Hans D. Brenner

Self‐healing strategies among schizophrenics: attempts at compensation for basic disorders

ABSTRACT– New experimental findings show that schizophrenics, as well as some of their non‐schizophrenic relatives, manifest basic cognitive disorders defined in terms of variables from the field of experimental psychology. These basic disorders can be regarded as markers ‐ if not, indeed, as psychological manifestations ‐ of vulnerability to schizophrenia. They can be associated with subjectively experienced forms of non‐clinically manifest impairments in psychological functioning. It was therefore hypothesised that schizophrenics, as well as non‐schizophrenic subjects vulnerable to schizophrenia, will, in the course of learning processes, develop compensatory efforts which may be more or less effective. It is assumed that effective efforts of this kind will take on special significance in stress situations which would tend to elicit the occurrence of a schizophrenic episode. Effective efforts at compensation for basic disorders should be able to act as a ‘buffer’ against negative stressor effects (moderator function), thus reducing the danger of a psychotic breakdown. These compensation efforts were studied in 40 inpatients in remission after an acute schizophrenic episode. It was found that significant correlations exist between the extent of subjectively experienced basic disorders and the number and kind of conscious compensation attempts. Although the findings to date are of a preliminary and purely descriptive nature they would seem to justify further research.

Cognitive therapy with schizophrenic patients: conceptual basis, present state, future directions

Schizophrenia may nowadays be most readily understood as a systemic disorder in which changes in the brain structure underlie individual cognitive abnormalities which for their part interact with environmental factors at the onset of the illness and during its course. From this, one may deduce the rationale for cognitive therapy for schizophrenic patients. Existing approaches may be systemised as direct, indirect and combined procedures. The latter are based on the assumption of the pervasive effects of elementary and complex cognitive dysfunctions at the levels of open behaviour. However, in a mirror‐design study with 21 schizophrenic patients according to DSM‐III‐R in which the effects of various intervention sequences were examined, it was not possible to find confirmation for this. This and other open questions have led to doubts expressed in current literature concerning the utility of cognitive therapy, especially with respect to the locus, nature and malleability of cognitive disorders, as well as the possibility of generalizing cognitive improvements. The latter are discussed in detail and possible future directions in cognitive therapy for schizophrenic patients are shown.

Training schizophrenic patients to manage their symptoms : predictors of treatment response to the German version of the symptom management module

This study examined whether patient demographic and clinical characteristics were predictors of differential treatment response in a sample of 57 schizophrenic patients who received the German version of the Symptom Management Module. Psychopathology, global functioning and knowledge about schizophrenia were assessed as dependent variables. Overall, patients improved over the treatment period on most dimensions of psychopathology as well as knowledge about psychosis. There was little evidence of differential treatment response as a function of either sociodemographic or clinical variables. However, gender was related to changes in psychopathology from pre- to posttreatment, with females improving less than males. Possible implications of these findings were discussed.

A multi-hospital evaluation of the Medication and Symptom Management Modules in Germany and Switzerland

The initial success of the Social and Independent Living Skills Modules has led to an interest in exploring their feasibility and effectiveness in other countries. To this end, the Medication Management and Symptom Management Modules were recently translated into German and field tested in a multi-center collaborative study with persons having schizophrenia. Results indicated high feasibility of the modules at all ten treatment sites. Patients who participated in a larger sample of the Symptom Management Module showed significant improvements in knowledge about their illness, negative symptoms, psychosocial functioning, as well as an increase in internal locus of control and a decrease in fatalism.

Teaching schizophrenic patients recreational, residential and vocational skills

Three therapy programs have recently been devised as a further development of the Integrated Psychological Therapy (IPT) for patients with schizophrenia. They offer targeted and structured behavior therapy in residential, vocational and recreational activity-three areas of rehabilitation which have been neglected in Europe, despite evidence from numerous prospective and retrospective studies showing severe impairment in these areas of psychosocial functioning in schizophrenia. The three therapy programs, aimed at enabling patients to lead more independent and satisfying lives in the community, have shown promise but need further research for their empirical validation.

Nonpharmacological Treatment Concepts of Negative Symptomatology

In the past decade, while various rating scales such as the Scales for the Assessment of Negative Symptoms (SANS) (Andreasen 1982), the Positive and Negative Syndrome Scale (PANSS; Kay et al. 1987), the Psychological Impairments Rating Schedule (PIRS; Jablensky 1978), and its revised version the Behavioral Observation Schedule (BOS; Atakan and Cooper 1989) were being devised to assess negative symptoms in schizophrenia, intensive research was being conducted on negative symptoms in the fields of psychopharmacology, pathophysiology, and brain morphology (see surveys, Den Boer et al. 1987; Crow 1989). Thus, biological research began to focus its attention on a syndrome which until then had been within the domain of psychosocial treatment. In cases where integrating studies of pharmacological, psychological, and social therapies into long-term treatment of schizophrenia have been carried out, they, however, did not especially aim at negative symptoms (Carpenter 1987). It is interesting to note that the lines along which research developed led researchers to test and adopt new and older substances which were known to be partly antagonistic to neuroleptics (e.g., amphetamines). There has also been growing interest lately in the observed behavior of chronic schizophrenics who attempt to “cure themselves” with drugs and medications (Liberman and Bowers 1990).

