schizophrenia case study psychology

Case Study of a Young Patient with Paranoid Schizophrenia

• January 2015
• International Journal of Psychology and Psychiatry 3(2):139

• Vallabh Government College, Mandi (Himachal Pradesh)

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Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

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ORIGINAL RESEARCH article

Intersubjectivity in schizophrenia: life story analysis of three cases.

• 1 Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Santiago, Chile
• 2 Escuela de Psicología, Facultad de Ciencias Sociales, Pontificia Universidad Católica de Chile, Santiago, Chile

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

Introduction

Pathological experiences are usually described as phenomena that are divorced from the life context in which they are manifested. Nevertheless, in the field of phenomenological psychopathology, symptoms have traditionally been considered from a more comprehensive perspective: they are embedded in the person’s life thus their contents and meanings can only be understood within the context of that life. In themselves “unhistorical,” symptoms become connected meaningfully only within the comprehensive picture of the patient’s life as a whole ( Jaspers, 1997 ).

An even stronger argument could be made to the effect that “no mental illness can be diagnosed, described, or explained without taking account of the patients’ subjectivity and their interpersonal relationships” ( Fuchs, 2012 , p. 342). It is clear that psychopathological manifestations cannot simply be reduced to the workings of the nervous system ( Fuchs, 2011 ). For that reason, the recommendation here would be not to establish linear or “cause/effect” relationships, but to approach mental illnesses with the notion of a “circular” mode of causality, regarding their emergence from subjective, neural, social, and environmental influences continuously interacting with each other ( Fuchs, 2012 ).

Contemporary psychopathological phenomenology regards schizophrenia as a paradigmatic disturbance of embodiment and intersubjectivity ( Dörr, 1970 , 1997 , 2005 , 2011 ; Blankenburg, 2001 , 2012 ; Fuchs, 2001 , 2005 , 2010a ; Sass and Parnas, 2003 ; Stanghellini, 2004 , 2009 , 2011 ). From this approach, it seems appropriate to use methods that attempt to characterize not only the patients’ symptomatic disturbances but also the interpersonal processes involved, broadening the scope of exploration to areas not taken into account in the criteriological manuals of diagnostic systems Diagnostic Statistical Manual of Mental Disorders (DSM) and International Classification of Deseases (ICD) ( Fuchs, 2010b ).

This paper presents the life story analysis of three cases that form part of the corresponding author’s doctoral dissertation entitled “Study of disorders of the pre-reflexive self and of the narratives of first admitted patients with schizophrenia” (unpublished), covering a total of 15 patients with schizophrenia during their first psychiatric hospitalization.

Here, “life-world” refers to the person’s subjectively experienced world, which emerges in the process of conceiving one’s self and the others through a history of social interactions ( Husserl, 1970 ; Schutz and Luckmann, 1973 ; Varela, 1990 ; Varela et al., 1991 ; Maturana and Varela, 1996 ).

Materials and Methods

Study design.

The study was developed within the qualitative paradigm, it being an explorative–descriptive type of study. This type of studies proceeds with inductive logic: in other words, both hypotheses and analysis categories are developed as the study progresses, and emerge from the data itself (Danhke, 1989 quoted in Hernández et al., 2003 ).

The so-called “critical case sampling” criteria was used, where the interest in an in-depth approach to the phenomena means working with few cases, with representativeness not being of key importance for these purposes. Thus, the significance and understanding emerged by qualitative inquiry have more to do with the richness of the cases chosen and also with the observational and analytical abilities of the researcher, rather than with size of the sample ( Patton, 1990 ; Schwartz and Jacobs, 1996 ; Creswell, 1998 ).

Participants

The broad research covered a total of 15 patients with schizophrenia during their first psychiatric hospitalization. All of them were males, aged between 18 and 25. Additional inclusion criteria were the following: (1) accessibility to the sample, (2) homogenous sample ( Halbreich and Kahn, 2003 ), and (3) earlier first onset and higher risk of developing schizophrenia in men ( Aleman et al., 2003 ).

The three cases were selected due to the variety of subtypes to illustrate the interpersonal processes involved in schizophrenia, taking the intersubjective dimension of the patients’ life stories into consideration. Cases 1, 2, and 3, as they appear in the paper, correspond to patients with diagnoses of disorganized-type, paranoid-type, and catatonic-type schizophrenia, respectively.

Instruments

In-depth interviews.

In-depth interviews were used to gather qualitative data from the first encounter with the patients and from their life stories. These interviews had open questions aimed at allowing for a natural manifestation of the patients’ accounts. For the first encounter, the recommendations on interviews for the phenomenological diagnosis of schizophrenia were taken into account ( Dörr, 2002 ), and clinical biographical focus criteria were used to perform the life story interviews ( Sharim, 2005 ).

Positive and Negative Syndrome Scale

The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987 ) is a rating scale used for measuring symptom severity of patients with schizophrenia. The name refers to the two types of symptoms: positive, which refers to an excess or distortion of normal functions (e.g., hallucinations and delusions), and negative, which represents a diminution or loss of normal functions.

The Examination of Anomalous Self-Experience

The Examination of Anomalous Self-Experience (EASE; Parnas et al., 2005 ) is a semi-structured interview for the phenomenological examination of disorders of the pre-reflexive self, postulated as early markers or basic phenotype of the schizophrenic spectrum ( Raballo et al., 2011 ). The EASE explores a variety of anomalous self-experiences, which typically precede the onset of positive symptoms and which also often underlie negative and disorganized symptoms ( Parnas and Handest, 2003 ).

Data gathering was performed by means of semi-structured interviews, which are characterized by the use of eminently “open” research questions. Less structured methods allow for the emergence of ideographic descriptions, personal beliefs and meanings, focusing on “how” the psychological processes occur ( Barbour, 2000 ).

Five encounters with the patients were carried out. These encounters were coordinated throughout the three following phases:

Phase I: A first encounter to record the patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episode (30–45 min interview carried out 1–2 weeks after hospitalization), following the confirmation of the diagnosis of schizophrenia in accordance with expert judgment and the standard diagnostic criteria of DSM-IV-R ( American Psychiatric Association, 2003 ) and ICD-10 ( OrganizaciónMundial de la Salud, 2003 ).

Phase II: Two subsequent encounters to carry out the EASE ( Parnas et al., 2005 ; 30–45 min per interview carried out 1 month after hospitalization), when patients did not score with “positive” symptomatology on the PANSS ( Kay et al., 1987 ).

Note: The results of Phase II of the broad research have not been included in this paper. The results from the EASE exploration will be published in a complementary paper focused on basic self-disorders entitled “The lived body in schizophrenia” (in preparation).

Phase III: Finally, two further encounters were held to perform the life story interviews (30–45 min per interview carried out 1–2 months after hospitalization). The first encounter started with the open instruction “tell me about your self,” “tell me about your life,” while the second one was focused mainly on the patients’ significant social interactions and personal meanings, also including their first image in life, their early dreams (hopes), their self-definition, and their expectations about the future.

All the interviews were recorded on video and fully transcribed for subsequent analysis. Extracts of the patients’ accounts were kept literally in quotes.

First Encounter (Phase I)

The patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episodes were summarized in corresponding descriptions containing the essential structure of the transcripts, which were obtained with the “Descriptive Phenomenological Method in Psychology” ( Giorgi, 2009 ), by following five steps: (1) the researcher reads the entire transcript in order to gain an overall sense, (2) the same transcript is then read more slowly, and underlined every time a transition in meaning is perceived, providing a series of units constituting meaning, (3) the researcher then eliminates redundancies and clarifies the meaning of the units, connecting them together to obtain a sense of the whole, (4) the arising units are expressed essentially in the language of the subject, revealing the essence of the situation for him, and finally, (5) there is the summarizing and integrating of the achieved understanding in a description with the essential structure of the transcript.

Life Story Interviews (Phase III)

The criteria of the clinical biographical focus were considered in the life story analysis, which are part of the so-called “clinical human sciences” paradigm ( Legrand, 1993 ; Sharim, 2005 , 2011 ). This approach stresses the life story method, in which the clinical dimension is constantly present, working primordially on singularity: case-by-case, story-by-story.

At the same time, the examination of singularity and heterogeneity of individual situations allows the progressive appearance of common processes that structure behavior and organize these situations ( Sharim, 2005 , 2011 ; Cornejo et al., 2008 ). This method highlights the role of the subject in recounting his life story, giving the possibility to analyze the reciprocal relationship between the subject’s determination by his history and his potential to create his own existence ( De Gaulejac, 1999 ; De Gaulejac et al., 2005 ).

The in-depth analysis of the life stories was developed under a course guided by the co-author of this paper. The course was called “Hermeneutic analysis of biographical material for the study of patients with schizophrenia” and took place during one academic semester at the Catholic University of Chile. The analysis focused on the personal meanings ( Fuchs and De Jaegher, 2009 ) by following the patients’ history of significant social interactions.

Therefore, the transcripts were analyzed by peer researchers (corresponding author and co-author of this paper) both clinical psychologists with a specialty in psychotherapy. To avoid bias each researcher previously made a separate analysis and then met for the co-analysis, ensuring with this procedure the validity of the qualitative research ( Maxwell, 1996 ; Morrow, 2005 ; Fischer, 2009 ).

Firstly, an individual (case-by-case) in-depth analysis of each narration using a hermeneutic approach was carried out. In this analysis each life story was re-constructed, carrying out a thematic and chronological ordering, which enabled the identification of “biographical milestones,” as well as the analytical axes in each life story. Second, a cross-sectional analysis was carried out contemplating the stories all together, revealing the differences, similarities, and shared structural dimensions.

Ethical Issues

The broad research, covering 15 patients with schizophrenia during their first psychiatric hospitalization, was regarded as entailing no physical, psychological, or social risks for the subjects involved, based on the Declaration of Helsinki principles, the Council for International Organizations of Medical Sciences (CIOMS) 1992 International Ethical Guidelines for Biomedical Research Involving Human Subjects, and the 1996 International Conference on Harmonisation (ICH) Good Clinical Practice guidelines, by the following Ethics Committees: (1) Research into Human Beings Ethics Committee of the University of Chile’s Medical Faculty, dated January 19, 2011. (2) Ethics Committee Research of the Psychiatric Hospital, dated August 2, 2012. (3) Ethics Committee Research of the North Metropolitan Health Service (Santiago, Chile), dated August 16, 2012.

The Ethics Committees also approved the patients’ and their tutors’ (legal representatives) consent documents. In this regard, the following ethical aspects were taken into account: (1) consent was informed and obtained from the patients’ tutors by the attending doctor at Phase I of the study, considering that as a patient affected by an acute episode of schizophrenia, his competence or capacity is diminished and he must be authorized to participate. (2) Consent was obtained directly from the patients at Phase II of the study. (3) Pseudonyms were employed to protect the identity of the patients and ensure confidentiality (internal codes were used for each patient to replace their original names).

Note: Careful attention was paid in this paper to the protection of the patients’ anonymity. Identifying information such as dates, locations, hospital numbers, etc., was avoided.

Individual Analysis (Case by Case)

Santiago (Santi) is an 18-year-old patient, diagnosed with disorganized-type schizophrenia. He has completed 8 years of basic school education. His father died of cancer 1 month before his hospitalization: until then, he lived with him and his two brothers. He is the middle brother. The patient’s mother left home when he was 12 years old.

First encounter . A first interview was carried out after 2 weeks of hospitalization. In this encounter, the patient indicates that although he considers himself to be a “normal” person, begins to recognize a “ repetitive failure .” It is primarily the mediating process of thinking that has become the main impediment in this case.

The patient indicates that he hears voices, which are as if his own thoughts were repeated inside his head, like an echo, “ as if I was reading them aloud but with my mouth closed .” Most of the voices repeat meaningless things that he does not understand. He also hears voices on the radio, repeating what he is thinking: these are voices of unknown people who seem to be talking to him. Additionally, it sometimes seems to him that some television personalities repeatedly say things to him, all sorts of non-sense. He does not know how or why they do.

There are periods in which the “repetitive failure” intensifies, to the extent that it prevents him leaving home, and that only by going to bed to sleep is he able to take a break from these thoughts. This has made it difficult for him to progress with his studies or concentrate. He feels that this situation is annoying for him and is harmful because he cannot live a normal life.

At first, the patient figured it was sort of a game, playing with the voices and thoughts, but he could not control it, he could not stop it, he kept on playing. This was sometimes unbearable for him, and has even made him want to hang himself.

Biographical milestones . The life story interviews were carried out after 2 months of hospitalization. The patient was receiving the usual pharmacological treatment and had recently completed 12 electroconvulsive therapy sessions.

“My mum left me when I was 12”

Santi begins his account by indicating that he has had a hard life. He refers to his parents’ divorce, and particularly to when his mother left him alone with his brothers when he was 12. His mother moved away from the city and got married again. “ It was very hard, when she wasn’t there and we lacked a mother’s love .”

In addition to being angry with his mother when she left home, Santi also points out that he did not get on with her as a child. He remembers that she used to get very annoyed with him when he and his father sometimes made fun of her.

The mother returned after 2 years for her children. Santi’s brothers agreed to go with her, but he preferred to remain with his father. At the age of 14, he was living alone with his father. However, the brothers returned 2 years later, when he was 16, due to the serious situation with the mother’s new husband, who beat them.

Santi states that he got on well with his brothers; they had an affectionate relationship, one of friends, between them. They helped each other out and shared the housework between them.

“I died in high school”

Santi acknowledges that a significant change took place in his life at school. As a young child, he was a very good pupil and wanted to study medicine, but at the age of 12 he lost interest in his studies, skipped school, and began taking drugs. He had to repeat the last school year twice due to absenteeism. He liked the typical tools of the medical trade and wanted to have a stethoscope. “ Now that I have them here (at the psychiatric hospital), I ask myself, why can’t I, if everyone else can? ”

He stopped taking drugs at the beginning of this year and returned to his studies. He wanted to study accountancy to earn money. He had recently started the first year of high school when he was hospitalized.

“My dad passed away recently”

Santi states that his first memory is one of being with his family, when he was 7. It is a memory of the time when they were still living with their mother. He recalls it was his father who took them to a pretty square at the center of the city. “ Nice memories, everything was nice with my dad. ”

The father worked in the public sector and had taken early retirement, the reason for which is unknown. He did not remarry or have a relationship with another woman. Santi has a very positive image of him. He describes him as hard worker, a good father and who liked to go out and play ball with him and his brothers.

Santi displays an empathetic attitude toward his father, even a certain loyalty, which is made clear when he recounts the time when his mother left home, and later when his brothers left. In fact, he decided to stay alone with his father, despite the pain caused by the separation from his mother and brothers. “ My dad went through an extremely painful time, to put it one way, he didn’t show it but, inside, he was feeling bad .”

The father passed away 3 months ago, from cancer, at the age of 65. He became ill a month before dying, and had immediately told his sons of his disease, so they were aware of how much longer the doctor had given him. The father was hospitalized at the time of his death.

Santi recognizes that he was very attached to his father, he states that “ even too much .” He realizes that he still has not gotten over the death of his father, “ because of my illness, I still have not gotten over it. I haven’t realized what it all really means .”

“ I see the future as nothing ”

Since the last 4 years, Santi has been becoming more and more distanced from the world, to the point where he is extremely isolated. He has no friends, does not study or work, takes no part in social activities and has not embarked on any romantic relationship.

During the week, he helped with some household chores, such as making lunch. Nor did he do anything special during the weekend, except go out to the square with his brother. He spent a lot of time in his room playing on his PlayStation. “ I see the future as nothing, the way I’m going. Not doing anything, not studying, because where will I get like this? It’s looking bad, isn’t it? I’m worried .”

Life story analysis . The patient took part in the interviews without any problems. He appeared interested in obtaining more information on his state of health and motivated to seek help to secure a speedy discharge. He interrupted the interviews on a number of occasions to ask what his illness was, if it was very serious and when his attending doctor would discharge him. Generally, he appeared constantly concerned about his state and anxious to put an end to his confinement.

His life story contains a series of events that could be regarded as stressful. It is certainly possible to establish a connection between the death of his father (i.e., the patient’s state of grief) and the emergence of the first acute episode, and also to identify his mother’s leaving home as the crucial biographical milestone in the development of the prodromal stage of schizophrenia. Somehow, the sense of abandonment in the world has come to dominate the patient’s life.

The scale of the emotional impact of the recent loss of a father is obvious: nevertheless, the patient at no time displays any signs of sadness and does not cry. Instead of a spontaneous emotional expression, he rationally discerns the seriousness of the situation and like a “witness” he testifies the tremendous impact this must have on his life.

He manifested an initial perplexity, conveyed with a degree of humor, in light of the apparent oddness and incomprehensibility of the account of his anomalous experiences (“the repetitive failure”). Nevertheless, although he recounts sad events in his life, any actual sadness can only be assumed. To put it one way, it is possible to “intuit” the patient’s suffering, through the loneliness, abandonment and lack of support in his life, rather than by means of an explicitly emotional manifestation on his part.

The patient notices the paradoxical situation involved (of being hospitalized) when he states that he regards himself as a “normal” person, except for his “repetitive failure.” Far from merely being a game, as he previously regarded it, it is now given the name of schizophrenia, a diagnosis that defines him as a seriously ill patient and justifies his compulsory commitment to a hospital. This has led him to realize that what is happening to him is not socially acceptable, and is thus regarded as more serious in his own judgment.

Angel is a 22-year-old patient, diagnosed with paranoid-type schizophrenia. He has 11 years of basic school education and lives with his parents and the eldest of his three sisters. He is the youngest of the siblings and the only brother. His family are evangelical Christians.

First encounter . A first encounter was carried out a week into his hospitalization. The patient has not been able to find a convincing explanation for the fear he feels, which he recognizes as his major impediment. He thinks he could be delivered over to the Tribulation – the Tribulation is a biblical time of pain.

About 3 months ago he began to feel persecuted by people. His house was the only place he felt safe, but for a few weeks now he has even begun to feel unsafe at home. The idea that somebody can hurt him comes from the fear he feels and he thinks that the worst thing would be that somebody kills him somehow, like stabbing him, for example. This fear is a distressing feeling, of wishing to escape, when he suddenly feels that something bad is going to happen to him.

He is quite concerned about his problem, and thinks a lot about it, and how to solve it. He wants to find a way to overcome the fear. He would like to find a “ clear and precise ” answer to what he should do, how he should live and how to face up to his fear. He wishes that the bible could tell him what to do in the Tribulation, “ if I was in that time, that it told me in light of this fear to do this or that, to face up to it, don’t be afraid, I’ll be with you .”

Biographical milestones . The life story interviews were carried out 1 month into the patient’s hospitalization. He was receiving usual pharmacological treatment and his suitability for electroconvulsive therapy was being assessed.

“ When I was a kid I went to school ”

Angel woke up one night and found himself alone at home: it was very dark and he started crying. This is the earliest image that he recalls from his childhood. He also remembers that he would sometimes run up the stairs because he thought that someone, “ perhaps the bogeyman ,” was after him.

He remarks that his grades were not great but things went well for him at school. During his childhood, he felt good because he went out to play and climb trees. He also liked to fix televisions and take apart toy cars. He stresses the fact that he was more outgoing and playful as a child.

His family was always good to him, and he notes that he had a happy childhood. He was closest to his mother, as she stayed at home and was very attentive and loving toward him. His mother was of good character, and only punished him on a couple of occasions, “ because once I hit my sister with a hammer, when I was playing, and my mum punished me, she gave me a slap on the behind .”

“My sisters were very critical of me”

Angel has three older sisters. He has had a difficult relationship with them, and particularly with the eldest. He points out that his sisters criticized him a great deal and made fun of him. Therefore, even as a child, he took great care to say the right thing, so as not to make a fool of himself and feel embarrassed.

He was not only concerned to ensure that he said the right thing, but also with his personal appearance. He was very sensitive about the comments his sisters made about him. He states that he was very shy as a child, and when he was embarrassed by something he would run away and did not want to come back.

“Then I went to high school”

At high school, Angel was unable to make friends. He notes that he changed, became less playful, less “chatty” and more reclusive. He did not play ball so much or join in with classmates as often.

He also comments that he found it difficult to appear in front of his classmates, and skipped school when he had to give a talk to the class on a subject. This got worse when he started to suffer from acne, which made him feel that people were looking at him too much and a little persecuted.

It was because of the acne that Angel began to skip school, until he stopped going completely and became totally isolated. “ By this point, the acne wasn’t as bad, but it was the fact I missed school, I skipped class a lot, I was embarrassed that I skipped school so much, and that’s why I stopped studying .”

“ Then I went out to work. That’s when it all went wrong ”

Angel does not think that his acne is any better, but somehow he learned to come to terms with this concern. He has spent a lot of time at home, in his room playing on his PlayStation. This is what he has mostly done over the last 4 years, as he admits. “ I didn’t see anyone except for my family, not friends, because it’s a bit solitary on the PlayStation, you get closed in on yourself when you’re on it .”

After 4 years, Angel went out to work. He notes that it is when everything went wrong. He had spent a lot of time at home, without going out. He notes that he was perhaps unprepared to go out and experience life like that all of a sudden. It was then that he began to feel that people were after him.

“ Now, as a person ”

In adolescence, Angel wanted to be an air force pilot but he could not apply because he did not finish his studies and was under the required height – “ it came as quite a blow, but I was still interested in mechanics .”

Angel does not have a clear vision of what the future holds, principally because he has not overcome the fear of being harmed and the thought that “somebody” will kill him, which is his most serious affliction. Nevertheless, he indicates that, if he can overcome his fear, he would like to work and study mechanics and electronics, which have been interests of his since childhood.

Life story analysis . The patient was very willing to take part in the interviews, although he generally appeared tired and dispirited. He seemed not to have much to say, or not to be ready to recount his story. He is of a religious disposition and a frequent reader of the Bible where, above all, he hoped to find an explanation for the problem affecting him: his fear.

His account is mainly based around the fear of being harmed, which is the subject of his delusion. He even appears, in a way, excited when talking about the problem of his fear and about the different explanations he uses to understand what is happening to him. Aside from this core problem afflicting him, his account barely touched on other aspects of his life, and he appeared to become dispirited, tired, and uninterested when moving away from the subject of his delusion.

He seems concerned that he is unable to find certainty in things, above all with regard to explaining his fear. He feels prey to a fear that is completely restrictive, and is unable to find a satisfactory explanation that would allow him to understand what is happening to him or to give a completely convincing response to overcome the situation. He is aware of the extent of the fear and the significant limitations it causes in his life, and of the lack of any clear orientation as to how to overcome it.

The patient conveys a feeling of “ontological” uncertainty or insecurity. From an early age in his life, the world (and others) acquired a sense of unreliability or threat. Shame and fear of ridicule are the predominant emotional aspects of his experience in childhood. Somehow, later on in adolescence these emotions led to the fear of persecution. Persecution progressively became a fear of being hurt until it reached the extreme point of a fear that he would be killed, which manifested itself in the first acute episode.

Salvador (Salva) is a 25-year-old patient, diagnosed with catatonic-type schizophrenia. He has completed 12 years of compulsory school education and lives with his father and older brother. His parents divorced 2 years ago.

First encounter . The first interview was carried out when the patient had been hospitalized for close to 2 weeks. He explains that 2 years ago started with an episode of mental illness: “ I was getting cramps in the back of my brain .” It was because of the confusion these cramps caused in his brain that he went to the psychiatrist. Then, he was diagnosed with depression and treated with medication for a year but the problem persisted.

He feels mental pressures, and indicates it is as if they squeeze his brain. His thoughts are jumbled up, all messed up with ideas. Reality gets distorted for him as well, as if he were in a constant dream. In addition, he has felt someone possessing his body and explains it as “demonic possession.” He thinks that spirits get in when someone is depressed. It is something he cannot control, something unpredictable, imminent.

The patient is worried about the state of his mental health. It worries him to “live like this,” and he feels a deep-seated desperation. He does not want to do anything and feels depressed, downcast, dispirited, and powerless. Before he was hospitalized, he wanted to committed suicide by jumping off a hill due to the desperation.

Biographical milestones . When the life story interviews were carried out, the patient had been hospitalized for a month and a half. He was receiving the usual pharmacological treatment.

“ My interest in religion began at the age of 8 ”

Salva completed his primary education at a Christian school. He liked the religious part of school because religion was taught in a fun way. When he was a child, he used to go to church with his family. “ I liked the teachings about love, love for one another, love for one’s neighbor .”

He points out that he was a very good student and got very good grades. He wanted to be a vet when he was a child, because he liked animals. He describes himself as a gentle, playful, brotherly, sweet boy.

“ They moved me to a worldly high school ”

The change of school had a negative impact on Salva. His performance suffered, and he went from being an outstanding student to being just an average one. He notes that students at the new school were treated more coldly.

He had wanted to be a vet since childhood but he could not go to university, as he did not pass the entrance exams. He therefore chose to study architectural drawing at a college, but did not manage to complete his first year there.

“ My mum was sweet to me when she was Evangelical ”

Salva had a good relationship with his mother as a child. He points out that his mother was very loving toward him whilst she was Evangelical. Later, however, for reasons unknown to him, she distanced herself from church. Their relationship deteriorated when he was a teenager.

He got on badly with his mother because, he explains, of their very different characters. His mother ill-treated him and frequently insulted him. This made him feel powerless. “ She was really aggressive, and punished and hit me for anything. She used to insult me in all kinds of ways, she called me mentally ill .”

His mother also fought with his father and brother. She drank, and when she did so she became more violent.

“ I went through a lot in 2010 ”

Salva states that he had his first episode of “mental illness” 2 years ago, and has not been able to work or study since then. “ I did nothing at home, just playing games on the computer; I’d play on it, football games and PlayStation. I spent a load of time doing that .”

It was in this same year that his mother left home and his father fell ill with diabetes. His brother had had a heart attack at the end of the previous year.

His mother left home to live with a new partner, saying she wanted her independence. At first he missed her, but was also angry. He did not want to see her or be with her after she left.

Salva continued to live with his father and brother. He feels very attached to them, and is concerned about their health. He feels he has a really great father, because he has had to play a double role. He gets on well with his brother too, who he regards as a second father.

“ It’s great at church, they treat me really well ”

Salva’s current friends are evangelicals and he joins them at church. He likes going to the church because there he got to know beautiful people and had a much closer relationship with God. “ I like being in communion with God, praying, singing, that’s how I look for protection .”

He has had four episodes of “demonic possessions,” all of which happened at church. It was at church where he was told that his bodily experiences were “possessions” and that they are somehow “normal.” However, the treatment he was given there was unsuccessful. They carried out “deliverances,” which are a way of getting the devil out the body with prayer.

At the moment, Salva does not know why these episodes have happened to him, or whether they are due to an illness, and has not even talked much about the matter with his attending doctor.

“ In the future, I want to study massage therapy ”

Over the course of the last 7 years, Salva worked on and off in a number of fields. He took jobs as a shelf stacker in a supermarket, a cleaner at a cinema and a shop assistant. His last job was 2 years ago selling fragrances in a street market.

He has remained socially isolated over the last 2 years, only keeping in touch with his evangelical friends at church sporadically. “ I’ve found it difficult to relate to people in recent years. I haven’t worked much or had much of a social life. I’ve been isolated .”

In the future he would like to have children, a wife and work giving massages, although he realizes that he remains scared about his mental state, that he feels vulnerable.

Life story analysis . The patient took part in the interviews willingly, although he did appear very tired and sleepy (he was constantly yawning). The disordered thoughts persist, as do his low spirits, mental pressures and the uncertainty in the face of possible new “possessions.” He talks about himself and his life quite candidly and seems naïve, as if recounted by a small child. He speaks calmly, slowly, with little verve. It is a story with few elements told at a basic level of articulation.

He is very religious, a habitual reader of the Bible and a regular churchgoer. Now, although the episodes were “demonic possessions,” fear does not appear to be the predominant or explicit emotion: it is rather the loss of control of his bodily experiences and the unpredictable nature of these episodes that make the patient desperate. In other words, his desperation is due to his inability to once again feel normal or healthy.

He left school 7 years ago and has not developed a specific plan to carry out his life. Although he wishes to have a “normal” life, his life project faces a vacuum. However, the lack of a plan does not seem to concern him at all. Instead, what most worries the patient at present is the state of his mental health, that is, the anomalous bodily experiences he is not able to control.

