Professional Documents
Culture Documents
In 1947, John Nash arrives at Princeton University. He is co-recipient, with Martin Hansen,
of the prestigious Carnegie Scholarship for mathematics. At a reception, he meets a group of
other promising math and science graduate students, Richard Sol, Ainsley, and Bender. He
also meets his roommate Charles Herman, a literature student.
Nash is under extreme pressure to publish, but he wants to publish his own original idea. His
inspiration comes when he and his fellow graduate students discuss how to approach a group
of women at a bar. Hansen quotes Adam Smith and advocates "every man for himself", but
Nash argues that a cooperative approach would lead to better chances of success. Nash
develops a new concept of governing dynamics and publishes an article on this. On the
strength of this, he is offered an appointment at MIT where Sol and Bender join him.
Some years later, Nash is invited to the Pentagon to crack encrypted enemy
telecommunication. Nash can decipher the code mentally, to the astonishment of other
decrypters. He considers his regular duties at MIT uninteresting and beneath his talents, so he
is pleased to be given a new assignment by his mysterious supervisor, William Parcher
(Harris) of the United States Department of Defense. He is to look for patterns in magazines
and newspapers in order to thwart a Soviet plot. Nash becomes increasingly obsessive about
searching for these hidden patterns and believes he is followed when he delivers his results to
a secret mailbox.
Meanwhile, a student, Alicia Larde (Connelly), asks him to dinner, and the two fall in love.
On a return visit to Princeton, Nash runs into Charles and his niece, Marcee (Cardone). With
Charles' encouragement, he proposes to Alicia and they marry.
Nash begins to fear for his life after witnessing a shootout between Parcher and Soviet agents,
but Parcher blackmails him into staying on his assignment. While delivering a guest lecture
at Harvard University, Nash tries to flee from people he thinks are foreign Russian agents, led
by Dr. Rosen (Plummer). After punching Rosen in an attempt to flee, Nash is forcibly sedated
and sent to a psychiatric facility he believes is run by the Soviets.
Dr. Rosen tells Alicia that Nash has paranoid schizophrenia and that Charles, Marcee, and
Parcher exist only in his imagination. Alicia investigates and finally confronts Nash with the
unopened documents he had delivered to the secret mailbox. Nash is given a course of insulin
shock therapy and eventually released. Frustrated with the side-effects of
the antipsychotic medication he is taking, which make him lethargic and unresponsive, he
secretly stops taking it. This causes a relapse and he meets Parcher again.
Shortly afterward, Alicia discovers Nash is once again working on his "assignment".
Realizing he has relapsed, Alicia rushes into the house to find her baby submerged in the tub.
Nash claims that Charles was watching the baby. Alicia calls Dr. Rosen, but Nash believes
Parcher is trying to kill her. He rushes in to push Parcher away, and accidentally knocks
Alicia and the baby to the ground. As Alicia flees the house with their baby, Nash jumps in
front of Alicia's car and begs her to stay. Nash tells her that he realizes that he has never seen
Marcee age, even though he's known her for three years. He finally accepts that Parcher and
other figures are hallucinations. Against Dr. Rosen's advice, Nash decides not to restart his
medication, believing that he can deal with his symptoms himself. Alicia decides to stay and
support him in this.
Nash returns to Princeton and approaches his old rival, Hansen, now head of the mathematics
department. He grants Nash permission to work out of the library and to audit classes. Over
the next two decades, Nash learns to ignore his hallucinations. By the late 1970s, he is
allowed to teach again.
In 1994, Nash wins the Nobel Memorial Prize in Economics for his revolutionary work
on game theory, and is honored by his fellow professors. The movie ends as Nash, Alicia, and
their son leave the auditorium in Stockholm; Nash sees Charles, Marcee, and Parcher
standing to one side and watching him.
Flow chart
1947: John Nash arrives at Princeton, He meets Martin Hansen, Richard Sol,
as a co-recipient of the Carnegie Ainsley, and Bender. He also meets his
Scholarship, to pursue a degree in roommate Charles Herman, a literature
mathematics. student.
Hansen quotes Adam Smith and Nash is driven by the need to publish an
advocates "every man for himself", but original idea and he is struck by inspiration
Nash argues that a cooperative at a bar with his friends, when they discuss
approach would lead to better chances how to approach a group of women.
of success.
Based on this idea he
publishes an article, The strength of the theory and article
forming a new concept of allows Nash to be offered an
governing dynamics appointment at MIT where Sol and
Bender join him.
