Shilpa Pai Regan. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
CSI; Law & Order; Me, Myself, and Irene. What do all these popular media programs have in common? They all share an unrealistic depiction of persons with schizophrenia as murderers, rapists, pedophiles, or persons possessing multiple personalities. Popular television programs and movies inaccurately portray most mental disorders, especially schizophrenia. It is common for people to be frightened of or not understand the unusual behaviors people with schizophrenia display. However, they are not inherently dangerous individuals or criminals. In fact, schizophrenics are not any more dangerous than any given person in the general population (American Psychiatric Association, 2000).
People who suffer from schizophrenia are experiencing psychotic problems. Loosely defined, psychosis refers to the presence of hallucinations or delusions. Schizophrenia is one of 10 psychotic disorders recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000), the guidebook for mental disorders, which delineates symptoms and criteria for diagnosis. The remaining nine psychotic disorders are schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, substance-induced psychotic disorder, psychotic disorder due to a general medical condition, and psychotic disorder not otherwise specified. Schizophrenia is composed of the Greek terms schizo (split) and phrene (mind). These Greek terms may explain why many people erroneously refer to schizophrenia as “multiple personalities.” The name actually refers to a disintegration of mental abilities (Green, 2001).
The purpose of this chapter is to provide an accurate clinical picture of schizophrenia. I will cover the history, symptoms, types, prognosis, etiology, and treatments.
History
In the late 19th century, mental disorders were classified by the German psychiatrist Emil Kraeplin into two categories, dementia praecox and manic depression. Dementia praecox literally translates to early dementia. In 1911, Eugene Bleuler, a Swiss psychiatrist, coined the term schizophrenia based on Kraeplin’s description of dementia praecox. Bleuler described schizophrenia as comprising the “four A’s.” First, he described a dysfunction in association, which now refers to thought disturbances, such as loose associations, derailment, and tangentiality. Second, Bleuler noted affectivitydeficits, including emotional lability or blunted affect. Ambivalence, the third term, referred to contradictory responses in emotion, motivation, and intelligence. The fourth term, autism, described a detachment from reality (Carson & Sanislow, 1993; Green, 2001).
Despite this fairly accurate description of what is now known as schizophrenia, the disorder was not introduced to the DSM until 1968 (DSM-II), likely due to translation difficulties. Extrapolating from Bleuler’s work, Kurt Schneider developed specific diagnostic criteria for schizophrenia: (a) the patient hears voices; (b) the voices are commenting on the patient’s behavior; (c) the voices discuss the patient; (d) external forces place thoughts in the person’s mind—thought insertion; (e) external forces remove thoughts—thought removal; (f) external forces control the patient’s emotions; (g) external forces control the patient’s impulses and voluntary acts; (h) the patient hears his or her thoughts broadcast to others; and (i) external forces impose bodily sensations. Schneider’s work provided specific descriptions of hallucinations and delusions still used today. The criteria for schizophrenia, as well as other mental disorders, have been modified over the years and, in 2000, were incorporated into the most recent version of the DSM, the DSM-IV-TR (Carson & Sanislow, 1993; Green, 2001).
Symptoms
Researchers distinguish between positive and negative schizophrenic symptoms. Positive symptoms involve an excess of functions, whereas negative symptoms involve the absence of behaviors or the loss of normal functioning (APA, 2000). These symptoms are referred to as the characteristic or active signs of schizophrenia. Crow (1985) differentiated between Type I schizophrenia and Type II schizophrenia based on positive and negative symptoms. Type I schizophrenia is characterized as acute schizophrenia with more positive symptoms, normal ventricular size, and increased levels of the neurotransmitter dopamine. Type II is characterized by increased negative symptoms, cognitive impairments, and brain abnormalities. A better prognosis is associated with Type I schizophrenia.
Other symptoms of schizophrenia include an impairment of occupational (e.g., inability to work), academic (e.g., failing), or interpersonal (e.g., cannot relate to people) functioning as well as an inability to take care of oneself. The symptoms cannot be the result of a medical problem, medications, or drug or alcohol use. This feature is important to note, as substance use can produce common symptoms (e.g., hallucinations) of schizophrenia. For diagnosis, symptoms of the disorder are present for a minimum of six months, with at least two characteristic symptoms mentioned below occurring for one month (APA, 2000). An educated clinician makes the diagnosis based on an interview with the patients and their family members. There are no medical tests (e.g, blood, brain scans) to confirm diagnosis (Green, 2001).
