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Running head: DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Is the Combination of Drugs and Psychotherapy better than Psychotherapy Alone for A Summary and Recommendation Paper The Faculty of the Adler Graduate School In Partial Fulfillment of the Requirement for the Degree of Master of Arts in Adlerian Counseling and Psychotherapy DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA In this literature review this researcher discusses the use of antipsychotic drugs and some of their side effects in combination with Cognitive Behavioral Therapy (CBT). The use of antipsychotic medications being the center of treatment for schizophrenia is well known. Looking at psychotherapy as being an alternative treatment for schizophrenics without the employment of medications is explored. Adlerian therapy and CBT for treatment of individuals with schizophrenia is analyzed with case studies that were successful in using these therapies. Schizophrenia has many symptoms; however, positive and negative symptoms are common with those who have paranoid schizophrenia. It is known that one can be diagnosed with schizophrenia experience one symptom without experiencing the other and vise verse. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Table of Contents The Combination of Drugs and Psychotherapy-------------------------------------------------------5
Zyprexa with Cognitive-Behavioral Therapy (CBT)----------------------------------------5
Clozaril with Cognitive-Behavioral Therapy (CBT)----------------------------------------6
DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Is the Combination of Drugs and Psychotherapy better than Psychotherapy Alone for There have been many case studies and research on the combination of drugs and psychotherapy for the treatment of schizophrenia. The first generation of drugs, such as Clozaril has been available since the 1950's. A second generation of drugs was released in the 1990's that is proven to be safer to ingest, such as Zyprexa. Some research suggests that Clozaril was at the top of the line for treating hallucinations and delusions; however the risk of giving the drug to patients was less beneficial to the body long term (Gillam, 2002). Antipsychotic medications are known to aid the reduction of psychotic symptoms of schizophrenia and potentially permit the patient to function more effectively and appropriately. The large majority of people with schizophrenia show substantial improvement when treated with antipsychotic drugs. However, some patients are resistant to the medications and a few do not seem to want to use them. As research suggests, there are several treatments for dealing with schizophrenia. Schizophrenia will be defined for the purposes of this paper. According to the Marriam-Webster.com (2012), schizophrenia is a psychotic disorder is known to be characterized by obvious deterioration in the level of functioning of daily living, being out of contact with the environment, and the breakdown of personality which is expressed as disorder of behavior, perception (hallucinations), and feeling, thought (delusions). This paper will discuss the combination of drugs and psychotherapy, more specifically the most common drugs used and currently being used to treat Paranoid Schizophrenia along with Cognitive- Behavioral Therapy (CBT). Compared with drugs and psychotherapy this literature review will also examine the use of psychotherapy alone from an Adlerian theory and Cognitive-Behavioral Therapy prospective. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA The Combination of Drugs and Psychotherapy
It is known that in order for treatment to be effective with severe and persistent mental illnesses the use of medication is essential. For less than 100 years drugs have been used for schizophrenia. Schizophrenia is a term that most clinical professionals do not like to deal with due to it being a severe mental illness, and the unpredictable behavior that those individuals possess. As stated above, Clozaril was seen to be more effective than other psychotic medications. There is the possibility of harsh side effects in particular, a condition called agranulocytosis, (Lun, Kejian, Jian, Jegga, Heng, Leming, Lin, 2011) which is the loss of the white blood cells that fight infection. Patients that have agranulocytosis should be closely observed with blood tests every one or two weeks. Newer drugs, such as Risperdal and Zyprexa, (Gillam, 2002) are safer than the older drugs or Clozaril due to the advanced studies of pharmacology. Although, the drugs do not alleviate schizophrenia or make certain that there are no further psychotic episodes they appear to be the main treatment now. Psychotherapy is another treatment option for a variety of mental disorders, either as a alternative to or in combination with medication (Simos, 2012). Zyprexa with Cognitive-Behavioral Therapy (CBT)
