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Predicting skill acquisition in social skills training for schizophrenia and schizoaffective disorder: The role of memory and symptomatology
307
motherapy. This paper will describe a randomized controlled trial of enriched social treatment for schizophrenics and their relatives. At year 3 in this 5-year study, 56 SADS-diagnosed schizophrenics and their relatives (N = 101) have been randomly allocated to receive one of the three treatments in addition to maintenance medication: a time-limited group social skills training program for the patient; a time-limited group psychoeducational intervention for the relatives; or, both treatments in parallel. Pre-treatment and at 4, 12, 18 and 24 months all patients are assessed on psychometrically validated measures of symptoms, illness episodes, service utilization and social functioning. All relatives are assessed in relation to illness burden, knowledge of the illness, expressed emotion, general health and social functioning. At inclusion into the study it was found that a majority of the patients experienced severe social dysfunction, moderate stress and minimal social support though most were satisfied with the amount of support available. The patients are young (Mdn - 27 years), predominately o and have a high school education or less (67%). Approximately 45% of the families male (77%), single (9OY), received a rating of high expressed emotion on the Five Minute Speech Sample and most lived with their ill relatives. The relatives experienced considerable burden. This paper will present the 12 month treatment-outcome data available on 52 patients and their families. Treatment-outcome differences will be presented on patient symptoms, social functioning and service utilization, and on family member knowledge of illness, burden, social functioning and general health. Results will be compared and contrasted with the findings of other treatment trials.
Predicting skill acquisition in social skills training for schizophrenia and schizoaffective disorder: The role of memory and symptomatology K.T. Mueser*, A.S. Bellack, J.H. Wade, M.S. Douglas Department of Psychiatry, Medical College of Pennsylvania at EPPI, 3200
HenryAvenue, Philadelphia, PA 19129, USA.
Introduction: A substantial body of evidence has accumulated over the past decade supporting the efficacy of Social Skills Training (SST) for improving the social and symptomatic outcome of schizophrenia. Despite the widespread acceptance of SST as a useful psychosocial treatment for schizophrenia, little is known regarding which patients benefit from this intervention and which do not. The identification of patient characteristics that are predictive of response to SST has important implications, both for making differential treatment recommendations and understanding the mechanisms that mediate clinical response to this intervention. The present learning study was conducted in order to examine the role of memory, symptomatology, history of illness, and demographic characteristics as predictors of the acquisition and maintenance of social skills taught in an acute care setting. Method: The subjects were 27 schizophrenic and 18 schizoaffective disorder (DSM-III-R) patients (55.6% male) receiving inpatient treatment for symptom exacerbation. Patients were referred to the SST group after their acute symptoms had remitted, an average of 15.2 days following admission. The SST group focused on teaching conflict resolution skills in l-hour sessions held thrice weekly over a 2-week period, with the average patient attending 4.7 sessions. Assessments of social skill (role play test), memory (the Wechsler Memory Scale), and symptomatology (BPRS) were conducted at pretreatment, posttreatment (end of 2 weeks), and at a l-month followup by persons blind to the patient’s performance in the group. Results: 1) Baseline analyses indicated that memory impairments were related to poor social skill, which were both related to negative symptoms (Anergia), but not positive symptoms (Thought Disorder, Hostility); 2) Repeated measures ANOVA revealed improvements over time in social skill and symptoms, but not in memory; multiple regressions indicated that changes in social skill were unrelated to changes in symptoms; 3) Good memory was predictive of the acquisition and maintenance of social skill; 4) Chronicity of illness, schizophrenia/schizoaffective diagnosis, and demographic characteristics were unrelated to baseline memory or social skills and were not predictive of social skill acquisition or maintenance. Discussion: The analysis of changes over time suggest that improvements in social skill were not secondary to improvements in symptoms or memory, and reflected learning in the brief SST group. The relationship between memory and social skill at baseline indicates that dysfunctional social performance in schizophrenia may be secondary to impairments in cognitive processing. These cognitive impairments may mediate response to SST, rendering the treatment less effective for those patients with the most severe deficits. Symptoms,
308 chronicity, and demographics, on the other hand, do not appear to mediate learning in SST. Cognitive processing ability may be an important factor limiting the utility of SSt in this population.