Positive Symptoms (Excess of Functions)
Delusions
Delusions are beliefs that are not true or are unlikely. They may also be a misinterpretation of reality (APA, 2000). It is impossible to convince a person suffering from a delusion that his or her beliefs are false. Interestingly, delusions are influenced by educational level and intelligence. Common delusions involve thought broadcasting, thought withdrawal, and thought insertion (Shean, 2004). There are several specific categories of delusions (APA, 2000):
(a) Grandiose. Individuals believe they are special or have special powers. For example, one individual I counseled believed that he wrote all the musical lyrics heard on the radio. This same person also believed that he belonged to “The Church,” a special religious organization that was sending him millions of dollars in the mail. Another individual believed that she worked for God and possessed powers to control weather systems.
(b) Persecutory. This is the most common type of delusion; The belief is that individuals/groups are conspiring or planning to attack the individual (APA, 2000). The individual just mentioned was convinced that the correctional officers in his prison were stealing all the money “The Church” was sending him. Another individual refused to brush her teeth because she believed that her toothpaste was poisoned (Iwamasa, 1999).
(c) Referential. This is also a common type of delusion whereby individuals believe that certain passages from books or the television are directly meant for them (APA, 2000). For example, one individual this author counseled believed that television commercials were specially made for him and that special messages were embedded in them.
(d) Somatic. These delusions are related to the structure or function of the body. For example, individuals might believe that spiders are invading their body and burrowing into their legs.
(e) Bizarre. These delusions are impossible and not understandable. For example, an individual may believe that an alien removed part of his or her brain. In contrast, nonbizarre delusions are unlikely but at least plausible.
Hallucinations
A hallucination is the perception of sensory information that does not exist. This perception is different from an illusion, which is a misinterpretation of reality (e.g., seeing a shape in a cloud). A hallucination can occur in any one of the five senses, olfactory (smell), visual, gustatory (taste), tactile, and auditory, with auditory being the most common. Most often, an individual will hear voices, especially two or more voices carrying on a conversation with each other about that individual’s behaviors (APA, 2000). The voices are often negative, making belittling comments about the person: “I hear voices of abusively cruel people talking to me constantly, even when no one is present …” (Wagner, 1996, p. 400).
Disorganized Speech/Thinking
This category of symptoms is often argued to be the telltale sign of schizophrenia. An individual’s speech is often difficult to comprehend or follow due to several features (APA, 2000):
(a) Derailment: A derailment or loose association occurs when an individual loses focus of a conversation and switches to another topic. For example, “I wanted to go, you know. It is no good … She was a beauty … Nobody knew me then, even though I was very old. Ah, why did they have to do that? I would have helped. My grandfather told me about the big one—it was good, in a bad sort of way. She must have been there. I have been hounded and hated since the day of infamy. You don’t understand—it hurts.”
(b) Neologisms: This refers to the creation of words. For example, “She loved to sing, ding, fling, ming, and ping, but she never zing bing.”
(c) Word salad: A word salad is a rare form of disorganized speech; you cannot understand the person’s speech because it is completely incomprehensible. For example, “I am the fresh prince elect for god almighty and never again until life do us part.”
(d) Tangentiality: This refers to a response that is unrelated or slightly related to the question at hand.
Disorganized/Catatonic Behavior
Behaviors are either disorganized or catatonic. First, disorganized behaviors present in numerous forms. Individuals have difficulty in everyday life, often with an inability to get dressed, cook meals, or bathe. This results in a very disheveled (e.g., dirty, unshaven, smelly) appearance. People with schizophrenia also dress unusually (e.g., wearing scarves, hats, coats on a summer day) or engage in inappropriate sexual behavior (e.g., public masturbation). They may also become agitated, triggering unprovoked shouting or swearing (APA, 2000). This behavior may account for the incorrect public perception that schizophrenics are violent.