Zyprexa is among the second generation medications which were first around the 1990's (Gillam, 2002). The dosage of medication and the choice of the drug are made by a qualified physician that is trained in the medical treatment of mental disorders. Given that an individual's chemistry varies the medication dosage is individualized for each patient, to reduce symptoms without producing bothersome side effects. "Zyprexa may cause some sadation, weight gain may be problematic in long term, but low risk of Extrapyramidal Side Effects (EPSE) or raised prolactin" (Gillam, 2002, p.30). It is difficult to predict which patients will fall into these two DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA groups and to distinguish them from the large majority of patients who do benefit from treatment, particularly CBT with antipsychotic drugs. CBT is known to help medication compliance and confront delusions and hallucinations for short and long term benefits (Gillam, 2002). According to Nelson (1997), pharmacological interventions and psychosocial accompany each other quite well. People with schizophrenia taking antipsychotic drugs have a great chance to gain liberation of their symptoms. Clozaril with Cognitive-Behavioral Therapy (CBT)
Treatment of schizophrenia has traditionally taken the form of typical antipsychotic medication, which is effective in treating positive symptoms, but has little or no effects on negative symptoms or cognitive deficits (Sharma, 1999). According to Manschreck, Redmond, Candela, & Maher (1999), the improvements of clozapine verbal fluency, set shifting and reaction time have been beneficial for use of the drug. Clozaril is known to be among the first generation medications for treating schizophrenia. Chlorpromazine is also among the first generation of antipsychotic medication (Gillam, 2002). These were known drugs that were effective and cheap at handling positive symptoms of schizophrenia but came with problematic side effects (Gillam, 2002). CBT is known for treating delusional beliefs' among other things by confronting evidence that supports delusional thinking rather than directly confronting the belief itself (Bradshaw, 1995, pg. 16). According to Gillam (2002), Clozaril should not be used as a first-line treatment but proven benefit for treatment resistance, postural hypotension, weight gain and sedation could be problematic. Blood monitoring is needed as it may cause fatal agranulocytosis. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA It is apparent that antipsychotics medications remain central to treating schizophrenia and other debilitating mental illnesses. Although, clozaril is an older drug and presents high risks of side effects it was known to get the job done, and if given, it should be in a low dosage. This researcher found that was also obvious that mental health professionals, in particular psychiatrists are biased to prescribing antipsychotic medications. Psychiatrists gain to stand a hefty price for prescribing antipsychotic medications, thus why they are central in treating mental health illnesses or any condition or illness for that matter. Psychiatrists no longer engage in talk therapy with patients, instead it is drug therapy. The more drugs a psychiatrists prescribe the more money he/she will get. According to Hickey (2011) of the Behaviorism and Mental Health, a Pennsylvania psychiatrist, Donald Levin stated that he treated between 50 to 60 patients once or twice weekly in talk-therapy sessions of 45 minutes each. Now, he treats 1,200 people in roughly 15-minute visits for prescription adjustments. He also shared that when he did talk therapy he knew his patients' inner lives and now he does not know their names. Later he wanted to make his patients happy, now it is just to keep them useful. It is evident that drugs can be very effective decreasing and alleviating symptoms; however, they do not educate the individual or family on how to respond and cope with this illness. The side effects of these drugs seemed to be secondly to getting stable and as close to being ‘normal' as much as possible. Very few first generation mediations are still being used due to the increase, adverse side effects, and the coming of new antipsychotic drugs. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA According to Hickey (2011) of the Behaviorism and Mental Health, psychiatrists can on average earn $150 dollars for three 15-minute medication visits as compared to $90 dollars for a 45-minute talk therapy session. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group (Hickey, 2011). Psychotherapy Alone
