Biological therapies: Drug therapy
Drug therapy, the most common treatment for sz, uses antipsychotic drugs. "Conventional/ typical" antipsychotic drugs are used to reduce the effects of dopamine, while "Atypical" antipsychotics work on reducting serotonin activity.
Antipsychotics (old-style chlorpromazine, and new style clozapine) are used to calm down symptoms of sz. The older antipsychotics block dopamine receptors where the new stlye block serotonin. Serotonin, a neurochemical, was not thought to be involved in sz, hence these are known as atypical drugs. Julien (2005) suggests these are more effective than the typical dopamine blocking drugs.
Effectiveness of drug therapy
a. There is no doubt that anti-psychotics have made the treatment of schizo much more effective and the management of the illness easier. The person with sz can now live a reasonable life in the community rather than being incarcerated, and a reduction in symptoms such as hallucinations and delusions has led to psychological therapies being used alongside.
b. Conventional drugs can treat positive symptoms but have no effect on the negative. Atypical drugs can also have an effect on negative symptoms.
c. Rzewuska (2002): patients symptoms return if they stop the drugs. This has led to the need to maintenance doses (top ups) but also increases the likelihood of side effects.
Appropriateness of drug therapy
a. Conventional anti-psychotics produce serious side effects akin to those of Parkinson's e.g. tremors, stiffness, immobility. They also produce "Tardive Dyskinesia" (lip smacking, facial tics) caused by phenothiazines destroying parts of the brain, affecting around 30% of those taking the drug and increasing with prolonged usage. Other side effects include low blood pressure, blurred vision and constipation
b. Atypical drugs have fewer side effects, but clozapine in rare cases can lead to death resulting from damage to the immune system. Other drugs have to be administered to counteract this and regular blood tests are necessary, making treatment expensive. Other atypical drugs can cause unwanted weight gain.
c. Szs often fail to comply with drug regimes, either because of a want to avoid side effects or poor memory, and this has lead to the "revolving door syndrome" where patients are in and out of hospital regularly. Doctors have tried to combat this with 'depot injections' which slowly release antopsychotics over a period of time.
Biological therapies: ECT
Electroconvulsive Therapy (ECT): A current is passed through the brain inducing a fit similar to epilepsy, lasting 15-60 seconds. This may be bilateral (2 electrodes, considered more effective but more likely to lead to side effects) or unilateral (1 electrode). A course of ECT will be repeated between 6-12 sessions, 2-3 times a week; maintenance doses may need to be given periodically.
The fearsome reputation of ECT comes from early use when large shocks were given without muscle relaxants or anesthetics, sometimes resulting in broken bones and occasionally burns to the brain.
Modern ECT involves small shocks given for short periods, given under anesthetics and muscle relaxants.
Evaluation of ECT for schizphrenia
+ Tharyan and Adams (2005) reviewed 26 studies where ECT was either used on its own or with anti-psychotic drugs. ECT was better than no treatment (control) in reduction of symptoms and prevention of relapse, but not as effective as anti-psychotics, though when used together with anti-psychotics effectiveness was enhanced.
Memory loss is a major side effect and is cumulative (gets worse over a course of treatment). Memory loss is usually temporary in a single treatment but with the need for multiple treatments of ECT, there is clearly a problem when maintenance is taken into account.
NICE (2003) said there is insufficient evidence to recommend ECT as an appropriate treatment for sz.
Psychological therapies: CBT
Cognitive Behavioural Therapy (CBT) usually takes place once a week for 5-20 sessions. It helps identify irrational and unhelpful thoughts and tries to change them. CBT cannot eliminate symptoms, but help sufferers cope with them.
Turkington (2004): Purpose of using CBT with szs is to help them to understand their symptoms; someone hearing voices which they attribute to some malign (bad) influence, needs to understand that they themselves are the source of the voices.
CBT may also help normalise the experience of sz. Patients may, for example, benefit from hearing about how common hallucinations and delusions are amongst people without a diagnosis. CBT may also focus on the patients beliefs about sz itself. Therapists may share the results of recent studies showing good long term prospects for sufferers.
