Ch 15abnormal psychology

8/10/2019 Ch 15abnormal psychology

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Treatments for Schizophrenia andOther Severe Mental Disorders

Chapter 15

Comer, AbnormalPsychology, 8eSlides & Handouts by Karen Clay Rhines, Ph.D.

Northampton Community College

How Is Schizophrenia Treated?

For much of human history, people withschizophrenia and other severe mental disorderswere considered beyond helpThough schizophrenia is still extremely difficult totreat, the discovery of antipsychotic drugs hasenabled people with the disorder to think clearlyand profit from psychotherapiesEach of the models offers treatments for

schizophrenia, and all have been influential atone time or another

Comer, Abnormal Psychology, 8e 2

Institutional Care in the Past

For more than half of the 20th century, peoplewith schizophrenia were institutionalized inpublic mental hospitals

Because patients failed to respond totraditional therapies, the primary goals of thehospitals were to restrain them and give themfood, shelter, and clothing



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The move toward institutionalization began in1793 with the practice of moral treatment

Hospitals were located in isolated areas toprotect patients from the stresses of daily lifeand to offer them a healthful psychologicalenvironment



States throughout the U.S. were required bylaw to establish public mental institutions(state hospitals) for patients who could notafford private care

Unfortunately, problems with overcrowding,understaffing, and poor patient outcomes led toloss of individual care and the creation of back

wards human warehouses filled withhopelessness



Many patients not only failed to improveunder these conditions but developedadditional symptoms, apparently as a result ofthe institutionalization itself

The most common pattern of decline was calledthe social breakdown syndrome, which involved:

Extreme withdrawal, anger, and physical aggressiveness

Loss of interest in personal appearance and functioning



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Institutional CareTakes a Turn for the Better

In the 1950s, clinicians developed twoinstitutional approaches that brought some hopeto chronic patients:

Milieu therapyBased on humanistic principles

Token economiesBased on behavioral principles

These approaches particularly helped improvethe personal care and self-image of patients,problem areas that were worsened byinstitutionalization



Milieu therapyThe premise is that institutions can help patientsmake clinical progress by creating a social climate(milieu) that promotes productive activity, self -respect, and individual responsibility

Research has shown that patients with schizophrenia inmilieu programs often leave the hospital at higher ratesthan patients receiving custodial care



The token economyBased on operant conditioning principles, tokeneconomies are used in institutions to change thebehavior of patients with schizophreniaPatients are rewarded when they behave in sociallyacceptable ways and are not rewarded when theybehave unacceptably

Immediate rewards are tokens that can later be exchangedfor food, cigarettes, privileges, and other desirable objectsAcceptable behaviors likely to be targeted include care foroneself and ones possessions, going to a work program,speaking normally, following ward rules, and showing self-control



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Milieu therapy and token economies havehelped improve the personal care and self-image of patients, problem areas worsened byinstitutionalization

They are still used in many mental hospitals,usually along with medication

This approach has also been applied to otherclinical problems


Antipsychotic Drugs

While milieu therapy and token economieshelped improve treatment outcomes, it wasthe discovery of antipsychotic drugs in the1950s that revolutionized treatment for thosesuffering from schizophrenia


Antipsychotic Drugs

The discovery of antipsychotic medications datesback to the 1940s, when researchers developedantihistamine drugs for allergiesIt was discovered that one group ofantihistamines, phenothiazines, could be used tocalm patients about to undergo surgery

Psychiatrists tested one of the drugs, chlorpromazine,on 6 patients with psychosis and observed a sharpreduction in their symptomsIn 1954, chlorpromazine (under the trade nameThorazine) was approved for sale in the U.S. as anantipsychotic drug



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Antipsychotic Drugs

Since the discovery of the phenothiazines,other kinds of antipsychotic drugs have beendeveloped

Those developed throughout the 1960s, 1970s,and 1980s are now referred to as conventionalantipsychotic drugs

Drugs developed in recent years are known asatypical or second -generation antipsychotics


How Effective AreAntipsychotic Drugs?

