Ch. 15

Front 1

TREATMENT for SCHIZO (Past)

Back 1

According to Comer, the schizophrenic has been “subjected to more mistreatment and indifference than perhaps any other group of patients.” Even though antipsychotic medications have significantly advanced
treatment, schizophrenics continue to be the targets of inadequate treatment.

Front 2

For the most part, most people with schizophrenia were institutionalized in a public mental health. The
original intent of institutional care was a good one. In 1793, Pinel introduced humane treatment to the
“insane” at the La Bicetre asylum.

The chief contribution of Pinel to the care of those with severe mental illnesses was to treat patients with sympathy and kindness. He opened up the windows, took off the restraints, and allowed these patients to connect with the mainstream of society.

Back 2

After Pinel’s efforts, humane institutional care spread across Europe and the United States. In the United
States, Dorthea Dix (above) pushed for increased institutional care. From 1845 to 1955, nearly 300 state
mental hospitals were opened in the United States.

Most of these 110 years, schizophrenic patients
received only the basic necessities of life. This was especially true in the 1940’s through the early 50’s.
However, humanists rescued institutional care in mid to late 1950’s with milieu therapy.

Front 3

Comer points out that in 1955 the mental hospital population grew to about 600,000 patients. This
translated into overcrowding, economic strain, lack of state funding, lack of qualified and caring personnel,
and too much restraint and not enough humane treatment.

The biggest “loser” in all of this was the
schizophrenic. Interestingly, most patients who lived on the back wards of state mental hospitals in the mid
1900’s were schizophrenics.

Back 3

The schizophrenic became the victim of the human warehouse. Because treatments for the schizophrenic
were not effective, they typically found themselves in straitjackets and in the chronically ill wards where
persons seldom recovered.

For the schizophrenic, the mental hospital guaranteed psychological decline and social breakdown. Patients who developed extreme withdrawal, anger, physical aggression, and loss of personal hygiene because of poor institutional care showed a pattern called social breakdown syndrome.

Front 4

In the late 50’s, the conditions in mental hospitals did take notice and things began to change. In response,
clinicians developed two unique approaches. These were milieu therapy and token economy programs.

As noted by Comer, milieu therapy is defined as “a humanistic approach to institutional treatment based on the belief that institutions can help patients recover by creating a climate that promotes self respect,
responsible behavior and meaningful activity.” It is obvious that milieu therapy has deep humanistic roots.

Back 4

Milieu therapy is a means to an end. Maxwell Jones, London psychiatrist, first established the concept of
milieu (means middle place) therapy to promote the mental health of institutionalized schizophrenics.
Jones called it the the therapeutic community. With this type of treatment, there is an active attempt to
remove the sterile and disease model climate of the mental hospital.

Instead, schizophrenic patients become
residents and are perceived as persons responsible for their own lives and decisions. Milieu therapy created
an environment that encouraged self-respect and responsibility.

Front 5

Milieu therapy creates a climate in which various activities are consistent outside the treatment setting. So hospital residents take on special responsibilities to raise their expectations of themselves. Milieu therapy
embraces the notion that both patient and hospital staff are both therapeutic agents of change. In other
words, when one changes the social environment one changes the patient!

Back 5

Research has shown that schizophrenics can change in this therapeutic climate and eventually leave the
hospital in greater numbers. However, their exodus from the inpatient milieu moves the schizophrenic to
“half way shelters.”

Front 6

Behavioral approaches were not considered viable interventions for mental disorders until the late 1950’s.
As a last resort, clinicians applied behavioral principles of change to the chronic and hopeless
schizophrenic. In particular, clinicians employed an operant technique known as a “token economy.”

Back 6

Token systems gave schizophrenic patients a reason to behave in acceptable and not bizarre ways. Tokens
were secondary reinforcers or like money that were exchanged for primary reinforcers (e.g., cigarettes,
privileges, food, etc…).

Schizophrenic patients were given a list of appropriate behaviors (e.g., making their bed, taking care of personal hygiene) and received tokens contingent upon their completion.

Front 7

Interventions studies indicated that token systems were quite effective in changing schizophrenic’s
psychotic like behaviors. Nevertheless, a number of intervention studies failed to use control groups.
Instead, they relied on behavioral baselines as a comparison.

Back 7

Without a control group, any change from
baseline could have been attributed to any change in the environment (e.g., staff attention) and not the
token system. Nevertheless, token systems decreased psychotic symptoms and was one’s best bet to be
discharged from the hospital.

Front 8

Closer scrutiny of token systems suggest that they may violate what the patient is entitled. Withholding a
comfortable bed or food because the patient has not achieved enough tokens may be construed as unethical
or even illegal.

Lastly, clinicians raise the question of token systems maintaining appropriate behavior outside the institution. A schizophrenic may behave normally because one feels compelled to do so, but
outside the hospital one does not see the reward.

Back 8

Token systems are not as popular as they once were in the 1950’s and 60’s. In fact, token systems were
criticized because they were unable to change the behaviors of the severely ill patients. However, they did
get results despite the unethical claims and lack of generalizability. Lastly, token systems have been
effective for other clinical populations (e.g., children with behavioral dysfunction).

