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Treatment and Therapies for Schizophrenia

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Treatment and Therapies for Schizophrenia

To effectively treat schizophrenia, considerable research has gone into studying the mental health disorder, and different theories as to how to treat it have been put forward as a result.

The result varies from biological to psychological treatments for schizophrenia. Biological treatments for schizophrenia tend to focus on the use of drugs (mainly antipsychotics), while psychological ones focus on therapy sessions with one-on-one interactions with the patient, talking through their symptoms and addressing them with a focus on behavioural and thought processes changes.

Biological treatments for schizophrenia

These therapies and treatment plans focus on drugs/medications to treat schizophrenia.

Antipsychotics are a form of drug treatment used to treat the positive and negative symptoms of schizophrenia. The two forms of antipsychotics are typical and atypical.

Typical antipsychotics

Typical antipsychotics are the first generation of antipsychotic drug therapy. Developed in the 1950s, they are known for treating positive symptoms. Since the advent of atypical antipsychotics (mentioned below), they have lost favour, as they have side effects some patients consider too severe to continue treatment consistently. Whether or not they are an outdated treatment or the more modern atypical antipsychotic drugs are better is still up for debate.

Typical antipsychotic drugs include:

  • Chlorpromazine

  • Haloperidol

They work by affecting the dopamine receptors (D2) in the mesolimbic pathway in the brain primarily (this is the reward centre) but also affect the rest of the brain unintentionally. They’re also known as dopamine antagonists, as they block these receptors and calm the dopamine system in the brain. Positive symptoms result from the increased subcortical dopamine release in the brain, possibly due to a defect in the cortical pathway through the nucleus accumbens (Brisch et al., 2014).

Treatment and Therapies for Schizophrenia Dopaminergic mesolimbic pathways StudySmarterThe main dopaminergic pathways of the human brain, GNU Free Documentation Licence, Wikimedia Commons

Side effects include:

  • Tardive Dyskinesia (uncontrollable muscle movements usually affecting the face).

  • Akathisia (uncomfortable restlessness).

  • Dry mouth.

  • Constipation.

Atypical antipsychotics

Some consider atypical antipsychotics, which were developed in the 1970s, as an improvement compared to typical antipsychotics. They are the second generation of antipsychotics and address positive AND negative symptoms by affecting multiple neurotransmitter systems.

Atypical antipsychotic drugs include:

  • Clozapine.

  • Olanzapine.

Atypical antipsychotics affect dopamine receptors in the limbic system. However, they do not affect the rest of the brain as typical antipsychotics do. They also work on:

  • Acetylcholine.

  • Glutamate.

  • Serotonin.

These neurotransmitters are associated with negative symptoms in schizophrenia. This is where atypical drugs differ, as dopamine affects the positive symptoms, and these neurotransmitters affect the negative symptoms.

Atypical antipsychotics are known for their supposed less severe side effects (although recent research is disputing this notion).

Side effects include:

  • Diabetes.

  • Tardive Dyskinesia (uncontrollable muscle movements usually affecting the face), which is less likely to happen with atypical antipsychotics.

  • Cardiovascular problems.

  • Weight gain.

Drug therapies have their specific weaknesses and strengths; we will evaluate these in the subtopic articles.

Psychological treatment for schizophrenia

As schizophrenia is a somewhat complex mental health disorder, there are multiple avenues of treatment. Psychological treatment for schizophrenia works through the disorder with an appointed psychiatrist/clinician/therapist.

There are multiple forms of psychological treatment.

Cognitive Behavioural Therapy (CBT)

Developed in the 1960s by Beck, cognitive behavioural therapy (CBT) focuses on addressing dysfunctional thought processes and behaviours. It encourages patients to work through symptoms such as delusions, hallucinations, and depression by evaluating these symptoms logically.

CBT lasts around 6 to 12 weeks, although this can vary depending on a patient’s needs. Patients work closely with an appointed therapist to build trust.

CBT addresses other issues, such as:

  • General, irrational beliefs, e.g., hearing people who are not there talking about you or hearing a voice narrate your daily life.

  • Self-image issues.

  • Beliefs about people’s perception of the patient (Do they hate the patient? Do people think they’re ugly? Do people think they’re a bad person?).

A process is identified and followed, whereby patients are:

  1. Assessed: Patients explain their issues to a therapist. These are identified, and patients are encouraged to reflect during this stage to understand better where these symptoms originate.

  2. Engaged with: After being assessed, the therapist then begins to logically work through the issues, such as identifying a delusion (for example, believing a neighbour is trying to kill the patient) and explaining why this isn’t the case; the neighbour has no ill intent towards the patient, they are friendly, and it would result in the neighbour being tried and imprisoned.

