Schizophrenia, the most common of the psychoses, is a challenging subject for the beginning social worker in a psychiatric setting. The purpose of this study, after reviewing the nature and cause of schizophrenia and indicating how it is currently treated in mental hospitals and clinics, is to assess (a) whether casework is an appropriate treatment method for this disorder; and (b) if so, what modification of casework is necessary to meet the schizophrenic person's needs. Schizophrenia is no longer regarded as a purely psychiatric concern. Current treatment aims at reduction of symptoms and improvement in social adjustment of the schizophrenic patient, not "cure" of the underlying pathology. According to modern psychiatry, the central problem in schizophrenia is the social malfunctioning of the patient, and social workers in the community as well as in clinical settings are being called upon with increasing frequency to aid in the treatment of this disorder. As foundation for this study, the orthopsychiatric literature available over the past decade on the psychopathology and treatment of the schizophrenic has been critically reviewed. From this material and from the personal experience of the writer in casework service to hospitalized schizophrenic patients, current concepts on the nature and cause of schizophrenia are defined, and present treatment measures evaluated. Casework as a method for treating schizophrenia is analyzed, and the phases of study, social diagnosis, planning and implementing treatment is applied to the schizophrenic patient's central problems, defense mechanisms, and impaired ego-functioning. "Ego breakdown" in schizophrenia is assessed, and contrasted with the ego-functioning of the normal, neurotic and sociopathic personality types. The conclusions of this study can only be applicable to schizophrenia in general, not to specific cases. Schizophrenia is psychogenic in origin, originating in early childhood when extreme anxiety and insecurity in the child are caused by faulty relationships with the parents, and in particular with the mother. The treatment of choice for schizophrenia is psychotherapy, with adjunctive physical therapies used to reduce symptoms and increase accessibility to personal contact. The supportive treatment method of casework and most of its techniques are eminently suited to treating the schizophrenic patient: the modifying treatment method, clarification, catharsis and interpretation of underlying conflicts, are not. The casework approach to the schizophrenic differs decidedly from that used with clients possessing stronger egos, who can tolerate the anxiety aroused by self-examination. The goals of casework with the schizophrenic patient are support of the constructive parts of the patient's personality, strengthening of his ego-functioning, and maintenance of his psychotic defenses until more constructive defenses are rebuilt. The schizophrenic patient's central problems are his withdrawal from reality due to fear, and his basic mistrust of people. A reality-oriented approach, directed to helping the patient cope more effectively with everyday problems, is used to overcome the schizophrenic patient's distrust and to renew his contact with the real world. / Arts, Faculty of / Social Work, School of / Graduate

Following a review of the relevant literature a Cognitive Behavioural treatment protocol for the prevention of relapse in schizophrenia is presented. This treatment protocol is investigated in a 12-month non-blind randomised controlled trial comparing Cognitive Behavioural Therapy and Treatment as Usual (CBT + TAU) versus Treatment as Usual (TAU) alone. Three studies of treatment outcome are described: relapse and admission, remission and social functioning, and psychological distress. 144 participants with a DSM-IV Schizophrenia spectrum disorder were randomised to receive either CBT + TAU (n = 72) or TAU alone (n = 72). 11 participants dropped out (6 from CBT + TAU, 5 from TAU alone) leaving a completers sample of 133. Participants were assessed at entry, 12-weeks, 26-weeks, and 52 weeks. CBT was delivered over two stages: a 5-session engagement phase which was provided between entry and 12-weeks, and a targeted CBT phase which was delivered on the appearance of early signs of relapse. Over 12-months CBT + TAU was associated with significant reductions in relapse and admission rate. The clinical significance of the reduced relapse and admission rate amongst the CBT + TAU group was investigated. First, receipt of CBT + TAU was associated with improved rates of remission over 12-months. Second, clinically significant improvements in social functioning were investigated. Again, receipt of CBT + TAU was associated with clinically significant improvements in prosocial activities. However, receipt of CBT + TAU was not associated with improvements in psychological distress over 12-months. The theory underpinning the cognitive behavioural treatment protocol predicted that negative appraisals of self and psychosis represent a cognitive vulnerability to relapse. This hypothesis was investigated during the present 2 Abstract study. After controlling for clinical, treatment and demographic variables, negative appraisals of self and entrapment in psychosis were associated with increased vulnerability to relapse, whilst negative appraisals of self were associated with reduced duration to relapse. Finally, an explorative study of changes in negative appraisals of psychosis and self over time, which were associated with relapsers versus non-relapsers from the TAU alone group, was conducted. This study found a strong association between the experience of relapse, increasing negative appraisals of psychosis and self, and the development of psychological co-morbidity in schizophrenia. Results of treatment outcome and theoretical analyses are discussed in terms of their relevance to the further development of psychological models and treatments for psychosis.