To what degree do negative symptoms and social adaptation influence motivation towards regular participation in group therapy by schizophrenic outpatients? B. Schmitz-Niehues*, W.P. Hornung Klinik fir Psychiatric der Westf: Willlelnls-Ulliversit~t,Albe&Schweitzer-Str. 11, D-4400 Miinster, Gemany Numerous studies have shown that group psychotherapy for chronic schizophrenic outpatients can have a positive influence on the extent of cognitive disturbances (Brenner et al, 1987) on the course of the illness and on the relapse rate (Wallace & Libermann, 1985). In a therapeutic project funded by the Ministry of Research and Technology of the FRG, a combined approach was developed for group therapy for chronically ill patients (Buchkremer et al., 1986). 189 patients fulfilling DSM-III-R criteria for schizophrenia took part in the study. The therapeutic offer comprised psycho-educational training for medication management, cognitive psychotherapy and recreational activities (as a control condition). Because of their illness, it is difficult to motivate schizophrenic patients to take regular advantage of the therapy offered to them. The question to be answered is, therefore: which variables influence adherence to therapy? In this connection, the extent of negative symptoms (SANS) and of social adaptation (job, residential situation, social contacts and GAS) were examined. The connections between the stated variables and participation in the different therapeutic groups are shown. The results assist in making decisions on which patients can be approached for group therapy of this kind.
The effect of a hospital treatment rates of a SPMI patient group T.B. Sullivan*, L. Ferrante,
model on the aftercare compliance
M. Kotcher
The New York Hospital-Come11 Medical Center Westchester Division, 21 Bloomingdale Road, White Plains, NY 10605, U.S.A.
Patients admitted to an inpatient unit which specializes in work with treatment-refractor and/or treatment non-compliant persons with severe and persistent mental illnesses (SPMI) such as chronic schizophrenia, rapid-cycling bipolar disorder, etc., were engaged in a treatment program emphasizing a multimodal, interdisciplinary and interpersonal approach to fostering a treatment alliance. The aim of the treatment program is to increase the patient’s availability to help as measured first by improved compliance and collaboration with aftercare treatment recommendations. Other goals include decreased symptom levels, over time, and improved quality of life. These goals and strategies have been formulated because of our observation, as well as that of others, that many potentially useful treatments, including but not limited to psychotropic treatment regimens, fail because of the patient’s apparent amotivation or the impact of delusional ideation on behavior, as well as other factors that impede collaboration. Our findings with this population suggest support for our treatment approach. Whereas the group we studied had high rates of noncompliance, and other measures of a poor treatment alliance, prior to treatment, following an intermediate-length stay on our unit (mean 3.5 months), we found a high rate of compliance with aftercare post-discharge (mean 90%). This contrasts with published data which reports, typically, compliance rates of approximately 30% for broader patient groups and treatment settings. These findings are also notable because most aftercare assignments are to institutions (clinics, day programs) that are not affiliated with our program. We are currently organizing follow-up studies to measure effects on other variables such as quality of life, attitude toward illness, and social adjustment, among others.
motherapy. This paper will describe a randomized controlled trial of enriched social treatment for schizophrenics and their relatives. At year 3 in this 5-year study, 56 SADS-diagnosed schizophrenics and their relatives (N = 101) have been randomly allocated to receive one of the three treatments in addition to maintenance medication: a time-limited group social skills training program for the patient; a time-limited group psychoeducational intervention for the relatives; or, both treatments in parallel. Pre-treatment and at 4, 12, 18 and 24 months all patients are assessed on psychometrically validated measures of symptoms, illness episodes, service utilization and social functioning. All relatives are assessed in relation to illness burden, knowledge of the illness, expressed emotion, general health and social functioning. At inclusion into the study it was found that a majority of the patients experienced severe social dysfunction, moderate stress and minimal social support though most were satisfied with the amount of support available. The patients are young (Mdn - 27 years), predominately o and have a high school education or less (67%). Approximately 45% of the families male (77%), single (9OY), received a rating of high expressed emotion on the Five Minute Speech Sample and most lived with their ill relatives. The relatives experienced considerable burden. This paper will present the 12 month treatment-outcome data available on 52 patients and their families. Treatment-outcome differences will be presented on patient symptoms, social functioning and service utilization, and on family member knowledge of illness, burden, social functioning and general health. Results will be compared and contrasted with the findings of other treatment trials.
Predicting skill acquisition in social skills training for schizophrenia and schizoaffective disorder: The role of memory and symptomatology K.T. Mueser*, A.S. Bellack, J.H. Wade, M.S. Douglas Department of Psychiatry, Medical College of Pennsylvania at EPPI, 3200
HenryAvenue, Philadelphia, PA 19129, USA.
