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1 Assessment of Function in Schizophrenia: Challenges & Opportunities Mamdouh EL-Adl MBBCh, MSc, MRCPsych Consultant Psychiatrist.

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Presentation on theme: "1 Assessment of Function in Schizophrenia: Challenges & Opportunities Mamdouh EL-Adl MBBCh, MSc, MRCPsych Consultant Psychiatrist."— Presentation transcript:

1 1 Assessment of Function in Schizophrenia: Challenges & Opportunities Mamdouh EL-Adl MBBCh, MSc, MRCPsych Consultant Psychiatrist

2 2 Overview I. Schizophrenia & Function. II. Challenges III. Social Behaviour: S. Function, S. Cognition & S. Skills. IV. Assessment of Function, Why? - Aim of healthcare - Health of the Nation - Modern NHS V. Assessment Scales: GAF, SOFAS, HoNOS, PSP. VI. Conclusion

3 3

4 4 I. Schizophrenia & Social Function

5 5 Schizophrenia & Function Impairment of social function (SF) is a central feature of Schizophrenia. Early studies focused on global aspects of social functioning & overt behaviours e.g. eye contact & conversation skills 1. Recently emphasis shifted to cognitive processes believed to underlie social behaviour i.e. social cognition. 1.Bellack AS, Morrison RL, Wixted JT & Mueser KT (1990). An analysis of social competence in Schizophrenia. Brit J Psychiatry, 156,809-818

6 6 Consequences of social impairment in Schizophrenia Early onset of illness: late adolescence or early adulthood. Affects multiple domains of function. Devastating effect on the development & maintenance of key social relationships. Severe impairment across multiple areas of role functioning e.g. friendships, work, marriage,….

7 7 Cognition 1 Cognitive impairment and neuropsychological deficits have been shown to be linked to functional status. Less is known about the cognitive and functional changes over time. 1. Matza, L.S., Buchanan, R., Purdon, S., Brewster-Jordan, J., Zhao, Y., Revicki, D.A. (2006). Measuring changes in functional status among patients with schizophrenia: The link with cognitive impairment [Electronic version]. Schizophrenia Bulletin, 32(4), 666-678.

8 8 The Treatment Course of Schizophrenia 1 Early intervention tends to lead to better outcomes and higher functioning. Early diagnosis and stabilization on treatment are likely to be associated better the long term prognosis. Medication compliance is directly related to reduced risk of relapse 1. NIMH

9 9 Schizophrenia & Social Function Early Onset Affects Development Affects Multiple Domains Devastating effect on development & Maintenance of key social relationships

10 10 II. Challenges

11 11 A few challenges To understand more about social cognition & social functioning (SF) in Schizophrenia To have sound SF outcome measures. Adaptation & validation of outcome measures for use in at–risk & early psychosis populations.

12 12 III. Social Behaviour!

13 13 Levels of Social behaviour The following represent different levels of Social behaviour: I. Social Functioning (SF). II. Social Cognition (SC). III. Social Skills (SS).

14 14 Social Functioning A broad multidimensional construct. Implies the overall performance across everyday domains 1 e.g. - independent living. - employment. - interpersonal relationship - recreation. Social functioning, community functioning & social competence can be used interchangeably. 1. Green MF (1996): What are the functional consequences of neurocognitive deficits in Schizophrenia? Am J Psychiatry,153(3),321–330

15 15 Social function

16 16 Social Function

17 17 Social Cognition (SC) SC: mental operations underlying social interactions. A specialised domain of cognition developed to solve social & adaptive problems & can be differentiated from non-SC (Penn et al, 1997).. The retrieval of knowledge relevant to conversation requires an adequate LT verbal memory. To send appropriate response, one must possess cognitive flexibility. Such Neurocognitive abilities (attention, working + verbal memory & executive functions) are impaired in Schizophrenia (Goldberg et al,1987;., Ne 1991).

18 18 Social skills (SS) - 1 Refers to cognitive, verbal & nonverbal behaviours necessary to engage in positive interpersonal interactions. A continuum ranging from: basic molecular to complex molar skills. Molecular skills: discrete observable behaviours e.g. eye contact, tone of voice. Molar skills result from smooth integration of molecular skills e.g. initiating a conversation.

