Abnormal Psychology

Abstract on Psychosocial Treatment of Schizophrenia

In this paper, the analysis of the literatures related with abnormal or special psychology has been done. Schizophrenia has been selected as a special abnormal psychological behavior, mainly noticed among human being. the cause, effect , family and social life of the patients has been specifically reviewed with the support multiple literatures. This essay has been fortified with the information collected for multiple research papers associated with the psychology and treatment of the patients with schizophrenia. Sign symptoms, therapy and the contribution of family and development of social skill has been analysed in this paper. 

Keywords: [Click here to add keywords.]

Schizophrenia, catatonic schizophrenia, social skill, cognitive skill, therapy, emotional wellbeing, nursing of schizophrenic patient.

Psychosocial treatment methods for schizophrenia patients: Critical review of successes, limitation, and future studies.

Introduction to Psychosocial Treatment of Schizophrenia

John Haslem provided the first-ever description of schizophrenia in 1910 (Hooley, 2017). Over the year's definitions have evolved, but many believe that schizophrenia is a form of brain disease. Historically schizophrenia was considered genetic; however, there is minimal evidence to support this (Rubin, 2011). The current concept of schizophrenia has been developed from the research of Eugene Blueler and Emil Kraeplin (Rubin, 2011). Blueler, identify the primary symptoms of this disorder as ambivalence autism disturbance of effect and disorder Association. Delusions and hallucinations were also considered symptoms; however, they were categorised as secondary (Rubin, 2011).

In today's society, the risk of developing schizophrenia is under 1%. One in 40 people in the world today will develop this illness (Hooley, 2017). Schizophrenia is a chronic illness with significant consequences on the individual's ability to function normally (Lauriello, Bustillo, & Keith, 1999). Owen et al., identified that unemployment for patients with sketch mania is between 80 to 90% an individual's life expectancy is reduced by 10 to 20 years (Owen, Sawa, & Mortensen, 2016). Over the years, psychosocial interventions have played a critical role in the treatment of many patients the aim of these interventions is improve the individual's overall level of functioning, quality of life and compliance with prescribed treatments (As, 1993). Psychological treatment of schizophrenia has not always been viewed as positive or beneficial. Past researchers lacked evidence to prove the link between psychological treatment and lower relapse rates (Rubin, 2011).

Although medication can stabilise stages of psychosis more than ever, it is not believed that antipsychotic medication is the only treatment beneficial. Instead, the medication should be used alongside psychological treatment to ensure the best recovery for each patient (Rubin, 2011). Several of these treatments have been considered evidence-based treatments (Rubin, 2011).

Schizophrenia has a special position in the study of psychiatry and has been identified under the spectrum of abnormal or special psychology. As per the research paper of Sue et al. (2015), Schizoid personality is related with special psychology which includes social seclusion, emotional coldness, and detachment from close relationship, secrets and more. On the contrary Levi-Belz et al. (2019) has mentioned that schizoid personality has an individual identity in the study of abnormal psychology, than that of schizophrenia. However, Lenzenweger (2018) has mentioned that Schizophrenia, schizoid and schizotypal personality have their close association as all of them share the same type of symptoms. In the context of diagnosis of such behavioural abnormalities, minute analysis of symptomatology is needed. Levi-Belz et al. (2019) has analysed and mentioned that the patient of schizophrenia experiences typical psychotic symptomatology which includes detachment from reality.

The following paper will begin by defining schizophrenia, followed by an evaluation of psychosocial treatments available. Firstly, family treatments for schizophrenia are reviewed followed by social skills learning, cognitive remediation and finally, cognitive behavioural treatment (CBT).

Schizophrenia

Schizophrenia is labelled as a severe mental illness characterised by positive symptoms (e.g., hallucinations and delusions), negative symptoms (impaired motivation and social withdrawal) and cognitive impairment (Owen et al., 2016). Positive symptoms tend to relapse and remit over time; however, the negative symptoms tend to be frequent and are linked with long term effects (Mueser, Deavers, Penn, & Cassisi, 2013).

The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM – 5) uses the following five criteria to diagnose individuals with schizophrenia;

(1) patients must show symptoms of at least one of the following for a least one month; delusions hallucinations disorganised speech, catatonic behaviour and negative symptoms,

(2) Individuals must have impairment in one of the significant areas of function for an extended period since the onset of the symptoms: work, self-care, or social relationships. The signs persist for a minimum of 6 months. They must include one month of symptoms (unless successfully treated)

(3) Schizoaffective disorder, depressive or bipolar have been ruled out,

(4) The symptoms cannot be caused by the effects of substances or any medical condition and lastly

(5), if the patient is on the autism spectrum, has a communication disorder of childhood-onset, the diagnosis of schizophrenia can only be made if delusions or hallucinations are evident (Hooley, 2017).

