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Schizophrenia
Chapter 12
Slides & Handouts by Karen Clay Rhines, Ph.D.
Comer, Fundamentals of
Abnormal Psychology, 7e
Psychosis

Psychosis is a state defined by a loss of contact
with reality



The ability to perceive and respond to the
environment is significantly disturbed; functioning
is impaired
Symptoms may include hallucinations (false
sensory perceptions) and/or delusions (false
beliefs)
Psychosis may be substance-induced or
caused by brain injury, but most psychoses
appear in the form of schizophrenia
Comer, Fundamentals of Abnormal
Psychology, 7e
2
Diagnosing Schizophrenia

The DSM-5 calls for a diagnosis of
schizophrenia only after symptoms of
psychosis continue for six months or more

Individuals must also show a deterioration
in their work, social relations, and ability to
care for themselves
Comer, Fundamentals of Abnormal
Psychology, 7e
3
Schizophrenia

Schizophrenia affects approximately 1 in
100 people in the world


About 2.5 million Americans currently have
the disorder
The financial and emotional costs are
enormous

Sufferers have an increased risk of suicide and
physical – often fatal – illness
Comer, Fundamentals of Abnormal
Psychology, 7e
4
Schizophrenia

Schizophrenia appears in all socioeconomic
groups, but is found more frequently in the
lower levels

Leading theorists argue that the stress of
poverty causes the disorder

Other theorists argue that the disorder causes
victims from higher social levels to fall to lower
social levels and remain at lower levels

This is called the “downward drift” theory
Comer, Fundamentals of Abnormal
Psychology, 7e
5
Comer, Fundamentals of
Abnormal Psychology, 7e
6
Schizophrenia

Equal numbers of men are women are
diagnosed


The average age of onset for men is 23 years,
compared to 27 years for women
Rates of diagnosis differ by marital status



3% of divorced or separated people
2% of single people
1% of married people

It is unclear whether marital problems are a cause or a
result
Comer, Fundamentals of Abnormal
Psychology, 7e
7
The Clinical Picture of
Schizophrenia

Schizophrenia produces many “clinical
pictures”

The symptoms, triggers, and course of
schizophrenia vary greatly

Some clinicians have argued that
schizophrenia is actually a group of distinct
disorders that share common features
Comer, Fundamentals of Abnormal
Psychology, 7e
8
What Are the Symptoms of
Schizophrenia?

Symptoms can be grouped into three
categories:

Positive symptoms

Negative symptoms

Psychomotor symptoms
Comer, Fundamentals of Abnormal
Psychology, 7e
9
What Are the Symptoms of
Schizophrenia?

Positive symptoms

These “pathological excesses” are bizarre additions
to a person’s behavior

Positive symptoms include:

Delusions – faulty interpretations of reality


Delusions may have a variety of bizarre content: being
controlled by others; persecution; reference; grandeur;
control
Disordered thinking and speech

May include loose associations or derailments, neologisms,
perseverations, and clang
Comer, Fundamentals of Abnormal
Psychology, 7e
10
What Are the Symptoms of
Schizophrenia?

Positive symptoms include:

Loose associations (derailment):


Neologisms (made-up words):


“It is an amorition law”
Perseveration


“The problem is insects. My brother used to collect insects. He’s
now a man 5 foot 10 inches. You know, 10 is my favorite number; I
also like to dance, draw, and watch TV.”
Patients repeat their words and statements again and again
Clang (rhymes):


How are you? “Well, hell, it’s well to tell”
How’s the weather? “So hot, you know it runs on a cot”
Comer, Fundamentals of Abnormal
Psychology, 7e
11
What Are the Symptoms of
Schizophrenia?

Positive symptoms include:

Heightened perceptions


People may feel that their senses are being flooded by sights and
sounds, making it impossible to attend to anything important
Hallucinations – sensory perceptions that occur in the
absence of external stimuli

Most common are auditory



Seem to be spoken directly to, or overheard by, the hallucinator
Hallucinations can involve any of the other senses: tactile,
somatic, visual, gustatory, or olfactory
Inappropriate affect – emotions that are unsuited to the
situation
Comer, Fundamentals of Abnormal
Psychology, 7e
12
What Are the Symptoms of
Schizophrenia?

