Tullio Scrimali, Liria Grimaldi
Department of Psychiatry, School of Medicine, University of Catania
Address all correspondence to:
Prof. Tullio Scrimali
Istituto di Clinica Psichiatrica della Università di Catania
Viale A Doria N.6, (95125) Catania (Italy)
Schizophrenia is the main issue in Psychiatry as far as clinical, psychopathological, rehabilitative and therapeutical aspects are concerned.
If we consider that the incidence of such a disorder is from 0.5% to 1% of the population, without substantial differences in the various areas of the world, we can easily understand how this pathology afflicts millions of people.
When we think how the whole family is involved in the illness, and consequently we consider the enormous costs which it provokes, it is easy to understand how the therapy of schizophrenia is the most important challenge for the present-day Psychiatry.
Facing such a complex reality, we must admit our lack of knowledge concerning the dynamics of this disorder and also a gap of a satisfactory therapeutical approach.
A legend to be put aside is that the introduction of neuroleptic drugs substantially modified the prognosis of schizophrenia.
An exhaustive meta-analysis, recently carried out by Warner (1991) and Collegues, about many studies, done during this century, both in the U.S.A. and Northern Europe, led us to the following:
Recovery rates have not significantly improved after the introduction of neuroleptic drugs.
The decrease of hospitalization during this century, was already noticeable before the introduction of neuroleptic drugs.
Such data can be found also in some evaluations made by contemporary researchers such as Watt and others and Wing. They believe that the introduction of the neuroleptic has not modified the long term course of schizophrenia. Two studies done by the World Health Organization, entitled "International Pilot Study of Schizophrenia " and "Determinants of Outcome of Severe Mental Disorders" (W.H.O., 1979; Jablensky et Al., 1992) have proven to be paradoxical.
The prognosis of schizophrenia is nowadays more favourable in developing countries, rather than in industrialized ones. We may explain these unexpected results in the sense that the organization of structured (and expensive) relief organizations, and also pharmacological treatment are not related to the prognosis of schizophrenia.
Low stressing, low competitive, social environment and the possibility, for the patient, in maintaing a positive social role, appears the most important variable for the course of schizophrenia.
Expressed Emotions studies have clearly shown the family role for the outcome of schizophrenia.
Therapeutical approach to schizophrenia is open to ulterior evolution. In fact, the pharmacological treatment can only modify the clinical phenomenology of the disorder, but not its course.
Neither systemic, nor cognitive and behavioral approach, are capable, today, of giving controlled data on their efficacy.
The general indeterminateness of the therapeutical approach is to be attributed to the lack of a satisfactory evidence on the etiopathogenesis of such a severe disorder.
During the past ten years, we developed some research concerning psychopathology, therapy and rehabilitation for schizophrenia.
This aspect, supported by experimental data, results in a problem concerning the dopaminergic brain systems and could outline a gap in human information processing; This may be documented by some psychophysiological parameters such as evoked brain potentials and eyes movement. We also have evidence of an altered autonomic reactivity, to sensorial stimuli, registered by monitoring of the electrodermal activity. Individual, biological vulnerability could be genetically determined or due to pre-natal factors and could even show temperamental, schyzotypical characteristics even when schizophrenia, is not present.
Basing on the above described biological gap, a negative social environment and a negative parenting, could lead to the development of a series of emotional, cognitive and behavioral attitudes related to communication; These issues, which may be summarized in a chronic hyperarousal, in some alteration of human information processing, mainly concerns social competencies.
A positive family environment and a favourable psychosocial situation could be a protection factor.
Life events and clinical outcome
A psychotic crisis may occur because of precipitating factors that may be of a biological type, for example the use of drugs, especially hallucinogens, or of psychosocial type, like starting a job, intensifying a study programme (the last years of high school or beginning University) or also sentimental disappointment.
Course of disorder and psychosocial factors
The course of schizophrenia, which has an intrinsic variability, can be significatively influenced by psychosocial factors. The most important one is the family emotional environment and therapeutical approach. Some controlled studies have shown that, a positive family environment, without any attitude of control or emotional hyperinvolvement, is a fundamental variable in the course.
Another important variable is an efficient therapeutical collaboration, defined by Kayton, Beck and Koh as a positive emotional involvement between the patient and the therapist within a relation of help.
Also social factors, such as positive friendships, a valid support at work and in the social context, play an important role.