Second, catatonic behavior ranges from nonmovement to excessive movement. The nonmovements can take several forms. For example, individuals may stop moving completely, becoming absolutely unaware of everything around him or her (termed catatonic stupor). An attempt to engage or interact with a person in this state is met with no response. This is qualitatively different from a person who is intentionally resisting being moved by caregivers or staff or following specific instructions. This active opposition is termed catatonic negativism. Still another form of nonmovement iscatatonic posturing, where a person actually holds a bizarre posture (e.g., extending one arm and one leg out while sitting) for lengthy periods of time. In contrast, excessive purposeless movements are termed catatonic excitement(APA, 2000).
Negative Symptoms (Absence/Loss of Functions)
Flattened Affect
Affect refers to a person’s current mood. Flattened affect describes a lack of emotions, or no normal emotional response. Individuals rarely engage in normal social interactions, making diminished or no eye contact or failing to appropriately smile or nod at people. Basically, there is no facial response or emotional connection (APA, 2000).
Alogia
Alogia is defined as “poverty of speech.” Alogia is influenced by the previously mentioned positive symptom of disordered thinking. Given that thoughts are haphazard or unusual, it is not surprising that speech will be affected. For example, individuals with schizophrenia may not speak or their replies will be quite brief (APA, 2000).
Avolition
Avolition describes apathy or a lack of goal-directed behaviors. A person with schizophrenia often has no desire to work or pursue employment, attend school, or engage in social activities (APA, 2000). He or she reports no interests and tends not to enjoy any activities. Individuals may often sit mindlessly in front of their televisions. Although positive symptoms are often treated with medications, this negative symptom persists, which often leads to individuals being labeled as lazy (Green, 2001).
Subtypes
Five subtypes (including residual) of schizophrenia exist; they are determined by the dominant symptomatology at the time of diagnosis (APA, 2000):
Catatonic
The predominant feature of catatonia is a motor function disturbance, placing individuals at an increased risk for fatigue and malnutrition. Self-injury and injury to others are also concerns necessitating supervision. Diagnosis of this type requires two of the following (APA, 2000):
(a) motor immobility, often manifested by waxy flexibility (catalepsy) or stupor;
(b) excessive and unnecessary motor activity;
(c) mutism or rigid posture or resistance to instruction (termed negativism);
(d) stereotyped movements, grimacing, or bizarre/inappropriate postures;
(e) echolalia (repeating of words/phrases recently spoken) or echopraxia (imitation of another’s movements).
Disorganized (Historically Termed Hebephrenic)
The disorganized type of schizophrenia requires the presence of disorganized speech (e.g., silliness, laughter), disorganized behavior, and flat or inappropriate affect. Disorganized behavior is evidenced by a lack of goals or an inability to perform daily activities, such as cooking, showering, and dressing (APA, 2000). Social, emotional, and cognitive impairments are typically related to the disorganized type (Shean, 2004).
Paranoid
Paranoid schizophrenia is dominated by delusions or auditory hallucinations. The delusions are normally grandiose or persecutory and characteristically involve one theme. A persecutory delusion often makes an individual susceptible to suicide. The hallucinations often follow the delusional content. Typically, anger, detachment, anxiety, argumentativeness, and a patronizing tone accompany paranoid schizophrenia. A combination of anger, persecutory delusions, and grandiose delusions may make the individual susceptible to violence. As previously mentioned, individuals with schizophrenia are not more violent than any other individual in the population (APA, 2000).
Undifferentiated
This type of schizophrenia is essentially a leftover category for symptoms not matching catatonic, disorganized, or paranoid schizophrenia (APA, 2000).
Prevalence/Onset/Prognosis
Schizophrenia occurs worldwide with rates ranging from 0.5 to 1.5 percent (APA, 2000; Green, 2001). Curiously high rates have been reported in Sweden, Croatia, West Ireland, and Northern Russia, whereas significantly low rates have been reported in British Columbia and South Pacific islands (Shean, 2004). Approximately 5,000 out of 10,000 cases are reported annually, with more cases occurring among urban-born rather than rural-born individuals (APA, 2000). The disorder was rare prior to the Industrialized Revolution and continues to be rare in non-industrialized cultures. Epidemiological studies have also found increased rates among migrants (Diforti, Lappin, & Murray, 2007). It occurs relatively equally among all ethnic groups. Yet, some studies report higher rates in African Americans and Asians in the United States and United Kingdom. These rates are likely the result of bias, lack of multicultural knowledge, or confounded with low socioeconomic status (Carson & Sanislow, 1993).