It is possible to make a connection between the emergence of the first acute episode and a series of stressful events that occurred in the patient’s life at that time: his mother left home, his father fell ill with diabetes and his brother had heart problems, all in the same year. Although, the negative impact of the change in high school and the deterioration of the relationship with his mother in his adolescence are the crucial biographical milestones identified in the development prodromal stage of schizophrenia.

Besides, what the patient explains as “spirits getting into” does not seem to correspond to a typically clinical depression (as it was diagnosed initially), but rather to a severe “passivity” of his own existence, which finds concrete form in his disembodied experiences.

Cross-Sectional Analysis

The cross-sectional analysis shows that a severe disorder of intersubjectivity starts developing in early adolescence. Beginning at an early stage, the patients progressively distance themselves from the social world. This distancing becomes a structural element, a key part in the prodromal stage of schizophrenia.

It is not an active deliberate distancing, but rather an overall difficulty that hampers the living of a normal life. It implies a progressive “passiveness” of the patients’ own existence, which manifests itself not only in the disturbances of self-experience and body alienations of the acute phases, but also in the patients’ radical withdrawal from the social world.

For several years, the patients have not worked or studied, have had no social life, and have stayed shut in at home watching television or playing on their PlayStation for hours at a time. Here, it is important to notice that the acute episode occurred at a time when they were planning to return to their studies or the world of work after a number of years of extreme isolation.

It is possible to make a connection between the prodromal stages of schizophrenia and several stressful events that occurred in the patients’ lives. It is also possible to follow a continuity in the experience of vulnerability regarding the main personal meaning configured early in life: the feeling of abandonment, the fear of ridicule and the feeling of powerlessness, corresponding to Cases 1, 2, and 3, respectively.

Nevertheless, the patients’ withdrawal from the social world is what eventually leads to the manifestation of their psychosis. Somehow, in their attempts to returning to intersubjectivity, all of a sudden the patients confront themselves with their own “vulnerability” of being in the world.

Although they have some ideas about what to do in the future, the patients are insufficiently prepared, and lack a specific plan to implement them properly. Their life project faces a vacuum. This is what makes their condition so severe: there is an interruption in the patients’ normal unfolding of life.

The patients do have a concept of what a “normal life” should be (basically, to study, to have a job, to marry, and to have a family), but they do not seem to possess the factual grounding needed to deal with the world, as if they were lacking the implicit “know how” to carry out the normal life they wish to live.

It should be noted that the patients’ life stories feature a series of healthy elements or personal qualities that reflect a certain nobility of character: sensitivity, authenticity, naivety, empathy, and innocence. There does not appear to be any secondary gain associated with the symptoms.

Key Findings

In acute phases of schizophrenia, patients’ accounts concentrate on (or are limited to) the disturbances of self-experience or body alienations. In other words, patients’ accounts lie outside the time-space dimension of the social context and exclude personal history. Body alienation appears to be the way in which the de-subjectivized accounts find concrete form (or are materialized).

The assessment of the life stories complements the symptomatic descriptions embedding them in the patients’ life-worlds, thus incorporating a social horizon. In this way, the dimension of intersubjectivity is illustrated in the patients’ history of significant social interactions, discovering the interpersonal elements to integrate in psychotherapeutic and prevention models.

The articulation of the patients’ life stories allow to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence. Thus, the spatiotemporal dimension of the personal history allows the understandability of the interpersonal processes involved in schizophrenia from a broader perspective.

From the individual analysis of the life stories, it is possible to identify the patients’ biographical milestones, the personal meanings involved in their significant social interactions, and also continuity in their experience of vulnerability of being in the world, which are useful elements to consider for psychotherapeutic treatment.

The cross-sectional analysis of the life stories shows that a severe disorder of intersubjectivity starts in early adolescence, which should be a useful element to consider for the early detection and on the prevention. Beginning at an early stage, the patients progressively distance themselves from the social world, ending in a radical withdrawal. This distancing becomes a structural element, a key part of the prodromal stage of schizophrenia, as it was found in every case of the broader sample covering 15 patients with schizophrenia.

Social interactions are interrupted prior to the emergence of acute symptoms, possibly due to the threatening or anxiety provoking encounters with others. Nevertheless, the underlying anguish was not measured in this study. Instead, the study shows the personal vulnerability that leads to a psychotic break (or to the culmination of the intersubjective interruption).

Clinical Implications

Psychotherapeutic interventions for patients with schizophrenia have been widely neglected in general. Current treatments are primarily with medication, including elctroconvulsive treatments in acute phases, thus following a medical-biological model that has not been questioned sufficiently. In this context, the intersubjective dimension seems extremely relevant for both the development of psychological treatments and the understanding of the interpersonal processes involved in schizophrenia (as an interruption in intersubjectivity).

From the very start of hospitalization, psychotherapeutic support would appear of fundamental importance. The patients should be accompanied on their return to intersubjectivity, whereas efforts should be made to provide proper emotional support for the realization of the overall problem affecting them. Prior to interventions focused on tasks (for example, successfully performing a social role, such as studying or working), the patients need to experience being in the world with another person, in a synchronous accompaniment of affective reciprocity.

In other words, the intersubjective dimension should be integrated in psychotherapeutic models focusing on the patients’ social interactions. These models should be oriented to developing a collaborative encounter between the patient and the therapist, as well as enhancing metacognitive capacities, as it has been shown to be helpful especially for the recovery of patients with schizophrenia in several case studies ( Dimaggio et al., 2008 ; Harder and Folke, 2012 ; Lysaker et al., 2013 ).

The process of recovering understandability would be a key aspect in overcoming the patients’ alienation. Therefore, special consideration should be given to psychotherapeutic approaches that focus upon encouraging patients’ self-understanding and the establishment of a common communicative base between patient and psychotherapist ( Holma and Aaltonen, 1997 , 2004a , b ; Seikkula and Olson, 2003 ; Seikkula et al., 2006 ). The idea is that the patient’s experience can be explicitly shared on the basis of a common meaning by a dialog process that takes into account the other’s point of view (or second person-perspective; Stanghellini and Lysaker, 2007 ).

Patients’ narrativity should improve along different levels of articulation, by the recognition of beliefs, the incorporation of emotions and the reconstruction of different meaningful life events. However, during acute phases delusional beliefs constitute the patients’ only available form of cognitive and interpersonal organization, so instead of confronting them, the focus should be placed on the difficulty in pragmatically comprehending others and on the experience of vulnerability ( Lysaker et al., 2011a , b , c ; Salvatore et al., 2012a , b ; Henriksen and Parnas, 2013 ; Škodlar et al., 2013 ).

Besides, acute psychosis in schizophrenia manifests itself with a collapse of the temporal dimension of the narrative plot, which leads to a de-contextualization of self-experience ( Holma and Aaltonen, 1997 , 2004a ; France and Uhlin, 2006 ). From the so called “literacy hypothesis” ( Havelock, 1980 , 1991 ), which belongs to studies that follow the transition from orality to literacy in the development of the thematic consciousness, it could be noted that in the acute phase the patients lose the modality of ordering their experience in consensual logical sequences, displaying a narrativity with epic or poetic characteristics ( Guidano, 1999 ).

The re-establishment of the consensual ordering given by the locational/situational aspects of the life story (by articulating the self-experience in thematic/chronological sequences; Havelock, 1980 , 1991 ; Bruner and Weisser, 1991 ; Narasimhan, 1991 ; Guidano, 1999 ; Irarrázaval, 2003 ; Bruner, 2004 ; Holma and Aaltonen, 2004a ) allows to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence.

In this sense, the articulation of the patients’ life stories, expressed as narrative creations of their own subjectivity (and meanings), allows for the spatiotemporal dimension “re-ordering,” as well as for the understanding of the interpersonal processes involved in schizophrenia from a broader perspective. This psychological understanding reveals the intersubjective dimension that connects the emergence of the acute episode with the patients’ biographies, taking into account the personal meaning at play in each case.

In the case of Santi, there appears to be a need for emotional support aimed at accompanying him in becoming aware of the magnitude of the loss caused by the recent death of his father and, subsequently, to help him to develop strategies to deal with his feeling of abandonment in the world.

With Angel, his fear of ridicule is a structural emotional trait that dominates his life and is becoming a fundamental part of his worldview. Here, it is most important to deal with his sense of embarrassment and help him to accept himself. The aim is to provide a new, positive meaning to the sense of himself, overcoming his fear of ridicule in his encounters with others, or in other words, recovering the legitimacy of the sense of himself.

Salva requires an intervention in terms of developing a more basic sense of self-embodiment, which would be aimed at reflecting the feelings of “the other,” to re-establish primordial reciprocity. Additionally, space needs to be created in which the patient can recover a feeling of protection in the world, overcoming the feeling of powerlessness.

From this viewpoint, taking into consideration the story the patient tells of himself improves the articulation of self-narrative, which should gradually be extended toward diverse areas of his life whose elaboration appears important for him to make his way back to daily life. It would be important to articulate the present considering the experience that takes place in the actual interpersonal context, and from here to articulate the future as a horizon of possibilities.

Therefore, reconstructing the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia, but also on the psychotherapeutic intervention best suited to each individual case. Moreover, when intervention in acute phases of schizophrenia focuses mainly on reducing “positive” symptomatology, without assessing the psychological and social elements that are part of the overall situation affecting the patient, relapse seems highly likely.

Limitations of the Study

Regarding the limitations of the study, mainstream scientific research in mental health has been dominated by quantitative methodologies and statistical analyses of big samples (representativeness), while the value of in-depth psychological analyses has been underestimated.

There is a predominant excessive confidence in the accuracy of numbers, as if they could not be easily manipulated in data analyses. This tendency has been supported by the illusion that numbers represent exactly (as a mathematical formula) the experience of the subject, rather than the patients’ own stories.

While qualitative methodology has been the tradition for research in humanities and social sciences, psychotherapy research has been developed using the methodologies of the medical sciences, which are mostly quantitative, being the randomized controlled trials being the favored design.

Nevertheless, research in psychotherapy should be guided by questions that are relevant to clinical practice. It should not be forgotten that methodologies are only means to carry out scientific research, but should not be the ultimate aim in themselves. Thus in this field of research it seems necessary to incorporate the questions psychotherapists need to answer to improve the practice of psychotherapy (to help patients), and then to choose the most appropriate methodologies.

However, one of the main advantages of qualitative studies is the open, mindful and detailed assessment of the subjective experience, enabling the emergence of the patients’ worldview and their personal meanings, which cannot be obtained by means of superficial assessments. Therefore, psychotherapists should also have a voice on the debate of which methodology is best suited to improving the practice of psychotherapy.

Future Directions

Certainly, it would be important to systematize the results of this study in a model of psychotherapeutic treatment for persons with schizophrenia, which should include the intersubjective dimension, starting from the hermeneutic analysis of the patients’ life-worlds toward a meaning-based psychotherapeutic practice. This model would eventually require evidence of effectiveness.

Moreover, it would be interesting to explore gender differences in the processes involved in schizophrenia, investigating prodromal and acute stages, as well as life stories of women with schizophrenia. In addition, improvement is needed regarding the differential diagnosis between acute phases of schizophrenia and acute phases of other severe mental disorders, such as major depression and bipolar disorder.

Finally, the future challenge in the field of phenomenological psychopathology would be to develop a comprehensive/unified philosophical framework for an embodied science of intersubjectivity. And, consistently, to continue developing coherent methodologies for empirical research, since this is the closest we can get to the patients’ life-worlds.

Author Contributions

Co-author Dariela Sharim made substantial contributions to the analysis and interpretation of data to include in the paper; she revised the paper critically for important intellectual content; she made a final approval of the actual version of the paper to be published; she agreed upon the accuracy and coherence of the development of the sections for the paper.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thank Thomas Fuchs from Heidelberg University, the Reviewers and the Editor for their helpful comments to improve the manuscript. Leonor Irarrázaval would like to thank Comisión Nacional de Investigación Científica y Tecnológica (CONICYT) for the grant “Beca Doctorado Nacional” (Doctorado en Psicoterapia UCH/PUC) and German Academic Exchange Service DAAD for the grant “Short duration research scholarships for doctoral students and young researchers.”

Aleman, A., Kahn, R. S., and Selten, J. P. (2003). Sex differences in the risk of schizophrenia: evidence from meta-analysis. Arch. Gen. Psychiatry 60, 565–571. doi: 10.1001/archpsyc.60.6.565

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text

American Psychiatric Association. (2003). DSM-IV-TR. Breviario: Criterios diagnósticos (Spanish edition) [DSM-IV-TR. Breviary: Diagnostic Criteria]. Barcelona: Masson.

Barbour, R. (2000). The role of qualitative research in broadening the “evidence base” for clinical practice. J. Eval. Clin. Pract. 6, 155–163. doi: 10.1046/j.1365-2753.2000.00213.x

Blankenburg, W. (2001). First steps towards a psychopathology of “common sense”. Philos. Psychiatry Psychol. 8, 303–315. doi: 10.1353/ppp.2002.0014

CrossRef Full Text

Blankenburg, W. (2012). La pérdida de la evidencia natural. Una contribución a la psicopatología de las esquizofrenias oligo-sintomáticas [The Loss of Natural Self-evidence. A Contribution to the Psychopathology of Oligo-symptomatic Schizophrenias], trans. O. Dörr and E. Edwards. Santiago de Chile: UDP Ediciones.

Bruner, G. (2004). Life as narrative. S oc. Res. 71, 691–710.

Bruner, G., and Weisser, S. (1991). “The invention of self: autobiography and its forms,” in Literacy and Orality , eds D. Olson and N. Torrance (New York, NY: Cambridge University Press), 129–148.

Cornejo, M., Mendoza, F., and Rojas, R. (2008). La Investigación con Relatos de Vida: Pistas y Opciones del Diseño Metodológico [Life Stories Research: tips and methodological design options]. Psykhe 17, 29–39. doi: 10.4067/S0718-22282008000100004

Creswell, J. W. (1998). Qualitative Inquiry and Research Design: Choosing Among Five Traditions . London: SAGE Publications.

Pubmed Abstract | Pubmed Full Text |

De Gaulejac, V. (1999). Historias de vida y Sociología Clínica [Life stories and clinical sociology]. Proposiciones 29, 89–102.

De Gaulejac, V., Marquez, S. R., and Ruiz, E. T. (2005). Historia de vida, psicoanálisis y sociologia clínica [Life story, psychoanalysis and clinical sociology]. México: Ediciones UAQ.

Dimaggio, G., Lysaker, P. H., Carcione, A., Nicolò, G., and Semerari, A. (2008). Know yourself and you shall know the other… to a certain extent: multiple paths of influence of self-reflection on mindreading. Conscious. Cogn. 17, 778–789. doi: 10.1016/j.concog.2008.02.005

Dörr, O. (1970). La esquizofrenia como necesidad de la historia vital [Schizophrenia as the necessity of the life history]. Rev. Chil. Neuropsiquiatr. 9, 3–14.

Dörr, O. (1997). Psiquiatría antropológica: Contribuciones a una psiquiatría de orientación fenomenológico antropológica [Anthropological Psychiatry: Contributions to a Psychiatry of Anthropological–Phenomenological Orientation]. Santiago de Chile: Editorial Universitaria.

Dörr, O. (2002). El papel de la fenomenología en la terapéutica psiquiátrica con especial referencia a la esquizofrenia [The role of phenomenology in the psychiatric treatment with special reference to schizophrenia]. Rev. Chil. Neuropsiquiatr. 40, 297–306. doi: 10.4067/S0717-92272002000400002

Dörr, O. (2005). Fenomenología del amor y psicopatología [Phenomenology of love and psychopathology]. Salud Ment. 28, 1–9.

Dörr, O. (2011). Fenomenología de la intersubjetividad en la enfermedad bipolar y en la esquizofrenia [Phenomenology of intersubjectivity in bipolar illness and schizophrenia]. Salud Ment. 34, 507–515.

Fischer, C. T. (2009). Bracketing in qualitative research: conceptual and practical matters. Psychother. Res. 19, 583–590. doi: 10.1080/10503300902798375

France, C. M., and Uhlin, B. D. (2006). Narrative as an outcome domain in psychosis. Psychol. Psychother. Theory Res. Pract. 79, 53–67. doi: 10.1348/147608305X41001

Fuchs, T. (2001). The tacit dimension. Commentary to W. Blankenburg’s ‘Steps towards a psychopathology of common sense’. Philos. Psychiatry Psychol. 323–326. doi: 10.1353/ppp.2002.0018

Fuchs, T. (2005). Corporealized and disembodied minds. A phenomenological view of the body in melancholia and schizophrenia. Philos. Psychiatry Psychol. 12, 95–107.

Fuchs, T. (2010a). “Phenomenology and psychopathology,” in Handbook of Phenomenology and the Cognitive Sciences , eds S. Gallagher and D. Schmicking (Dordrecht: Springer), 547–573.

Fuchs, T. (2010b). Subjectivity and intersubjectivity in psychiatric diagnosis. Psychopathology 43, 268–274. doi: 10.1159/000315126

Fuchs, T. (2011). The brain – a mediating organ. J. Conscious. Stud. 18, 196–221.

Fuchs, T. (2012). “Are mental illnesses diseases of the brain?,” in Critical Neuroscience. A Handbook of the Social and Cultural Contexts of Neuroscience , eds S. Choudhury and J. Slaby (West Sussex: Blackwell Publishing Ltd), 331–343.

Fuchs, T., and De Jaegher, H. (2009). Enactive intersubjectivity: participatory sense-making and mutual incorporation. Phenomenol. Cogn. Sci. 8, 465–486. doi: 10.1007/s11097-009-9136–9134

Giorgi, A. (2009). The Descriptive Phenomenological Method in Psychology . Pittsburgh, PA: Duquesne University Press.

Guidano, V. F. (1999). Psicoterapia: Aspectos metodológicos, cuestiones clínicas y problemas abiertos desde una perspectiva post-racionalista [Psychotherapy: methodological issues, clinical issues and open problems from a post-rationalist perspective]. Rev. Psicoter. 37, 95–105.

Halbreich, U., and Kahn, L. S. (2003). Hormonal aspects of schizophrenias: an overview. Psychoneuroendocrinology 28, 1–16. doi: 10.1016/S0306-4530(02)00124-5

Harder, S., and Folke, S. (2012). Affect regulation and metacognition in psychotherapy of psychosis: an integrative approach. J. Psychother. Integr. 22, 330–343. doi: 10.1037/a0029578

Havelock, E. (1980). The coming of literate communication to western culture. J. Commun. 30, 90–98. doi: 10.1111/j.1460-2466.1980.tb01774.x

Havelock, E. (1991). “The oral-literate equation: a formula for the modern mind,” in Literacy and Orality , eds D. Olson and N. Torrance (New York: Cambridge University Press), 11–27.

Henriksen, M. G., and Parnas, J. (2013). Self-disorders and schizophrenia: a phenomenological reappraisal of poor insight and noncompliance. Schizophr. Bull. doi: 10.1093/schbul/sbt087 [Epub ahead of print].

Hernández, R., Fernández, C., and Baptista, P. (2003). Metodología de la investigación . México: McGraw Hill.

Holma, J., and Aaltonen, J. (1997). The sense of agency and the search for narrative in acute psychosis. Contemp. Fam. Ther. 19, 463–477. doi: 10.1023/A:1026174819842

Holma, J., and Aaltonen, J. (2004a). The experience of time in acute psychosis and schizophrenia. Contemp. Fam. Ther. 20, 265–276. doi: 10.1023/A:1022408727490

Holma, J., and Aaltonen, J. (2004b). Narrative understanding in acute psychosis. Contemp. Fam. Ther. 20, 253–263. doi: 10.1023/A:1022432810652

Husserl, E. (1970). The Crisis of European Sciences and Transcendental Phenomenology. An Introduction to Phenomenological Philosophy . Evanston: Northwestern University Press.

Irarrázaval, L. (2003). Estado Psicótico Maniacal. Una Aproximación Post-racionalista. Tratamiento y Análisis de un Caso [Maniac psychotic state. A post-rationalist approach to the intervention and analysis of a case]. Rev. Psicoter. 56, 63–82.

Jaspers, K. (1997). General Psychopathology , trans. J. Hoenig and M. W. Hamilton. London: The Johns Hopkins University Press.

Kay, S. R., Fiszbein, A., and Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr. Bull. 13, 261–276. doi: 10.1093/schbul/13.2.261

Legrand, M. (1993). L’approche biographique [The Biographic Approach]. Paris: Descleé de Brouwer.

Lysaker, P. H., Buck, K. D., Carcione, A., Procacci, M., Salvatore, G., Nicolò, G., et al. (2011a). Addressing metacognitive capacity for self reflection in the psychotherapy for schizophrenia: a conceptual model of the key tasks and processes. Psychol. Psychother. Theory Res. Pract. 84, 58–69. doi: 10.1348/147608310X520436

Lysaker, P. H., Erickson, M. A., Buck, B., Buck, K. D., Olesek, K., Grant, M., et al. (2011b). Metacognition and social function in schizophrenia: associations over a period of five months. Cogn. Neuropsychiatry 16, 241–255. doi: 10.1080/13546805.2010.530470

Lysaker, P. H., Dimaggio, G., Buck, K. D., Callaway, S., Salvatore, G., Carcione, A., et al. (2011c). Poor insight in schizophrenia: links between different forms of metacognition with awareness of symptoms, treatment need, and consequences of illness. Compr. Psychiatry 52, 253–260. doi: 10.1016/j.comppsych.2010.07.007

Lysaker, P. H., Buck, K. D., Fogley, R., Ringer, J., Harder, S., Hasson-Ohayon, I., et al. (2013). The mutual development of intersubjectivity and metacognitive capacity in the psychotherapy for persons with schizophrenia with severe paranoid delusions. J. Contemp. Psychother. 43, 63–72. doi: 10.1007/s10879-012-9218-4

Maturana, H., and Varela, F. (1996). El árbol del conocimiento [The Tree of Knowledge]. Santiago de Chile: Editorial Universitaria.

Maxwell, J. (1996). Qualitative Research Design: An Interactive Approach . London: Sage publications.

Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. J. Counsel. Psychol. 52, 250–260. doi: 10.1037/0022-0167.52.2.250

Narasimhan, R. (1991). “Literacy: its characterization and implications,” in Literacy and Orality , eds D. Olson and N. Torrance (New York, NY: Cambridge University Press), 177–197.

Organización Mundial de la Salud. (2003). CIE-10. Trastornos mentales y del comportamiento [ICD-10. Mental and behavioral diseases]. Madrid: Meditor.

Parnas, J., and Handest, P. (2003). Phenomenology of anomalous self-experience in early schizophrenia. Compr. Psychiatry 44, 121–134. doi: 10.1053/comp.2003.50017

Parnas, J., Moeller, P., Kircher, T., Thalbitzer, J., Jannson, L., Handest, P., et al. (2005). EASE: Examination of Anomalous Self-Experience. Psychopathology 38, 236–258. doi: 10.1159/000088441

Patton, M. (1990). Qualitative Evaluation and Research Methods , 2nd Edn. Newbury Park, CA: Sage Publications.

Raballo, A., Sæbye, D., and Parnas, J. (2011). Looking at the schizophrenia spectrum through the prism of self-disorders: an empirical study. Schizophr. Bull. 37, 344–351. doi: 10.1093/schbul/sbp056

Salvatore, G., Lysaker, P. H., Popolo, R., Procacci, M., Carcione, A., Dimaggio, G., et al. (2012a). Vulnerable self, poor understanding of others’ minds, threat anticipation and cognitive biases as triggers for delusional experience in schizophrenia: a theoretical model. Clin. Psychol. Psychother. 19, 247–259. doi: 10.1002/cpp.746

Salvatore, G., Lysaker, P. H., Gumley, A., Popolo, R., Mari, J., Dimaggio, G., et al. (2012b). Out of illness experience: metacognition-oriented therapy for promoting self-awareness in individuals with psychosis. Am. J. Psychother. 66, 85–106.

Sass, L., and Parnas, J. (2003). Schizophrenia, consciousness, and the self. Schizophr. Bull. 29, 427–444. doi: 10.1093/oxfordjournals.schbul.a007017

Schutz, A., and Luckmann, T. (1973). The Structures of the Life-world , trans R. Zaner and T. Engelhardt. Evanston: Northwestern University Press.

Schwartz, H., and Jacobs, J. (1996). Sociología Cualitativa . México: Editorial Trillas.

Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Keränenm, J., and Lehtinen, K. (2006). Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: treatment principles, follow-up outcomes, and two case studies. Psychother. Res. 16, 214–228. doi: 10.1080/10503300500268490

Seikkula, J., and Olson, M. (2003). The open dialogue approach to acute psychosis: its poetics and micropolitics. Fam. Process 42, 403–418. doi: 10.1111/j.1545-5300.2003.00403.x

Sharim, D. (2005). La identidad de género en tiempos de cambio: Una aproximación desde los relatos de vida [Gender identity in times of changes: an approach from life stories]. Psykhe 14, 19–32.

Sharim, D. (2011). Relatos de historias de pareja en el chile actual: la intimidad como un monólogo colectivo [Life stories of couples in Chile today: intimacy as a collective monologue]. Psicol. Estud. 16, 347–358. doi: 10.1590/S1413-73722011000300002

Škodlar, B., Henriksen, M. G., Sass, L. A., Nelson, B., and Parnas, J. (2013). Cognitive-behavioral therapy for schizophrenia: a critical evaluation of its theoretical framework from a clinical-phenomenological perspective. Psychopathology 46, 249–265. doi: 10.1159/000342536

Stanghellini, G. (2004). Disembodied Spirits and Deanimated Bodies: The Psychopathology of Common Sense . Oxford: Oxford University Press. doi: 10.1093/med/9780198520894.001.0001

Stanghellini, G. (2009). Embodiment and schizophrenia. World Psychiatry 8, 56–59.

Stanghellini, G. (2011). Phenomenological psychopathology, profundity, and schizophrenia. Philos. Psychiatry Psychol. 18, 163–166. doi: 10.1353/ppp.2011.0022

Stanghellini, G., and Lysaker, P. H. (2007). The psychotherapy of schizophrenia through the lens of phenomenology: intersubjectivity and the search for the recovery of first- and second-person awareness. Am. J. Psychother. 61, 163–179.

Varela, F. (1990). Conocer: Las ciencias cognitivas: tendencias y perspectivas. Cartografía de las ideas actuales [To Know: Cognitive Sciences: Trends and Prospects. Cartography of Current Ideas]. Barcelona: Gedisa.

Varela, F., Thompson, E., and Rosch, E. (1991). The Embodied Mind: Cognitive Science and Human Experience . Cambridge: MIT Press. doi: 10.1207/s15327884mca0304_9

Keywords : schizophrenia, phenomenology, hermeneutic, intersubjectivity, life stories, clinical psychology

Citation: Irarrázaval L and Sharim D (2014) Intersubjectivity in schizophrenia: life story analysis of three cases. Front. Psychol . 5 :100. doi: 10.3389/fpsyg.2014.00100

Received: 03 December 2013; Accepted: 24 January 2014; Published online: 12 February 2014.

Reviewed by:

Copyright © 2014 Irarrázaval and Sharim. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Leonor Irarrázaval, Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Av. Manuel Rodríguez Sur 253, Oficina 206, Santiago CP 8370057, Santiago de Chile, Chile e-mail: [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia, learning objectives.

• Identify and describe the diagnostic criteria and major symptoms of schizophrenia
• Differentiate between the positive and negative symptoms of schizophrenia

Schizophrenia  is a complex and significant psychological disorder characterized by major disturbances in thought, perception, emotion, and behavior. About 1% of the population experiences schizophrenia in their lifetime (i.e., over three million people in the United States alone), and usually, the disorder is first diagnosed during early adulthood (early to mid-20s). Most people with schizophrenia experience significant difficulties in many day-to-day activities, such as holding a job, paying bills, caring for oneself (grooming and hygiene), and maintaining relationships with others. However, contrary to common assumptions, a recent review of studies on schizophrenia (Vita & Barlati, 2018 [1] ) found a wide range of outcomes for persons who have schizophrenia, ranging from persons with severe symptoms and repeated episodes of remission and subsequent hospitalization to persons who experience a single episode that meets criteria followed by complete remission (although they usually continue to participate in treatment). Vita and Barlati (2018) also found that possibly up to half of the individuals diagnosed with schizophrenia either recovered or demonstrated significant improvement over time. They recommended that clinicians and society focus on two outcomes of consideration for persons with schizophrenia: clinical remission (significant reduction of symptoms and severity) and social functioning (e.g., ability to work, to function as a family member or in relationships, enjoy recreation, and dwell in independent living) in thinking about recovery.