CBT adopts the ‘ABC (later expanded to the ABCDE model)’ method to work through this process.

This is known as:

  • Activating Event: What is causing the problem?

  • Behaviour and Beliefs: How does the patient react in these situations?

  • Consequences: What impact does this have on the patient’s life and relationships with others?

  • Disputing Irrational Beliefs: Working with the therapist to logically dispute and deconstruct these irrational beliefs.

  • Effect Restructuring: Working with the therapist to establish the actual reality of the situation, rather than believing the irrational thoughts.

If a patient believes someone is following them, this is the activating event. They then begin to act secretive/have extreme behavioural responses, and this is the behaviour and beliefs change. The consequences are irrational thoughts affecting how a patient operates daily life, as they may avoid certain activities crucial to daily living, such as grocery shopping and exercise. The therapist then disputes this irrational belief, working through it logically, which restructures the event for the patient.

Disputing irrational beliefs can be addressed using these methods:

  • Reality testing.

  • Normalisation.

  • Critical analysis of ideas together (therapist and patient).

CBT also can follow the ‘CSE’ model, a method similar to the ABC model.

Coping Strategy Enhancement (CSE) encourages patients to develop and apply their coping strategies, teaching them how to do so in the hopes of reducing the frequency and intensity of psychotic symptoms in schizophrenia.

It has two components:

  1. Education and rapport training: The patient and clinician work together.

  2. Symptom targeting: Clinicians will target a patient’s specific symptom and work towards coping strategies within a given session.

Family therapy

Family therapy is a form of treatment that involves the patient and their respective family members, especially those who live in the same household.

It focuses on reducing expressed emotion (EE), stress, and guilt within family members who live with the patient. Usually, it is given through group sessions involving the patient and their family.

Family therapy tends to last for up to a year.

Like CBT, family therapy involves assessing the patient and the family and providing the appropriate treatment. It does so by:

  1. Preliminary analysis: interviews and active observations are made of the family members and the patient.

  2. Information transfer: the therapist encourages family members to learn about schizophrenia and what it entails, with the goal of education on the disorder reducing issues with EE and stress.

Information transfer is known as psychoeducation. It informs people about schizophrenia, reducing levels of ignorance and misinformation in the hopes of helping family members cope.

Teaching family members communication training can be done in the following ways:

  • Compromise and negotiation involve weekly meetings to air out issues.

  • Being family centred: the whole family is the focus, not just the patient.

These methods should improve problem-solving skills for the family involved, rather than resorting to negative behaviours that worsen schizophrenic symptoms in the patient and dismantle relationships.

Token economy

Token economy systems (TES), developed in the 1960s, are reward systems to encourage good behaviours in a patient with schizophrenia, treating maladaptive behaviours (behaviours preventing a patient from adapting to new situations). This indirectly treats most negative symptoms of schizophrenia.

It involves a system introduced when the patient is first hospitalised, as TES were particularly popular when institutionalisation was common for schizophrenic patients.

Tokens, such as physical items (chips or plastic coins) or a tally system, are used as a secondary reinforcer earned through good behaviour. This can include:

  • Getting up on time.

  • Getting washed and dressed.

  • Brushing teeth.

Once patients earn enough tokens, a patient can trade them in for a reward, known as the primary reinforcer. Secondary reinforcers gain power through being associated with the primary reinforcer.

Three examples, established by Matson et al. (2016), are good examples of behaviours tackled by token economy systems:

  • Personal care (issues with hygiene such as showering, changing clothes, and brushing teeth).

  • Condition related behaviour (issues with positive and negative symptoms).

  • Social behaviour (issues with socialising with other people)

It is a motivational therapy but has underlying issues. Mainly, patients have to want to do the above behaviours.

TES works by being specific to patients, using their favourite things to encourage desirable behaviours. TES has fallen out of favour over the years due to a lack of need for the hospitalisation of patients and questionable ethical issues.

Interactionist spproach/diathesis-stress model

The interactionist approach combines psychological, biological and social factors, and it considers how this affects the development of schizophrenia and the subsequent treatment options for schizophrenia.

It is holistic in that it considers the patient as a whole person, rather than identifying them through their mental health disorder alone (a reductionist issue).

The most well-known interactionist approach is the diathesis-stress model.

The diathesis-stress model

The diathesis-stress model suggests schizophrenia is due to an internal vulnerability (diathesis) and an external environmental factor (stressor). This diathesis is predisposed and was potentially (in that, this was what we once believed) due to one specific gene: the schizogene.

