What you'll learn

• How antipsychotic drugs modify schizophrenia symptoms through brain chemistry.
• How cognitive behavioural therapy helps people reinterpret symptoms and reduce distress.
• How to evaluate both methods using AO1, AO2 and AO3.
• How treatment studies link to Component 2 research methods and inferential testing.

Starting point: what is being modified?

Schizophrenia is a severe mental health condition involving disruption to thinking, perception, emotion and behaviour. In this topic, “modifying the behaviour” means reducing the impact of schizophrenia symptoms and improving everyday functioning.

The two key methods you need are antipsychotic drugs and cognitive behavioural therapy, often called CBT. They work at different levels: drugs mainly target brain chemistry, while CBT targets beliefs, interpretations and coping behaviour.

Method 1: antipsychotic drugs

The basic idea

A neurotransmitter is a chemical messenger that carries signals between nerve cells. Dopamine is one neurotransmitter involved in reward, motivation and perception. A synapse is the gap between two neurons where neurotransmitters are released.

Antipsychotic drugs are linked to the dopamine hypothesis, which suggests that some symptoms of schizophrenia are associated with excessive dopamine activity, especially in brain pathways involved in salience and perception.

Typical antipsychotics

Typical antipsychotics, also called first-generation antipsychotics, include chlorpromazine and haloperidol. They mainly act as dopamine antagonists, meaning they block dopamine receptors, especially D2 receptors.

By blocking D2 receptors, they reduce dopamine overstimulation. This can reduce positive symptoms such as hallucinations and delusions.

However, dopamine is also involved in movement. Blocking dopamine in movement pathways can cause extrapyramidal side effects, meaning movement-related side effects such as stiffness, tremors or restlessness. Long-term use may lead to tardive dyskinesia, which involves involuntary movements and can sometimes be irreversible.

Atypical antipsychotics

Atypical antipsychotics, also called second-generation antipsychotics, include clozapine, risperidone and olanzapine. They still affect dopamine, but many also act on serotonin systems.

Clozapine is often used for treatment-resistant schizophrenia, meaning symptoms have not responded well to other medication. It can be effective, but it carries a risk of agranulocytosis, a dangerous reduction in white blood cells, so patients need regular blood monitoring.

Evaluating antipsychotic drugs

Strength: strong evidence for symptom reduction

There is substantial research support for antipsychotics. Thornley et al. (2003) reviewed evidence on chlorpromazine and found it was more effective than placebo for reducing symptoms and relapse, although side effects were common.

Leucht et al. (2012) also found that antipsychotics were effective in relapse prevention compared with placebo. This supports real-world use because relapse is a major issue in schizophrenia care.

Strength: useful in acute episodes

Antipsychotics can work faster than talking therapies for acute psychosis. If someone is very distressed, confused or at risk, medication may reduce intensity enough for them to engage with further support.

Weakness: side effects and adherence

Side effects can be serious. Typical antipsychotics are associated with movement problems, while atypical drugs can cause weight gain, diabetes risk and sedation. This creates an ethical and practical issue: a treatment can be effective but still difficult to tolerate.

Weakness: reductionism

A purely biological treatment can be criticised as reductionist, meaning it explains a complex disorder too narrowly. Schizophrenia involves cognition, family stress, trauma, social support, poverty, stigma and culture, not just dopamine.

Ethical issues

The BPS Code of Ethics and Conduct highlights consent, protection from harm, confidentiality, right to withdraw, deception and debriefing. In drug treatment and drug trials, informed consent can be complicated if the person is acutely psychotic. Clinicians must monitor side effects carefully, protect patients from harm and ensure medication is not used simply as a form of social control.

Method 2: cognitive behavioural therapy

The basic idea

CBT does not simply tell someone their hallucinations or delusions are “wrong”. Instead, it works collaboratively. The therapist and client build a formulation, meaning a shared explanation of how thoughts, feelings, symptoms and behaviours maintain distress.

How CBT modifies schizophrenia

CBT targets the cycle between:

• a trigger, such as stress or a voice;
• an interpretation, such as “the voice is all-powerful”;
• an emotion, such as fear or shame;
• a behaviour, such as withdrawal, checking or avoidance.

The therapist may use reality testing, where beliefs are gently examined against evidence, and behavioural experiments, where the person tests predictions in a safe, planned way.

CBT can also include coping strategies for voices, activity scheduling for negative symptoms, relapse planning and work on self-esteem.

Evaluating CBT

Strength: evidence for reducing distress and improving coping

Sensky et al. (2000) compared CBT with befriending in patients with persistent symptoms despite medication. Both groups improved at first, but CBT showed better maintenance of improvement at follow-up. This suggests CBT may have lasting benefits because it teaches skills the person can keep using.

Meta-analyses such as Wykes et al. (2008) suggest CBT has beneficial effects, although effect sizes vary. This supports CBT as part of a broader treatment package.

Strength: fewer biological side effects

CBT does not carry drug side effects such as movement disorders or metabolic problems. It can also increase autonomy because the person learns coping strategies and becomes more involved in their own treatment.

Weakness: effects may be modest

Jauhar et al. (2014) argued that when studies used stronger controls and reduced bias, CBT effects on core psychotic symptoms were smaller than sometimes claimed. This is important AO3: CBT may be helpful, but it should not be exaggerated as a complete replacement for medication.

Weakness: access and engagement

CBT requires trained therapists, regular attendance and the ability to reflect on thoughts and experiences. During acute psychosis, a person may be too distressed or suspicious to engage fully.

Ethical issues

CBT must avoid confrontation. Directly challenging a delusion too forcefully could increase distress or damage trust. Ethical therapy should be collaborative, respect confidentiality, gain informed consent and include safeguarding if there is risk of harm.

Comparing the two methods

Antipsychotics and CBT are not rivals in a simple “one is right, one is wrong” way. They modify schizophrenia differently.

Antipsychotics are often most useful for reducing acute positive symptoms and relapse risk. CBT is often most useful for helping people understand experiences, reduce distress, improve coping and support recovery.

NICE guidance in the UK generally recommends antipsychotic medication alongside psychological interventions such as CBTp and family intervention. This supports an interactionist approach, meaning biological and psychological factors are treated together.

Component 2 research methods link

Treatment evidence often comes from a randomised controlled trial, or RCT, where participants are randomly allocated to conditions such as drug versus placebo or CBT versus control therapy. A meta-analysis combines results from multiple studies.

If you are asked about statistics, choose the inferential test from the design and data type:

• Unrelated t-test: difference between two independent groups using interval data.
• Related t-test: difference in related or repeated-measures interval data.
• Mann-Whitney U: difference between two independent groups using ordinal or non-parametric data.
• Wilcoxon signed-ranks: difference between related conditions using ordinal or non-parametric data.
• Spearman’s rho: correlation between two variables using ordinal/ranked data.
• Chi-square: association or difference using nominal frequency data.
• Binomial sign test: direction of change in related nominal data.

Researchers usually test at $p\le 0.05$. They compare an observed value with a critical value from a table. One-tailed tests are used for directional hypotheses, such as “CBT will reduce distress”; two-tailed tests are used for non-directional hypotheses, such as “CBT will affect distress”. A Type I error is a false positive, while a Type II error is a false negative.