AbPsy-Chapter-6 PDF

BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Chapter 6: Schizophrenia Spectrum Somatic delusions...

BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Chapter 6: Schizophrenia Spectrum Somatic delusions focus on preoccupations regarding health and organ and Other Psychotic Disorders function. SCHIZOPHRENIA SPECTRUM AND OTHER Delusions that express a loss of control over mind or body are PSYCHOTIC DISORDERS generally considered to be bizarre: Schizophrenia Spectrum and Other Psychotic Thought Withdrawal Disorders these include the belief that one’s thoughts have Schizophrenia spectrum and other psychotic been “removed” by some outside force disorders include schizophrenia, other psychotic disorders, and schizotypal (personality) disorder. Thought Insertion that alien thoughts have been put into one’s mind They are defined by abnormalities in one or more of the following five domains: delusions, Delusions of Control hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor that one’s body or actions are being acted on or behavior (including catatonia), and negative manipulated by some outside force. symptoms. HALLUCINATIONS KEY FEATURES THAT DEFINE THE PSYCHOTIC DISORDERS Hallucinations perception-like experiences that occur without an DELUSIONS external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not Delusions under voluntary control. fixed beliefs that are not amenable to change in light of conflicting evidence. Their content may include a Auditory hallucinations variety of themes (e.g., persecutory, referential, usually experienced as voices, whether familiar or somatic, religious, grandiose). unfamiliar, that are perceived as distinct from the individual’s own thoughts. Persecutory delusions belief that one is going to be harmed, harassed, and The hallucinations must occur in the context of a clear so forth by an individual, organization, or other group sensorium: Referential delusions Hypnagogic belief that certain gestures, comments, those that occur while falling asleep environmental cues, and so forth are directed at oneself Hypnopompic waking up Grandiose delusions when an individual believes that he or she has DISORGANIZED THINKING (SPEECH) exceptional abilities, wealth, or fame. Disorganized Thinking (Speech) (formal thought Erotomanic delusions disorder) when an individual believes falsely that another typically inferred from the individual’s speech. The person is in love with him or her. individual may switch from one topic to another (derailment or loose associations) Nihilistic delusions Tangentiality involve the conviction that a major catastrophe will occur answers to questions may be obliquely related or completely unrelated 1 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Incoherence or “word salad” Other negative symptoms: rarely, speech may be so severely disorganized that it is nearly incomprehensible and resembles Alogia receptive aphasia in its linguistic disorganization. manifested by diminished speech output GROSSLY DISORGANIZED OR ABNORMAL MOTOR Anhedonia BEHAVIOR (INCLUDING CATATONIA) the decreased ability to experience pleasure. Grossly Disorganized or Abnormal Motor Behavior Asociality (Including Catatonia) refers to the apparent lack of interest in social may manifest itself in a variety of ways, ranging from interactions and may be associated with avolition, childlike “silliness” to unpredictable agitation. but it can also be a manifestation of limited Problems may be noted in any form of goal-directed opportunities for social interactions. behavior, leading to difficulties in performing activities of daily living. PERSPECTIVE ON SCHIZOPHRENIA Catatonic behavior Schizophrenia marked decrease in reactivity to the environment. Disorder characterized by a broad spectrum of cognitive and emotional dysfunctions including  This ranges from resistance to instructions delusions and hallucinations, disorganized speech (negativism); and behavior, and inappropriate emotions.  To maintaining a rigid, inappropriate or bizarre This disorder can disrupt a person’s perception, posture; thought, speech, and movement: almost every aspects of daily functioning.  To a complete lack of verbal and motor responses (mutism and stupor) Despite of important advances in treatment, full recovery from schizophrenia has a low base rate of  It can also include purposeless and excessive 1 in 7 patients. motor activity without obvious cause (catatonic excitement Widespread affecting approximately 1 of every 100 people at some point in their lives NEGATIVE SYMPTOMS EARLY FIGURES IN THE HISTORY OF Negative Symptoms SCHIZOPHRENIA account for a substantial portion of the morbidity associated with schizophrenia but are less prominent Emil Kraepelin in other psychotic disorders. A German psychiatrist who unified the distinct categories of schizophrenia (hebephrenic, catatonic, TWO NEGATIVE SYMPTOMS: and paranoid) under the name dementia praecox Diminished Emotional Expression He built on the writings of Haslam, Pinel and Morel includes reductions in the expression of emotions in to give us today what stands today as the most the face, eye contact, intonation of speech (prosody), enduring description and categorization of and movements of the hand, head, and face that schizophrenia normally give an emotional emphasis to speech. Two of Kraepelin’s accomplishments: (1) he Avolition combined several symptoms of insanity that has is a decrease in motivated self-initiated purposeful usually been viewed as reflecting separate and activities. The individual may sit for long periods of distinct disorders. (2) distinguished dementia time and show little interest in participating in work or praecox from manic-depressive illness (now called social activities bipolar disorder). 2 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL major areas, such as work, interpersonal relations, Catatonia – alternating immobility and excited or self-care, is markedly below the level achieved agitation prior to the onset Hebephrenia – silly and immature emotionality C. Continuous signs of the disturbance persist for at least 6 months. This 6- month period must include at Paranoia – delusions of grandeur or persecution least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase Eugen Bleuler symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or Swiss psychiatrist who introduced the term Schizophrenia residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an Schizophrenia Greek words for “split” (skhizein) and attenuated form (e.g., odd beliefs, unusual “mind” (phren) perceptual experiences). Bleuler’s belief that underlying all the unusual D. Schizoaffective disorder and depressive or bipolar behaviors shown by people with this disorder was an disorder with psychotic features have been ruled out associative splitting of the basic functions of because either 1) no major depressive or manic personality. episodes have occurred concurrently with the activephase symptoms, or 2) if mood episodes have John Haslam occurred during active-phase symptoms, they have Superintendent of a