Summary: Cognitive Behavior Therapy For Schizophrenia
Treatment for schizophrenia
As several factors are involved in the aetiology of schizophrenia, comprehensive treatment may require a combination of several treatment methods. As it is not realistic for every patient to receive a combination of several treatments, clinicians should devise individualised treatment plans taking into consideration patient’s background and their most severe and harmful symptomology.
Biological treatments
Antipsychotic drugs
Antipsychotic drugs are typically an efficacious treatment for the positive symptoms of schizophrenia (Foussias & Remington, 2010). Most antipsychotics are thought to reduce positive symptoms because they block dopamine receptors. Therefore, their effectiveness reinforces the dopamine hypothesis. …show more content…
However, it is unclear how some evidence fits with the dopamine hypothesis. For example, antipsychotics start blocking dopamine receptors in the brain within hours of administration but symptoms do not improve until about 6 weeks after the beginning of treatment (Smieskova et al., 2009). Antipsychotics have been found to reduce attentional biases in patients with schizophrenia and cannabis use disorder (Machielsen, Valtman, van den Brink & de Haan, 2014), suggesting that, in some cases, antipsychotics may also reduce cognitive biases involved in the aetiology of schizophrenia.
Compared to other treatments, antipsychotics are relatively cheap, easy to administer and less time-consuming. However, the clinical effectiveness of antipsychotics is impaired because patients often stop taking them. One study found that out of 1493 participants with schizophrenia, 74% had stopped taking their antipsychotic medication within 18 months (Lieberman et al., 2005). Most participants cited intolerable side effects as their reason. For example, weight gain (Bak, Fransen, Janssen, van Os & Drukker, 2014), sexual dysfunction (Egilmez, Celik & Kalenderoglu, 2016) and movement disorders (Grilly, 2002). Until further research establishes a way to reduce these side effects, the best way to improve the effectiveness of antipsychotics may be to help patients to manage their side effects (Danzer & Rieger, 2016). Relapse rates are high when antipsychotic treatment is discontinued (Emsley, Kilian & Phahladira, 2016) as antidepressants merely supress, rather than eliminate, symptoms. Therefore, and as antipsychotics are not addictive, it may be recommended that people with schizophrenia take antipsychotic medication long-term (Emsley, Kilian & Phahladira, 2016).
Electroconvulsive therapy
Electroconvulsive therapy (ECT) induces short seizures by passing an electric current through the patient’s brain. ECT was previously used extensively to treat schizophrenia but, as it is very invasive, it is now only used for drug-resistant patients or those who exhibit suicidal behaviour (Pompili et al., 2013). ECT is particularly effective for treating catatonia, and is mildly effective for delusions, hallucinations or disorganised thinking (Zervas, Theleritis & Soldatos, 2012). It may also improve responsivity to antipsychotic medication (Zervas, Theleritis & Soldatos, 2012).
Potential new biological treatments
The efficacy of alternative treatments for schizophrenia is currently being investigated. Some suggest that deep brain stimulation (Kuhn et al., 2011; Klein et al., 2013) and transcranial magnetic stimulation (Dougall et al., 2015) could become viable treatments for schizophrenia in the future. For example, Mikell, Sinha and Sheth (2016) propose targeting certain brain pathways with deep brain stimulation based on dopamine dysfunction. However, currently there is not enough human evidence to either support or refute their use to treat schizophrenia.
Psychological treatments
Cognitive behavioural therapy for psychosis (CBTp)
Cognitive behaviour therapy for psychosis (CBTp) is a talking therapy that identifies and challenges the patient’s abnormal cognitive biases.
A recent meta-analysis concludes that CBTp is most effective at improving negative symptoms (Naeem et al., 2016). CBTp can also reduce auditory hallucinations (van der Gaag, Valmaggia & Smit, 2014) and is effective at reducing delusions (Mehl, Werner & Lincoln, 2015; Serruya & Grant, 2009). Furthermore, CBTp can help patients to cope with side effects from antipsychotics which may improve their adherence to, and therefore the effectiveness of, their medication. Perhaps CBTp could also reduce safety behaviours that negatively reinforce delusions (Freeman et al., 2007). Unfortunately, cognitive behavioural therapies can be time consuming as multiple sessions are required. This is expensive to provide and there are often issues with patients’ attendance (Karbasi, Arman & Maracy, 2010).
Social skills training
For comprehensive treatment of schizophrenia, it is vital to rebuild skills that are lost due to its symptoms. The negative symptoms of schizophrenia often cause social withdrawal and inappropriate social behaviours. These social deficits are usually negatively reinforced, causing them to worsen. Social skills training focusses on appropriate conversational skills, physical gestures, eye-contact and facial expressions. It has been found to moderately improve social and daily living skills, community functioning and to reduce negative symptoms (Kurtz & Mueser, 2008).
