PSYCHOSOCIAL APPROACHES IN SCHIZOPHRENIA

PRESENTER : DR.D.ARCHANAA CHAIRPERSON : MS.NEETHI

INTRODUCTION
Recent evidence indicates that schizophrenia is a

complex neurodevelopmental disorder, or set of disorders, etiologically related to genetic factors, prenatal and perinatal insults, or both. with the onset of psychosis typically occurring during late adolescence or early adulthood critical learning opportunities, is significantly derailed for persons with schizophrenia.

INTRODUCTION
A small percentage of patients recover completely

and many have good outcomes in at least some domains, but the majority of persons with schizophrenia continue to be plagued by symptoms, cognitive difficulties, and psychosocial problems
antipsychotic medications have little impact on

psychosocial functioning and cognitive impairment

INTRODUCTION
Psychosocial treatments have become a fundamental

part of the care provided to persons with schizophrenia. help people cope with their illness and improve their functioning and QOL by enabling them to acquire the skills and supports needed to be successful in usual adult roles and in the environments . Normative adult roles include living independently, attending school, working in competitive jobs, relating to family, having friends, and having intimate relationships

 The term evidence-based practice, based on the

principles of evidence-based medicine, refers to the application of empirical data to the treatment of mental health problems, with the goal of improving the quality of care In 2004, the American Psychological Association established a task force on evidence-based practice and issued a policy statement encouraging the development of health care policies that integrate research findings, clinical skill, and patient values.

PORT
the U.S. Agency for Healthcare Research and Quality

undertook the Patient Outcomes Research Team (PORT), first in the early 1990s followed by an update in 2003, to develop research-based treatment recommendations for schizophrenia. Several of the psychosocial treatments (i.e., social skills training, cognitive behaviorally oriented therapy, supported employment, and token economy interventions) were included in the PORT treatment recommendations for schizophrenia and are considered to be evidence-based practice

Psychosocial Theories
Stress and Relapse In a diathesis-stress model, exposure to frequent and intense stress may increase the likelihood of schizophrenia for individuals with a biological vulnerability for that disorder.
Stress

may also trigger the onset of new schizophrenic episodes.

Association

between stress and schizophrenia may be bi-directional (prodromal symptoms may increase stress and stress may increase prodromal symptoms)

Psychodynamic Theories
Currently little support for these theories. Schizophrenia results from childhood neglect from

the mother, resulting in regression to infant levels of functioning.

Schizophrenogenic mother Mothers who are

overprotective and rejecting at the same time.

Expressed Emotion
Describes a family interaction style wherein family

members are over-involved, over-protective, and voice negative emotions towards the family member with schizophrenia.

Expectations that the individual with schizophrenia

has some control over symptoms.

Associated with relapse to schizophrenia.

 Some evidence that family processes play a role in

relapse of schizophrenia patients following stabilisation

Relapse

more likely (58% vs. 10%) where family is high in expressed emotion (Brown et al, 1966) high in criticism, hostility & overinvolvement lead to more relapse (Vaughn & Leff, 1976)

Families

Double Bind Theory (Bateson, 1956)

Schizophrenia is a consequence of abnormal patterns

in family communication

The patient is a symptom of a family-wide problem They become ill to protect the stability of the family system

In a double bind situation a person is given mutually

contradictory signals by another person

This places them in an impossible situation, causing internal conflict Schizophrenic symptoms represent an attempt to escape from the double bind

PSYCHOSOCIAL APPROACHES

Features of Schizophrenia
Positive symptoms Delusions Hallucinations
Negative symptoms Anhedonia Affective flattening Avolition Social withdrawal Alogia

Functional Impairments Work/school Interpersonal relationships Self-care

Cognitive deficits Attention Memory Verbal fluency Executive function (eg, abstraction)

Disorganization Speech Behavior

Mood symptoms Depression/Anxiety Aggression/Hostility Suicidality

SOCIAL SKILLS TRAINING

Social dysfunction is a defining characteristic of

schizophrenia. People with this illness have difficulty fulfilling social roles The term skill is used to emphasize that social competence is based on a set of learned abilities Based on social learning principles SST emphasizes the role of behavioral rehearsal in skill development

Contd.
Social dysfunction is hypothesized to result from

three circumstances : subtle attention deficits in childhood that interfere with the development of social relationships and acquisition of basic social skills. schizophrenia often strikes first in late adolescence or young adulthood, a critical period for mastery of adult social roles and skills. individuals with schizophrenia gradually develop isolated lives, punctuated by periods in psychiatric hospitals or in community residences.