British hospital. In Observations been present for a minority of the total duration of the on Madness and Melancholy, he outlined a active and residual periods of the illness. description of the symptoms of schizophrenia. E. The disturbance is not attributable to the Philippe Pinel physiological effects of a substance (e.g., a drug of A French physician who described cases of abuse, a medication) or another medical condition. schizophrenia. F. If there is a history of autism spectrum disorder or a Benedict Morel communication disorder of childhood onset, the Physician at a French institution who used the term additional diagnosis of schizophrenia is made only if démence précoce (in Latin, dementia praecox), prominent delusions or hallucinations, in addition to meaning early or premature (précoce) loss of mind the other required symptoms of schizophrenia, are (démence) to describe schizophrenia. also present for at least 1 month (or less if successfully treated). DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA CLINICAL DESCRIPTION, SYMPTOMS & A. Two (or more) of the following, each present for a SUBTYPES significant portion of time during a 1-month period (or less if successfully treated). At least one of these SCHIZOTYPAL (PERSONALITY) DISORDER must be (1), (2), or (3): Schizotypal (Personality) Disorder 1. Delusions. Criteria and text for schizotypal personality disorder 2. Hallucinations. can be found in the chapter “Personality Disorders.” 3. Disorganized speech (e.g., frequent Because this disorder is considered part of the derailment orincoherence). schizophrenia spectrum of disorders, and is labeled 4. Grossly disorganized or catatonic behavior. in this section of ICD-10 as schizotypal disorder, it is 5. Negative symptoms (i.e., diminished listed in this chapter and discussed in detail in the emotional expressionor avolition). DSM-5- TR chapter “Personality Disorders.” B. For a significant portion of the time since the onset of The diagnosis schizotypal personality disorder the disturbance, level of functioning in one or more captures a pervasive pattern of social and 3 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL interpersonal deficits, including reduced capacity for o Grandiose type: close relationships; cognitive or perceptual o Jealous type: distortions; and eccentricities of behavior, usually o Persecutory type: beginning by early adulthood but in some cases first o Somatic type: becoming apparent in childhood and adolescence. o Mixed type: Abnormalities of beliefs, thinking, and perception are o Unspecified type: below the threshold for the diagnosis of a psychotic disorder  Specify if: DELUSIONAL DISORDER o With bizarre content: Delusional Disorder  Specify if: The following course specifiers are The major feature of delusional disorder is a only to be used after a 1-year duration of the persistent belief that is contrary to reality, in the disorder absence of other characteristics of schizophrenia. Prevalence Characterized by a persistent delusion that is not the The lifetime prevalence of delusional disorder has result of an organic factor such as brain seizures or been estimated at around of any severe psychosis. 0.2% in a Finnish sample, and the most frequent Tend not to have flat affect, anhedonia, or other subtype is persecutory. negative symptoms of schizophrenia; importantly, however, they may become socially isolated Delusional disorder, jealous type, is probably more because they are suspicious of others. common in men than in women, but there are no major sex or gender differences in the overall DIAGNOSTIC CRITERIA FOR DELUSIONAL frequency of delusional disorder or in the content of DISORDER the delusions. A. The presence of one (or more) delusions with a Development and Course duration of 1 month or longer. On average, global functioning is generally better than that observed in schizophrenia. Although the B. Criterion A for schizophrenia has never been met. diagnosis is generally stable, a proportion of Note: Hallucinations, if present, are not prominent individuals go on to develop schizophrenia. Whereas and are related to the delusional theme (e.g., the about a third of individuals with delusional disorder of sensation of being infested with insects associated 1–3 months’ duration subsequently receive a with delusions of infestation). diagnosis of schizophrenia, the diagnosis of delusional disorder is (wala na karugtong sa ppt) C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, BRIEF PSYCHOTIC DISORDER and behavior is not obviously bizarre or odd. 24 Brief Psychotic Disorder D. If manic or major depressive episodes have Typically experience emotional turmoil or occurred, these have been brief relative to the overwhelming confusion duration of the delusional periods. They may have rapid shifts from one intense affect E. The disturbance is not attributable to the to another. physiological effects of a substance or another medical condition and is not better explained by Although the disturbance is brief, the level of another mental disorder, such as body dysmorphic impairment may be severe, and supervision may be disorder or obsessive-compulsive disorder. required to ensure that nutritional and hygienic needs are met and that the individual is protected  Specify whether: o Erotomanic type: 4 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL from the consequences of poor judgment, cognitive the duration of psychotic symptoms may be quite impairment, or acting on the basis of delusions brief (e.g., a few days). Although brief psychotic disorder by definition reaches a full remission within DIAGNOSTIC CRITERIA FOR BRIEF PSYCHOTIC 1 month, subsequently more than 50% of the DISORDER individuals experience a relapse. A. Presence of one (or more) of the following Despite the possibility of relapse, for most symptoms. At least one of these must be (1), (2), or individuals, outcome is favorable in terms of social (3): functioning and symptomatology. 1. Delusions. SCHIZOPHRENIFORM 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment Schizophreniform or incoherence). Some people experience the symptoms of 4. Grossly disorganized or catatonic behavior. schizophrenia for a few months only; they can usually resume normal lives. The symptoms Note: Do not include a symptom if it is a sometimes disappear as the result of successful culturally sanctioned response. treatment, but they often do so for reasons unknown. B. Duration of an episode of the disturbance is at least The label schizophreniform disorder classifies these 1 day but less than 1 month, with eventual full return symptoms, but because relatively few studies are to premorbid level of functioning. 