Front 9

ANTIPSYCHOTIC MEDICATION

Back 9

Antipsychotic medication changed our view of schizophrenia forever. Chlorpromazine was the first to be used. Its trade name is thorazine.

First, it reduced a number of psychotic symptoms. Second, it has become the mainstay of schizophrenic treatment. Third, it generated theory about the biochemical abnormalities of the brain.

Front 10

The history of antipsychotic medications is a strange one. First, Laboit discovered that a phenothiazines
had a calming effect on patients before surgery. Originally marketed as an antihistamine, Delay and
Deniker discovered that chlorpromazine (thorazine) actually reduced psychotic symptoms in a small sample
of schizophrenics.

Back 10

After these initial studies, the treatment of schizophrenics was revolutionized forever. Since the
introduction of thorazine, other conventional or typical antipsychotics have been developed.

Front 11

The schizophrenic symptom most likely to be relieved by a typical antipsychotic medication is the delusion.
It became apparent that if one could only have one treatment for schizophrenia, antipsychotic medications
were the likely choice.

However, early as well as more developed typical antipsychotic drugs had severe side-effects. We will examine this phenomenon shortly.

Back 11

Remember, phenothiazines block the receptor sites that activate dopamine activity. As a result of ongoing medication, excessive dopamine receptors are neutralized and normal dopamine receptors are produced thus causing healthy dopamine activity.

Front 12

How effective are these medications? Are there dangerous side effects with continued use? Research has shown consistently that antipsychotic medications significantly reduce the symptoms of schizophrenia. The
slide to the right illustrates the effectiveness of antipsychotics.

Back 12

The effectiveness of medications is especially indicated when schizophrenic patients go off their medication.
On the other hand, conventional antipsychotic medications have been called neuroleptics because of their undesirable motor side-effects. Let’s look at some of the negative outcomes of long-term use of
antipsychotic medications.

Front 13

Let’s take a closer look at some of the side effects of antipsychotic medications. First, one negative outcome
of the conventional neuroleptics (e.g., thorazine) is that of extrapyramidal effects. These effects are marked
by tremors and uncontrollable movements.

Back 13

Comer identifies three extrapyramidal or medication conditions. These include: Parkinsonian and related
symptoms, Neuroleptic malignant syndrome, and tardive dyskinesia. Let’s begin with Parkinsonian related
symptoms.

Front 14

After prolonged exposure to conventional antipsychotics, schizophrenics show Parkinson like symptoms. Interestingly, most of these conditions can be treated with anti-Parkinson drugs or continued used of the antipsychotic medication.

First, let’s start with dystonia. Symptoms include dystonia (involuntary muscle contractions that lead to uncontrollable movements of the face, tongue, neck, and back).

Back 14

Second, one can experience akathisia (a condition like restless leg syndrome in which one feels restlessness,
agitation, soreness in joints and discomfort if limbs cannot be moved). Brain research indicates that
reduced dopamine activity in the substantia nigra appears responsible for these two motor side-effects.

Front 15

What is neuroleptic malignant syndrome? This is a dangerous condition that can be fatal. As a result of
long-term use of antipsychotic drugs, one can develop severe muscle rigidity, dysfunction of the autonomic
nervous system, fever, and altered states of consciousness.

The course of action is predictably removal of antipsychotic medication. Furthermore, a person with this condition can experience a potentially fatal reaction of the automatic nervous system.

Back 15

Lastly, the schizophrenic can experience tardive dyskinesia. Tardive dyskinesia usually appears after
extended use of antipsychotic medications. Most noticeable symptoms include lip smacking, involuntary
chewing, tic like movements of the tongue, mouth, face, and often the entire body, and purposeless and
jerky movement of the body. In addition, TD can be overlooked because its symptoms are similar to
schizophrenia.

Front 16

The key element of diagnosing tardive dyskinesia is recognizing it early. This condition typically requires at
least a year to develop. If detected early enough, the removal of conventional antipsychotics can make a
difference. According to Comer, if not detected, elderly schizophrenics have six times greater chance of
developing tardive dyskinesia. The most effective way of treating tardive dyskinesia is to stop the
conventional antipsychotics.

Back 16

Psychiatrists have become wiser in their use of conventional antipsychotic medications. In previous years, if the medication doses were ineffective, psychiatrists often increased the medications (increases may be alright with SRI’s like prozac). Today, if the medications prove ineffective, the psychiatrist will discontinue the medication or explore other options.

Front 17

What happens if conventional antipsychotics prove ineffective? Psychiatrists can opt for atypical
antipsychotics like Risperdal, Clozapine, Zyprexa, and Seroquel. What appears to be encouraging about
these medications is their positive effects on Type II symptoms.

These medications appear to be influential
at D-1 receptors. These receptors are sensitive to serotonin neurotransmitter. Clozapine or Clozaril is the
most widely used atypical antipsychotic medication.

Back 17

One major benefit of these medications centers on their minimal side-effects, especially those related to the
extrapyramidal system. However, in some cases, schizophrenics taking these medications for an extensive period of time can develop a condition called agranulocytosis.

Front 18

This condition involves a “life threatening reduction in white blood cells. This condition is sometimes
produced by clozapin….” The lesson to this story is for the schizophrenic to order frequent blood screens to
monitor white blood cell counts.

Back 18

THE END!