A few years later Nash is He meets a student, Alicia, during class and
invited to the soon later she asks him to dinner. On a visit to
Pentagon to crack encrypte Princeton he meets Charles and his niece
d enemy Marcee. On his encouragement, he proposes
telecommunication. He is to Alicia and they get married.
able to perform this task,
mentally, without much
effort
While delivering a guest lecture at Harvard University, Nash tries to flee from people he
thinks are foreign Russian agents, led by Dr. Rosen. After punching Rosen in an attempt to
flee, Nash is forcibly sedated and sent to a psychiatric facility he believes is run by the
Soviets.
Dr. Rosen tells Alicia that Nash Upon investigating Alicia discovers all of Nash’s
has paranoid schizophrenia and ‘work’. She shows him all of the unopened
that Charles, Marcee, and documents he believed he’d been dropping off at
Parcher exist only in his the secret mailbox. He is given a course of insulin
imagination. shock therapy and eventually released.
Against Dr. Rosen’s advice, Nash decides not to restart medication and find a way to deal with
his symptoms the way he deals with problems that have no solutions. Alicia decides to support
him.
Nash returns to Princeton where his old Over the course of 2 decades he
rival Hansen (now head of the dept.) learns to ignore his hallucinations
grants him permission to work out of and by the late 1970s begins
the library and audit classes teaching again.
1994: Nash wins the Nobel Memorial Prize in Economics for his revolutionary work on game
theory.
In the end Nash, Alicia, and their son leave the auditorium in Stockholm; Nash sees Charles,
Marcee, and Parcher standing to one side and watching him.
Two (or more ) of the following , each present for a significant portion of time during a 1
month period (or if less successfully treated).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition)
Criterion B-
social / occupational dysfunction : for a significant portion of the time since the onset of the
disturbance, one or more major areas of functioning , such as work, interpersonal
relations, or self care , are markedly below the level achieved prior to the on set (or
when the onset is in childhood or adolescence, failure to achieve expected level of
interpersonal, academic or occupational achievement).
Icd 10
Paranoid schizophrenia
Positive syndrome: signs and symptoms in which something have been added to the normal
repertoire of the behaviour and experience. Presence of characteristic psychotic symptoms
(hallucinations, delusions, etc). It responds to treatment much more than negative syndrome.
Alogia: Absence or little speech. Tendency to speak very little or to convey little
substance of meaning (poverty of content)
Anhedonia: Absence of pleasure from life, i.e., Feeling no joy or pleasure from life or any
activities or relationships
Apathy: Feelings of indifference towards people, activities, and events
Affective blunting: Restricted range of emotions (i.e., emotional feeling, tone, or mood)
Avolition: Absence of will, ambition, or drive to take action or accomplish tasks
Catatonia: Psychologically induced immobility occasionally marked by periods of
agitation or excitement; the client seems motionless, as if in a trance.
Flat affect: Absence of any facial expression that would indicate emotions or mood
Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks
Content: what is being thought about (in case of psychotic disorders,) abnormalities
in content would include delusions)
Form: abnormalities of the way thoughts are linked together
Stream or flow: how it is being thought about - the amount and speed of thinking
This includes at one end of severity - Circumstantiality – to Word Salad at the other end of
the scale.
Circumstantiality: A person talks at length about irrelevant and trivial details (i.e.
circumstances) and is very delayed at reaching its goal. (Excessive long windedness.).
However, there is a clear association between sentences. A patient afflicted with this
condition, for example, when asked about a certain recipe, could give minute details about
going to the grocery store, the shopping experience, people there, and so on.
Tangentiality: - Replying to questions in an irrelevant manner and never reaching the goal.
However, there is a clear association between sentences (but end is not reached) e.g.: Q:
"What city are you from?" A: "Well, that's a hard question. I really don't know where my
relatives came from, so I don't know if I'm Irish or French."
Word Salad: (or incoherence) - Word salad is at the extreme end of the scale. Speech that
is unintelligible due to the fact that, though the individual words are real words, the manner
in which they are strung together results in incoherent gibberish, e.g. the question “Why do
people believe in God?” elicits a response like “Because he makes a twirl in life, my box is
broken help me blue elephant. Isn’t lettuce brave? I like electrons. Hello, beautiful.”
Thus, the words are just random words. E.g. Blue afraid you no carpet cat.
Neologisms - New word formations. e.g. “I got so angry I picked up a dish and threw it at
the geshinker”, “handshoes” (gloves).