Introduction: A substantial body of evidence has accumulated over the past decade supporting the efficacy of Social Skills Training (SST) for improving the social and symptomatic outcome of schizophrenia. Despite the widespread acceptance of SST as a useful psychosocial treatment for schizophrenia, little is known regarding which patients benefit from this intervention and which do not. The identification of patient characteristics that are predictive of response to SST has important implications, both for making differential treatment recommendations and understanding the mechanisms that mediate clinical response to this intervention. The present learning study was conducted in order to examine the role of memory, symptomatology, history of illness, and demographic characteristics as predictors of the acquisition and maintenance of social skills taught in an acute care setting. Method: The subjects were 27 schizophrenic and 18 schizoaffective disorder (DSM-III-R) patients (55.6% male) receiving inpatient treatment for symptom exacerbation. Patients were referred to the SST group after their acute symptoms had remitted, an average of 15.2 days following admission. The SST group focused on teaching conflict resolution skills in l-hour sessions held thrice weekly over a 2-week period, with the average patient attending 4.7 sessions. Assessments of social skill (role play test), memory (the Wechsler Memory Scale), and symptomatology (BPRS) were conducted at pretreatment, posttreatment (end of 2 weeks), and at a l-month followup by persons blind to the patient’s performance in the group. Results: 1) Baseline analyses indicated that memory impairments were related to poor social skill, which were both related to negative symptoms (Anergia), but not positive symptoms (Thought Disorder, Hostility); 2) Repeated measures ANOVA revealed improvements over time in social skill and symptoms, but not in memory; multiple regressions indicated that changes in social skill were unrelated to changes in symptoms; 3) Good memory was predictive of the acquisition and maintenance of social skill; 4) Chronicity of illness, schizophrenia/schizoaffective diagnosis, and demographic characteristics were unrelated to baseline memory or social skills and were not predictive of social skill acquisition or maintenance. Discussion: The analysis of changes over time suggest that improvements in social skill were not secondary to improvements in symptoms or memory, and reflected learning in the brief SST group. The relationship between memory and social skill at baseline indicates that dysfunctional social performance in schizophrenia may be secondary to impairments in cognitive processing. These cognitive impairments may mediate response to SST, rendering the treatment less effective for those patients with the most severe deficits. Symptoms,
308 chronicity, and demographics, on the other hand, do not appear to mediate learning in SST. Cognitive processing ability may be an important factor limiting the utility of SSt in this population.
To what degree do negative symptoms and social adaptation influence motivation towards regular participation in group therapy by schizophrenic outpatients? B. Schmitz-Niehues*, W.P. Hornung Klinik fir Psychiatric der Westf: Willlelnls-Ulliversit~t,Albe&Schweitzer-Str. 11, D-4400 Miinster, Gemany Numerous studies have shown that group psychotherapy for chronic schizophrenic outpatients can have a positive influence on the extent of cognitive disturbances (Brenner et al, 1987) on the course of the illness and on the relapse rate (Wallace & Libermann, 1985). In a therapeutic project funded by the Ministry of Research and Technology of the FRG, a combined approach was developed for group therapy for chronically ill patients (Buchkremer et al., 1986). 189 patients fulfilling DSM-III-R criteria for schizophrenia took part in the study. The therapeutic offer comprised psycho-educational training for medication management, cognitive psychotherapy and recreational activities (as a control condition). Because of their illness, it is difficult to motivate schizophrenic patients to take regular advantage of the therapy offered to them. The question to be answered is, therefore: which variables influence adherence to therapy? In this connection, the extent of negative symptoms (SANS) and of social adaptation (job, residential situation, social contacts and GAS) were examined. The connections between the stated variables and participation in the different therapeutic groups are shown. The results assist in making decisions on which patients can be approached for group therapy of this kind.
The effect of a hospital treatment rates of a SPMI patient group T.B. Sullivan*, L. Ferrante,
model on the aftercare compliance
M. Kotcher
The New York Hospital-Come11 Medical Center Westchester Division, 21 Bloomingdale Road, White Plains, NY 10605, U.S.A.
Patients admitted to an inpatient unit which specializes in work with treatment-refractor and/or treatment non-compliant persons with severe and persistent mental illnesses (SPMI) such as chronic schizophrenia, rapid-cycling bipolar disorder, etc., were engaged in a treatment program emphasizing a multimodal, interdisciplinary and interpersonal approach to fostering a treatment alliance. The aim of the treatment program is to increase the patient’s availability to help as measured first by improved compliance and collaboration with aftercare treatment recommendations. Other goals include decreased symptom levels, over time, and improved quality of life. These goals and strategies have been formulated because of our observation, as well as that of others, that many potentially useful treatments, including but not limited to psychotropic treatment regimens, fail because of the patient’s apparent amotivation or the impact of delusional ideation on behavior, as well as other factors that impede collaboration. Our findings with this population suggest support for our treatment approach. Whereas the group we studied had high rates of noncompliance, and other measures of a poor treatment alliance, prior to treatment, following an intermediate-length stay on our unit (mean 3.5 months), we found a high rate of compliance with aftercare post-discharge (mean 90%). This contrasts with published data which reports, typically, compliance rates of approximately 30% for broader patient groups and treatment settings. These findings are also notable because most aftercare assignments are to institutions (clinics, day programs) that are not affiliated with our program. We are currently organizing follow-up studies to measure effects on other variables such as quality of life, attitude toward illness, and social adjustment, among others.