30 available on this disorder, data on important aspects of it are sparse. C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIFORM features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to A. Two (or more) of the following, each present for a the physiological effects of a substance (e.g., a drug significant portion of time during a 1- month period of abuse, a medication) or another medical condition. (or less if successfully treated). At least one of these must be (1), (2), or (3):  Specify if: 1. Delusions. o With marked stressor(s) (brief reactive 2. Hallucinations. psychosis): 3. Disorganized speech (e.g., frequent derailment o Without marked stressor(s): or incoherence). o With peripartum onset 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional  Specify if: With catatonia expression or avolition). Prevalence B. An episode of the disorder lasts at least 1 month but Brief psychotic disorder may account for 2%–7% of less than 6 months. When the diagnosis must be cases of first-onset psychosis in several countries. made without waiting for recovery, it should be qualified as “provisional.” 34 Development and Course Brief psychotic disorder may appear in adolescence C. Schizoaffective disorder and depressive or bipolar or early adulthood, and onset can occur across the disorder with psychotic features have been ruled out life span, with the average age at onset being the because either 1) no major depressive or manic mid-30s. episodes have occurred concurrently with the active- phase symptoms, or 2) if mood episodes have Diagnosis of brief psychotic disorder requires a full occurred during active-phase symptoms, they have remission of all symptoms and an eventual full return been present for a minority of the total duration of the to the premorbid level of functioning within 1 month active and residual periods of the illness. of the onset of the disturbance. In some individuals, 5 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL D. The disturbance is not attributable to the may be less severe and pervasive than those in physiological effects of a substance (e.g., a drug of schizophrenia abuse, a medication) or another medical condition. DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE  Specify if: DISORDER o With good prognostic features: A. An uninterrupted period of illness during which there o Without good prognostic features: is a major mood episode (major depressive or manic) have not been present. concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include  Specify if: With catatonia Criterion A1: Depressed mood. Prevalence B. Delusions or hallucinations for 2 or more weeks in Incidence of schizophreniform disorder across the absence of a major mood episode (depressive or sociocultural settings is likely similar to that observed manic) during the lifetime duration of the illness. in schizophrenia. C. Symptoms that meet criteria for a major mood In the United States and other high income countries, episode are present for the majority of the total the incidence is low, possibly fivefold less than that duration of the active and residual portions of the of schizophrenia. In lower-income countries, the illness. incidence may be higher, especially for the specifier “with good prognostic features”; in some of these D. The disturbance is not attributable to the effects of a settings schizophreniform disorder may be as substance (e.g., a drug of abuse, a medication) or common as schizophrenia. another medical condition. Development and Course  Specify whether: The development of schizophreniform disorder is o F25.0 Bipolar type: similar to that of schizophrenia. o F25.1 Depressive type: About one-third of individuals with an initial diagnosis  Specify if: With catatonia of schizophreniform disorder (provisional) recover within the 6-month period and schizophreniform  Specify if: The following course specifiers are disorder is their final diagnosis. The majority of the only to be used after a 1-year duration of the remaining two-thirds of individuals will eventually disorder and if they are not in contradiction to receive a diagnosis of schizophrenia or the diagnostic course criteria. schizoaffective disorder. Prevalence SCHIZOAFFECTIVE DISORDER Schizoaffective disorder appears to be about one- Schizoaffective Disorder third as common as schizophrenia. The diagnosis of schizoaffective disorder is based on the assessment of an uninterrupted period of illness Lifetime prevalence of schizoaffective disorder was estimated to be 0.3% in a Finnish sample and is during which the individual continues to display active or residual symptoms of psychotic illness. higher in women than in men when DSM-IV diagnostic criteria were used. Restricted social contact and difficulties with self- care are associated with schizoaffective disorder, but This rate would be expected to be lower because of the more stringent requirement of DSM-5 Criterion C negative symptoms may be less severe and less persistent than those seen in schizophrenia. (i.e., mood symptoms meeting criteria for a major mood episode must be present for the majority of the total duration of the active and residual portion of the Anosognosia (i.e., poor insight) is also common in illness). schizoaffective disorder, but the deficits in insight 6 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Development and Course C. The disturbance is not better explained by a The typical age at onset of schizoaffective disorder psychotic disorder that is not substance/medication- is early adulthood, although onset can occur anytime induced. Such evidence of an independent psychotic from adolescence to late in life. disorder could include the following: A significant number of individuals diagnosed with The symptoms preceded the onset of the another psychotic illness initially will receive the substance/medication use; the symptoms persist for diagnosis schizoaffective disorder later when the a substantial period of time (e.g., about 1 month) pattern of mood episodes has become more after the cessation of acute withdrawal or severe apparent, whereas others may be diagnosed with intoxication; or there is other evidence of an mood disorders before independent psychotic independent nonsubstance/ medication-induced symptoms are detected. psychotic disorder (e.g., a history of recurrent non- substance/medication-relatedepisodes). SUBSTANCE/MEDICATION-INDUCED PSYCHOTIC DISORDER D. The disturbance does not occur exclusively during the course of a delirium. Substance/Medication-Induced Psychotic Disorder The essential features of substance/medication- E. The disturbance causes clinically significant distress induced psychotic disorder are prominent delusions or impairment in social, occupational, or other and/or hallucinations that are judged to be due to the important areas of functioning. physiological effects of a substance/medication (i.e., a drug of abuse, a medication, or a toxin exposure). Prevalence Prevalence of substance/medication-induced Hallucinations that the individual realizes are psychotic disorder in the general population is substance/medication-induced are not included here unknown. Between 7% and 25% of individuals and instead would be diagnosed as substance presenting with a first episode of psychosis in intoxication or substance withdrawal with the different settings are reported to have accompanying specifier “with perceptual substance/medication-induced psychotic disorder. disturbances” (applies to alcohol withdrawal; cannabis intoxication; sedative, hypnotic, or PSYCHOTIC DISORDER DUE TO ANOTHER anxiolytic withdrawal; and stimulant intoxication). MEDICAL CONDITION DIAGNOSTIC CRITERIA FOR Psychotic Disorder Due to Another Medical SUBSTANCE/MEDICATION-INDUCED PSYCHOTIC Condition DISORDER The essential features of psychotic disorder due to another medical condition are prominent delusions A. Presence of one or both of the following symptoms: or hallucinations that are judged to be attributable to the physiological effects of another medical condition 1. Delusions. and are not better explained by another mental 2. Hallucinations. disorder (e.g., the symptoms are not a psychologically mediated response to a severe B. There is evidence from the history, physical medical condition, in which case a diagnosis of brief examination, or laboratory findings of both (1) and psychotic disorder, with marked stressor, would be (2): appropriate). 