Research has shown that antipsychotic drugsreduce schizophrenia symptoms in at least 65% ofpatients

In direct comparisons, drugs appear to be moreeffective than any other approach used alone

In most cases, the drugs produce the maximumlevel of improvement within the first six monthsof treatment

Symptoms may return if patients stop taking the drugstoo soon



Antipsychotic drugs, particularly theconventional ones, reduce the positivesymptoms of schizophrenia more completely,or at least more quickly, than the negativesymptoms

Correspondingly, people who display largelypositive symptoms generally have better rates ofrecovery than those with primarily negativesymptoms



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Although the use of such drugs is now widelyaccepted, patients often dislike the powerfuleffects of the drugs, and some refuse to takethem


The Unwanted Effects ofConventional Antipsychotic Drugs

In addition to reducing psychotic symptoms,conventional antipsychotic drugs sometimesproduce disturbing movement problems

The most common of these effects produceParkinsonian symptoms, reactions that closelyresemble features of the neurological disorderParkinsons disease


The Unwanted Effects ofConventional Antipsychotic Drugs

In as many as 1% of patients, particularly elderlyones, conventional antipsychotic drugs produceneuroleptic malignant syndrome a severe,potentially fatal reaction

Symptoms include muscle rigidity, fever, alteredconsciousness, and improper functioning of theautonomic nervous system

As soon as the syndrome is recognized, drug useis discontinued and each symptom is treatedmedically

Individuals may also be given dopamine-enhancingdrugs



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Unwanted Effects ofConventional Antipsychotic Drugs

A more difficult side effect of conventionalantipsychotic drugs appears up to 1 year afterstarting the medication

This reaction, called tardive dyskinesia, involveswrithing or tic-like involuntary movements, usuallyof the mouth, lips, tongue, legs, or body

It affects more than 10% of those taking the drugs

Tardive dyskinesia can be difficult, sometimesimpossible, to eliminate


Newer Antipsychotic Drugs

In recent years, new antipsychotic drugs havebeen developed

Examples: Clozaril, Risperdal, Zyprexa, Seroquel,Geodon, and Abilify


Newer Antipsychotic Drugs

These new drugs are called atypical becausetheir biological operation differs from that ofconventional antipsychotics

They appear more effective than conventionalantipsychotic drugs, especially for negative symptomsThey cause few extrapyramidal side effects and seemless likely to case tardive dyskinesiaThey do, however, carry a risk of agranulocytosis, alife-threatening drop in white blood cellsThey also may cause weight gain, dizziness, andsignificant elevations in blood sugar



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Psychotherapy

Before the discovery of antipsychotic drugs,psychotherapy was not an option for peoplewith schizophrenia

Most were too far removed from reality to profitfrom psychotherapy


Psychotherapy

Today, psychotherapy is successful in manymore cases of schizophrenia

The most helpful forms of psychotherapy includecognitive-behavioral therapy and two broadersociocultural therapies: family therapy and socialtherapy

These approaches are often combined


Psychotherapy

Cognitive-behavioral therapyTechniques that seek to change how individualsview and react to their hallucinatory experiences,including:

Provide education and evidence of the bio logical causesof hallucinations

Help clients learn about the comings and goings oftheir own hallucinations and delusions

Challenge clients inaccurate ideas about the power oftheir hallucinations



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Psychotherapy

Cognitive-behavioral therapy An increasing number of clinicians employ

techniques that seek to change how individualsview and react to their hallucinatory experiences,including:

Teach clients to reattribute and more accuratelyinterpret their hallucinations

Teach techniques for coping with their unpleasantsensations


Psychotherapy

Family therapy Over 50% of persons recovering from

schizophrenia and other severe disorder live withfamily members

This creates significant family stress Those who live with relatives who display high levels of

expressed emotion are at greater risk for relapse thanthose who live with more positive or supportive

families


Psychotherapy

Family therapy Family therapy attempts to address such issues,

create more realistic expectations, and providepsychoeducation about the disorder

Families may also turn to family support groupsand family psychoeducation programs

Although research has yet to determine the usefulnessof these groups, the approach has become popular



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Psychotherapy

Social TherapyMany clinicians believe that the treatment of

people with schizophrenia should includetechniques that address social and personaldifficulties in the clients lives

These include: practical advice, problem solving,decision making, social skills training, medicationmanagement, employment counseling, financialassistance, and housing

Research finds that this approach reducesrehospitalization


The Community Approach

The community approach is the broadestapproach for the treatment of schizophrenia andother severe mental disorders

In 1963, Congress passed the Community MentalHealth Act, which said that patients should be able toreceive care within their own communities, ratherthan being transported to institutions far from home

This Act led to massive deinstitutionalization of patients withschizophrenia

Unfortunately, community care was (and is) inadequate fortheir careThe result is a revolving door syndrome


What Are the Features ofEffective Community Care?