Echolalia - Echoing of other people’s speech e.g. “Can we talk for a few minutes?”, “Talk
for a few minutes”.
Blocking - The patient stops speaking, and after a period of seconds, indicates that he/she is
unable to remember what he/she had intended to say. Blocking may give rise to the delusion
that thoughts have been withdrawn from the head (thought withdrawal).
“My thoughts get all jumbled up. I start thinking or talking about something but I
never get there. Instead I wander off in the wrong direction and get caught up with all
sorts of different things that may be connected with the things I want to say but in a
way I can’t explain. People listening to me get more lost than I do.”
Flight of ideas: Rapidly shifting from one topic to another which are related via superficial
associations. Still, in its extreme forms, flight of ideas involves cognitive incoherence and
disorganization. E.g. Doctor: How are you sleeping at night?
Patient: Why would I sleep tonight? Would you be able to do my work? I whistle
while I play and I am happy to do it all? Okay so that is like a haul.
(Types of flight of ideas: 1) where there is rhyming or clanging, eg, “well, hell bell”, 2)
where there is distraction, eg, a patient talking about his appetite sees another patient walk
past the window and assumes that patient is going for ECT and starts talking about ECT.)
A false belief based about external reality that is firmly sustained despite evidence to the
contrary. The belief is not one ordinarily accepted by other members of the person’s culture.
In schizophrenia the delusions are usually bizarre (compared to non bizarre delusions in
delusional disorder). Delusions are deemed bizarre if they are clearly implausible, not
understandable, and not derived from ordinary life experiences (e.g. an individual’s belief
that a stranger has removed his or her internal organs and replaced them with someone else’s
organs without leaving any scars or wounds or when a person believes that he has invisible
wings and can fly).
Because of its importance in schizophrenia, delusion has been called “the basic characteristic
of madness” (Jaspers, 1963). Disturbances in thought usually involve certain types of
delusions or false beliefs. Various kinds of delusions may be there:
3) Thought withdrawal (the belief that an outside force, person, is removing or extracting
a person's thoughts) are also examples of delusions of control.
Out of the above, the main type of delusion usually seen in schizophrenia includes
delusion of grandeur. A person with delusion(s) of grandeur would believe that he is
famous and important (such as Mother Teresa or Jesus Christ) and he would be trying to
“save the world”.
Auditory: Hearing voices when there is no auditory stimulus is the most common type
of auditory hallucination in mental disorders. The voice may be heard either inside or
outside one's head and is generally considered more severe when coming from outside one's
head. The voices may be male or female, recognized as the voice of someone familiar or not
recognized as familiar, and may be critical or positive. In schizophrenia, the content of what
the voices say is usually unpleasant and negative. In schizophrenia, a common symptom is
to hear voices conversing and/or commenting. When someone hears voices conversing, they
hear two or more voices speaking to each other (usually about the person who is
hallucinating). In voices commenting, the person hears a voice making comments about his
or her behavior or thoughts, typically in the third person (such as, "isn't he silly").
Sometimes the voices consist of hearing a "running commentary" on the person's behavior
as it occurs ("she is showering"). Other times, the voices may tell the person to do
something (commonly referred to as "command hallucinations").
Gustatory: A false perception of taste. Usually, the experience is unpleasant. For
instance, an individual may complain of a persistent taste of metal. This type of
hallucination is more commonly seen in some medical disorders (such as epilepsy) than in
mental disorders.
Olfactory hallucination: A false perception of odor or smell. Typically, the experience is
very unpleasant. For example, the person may smell decaying fish, dead bodies, or burning
rubber. Sometimes, those experiencing olfactory hallucinations believe the odor emanates
from them. Olfactory hallucinations are more typical of medical disorders than mental
disorders.
Somatic/tactile hallucination: A false perception or sensation of touch or something
happening in or on the body. A common tactile hallucination is feeling like something is
crawling under or on the skin (also known as “Formication”).
Visual hallucination: A false perception of sight. The content of the hallucination may
be anything (such as shapes, colors, and flashes of light) but are typically people or human-
like figures. For example, one may perceive a person standing before them when no one is
present.
Research (e.g McGuire 1996) has indicated that auditory hallucinations occur when the
individual misiterprets his own self generated thoughts as coming from another source.
2. Breakdown of perceptual selectivity: The person seems unable to sort out and process
the mass of sensory information to which all of us are exposed to.