1. The symptoms in Criterion A developed during Hallucinations can occur in any sensory modality or soon after substance intoxication or (i.e., visual, olfactory, gustatory, tactile, or auditory), withdrawal or after exposure to or withdrawal but certain etiological factors are likely to evoke from a medication. specific hallucinatory phenomena 2. The involved substance/medication is capable of producing the symptoms in Criterion A. 7 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL DIAGNOSTIC CRITERIA FOR PSYCHOTIC DISORDER of definitions of schizophrenia, found no difference in DUE TO ANOTHER MEDICAL CONDITION prevalence between the sexes. A. Prominent hallucinations or delusions. Causes of Schizophrenia Studying schizophrenia reveals the many levels on B. There is evidence from the history, physical which we must decipher what makes us behave the examination, or laboratory findings that the way we do. To uncover the causes of this disorder, disturbance is the direct pathophysiological researchers look in several areas: consequence of another medical condition.  The possible genes involved in schizophrenia, C. The disturbance is not better explained by another mental disorder.  The chemical action of the drugs that help many people with this disorder, D. The disturbance does not occur exclusively during the course of a delirium.  Abnormalities in the working of the brains of people with schizophrenia, and E. The disturbance causes clinically significant distress or impairment in social, occupational, or other  Environmental risk factors that may precipitate important areas of functioning. the onset of the symptoms (Harrison, 2012; Murray & Castle, 2012  Specify whether: Code based on predominant symptom: Development Severe symptoms of schizophrenia first occur in late o F06.2With delusions: adolescence or early adulthood. o F06.0With hallucinations: Children who go on to develop schizophrenia show PREVALENCE AND CAUSES OF early clinical features such as mild abnormalities, SCHIZOPHRENIA poor motor coordination and mild cognitive and social problems. Prevalence of Schizophrenia The estimated lifetime prevalence of schizophrenia 85% go through prodromal stage a 1-2 year period is approximately 0.3%– 0.7%, with variation over a before the serious symptoms occur. fivefold range in meta-analyses of nationally representative surveys. Studies have shown Once the symptoms begins it can take 2 years to increased prevalence and incidence of around 10 years before the person at high risk meets schizophrenia for some groups based on migration the full criteria for a psychotic disorder. and refugee status, urbanicity, and the economic status and latitude of the country. It is important to Highest period of risk for patients to develop a full- note that the reported prevalence and incidence of fledged psychotic disorder is during the first two schizophrenia may be affected by the fact that some years following their first displays of mild symptoms. groups are more likely to be misdiagnosed or over diagnosed. Once treated, patients with this disorder will often improve but will also got through a pattern of relapse The sex ratio differs across samples and and recovery. populations: for example, presentations with prominent negative symptoms and longer duration of disorder (associated with poorer outcome) show People with schizophrenia have a poorer prognosis compare with some disorders higher incidence rates for men, whereas definitions allowing for the inclusion of more mood symptoms Figure 13.2 and brief presentations (associated with better The longitudinal course of schizophrenia is depicted starting outcome) show equivalent risks for both sexes. A at birth through old age. The severity of the symptoms is large worldwide study, which was based on a range showing on the left axis, and the changes in symptoms across 8 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL each phase (premorbid, prodromal, onset, and chronic) are GENETICS INFLUENCES labeled. Genes are responsible for making some individuals vulnerable to schizophrenia. Family Studies In 1938, Franz Kallmann published a major study of the families of people with schizophrenia (Kallmann, 1938). Kallmann examined family members of more than 1,000 people diagnosed with schizophrenia in a Berlin psychiatric hospital. Kallmann showed that the severity of the parent’s disorder influenced the likelihood of the child’s having schizophrenia: The  Premorbid: Mild motor cognitive and social more severe the parent’s schizophrenia, the more impairments likely the children were to develop it.  Prodromal: Unusual psychotic like behaviors Twin Studies If they are raised together, identical twins share  Onset/deterioration: Positive negative, 100% of their genes and 100% of their environment, cognitive and mood symptoms whereas fraternal twins share only about 50% of their genes and 100% of their environment.  Chronic/residual: Positive, negative and cognitive symptom Even identical siblings can have different prenatal and family experiences and can therefore be CULTURAL FACTORS exposed to varying degrees of biological and environmental stress. Cultural Factors The course and outcome of schizophrenia vary from Even siblings who are close in every aspect of their culture to culture lives can still have considerably different experiences physically and socially as they grow up, In the United States, proportionately more African which may result in vastly different outcomes. Americans receive the diagnosis of schizophrenia than Caucasians (Schwartz & Feisthamel, 2009). Adoption Studies Several adoption studies have distinguished the Research from both England and the United States roles of the environment and genetics as they affect suggests that people from devalued ethnic minority schizophrenia. groups (Afro-Caribbean in England and African Americans and Puerto Ricans in the United States) These studies often span many years; because may be victims of bias and stereotyping (Jones & people often do not show the first signs of Gray, 1986; Lewis, Croft-Jeffreys, & Anthony, 1990); schizophrenia until middle age, researchers need to