With these different aspects, in mind, in these past years, we developed an integrated approach to therapy of schizophrenia, caracterized by a complex and cognitive inspiration.
One of the most critical aspects, concerning biological vulnerability of the schizophrenic patient, is the disfunction in tacit and explicit knowledge activities.
Tacit knowledge is hyperfunctioning. This means that the vulnerable subject, since childhood, (and particulary at the onset of the illness), has great difficulty to utilize correctly, for the development of Self, the categories of abstract thought compared to the healthy subjects.
For the schizophrenic patients, the competence of reflecting critically on Self and on their own experiences, is greatly reduced. Equally reduced is the capability of contructing theories for progressive maturation (or self awareness) and for a better adjustment to life difficulties.
This means, that for a schizophrenic subject it is almost impossible to make comparisons in different situations. They cannot understand why a particular situation (within the family, at work or with social relationships) is so difficult and painful. They cannot give a significance, through critical consideration, to something they liked or disliked, such as watching a movie or reading a book. The ability of knowing through the emotions is higly noticable. Therefore, schizophrenic patients feel fear and enthusiasm, love and hate more profondly than healthy subjects, but they face great difficulties when giving meaning to such emotions. These inputs, far from improving the knowledge of himself/herself and the others productivly, make them feel lost in a labyrinth.
A disability can be found regarding the dialogue with Self and concerning communication, which is fruitless and disfunctional and overlaps the difficulties the subject feels towards self.
In the case that emotional enviromennt is one of a highly Expressed Emotions, the family, far from supporting and strengthening the patient, act as a amplifier of problems.
The family with high Expressed Emotion tipically dramatize and enhance any emotional disorder; This will stress the patient, and a closed loop is enstablished A similar, negative effect is verified on the patients ability to reflect, in a critical way, about themself and their experiences. This kind of family is unable to use positively cognitive competences, also in Problem Solving or Coping strategies.
From a psychoherapeutic and rehabilitative viewpoint, separable one from the other only in theorethical terms, what the above said is extremely important. The rationale of intervention must not be a simply tactical one of recovery of specific competences, but also strategical one. Through the tactical construction at various stages of the treatment, should stimulate a progressive adjustment to self reflection, the current situation, coping and problem solving and communicating in a constructive way.
It also necessary to work with the family in a similar way. This in order to replace its role of stress carrier with a new role of adequate support.
We can arrive at this through the a cognitive rehabilitative psychotherapy. Besides using the cognitive techniques to train the patient to be capable of self-criticism, coping and solving problem, the psychotherapist must act, more than in any other disorder, as a Secur-Base.
It will take time before the schizophrenic patient acquires competences in communication and the ability to discuss. The maintaning of the therapeutical relationship will be determined by trust in the therapist, as well as the sicurity and protection felt by the patient through therapy. He or she must experience the therapeutical relationship as a secure base.
We must stress the important role of the competences concerning communication: Establishing a correct expression of positive or negative feelings, and improve the capabilitis of asking something constructively, or listening in an active participating way is very important.
As already said, the psychotherapeutical and rehabilitative treatment are part of the same therapeutical project.
We need to work with the patient, and the family separetly. Because of the seriousness of the problem, associated to the disability, this therapy must be multi-contextual, since it is carried out in the psychotherapy surgery, the patient's house and in various social situation.
The rehabilitation therapist works mainly at the patient's house. The rehabilitation work is also done the in all those situations that the equipe believe important for therapy.
The shared experience will allow the patient to face all situations so far avoided, and it will strengthen the feeling of trust and protection they feel toward the therapist. The latter will act as mediator between the patient and the environment, allowing the patient to overcome the narrow behavioral limits determined by the illness.
From this role of privileged observer, the rehabilitation therapist will be able to evaluate emotional resonance caused by new experiences, and will contribute in training the patient to use cognitive abilities. Therefore will become independent and well balanced.
The role of the rehabilitation therapist will then be maintaining the therapeutical relationship in a mobile setting that may solve the specific difficulties of schizophrenia.