Negative symptoms

These “pathological deficits” are characteristics
that are lacking in an individual

Negative symptoms include:

Poverty of speech (alogia)

Reduction of quantity of speech or speech content

May also say quite a bit but convey little meaning
Comer, Fundamentals of Abnormal
Psychology, 7e
13
What Are the Symptoms of
Schizophrenia?

Negative symptoms include:

Blunted and flat affect

Show less emotion than most people

Avoidance of eye contact

Immobile, expressionless face

Monotonous voice, low and difficult to hear

Anhedonia – general lack of pleasure or enjoyment
Comer, Fundamentals of Abnormal
Psychology, 7e
14
What Are the Symptoms of
Schizophrenia?

Negative symptoms include:


Loss of volition (loss of motivation or directedness)

Feeling drained of energy and interest in normal goals

Inability to start or follow through on a course of action

Ambivalence – conflicted feelings about most things
Social withdrawal

May withdraw from social environment and attend only to
their own ideas and fantasies

Seems to lead to a breakdown of social skills, including the
ability to accurately recognize other people’s needs and
emotions
Comer, Fundamentals of Abnormal
Psychology, 7e
15
What Are the Symptoms of
Schizophrenia?

Psychomotor symptoms


People with schizophrenia sometimes
experience psychomotor symptoms

Awkward movements, repeated grimaces, odd
gestures

The movements seem to have a magical quality
These symptoms may take extreme forms,
collectively called catatonia

Includes stupor, rigidity, posturing, or excitement
Comer, Fundamentals of Abnormal
Psychology, 7e
16
What Is the Course of
Schizophrenia?

Schizophrenia usually first appears between
the late teens and mid-30s

Many sufferers experience three phases:

Prodromal – beginning of deterioration; mild
symptoms

Active – symptoms become apparent

Residual – a return to prodromal-like levels

One-quarter of patients fully recover; three-quarters
continue to have residual problems
Comer, Fundamentals of Abnormal
Psychology, 7e
17
What Is the Course of
Schizophrenia?


Each phase of the disorder may last for days or
years
A fuller recovery from the disorder is more
likely in people:





With good premorbid functioning
Whose disorder was triggered by stress
With abrupt onset
With later onset (during middle age)
Who receive early treatment
Comer, Fundamentals of Abnormal
Psychology, 7e
18
What Is the Course of
Schizophrenia?

Many researchers believe that a distinction
between Type I and Type II schizophrenia helps
predict the course of the disorder

Type I schizophrenia is dominated by positive
symptoms



Seem to have better adjustment prior to the disorder, later
onset of symptoms, and greater likelihood of improvement
May be linked more closely to biochemical abnormalities in
the brain
Type II schizophrenia is dominated by negative
symptoms

May be tied largely to structural abnormalities in the brain
Comer, Fundamentals of Abnormal
Psychology, 7e
19
How Do Theorists Explain
Schizophrenia?

As with many other disorders, biological,
psychological, and sociocultural theorists have
proposed explanations


Biological explanations have received the most
research support
A diathesis-stress relationship may be at work

People with a biological predisposition will
develop schizophrenia only if certain kinds of
stressors or events are also present
Comer, Fundamentals of Abnormal
Psychology, 7e
20
Biological Views

Genetic and biological studies of
schizophrenia have dominated clinical
research in the last several decades

These studies have revealed the key roles of
inheritance and brain activity and have opened
the door to important changes in treatment
Comer, Fundamentals of Abnormal
Psychology, 7e
21
Biological Views

Genetic factors

Following the principles of a diathesis-stress
approach, genetic researchers believe that
some people inherit a biological predisposition
to schizophrenia

This disposition (and disorder) are triggered by
later exposure to extreme stress

This theory has been supported by studies of
relatives, twins, and adoptees, and by genetic
linkage studies and molecular biology
Comer, Fundamentals of Abnormal
Psychology, 7e
22
Biological Views

Genetic factors

Family pedigree studies have repeatedly found
that schizophrenia is more common among
relatives of people with the disorder

The more closely related they are to the person with
schizophrenia, the greater their likelihood for
developing the disorder
Comer, Fundamentals of Abnormal
Psychology, 7e
23
Comer, Fundamentals of Abnormal
Psychology, 7e
24
Biological Views

Genetic factors

Twins have received particular research study

Studies of identical twins have found that if one
twin develops the disorder, there is a 48% chance
that the other twin will do so as well

If the twins are fraternal, the second twin has a 17%
chance of developing the disorder
Comer, Fundamentals of Abnormal
Psychology, 7e
25
Biological Views