According to Mosak (1995), therapists can treat schizophrenic individuals without employing the use of drugs and that it is possible to ‘cure' schizophrenia without utilization of drugs. This researcher has found that some mental health professionals are reluctant to do psychotherapy with severe mental illness patients, more particularly schizophrenia. "Schizophrenia is considered a risk in psychotherapy because often it is not amenable to treatment" (Angers, 1975, p. 121). In doing research, without the employment of drugs it has surfaced that not all individuals diagnosed with schizophrenia has desirable outcomes. Due to the lifelong sentence for this illness, many individuals with schizophrenia at some point, stop taking their medication. Some individuals do not like the use of antipsychotic medications because of the lack of functionality which impairs the body's ability to respond or engage in daily activities. These are known undesirable side effects that one can experience while using antipsychotic medications. Research suggests that several antipsychotic medications are prescribed to individuals with schizophrenia and often time's additional medications are prescribed to reduce or alleviate the side effects of that drug(s). There are several known treatments for schizophrenia, however, the use of Adlerian Therapy and Cognitive- Behavioral Therapy seem to be the most interesting use to treat a person with schizophrenia. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Adlerian Theory
Alfred Adler was a psychiatrist and philosopher; who stressed the need to understand individuals within their social context. He believed we have one basic goal and desire: to feel significant and to belong. Adler was known to have developed the first holistic theory of psychopathology, personality, and psychotherapy that was closely connected to a humanistic philosophy of living. Alfred Adler started with Sigmund Freud and Freud's colleagues in 1902 (Fiebert, 1997), which was a discussion group, the Vienna Psychoanalytic Society. Adler introduced his theory and it was dismissed due to the clear common sense theme. Adler was known to be the first to be separated from the group. The clinical books and journal articles that Adler wrote revealed a deep insight into the art of healing, an uncommon understanding of mental disorders, and a great inspiration for encouraging optimal human development (Ansbacher, 1992). According to Adler, when we feel encouraged, we feel capable and appreciated and will generally unite and act in a cooperative way. When we feel discouraged, we may act in unwholesome ways by competing, withdrawing, or simply giving up. It is in finding ways of expressing, acknowledging, and accepting respect, encouragement, and social interest that help us feel fulfilled and confident (Ansbacher, 1992). In the case of a black male college student who was diagnosed with paranoid schizophrenia Mosak (1995), by his schools' health center and referred out to receive help. He began hearing people crawl in the overhead above the ceiling with the purpose to harm him. The noises began after he had his first affair with a married woman and feared that the husband would come after him. While in therapy, the patient expressed that he was scared of his mother and generalized this fear to all women. After much review, the patient was entitled to a refund DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA check through his insurance and the secretary, who was a woman, was to give him the check which created a problem since he had formulated that women are evil and mean people. Ultimately this meant that he would have to change his convictions of women. A triple-pronged approach was used for treatment (Mosak, 1995). The first step was to engage in Adlerian psychotherapy using multiple psychotherapies, examined the lifestyle (Adler 1931/1958; Shulman & Mosak, 1988) and used the data to the handling of the life tasks (Dreikurs & Mosak 1966/1977a, 1967/1977b; Mosak & Dreikurs, 1967/1977). When treating schizophrenic patients a therapist should create a sense of hope, rapport, or contact (Arieti, 1980) relatedness, to lessen the anxiety of the patient. Since then therapy termed, there has not been any recurrence of his symptoms (Mosak, 1995). This was a successful treatment of schizophrenia without the use of Cognitive-Behavioral Therapy
