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Schizophrenia is a heterogeneous disorder and can be characterized by any of the following symptoms: intellectual deterioration, emotional blunting, disorganized speech, disorganized behavior, social isolation, delusions, and/or hallucinations (American Psychiatric Association [APA], 2000). In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) schizophrenia has now been divided into five subcategories (APA, 2000). These subtypes are defined based on the presence of positive symptoms (excesses, such as hallucinations and delusions) or negative symptoms (deficits, such as social isolation and poverty of speech) of behavior in the presentation of the disorder.
There is no defined cause for schizophrenia although many have been proposed. First, it is generally acknowledged that schizophrenia is at least in part caused by an imbalance of neurotransmitters. The classical "dopamine hypothesis" of schizophrenia has asserted that there is a hyperactivity in dopaminergic transmission at the dopamine D2 receptor in the projections to the limbic system in the brain (Matthysse, 1974). Despite several limitations this hypothesis still remains the most popular of the neurochemical theories. The other line of evidence is heredity, suggesting genes play a role in schizophrenia. However, it is still unclear if schizophrenia is the result of a single mutated gene, a series of mutated genes, or a mutated gene passed from parents. The concordance rate between monozygotic twins for schizophrenia is around .5 in most studies (Cohen, 2003; Sadock & Sadock, 2007).
Psychotherapy for schizophrenia has rarely been considered a first line treatment and the first line treatments for schizophrenia today consist of medications. Older drugs such as and Haldol primarily work as dopamine antagonists, whereas new atypical antipsychotics such as risperadal and clozipine affect dopamine and serotonin. Of course problems with medications have been compliance and side effect profiles (APA. 2000). Older drugs are associated with side effects such as tardive dyskinesia (uncontrollable movements), whereas the atypical antipsychotic drugs have fewer side effects (but each drug still has a side effect profile). The side-effects of the medications often lead to their discontinuation by the patient. All medications for schizophrenia take several weeks before they take effect (another problem for the dopamine hypothesis as dopamine is blocked soon after the drug is taken) and up to 20% of patients will not respond to medication at all (Hyman & Fenton, 2003). The pharmacological treatments for psychotic illnesses have grown exponentially in the past quarter of a century using antipsychotic medications and mood stabilizers, which has led to a limited focus in the current psychiatric textbooks only describing the medications available and helping patients understand the limitations of what can be offered (Cohen, 2003; Sadock & Sadock, 2007).
The problem with the medical model of treatment for schizophrenia
Despite the use of medications, there are some pitfalls to the medical model. First, in the pre-neuroleptic period before these drugs were developed and before there were long-term follow-up studies approximately two-thirds of schizophrenic patients made good social recoveries (Bleuler 1968; Ciompi 1980). Based on a large meta-analysis of patients covering nearly a 100 years from 1895 to 1992 it also appears that outcome for persons with a diagnosis of schizophrenia is worse now than it was before treatment with neuroleptics medications dominated the field (Hegarty, et al., 1994). The World Health Organization's (WHO) findings from a nine-country study of schizophrenia indicated that at the five-year follow-up period nearly 63% of patients from third world developing countries were doing well compared to 39% of those from developed countries. The most parsimonious explanation that could be offered for this surprising finding is that only 16% of third world country patients were maintained on neuroleptics medications compared with 59% from developed countries (Whitaker, 2002). Moreover, patients on long-term medication therapy have significantly shorter life expectancies and a higher rate of other chronic health issues. In a similar vein there is an emergent body of research that indicates that many of the standard treatments in psychiatry (e.g., medications) are no more effective than active placebos (e.g., see Kirsch, 2010). Thus, the perhaps viewing schizophrenia as a brain disease is missing something. Moreover numerous studies that have demonstrated psychotherapy and understanding care is more effective for schizophrenia than medications have been ignored by modern psychiatry (Whitaker, 2002).
