Source: Abnormal Psychology textbook (University of Florida)
Tags: schizophrenia treatment, antipsychotics, neuroleptics, chlorpromazine, clozapine, atypical antipsychotics, tardive dyskinesia, family therapy, assertive community treatment, CBT for psychosis, cross-cultural treatment
Difficulty: Intermediate | Prerequisites: Parts 1 and 2 of these notes (Symptoms/Diagnosis and Causes/Theories). Understanding the dopamine hypothesis is particularly helpful for the medication section.
Treatment of schizophrenia has evolved from crude early interventions (brain surgery, insulin comas) to a combination of antipsychotic medication and psychosocial therapies. Medication alone rarely restores full functioning. The current best practice combines drug therapy with cognitive, behavioural, social, and family interventions, ideally delivered through community-based programmes. Cross-cultural approaches to treatment also matter, particularly in developing countries where family and folk healing traditions play a central role.
Typical antipsychotics (neuroleptics) reduce positive symptoms by blocking dopamine but carry serious side effects, including tardive dyskinesia. Atypical antipsychotics are more effective overall with fewer neurological side effects, though they bring their own risks (weight gain, metabolic issues). Medication alone does not restore full functioning, so psychological treatments (cognitive, behavioural, social, family therapy) and assertive community treatment programmes are essential. Ongoing treatment is usually necessary, and funding for community care remains inadequate.
Neuroleptics (typical antipsychotics)
The first generation of antipsychotic drugs, beginning with chlorpromazine in the 1950s. They work by blocking dopamine receptors, reducing positive symptoms such as hallucinations and delusions. In simple terms, these drugs turn down the dopamine signal in the brain, which helps with the more dramatic symptoms but does little for negative ones.
Chlorpromazine
The first effective antipsychotic drug, introduced in the 1950s. A phenothiazine that calms agitation and reduces hallucinations and delusions.
Phenothiazines
A class of typical antipsychotic drugs that block dopamine reuptake. Examples include chlorpromazine, trifluoperazine (Stelazine), thioridazine (Mellaril), fluphenazine (Prolixin), and perphenazine (Trilafon).
Tardive dyskinesia
A neurological disorder involving involuntary movements of the tongue, face, mouth, or jaw. The person may smack their lips, make sucking sounds, stick out their tongue, puff their cheeks, or make other involuntary movements. It is irreversible and occurs in approximately 20% of people with long-term phenothiazine use. Think of it as permanent damage to motor control caused by years on these drugs.
Akinesia
A side effect of antipsychotics characterised by slowed motor activity, monotone speech, and an expressionless face.
Akathisia
Agitation that causes people to pace and be unable to sit still. A Parkinsonian side effect of phenothiazines.
Atypical antipsychotics
Second-generation antipsychotic drugs that are generally more effective than typical antipsychotics, with fewer neurological side effects. They work on dopamine (often the D4 receptor) and other neurotransmitter systems, including serotonin.
Clozapine
An atypical antipsychotic that binds to the D4 dopamine receptor and also influences serotonin. Helps many people who did not respond to typical antipsychotics and reduces both positive and negative symptoms. Does not cause tardive dyskinesia, but carries the risk of agranulocytosis (a potentially fatal deficiency of infection-fighting granulocytes), so patients must be monitored closely. Used only after other atypical antipsychotics have been tried.
Agranulocytosis
A deficiency of granulocytes, substances produced by bone marrow that fight infection. A potentially fatal side effect of clozapine that requires close monitoring.
Assertive community treatment (ACT)
Comprehensive community-based treatment programmes that rely on multidisciplinary teams (medical professionals, social workers, psychologists) to provide 24-hour care. They help people with schizophrenia integrate into society, maintain medication, develop skills, and function at the highest possible level. Considered the gold standard for community-based treatment.
Expressed emotion interventions
Family-based treatments that educate families about schizophrenia, teach communication and problem-solving skills, and reduce criticism and overinvolvement. Combined with medication, these are more effective than medication alone.
Early treatments were based on the prevailing theories of the time and were often harmful.
Brain surgeries attempted to fix or remove areas thought to cause hallucinations or delusions. Patients were sometimes calmer but often suffered severe cognitive and emotional deficits.
Insulin coma therapy (1930s) involved massive doses of insulin to induce a coma. It was very dangerous and rarely helped.
Electroconvulsive therapy was tried but had little effect on schizophrenia.
Before effective medication, many patients were simply warehoused in institutions with no treatment.
Chlorpromazine, discovered by Delay and Deniker, was the breakthrough. It calms agitation and reduces hallucinations and delusions.
Other phenothiazines followed: trifluoperazine (Stelazine), thioridazine (Mellaril), fluphenazine (Prolixin), perphenazine (Trilafon).
Butyrophenones and thioxanthenes were additional drug classes introduced after phenothiazines.
Mechanism: block dopamine receptors, reducing dopamine's action in the brain.
These drugs allowed many people to control positive symptoms and substantially reduced the number of people needing hospitalisation.
Limitations:
Some people do not respond at all.