in other words, they may be more likely to receive a be sure all the offspring reach that point before diagnosis of schizophrenia than members of a drawing conclusions. dominant group. If an adopted child had a biological mother with The differing rates of schizophrenia, therefore, may schizophrenia, that child had about a 5% chance of be partially the result of misdiagnosis rather than the having the disorder (compared to about only 1% in result of any real cultural distinctions. An additional the general population) factor contributing to this imbalance may be the levels of stress associated with factors such as However, if the biological mother had schizophrenia stigma, isolation, and discrimination or one of the related psychotic disorders (for example, delusional disorder or schizophreniform disorder), the risk that the adopted child would have 9 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL one of these disorders rose to about 22% (Tienari et disorder and then find the gene or genes that cause al., 2003;Tienari,Wahlberg, &Wynne, 2006). these difficulties—a strategy called endophenotyping (Braff et al., 2007). The Offspring of Twins Twin and adoption studies strongly suggest a genetic NEUROBIOLOGICAL INFLUENCES component for schizophrenia, but what about children who develop schizophrenia even though Dopamine their parents do not. One of the most enduring yet controversial theories of the cause of schizophrenia involves the neurotransmitter dopamine. Antipsychotic medications points to the possibility that the dopamine system is too active in people with schizophrenia. When drugs are administered that are known to increase dopamine (agonists), there is an increase in schizophrenic behavior; when drugs that are known to decrease dopamine activity (antagonists) are used, and schizophrenic symptoms tend to diminish. Cognitive impairment is regarded as a core feature of schizophrenia. People with schizophrenia perform much worse (on average Linkage and Association Studies almost a full standard deviation worse) than healthy Genetic linkage and association studies rely on traits controls on a broad range of neuropsychological such as blood types (whose exact location on the tests. Almost all aspects of cognition (involving chromosome is already known) inherited in families attention, language, and memory) are impaired. In with the disorder you are looking for—in this case, the area of auditory information processing, people schizophrenia. Because researchers have with schizophrenia show problems with a process determined the location of the genes for these traits called sensory gating. (called marker genes), they can make a rough guess about the location of the disorder genes inherited BRAIN STRUCTURE with them. Brain Structure  For example, regions of chromosomes 1, 2, 3, Evidence for neurological damage in people with 5, 6, 8, 10, 11, 13, 20, and 22 are implicated in schizophrenia comes from a number of this disorder (Kirov & Owen, 2009). Three of the observations. most reliable genetic influences that make one susceptible to schizophrenia include sections on Many children with a parent who has the disorder, chromosome 8 (called Neuregulin 1 or NRG1), and who are therefore at risk, tend to show subtle but chromosome 6 (called dystrobrevin-binding observable neurological problems, such as abnormal protein 1 or DTNBP1), and chromosome 22 reflexes and inattentiveness (Buka, (called catecholamine O methyl transferase or Seidman,Tsuang, & Goldstein, 2013) COMT) (Murray & Castle, 2012) Adults who have schizophrenia show deficits in their Endophenotypes ability to perform certain tasks and to attend during Genetic research on schizophrenia is evolving, and reaction time exercises (Cleghorn & Albert, 1990). the information on the findings from these sophisticated studies is now being combined with One of the most reliable observations about the brain advances in our understanding of specific deficits in people with schizophrenia involves the size of the found in people with this disorder. Remember, in ventricles (showed enlargement). complex disorders such as this, researchers are not looking for a “schizophrenia gene” or genes. Instead, Enlarged ventricles are observed more often in men researchers try to find basic processes that than in women (Abel, Drake, & Goldstein, 2010). contribute to the behaviors or symptoms of the 10 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Ventricles seem to enlarge in proportion to age and PSYCHOLOGICAL AND SOCIAL INFLUENCES to the duration of the schizophrenia. Stress Frontal lobes of the brain may be less active in It is important to learn how much and what kind of people with schizophrenia than in people without the stress makes a person with a predisposition for disorder, a phenomenon sometimes known as schizophrenia develop the disorder. hypofrontality (hypo means “less active,” or “deficient”). Researchers have studied the effects of a variety of stressors on schizophrenia. Living in a large city, for It appears that several brain sites are implicated in example, is associated with an increased risk of the cognitive dysfunction observed among people developing schizophrenia—suggesting the stress of with schizophrenia, especially the prefrontal cortex, urban living may precipitate its onset (Boydell & various related cortical regions, and subcortical Allardyce, 2012). circuits, including the thalamus and the striatum (Shenton & Kubicki, 2009). Dohrenwend and Egri (1981) observed that otherwise healthy people who engage in combat This dysfunction seems to occur before the onset of during a war often display temporary symptoms that schizophrenia. In other words, brain variations may resemble those of schizophrenia. develop progressively, beginning before the symptoms of the disorder are apparent, perhaps In a classic study, Brown and Birley (1968; Birley & prenatally Brown, 1970) examined people whose onset of schizophrenia could be dated within a week. Prenatal and Perinatal Influences Prenatal – before birth; perinatal – around the time of These individuals had experienced a high number of birth stressful life events in the 3 weeks before they started showing signs of the disorder. Fetal exposure to viral infection, pregnancy complications, and delivery complications are among In a large-scale study sponsored by the World Health the environmental influences that seem to affect Organization, researchers also looked at the role of whether or not someone develops schizophrenia. life events in the onset of schizophrenia (Day et al., 1987). This cross-national study confirmed the Several studies have shown that schizophrenia may findings of Brown and Birley across eight research be associated with prenatal exposure to influenza, centers. viruses, or infections. Do the symptoms of schizophrenia become The indications that virus like diseases may cause worse as a result of stressful life experiences? damage to the fetal brain, which later may cause the symptoms of schizophrenia, are suggestive and may  A simple vulnerability can develop into a severe help