There are three identified subtypes of schizophrenia: paranoid schizophrenia, disorganised schizophrenia, and catatonic schizophrenia. Paranoid schizophrenia is the most common form and is evident in patients when their delusions are fixed beliefs and seem real to them even when strong evidence is provided to disprove the delusions. Examples of these delusions may be a co-worker is trying to hurt you by poisoning your food; as a result, patients stay at home and distance themselves from social settings (Hooley, 2017). The second subtype, disorganised schizophrenia causes individuals to have an unorganised thought process. Some of the symptoms include pacing or walking in circles, forgetting, or losing things and use of nonsense words. These symptoms have a considerable impact on patients' thoughts, speech, behaviour and emotion and interfere with the ability to function in their everyday lives (Hooley, 2017). The final subtype, catatonic, and causes patients to have trouble differentiating what is real to what is not. This subtype affects people in severe ways, individuals may stay still and mute, or they might be the opposite for no reason (Hooley, 2017).

Schizophrenia is clinically diagnosed based on the patient's history and also the examination of mental state. There is no diagnostic testing or biomarkers available to clinicians to assist in diagnosing patients (Owen et al., 2016).

Although there is constant research into new medication for schizophrenic patients, full recovery is sporadic, and many researchers believe full recover sheds scepticism on the accuracy of the diagnosis (Lauriello et al., 1999)

Patients diagnosed with schizophrenia have a 75% chance of recovery from their first psychotic episode. However, rates of compliance for taking prescribed medication are meagre, even with those showing system symptoms for the first time (Addington, Piskulic, & Marshall, 2010). Researchers found that even with constant medication relapse rates are staggeringly high. Furthermore, individuals function recovery remains a significant problem (Addington et al., 2010). Functional recovery refers to individual social relationships, ability to work and attend school. Therefore to help improve the relapse rate, more research must be done on psychosocial treatments to complement pharmacotherapy (Addington et al., 2010).

The goals of psychosocial are to help patients improve functional recovery and decrease isolation, depression, self-harm, and substance abuse, to name a few. Every schizophrenic patient should have access to psychosocial and psychological interventions. The primary psychosocial treatments available are family intervention, social skills learning cognitive behavioural therapy, and cognitive remediation.

The analysis of symptoms of schizophrenia has a special role to outline this psychological disorder more prominently. Departure from reality is the elementary aspect, which initially helps to identify the association of schizophrenia with the patist

As per the idea of Stip et al. (2018), schizophrenia is tagged with special sensory experiences like visual, auditory, touch, smell or taste which have not been experienced by others in the same environment. The psychotic experience of the patient are represented as untrue, as the patient

stick with that experience very tightly. Often a swing of the patient’s sense is noticed between reality and unreality. This is associated with catatonic schizophrenia. In the previous paragraph, the initial idea of such schizophrenia has been introduced, in which the patient has confusion in the differentiation of reality and non-reality. As per the viewpoint of Ungvari et al. (2018), in the catatonic schizophrenia patient either turns hyperactive and shows maniac expression or turns no-reactive (mute or still). Hence, from the analysis of Ungvari et al. (2018), it can be mentioned that catatonic schizophrenia shows extreme types of psychotic behaviour. Hence, this paper has a vital contribution to the study regarding literature review about schizophrenia. Repetitions of the same words are associated with this type. Parroting the words of others meaninglessly is also tagged with the psychotic behaviour of this type of schizophrenia.

The analysis of the movement and postures has also a special role in the context of schizophrenia. The research regarding the inappropriate posture of the patient of catatonic schizophrenia has been done. It has been identified that the patient often shows psychomotor symptoms among which waxy flexibility is a notable one. As per the idea of Rasmussen et al. (2016), the patient remains locked in an awkward posture or position for a prolonged period and the patient has a tendency to resist the attempts which are generally done to move them. Hence, from this angle, it can be mentioned that waxy flexibility is a major factor which helps to figure out the occurrence, development of severity of the schizophrenic attack. Additionally, in the case of schizophrenic attack, the patient often does stereotype activities, without any logical reason behind them. For example, uncontrolled rocking for prolonged time, moving in a circle or same trac repeatedly or recurrent performance of same activity without any logic can be considered as stereotype activity of the patient of schizophrenia. However, it is quite critical to identify the occurrence of schizophrenia with stereotype activity as it is tagged with other abnormal or special psychology In the case of obsessive compulsive behaviour, the repetition of same activity like fondling with water or walking repeatedly in the same tract has been noticed with different severity. However, waxy flexibility is the classic symptom to identify Schizophrenia.