Unlike other conditions such as depression or anxiety that almost all people can relate to in some ways, it is more difficult for most people to see the symptoms of schizophrenia and other psychotic disorders as part of the normal continuum of human experiences. However, the types of psychotic symptoms that characterize disorders like schizophrenia are on a continuum with normal mental experiences. For example, work by Jim van Os in the Netherlands has shown that a surprisingly large percentage of the general population (10%+) experience psychotic-like symptoms, though many fewer have multiple experiences and most will not continue to experience these symptoms in the long run (Verdoux & van Os, 2002). Similarly, work in a general population of adolescents and young adults in Kenya has also shown that a relatively high percentage of individuals experience one or more psychotic-like experiences (~19%) at some point in their lives (Mamah et al., 2012; Ndetei et al., 2012), though again most will not go on to develop a full-blown psychotic disorder.

So, what is schizophrenia? It is important to realize that schizophrenia is not a condition involving a split personality; that is, schizophrenia is not the same as dissociative identity disorder (previously known as multiple personality disorder). These disorders are sometimes confused because the word schizophrenia first coined by the Swiss psychiatrist Eugen Bleuler in 1911, derives from Greek words that refer to a “splitting” (schizo) of the mind (phrene) (Green, 2001). In the case of schizophrenia, the “split” is usually interpreted as between cognition (thinking and communicating) and emotions (see the discussion of flat affect below). Schizophrenia is considered a psychotic disorder (while dissociative disorders are not), which impairs a person’s thoughts, perceptions, and behaviors to the point where that individual is not able to function normally in life. Individuals who suffer from psychotic disorders experience a major disconnection with the world around them and do not share in the normal perception of the external environment. In other words, terms like psychosis  or psychotic  do not have anything to do with violence, serial killers, or other common misunderstandings; psychosis refers specifically to the presence of hallucinations (sensory distortions), delusions (unusual beliefs), or disorganized thought processes and can also occur during severe instances with other disorders.

Schizophrenia was once classified into distinct subtypes, such as paranoid, catatonic, disorganized, residual, or undifferentiated, but that method has since been replaced by approaching schizophrenia as a spectrum of disorders with varying degrees of severity and displaying several aspects of the subtypes. Now, schizophrenia subtypes are not listed in the DSM-5, as the subtypes would often change or coexist, but clinicians still sometimes specify a dominant type of subtype, such as “schizophrenia with paranoia.” The spectrum of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional disorder, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, and psychosis associated with substance use or medical conditions. These are all disorders of psychosis, with schizophrenia and schizoaffective disorder (schizophrenia combined with a mood disorder) being the most severe and personality disorders being less severe.

Symptoms of Schizophrenia

The main symptoms of schizophrenia can be categorized as either positive symptoms or negative symptoms. Positive symptoms are symptoms of addition, meaning they add something atypical or unusual to what other individuals experience, do, or think. Examples include hallucinations, delusions, and disorganized thinking and behaviors. Negative symptoms are those that result in noticeable decreases or absences in common behaviors, emotions, or drives (APA, 2013; Green, 2001). Examples include flattened emotional expression, lack of motivation for self-care, or significant social withdrawal.

Positive Symptoms

A hallucination is a perceptual experience that occurs in the absence of external stimulation. Auditory hallucinations (hearing voices) occur in roughly two-thirds of patients with schizophrenia and are by far the most common form of hallucination (Andreasen, 1987). The auditory voices may be familiar or unfamiliar, they may have a conversation or argue, or the voices may provide a running commentary on the person’s behavior (Tsuang, Farone, & Green, 1999).   

Figure 1 . Tactile hallucinations, like that of imaginary spiders crawling on the skin, are another type of hallucination.

Less common are visual hallucinations (seeing things that are not there) and olfactory hallucinations (smelling odors that are not actually present). In interacting with persons with psychotic symptoms, it is helpful to remember that although you may not hear what they are hearing nor see what they are seeing or experiencing, they are having those sensory experiences. To them, these experiences seem as real as you seeing a car drive by on the street or hearing a neighbor’s dog barking. Telling them they are wrong or that those things are not happening does not improve your ability to relate to them or help them reconnect to the world around them. Instead, try to understand what they are experiencing and demonstrate empathy and understanding.

Delusions are beliefs that are contrary to reality and are firmly held even in the face of contradictory evidence. Many of us hold beliefs that some would consider odd, but a delusion is easily identified because it is absurd according to normal social and cultural standards. A person with schizophrenia may believe that his mother is plotting with the FBI to poison his coffee or that his neighbor is an enemy spy who wants to kill him. These kinds of delusions are known as paranoid delusions , which involve the false belief that other people or agencies are plotting against the person. People with schizophrenia also may hold grandiose delusions , which are beliefs that one holds special power, unique knowledge, or is extremely important. For example, the person who claims to be Jesus Christ, or who claims to have knowledge going back 5,000 years, or who claims to be a great philosopher is experiencing grandiose delusions. Other delusions include the belief that one’s thoughts are being removed from their head (thought withdrawal) or thoughts have been placed inside one’s head (thought insertion). Another type of delusion is a  somatic delusion , which is the belief that something highly abnormal and improbable is happening to one’s body (e.g., that one’s kidneys are being eaten by cockroaches).

Disorganized thinking refers to disjointed and incoherent thought processes—usually detected by what a person says. Individuals might ramble, exhibit loose associations (jump from topic to topic), or talk in a way that is so disorganized and incomprehensible that it seems as though the person is randomly combining words. Disorganized thinking is also exhibited by blatantly illogical remarks (e.g., “Fenway Park is in Boston. I live in Boston. I live at Fenway Park.”) and by tangentiality: responding to others’ statements or questions by remarks that are either barely related or unrelated to what was said or asked. For example, if a person diagnosed with schizophrenia is asked if she is interested in receiving special job training, she might state that she once rode on a train somewhere. To a person with schizophrenia, the tangential (slightly related) connection between job training and riding a train are sufficient enough to cause such a response.

As another example, at the beginning of an interview, a clinician remarked in passing that he forgot to bring his pen to take notes. The patient begins to talk about living on a farm as a child and taking care of pigs which was tangential to the focus of the conversation. However, there is a linguistic association between “pen” (writing tool) and an animal enclosure (pen) on a farm. In persons without thought disorder or disorganized thinking, the brain would light up with these language associations, but would quickly sort through them and prioritize those that match the context. For someone with schizophrenia, these filters and the ability to determine the appropriate context are usually impaired.

Disorganized or abnormal motor behavior refers to unusual behaviors and movements: becoming unusually active, exhibiting silly child-like behaviors (giggling and self-absorbed smiling), engaging in repeated and purposeless movements, or displaying odd facial expressions and gestures. In some cases, the person will exhibit catatonic behaviors that show decreased reactivity to the external environment, such as posturing, in which the person maintains a rigid and bizarre posture for long periods of time, or catatonic stupor, a complete lack of movement and verbal behavior. Another way catatonia is displayed is through  waxy  flexibility , which occurs when another person places an individual with schizophrenia in an unusual or uncomfortable position and they remain in that position, sometimes for hours.

Negative Symptoms

Unlike positive symptoms, negative symptoms are symptoms where ordinary and expected behaviors may be reduced or absent. A person who exhibits diminished emotional expression displays little emotion in his facial expressions, speech, or movements, even when such expressions are normal or expected (also known as flat affect where affect  is a noun meaning the display of emotion). It is important to recognize, however, that although the person may have difficulty expressing their emotions the way most people do, they still experience the full range of normal human emotions [2] . Avolition (lack of volition) is characterized by a lack of motivation to engage in self-initiated and meaningful activity, including the most basic of daily living tasks such as bathing and grooming. Alogia (lack of speech; from the Greek logos  meaning word or speech) refers to reduced speech output; in simple terms, patients do not speak or respond much in interactions with others. Another negative symptom is asociality, or social withdrawal and lack of interest in engaging in social interactions with others (this is differentiated from antisocial activity such as that of persons with antisocial personality disorder who are “against” or “anti” society). A final negative symptom, anhedonia, refers to an inability to experience pleasure. One who exhibits anhedonia expresses little interest in what most people consider to be pleasurable activities, such as hobbies, recreation, or sexual activity.

In their review of schizophrenia research, Vita and Barlati (2018) note that positive symptoms receive much attention, but negative and cognitive symptoms are often not treated effectively, leading persons to not achieve “functional” (or daily living) levels of remission. In addition to the use of some of the newer antipsychotics that may help with negative symptoms, psychosocial treatments are important in reducing negative symptoms and improving the person’s ability to function well in their life.

Diagnostic Criteria

The diagnostic criteria for schizophrenia are listed below:

A. Two (or more) of the following must each present for a significant portion of time during a one-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

• hallucinations
• disorganized speech (e.g., frequent derailment or incoherence)
• grossly disorganized or catatonic behavior
• negative symptoms (i.e., diminished emotional expression or avolition)

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Duration: continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs or unusual perceptual experiences). [3]

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effect of a substance (e.g., drug abuse or a medication) or other medical condition.

F. If there is a history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least one month (or less if successfully treated). [4]

Link to Learning

Watch this video and try to identify which classic symptoms of schizophrenia are shown . See if you can describe the positive and negative symptoms that this individual exhibits.

Watch this video for an overview of schizophrenia, including the causes and symptoms you’ve learned about thus far.

You can view the transcript for “Schizophrenia – causes, symptoms, diagnosis, treatment & pathology” here (opens in new window) .

Risk Factors for Developing Schizophrenia

Consistent with the biopsychosocial model, several factors contribute to the risk of developing schizophrenia:

• Genetics:  It is clear that there are important genetic contributions to the likelihood that someone will develop schizophrenia, with consistent evidence from family, twin, and adoption studies. (Sullivan, Kendler, & Neale, 2003). However, there is no “schizophrenia gene” and it is likely that the genetic risk for schizophrenia reflects the summation of many different genes that each contribute something to the likelihood of developing psychosis (Gottesman & Shields, 1967; Owen, Craddock, & O’Donovan, 2010). Further, schizophrenia is a very heterogeneous disorder, which means that two different people with schizophrenia may each have very different symptoms (e.g., one has hallucinations and delusions, the other has disorganized speech and negative symptoms). This makes it even more challenging to identify specific genes associated with risk for psychosis. Importantly, many studies also now suggest that at least some of the genes potentially associated with schizophrenia are also associated with other mental health conditions, including bipolar disorder, depression, and autism (Gejman, Sanders, & Kendler, 2011; Y. Kim, Zerwas, Trace, & Sullivan, 2011; Owen et al., 2010; Rutter, Kim-Cohen, & Maughan, 2006).
• Environment: There are also a number of environmental factors that are associated with an increased risk of developing schizophrenia. For example, problems during pregnancy such as increased stress, infection, malnutrition, and/or diabetes have been associated with increased risk of schizophrenia. In addition, complications that occur at the time of birth and which cause hypoxia (lack of oxygen) are also associated with an increased risk for developing schizophrenia (M. Cannon, Jones, & Murray, 2002; Miller et al., 2011). Children born to older fathers are also at a somewhat increased risk of developing schizophrenia. Further, using cannabis increases risk for developing psychosis, especially if you have other risk factors (Casadio, Fernandes, Murray, & Di Forti, 2011; Luzi, Morrison, Powell, di Forti, & Murray, 2008). The likelihood of developing schizophrenia is also higher for kids who grow up in urban settings (March et al., 2008) and for some marginalized ethnic groups (Bourque, van der Ven, & Malla, 2011). Both of these factors may reflect higher social and environmental stress in these settings. Unfortunately, none of these risk factors is specific enough to be particularly useful in a clinical setting, and most people with these risk factors do not develop schizophrenia. However, together they are beginning to give us clues as the neurodevelopmental factors that may lead someone to be at an increased risk for developing this disease.
• Brain structure and function:  Scientists think that differences in brain structure, function, and interactions among neurotransmitters may contribute to the development of schizophrenia. For example, differences in the volumes of specific components of the brain, in the way regions of the brain are connected and work together, and in neurotransmitters, such as dopamine, are found in people with schizophrenia. Differences in brain connections and brain circuits seen in people with schizophrenia may begin developing before birth. Changes to the brain that occur during puberty may trigger psychotic episodes in people who are vulnerable due to genetics, environmental exposures, or the types of brain differences mentioned above.

An important research area on risk for psychosis has been work with individuals who may be at clinical high risk. These are individuals who are showing attenuated (milder) symptoms of psychosis that have developed recently and who are experiencing some distress or disability associated with these symptoms. When people with these types of symptoms are followed over time, about 35% of them develop a psychotic disorder (T. D. Cannon et al., 2008), most frequently schizophrenia (Fusar-Poli, McGuire, & Borgwardt, 2012). In order to identify these individuals, a new category of diagnosis, called “Attenuated Psychotic Syndrome,” was added to Section III (the section for disorders in need of further study) of the DSM-5 (APA, 2013). However, adding this diagnostic category to the DSM-5 created a good deal of controversy (Batstra & Frances, 2012; Fusar-Poli & Yung, 2012). Many scientists and clinicians have been worried that including risk states in the DSM-5 would create mental disorders where none exist, that these individuals are often already seeking treatment for other problems, and that it is not clear that we have good treatments to stop these individuals from developing to psychosis. However, the counterarguments have been that there is evidence that individuals with high-risk symptoms develop psychosis at a much higher rate than individuals with other types of psychiatric symptoms, and that the inclusion of Attenuated Psychotic Syndrome in Section III will spur important research that might have clinical benefits. Further, there is some evidence that non-invasive treatments such as omega-3 fatty acids and intensive family intervention may help reduce the development of full-blown psychosis (Preti & Cella, 2010) in people who have high-risk symptoms.

Treatments and Therapies

The causes of schizophrenia are complex and are not fully understood, so current treatments focus on managing symptoms and solving problems related to day-to-day functioning.

Antipsychotic Medications

Antipsychotic medications can help reduce the intensity and frequency of psychotic symptoms. The medications are usually taken daily in pill or liquid forms. Some antipsychotic medications are given as injections once or twice a month, which some individuals find to be more convenient than daily oral doses. Patients whose symptoms do not improve with standard antipsychotic medication typically receive clozapine. People treated with clozapine must undergo routine blood testing to detect a potentially dangerous side effect that occurs in 1%-2% of patients.

Many people taking antipsychotic medications have side effects such as weight gain, dry mouth, restlessness, and drowsiness when they start taking these medications. Some of these side effects subside over time, but others may persist, which may cause some people to consider stopping their antipsychotic medication. Suddenly stopping medication can be dangerous and it can make schizophrenia symptoms worse. People should not stop taking antipsychotic medication without talking to a health care provider first.

Psychosocial Treatments

Cognitive behavioral therapy (CBT), behavioral skills training, supported employment, and cognitive remediation interventions may help address the negative and cognitive symptoms of schizophrenia. A combination of these therapies and antipsychotic medication is common. Psychosocial treatments can be helpful for teaching and improving coping skills to address the everyday challenges of schizophrenia. These treatments may help people pursue their life goals, such as attending school, working, or forming relationships. Individuals who participate in regular psychosocial treatment are less likely to relapse or be hospitalized.

Family Education and Support

Educational programs for family members, significant others, and friends offer instruction about schizophrenia symptoms and treatments, and strategies for assisting the person with the illness. Increasing key supporters’ understanding of psychotic symptoms, treatment options, and the course of recovery can lessen their distress, bolster coping and empowerment, and strengthen their capacity to offer effective assistance. Family-based services may be provided on an individual basis or through multi-family workshops and support groups.

Coordinated Specialty Care

Coordinated specialty care (CSC) is a general term used to describe recovery-oriented treatment programs for people with first-episode psychosis, an early stage of schizophrenia. A team of health professionals and specialists deliver coordinated specialty care (CSC), which includes psychotherapy, medication management, case management, employment and education support, and family education and support. The person with early psychosis and the team work together to make treatment decisions, involving family members as much as possible. Compared to typical care for early psychosis, coordinated specialty care (CSC) is more effective at reducing symptoms, improving quality of life, and increasing involvement in work or school.

Assertive Community Treatment

Assertive community treatment (ACT) is designed especially for individuals with schizophrenia who are at risk for repeated hospitalizations or homelessness. The key elements of assertive community treatment (ACT) include a multidisciplinary team, a clinician who prescribes medication, a shared caseload among team members, direct service provision by team members, a high frequency of patient contact, low patient-to-staff ratios, and outreach to patients in the community. Assertive community treatment (ACT) reduces hospitalizations and homelessness among individuals with schizophrenia.

Key Takeaways: Schizophrenia

Forensic psychology.

In August 2013, 17-year-old Cody Metzker-Madsen attacked five-year-old Dominic Elkins on his foster parents’ property. Believing that he was fighting goblins and that Dominic was the goblin commander, Metzker-Madsen beat Dominic with a brick and then held him face down in a creek. Dr. Alan Goldstein, a clinical and forensic psychologist, testified that Metzker-Madsen believed that the goblins he saw were real and was not aware that it was Dominic at the time. He was found not guilty by reason of insanity and was not held legally responsible for Dominic’s death (Nelson, 2014). Cody was also found to be a danger to himself or others. He will be held in a psychiatric facility until he is judged to be no longer dangerous. This does not mean that he “got away with” anything. In fact, according to the American Psychiatric Association, individuals who are found not guilty by reason of insanity are often confined to psychiatric hospitals for as long or longer than they would have spent in prison for a conviction.

Hollywood depictions and news reports to the contrary, most people with schizophrenia are not violent. Only 3%-5% of violent acts are committed by individuals diagnosed with severe mental illness, whereas individuals with severe mental illnesses are more than 10 times as likely to be victims of crime (MentalHealth.gov, 2017). The most common conditions linked to violence are psychopathic personality (severe antisocial personality disorder), bipolar disorder, and persons who are abusing drugs (especially alcohol). The psychologists who work with individuals such as Metzker-Madsen are part of the subdiscipline of forensic psychology. Forensic psychologists are involved in psychological assessment and treatment of individuals involved with the legal system. They use their knowledge of human behavior and mental illness to assist the judicial and legal system in making decisions in cases involving such issues as personal injury suits, workers’ compensation, competency to stand trial, and pleas of not guilty by reason of insanity.

catatonic behavior:  decreased reactivity to the environment; includes posturing and catatonic stupor

delusion:  belief that is contrary to reality and is firmly held, despite contradictory evidence

disorganized/abnormal motor behavior:  highly unusual behaviors and movements (such as child-like behaviors), repeated and purposeless movements, and displaying odd facial expressions and gestures

disorganized thinking:  disjointed and incoherent thought processes, usually detected by what a person says

dopamine hypothesis:  theory of schizophrenia that proposes that an overabundance of dopamine or dopamine receptors is responsible for the onset and maintenance of schizophrenia

grandiose delusion:  characterized by beliefs that one holds special power, unique knowledge, or is extremely important

hallucination: a perceptual experience that occurs in the absence of external stimulation, such as the auditory hallucinations (hearing voices) common to schizophrenia

negative symptom: characterized by decreases and absences in certain normal behaviors, emotions, or drives, such as an expressionless face, lack of motivation to engage in activities, reduced speech, lack of social engagement, and inability to experience pleasure

paranoid delusion:  characterized by beliefs that others are out to harm them

prodromal symptom:  in schizophrenia, one of the early minor symptoms of psychosis

schizophrenia: a severe disorder characterized by major disturbances in thought, perception, emotion, and behavior with symptoms that include hallucinations, delusions, disorganized thinking and behavior, and negative symptoms

somatic delusion:  belief that something highly unusual is happening to one’s body or internal organs

• Vita, A. & Barlati, S. (2018). Recovery from Schizophrenia: Is it possible? Current Opinion Psychiatry , 31(3), 246-255. DOI: 10.1097/YCO.0000000000000407 ↵
• Publishing, Harvard Health. “The Negative Symptoms of Schizophrenia.” Harvard Health . Accessed December 31, 2020. https://www.health.harvard.edu/mental-health/the-negative-symptoms-of-schizophrenia . ↵
• Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.22, DSM-IV to DSM-5 Schizophrenia Comparison . Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22 ↵
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Publisher. ↵
• Modification, adaptation, and original content. Authored by : Anton Tolman for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia. Authored by : OpenStax College. Located at : http://cnx.org/contents/[email protected]:gGD_wNTe@5/Schizophrenia . License : CC BY: Attribution . License Terms : Download for free at http://cnx.org/content/col11629/latest/.
• Information on positive symptoms of schizophrenia. Provided by : Boundless. Located at : https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/psychological-disorders-18/schizophrenia-spectrum-and-other-psychotic-disorders-94/introduction-to-schizophrenia-and-psychosis-360-12895/ . Project : Boundless Psychology. License : CC BY-SA: Attribution-ShareAlike
• Tactile hallucination image. Authored by : Angela Mariam Thomas. Located at : https://commons.wikimedia.org/wiki/File:Tactile_hallucination.jpg . License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia lobes picture. Authored by : BruceBlaus. Located at : https://commons.wikimedia.org/wiki/File:Schizophrenia_(Brain).png . License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Schizophrenia . License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia Spectrum Disorders . Authored by : Deanna M. Barch . Provided by : Washington University in St. Louis. Located at : https://nobaproject.com/modules/schizophrenia-spectrum-disorders . Project : The Noba Project. License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
• Schizophrenia causes, symptoms, diagnosis, treatment & pathology. Provided by : Osmosis. Located at : https://www.youtube.com/watch?v=PURvJV2SMso . License : Other . License Terms : Standard YouTube License
• Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Provided by : Substance Abuse and Mental Health Services Administration. Located at : https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22/ . Project : SAMHSA. License : Public Domain: No Known Copyright
• Schizophrenia. Provided by : NIMH. Located at : https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml . License : Public Domain: No Known Copyright

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Article Contents

Introduction, external influences, 1997–2003, conclusions, conflict of interest.

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National Institute of Mental Health Support for Cognitive Treatment Development in Schizophrenia: A Narrative Review

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Robert K Heinssen, Sarah E Morris, Joel T Sherrill, National Institute of Mental Health Support for Cognitive Treatment Development in Schizophrenia: A Narrative Review, Schizophrenia Bulletin , Volume 50, Issue 5, September 2024, Pages 972–983, https://doi.org/10.1093/schbul/sbae109

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For several decades the National Institute of Mental Health (NIMH) has supported basic and translational research into cognitive impairment in schizophrenia. This article describes the Institute’s ongoing commitment to cognitive assessment and intervention research, as reflected by three signature initiatives—Measurement and Treatment Research to Improve Cognition in Schizophrenia; Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia; and Research Domain Criteria—and related funding announcements that span basic experimental studies, efficacy and comparative effectiveness trials, and implementation research designed to promote cognitive healthcare in real-world treatment settings. We discuss how trends in science and public health policy since the early 2000s have influenced NIMH treatment development activities, resulting in greater attention to (1) inclusive teams that reflect end-user perspectives on the utility of proposed studies; (2) measurement of discrete neurocognitive processes to inform targeted interventions; (3) clinical trials that produce useful information about putative illness mechanisms, promising treatment targets, and downstream clinical effects; and (4) “productive urgency” in pursuing feasible and effective cognitive interventions for psychosis. Programs employing these principles have catalyzed cognitive measurement, drug development, and behavioral intervention approaches that aim to improve neurocognition and community functioning among persons with schizophrenia. NIMH will maintain support for innovative and impactful investigator-initiated research that advances patient-centered, clinically effective, and continuously improving cognitive health care for persons with psychotic disorders.

In 1992, the Schizophrenia Bulletin published several prescient articles and commentaries on the theme of cognitive therapy for schizophrenia. 1–7 These papers signaled fresh interest in interventions for improving attention, memory, learning, and problem-solving among persons with schizophrenia, and considered a variety of biobehavioral approaches to promote greater clinical, social, and vocational recovery. The authors’ perspectives on key questions about cognitive interventions (eg, cognitive targets, mechanisms of treatment effects, and implementation barriers); clinical research methods (eg, ecologically valid measures, trial designs, and mediation analyses); and alliances to promote uptake of effective practices (eg, partnerships between service users, family members, clinicians, and scientists) foreshadowed later efforts by the National Institute of Mental Health (NIMH) to promote cognitive treatment development in psychosis.

The present article summarizes NIMH initiatives since the early 2000s that aimed to facilitate cognitive intervention research for schizophrenia and related disorders. We first describe external developments between 1997 and 2003 that motivated NIMH to explore new tactics for stimulating treatment development research. We then examine specific NIMH initiatives between 2002 and 2012 that catalyzed cognitive measurement, drug development, and rehabilitation research aimed at improving neurocognition and community functioning in schizophrenia. Next, we consider recent science and policy developments intended to speed treatment development research along the discovery-translation-implementation pathway. We conclude by summarizing lessons that may benefit future efforts to advance patient-centered, clinically effective, and continuously improving cognitive health care for persons with psychotic disorders.

NIMH is the lead government agency in the United States for research on mental disorders. In setting its scientific priorities, the Institute considers input from diverse external sources, including other federal agencies, the extramural research community, advocacy and professional organizations, clinical providers and health system administrators, and persons who use mental health services. The period between 1997 and 2003 was a fertile time for interaction, with synergistic initiatives by the US Surgeon General, a Presidential Commission, and the Director of the National Institutes of Health (NIH) that convened diverse constituents to consider mental health and clinical research ecosystems and to recommend strategies for improving links between science and services.

The Surgeon General’s Report on Mental Health, 8 initiated in 1997, was an ambitious effort to summarize scientific evidence underlying the epidemiology, diagnosis, and treatment of mental disorders, and to describe gaps between what is known through research and application of advances in real-world settings. Based on an extensive review of the literature, the report conveyed optimism about the research supporting the efficacy and range of treatments available for many disorders. While the Surgeon General recommended strongly that people seek help for mental disorders, 9 the report highlighted important areas of scientific uncertainty. The Surgeon General called for continued investment in mental health research, emphasizing integrative neuroscience and molecular genetics studies to identify novel targets for pharmacologic and psychosocial interventions as well as new approaches to health services implementation research.

The President’s New Freedom Commission on Mental Health (2002–2003) extended the Surgeon General’s analysis to include a comprehensive study of the US mental health service delivery system across public and private sectors. 10 The Commission recognized enormous progress in the scientific study of interventions for mental disorders but noted an absence of cures and spotty implementation of evidence-based services in real-world settings. The Commission’s final report advocated a major, long-term commitment to basic research to promote recovery and resilience, and ultimately to cure and prevent mental illness. It also emphasized the need for applied research to study the dissemination, implementation, effectiveness, and sustainment of evidence-based interventions in communities, and to speed testing of emerging innovations in field settings. 11

The NIH Roadmap initiative, launched by the NIH Director in 2002–2003, reexamined the NIH research portfolio to identify scientific gaps and to consider novel methods, technologies, and large-scale projects to transform the process of medical research. 12 The Roadmap engaged hundreds of NIH staff, extramural scientists, and the lay public in a deliberative process of assessing scientific challenges, enumerating roadblocks to progress, and proposing bold ideas to increase the efficiency and impact of biomedical research. Three major themes—ie, new pathways to discovery, research teams of the future, and reengineering the clinical research enterprise—organized initiatives to promote state-of-the-art technologies, interdisciplinary team science, and clinical research via academic-community partnerships. Collectively, these programs aimed to speed the movement of research from the laboratory to the patient’s bedside within a decade. 13

Impact of External Initiatives on NIMH Treatment Development Activities

NIMH leaders and scientist administrators engaged actively in committees, work groups, and public meetings that supported the Surgeon General’s Report, the President’s New Freedom Commission, and the NIH Roadmap process. NIMH staff contributed to planning, convening, synthesizing, and reporting activities, learned new approaches from government and private sector partners, and adopted several best practices in subsequent cognitive treatment development efforts:

Include Key Partners.

All 3 external projects recognized the need for broad input and new partnerships to understand and address complex medical problems. 8 , 10 , 12 In addition to representatives from academia and government, nontraditional experts were included, such as persons with lived experience, professionals with practical experience in organizing, delivering, and financing mental health services, and representatives of private foundations and patient advocacy organizations. The Surgeon General’s report 8 and the NIH Roadmap 12 advocated stronger partnerships with biotechnology and pharmaceutical industries and greater collaboration between federal agencies with shared responsibilities for developing, regulating, and delivering evidence-based treatments.