Aaron Beck, a psychiatrist in Philadelphia, and Albert Ellis, a New York psychologist, are known to be the founders of CBT. CBT is a known form of psychotherapy in which the therapist and the client work together as a team to identify and solve problems. This psychotherapeutic approach is known to address dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic process. Beck realized the importance between thoughts and feelings. He called these cognitions automatic thoughts, to describe emotion-filled thoughts that might pop up in the mind. It's not events themselves that upset us, but the meanings we give them. If our thoughts are too negative, it can block us from seeing things or doing things that do not fit; that disconfirms what we believe is true. In other words, we continue to hold on to the same old thoughts and fail to learn anything new. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Cognitive therapy has been extended to and studied for adolescents and children, couples, and families. In doing CBT, a patient can be confident that this will help in symptom reduction, recovery, and the prevention of relapse (Morrison, 2001). According to Christodoulides, Dudley, Brown, Turkington, & Beck, (2008), a woman diagnosed with schizophrenia for 6 years. Before receiving CBT treatment, she was hospitalized three different occasions, with a total of 110 days. She experienced auditory hallucinations of a critical female voice that demanded she harm herself. The therapy was focused on boosting her self-efficacy in relation to the voice and guiding her to a less threatening explanation of her phenomena (Christodoulides et al. 2008). Schema-based work was used with her, which were centered upon negative core beliefs. Which were believed to have been developed during her childhood, she described as uncaring and cold. During the course of her CBT treatment and follow-up, she remained off antipsychotic medication. She received 28 sessions of CBT. "Although CBT is integrated and draws from various traditions, it also tries to remain true to its roots in a method that is practical, systematic, concrete, and empirical. Along with helping clients face squarely the inescapable reality of the pain in their lives, cognitive-behavior therapists attempt to address their specific symptoms and help them to develop tools they can use to live fully, even in the face of hard knowledge that life is always a gamble" (Dattilio & Hanna, Psychotherapy can also be a main source of treatment for Schizophrenia. There is no argument that working with schizophrenics has its frustrations and difficulties for both the patient and therapist (Mosak, 1995). From the articles found, all of the case studies chosen at random were a success. It is clear that alternative interventions can take time, sometimes years DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA (Mosak, 1995), however, patients should be allowed to make an inform decision as to which treatment suits them best. According to Angers (1975) if more professionals accept the challenge, treating schizophrenia would not be such a treatment risk. As stated above, Adlerian therapy is finding ways of expressing, acknowledging, and accepting respect, encouragement, and social interest that help us feel fulfilled and confident (Ansbacher, 1992). As discussed, CBT is another way to make an individual aware of their thinking and potentially getting to the root cause what is happening in their life. Engaging in psychotherapy alone seems to be the best way at getting to a good quality of life. Together both psychotherapies work just as good if not better than the use of drugs. According the Christodoulides et al. (2008) the utilization of CBT for psychosis without the employment of antipsychotic medication is feasible and can create clinically significant treatment gains in overall depressive, psychopathology and negative symptoms for some patients with schizophrenia. The case study mentioned above is one of the many successful examples of treating schizophrenia with psychotherapy alone without the employment of drugs. No individual is the same and should be treated as such, therefore, each treatment of a schizophrenic individual should be carefully planned for to ensure a holistic approach. Schizophrenia is a chronic and debilitating disorder characterized by a heterogeneous group of symptoms, including positive symptoms (delusions, hallucinations, disorganized thought), negative symptoms (flattened affect, stereotyped thinking, difficulty in abstract thinking) and multifaceted cognitive deficits, most prominently in the areas of attention, memory and executive functioning (Rund & Borg, 1999). There are several types of symptoms for individuals with schizophrenia, however, positive and negative symptoms are known to be DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA common with individuals that have paranoid schizophrenia. According to Perivoliotis & Cather (2009) for one to be diagnosed with schizophrenia, there must be a drastic decrease in functioning, showing at least one significant occupational or social "failure" in the life of individuals with this disorder. The history of individuals with schizophrenia frequently reveals that there are repeated failures, particularly