The onset of schizophrenia is often slow and gradual, beginning with prodromal symptoms or the first signs of schizophrenia. Prodromal symptoms include sleep disturbances, diminished energy, anxiety, depression, irritability, tension, withdrawal, distrust, and decreased communication. These symptoms are often not recognized by family members as schizophrenia and are believed to be a normal phase of development (APA, 2000). The prodromal phase is followed by the acute phase, characterized by active symptoms of delusions, hallucinations, avolition, and anhedonia (Shean, 2004). The onset of the acute phase distinguishes the prodromal symptoms as schizophrenia. Men experience an earlier onset of the acute symptoms, beginning in the late teens to early 20s, whereas women are diagnosed later in life, in the mid to late 20s (Green, 2001). The earliest age of onset is documented at 5 to 6 years of age.
Although the course of schizophrenia is highly varied, approximately 20 to 30 percent of diagnosed individuals experience a good outcome, with the ability to hold a paying job (Green, 2001; Shean, 2004). It is important to note that “good outcome” does not refer to a return to normal functioning. A full recovery is not common and those experiencing improved outcomes are believed to be in the residual phase of schizophrenia (APA, 2000). Prominent positive symptoms (e.g., hallucinations, delusions, disorganized speech and behavior) do not occur in the residual phase. Negative symptoms (self-neglect, anhedonia, withdrawal) and a minimum of two reduced positive symptoms (e.g., odd beliefs) do exist.
Schizophrenia is listed as one of the top five causes of disability worldwide (Green, 2001). Ten percent of cases have a lifetime hospitalization due to severe psychosis. Most individuals experience numerous relapses, especially 6 to 10 years after their first episode (Shean, 2004). Women tend to have a better prognosis than men due to their later onset of symptoms. However, any individual with an earlier onset has poorer adjustment, likely due to increased motor impairments and cognitive dysfunctions (APA, 2000; Manschreck, Mayer, & Candela, 2004).
The subtype of schizophrenia also influences onset and prognosis. Onset of the paranoid type occurs later in life with better remission rates than the other subtypes, specifically with maintaining employment and living autonomously. The onset of disorganized schizophrenia is early and insidious, with a decreased likelihood of remission (APA, 2000). As mentioned earlier, Type I schizophrenia has a better prognosis than Type II schizophrenia. Regardless, medications and psychosocial treatments are required for improvement (Shean, 2004).
There is a shorter life expectancy for individuals with schizophrenia due to a high suicide rate. Approximately 10 percent complete suicide, with 20 to 40 percent attempting suicide. Specific risk factors for suicide include men, individuals younger than 45 years of age, recent hospital discharge, depressive symptoms, and unemployment (APA, 2000).
Presentation
Individuals with schizophrenia may have motor delays and be physically awkward, with poor coordination and confusion of their right and left (APA, 2000). They also have poor visual skills, with abnormal saccadic eye movements and difficulty following slow and regular movements of a visual stimulus (eye tracking). Approximately 15 percent of the normal population has difficulty eye tracking as compared to 20 to 80 percent of schizophrenic patients (Shean, 2004). Their eyes also appear narrower or wider than those of normal individuals. Cognitive functioning is also affected, termed cognitive dysmetria. Individuals possess time difficulties, confusing past, present, and future in relation to themselves and others (Andreasen, Paradiso, & O’Leary, 1998). Other abnormalities include slower reaction times, lower intelligence scores, ear deformities, fingerpad differences, and difficulty concentrating (Carson & Sanislow, 1993). Unusual sleep patterns often emerge, with daytime sleeping and nighttime restlessness or increased activity. They also may sniff, grunt, or cluck their tongue (could be due to meds). They also tend to be nicotine dependent, developing emphysema or other pulmonary or cardiac problems. Schizophrenia also has a 47 percent comorbidity to drug and alcohol use.