Successful challenge with clozapine in a history of eosinophilia

Eosinophilia has been encountered from 0.2 to 61.7% in clozapine-treated patients, mostly with a transient course and spontaneous remission. There have been few reports, however, which have investigated a challenge with clozapine in patients previously showing eosinophilia. Two case reports are presented: the first with clozapine challenge after eosinophilia, the second under clozapine treatment and no previous haematological side effects. The challenge case showed eosinophilia with 1.2 10(9)/l (z = 1.79, p = 0.04) being followed by normalization despite clozapine continuation, whereas the maximum value reached 2.1 10(9)/l in the single episode case, with consecutive normalization and uninterrupted treatment. Eosinophilia caused by clozapine was observed in challenge, preceded by a faster neutrophil production and consecutive decrease (z = 2.27, p = 0.01). A challenge with clozapine was feasible and showed no clinical symptoms of eosinophilia.

The Importance of Cognitive Processes for the Integrative Treatment of Persons with Schizophrenia

Cognitive impairment is a hallmark of schizophrenia. Such impairment precedes the onset of the illness and typically endures over time.1 Alterations in cognitive processing, such as deficient source monitoring2,3 or lack of connectivity,4 are considered essential pathologic mechanisms involved in the development of schizophrenia. Reasoning biases such as “externalization” or “jumping to conclusions” contribute to the emergence and maintenance of delusions and hallucinations.5 Most important, however, cognitive impairment substantially interferes with everyday functioning. Deficits in everyday functioning are associated with the pervasive disability seen in schizophrenia. In recent years, research has increasingly shown that cognitive impairment is at the base of the skill deficits observed in schizophrenia patients and, thus, is a barrier to functional recovery.6–8

Bewältigungsorientierte Therapie bei psychisch Erkrankten

In den letzten 15 Jahren sind neben Therapien zur Verbesserung kognitiver und sozialer Funktionen insbesondere psychoedukative Ansatze in Kombination mit Psychopharmakatherapie starker in den Mittelpunkt der Behandlung schizophren Erkrankter geruckt (Schaub und Brenner 1996). Diese Ansatze haben folgende Gemeinsamkeiten (Schaub et al. 1996a): Der Erkrankte wird als aktiver Partner in die Behandlung integriert. Die Vermittlung von Informationen zur Erkrankung und Behandlung auf der Grundlage des Vulnerabilitat-Streβ-Bewaltigungs-Modells (Nuechterlein und Dawson 1984) sowie die Verbesserung der Bewaltigungskompetenz im Umgang mit der Erkrankung and spezifischen Symptomen (z. B. Fruhwarnsignalen, chronischen Symptomen), Belastungen und potentiellen Krisen spielen eine wichtige Rolle. Liegt der Akzent auf der Informationsvermittlung, bezeichnet man diese Ansatze als psychoedukativ, bei starkerer Akzentuierung des Copingaspekts als bewanuale vor: Module zum Medikations- und Symptom-Management der Arbeitsgruppe um Liberman (1986,1988, dt. Ubersetzung Brenner 1989,1990), Psycho-edukatives Training fur schizophrene Patienten (PTS) (Kieserg und Hornung 1996), Psychoedukative Gruppenarbeit mit sc hizophren und schizoaffektiv erkrankten Menschen (PEGASUS) (Wienberg et al. 1995) und Psychoedukative Gruppen fur Patienten und Angehorige (Bauml et al. 1996). In diesem Zusammenhang erwahnenswert ist zudem das einzeltherapeutische Vorgehen von Sullwold and Herrlich (1990).

Sozioemotionale Therapieprogramme in der psychiatrischen Rehabilitation

Auch wenn erste Ansatze sozioemotionaler Therapieprogramme fur psychiatrische Patienten bereits vor ungefahr 50 Jahren entwickelt wurden (z. B. Ellis 1955), sind sie im Vergleich zu Therapieprogrammen zur Informationsverarbeitung und zu sozialen Fertigkeiten bis heute klar in der Minderzahl. Dies ist erstaunlich, da sich das Verstandnis der Emotionen im Allgemeinen und ihre Beziehung zu psychiatrischen Storungen im Speziellen, dramatisch verandert hat. Im Gegensatz zu fruher werden heute Emotionen als objektivierbar und therapierbar verstanden. Zudem ist bekannt, dass Patienten mit chronischen psychischen Erkrankungen krankheitsspezifische Defizite in der Emotionsverarbeitung aufweisen, die mit neurobiologischen Dysfunktionen korrelieren. Dieses Kapitel beginnt mit einem kurzen historischen Abriss des Verstandnisses von Emotionen, gefolgt von einer Darstellung der Defizite chronisch psychisch Kranker, speziell schizophrener Patienten, in der Emotionsverarbeitung. Daran schliest sich die Beschreibung sozioemotionalerTherapieinterventionen in der Rehabilitation an. Diese unterscheiden sich formal gesehen nicht von anderen in der psychiatrischen Rehabilitation eingesetzten Trainingsverfahren, beinhalten aber spezifische Interventionen zur Verbesserung einer unangemessenen Bewaltigung von Emotionen. Ihr Ziel ist es, den Teilnehmern hilfreiche Strategien zu vermitteln, um sich in sozialen Situationen emotional zurechtzufinden und dadurch Ruckfalle zu vermeiden. Sie zeichnen sich durch ein strukturiertes, zielgerichtetes und auf ihre Effektivitat hin evaluiertes Vorgehen aus.