All above said may be summarized and carried out in a structured protocol as follows:
Multimodal assessment (clinical, psychometric, psychophysiological and neuropsychological)
Of the patient (during hospital recovery)
Of the family (summoning of relatives to the hospital immediately after clinical compensation )
Of the life environment and of secondary network (with the collaboration of the psychiatric worker)
Multimodal and multicontextual therapy
Unit of crisis
Interventions on the environmental niche
Rehabilitation and therapy in convalescent homes
Of the patient
Of the family
Social and work re-instatement
An educational intervention involving population is necessary to favour the knowledge of schzophrenia. This will make the schizophrenic patient's acceptance in society easier. In this occasion we are only able, for time reasons, to illustrate schematically these various aspects with the help of slides and transparencies.
Unit of crisis
A comfortable room with low sensorial stimulation (pastel colours, lack of noise, lack of any apparatus or furniture that may create a feeling of fear).
In this unit the medical and qualified nursing staff should establish a warm relationship with the patient. low.
At this stage it is necessary to limit the presence of family members who could trigger anxiety.
After overcoming the crisis, the patient may be admitted to the ward where has more than one bed ( three beds, in our Department).
At this stage patient and family assessment is done and a therapeutical alliance will be established.
The following areas are evaluated:
Late latencies evoked brain potentials (P.300).
Test of acoustic discrimination
Study of the emotional activation profile
Eye movement registration.
Diagnosis according to the D.S.M. IV
Evaluation of the patient's status through the "Brief Psychiatric Rating Scale".
Of the disability:
We use a test we developed which allows us to evaluate several areas;
Expressed Emotions, through the Five Minute Speech Sample.
Psychophysiological evaluation of the patient's emotional response in the presence of the family.
Evaluation of the family functioning through the Family Assessment Measure a Canadian instrument which wetranslated and validated for use with the italian population.
Psychopathological evaluation of each family member through the Middlesex Hospital Questionnaire.
Of the situation at home (visit at home).
Of the district social resources.
Of the work site.
COGNITIVE AND BEHAVIOURAL THERAPY FOR THE PATIENT
COPING AND PROBLEM SOLVING
Planning and structuring all daily activities
Ability of detecting and coping with the thoughts interfering with action (self-instructional training.)
Behavioural techniques (role playing and modeling.)
TREATMENT OF COGNITIVE DISTORSION AND OF DELIRIUM
Cognitive restructuring. The patient must be trained to change from an absolutist attitude: "I am crazy" to a different point of view "I have some problems."
Developing a more viable theory of what is happening, whith the patient This theory refers to a specific pathology rather than to mysterious and often transcendental experiences.
Concerning deliriums, we should train the patient to develop a relativist using a three columns diary for homework.
MANAGEMENT OF HALLUCINATORY PHENOMENA
It mainly refers to acoustic hallucinations and is founded on the observation that hallucinations start when the patient expects them. This usually occurs when the patient undergoes emotional stressor when a non optimal sensorial stimulation occurs.
In fact, both excesses of information (confusion, noises, colourful and strong lights) and the lack of sensorial data. For example, this could happen during the night when there is silence and there is only a night light.
The treatment rationale is based upon the following issues.
The patient must understand the relationship between arousal and the presence of disperceptive phenomena. This is done throughsystemic monitoring using appropriate home wok.
The patient must be able to insert disperceptive phenomena into a this new interpretative frame which can be summarized as following. -I am not experiencing something paranormal but just a symptom of my illness-
EMOTIONAL ADJUSTMENT AND SELF CONTROL
We did some preliminary research about biofeedback with psychotic patients. It is important to underline that, in schizophrenic patients, biofeedback is to be used with particular care. In fact, for the schizophrenic patient, working with an electronic device, may be stressful and provoke an increase in the delusional attitude concerning external influences.
In 1983, Alan Breier and John Strauss published a very interesting article about "Self Control in Psychotic Disorders."
They developed the idea that some patients may be or become able to exert control over their own psychiatric symptoms. According to Breier and Strauss, in the schizophrenic patients a three-staged self-regulation process can be established.
In the first stage a person becomes aware of the existence of psychotic or pre-psychotic behaviour by means of self-monitoring.
In the second stage, called "self-evaluation", the person recognizes the implications of this behaviour as a sign of disorder.
Once these symptoms or their precursors are detected, stage three occurs, in which the mechanisms of self-control are employed.
Relaxing is considered an instrument to reduce anxiety and,consequently, some psychotic symptoms like hallucinations. This hypothesis implies a stress origin for the exacerbation of symptoms, which is compatible with the dyathesis-stress model of schizophrenic disorders. Breier and Strauss proposed, to reduce anxiety, the use of instruments such asself-training, decreased and increased involvement in the patients' activity.