Cognitive remediation
therapy
In a similar way, cognitive remediation therapy focuses on improving cognitive deficits associated with schizophrenia. Patients are usually asked to carry out a number of paper-and-pencil or computer-based cognitive tasks to improve attention, memory and problem solving over several sessions. This therapy has been found to improve working memory and cognitive flexibility (Wykes et al., 2007).
Like CBTp, social skills training and cognitive remediation therapy are time-consuming and expensive as they require several sessions. Although, they are worthwhile as they have the potential to resolve some of the impact of schizophrenia and aid successful functioning in everyday community life.
Family therapy
The family environment can significantly affect people with schizophrenia. For example, familial warmth and positive regard facilitates recovery from schizophrenia, whereas criticism and forced hospitalisation may not (Aldersey & Whitley, 2015). The family can facilitate recovery from schizophrenia by providing both moral and practical support and being an intrinsic motivation for recovery (Aldersey & Whitley, 2015). People with schizophrenia who have family therapy are significantly less likely to relapse than those who have individual therapy (Falloon, Boyd & McGill, 1984). A variety of family therapy techniques exist but family members are usually encouraged to express and to listen to each other’s constructive positive and negative emotions. Family therapy may reduce relapse rates by lowering EE, as it aims to reduce dysfunctional communication.
Conclusions
In summary, schizophrenia is a severe mental illness with a range of characteristic symptoms, including: hallucinations, delusions, motor behaviours, cognitive impairments and negative symptoms. People can be genetically predisposed to schizophrenia, but other biological, social and psychological factors may contribute to its development. Clinicians need to take into consideration a patients’ symptoms, comorbid illnesses, family history of schizophrenia, personal drug history, family environment, and socioeconomic status into consideration to design effective individual-tailored treatment plans. In most cases, some combination of antipsychotics, cognitive behaviour therapy for psychosis, social skills training, cognitive remediation therapy and family therapy is likely to be effective, with ECT being recommended for drug-resistant patients and catatonic symptoms. Together, these treatments comprehensively target the positive and negative symptoms of schizophrenia, prevent relapse and help people with schizophrenia to function successfully in the community.
As several factors are involved in the aetiology of schizophrenia, comprehensive treatment may require a combination of several treatment methods. As it is not realistic for every patient to receive a combination of several treatments, clinicians should devise individualised treatment plans taking into consideration patient’s background and their most severe and harmful symptomology.
Biological treatments
Antipsychotic drugs
Antipsychotic drugs are typically an efficacious treatment for the positive symptoms of schizophrenia (Foussias & Remington, 2010). Most antipsychotics are thought to reduce positive symptoms because they block dopamine receptors. Therefore, their effectiveness reinforces the dopamine hypothesis. …show more content…
However, it is unclear how some evidence fits with the dopamine hypothesis. For example, antipsychotics start blocking dopamine receptors in the brain within hours of administration but symptoms do not improve until about 6 weeks after the beginning of treatment (Smieskova et al., 2009). Antipsychotics have been found to reduce attentional biases in patients with schizophrenia and cannabis use disorder (Machielsen, Valtman, van den Brink & de Haan, 2014), suggesting that, in some cases, antipsychotics may also reduce cognitive biases involved in the aetiology of schizophrenia.
Compared to other treatments, antipsychotics are relatively cheap, easy to administer and less time-consuming. However, the clinical effectiveness of antipsychotics is impaired because patients often stop taking them. One study found that out of 1493 participants with schizophrenia, 74% had stopped taking their antipsychotic medication within 18 months (Lieberman et al., 2005). Most participants cited intolerable side effects as their reason. For example, weight gain (Bak, Fransen, Janssen, van Os & Drukker, 2014), sexual dysfunction (Egilmez, Celik & Kalenderoglu, 2016) and movement disorders (Grilly, 2002). Until further research establishes a way to reduce these side effects, the best way to improve the effectiveness of antipsychotics may be to help patients to manage their side effects (Danzer & Rieger, 2016). Relapse rates are high when antipsychotic treatment is discontinued (Emsley, Kilian & Phahladira, 2016) as antidepressants merely supress, rather than eliminate, symptoms. Therefore, and as antipsychotics are not addictive, it may be recommended that people with schizophrenia take antipsychotic medication long-term (Emsley, Kilian & Phahladira, 2016).