Promote Transparency.

The New Freedom Commission utilized several tactics to increase transparency, including open meetings, regular opportunities for public input, and timely reports from subcommittees and the overall Commission. 11 For example, monthly working meetings included open deliberation and dedicated time for public testimony from advocacy groups, professional organizations, and members of the public. In addition, an interactive public website encouraged participation outside in-person meetings; over 2300 individuals submitted comments, concerns, and ideas for consideration. Finally, detailed reports from 15 subcommittees were made available, along with an interim progress report 14 that generated spirited commentary that influenced the final phase of the Commission’s work.

Encourage “Productive Urgency”.

The cadence, operations, and deliverables of the President’s New Freedom Commission and the NIH Roadmap set new standards for rapid policy analysis and strategic planning. Aggressive one-year timelines were established to direct effort to urgent problems in mental health delivery systems 11 as well as respond to heightened public expectations for NIH-supported research. 12 Subcommittees and working groups, comprised of government and private sector experts with relevant expertise, tackled key issues in parallel, with overall coordination of efforts by Commissioners and NIH leaders, respectively. This formula was successful in generating understandable goals, concrete recommendations, and performance benchmarks for assessing the impact of new initiatives. 13 , 15 The urgency, efficiency, and productivity that characterized these initiatives influenced NIMH’s ensuing efforts to spur cognitive treatment development research in schizophrenia.

NIMH Cognitive Treatment Development Initiatives, 2002–2012

The Surgeon General’s report identified cognitive dysfunction as a key feature of schizophrenia and noted a paucity of evidence-based treatments for cognitive symptoms. 8 Hyman and Fenton 16 echoed these observations and suggested cognitive impairment as a “test case” for new approaches to schizophrenia therapeutics. Specifically, they proposed a framework for drug and psychosocial intervention development that would (1) dissect schizophrenia into component symptom complexes such as cognitive deficits; (2) develop measures to define new clinical targets as endpoints in human clinical trials; (3) direct interventions at the narrower clinical targets; (4) employ novel experimental designs to evaluate efficacy and clinical significance; and (5) draw on cognitive neuroscience and neuroimaging research to clarify neural mechanisms involved in cognition and to develop objective biomarkers for cognitive deficits. Hyman’s and Fenton’s commentary signaled a new approach to assessment and treatment development in schizophrenia that influenced NIMH initiatives over a 10-year period.

Measurement and Treatment Research to Improve Cognition in Schizophrenia

In 2002, NIMH announced the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative, a multiyear effort to identify and remedy barriers to drug development and testing for cognition in schizophrenia. 17 Following a competitive selection process, a contract was awarded to UCLA (Stephen Marder and Michael Green, co-principal investigators) to engage the pharmaceutical industry, the academic community, and government agencies, including the US Food and Drug Administration (FDA), in a consensus-oriented process to identify cognitive targets for intervention; select reliable and valid neuropsychological measures to assess cognition as a dependent variable in treatment trials; propose experimental designs to establish the efficacy of agents to enhance cognition in schizophrenia; and identify potential molecular targets for new therapeutic agents. The contract mechanism allowed a high level of collaboration between NIMH staff and the MATRICS team to pursue these goals. Importantly, coordinated efforts between NIMH leaders and MATRICS investigators spurred conversations and new alliances among key actors in the drug development space, including psychopharmacologists, 18 the FDA, 19 and persons with lived experience. 20

The MATRICS team convened 6 interlocking conferences over a 2-year period, with timely reports that conveyed the focus, process, and outcomes of each meeting. 18 , 19 , 21–23 Concrete achievements that sprang from these activities include the following:

The MATRICS Consensus Cognitive Battery (MCCB) was developed using quantitative analyses and expert consensus methods and was field tested in a 5-site psychometric and validation study. 24 To facilitate interpretation of results using a common scaling across tests, the MCCB was co-normed using data obtained from a representative US community sample. 25

To meet the FDA’s requirement for functionally meaningful co-primary measures in cognitive intervention trials, 4 potential measures were evaluated alongside the MCCB for reliability, utility, practicality, and relationship to cognitive performance. 26

In 2005, the NIMH National Advisory Mental Health Council (NAMHC) and the FDA recommended the MCCB as the standard cognitive performance battery in clinical trials of potential cognition-enhancing interventions. 24

The MCCB has been translated into over 39 languages 27 and is now widely used to assess neurocognition in schizophrenia clinical studies. Since 2004, the MCCB has been cited in ~500 scientific publications and included as an outcome measure in ~170 clinical studies registered in ClinicalTrials.gov.

The FDA-NIMH-MATRICS workshop on clinical trial design for neurocognitive drugs for schizophrenia 19 developed guidelines for subject selection, co-primary outcome measures, and statistical approaches for clinical trials involving cognitive-enhancing drugs, which were later updated based on practical experience. 28

The MATRICS initiative was successful in catalyzing studies of procognitive drugs in schizophrenia, but new medications have proved elusive. 29 Green et al 30 , 31 reviewed cognitive intervention studies launched since MATRICS and identified several methodological factors that may hinder efforts to identify efficacious drugs. Those authors also noted broader scientific issues that impede drug discovery, including our incomplete understanding of the pathophysiology of cognitive impairment and error variance attributed to clinical and functional heterogeneity across schizophrenia spectrum disorders. 31 Two ensuing NIMH initiatives considered these important scientific considerations in turn.

Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia

The final meeting of the MATRICS program focused on new preclinical and clinical research approaches for assessing and improving cognition in schizophrenia. 23 A strong case was made for applying methods derived from experimental cognitive psychology and cognitive neuroscience to examine the integrity of specific cognitive systems implicated in schizophrenia and to directly measure the effects of drugs on cognition-related brain activity. 32 Responding to these recommendations, Cameron Carter and Deanna Barch proposed the Cognitive Neuroscience Treatment Research to Improve Cognition in Schizophrenia (CNTRICS) conference series 33 and were awarded consecutive research conference grants to articulate a neuroscience research agenda that would extend the work started by MATRICS.

Between 2007 and 2011 the CNTRICS steering committee organized 7 meetings that brought together experts from the basic and clinical sciences, researchers from academia and industry who use animal models, and individuals with experience in clinical trials, psychometrics, and cognitive rehabilitation in schizophrenia to explore potential benefits of using constructs, tasks, and tools from cognitive neuroscience to better understand and treat cognitive impairments in psychosis. 34 , 35 Interactive surveys, quantitative summaries, and consensus-building methods were employed across meetings to identify cognitive systems and component processes that could serve as targets for measurement and treatment development; to address psychometric issues relevant for adapting experimental cognitive tasks for use in clinical trials; to select candidate experimental tasks that measure key cognitive constructs implicated in schizophrenia; to consider promising imaging biomarkers for use in cognitive treatment development research; and to facilitate development of translational animal model paradigms for exploring cognitive and affective constructs. In addition, the steering committee introduced an innovative buddy system that paired prominent cognitive neuroscientists with well-known clinical researchers with schizophrenia expertise to maintain a patient-centered focus in CNTRICS deliberations.

Midway through the CNTRICS process, NIMH published a funding opportunity announcement to solicit proposals for research aimed at adapting and optimizing experimental cognitive measures for use in treatment trials of schizophrenia (RFA-MH-08-090). Among the studies selected for funding, a 5-site collaborative project came together as the “Cognitive Neuroscience Test Reliability and Clinical Applications for Schizophrenia (CNTRaCS) Consortium.” CNTRaCS investigators proposed a transdisciplinary approach for (1) cognitive task selection; (2) adaptation of validated paradigms for clinical research; (3) psychometric evaluation of new measures; and (4) maintaining construct validity of modified tasks. Since 2008, CNTRaCS has pursued translational measurement development for cognitive constructs identified in CNTRICS (ie, goal maintenance; relational encoding and retrieval in episodic memory; gain control; visual integration; working memory; and reinforcement learning) and produced a variety of cognitive neuroscience-based approaches for clinical research studies, including imaging biomarkers. 36

Together, CNTRICS and CNTRaCS achieved the respective goals of establishing a neuroscience research agenda for cognitive treatment development in schizophrenia and adapting validated laboratory tasks of cognitive operations for use in clinical trials. Over 60 scientific publications describe the scientific discourse that occurred during CNTRICS meetings as well as methods, results, and products from the CNTRaCS research program. Cognitive task paradigms developed by CNTRaCS are freely available to the field and industry ( https://cntracs.ucdavis.edu/ ), including tasks and associated computational models appropriate for clinical trials as well as research conducted within the NIMH Research Domain Criteria framework. 37

Research Domain Criteria

NIMH launched the Research Domain Criteria (RDoC) initiative in 2009 to provide a framework for research that explores novel ways of characterizing and classifying mental disorders. The rationale for this new approach was that the ecosystem of research funding, peer review of grant applications and scientific publications, and regulatory activities was over-focused on studies of highly heterogenous mental disorders as defined in longstanding diagnostic systems. The overarching RDoC hypothesis is that mental disorders may be better understood if the tools and concepts of modern behavioral neuroscience are used to dissect heterogeneity within psychopathology and assess functional domains that could be targeted for treatment in a more precise and individualized way.

The RDoC framework was informed by a series of workshops in 2010–2012—and an additional workshop in 2018—which closely modeled the MATRICS and CNTRICS meetings. These workshops engaged over 200 leading scientists and NIMH staff in discussions of the RDoC approach and the development of a set of exemplar constructs and associated elements that provide a shared vocabulary for this scientific endeavor. The first workshops focused on Working Memory 38 and Cognitive Systems, 39 built directly on the knowledge base created by CNTRICS. These workshops adopted CNTRICS’ focus on integrating knowledge from cognitive and affective neuroscience into novel approaches for translational research, a focus that persisted throughout the workshop series. In contrast to MATRICS, NIMH did not develop a formal battery of specified tasks for assessing RDoC domains but instead encouraged investigators to flexibly select measures that are fit for purpose. Participants in this series of formative RDoC workshops populated the RDoC matrix with exemplars of tasks and tools, including several CNTRaCS tasks, which could be used to assess constructs related to RDoC cognitive systems domains.

NIMH has published 19 RDoC-focused funding opportunity announcements since 2011. More than one hundred research projects adopting RDoC principles have been funded, along with many others awarded under other NIH funding mechanisms. Among these grants are several projects that examine cognitive constructs such as language 40 and perception 41 in psychosis which may lead to novel treatment targets or outcome measures. Most recently, the NIMH RDoC Unit launched the Individually Measured Phenotypes to Advance Computational Translation in Mental Health (IMPACT-MH) initiative (RFA-MH-23-105). Projects supported through IMPACT-MH will combine data from cognitive tasks and device-based behavioral measures with electronic health records information to derive novel clinical signatures that can be assessed at the individual level to improve clinical decision-making and predict clinical outcomes.

NIMH Workshop on Cognitive Training in Mental Disorders

During the period when MATRICS/CNTRICS/RDoC initiatives were being developed (2002–2012), NIMH observed growing interest among extramural scientists for nonpharmacologic cognitive training and rehabilitation interventions, with successful research proposals involving patients from diverse diagnostic categories and across developmental stages. In addition, an annual conference sponsored by the Columbia University Irving Medical Center brought together researchers, clinicians, and healthcare administrators to share experiences and perspectives on cognitive remediation in psychiatry and to focus attention on emerging translational, clinical, and implementation research questions. 42 To learn from the expanding cadre of cognitive interventionists, NIMH convened a state-of-the-science meeting in 2012 to review evidence for the efficacy of cognitive training approaches across psychiatric illnesses, including schizophrenia, and to identify knowledge gaps, new research opportunities, and examples of research-to-practice implementation. 43 The workshop included investigators from academia, military research agencies, and the NIMH Intramural Research Program; representatives of digital health companies, state mental health authorities, and community behavioral health systems; and health scientist administrators from several NIH institutes. Approximately one-quarter of participants were veterans of the MATRICS, CNTRICS, and/or RDoC initiatives, which provided valuable scientific continuity.

For purposes of the workshop, cognitive training (CT) was differentiated from other behavioral and psychosocial interventions that address problematic cognitions as part of a broader therapeutic approach, such as cognitive behavioral therapy or psychoeducation. CT was defined more precisely as “an intervention that uses specifically designed and behaviorally constrained cognitive or socio-affective learning events, delivered in a scalable and reproducible manner, to potentially improve neural system operations.” 44 The workshop addressed the current state of knowledge regarding (1) the neuroscience basis for cognitive, affective, and neural processes targeted by CT; (2) evidence of CT efficacy for improving neurocognitive processes and functioning; (3) hypothesized mechanisms of CT treatment effects; (4) approaches that combine CT with other treatment modalities; (5) predictors of treatment response; and (6) what has been learned from efforts to implement CT in clinical practice.

Keshavan et al. summarized the workshop’s presentations, discussions, and recommendations for future research. 44 The authors concluded that “overall, the evidence thus far supports the neurobiological rationale and the efficacy of cognitive training in schizophrenia, but replication of positive results is needed; many questions remain with regard to therapeutic mechanisms, key therapeutic ingredients, and approaches to dissemination in routine clinical settings.” Several considerations for the design of CT trials echo lessons from the MATRICS initiative 29 , 31 ; ie, the importance of detailed participant characterization, including baseline cognitive functioning; choosing appropriate inclusion/exclusion criteria; measuring specific (vs global) cognitive operations as treatment targets and outcomes; and accounting for mediators, moderators, and mechanisms of treatment effects. Other recommendations emphasized up-front attention to end-user perspectives, clinical workflows, and provider requirements in intended delivery settings, and including outcome measures that are meaningful to healthcare policymakers. Together, these recommendations encouraged best practices for advancing interventions that target core neurocognitive operations necessary for clinical, social, and educational/vocational recovery, and for positioning new interventions for rapid adoption in clinical practice.

Impact of NIMH Cognitive Treatment Development Initiatives

The MATRICS, CNTRICS, and RDoC initiatives were largely successful in replicating the inclusiveness, transparency, and productive urgency that characterized the Surgeon General’s Report, the President’s New Freedom Commission, and the NIH Roadmap. Each NIMH initiative brought together diverse constituents to work through complex scientific questions, and through progressive encounters, to establish a common framework and vocabulary for analyzing problems and imagining potential solutions. Frederick Frese, a respected mental health “prosumer,” contributed significantly to the MATRICS Neurocognition Committee 24 as a champion of recovery principles 20 and stigma-free, nonpejorative language about cognition in schizophrenia. 45 The unique value of this lived experience perspective prompted NIMH to encourage similar engagement with service users in subsequent research initiatives, as described below.

The cadence of MATRICS, CNTRICS, and RDoC meetings, the continuity of participants across initiatives, and new collaborations among diverse partners fostered interdisciplinary teams that later tackled translational research goals. The co-creation of new research concepts, methods, and products by such teams were essential factors in generating broad enthusiasm for cognitive treatment activities in schizophrenia. Indeed, ~750 scientific papers, review articles, and book chapters have been published since 2002 that are based on MATRICS, CNTRICS, or RDoC contributions to the assessment and treatment of cognitive symptoms in schizophrenia.

Science and Policy Trends, 2013–2023

Between 2002 and 2012, NIMH-supported initiatives created momentum for neuroscience-based studies in schizophrenia that focused on illness mechanisms and targeted interventions based on mechanistic insights. A small number of competitive funding opportunities incentivized the development of new assessment tools and clinical trial methods, but most funded studies used traditional grant mechanisms to support investigator-initiated projects. In the subsequent decade, new science and NIMH policy developments influenced trends in cognitive intervention research, including new expectations for clinical trials and implementation of science studies.

Experimental Therapeutics Paradigm for Clinical Trials

By 2010, major pharmaceutical companies had exited the field of psychiatry, citing poor understanding of disease mechanisms, a lack of biomarkers and valid animal models, and high failure rates in clinical trials. 46 , 47 The dramatic change in industry priorities prompted NIMH to seek guidance on how to better align basic, clinical, and intervention research to support pharmacologic treatment development. The NAMHC workgroup report, “From Discovery to Cure” 48 recommended several changes to the NIMH clinical trials portfolio to accelerate translational efforts, including a shift towards an experimental therapeutics model, “in which interventions are used as probes of disease mechanisms as well as tests of efficacy.” 49

Since 2014, NIMH has solicited clinical trial applications through a dedicated set of funding announcements that cover the intervention development pipeline, including first-in-human and early-stage clinical trials of novel investigational drugs or devices; pilot research to develop and test innovative psychosocial interventions; confirmatory efficacy trials; and comparative effectiveness trials. In each case, an experimental therapeutics approach is required, where projects (1) identify a mechanistic target or mediator for the intervention being tested; (2) measure the intervention’s impact on the hypothesized target; and (3) examine whether changes in targets are associated with changes in distal clinical or services outcomes. Trials designed in this manner are informative for basic, translational, and intervention research in that studies produce useful information about putative illness mechanisms, promising treatment targets, and downstream clinical effects.

Implementation and Sustainment of Evidence-Based Interventions

Reports from the Surgeon General, 8 the President’s New Freedom Commission, 10 the Institute of Medicine, 50 and a NAMHC workgroup on mental health services research 51 all noted long delays between the reporting of scientific findings and the translation of new knowledge into clinical practice. To address this “implementation gap,” NIMH began promoting deployment-focused approaches to intervention development, testing, and dissemination, 52 starting with the Recovery After an Initial Schizophrenia Episode (RAISE) initiative. 53 Subsequent deployment-focused studies have considered the perspective of end-users (eg, service users, clinicians, health care administrators, and payers) and characteristics of the ultimate delivery settings (eg, workforce capacity, training resources, clinical workflows) to help ensure that proposed interventions are feasible and scalable, and that research results are actionable for improving practice.

This approach is elaborated in current NIMH research initiatives aimed at accelerating the implementation and continuous improvement of new practices in diverse, real-world healthcare settings, including the ALACRITY Research Centers 54 program, EPINET Research Networks, 55 and funding announcements for comparative effectiveness trials (eg, PAR-21-130; PAR-21-131). Through these initiatives, NIMH strongly encourages meaningful involvement of mental health service users and family members in multiple roles throughout the research enterprise. For example, serving as a principal or co-principal investigator of a research project; membership in a project’s executive committee or external advisory group; as a practice-partner member of a transdisciplinary research team; or as a research participant whose lived experience perspectives are systematically assessed via qualitative and/or quantitative methods.

Impact of Experimental Therapeutics and Implementation of Science Funding Announcements

Extramural scientists have successfully pivoted to experimental therapeutics trials to test cognitive interventions for persons with psychotic disorders, as evidenced by research grant projects awarded across all stages of the intervention pipeline. Many funded projects are taking cognitive treatment in new directions, including (1) interventions that target social cognitive processes; (2) approaches that combine cognitive training with other therapies to improve neurocognitive outcomes or promote generalization of training effects (eg, procognitive medications, neuromodulation techniques, aerobic exercise, or behavioral skills training); (3) studies that integrate cognitive interventions into treatment programs for early psychosis; and (4) efforts to address heterogeneity in neurocognitive functioning through personalized cognitive training.

Several deployment-focused implementation projects are examining the adoption and sustainment of cognitive training interventions in real-world community settings. For example, one ALACRITY Center subproject focuses on improving the accessibility and personalization of cognitive remediation for schizophrenia in publicly funded outpatient mental health clinics (P50MH115843). An EPINET network project is testing the feasibility and real-world effectiveness of a neuroscience-informed cognitive training program that pairs social cognitive training with a research-supported mobile application to improve outcomes in first-episode psychosis (R01MH120589). A third implementation project is testing an environmental intervention to bypass cognitive and motivational difficulties associated with schizophrenia to increase adherence to medications and improve functional outcomes among persons receiving treatment in community mental health centers (R01MH11701).

Reflections and Considerations for Future Research

Cognitive treatment development in the United States has progressed substantially since 1992, when thought leaders debated whether cognitive intervention in schizophrenia was possible and if so, how clinical studies should proceed. 1–7 In the ensuing decades, NIMH has employed both top-down and bottom-up approaches to support basic, translational, and implementation research in cognitive treatment for psychosis. The MATRICS, CNTRICS, and RDoC initiatives illustrate the former tactic, where NIMH staff collaborated closely with extramural scientists and others to organize a neuroscience research agenda around cognitive therapeutics. These efforts over a 10-year period helped to cultivate a vibrant learning community that embraced the challenges of delineating cognitive systems implicated in schizophrenia and developing new animal models, clinical assessments, and intervention methods. Afterwards, NIMH shifted its focus to standing funding announcements designed to support innovative and impactful investigator-initiated research projects. Over the past decade, the science supporting cognitive treatment efficacy and implementation has advanced and evolved, propelled by the interests, creativity, and energy of the extramural research community.

Partnerships with other government agencies, industry, and persons with lived experience have grown over time and continue to benefit NIMH treatment development activities. For example, the Accelerating Medicines Partnership Program for Schizophrenia (AMP SCZ) 56 is a public-private endeavor between NIMH, the FDA, the European Medicines Agency, pharmaceutical companies, and other private-sector partners to generate tools that will aid the development of early-stage treatments for people who are at risk for schizophrenia. Persons with lived experience contribute to the leadership and operation of AMP SCZ, which has enriched both the science and real-world relevance of the project. 57 , 58 This aspect of AMP SCZ is consistent with NIMH’s expanded vision of team science, which includes individuals with lived experience, family members, frontline clinicians, and payers as colleagues in clinical research efforts. 54 , 55 It is also an Institute priority to include members of historically underrepresented groups in team science, ie, persons from racial, ethnic, and sexual and gender minority groups as well as individuals from lower socioeconomic strata.

Collectively, external influences and NIMH initiatives have helped set a direction for the next phase of science-to-service research in cognitive treatment for persons with psychotic disorders. The 2023 White House Report on Mental Health Research Priorities, 59 developed to address the mental health crisis exacerbated by the COVID-19 pandemic, provides additional guidance. For example, the White House Report calls for new scientific efforts to (1) support and expand the supply, capacity, and diversity of the mental health workforce; (2) increase the availability, quality, and impact of evidence-based services across a range of settings; (3) foster long-term engagement in care and recovery among persons receiving mental health treatments; and (4) develop and test strategies for provider training, supervision, and performance feedback to ensure sustained implementation of high-quality interventions. To reduce mental health disparities and advance equity, the Report encourages research that addresses social determinants of health, applies community-based participatory methods to ensure the responsiveness of interventions, and oversamples members of historically underrepresented groups in mental health studies.

These priorities are highly relevant to cognitive treatment of psychosis in the United States, where the cognitive intervention workforce is small, evidence-based programs are rarely available outside of academic research clinics, and few individuals with lived experience receive needed therapies. A forward-looking collaboration between the New York State Office of Mental Health (OMH) and Columbia University 60 addresses these limitations through a multiyear project to implement cognitive health services in state-operated outpatient clinics for persons with serious mental illness (SMI). In a series of richly detailed papers, 61–66 Medalia, Saperstein, and colleagues describe a systematic process for introducing cognitive remediation practices in large systems of psychiatric care. Their deployment-focused, phased, and data-driven approach stands out as a case study in implementation excellence.

Table 1 presents current views about the stages of successful implementation, as summarized in the National Implementation Research Network’s synthesis of implementation research and practice studies, 67 as well as best practices for promoting the adoption, installation, and sustainment of evidence-based programs, 68 per guidance provided by the Substance Abuse and Mental Health Services Administration regarding implementation of evidence-based programs. The New York State effort largely follows these recommendations, including (1) close collaboration between OMH officials, local facility personnel, and cognitive remediation experts on implementation choices, methods, and resources; (2) a standardized and sustainable staff training program that teaches evidence-based practices to busy clinicians and supports treatment fidelity; (3) program evaluation activities that support provision of high-quality care; and (4) treatment adaptations that meet the needs of a culturally diverse and multilingual SMI population. Several noteworthy features of the project include the following:

Stages of Implementation and Best Practices to Promote Adoption, Installation, and Continuity of Evidence-Based Programs

Note : Stages of implementation are based on the National Implementation Research Network’s synthesis of implementation research and practice studies. 67 Recommended actions are from guidance provided by the Substance Abuse and Mental Health Services Administration regarding implementation of evidence-based programs. 68 .

Cognitive remediation experts worked closely with OMH leaders and local clinic administrators to operationalize a public psychiatry model of cognitive health and to solve pragmatic questions about staffing models, clinical workflows, information technology needs, and billing practices.

Cognitive remediation services were implemented in a staggered manner, starting with outpatient clinics serving adults with SMI diagnoses 61 and later expanded to Coordinated Specialty Care (CSC) programs for first-episode psychosis. 62 , 63 The latter effort adopted recovery values, organizational principles, and implementation methods pioneered in the adult SMI programs, but modified them to address the needs and perspectives of younger service users. 64

Workforce development programs were created to build broad and enduring support for cognitive remediation interventions. All clinical and support staff received education about cognitive health and recovery; selected clinicians received targeted training and ongoing supervision in cognitive assessment, treatment planning, and intervention practices. Train-the-trainer classes were established to maintain a pool of competent instructors to teach these skills to new clinicians, as needed.

Clinicians collect program evaluation data as part of routine care; supervisors use these data to monitor treatment fidelity and troubleshoot implementation problems in real-time. Pragmatic measures of service utilization, dropout rates, and participant satisfaction confirm the fidelity, acceptability, and perceived effectiveness of cognitive remediation in state-operated clinics, 65 but also identify areas for further improvement. 66

The New York State implementation experiment responds to several research priorities outlined in the recent White House Report. 59 The initiative successfully expands the cognitive remediation workforce to include psychologists, nurses, physicians, social workers, and mental health counselors who work in community treatment settings. The public psychiatry model 61 assures that almost all persons served in state-operated clinics for adults, and CSC programs for youth, are eligible to receive cognitive health services. Integrating cognitive remediation into existing multidisciplinary rehabilitation programs furthers OMH’s commitment to person-centered, recovery-oriented treatment that fosters patients’ independence and community engagement. Innovative methods for training clinicians, tracking their performance, and maintaining treatment fidelity are sustaining the implementation of high-quality interventions over time. Finally, the extension of cognitive health services into CSC programs illustrates the importance of involving end-users, eg, CSC service providers 62 and persons with lived experience, 64 in developing interventions that are feasible to implement and responsive to the needs and preferences of the target population.

While these accomplishments are a clear step forward, further research in public sector settings is needed to (1) optimize the delivery of cognitive interventions (eg, increase referrals, participant enrollment, and service utilization); (2) eliminate potential inequalities in access, quality, or effectiveness of services for populations with health disparities 69 ; (3) evaluate the impact of cognitive interventions on objective measures of patients’ social, educational, and vocational functioning; and (4) determine the cost-effectiveness of combining cognitive remediation programs with traditional psychiatric rehabilitation services. These and similar practice-oriented research questions could be explored within a learning health care framework, where data collected as part of routine care are used to study the implementation, adaptation, and effectiveness of evidence-based interventions in public health clinics. 70 Such an approach ensures that research findings are directly relevant to representative sets of patients, clinicians, and health care system administrators, while clinical practice benefits from continuous data-driven improvement. 71

Throughout 2024, NIMH is celebrating 75 years of basic, translational, and health services research that has deepened our understanding of mental disorders and broadened the therapeutic armamentarium. Cognitive intervention research for schizophrenia has featured prominently in the Institute’s scientific portfolio, with sequential treatment development initiatives over the past 2 decades. A core set of principles guided these efforts, including convening diverse learning communities, using structured encounters to establish a common scientific framework and vocabulary for understanding complex challenges, and creating funding opportunities that encourage interdisciplinary, deployment-focused studies. Increasingly, teams that partner translational scientists, implementation researchers, and mental health shareholders, eg, service users, family members, clinicians, payers, and policymakers, are developing and testing interventions that align with conditions encountered in real-world treatment systems. This approach holds promise for speeding the introduction of evidence-based practices in these settings, thereby narrowing the typical research-to-implementation gap. 72 Going forward, science-to-service studies conducted within the learning health model will further accelerate progress toward clinically effective, continuously improving, and accessible cognitive health care for all persons with psychotic disorders.

The authors have no conflicts of interest to disclose. The views expressed in this article do not necessarily represent the views of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.

Bonnie J , Spring LR. Cognitive remediation in schizophrenia: Should we attempt it ? Schizophr Bull. 1992 ; 18 ( 1 ): 15 – 20 .

