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Treatment
CenterSite Staff

Treatments for schizophreniform disorders have vastly improved in the last decade. There are many newer medications that can help control nearly all the symptoms associated with Schizophrenia and related disorders. Supportive psychotherapy can also help a person get their lives back together. Learn the details of these treatments and other treatment options here.

Schizophrenia
Schizoaffective Disorder

Schizophrenia

Introduction

Schizophrenia usually first appears in a person during their late teens or throughout their twenties. It affects more men than women, and is considered a life-long condition which rarely is "cured," but rather treated. The primary treatment for schizophrenia and similar thought disorders is medication. Unfortunately, compliance with a medication regimen is often one of the largest problems associated with the ongoing treatment of schizophrenia. Because people who live with this disorder often go off of their medication during periods throughout their lives, the repercussions of this loss of treatment are acutely felt not only by the individual, but also by their family and friends as well.

Successful treatment of schizophrenia, therefore, depends upon a life-long regimen of both drug and psychosocial support therapies. While the medication helps control the psychosis associated with schizophrenia (e.g., the delusions and hallucinations), it cannot help the person find a job, learn to be effective in social relationships, increase the individual's coping skills, and help them learn to communicate and work well with others. Poverty, homelessness, and unemployment are often associated with this disorder, but they don't have to be. If the individual finds appropriate treatment and sticks with it, a person with schizophrenia can lead a happy and successful life. But the initial recovery from the first symptoms of schizophrenia can be an extremely lonely experience. Individuals coping with the onset of schizophrenia for the first time in their lives require all the support that their families, friends, and communities can provide.

With such support, determination, and understanding, someone who has schizophrenia can learn to cope and live with it for their entire life. But stability with this disorder means complying with the treatment plan set up between the person and their therapist or doctor, and maintaining the balance provided for by the medication and therapy. A sudden stopping of treatment will most often lead to a relapse of the symptoms associated with schizophrenia and then a gradual recovery as treatment is reinstated.

Psychotherapy

Psychotherapy is not the treatment of choice for someone with schizophrenia. Used as an adjunct to a good medication plan, however, psychotherapy can help maintain the individual on their medication, learn needed social skills, and support the person's weekly goals and activities in their community. This may include advice, reassurance, education, modeling, limit setting, and reality testing with the therapist. Encouragement in setting small goals and reaching them can often be helpful.

People with schizophrenia often have a difficult time performing ordinary life skills such as cooking and personal grooming as well as communicating with others in the family and at work. Therapy or rehabilitation therapy can help a person regain the confidence to take care of themselves and live a fuller life.
Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with schizophrenic outpatients. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; on social and work roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on some practical recreational or work activity. This supportive group therapy can be especially helpful in decreasing social isolation and increasing reality testing (Long, 1996).

Family therapy can significantly decrease relapse rates for the schizophrenic family member. In high-stress families, schizophrenic patients given standard aftercare relapse 50-60% of the time in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below 10 percent. This therapy encourages the family to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to select and implement the consensual best solution. (Long, 1996).

Medications

Schizophrenia appears to be a combination of a thought disorder, mood disorder, and anxiety disorder. The medical management of schizophrenia often requires a combination of antipsychotic, antidepressant, and antianxiety medication. Unfortunately, after the first year of treatment, only a minority of schizophrenic outpatients remain on their oral medications (Long, 1996).

Antipsychotic medications help to normalize the biochemical imbalances that cause schizophrenia. They are also important in reducing the likelihood of relapse. There are two major types of antipsychotics, traditional and new antipsychotics.

Traditional antipsychotics effectively control the hallucinations, delusions, and confusion of schizophrenia. This type of antipsychotic drug, such as haloperidol, chlorpromazine, and fluphenazine, has been available since the mid-1950s. These drugs primarily block dopamine receptors and are effective in treating the "positive" symptoms of schizophrenia.

Side effects for antipsychotics may cause a patient to stop taking them. However, it is important to talk with your doctor before making any changes in medication since many side effects can be controlled. Be sure to weigh the risks against the potential benefits that antipsychotic drugs can provide.

Mild side effects from these medications can include: dry mouth, blurred vision, constipation, drowsiness and dizziness. These side affects usually disappear a few weeks after the person starts treatment.
More serious side effects can include: trouble with muscle control, muscle spasms or cramps in the head and neck, fidgeting or pacing, tremors and shuffling of the feet (much like those affecting people with Parkinson's disease).