There have been successful non-medication approaches to treating schizophrenia in the past. For example the most famous of these is Diabasis, an experimental residential facility in San Francisco, CA in the 1970s founded by John Weir Perry, a Jungian trained psychiatrist who advocated not using medications to treat schizophrenics. The facility contained schizophrenic patients who were treated with a combination of psychotherapy that was based on Jungian principles and Weir's additions to Jungian theory. Medication use was not allowed (Perry, 1974; 1999). The residence consisted of typical living facilities and the addition of a "venting room" used to let the residents express their personal concerns, regardless of the issue, their nature, or of their intensity. Perry believed that professional mental health care workers had stereotyped conceptualizations of schizophrenic patients that would interfere with the type of treatment that these patients actually required so he used non-professional health care workers to work with the clients in his facility. Perry (1999) later reported that the qualifications he sought for the workers included being open to different experiences, being gregarious, and able to be a good listener. The staff's duties consisted of mostly of caretaking, some therapy (primarily listening and empathizing) and other chores. The complete details of the program can be found in Perry (1999). The general treatment protocol at Diabasis consisted of meditation, painting, massage, dance, and forms of talk therapy. In 1999 Perry published some of the data on his program, which unfortunately had closed after just a few years of operation because of budget cutbacks. According to the data the average length of stay for a client was only 48 days. Perry reported that even the most severely psychotic patients were coherent within two to six days. In his report Perry claimed to have an 85% success rate without remissions. He also noted better outcomes for those clients with fewer than three previous psychotic outbreaks.
There are other studies that indicate that newly identified schizophrenic patients who are treated with specialized psycho-social methods and few or no neuroleptic drugs, recover as well as drug-treated patients in the short run (e.g., Mosher and Menn, 1978; 1979). At two-year follow-ups of patients treated in programs without drugs indicates that these patients have better outcomes than patients in similar programs who receive neuroleptics medications (Bola and Mosher, 2003). Therefore, consistent with Perry (1999) it appears justified to expect recovery for most persons with early-episode psychosis if the proper conditions can be maintained to foster their recovery.
Rationale for the research and hypothesis
However, there have been no randomized controlled trials comparing residential treatment outlined by Perry and Mosher and associates (Soteria project) to standard pharmacotherapy for schizophrenia. The reason for this is that psychiatry has eschewed its back on any treatment for schizophrenia that does not consist of medications. Using a true control group for patients with a severe disorder like schizophrenia brings up ethical concerns as well. However, it would be acceptable to use random assignment to two treatment conditions, one medication and one residential to test the issue. Such a study comparing the effects of residential treatment vs. standard treatment with a long-term follow-up would answer many questions regarding the effectiveness of nonstandard residential treatments that apply the principles of Perry and Mosher vs. medication. Based on previous findings it is proposed that residential treatment for newly diagnosed people with schizophrenia will demonstrate equivalent efficacy to the standard medical treatments at the end of the treatment period; however, over a two-year follow-up period patients in the residential treatment program will demonstrate fewer relapses and better social and occupational functioning.
Thirty first time diagnosed participants with schizophrenia will be randomly assigned to residential treatment or standard treatment with medications. The participants will not have any other psychiatric diagnoses, have never been on psychiatric medications, no history of substance abuse, and no serious medical disorders.
There will be 15 patients in each condition and there will be an effort to match patient pairs on demographic variables such as gender, age, education, etc. And the type and severity of their disorder and then randomly assign each to one of the two treatment conditions. The diagnosis of schizophrenia will be made by a licensed psychiatrist in the context of a community mental health center, hospital, or other psychiatric facility. Medications in the medication group will be prescribed by a psychiatrist.
Materials and Resources
Residential facility with 6 rooms for patients, group room, kitchen, dining room, two bathrooms, staff headquarters, furniture, appliances. Food, hygiene supplies, toiletries to be replenished weekly.
Assessment and statistical analysis materials:
Only standardized instruments that have been previously used for the assessment of symptoms and social functioning in schizophrenia will be used for the study. The following are three instruments will be used:
The Brief Psychiatric Rating Scale…[continue]
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