Family Interventions

A diagnosis of schizophrenia has a considerable impact on not only the individual but also the family members; many family members experience significant stress anxiety and depression. Initially, the family intervention was focused on addressing the issues associated with the patience the programmes educated family members on the illness. However, they were poorly designed in target families who had a chronically ill relative for many years. It has become apparent that family members play a significant role in supporting individuals with long-term mental illnesses. Studies have shown that over 60% of patients returned to live with their relatives. Research into family treatment for schizophrenia has shown success for both patients and family members (Lauriello et al., 1999) A milestone study conduct by Goldstein et al., 1978 indicated that patients who family attended a six-week family therapy treatment were significantly less likely to relapse, regardless of the medication status of the patient (Lauriello et al., 1999). This particular therapy taught families effective communication and to problem solve disagreements with the diagnosed relative (Lauriello et al., 1999).

Nevertheless, some research has found that family interventions do not need to be as extensive to provide the same results (Castle, 2012). More recently, Piling et al. (2002), Conducted a meta-analysis highlighting the benefits of family interventions over other treatments such as pharmacology in reducing symptoms and decreasing relapse rates. Similarly, Falloon et al. found a decrease in relapse rates of roughly 40% for patients who had family intervention (Castle, 2012). In contrast, Leff,(1996) found that patients who had increased family -time with a family member that rated hostile or over-involved were at risk of relapse despite adequate medication compliance (Lauriello et al., 1999). Furthermore, Kottgen et al. study had a negative effect on patients. In the study, family members were encouraged relatives to voice their negative feelings, to develop insight into the critical comments directed at patients (Lauriello et al., 1999).

One of the criticisms of family intervention has been a limited focus on patients relapse and re-hospitalisation (Castle, 2012). It has been noted that resources have been extensively used for family members benefit and not to reduce patients' symptoms of relapse rates and does not focus on individual's social adjustment or functional recovery (Lauriello et al., 1999).

Today, this form of treatment is considered efficient and well researched; however, it has been established that extensive family intervention doe not provide better results than simple family intervention programs (Castle, 2012).

The effectiveness of simple family intervention over extensive family intervention has been noticed. However, in multiple cases, schizophrenic patients are socially rejected which has an intensive negative impact over the well-being and quality of life of the patient. Additionally, the rejection from family members and unnecessary fear from the patient has also been noticed in the social context, which has adverse impacts over the clinical condition of the patient. This factor can be represented as social exclusion of the patient with special psychological orientation. As per the viewpoint of Engel et al. (2016), the maximum degree of social exclusion is experienced by the patient with schizophrenia and it has been identified that the psychological breakdown of the patient often takes place with such social exclusion. As per the idea of Sue et al. (2015), cognitive impairment and reduction in the self-esteem of the patient takes place with the issue of social exclusion for the schizophrenic patient. Hence, from this angle, it can be mentioned that the study of Sue et al. (2015) has an important contribution to this literature review regarding abnormal psychology.

The phase of return of the schizophrenic patient to the community and family should be dealt with special care and this factor has been amplified in the study of Lenzenweger (2018). It has further been mentioned by the researcher, that the family member and especially the very close family member of the pat should take the charge of nursing in the post-schizophrenic attack. The expression of signs and symptoms of schizophrenia takes place in specific sessions and often certain irritant causes initiates the relapse of schizophrenia attack. The session of schizophrenia attack is described as psychotic episodes. As per the viewpoint of Tadokoro et al. (2017), the relapse of psychotic episode of schizophrenia takes place with irregularity in psychotic medicine, stressful daily routine for prolonged period, severe emotional stress or any visual clue often invokes the recurrence of psychotic episode for schizophrenic patients. It has further been identified that 28% of the patients with chronic schizophrenia shows the recurrence of psychotic episodes once a year, while 54% of patient have shown the recurrence, for once in three year. All these recurrences have been examined for the patients in the post-treatment phase. The discontinuation of antipsychotic drugs often invokes the relapse of the acute condition in the patient. The rate of discontinuation of antipsychotic medication is about 38% in the total population. Hence, this is one of the major contributions in this literature review which has helped in the identification of the family, association and irritant causes of schizophrenia. Hence, it is the responsibility of the family members of the patient to safeguard from any impulse which may trigger a psychotic episode for the patient with schizophrenia. Wang et al. (2017) has analysed and mentioned that emotional caregiving is one of the major wings of nursing which is deeply associated with the wellbeing of the patients having psychotic issues like schizophrenia. The providence of support and emotional care should be performed by the very close family members of the patients. It has further identified that meaningful interaction and providence of support towards the point of special interest or inclination of the patient have appreciable outcomes along with regular medication. (Sue et al., 2015) has mentioned that the involvement of the patient in paintings, study, handcrafts or music therapy has a good outcome which helps to minimise the patient from any recurrence of psychotic episode.

