9 Psychological & Social interventions

Psychological and social interventions
Psychotherapy may be used in the treatment of schizophrenia. It has been reported that, despite evidence and recommendations, treatment is often confined to pharmacotherapy alone because of reimbursement problems or lack of training[92]
Cognitive behavioral therapy may focus on the direct reduction of the symptoms, or on related aspects, such as issues of self-esteem, social functioning, and insight. Although the results of early trials with cognitive behavioral therapy (CBT) were inconclusive,[93] more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia.[94] There have also been advances in social skills training[95]
Another approach is cognitive remediation therapy, a technique aimed at remediating the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by fMRI.[96] A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy[97]
A recent randomised controlled trial found that music therapy significantly improved symptom scores in a group of patients diagnosed with schizophrenia.[98] A notable early mention of the beneficial effect of music on mental illness was in 1621 by Robert Burton in The Anatomy of Melancholy.[99]
Therapy which addresses the whole family system of an individual with a diagnosis of schizophrenia, including through psychological education, has also been found to have significant benefits[100][101]
Community services
Support services available can include drop-in centers, visits from members of a 'community mental health team' or Assertive Community Treatment team, supported employment[102] and patient-led support groups.
In recent years the importance of service-user led recovery based movements has grown substantially throughout Europe and America. Groups such as the Hearing Voices Network and more recently, the Paranoia Network, have developed a self-help approach that aims to provide support and assistance outside of the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for mental illness or mental health, they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Peer-to-peer suppport is also developing a professional footing with partnerships between hospitals and consumer run groups becoming more common. These services work towards remediating social withdrawal, building social skills and reducing rehospitalization.
In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better[103] than for people in the West. The reasons for this effect are not clear, although cross-cultural studies are being conducted.
Inpatient services
Hospitalization may occur, with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur.
Prognosis
Prognosis for any particular individual affected by schizophrenia is particularly hard to judge as treatment and access to treatment is continually changing, as new methods become available and medical recommendations change.
One retrospective study has shown that about a third of people make a full recovery, about a third show improvement but not a full recovery, and a third remain ill.[104] A more recent study using stricter recovery criteria (i.e. concurrent remission of positive and negative symptoms and specific instances of adequate social / vocational functioning) reported a recovery rate of 13.7%.[105]
The exact definition of what constitutes a recovery has not been widely defined, however, although criteria have recently been suggested to define a remission in symptoms.[85] Therefore, this makes it difficult to give an exact estimate as recovery and remission rates are not always comparable across studies.
The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies' findings were that these patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),[106] despite the fact antipsychotic drugs are typically not widely available in poorer countries, thus raising questions about the effectiveness of such drug-based treatments.
Prognosis also depends on some other factors. Females tend to show recovery rates higher than males, and acute and sudden onset of schizophrenia is associated with higher rates of recovery, while gradual onset is associated with lower rates. Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Pre-morbid functioning and positive prognosis also seem to be correlated.
In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80-85% of that of the general population. Women with a diagnosis of schizophrenia were found to have a slightly better life expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a better life expectancy than substance abuse, personality disorder, heart attack and stroke.[107]
There is an extremely high suicide rate associated with schizophrenia. A recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime.[108] Another study suggested that 10% of persons with schizophrenia die by suicide.[109]
Recovery and rehabilitation
Just as the clarity of the diagnosis itself attacts controversy and criticism, it is difficult to establish a clear picture of recovery and rehabilitation. Both long ago and in the recent past, patients in developed countries were told that chances of recovery were limited, with statistics being quoted to support this negative prognosis. Today, with the advent of a vocal "Recovery Movement" in mental health, and longitudinal studies indicating better rates of recovery than previously assumed, attention is drawn to cultural and local factors in impeding or accelerating recovery and different models of rehabilitation and recovery.[110][111]
Drug use
The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to tease apart. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion, paranoia and anhedonia are all considered to be core features.
The rate of substance use is known to be particularly high in this group. In a recent study, 60% of people with schizophrenia were found to use substances and 37% would be diagnosable with a substance use disorder.[112]
Amphetamines
As amphetamines trigger the release of dopamine and excessive dopamine function is believed to be responsible for many symptoms of schizophrenia (known as the dopamine hypothesis of schizophrenia), amphetamines may worsen schizophrenia symptoms.
Hallucinogens
Schizophrenia can sometimes be triggered by heavy use of hallucinogenic or stimulant drugs [113], although some claim that a predisposition towards developing schizophrenia is needed for this to occur. There is also some evidence suggesting that people suffering schizophrenia but responding to treatment can have relapse because of subsequent drug use. Some widely known cases where hallucinogens have been suspected of precipitating schizophrenia are Pink Floyd founder-member Syd Barrett and The Beach Boys producer, arranger and songwriter Brian Wilson.