explain why some people with schizophrenia disorder from the interchange between gene– behave the way they do (Murray & Castle, 2012). environment The evidence of pregnancy complications (for  Important research will isolate the gene– example, bleeding) and delivery complications (for environment interactions in this area. For example, asphyxia or lack of oxygen) and their example, some studies now show that particular relationship to later schizophrenia suggest, on the gene variances may predict which individuals surface, that this type of environmental stress with schizophrenia will be more likely to react combined with genetic and other variables may negatively (such as relapse) with increased trigger the expression of the disorder (Kotlicka- stress (Ascher-Svanum et al., 2010). These Antczak, Pawelczyk, Rabe-Jablońska, Śmigielski, & types of studies point to how stress can impact Pawelczyk, 2014; Suvisaari et al., 2013). people with schizophrenia and may suggest useful treatments (such as cognitive behavioral therapy to help them cope more appropriately) (Ascher- Svanum et al., 2010). 11 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Families and Relapse keep your mind off it.” That’s even too much A great deal of research has studied how interactions trouble. within the family affect people who have schizophrenia. o I’ve tried to jolly him out of it and pestered him into doing things. Maybe I’ve overdone The term schizophrenogenic mother was used for it, I don’t know. a time to describe a mother whose cold, dominant, and rejecting nature was thought to cause  Low Expressed Emotion schizophrenia in her children (Fromm-Reichmann, 1948). o I know it’s better for her to be on her own, to get away from me and try to do The term double bind communication was used to things on her own. portray a communication style that produced conflicting messages, which, in turn, caused o Whatever she does suits me. schizophrenia to develop (Bateson, 1959) o I just tend to let it go because I know that when she wants to speak she will Recent work has focused more on how family speak. (Hooley, 1985, p. 134) 71 interactions contribute not to the onset of schizophrenia but to relapse after initial symptoms are observed. This style suggests that families with high expressed emotion view the symptoms of schizophrenia as controllable and that the hostility arises when family Emotional communication style known as members think that patients just do not want to help expressed emotion (EE) was formulated by George themselves (Hooley & Campbell, 2002; McNab, W. Brown and his colleagues in London. Haslam, & Burnett, 2007). Following a sample of people who had been discharged from the hospital after an episode of The literature on expressed emotion is valuable to our understanding of why symptoms of schizophrenic symptoms, the researchers found that schizophrenia recur and may show us how to treat former patients who had limited contact with their people with this disorder and their families so that relatives did better than the patients who spent they do not experience further psychotic episodes longer periods with their families (Brown, 1959). (Cechnicki et al., 2013). Additional research results indicated that if the levels of criticism (disapproval), hostility (animosity), and TREATMENT OF SCHIZOPHRENIA emotional overinvolvement (intrusiveness) Treatment of Schizophrenia expressed by the families were high, patients tended to relapse (Brown, Monck, Carstairs, &Wing, 1962). In the Western world today, treatment usually begins with one of the neuroleptic drugs invaluable in reducing the symptoms of schizophrenia for many Other researchers have since found that ratings of people. They are typically used with a variety of high expressed emotion in a family are a good psychosocial treatments to reduce relapse, predictor of relapse among people with chronic compensate for skills deficits, and improve schizophrenia (Cechnicki, Bielańska, cooperation for taking the medications (Cunningham Hanuszkiewicz, & Daren, 2013). If you have Owens & Johnstone, 2012). schizophrenia and live in a family with high expressed emotion, you are 3.7 times more likely to relapse than if you lived in a family with low Biological Interventions expressed emotion (Kavanagh, 1992; Parker & Researchers have assumed for more than 100 years Hadzi-Pavlovic, 1990). 70 that schizophrenia requires some form of biological intervention.  High Expressed Emotion Kraepelin, who so eloquently described dementia o I always say, “Why don’t you pick up a book, praecox in the late 19th century, saw the disorder as do a crossword or something like that to a brain disease. Lacking a biological treatment, he 12 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL routinely recommended that the physician use “good In general, each drug is effective with some people patience, kindly disposition, and self-control” to calm and not with others. excited patients (Nagel, 1991). Clinicians and patients often must go through a trial This approach was seen as only a temporary way of and- error process to find the medication that works helping the person through disturbing times and was best, and some individuals do not benefit not thought to be an actual treatment. significantly from any of them. During the 1930s, several novel biological The earliest neuroleptic drugs, called conventional or treatments were tried One approach was to inject first-generation antipsychotics (such as Haldol and massive doses of insulin—the drug that given in Thorazine), are effective for approximately 60% to smaller doses is used to treat diabetes—to induce 70% of people who try them (Cunningham Owens & comas in people suffering from schizophrenia. Johnstone, 2012) 77 Insulin coma therapy was thought for a time to be Many people are not helped by antipsychotics, helpful, but closer examination showed it carried however, or they experience unpleasant side effects. great risk of serious illness and death. Fortunately, some people respond well to newer medications— sometimes called atypical or second- During this time, psychosurgery, including generation antipsychotics; prefrontal lobotomies, was introduced, and in the late 1930s, electroconvulsive therapy (ECT) was The most common are risperidone and olanzapine. advanced as a treatment for schizophrenia. These newer drugs were in part developed to help As with earlier drastic treatments, initial enthusiasm patients who were previously unresponsive to for ECT faded because it was found not to be medications. beneficial for most people with schizophrenia— although it is still used with a limited number of A comparison of multiple clinical trials shows better people today, sometimes in combination with efficacy, though small, in preventing symptoms antipsychotic medications (Zervas,Theleritis, & reemergence for these newer drugs over the Soldatos, 2012). previous ones. Antipsychotic Medications Studies found out that the second-generation drugs Neuroleptics (meaning “taking hold of the nerves”), were no more effective or better tolerated than the