Etiology
Genetic
There is a strong heritability component to schizophrenia, accounting for 50 to 80 percent of schizophrenia development (Shean, 2004). First-degree biological relatives of schizophrenics are 10 times more at risk for developing the disorder (APA, 2000). This statistic suggests that the closer your familial relation to a person with schizophrenia, the more likely you are to develop the disorder. For example, monozygotic twins (100 percent genes in common) and children of two schizophrenic parents are at a 45 percent risk for developing the disorder. Dizygotic twins (50 percent of genes in common) have a 17 percent risk, children of one schizophrenic parent have a 9 percent risk, and uncles and aunts have a 2 percent risk. Yet, a familial relation to schizophrenia is not a guaranteed cause for the disorder. Approximately 65 percent of individuals with schizophrenia do not have a first-degree or second-degree biological relative with the disorder (Shean, 2004).
Biological
Brain
There is no one brain abnormality attributed to all schizophrenic patients. Actually, imaging studies show that brain dysfunctions are heterogeneous across schizophrenics. These scans have revealed enlarged ventricles, indicating fluid-filled space and a lack of brain cells. Such ventricular enlargements are the most common structural anomaly and may be correlated with poor outcome (Staal, Pol, & Kahn, 1999; Van Horn, Berman, & Weinberger, 1996). Researchers have located abnormalities (e.g., decreased volume, lack of neurotransmitters) in the temporal lobe (hearing), amygdala (structure for emotions), and hippocampus (structure for memory). The nucleus accumbens appears to be dysfunctional as well. This structure is controlled by the amygdala and hippocampus, which in turn interacts with the prefrontal cortex. Responsible for higher executive functioning, the prefrontal cortex controls speech, decision making, and motor planning. Regarding specific schizophrenic symptoms, negative symptoms have been linked to decreased blood flow in the prefrontal cortex, termed hypofrontality, whereas positive symptoms have been linked to increased cerebral blood flow in the temporal lobe (APA, 2000; Shean, 2004).
Neurotransmitters
Different types of neurotransmitters (see Chapter 14, Neurotransmission, for more information on neurons and neurotransmitters) control specific actions (e.g., acetylcholine controls motor movement). Dopamine is the neurotransmitter involved in schizophrenia. It was discovered when dopamine agonistic drugs produced an excess of dopamine in control groups, producing delusions and hallucinations. Postmortem studies comparing normal and schizophrenic brains have implicated an excess of dopamine or an excess of dopamine receptors in the disorder. Research revealed higher concentrations of dopamine in the nucleus accumbens and amygdala as well as increased dopamine receptors (specifically D2 receptors) in other areas of the brain (Carson & Sanislow, 1993; Kahn, Davidson, & Davis, 1996).
Vulnerability/Risk
The diathesis stress model refers to a biological predisposition to a disease that is triggered by one or several environmental stressors (Shean, 2004). Schizophrenia likely develops from a combination of the underlying genetic link and brain dysfunctions that are activated by adverse environmental factors (Meehl, 1972).
Communication
Families of schizophrenic patients often show dysfunctional communication styles. First, there is evidence of high expressed emotion. Expressed emotion (EE) refers to a high degree of intrusiveness, criticism, guilt inducement, and anger. High EE is associated with higher relapse rates and increased hospitalization (Carson & Sanislow, 1993; King & Dixon, 1999; Shean, 2004). Second, double-bind communication refers to contradictory messages, which lead a person not to trust his or her own feelings and to develop distorted views of self and others (Bateson, Jackson, Haley, & Weakland, 1956). For example, a parent might be holding or embracing her child and simultaneously admonishing the child for hugging her. However, recent research is equivocal regarding the relation between double bind and schizophrenia (Koopmans, 1997). Third, families may present a confusing environment due to communication problems where members do not understand their role or responsibilities. Finally, communication styles may be intimidating or demoralizing.
Prenatal Infections
The neurodevelopmental hypothesis refers to a disruption in brain development during the prenatal and early neonatal periods, which may lead to schizophrenia. Researchers conjectured that prenatal infections (e.g., influenza) cause these neurodevelopmental problems, which include enlarged cerebral ventricles, decreased hippocampus volume, physical abnormalities, and motor anomalies (Brown & Susser, 2002).