Genetic factors

Adoption studies have compared adults with
schizophrenia, who were adopted as infants, with
both their biological and adoptive relatives


Because they were reared apart from their biological
relatives, similar symptoms in those relatives would
indicate genetic influences; similarities to their adoptive
relatives would suggest environmental influences
Researchers have found that the biological
relatives of adoptees with schizophrenia are more
likely to display schizophrenic symptoms than are
their adoptive relatives
Comer, Fundamentals of Abnormal
Psychology, 7e
26
Biological Views

Genetic factors

Genetic linkage and molecular biology studies
have been used to pinpoint the possible genetic
factors in schizophrenia

These varied findings may indicate:

A case of “mistaken identity” – that is, some of these gene
sites do not contribute to the disorder;

Different kinds of schizophrenia are linked to different genes;
or

Schizophrenia, like many disorders, is a polygenic disorder,
caused by a combination of gene defects
Comer, Fundamentals of Abnormal
Psychology, 7e
27
Biological Views

Genetic factors

Genetic factors may lead to the development of
schizophrenia through two kinds of
(potentially inherited) biological
abnormalities:

Biochemical abnormalities

Abnormal brain structure
Comer, Fundamentals of Abnormal
Psychology, 7e
28
Biological Views

Biochemical abnormalities

Over the past four decades, researchers have
developed a dopamine hypothesis to explain
their findings on schizophrenia:


Certain neurons using dopamine fire too often,
producing symptoms of schizophrenia
This theory is based on the effectiveness of
antipsychotic medications
Comer, Fundamentals of Abnormal
Psychology, 7e
29
Biological Views

Biochemical abnormalities



Originally developed for treatment of allergies,
antipsychotic drugs were found to cause a
Parkinson’s disease-like tremor response in
patients
Scientists knew that Parkinson’s patients had
abnormally low levels of dopamine, which caused
their shaking
This relationship between symptoms suggested
that symptoms of schizophrenia were related to
excess dopamine
Comer, Fundamentals of Abnormal
Psychology, 7e
30
Biological Views

Biochemical abnormalities

Research since the 1960s has supported and
clarified this hypothesis

Example: patients with Parkinson’s disease develop
schizophrenic symptoms if they take too much Ldopa, a medication that raises dopamine levels

Example: people who take high doses of
amphetamines, which increase dopamine activity in
the brain, may develop amphetamine psychosis – a
syndrome similar to schizophrenia
Comer, Fundamentals of Abnormal
Psychology, 7e
31
Biological Views

Biochemical abnormalities

Investigators have also located the dopamine receptors
to which antipsychotic drugs bind


The drugs are apparently dopamine antagonists that bind to
the receptors, preventing dopamine binding and neuron firing
These findings suggest that, in schizophrenia,
messages traveling from dopamine-sending neurons to
dopamine-receptors (particularly
D-2) may be transmitted too easily or too often

This is an appealing theory, because certain dopamine
receptors are known to play a key role in guiding attention
Comer, Fundamentals of Abnormal
Psychology, 7e
32
Biological Views

Biochemical abnormalities

Though enlightening, the dopamine hypothesis
has certain problems

It has been challenged by the discovery of a new type of
antipsychotic drug (“atypical” antipsychotics), which are
more effective than traditional antipsychotics and also
bind to D-1 receptors and to serotonin receptors

It may be that schizophrenia is related to abnormal activity
or interactions of both dopamine and serotonin and perhaps
other neurotransmitters as well, rather than to dopamine
activity alone
Comer, Fundamentals of Abnormal
Psychology, 7e
33
Biological Views

Abnormal brain structure

During the past decade, researchers have also linked
schizophrenia (particularly cases dominated by
negative symptoms) to abnormalities in brain
structure

For example, brain scans have found that many people with
schizophrenia have enlarged ventricles – the brain cavities
that contain cerebrospinal fluid


This enlargement may be a sign of poor development or damage in
related brain regions
People with schizophrenia have also been found to have
smaller temporal and frontal lobes, smaller amounts of grey
matter, and abnormal blood flow to certain brain areas
Comer, Fundamentals of Abnormal
Psychology, 7e
34
Biological Views

Viral problems

Some investigators suggest that the brain
abnormalities seen in schizophrenia result
from exposure to viruses before birth