Side effects due to prolonged use of traditional antipsychotic medications include: facial ticks, thrusting and rolling of the tongue, lip licking, panting and grimacing.

The newer antipsychotics, such as Clozaril (clozapine), Risperidal (respiridone), and Zyprexa (olonzapine), which are serotonin-dopamine antagonists (SDAs) block both serotonin and dopamine receptors, thereby treating both the "positive" and "negative" symptoms of schizophrenia. These newer medications are effective in treating a broader range of symptoms of schizophrenia, and have fewer side effects than traditional antipsychotics.

Coping Guidelines For The Family

  1. Establish a daily routine for the patient to follow.
  2. Help the patient stay on the medication.
  3. Keep the lines of communication open about problems or fears the patient may have.
  4. Understand that caring for the patient can be emotionally and physically exhausting. Take time for yourself.
  5. Keep your communications simple and brief when speaking with the patient.
  6. Be patient and calm.
  7. Ask for help if you need it; join a support group.

Self-Help

The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Adjunctive community support groups in concurrence with psychotherapy are usually beneficial to most people who suffer from schizophrenia. Caution should be utilized, however, if the person's symptoms aren't under control of a medication. People with this disorder often have a difficult time in social situations, therefore a support group should not be considered as an initial treatment option. As the person progresses in treatment, a support group may be a useful option to help the person make the transition back into daily social life.

Another use of self-help is for the family members of someone who lives with schizophrenia. The stress and hardships caused from having a loved one with this disorder are often overwhelming and difficult to cope with for a family. Family members should use a support group within their community to share common experiences and learn about ways to best deal with their frustrations, feelings of helplessness, and anger.
Research suggests that other types of self-help, such as exercise, stress management, and getting adequate rest can really help to manage symptoms of Schizophrenia. First, there appears to be a negative correlation between mental illness and physical fitness in general Studies indicate that because of exercise's affect on improving mood that consistent regular exercise can help improve mood in those with Schizoaffective disorder and Schizophrenia. Exercise has also been found to improve motivation levels of those with Schizophrenia, which helps them to stick with other important aspects of their treatment regimen. A consistent exercise program was also found to enhance the social skills of those with Schizophrenia as well as help them to think more clearly.

Stress management tools can also be quite helpful in managing the symptoms of Schizophrenia. Often schizophrenic symptoms, especially psychotic episodes, are worsened by stressful times. So, by engaging in common stress management techniques such as deep breathing, progressive muscle relaxation, getting enough sleep, and time management skills it can also help reduce the likelihood of facilitating a psychotic episode.

Schizoaffective Disorder

Introduction

Schizoaffective disorder is best treated with both psychotherapy and appropriate medication. This disorder largely consists of both a thought disorder and a mood disorder. This combination of symptoms can make treatment especially difficult, because the individual can be very depressed and suicidal, but refuse to take medication because of an irrational fear or paranoia (a symptom of the thought disorder).

Because of the complications experienced in this disorder, a patient can often be homeless, near or in poverty, on welfare, unemployed, and with little to no family or general social support. This suggests that a treatment approach which is holistic and touches upon the psychological, social, and biological aspect of this disorder will be most effective. Compiling an energetic treatment team of a psychologist, social worker, and psychiatrist who can work together to help the individual will likely be the most effective. Often, because of the need for stability in the patient's life, the individual will be involved in a day treatment program rather than individual psychotherapy. Recovery from this disorder is usually not the goal of treatment; rather, stable, long-term maintenance is the goal. Medication compliance is far more likely in clients who have a good stable social support and treatment network as opposed to those who do not.

Psychotherapy

Because people who suffer from this disorder are often poor (due to chronic unemployment), they usually present for treatment at hospitals and community mental health centers. If there are no hospitals or centers willing or able to admit them, however, the client is left with only his family or few friends to use as support in his or her disorder. This can create an inordinate burden on the family and strain important relationships within the client's life. While certainly families can provide a certain level of support, they usually cannot attend to all of the daily needs of someone with this disorder.