“I feel like I am too alert…..everything seems to come pouring at once….My nerves seem
supersenstive…..things seem so vivid and they come to me like a flood from a broken bank”
Various peculiarities are seen especially in catatonic schizophrenia. Various forms may
include:
E. Emotional Dysfunction:
Anhedonia is an inability to experience pleasure from normally pleasurable life events such
as eating, exercise, and social interactions.
Emotional shallowness or “Blunting”: the person may appear almost emotionless so that
even the most dramatic events produce at most an intellectual recognition of what is
happening. This may reflect lack of expressiveness and not a lack of feeling.
Strong Affect: Strong Affect may be shown in certain situations but the emotion clashes with
the situation. For e.g. the person may respond to the news of parent’s death with gleeful
hilarity.
Persons suffering from schizophrenia may be confused about their sense of identity and may
even have a delusion of a new identity such as Christ. He may also be uncertain about the
boundaries separating the self from the rest of the world leading to frightening “cosmic” or
“oceanic” feelings of somehow intimately tied up with universal powers including God or the
Devil.
G. Disrupted Volition:
The individual is unable to carry out goal directed activity even in areas of daily routine such
as work, self care etc.
For e.g. the person may no longer maintain minimal standards of personal hygiene or may
show profound disregard of personal safety and health. This has been attributed to frontal
lobes and executive functioning.
H. Retreat to an Inner World:
This involves disengagement from the external world and in extreme cases can be seen as a
deliberate attempt to avoid being overwhelmed. There is a rich elaboration of inner world
(fantastic ideas, creation of strange beings).
Subtypes
1. Paranoid Type (where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent. Delusions are mainly
characterized by persecutory -feeling victimized or spied on- or grandiose delusions,
hallucinations)
2. Catatonic Type (prominent psychomotor disturbances are evident. Symptoms can
include catatonic stupor and waxy flexibility i.e. the patient may be either motionless
or there may be excessive motor activity).
3. Disorganized Type (characterized by grossly inappropriate or flat affect,
incoherence, loose associations, and extremely disorganized behavior).
4. Residual Type (mild indications of schizophrenia shown by individuals in remission
following a schizophrenic episode) and
5.Undifferentiated Type (psychotic symptoms are present but the criteria for paranoid,
disorganized, or catatonic types have not been met).
Genetic factors-
Schizophrenia concordance rates for identical twins are routinely and consistently found to be
significantly higher than those for fraternal twins or ordinary siblings. Study has shown a
higher concordance for schizophrenia among identical, or monozygotic (MZ), twins than
among people related in any other way, including fraternal, or dizygotic (DZ), twins.
Two conclusions can therefore be drawn: First, genes undoubtedly play a role in causing
schizophrenia. Second, genes themselves are not the whole story. Twin studies provide some
of the most solid evidence that the environment plays an important role in the development of
schizophrenia .
If concordance is greater among the patients’ biological than adoptive relatives, a hereditary
influence is strongly suggested; the reverse pattern would argue for environmental causation.
Our genetic makeup may control how sensitive we are to certain aspects of our environments.
If we have no genetic risk, certain kinds of environmental influences may not affect us very
much. But if we have high genetic risk, we may be much more vulnerable to certain types of
environmental risks such as high communication deviance or adverse family environments.
Prenatal exposures-
Kraepelin (1919) suggests that “infections in the years of development might have a causal
significance” for schizophrenia.. Maternal infections such as rubella (German measles) and
toxoplasmosis (a parasitic infection) that occur during this time have also been linked to
increased risk for the later development of schizophrenia (Brown, 2011). Also,
incompatibility between the mother and the fetus is a major cause of blood disease in
newborns. Interestingly, Rh incompatibility also seems to be associated with increased risk
for schizophrenia Patients with schizophrenia are much more likely to have been born
following a pregnancy or delivery that was complicated in some way (Cannon et al., 2002). If
a mother experiences an extremely stressful event late in her rst trimester of pregnancy or
early in the second trimester the risk of schizophrenia in her child is increased (King et al.,
2010). Currently, it is thought that the increase in stress hor- mones that pass to the fetus via
the placenta might have nega- tive e ects on the developing brain, although the mechanisms
through which maternal stress increases risk for schizophrenia are not yet well understood.
Brain abnormalities-
People suffering from schizophrenia reveal abnormalities in the structure and function of the
brain as well as in neurotransmitter activities. Other cognitive deficits are also apparent.
Patients with schizophrenia have problems with the active, functional allocation of attentional
resources , i.e, they are unable to attend well on demand. Studies of chronically ill patients of
schizophrenia suggest that decreases in brain tissue and increases in the size of the brain
ventricles are not limited to the early phases of this illness. Instead, progressive brain
deterioration continues for many years.
