The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, has been updated to reflect a change in the classification of schizophrenia. Once thought to be a single disorder with relatively consistent symptomology, the current understanding of schizophrenia has been significantly broadened to encompass a range of presentations. The new name, Schizophrenia Spectrum and Other Psychotic Disorders, reflects this change. I would recommend looking at a comparison of the DSM-4 and DSM-5 classifications for more information (see resource link below).
Treatment modalities depend upon the individual presentation of the disorder. While the DSM-5 has eliminated the use of diagnostic “types” (Paranoid Type, Disorganized Type, Catatonic Type, Undifferentiated Type, Residual Type), treatment remains focused on controlling the symptoms that manifest in each of the four phases: Premorbid, Prodromal, Schizophrenia, and Residual. As we look at each, remember that the names of the two main categories of symptoms are a bit misleading. “Positive symptoms” are not good; rather, they refer to an excess or hyperactivity in thought processing and result in an impaired concept of reality. Delusions, hallucinations, disorganized speech, and disorganized behavior are positive symptoms. “Negative symptoms” blunt or suppress emotions and behavior. Depression, anhedonia, avolition, alogia, and flat affect are negative symptoms.
In the Premorbid Phase, personality changes are subtle and are commonly mistaken for shyness and introversion. Symptoms are generally negative. Treatment is uncommon.
In the Prodromal Phase, the individual typically withdraws further from social interactions and often exhibits more apparent symptoms of disordered thinking. Treatment in the prodromal phase is focused on retaining and improving the individual’s ability to function within the social context and to carry out activities of daily living. Treatment may include cognitive behavioral therapy (CBT), social skills training, and family therapy. Pharmacological therapy may be prescribed to complement these modalities, but this remains controversial and varies widely among health care providers.
In the third phase, Schizophrenia, the individual’s cognitive impairment has progressed into active and overt symptoms that limit his or her ability to carry out activities of daily living. In addition to therapy, pharmacological treatment is common.
The Residual Phase is characterized by a remission from positive symptoms. The individual may still experience significant cognitive impairment and often retains negative symptoms of the disorder. Pharmacological treatment may continue to serve as an adjunct to therapy on a case-by-case basis. The use of maintenance medication depends upon the severity and duration of the individual’s active phase, as well as his or her precipitating factors. An individual who has an acute “psychotic break” following an adverse or traumatic experience has a better prognosis than an individual whose onset was gradual.
Early intervention is correlated with improved outcomes in Schizophrenia Spectrum Disorder. The goal of treatment is to improve the individual’s capacity to manage stress and adapt to challenges, to control symptoms, and to promote recovery.
Goals specific to non-pharmacological therapies, such as CBT and family therapy, include improving interpersonal communication and decreasing maladaptive behaviors. CBT uses positive reinforcement to help individuals anticipate problems and develop appropriate responses to stressful situations. Family therapy strengthens the individual’s support system by encouraging understanding of the disorder, teaching methods for effective coping, and promoting treatment adherence.
Social skills training is a community-based treatment program intended to enhance the individual’s ability to carry out activities of daily living, develop interpersonal relationships, and maintain or improve independence. Skills training includes vocational rehabilitation, group therapy, and treatment for co-occurring disorders.
Pharmacological treatment depends upon individual presentation but commonly includes typical or atypical anti-psychotics. These medications block the receptor sites for one or more neurotransmitters associated with the positive symptoms of schizophrenia. They are commonly given during the acute phase, active Schizophrenia, but may be used in maintenance therapy for individuals likely to experience a relapse. Although the use of anti-psychotics is associated with improved long-term outcomes and shorter active phases, their benefits are frequently accompanied by undesirable side effects that decrease adherence to the treatment regimen. These include extrapyramidal symptoms (involuntary muscle twitching and movement), gynecomastia (enlargement of male breast tissue), drowsiness, and weight gain.