Electroconvulsive therapy
Electroconvulsive therapy (ECT) induces short seizures by passing an electric current through the patient’s brain. ECT was previously used extensively to treat schizophrenia but, as it is very invasive, it is now only used for drug-resistant patients or those who exhibit suicidal behaviour (Pompili et al., 2013). ECT is particularly effective for treating catatonia, and is mildly effective for delusions, hallucinations or disorganised thinking (Zervas, Theleritis & Soldatos, 2012). It may also improve responsivity to antipsychotic medication (Zervas, Theleritis & Soldatos, 2012).
Potential new biological treatments
The efficacy of alternative treatments for schizophrenia is currently being investigated. Some suggest that deep brain stimulation (Kuhn et al., 2011; Klein et al., 2013) and transcranial magnetic stimulation (Dougall et al., 2015) could become viable treatments for schizophrenia in the future. For example, Mikell, Sinha and Sheth (2016) propose targeting certain brain pathways with deep brain stimulation based on dopamine dysfunction. However, currently there is not enough human evidence to either support or refute their use to treat schizophrenia.
Psychological treatments
Cognitive behavioural therapy for psychosis (CBTp)
Cognitive behaviour therapy for psychosis (CBTp) is a talking therapy that identifies and challenges the patient’s abnormal cognitive biases.
A recent meta-analysis concludes that CBTp is most effective at improving negative symptoms (Naeem et al., 2016). CBTp can also reduce auditory hallucinations (van der Gaag, Valmaggia & Smit, 2014) and is effective at reducing delusions (Mehl, Werner & Lincoln, 2015; Serruya & Grant, 2009). Furthermore, CBTp can help patients to cope with side effects from antipsychotics which may improve their adherence to, and therefore the effectiveness of, their medication. Perhaps CBTp could also reduce safety behaviours that negatively reinforce delusions (Freeman et al., 2007). Unfortunately, cognitive behavioural therapies can be time consuming as multiple sessions are required. This is expensive to provide and there are often issues with patients’ attendance (Karbasi, Arman & Maracy, 2010).
Social skills training
For comprehensive treatment of schizophrenia, it is vital to rebuild skills that are lost due to its symptoms. The negative symptoms of schizophrenia often cause social withdrawal and inappropriate social behaviours. These social deficits are usually negatively reinforced, causing them to worsen. Social skills training focusses on appropriate conversational skills, physical gestures, eye-contact and facial expressions. It has been found to moderately improve social and daily living skills, community functioning and to reduce negative symptoms (Kurtz & Mueser, 2008).
Cognitive remediation
therapy
In a similar way, cognitive remediation therapy focuses on improving cognitive deficits associated with schizophrenia. Patients are usually asked to carry out a number of paper-and-pencil or computer-based cognitive tasks to improve attention, memory and problem solving over several sessions. This therapy has been found to improve working memory and cognitive flexibility (Wykes et al., 2007).
Like CBTp, social skills training and cognitive remediation therapy are time-consuming and expensive as they require several sessions. Although, they are worthwhile as they have the potential to resolve some of the impact of schizophrenia and aid successful functioning in everyday community life.
Family therapy
The family environment can significantly affect people with schizophrenia. For example, familial warmth and positive regard facilitates recovery from schizophrenia, whereas criticism and forced hospitalisation may not (Aldersey & Whitley, 2015). The family can facilitate recovery from schizophrenia by providing both moral and practical support and being an intrinsic motivation for recovery (Aldersey & Whitley, 2015). People with schizophrenia who have family therapy are significantly less likely to relapse than those who have individual therapy (Falloon, Boyd & McGill, 1984). A variety of family therapy techniques exist but family members are usually encouraged to express and to listen to each other’s constructive positive and negative emotions. Family therapy may reduce relapse rates by lowering EE, as it aims to reduce dysfunctional communication.
Conclusions
In summary, schizophrenia is a severe mental illness with a range of characteristic symptoms, including: hallucinations, delusions, motor behaviours, cognitive impairments and negative symptoms. People can be genetically predisposed to schizophrenia, but other biological, social and psychological factors may contribute to its development. Clinicians need to take into consideration a patients’ symptoms, comorbid illnesses, family history of schizophrenia, personal drug history, family environment, and socioeconomic status into consideration to design effective individual-tailored treatment plans. In most cases, some combination of antipsychotics, cognitive behaviour therapy for psychosis, social skills training, cognitive remediation therapy and family therapy is likely to be effective, with ECT being recommended for drug-resistant patients and catatonic symptoms. Together, these treatments comprehensively target the positive and negative symptoms of schizophrenia, prevent relapse and help people with schizophrenia to function successfully in the community.