Some of the evidence comes from animal model
investigations and other is circumstantial
Comer, Fundamentals of Abnormal
Psychology, 7e
35
Biological Views

Viral problems



Circumstantial evidence for this theory comes from the
unusually large number of people with schizophrenia
who were born in winter months
More direct evidence comes from studies showing that
mothers of children with schizophrenia were more
often exposed to the influenza virus during pregnancy
than mothers of children without schizophrenia
Other studies have found a link between schizophrenia
and antibodies to certain viruses, suggesting that
people had at some point been exposed to those
particular viruses
Comer, Fundamentals of Abnormal
Psychology, 7e
36
Biological Views

While the biochemical, brain structure, and
viral findings are beginning to shed much
light on the mysteries of schizophrenia, they
offer only a partial explanation

Some people who have these biological problems
never develop schizophrenia

Might be because biology sets the stage for the disorder,
but psychological and sociocultural factors must be
present for it to appear
Comer, Fundamentals of Abnormal
Psychology, 7e
37
Psychological Views

When schizophrenia investigators began to
identify genetic and biological factors
linked to schizophrenia, clinicians largely
abandoned psychological theories

During the past few decades, however,
psychological factors are again being
considered important

Leading psychological explanations come from the
psychodynamic and cognitive perspectives
Comer, Fundamentals of Abnormal
Psychology, 7e
38
Psychological Views

The psychodynamic explanation

Freud believed that schizophrenia develops from two
processes:



Regression to a pre-ego stage
Efforts to re-establish ego control
He proposed that when their world is extremely harsh,
people who develop schizophrenia regress to the
earliest points in their development (primary
narcissism), in which they recognize and meet only
their own needs

This regression leads to self-centered symptoms such as
neologisms, loose associations, and delusions of grandeur
Comer, Fundamentals of Abnormal
Psychology, 7e
39
Psychological Views

The psychodynamic explanation


Freud’s theory posits that attempts to reestablish ego
control from such a state fail and lead to further
schizophrenic symptoms
Years later, another psychodynamic theorist elaborated
on Freud’s idea of harsh parents


The theory of schizophrenogenic mothers proposed that
mothers of people with schizophrenia were cold, domineering,
and uninterested in their children’s needs
Both of these theories have received little research
support and have been rejected by most
psychodynamic theorists
Comer, Fundamentals of Abnormal
Psychology, 7e
40
Psychological Views

The cognitive view


Leading cognitive theorists agree that biological
factors produce symptoms
They argue that further features of the disorder
emerge because of faulty interpretation and a
misunderstanding of symptoms


Example: a man experiences auditory hallucinations and
approaches his friends for help; they deny the reality of
his sensations; he concludes that they are trying to hide
the truth from him; he begins to reject all feedback and
starts feeling persecuted
There is little direct research support for this view
Comer, Fundamentals of Abnormal
Psychology, 7e
41
Sociocultural Views

Sociocultural theorists believe that three main
social forces contribute to schizophrenia:




Multicultural factors
Social labeling
Family dysfunction
Although these forces are considered
important in the development of
schizophrenia, research has not yet clarified
what their precise causal relationships might
be
Comer, Fundamentals of Abnormal
Psychology, 7e
42
Sociocultural Views

Multicultural Factors

Rates of the disorder differ between racial and
ethnic groups

As many as 2.1% of African Americans are
diagnosed, compared with 1.4% of Caucasians

One possibility to explain this finding is that African
Americans are more prone to develop the disorder

Another explanation is that clinicians from majority
groups are unintentionally biased in their diagnoses or
misread cultural differences as symptoms of
schizophrenia
Comer, Fundamentals of Abnormal
Psychology, 7e
43
Sociocultural Views

Multicultural Factors

Rates of the disorder differ between racial and
ethnic groups

Yet another explanation may lie in the economic sphere

African Americans are more likely to be poor and, when
economic differences are controlled for, rates of
schizophrenia become closer

Consistent with the economic explanation, Hispanic
Americans who also are, on average, economically
disadvantaged, appear to have a much higher likelihood of
being diagnosed than white Americans (although not as high
as that of African Americans)
Comer, Fundamentals of Abnormal
Psychology, 7e
44
Sociocultural Factors

Multicultural Factors

Although the overall prevalence is stable, the
course and outcome of schizophrenia differs
between countries