Psychosocial and cultural factors
Theories that were popular many decades ago, for example, the idea that schizophrenia was
caused by destructive parental interactions (Lidz et al., 1965)—have foundered for lack of
empirical support. Patients who returned home to live with parents or with a spouse were at
higher risk of relapse than patients who left the hospital to live alone or with siblings. Brown
reasoned that highly emotional family environments might be stressful to patients. Being
raised in an urban environment seems to increase a person’s risk of developing schizophrenia.
Research is also showing that recent immigrants have much higher risks of developing
schizophrenia than do people who are native to the country of immigration. Also, it is found
that people with schizophrenia are twice as likely as people in the general population to
smoke cannabis (van Os et al., 2002).
Genetic factors-
There is a strong association between the closeness of the blood relationship (i.e., level of
gene sharing or consanguinity) and the risk for developing the disorder. Towards the end of
the movie it is mentioned that john’s son is also diagnosed with schizophrenia. This could
depict that there is a tendency for schizophrenia to run in the genes of his family, which could
have been passed on to john from either his first degree relatives or second degree relatives.
Of course, just because something runs in families does not automatically implicate genetic
factors. e terms familial and genetic are not synonymous, and a disorder can run in a family
for non genetic reasons
Personality –
It is observed throughout the movie that john has an asocial personality. He tends to keep
things to himself, not sharing his emotions with others around him. He finds it difficult to
make conversations with people as he told his wife and charles in the movie. Also, many
around him consider his overt behavior strange. His body language and his reactions to things
are not familiar. This could be a causal factor in johns life that led to schizophrenia. He
shown to be consistently anxious and restless about things around him that usually led to a
nervous breakdown. Stress over everything that constantly presses him throughout the movie
can also be a predisposed factor that led to the disorder.
Environmental factors-
It is observed in the movie that Nash’s hallucinations and delusions get stronger once he is
found in stressful environments, i.e, when his workload is at its peak. He was found to be in
constant state of dilemma when he was given deadlines to finish his work. Such stressful
environment conditions could have led to his disorder. Even though his childhood is not
shown in the movie, but certain statements like how he does not like people and people do
not like him, made by john, show that probably the environment he was brought up in his
childhood wasn’t favorable or the people he lived with were troublesome.
The film A Beautiful Mind is based on the life of American mathematician, John
Nash. The film won four Academy Awards for Best Picture, Best Director (Ron
Howard), Best Adapted Screenplay and Best Supporting Actress (Jennifer Connelly).
John Nash was played by Russell Crowe who received a nomination for Best Actor.
The movie focuses on Nash's struggle with paranoid schizophrenia during the 1940s
and 1950s. While the movie takes a few dramatic liberties with its depiction of
schizophrenia, it also provides a fairly accurate portrayal of the disease. For
example, symptoms typically begin in early adulthood for males and often involve a
significant stressor, such as beginning graduate courses at Princeton University. The
film brings Nash's paranoid delusions to life through the character of William
Parcher, a fictional agent for the United States Department of Defense. Nash
becomes fixated on his missions, which ultimately leads to hospitalization and
psychiatric treatment. The psychosocial consequences the illness has on Nash's
career and family are also reality for many patients suffering from severe mental
illness. The movie also takes advantage of symptoms such as delusions, reduced
speaking/”flat effect”, and various cognitive symptoms such as poor executive
functioning but these are all valid and common symptoms of schizophrenia as we
know it (National Institute of Mental Health). These symptoms are put into effect in
the beginning of the movie when Charles appears and also when John is talking to
the other graduate students, although the cognitive symptoms do not appear until
other key scenes in the move. He does not speak a lot and when he does it is not
with a lot of emotion, which can be attributed to the onset of his disability. However,
although the symptoms are accurate, John never had delusions figures such as
Charles, he suffered mostly from auditory delusions. The movie also depicts
delusions of grandeur as well as delusions of persecution. John Nash starts to
believe himself as an extremely important person who is helping the US army to
break codes of the Russians. Delusions of persecution are portrayed when he fears
that there’s someone out to kill him and his wife because he is of importance. Until
the middle of the 20th century there were no drugs available for the treatment of
schizophrenia and treatment, such as it was, consisted of confining the person in one of the
large institutional asylums and administering powerful doses of sedative drugs to restrict
their psychotic behavior. The film highlights another important component of mental
health treatment; medication adverse effects. This scene takes place in the 1950’s,
and is reflected in the treatments that were used. It was during this time that new
treatments were being developed to attempt to cure schizophrenia, which is shown
when John is forced to undergo insulin shock therapy a couple times a week. The
results of this treatment were horrible and eventually were discredited as anti-
psychotic drugs were introduced (ABC News). The introduction of anti-psychotic
drugs plays a very important role in allowing schizophrenic people to lead normal
lives. Nash begins treatment with an antipsychotic medication and experiences
sedation and sexual dysfunction. He complains he is unable to think clearly and
develop new areas for research, which causes him to self-discontinue his
medication. After some time off the antipsychotic, his delusions return and he
decompensates. This scenario is an excellent teaching opportunity for pharmacy
students and conveys the realistic struggle with medication adherence in this patient
population. While the film does an impressive job with communicating many common
components of paranoid schizophrenia, there are a few inaccuracies or
dramatizations. For example, the film depicts Nash's hallucinations as complex
visual hallucinations, which is uncommon and most often reported as auditory
hallucinations (hearing voices).