Drugs such as ketamine, PCP, and LSD have been used to mimic schizophrenia for research purposes, although this has now fallen out of favor with the scientific research community, as the differences between the drug induced states and the typical presentation of schizophrenia have become clear.
Hallucinogenic drugs were also briefly tested as possible treatments for schizophrenia by psychiatrists such as Humphry Osmond and Abram Hoffer in the 1950s. It was mainly for this experimental treatment of schizophrenia that LSD administration was legal, briefly before its use as a recreational drug led to its criminalization.
Cannabis
There is evidence that cannabis use can contribute to schizophrenia. Some studies suggest that cannabis is neither a sufficient nor necessary factor in developing schizophrenia, but that cannabis may significantly increase the risk of developing schizophrenia and may be, among other things, a significant causal factor. Nevertheless, some previous research in this area has been criticised as it has often not been clear whether cannabis use is a cause or effect of schizophrenia. To address this issue, a recent review of studies from which a causal contribution to schizophrenia can be assessed has suggested that cannabis statistically doubles the risk of developing schizophrenia on the individual level, and may, assuming a causal relationship, be responsible for up to 8% of cases in the population.[114]
An older longitudinal study, published in 1987, suggested six-fold increase of schizophrenia risks for high consumers of cannabis (use on more than fifty occasions) in Sweden. [115]
Tobacco
People with schizophrenia tend to smoke significantly more tobacco than the general population. The rates are exceptionally high amongst institutionalized patients and homeless people. In a UK census from 1993, 74% of people with schizophrenia living in institutions were found to be smokers.[116][117] A 1999 study that covered all people with schizophrenia in Nithsdale, Scotland found a 58% prevalence rate of cigarette smoking, to compare with 28% in the general population.[118] An older study found that as much as 88% of outpatients with schizophrenia were smokers.[119]
Despite the higher prevalence of tobacco smoking, people diagnosed with schizophrenia have a much lower than average chance of developing and dying from lung cancer. While the reason for this is unknown, it may be because of a genetic resistance to the cancer, a side-effect of drugs being taken, or a statistical effect of increased likelihood of dying from causes other than lung cancer.[4]
A recent study of over 50,000 Swedish conscripts found that there was a small but significant protective effect of smoking cigarettes on the risk of developing schizophrenia later in life.[120] While the authors of the study stressed that the risks of smoking far outweigh these minor benefits, this study provides further evidence for the 'self-medication' theory of smoking in schizophrenia and may give clues as to how schizophrenia might develop at the molecular level. Furthermore, many people with schizophrenia have smoked tobacco products long before they are diagnosed with the illness, and some groups advocate that the chemicals in tobacco have actually contributed to the onset of the illness and have no benefit of any kind.
It is of interest that cigarette smoking affects liver function such that the antipsychotic drugs used to treat schizophrenia are broken down in the blood stream more quickly. This means that smokers with schizophrenia need slightly higher doses of antipsychotic drugs in order for them to be effective than do their non-smoking counterparts.
The increased rate of smoking in schizophrenia may be due to a desire to self-medicate with nicotine. One possible reason is that smoking produces a short term effect to improve alertness and cognitive functioning in persons who suffer this illness.[121] It has been postulated that the mechanism of this effect is that people with schizophrenia have a disturbance of nicotinic receptor functioning which is temporarily abated by tobacco use.[121]
Alternative approaches
An approach broadly known as the anti-psychiatry movement, notably most active in the 1960s, has opposed the orthodox medical view of schizophrenia as an illness.
Psychiatrist Thomas Szasz argues that psychiatric patients are not ill but are just individuals with unconventional thoughts and behavior that make society uncomfortable. He argues that society unjustly seeks to control such individuals by classifying their behavior as an illness and forcibly treating them as a method of social control. According to this view, "schizophrenia" does not actually exist but is merely a form of social constructionism, created by society's concept of what constitutes normality and abnormality. It is worth noting that Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that it should be conducted between consenting adults, rather than imposed upon anyone against his or her will.
Similarly, psychiatrists R. D. Laing, Silvano Arieti, Theodore Lidz and presently Colin Ross[122] have argued that the symptoms of what is normally called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were revolutionary in valuing the content of psychotic experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. Laing's work, co-authored with Aaron Esterson, Sanity, Madness and the Family (1964) described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations. Arieti's Interpretation of Schizophrenia won the 1975 scientific National Book Award in the United States. In the books Schizophrenia and the Family and The Origin and Treatment of Schizophrenic Disorders Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children.
In the 1976 book The Origin of Consciousness in the Breakdown of the Bicameral Mind, psychologist Julian Jaynes proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness. This would take the form of a "bicameral mind" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. This theory was briefly controversial. Continuing research has failed to either further confirm or refute the thesis.