Contd.
cognitive impairment of schizophrenia is associated

with deficits in social cognition

social competence is based on three component

skills: (1) social perception, or receiving skills; (2) social cognition, or processing skills; and (3) behavioral response, or expressive skills.

COMPONENTS OF SST
Expressive Behaviors

Speech content Paralinguistic features -Voice volume, Speech rate, Pitch, Intonation Nonverbal behaviors Eye contact (gaze) Posture Facial expression

COMPONENTS OF SST
Receptive Skills (social perception)

Attention to and interpretation of relevant cues Emotion recognition Processing Skills Analysis of the demands of the situation Incorporation of relevant contextual information Social problem solving Interactive Behaviors Response timing Use of social reinforcers

TECHNIQUES OF SST
role play of simulated conversations

Trainer instructs on how to perform the skill, and

then models the behavior (demonstrates) identifies a relevant social situation in which the

patient engages in a role play with the trainer Feedback & positive reinforcement by trainer Sugesstions and corrections conducted in small groups of 6 8 patients 3 5 times per week

 The content of training programs is organized into

curricula, such as job interview skills, medication management skills,dating skills, and assertion skills Duration of training - four to eight sessions for a very circumscribed program, such as safe sex skills 6 months to 2 years for a comprehensive programme Training is structured so as to minimize demands on neurocognitive capacity.

 Limitation of SST concerns transfer of training, or

generalization of newly learned skills, to the community. SST produced significantly greater improvements than occupational therapy in independent living skills in the community over the 2-year trial, although the differences tended to decrease after the 6-month active treatment phase ended

IVAST
IN VIVO AMPLIFIED SOCIAL TRAINING

combines standard skills training with intensive case

management. The case manager helps support completion of homework assignments, identifies and reinforces opportunities to use trained skills, and establishes links with support systems (e.g., significant others) in the community to reinforce the use of newly learned skills.

VOCATIONAL REHABILITATION
Impairment of vocational role function is a common

complication related to schizophrenia Employment - <15 % Pts expressed interest to work but difficulty obtaining and maintaining employment Previously train then place models were used did not improve the rate of competitive employment among persons with schizophrenia

SUPPORTED EMPLOYMENT
Place then train model

rapid job search without extensive pre-employment

assessment or training. After which, patients are helped to learn the skills and provided with support needed to be successful mainstream jobs in the competitive labor market, owned by the employee rather than the rehabilitation program, with regular pay at or above minimum wage and supervision by the employer

IPS
Individual placement and support (IPS) model of

supported employment. PRIMARY GOAL : To assisst obtaining and maintaining competitive employment in a job of their choice, improving their vocational satisfaction, self-esteem, and overall quality of life. The major components of the IPS model are : Competitive employment in the community Rapid search for job

 Integration of vocational & mental health services

Patient preference
Ongoing support assessment & training no evidence that supported employment exacerbates

symptoms by increasing stress levels. Several factors may complicate the provision of supported employment: Cognitive symptoms Negative symptoms Poor economic status of the country

CLINICAL ISSUES
LIMITATIONS:

Most of jobs are part time, relatively low paying, and

rarely enable people to get off benefits 1/3 rd of patients work briefly , while others have difficulty maintaining consistent employment
ETHICAL ISSUES :

Disclosing facts about illness to employers

Stigma at work place

RESEARCH
A number of RCT s show that supported employment

leads to higher rates of employment, higher earnings, more hours worked, and longer job tenure in competitive jobs. Symptom exacerbations, clinical instability, relapse, and other negative outcomes are not higher in supported employment compared with other types of vocational programs. recent review of employment in schizophrenia, associated with positive outcomes in social functioning, self-esteem, & QOL

 supported employment is widely considered an

evidence-based practice in mental health treatment for schizophrenia. Nevertheless, employment rates and overall income still remain quite low.