Some theorists believe that the psychosocial
environments of developing countries tend to be
more supportive than developed countries, leading
to more favorable outcomes for people with
schizophrenia
Comer, Fundamentals of Abnormal
Psychology, 7e
45
Sociocultural Views

Social labeling

Many sociocultural theorists believe that the
features of schizophrenia are influenced by the
diagnosis itself



Society labels people who fail to conform to certain
norms of behavior
Once assigned, the label becomes a self-fulfilling
prophecy
The dangers of social labeling have been well
demonstrated

Example: Rosenhan’s 1973 “pseudo-patient” study
Comer, Fundamentals of Abnormal
Psychology, 7e
46
Sociocultural Views

Family dysfunctioning

Many studies suggest that schizophrenia is often
linked to family stress:

Parents of people with the disorder often:




Display more conflict
Have greater difficulty communicating
Are more critical of and overinvolved with their children than other
parents
Family theorists have long recognized that some families are
high in “expressed emotion” – family members frequently
express criticism and hostility and intrude on each other’s
privacy

Individuals who are trying to recover from schizophrenia are almost
four times more likely to relapse if they live with such a family
Comer, Fundamentals of Abnormal
Psychology, 7e
47
Sociocultural Views

Although the sociocultural causes of
schizophrenia, like the psychological
causes, have yet to be fully understood,
many clinicians currently believe that such
factors play an important role in the
disorder
Comer, Fundamentals of Abnormal
Psychology, 7e
48
How Are Schizophrenia and Other
Severe Mental Disorders Treated?

For much of human history, people with
schizophrenia and other severe mental
disorders were considered beyond help

Though schizophrenia is still extremely
difficult to treat, the discovery of
antipsychotic drugs has enabled people
with the disorder to think clearly and profit
from psychotherapies
Comer, Fundamentals of Abnormal
Psychology, 7e
49
How Are Schizophrenia and Other
Severe Mental Disorders Treated?


It is important to keep in mind that
throughout much of the 20th century, the label
“schizophrenia” was assigned to most people
with psychosis
Clinical theorists now realize that many
people with psychotic symptoms are instead
displaying other disorders and were
inaccurately diagnosed

As such, discussions of past and current
approaches to schizophrenia often apply to other
mental illnesses as well
Comer, Fundamentals of Abnormal
Psychology, 7e
50
Institutional Care in the Past

For more than half of the 20th century,
people with schizophrenia were
institutionalized in public mental hospitals

Because patients failed to respond to
traditional therapies, the primary goals of
the hospitals were to restrain them and
give them food, shelter, and clothing
Comer, Fundamentals of Abnormal
Psychology, 7e
51
Institutional Care in the Past

The move toward institutionalization
began in 1793 with the practice of “moral
treatment”

Hospitals were located in isolated areas to
protect patients from the stresses of daily
life and to offer them a healthful
psychological environment
Comer, Fundamentals of Abnormal
Psychology, 7e
52
Institutional Care in the Past

States throughout the U.S. were required
by law to establish public mental
institutions (state hospitals) for patients
who could not afford private care

Unfortunately, problems with overcrowding,
understaffing, and poor patient outcomes led
to loss of individual care and the creation of
“back wards” – human warehouses filled with
hopelessness
Comer, Fundamentals of Abnormal
Psychology, 7e
53
Institutional Care
Takes a Turn for the Better

In the 1950s, clinicians developed two institutional
approaches that brought some hope to chronic
patients:

Milieu therapy


Token economies


Based on humanistic principles
Based on behavioral principles
These approaches particularly helped improve the
personal care and self-image of patients, problem
areas that had been worsened by
institutionalization
Comer, Fundamentals of Abnormal
Psychology, 7e
54
Institutional Care
Takes a Turn for the Better

Milieu therapy


The premise is that institutions can help patients
make clinical progress by creating a social climate
(“milieu”) that promotes productive activity, selfrespect, and individual responsibility
Milieu-style programs have been set up in
institutions throughout the Western world with
moderate success

Research has shown that patients with schizophrenia in
milieu programs often leave the hospital at higher rates
than patients receiving custodial care
Comer, Fundamentals of Abnormal
Psychology, 7e
55
Institutional Care
Takes a Turn for the Better

The token economy


Based on operant conditioning principles, token
economies are used in institutions to change the
behavior of patients with schizophrenia
Patients are rewarded when they behave in socially
acceptable ways and are not rewarded when they
behave unacceptably