More effective for positive symptoms; much less effective for negative symptoms.
Many people who take them are no longer psychotic but still cannot hold a job or maintain relationships.
Must be taken continuously; stopping leads to relapse.
Side effects:
General: grogginess, dry mouth, blurred vision, drooling, sexual dysfunction, visual disturbances, weight gain or loss, constipation, menstrual irregularities, and depression.
Akinesia: slowed motor activity, monotone speech, expressionless face.
Parkinsonian effects: muscle stiffness, freezing of facial muscles, tremors, spasms, and akathisia (inability to sit still). These likely occur because the drug reduces dopamine function (low dopamine also causes Parkinson's disease).
Tardive dyskinesia: involuntary movements of the tongue, face, mouth, or jaw. Irreversible. Occurs in approximately 20% of long-term users.
Clinicians usually prescribe the lowest effective dose to minimise side effects, but this often does not restore full functioning.
Negative symptoms may persist alongside mild positive symptoms, resulting in ongoing difficulty functioning, frequent hospitalisation, and difficulties outside the hospital.
More effective overall and produce fewer neurological side effects than typical antipsychotics.
Clozapine:
Binds to the D4 dopamine receptor and also influences serotonin.
Helped many people who did not respond to neuroleptics.
Reduces both positive and negative symptoms.
Does not cause tardive dyskinesia.
Side effects include dizziness, nausea, sedation, seizures, hypersalivation, weight gain, tachycardia, and agranulocytosis (potentially fatal, requiring close monitoring).
Used only after other atypical antipsychotics have been tried, because of the agranulocytosis risk.
Other atypical antipsychotics:
Risperidone (Risperdal), olanzapine (Zyprexa), ziprasidone (Geodon/Zeldox).
Do not cause agranulocytosis but carry their own side effects: significant weight gain, increased risk for diabetes, sexual dysfunction, sedation, low blood pressure, seizures, gastrointestinal problems, vision problems, and concentration difficulties.
In a comparative study, the six-month remission rate was highest for olanzapine, followed by quetiapine, perphenazine, ziprasidone, and risperidone, though overall remission rates were low.
Medication alone can reduce symptoms but usually does not fully restore functioning. Comprehensive treatment is tailored to each individual's specific deficits and is given alongside medication.
Help patients recognise and change demoralising attitudes about their illness.
Encourage help-seeking and participation in society to the extent possible.
Use operant conditioning and modelling to teach practical skills: initiating and maintaining conversations, asking for help, persisting in everyday activities like cooking or cleaning.
Family members may be trained to ignore schizophrenia-related behaviours and reinforce socially acceptable ones.
Increase contact between people with schizophrenia and supportive others (e.g. self-help groups).
Groups discuss the impact of the disorder, frustration with being misunderstood, fear of relapse, and experiences with medication.
Members help one another learn social and problem-solving skills through feedback and role-play.
Provides basic education about schizophrenia to help family members cope with the behaviours and impact of the disorder.
Teaches families about causes, symptoms, medications, and side effects, increasing tolerance and enabling better monitoring.
Develops communication and problem-solving skills to manage issues and reduce stress.
Teaches specific behavioural techniques for encouraging constructive behaviour.
When combined with drug therapy, family therapy is more effective than medication alone, improving medication adherence, reducing relapse, and enhancing social functioning and quality of life (Guo et al.).
Culturally sensitive family therapy is especially important in cultures where families are expected to be the primary carers.
Multidisciplinary teams provide comprehensive services 24 hours a day.
Goals: societal integration, medication maintenance, skills development, and highest possible level of functioning.
The Fairweather Lodge is an example: a residential treatment centre where residents fared better than those in other settings.
Other programmes provide skills training, vocational rehabilitation, and social support.
ACT reduces time spent in hospital and can be cost-effective.
Considered the gold standard for community-based treatment.
Treatment often needs to be ongoing.
Chronic underfunding remains a major problem. Financial burdens fall to state and local governments or families who often lack resources.
In practice, most people with schizophrenia receive little to no care. If hospitalised, they are often discharged after a short stay with no follow-up. Many end up in nursing homes, single-room hotels, homeless, or in prison.
In developing countries and parts of industrialised countries, folk or religious healers treat schizophrenia according to cultural beliefs about the meaning and causes of symptoms.
Methods used by healers:
Structural model: Body, emotion, and cognition are interrelated levels. Symptoms arise when integration is lost. Healing involves reintegrating these levels through diet change, environmental change, herbal medicines, and rituals.
Social support model: Symptoms arise from conflictual social relationships. Healing involves mobilising family to support the person through the crisis and reintegrating them into a positive social network.
Persuasive model: Rituals can transform the meaning of symptoms, diminishing their felt pain.
Clinical model: The patient's faith in the healer's ability to provide a cure is itself sufficient.
Family care is more likely in developing countries, making family-inclusive interventions especially important in those settings.
Students often assume atypical antipsychotics have no serious side effects. They do: significant weight gain, metabolic syndrome, diabetes risk, and in the case of clozapine, potentially fatal agranulocytosis.
