A look at a wide variety of treatments for schizophrenia, following the CIE A2 Psychology syllabus

1. Schizophrenia:
Treatments

2. Biological; Behavioral; Cognitive-Behavioral

3. Biological
1. First-generation Antipsychotics
2. Second-generation Antipsychotics (Also called Atypical)
3. Electroconvulsive Therapy

4. Conventional Antipsychotic Medication
1. Discovered in 1951 in France while attempting to find a
powerful antihistamine
2. 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.

5. 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.

6. Conventional Antipsychotics: Side Effects
1. “Extrapyramidal Effects” Movement/muscle problems
1. Parkinsonian Symptoms: 50% of those taking first generation side
effects experience these:
1. Rigid muscles
2. Muscle tremors
3. Move slowly, shuffle feet, little facial movement
These symptoms can be treated with L-dopa or by reducing the dose
of the antipsychotic medications.

7. 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.

8. Conventional Antipsychotics
Most Commonly Prescribed:
1. Haloperidol
2. Chlorpromazine

9. 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.

10. Atypical Antipsychotics
1. 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….

11. 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

12. 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)

13. 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.

14. 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.

15. 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

16. 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.

17. 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

18. 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)

19. 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.

20. 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?

21. 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.

22. What did the CBT Treatment Include?
There were two basic stages:
1. Creating a foundation for the CBT
2. The actual CBT

23. 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)

24. 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.

25. 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.

26. 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.

27. 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.