The format of psychotherapy will usually be individual, because the individual suffering from this disorder is usually too socially uncomfortable to be able to adequately tolerate group therapy. Supportive, client-centered, non-directive psychotherapy is a modality often used. This modality offers clients a warm, positive, change-oriented environment in which to explore their own growth while feeling stable and secure. A problem-solving approach can also be very beneficial in helping the individual learn better problem-solving and daily coping skills. Therapy should be relatively concrete, focusing on day-to-day functioning. Relationship issues can also be raised, especially when such issues revolve around the patient's family. Certain behavioral techniques have also been found to be effective with people who have this disorder. Social skills and occupational skills training, for instance, can be very beneficial.

At some point in therapy, the family can be brought in for psychoeducational sessions to learn how to predict when the patient is likely to deteriorate. Group therapy in inpatient settings tends to be more beneficial than in mixed outpatient groups. Group work in such a setting usually focuses on daily-living problems, general relationship issues, and other specific areas. For instance, discussion of occupational roles and future educational plans might occur.

Since the patient will often have many issues surrounding unemployment, disability, or welfare, a social worker is usually an important part of the treatment team. This professional can ensure the client doesn't fall between agency cracks and that he or she remains out of poverty.

Hospitalization

Individuals who are suffering from an acute psychotic episode during this disorder usually require immediate hospitalization to stabilize them on an anti-psychotic medication. Sometimes such an individual presents at the emergency room in a confused or disoriented state. Other times the patient may have resorted to alcohol to try and treat unwanted feelings, and show up to the E.R. disorganized and drunk. It is vitally important, therefore, for E.R. personnel to be aware of a patient's medical history in this case before treatment can be administered.

Individuals with schizoaffective disorder can easily deteriorate when social support has been removed from their lives, or they suffer any type of serious life stressor (such as an unexpected death, relationship loss, etc.). The individual can become severely depressed and decompensate rapidly. Clinicians should always be aware of this possibility and keep careful tabs on the patient if he or she has missed a regularly scheduled appointment.

Medications

Antipsychotics, or what are also called neuroleptic medications, are the treatment of choice for Schizophrenia. Evidence to date suggests that all of the antipsychotic drugs (except clozapine) are similarly effective in treating psychoses, with the differences being in milligram potency and side effects. Clozapine (Clozaril) has been proven to be more effective than all other antipsychotic drugs, but its serious side-effects limit its use.

Individual patients may respond to one drug better than another, and a history of a favorable response to treatment with a given drug in either the patient or a family member should lead to use of that particular drug as the drug of first choice. If the initial choice is not effective in 2-4 weeks, it is reasonable to try another antipsychotic drug with a different chemical structure.

Often an agitated, psychotic patient can be calmed in 1-2 days on antipsychotic drugs. Usually the psychosis gradually resolves only after 2-6 weeks of a high-dose antipsychotic drug regimen. A common error is to dramatically reduce antipsychotic drug dosage just as the patient improves or leaves the hospital. This error almost guarantees a relapse. Major reduction in antipsychotic drug dosage should be avoided for at least 3-6 months after hospital discharge. Decreases in antipsychotic drug dosage should be done gradually. It takes at least 2 weeks for the body to reach a new equilibrium in antipsychotic drug level after a dose reduction.

Sometimes patients view the side-effects of the antipsychotic drugs as being worse than their original psychosis. Thus, clinicians must be skillful in preventing these side-effects. Sometimes these side-effects can be removed by simply reducing the patient's antipsychotic drug dosage. Unfortunately, such a reduction in drug dosage often causes patients to relapse back into psychosis. Therefore clinicians have no choice but to use antipsychotic medications even though there is the possibility of experiencing the following side-effects:

1.Acute Dystonic Reactions:
These are muscular spasms mainly affecting the musculature of the head and neck, which can seem frightening and bizarre. Because high doses are more likely to produce such effects, they are best avoided by starting with lower antipsychotic drug dosages.

2.Akathisia:
Akathisia is experienced as an inability to sit or stand still, with a subjective feeling of anxiety, also called "restless leg syndrome". These symptoms can be treated with beta-blockers (atenolol, propranolol), benzodiazepines (clonazepam, lorazepam), or anti-parkinson drugs (benztropine, procyclidine).

3.Parkinsonism:
A key feature of parkinsonism, called akinesia, is diminution of the swing of the arms when walking and loss of facial expression. These parkinsonian side-effects of antipsychotic drugs usually respond to the addition of an anti-parkinson drug ( benztropine, procyclidine).