Psychiatrist Tim Crow has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for language.[123] Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down.
Researchers into shamanism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman.[124] Certainly, the experience of having access to multiple realities is not uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the altered states of consciousness psychiatrists label as illness. Psychohistorians, on the other hand, accept the psychiatric diagnoses. However, unlike the current medical model of mental disorders they argue that poor parenting in tribal societies causes the shaman’s schizoid personalities.[125] Speculations regarding primary and important religious figures as having schizophrenia abound. Commentators such as Paul Kurtz and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.[126]
Alternative medicine tends to hold the view that schizophrenia is primarily caused by imbalances in the body's reserves and absorption of dietary minerals, vitamins, fats, and/or the presence of excessive levels of toxic heavy metals. The body's adverse reactions to gluten are also strongly implicated in some alternative theories (see gluten-free, casein-free diet). Although this theory is generally deemed to be unproven, it is worth noting that it was positively discussed in the Lancet in 1970,[127] the British Medical Journal in 1973,[128] and other publications.[129] A recent literature by scientists at Johns Hopkins University confirms some of these findings.[130] The branch of alternative medicine that deals with these views regarding the cause of schizophrenia, is known as orthomolecular psychiatry. Hoffer and Walker, in their book Orthomolecular Nutrition (Keats Publishing, 1978), argue that schizophrenia can be treated effectively with doses of Vitamin B-3 (Niacin).
One theory put forward by psychiatrists E. Fuller Torrey and R.H. Yolken is that the parasite Toxoplasma gondii leads to some, if not many, cases of schizophrenia.[131] This is supported by evidence that significantly higher levels of Toxoplasma antibodies in schizophrenia patients compared to the general population.[132]
An additional approach is suggested by the work of Richard Bandler who argues that "The usual difference between someone who hallucinates and someone who visualizes normally, is that the person who hallucinates doesn't know he's doing it or doesn't have any choice about it." (Time for a Change, p107). He suggests that because visualization is a sophisticated mental capability, schizophrenia is a skill, albeit an involuntary and dysfunctional one that is being used but not controlled. He therefore suggests that a significant route to treating schizophrenia might be to teach the missing skill - how to distinguish created reality from consensus external reality, to reduce its maladaptive impact, and ultimately how to exercise appropriate control over the vizualization or auditory process. Hypnotic approaches have been explored by the physician Milton H. Erickson as a means of facilitating this.
Regarding schizophrenia as a waking dreamer syndrome, Jie Zhang hypothesizes that the hallucinations of schizophrenia are caused by the activation of the continual-activation mechanism during waking, a mechanism that induces dreaming while asleep, due to the malfunction of the continual-activation thresholds in the conscious part of brain.[133]
Popular culture
The Marathi film Devrai (Featuring Atul Kulkarni) is a presentation of a patient with schizophrenia. The film, set in the Konkan region of Maharashtra in Western India, shows the behavior, mentality, and struggle of the patient as well as his loved-ones. It also portrays the treatment of this mental illness using medication, dedication and lots of patience of the close relatives of the patient.
The book and film A Beautiful Mind chronicled the life of John Forbes Nash, a Nobel-Prize-winning mathematician who was diagnosed with schizophrenia.
In Bulgakov's Master and Margarita the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death.
The book The Eden Express by Mark Vonnegut accounts his struggle into schizophrenia and his journey back to sanity.
In the book Misery by Stephen King, the antagonist Annie Wilkes is thought to suffer from a form of schizophrenia, in addition to other psychological disorders that makes her very argumentative and not able to easily distinguish between fiction and reality.
EastEnders featured a very successful storyline in 1996 that involved a character suffering from schizophrenia, triggered by the loss of a relative.
Paul C. Elliot's stage play Perspective follows three institutionalized patients with schizophrenia through visiting day with family members. The play is written from a patients' perspective to give the viewer a feeling as to what those suffering from schizophrenia experience.
The effects of untreated schizophrenia on the family are documented in Virginia Holman's autobiography, Rescuing Patty Hearst (Simon & Schuster 2003). The book also discusses the legal impediments to treatment that face many people with schizophrenia and their families.
The PC Video Game Max Payne and Max Payne 2 portrays schizophrenia
Nicole Diver, from F. Scott Fitzgerald's "Tender Is the Night" is diagnosed with schizophrenia.
Also see Lobotomy in Popular Culture
In the television show Dirt photographer Don Konkey is a schizophrenic.
In the novel Sophie's Choice by William Styron, the character Nathan Landau has paranoid schizophrenia.
In the adaption of the novel and picture, a blond blue eyed boy suffers through a life whilst dealing with schizophrenia. (Title coming;)
Peter Evans, in the 2007 movie Bug, is a paranoid schizophrenic loner.