in work, social domains, and school. One credible source of these failures is neurocognitive impairment (Perivoliotis & Cather, 2009), which is often visible as difficulties sustaining concentration, generating and implementing plans, gathering information from the environment, and solving problems for which solutions are not immediately apparent (Perivoliotis & Cather, 2009). Neurocognitive impairment is associated with negative symptoms more than with positive or disorganized symptoms and has been repeatedly found to be the best predictor of functional outcome in schizophrenia (Perivoliotis & Cather, 2009). Stress is known to be a factor that brings on the positive and negative symptoms for a paranoid schizophrenic. Positive Symptoms
Normally, when one expresses that they are experiencing positive symptoms, it can be assumed that these symptoms are ‘good'; so to speak. What are positive symptoms? Positive symptoms are known to be things that are ‘added' or ‘new' to ones personality or how they experience life because of schizophrenia. As stated earlier, known positive symptoms are hallucinations, disorganized thoughts, delusions (Rund and Borg 1999), and shows emotions that do not fit the situation. Individuals with schizophrenia are known for having hallucinations and According to Frith & Fletcher (1995) the term hallucinations derived from the Latin word ‘alucinari', which means to wonder in speech or thought. ‘Alussein' is a Greek word that means DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA ill at ease or distraught (Frith & Fletcher, 1995). It is essential to distinguish between illusions, the object is there but is thought to be distorted and a hallucination, and from a delusion, a false belief over a false perception (Frith & Fletcher, 1995) According to the DSM-IIIR (1987), quoted from Zuk & Zuk (1992), the definition of delusion is, "A false personal belief based on incorrect inference about external reality and firmly held in spite of what almost everybody else believes and in spite of what constitutes incontrovertible and obvious proof to the contrary (p. 395)". Delusions are a mental disorder (Zuk & Zuk, 1992) which can be present where the central nervous system has been affected by drugs, infections, or tumors (Zuk & Zuk, 1992). Within one having delusions, there can be other types of delusions present (Zuk & Zuk, 1992), such as persecutory, which is most common, somatic, and grandiose (Zuk & Zuk, 1992). The suspicion that this may be, in fact, happening is not sufficient to institute this diagnosis. The patient must convey the conviction that he or she has been allocated, and that extreme measures may be necessary to protect their life (Zuk & Zuk, According to the Harvard Mental Health Letter (2006) positive symptoms seem to make treatment more urgent, and usually they can be treated effectively with antipsychotic medications. Reason for treatment after one expresses that they are experiencing positive symptoms because having positive symptoms disconnects one from reality and can cause individual (s) to be harmful to themselves and/ or others. Negative Symptoms
Negative symptoms are not ‘bad' symptoms, these are known for the loss of a part in an individual's personality or the way they experience life by being schizophrenic. According to the Harvard Mental Health Letter (2006) these are the main reason persons with schizophrenia DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA cannot hold jobs, live independently, manage everyday social life, and establish personal Some known negative symptoms that one could experience is blunted affect; scarcity of facial expressions and communicative gestures, reduction of spontaneous movements, lack of voice modulation and poor eye contact (Makinen, Miettunen, Isohanni, & Koponen, 2008). Alogia is another known symptom which includes few words, the person talks little, and poverty of speech (Makinen, Miettunen, Isohanni, & Koponen, 2008). Anhedonia, that is the inability to experience pleasure, reduced interest in sexual activities, the inability to experience closeness, and scarcity of recreational and leisure activities, (Makinen, Miettunen, Isohanni, & Koponen, 2008). Avolition is also common in negative symptoms reduced motivation and poor hygiene. Individuals who display asociality have reduced social interactions, few friends, and poorer relations with friends (Makinen, Miettunen, Isohanni, & Koponen, 2008). The occurrences of negative symptoms in schizophrenic individuals are high in the first-episode of psychosis (Makinen, Miettunen, Isohanni, & Koponen, 2008). It is obvious that schizophrenia is a disabling mental health illness. Although, this life long illness is undesirable, it can be maintained quite effectively with proper diagnoses to ensure