People recovering from schizophrenia and othersevere disorders need medication,psychotherapy, help in handling daily pressuresand responsibilities, guidance in makingdecisions, training in social skills, residentialsupervision, and vocational counseling

This combination of services sometimes is calledassertive community treatment

Other key features are



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Coordinated servicesCommunity mental health centers provide medications,

psychotherapy, and inpatient emergency careCoordination of services is especially important formentally ill chemical abusers (MICAs)

Short-term hospitalizationIf treatment on an outpatient basis is unsuccessful,patients may be transferred to short-term hospitalprogramsAfter being hospitalized for up to a few weeks, patients arereleased to aftercare programs for follow-up in thecommunity



Partial hospitalizationIf patient needs fall between full hospitalization andoutpatient care, day center programs may be effective

These programs provide daily supervised activitiesand programs to improve social skills

Another kind of institution that has become popular isthe semihospital, or residential crisis center housesor other structures in the community that provide 24-

hour nursing care for those with severe mentaldisorders



Supervised residencesHalfway houses (or group homes) provide shelterand supervision for those patients who are unableto live alone or with their families, but who do notrequire hospitalizationStaff are usually paraprofessionalsHouses are run with a milieu therapy philosophyThese programs help those with schizophreniaadjust to community life and avoidrehospitalization



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Occupational training and supportPaid employment provides income,

independence, self-respect, and the stimulation ofworking with othersMany people recovering from schizophreniareceive occupational training in a shelteredworkshop a supervised workplace for employeeswho are not ready for competitive or complicated

jobsAn alternative work opportunity for individuals withsevere disorders is supported employment


How Has CommunityTreatment Failed?

There is no doubt that effective communityprograms can help people with schizophrenia andother severe mental disorders recoverHowever, fewer than half of all people who needthem receive appropriate community mentalhealth services

In any given year, 40% to 60% of all people withschizophrenia receive no treatment at allTwo factors are primarily responsible:

Poor coordination of servicesShortage of services



Poor coordination of servicesMental health agencies in a community often fail tocommunicate with one anotherTo combat this problem, a growing number ofcommunity therapists have become case managers forpeople suffering from schizophrenia

Case managers offer therapy and advice, teach problem-solving and social skills, and ensure compliance withmedicationsCase managers also try to coordinate available communityservices for their clients, guide them through the system andprotect their legal rights



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Shortage of servicesThe number of community programs available to

people with schizophrenia falls woefully shortThe centers that do exist generally fail to provideadequate services for people with severedisordersWhile there are various reasons for theseshortages, the primary one is economic


What Are the Consequences ofInadequate Community Treatment?

When community treatment fails, manypeople suffering from schizophrenia and othersevere mental disorders receive no treatmentat all

Many return to their families and receivemedication and perhaps emotional and financialsupport, but little else in the way of treatment


What Are the Consequences of InadequateCommunity Treatment?

Around 8% of patients enter an alternative carefacility (such as a nursing home), where theyreceive custodial care and medicationAs many as 18% are placed in privately runresidences where supervision is provided byuntrained individualsAnother 34% of patients are placed in single-room occupancy hotels, generally in rundownenvironments, where they survive ongovernment disability payments



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What Are the Consequences of InadequateCommunity Treatment?

Finally, a great number of people sufferingfrom schizophrenia become homeless

Approximately one-third of the homeless peoplein America have a severe mental disorder,commonly schizophrenia


The Promise ofCommunity Treatment

Despite these very serious problems, propercommunity care has shown great potential forassisting in recovery from schizophrenia

In addition, a number of national interest groups,including the National Alliance on Mental Illness(NAMI), have formed to push for bettercommunity treatment


The Promise ofCommunity Treatment

Today, community care is a major feature oftreatment for people recovering from severemental disorders in countries around theworld

Both in the U.S. and abroad, varied and well-coordinated community treatment is seen asan important part of the solution to theproblem of schizophrenia


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Ch 15abnormal psychology