Coping with symptoms of relapse in schizophrenia

Coping in residual schizophrenia: Re-analysis of ways of Coping checklist

Background & objectives:

Persons with schizophrenia use various coping strategies to adapt to distressing symptoms as well as to deal with daily stressors. Efforts have been made to explore alternative frameworks of coping using Ways of Coping Checklist (WCC) in persons with schizophrenia. This study aimed to re-analyze (factor analysis) the revised-WCC in Indian patients with residual schizophrenia. The secondary aim of the study was to evaluate the relationship of new framework of coping with psychopathology, disability and quality of life (QOL).

Methods:

Using a cross-sectional design, 103 patients with residual schizophrenia were assessed on WCC. A principal component analysis with varimax rotation was carried out to determine the factor structure of WCC.

Results:

Factor analysis yielded six factors which explained 51.6 per cent of the total variance and had acceptable-to-good internal consistency. Based on the type of items loaded, the six factors were named as follows: active and growth-oriented coping, accepting and fantasizing, reflective and confrontative coping, detachment, seeking social support and negative emotional coping. Patients most often used coping strategy of seeking social support, followed by ‘accepting and fantasizing’ and ‘active and growth-oriented coping’. Correlation analysis showed that those who more often used ‘active and growth-oriented coping’ had less negative symptoms, lower level of disability and higher spiritual and overall QOL.

Interpretation & conclusions:

The factor structure of revised-WCC was different among patients with schizophrenia when compared with individuals without mental illness, living in the community. It was evident that use of certain adaptive coping strategies was associated with better QOL and lower level of psychopathology. Our findings provided a framework of coping in patients with residual schizophrenia and suggested that promotion of certain coping strategies might be useful in improving the QOL and reduction of psychopathology in patients with schizophrenia.

Do sleep abnormalities and misaligned sleep/circadian rhythm patterns represent early clinical characteristics for developing psychosis in high risk populations?

Sleep architecture changes, such as slow-wave sleep (SWS) percentage variations and reductions in latency and density of rapid eye movement (REM), are found in most patients with schizophrenia and are considered to be an important part of the pathophysiology of the disorder. In addition to these sleep parameters changes, disruptions in sleep homeostasis and the sleep/circadian rhythm also occur in these patients. Sleep/circadian rhythm abnormalities negatively affect neocortical plasticity and cognition and often precede the diagnosis of the illness. Thus, it has been suggested that the sleep/circadian rhythm might be involved in the pathophysiology of psychosis. Recent advances in the identification of individuals at a high risk for developing schizophrenia allow us to investigate several neurobiological processes involved in the development of psychosis. In this article, we review the current evidence of the effects of sleep parameter abnormalities, disruptions in sleep homeostasis and misalignments of sleep circadian rhythm on the early stages of schizophrenia. In addition, we discuss the preliminary evidence of sleep and circadian rhythm abnormalities during the prodromal stages of psychosis and propose that these abnormalities can be explored as potential predictors, as an adjunct to clinical diagnosis, of developing a psychotic disorder in at risk populations.

Reliability and validity of the Japanese semistructured interview version of the Early Signs Scale (ESS-JI) for outpatients with schizophrenia (study 1)

The purpose of this study was to develop a semistructured interview for the Japanese version of the Early Signs Scale (ESS-JI), as well as to examine its reliability and validity. We conducted a cross-sectional study in Japan. Participants were recruited from a psychiatric clinic. The survey included 25 participants with schizophrenia; of these, 21 participants gave informed consent. For the analysis, we used data from 15 outpatients who had no missing values on the ESS-JI. Of the participants, 70% were female, and the mean age was 41.2 years. The ESS-JI was developed by the authors using a translation-back-translation procedure. Internal consistency was assessed by Cronbach's alpha coefficients, and test-retest reliability was assessed by Pearson's correlation coefficients. Correlations with other scales, such as the Behaviour and Symptom Identification Scale (BASIS-32) and the Self-Efficacy for Community Living Scale (SECL), were used to examine the concurrent and construct validity of the ESS-JI. Cronbach's alpha coefficients were high for the ESS-JI. Pearson's correlation coefficients also indicated good test-retest reliability. The ESS-JI was significantly and positively correlated with the BASIS-32. In contrast, the ESS-JI had a significant negative correlation with the SECL. This study confirmed the reliability and validity of the ESS-JI for outpatients with schizophrenia.