Acute stages Acute symptoms Predominantly positivestages Predominantly positive symptoms

Chronic stage Predominantly negative symp, Disability/handicap

Inpatient treatment Pharmacotherapy Supportive therapy Psychoeducation

Outpatient treatment Individual family Pharmacotherapy psychoeducation Supportive therapy family therapy Functional assessment Skill development

Relapse

Community care Day care centre Sheltered workshop Residential setting

CBT
CBT is a psychological approach to treatment that is

focused on the interrelationship between thoughts, behaviors, and feelings.

In CBT, the therapist and patient work

collaboratively using specific techniques to help make changes in the person's thinking and behaviors in order to bring about changes in how he or she is feeling and to reduce the symptoms he or she is experiencing.

Contd.
PRIOR VIEW - patients with schizophrenia were too

cognitive and psychologically impaired to engage in and benefit from CBT. However, findings from the past two decades suggest that schizophrenia patients can benefit from CBT CBT presumes that psychotic symptoms are psychological processes that occur on a continuum with non psychotic experience interpretations of psychotic experiences can be modified, thereby leading to decreased distress associated with those experiences and reductions in the experiences themselves.

CLINICAL ISSUES
clinical issues considered in implementing CBT :

Motivational factors
Negative symptoms CBT not a substitute for pharmacotherapy

adaptation of CBT techniques to accommodate the

cognitive deficits Problem solving training Cognitive retraining

TECHNIQUES
BEHAVIOURAL STRATERGIES: Behavioral activation Pleasant activity scheduling

Relaxation/stress reduction
Self-monitoring Behavioral experiments

 COGNITIVE STRATERGIES: Identifying automatic thoughts Hypothesis testing

Identifying alternative explanations

Exploring evidence Cognitive control strategies

NOTE - delusional beliefs must be addressed with

caution

Psychological intervention for voices

Competing information: Thought stopping: elastic band / stop it Competing auditory stimuli: personal stereo,humming, singing, speaking loudly Self monitoring:keeping a diary

Cont ..
Anxiety reduction: breathing techniques,

relaxation exercises, systematic desensitization Cognitive: -belief modification: investigating events that activate voice, exploration of evidence for belief -focussing: encourage identification of the contents of the voice as internally generated -coping skills enhancement: own coping strategies for dealing with voices

Psychological intervention for delusions

Belief modification:beliefs are ordered into levels

of conviction, with the least well held belief being tackled first, by trying to disentangle the types of evidence used to support the belief and generating alternative explanations Behavioral experiments: test the veracity of delusional belief and supporting evidence Reattribution: attribute negative events not to people but to situations

RESEARCH
A number of RCTs show that CBT leads to modest

improvements in positive symptoms, negative symptoms, and overall symptom levels inconsistencies across studies CBT was superior to supportive counseling at the end of treatment, but that the differences between the two treatment groups diminished by 1- and 2year follow-ups cognitive impairment is not a barrier to improvement in CBT

RESEARCH
relatively few long-term follow-up data available on

CBT for schizophrenia, and almost no information about how treatment gains might be maintained over time. In addition, there is contradictory evidence about whether CBT is better suited for different phases of illness It is increasingly considered to be an evidence-based practice for schizophrenia and has become a standard of care in the United Kingdom.

TOKEN ECONOMY
behavioral reinforcement programs based on the

principles of social learning The key elements of token economies are: (1) identification of target behaviors that are considered desirable (2) earning points or tokens for engaging in these behaviors, (3) redeeming the points in exchange for material items or privileges, and (4) participation by all patients in the treatment setting

PRINCIPLES
The principles of operant conditioning and social

learning law of effect posits that the frequency of a behavior is determined by the consequences (i.e., effects) of the behavior. Therefore, behaviors that are reinforced by positive consequences will be more likely to occur in the future, and behaviors that are followed by negative consequences (i.e., punishment) are less likely to occur again

 law of association by contiguity.- two events will

come to be associated with each other if they occur together. That is, a neutral stimulus that occurs together with a positive consequence will become reinforcing social reinforcement is an important aspect of token economies. Social reinforcement includes any interpersonal communication, verbal or nonverbal, that is perceived as approving or reinforcing to the patient.

