No More Meds: Schizophrenia and Cognitive Behavioral Therapy

by Brendan Pease

Imagine a high school student named Lisa. A high achiever, both academically and athletically, Lisa gains admission to Duke University in her senior year, is voted “Most Likely to Succeed” by the student body, and is loved by classmates and teachers alike. From the outside, she seems to have a perfect life. But, on the inside, Lisa sees herself as a failure. Every day, she hears voices in her head telling her that the people around her hate her because she is stupid and ugly, and not at all the bright student and gifted athlete that she is. This is exactly how Lisa Halpern, a writer and lecturer who suffered from schizophrenia in her teenage years and into her twenties, describes her high school experience (1).

Approximately one percent of the world’s population has schizophrenia, a tragic mental health disorder best known for causing hallucinations and delusions. Those who have the disorder are often paranoid and plagued with emotional problems, making it difficult for them to focus on tasks, hold full-time jobs, or maintain normal social relationships. The disease has such a profound effect on those who have it that forty percent of schizophrenics attempt to commit suicide (1). Carrying a heavy stigma, the disorder also has a reputation for causing people, driven by voices that they hear in their heads, to commit violent crimes (1). Although the vast majority of schizophrenics are never violent, many report hearing a voice or voices—ranging from friendly to demonic—inside their heads, which can leave a lasting impact on their life, as well as the lives of those around them.

Typical Treatments

The most common first line of defense against schizophrenia often includes antipsychotic medication. In essence, the main goal of these medications is to restore healthy levels of various neurotransmitters, such as dopamine, by targeting proteins or other molecules involved in the central nervous system (3). There are currently over 20 antipsychotic medications on the market that are often prescribed to schizophrenics, regardless of their age or how long they have had the disease. The most commonly used antipsychotics include risperidone, haloperidol, and clozapine.  But despite the widespread usage of antipsychotics, they are often criticized, and there is never a shortage of controversy about their usage (2).

By far the most common objection to antipsychotics is that their side effects do not justify any benefits gained by taking them. When taken over extended periods of time, these medications can cause significant weight gain, uncontrolled muscle movements, and an increased risk of cardiac problems and heart attacks, to name just a few common side effects (2). In fact, a major obstacle in the road to successfully treating schizophrenia is patient non-adherence to treatment plans, which often stems from patients’ inability to cope with the unwanted impacts of the drugs on their daily lives and overall health (4).

In addition to the numerous side effects of antipsychotic medications, recent studies have called into question their overall scientific effectiveness, as well. Several recently published studies have shown that antipsychotic drugs may be less effective than placebos in children and adults (2). After being treated with antipsychotics for a while, many patients may also develop resistance to the medications, because their bodies learn to compensate for the effects of the drugs. In 2012, a study released by the Mount Sinai School of Medicine found that an enzyme in the brain, HDAC2, was highly expressed in the brains of mice treated with antipsychotics. This higher level of expression in turn caused lower expression of the Metabotropic Glutamate Receptor 2, or mGlu2. A common target of antipsychotics, mGlu2 is a protein that is highly involved in the regulation of neurotransmitters, which are imbalanced in those with schizophrenia. Because many antipsychotics work to increase the production and presence of mGlu2, resistance to this effect is a major molecular setback to the effectiveness of antipsychotics (3).

Though the National Institute of Health has long advocated for the use of antipsychotic medication to treat schizophrenia, the organization acknowledges that the main symptoms of schizophrenia cannot be treated adequately with medication alone. This is due not only to the nature of schizophrenia itself, but also to the fact that many people who suffer from schizophrenia also have other comorbid mental health issues, such as mood disorders, depression, and anxiety disorders (5). In general, this seems to be an important component of schizophrenia treatment that is missing from the antipsychotic-centered status quo; luckily, recent studies have aimed to fill in this gap.

Cognitive Behavioral Therapy

One particularly promising method of treatment that is beginning to be used instead of or in conjunction with antipsychotics is cognitive behavioral therapy (CBT). CBT differs from traditional psychotherapy in that it focuses on behavioral and cognitive processes that negatively affect the patient’s life. It is also goal-oriented, requiring the therapist and the patient to work together toward the ultimate goal of changing harmful thought processes that the patient experiences, as opposed to more passive traditional psychotherapy in which there is less emphasis on the therapist and the patient actively working together. Scientific studies of CBT have already demonstrated its effectiveness for a range of mental illnesses, such as substance abuse and mood, anxiety, personality, sleeping, and eating disorders. (6). Although there has not yet been any evidence proving whether or not CBT could be used to treat schizophrenia, two studies published this year have provided support for the fact that CBT may also be an effective way to treat schizophrenia.

