Towards a Comprehensive Therapy for Schizophrenia

Schizophrenia is a severe mental illness that profoundly affects an individual’s functioning in numerous domains, including interpersonal (i.e., social skills), intrapersonal (i.e., sense of self), occupational, and cognitive (e.g., conceptual skills). Since the advent of neuroleptics in the 1950s, major inroads have been made in ameliorating deficits in these areas. However, traditional neuroleptics, such as chlorpromazine, while alleviating many florid “positive symptoms” of schizophrenia (i.e., hallucinations and delusions), did not “restore” or “remediate” social or occupational skills. Furthermore, many neuroleptics were beset by untoward side effects (e.g., akathisia), and they were fairly ineffective in reducing the “negative symptoms” of the disorder (e.g., flat affect, anhedonia), which are often associated with negative outcome. Thus, from the 1970s to the present, many psychosocial and pharmacological interventions emerged to address treatment gaps in the literature. From the pioneering work on token economies to family treatment of expressed emotion, the unfolded picture was one of multimodal intervention. Thus, this book is written within the spirit of psychosocial and pharmacological integrated therapies.

This text comprises papers from the fourth international symposium on schizophrenia held in Bern, Switzerland, in 1993. Consistent with most published versions of symposia, many chapters summarize the presenter’s previous work and describe recently completed and ongoing projects. An advantage of published proceedings is that the reader is privy to the contributor’s unique perspective on a given topic, particularly in works in progress that may be “cutting edge.” Chapters on “Emotional Management Training” by Hodel and Brenner and “Coping-Oriented Therapy” by Schaub and colleagues, in particular, present preliminary findings of promise. Because the edited volume is limited to symposium presenters, a weakness is that viewpoints of important scientists may not be equally represented. This situation is particularly true in view of the limited coverage of some topics (and techniques) relevant to the treatment of schizophrenia, such as token economies, cognitive therapy for positive symptoms (as conducted primarily in the United Kingdom), issues in dual diagnoses (e.g., substance abuse and mental retardation), psychoeducational and behavioral family treatment, and structured skill modules. The restricted breadth of the coverage notwithstanding, this book effectively strikes a balance between theoretical perspectives on psychopathology and specific clinical interventions by addressing the psychosocial and neurochemical anomalies associated with schizophrenia.

Five broad sections of two to five chapters each are presented. The first section, Unfolding of the Area, is devoted to the application of systems and chaos theory to the treatment and psychopathology of schizophrenia, respectively. These chapters, particularly the two on chaos theory, will probably appeal to the reader who is more interested in basic research than practical applications. The second section, Focus on Biological Vulnerability, comprises two chapters devoted to the efficacy of atypical neuroleptics. The chapter by Moller and colleagues describes research on whether negative symptoms can be influenced by neuroleptics, long a vexing issue in the pharmacological treatment of schizophrenia. The third section, Focus on Influencing Cognitive Vulnerability, consists of four chapters on different aspects of cognitive dysfunction in schizophrenia. Especially recommended is the chapter by Green and colleagues, which summarizes a program of studies devoted to remediation of executive and visual processing skills.

The fourth section, Focus on Weakening Stressors and/or Strengthening Protectors and Promoting Social Network and Social Support, will likely be the section of most interest to practitioners and clinical researchers. Three chapters are of particular note. These are Bellack’s review of social skills assessment and training, Test and colleagues’ overview of their program of assertive community treatment, and Goldstein and colleagues’ work on the interactive behavior between the identified patient and the patients’ relatives that may precipitate displays of high expressed emotion. The final section comprises five chapters listed under the rubric Focus on the Concept of Illness and on Coping Aimed at Episode Prevention. Gaebel’s chapter on pharmacological strategies for relapse prevention (i.e., low doses and intermittent strategies) not only reviews the research in this area but identifies significant weaknesses in the premises underlying these approaches (i.e., the low association between prodromal symptoms and subsequent relapse rate). Finally, the chapters by Strauss and by Sarwer-Foner, which focus on the individual’s experience of schizophrenia and sense of self, will be a pleasant respite for readers who feel that the field tends to overemphasize biological and neurochemical aspects at the expense of personal aspects of schizophrenia.

In summary, Towards a Comprehensive Therapy for Schizophrenia will likely appeal to clinical researchers and graduate students in the field who are looking for a brief reference source on the treatment of schizophrenia. Its limited scope and lack of attention to the details of specific clinical interventions (a goal to which the book does not aspire), make it less relevant reading for the practitioner. These issues, of course, are typical of books based on symposia and should be evaluated accordingly.