We now understand that schizophrenia is a polygenetic disorder and results from dopamine imbalances in the brain.

Studies have found that early childhood trauma can act as a trigger for schizophrenia to develop. Issues such as:

  • Birthing complications,

  • General pregnancy complications.

  • Negative life experiences (such as academic pressures or emotional breakups).

  • Childhood traumas (expressed emotion, family dysfunction) altering neurological development - Read (2001).

Drug abuse has also been linked to the development of schizophrenia, such as using cannabis (increasing levels of paranoia, a positive symptom in schizophrenia).

Two prominent cases involving the diathesis-stress model are:

  1. Gottesman (1991): twin study, where they compared identical twins with non-identical twins. Only 48% of identical twins developed schizophrenia, despite sharing 100% of their DNA - this suggests that both of these twins have a genetic vulnerability to schizophrenia. However, only one had a psychological experience to trigger the disorder.

  2. Tienari (2004): This study investigated adopted biological children of schizophrenic mothers. 36.8% of the children developed schizophrenia in dysfunctional households, compared to just 5.8% of children in healthy households. There is genetic vulnerability, and the family household acted as a stressor to trigger schizophrenia.

The interactionist approach understandably encourages a combination of biological and psychological therapies to treat schizophrenia. It is supported by studies that show combining antipsychotic treatment with a form of therapy reduces symptoms and rehospitalisation.

Antipsychotics, in a lot of cases, reduce symptoms to allow for patients to undergo therapy.

The interactionist approach and the diathesis-stress model have their own weaknesses and strengths, evaluated in subtopic specific articles.


Treatment and Therapies for Schizophrenia - Key takeaways

  • Treatments and therapies is divided into two main categories: biological and psychological.
  • Biological treatments involve the use of antipsychotic drugs. These can be typical (affecting only dopamine) or atypical (affecting dopamine, acetylcholine, glutamate and serotonin). Typical antipsychotics address positive symptoms, whilst atypical antipsychotics address positive and negative symptoms.
  • Typical antipsychotics have more severe side effects (such as dry mouth, tardive dyskinesia, and akathisia), atypical antipsychotics have less severe side effects (such as weight gain and tardive dyskinesia - although less often). Although this is not necessarily true, atypical antipsychotics are seen as the more modern treatment for schizophrenia.
  • Psychological therapies include cognitive behavioural therapy, family therapy and token economy.
  • CBT uses the ABC(DE) and CSE model and usually lasts around 6 to 12 weeks. It involves an assessment and engagement phase, where issues are worked through logically. CBT encourages patients to work on their behaviours.
  • CSE involves education and rapport training and symptom-specific targeting.
  • Family therapy includes the whole family and the patient, encouraging communication and working through issues together. This reduces expressed emotion, stress and guilt, both in the patient and the family members.
  • Token economy adopts a reward system to encourage good behaviours and treat patients’ maladaptive behaviours.
  • The interactionist approach combines all therapies and effects to explain the development of schizophrenia.
  • It is mainly known for the diathesis-stress model, which includes an internal vulnerability (diathesis, polygenetic) and an external, environmental stressor that triggers schizophrenia. This can consist of childhood traumas, high levels of expressed emotions, and academic pressures.
  • The interactionist approach encourages a combination of biological and psychological therapies.

Frequently Asked Questions about Treatment and Therapies for Schizophrenia

There are multiple forms of treatment available for schizophrenia, and they can be biological or psychological. Schizophrenia can either be treated through medication, such as typical and atypical antipsychotics, or through therapy, such as family therapy, cognitive behavioural therapy, and token economy systems. Biological and psychological treatments can also be combined. 

Treatment for schizophrenia is subjective. One treatment plan may be more effective for one person than another. Typically, drug treatments are quite effective in addressing symptoms of the disorder, and therapy offers effective treatment in addressing the underlying causes. 

There are multiple types of therapies for schizophrenia: cognitive behavioural therapy, family therapy, and token economy systems are examples. 

Not entirely. It can be treated to lessen the symptoms and improve the quality of life for patients, but the condition is incredibly complex and hard to pinpoint exactly what is causing it.

Typically, patients are assessed and then prescribed medication in the form of antipsychotic drugs as the first line of treatment for their disorder.

Final Treatment and Therapies for Schizophrenia Quiz

Question

What are the two types of antipsychotics?

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Answer

Typical and Atypical.

Show question

Question

What are typical antipsychotics and how do they work?

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Answer

Typical antipsychotics are the first generation of drug therapies available for schizophrenia. They work by blocking dopamine 2 (D2) receptors in the mesolimbic pathway in the brain. They’re known as dopamine-antagonists.