Evaluation of CBT
a. Some supportive evidence: Pilling et al (2002) reviewed 8 random control trials varying in length of treatment and outcome measurement and found CBT was better than standard care, particularly long term. Some studies do not find an initial positive effect for CBT but still find long term success.
b. NICE (2002) feel CBT is an appropriate treatment for sz, particularly for new patients.
c. Turkington (2002): since CBT enhances the sz's understanding of their symptoms, it also helped them to see the need to keep up with their medication. However, with understanding also came depression because of the severity of their symptoms.
Psychological therapies: Family Intervention
Health professionals will involve the family of a returning sz (in remissions) in order that they better understand both the nature of the illness and how to be more supportive towards their child by expressing low EE. Central to the family intervention programmes is the emphasis on inclusion and sharing information; they help develop a cooperative and trusting relationship with the family group. The family and individual are also trained to recognise early signs of relapse so they can respond rapidly to reduce the severity,
+ Pharoah (2003) meta analysis found family interventions were effective in reducing rates of relapse and admission to hospital in people with sz. Family intervention can also help with compliance to taking medication, which contributes to an effective outcome from drug therapy. HOWEVER, the analysis revealed a wide range of outcomes so the results are not conclusive - the therapy is used in current practice but will obviously be more effective in people who still live or are in close contact with their families.
Psychological therapies: Psychoanalysis
Psycho-dynamic therapies originated with the work of Freud. Classical psychoanalysis is very intensive, taking place 4-5 times/week and lasting for several years.
To a psycho-dynamic therapist, the symptoms of sz are rooted in early relationships. One aim of therapy for sz is to give patients insight into these links between symptoms and early life. For example, that our sense of self develops in childhood through relationships with others, but if these fail this can lead to poor sense of self, thus explaining why people with sz have poor metarepresentation and why they struggle to distinguish between their own thoughts and external stimuli.
Therapists expect transference from the client i.e. when the client offloads all their negative energy. Therapists are taught to deal with this and, as part of the therapy can act as a surrogate parent to the client, offering a positive role model in the place of the clients own parental experience.
Evaluation of psychoanalysis
- - The theoretical basis for treating sz psycho-dynamically is weak; even Freud questioned whether psychoanalysis would ever be capable of tackling sz.
- + Having said this, there is actually quite good evidence for the effectiveness of psycho-dynamic therapy for sz. Gottdeiner and Haslam (2002) found in a meta-analysis that CBT and psychoanalysis were equally effective. Controversially, this study suggests psychoanalysis works without anti-psychotics.
- Gottdeiner (2006) argues that the evidence supporting psycho-dynamic is strong enough to see it as generally appropriate for use with sz, but this is considered controversial because of the weak theoretical basis and the relatively small body of supporting evidence
- NICE guidelines for the treatment of sz comment that it is appropriate to make use of psycho-dynamic principles to understand the experiences of patients within their families but do not mention the use of psycho-dynamic therapies.
Tarrier (1990) suggest the over-stimulation caused by psychoanalysis could cause relapse. It has been found patients exposed to psychoanalytic therapy may need longer hospitalisation, develop worse symptoms and are more likely to refuse further treatment.
There is considerable evidence that social factors affect the course of sz, therefore it makes sense to assume that some kind of social intervention might have a theraputic effect on people with sz.
Wing & Brown (1970) compared female inpatients on a range of positive and negative symptoms and found marked differences in negative symptoms between those women from wards which were stimulating and those which were not. After social changes were made to the less-stimulation hospital, significant improvements were observed in about 1/3rd of patients.
Social Skills Training (SST) has been developed to help modify or improve the social behaviour of people diagnosed with sz. It is an active therapy that uses behavioural techniques such as modelling, reinforcement, role playing and practice in real life situations to enable individuals to acquire appropriate verbal and non verbal skills.
Birchwood and Spencer (1999) reviewed research into SST and found programmes were generally beneficial in increasing the persons competence and assertiveness, but this needs to be maintained otherwise social skills deteriorate again.