See also
Antipsychotic
Biopsychiatry controversy
Delusion
Disorganized schizophrenia
Dopamine hypothesis of schizophrenia
Formal thought disorder
Hallucination
Histamine
Interpretation of Schizophrenia (book)
Psychoanalysis
Psychosis
Schizoaffective disorder
Schizoid personality disorder
Schizotypy
Soteria
Tardive dysphrenia
Toxoplasma
Trauma model of mental disorders
Further reading
Bentall, R. (2003) Madness explained: Psychosis and Human Nature. London: Penguin Books Ltd. ISBN 0-7139-9249-2
Boyle, Mary, (1993), Schizophrenia: A Scientific Delusion, Routledge, ISBN 0-415-09700-2
Deveson, Anne (1991), Tell Me I'm Here. Penguin. ISBN 0-14-027257-7
Fallon, James H. et. al. (2003) The Neuroanatomy of Schizophrenia: Circuitry and Neurotransmitter Systems. Clinical Neuroscience Research 3:77-107. [2]
Green, M.F. (2001) Schizophrenia Revealed: From Neurons to Social Interactions. New York: W.W. Norton. ISBN 0-393-70334-7
Jones, S. and Hayward, P. (2004) Coping with Schizophrenia: A Guide for Patients, Families and Caregivers. ISBN 1-85168-344-5
Keen, T. M. (1999) Schizophrenia: orthodoxy and heresies. A review of alternative possibilities. Journal of Psychiatric and Mental Health Nursing, 1999, 6, 415-424. pdf
Noll, Richard (2007) The Encyclopedia of Schizophrenia and Other Psychotic Disorders, Third Edition ISBN 0-8160-6405-9
Read, J., Mosher, L.R., Bentall, R. (2004) Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. ISBN 1-58391-906-6. A critical approach to biological and genetic theories, and a review of social influences on schizophrenia.
Szasz, T. (1976) Schizophrenia: The Sacred Symbol of Psychiatry. New York: Basic Books. ISBN 0-465-07222-4
Tausk, V. : "Sexuality, War, and Schizophrenia: Collected Psychoanalytic Papers", Publisher: Transaction Publishers 1991, ISBN 0-88738-365-3 (On the Origin of the 'Influencing Machine' in Schizophrenia.)
Torrey, E.F., M.D. (2006) Surviving Schizophrenia: A Manual for Families, Consumers, and Providers (5th Edition). Quill (HarperCollins Publishers) ISBN 0-06-084259-8
Vonnegut, M. The Eden Express. ISBN 0-553-02755-7. A personal account of schizophrenia.
Wiencke, Markus (2006) Schizophrenie als Ergebnis von Wechselwirkungen: Georg Simmels Individualitätskonzept in der Klinischen Psychologie. In David Kim (ed.), Georg Simmel in Translation: Interdisciplinary Border-Crossings in Culture and Modernity (pp. 123-155). Cambridge Scholars Press, Cambridge, ISBN 1-84718-060-5
External links
News, information and further description
DSM V scholarly debates on schizophrenia
NPR: the sight and sounds of schizophrenia
National Mental Health Association fact sheet on schizophrenia
Understanding Schizophrenia - A factsheet from the mental health charity Mind
DSM-IV-TR Full diagnostic criteria for schizophrenia
World Health Organisation data on schizophrenia from 'The World Health Report 2001. Mental Health: New Understanding, New Hope'
National Institute of Mental Health (USA) Schizophrenia information
Childhood Schizophrenia Summary
National Mental Health Consumers' Self-Help Clearinghouse
UCLA Laboratory of Neuro Imaging definition
The current World Health Organisation definition of Schizophrenia
A directory of free full-text articles on diagnosis and management of schizophrenia
Schizophrenia by WebMD (pharmaceutical company sponsored).
Schizophrenia.com - information and support site.
Schizophrenia in history
Symptoms in Schizophrenia Film made in 1940 showing some of the symptoms of Schizophrenia.
http://www.sciencedaily.com/news/mind_brain/schizophrenia/
Open The Doors - information on global programme to fight stigma and discrimination because of Schizophrenia. The World Psychiatric Association (WPA)
Scientific American Magazine (January 2004 Issue) Decoding Schizophrenia
Schizophrenia Research Forum
Charities and support groups
Schizophrenics Anonymous
SANE UK mental health charity focused on schizophrenia that supports sufferers, runs a helpline and carries out research into mental illness
The Schizophrenia Association of Great Britain
CASL The Campaign for Abolition of the Schizophrenia Label.
WFSAD The World Fellowship for Schizophrenia and Allied Disorders is an education and support network for families of people with schizophrenia.