Drug therapies are by far the most common of treatments for people with schizophrenia. They have been available since the 1950s according to Bellenir (2000). The aim of anti-psychotic medications is to reduce the psychotic symptoms of schizophrenia and they have made life much easier for many suffering from this disorder. "Anti-psychotic drugs are the best treatment now available," according to Bellenir (2000). The Mental Health Disorders Sourcebook mentions that these drugs are especially effective in treating certain symptoms such as hallucinations and delusions. One of the most important aspects of anti-psychotic medications is to individualize the dose for each person. Supplemental treatments may also be necessary to deal with side effects from the anti-psychotics themselves. Recently, a number of new anti-psychotic drugs known as "'atypical anti-psychotics'" have been developed. One of these new drugs, known as clozapine, has been shown to be particularly effective. There is, however, the possibility of severe side effects which require the patient to be monitored and have blood drawn once every one or two weeks. Other, newer medications such as risperidone and olanzapine are even safer than clozapine and older anti-psychotics but may not be as effective. The newer anti-psychotics do not work as well on symptoms such as reduced motivation and emotional expressiveness. These drugs are a vast improvement over the older anti-psychotics known as "neuroleptics," but may have harsh side-effects.
Treatment with these drugs may produce symptoms such as drowsiness, restlessness, muscle spasms, tremor, dry mouth, or blurring of vision. This is one of the reasons that doctors often must supplement anti-psychotic medication with other drugs in order to deal with serious side effects. Another way to reduce side effects is to simply lower the dose. The APA Practice Guidelines for the Treatment of Psychiatric Disorders Compendium 2000 warns that this lowered dose should not fall below one fifth of the original dose and should be kept at least at a functional level.
It is worth reviewing the specific efficacy of common anti-psychotics. The neuroleptics category represents older drugs which are part of the family phenothiazine. In 1952, Delay and Deniker used this family of drugs on violent patients and reported success in the form of relaxation, reduced psychotic symptoms and lowered hostility towards the environment without marked drowsiness.
Problems with phenothiazines include neurological disorders of movement resembling Parkinson's Disease, such as tremors and rigidity. In some cases, the side effects can paradoxically increase with reduced dosage according to a study by Warner (1985). According to a study by Jeste and Wyatt (1981), 20% of long-term users develop a facial tic, a condition known as tartive-dyskenisia. A Northwick Park hospital report claims that 42% of patients on maintenance medication relapsed after 2 years. According to a review of a 1976 study by Vaughn and Leff, the success of neuroleptic drugs is also dependent on the family environment. Patients with a high stress family environments experience significantly higher relapse rates.
Beckman and Hass (1980) found that benzodiazepines are effective in treating auditory hallucinations. One drug in particular, diazepam, has a marked therapeutic effect, although it has also shown to be addictive.
Another drug, the androgynous, endorphin-antagonist naloxone, has been shown to prevent hallucinations. This medication has not attained much popularity due to its high cost and short shelf-life according to Slade and Bentall (2000).
In conclusion, drug therapies represent a wonderful advancement in the treatment of hallucinations in people with scizophrenia. However, the side-effects of these treatments range from mild to potentially harmful. Indeed, in a recent study conducted by Dr. Jonathan Hellewell, consultant psychiatrist from the Trafford General Hospital in Manchester, England, of the over 1,300 patients with schizophrenia 87% of patients reported Extra Pyramidal Side-effects and 47% reported having sexual side effects. This is particularly troublesome because many patients will stop taking their medication as a result of the side effects. This suggests that psychiatrists are not doing enough to titrate the patients dosage and that there is not enough follow-up work with the patient to find the best dosage. We may, therefore, conclude that in addition to simple drug treatments, social and behavioral treatments may be necessary for some patients to maintain an effective treatment plan.
In addition to the many drugs for treating schizophrenic hallucinations, there are also many other approaches. Most of these are behavioral: including operant therapy, systematic desensitization, thought stopping and counter-stimulation.
One process involving the internalization of responsibility for voices is First-person-singular therapy. The theory behind this type of therapy is that " ' Regardless of orientation, a key factor in auditory hallucinations is the message of maximum external control and minimum personal responsibility.' " In a study review of Robert Greene (1978) by Slade and Bentall (1988), it is reported that two patients that were instructed to refer to the voices and accept them as coming from inside oneself, the review reported full recoveries after having fully accepted and implemented this approach. Little other research using this method has been done according to Slade and Bentall (1988).
Psychological treatments in general seem to have some
efficacy regardless of conflicting styles.
The explanation suggested by Slade and Bentall 1988 is that perhaps these
different methods work at different "levels of the hallucinatory
mechanism." They also suggest
that these processes may share some common therapeutic effect.
Unfortunately the most likely commonality is very likely to be a placebo
effect. Slade and Bentall (1988) go
on to claim that a careful examination of the data in the studies they reviewed
suggests that there may be three shared processes that contribute to the
method's success. The suggested
common processes are,
(a) Focusing;
(b) Anxiety reduction;
(c) Distraction/ counter-stimulation.
Evidence for anxiety reduction being a commonality in working treatments is that some procedures cannot account for the reduction of voices in terms of focusing on them since the process involves relaxing.