Immediate rewards are tokens that can later be exchanged for
food, cigarettes, privileges, and other desirable objects
Acceptable behaviors likely to be targeted include care for
oneself and one’s possessions, going to a work program,
speaking normally, following ward rules, and showing selfcontrol
Comer, Fundamentals of Abnormal
Psychology, 7e
56
Institutional Care
Takes a Turn for the Better

The token economy


Researchers have found that token economies help
reduce psychotic and related behavior
However, questions have been raised about such
programs:


Many research studies have been uncontrolled; instead
of patients being randomly assigned to groups, a whole
ward will participate in the program
Are such programs truly effective? For example, patients
may change overt behaviors but not underlying
psychotic beliefs
Comer, Fundamentals of Abnormal
Psychology, 7e
57
Institutional Care
Takes a Turn for the Better

Token economy programs are no longer as
popular as they once were but they are still
used in many mental hospitals, usually
along with medication

This approach has also been applied to other
clinical problems
Comer, Fundamentals of Abnormal
Psychology, 7e
58
Antipsychotic Drugs

While milieu therapy and token economies
helped improve treatment outcomes, it was
the discovery of antipsychotic drugs in the
1950s that revolutionized treatment for
those suffering from schizophrenia
Comer, Fundamentals of Abnormal
Psychology, 7e
59
Antipsychotic Drugs


The discovery of antipsychotic medications dates
back to the 1940s, when researchers developed
antihistamine drugs for allergies
It was discovered that one group of antihistamines,
phenothiazines, could be used to calm patients
about to undergo surgery


Psychiatrists tested one of the drugs, chlorpromazine,
on 6 patients with psychosis and observed a sharp
reduction in their symptoms
In 1954, chlorpromazine (under the trade name
Thorazine) was approved for sale in the U.S. as an
antipsychotic drug
Comer, Fundamentals of Abnormal
Psychology, 7e
60
Antipsychotic Drugs

Since the discovery of the phenothiazines,
other kinds of antipsychotic drugs have been
developed

Those developed throughout the 1960s, 1970s, and
1980s are now referred to as “conventional”
antipsychotic drugs


These drugs are also known as neuroleptic drugs,
because they often produce undesired movement effects
similar to symptoms of neurological diseases
Drugs developed in recent years are known as
“atypical” or “second-generation” antipsychotics
Comer, Fundamentals of Abnormal
Psychology, 7e
61
How Effective Are
Antipsychotic Drugs?

Research has shown that antipsychotic drugs
reduce schizophrenia symptoms in at least
65% of patients


In direct comparisons, drugs appear to be more
effective than any other approach used alone
In most cases, the drugs produce the
maximum level of improvement within the
first six months of treatment

Symptoms may return if patients stop taking the
drugs too soon
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How Effective Are
Antipsychotic Drugs?

Antipsychotic drugs, particularly the
conventional ones, reduce the positive
symptoms of schizophrenia more
completely, or at least more quickly, than
the negative symptoms

Although the use of such drugs is now
widely accepted, patients often dislike the
powerful effects of the drugs, and some
refuse to take them
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The Unwanted Effects of
Conventional Antipsychotic Drugs

In addition to reducing psychotic
symptoms, conventional antipsychotic
drugs sometimes produce disturbing
movement problems

These are called “extrapyramidal effects”
because they appear to be caused by the drugs’
impact on the extrapyramidal areas of the
brain
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The Unwanted Effects of
Conventional Antipsychotic Drugs

The most common of these effects are
Parkinsonian symptoms, reactions that closely
resemble features of the neurological disorder
Parkinson’s disease, including:

Muscle tremor and rigidity

Bizarre movements of the face, neck, tongue, and
back

Great restlessness, agitation, and discomfort in the
limbs
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The Unwanted Effects of
Conventional Antipsychotic Drugs

A more difficult side effect of conventional
antipsychotic drugs appears up to 1 year after
starting the medication

This reaction, called tardive dyskinesia, involves
writhing or tic-like involuntary movements,
usually of the mouth, lips, tongue, legs, or body

It affects more than 10% of those taking the drugs and
patients over 50 years of age seem to be at greater risk

Tardive dyskinesia can be difficult, sometimes
impossible, to eliminate
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The Unwanted Effects of
Conventional Antipsychotic Drugs

Since learning of the unwanted side effects
of conventional antipsychotic drugs,
clinicians have become more careful in
their prescription practices