Before the 1950s the prognosis for schizophrenia was bleak. Treatment options were very
limited. Agitated patients might be put in straitjackets or treated with electroconvulsive
“shock” therapy. Most lived in remote and forbidding institutions that they were expected
never to leave (Deutsch, 1948).
ramatic improvement came in the 1950s when a class of
drugs known as antipsychotics were introduced. Pharmaco- therapy (treatment by drugs) with
these medications rapidly transformed the environment of mental hospitals by calming
patients and virtually eliminating their wild, dangerous, and out-of-control behaviors. A new
and more hopeful era had arrived.
Pharmacological Approaches
There is overwhelming evidence that antipsychotic medications help patients. Large numbers
of clinical trials have demonstrated the efficacy and effectiveness of these drugs (Sharif et al.,
2007). Also, the earlier patients receive these medications, the better they tend to do over the
longer term (Marshall et al., 2005; Perkins et al., 2004). As we discussed earlier, first-
generation antipsychotics are thought to work because they are dopamine antagonists. is
means that they block the action of dopamine, primarily by blocking (occupying) the D2
dopamine receptors.
Psychosocial Approaches
For a long time, medications were often the only form of treatment that patients with
schizophrenia received. But things are now very different. Psychosocial interventions are also
now available. Some of these approaches, which are typically used in conjunction with
medication, are briefly described below.
FAMILY THERAPY e literature that links relapse in patients with schizophrenia to high
family levels of expressed emotion (EE) inspired several investigators to develop family
intervention programs. e idea was to reduce relapse in schizophrenia by changing those
aspects of the patient–relative relationship that were regarded as central to the EE construct.
At a practical level, this generally involves working with patients and their families to
educate them about schizophrenia, to help them improve their coping and problem-solving
skills, and to enhance communication skills, especially the clarity of family communication.
In general, the results of research studies in this area have shown that patients do better
clinically and relapse rates are
lower when families receive family treatment (see Pfammatter et al., 2006). Studies done in
China indicate that these treatment approaches can also be used in other cultures (Xiong et
al., 1994). Despite this, family treatment is still not a routine element in the accepted standard
of care for patients with schizophrenia (Lehman et al., 1998). Given its clear benefits to
patients and its considerable cost-effectiveness (Tarrier et al. [1991] calculate that family
treatment results in an average cost savings of 27 percent per patient), this seems very
unfortunate.
CASE MANAGEMENT Case managers are people who help patients find the services they
need in order to function in the community. Essentially, the case manager acts as a broker,
referring the patient to the people who will pro- vide the needed service (e.g., help with
housing, treatment, employment, and the like). Assertive community treatment programs are
a specialized form of case management. Typically, they involve multidisciplinary teams with
limited caseloads to ensure that discharged patients don’t get over- looked and “lost in the
system.” The multidisciplinary team delivers all the services the patient needs (see DeLuca et
al., 2008; Mueser et al., 1998).
One way to help improve the functional outcomes of patients with schizophrenia is through
social-skills training.
INDIVIDUAL TREATMENT
Before 1960 the optimal treatment for patients with schizophrenia was psychoanalytically
oriented therapy based on a Freudian type of approach. This is what Nobel Prize–winning
mathematician John Nash received when he was a patient at McLean Hospital in
Massachusetts in 1958 (Nash’s story is told in Box 13.5 on page 490). By 1980, however,
things had changed. Research began to suggest that in some cases, psychodynamic treatments
made patients worse (see Mueser & Berenbaum, 1990). is form of individual treatment thus
fell out of favor.