A new study published in The Lancet in February, 2014, provides more concrete evidence for the effectiveness of treating schizophrenia patients with CBT. In trials at two different health centers in the United Kingdom, researchers at the University of Manchester conducted a study comparing the outcomes of schizophrenic patients who had received antipsychotic drugs with those who had instead received cognitive behavioral therapy. As a metric for outcomes, researchers used the Positive and Negative Syndrome Scale (PANSS), which is commonly used to assess schizophrenia; the higher a patient’s PANSS score is, the more symptoms of schizophrenia that the patient is experiencing. At the conclusion of the study, the researchers found that the mean PANSS scores for those who received CBT was consistently lower than scores for the group that received antipsychotics (4). This result was further supported by a smaller study published by the British Journal of Psychiatry, which used a series of randomized trials to show that CBT has a positive effect on schizophrenic symptoms (7).

As more research is being done on CBT, and as CBT training becomes more widely available to psychologists, psychiatrists, social workers, and psychiatric nurses, additional CBT methods are being developed for schizophrenia treatment sessions (6). One common technique, known as reality testing, involves encouraging the patient to evaluate the reality base of a belief or assumption. This is often done via lines of questioning designed to explore the rationale behind the patient’s beliefs. Common questions might include: “How do you know that what you perceive is actually happening? What do you think causes this to happen? When you think through it now, are these reasons good enough?” Another common technique involves encouraging the patient to run miniature “behavioral experiments” to test certain beliefs. For example, if a patient believes his or her neighbor is communicating threats by sneezing, the patient may set up an experiment in which he or she watches a television program to evaluate other theories that could explain the neighbor’s sneezing—such as sickness or allergies (8). One of the most common CBT techniques used with patients with a variety of mental disorders is “normalization”; in these sessions, therapists reassure their patients that normal people occasionally hear voices or see objects that aren’t there, encouraging patients to view themselves as normal (2). Using these common CBT techniques, trained therapists are eventually able to improve schizophrenic patients’ modes of thinking and behavior, alleviating patients’ symptoms and improving their quality of life.

Despite the growing body of evidence that CBT is an effective way to treat and manage schizophrenia, there are still some actions that need to be taken before CBT is used as frequently as antipsychotics. Many CBT and schizophrenia researchers have recently called for additional research, including the researchers at the University of Manchester, who are hoping that a larger and more definitive trial will support their results in the near future (4). In addition, CBT is an active intervention that commonly requires patients to practice techniques outside of sessions; thus, patient adherence over a long period of time is a crucial aspect of CBT’s success, just as it is for other schizophrenia treatments (6). Perhaps the biggest obstacle to widespread usage of CBT is that CBT does not directly address one of schizophrenia’s defining characteristics: neurotransmitter imbalance in the brain. While it is possible that CBT causes changes in behavior that will in turn affect neurotransmitter concentrations, the link between neurotransmitters and behavior is still not well understood. Though CBT may effectively manage symptoms, it is possible that another form of treatment will be needed to mechanistically address the neurobiology behind schizophrenia (2).

It is clear that the status quo for treating schizophrenia with antipsychotics has its weaknesses, both scientifically and in its side effects and patient adherence. However, in light of recent studies, cognitive behavioral therapy may represent the possibility of a bright future for schizophrenia patients and a new protocol for treatment. With more research, CBT may become the go-to treatment for schizophrenia, and antipsychotics may become a relic of the past.

Brendan Pease ‘17 is a freshman in Thayer Hall.

References

  1. Halpern, L.  What It’s Like to Have Schizophrenia.  Retrieved from   http://www.lhj.com/health/conditions/mental-health/symptoms-treatment-schizophrenia/
  2. Balter, M.  Schizophrenia: Time to Flush the Meds?  Science.  (Feb, 2014).
  3. Nauert, R.  How Drugs for Schizophrenia Sow Seeds of Resistance.  PsychCentral.  (Aug, 2012).
  4. Morrison, A. et al.  Cognitive Therapy for People with Schizophrenia Spectrum Disorders Not Taking Antipsychotic Drugs: a Single-blind Randomised Controlled Trial.  The Lancet.  (Feb, 2014).
  5. Morrison, A. et al.  Cognitive Behavior Therapy for People with Schizophrenia.
  6. Duckworth, K. & Freedman, J.  Cognitive Behavioral Therapy.  National Alliance on Mental Illness. (July, 2012).
  7. Duckworth, K. & Freedman, J.  Cognitive Behavioral Therapy.  National Alliance on Mental Illness. (July, 2012).
  8. Jauhar, S. et al.  Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias.  The British Journal of Psychiatry 204, 20-29.  (Jan, 2014).
  9. Tai, S. & Turkington, D.  The Evolution of Cognitive Behavior Therapy for Schizophrenia: Current Practice and Recent Developments.  Schizophrenia Bulletin 35, 865-873.  (2009).

 

Categories: Spring 2014

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