Day # 10: Nonpharmacologic Treatment of Psychotic Disorders

Today we are continuing our current theme of psychotic disorders and we now have enough background to start discussing treatment and management. Pharmacological treatment is essential for the treatment of psychosis, but we are first going to take one day to talk about the nonpharmacologic interventions and management of these patients. I don't think this topic gets enough coverage, so hopefully it's a helpful introduction!

Today's Content Level: Intermediate; Advanced

Social Skills Training

•Patients with schizophrenia often have noticeable deficits in social interactions and this affects the way the person relates to others. This can include poor eye contact, unusual delays in response, odd facial expressions, lack of spontaneity in social situations, and inaccurate perception of emotions in other people.

•Social skills training (aka behavioral skills therapy) addresses these behaviors through the use of video (interactions between the patient and examples), role playing, and homework assignments for specific skills.

•Has been shown to reduce relapse rates as measured by the need for hospitalization.

•Can also include group therapy.

Family-Oriented Therapies

•There is a role for family oriented therapy in acute and long-term settings.

•Patients with schizophrenia are often discharged in only a partially remitted condition, and, in this scenario, the family members benefit from a brief but intensive course of family therapy.

•Family therapy in the acute setting should focus on the immediate situation, identifying potentially troublesome situations, and creating a plan of action if/when problems emerge. It also addresses the needs of the family and provides resources as available.

•Of note, family members may encourage a relative with schizophrenia to resume regular activities too quickly. The therapists job is to help the patient and family understand the condition, manage expectations, and encourage open discussion of the psychotic episode and events leading up to it.

•In the long-term, therapists can later direct family therapy towards longer term application of stress-reducing and coping strategies and gradual reintegration into daily life.

•Therapists should seek to control the emotional intensity of family sessions. The excessive expression of emotion from family members can damage a patient's recovery process and is associated with worse outcomes. This is sometimes called high "expressed emotion (EE)."

APA CPG for the Tx of Schizophrenia

Case Management

•There are often multiple professionals involved in the treatment of these patients (psychiatrist, social worker, occupational therapists, primary care provider, etc.). It is helpful to have one person that ensures their efforts are coordinated, the family is kept informed, and the patient complies with appointments and treatment plans.

Assertive Community Treatment (ACT)

•Patient are assigned to one multidisciplinary team (case manager, psychiatrist, nurse, general physicians, therapists) and delivers all services when and where needed by the patient 24/7. It is a mobile and intensive intervention that provides treatment, rehabilitation, and support activities to include home delivery of medications, monitoring of mental and physical health, social skill development, frequent contact with family members, and increased community involvement.

•This model of treatment is designed for severe and chronic mental illness. It effectively decreases hospitalizations, but, as you can imagine, it is labor intensive and expensive to administer.

Vocational therapy

•Enabling patients to become employed is a sign of recovery but can also be a means towards achieving recovery.

•Methods include sheltered workshops, job clubs, and part-time or transitional employment programs.

Individual Therapy

•Therapy is helpful for patients with schizophrenia and the effects are additive to those of medications.

•Although sometimes difficult, developing a therapeutic relationship in this population is absolutely critical, as studies emphasize that the patients who form a good therapeutic alliance are more likely to remain in therapy, remain compliant with their medications, and have good outcomes at 2-year follow up evaluations. This can be difficult as they are likely to become suspicious, anxious, hostile, or regress when someone attempts to draw close.

•Recent evidence reveals that multiple psychotherapy modalities can be helpful in schizophrenia which includes CBT and DBT. I will briefly highlight a few other treatments below.

• Personal therapy: developed specifically for patients with schizophrenia to enhance personal and social adjustment. Includes social skills training, relaxation exercises, psychoeducation, and self-awareness/reflection. Shown to produce a lower relapse rate after three years compared to controls.

• Cognitive training: cognitive training or "cognitive remediation" is a recent technique that utilizes computer generated exercises to improve cognition and working memory. This has been shown to translate into more affective social functioning.

• Art therapy: many patients benefit from art therapy, which can provide them with an outlet for their constant internal "bombardment of imagery." It can help provide an alternative framework to communicate with others and share their inner thoughts with others.

Conclusion

As I mentioned before, I don't think this topic gets enough coverage, so I hope it is a helpful introduction. There is a lot here, so feel free to explore the linked articles if you are interested. This is to make you aware of some of the resources out there, but this type of information is often best learned by experiencing it in person.

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Sources from todays post include:

Kaplan and Sadock's Synopsis of Psychiatry

Pocket Psychiatry

And the articles linked in the main body of todays post.

See our full list of book recommendations