of schizophrenia are influenced by the diagnosis itself
        • Society labels people who fail to conform to certain norms of behavior
        • Once assigned, the label becomes a self-fulfilling prophecy
      • The dangers of social labeling have been well demonstrated
        • Example: Rosenhan “pseudo-patient” study
  • 46. Sociocultural Views
    • Family dysfunctioning
      • A number of studies suggest that schizophrenia is often linked to family stress:
        • Parents of people with the disorder often:
          • Display more conflict
          • Have greater difficulty communicating
          • Are more critical of and overinvolved with their children than other parents
        • Family theorists have long recognized that some families are high in “expressed emotion” – family members frequently express criticism and hostility and intrude on each other’s privacy
          • Individuals who are trying to recover from schizophrenia are almost four times more likely to relapse if they live with such a family
  • 47. How Are Schizophrenia and Other Severe Mental Disorders Treated?
    • For much of human history, people with schizophrenia were considered beyond help and without hope
    • 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
    • An historical perspective of treatment allows the best understanding of the nature, problems, and promise of modern approaches
  • 48. Institutional Care in the Past
    • For more than half of the 20 th 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
  • 49. Institutional Care in the Past
    • The move toward institutionalization began in 1793 with the practice of “moral treatment”
    • Hospitals were created in isolated areas to protect patients from the stresses of daily life and to offer them a healthful psychological environment
  • 50. 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” – human warehouses filled with hopelessness
  • 51. 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
  • 52. Institutional Care Takes a Turn for the Better
    • Milieu therapy
      • The guiding principle 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 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
  • 53. 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
  • 54. 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 and they are not as popular as they once were
  • 55. 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
  • 56. 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
  • 57. 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
  • 58. How Effective Are Antipsychotic Drugs?
    • Research has repeatedly 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
  • 59. 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
    • 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
  • 60. The 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
  • 61. The 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
      • Dystonia (bizarre movements of the face, neck, tongue, and back)
      • Akathisia (great restlessness, agitation, and discomfort in the limbs)
  • 62. 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
  • 63. 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
  • 64. New Antipsychotic Drugs
    • In recent years, new antipsychotic drugs have been developed
      • Examples: Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, and Abilify
  • 65. New 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
        • Some do produce significant undesired effects
  • 66. Psychotherapy
    • Before the discovery of antipsychotic drugs, psychotherapy was not an option for people with schizophrenia
      • Most were simply too far removed from reality to profit from psychotherapy
  • 67. Psychotherapy
    • Today, psychotherapy can be very helpful when used in combination with medication
      • The most helpful forms of psychotherapy include cognitive-behavioral therapy and two broader sociocultural therapies: family therapy and social therapy
      • Often these approaches are combined
  • 68. 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
  • 69. 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:
        • Teach clients to reattribute and more accurately interpret their hallucinations
        • Teach techniques for coping with their unpleasant sensations
  • 70. Psychotherapy
    • Cognitive-behavioral therapy
      • New-wave cognitive behavioral therapists believe that the most useful goal of treatment is often to help patients accept their streams of problematic thoughts rather than to judge them, act on them, or try to change them
  • 71. Psychotherapy
    • Cognitive-behavioral therapy
      • Studies indicate that the various forms of cognitive-behavioral treatment are often very helpful to clients
  • 72. Psychotherapy
    • Family therapy
      • Over 50% of persons recovering from schizophrenia 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
      • Family therapy attempts to address such issues, create more realistic expectations, and provide psychoeducation about the disorder
      • Families may also turn to family support groups and family psychoeducation programs
  • 73. 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
  • 74. The Community Approach
    • The community approach is the broadest approach for the treatment of schizophrenia
      • 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 four decades of deinstitutionalization of patients with schizophrenia
        • Unfortunately, community care was (and is) inadequate for their care
          • The result is a “revolving door” syndrome
  • 75. 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
    • Other key features are…
  • 76. 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)
    • 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
  • 77. What Are the Features of Effective Community Care?
    • Partial hospitalization
      • If patients’ 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
  • 78. 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
      • Houses are run with a milieu therapy philosophy
      • These programs help those with schizophrenia adjust to community life and avoid rehospitalization
  • 79. What Are the Features of Effective Community Care?
    • Occupational training
      • 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
  • 80. How Has Community Treatment Failed?
    • There is no doubt that effective community programs can help people with schizophrenia 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
  • 81. 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
  • 82. How Has Community Treatment Failed?
    • Shortage of services
      • The number of community programs available to people with schizophrenia is woefully short
      • The centers that do exist generally fail to provide adequate services for people with severe disorders
      • This shortage is due to primarily to funding shortages
  • 83. What Are the Consequences of Inadequate Community Treatment?
    • When community treatment fails, many people suffering from schizophrenia 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
  • 84. 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 live in totally unsupervised settings
  • 85. 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
  • 86. The Promise of Community Treatment
    • Despite these very serious problems, proper community care has shown great potential for assisting in recovery from schizophrenia
      • Another important advancement has been the formation of a number of national interest groups, including the National Alliance on Mental Illness (NAMI), to push for better community treatment
  • 87. The Promise of Community Treatment
    • Today, community care is a major feature of treatment for people recovering from schizophrenia 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

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