We tried to use the electrodermal biofeedback as an instrument to reduce anxiety in the schizophrenic patients with a non acute clinical situation. The control of arousal by means of biofeedback can be, according to our personal experience, an instrument to modify the patient's attitude towards hallucination, lack of behavioural control, aggressive behaviour and other psychotic symptoms. A particular typology of biofeedback that may be successfully used with the schizophrenic patients, still according to our experience, is the video-monitoring and thevideofeedback, particularly useful to improve verbal and non-verbal communication and improve the patient's ability of self-observation.
Meeting and discussion groups.
Group music therapy.
Physical activity with videofeedback and videomonitoring.
Sport practice (team tournaments with the services operators.)
RECONSTRUCTION OF PSYCHOTIC EXPERIENCE INTO BIOGRAPHICAL PERSPECTIVE
Such an important aspect is a crucial step towards recovery. It implies the acceptance of the psychotic experience as consequence of the development of the patient.
Schizophrenia is characterized by marked disability and inability, not only concerning patient but also family members. So rehabilitation strategy must include the family. Planning of a rehabilitation programme requires an accurate disability assessment. Literature give various instruments fordisability assessment such as:
Social Adjustment Scale, Self Assessment Guide, Social Behaviour Assessment Schedule, Disability Assessment Schedule etcetera We have developed and instrument to assess social and behavioural disability called A.M.D.P. It was especially designed for the Rehabilitation Therapist.
The A.M.D.P. can evaluate, through a specific score, the following eleven areas:
Area 1) Patient's physical appearance.
Area 2) Behaviour towards himself/herself and the others.
Area 3) Productive work.
Area 4) Instrumental and orienting abilities connected to environment.
Area 5) Use of spare time.
Area 6) Interpersonal relationships.
Area 7) Home and connected environmental features.
Area 8) Social role of the patient before and after the illness.
Area 9) Behaviour while in the hospital.
Area 10) Education.
Area 11) Behaviour the phase of assessment.
After the assessment, our aim is to improve problem-solving performances, communication, social competences and neurocognitivecompetenncies
An aspect to be underlined is the preparation of the setting for therapy.
It can be said that many patients admitted in our Department are influenced by their attitude following which they expect only pharmacological treatment.
In Italy the most popular requested form treatment is the intravenous drip.
Concerning family, we should say that presence a psychotic subject produces a series of negative consequences.
Our recent investigation allowed us to study these aspects in a sample of relatives of schizophrenic patients;
We found anotable presence of depression and anxiety.
The schedule for family treament, we developed, includes three possible itineraries
A preliminary stage of family assessment is very important.
We use the Five Minutes Speech Sample to evaluate Expressed Emotions, and Family Assessment Measure.
A home visit is also necessary for a more complete evaluation.
If the family is with Low Expressed Emotion, and is characterized by satisfactory equilibrium, we can use a psychoeducational intervention.
If the family is with High Expressed Emotions, a cognitive treatment may be necessary to improve problem solving stragies and communication abilities
An intervention on the network must be carried out when the patient lives and works in an adverse environment. In this case, a psychoeducational approach carried out by the rehabilitation therapist may be resolutory.
We would like to give an example of one of our patients who was continuously and severely criticized by her colleagues and by a superior, for her lack of efficiency at work. This caused crisis and some periods of hospitalization The rehabilitation therapist interveneed at work to change the colleagues and superiors' attitude towards the patient; They understood she was affected by a severe illness that, for italian law,could give a disability pension. But if she continued her job, even in a poor way, it was a positive situation for the patient and an economic advantage for the community.
To conclude, we must say something about results and the cost.
In the past ten years we have collected experimantal data concerning twenty patients, treated according to the above program. The parameter of clinical improvement we used is a comparison between relapses during the previous pharmacological treatment (baseline) and the period following our treatment.
The comparison was made following parameters:
Clinical symptomatology, measured using the Psychiatric Symptoms Scale.
Number of new admissions in the wards.
Social adjustment, evaluated through Global Assessment of Functioning Scale (A.P.A, 1994.)
The results were very encouraging. The treatment cost were cheap, if evaluated in the lights of cost-benefit. To conclude, we have to underline that, for the application of such a therapeuthical programme, we need to train Psychiatrists, Psychotherpaists, Social Workers and Rehabilitation Therapists in a homogeneous way in the light of a cognitive approach.
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