Social Skill Learning

Individuals diagnosed with schizophrenia tend to lack social skills; this is one of the significant issues addressed through psychosocial treatments. These rehabilitative of interventions have been tested since the 1980s. Social skill learning focuses on individuals learning the theory behind the illness in the hopes it will ensure patients to have a better understanding and improve their social functioning. This treatment works directly with patients to identify and remediate issues in their daily living, employment and relationships. There are three forms of social skill learning, the basic model, the social problem-solving model and the cognitive remediation model.

The basic social skills model is completed by patients significantly impaired and hospitalised. Throughout this programme, complex social scenarios are broken down into steps. These steps are then taught by the therapist modelling the crack behaviour; patients are then asked to repeat the behaviour shown. Once this is master, patients participate in role-playing exercising control settings. The final step of this programme is for the individuals to complete the behaviour learned in a natural setting.

Bellack and Mueser, 1993, support the effectiveness of this model if the patients complete regular sessions for up to 12 months. However, whether relearning social skills leads to a decrease in relapse rates is still to be determined.

The Social problem-solving model concentrates on information processing which are thought to be a cause of patients lack of social skills. Similarly, to the basic social skills model, behaviour is broken down into steps and retaught to patients. This treatment identifies the areas for each individual that need assistance with such as medication and symptom management, interpersonal skills, self-care, employment or leisure activities. The aim is help individuals learn and adapt their skills to different environments and become more flexible in social scenarios. Marder and colleagues completed a study in 1996, identifying a benefit of for patients in the social problem-solving treatment however, there was no significance in relapse rates.

The final model was cognitive remediation,

Cognitive Remediation

  • The best example of cognitive remediation and its use in social skills training is the Integrated Psychological Treatment (Brenner et al 1992) for schizophrenia developed by Swiss researchers. Patients attend a group three times a week for 3 months. They use computer games to improve card sorting and concept formation in a phase termed the "Cognitive Differentiation Subprogram." This is followed by social problem-solving exercises in the "Social Perception and Verbal Communication Subprograms" phases. Finally, "Social Skills and Interpersonal Problem-Solving Subprograms" resembling traditional social skills training, is taught. The controlled studies of Integrated Psychological Treatment in schizophrenia show some improvement in cognition and social skills but did not predict which specific social skills could be better learned. There have been no studies that assess its effect on symptoms, social adjustment, or competence (Lauriello et al., 1999).
  • The hope of cognitive remediation is to identify specific cognitive deficits that are the underlying cause of poor social skills functioning. If the underlying cognitive impairment can be improved then social skills can be better taught and social competence should improve globally (Lauriello et al., 1999).
  • Patients with schizophrenia have a variety of cognitive impairments (Braff 1993). The cognitive impairments are generalised affecting attention, memory, and planning most significantly (Lauriello et al., 1999).
  • all forms of SST can improve social competence in the laboratory and the clinic. The problem solving approach may also have an effect on social adjustment, but its clinical significance is not clear. Therapeutic effects have been demonstrated for some SST programs in clinical measures like relapse rate, but due to the limited durability "booster" sessions may be required. There is no evidence that patients that learn social skills are more likely to become competitively employed (Lauriello et al., 1999).
  • Hogarty and coworkers (1986, 1991) compared relapse rates at 12 and 24 months for schizophrenic outpatients assigned to antipsychotic medications or antipsychotic medication plus SST. At one year of follow-up, there was a significant difference in the relapse rate of the SST group plus drug compared to the medication alone group (30% versus 46%) (Hogarty et al 1986). While the original intention of the study was to taper SST to biweekly after the first year, in reality, weekly treatment continued for 21 months. The researchers decided to provide a biweekly treatment in the final 3 months to prepare for termination. The superiority of the SST plus drug lasted only as long as the weekly intervention was in place and could not be sustained in a biweekly fashion (Lauriello et al., 1999).

