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Negative Entropy: A Cognitive and complex approach to therapy and rehabilitation of schizophrenia

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)
Telephone: 39-337-955813
Fax: 39-95-336999

INTRODUCTION

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.

Vulnerability

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.  

Development history

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
            Inpatients ward
            Day hospital
            Surgery

Interventions on the environmental niche

Rehabilitation and therapy in convalescent homes

Community Homes  
Rehabilitation:

       Of the patient
       Of the family     

Social and work re-instatement    

Corollary:
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. 

HOSPITALIZATION

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.


Inpatients ward

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.  

PATIENT'S ASSESSMENT    

The following areas are evaluated:

Psychophysiological:    

            Late latencies evoked  brain potentials (P.300).
            Test of acoustic discrimination
            Study of the emotional activation profile
            Eye movement registration.    

Clinical:

            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;    

FAMILY ASSESSMENT   

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.    

AFTER DISCHARGE

Psychosocial assessment:

          Of the situation at home (visit at home).
          Of the district social resources.
          Of the work site.

 Treatment: 

          Day Hospital
          Surgery    

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.

 
SOCIALIZATION

     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.

REHABILITATION

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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