TECHNIQUES
The goals of treatment in a token economy are to

(1) teach behaviors that will improve a patient's

ability to successfully move to and remain in a less restrictive setting, (2) provide incentives for performing desired behaviors, and (3) reduce the frequency of problem Behaviors encompass activities of daily living ,social interaction, active treatment participation, and medication adherence

 LIMITATIONS:

administrative and financial requirements for

establishing & maintaining a token economy system questionable generalization of positive behaviors beyond the structure of the token economy patient rights need to be taken into consideration so that basic needs are not included as reinforcers and basic necessities are not withheld some reinforcers used in the past are considered unethical by today's standards

RESEARCH
The strongest evidence is for improvement on

ratings of behavior such as the Wing Ward Behavior Scale or the Nurse Observation Scale for Inpatient Evaluation very few of the studies have included follow-up after discharge from the hospital unclear how directly applicable the findings are to short-stay hospital settings or community-based treatment settings

SUBSTANCE ABUSE REHABILITATION

50 % of adults with schizophrenia have at least one

co-occurring substance abuse Efforts began in the 1980s to combine, or integrate, mental health and substance abuse interventions for people with dual disorders Several features of integrated dual diagnosis treatment are associated with better outcomes and thus are considered evidence-based principles. They are :

 Integration

Stage wise intervention

Assertive outreach Motivational intervention

Counselling
Social support intervention Long term perspective

Comprehensiveness

BTSAS
Behavioral Treatment for Substance Abuse in

People with Serious Mental Illness administered to small groups (four to six) twice per week for 6 months. highly structured social learning intervention Each session adheres to the same basic structure: (1) A urine sample is secured and the results are announced to the group

TECHNIQUES
(2) Each subject is then assisted in setting realistic

goals for decreased drug use until the next session, and signs a goal contract. (3) The remainder of each session follows a structured curriculum for drug abuse education, skills training, and relapse prevention
Urine samples were collected from all subjects at

every session, providing an objective measure of drug use throughout the 6 months of the trial.

RESEARCH
Subjects in BTSAS had a significantly higher

proportion of clean urine tests over the 6 months of treatment

BTSAS subjects also attended significantly more

sessions, and they reported having more money available for living expenses (e.g., they spent less on drugs) and had fewer hospital admissions

Assertive Community Treatment

Multidisciplinary teams: social workers,

psychologists, occupational therapists, case managers Staff:patient ratio about 1:10 Outreach, contact as needed Effective at reducing hospitalizations Cost-effective when targeted at high hospital users

Family Psychoeducation
Provides information about schizophrenia:

course, symptoms, treatments, coping strate One aim is to decrease expressed emotion (hostility, criticism, etc.) To build up an alliance with relatives who care for the schizophrenic member To reduce adverse family atmosphere

Family interventions
To enhance the problem solving capacity of

relatives To decrease expressions of anger and guilt To maintain reasonable expectations of patient performance To set limits safeguarding relatives own well being To achieve changes in relatives behavior and beliefs

Community setting

Aimed at helping the individual compensate for the disability by locating living and working environments that can accommodate to the residual deficits and symptoms
Non intrusive, non demanding social environment with more object focussed activity such as occupational therapy

Cont..

Day care: psychiatric , psychosocial and prevocational treatment programs -day hospital -day care centre Its a more supportive ,long term management and maintenance oriented service
A.

Cont ..
B. Residential care: -Half Way Homes Intermediary point between leaving the hospital and returning to the family For developing and maintaining adequate self help and social skills for reentering the community, the family is prepared to receive the patient with an emphasis on psychoeducation and reduction of expressed emotion

Conclusion
Indian families more tolerant but increasing

urbanization changing trends Theres an urgent need for more day care centres which can provide respite to family as well as make patient feel less stigmatised Rehabilitation in india is in infancy and it is necessary that we pool our expertise and knowledge base so that we make optimal use of the available resources

CONCLUSION

Although there is strong evidence supporting the use

of the psychosocial approaches to the treatment of schizophrenia many unanswered questions remain.
Future research will need to investigate on how best

to combine psychosocial interventions for maximal benefit, cost-effectiveness o, and their long-term benefits

CONCLUSION
Continued efforts to increase uptake of these

treatments into the mental health service system will be important

Mental health administrators, clinicians, and

researchers can engage with consumers in their efforts to make recovery-oriented, empirically supported psychosocial treatments available for persons with schizophrenia

THANK U