Distraction/ counter-stimulation is a distinctive feature of some treatments. In general treatments with this feature tend to work immediately but cease to prevent voices once the distracting action is stopped. For this reason these kinds of treatments are less effective in clinical settings. Long-term successes using this methodology are described as resulting from the patient developing useful strategies for every-day life based on these distraction/ counter-stimulation treatments.
Interestingly, systematic surveys of coping mechanisms used
by patients themselves seem to have a correlation with the three main aspects
that attribute to successful psychological treatments.
The first of two studies "…interviewed 40 consecutive outpatients
meeting the Research Diagnostic Criteria for schizophrenia." This study concluded with the authors placing the different
coping mechanisms into three main groups. The
first was behavior changes; the second, was changes in physiological arousal;
the third was cognitive strategies. (Slade,
Bentall 1988 p 202). The table
below shows a clear illustration of the distribution.
It is noticeable from the data that of the features mentioned that contribute to effective psychological treatment only two are well represented in this study population. With respect to the anxiety reduction aspect of psychological treatments 73% of patients reported relaxation or sleep as a mechanism they used. The feature of distraction or counter-stimulation was represented in the form of postural change, which 63% reported using, leisure actives, which 73% reported using, physical exercise, reported by 55%, and reduced attention to the voices which was used by 73%. The third aspect of effective psychological treatments, focusing, was not present in abundance however.
A second study involving 25 patients suffering from auditory hallucinations was reported in Slade and Bentall (1988). The patients were living in the community and receiving phenothiazine medication. The study was carried out by Tarrier (1987) and used methods like the study above to obtain their data. Their data was similar in that there was not use of focusing as a coping mechanism.
To sum up, many of these coping mechanisms share concepts and features with the existing psychological treatments. But, according to Slade and Bentall 1988, "...few patients seem to have discovered for themselves what amounts to perhaps the most efficacious of methods: focusing." This is one way in which clinicians are useful; to make patients aware of potentially effective coping mechanisms they may not have considered themselves.
ECT or electro-convulsive therapy "has been studied in the acute phase of schizophrenia." According to the American Psychiatric Association [APA] (2000). The [APA] 2000 also reports several studies have revealed that ECT is as effective as anti-psychotic medications. These studies were done by Horowitz (1977), Hsu and Starzynski (1986), Strober et al. (1988), Alessi et al. (1994), Cambell et al. (1984). It also mentions other studies that have shown ECT to be not as effective as anti-psychotics alone such as Galenberg (1976) and Black et al. (1987) sited in [APA] (2000). Apparently there is still something of a discrepancy in findings but in a significant majority of studies, the use of ECT to the use of anti-psychotic medications reveal that "…the combination is more effective than either treatment alone." ECT has also been shown to be less effective for patients with chronic schizophrenia than for first admission patients (50% to 70% of those who have had schizophrenia for less than 1 year return to the community in an improved condition, but only 20% of those who have had continuous episodes for over 3 years do the same) this is supported by evidence provided in the form of studies reviewed in [APA] (2000) such as Carlson (1990), Cohen et al. (1994), Lier et al. (1989), Lindhout and Meinardi (1984) and Rosa (1991). It should be noted that as of now the efficacy of continual ECT treatment has not been investigated enough according to the [APA] (2000).
There are in actuality two types of ECT. The first in unilateral non-dominant-hemisphere ECT and the second is bilateral ECT. There has been no significant difference shown by studies, but the studies are not completely definitive, again according to the [APA] (2000) review of a study by Swann et al. (1990).
Side effects of ECT are mainly cognitive ones associated with a "…transient postictal confusional state…" ([APA] 2000). Other unfortunate side effects include "…longer periods of anterograde and retrograde memory interference…" The [APA] review of work by Escobar and Tuason (1980) does say that "…memory impairment typically resolves in a few weeks after cessation of treatment, except for some recent autobiographical memories." It should be noted that according to the [APA] (2000) Unilateral ECT causes less cognitive impairment.
ECT has long been an alternative to drug treatments. The procedure has improved much since it was first implemented. However, there may now be an alternative to ECT. TMS stands for Transcranial Magnetic Stimulation. Instead of using electricity to alter the neurochemistry of a patient, TMS uses magnets. The Yale dept. of psychology website reports that there has been no display of cognitive ability reduction with TMS that is present after the use of ECT. In ABC News (2001), Dr. Ralph Hoffman, "acting director of the Yale Psychiatric Institute…" is said to have tested the TMS on 12 patients. Each patient apparently received 40 minutes of treatment over four days. The results showed that 8 of the 12 responded to the treatment. The report also noted that some patients didn't respond immediately to the treatment but did later on. Another web report done by the Yale University School of Medicine claimed that because auditory hallucinations arise from speech processing areas of the brain, a repeated magnetic pulse (roughly the strength of an MRI scan which has been shown to "…induce sustained reductions in cortical activation." could alleviate many patients of their voices. This report outlines a study in which 'sham stimulation' results were compared to 'active stimulation' results to determine any real benefit from the treatment. The following graph shows the results of their data. Hallucination rating refers to severity.
To ensure the illusion of the 'sham stimulation', the
magnet was angled such that the stimulation occurred in the scalp but not in the
brain in sham simulation trials. "In
all cases, 'voices' were resistant to medication therapy" according to Yale
University: school of medicing (2001).