Google Scholar

Brenner HD , Hodel B , Roder V , Corrigan P. Treatment of cognitive dysfunctions and behavioral deficits in schizophrenia . Schizophr Bull. 1992 ; 18 ( 1 ): 21 – 26 .

Liberman RP , Green MF. Whither cognitive-behavioral therapy for schizophrenia ? Schizophr Bull. 1992 ; 18 ( 1 ): 27 – 35 .

Braff DL. Reply to cognitive therapy and schizophrenia . Schizophr Bull. 1992 ; 18 ( 1 ): 37 – 38 .

Spaulding WD. Design prerequisites for research on cognitive therapy for schizophrenia . Schizophr Bull. 1992 ; 18 ( 1 ): 39 – 42 .

Bellack AS. Cognitive rehabilitation for schizophrenia: Is it possible? Is it necessary ? Schizophr Bull. 1992 ; 18 ( 1 ): 43 – 50 .

Hogarty GE , Flesher S. Cognitive remediation in schizophrenia: proceed…with caution! Schizophr Bull. 1992 ; 18 ( 1 ): 51 – 57 .

U.S. Department of Health and Human Services . Mental Health: A Report of the Surgeon General . Rockville, MD : U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health ; 1999 . https://profiles.nlm.nih.gov/spotlight/nn/catalog/nlm:nlmuid-101584932X120-doc . Date accessed June 2, 2024 .

Google Preview

Satcher D. Mental health: a report of the Surgeon General—Executive summary . Professional Psychology: Research and Practice . 2000 ; 31 ( 1 ): 5 – 13 .

The President’s New Freedom Commission on Mental Health . Achieving the Promise: Transforming Mental Health Care in America. Final Report . U.S. Department of Health and Human Services, Pub. No. SMA-03-3832 ; 2003 . https://www.govinfo.gov/app/details/GOVPUB-PR-PURL-LPS36928 . Date accessed June 2, 2024 .

Hogan MF. The President’s new freedom commission: recommendations to transform mental health care in America . Psychiatr Serv. 2003 ; 54 ( 11 ): 1467 – 1474 .

Zerhouni E. The NIH roadmap . Science. 2003 ; 302 ( 5642 ): 63 – 72 .

National Institutes of Health Office of Strategic Coordination – The Common Fund . A Decade of Discovery: The NIH Roadmap and Common Fund . NIH Pub No. 14-8013 ; 2015 . https://commonfund.nih.gov/sites/default/files/ADecadeofDiscoveryNIHRoadmapCF.pdf . Date accessed June 2, 2024 .

The President’s New Freedom Commission on Mental Health . Interim Report to the President , 2002 . https://web.archive.org/web/20050310141415/http://www.mentalhealthcommission.gov/reports/interim_toc.htm . Date accessed June 2, 2024 .

Daly R. New freedom commission members assess report’s impact . Psychiatr News . 2006 ; 41 : 1 – 41 . doi: 10.1176/pn.41.9.0001a

Hyman SE , Fenton WS. What are the right targets for psychopharmacology ? Science. 2003 ; 299 ( 5605 ): 350 – 351 .

Fenton WS , Stover EL , Insel TR. Breaking the log-jam in treatment development for cognition in schizophrenia: NIMH perspective . Psychopharmacology (Berl). 2003 ; 169 ( 3-4 ): 365 – 366 .

Geyer MA , Tamminga CA. Measurement and treatment research to improve cognition in schizophrenia: neuropharmacological aspects . Psychopharmacology (Berl). 2004 ; 174 ( 1 ): 1 – 2 .

Buchanan RW , Davis M , Goff D , et al.  . A summary of the FDA-NIMH-MATRICS workshop on clinical trial design for neurocognitive drugs for schizophrenia . Schizophr Bull. 2005 ; 31 ( 1 ): 5 – 19 .

Frese FJ , Knight EL , Saks E. Recovery from schizophrenia: with views of psychiatrists, psychologists, and others diagnosed with this disorder . Schizophr Bull. 2009 ; 35 ( 2 ): 370 – 380 .

Nuechterlein KH , Barch DM , Gold JM , Goldberg TE , Green MF , Heaton RK. Identification of separable cognitive factors in schizophrenia . Schizophr Res. 2004 ; 72 ( 1 ): 29 – 39 .

Green MF , Nuechterlein KH , Gold JM , et al.  . Approaching a Consensus Cognitive Battery for clinical trials in schizophrenia: the NIMH-MATRICS conference to select cognitive domains and test criteria . Biol Psychiatry. 2004 ; 56 ( 5 ): 301 – 307 .

Geyer MA , Heinssen RK. New approaches to measurement and treatment research to improve cognition in schizophrenia . Schizophr Bull. 2005 ; 31 ( 4 ): 806 – 809 .

Nuechterlein KH , Green MF , Kern RS , et al.  . The MATRICS Consensus Cognitive Battery, Part 1: test selection, reliability, and validity . Am J Psychiatry. 2008 ; 165 ( 2 ): 203 – 213 .

Kern RS , Nuechterlein KH , Green MF , et al.  . The MATRICS consensus cognitive battery, Part 2: Co-norming and standardization . Am J Psychiatry. 2008 ; 165 ( 2 ): 214 – 220 .

Green MF , Nuechterlein KH , Kern RS , et al.  . Functional Co-primary measures for clinical trials in schizophrenia: results from the MATRICS psychometric and standardization study . Am J Psychiatry. 2008 ; 165 ( 2 ): 221 – 228 .

Nuechterlein KH , Green MF , Kern RS. The MATRICS consensus cognitive battery: an update . In: Barch DM , Young JW , eds. Cognitive Functioning in Schizophrenia: Leveraging the RDoC Framework . Cham, Switzerland : Springer Nature ; 2023 : 1 – 18 .

Buchanan RW , Keefe RSE , Umbricht D , Green MF , Laughren T , Marder SR. The FDA-NIMH-MATRICS guidelines for clinical trial design of cognitive-enhancing drugs: what do we know 5 years later ? Schizophr Bull. 2010 ; 37 ( 6 ): 1209 – 1217 .

Marder SR. Lessons from MATRICS . Schizophr Bull. 2011 ; 37 ( 2 ): 233 – 234 .

Green MF , Horan WP , Lee J. Nonsocial and social cognition in schizophrenia: current evidence and future directions . World Psychiatry . 2019 ; 18 ( 2 ): 146 – 161 .

Horan WP , Catalano LT , Green MF. An update on treatment of cognitive impairment associated with schizophrenia . In: Barch DM , Young JW , eds. Cognitive Functioning in Schizophrenia: Leveraging the RDoC Framework . Cham, Switzerland : Springer Nature ; 2023 : 407 – 436 .

Carter CS. Applying new approaches from cognitive neuroscience to enhance drug development for the treatment of impaired cognition in schizophrenia . Schizophr Bull. 2005 ; 31 ( 4 ): 810 – 815 .

Carter CS , Barch DM. Cognitive neuroscience-based approaches to measuring and improving treatment effects on cognition in schizophrenia: The CNTRICS Initiative . Schizophr Bull. 2007 ; 33 ( 5 ): 1131 – 1137 .

Cohen JD , Insel TR. Cognitive neuroscience and schizophrenia: translational research in need of a translator . Biol Psychiatry. 2008 ; 64 ( 1 ): 2 – 3 .

Carter CS , Barch DM , Buchanan RW , et al.  . Identifying cognitive mechanisms targeted for treatment development in schizophrenia: an overview of the first meeting of the cognitive neuroscience treatment research to improve cognition in schizophrenia initiative . Biol Psychiatry. 2008 ; 64 ( 1 ): 4 – 10 .

Barch DM , Boudewyn MA , Carter CS , et al.  . Cognitive [Computational] neuroscience test reliability and clinical applications for serious mental illness (CNTRaCS) Consortium: Progress and Future Directions . Curr Top Behav Neurosci . 2023 ; 63 : 19 – 60 .

Morris SE , Sanislow CA , Pacheco J , Vaidyanathan U , Gordon JA , Cuthbert BN. Revisiting the seven pillars of RDoC . BMC Med. 2022 ; 20 : 220 .

National Institute of Mental Health . Working Memory: Workshop Proceedings ; 2010 . https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/working-memory-workshop-proceedings. Date accessed June 2, 2024 .

National Institute of Mental Health . Cognitive Systems: Workshop Proceedings ; 2011 . https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/cognitive-systems-workshop-proceedings . Date accessed June 2, 2024 .

Bilgrami ZR , Sarac C , Srivastava A , et al.  . Construct validity for computational linguistic metrics in individuals at clinical risk for psychosis: associations with clinical ratings . Schizophr Res. 2022 ; 245 : 90 – 96 .

Bansal S , Bae G , Robinson BM , et al.  . Association between failures in perceptual updating and the severity of psychosis in schizophrenia . JAMA Psychiatry . 2022 ; 79 ( 2 ): 169 – 177 .

Columbia University Irving Medical Center . Cognitive Remediation in Psychiatry: New Directions in the 21st Century . 2024 . http://www.cognitive-remediation.org/ . Date accessed June 2, 2024 .

National Institute of Mental Health . Cognitive Training in Mental Disorders: Advancing the Science ; 2012 . https://web.archive.org/web/20120916071834/http://www.mentalhealth.gov/research-funding/scientific-meetings/2012/cognitive-training-in-mental-disorders-advancing-the-science/index.shtml . Date accessed June 2, 2024 .

Keshavan MS , Vinogradov S , Rumsey J , Sherrill J , Wagner A. Cognitive training in mental disorders: updated and future directions . Am J Psychiatry. 2014 ; 171 ( 5 ): 510 – 522 .

Bromley E. A Collaborative approach to targeted treatment development for schizophrenia: a qualitative evaluation of the NIMH-MATRICS Project . Schizophr Bull. 2005 ; 31 ( 4 ): 954 – 961 .

Miller G. Is pharma running out of brainy ideas ? Science. 2010 ; 329 ( 5991 ): 502 – 504 .

Hyman SE. Revolution stalled . Science Transl Med . 2012 ; 4 ( 155 ): 155cm111 .

National Advisory Mental Health Council Workgroup . From Discovery to Cure: Accelerating the Development of New and Personalized Interventions for Mental Illness ; 2010 . https://www.nimh.nih.gov/sites/default/files/documents/about/advisory-boards-and-groups/namhc/reports/fromdiscoverytocure.pdf . Date accessed June 2, 2024 .

Insel TR , Gogtay N. National Institute of Mental Health Clinical Trials: New Opportunities, New Expectations . JAMA Psychiatry . 2014 ; 71 ( 7 ): 745 – 746 .

Institute of Medicine . Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC : National Academies Press ; 2001 .

National Advisory Mental Health Council Workgroup . The Road Ahead: Research Partnerships to Transform Services ; 2006 , https://www.nimh.nih.gov/sites/default/files/documents/about/advisory-boards-and-groups/namhc/reports/road-ahead.pdf . Date accessed June 2, 2024 .

Weisz JR. Bridging the research-practice divide in youth psychotherapy: the deployment-focused model and transdiagnostic treatment . Verhaltenstherapie . 2015 ; 25 : 129 – 132 .

National Institute of Mental Health . Recovery After an Initial Schizophrenia Episode (RAISE) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/recovery-after-an-initial-schizophrenia-episode-raise . Date accessed June 2, 2024 .

National Institute of Mental Health . Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness (ALACRITY) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/advanced-laboratories-for-accelerating-the-reach-and-impact-of-treatments-for-youth-and-adults-with-mental-illness-alacrity . Date accessed June 2, 2024 .

National Institute of Mental Health . Early Psychosis Intervention Network (EPINET) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/early-psychosis-intervention-network-epinet . Date accessed June 2, 2024 .

National Institute of Mental Health . Accelerating Medicines Partnership® Program for Schizophrenia (AMP® SCZ) . https://www.nimh.nih.gov/research/research-funded-by-nimh/research-initiatives/accelerating-medicines-partnershipr-program-schizophrenia-ampr-scz . Date accessed June 2, 2024 .

Larrauri CA. He Who Has Hope, Has Everything . Psychiatr Serv. 2023 ; 74 ( 8 ): 892 – 893 .

Larrauri CA , Staglin B. Leading science with lived experience , Schizophr Bull . 2022 ; sbab147 , doi: 10.1093/schbul/sbab147

White House Office of Science & Technology Policy . White House Report on Mental Health Research Priorities ; 2023 . https://www.whitehouse.gov/wp-content/uploads/2023/02/White-House-Report-on-Mental-Health-Research-Priorities.pdf . Date accessed June 2, 2024 .

Medalia A , Erlich M. Why cognitive health matters . Am J Public Health . 2017 ; 107 ( 1 ): 45 – 47 .

Medalia A , Saperstein AM , Erlich MD , Sederer LI. Cognitive remediation in large systems of psychiatric care . CNS Spectr. 2019 ; 24 ( 1 ): 163 – 173 .

Saperstein AM , Medalia A , Bello I , Dixon LB. Addressing cognitive health in coordinated specialty care for early psychosis: real-world perspectives . Early Interv Psychiatry 2021 ; 15 ( 2 ): 374 – 379 .

Saperstein AM , Medalia A , Malinovsky I , Bello I , Dixon LB. Toolkit for assessing and addressing cognitive health in early psychosis: evaluation of feasibility and utility in a coordinated specialty care setting . Early Interv Psychiatry . 2021 ; 15 ( 5 ): 1376 – 1381 .

Saperstein AM , Bello I , Nossel I , Dixon LB , Medalia A. Implementation of cognitive health services in large systems of care: highlights from coordinated specialty care for first episode psychosis . Schizophr Bull . 2024 ; sbae030 , doi: 10.1093/schbul/sbae030 .

Soumet-Leman C , Medalia A , Erlich MD. Acceptability and perceived effectiveness of cognitive remediation in clinical practice . Psychiatr Serv. 2018 ; 69 ( 4 ): 493 – 494 .

Medalia A , Erlich MD , Soumet-Leman C , Saperstein AM. Translating cognitive behavioral interventions from bench to bedside: the feasibility and acceptability of cognitive remediation in research as compared to clinical settings . Schizophr Res. 2019 ; 203 : 49 – 54 .

Fixsen DL , Naoom SF , Blase KA , Friedman RM , Wallace F. Implementation Research: A Synthesis of the Literature . Tampa, FL : University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network (FMHI Publication #231) ; 2005 .

Substance Abuse and Mental Health Services Administration National Registry of Evidence-Based Programs and Practices (NREPP) . A Road Map to Implementing Evidence-Based Programs ; 2012 . https://web.archive.org/web/20130218035856/http://nrepp.samhsa.gov/Courses/Implementations/resources/imp_course.pdf . Date accessed June 2, 2024 .

National Institute on Minority Health and Health Disparities . Minority Health and Health Disparities Definitions . https://www.nimhd.nih.gov/resources/understanding-health-disparities/minority-health-and-health-disparities-definitions.html . Date accessed June 2, 2024 .

Heinssen RK , Azrin ST. A national learning health experiment in early psychosis research and care . Psychiatr Serv. 2022 ; 73 ( 9 ): 962 – 964 .

Blanco C , Heinssen RK , Tenhula WN. Public sector learning health care systems—improving patient experience, workforce well-being, and recovery outcomes . JAMA Psychiatry . 2024 ; 81 ( 1 ): 9 – 10 .

McGinty EE , Alegria M , Beidas RS , et al.  . The Lancet Psychiatry Commission: Transforming mental health implementation research . Lancet Psychiatry . 2024 ; 11 ( 5 ): 368 – 396 .

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Understanding Schizophrenia: A Case Study

Schizophrenia is characterized mainly, by the gross distortion of reality, withdrawal from social interaction, disorganization and fragmentation of perception, thoughts and emotions. Insight is an important concept in clinical psychiatry, a lack of insight is particularly common in schizophrenia patient. Previous studies reported that between 50-80% of patients with schizophrenia do not believe, they have a disorder. By the help of psychological assessment, we can come to know an individual's problems especially in cases, where patient is hesitant or has less insight into illness. Assessment is also important for the psychological management of the illness. Knowing the strengths and weaknesses of that particular individual with psychological analysis tools can help to make better plan for the treatment. The present study was designed to assess the cognitive functioning, to elicit severity of psychopathology, understanding diagnostic indicators, personality traits that make the individual vulnerable to the disorder and interpersonal relationship in order to plan effective management. Schizophrenia is a chronic disorder, characterized mainly by the gross distortion of reality, withdrawal from social interaction, and disorganization and fragmentation of perception, thought and emotion. Approximately, 1% world population suffering with the problem of Schizophrenia. Both male and female are almost equally affected with slight male predominance. Schizophrenia is socioeconomic burden with suicidal rate of 10% and expense of 0.02-1.65% of GDP spent on treatment. Other co-morbid factors associated with Schizophrenia are diabetes, Obesity, HIV infection many metabolic disorders etc. Clinically, schizophrenia is a syndrome of variables symptoms, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over the time, but the effect of the illness is always severe and is usually long-lasting. Patients with schizophrenia usually get relapse after treatment. The most common cause for the relapse is non-adherent with the medication. The relapse rate of schizophrenia increases later time on from 53.7% at 2 years to

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Inayat ullah Shah

Despite a large body of research evaluating factors associated with the relapse of psychosis in schizophrenia, no studies in Pakistan have been undertaken to date to identify any such factors, including specific cultural factors pertinent to Pakistan. Semistructured interviews and psychometric measures were undertaken with 60 patients diagnosed with schizophrenia (49 male and 11 female) and their caregivers at four psychiatric hospitals in the Peshawar region in Pakistan. Factors significantly associated with psychotic relapse included treatment non-adherence, comorbid active psychiatric illnesses, poor social support, and high expressed emotion in living environments (P &lt; 0.05). The attribution of symptoms to social and cultural values (97%) and a poor knowledge of psychosis by family members (88%) was also prevalent. In addition to many well-documented factors associated with psychotic relapse, beliefs in social and cultural myths and values were found to be an important, and p...

Octavian Vasiliu

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Schizophrenia A-level Revisions Notes

Bruce Johnson

A-level Psychology Teacher

B.A., Educational Psychology, University of Exeter

Bruce Johnson is an A-level psychology teacher, and head of the sixth form at Caterham High School.

Learn about our Editorial Process

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

What do the examiners look for?

• Accurate and detailed knowledge
• Clear, coherent, and focused answers
• Effective use of terminology (use the “technical terms”)

In application questions, examiners look for “effective application to the scenario” which means that you need to describe the theory and explain the scenario using the theory making the links between the two very clear. If there is more than one individual in the scenario you must mention all of the characters to get to the top band.

Difference between AS and A level answers

The descriptions follow the same criteria; however you have to use the issues and debates effectively in your answers. “Effectively” means that it needs to be clearly linked and explained in the context of the answer.

Read the model answers to get a clearer idea of what is needed.

Exam Advice

You MUST revise everything – because the exam board could choose any question, however, it does make sense to spend more time on those topics which have not appeared for a while.

With these particular questions there is a sizeable risk that people don’t understand the difference between the questions, and then write about the wrong thing.

Make sure you know which is which, for example do you understand the difference between “genetic explanation” and “neural correlates explanation”, and do you have a model essay for each?

Schizophrenia is a severe mental illness where contact with reality and insight are impaired, an example of psychosis.

Section 1: Diagnosis and Classification of Schizophrenia

Classification is the process of organising symptoms into categories based on which symptoms cluster together in sufferers. Psychologists use the DSM and ICD to diagnose a patient with schizophrenia.

Diagnosis refers to the assigning of a label of a disorder to a patient. The ICD-10 (only negative symptoms need to be present) is used worldwide and the DSM-5 (only positive symptoms need to be present) is used in America.

In order to diagnose Schizophrenia the Mental Health Profession developed the DSM (Diagnostic and Statistical Manual) still used today as a method of classifying mental disorders (particularly in the USA).

It is also used as a basis for the ICD (International Classification of Diseases) used by the World Health Organisation in classifying all disorders (mental and physical).

Note: you may come across the terms DSM-IV and ICD-10. These refer to the latest editions of the two classification systems.

Positive Symptoms

an excess or distortion of normal functions: including hallucinations and delusions.

Positive symptoms are an excess or distortion of normal functions, for example hallucinations, delusions and thought disturbances such as thought insertion.

• Hallucinations are usually auditory or visual perceptions of things that are not present. Imagined stimuli could involve any of the senses. Voices are usually heard coming from outside the person’s head giving instructions on how to behave. • Delusions are false beliefs. Usually the person has convinced him/herself that he/she is someone powerful or important, such as Jesus Christ, the Queen (e.g. Delusions of Grandeur). There are also delusions of being paranoid, worrying that people are out to get them. • Psychomotor Disturbances: Stereotypyical – Rocking backwards and forwards, twitches, & repetitive behaviors. Catatonia- staying in position for hours/days on end, cut off from the world.

Negative Symptoms

where normal functions are limited: including speech poverty and avolition.

Negative symptoms are a diminution or loss of normal functions such as psychomotor disturbances, avolition (the reduction of goal-directed behavior), disturbances of mood and thought disorders.

• Thought disorder in which there are breaks in the train of thought and the person appears to make illogical jumps from one topic to another (loose association). Words may become confused and sentences incoherent (so called ‘word salad). Broadcasting is a thought disorder whereby a person believes their thoughts are being broadcast to others, for example over the radio or through TV. Alogia – aka speech poverty – is a thought disorder were correct words are used but with little meaning. • Avolition: Lack of volition (i.e. desire): in which a person becomes totally apathetic and sits around waiting for things to happen. They engage in no self motivated behavior. Their get up and go has got up and gone!

Classification

Slater & Roth (1969) say that hallucinations are the least important of all the symptoms, as they are not exclusive to schizophrenic people.

Classification and diagnosis does have advantages as it allows doctors to communicate more effectively about a patient and use similar terminology when discussing them. In addition, they can then predict the outcome of the disorder and suggest related treatment to help the patient.

Scheff (1966) points out that diagnosis classification labels the individual, and this can have many adverse effects, such as a self-fulfilling prophecy (patients may begin to act how they are expected to act), and lower self-esteem.

Ethics – do the benefits of classification (care, treatment, safety) outweigh the costs (possible misdiagnosis, mistreatment, loss of rights and responsibility, prejudice due to labelling).

Reliability and Validity in Diagnosis and Classification of Schizophrenia

with reference to co-morbidity, culture and gender bias and symptom overlap.

Reliability

For the classification system to be reliable, differfent clinicians using the same system (e.g. DSM) should arrive at the same diagnosis for the same individual.

Reliability is the level of agreement on the diagnosis by different psychiatrists across time and cultures; stability of diagnosis over time given no change in symptoms.

Diagnosis of schizophrenia is difficult as the practitioner has no physical signs but only symptoms (what the patient reports) to make a decision on.

Jakobsen et al. (2005) tested the reliability of the ICD-10 classification system in diagnosing schizophrenia. A hundred Danish patients with a history of psychosis were assessed using operational criteria, and a concordance rate of 98% was obtained. This demonstrates the high reliability of the clinical diagnosis of schizophrenia using up-to-date classification.

Comorbidity describes people who suffer from two or more mental disorders. For example, schizophrenia and depression are often found together. This makes it more difficult to confidently diagnose schizophrenia. Comorbidity occurs because the symptoms of different disorders overlap. For example, major depression and schizophrenia both involve very low levels of motivation. This creates problems of reliability. Does the low motivation reflect depression or schizophrenia, or both?

Gender bias: Loring and Powell (1988) found that some behavior which was regarded as psychotic in males was not regarded as psychotic in females.

Validity – the extent to which schizophrenia is a unique syndrome with characteristics, signs and symptoms.

For the classification system to be valid it should be meaningful and classify a real pattern of symptoms, which result from a real underlying cause.

The validity of schizophrenia as a single disorder is questioned by many. This is a useful point to emphasise in any essay on the disorder. There is no such thing as a ‘normal’ schizophrenic exhibiting the usual symptoms.

Since their are problems with the validity of diagnois classification, unsuitable treatment may be administered, sometimes on an involuntary basis. This raises practical and ethical issues when selecting different types of tretment.

Problems of validity: Are we really testing what we think we are testing? In the USA only 20% of psychiatric patients were classed as having schizophrenia in the 1930s but this rose to 80% in the 1950s . In London the rate remained at 20%, suggesting neither group had a valid definition of schizophrenia.

Neuropsychologist Michael Foster Green suggests that neurocognitive deficits in basic functions such as memory, attention, central executive and problem solving skills may combine to have an outcome which we are labelling “Schizophrenia” as if it was the cause when in fact it is simply an umbrella term for a set of effects.

Predictive validity. If diagnosis leads to successful treatment, the diagnosis can be seen as valid. But in fact some Schizophrenics are successfully treated whereas others are not. Heather (1976) there is only a 50% chance of predicting what treatment a patient will receive based on diagnosis, suggesting that diagnosis is not valid.

Aetiological validity – for a diagnosis to be valid, all patients diagnosed as schizophrenic should have the same cause for their disorder. This is not the case with schizophrenia: The causes may be one of biological or psychological or both.

David Rosenhan (1973) famous experiment involving Pseudopatients led to 8 normal people being kept in hospital despite behaving normally. This suggests the doctors had no valid method for detecting schizophrenia. They assumed the bogus patients were schizophrenic with no real evidence. In a follow up study they rejected genuine patients whom they assumed were part of the deception.

Culture – One of the biggest controversies in relation to classification and diagnosis is to do with cultural relativism and variations in diagnosis. For example in some Asian countries people are not expected to show emotional expression, whereas in certain Arabic cultures public emotion is encouraged and understood. Without this knowledge a person displaying overt emotional behavior in a Western culture might be regarded as abnormal. Cochrane (1977) reported that the incidence of schizophrenia in the West Indies and the UK is 1 %, but that people of Afro-Caribbean origin are seven times more likely to be diagnosed as schizophrenic when living in the UK.

Cultural bias – African Americans and those of Afro-carribean descent are more likely to be diagnosed than their white counterparts but diagnostic rates in Africa and the West Indies is low – Western over diagnosis is a result of cultural norms and the diagnosis lacks validity.

Section 2: Biological Explanations for Schizophrenia

Family studies find individuals who have schizophrenia and determine whether their biological relatives are similarly affected more often than non-biological relatives.

There are two types of twins – identical (monozygotic) and fraternal (dizygotic). To form identical twins, one fertilised egg (ovum) splits and develops two babies with exactly the same genetic information.

• Gottesman (1991) found that MZ twins have a 48% risk of getting schizophrenia whereas DZ twins have a 17% risk rate. This is evidence that the higher the degree of genetic relativeness, the higher the risk of getting schizophrenia. • Benzel et al. (2007) three genes: COMT, DRD4, AKT1 – have all been associated with excess dopamine in specific D2 receptors, leading to acute episodes, positive symptoms which include delusions, hallucinations, strange attitudes. • Research by Miyakawa et al. (2003) studied DNA from human families affected by schizophrenia and found that those with the disease were more likely to have a defective version of a gene, called PPP3CC which is associated with the production of calcineurin which regulates the immune system. Also, research by Sherrington et al. (1988) has found a gene located on chromosome 5 which has been linked in a small number of extended families where they have the disorder. • Evidence suggests that the closer the biological relationship, the greater the risk of developing schizophrenia. Kendler (1985) has shown that first-degree relatives of those with schizophrenia are 18 times more at risk than the general population. Gottesman (1991) has found that schizophrenia is more common in the biological relatives of a schizophrenic, and that the closer the degree of genetic relatedness, the greater the risk.

Very important to note genetics are only partly responsible, otherwise identical twins would have 100% concordance rates.

One weakness of the genetic explanation of schizophrenia is that there are methodological problems. Family, twin and adoption studies must be considered cautiously because they are retrospective, and diagnosis may be biased by knowledge that other family members who may have been diagnosed. This suggests that there may be problems of demand characteristics.

A second weakness is the problem of nature-v-Nurture. It is very difficult to separate out the influence of nature-v-nurture. The fact that the concordance rates are not 100% means that schizophrenia cannot wholly be explained by genes and it could be that the individual has a pre-disposition to schizophrenia and simply makes the individual more at risk of developing the disorder. This suggests that the biological account cannot give a full explanation of the disorder.

A final weakness of the genetic explanation of schizophrenia is that it is biologically reductionist. The Genome Project has increased understanding of the complexity of the gene. Given that a much lower number of genes exist than anticipated, it is now recognised that genes have multiple functions and that many genes behavior.