Researchers first implicated prenatal infections because of the correlation between schizophrenia rates and winter and early spring births. A 5 to 15 percent increased risk of schizophrenia occurs in births between January and March. Researchers discovered that the mother’s contraction of influenza specifically during the second trimester or between four to six months’ gestation increased the risk of schizophrenia (Brown & Susser, 2002). Researchers surmised that mothers produce antibodies in response to the influenza virus, which disrupted neurodevelopment in the fetus. In addition to influenza, tuberculosis, pneumonia, and acute bronchitis are other maternal infections that increase the risk of schizophrenia. Later research linked urban births to a 150 to 200 percent increase in schizophrenia development as compared to the incidence in rural births. The crowded environment in cities led to an increased transmission of infections. In sum, for those afflicted with schizophrenia, approximately 34.6 percent of urban births and 10.5 percent of seasonal births account for the disorder (Mortensen, Pedersen, & Westergaard, 1999).
Socioeconomic Status
Research has revealed that higher rates of schizophrenia occur in lower socioeconomic populations. Two hypotheses exist concerning this finding, downward drift and breeder hypothesis. Now unfounded, downward drift refers to diagnosed individuals moving down the economic ladder due to an inability to maintain employment (Shean, 2004). The breeder hypothesis speculates that lower-class families spawn more individuals diagnosed with schizophrenia. It is not that individuals from lower socioeconomic statuses possess mutated or inferior genes that produce schizophrenia. Rather, an amalgamation of factors (i.e., poor diet, crime, decreased health care, limited education) in poor environments increases the vulnerability to schizophrenia.
Miscellaneous Prenatal Factors
Research has associated preeclampsia, low birth weight, prematurity, and maternal malnutrition to increased risks for schizophrenia (Geddes et al., 1999). Earlier researchers attributed increased schizophrenia rates to the children of mothers who learned of a trauma during pregnancy. The study compared two groups: (a) one group included children one year old and younger, (b) the second group was fetuses. Mothers learned of their husbands’ death due to war. The group in utero had higher rates of schizophrenia than did the children already born (Huttunen & Niskanen, 1978). The differential rates were attributed to a disruption in neural development. Although neural deficits have been documented in later research, it is important to note that this study was naturalistic and the differences may be due to many other factors rather than the researchers’ conjectures. As such, Kinney (2001) followed up this research, reviewing past literature on prenatal distress. Results from human and animal studies, postnatal behavior, brain chemistry, and control group studies on in utero exposure to maternal stress attributed maternal stress to the risk for schizophrenia. However, specific risk estimates are difficult to attain.
Treatment
The primary treatment for schizophrenia is biologically based. Past ineffective biological treatments included hydrotherapy, insulin coma, and electroconvulsive therapy (ECT). Currently, medications are the first line of treatment. They do not cure schizophrenia, but abate positive symptoms. The best outcome is associated with a combination of medication and psychosocial treatments (Carson & Sanislow, 1993). Effective psychosocial treatments include family therapy, pyschoeducation, community treatment, token economy social learning, cognitive-behavioral therapy, and employment (Lehman et al., 2004). Although treatment effectiveness has been documented, sadly, over 50 percent of those suffering from schizophrenia do not receive treatment for their condition (National Alliance on Mental Illness, 1998).
Medications
Medications used to treat schizophrenia are referred to as antipsychotics or neuroleptics (acting on nervous system). The first antipsychotic, phenothiazine, was successfully used in 1951 to treat psychosis. There are six classes of typical antipsychotics used in the United States: phenothiazines, thioxanthenes, butyrophenones, dibenzoxapines, dihydroindolones, and dibenzodiazepines. These medications are also used to treat other psychotic disorders, not solely schizophrenia. The typical antipsychotics successfully diminish positive symptoms (hallucinations, delusions, disorganized thoughts), but are ineffective against negative symptoms. The medications reach full effect in 3 weeks and work by attaching to D2 receptor sites. Efficacy studies report 60 to 70 percent improvement rates. Approximately 30 percent respond poorly and 8 percent are completely nonresponsive (Green, 2001; Meltzer, Yamamtot, Lowy, & Stockmeier, 1996; Shean, 2004).