that it is in fact schizophrenia. Mental health professionals are able to educate the patient on their choices of treatment. Positive and Negative symptoms are common with schizophrenic individuals. It is possible to experience one category without the other. One of the main reasons for initially seeking treatment is for positive symptoms which seem to make treatment more urgent. One of the sole reasons for treatment is because positive symptoms disconnects one from reality and can cause individual (s) to be harmful to themselves and/ or others. Antipsychotic DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA medications are central to treating schizophrenia; however, psychotherapy has been proven to work as well, if not better than putting individuals on antipsychotic medications. This researcher feels that in order for schizophrenic individuals to be properly helped providers must give full options for treatment. Final Summary
There is still much research to be done with this population to ensure that these individuals get the best care possible. It is apparent that antipsychotics medications remain central to treating schizophrenia and other debilitating mental illnesses. Psychotherapy can also be a main source of treatment for Schizophrenia as well as other mental illnesses. This researcher found that was also obvious that mental health professionals, in particular psychiatrists are biased to prescribing antipsychotic medications. Psychiatrists gain to stand a hefty price for prescribing antipsychotic medications, thus why they are central in treating mental health illnesses or any condition or illness for that matter. Psychiatrists no longer engage in talk therapy with patients, instead it is drug therapy. The more drugs a psychiatrists prescribe the more money he/she will get. What is evident is that drugs can be very effective at decreasing and alleviating symptoms; however, they do not educate the individual or family on how to respond and cope with this illness. Because this our society is fixation on fast and quick results the side effects of these drugs seemed to be secondly to getting stable and as close to being ‘normal' as much as possible. No individual is the same and should be treated as such, therefore, each treatment of a schizophrenic individual should be carefully planned for to ensure a holistic Psychotherapy without the use of drugs can take years, however, patients and/ or families should be allowed to make an inform decision as to which treatment suits them best. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA The case study mentioned above is one of the many successful examples of treating schizophrenia with psychotherapy alone without the employment of drugs. Typically, patients with schizophrenia using the combination of antipsychotic drugs and psychotherapy can see results within the first six to nine months of starting treatment. Psychotherapy, in general, works at getting to the root cause of an illness and treating the person as an individual and not as a case. Engaging in psychotherapy alone seems to be the best way at getting to a good quality of life. It is obvious that schizophrenia is a disabling mental health illness. Mental health professionals should be able to educate the patient and their families on their choices for treatment. It is apparent that each treatment, the use of antipsychotic medications and the use of psychotherapy alone has it merits and demerits for treating schizophrenia, however, it is not up the provider to decide what is best for the client. Ultimately, it is the clients and family's choice which treatment they will participant. With proper support, psycho education of the illness, and deciding which psychotherapy treatment to engage in, Adlerian or CBT, the patient and/ or family should be able to make an informed decision and be satisfied with their choice. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Andreasen, N. C., & Flaum, M. (1991). Schizophrenia: The characteristic symptoms. Schizophrenia Bulletin, 17(1), 27-49. Adler, A. (1958). What life should mean to you. New York: Capricorn. (Original work published Angers, W. P. (1975). Adlerian psychotherapy with schizophrenics. Journal of Clinical Psychology, 31(1), 121-126. Ansbacher, H. L. (1992). Alfred Adler, pioneer in prevention of mental disorders. Individual Psychology: The Journal of Adlerian Theory, Research & Practice, 48(1), 3. Arieti, S. (1980). Psychotherapy of Schizophrenia: New and Revised Procedures. American Journal of Psychotherapy, 34(4), 464. Bradshaw, T. (1995). Psychological interventions with psychotic symptoms: a review. Mental Health Nursing. 