This work addresses some of the difficulties encountered while working in psychotherapy with a residual schizophrenic. While there is an abundance of literature on psychotherapy for schizophrenia, both supporting and also refuting its merit, what the literature fails to reveal is that there appears to be a class of schizophrenic who, while apsychotic and able to communicate in the everyday sense of the word, is in a psychic space which speaks of a break with the basic relational elements of the human order. The quality of the patient's psychic life is such that almost nothing of what the literature describes as useful and appropriate in working with schizophrenics seems to help in the psychotherapeutic work with this type of patient. This study describes these issues with relevance to a particular residual schizophrenic. The Illustrative-didactic case-study method was used to discuss the four-and- a-half month psychotherapy with this patient. The patient's early developmental history, premorbid personality functioning, family and interpersonal relationships, mental state, diagnosis and a rationale for psychotherapy were presented and considered in detail. The structure of the psychotherapeutic process was reviewed in depth. The hermeneutic guidelines to understanding the case were drawn from Object-Relations Psychoanalytic theory, particularly Balint, Khan, Karon & VandenBos, Bollas, Romanyshyn, Perry, Symington, Fordham and others. Various psychic and personality features, as unveiled through the psychotherapeutic process, were elaborated and the implications of these for the therapeutic endeavour were considered as follows: Firstly, the psychic space of the patient, which precluded mirroring, symbolization find object-relationship - and which made psychotherapy untenable, was discussed. Secondly, therapeutic ambivalence and other counter-transference issues were reviewed. Thirdly, the shadow sides of both therapeutic optimism and of psychotherapeutic change were considered. Fourthly, the issues of therapeutic failure and of other treatment possibilities for a residual schizophrenic patient were examined. It was concluded that there needs to be an important countertransference shift with regard to the psychotherapeutic goals for those patients whose condition may be chronic, and for whom it appears that psychotherapy is not going to be of any therapeutic benefit - find where an 'empathic accompaniment' might be as much as it is possible to hope for or achieve.

I examined the effects of a residential treatment program on symptoms and mental health service use in 14 chronic schizophrenics. The clients chosen for this study were the most difficult clients in this population due to continued high service usage (i.e., time spent in locked facilities). All 14 clients had been in a locked facility at least 1 year immediately prior to treatment. The program included skills training, reinforcement for incompatible behavior, and a token economy. The clients' symptomology was recorded twice a day. My hypotheses were that symptoms would decrease due to the program, and clients mental health service use would also decrease in a 1 year follow-up. Mental health service use (time spent in a locked facility) did decrease dramatically after treatment. All 14 clients had a decrease in the amount of time spent in locked facilities after treatment. The total cost for these clients in locked facilities the year immediately prior to treatment was conservatively estimated at $776,500. The annualized figure of the total cost of these 14 clients after treatment was estimated at $44,775, saving San Joaquin County approximately $721,725 in 1 year. The results did not support the hypothesis that the program reliably decreases schizophrenic symptomology as we measured it.

Aims: A case-control study is done aiming(i)to explore the prevalence of OCSs and OCD among patients with Schizophrenia treated with Clozapine(Target group)in comparison with those treated with Haloperidol(Control group), (ii) to identify the associative factors in relationship with OCSs and OCD in Schizophrenia patients treated with Clozapine in comparison with Haloperidol , (iii)to find out predictors for the increase of OCSs and OCD among patients treated with Clozapine in comparison with Haloperidol. All these information may contribute to the understanding of the underlying etiology of OCSs and OCD. Method: Sample is comprised with patients aged 18-65 who meet the diagnostic criteria of Schizophrenia-spectrum disorder based on ICD 10 and retrieval of medical records. A total of 120 patients, comprising 30 males and 30 females patients currently prescribed with Clozapine(Target group)whereas30 male and 30 female patients are currently prescribed with Haloperidol (Control group)were identified from the Schizophrenia outpatient clinic in the same hospital. Both groups will be matched with gender. Obsessive compulsive symptoms were measured with the Chinese version of Yale-Brown Obsessive-Compulsive Scale to rate the severity of the symptoms. The severity of Schizophrenia symptoms was rated by the Positive and Negative Syndrome Scale, and the Clinical Global Impression was used to measure severity symptoms in general. The social functioning of patient was rated by The Social and Occupational Functioning Assessment Scale(SOFAS). A clinical interview questionnaire was developed to determine the social and demographic characteristics, as well as other clinical features of the disorder. It included patient’s age, frequency of hospitalisation, age of onset and duration of Schizophrenia, age of onset and duration of OCSs and OCD and age of first hospitalisation, Duration of Untreated Psychosis (DUP) and current antipsychotic medication dosage( Chlorpromazine equivalent dose). Results: From the 120 patients identified and approached, 96 (80%) patients (48 male and 48 female patients) were consented for the study. The current study found that among those prescribed with Clozapine (Target group), there were 26.5% comorbid with OCSs and OCD, whereas none patients reported OCSs and OCD among the Haloperidol Control group. Patients with OCSs and OCD were significantly correlated with PANSS Positive Syndrome Score and PANSS Total Syndrome Score factors analysis by the N Par test of Mann-Whitney U, Wilcoxon W and Z score for Asymp. Using correlations test analysis, the most significantly factors to OCSs and OCD are Clozapine (Target group), PANSS Positive Syndrome Score and PANSS Total Syndrome Score. Result showed that those three factors cannot be the prediction of OCSs and OCD from the Binary logistic regression analysis. / published_or_final_version / Psychological Medicine / Master / Master of Psychological Medicine