Unfortunately, numerous extrapyramidal side effects accompany the typical antipsychotics. Also referred to as pseudoparkinsonism, the side effects include tremors, involuntary muscle contractions, restlessness (akathisia), impaired body movements (akinesia), muscle cramping (dystonia), and tardive dyskinesia (e.g., lip smacking, chewing, tongue protrusions, shuffling gait). Tardive dyskinesia is irreversible even when medications cease. As such, it is not surprising that many patients prefer not to take these medications. One study found that approximately 70 percent of patients experience side effects, with limited individuals receiving appropriate treatment for their side effects (NAMI, 1998). Fortunately, atypical antipsychotics were developed in 1989 that improved positive and negative symptoms with minimal side effects. However, atypical antipsychotics are utilized only when the typical antipsychotics are ineffective due to a potentially fatal bone marrow suppression in some individuals. Common antipsychotics include Clozapine, Seroquel, Zyprexa, and Resperidal (Green, 2001; Meltzer et al., 1996; Shean, 2004). Although antipsychotics are effective, research has revealed that most patients receive an inappropriate dosage of their medications. In addition, African Americans are more likely to be overmedicated on antipsychotics compared to Caucasians (27.4 percent vs. 15.9 percent; NAMI, 1998).
Psychosocial Treatments
As previously mentioned, the most effective treatment for schizophrenia requires a combination of pharmacotherapy and psychosocial treatments that are designed on an individual basis. The most effective psychosocial treatments were updated in 2004. First, psychoeducation, where individuals are educated on their symptoms, medications, available treatments, relapse prevention strategies, and medication adherence, is an integral part of treatment. Family members are also educated on these subjects. A second highly recommended treatment is family therapy. Ongoing structured contact for a minimum of nine months is a necessity for any improvement. A family intervention provides emotional support, schizophrenia education, crisis management, and skills to cope with symptoms. Research has discovered that family interventions reduce relapse rates, hospital admissions, and family burden, and increase patient family relations as compared to medication alone, individual supportive therapy, and intensive case management (Lehman et al., 2004). Bertrando and colleagues (2006) also found that family therapy decreased expressed emotion by increasing positive comments and warmth and decreasing hostility and criticism. Yet, the specific components for effective family therapy have not been identified. A third psychosocial treatment is supportive employment, which consists of individualized job development, ongoing job support, and integration of vocational and mental health services. In contrast to previous thinking, competitive employment does not increase stress or symptoms. Rather, it leads to improved functioning. Fourth, assertive community treatment (ACT) is effective for individuals who were recently homeless or are at increased risk for relapse. ACT consists of a multidisciplinary team of a psychiatrist, nurse, social worker, case manager, and treatment staff. This team ensures medication compliance, rehabilitation, social service necessities, and other clinical needs. Similar to previous psychosocial treatments, ACT decreases the length of hospitalizations and improves living conditions of patients in the community. Fifth, a skills training program provides individuals with training to improve social skills and daily living skills. The training consists of modeling, feedback for correction, social reinforcement, and behaviorally based training (Lehman et al., 2004). Finally, a cognitive behavior therapy (CBT) program is effective for individuals continuing to experience residual psychotic symptoms. CBT assists individuals in targeting and restructuring irrational beliefs and behaviors that place them at increased risk for self-harm or harm to others. It also aids individuals in developing beliefs that reinforce behavior change. An integral part of the treatment process is the assignment of homework. Research has revealed that homework completion contributes to increased improvement rates (60 percent). CBT effectively reduces delusions, hallucinations, and negative symptoms, while increasing self-esteem (Dunn, Morrison, & Bentall, 2006; Gumley et al., 2006; Lehman et al., 2004).
Summary
Schizophrenia is a psychotic disorder found worldwide, affecting men, women, children, and all ethnic groups. Symptoms include delusions, hallucinations, disorganized thinking, disorganized behavior, avolition, flattened affect, and alogia. The disorder leads to impairments in social, occupational, familial, and cognitive functioning. Schizophrenia develops from a genetic predisposition or brain abnormalities activated by adverse environmental factors. Unfortunately, the affliction is incurable, but symptoms can be ameliorated by a combined treatment regimen of antipsychotic medications and psychosocial factors.