There is considerable debate about the nature of schizophrenia and other psychotic disorders, with the differing conceptions leading to dramatically different ideas about how best to treat people struggling with psychosis.
The Conventional Belief
In the American Psychiatric Association’s Diagnostic and Statistical Manual, schizophrenia is defined by what the field terms “positive” and “negative” symptoms. “Positive” symptoms are experiences that psychiatry considers as additional to “normal” functioning (i.e., hallucinations and delusions). “Negative” symptoms are experiences that psychiatry considers as reducing “normal” functioning (e.g., apathy, isolation, emotional flatness). There are also cognitive symptoms, such as confusion and illogical or circular thinking.
Hallucinations include hearing sounds (often including voices) that others do not hear, and seeing things that others do not see. Delusions are defined as beliefs that are not “normal” or supported by objective evidence. Psychiatrists consider themselves able to define when a person’s beliefs are delusional or whether the person has reason for those beliefs. Some specific delusions include paranoia (delusional fear) and grandiosity (delusions of superiority).
It is the “negative” and cognitive symptoms that most impede functioning. It’s difficult to work when you feel apathetic; it’s difficult to connect with others if you feel emotionally blank. It’s difficult to do either when you feel confused, or if others are confused by what you perceive as your normal conversation.
According to the medical model of the psychiatric field, schizophrenia is the result of a still-unidentified neural pathology (brain illness) that necessitates treatment with neuroleptic medication (major tranquilizers). The illness is said to be “chronic,” necessitating life-long use of the drugs.
In addition to the schizophrenia diagnosis, the Diagnostic and Statistical Manual lists a number of other psychotic disorders, which are seen as less severe. However, in general, the thought is that such disorders are the result of a chronic brain illness, which requires long-term use of antipsychotics.
Those promoting alternative conceptions to the disease model argue that there are many pathways to a psychotic episode, with trauma a well-known risk. Other risk factors may include a lack of sleep, poor physical health, overwhelming stress, social isolation, family stress, poverty, use of psychotropic drugs, and diseases that are known to often include psychotic symptoms, such as Parkinson’s disease. While there may be other biological factors that can lead to psychosis, these factors are understood to be unknown.
Given this understanding, alternative treatments seek to help a psychotic person by providing shelter and a therapeutic environment that can reduce stress and social isolation, and provide a sense of hope. Psychiatric medications are not seen as a “cure” or as an “antidote” to a disease, but rather as drugs that may, when selectively prescribed, and mostly for shorter periods of time, help a person reach a more stable state. This recovery process may take months or even several years of support.
In this alternative world, schizophrenia is understood to be a catch-all term that describes people with widely varying “symptoms,” as opposed to a term describing a categorical disease. Thus many argue that schizophrenia is a diagnostic term that should be retired.
Diagnoses in the DSM
There are a number of mental health diagnoses in the American Psychiatric Association’s Diagnostic and Statistical Manual that are meant to categorize “psychotic” disorders. There are also “unspecified” and “not elsewhere classified” diagnoses that can be used to diagnose someone who does not actually meet the criteria for the “disorder.” Some of the diagnoses exhibit high overlap, and most of them include vague or ambiguous criteria.
Schizophrenia: The archetypal diagnosis of psychosis.
Schizophreniform disorder: Essentially the same as schizophrenia, but for a shorter time.
Brief psychotic disorder: Psychotic symptoms that last for a short time, then go away on their own.
Delusional disorder: Diagnosed if the person only has delusional thinking, but not other psychotic experiences.
Schizotypal disorder: Diagnosed if the main feature of the psychotic experiences is social withdrawal, “paranoia” about others, and so-called “eccentric” behavior.
Schizoid personality disorder: Despite the similarities in name, there are no psychotic elements in this diagnosis. Instead, it is diagnosed for people who don’t enjoy spending time with others, have difficulty communicating with others, and have limited emotional expressiveness.
Schizoaffective disorder: Psychotic experiences combined with depressive experiences.
Depression with psychotic features: See above.
Catatonia: a specifier, added to another diagnosis. It’s used when people stop moving, appearing paralyzed.
Bipolar disorder with psychotic features: The diagnosis of bipolar disorder is characterized by alternating periods of depression and mania or hypomania. During manic episodes, psychotic features may be present, such as delusional thinking.
Although neuroleptic drugs appear to reduce hallucinations and delusions slightly better than placebo in the short-term, more than half of people who take them do not receive a significant benefit.
Since schizophrenia and psychotic disorders are often conceived of as chronic illnesses, psychiatrists often recommend that people so diagnosed stay on the drugs indefinitely. However, a number of researchers have written that it appears the drugs may increase the chronicity of the disorder. Indeed, a number of naturalistic studies have found that those off antipsychotic medication, as a group, have higher recovery rates and better functioning.
Alternative Programs and Approaches
As antipsychotics are regularly presented as a necessary treatment for schizophrenia and other psychotic disorders, the research on non-drug therapies, as stand-alone treatments, is sparse. The research that has found better long-term outcomes for unmedicated patients has mostly come from naturalistic studies that have followed people diagnosed with psychotic disorders for longer periods of time and assessed their recovery rates and function.