these medications provided the first real hope that older drugs. help was available for people with schizophrenia. These results point out how important it is to carefully Neuroleptics help people think more clearly and study the outcomes of all new treatments. reduce hallucinations and delusions (if effective). Table 13.2 Commonly Used Antipsychotic Medications They work by affecting the positive symptoms Class Example Degree of (delusions, hallucinations, and agitation) and to a Extrapyramidal lesser extent the negative and disorganized ones, Side Effects such as social deficits. Conventional Antipsychotics Dopamine theory of schizophrenia that the Chlorpromazine/ Moderate neuroleptics are dopamine antagonists. One of their Thorazine major actions in the brain is to interfere with the Fluphenazine/ High dopamine neurotransmitter system. They can also Prolixin affect other systems, however, such as the Phenothiazines Mesoridazine/ Low serotonergic and glutamate system. We are just Serentil beginning to understand the mechanisms by which Perphenazine/ High these drugs work. Trilafon 13 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Thioridazine/ Low ADDITIONAL BIOLOGICAL TREATMENT Mellaril Trifluoperazine/ High Additional Biological Treatment Stelazine Transcranial magnetic stimulation, this technique Butyrophenone Haloperidol/Haldol High uses wire coils to repeatedly generate magnetic Loxapine/Loxitane High fields—up to 50 times per second—that pass Others Molindone/Moban Low through the skull to the brain. Thiothixene/ High Navane This input seems to interrupt temporarily the normal Aripiprazole/Abilify Low communication to that part of the brain. Clozapine/Clozaril Low Olanzapine/ Low Hoffman and colleagues (2000, 2003) used this Second- Zyprexa technique to stimulate the area of the brain involved Generation Quetiapine/ Low in hallucinations for individuals with schizophrenia Agents Seroquel who experienced auditory hallucinations. Risperidone/ Low Risperdal They found that many of the individuals experienced Ziprasidone/ Low improvement following transcranial magnetic Geodon stimulation. *The trade name is in italics. Subsequent studies have also shown promising NONCOMPLIANCE WITH MEDICATION: WHY? results (Dougall, Maayan, Soares-Weiser, McDermott, & McIntosh, 2015) but more stringent What factors seem to be related to patients’ clinical trials are needed to demonstrate that this noncompliance with a medication? (Haddad, Brain, treatment works. & Scott, 2014). Negative doctor–patient relationships; Follow-up data is needed to test whether the Cost of the medication; improvements last. Stigma; Poor social support; Preliminary research has shown that though this Negative side effects; intervention may modestly improve auditory hallucinations, its effects last less than a month Extrapyramidal symptoms (motor difficulties similar to those (Slotema,Aleman, Daskalakis, & Sommer, 2012). experienced by people with Parkinson’s disease). Lastly, recent research has explored the added Parkinsonian Symptoms effect of the medication modafinil when taken in Akinesia is one of the most common; it includes an addition to antipsychotic medications. expressionless face, slow motor activity, and monotonous speech. Modafinil is a cognitive enhancer with low abuse potential. Tardive dyskinesia, which involves involuntary movements of the tongue, face, mouth, or jaw and In schizophrenia, this drug may improve cognitive can include protrusions of the tongue, puffing of the functions, such as memory and problem solving. cheeks, puckering of the mouth, and chewing movements. Some limited research also suggests that the drug may improve emotion processing in schizophrenia Researchers have made this a major treatment issue (Scoriels, Jones, & Sahakian, 2013). in schizophrenia, realizing that medications can’t be successful if they aren’t taken regularly 14 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL PSYCHOSOCIAL INTERVENTIONS care, and vocational skills, and more of them could be discharged from the hospital. Psychosocial Interventions Few believe that psychological factors cause people This study was one of the first to show that people to have schizophrenia or that traditional suffering from the debilitating effects of psychotherapeutic approaches will cure them. schizophrenia can learn to perform some skills they need to live more independently. Despite the great promise of drug treatment, the problems with ineffectiveness, inconsistent use, and During the years since 1955, many efforts have relapse suggest that by themselves drugs may not combined to halt the routine institutionalization of be effective with many people. people with schizophrenia in the United States (Fakhoury & Priebe, 2007). Until relatively recently, most people with severe and chronic cases of schizophrenia were treated in This trend has occurred partly because of court hospital settings. rulings that limit involuntary hospitalization and partly because of the relative success of antipsychotic During the 19th century, inpatient care involved medication. “moral treatment,” which emphasized improving patients’ socialization, helping them establish The bad news is that policies of deinstitutionalization routines for self-control, and showing them the value have often been ill conceived, with the result that of work and religion (Tenhula et al., 2009) many people who have schizophrenia or other serious psychological disorders are homeless—the Various types of such “milieu” treatments (changing number is estimated at between 150,000 and the physical and social environment—usually to 200,000 people in the United States alone (Foster, make institutional settings more homelike) have Gable, & Buckley, 2012; Pearson, Montgomery, & been popular, but, with one important exception: Locke, 2009). None seems to have helped people with schizophrenia. The good news is that more attention is being focused on supporting these people in their Gordon Paul and Robert Lentz conducted pioneering communities, among their friends and families. work in the 1970s at a mental health center in Illinois (Paul & Lentz, 1977). The trend is away from creating better hospital environments and toward the perhaps more difficult Borrowing from the behavioral approaches used by task of addressing complex problems in the less Ted Ayllon and Nate Azrin (1968), Paul and Lentz predictable and insecure world outside. designed an environment for inpatients that encouraged appropriate socialization, participation in So far, only a small fraction of the growing number of group sessions, and self-care such as bed making homeless individuals with mental disorders is being while discouraging violent outbursts. helped. They set up an elaborate token economy, in which Clinicians attempt to reteach social skills such as residents could earn access to meals and small basic conversation, assertiveness, and relationship luxuries by behaving appropriately. building to people with schizophrenia (Mueser & Marcello, 2011). This incentive system was combined with a full schedule of daily activities. Paul and Lentz compared Therapists divide complex social skills into their the effectiveness of applied behavioral (or social component parts, which they model. learning) principles with traditional inpatient environments. Then the clients do role-playing and ultimately practice their new skills in the “real world,” all the In general, they found that patients who went through while receiving feedback and encouragement at their program did better than others on social, self- signs of progress. 