Schizophrenia - The Cambridge MRCPsych Course

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Transcript Schizophrenia - The Cambridge MRCPsych Course

Non-drug treatments
(psycho-social interventions)
What we will cover
What is ‘recovery’
What is the stress-vulnerability model
Factors associated with relapse
Interventions to reduce risk of relapse
Interventions to reduce impact of
Rehabilitation in chronic illness
• ‘The process whereby a disabled person is
enabled to use their residual abilities to
function effectively in as normal a social
situation as possible’ (Bennett 1978)
• ‘Maximising quality of life’
(Sullivan et al 1992)
Recovery in chronic illness
• Not the dictionary meaning!
• ‘Recovery is an internal, ongoing process
requiring adaptation and coping skills,
promoted by social supports,
empowerment and some form of
spirituality or philosophy’ (Campbell 1997)
• ‘…a first-person concept, “I have a
problem, but with help I can grow beyond
it”’ (Prior 1999)
Supporting recovery
• Need to consider:
• the features of the disorder
• the predisposing, precipitating and
maintaining factors
What is schizophrenia?(ICD10)
• *thought echo, insertion, withdrawal,
• *delusions of control, delusional
• *auditory hallucinations – running
commentary, discussing patient or coming
from patient’s body
• *persistent bizarre delusions
ICD10 features cont…
Persistent hallucinations
Thought disorder
Catatonic behaviour
Apathy, poverty of speech, blunted or
incongruous affect
• Loss of interest, aimlessness, selfabsorption, social withdrawal
Stress Vulnerability
• Psychosis arises from environmental
stress reacting with a predisposition for
psychosis (biological and environmental)
• Various models:
• Zubin and Spring 1977
• Neuchterlein 1987
• Strauss and Carpenter 1981
• Ciompi 1988
Strauss & Carpenter’s 3 stage
• Genetic endowment
• Early environment (winter births, birth
• May lead to
abnormality conferring vulnerability to
Stage 2
• Biological factors eg drug/alcohol misuse
• Psychological factors eg life events
• Ongoing environmental influences eg
family environment, wider social
environment, physical environment
• May precipitate psychosis in a vulnerable
Stage 3
• Once the acute syndrome has formed, the
initial stressors and new ones may
converge to influence subsequent course
and outcome
• Influence of stigma, sick role, loss of social
role and contacts
Adapted from Falloon & Shenehan (1990)
Life event
Treatment strategies
• For relapse prevention, aim to maximise
distance between stress level and
vulnerability threshold
• Keep ambient stress levels low
• Reduce impact of life events
• Raise vulnerability threshold
Factors associated with relapse
• Non-concordance with medication – may
be most common cause of relapse
(Weiden & Glazer 1997)
• Misuse of drugs and alcohol – consistent
predictor of relapse (Le Duc & Mittleman
1995, Ayuso-Gutierrez & del Rio Vega
Factors associated with relapse
• Expressed Emotion – critical or emotionally
over-involved family environment (Vaughn & Leff
1976, Bebbington & Kuipers 1994)
• Face-to-face contact time >35hrs (Leff & Vaughn
• Life events (Brown & Birley, 1968; largely
replicated in multicentre WHO study – Day et al
1987, but other studies have not replicated the
Improving concordance - PSI
• Patients with schizophrenia who are dissatisfied
with their treatment are more likely to drop out
and to be rehospitalized (Priebe & Broker 1999)
• Engagement – assertive outreach techniques,
build a therapeutic alliance by providing practical
• Psychoeducation – ‘systematic administration of
info regarding symptoms, aetiology, treatment
and course with the goals of improving
understanding and changing behaviour’ (Glick et
al 1994)
Drugs & alcohol - PSI
• Inform and advise (Austoker 1994)
• Motivational interviewing (Miller &Rollnick
1991- review)
• CBT (Grabowski & Schmitz 1998)
High EE - PSI
• Family therapy to reduce EE
• Meta-analysis of studies confirms good
results (British National Schizophrenia
Guideline Group Kuipers et al 1999; Pilling
et al 2002)
• Best results obtained by working with
individual families (not groups) who rate
high (not low) on measures of EE
Psychosocial stress - PSI
• Social work and occupational therapy
interventions to modify environment:
• poverty (accessing work or benefits)
• poor housing (liase with social housing)
• loss of social role and contacts (promote
meaningful occupation)
Psychosocial stress –PSI cont
• Crisis intervention – maintains social
contacts and support mechanisms,
promotes coping strategies (vulnerability
may be less in individuals with better
social support and a coping strategy
characterized by active support seeking –
Hultman et al 1997)
• Respite admission may be more suitable
for more vulnerable patients
PSI for symptom control
• Some of the clinical features of
schizophrenia may also be improved
through the use of psychosocial
interventions eg:
• Social dysfunction
• Delusions and hallucinations
• Cognitive impairment
CBT for psychosis
• Methodological limitations mean results
must be interpreted with caution
• A Cochrane review of RCTs of CBT in
schizophrenia (Jones et al 2000)
demonstrated that CBT significantly
reduced the odds of relapse or
readmission at 18 month follow-up
• Is this generalisable?
Principles of CBT for psychosis
• Negotiate a shared conceptualization of the
problems and establish a therapeutic alliance
• Help the patient to view the phenomena as
quantifiable and multidimensional, not ‘all or
• Help the patient view the experience as falling
along a continuum including normal everyday
• Explain shifts along the continuum in terms of
stress-vulnerability model
Social skills training
• The most widely used PSI in the rehabilitation of
severely mentally ill people (Liberman et al
1986, 1989, 1993)
• Teaches social norms and rules to improve
ability to interpret cues and respond
• Effective at improving social competence but
does not have an established impact on the
course of the illness (Heinssen et al 2000)
Principles of social skills training
• Complex interpersonal behaviours are
broken down into small steps
• The steps are taught using motivational
interviewing, didactic and Socratic
instruction, shaping, modelling, corrective
feedback, role play and homework
• Training is adapted to the individual’s
deficits and cognitive impairment.
NICE guidelines
• CBT should be available as a treatment
option for people with schizophrenia
• Family interventions should be available to
the families of people with schizophrenia
who are living with or are in close contact
with the service user
Summary 1
• Schizophrenia can be understood as resulting
from an interaction between biological,
psychological and social factors that predispose
to, precipitate and maintain the illness.
• A variety of psychosocial interventions have
been developed, with the aims of reducing the
likelihood of illness recurring and of reducing the
distress and dysfunction associated with the
Summary 2
• There is good evidence for the
effectiveness of some of these
• With newer treatments, it is not yet clear
whether research evidence for
effectiveness translates to everyday
Summary 3
• Current guidelines recommend the use of
CBT and family work in the treatment of
• Opportunities to train in these treatment
modalities are available locally