Schizophrenia Etiology and Treatment Notes

Schizophrenia Etiology

• Causes of Schizophrenia
  • No known single cause.
  • Research focuses on:
    • Biological factors: Most promising explanation with the most research support.
    • Sociocultural factors.

Schizophrenia: Developmental Factors

• Early-onset schizophrenia (EOS): Diagnosed in children under 18.
  • Symptoms include social withdrawal, difficulty interacting with peers, and school adjustment problems.
  • Earlier onset is associated with worse outcomes.
  • Studies indicate adults with schizophrenia were often less sociable as children.

Biological Factors

• Genetic factors
  • Diathesis-stress account:
    • Biological predisposition for schizophrenia.
    • The disorder is triggered by later exposure to stress.

Biological Factors: Genetics and Family Studies

• Twin studies suggest a heritability estimate as high as 79%, but at least nearly 50%.
• Hundreds of genes (polygenic influence) are likely to play a role, in addition to epigenetic and environmental factors.

Biological Factors: Genetic Factors & Biochemical Abnormalities

• Biochemical abnormality theory:
  • Dopamine hypothesis: Increased dopamine levels are associated with schizophrenia.
  • Serotonin hypothesis: Decreased serotonin is associated with negative symptoms.
• Abnormal brain structure theory:
  • Larger ventricles in the brain.
  • Loss of gray matter.
  • Prenatal Viral Theory

New Targets for Schizophrenia Treatment

• Research is expanding beyond the dopamine hypothesis to identify new treatment targets.

Biological Factors: Cannabis Use

• Cannabis use increases the chance of developing schizophrenia.
  • Swedish army study: Heavy cannabis use at 18 years = 600% more likely than nonusers 15 years later; as use increases, risk increases.
  • Cannabis use while the brain is still developing boosts dopamine levels.
  • Genetic vulnerability + cannabis use can lead to the development of schizophrenia.
  • Theory involves the cannabinoid receptor system (Müller-Vahl & Emrich, 2008).

Sociocultural Factors: Family Influences

• No evidence supports the "schizophrenogenic mother" theory.
• Expressed emotion (EE) is a family's emotional involvement and critical attitude.
  • High EE may increase the likelihood of relapse and rehospitalization.
  • Difficult to change family patterns once they have been established.
• Gene–environment correlation:
  • Individuals at increased genetic risk for schizophrenia may also be exposed to environments that increase risk.

Schizophrenia Treatment

• Antipsychotic medication
• Electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS)
• Institutional care
• Community treatment
• Psychotherapy

Treatment: Antipsychotic Medications

• 1950s: Phenothiazines (calmed patients).
• Drugs developed 1960s-80s = "conventional" antipsychotic drugs.
  • Also known as neuroleptic drugs, often produce undesired movement effects similar to symptoms of neurological diseases (e.g., extrapyramidal symptoms).
• Recent drug development = "atypical" or "second-generation" antipsychotics.
  • Targets positive symptoms more than (or quicker than) negative symptoms.

Side Effects of Conventional Antipsychotic Drugs

• Conventional antipsychotic drugs often produce serious movement problems.
  • Extrapyramidal symptoms (EPS).
  • Parkinsonian-related symptoms result from reductions in dopamine activity.
  • Often symptoms can be reversed if an anti-Parkinsonian drug is taken along with the antipsychotic.
  • Challenges with medication compliance.

Side Effects of (Conventional) Antipsychotic Drugs

• "Tardive dyskinesia" is a more difficult side effect that appears with long-term medication use.
  • It involves involuntary movements, usually of the mouth, lips, tongue, legs, or body.
  • Affects 10(+)% of those taking the drug.
  • It can be irreversible.
  • Usually develops after taking the drug for >1 year.
• Atypical, second-generation antipsychotics appear more effective, cause less EPS, and are less likely to cause tardive dyskinesia, though some still have other significant side effects.

Institutional Care

• 1950s: Two institutional approaches brought some hope to chronic patients:
  • Milieu therapy (supportive social environment).
    • Based on humanistic principles.
    • Creating a respectful social climate.
    • Moderate success in Western cultures.
  • Token economies (rewarding desired target behavior).
    • Based on behavioral principles (operant conditioning).
    • Targets: Socially Acceptable behaviors:
      • Care for oneself and one’s possessions (e.g., hygiene, medication).
      • Going to a work program.
      • Showing self-control.

Community Care

• Broadest approach for treatment
• Massive deinstitutionalization in the 50s & 60s
• The result is a "revolving door" syndrome
• Multi-leveled care:
  • medication
  • psychotherapy
  • help in handling daily pressures & responsibilities
  • guidance in making decisions
  • training in social skills
  • residential supervision
  • vocational counseling
• Combination of services = best outcomes

Community Treatment: Shortages

• Fewer than half of all people who need services receive them in the community.
• Two factors are primarily responsible:
  • Poor coordination of services: Mental health agencies within the community often fail to communicate.
  • Shortage of services:
    • Few community programs.
    • Lack of mental health professionals.
    • Funding shortages.

Inadequate Community Treatment

• When community treatment fails, many people with schizophrenia receive no treatment at all.
• Distribution of individuals with schizophrenia in different settings:
  • Homeless (5%)
  • Hospitals (5%)
  • Jails and prisons (6%)
  • Nursing homes (8%)
  • Unsupervised living (34%)
  • Supervised living (e.g., halfway house) (18%)
  • Living with a family member (25%)

Effective Community Care Components

• Coordinated services:
  • Community mental health centers provide multi-level care.
  • Four components: personalized medication management, family psychoeducation, individualized resilience-focused illness self-management therapy, and supported education and employment.
• Short-term or partial hospitalization:
  • Few weeks (rather than months/years).
  • Day centers or day hospitals for supervised daily activities, therapy, or social skill programs; return to homes at night.
• Supervised residences:
  • Houses are run with a milieu therapy philosophy.
  • Helps with adjusting to community life & avoiding rehospitalization.
• Occupational training:
  • Supervised workplace for employees who are not ready for competitive or complicated jobs.

Psychotherapy

• Psychotherapy can be helpful.
• Most helpful forms:
  • Cognitive-behavioral therapy.
  • Family therapy.
  • Social therapy.
  • These approaches are often combined.

Cognitive Behavioral Therapy

• Psychoeducation: Educates patients and family members.
  • Reduces family members’ distress.
  • Allows clinicians to increase the effectiveness of their work with the patient and caregiver.
• Cognitive Behavioral Therapy for Psychosis: Aims to reduce or eliminate psychotic symptoms.
  • Psychoeducation about psychosis.
  • Exploration of individual beliefs about psychosis.
  • Education in using coping strategies to deal with the symptoms.
  • Improving self-esteem.

Family Therapy

• About 25% of persons recovering from schizophrenia live with family members.
• Family therapy attempts to:
  • Create more realistic expectations.
  • Provide psychoeducation about the disorder.

Social Therapy

• Research has shown that this approach reduces re-hospitalization
• Social cognition treatment
  • Changing attributional biases
  • Emotional perception
  • Social perception
  • Theory of mind
  • Facial affect recognition
  • Use of video instruction, role playing, and practice exercises
• Social skills training
  • Nonverbal skills (eye contact, vocal tone, voice volume)
  • Verbal skills (initiating and maintaining conversations, expressing feelings, acting assertively)