Show question

Question

What are atypical antipsychotics and how do they work?

Show answer

Answer

Atypical antipsychotics are considered to be the second generation of antipsychotic drug treatments. They work by blocking dopamine receptors in the limbic pathway of the brain and affecting other neurotransmitters - acetylcholine, glutamate and serotonin.

Show question

Question

What are the side effects of typical antipsychotics? 


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Answer

Tardive dyskinesia, akathisia, dry mouth.

Show question

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What are the side effects of atypical antipsychotics?

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Answer

Tardive dyskinesia (less severe), weight gain, cardiovascular problems.

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What are the types of psychological therapies?

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Cognitive behavioural therapy, family therapy and token economy.

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What are the stages of CBT?

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Assessment and engagement. Includes the ABC(DE) and the CSE models.

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How can irrational beliefs be disputed in CBT?

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Answer

Through reality testing, normalisation and critical analysis of ideas together.

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Define family therapy. 


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Family therapy, also known as systemic therapy, is a form of psychological treatment used for patients with schizophrenia, involving a therapist and group sessions.

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What steps are taken in the process of giving family therapy?

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Answer

Preliminary analysis and information transfer.

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What is psychoeducation? 


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It is the process of educating the family involved about the disorder and the effects of outside influences on it.

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What are token economy systems? 


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Answer

They are reward systems put in place to encourage good behaviours in a patient with schizophrenia, treating maladaptive behaviours (behaviours preventing a patient from adapting to new situations).

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Question

What are the primary and secondary reinforcers in token economy systems?

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Primary reinforcers are the reward, and they give power and are associated with the tokens, which are the secondary reinforcers (usually tangible/physical items to be exchanged for the reward).

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What is the interactionist approach to schizophrenia?

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Answer

The interactionist approach is the consideration of how the combination of biological, psychological, and social factors explain the development of schizophrenia.

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What is the diathesis-stress model?


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It suggests that schizophrenia is due to a diathesis (an internal vulnerability) and an environmental trigger (stressor). It is a polygenetic disorder triggered by something environmental.

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Is the internal vulnerability predisposed?

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Yes.

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Name three childhood issues that can act as a stressor that triggers schizophrenia.

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Answer

Birthing complications, childhood trauma and academic pressures.

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What are drug therapies?

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Drug therapies are the biological side of treatment for schizophrenia. 

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What are the two types of antipsychotics?

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Answer

Typical and atypical.

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What are typical antipsychotics? 


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Typical antipsychotics are the first generation of drug therapies available for schizophrenia. They were developed in the 1950s, and have lost popularity since the advent of atypical antipsychotics for several reasons.

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How do typical antipsychotics work?

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Answer

They work by blocking the dopamine 2 receptor (D2), reducing the uptake of dopamine in the mesolimbic pathway (also known as the reward pathway), and can differ in potency. By blocking the D2 receptors and effectively calming the dopamine system in the brain, typical antipsychotics lower the intensity of positive symptoms. They can often be referred to as dopamine antagonists.

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What are some side effects of typical antipsychotics?

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Dry mouth, constipation, low energy, sedation, tardive dyskinesia (uncontrollable muscle movements usually affecting the face), akathisia (uncomfortable restlessness).

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What are atypical antipsychotics? 


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Atypical antipsychotics are considered to be the second generation of antipsychotic drug treatments. Developed in the 1970s, it was stated that they avoid the more severe side effects of typical antipsychotics.

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How do atypical antipsychotics work, how do they differ from typical antipsychotics?

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They work somewhat similarly to typical antipsychotics in that they block D2 dopamine receptors in the limbic system, however, they do not affect D3 receptors in other parts of the brain. The reduction of intensity in positive symptoms occurs as a result, but they also act on other neurotransmitters such as serotonin and glutamate.

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What are some side effects of atypical antipsychotics?

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Cardiovascular problems, weight gain, drowsiness, diabetes, tardive Dyskinesia (uncontrollable muscle movements usually affecting the face) - although, this is less likely to happen with atypical antipsychotics.

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What are some strengths of using drug therapies to treat schizophrenia? 


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Antipsychotics have been found to have proven efficacy in treating positive and negative symptoms of schizophrenia. They reduce institutionalised hospital treatments and encourage patient independence. Atypical antipsychotics have shown to have fewer side effects than typical antipsychotics, although both are effective at treating symptoms.

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What are some of the weaknesses of using drug therapies to treat schizophrenia? 