Awareness of early warning signs and help-seeking behaviours among patients with schizophrenia who utilize social rehabilitation facilities in Japan

The purpose of this study was to examine the relationship between early warning signs (EWS) and early help-seeking behaviours (HSB) and to identify the characteristics of patients with schizophrenia who sought early help. A cross-sectional study was carried out in 2004 using a self-reported questionnaire. Participants were recruited from social rehabilitation facilities for the mentally ill; 224 subjects participated, 170 of whom had schizophrenia. The survey included questions about demographic characteristics, self-care behaviours (HSB, recognition of EWS and others) and current service utilization and satisfaction. Fisher's exact test and Student's t-test were used to compare the characteristics of study participants. Logistic regression analyses were used to examine the association between recognition of EWS and early HSB.We found that 96 (56.5%) of 170 patients with schizophrenia reported at least one occasion of early HSB during their deterioration. Early HSB were related to the following factors: recognition of EWS, consultation with non-professional and professional support persons during deterioration, consulting with public mental health workers and living with family. Care and support should be offered to patients with schizophrenia to enable them to recognize their own mental deterioration.

Sleep disturbances in patients with schizophrenia : impact and effect of antipsychotics

Difficulties initiating or maintaining sleep are frequently encountered in patients with schizophrenia. Disturbed sleep can be found in 30-80% of schizophrenic patients, depending on the degree of psychotic symptomatology. Measured by polysomnography, reduced sleep efficiency and total sleep time, as well as increased sleep latency, are found in most patients with schizophrenia and appear to be an important part of the pathophysiology of this disorder. Some studies also reported alterations of stage 2 sleep, slow-wave sleep (SWS) and rapid eye movement (REM) sleep variables, i.e. reduced REM latency and REM density. A number of sleep parameters, such as the amount of SWS and the REM latency, are significantly correlated to clinical variables, including severity of illness, positive symptoms, negative symptoms, outcome, neurocognitive impairment and brain structure.Concerning specific sleep disorders, there is some evidence that schizophrenic patients carry a higher risk of experiencing a sleep-related breathing disorder, especially those demonstrating the known risk factors, including being overweight but also long-term use of antipsychotics. However, it is still unclear whether periodic leg movements in sleep or restless legs syndrome (RLS) are found with a higher or lower prevalence in schizophrenic patients than in healthy controls.There are no consistent effects of first-generation antipsychotics on measures of sleep continuity and sleep structure, including the percentage of sleep stages or sleep and REM latency in healthy controls. In contrast to first-generation antipsychotics, the studied atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone, ziprasidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity, with an increase in either total sleep time (TST) or sleep efficiency, and individually varying effects on other sleep parameters, such as an increase in REM latency observed for olanzapine, quetiapine and ziprasidone, and an increase in SWS documented for olanzapine and ziprasidone in healthy subjects.The treatment of schizophrenic patients with first-generation antipsychotics is consistently associated with an increase in TST and sleep efficiency, and mostly an increase in REM latency, whereas the influence on specific sleep stages is more variable. On the other hand, withdrawal of such treatment is followed by a change in sleep structure mainly in the opposite direction, indicating a deterioration of sleep quality. On the background of the rather inconsistent effects of first-generation antipsychotics observed in healthy subjects, it appears possible that the high-potency drugs exert their effects on sleep in schizophrenic patients, for the most part, in an indirect way by suppressing stressful psychotic symptomatology. In contrast, the available data concerning second-generation antipsychotics (clozapine, olanzapine, risperidone and paliperidone) demonstrate a relatively consistent effect on measures of sleep continuity in patients and healthy subjects, with an increase in TST and sleep efficiency or a decrease in wakefulness. Additionally, clozapine and olanzapine demonstrate comparable influences on other sleep variables, such as SWS or REM density, in controls and schizophrenic patients. Possibly, the effects of second-generation antipsychotics observed on sleep in healthy subjects and schizophrenic patients might involve the action of these drugs on symptomatology, such as depression, cognitive impairment, and negative and positive symptoms.Specific sleep disorders, such as RLS, sleep-related breathing disorders, night-eating syndrome, somnambulism and rhythm disorders have been described as possible adverse effects of antipsychotics and should be considered in the differential diagnosis of disturbed or unrestful sleep in this population.