Schizophrenia is a multi-factorial trait as it is the result of multiple genes and environmental factors. This suggests that the research into gene mapping is oversimplistic as schizophrenia is not due to a single gene.

The Dopamine Hypothesis

• Dopamine is a neurotransmitter. It is one of the chemicals in the brain which causes neurons to fire. The original dopamine hypothesis stated that schizophrenia suffered from an excessive amount of dopamine. This causes the neurons that use dopamine to fire too often and transmit too many messages. • High dopamine activity leads to acute episodes, and positive symptoms which include: delusions, hallucinations, confused thinking. • Evidence for this comes from that fact that amphetamines increase the amounts of dopamine . Large doses of amphetamine given to people with no history of psychological disorders produce behavior which is very similar to paranoid schizophrenia. Small doses given to people already suffering from schizophrenia tend to worsen their symptoms. • A second explanation developed, which suggests that it is not excessive dopamine but that fact that there are more dopamine receptors. More receptors lead to more firing and an over production of messages. Autopsies have found that there are generally a large number of dopamine receptors (Owen et al., 1987) and there was an increase in the amount of dopamine in the left amygdale (falkai et al. 1988) and increased dopamine in the caudate nucleus and putamen (Owen et al, 1978).

One criticism of the dopamine hypothesis is there is a problem with the chicken and egg. Is the raised dopamine levels the cause of the schizophrenia, or is it the raised dopamine level the result of schizophrenia?

It is not clear which comes first. This suggests that one needs to be careful when establishing cause and effect relationships in schizophrenic patients.

One of the biggest criticisms of the dopamine hypothesis came when Farde et al found no difference between schizophrenics’ levels of dopamine compared with ‘healthy’ individuals in 1990.

Noll (2009) also argues around one third of patients do not respond to drugs which block dopamine so other neurotransmitters may be involved.

A final weakness of the dopamine hypothesis is that it is biologically deterministic. The reason for this is because if the individual does have excessive amounts of dopamine then does it really mean that thy ey will develop schizophrenia? This suggests that the dopamine hypothesis does not account for freewill.

Neural Correlates

• Neural correlates are patterns of structure or activity in the brain that occur in conjunction with schizophrenia • People with schizophrenia have abnormally large ventricles in the brain . Ventricles are fluid filled cavities (i.e. holes) in the brain that supply nutrients and remove waste. This means that the brains of schizophrenics are lighter than normal. The ventricles of a person with schizophrenia are on average about 15% bigger than normal (Torrey, 2002).

A strength is that the research into enlarged ventricles and neurotransmitter levels have high reliability. The reason for this is because the research is carried out in highly controlled environments, which specialist, high tech equipment such as MRI and PET scans.

These machines take accurate readings of brain regions such as the frontal and pre-frontal cortex, the basil ganglia, the hippocampus and the amygdale. This suggests that if this research was tested and re-tested the same results would be achieved.

Supporting evidence for the brain structure explanation comes from further empirical support from Suddath et al. (1990). He used MRI (magnetic resonance imaging) to obtain pictures of the brain structure of MZ twins in which one twin was schizophrenic.

The schizophrenic twin generally had more enlarged ventricles and a reduced anterior hypothalamus. The differences were so large the schizophrenic twins could be easily identified from the brain images in 12 out of 15 pairs.

This suggests that there is wider academic credibility for enlarged ventricles determining the likelihood of schizophrenia developing.

A second weakness of the neuroanatomical explanations is that it is biologically deterministic. The reason for this is because if the individual does have large ventricles then does it really mean that they will develop schizophrenia? This suggests that the dopamine hypothesis does not account for freewill.

Section 3: Psychological Explanations for Schizophrenia

Family dysfunction.

Family Dysfunction refers to any forms of abnormal processes within a family such as conflict, communication problems, cold parenting, criticism, control and high levels of expressed emotions. These may be risk factors for the development and maintenance of schizophrenia.

• Laing and others rejected the medical / biological explanation of mental disorders. They did not believe that schizophrenia was a disease. They believed that schizophrenia was a result of social pressures from life. Laing believed that schizophrenia was a result of the interactions between people, especially in families. • Bateson et al. (1956) suggested the double bind theory, which suggests that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia. For example parents who say they care whilst appearing critical or who express love whilst appearing angry. They did not believe that schizophrenia was a disease. They believed that schizophrenia was a result of social pressures from life. • Prolonged exposure to such interactions prevents the development of an internally coherent construction of reality; in the long run, this manifests itself as typically schizophrenic symptoms such as flattening affect, delusions and hallucinations, incoherent thinking and speaking, and in some cases paranoia. • Another family variable associated with schizophrenia is a negative emotional climate, or more generally a high degree of expressed emotion (EE). EE is a family communication style that involves criticism, hostility and emotional over-involvement. The researchers concluded that this is more important in maintaining schizophrenia than in causing it in the first place, (Brown et al 1958). Schizophrenics returning to such a family were more likely to relapse into the disorder than those returning to a family low in EE. The rate of relapse was particularly high if returning to a high EE family was coupled with no medication.

One strength of the double bind explanation comes from further empirical support provided by Berger (1965). They found that schizophrenics reported a higher recall of double bind statements by their mothers than non-schizophrenics.

However, evidence may not be reliable as patient’s recall may be affected by their schizophrenia. This suggests that there is wider academic credibility for the idea of contradictory messages causing schizophrenia.

A second strength of the research into expressed emotion (EE) is that it has practical applications. For example Hogarty (1991) produced a type of therapy session, which reduced social conflicts between parents and their children which reduced EE and thus relapse rates.

This suggests that gaining an insight into family relationships allows psychiatric professionals to help improve the quality of patient’s lives.

Individual differences – EE is associated with relapse but not all patients who live in high EE families relapse and not all patients in low EE families avoid relapse – Family dysfunction is an incomplete explanation for schizophrenia.

A weakness of the family relationsships appraoch is that there is a problem of cause and effect. Mischler & Waxler (1968) found significant differences in the way mothers spoke to their schizophrenic daughters compared to their normal daughters, which suggests that dysfunctional communication may be a result of living with the schizophrenic rather than the cause of the disorder.

This suggests that there is a problem of the chicken and egg scenario in relation to expressed emotion causing schizophrenia.

A second weakness of the double bind theory is that there are ethical issues. There are serious ethical concerns in blaming the family, particularly as there is little evidence upon which to base this.

Gender bias is also an issue as the mother tends to be blamed the most, which means such research is highly socially sensitive. This suggests that the research therefore does not protect individuals from harm.

Cause and effect – It remains unclear whether cognitive factors cause schizophrenia or if schizophrenia causes these cognitions – Family dysfunction may not be a valid explanation for schizophrenia.

Cognitive explanations

including dysfunctional thought processing.

Cognitive approaches examine how people think, how they process information. Researchers have focused on two factors which appear to be related to some of the experiences and behaviors of people diagnosed with schizophrenia.

First, cognitive deficits which are impairments in thought processes such as perception, memory and attention. Second, cognitive biases are present when people notice, pay attention to, or remember certain types of information better than other.

Cognitive Deficits

• There is evidence that people diagnosed as schizophrenic have difficulties in processing various types of information, for example visual and auditory information. Research indicates their attention skills may be deficient – they often appear easily distracted. • A number of researchers have suggested that difficulties in understanding other people’s behavior might explain some of the experiences of those diagnosed as schizophrenic. Social behavior depends, in part, on using other people’s actions as clues for understanding what they might be thinking. Some people who have been diagnosed as schizophrenic appear to have difficulties with this skill. • Cognitive deficits have been suggested as possible explanations for a range of behaviors associated with schizophrenia. These include reduced levels of emotional expression, disorganised speech and delusions.

Cognitive Biases

• Cognitive biases refer to selective attention. The idea of cognitive biases has been used to explain some of the behaviors which have been traditionally regarded as ‘symptoms’ of ‘schizophrenia’. • Delusions: The most common delusion that people diagnosed with schizophrenia report is that others are trying to harm or kill them – delusions of persecution. Research suggests that these delusions are associated with specific biases in reasoning about and explaining social situations. Many people who experience feelings of persecution have a general tendency to assume that other people cause the things that go wrong with their lives.

A strength of the cognitive explanation is that it has practical applications. Yellowless et al. (2002) developed a machine that produced virtual hallucinations, such as hearing the television telling you to kill yourself or one person’s face morphing into another’s.

The intention is to show schizophrenics that their hallucinations are not real. This suggests that understanding the effects of cognitive deficits allows psychologists to create new initiatives for schizophrenics and improve the quality of their lives.

A final strength is that it takes on board the nurture approach to the development of schizophrenia. For example, it suggests that schizophrenic behavior is the cause of environmental factors such as cognitive factors.

One weakness of the cognitive explanation is that there are problems with cause and effect. Cognitive approaches do not explain the causes of cognitive deficits – where they come from in the first place.

Is it the cognitive deficits which causes the schizophrenic behavior or is the schizophrenia that causes the cognitive deficits? This suggests that there are problems with the chicken and egg problem.

A second weakness of the cognitive model is that it is reductionist. The reason for this is because the approach does not consider other factors such as genes.

It could be that the problems caused by low neurotransmitters creates the cognitive deficits. This suggests that the cognitive approach is oversimplistic when consider the explanation of schizophrenia.

Section 4: Drug Therapy: typical and atypical antipsychotics

Drug therapy is a biological treatment for schizophrenia. Antipsychotic drugs are used to reduce the intensity of symptoms (particularly positive symptoms).

Typical Antipsychotics

• First generation Antipsychotics are called “Typical Antipsychotics” Eg. Chlorpromazine and Haloperidol. • Typical antipsychotic drugs are used to reduce the intensity of positive symptoms, blocking dopamine receptors in the synapses of the brain and thus reducing the action of dopamine. • They arrest dopamine production by blocking the D2 receptors in synapses that absorb dopamine, in the mesolimbic pathway thus reducing positive symptoms, such as auditory hallucinations. • But they tended to block ALL types of dopamine activity, (in other parts of the brain as well) and this caused side effects and may have been harmful.

Atypical Antipsychotics

• Newer drugs, called “atypical antipsychotics” attempt to target D2 dopamine activity in the limbic system but not D3 receptors in other parts of the brain. • Atypical antipsychotics such as Clozapine bind to dopamine, serotonin and glutamate receptors. • Atypical antipsychotic drugs work on negative symptoms, improving mood, cognitive functions and reducing depression and anxiety. • They also have some effect on other neurotransmitters such as serotonin . They generally have fewer side effects eg. less effect on movement Eg. Clozapine, Olazapine and Risperidone.

Since the mid-1950s antipsychotic medications have greatly improved treatment. Medications reduce positive symptoms particularly hallucinations and delusions; and usually allow the patient to function more effectively and appropriately.

Antipsychotic drugs are highly effective as they are relatively cheap to produce, easy to administer and have a positive effect on many sufferers. However they do not “cure” schizophrenia, rather they dampen symptoms down so that patients can live fairly normal lives in the community.

Kahn et al. (2008) found that antipsychotics are generally effective for at least one year, but second- generation drugs were no more effective than first-generation ones.

Some sufferers only take a course of antipsychotics once, while others have to take a regular dose in order to prevent symptoms from reappearing.

There is a sizeable minority who do not respond to drug treatment. Pills are not as helpful with other symptoms, especially emotional problems.

Older antipsychotics like haloperidol or chlorpromazine may produce side effects Sometimes when people with schizophrenia become depressed, so it is common to prescribe anti-depressants at the same time as the anti-psychotics.

All patients are in danger of relapsing but without medication the relapses are more common and more severe which suggests the drugs are effective.

Clozapine targets multiple neurotransmitters, not just dopamine, and has been shown to be more effective than other antipsychotics, although the possibility of severe side effects – in particular, loss of the white blood cells that fight infection.

Even newer antipsychotic drugs, such as risperidone and olanzapine are safer, and they also may be better tolerated. They may or may not treat the illness as well as clozapine, however.

Meta–analysis by Crossley Et Al (2010) suggested that Atypical antipsychotics are no more effective, but do have less side effects.

Recovery may be due to psychological factors – The placebo effect is when patients’ symptoms are reduced because they believe that it should.

However, Thornley et al carried out a meta-analysis comparing the effects of Chlorpromazine to placebo conditions and found Chlorpromazine to be associated with better overall functioning – Drug therapy is an effective treatment for SZ.

RWA – Offering drugs can lead to an enhanced quality of life as patients are given independence – Positive impact on the economy as patients can return to work and no longer need to be provided with institutional care.

Ethical issues – Antipsychotics have been used in hospitals to calm patients and make them easier for staff to work with rather than for the patients’ benefit – Can lead to the abuse of the Human Rights Act (no one should be subject to degrading treatment).

Severe side effects – Long term use can result in tardive dyskinesia which manifests as involuntary facial movements such as blinking and lip smacking – While they may be effective, the severity of the side effects mean the costs outweigh the benefits therefore they are not an appropriate treatment.

In most cases the original “typical antipsychotics” have more side effects, so if the exam paper asks for two biological therapies you can write about typical anti-psychotics and emphasise the side effects, then you can write about the atypical antipsychotics and give them credit for having less side effects.

Section 5: Psychological Therapies for Schizophrenia

Family therapy.

Family therapy is a form of therapy carried out with members of the family with the aim of improving their communication and reducing the stress of living as a family.

Family Therapy aims to reduce levels of expressed emotion, and reduced the likelihood of relapse.

Aims of Family Therapy

• To educate relatives about schizophrenia. • To stabilize the social authority of the doctor and the family. • To improve how the family communicated and handled the situation. • To teach patients and carers more effective stress management techniques.

Methods used in Family Therapy

• Pharoah identified examples of how family therapy works: It helps family members achieve a balance between caring for the individual and maintaining their own lives, it reduces anger and guilt, it improves their ability to anticipate and solve problems and forms a therapeutic alliance. • Families taught to have weekly family meetings solving problems on family and individual goals, resolve conflict between members, and pinpoint stressors. • Preliminary analysis: Through interviews and observation the therapist identifies strengths and weaknesses of family members and identifies problem behaviors. • Information transfer – teaching the patient and the family the actual facts about the illness, it’s causes, the influence of drug abuse, and the effect of stress and guilt. • Communication skills training – teach family to listen, to express emotions and to discuss things. Additional communication skills are taught, such as “compromise and negotiation,” and “requesting a time out” . This is mainly aimed at lowering expressed emotion.

A study by Anderson et al. (1991) found a relapse rate of almost 40% when patients had drugs only, compared to only 20 % when Family Therapy or Social Skills training were used and the relapse rate was less than 5% when both were used together with the medication.

Pharaoh et al. (2003) meta – analysis found family interventions help the patient to understand their illness and to live with it, developing emotional strength and coping skills, thus reducing rates of relapse.

Pharoah identified examples of how family therapy works: It helps family members achieve a balance between caring for the individual and maintaining their own lives, it reduces anger and guilt, it improves their ability to anticipate and solve problems and forms a therapeutic alliance.

Economic Benefits: Family therapy is highly cost effective because it reduces relapse rates, so the patients are less likely to take up hospital beds and resources. The NICE review of family therapy studies demonstrated that it was associated with significant cost savings when offered to patients alongside the standard care – Relapse rates are also lower which suggests the savings could be even higher.

Lobban (2013) reports that other family members felt they were able to cope better thanks to family therapy. In more extreme cases the patient might be unable to cope with the pressures of having to discuss their ideas and feelings and could become stressed by the therapy, or over-fixated with the details of their illness.

Token Economy

• Token economies aim to manage schizophrenia rather than treat it. • They are a form of behavioral therapy where desirable behaviors are encouraged by the use of selective reinforcement and is based on operant conditioning. • When desired behavior is displayed eg. Getting dressed, tokens (in the form of coloured discs) are given immediately as secondary reinforcers which can be exchanged for rewards eg. Sweets and cigarettes. • This manages schizophrenia because it maintains desirable behavior and no longer reinforces undesirable behavior. • The focus of a token economy is on shaping and positively reinforcing desired behaviors and NOT on punishing undesirable behaviors. The technique alleviates negative symptoms such as poor motivation, and nurses subsequently view patients more positively, which raises staff morale and has beneficial outcomes for patients. • It can also reduce positive symptoms by not rewarding them, but rewarding desirable behavior instead. Desirable behavior includes self-care, taking medication, work skills, and treatment participation.

Paul and Lentz (1977) Token economy led to better overall patient functioning and less behavioral disturbance, More cost-effective (lower hospital costs)

Upper and Newton (1971) found that the weight gain associated with taking antipsychotics was addressed with token economy regimes. Chronic schizophrenics achieved 3lbs of weight loss a week.

McMonagle and Sultana (2000) reviewed token economy regimes over a 15-year period, finding that they did reduce negative symptoms, though it was unclear if behavioral changes were maintained beyond the treatment programme.

It is difficult to keep this treatment going once the patients are back at home in the community. Kazdin et al. Found that changes in behavior achieved through token economies do not remain when tokens are with¬drawn, suggesting that such treatments address effects of schizophrenia rather than causes. It is not a cure.

There have also been ethical concerns as such a process is seen to be dehumanising, subjecting the patient to a regime which takes away their right to make choices.

In the 1950s and 60s nurses often “rewarded” patients with cigarettes. Due to the pivotal role of dopamine in schizophrenia this led to a culture of heavy smoking an nicotine addiction in psychiatric hospitals of the era.

Ethical issues – Severely ill patients can’t get privileges because they are less able to comply with desirable behaviors than moderately ill patients – They may suffer from discrimination

Cognitive Behavioral Therapy

In CBT, patients may be taught to recognise examples of dysfunctional or delusional thinking, then may receive help on how to avoid acting on these thoughts. This will not get rid of the symptoms of schizophrenia but it can make patients better able to cope with them.

Central idea: Patients problems are based on incorrect beliefs and expectations. CBT aims to identify and alter irrational thinking including regarding:

• General beliefs.
• Self image.
• Beliefs about what others think.
• Expectations of how others will act.
• Methods of coping with problems.

In theory, when the misunderstandings have been swept away, emotional attitudes will also improve.

Assessment : The therapist encourages the patient to explain their concerns.

• describing delusions • reflecting on relationships • laying out what they hope to achieve through the therapy.

Engagement :

The therapist wins the trust of the patient, so they can work together. This requires honesty, patience and unconditional acceptance. The therapist needs to accept that the illusions may seem real to the patient at the time and should be dealt with accordingly.

ABC : Get the patients to understand what is really happening in their life:

A: Antecedent – what is triggering your problem ? B: behavior – how do you react in these situations ? C: Consequences – what impact does that have on your relationships with others?

Normalisation :

Help the patient realise it is normal to have negative thoughts in certain situations. Therefore there is no need to feel stressed or ashamed about them.

Critical Collaborative Analysis :

Carrying on a logical discussion till the patient begins to see where their ideas are going wrong and why they developed. Work out ways to recognise negative thoughts and test faulty beliefs when they arise, and then challenge and re-think them.

Developing Alternative Explanations :

Helping the patient to find logical reasons for the things which trouble them Let the patient develop their own alternatives to their previous maladaptive behavior by looking at coping strategies and alternative explanations.

Another form of CBT: Coping Strategy Enhancement (CSE)

• Tarrier (1987) used detailed interview techniques, and found that people with schizophrenia can often identify triggers to the onset of their psychotic symptoms, and then develop their own methods of coping with the distress caused. These might include things as simple as turning up the TV to drown out the voices they were hearing! • At least 73% of his sample reported that these strategies were successful in managing their symptoms. • CSE aims to teach individuals to develop and apply effective coping strategies which will reduce the frequency, intensity and duration of psychotic symptoms and alleviate the accompanying distress. There are two components: 1. Education and rapport training: therapist and client work together to improve the effectiveness of the client’s own coping strategies and develop new ones. 2. Symptom targeting: a specific symptom is selected for which a particular coping strategy can be devised Strategies are practised within a session and the client is helped through any problems in applying it. They are then given homework tasks to practice, and keep a record of how it worked.

CBT does seem to reduce relapses and readmissions to hospital (NICE 2014). However, the fact that these people were on medication and having regular meetings with doctors would be expected to have that effect anyway.

Turkington et al. (2006) CBT is highly effective and should be used as a mainstream treatment for schizophrenia wherever possible.

Tarrier (2005) reviewed trials of CBT, finding evidence of reduced symptoms, especially positive ones, and lower relapse rates.

Requires self-awareness and willingness to engage – Held back by the symptoms schizophrenics encounter – It is an ineffective treatment likely to lead to disengagement.

Lengthy – It takes months compared to drug therapy that takes weeks which leads to disengaged treatment as they don’t see immediate effects – A patient who is very distressed and perhaps suicidal may benefit better in the short term from antipsychotics.

Addington and Addington (2005) claim that CBT is of little use in the early stages of an acute schizophrenic episode, but perhaps more useful when the patient is more calm and beginning to worry about how life will be after they recover. In other words, it doesn’t cure schizophrenia, it just helps people get over it.

Research in Hampshire, by Kingdon and Kirschen (2006) found that CBT is not suitable for all patients, especially those who are too thought disorientated or agitated, who refuse medication, or who are too paranoid to form trusting alliances with practitioners.

As there is strong evidence that relapse is related to stress and expressed emotion within the family, it seems likely that CBT should be employed alongside family therapy in order to reduce the pressures on the individual patient.

Section 6: Interactionist Approach

The Interactionist approach acknowledges that there are a range of factors (including biological and psychological) which are involved in the development of schizophrenia.

The Diathesis-stress Model

• The diathesis-stress model states that both a vulnerability to SZ and a stress trigger are necessary to develop the condition. • Zubin and Spring suggest that a person may be born with a predisposition towards schizophrenia which is then triggered by stress in everyday life. But if they have a supportive environment and/or good coping skills the illness may not develop. • Concordance rates are never 100% which suggests that environmental factors must also play a role in the development of SZ. MZ twins may have the same genetic vulnerability but can be triggered by different stressors. • Tienari Et. A. (2004): Adopted children from families with schizophrenia had more chance of developing the illness than children from normal families. This supports a genetic link. However, those children from families schizophrenia were less likely to develop the illness if placed in a “good” family with kind relationships, empathy, security, etc. So environment does play a part in triggering the illness.

Holistic – Identifies that patients have different triggers, genes etc. – Patients can receive different treatments for their SZ which will be more effective.

Falloon et al (1996) stress – such as divorce or bereavement, causes the brain to be flooded with neurotransmitters which brings on the acute episode.

Brown and Birley (1968) 50% people who had an acute schizophrenic episode had experienced a major life event in 3 weeks prior.

Substance abuse: Amphetamine and Cannabis and other drugs have also been identified as triggers as they affect serotonin and glutamate levels.

Vasos (2012) Found the risk of schizophrenia was 2.37 times greater in cities than it was in the countryside, probably due to stress levels. Hickling (1999) the stress of urban living made African-Carribean immigrants in Britain 8 to 10 times more likely to experience schizophrenia.

Faris and Dunham (1939) found clear pattern of correlation between inner city environments and levels of psychosis. Pederson and Mortensen (Denmark 2001) found Scandanavian villages have very LOW levels of psychosis, but 15 years of living in a city increased risk.

Fox (1990): It is more likely that factors associated with living in poorer conditions (e.g. stress) may trigger the onset of schizophrenia, rather than individuals with schizophrenia moving down in social status.

Bentall’s meta-analysis (2012) shows that stress arising from abuse in childhood increases the risk of developing schizophrenia.

Toyokawa, Et. Al (2011) suggest many aspects of urban living – ranging from life stressors to the use of drugs, can have an effect on human epigenetics. So the stressors of modern living could cause increased schizophrenia in future generations.

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• v.62(4); Fall 2010

Language: English | French

Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy

Purpose: The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.

Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.

Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time.

Intervention: The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal.

Implications: This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.

RÉSUMÉ

Objectif : L'objectif de cette étude de cas consiste à démontrer l'importance de réaliser des entrevues en profondeur avec les patients. Le cas étudié concerne un homme dirigé vers la physiothérapie en raison d'une dysfonction musculosquelettique. Au cours de l'entrevue avec ce patient, un problème psychiatrique a été décelé; par la suite, de la schizophrénie a été diagnostiquée. Le deuxième objectif de cette étude de cas est d'éduquer et de sensibiliser les physiothérapeutes aux signes et aux symptômes aisément reconnaissables de la schizophrénie.

Description du client : Le patient est un jeune homme de 19 ans qui souffre de douleurs chroniques à l'épaule, au coude et au poignet et qui avait été dirigé en physiothérapie. Au cours de l'entrevue, le patient a déclaré qu'il recevait des signaux provenant d'un appareil électronique implanté dans son corps.

Mesures et résultats : L'évaluation préliminaire du physiothérapeute a permis d'identifier un problème qui nécessitait que le patient soit redirigé vers un médecin. Une gestion plus poussée de la dysfonction musculosquelettique de ce patient a été jugée inappropriée à cette étape.

Intervention : Le patient a été dirigé vers une investigation médicale plus approfondie, puisqu'il manifestait des signes de possibles problèmes psychiatriques. Le patient a par la suite été diagnostiqué comme schizophrène et on lui a prescrit du Risperdal.

Implication : Cette étude de cas vient réaffirmer l'importance, pour le physiothérapeute, de procéder à des entrevues approfondies avec les patients pour s'assurer qu'il n'y a pas d'autres problèmes que les seules dysfonctions musculosquelettiques. Les patients qui souhaitent obtenir une évaluation et un traitement musculosquelettique peuvent souffrir aussi d'un problème psychiatrique primaire ou secondaire non diagnostiqué qui exige d'être reconnu par le physiothérapeute et qui nécessitera vraisemblablement une attention médicale ultérieure.

INTRODUCTION

A recent US study demonstrated that less than one-third of diagnoses provided to physical therapists by primary-care physicians are specific. 1 The same study illustrated that physical therapists must assume a greater diagnostic role and must routinely provide medical screening and differential diagnosis of pathology during the examination. 1 Similarly, studies conducted in Australia and Canada have concluded that the majority of referrals for physical therapy are not provided with a specific diagnosis. 2 , 3 Medical screening is important, since physical therapists are increasingly functioning as the primary contact for patients with neuromusculoskeletal dysfunctions, 4 , 5 which means a greater likelihood of encountering patients with non-musculoskeletal disorders, including psychiatric disorders.

As demonstrated by the World Health Organization's International Classification of Functioning, Disability and Health, it is imperative to take an individual's psychological state into account, since disorders in this area can lead to disability. 6 Many psychiatric conditions are commonly encountered in physical therapy practice; for example, depression, anxiety, and fear-avoidance have all been associated with low back, neck, and widespread musculoskeletal pain. 7 – 9 These psychiatric disorders have been identified both as risk factors for musculoskeletal dysfunction and as an important secondary psychosocial aspect of disablement. 7 – 10 It is therefore important for physical therapists to consider the primary and secondary roles of psychopathology in disability.

Although various models of primary-care physical therapy have demonstrated physical therapists' expertise in the realm of neuromusculoskeletal dysfunctions, there is a need for increased competencies in academic, clinical, and affective domains. 5 Few et al. propose a hypothesis-oriented algorithm for symptom-based diagnosis through which physical therapists can arrive at a diagnostic impression. 11 This algorithm takes into account the various causes of pathology, including psychogenic disorders. 11 Although additional research is necessary to validate Few et al.'s algorithm, it provides one model that considers underlying pathologies in determining the appropriateness of physical therapy intervention. 11 The present case report further illustrates the importance of considering the patient's affective and psychological state in order to more effectively screen for and identify psychiatric disorders that require medical referral.

The purpose of this case report is to demonstrate the importance of a thorough patient interview. We present the case of a man, referred for physical therapy for a musculoskeletal dysfunction, who was determined during the patient interview to have an undiagnosed psychiatric disorder, later identified as schizophrenia. In addition, this report is intended to educate physical therapists about the recognizable signs and symptoms of schizophrenia.

CASE DESCRIPTION

The patient was a 19-year-old male university student. His recreational activities included skateboarding, snowboarding, break dancing, and weight training. The patient first sought medical attention from a sport medicine physician in January 2006, when he reported right lateral wrist pain since falling and hitting the ulnar aspect of his wrist while skateboarding in October 2005. Plain film radiographs taken after the injury were negative, and the patient did not receive any treatment. The physician found no wrist swelling, minimal tenderness over the ulnar aspect of the right wrist, full functional strength, and minimally restricted range of motion (ROM). The patient was given ROM exercises and was diagnosed with a right wrist contusion.

