Schizophrenia and Other Psychotic Disorders

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Richard L. Munich, Carol A. Tamminga: Schizophrenia and Other Psychotic Disorders, in Gabbard’s Treatments of

Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc.

DOI: 10.1176/appi.books.9781585622986.265156. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part IV. Schizophrenia and Other Psychotic Disorders >

Schizophrenia and Other Psychotic Disorders

INTRODUCTION

Schizophrenia presents as a heterogeneous and phasic illness, with disabilities affecting perception,

cognition, language, memory, emotion, volition, and social and adaptive behaviors. The current

formulation about its pathophysiology posits neuroanatomic and neurochemical abnormalities that

can be either genetically or environmentally induced. These neurobiological substrates can produce

vulnerability in a particular person that makes him or her sensitive to a variety of psychosocial and

physical stressors. When a stressor coincides with the vulnerability, occasionally early in life but

usually in late adolescence or early adulthood, afflicted persons develop a steadily worsening

cascade of changes in their neurochemical, cognitive, and interpersonal structures. Full recovery

from these changes is the exception rather than the rule. This complex view of the schizophrenic

process has moved treatment from a rigid dichotomy between somatic and psychosocial approaches

to the more broadly integrated but highly focused biopsychosocial interventions detailed in the

three chapters in this section.

In Chapter 20, “Clinical Psychopharmacology and Cognitive Remediation,” Carol Tamminga, M.D.,

Allen Bellack, Ph.D., Stephen Marder, M.D., and Wayne Fenton, M.D., outline the first and second

generation of drugs available for treatment, potential new treatment directions for the

pharmacotherapeutics of cognition, and cognitive remediation treatments for improving cognitive

performance in schizophrenia. The authors pay close attention to the growing concerns about the

metabolic side effects of these medications, as well as the reduction of motor side effects

associated with first-generation antipsychotics. The chapter makes use of the important research of

the past decade, demonstrating the importance of the cognitive characteristics and sequelae of the

illness and outlining the domains and molecular targets of intervention. The chapter closes with

approaches to and guidelines for cognitive remediation strategies, demonstrating how the

biological approach is beginning to more formally include psychological domains.

This trend is continued in Chapter 21, “Individual and Family Psychotherapies,” by Wayne Fenton,

M.D. In this chapter focusing on factors that interfere with adaptation such as denial,

demoralization, personal and family relationships, and self-esteem, the author briefly summarizes

traditional approaches to individual psychotherapy and then moves to a consideration of more

contemporary, evidence-based cognitive-behavioral and personal psychotherapies. He outlines how

these modalities can be flexibly integrated into and utilized with a hierarchical assessment of the

patient’s needs and current state. Finally, a substantial number of persons with schizophrenia and

related disorders continue to live with their family of origin, and the chapter welcomes these

families into a full treatment partnership with the identified patient and clinical team.

The enormous debt we owe to the work of the late Wayne Fenton will be clear to the readers of this

section. He was an esteemed colleague whose dedication to the field and to his patients inspired us

all.

The theme of integrated biopsychosocial treatment for schizophrenia is continued in Chapter 22,

“Psychiatric Rehabilitation,” by Alex Kopelowicz, M.D., Charles J. Wallace, Ph.D., and Robert Paul

Liberman, M.D. Along with William Anthony in Boston and J. K. Wing in England, these investigators

and practitioners helped define and develop the technology required to integrate psychiatric

rehabilitation into the contemporary treatment armamentarium. The authors of this chapter amply

document the enlarging need and role for rehabilitative services that include motivational

enhancements, involvement of family members in treatment, empowering of patients, improvedPrint: Schizophrenia and Other Psychotic Disorders http://www.psychiatryonline.com/popup.aspx?aID=265160&print=yes…

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reliability of medication use through education, relapse prevention plans, and phasic attunement of

psychopharmacological and psychosocial treatments. Skills training, the centerpiece of psychiatric

rehabilitation, is fostered through well-established training modules and cognitive-behavioral

therapy enhancements and their implementation and support in vocational rehabilitation

modalities. As always, this group is ever mindful of and includes in the chapter material about

disseminating and accessing resources.

Schizophrenia is a tragic illness that tends to be persistent and to lead to both cognitive and social

deterioration. Early detection, modern treatment methods, and long-term outcome studies, along

with broad discoveries in basic neuroscience, offer more hope for this illness than in the past,

although much more remains to be done. Clinicians using increasingly sophisticated and focused

pharmacological and psychosocial interventions are making an effort to meet patients and their

families where they are, to foster a new kind of alliance, and to offer treatments that will help

reduce the residual impairments that are so common in this illness.

Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.