This study examines the relationship between attitude and outcome of 30 schizophrenic outpatients. Attitude is measured using the modes of response to psychosis proposed by MayerGross in 1920 and operationalised into questionnaire form by Soskis and Bowers (1969) and McGlashan and Carpenter (1981). The outcome is defined by the number ofrehospitalizations since the first diagnosis of schizophrenia. Results show a significant relationship between attitude and outcome. Positive attitude toward the illness and positive attitude toward the future were both significantly correlated with a positive outcome (lower rate of rehospitalization). Similarly, both negative attitudes toward the illness and negative attitude toward the future were significantly correlated with a negative outcome (higher rate of rehospitalization). There was a stronger correlation between positive attitudes and positive outcome than between negative attitudes and negative outcome. The relationship between attitude and outcome in schizophrenia is used to suggest alternative ways of conceptualizing and managing the condition. The findings of this study are also used to develop recommendations for further research. / Thesis (M.Soc.Sc.)-University of Natal, Pietermaritzburg, 1999.

published_or_final_version / Psychiatry / Master / Master of Philosophy

Purpose: A systematic review and meta-analysis was conducted to identify what factors have been investigated as correlates of the 4 key domains of treatment decision making capacity (TDMC) in people who have experienced psychosis (understanding, reasoning, appreciation, communication) and to provide estimates of the magnitude of these correlations, taking into account study quality. A novel empirical study was conducted to test the hypothesis that variance in psychosis-specific cognitive biases (including the well-established ‘jumping to conclusions’ bias) would account for unique variance in TDMC domains in those with psychosis, after taking into account the known contribution of symptoms and insight. A secondary aim of the empirical study was to examine for the first time the relationship between TDMC and personal recovery in this group, and post hoc analyses of the relationship between cognitive biases, emotional distress and TDMC were also conducted. Methods: Electronic databases were systematically searched for literature on the schizophrenia and psychosis and treatment decision making capacity. Pooled estimates of correlation were estimated for factors with data from three or more studies, and both study and outcome quality were systematically assessed. A cross-sectional observational study was conducted, and individuals with psychosis completed measures of TDMC, cognitive biases, psychotic symptoms and recovery. Multiple regression was used to examine the primary and secondary hypotheses, and mediation analyses were used to conduct the post hoc analyses. Additional data from a parallel study was incorporated to increase power. Results: Twenty-four studies met inclusion criteria for the systematic review and meta-analysis. Low to moderate quality evidence suggested that the ability of people with psychosis to understand treatment-relevant information was strongly associated with overall psychotic symptom severity, verbal cognitive functioning and years of education, but not depression (moderate quality evidence). Low quality evidence suggested reasoning was strongly associated with verbal cognitive functioning and moderately associated with symptoms. Appreciation was associated with symptoms, but it and communication were generally poorly studied. Findings from the empirical study suggest that cognitive biases, and the Jumping to Conclusions bias in particular, predicts a moderate amount of the variance in the understanding and reasoning TDMC domains, but did not add predictive power to a model containing symptoms, insight, and cognition. The appreciation domain was strongly predicted by cognitive biases, insight, and cognition. TDMC was not found to be correlated with personal recovery and post hoc analyses did not find that emotional distress mediated any relationship between cognitive biases and TDMC. Conclusions: The meta-analysis confirms there is a robust association between symptoms and TDMC in psychosis, as currently conceived. The empirical study suggests cognitive biases may be related to TDMC, even after taking into account the contribution of symptoms. Larger studies, perhaps employing experimental procedures, are required to clarify the exact nature of this relationship. The lack of any relationship between TDMC and service-user defined recovery from psychosis is notable, and lends support to those calling for a conceptualisation of TDMC that takes greater account of this concept.