Over the next 22 months, the patient returned to the same sport medicine clinic 10 times, reporting pain in his wrist, shoulder, elbow, knee, ankle, and neck. He stated that the elbow, wrist, and shoulder injuries were due to falls while skateboarding and snowboarding or to overuse during weight training; some injuries had no apparent cause. Over the course of his medical care, the patient followed up with three different physicians at the same clinic. He was diagnosed by these physicians, in order of occurrence, with (1) right wrist contusion and sprain; (2) right wrist impingement and left wrist strain; (3) right shoulder supraspinatus tendinopathy; (4) right peroneal overuse injury and strain; (5) disuse adhesions of the right peroneals and right hip adhesions; (6) right ankle neuropathic pain secondary to nerve injury and sprain and right-knee patellofemoral pain syndrome (PFPS); (7) neuropathic pain of the right peroneal nerve; (8) trauma-induced left-knee PFPS; (9) ongoing post-traumatic left-knee PFPS; and (10) right levator scapula strain, chronic right infraspinatus strain, right elbow ulnar ridge contusion, and right wrist chronic distal ulnar impingement secondary to malaligned triangular fibrocartilage complex (TFCC).

After his tenth visit to a physician, the patient was referred for physical therapy for chronic right levator scapula strain and right supraspinatus strain. During the interview, the patient stated that he had right shoulder pain because of a snowboarding injury sustained 1 year earlier and because of a fall onto the lateral right shoulder 2 years ago. Aggravating activities to the shoulder included pull-ups, rowing, and free weights. No position or movement alleviated his pain, and the pain did not fluctuate over the course of the day. His sleep was disturbed only when lying on the right shoulder. The patient was in generally good health, but he said that his right wrist and left knee occasionally felt cold for no apparent reason. He denied experiencing any loss of sensation, decreased blood flow, or numbness or tingling in the knee and wrist. The patient said he believed that his knee and wrist became cold as a result of electromagnetic impulses sent to the joint via an electrical implant in his body and that this device was the cause of his ongoing shoulder pain.

According to the patient, this device had been implanted into his body 2 years earlier by a government organization (the Central Intelligence Agency, the US government, or the US Army) to control his actions. Electromagnetic impulses generated by the implant had caused his falls and injuries; they also caused his joints to become cold or painful when he was doing something “they” did not want him to do, such as break dancing, snowboarding, skateboarding, or exercising. The patient also believed that many other people unknowingly had implants; he claimed that friends, neighbours, professors, and strangers were “working with them” and that they “emotionally abuse[d]” him by giving signs such as kicking a leg back to let him know he was being watched. Furthermore, he indicated that he often received commands telling him to harm his friends or family and that these orders came either from the electrical implant or from the people he claimed were emotionally abusing him. He therefore distanced himself from some friends because he did not want to follow through with these commands. I asked the patient if he felt he would harm himself or others because of his psychotic-like symptoms. He denied any desire to inflict harm on himself or others. Had he posed a threat to himself or others, he would have been “formed” (i.e., committed to a psychiatric facility by the appropriate medical professional).

The patient's past medical and family history were unremarkable. He did not use any prescription or over-the-counter medications, but he felt his thoughts about electrical implants were decreased by the use of marijuana, which he used socially. He was a non-smoker and a social consumer of alcohol. He had a normal gait and appeared comfortable in an unsupported seated position. He denied any weight changes, bowel or bladder problems, night pain, or difficulty breathing.

PHYSICAL EXAMINATION

The patient reported a maximum verbal numeric pain rating scale (NPRS) score of 8/10 and a minimum score of 0/10, with pain usually present in the shoulder. In a double-blind, placebo-controlled, multi-centre chronic pain study, when the baseline NPRS raw score fluctuated by 0 points, the sensitivity and specificity were 95.32% and 31.80% respectively; 12 , 13 when there was a 4-point raw score change, the sensitivity and specificity were 35.92% and 96.92% respectively. 12 The patient stated that when he experienced shoulder pain, it was located on the anterior, posterior, and lateral aspects of his shoulder and radiated down to his elbow and wrist. He reported 0/10 shoulder pain while seated.

Standing posture was assessed in the frontal and sagittal planes. 14 The patient had a mild forward head posture and internally rotated glenohumeral joints in the sagittal plane. The frontal-plane analysis revealed a slight elevation of the right shoulder and level iliac crests. Such visual assessment of cervical and lumbar lordosis has an intrarater reliability of k =0.50 but an interrater reliability of k =0.16. 15

In the frontal plane, the right scapula was abducted four finger-widths from the mid-thoracic spine, and the left scapula was abducted three finger-widths. The scapulas were superiorly rotated bilaterally. Surface palpation of the acromial angle, inferior angle, and spine of the scapula differed less than 0.98 cm, 0.46 cm, and 0.67 cm, respectively, from the actual bony location, with a 95% confidence interval. 16 There was visible hypertrophy of the pectoralis major muscle bilaterally. Active and passive ROM were tested for the shoulders as recommended by Magee. 14 The patient had full bilateral active ROM, with minimal pain at end-range flexion and abduction that was not increased with overpressure in accordance with Magee. 14 He had full passive ROM with no pain reported.

Manual muscle testing based on Hislop and Montgomery revealed 4/5 strength of external rotation at 0° and 45° of abduction, with pain reported along the anterolateral shoulder. 17 Testing also showed 3/5 strength and no pain with resisted abduction with the arm at the side at approximately 30° of abduction. 18 Manual muscle testing is a useful clinical assessment tool, although a recent literature review suggested that further testing is required for scientific validation. 18 Palpation of the shoulder, as described by Hoppenfeld, revealed slight tenderness over the greater tubercle, as well as along the length of the levator scapula muscle. 19

Special tests were negative for the sulcus sign, Speed's test, the drop arm test, and the empty can test, as described by Magee. 14 Research shows that Speed's test has a sensitivity and specificity of 32% and 61% for biceps and labral pathology respectively; 20 the drop arm test has a sensitivity of 27% and a specificity of 88% as a specific test for rotator cuff tears, and the empty can test has a sensitivity of 44% and a specificity of 90% in diagnosing complete or partial rotator cuff tears. 20 , 21 The Neer and Hawkins-Kennedy impingement tests were both negative. 14 According to a meta-analysis by Hegedus et al., the Neer test is 79% sensitive and 53% specific, while the Hawkins-Kennedy test is 79% sensitive and 59% specific, for impingement. 21

I (NS) diagnosed the patient with mild supraspinatus tendinosis, with no evidence of tearing of the rotator cuff muscles, based on the following findings drawn from the patient interview: shoulder pain aggravated by pull-ups, rowing, and free weights; increased pain when lying on the affected shoulder. Additional significant findings from the physical examination included full shoulder active ROM with minimal pain at end-range flexion and abduction; pain along the anterior lateral shoulder with resisted testing of external rotation at 0° and 45° of abduction; negative drop arm and empty can tests; and tenderness over the greater tubercle of the humerus. The musculoskeletal dysfunction did not explain the level of pain reported by the patient (maximum NPRS 8/10), nor was the physical examination able to reproduce the exact location of the reported shoulder pain or the elbow, wrist, and knee pain described by the patient.

I was concerned about a serious pathology or a psychological disorder, given that this 19-year-old had made 10 medical appointments over 22 months for 6 different regions of the body; in my experience of examining and treating patients between the ages of 18 and 25, the frequency of the appointments and the variation in afflicted body parts are not typical of a young patient. The patient's description of his shoulder pain, in terms of location and severity, was not reproducible by physical examination. Throughout our interview, the patient did not maintain good eye contact, spoke in a monotone voice, and had an overall flat affect. Even when he described his beliefs about implants and government control, his voice and demeanour remained expressionless. The patient described persecutory delusions, command hallucinations, and social isolation from friends and family, all of which are signs of psychosis according to the Diagnostic and Statistical Manual of Mental Health . 22

Based on the findings from the patient interview and the physical examination, the patient did have symptoms consistent with a known musculoskeletal dysfunction; however, the undiagnosed and uncontrolled psychiatric symptoms made it more appropriate to refer him back to the physician for evaluation and treatment of his psychosis than to provide physical therapy intervention for his shoulder dysfunction. Furthermore, because research shows that the rate of suicide among patients with schizophrenia can range from 2% or 4% to as high as 15% 23 , 24 and that the rate of suicide is highest among patients close to the date of diagnosis, early recognition is crucial. 23

INTERVENTION

Based on the findings from the patient interview and the signs and symptoms of psychiatric disorders, I explained to the patient that there was a need for further medical investigation. Although the patient did not agree with this initial assessment, he did consent to a follow-up with the referring physician.

I spoke to the referring physician in person and explained to him my findings from the patient interview, specifically the patient's belief that he had electrical implants in his body. I also pointed out the patient's affect and the limited physical findings during the physical examination. I provided the physician with some direct quotes from the patient to demonstrate the level of psychosis he was presenting with. I stated my conclusion that the patient was suffering from some form of psychosis that precluded physical therapy treatment for his shoulder at that time. The referring physician was quite concerned about the patient and called him during our meeting to arrange a follow-up medical appointment.

The physician examined the patient, made similar observations, concurred with my assessment, and concluded that the patient was experiencing some form of psychosis. The plan of care involved referral to a psychiatrist, follow-up with the physician, and explaining to the patient that physical therapy would not be appropriate at this time because of the presence of a serious psychiatric disorder. The patient did not believe that he had a psychiatric disorder, but he was willing to follow up with a psychiatrist. The physician noted that the patient was not a threat to himself or others and that he did not report having homicidal or suicidal thoughts.

The patient followed up with the psychiatrist 11 days after his appointment with the physician. He was diagnosed with schizophrenia and started on a daily dose of risperidone (Risperdal). The patient was also instructed to follow up with the psychiatrist every second week to ensure compliance with the medication and to discuss progress. Further details of the psychiatric assessment and treatment were not available for this case report. Outcomes are also unavailable for this case report, since follow-up by the physical therapist was not possible.

Case Summary

This case report describes a 19-year-old man referred to physical therapy with shoulder, wrist, and knee pain who was later diagnosed with a psychiatric disorder. After completing a thorough patient interview and physical examination, I concluded that the patient was suffering from an undiagnosed psychiatric disorder that required medical referral. The interview revealed that the patient had delusions about electrical devices' being implanted in his body and was experiencing various forms of hallucination. The patient was promptly referred for medical consult and was diagnosed with schizophrenia by a psychiatrist.

Patient Symptoms and Schizophrenia

Schizophrenia is a psychiatric disorder affecting between 0.5% and 1.5% of adults worldwide, with a slightly greater prevalence in men. 22 The age of onset may be from 5 to 60 years; however, more than 50% of first episodes occur between the ages of 15 and 24. 22 , 25 , 26 An earlier onset is more common among men, while later onset is more common among women. 25 Schizophrenia shows a higher incidence in individuals born in urban areas than in those born in rural areas. 22 , 25 Because the patient in the present case fell into several of these categories (male, born in an urban area, experienced onset of symptoms around age 17) and presented with clear symptoms of a psychiatric disorder (delusions, hallucinations), schizophrenia seemed the most likely diagnosis.

The signs and symptoms of schizophrenia are classified as either positive or negative. 22 Positive symptoms are an excess of normal function and include delusions, hallucinations, and disorganized speech; 22 , 27 negative symptoms are a deficiency of normal function and include limited goal-directed behaviour (avolition), limited fluency and productivity of speech and thought, and a flat affect. 22 , 27 The diagnosis of schizophrenia requires the presence of at least two of these positive or negative symptoms lasting at least 6 months. 22 , 27 In this case, the patient presented with delusions (e.g., electrical implants trying to control his and others' actions), including persecutory delusions (e.g., “they are emotionally abusing me”), hallucinations (e.g., hearing voices, seeing signs), and a flat affect. Since the patient was enrolled in university at the time of diagnosis, his cognitive function is assumed to be well preserved. The patient reported no change in symptoms for 2 years.

Schizophrenia is subdivided into five types: paranoid, disorganized, catatonic, undifferentiated, and residual (see Table ​ Table1 1 ). 22 , 28 Based on these observations and on the literature, the patient's symptoms were suggestive of paranoid schizophrenia, 22 which is the most prevalent form of schizophrenia in most parts of the world. 22

Schizophrenia Subtypes 6

The aetiology of schizophrenia remains unknown. 29 , 30 There is a strong genetic predisposition. 29 , 30 Patients who experience the onset of schizophrenia before age 22 are 10 times more likely to have a history of a complicated caesarean birth than patients with a later onset of schizophrenia, which suggests a possible neurodevelopmental factor in early-onset schizophrenia. 31 Mild childhood head injuries may play a role in the expression of schizophrenia in families with a strong genetic predisposition to this disorder. 32 Psychological stress has also been implicated in the onset of schizophrenia, since it often precipitates the first psychotic episode or increases the likelihood of a relapse. 33 , 34 In this case, the patient described a family “break-up” which may have precipitated the onset of psychosis. Details about his childhood head injuries and the circumstances of his birth were not obtained. After being diagnosed with schizophrenia, the patient revealed to the referring physician that his father had experienced something similar when he was younger, which may point to a genetic predisposition.

There are no conclusive diagnostic tests for schizophrenia. 22 However, imaging studies have suggested neurophysiologic changes as an associated finding. Volumetric magnetic resonance imaging (MRI) studies of patients with schizophrenia have demonstrated an overall reduction in grey matter; an increase in white matter; decreased size of the amygdala, hippocampus, and parahippocampus; an overall reduction in brain volume; and larger lateral ventricles relative to a control group. 35 – 37

Psychiatric Disorders as They Relate to Musculoskeletal Dysfunction

As primary-care practitioners, physical therapists may encounter patients with possible psychiatric disorders such as schizophrenia. However, the physical therapy literature on psychiatric disorders as they relate to musculoskeletal disorders focuses mainly on low back pain (LBP). 7 , 8 In an examination of a large number of physical and psychological factors, one prospective case-control study points to the importance of psychological variables as a risk factor for chronic LBP and widespread musculoskeletal pain. 8 Previous research has also concurred with this study in implicating psychological variables as risk factors for LBP and neck pain. 9 , 10 These articles provide a link between psychological disorders and patients seeking physical therapy for musculoskeletal dysfunctions.

In this case report, the physical examination was suggestive of a mild supraspinatus tendinosis, but this did not explain the severity of pain reported by the patient or the referral of pain to the elbow, wrist, and knee. One of the limitations of the physical examination was that there was not sufficient time to perform physical examination of the elbow, wrist, and knee. The patient's undiagnosed and uncontrolled psychiatric symptoms took priority over the musculoskeletal dysfunction and required immediate medical referral without physical therapy intervention. Because of the inconsistencies between interview and physical examination, as well as the patient's perception that an electrical implant was causing his musculoskeletal pain, there is a possibility that at least some of his musculoskeletal symptoms may have been manifestations of his psychiatric disorder.

Effective Patient Interviews

The medical literature indicates that 50% of all mental illness is recognized during the interview process as part of medical assessment by the primary-care physician. 38 As physical therapists embrace their role as providers of primary care, 4 , 5 they must rely on their skills in patient interviewing and physical examination to rule out medical pathology. Improved assessment skills by the physical therapist may help to identify primary or secondary medical pathologies that have not previously been diagnosed. Within the peer-reviewed literature, a number of case studies demonstrate identification of non-musculoskeletal or visceral pathology that can manifest as musculoskeletal disorders; 39 – 41 these case studies are examples of how physical therapists can perform an initial assessment, identify a medical pathology that precludes treatment, and make an appropriate referral. During a patient interview, physical therapists must be well aware of the psychological and psychosocial aspects of the examination to identify relevant aspects of the patient's demeanour (e.g., appropriate self-care) and emotional state (e.g., inappropriate affect). The patient interview should consist of non-leading, open-ended questions about how pain in multiple areas is related and how it is caused. Furthermore, physical therapists should avoid rationalizing the patient's symptoms during the interview process. At a minimum, patients should be permitted to speak about and describe their symptoms in a way that is meaningful to them.

Schizophrenia and Primary Care

Schizophrenia is most often initially recognized by the primary-care physician. 42 Psychiatrists, psychologists, and even the lay community have also been noted in the literature as making the initial identification. 43 – 45 Although conspicuously absent from the literature on the initial identification of schizophrenia, physical therapists are in a position to be important first-contact care providers who can make the initial identification of schizophrenia, and other psychiatric disorders, through effective patient interviews. Although labelling patients as having a psychiatric disorder is outside physical therapists' scope of practice, the diagnostic process is not exclusive to any one profession. In this case, the process of diagnosis, which involves assessing the patient, grouping findings, interpreting the data, and identifying the patient's problems, led me to conclude that the primary dysfunction was psychiatric in nature. 46 This process, which Few et al. call “diagnostic reasoning,” is well within physical therapists' scope of practice and is something we constantly engage in during our daily clinical practice. 11 Diagnostic reasoning involves taking into account all of the possible pathological structures and determining the most likely cause of the patient's symptoms. In practice, expert clinicians do not follow standardized protocols; 46 rather, they pay attention to cues provided by the patient, recognize patterns, and test hypotheses to arrive at a probable cause for the patient's symptoms. 11

IMPLICATIONS AND FUTURE DIRECTIONs

The medical literature has identified gaps in the knowledge of primary-care physicians, specifically a lack of awareness of the symptoms and epidemiology of schizophrenia. 28 To facilitate early recognition, referral, and diagnosis of schizophrenia, the medical literature has suggested increased collaboration among family physicians and mental-health professionals, as well as ongoing mental-health training for family physicians. 47 , 48 Physical therapists should also heed these suggestions. A study in the physical therapy literature recommends mental-health training for recognizing the symptoms of depression in a population with LBP; 7 the same study, conducted in Australia, concluded that physical therapists' ability to recognize depressive symptoms in an outpatient setting was poor. 7

An initial step to address these gaps could be a position paper that draws on the medical literature to inform physical therapists about the presence, prevalence, signs, and symptoms of common psychiatric disorders. As well, future research needs to focus on the incidence of musculoskeletal signs and symptoms in patients with common psychiatric disorders.

KEY MESSAGES

What is already known on this topic.

To the authors' knowledge, there are no known studies in the literature describing a case of a patient referred to physical therapy for musculoskeletal dysfunction who was later diagnosed with schizophrenia.

What This Study Adds

This case report contributes to the existing literature on physical therapists functioning as competent providers of primary care who have the knowledge and skills needed to rule out non-musculoskeletal pathology. It also educates physical therapists about the signs and symptoms of schizophrenia.

Shah N, Nakamura Y. Case report: schizophrenia discovered during the patient interview in a man with shoulder pain referred for physical therapy. Physiother Can. 2010;62:308–315

Psychosis, OCD, and Questions of Reality

What ocd and psychosis can tell us about how we connect with the world..

Updated September 2, 2024 | Reviewed by Michelle Quirk

• What Is Obsessive-Compulsive Disorder?
• Take our Generalized Anxiety Disorder Test
• Find counselling to treat OCD
• Intrusive thoughts in OCD can sometimes be misunderstood as hearing voices.
• Individuals with schizophrenia have an increased risk of OCD compared with those without.
• For some, there is some clinical overlap such as a voice instructing a person to engage in OCD rituals.

"What does that mean?" "It means you are disconnected from reality."

I still remember looking up at the psychologist who had shared her impressions with me of my psychosis . At just 13 years old, the term "disconnected from reality" mystified me. As an adult and therapist specializing in psychosis, it still does.

Reality in Psychosis

An objective reality is nearly impossible to define. There is consensus on a few topics. For example, most would agree that we share this interaction on Earth. Yet, even in these consensus pieces, the variations in experience are wild. Most people have at least one belief that could be called unusual.

Many clinicians find the concept of fixation more accurate in defining psychosis and especially delusion. A delusion is difficult to challenge; it doesn't typically bow to reason.

Reality in Obsessive-Compulsive Disorder

On the opposing side, we have conditions of doubt. Most notably, obsessive-compulsive disorder (OCD). In OCD, one's belief in oneself as a reliable narrator is often shaky, so much as to spark rituals of checking, reassurance seeking, counting, and washing to verify.

OCD is stereotyped as a condition of organization and psychosis one of disorganization. One would think there would be little overlap, but this is not the case.

Differentiation and Treatment

Differential diagnosis between OCD and psychosis is sometimes tricky. For example, intrusive thoughts can sometimes be voice-like, so loud that a person shudders. Similarly, voices in psychosis have been noted to sometimes give commands including ones at times that appear like OCD rituals.

Both individuals with OCD and psychosis might report fear of losing touch. In a sense, both are conditions of how we relate to reality.

To make matters even more confusing, comorbidity between OCD and psychotic disorders like schizophrenia is high. Research suggests that between 12 and 24 percent of individuals with a schizophrenia spectrum disorder may also have OCD (Pardossi et al., 2024).

Accurate diagnosis is key here as treatment of OCD and schizophrenia spectrum disorders is quite different both in psychotherapy and with medication . While individuals who have experienced psychosis may be encouraged to reality check in cognitive behavioral therapy to test the integrity of their perceptions, tolerating uncertainty is a common objective in psychotherapy for OCD.

A Philosophical Question

Still, the overlap in these conditions and their comorbidity furnish questions regarding doubt, belief, and the nature of reality. In a world where some may estimate we live in a simulation, and, by contrast, others turn to faiths of all kinds to explain reality, and still others hold rigidly to what is readily observable by our fragile senses, it can be asked, is anyone connected to reality?

Pardossi, S., Cuomo, A., & Fagiolini, A. (2024). Unraveling the Boundaries, Overlaps, and Connections between Schizophrenia and Obsessive–Compulsive Disorder (OCD). Journal of Clinical Medicine , 13 (16), 4739.

Jennifer Gerlach, LCSW, is a psychotherapist based in Southern Illinois who specializes in psychosis, mood disorders, and young adult mental health.

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• Published: 02 September 2024

Updated rationale for the initial antipsychotic selection for patients with schizophrenia

• Matej Markota 1 ,
• Robert J. Morgan III   ORCID: orcid.org/0000-0003-0103-2090 1 &
• Jonathan G. Leung   ORCID: orcid.org/0000-0003-3836-9375 1 , 2  

Schizophrenia volume  10 , Article number:  74 ( 2024 ) Cite this article

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• Psychiatric disorders
• Schizophrenia

Introduction

Expert groups differ in their recommendations for early-stage schizophrenia treatment. Some expert groups, including American Psychiatric Association (APA), are non-directive and do not specify preferred agents for patients with first-episode psychosis 1 , 2 , 3 . This approach, while patient-centric, may challenge early practitioners and learners. Others offer algorithmic guidelines, but existing algorithms only partially agree on “first-line” treatments (see the section “Summary of first-line treatment options for patients without concurrent violence” for definition), reflecting the complexity of risk-benefit analysis 4 , 5 , 6 , 7 , 8 , 9 . In addition, updates to guidelines are essential to incorporate the latest research.

Based on up-to-date evidence (as of January 2024), we present a rationale for the selection of “first-line treatments” for patients with early-stage schizophrenia and challenges surrounding the selection of these agents. We present a general rationale, such that when idiographic factors of individuals dictate a different approach, the considerations discussed here should defer to individualized plans, and patients and practitioners should engage in shared decision-making at every step.

Initial patient stratification

After diagnosis of schizophrenia spectrum disorder is made and need for treatment established, patients in this algorithm are stratified into two groups (see the section “Treatment of patients with violence” for rationale) based on comorbid violence (in research studies typically defined as high score on the Positive and Negative Syndrome Scale (PANSS) hostility item or Modified Overt Aggression Scale 10 , 11 ; henceforward “violence” will be used for simplicity). Figure 1 summarizes selection of antipsychotics proposed in this manuscript.

The figure summarizes the guiding factors and sequential options involved in the decision-making process for selecting antipsychotic medications. *In alphabetical order.

Treatment of patients without violence

Initial treatment of patients without concurrent violence.

Clinicians face challenges in balancing efficacy and side effects when prescribing antipsychotics to treatment-naive patients. Existing algorithms approach this issue by assigning high significance to a few side effects, such as weight gain and/or tardive dyskinesia, commonly leading to exclusion of agents such as olanzapine and first-generation antipsychotics (FGAs), respectively, as first-line treatments 4 , 5 , 9 . The approach here deviates from such a rationale. In our opinion, selection of first-line treatments should be guided by three key overlapping factors:

Overall efficacy: Randomized controlled trials (RCTs) comparing antipsychotics with long-term follow-up should be preferentially considered. Most RCTs are only several weeks long 12 . Since schizophrenia is a disorder requiring treatment far longer in duration, shorter duration RCTs are less relevant (though still important) and have less external validity compared to studies with longer outcomes 3 .

All-cause discontinuation: Discontinuation is typically influenced by perceived (in)efficacy and tolerability 13 . Instead of weighing risks of particular side effects against effectiveness, we use all-cause discontinuation rates as a surrogate measure of side effect burden versus effectiveness. All-cause discontinuation is ideally based on RCTs with long-term follow-up.

Mortality: Schizophrenia has one of the highest mortality risks of all psychiatric disorders 14 . While complex and difficult to study, mortality is a crucial outcome deserving attention for antipsychotic selection 3 , 15 . There is an emerging consensus that untreated psychosis has more adverse health effects compared to risks posed by antipsychotics 16 , 17 , but there is little guidance on how to weigh risk of discontinuation (and associated risks of untreated psychosis) versus long-term side effects. One could imagine a scenario of a weight-gaining antipsychotic with higher efficacy and lower overall discontinuation rate initially, but higher long-term mortality because of cardiovascular problems associated with weight gain over a longer period. Increased mortality may exclude this medication from first-line therapies. Conversely, if a weight-gaining antipsychotic has higher efficacy, lower discontinuation rates, and similar or lower long-term mortality relative to alternative treatments, there is no convincing reason to exclude it from first-line treatments. Thus, mortality data combines the above factors to allow determination of the “safest” first-line treatment choices.

Regarding criteria 1 & 2 above we discuss selection of key published literature here. With regard to criterion 3, RCTs generally do not offer long-term mortality data, and we discuss relevant mortality literature for each medication below.

There is only one large-scale network meta-analysis focused directly on comparing RCTs of antipsychotics with at least 6-month follow-up of acutely ill patients 12 . Amongst all non-clozapine antipsychotics available in the U.S., five antipsychotics—lurasidone, olanzapine, perphenazine, risperidone, and aripiprazole—rank highest for overall efficacy and lowest overall discontinuation 12 .

Aripiprazole and risperidone are among first-line treatment options in most existing algorithms, and we find their place here to be non-controversial 4 , 5 , 7 , 9 . Sections below will contrast the remaining three antipsychotics to aripiprazole and risperidone to demonstrate how our rationale diverges from existing protocols.

In RCTs, olanzapine consistently demonstrates superior efficacy compared to risperidone or aripiprazole; evidence is of moderate confidence and small effect size 12 . In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial, the number need to treat for olanzapine versus risperidone was ~10; for olanzapine versus perphenazine it was 9; and for olanzapine versus quetiapine it was 5.5 18 . While equivalent dose of olanzapine was higher relative to other agents in CATIE 19 , other trials with comparable doses confirmed favorable efficacy of olanzapine over risperidone 20 , 21 . In addition, olanzapine has a significantly lower discontinuation rate, indicating favorable efficacy-to-tolerability ratio 12 . In a Finnish cohort study of patients discharged from first schizophrenia-related hospitalization, those discharged on oral olanzapine had lower risk of rehospitalization versus oral risperidone 22 .

On the other hand, olanzapine is associated with significantly more weight gain; higher total cholesterol and triglycerides (compared to aripiprazole, lurasidone, and risperidone) 12 , 23 ; and is more strongly associated with incident diabetes relative to risperidone 24 . Since cardiovascular disease affects patients with schizophrenia at high rates, such side effects deserve serious attention 25 . Studies in adults with mean duration of 42 weeks show that olanzapine leads to 3 kg more of weight gain compared to aripiprazole and about 2 kg more compared to risperidone 12 ; younger antipsychotic-naive patients may show more pronounced differences 26 . In the CATIE trial, olanzapine relative to risperidone was associated with an increase of 1% in the 10-year coronary heart disease risk, which was statistically significant 27 . However, consistent with its favorable efficacy profile and the hypothesis that improved psychiatric status leads to healthier lifestyles, Solmi and colleagues found that olanzapine ranked best among non-clozapine antipsychotics with regard to patients’ adherence to cardiometabolic drugs 28 . While olanzapine is clearly more metabolically unfavorable than other potential first-line agents, the key question is whether olanzapine’s advantages outweigh its disadvantages. We will attempt to answer this question quantitatively based on most recent data on antipsychotic-associated mortality.