It is a common error to think medication fully treats schizophrenia. It manages symptoms (primarily positive ones) but rarely restores full social and occupational functioning without psychosocial support.
Students sometimes confuse tardive dyskinesia with a symptom of schizophrenia. It is a side effect of long-term antipsychotic use, not a feature of the disorder itself.
The role of family therapy is sometimes misunderstood as blaming families. Modern family therapy educates and supports families; it does not attribute the disorder to their behaviour.
⚠️ Know the mechanism of typical antipsychotics (blocking dopamine receptors) and why they treat positive but not negative symptoms.
⚠️ Be able to define tardive dyskinesia, state its prevalence (approximately 20% of long-term users), and explain that it is irreversible.
⚠️ Understand why clozapine is a last resort despite being highly effective (agranulocytosis risk).
⚠️ Know that medication alone rarely restores full functioning, and that comprehensive treatment combining medication with psychosocial interventions is the evidence-based standard.
⚠️ Assertive community treatment is the gold standard for community-based care. Be able to describe what it involves.
⚠️ Expressed emotion interventions reduce relapse rates when combined with medication.
True or False: Chlorpromazine was introduced in the 1970s. False. It was introduced in the 1950s.
Fill in the blank: Tardive dyskinesia is ______ (reversible/irreversible) and occurs in approximately ______% of long-term phenothiazine users. Irreversible; 20%.
True or False: Clozapine is typically the first atypical antipsychotic prescribed. False. It is used only after other atypical antipsychotics have been tried, due to the risk of agranulocytosis.
Fill in the blank: ______ is considered the gold standard for community-based treatment of schizophrenia. Assertive community treatment (ACT).
True or False: Family therapy for schizophrenia is based on the premise that families cause the disorder. False. Modern family therapy educates and supports families. It does not blame them for the disorder.
Q: Why are typical antipsychotics more effective against positive symptoms than negative symptoms?
A: Typical antipsychotics work by blocking dopamine receptors, reducing dopamine activity in the brain. Positive symptoms (hallucinations, delusions) are associated with excessive dopamine in the mesolimbic pathway, so blocking dopamine there helps. Negative symptoms are associated with low dopamine in the prefrontal cortex, so further reducing dopamine activity does nothing to help and may even worsen these symptoms.
Q: What is tardive dyskinesia, and why is it clinically significant?
A: Tardive dyskinesia is a neurological disorder involving involuntary movements of the tongue, face, mouth, or jaw (lip-smacking, sucking sounds, tongue protrusion, cheek puffing). It is clinically significant because it is irreversible, occurs in about 20% of people on long-term phenothiazine use, and represents permanent neurological damage from the treatment itself.
Q: Compare clozapine with other atypical antipsychotics in terms of effectiveness and side effects.
A: Clozapine is often more effective than other atypicals, helping people who did not respond to any other antipsychotic. It reduces both positive and negative symptoms and does not cause tardive dyskinesia. However, it carries the risk of agranulocytosis, a potentially fatal blood condition, and other side effects including seizures, weight gain, and tachycardia. Other atypicals (risperidone, olanzapine, ziprasidone) avoid the agranulocytosis risk but still cause significant weight gain, metabolic problems, and other side effects.
Q: Why is assertive community treatment considered the gold standard for community-based care?
A: ACT provides comprehensive, multidisciplinary, 24-hour services that help people integrate into society, maintain medication, develop needed skills, and function at their highest possible level. Research shows it reduces time spent in hospital, can be cost-effective, and provides the kind of ongoing, individualised support that medication alone cannot offer.
Q: What are the four models of cross-cultural healing described in the chapter?
A: (1) Structural model: symptoms arise from lost integration of body, emotion, and cognition; healed through diet, environment, herbs, and rituals. (2) Social support model: symptoms arise from conflictual relationships; healed by mobilising kin support and reintegrating the person into a positive social network. (3) Persuasive model: rituals transform the meaning of symptoms, reducing their impact. (4) Clinical model: the patient's faith in the healer is itself sufficient for improvement.
The pharmacology here connects to the broader study of psychopharmacology in clinical psychology and to biological psychology's treatment of neurotransmitter systems. Family therapy and expressed emotion link to systems theories in family psychology. Assertive community treatment relates to public health and health policy discussions about deinstitutionalisation and the treatment gap. Cross-cultural treatment models tie into medical anthropology and the study of culture-bound syndromes.
antipsychotic drugs, neuroleptics, typical antipsychotics, atypical antipsychotics, chlorpromazine, phenothiazines, clozapine, risperidone, olanzapine, ziprasidone, quetiapine, tardive dyskinesia, akinesia, akathisia, agranulocytosis, dopamine receptor, D4 receptor, side effects of antipsychotics, cognitive behavioural therapy for psychosis, family therapy, expressed emotion, assertive community treatment, ACT, Fairweather Lodge, community-based treatment, social interventions, behavioural therapy, cross-cultural treatment, structural model, social support model, persuasive model, clinical model, deinstitutionalisation, abnormal psychology chapter 8