Behavioral Approaches to Schizophrenia

Description of the Strategy

Schizophrenia is a severe, chronic mental disorder characterized by various behavioral, emotional, and cognitive disturbances. Although the phenomenology of the disorder is highly heterogeneous, common characteristics of the illness can generally be classified into four domains: positive symptoms, negative symptoms, cognitive impairment, and social dysfunction. Positive symptoms include hallucinations, delusions, and disorganization of thinking, speech, and behavior that schizophrenia patients experience. Negative symptoms consist of deficiencies compared with nonpatients, such as a reduced range of emotional experience and expression, social withdrawal, and diminution in goal-directed behavior. In addition to positive and negative symptoms, schizophrenia is associated with diminished life satisfaction, poor social and occupational functioning, neurocognitive impairments, and profound deficits in social competence. Cognitive impairment is now recognized as a key characteristic of schizophrenia that has a significant (negative) impact on functioning. Finally, social dysfunction is a defining feature of schizophrenia that is stable over time and predictive of the course and outcome of the illness. Cognitive and social deficits are relatively independent of positive and negative symptoms and are not responsive to medication.

Antipsychotic medications play a central role in the treatment of schizophrenia. However, despite striking benefits provided by antipsychotic medication, medication alone does not and cannot be expected to restore premorbid levels of psychosocial function, lead to normative role performance, or produce an acceptable quality of life for most individuals with schizophrenia. As such, behavioral treatment strategies play a key role in the comprehensive care of individuals with schizophrenia. The empirical literature on psychosocial interventions for schizophrenia has expanded dramatically over the last decade, and their acceptance as part of a comprehensive system of care for severally ill patients has grown accordingly. Areas of dysfunction that had seemed immune to psychosocial interventions, including cognitive dysfunction, social avoidance, and psychotic symptoms, are now seen as reasonable targets of treatment. Four of the best supported and most promising behavioral approaches to schizophrenia, each of which targets different aspects of this multifaceted disorder, will be presented in this section: social skills training (SST), cognitive behavior therapy (CBT), cognitive remediation (CR), and token economies (TE). For each of these four key types of intervention, we will provide (a) description of the intervention, (b) research basis, (c) relevant target populations, and (d) complications. Finally, a case illustration of SST will be presented.

Social Skills Training (SST)