The Hearing Voices Movement
The Hearing Voices Network is focused on an alternative way of understanding psychotic experiences. Instead of following the disease model, the movement allows for individuals and communities to express and promote their own understanding of their experiences. It provides a community in which people can share their experiences with others who have similar ways of understanding, as well as access treatment providers who have more respect for individual experiences beyond the medical model. In a sense, it is a grassroots movement in which people with these experiences can share what worked and what didn’t work for them, without the assumptions of “chronic illness.”
There is little research, however, on the “effectiveness” of Hearing Voices as a therapy. Many who participate in Hearing Voices groups take antipsychotics; many do not.
Open Dialogue provides an alternative method for dealing with or “treating” psychotic experiences. The treatment was developed in Northern Finland in the 1990s. Psychosis is not conceived of as a disease, but rather a disruption in the spaces between people, and the dialogical therapy is designed to help heal those spaces, and in that manner help a psychotic person reintegrate into family and other social environments. The therapy is designed to help their patients see themselves as able to function well in society and pursue ambitions they may have had before their psychotic episode.
As practiced in northern Finland, antipsychotics are prescribed in a selective, limited manner. In the first weeks, antipsychotics are not prescribed, as the team of therapists wait to see if the psychotic person can improve without the use of the drugs. If the person has not improved after a few weeks, then a low dose of an antipsychotic is prescribed. An effort is then made after six months or so to see if patients placed on the medication can safely withdraw from them.
The Open Dialogue researchers in northern Finland reported the following outcomes for first-episode psychotic patients: at the end of five years, 80% are asymptomatic and working or back in school. Only 20% have gone on to long-term disability. Two-thirds of the first-episode patients have never been exposed to antipsychotics during the five years; another 13% may have used them for a time but are off the drugs at the end of five years; and the remaining 20% take antipsychotics on a regular basis.
This form of care is now being introduced into the United States and any number of European countries, although in general, there isn’t the same focus on limiting the use of antipsychotics as was the case in northern Finland when this therapy was first developed.
In the late 1970s, a residential program called Soteria was studied. People experiencing a psychotic episode who normally would have been hospitalized were instead treated in a house staffed by “ordinary” people who could “be with” those who were psychotic. Time and community were thought to provide a place for healing. Antipsychotics were used in a selective manner, much the same as in Open Dialogue in northern Finland: patients were not immediately put on the drugs, and then they were prescribed at low doses if, after a couple of weeks, they were not getting better. After a time on the drugs, the patients could then try to taper from them.
The program was run as an experiment, with the Soteria outcomes compared to conventional hospital treatment. At the end of six weeks, psychotic symptoms had abated just as much in the Soteria group as those treated in the hospital with antipsychotics. At the end of two years, the Soteria patients had lower psychopathology scores, fewer hospital readmissions, and better global adjustment. Forty-two percent of the Soteria patients had never been exposed to antipsychotics; thirty-nine percent had used them on a temporary basis; and 19% had used them continuously.
The original Soteria houses in California remained open for 12 years, and this form of care mostly vanished in the United States and other western countries. However, Israel has now opened three Soteria houses, and in these environments, there is once again an effort to use antipsychotics in a more selective, limited manner.
Psychosocial Treatment of Psychosis
Aside from the rare studies using Open Dialogue or Soteria approaches, most treatment of psychosis includes neuroleptic medication. These psychosocial interventions have been tested as add-ons to medication treatment. An overall review of interventions can be found here.
Cognitive-Behavioral Therapy (CBT)
CBT focuses on identifying and challenging/changing “distorted” or “maladaptive” thoughts (cognitions) about the self and the world. CBT includes homework, in which the client identifies when these thoughts arise, and challenges them in real-time using logic and alternative explanations.
CBT for psychosis may help people assess their beliefs and challenge delusions. Conversely, it may help people engage with work, hygiene, social interactions, and other activities of daily life despite the presence of delusions/hallucinations. In this way it can improve overall functioning and quality of life.
A work-related CBT intervention (the Indianapolis Vocational Rehabilitation Program) appeared to improve ability to go to work and to perform well when at work.
In a few limited studies, yoga has been shown to improve positive and negative psychotic symptoms, as well as improve overall functioning and physical health. More research is needed to clarify these effects.
A recent review found that group mindfulness interventions have a positive effect, particularly on depressive symptoms, for people with psychosis. However, this intervention may not be very effective for reducing psychotic symptoms. Like CBT, it may also improve ability to go to work and perform well at work, especially if it is specifically designed for vocational rehabilitation.
According to a review of supplements, Folic acid may help improve both positive and negative symptoms of psychosis. Vitamin D may help improve overall functioning. Vitamin B12 has been shown in some studies, but not in others, to be lower in people with psychosis; it is unclear if this is a causal factor or a result of dietary changes.
Research compiled by Peter Simons