Individual treatment for schizophrenia now takes a different form. Hogarty and colleagues
(1997a, 1997b) have re- ported on a controlled 3-year trial of what they call “personal
therapy.” Personal therapy is a nonpsychodynamic approach that equips patients with a broad
range of coping techniques and skills. The therapy is staged, which means that it comprises
different components that are administered at different points in the patient’s recovery. For
example, in the early stages, patients examine the relationship between their symptoms and
their stress levels. They also learn relaxation and some cognitive techniques. Later, the focus
is on social and vocational skills. Overall, this treatment appears to be very effective in
enhancing the social adjustment and social role performance of discharged patients.
Ethics-
Informed consent
Clinicians who treat patients with schizophrenia may encounter a variety of ethical issues
related to both psychiatric and medical treatment of patients. While informed consent is a
crucial aspect of the care of all patients, it may present special challenges for patients with
schizophrenia. Schizophrenia is a severe mental illness that is frequently accompanied by
neuropsychological deficits. These impairments, as well as psychotic symptoms and lack of
insight, can affect patients' abilities to make fully informed decisions about their own care.
Ensuring that consent for treatment is informed, voluntary, and competent can thus become a
more difficult endeavour. The ethical principles underlying treatment of these patients,
however, are the same as those guiding treatment of all patients. Informed consent, as an
embodiment of these ethical principles, represents the expression of individual rights in both
clinical and research contexts. Attention to the process of informed consent as an ongoing
dialogue strengthens the clinician-patient relationship, improves adherence, and helps the
patient clarify options, values, and preferences. In the research setting, psychiatric researchers
are increasingly concerned with maximizing the abilities of individuals with severe mental
illnesses such as schizophrenia to provide meaningful informed consent for protocols.
Telling Half-Truths to Patients with Schizophrenia Who Are Paranoid
Ethically, the degree to which a psychiatrist withholds information may disrespect a
patient’s autonomy and may even be regarded as lying by omission. However, this
ethical “price” may be warranted due to other competing and mutually exclusive
values that may benefit the patient in other ways.
This same conflict may exist when psychiatrists treat patients with schizophrenia
who have paranoia. Most psychiatrists generally believe that to be maximally
effective, they should not directly confront the delusions of patients. The use of this
partial truth may reduce the risk of avoidable harm, but others have carried this same
approach still further. The gains from psychiatrists sharing partial truths may not be
evidence-based.
An emerging shift in both clinical thinking and the underlying ethics of psychiatry is
placing greater emphasis on the quality of life for patients with schizophrenia, as
opposed to primarily trying only to give them relief from their symptoms. One way to
improve a patient’s quality of life is by allowing more input by the patient regarding
his or her care.
Some patients with schizophrenia are exceptionally ambitious. This may cause some
conflict for them and for their psychiatrists.
Shared decision making is an approach some psychiatrists use with patients with
schizophrenia. Using this approach, the psychiatrist provides the patient with more
information and involves him or her more in treatment decisions. This approach,
according to Hamann,“explicitly goes beyond informed consent.” It aims to decrease
“the informational and power asymmetry between doctors and patients by increasing
the patient’s information and control over treatment decisions.”This may involve the
use of directional aids. These aids may depict for the patient the relative pros and
cons of different scenarios (e.g., switching to a different antipsychotic drug), and then
the choice is made to a greater extent by the patient. Respecting patients by
respecting their autonomy is a value independent of actual consequences. It may be
that this value should prevail, even over a psychiatrist’s more traditional value of
protecting patients, despite the fact that patients with schizophrenia may be more
prone to losing decision-making capacity.
Prodromal Schizophrenia
Perhaps the most difficult ethical question raised in regard to the treatment of
patients with schizophrenia over the last decade is if or when a psychiatrist should
tell a patient that he or she is at an increased risk of developing schizophrenia.
Furthermore, if the psychiatrist does inform the patient of the risk to develop
schizophrenia, another ethical dilemma is whether or not to initiate some form of
pharmacological treatment for the patient..
Some psychiatrists believe that telling persons that they are at risk for developing
schizophrenia, much less treating them, is not necessary. “Risk for schizophrenia is
generally not mentioned to either patients or family members, since we don’t believe
the available information justifies such use of diagnostic labels with only attenuated
symptoms.”