Cognitive Behavioural Therapy

  • Recently, there has been an interest in another form of psychotherapy, cognitive-behavioral therapy (CBT) for schizophrenia. In this paradigm, the therapy focuses on the content of the symptoms (Lauriello et al., 1999).
  • A related approach, following the use of CBT for depression, utilises a systematic verbal challenge to the prevailing delusional belief (Chadwick et al 1994). This is followed by a "behavioral experiment" contradicting the delusion (reality-testing) that reinforces the verbal challenge. While there has been success with delusions, chronic hallucinations seem particularly resistant to CBT. One possible explanation is that the continued internal stimuli overwhelm any verbal or external challenge. A recent approach focuses on the meaning of the hallucinations to allow the patient to see that the voices are a product of his or her own mind (Bentall et al 1994). These CBT studies are preliminary, and need replication in well controlled larger samples (Lauriello et al., 1999).
  • CBTs is currently considered a well-established or evidence-based treatment for schizophrenia based on the strength of research support (Rubin, 2011).
  • CBT is considered a front-line treatment in the United Kingdom, and it is recommended that CBTs be offered to all persons with schizophrenia (Rubin, 2011).
  • The goal of CBT is to reduce the symptoms of schizophrenia by targeting the underlying deficits and biases in information processing that lead to the formation and maintenance of delusions and hallucinations (Rubin, 2011).
  • Secondary goals are to reduce emotional distress associated with psychosis and to improve social functioning at large (Rubin, 2011).
  • CBT is considered both a comprehensive and symptom focused treatment (Rubin, 2011).
  • One limitation of CBT is that too often clinicians and researchers use their own set of techniques and procedures, which makes it hard to fin commonalities across approaches. Sadly, there is no single agreed upon set of methods for CBTs
  • At present, there is more research to support the use of CBT with individual clients rather than in groups.

In the social skill development, the patient has to be involved in the process which helps to develop the meaningful interactive skill of the patient. As per the idea of Joyal et al. (2016), language and speech therapy intervention has a better outcome in the development of social skills of a patient who have experienced a mild to severe psychotic episode of schizophrenia. The patient of schizophrenia often faces difficulty in speaking meaningful words or sentences in the time of psychotic attack. In the previous section the discussion related to the same issue has been done. The patient often shows parroting the same words without any reason or speaking meaningless words for repeated times without any logic as well. The therapy for language and verbal communication helps in the regeneration of the cognitive skill and communicative skill of the patients and this can be performed either by family members or by professional caregivers or special therapists. This helps the patient to get back to their profession or academic care and helps to lead a better and high-quality life. The application of the same thing has been done for the patients, who have faced the desensitization of the verbal communication skill, especially speech in the initial stage. The social interaction of the patient also gets developed with this type of therapy and this will further help the patient to avoid the issue of social exclusion. Moreover, the involvement of the patient in any social activity will also help the ame to get a better quality of life and to get the scope to interact with a wide range of people which may act as a therapy for the betterment of their condition.

Conclusion on Psychosocial Treatment of Schizophrenia

Summarise

  • many patients must be trained in skills that they never learned or were lost because of the illness. The challenge for the psychosocial treatments is to show significant and enduring gains in the very symptoms that appear the most resistant to medication. Our review highlights some of the potential benefits of psychosocial treatment, but also the limited gains reported and the incomplete research for some modalities (Lauriello et al., 1999).
  • Studies give support to the view that some schizophrenic patients may benefit from psychotherapy (Melle & Friis, 1991)
  • The National Institute of Mental Health (NIMH) Treatment Strategies for Schizophrenia (TSS) Study (Schooler et al 1997) reported that a simple family intervention and a more intensive family treatment showed no differences

Implications

  • working with families shows strong benefits, specifically in reducing relapses. This is true regardless of whether there are identifiable conflicts among the family. All families that are involved with a schizophrenic patient should be included in a psycho-education program (Lauriello et al., 1999).
  • Multiple studies show superiority of family therapy compared to no psychosocial intervention but no one family therapy has been proven superior to another active intervention (Lauriello et al., 1999).

Future Studies

  • Further research is needed to determine new ways of administering family therapy and may include developing a sophistication in computer programming and interactive networking (Lauriello et al., 1999).

