Treatment and management of patients with schizophrenia

Abstract

In schizophrenia, the years before psychosis are morbid, not premorbid. Widespread, low-grade corruption of circuitry (brain damage) occurs, resulting in enduring deficits in cognitive, social, and motor functioning and motivation. These deficits persist during patients’ lifetime and do not respond to medication or talking. Expectations of patients’ functioning must be modified (reduced); interactions and environments must be accommodated to support best residual functioning, and prostheses (mechanical or actions of others) must replace functions no longer available. One of the deficits—anosognosia—interferes with treatment efforts. When the circuits managing dopamine neurons in the ventral tegmental area are corrupted, storms of dopamine imbue random items of sensory experience and intrapsychic life with salience—psychosis appears. Early and uninterrupted dopamine antagonist medication results in sustained remission of psychosis but is rarely achieved because of the inadequacies of standard care. Enduring engagement by multi-disciplinary teams is the necessary response to the neurobiology of schizophrenia.