Coping with hallucinated voices in schizophrenia: a review of self-initiated strategies and therapeutic interventions

This article reviews the state of knowledge about strategies used by people with a diagnosis of schizophrenia to cope with hallucinated voices, and considers the role of coping in psychological treatments for persisting symptoms. The use of self-initiated ('natural') coping strategies appears almost universal amongst voice-hearers. These strategies are similar across cultures, and include diverse behaviours, only a minority of which is specific to hallucinations. Most strategies are reported by at least some users to be effective, but more sophisticated outcome studies are lacking. Some evidence for the efficacy of certain behavioural techniques of coping, for the manipulation of auditory input, and for strategies involving subvocalisation, is available from experimental studies. Therapeutic enhancement of natural coping strategies for persisting symptoms has demonstrated some efficacy, but its benefit for voices is unknown. Despite this, it has become an established part of some CBT interventions for psychosis. Further advances in knowledge and practice may come from utilisation of coping models in research, longitudinal and ideographic methods of study and a movement away from descriptive coping lists to investigations of coping styles, mechanisms of action, and the process of coping.

Recognition of early warning signs in patients with schizophrenia: a review of the literature

This article reviews and discusses the literature on the recognition of the early warning signs of psychosis. The assumption is that nurses, in the everyday exercise of their profession, can contribute to the prevention of psychotic relapse in schizophrenic patients by the early recognition of warning signs. First, the process of psychotic relapse and the factors that influence it are described. Then research on the early signs of psychosis is discussed. This article questions the most common early signs, when they occur, and who can recognize them. Then the predictive value of the early signs is considered: how well can psychotic relapse be predicted with these early signs? Finally, the research on the effects of early recognition and early intervention is discussed, primarily with respect to the question of whether psychotic relapses can actually be prevented by making use of preventive intervention strategies. The conclusion is that the preliminary results are hopeful and invite further research on such matters as the application of this intervention strategy within nursing practice.

The role of early warning symptoms in the detection and prevention of relapse in schizophrenia

OBJECTIVE

The capacity of most clinical programs to detect early signs of relapse in schizophrenia and to implement strategies to prevent clinical progression remains unevaluated. The aim of this paper is to review the literature on the detection of relapse in schizophrenia and to draw conclusions that may be of use in the implementation of clinical programs.

METHOD

The relevant literature identified by standard search methods is explored and analysed.

RESULTS

Few studies have the capacity to directly address the question as to whether it is possible to predict relapse with a high degree of predictive power. Recently, the implementation of a multifactorial approach to relapse prediction appears to have offered substantial benefits.

CONCLUSIONS

The prediction of episodes of psychotic relapse is a realistic goal. Evidence indicates that interventions based upon programs of early detection can reduce rates of illness relapse. Prediction of relapse is most successful when implemented in a multifactorial way that involves specific and non-specific symptoms, structured ratings, clinical judgement, families, patients and clinicians.

Maastricht Assessment of Coping Strategies (MACS-I): a brief instrument to assess coping with psychotic symptoms

OBJECTIVE

To examine the reliability of a brief instrument to assess coping with symptoms by patients with psychotic illness.