References for Psychosocial Treatment of Schizophrenia

Addington, J., Piskulic, D., & Marshall, C. (2010). Psychosocial Treatments for Schizophrenia. Current Directions in Psychological Science, 19(4), 260-263. doi:10.1177/0963721410377743

As, B. (1993). Psychosocial treatment for schizophrenia. Schizophrenia bulletin /, 6(1), 317-336. doi:info:doi/

Castle, D. a. (2012). Pharmacological and Psychosocial Treatments in Schizophrenia (3rd edition. ed.): Independence : CRC Press.

Hooley, J. M. a. (2017). Abnormal psychology / Jill M. Hooley, Harvard University, James N. Butcher, University of Minnesota, Matthew K. Nock, Harvard University, Susan Mineka, Northwestern University (Seventeenth edition. Global edition.. ed.): Boston : Pearson.

Lauriello, J., Bustillo, J., & Keith, S. J. (1999). A critical review of research on psychosocial treatment of schizophrenia. Biological psychiatry (1969), 46(10), 1409-1417. doi:10.1016/S0006-3223(99)00100-6

Melle, I., & Friis, S. (1991). Psychosocial treatment of schizophrenia. Nordisk psykiatrisk tidsskrift. Nordic journal of psychiatry, 45(2), 97-108. doi:10.3109/08039489109103273

Mueser, K. T., Deavers, F., Penn, D. L., & Cassisi, J. E. (2013). Psychosocial Treatments for Schizophrenia. Annu. Rev. Clin. Psychol., 9(1), 465-497. doi:10.1146/annurev-clinpsy-050212-185620

Owen, M. J., Sawa, A., & Mortensen, P. B. (2016). Schizophrenia. The Lancet, 388(10039), 86-97. doi:10.1016/S0140-6736(15)01121-6

Rubin, A. a. (2011). Psychosocial Treatment of Schizophrenia (1st edition. ed.): New York : John Wiley & Sons, Incorporated.

Engel, M., Fritzsche, A., & Lincoln, T. M. (2016). Anticipation and experience of emotions in patients with schizophrenia and negative symptoms. An experimental study in a social context. Schizophrenia research, 170(1), 191-197. https://doi.org/10.1016/j.schres.2015.11.028

Joyal, M., Bonneau, A., & Fecteau, S. (2016). Speech and language therapies to improve pragmatics and discourse skills in patients with schizophrenia. Psychiatry Research, 240, 88-95. https://doi.org/10.1016/j.psychres.2016.04.010

Lenzenweger, M. F. (2018). Schizotypy, schizotypic psychopathology and schizophrenia. World Psychiatry, 17(1), 25. https://doi.org/10.1002/wps.20479

Levi-Belz, Y., Gvion, Y., Levi, U., & Apter, A. (2019). Beyond the mental pain: a case-control study on the contribution of schizoid personality disorder symptoms to medically serious suicide attempts. Comprehensive psychiatry, 90, 102-109. https://doi.org/10.1016/j.comppsych.2019.02.005

Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016). Catatonia: our current understanding of its diagnosis, treatment and pathophysiology. World journal of psychiatry, 6(4), 391. https://doi.org/10.5498/wjp.v6.i4.391

Stip, E., Blain-Juste, M. E., Farmer, O., Fournier-Gosselin, M. P., & Lespérance, P. (2018). Catatonia with schizophrenia: from ECT to rTMS. L'Encéphale, 44(2), 183-187. https://doi.org/10.1016/j.encep.2017.09.008

Sue, D., Sue, D. W., Sue, S., & Sue, D. M. (2015). Understanding abnormal behavior. Cengage Learning. https://college.cengage.com/psychology/sue/abnormal/8e/instructors/sue_irm.pdf

Tadokoro, S., Nonomura, N., Kanahara, N., Hashimoto, K., & Iyo, M. (2017). Reduction of severity of recurrent psychotic episode by sustained treatment with aripiprazole in a schizophrenic patient with dopamine supersensitivity: a case report. Clinical Psychopharmacology and Neuroscience, 15(1), 79. https://doi.org/10.9758/cpn.2017.15.1.79

Ungvari, G. S., Gerevich, J., Takács, R., & Gazdag, G. (2018). Schizophrenia with prominent catatonic features: A selective review. Schizophrenia research, 200, 77-84. https://doi.org/10.1016/j.schres.2017.08.008

Wang, X., Chen, Q., & Yang, M. (2017). Effect of caregivers’ expressed emotion on the care burden and rehospitalization rate of schizophrenia. Patient preference and adherence, 11, 1505. https://doi.org/10.2147/PPA.S143873

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