Others feel this same way because they believe that far too many of these persons
would later turn out to be “false positives” for schizophrenia. Disclosing the full truth
may scare these patients and their families profoundly. Informing a patient of his or
her prodromal state may become a self-fulfilling prophecy.
Psychiatrists treating patients with schizophrenia may face ethical conflicts. These
conflicts often are between helping these patients maximally and respecting their
autonomy optimally.
Achieving treatment adherence in schizophrenia is a great challenge. The reasons for lack of
treatment adherence are complex, vary considerably from patient to patient, and have been
categorized as follows: patient-related factors (e.g., persecutory delusions, lack of insight,
health care beliefs), medication-related factors (e.g., lack of efficacy, distressing side effects),
environmental factors (e.g., caregiver support, cost) and clinician-related factors (e.g.,
therapeutic alliance) (Fenton et al., 1997).
Studies raise hope for new treatments, preventive approaches for schizophrenia
• The contributions of altered genetics and brain connectivity to the biology of schizophrenia.
While the idea that schizophrenia is a disease of "disconnectivity" is not new, it has recently
been validated by modern genetic and brain imaging techniques. Connectome-based studies
may inform the development of new approaches to schizophrenia treatment.
• A renewed focus on the schizophrenia "prodrome"—a critical early period with
opportunities for early detection and intervention. This line of research has enabled
identification of young people at "clinical high risk," with the potential to develop
interventions to prevent or delay development of schizophrenia.
• The identification of risks faced by offspring of parents with schizophrenia—including
increased rates not only of psychotic disorders, but also depression/anxiety and other mental
health conditions. Research suggests that children at "familial high risk" can be identified
early, with important implications for predicting later risk.
One promising therapy for patients early in the course of psychosis is "cognitive
remediation"—a psychological treatment to improve thinking skills, that may be especially
helpful during the prodromal period. Another paper highlights emerging treatment and
preventive approaches. Recent evidence suggests possible benefits of some "repurposed"
treatments and supplements, such as B-vitamins and omega-3 fatty acids.
Antipsychotic Drugs
There are many antipsychotic drugs currently on the market available to treat
schizophrenia, some of which have been available for many years. Generally
speaking, there are two broad classes of antipsychotics available: conventional
antipsychotics and atypical antipsychotics.
Over the years a great deal of progress has been made in the management of
schizophrenia. The introduction of atypical antipsychotics has proved successful
since they are generally associated with fewer extrapyramidal side effects than the
conventional agents. It would also appear that the pharmaceutical industry still
considers this disease as an attractive target for drug design and there are, indeed,
many novel agents in early development. For this progress to continue, it is vital
research into developing new agents is maintained.
Support groups
Many people have had really positive experiences from support groups and have found that
the opportunity to discuss their symptoms and their everyday problems with other people
who have the same unique experience of the way that psychotic thoughts work has been a
valuable part of their recovery.
Family therapy
Studies have shown that the way that a person’s family and friends react to their
schizophrenia can greatly affect the pace of their recovery. Families who become very
intensely emotional because of their loved one’s behaviour, either hostile or overly
concerned, can often obstruct the sufferers pathway to recovery.
Alternative therapies
Some alternative therapies such as herbal remedies have a track record stretching back
centuries. Valerian, for instance, is a longstanding remedy for mental health problems and
was widely prescribed for anxiety during the blitz. However some of the newer alternative
methods have no such history to support them.
Diet and exercise
Every encouragement should be given to people with schizophrenia to have a regular, well
balanced diet and to avoid fasting or alternatively junk food and binge eating.
Professor David Horrobin whose pioneering work The Madness of Adam and Eve proposed
treating schizophrenia with Omega 3 and 6 supplements. However some practitioners have
gone further than this and suggested that some aspects of diet may be key to good mental
health. Professor David Horrobin has undertaken lengthy research into the effect of using
Omega 3 and Omega 6 fatty acid supplements to treat positive symptoms and has reported
good results even in some patients previously unresponsive to antipsychotics.
There has also been some work done on the usefulness of vitamin supplements. There is
some evidence that the extrapyrimidal effects of the typical antipsychotics may be alleviated
using vitamin E and B6 supplements. Frequent exercise is vital. It will not only help to
maintain your physical health but it will also help you relax and get a regular sleep pattern.
The importance of having a good diet and plenty of exercise should not be underestimated.
People living with schizophrenia also suffer a higher incidence of physical health conditions
such as diabetes and heart problems and infectious conditions such as hepatitis and HIV