Schizophrenia is a severe and debilitating mental disorder. It is often characterized by breaks from reality, including hallucinations (hearing voices, seeing things that are not really there) and delusions (fixed beliefs that are not true, such as believing one has superpowers). These symptoms are identified as positive symptoms and taken together, are known to be what is called psychosis. Individuals diagnosed with schizophrenia also experience negative symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders (2013), negative symptoms are comprised of diminished emotional expression and a lack of self-initiated purposeful activities such as low mood, decreased ability to experience pleasure, and the lack of interest in social activities, to name only a few. Approximately 21 million people worldwide are diagnosed with schizophrenia (Schizophrenia, n.d.). Further, it has been reported that 5-6% of people with schizophrenia die by suicide, and roughly 20% attempt suicide (American Psychiatric Association, 2013). Despite these alarming facts, fortunately schizophrenia is treatable. With the proper use of antipsychotic medication, psychotic symptoms may be reduced, providing the individual with the ability to function more effectively and appropriately (Schizophrenia, n.d.). Although antipsychotics have been shown to be beneficial in reducing psychotic symptoms, there is a major issue regarding treatment resistance.
What does treatment resistance mean and what are some underlying factors?
Treatment resistance is commonly understood as a failure to adhere to treatment guidelines, such as discontinuing the use of medication before clinically advised, or failure to seek out treatment when needed. Conversely, in their recent study, Ahmed Hassan and Vincenzo De Luca (2015) examined another form of treatment resistance. This type of treatment resistance involves patients who comply with the treatment guidelines. These individuals take the required dose of medication to alleviate their psychotic symptoms, however their bodies resist the effects of the antipsychotic medication. As such, their psychotic symptoms persist, despite adhering to the clinically recommended treatment procedure.
Ahmed Hassan and Vincenzo De Luca (2015) examined the relationship between childhood and lifetime adversities in schizophrenia patients and the effects it has on the resistance to antipsychotic treatment, suggesting possible underlying factors that contribute to treatment resistance. In this study, patients with schizophrenia were required to complete the Stressful Life Events Screening Questionnaire and the Childhood Trauma Questionnaire in order to reliably assess traumatic experiences throughout the patients’ lifetime. Their results reveal that patients who resisted treatment reported an average of 4.5 lifetime traumatic events, with over half of these patients reporting 4 or more traumatic experiences (traumatic events included, but not limited to: sexual abuse, emotional abuse, and emotional neglect). In contrast, non-treatment resistant patients reported only 2.5 traumatic lifetime events, on average (Hassan & De Luca, 2015). In short, there is a positive correlation between lifetime adversities and treatment resistance among those diagnosed with schizophrenia. What this means, is that as the number of traumatic events in one’s life increases, so does their likelihood of resisting antipsychotic medication, should they be diagnosed with schizophrenia. This poses as a problem because while these individuals may be struggling to cope with the effects of their traumatic life experiences, they may also continue to face the terrifying symptoms of schizophrenia despite having taken their medication.
Not only is it important to address exposure to traumatic events in effort to reduce treatment resistance, it is also important to address such events as early as possible as they pose as a potential risk factor for developing a psychotic illness (Hassan & De Luca, 2015). Life adversities, while not the only factor, could contribute to the development of a mental illness, including psychosis. Thus, these traumatic events should not be overlooked.
So, now what?
Well, this new knowledge provides insight as to why this form of treatment resistance may occur in individuals who comply with the treatment process. This information informs us that focusing on and addressing underlying factors, such as traumatic life experiences, may aid significantly in reducing treatment resistance. Furthermore, the fact that individuals who experience more lifetime trauma may be more likely to experience treatment resistance could imply some sort of biological changes in the brain. These potential changes could result from the traumatic experiences, possibly inhibiting any effects of the antipsychotic medication. It is imperative that individuals who are diagnosed with schizophrenia are not just prescribed medication and sent on their way. Further ongoing treatment (such as therapy) is required. In fact, it is common for schizophrenia treatment to include both antipsychotics and Cognitive Behavioural Therapy. Cognitive Behavioural Therapy (CBT) is a common method of therapy used by psychologists to treat a wide range of mental illnesses. This therapy identifies and addresses maladaptive thoughts and guides people to alter such thoughts, allowing for a healthier and more adaptive thinking style. As mentioned, CBT is useful in treating schizophrenia as it used to address the positive and negative symptoms (hallucinations, delusions, low mood, etc). However, given what we now know with regards to how lifetime adversities effect resistance to antipsychotic treatment in schizophrenia patients, it is important that CBT also focuses on any trauma a patient experiences, in attempt to reduce the likelihood of resistance to treatment. Doing so might equip them with certain abilities and techniques needed in order to cope with not only their traumatic events, but also the illness. In addition, it might be wise to incorporate a comprehensive review specifically on the patient’s exposure to traumatic events during a clinical assessment. This could enable doctors to recognize how traumatic events might influence a patient’s likelihood of treatment resistance to antipsychotic medication.
It would be wise for future research to address biological differences in the brain between those with fewer lifetime trauma and those who have experienced a lot of trauma throughout their lifetime. It would be interesting to examine any possible brain differences between the two (fewer lifetime adversities and a lot of lifetime adversities) that might affect the effects of the antipsychotic treatment. Even more so, future research might benefit from examining how CBT effects the likelihood of treatment resistance among patients who have experienced lifetime trauma. If the CBT is directed at addressing the individual’s traumatic experiences, it would be compelling to examine whether or not this reduces treatment resistance among the individual.
Of course this does not go without saying that there are some challenges that may be faced in addressing this issue. For example, reporting on past traumatic events is retrospective, which could involve some error recalling specific events, especially traumatic ones. Further, every trauma experienced by an individual is going to effect them differently. Nonetheless, it is imperative that we understand some of the underlying factors influencing treatment resistance and even more so, if this information can generalize to other disorders beyond schizophrenia. Just by acknowledging this new information, we can be cognizant of this issue, allowing us to be one step closer to a solution.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, D.C: American Psychiatric Association.
Hassan, A.N., & De Luca, V. (2015). The effect of lifetime adversities on resistance to antipsychotic treatment in schizophrenia patients. Schizophrenia Research, 161, 496-500. doi: http://dx.doi.org/10.1016/j.schres.2014.10.048