15, 4, 15-17. Chomsky, N. (1965). Aspects of the theory of syntax. Cambridge, MA: MIT Press. Christodoulides, T. T., Dudley, R. R., Brown, S. S., Turkington, D. D., & Beck, A. T. (2008). Cognitive behaviour therapy in patients with schizophrenia who are not prescribed antipsychotic medication: A case series. Psychology & Psychotherapy: Theory, Research & Practice, 81(2), 199-207. doi:10.1348/147608308X278295 Dattilio, F. M., & Hanna, M. A. (2012). Collaboration in cognitive-behavioral therapy. Journal of Clinical Psychology, 68(2), 146-158. doi:10.1002/jclp.21831 Dreikurs, R., & Mosak, H. H (1977a). The tasks of life I. Adler's three tasks. In H. H. Mosak, On purpose (pp. 93-99). Chicago: Alfred Adler Institute. (Original work published 1966) DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Dreikurs, R., & Mosak, H. H (1977b). The tasks of life II. The fouth life task. In H. H. Mosak, On purpose (pp. 100-107). Chicago: Alfred Adler Institute. (Original work published Fiebert, M. S. (1997). In and out of Freud's shadow: A chronology of Adler's relationship with Freud. Individual Psychology: Journal of Adlerian Theory, Research & Practice, 53(3), Frith, C., & Fletcher, P. (1995). Voices from nowhere. Critical Quarterly, 37(2), 71. Gillam, T. (2002). Treating schizophrenia:. Mental Health Practice, 6(4), 28. Hickey, P. (2011). Psychiatrists are drug pushers. Behaviorism and Mental Health. Retrieved Lun, Y., Kejian, W., Jian, C., Jegga, A. G., Heng, L., Leming, S., & . Lin, H. (2011). Exploring off-targets and off-systems for adverse drug reactions via chemical-protein interactome -- clozapine-induced agranulocytosis as a case study. Clos Computational Biology, 7(3), 1- 13. doi:10.1371/journal.pcbi.1002016 Makinen, J. J., Miettunen, J. J., Isohanni, M. M., & Koponen, H. H. (2008). Negative symptoms in schizophrenia—A review. Nordic Journal of Psychiatry, 62(5), 334-341. Manschreck, T. C., Redmond, D. A., Candela, S. F., & Maher, B. A. (1999). Effects of clozapine on psychiatric symptoms, cognition, and functional outcome in schizophrenia. The Journal Of Neuropsychiatry And Clinical Neurosciences, 11(4), 481-489. Merriam-Webster.com. (2012). Schizophrenia. Retrieved from http://www.merriam- DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Morrison, A. (2001). Cognitive therapy for auditory hallucinations as an alternative to antipsychotic medication: A case series. Clinical Psychology and Psychotherapy, 8, 136– Mosak, H. H. (1995). Drugless psychotherapy with schizophrenics. Individual Psychology: The Journal of Adlerian Theory, Research & Practice, 51(1), 61. Nelson, H. (1997). Cognitive behavioral therapy with schizophrenia: A Practice Manual. Cheltenham, Stanley Thornes. Perivoliotis, D., & Cather, C. (2009). Cognitive behavioral therapy of negative symptoms. Journal of Clinical Psychology, 65(8), 815-830. doi:10.1002/jclp.20614 Rund B. R., Borg N. E. (1999) Cognitive deficits and cognitive training in schizophrenic patients: a review. Acta Psychiatr Scand 100, 85–95 Simos, G. (2012). Collaboration in psychopharmacotherapy. Journal of Clinical Psychology, 68(2), 198-208. doi:10.1002/jclp.21836 Sharma T. (1999) Cognitive effects of conventional and atypical antipsychotics in schizophrenia. Br J Psychiatry Suppl 38, 44–51 Sharma, T., Hughes, C., Soni, W., & Kumari, V. (2003). Cognitive effects of olanzapine and clozapine treatment in chronic schizophrenia. Psychopharmacology, 169(3-4), 398-403. Shulman, B. H., & Mosak, H. H. (1988). Manual for life style assessment. Muncie, IN: Accelerated Development. The negative symptoms of schizophrenia. (Cover story). (2006). Harvard Mental Health Letter, 23(1), 1-3. DRUGS, PSYCHOTHERAPY, AND SCHIZOPHRENIA Zuk, G. H., & Zuk, C. (1992). The logic of delusion. Contemporary Family Therapy: An International Journal, 14(4), 273-283

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Tax Services CONTENTS Deloitte in Cyprus . 1 Income Tax - Individuals . 2-7 Income Tax - Companies . 8-16 Special Contribution for Defence . 17-20 Profi ts from Shipping Activities . 21 Capital Gains Tax . 22-23 Immovable Property Tax . 24 Maintenance of Accounting Books and Records . 26 Tax Treaties . 27-31 Tax Diary . 32-34 Value Added Tax . 35-38

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Medical Practitioner, Dr E New Zealand Men's Clinic Ltd A Report by the Health and Disability Commissioner 08HDC02899 08HDC05986 08HDC07100 08HDC09984 Opinion 08HDC02899, 08HDC05986, 08HDC07100, 08HDC09984 Overview This report considers the service(s) provided to four men who attended the New Zealand Men's Clinic (the Clinic) and were seen by the Clinic's sole medical practitioner, Dr E. The Clinic specialises in the treatment of erectile dysfunction, premature ejaculation, and related complaints. The four men complained about the service provided by Dr E and the Clinic. This investigation has reviewed the standard of assessment and clinical examination performed.