In a 1-year, open label, randomized trial, ziprasidone and olanzapine had the same rate of non-suicidal mortality in patients with schizophrenia 29 . A prospective Finnish register study with 5-year follow-up of patients with first-episode schizophrenia found decreased overall mortality with olanzapine relative to non-users of antipsychotics; this effect was not observed for risperidone 30 . An 11-year follow-up study in patients with schizophrenia from Finland compared several antipsychotics with perphenazine serving as a reference. Overall mortality in users of olanzapine was not significantly different compared to perphenazine, but mortality was significantly higher in patients on risperidone 31 . Risk of death from ischemic heart disease was similar between risperidone and olanzapine, though trended higher in risperidone 31 . Cumulative exposure to olanzapine was similarly associated with a trend toward lower mortality relative to risperidone 31 . A study with up to 20 years of follow-up (FIN-20) found that monotherapy with olanzapine, risperidone, or aripiprazole was associated with the same risk of somatic hospitalization and same risk of cardiovascular hospitalization 32 . Overall mortality in patients on monotherapy with olanzapine was not different from aripiprazole and lower for olanzapine compared to risperidone; cardiovascular mortality was similar in patients on olanzapine and aripiprazole and trended towards lower mortality in olanzapine versus risperidone 32 . A number of large-scale studies not limited to schizophrenia describe similar findings 33 , 34 .

To summarize, the higher metabolic burden of olanzapine is a serious problem for some patients. However, decisions about olanzapine’s use as a first-line agent cannot simply be reduced to reflexive exclusion based on metabolic risk. Based on the three key criteria and findings described above, we do not see a legitimate reason to include risperidone among first-line treatment options while excluding olanzapine. Rather, we believe there are sufficient and legitimate reasons to consider olanzapine as a valid first-line treatment option (see the section “Summary of first-line treatment options for patients without concurrent violence”) while appropriately monitoring for metabolic effects. This conclusion is contrary to several existing algorithms and recommendations 5 , 6 , 9 , 35 but in agreement with the Texas Medication Algorithm Project 7 . As discussed in the introduction, individual patient preferences are crucial, side effects influence adherence 36 , and thus for patients who list weight gain as a particularly undesirable outcome olanzapine should be reserved for later trials.

Perphenazine

Perphenazine is excluded from first-line treatment options due to recognized risk of tardive dyskinesia (TD) and other extrapyramidal side effects (EPS) associated with FGAs 4 , 5 , 6 , 7 , 9 . However, there is considerable variability in TD risk within FGA and second-generation antipsychotic (SGA) classes, a nuance frequently ignored by other algorithms. Perphenazine has one of the lowest known risks of TD among FGAs 37 . It also may have a lower risk of TD relative to some SGAs (e.g., lurasidone) 37 . Perphenazine users have higher antiparkinsonian medication use than aripiprazole users, but similar to risperidone users; akathisia risk is also comparable between perphenazine and risperidone 12 . Perphenazine trends toward less weight gain compared to aripiprazole and risperidone, and demonstrates significance versus olanzapine [12]. It is linked to lower prolactin elevation than risperidone 12 . Finally, in CATIE, perphenazine outperformed olanzapine and risperidone in exploratory analysis of neurocognitive performance at 18 months but not in the primary outcome of neurocognitive scores at 2 months 38 .

In the context of overall mortality, perphenazine outperformed risperidone in the 11-year follow-up study (as discussed in the section “Olanzapine”) 31 . In FIN-20, oral perphenazine trended toward lower risk of somatic hospitalization relative to risperidone 32 .

There is paucity of studies on perphenazine in first-episode psychosis (see the “Summary” section). Aside from this limitation, we see no other compelling rationale to include risperidone in first-line treatment options while excluding perphenazine. This contrasts with other available algorithms 4 , 5 , 6 , 7 , 9 .

Lurasidone performed well in the recent network meta-analysis with regard to efficacy; however, evidence was low level 12 . Thus, true comparative efficacy remains uncertain, and mortality data is lacking, so lurasidone’s place amongst first-line treatment options remains unknown. Including mortality as a key selection factor risks excluding more novel antipsychotics which by definition will not have 10- to 20-year mortality data available. Hence, lurasidone’s known advantages and disadvantages need to be carefully weighed against aripiprazole, risperidone, olanzapine, and perphenazine.

Lurasidone has a favorable metabolic profile, similar to aripiprazole, but the latter has advantages of lower risk of EPS, easier administration (due to no caloric restrictions), and availability of long-acting formulation 12 , 39 , 40 . A second possible advantage of lurasidone is an antidepressant effect, but evidence from long-term trials is limited 12 . Short-term trials on depressive symptoms in patients with schizophrenia show that lurasidone did not outperform aripiprazole, olanzapine, or risperidone 41 . In summary, the currently available literature fails to reveal compelling advantages of lurasidone over aripiprazole or perphenazine (see the section “Perphenazine“). Consequently, based on the three core criteria and a fruitless analysis of other potential advantages, lurasidone does not currently merit inclusion among first-line treatment options, a conclusion that deviates from other algorithms 4 , 5 .

Summary of first-line treatment options for patients without concurrent violence

It is important to clarify the notion of “first-line treatment option” as used in this text. Given high number of Food and Drug Administration (FDA) approved antipsychotics in the U.S., it is impossible to comprehensively discuss advantages and side effects of all available medications within the confines of a clinical encounter. In our interpretation, “first-line options” pertain to a limited range of medications that can feasibly be discussed with a patient during a clinical encounter. Based on discussion above, we posit that it is reasonable to discuss risks and benefits of aripiprazole, risperidone, olanzapine, and perphenazine in this context.

Treatment after first unsuccessful trial

This algorithm does not meaningfully deviate from other algorithms and recommendations; hence we only provide a brief summary 1 , 4 , 5 , 7 . If initial trial does not lead to clinically satisfactory response despite sufficient duration 42 , 43 and dose 44 , we recommend switching 45 to monotherapy with an alternative antipsychotic with a different mechanism of action or metabolism. If initial failed trial was due to side effects, alternative antipsychotic with low propensity for that specific side effect should be selected 12 . Clozapine should be offered after two failed trials with appropriate monitoring 1 , 8 , 46 , 47 , 48 .

Treatment of patients with violence

Initial treatment of patients with concurrent violence.

Approximately 9% of first-episode patients present with at least moderate hostility 49 . Rates of homicide in patients with psychosis were found to be elevated before treatment and decrease post-treatment 50 . It is crucial not to view violence solely as a psychopharmacological issue, and it is essential to understand the context within which it occurs and establish a therapeutic alliance. However, violence can disrupt development of therapeutic alliance, limit access to health care, and impair functioning in the community. Hostility is also associated with higher all-cause antipsychotic discontinuation 51 . Therefore, pharmacological means of decreasing violence is an important consideration, and differential effects of antipsychotics on violence merit attention.

A Swedish registry study found that use of clozapine, risperidone, or olanzapine was associated with fewer violent crime arrests in patients with psychotic disorders, compared to aripiprazole, haloperidol, or quetiapine 52 . Two randomized, double-blinded trials demonstrated that clozapine is superior to olanzapine which, in turn, was superior to haloperidol in reducing the number and severity of physical assaults and aggressive events in patients with schizophrenia 11 . In an open, randomized, European First Episode Schizophrenia Trial (EUFEST), olanzapine was superior to haloperidol, quetiapine, and amisulpride in decreasing hostility scores in the first 3 months 10 . In CATIE, olanzapine decreased hostility scores significantly more than perphenazine, quetiapine, risperidone, or ziprasidone 53 , and superiority was maintained beyond 9 months.

Given these outcomes, we recommend olanzapine as the preferred first-line treatment for patients with schizophrenia and significant violence concerns. In our opinion, the potential benefit of mitigating violence outweighs the concern for metabolic side effects. Olanzapine’s lower overall discontinuation rate also supports its preference in this population 12 , 52 . Finally, olanzapine offers the advantage of both oral, short-acting intramuscular, and long-acting (though latter is rarely used due to monitoring barriers and risk of post-injection delirium-sedation syndrome) formulations. If adherence with oral medications is a concern, preference for long-acting injectable (LAI) medications can be considered 54 . In summary, unless other individual characteristics of a patient dictate otherwise, we believe that patients with schizophrenia and comorbid violence should preferentially be offered olanzapine as a first-line treatment.

If violence does not meaningfully improve with olanzapine, offering a non-clozapine antipsychotic as the next step could be considered suboptimal 11 , 52 , 55 , 56 . While clozapine is typically recommended after two unsuccessful trials in patients without violence, we propose modifying this strategy in patients with significant violence. After trialing olanzapine, if laboratory monitoring and medication compliance are feasible, clozapine should be offered as second-line treatment without the requirement of two failed trials. This aligns with APA’s recommendation to offer clozapine in patients with aggression (though APA does not recommend use of clozapine after one failed trial), as well as with Texas Medication Algorithm Project recommending early trial of clozapine in patients with violence 1 , 7 .

We propose a stepwise treatment rationale for patients with early-stage schizophrenia that diverges in small but important ways from established algorithms. The first point of departure is early patient stratification based on the presence or absence of comorbid violence. For patients with comorbid violence, we advocate for initiation of olanzapine as a preferred first-line treatment option, then (when feasible) clozapine if olanzapine fails. We also diverge in our selection of “first-line” (see the section “Summary of first-line treatment options for patients without concurrent violence”) treatment options for the general patient population, endorsing aripiprazole and risperidone 4 , 5 , 6 , 7 , 9 but also recommending olanzapine and perphenazine as first-line options. Conversely, we demur regarding lurasidone, opining that its inclusion as a first-line agent may not (yet) be warranted.

Our proposed rationale has several limitations. First, this manuscript focuses on five antipsychotics which were selected based on long-term follow-up of acutely ill patients, but not first-episode patients 12 . Another reasonable strategy to select relevant literature for first-line treatments in drug naive patients would be to focus solely on trials with first-episode patients. However, there are fewer long-term studies available on this topic, and the available network meta-analyses and systematic reviews found no convincing difference in treatment response between first-episode patients compared to the general patient population—with the exception of quetiapine and olanzapine outperforming haloperidol, and olanzapine outperforming risperidone for negative symptoms 57 , 58 , 59 , 60 . These findings align with our recommendations. On a similar theme, it is often mentioned that antipsychotic-naive patients and those with shorter illness duration respond better to antipsychotics 61 , and hence focusing on overall efficacy may be less relevant in early stages of illness. However, medications that have traditionally been considered to be less efficacious, such as aripiprazole 62 , have nonetheless made it into our treatment recommendations based on the three key criteria, which we find reassuring.

Second, selection of antipsychotics for this Perspective was based on meta-analytic evidence of studies with longer follow-up durations 12 . This decision has at least two downstream consequences: it can exclude reasonable medication options that have not yet been tested in long-term trials, and the number of studies supporting our recommendations is lower relative to shorter-term trials. For example, perphenazine inclusion in our recommendations is based mostly on the CATIE trial; however, we note that studies with other designs, nonetheless support efficacy of perphenazine 41 , 63 .

Third, one of our core criteria for antipsychotic selection is association between specific antipsychotics and mortality. Mortality is inherently difficult to study, especially because randomized trials tend to be brief and epidemiological studies are prone to confounding. Despite these challenges, we believe that sufficient data has accumulated to give relevant guidance. Mortality is also a problematic criterion for novel antipsychotics due to absence of available long-term mortality data. As with lurasidone, serious consideration of novel antipsychotics as first-line agents will require more expansive analyses and consideration of novel advantages. At the time of this publication, trace amine-associated receptor 1 agents failed phase 3 trials, and xanomeline-trospium combination and emraclidine are not FDA-approved 64 . Current short-term trials have not demonstrated advantages of cariprazine or brexpiprazole, with perhaps the exception of cariprazine for negative symptoms 41 , 65 , 66 . Should any of the newer (e.g., brexpiprazole, cariprazine, lumateperone) or novel antipsychotics demonstrate superiority in efficacy and tolerability, our rationale does not prohibit their adoption as first-line treatments. Similarly, we did not deliberate on paliperidone, a newer but pharmacologically similar agent to risperidone, that has shown similar efficacy and discontinuation rates relative to risperidone in available meta-analyses 12 , 41 . This omission is based on non-pharmacological complexities associated with paliperidone use; in particular Medicaid in some states does not cover oral paliperidone, and its long-acting formulation is presently non-generic and may be expensive based on patient pharmacy benefits, leading to potential insurance/financial reasons for discontinuation in clinical practice in the United States. All authors of this Perspective clinically practice within the United States and have focused on agents available in the region. Based on the available literature, amisulpride is promising with regard to all three criteria 12 , 67 , 68 . However, since this agent is not available in the United States for treatment of schizophrenia, we have no firsthand experience with this medication, and we welcome other authors’ opinions on this matter.

Some of the recommended “first-line” antipsychotics are available as LAI formulations. The data on the clinical benefits (e.g., reduced hospitalization, decreased mortality) of LAIs is mixed 14 , 69 , and success likely depends on more than just pharmacology, such as the supports in place within LAI clinics (e.g., effort invested in reaching out and arranging follow-ups for patients who miss LAI appointments). We are of the opinion that LAIs are a reasonable option for patients in early stages of illness, that they should be offered to patients early and should not be reserved only for patients with documented adherence difficulties. In addition to potential clinical benefits, other relevant discussion points may include reduction of pill burden, convenience, extended-interval dosing, variable formulations, and decreased peak and trough effects. Stigma, costs, access to administration, and fear of needles may be barriers to LAIs.

Lastly, for all four “first-line” options listed here (olanzapine, perphenazine, aripiprazole, risperidone) and clozapine, women have been found to reach higher plasma concentrations in relation to dose, increasing risk of overmedication 70 , 71 , 72 , 73 . However, many other factors (e.g., smoking, race, co-prescribed medications, age, body weight, etc.) also influence concentration-to-dose ratio; hence sex is only one factor to consider in appropriate dosing of antipsychotics 70 , 71 , 72 , 73 . In addition to the limitations listed above, our rationale will require continued refinement as new data on older antipsychotics emerges, recognizing the dynamic nature of psychopharmacology.

Keepers, G. A. et al. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Am. J. Psychiatry 177 , 868–872 (2020).

Article   PubMed   Google Scholar  

Remington, G. et al. Guidelines for the pharmacotherapy of schizophrenia in adults. Can. J. Psychiatry 62 , 604–616 (2017).

Article   PubMed   PubMed Central   Google Scholar  

Barnes, T. R. et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J. Psychopharmacol. 34 , 3–78 (2020).

Taylor, D. M., Barnes, T, R. E. & Young, A. H. The Maudsley Prescribing Guidelines in Psychiatry . 14th edn (Wiley-Blackwell, 2021).

Osser, D. Schizophrenia. https://psychopharm.mobi/algo_live/# (2020).

Galletly, C. et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust. N.Z. J. Psychiatry 50 , 410–472 (2016).

Argo, T. et al. Texas Medication Algorithm Project Procedural Manual: Schizophrenia Algorithm (Texas Department of State Health Services, 2008).

Hasan, A. et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J. Biol. Psychiatry 13 , 318–378 (2012).

Takeuchi, H. et al. Pharmacological treatment algorithms for the acute phase, agitation, and maintenance phase of first-episode schizophrenia: Japanese Society of Clinical Neuropsychopharmacology treatment algorithms. Hum. Psychopharmacol. 36 , e2804 (2021).

Volavka, J. et al. Efficacy of antipsychotic drugs against hostility in the European First-Episode Schizophrenia Trial (EUFEST). J. Clin. Psychiatry 72 , 955–961 (2011).

Krakowski, M. I., Czobor, P., Citrome, L., Bark, N. & Cooper, T. B. Atypical antipsychotic agents in the treatment of violent patients with schizophrenia and schizoaffective disorder. Arch. Gen. Psychiatry 63 , 622–629 (2006).

Article   CAS   PubMed   Google Scholar  

Leucht, S. et al. Long-term efficacy of antipsychotic drugs in initially acutely ill adults with schizophrenia: systematic review and network meta-analysis. World Psychiatry 22 , 315–324 (2023).

Lieberman, J. A. et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N. Engl. J. Med. 353 , 1209–1223 (2005).

Correll, C. U. et al. Mortality in people with schizophrenia: a systematic review and meta-analysis of relative risk and aggravating or attenuating factors. World Psychiatry 21 , 248–271 (2022).

Torniainen, M. et al. Antipsychotic treatment and mortality in schizophrenia. Schizophr. Bull. 41 , 656–663 (2015).

Correll, C. U. & Kane, J. M. Ranking antipsychotics for efficacy and safety in schizophrenia. JAMA Psychiatry 77 , 225–226 (2020).

Vermeulen, J. et al. Antipsychotic medication and long-term mortality risk in patients with schizophrenia; a systematic review and meta-analysis. Psychol. Med. 47 , 2217–2228 (2017).

Citrome, L. & Stroup, T. S. Schizophrenia, clinical antipsychotic trials of intervention effectiveness (CATIE) and number needed to treat: how can CATIE inform clinicians? Int. J. Clin. Pract. 60 , 933–940 (2006).

Meltzer, H. Y. & Bobo, W. V. Interpreting the efficacy findings in the CATIE study: what clinicians should know. CNS Spectr. 11 , 14–24 (2006).

Tran, P. V. et al. Double-blind comparison of olanzapine versus risperidone in the treatment of schizophrenia and other psychotic disorders. J. Clin. Psychopharmacol. 17 , 407–418 (1997).

Gureje, O. et al. Olanzapine vs risperidone in the management of schizophrenia: a randomized double-blind trial in Australia and New Zealand. Schizophr. Res. 61 , 303–314 (2003).

Tiihonen, J. et al. A nationwide cohort study of oral and depot antipsychotics after first hospitalization for schizophrenia. Am. J. Psychiatry 168 , 603–609 (2011).

Burschinski, A. et al. Metabolic side effects in persons with schizophrenia during mid- to long-term treatment with antipsychotics: a network meta-analysis of randomized controlled trials. World Psychiatry 22 , 116–128 (2023).

Gianfrancesco, F. D., Grogg, A. L., Mahmoud, R. A. & Nasrallah, H. A. Differential effects of risperidone, olanzapine, clozapine, and conventional antipsychotics on type 2 diabetes: findings from a large health plan database. J. Clin. Psychiatry 63 , 4485 (2002).

Article   Google Scholar  

Correll, C. U. et al. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large‐scale meta‐analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry 16 , 163–180 (2017).

Correll, C. U. et al. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. Jama 302 , 1765–1773 (2009).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Daumit, G. L. et al. Antipsychotic effects on estimated 10-year coronary heart disease risk in the CATIE schizophrenia study. Schizophr. Res. 105 , 175–187 (2008).

Solmi, M. et al. Antipsychotics use is associated with greater adherence to cardiometabolic medications in patients with schizophrenia: results from a nationwide, within-subject design study. Schizophr. Bull. 48 , 166–175 (2022).

Strom, B. L. et al. Comparative mortality associated with ziprasidone and olanzapine in real-world use among 18,154 patients with schizophrenia: the Ziprasidone Observational Study of Cardiac Outcomes (ZODIAC). Am. J. Psychiatry 168 , 193–201 (2011).

Kiviniemi, M. et al. Antipsychotics and mortality in first-onset schizophrenia: prospective Finnish register study with 5-year follow-up. Schizophr. Res. 150 , 274–280 (2013).

Tiihonen, J. et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 374 , 620–627 (2009).

Taipale, H. et al. 20-year follow-up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry 19 , 61–68 (2020).

Pasternak, B., Svanström, H., Ranthe, M. F., Melbye, M. & Hviid, A. Atypical antipsychotics olanzapine, quetiapine, and risperidone and risk of acute major cardiovascular events in young and middle-aged adults: a nationwide register-based cohort study in Denmark. CNS drugs 28 , 963–973 (2014).

Ray, W. A., Chung, C. P., Murray, K. T., Hall, K. & Stein, C. M. Atypical antipsychotic drugs and the risk of sudden cardiac death. N. Engl. J. Med. 360 , 225–235 (2009).

Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B. & Dixon, L. B. The schizophrenia patient outcomes research team (PORT): updated treatment recommendations 2009. Schizophr. Bull. 36 , 94–103 (2010).

DiBonaventura, M., Gabriel, S., Dupclay, L., Gupta, S. & Kim, E. A patient perspective of the impact of medication side effects on adherence: results of a cross-sectional nationwide survey of patients with schizophrenia. BMC psychiatry 12 , 1–7 (2012).

Carbon, M., Kane, J. M., Leucht, S. & Correll, C. U. Tardive dyskinesia risk with first- and second-generation antipsychotics in comparative randomized controlled trials: a meta-analysis. World Psychiatry 17 , 330–340 (2018).

Keefe, R. S. et al. Neurocognitive effects of antipsychotic medications in patients with chronic schizophrenia in the CATIE Trial. Arch. Gen. Psychiatry 64 , 633–647 (2007).

Wu, H. et al. Antipsychotic-induced weight gain: dose-response meta-analysis of randomized controlled trials. Schizophr. Bull. 48 , 643–654 (2022).

Carbon, M., Kane, J. M., Leucht, S. & Correll, C. U. Tardive dyskinesia risk with first‐and second‐generation antipsychotics in comparative randomized controlled trials: a meta‐analysis. World Psychiatry 17 , 330–340 (2018).

Huhn, M. et al. Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis. Lancet 394 , 939–951 (2019).

Samara, M. T. et al. Early improvement as a predictor of later response to antipsychotics in schizophrenia: a diagnostic test review. Am. J. Psychiatry 172 , 617–629 (2015).

Agid, O., Kapur, S., Arenovich, T. & Zipursky, R. B. Delayed-onset hypothesis of antipsychotic action: a hypothesis tested and rejected. Arch. Gen. Psychiatry 60 , 1228–1235 (2003).

Leucht, S. et al. Dose-response meta-analysis of antipsychotic drugs for acute schizophrenia. Am. J. Psychiatry 177 , 342–353 (2020).

Heres, S. et al. Changing the antipsychotic in early nonimprovers to amisulpride or olanzapine: randomized, double-blind trial in patients with schizophrenia. Schizophr. Bull. 48 , 1273–1283 (2022).

Leung, J. G. et al. A systematic review of clozapine‐associated inflammation and related monitoring. Pharmacotherapy: J. Hum. Pharmacol. Drug Ther. 43 , 1364 (2023).

Article   CAS   Google Scholar  

Leung, J. G., Allen, N. D. & Markota, M. A case series of clozapine titrations affected by inflammatory processes. Schizophr. Res. 268 , 94–97 (2023).

PubMed   Google Scholar  

De Leon, J. et al. An international adult guideline for making clozapine titration safer by using six ancestry-based personalized dosing titrations, CRP, and clozapine levels. Pharmacopsychiatry 55 , 73–86 (2022).

Faay, M. D. M. et al. Hostility and aggressive behaviour in first episode psychosis: Results from the OPTiMiSE trial. Schizophr. Res. 223 , 271–278 (2020).

Nielssen, O. & Large, M. Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr. Bull. 36 , 702–712 (2010).

Volavka, J. et al. Hostility in schizophrenia: an integrated analysis of the combined Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the European First Episode Schizophrenia Trial (EUFEST) studies. Eur. Psychiatry 31 , 13–19 (2016).

Sariaslan, A., Leucht, S., Zetterqvist, J., Lichtenstein, P. & Fazel, S. Associations between individual antipsychotics and the risk of arrests and convictions of violent and other crime: a nationwide within-individual study of 74 925 persons. Psychol. Med. 52 , 3792–3800 (2022).

Volavka, J., Czobor, P., Citrome, L. & Van Dorn, R. A. Effectiveness of antipsychotic drugs against hostility in patients with schizophrenia in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study - ADDENDUM. CNS Spectr. 19 , 466 (2014).

Strassnig, M. T., Nascimento, V., Deckler, E. & Harvey, P. D. Pharmacological treatment of violence in schizophrenia. CNS Spectr. 25 , 207–215 (2020).

Bhavsar, V. et al. Clozapine treatment and offending: a within-subject study of patients with psychotic disorders in Sweden. Schizophr. Bull. 46 , 303–310 (2020).

Krakowski, M., Tural, U. & Czobor, P. The importance of conduct disorder in the treatment of violence in schizophrenia: efficacy of clozapine compared with olanzapine and haloperidol. Am. J. Psychiatry 178 , 266–274 (2021).

Zhu, Y. et al. Antipsychotic drugs for the acute treatment of patients with a first episode of schizophrenia: a systematic review with pairwise and network meta-analyses. Lancet Psychiatry 4 , 694–705 (2017).

Leucht, S. et al. The response of subgroups of patients with schizophrenia to different antipsychotic drugs: a systematic review and meta-analysis. Lancet Psychiatry 9 , 884–893 (2022).

McDonagh, M. S. et al. Treatments for Schizophrenia in Adults: A Systematic Review (2018).

Green, A. et al. Olanzapine and haloperidol in first episode psychosis: two-year data. Schizophr. Res. 86 , 234–243 (2006).

Zhu, Y. et al. How well do patients with a first episode of schizophrenia respond to antipsychotics: a systematic review and meta-analysis. Eur. Neuropsychopharmacol. 27 , 835–844 (2017).

McCue, R. E. et al. Comparative effectiveness of second-generation antipsychotics and haloperidol in acute schizophrenia. Br. J. Psychiatry 189 , 433–440 (2006).

Kane, J. M. et al. Aripiprazole for treatment-resistant schizophrenia: results of a multicenter, randomized, double-blind, comparison study versus perphenazine. J. Clin. Psychiatry 68 , 213–223 (2007).

Sumitomo-Pharma. Sumitomo Pharma and Otsuka Announce Topline Results from Phase 3 DIAMOND 1 and DIAMOND 2 Clinical Studies Evaluating Ulotaront in Schizophrenia . https://www.sumitomo-pharma.com/news/20230731-1.html (2023).

Phalguni, A. et al. Systematic literature review and network meta-analysis of lurasidone, brexpiprazole and cariprazine for schizophrenia. Int. Clin. Psychopharmacol. 38 , 45–56 (2023).

Fleischhacker, W. et al. The efficacy of cariprazine in negative symptoms of schizophrenia: Post hoc analyses of PANSS individual items and PANSS-derived factors. Eur. Psychiatry 58 , 1–9 (2019).

Pridan, S., Baruch, Y., Swartz, M. & Barak, Y. Amisulpride for older patients with long-standing schizophrenia. J. Clin. Psychopharmacol. 34 , 736–737 (2014).

Lao, K. S. et al. Mortality risk associated with haloperidol use compared with other antipsychotics: an 11-year population-based propensity-score-matched cohort study. CNS Drugs 34 , 197–206 (2020).

Olfson, M., Marcus, S. C. & Ascher-Svanum, H. Treatment of schizophrenia with long-acting fluphenazine, haloperidol, or risperidone. Schizophr. Bull. 33 , 1379–1387 (2007).

Jönsson, A. K., Spigset, O. & Reis, M. A compilation of serum concentrations of 12 antipsychotic drugs in a therapeutic drug monitoring setting. Ther. Drug Monit. 41 , 348–356 (2019).

Weiss, U., Marksteiner, J., Kemmler, G., Saria, A. & Aichhorn, W. Effects of age and sex on olanzapine plasma concentrations. J. Clin. Psychopharmacol. 25 , 570–574 (2005).

Castberg, I., Westin, A. A., Skogvoll, E. & Spigset, O. Effects of age and gender on the serum levels of clozapine, olanzapine, risperidone, and quetiapine. Acta Psychiatr. Scand. 136 , 455–464 (2017).

Patel, M. X. et al. Plasma olanzapine in relation to prescribed dose and other factors: data from a therapeutic drug monitoring service, 1999-2009. J. Clin. Psychopharmacol. 31 , 411–417 (2011).

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Markota, M., Morgan, R.J. & Leung, J.G. Updated rationale for the initial antipsychotic selection for patients with schizophrenia. Schizophr 10 , 74 (2024). https://doi.org/10.1038/s41537-024-00492-y

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