METHOD

A semi-structured interview (MACS) was developed to assess the amounts of distress, control and coping in relation to psychotic symptoms. Two raters interviewed 23 symptomatic but stable patients with a diagnosis of chronic schizophrenia on two separate occasions. Case managers were also interviewed.

RESULTS

Both the number of coping strategies used for different groups of symptoms, and the amount of coping used in different domains of coping strategies could be assessed reliably between interviewers (intraclass correlation coefficients range: 0.90-0.97) and between interview sessions (ICCs range: 0.75-0.80). Reliability with case managers, however, was low.

CONCLUSION

The MACS may be a reliable and useful instrument to assess coping in relation to subjective experience of distress by and control over psychotic symptoms.

Psychoeducational training for schizophrenic patients: background, procedure and empirical findings

As neuroleptic therapy alone still fails to other effective relapse prevention in schizophrenic patients, psychoeducational therapeutic approaches have been developed as an additional aid for patients and their families. This article details the central characteristics of these approaches. A psychoeducational group program for schizophrenic outpatients, the efficacy of which was investigated within the scope of a German controlled intervention study on 191 patients, is also presented. The article describes in detail the methods used and the therapeutic objectives, reporting on changes in the attitudes of patients to their medication. At the end of the training program, patients who had attended regularly showed significantly better medication compliance and were more reserved with respect to their medication self-management. After 1 year the positive effects had diminished. However, booster sessions or participation of the psychiatrist in charge as group therapist would have had longer lasting effects.

Prodromal symptoms in schizophrenia

This paper describes a prospective study of the relationship between non-psychotic prodromal symptoms and psychotic symptoms in 55 schizophrenic (DSM-III-R) out-patients. Once a month, a number of non-psychotic symptoms generally regarded as prodromal symptoms in schizophrenia were assessed, as well as psychotic symptoms, with standardised self-administered instruments and rating scales for a minimum of 12 months (range 12-29). The data were analysed for each patient using a longitudinal correlational design with a 1-month lag between the prodromal and psychotic symptoms over the total period. Results showed that in less than one-fifth of subjects did any of the prodromal symptoms, individually or in combination, show a significantly positive correlation with the subsequent level of psychotic symptoms. Such relationships were significant in an even smaller proportion of subjects when the confounding effect of concurrent psychotic symptoms on prodromal symptoms was partialled out. High levels of prodromal symptoms appeared to have adequate specificity but low sensitivity in their power to predict high levels of subsequent psychotic symptoms. There were no differences in age, gender, medication levels, and the number of previous admissions between the subjects who did or did not show a relationship between putative prodromal symptoms and psychotic symptoms.

Prodromal signs of relapse in schizophrenia

Fifty-six patients who were hospitalised for a schizophrenic episode were followed up for nine months after discharge. The Psychiatric Assessment Scale (PAS, Krawiecka et al., 1977) was administered at monthly intervals during this period. Twenty-three patients relapsed of which data were available for sixteen. In these sixteen patients who relapsed comparisons were made of the PAS symptoms between the month prior to relapse and the month preceding this. Sixteen patients who did not relapse were randomly matched with the relapsing patients and an index point comparable in time to relapse onset in the matched relapsed patient was identified. Comparisons were made on the PAS symptoms using a repeated measures ANOVA to compare relapsers and non relapsers on the month prior to relapse and the month which preceded this. Discriminant function analysis was used to predict relapse by analysis of those PAS symptoms which showed an increase in the month before relapse. This suggested that the measures of depression and hallucinations significantly increased in the month prior to relapse compared to the preceding month in relapsers but not non-relapsers. The results of this study closely agree with previous published results even though there were some differences between studies in the patient samples.

Claimed simulation of insanity. A coping strategy in mania

The coping strategy of claimed simulation of insanity observed at the onset of psychotic episodes in a manic patient is reported here. There is a need for systematic research on coping strategies in affective psychosis in order to develop techniques to help contain or prevent relapses.