4.Tardive Dyskinesia:
Between 10 to 20 percent of patients receiving antipsychotic agents develop some degree of tardive dyskinesia, which includes movements of the tongue, slow involuntary contractions of the head, limbs, trunk, or neck called choreoathetosis caused by an impairment of tone in the muscle (usually in large muscle groups), may also be observed, as well as irregular breathing and, perhaps, grunting. It is now known that many cases of tardive dyskinesia are reversible and that many cases do not progress. The recommended treatment of tardive dyskinesia is to lower the dosage of antipsychotic drugs and hope for gradual remission of the choreoathetoid movements.

5.Neuroleptic Malignant Syndrome:
Antipsychotic agents potentiate anticholinergic drugs, and toxic psychosis may occur. Toxic psychosis usually appears early in treatment and, more commonly, at night and in elderly patients. Withdrawal of the offending agents is the treatment of choice. Antipsychotic drugs often interfere with body temperature regulation. Therefore, in hot climates this situation may result in hyperthermia and in cold climates hypothermia.

6. Hypersomnia And Lethargy:
Many patients on antipsychotic drugs sleep 12-14 hours per day and develop marked lethargy. Often these side-effects disappear when treated with the newer SSRI ( selective serotonin re-uptake inhibitor) antidepressants (e.g., fluoxetine, paroxetine). These antidepressants usually are given for 6 or more months.

Antipsychotic agents may affect libido and may produce difficulty in achieving and maintaining erection. Inability to reach orgasm or ejaculation and retrograde ejaculation have been reported. Antipsychotics also may cause amenorrhea (painful or irregular menses), lactation, hirsutism (excessive hair growth), and gynecomastia (enlargement of the male nipples).

Weight gain may be more liable to occur with any antipsychotic drug, which causes increase in the need to sleep and lethargy. Studies suggest that many antipsychotic drugs taken during pregnancy do not result in fetal abnormalities. Because these agents reach the fetal circulation, they may affect the newborn, thus producing postnatal depression and also dystonic symptoms.

The older (tricyclic) antidepressants often worsen schizoaffective disorder. However, the newer SSRI antidepressants (e.g., fluoxetine, paroxetine) have dramatically benefited many apathetic or depressed schizoaffective patients.

Benzodiazepines (e.g., lorazepam, clonazepam) often can dramatically reduce the agitation and anxiety of schizoaffective patients. This is often especially true for those suffering from catatonic excitement or stupor. Clonazepam also is an effective treatment for akathisia (restless leg syndrome).

If the patient does not respond to antipsychotic treatment alone, lithium may be added for 2 to 3 months on a trial basis. Combined lithium-antipsychotic drug therapy is helpful in a significant percentage of patients.

The addition of the mood stabilizing medications carbamazepine, clonazepam, or valproate to antipsychotic drug refractory schizoaffective patients has been reported to sometimes be effective. This benefit is more often seen in patients suffering from bipolar disorder. Acute psychotic agitation or catatonia often responds to the benzodiazepine that has a mood stabilizing effect called clonazepam.

Self-Help

The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. However, support groups in which patients can participate, sometimes with family members, other times in a group with others who suffer from this same disorder, can be very helpful. Often these groups, like regular therapy groups, will focus on specific topics each week, which will be of benefit to the client. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings.
Patients can be encouraged to try out new coping skills and emotion regulation with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new social relationships with others.

Research suggests that other types of self-help, such as exercise, stress management, and getting adequate rest can really help to manage symptoms of Schizoaffective disorder. First, there appears to be a negative correlation between mental illness and physical fitness in general Studies indicate that because of exercise's affect on improving mood that consistent regular exercise can help improve mood in those with Schizoaffective disorder. Exercise has also been found to improve motivation levels of those with schizophrenic symptoms, which helps them to stick with other important aspects of their treatment regimen. A consistent exercise program was also found to enhance the social skills of those with Schizophrenic symptoms as well as help them to think more clearly.

Stress management tools can also be quite helpful in managing the symptoms of Schizoaffective Disorder. Often schizoaffective symptoms, especially psychotic or manic episodes, are worsened by stressful times. So, by engaging in common stress management techniques such as deep breathing, progressive muscle relaxation, getting enough sleep, and time management skills it can also help reduce the likelihood of facilitating a psychotic or manic episode.

References:
National Mental Health Association
National Institute for Mental Health
National Alliance for the Mentally Ill
Internet Mental Health

 

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