They try to prescribe the lowest effective dose

They gradually reduce or stop medication
weeks or months after the patient begins
functioning normally
Comer, Fundamentals of Abnormal
Psychology, 7e
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Newer Antipsychotic Drugs

In recent years, new antipsychotic drugs
have been developed

Examples: Clozaril, Risperdal, Zyprexa,
Seroquel, Geodon, and Abilify
Comer, Fundamentals of Abnormal
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Newer Antipsychotic Drugs

These new drugs are called “atypical” because
their biological operation differs from that of
conventional antipsychotics

They appear more effective than conventional
antipsychotic drugs, especially for negative
symptoms

They cause few extrapyramidal side effects and
seem less likely to case tardive dyskinesia

Some, however, do produce significant undesirable
effects of their own
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Psychotherapy

Before the discovery of antipsychotic drugs,
psychotherapy was not an option for people
with schizophrenia


Most were too far removed from reality to profit
from psychotherapy
By helping to relieve their thought and
perceptual disturbances, antipsychotic drugs
allow people with schizophrenia to learn
about their disorder, participate in therapy,
think more clearly, and make changes in their
behavior
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Psychotherapy

The most helpful forms of psychotherapy
include cognitive-behavioral therapy and
two broader sociocultural therapies: family
therapy and social therapy

These approaches are often combined
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Psychotherapy

Cognitive-behavioral therapy

An increasing number of clinicians employ
techniques that seek to change how individuals
view and react to their hallucinatory experiences,
including:

Provide education and evidence of the biological causes
of hallucinations

Help clients learn about the “comings and goings” of
their own hallucinations and delusions

Challenge clients’ inaccurate ideas about the power of
their hallucinations
Comer, Fundamentals of Abnormal
Psychology, 7e
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Psychotherapy

Cognitive-behavioral therapy

An increasing number of clinicians employ
techniques that seek to change how individuals
view and react to their hallucinatory
experiences, including:

Teach clients to reattribute and more accurately
interpret their hallucinations

Teach techniques for coping with their unpleasant
sensations
Comer, Fundamentals of Abnormal
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Psychotherapy

Cognitive-behavioral therapy

New-wave cognitive-behavioral therapies also
help clients to accept their streams of
problematic thoughts

These techniques help patients gain a greater
sense of control, become more functional, and
move forward in life

Studies indicate that these various techniques
are often very helpful
Comer, Fundamentals of Abnormal
Psychology, 7e
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Psychotherapy

Family therapy

Over 50% of persons recovering from
schizophrenia and other severe disorder live
with family members

This creates significant family stress

Those who live with relatives who display high
levels of expressed emotion are at greater risk for
relapse than those who live with more positive or
supportive families
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Psychology, 7e
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Psychotherapy

Family therapy

Family therapy attempts to address such
issues, create more realistic expectations, and
provide psychoeducation about the disorder

Families may also turn to family support groups
and family psychoeducation programs

Although research has yet to determine the
usefulness of these groups, the approach has
become popular
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Psychotherapy

Social Therapy

Many clinicians believe that the treatment of
people with schizophrenia should include
techniques that address social and personal
difficulties in the clients’ lives


These include: practical advice, problem solving,
decision making, social skills training, medication
management, employment counseling, financial
assistance, and housing
Research finds that this approach reduces
rehospitalization
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The Community Approach

The community approach is the broadest approach
for the treatment of schizophrenia and other severe
mental disorders

In 1963, Congress passed the Community Mental
Health Act, which provided that patients should be
able to receive care within their own communities,
rather than being transported to institutions far from
home


This Act led to massive deinstitutionalization of patients with
schizophrenia
Unfortunately, community care was (and is) inadequate for
their care

The result is a “revolving door” syndrome
Comer, Fundamentals of Abnormal
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What Are the Features of
Effective Community Care?

People recovering from schizophrenia and
other severe disorders need medication,
psychotherapy, help in handling daily
pressures and responsibilities, guidance in
making decisions, training in social skills,
residential supervision, and vocational
counseling


This combination of services sometimes is called
assertive community treatment
Other key features are…
Comer, Fundamentals of Abnormal
Psychology, 7e
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What Are the Features of
Effective Community Care?