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Antipsychotics cause severe side effects in some patients, such as tardive dyskinesia, and therefore many patients stop taking their medication, creating a revolving door of treatment. They are only suppressing the symptoms of schizophrenia, not treating the root cause. There’s also not enough evidence to suggest second-generation antipsychotics are significantly better than first-generation antipsychotics, so there’s no need to separate them as such.

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What did Leucht et al. (2013) find in their study? 


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They found that when 15 antipsychotic drugs were compared to their controls (placebo) in the acute treatment of schizophrenia, they were more effective than their placebos, so treatments targeting dopamine are effective in reducing symptoms.

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What did Schooler et al. (2005) find in their study? 


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When comparing haloperidol to risperidone, low doses of antipsychotic drugs were able to significantly improve symptoms of psychosis associated with schizophrenia in first-episode patients

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What did Kahn et al. (2008) find in their study?

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Khan found that antipsychotics were effective for at least one year, however, there was no evidence to suggest that second-generation antipsychotics were more effective than first-generation antipsychotics.

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What did Tarrier et al. (1998) find in their study? 


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Combined treatment of antipsychotics and CBT seems to be the most effective treatment plan.

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What is cognitive behavioural therapy (CBT)?

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CBT is a form of psychological therapy that focuses on teaching patients to recognise their dysfunctional thoughts and behaviours, how to rationalise these thoughts using logic, and how to avoid acting on these thoughts.

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How long does CBT usually take?

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Around 6 to 12 weeks depending on the patient’s needs.

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What are the stages of CBT?

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Assessment and engagement.

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What are the two different methods a clinician can use to work through CBT with a patient? 


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The ABC and CSE methods.

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What is the ABC method?

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The ABC method includes finding out the patient's Activating event, Behaviours and beliefs, and the Consequences of these beliefs. ABC was expanded in the 1990s to include Disputing the beliefs (D) and restructuring the Events (E).

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How does the ABC method dispute a patient with schizophrenia’s belief systems?

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By reality testing, normalisation, and critically analysing ideas together, developing new explanations as a result. This helps patients see past their delusions and hallucinations using logic and encouraging independence.

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What is the CSE method?

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Coping Strategy Enhancement (CSE) encourages patients to develop and apply their coping strategies, teaching them how to do so in the hopes of reducing the frequency and intensity of their psychotic symptoms.

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How does the CSE method work through a patient's schizophrenia?

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Answer

By education and rapport training, building trust between the clinician and the patient to find out what the current coping strategies are and developing them/new ones. CSE also targets specific symptoms to develop coping strategies for and normally assigns homework/a monitoring system for the patient. 

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Name two strengths of using CBT to treat schizophrenia. 


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CBT has been proven to be effective in treating positive and negative symptoms in studies (Turkington et al., 2006). It has also been shown to reduce relapse rates and readmissions to hospitals.

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Name two weaknesses of using CBT for schizophrenia treatment.

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It’s a lengthy process, so it has issues with being more expensive than drug treatments and patients often drop out early. Most meta-analysis reviews fail to consider potential biases, and Jauhar et al. (2014) found that, when including the examination of potential biases in their meta-analysis of CBT effects on schizophrenic symptoms, CBT has a therapeutic effect in the ‘small’ range, reducing further when biases (masking, publication bias) are taken into account.

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What did Rathod et al. (2008) find in their study?

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They found that CBT had large clinical effects on positive and negative symptoms.

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When something is being masked in a study, what does that entail?

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If something is being masked, it means it is being kept hidden from the individual being studied and/or the investigators to avoid potential bias occurring.

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Name another form of bias that can occur in research, that was found to be a problem in some meta-analysis reviews. 


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Publication bias.

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What does the term ‘normalisation’ mean when conducting CBT on patients with schizophrenia? 


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It is when patients are taught that their negative thoughts are not always inappropriate or bad, and can be normal in certain situations.

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What did Kingdon and Kirschen (2006) find in their study? 


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They found that CBT is not appropriate for every patient with schizophrenia. It depends on the individual and how they respond to treatment, and how severe their symptoms are.

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Define family therapy.

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Answer

Family therapy, also known as systemic therapy, is a form of psychological treatment used for patients with schizophrenia, involving a therapist and group sessions.

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What is the average length of family therapy?

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Usually, family therapy lasts for up to a year.

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What are the goals of family therapy?

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Family therapy intends to improve patient and family relationships and communication styles. This should address issues such as stress in the household, reducing levels of expressed emotion (EE) and relapse rate in schizophrenia. 

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Question

What are the processes of family therapy?

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Answer

Preliminary analysis, information transfer, and communication training.

Show question

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