Thesis (MA)--University of Stellenbosch, 2002. / ENGLISH ABSTRACT: Schizophrenia is known to produce positive (e.g. hallucinations) and negative symptoms (e.g. social withdrawal). Cognitive dysfunction has long been recognised as common in schizophrenia and is now accepted as a third cardinal feature, thought strongly to be associated with negative symptoms. While positive symptoms may respond well to antipsychotic medication, the negative symptoms have typically been resistant to all forms of intervention. A current study looking at the efficacy of Eicosapentaenoic Acid (EPA), indicated a potential for negative symptoms to improve, although not significantly (P=O.14). The purpose of this research was to expand the above mentioned study, by evaluating the potential of EPA for improving cognitive function in patients with schizophrenia. Forty patients diagnosed with schizophrenia were randomly ascribed to one of two groups in a 12 week, double-blind, placebo-controlled study. The following neuropsychological tests were administered to patients at baseline and end point: Mini Mental State Examination (MMSE); Rey Auditory-Verbal Learning Test (RAVLT); Visual Reproduction, Wechsler Memory Scale - Revised (VR, WMS-R); Rey-Osterreith Complex Figure Test (ROCFT); Trail Making Tests (TMT-A; TMTB); Controlled Oral Word Association Test (COWAT); Similarities, South African Wechsler Adult Intelligence Scale - Revised (Similarities, SAWAIS-R); Boston Naming Test (BNT). There were no overall significant differences in neuropsychological function between the experimental (EPA) and the control (Placebo) group. In some isolated tests the experimental group did significantly better than the control group, but for other tests the control group did significantly better than the experimental group. Large intragroup variation - particularly within the EPA group - was indicated. In the EPA group only one out of 25 independent neuropsychological test scores showed a significant correlation with the symptom severity on the Positive and Negative Syndrome Scale (PANSS) total score (% change). There were no significant correlations between any of the neuropsychological test scores in the EPA group and on the dyskinesia subscore of the Extrapyramidal Symptom Rating Scale (ESRS). There was no evidence to support the hypothesis that EPA improved cognitive functioning in patients with schizophrenia. / AFRIKAANSE OPSOMMING: Dit is bekend dat skisofrenie positiewe (bv. hallusinasies) en negatiewe simptome (bv. sosiale onttrekking) voortbring. Kognitiewe disfunksie word lank reeds beskou as algemeen in skisofrenie en word nou aanvaar as 'n derde kardinale eienskap wat sterk geassosieer word met negatiewe simptome. Terwyl positiewe simptome goed reageer op antipsigotiese medikasie, is die negatiewe simptome tipies meer weerstandig teen all vorme van intervensie. 'n Huidige studie wat die effektiwiteit van Eicosapentaenoic Acid (EPA) ondersoek, het 'n potensiaal vir die verbetering in negatiewe simptome aangedui, alhoewel nie beduidend nie (P=O.14). Die doel van hierdie navorsing was om bogenoemde studie uit te brei, deur te evalueer wat die potensiaal van EPA is om kognitiewe simptome in pasiente met skisofrenie te verbeter. Veertig pasiente gediagnoseer met skisofrenie is ewekansig toegewys aan een van twee groepe in 'n 12 weke, dubbel-blinde, plasebo-gekontroleerde studie. Die volgende neurosielkundige toetse is afgeneem op pasiente by basislyn en eindpunt: Mini Mental State Examination (MMSE); Rey Auditory-Verbal Learning Test (RAVLT); Visual Reproduction, Wechsler Memory Scale - Revised (VR, WMS-R); Rey-Osterreith Complex Figure Test (ROCFT); Trail Making Tests (TMT-A; TMT-B); Control/ed Oral Word Association Test (COWAT); Similarities, South African Wechsler Adult Intelligence Scale - Revised (Similarities, SAWAIS-R); Boston Naming Test (BNT). Daar was geen beduidende verskille in neurosielkundige funksionering tussen die eksperimentele (EPA) en kontrole (Plasebo) groep nie. In 'n paar geïsoleerde toetse het die eksperimentele groep beduidend beter as die kontrolegroep gevaar, maar op ander toetse het die kontrolegroep beduidend beter as die eksperimentele groep gevaar. Groot intragroep variansie - in veral die EPA groep is aangetref In die EPA groep het slegs een uit die 25 onafhanklike neurosielkundige toetstellings gedui op 'n beduidende korrelasie met die ems van simptome op die Positive and Negative Syndrome Scale (PANSS) totale telling (% verandering). Daar was geen beduidende korrelasie tussen enige van die neurosielkundige toetstellings in die EPA groep en op die diskinesie-subtelling op die Extrapyramidal Symptom Rating Scale (ESRS) nie. Daar was geen bewyse om die hipotese te steun dat EPA kognitiewe funksionering in pasiënte met skisofrenie verbeter nie.

published_or_final_version / Psychiatry / Doctoral / Doctor of Philosophy