Coordinated services



Community mental health centers provide medications,
psychotherapy, and inpatient emergency care
Coordination of services is especially important for mentally
ill chemical abusers (MICAs) or dual-diagnosis patients
Short-term hospitalization


If treatment on an outpatient basis is unsuccessful, patients
may be transferred to short-term hospital programs
After being hospitalized for up to a few weeks, patients are
released to aftercare programs for follow-up in the
community
Comer, Fundamentals of Abnormal
Psychology, 7e
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What Are the Features of
Effective Community Care?

Partial hospitalization



If patient needs fall between full hospitalization
and outpatient care, day center programs may be
effective
These programs provide daily supervised activities
and programs to improve social skills
Another kind of institution that has become
popular is the semihospital, or residential crisis
center – houses or other structures in the
community that provide 24-hour nursing care for
those with severe mental disorders
Comer, Fundamentals of Abnormal
Psychology, 7e
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What Are the Features of
Effective Community Care?

Supervised residences

Halfway houses (or group homes) provide shelter
and supervision for those patients who are unable
to live alone or with their families, but who do not
require hospitalization

Staff are usually paraprofessionals

Houses are run with a milieu therapy philosophy

These programs help those with schizophrenia
adjust to community life and avoid
rehospitalization
Comer, Fundamentals of Abnormal
Psychology, 7e
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What Are the Features of
Effective Community Care?

Occupational training and support


Paid employment provides income, independence,
self-respect, and the stimulation of working with
others
Many people recovering from schizophrenia
receive occupational training in a sheltered
workshop – a supervised workplace for employees
who are not ready for competitive or complicated
jobs

An alternative work opportunity for individuals with
severe disorders is supported employment
Comer, Fundamentals of Abnormal
Psychology, 7e
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How Has Community
Treatment Failed?


There is no doubt that effective community
programs can help people with schizophrenia and
other severe mental disorders recover
However, fewer than half of all people who need
them receive appropriate community mental health
services


In any given year, 40% to 60% of all people with
schizophrenia receive no treatment at all
Two factors are primarily responsible:


Poor coordination of services
Shortage of services
Comer, Fundamentals of Abnormal
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How Has Community
Treatment Failed?

Poor coordination of services


Mental health agencies in a community often fail
to communicate with one another
To combat this problem, a growing number of
community therapists have become case managers
for people suffering from schizophrenia


Case managers offer therapy and advice, teach problemsolving and social skills, and ensure compliance with
medications
Case managers also try to coordinate available
community services for their clients, guide them through
the system and protect their legal rights
Comer, Fundamentals of Abnormal
Psychology, 7e
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How Has Community
Treatment Failed?

Shortage of services

The number of community programs available
to people with schizophrenia falls woefully
short

The centers that do exist generally fail to
provide adequate services for people with
severe disorders

While there are various reasons for these
shortages, the primary one is economic
Comer, Fundamentals of Abnormal
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What Are the Consequences of
Inadequate Community Treatment?

When community treatment fails, many
people suffering from schizophrenia and
other severe mental disorders receive no
treatment at all

Many return to their families and receive
medication and perhaps emotional and
financial support, but little else in the way of
treatment
Comer, Fundamentals of Abnormal
Psychology, 7e
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What Are the Consequences of
Inadequate Community Treatment?



Around 8% of patients enter an alternative
care facility (such as a nursing home), where
they receive custodial care and medication
As many as 18% are placed in privately run
residences where supervision is provided by
untrained individuals
Another 34% of patients are placed in singleroom occupancy hotels, generally in rundown
environments, where they survive on
government disability payments
Comer, Fundamentals of Abnormal
Psychology, 7e
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What Are the Consequences of
Inadequate Community Treatment?

Finally, a large number of people suffering
from schizophrenia become homeless

Approximately one-third of the homeless
people in America have a severe mental
disorder, commonly schizophrenia
Comer, Fundamentals of Abnormal
Psychology, 7e
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The Promise of
Community Treatment

Despite these very serious problems,
proper community care has shown great
potential for assisting in recovery from
schizophrenia

In addition, a number of national interest
groups, including the National Alliance on
Mental Illness (NAMI), have formed to push
for better community treatment
Comer, Fundamentals of Abnormal
Psychology, 7e
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The Promise of
Community Treatment

Today, community care is a major feature
of treatment for people recovering from
severe mental disorders in countries
around the world

Both in the U.S. and abroad, varied and
wellcoordinated community treatment is
seen as an important part of the solution to
the problem of schizophrenia
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