15 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL Another psychosocial intervention for schizophrenia less robust 2 years after intervention (Cunningham is cognitive remediation aimed at improving cognitive Owens & Johnstone, 2012). processes, such as attention, executive functioning, and memory, all of which are associated with This type of therapy, therefore, must be ongoing if impairments over the course of schizophrenia. patients and their families are to benefit from it. Impairment in these cognitive areas predicts Research suggests that individual social skills patients’ overall functioning and poor response to training, family intervention, and vocational other treatments (e.g., psychological rehabilitation or rehabilitation may be helpful additions to biological social skills training) (Mueser, Deavers, Penn, & (drug) treatment for schizophrenia. Cassisi, 2013). Significant relapses may be avoided or delayed by Thus, a primary goal of cognitive remediation is to such psychosocial interventions. improve cognitive processes for those suffering from schizophrenia in order to increase these individuals’ Table 13.4 An Integrative Treatment Approach functioning in the community Treatment Description Collaborative Using antipsychotic Several studies have addressed these issues in a psychopharmacology medications to treat the variety of ways (Falloon et al., 1985; Hogarty et al., main symptoms of the 1986, 1991), and behavioral family therapy has been disorder (hallucinations, used to teach the families of people with delusions), as well as using schizophrenia to be more supportive (Dixon & other medications for Lehman, 1995; Mueser, Liberman, & Glynn, 1990). secondary symptoms (for example, antidepressant Research on professionals who provide care for medication for people with people who have schizophrenia, and who may secondary depression) display high levels of express Assertive community Providing support in the treatment community, with emphasis In contrast to traditional therapy, behavioral family on small caseloads for care therapy resembles classroom education (Falloon, providers, services in the 2015; Lefley, 2009). community setting rather than a clinic, and 24-hour Family members are informed about schizophrenia coverage and its treatment, relieved of the myth that they Family psychoeducation Assisting family members, caused the disorder, and taught practical facts about including educating them antipsychotic medications and their side effects.and about the disorder and its emotion, is also an active area of study (Cunningham management, helping them Owens & Johnstone, 2012). reduce stress and tension in the home, and providing They are also helped with communication skills so social support that they can become more empathic listeners, and Supportive employment Providing sufficient support they learn constructive ways of expressing negative before and during feelings to replace the harsh criticism that employment so that the characterizes some family interactions. person can find and keep a meaningful job In addition, they learn problem-solving skills to help Illness management and Helping the individual them resolve conflicts that arise. recovery become an active participant in treatment, Like the research on social skills training, outcome including providing research suggests that the effects of behavioral education about the family therapy are significant during the first year but disorder, teaching effective use of medication strategies for collaborating with 16 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL clinicians, and coping with symptoms when they o High expressed emotion (family criticism, reoccur hostility, and/or intrusion) Integrated dual-disorders Treating coexisting treatment substance use o Sometimes no obvious trigger PREVENTION  Biological Influences Prevention o Inherited tendency (multiple genes) to One strategy for preventing a disorder such as develop disease schizophrenia— which typically first shows itself in early adulthood—is to identify and treat children who o Prenatal/birth complications-viral infection may be at risk for getting the disorder later in life. during pregnancy/birth injury affect child's brain cells Instability of early family rearing environment, which suggests that environmental influences may o Brain chemistry (abnormalities in the trigger the onset of schizophrenia (Cannon et al., dopamine and glutamate systems 1991). o Brain structure (enlarged ventricles) Poor parenting may place additional strain on a  Behavioral Influences vulnerable person who is already at risk. o Positive symptoms: Active manifestations One approach to prevention of schizophrenia of abnormal behavior (delusions, receiving increased attention is the treatment of hallucinations. disorganized speech, odd persons in the prodromal stages of the disorder. body movements, or catatonia) Here the individual is beginning to show early mild o Negative symptoms: signs of schizophrenia (e.g., hallucinations, delusions) but is aware of these changes.  Flat affect lack of emotional expression  Avolition (lack of initiative, apathy)  Alogia (relative absence in amount or content of speech)  Emotional and Cognitive Influences o Interaction styles that are high in criticism, hostility, and emotional overinvolvement can trigger a relapse  Social Influences o Environment (early family experiences) can Schizophrenia disrupts perception of the world, trigger onset thought, speech, movement, and almost every other aspect of daily functioning. o Culture influences interpretation of disease/symptoms (hallucinations, Usually chronic with a high relapse rate; complete delusions) recovery from schizophrenia is rare. Trigger (Causes) o Stressful, traumatic life event 17 I  BATANGAS STATE UNIVERSITY COLLEGE OF PSYCHOLOGY ABNORMAL PSYCHOLOGY PROF. RHONA L. CAGAMPAN, RPsy ADAPTED FROM: PPT MATERIAL TREATMENT OF SCHIZOPHRENIA Individual, Group, and Family Therapy Can help patient and family understand the disease and symptom triggers. Teaches families communication skills. Provides resources for dealing with emotional and practical challenges. Social Skills Training Can occur in hospital or community settings. Teaches the person with schizophrenia social, self- care, and vocational skills Medications Taking neuroleptic medications may help people with schizophrenia to:  Clarify thinking and perceptions of reality  Reduce hallucinations and delusions Drug treatment must be consistent to be effective. Inconsistent dosage may aggravate existing symptoms or create new ones. 18 I