19 19 Social skills (SS) - 2 Numerous models proposed e.g. Sequential 3 process deposit model: 1.Perception: social information/cues received. 2.Processed: interpretation of cues, retrieval of relevant knowledge from memory & response generation/selection. 3.Sending: response is sent with the aid of verbal & non-verbal skills e.g. verbal fluency, tone, gestures & eye contact.

20 20 Social Skills in Schizophrenia 3-process model: 1. Perception: receiving & recognition. 2. Processing: generate/select a response 3. Sending: verbal & non-verbal.

21 21 Social behaviour

22 22 Social Skills cognitive, verbal & non-verbal behaviours necessary to engage in a positive interpersonal interactions

23 23 Social Skills

24 24 IV. Assessment of Function

25 25 Why assess? A. Aim of healthcare. B. Health of the nation strategy C. Modern NHS: - - Foundation trusts. - Payment by results.

26 26 A. Aim of healthcare (1) To improve or maintain the overall functional capacity and general health of the patients 1. 1.Jenkinson C & McGee H: Patient assessed outcomes: Measuring Health Status & Quality of Life. In Assessment & Evaluation of Health & Medical Care, a methods text. Edited by Chris Jenkins (2002):64–84.

27 27 A. Aim of health Care (2) Historically medical care has concentrated on: - Diagnosis & treatment 1 - Intervention was based on traditional clinical, radiological & lab. measures 2. - Evaluation of medical treatment has relied on morbidity & mortality. This approach tended to overlook global functioning, well being & quality of life i.e. outcome measures did not always reflect those of patients 3,4. 1.Wasson J, Keller A, Rubenstein L, Hays R, Nelson E, Johnson D & The Dartmouth Primary Care COOP Project (1992): Benefits & obstacles of health status assessment in ambulatory settings: the clinicians point of view. 2.Albrecht G (1994) Subjective health assessment, in C Jenkinson (ed.): Measuring health & medical outcomes. London UCL Press 3.Blazer D & Houpt J (1979) Perception of the poor in the healthy older adult, Journal of the Am Geriatrics Society, 27:330–4 4.Jenkinson C (1994a) Measuring Health & Medical Outcomes: an overview, in C Jenkinson (ed.) measuring health & medical outcomes. London: UCL Press

28 28 A. Aim of health Care (3) Over the past few decades there has been - gradual shift from this approach. - incorporation of patients based data into evaluation of care The recognition of patients view as central to monitoring & evaluation of care has led to development of numerous approaches to measure the function & subjective well being.

29 29 B. Health of the nation strategy (DOH,1992) 3 targets for improving mental health: 1. To improve health & social functioning (H&SF) of mentally ill people. 2. Suicide rates in general. 3. Suicide rates in related to mental illness

30 30 R.C.Psychiatrists Research Unit (CRU) - 1 CRU received fund to develop a set of scales to measure H & S F, to be used routinely by mental health clinicians. Health & Social gain for mentally ill covers several concepts: 1. improvement in mental, physical & social functioning > what is expected without intervention. 2. maintenance of an optimal functional state by preventing, slowing &/or mitigating deterioration.

31 31 R.C.Psychiatrists Research Unit (CRU) - 2 The context of this development assumed that: 1. The new instrument would be usable across the whole range of contacts between patients & clinicians at a reasonable cost. 2. An eventual national system for data collection (of adequate quality & sensitivity). Wing JK, Curtis RH & Beevor AS (1996): HoNOS: report on Research & Development, July 1993 –Dec 1995, College Research Unit, Executive summary:1-8.

32 32 Early Intervention Assessment of function & its rate of change in FEP should be established 1. Recovery from psychotic symptoms is common after FEP (75 – 90% achieving remission one year after treatment) 2,3. However functional recovery (e.g. social, vocational, interpersonal) remains a major challenge 4,5. Improving treatment for negative & cognitive symptoms in F.E. Schizophrenia is an area of major importance in future research as these symptoms affect patients functional recovery 6. 1.Ehmann T &Hanson L. Assessment in Best Care in Early Psychosis Intervention edited by Ehmann T, MacEwan GW & Honer WG 2004:25-29 2.Norman RM, Mala AK, Duration of untreated psychosis: a critical examintion of the concept & its importance. Psychol med 2001;31:381-400 3.Addington J, Van Mastrigt S, Hutchinson J, Addington D. Pathways to care: help seeking behaviour in FEP. Acta Psychiatr Scand 2002;106:358-64 4.Walter G, Wiltshire C, Anderson J, Storm V. The pharmacological treatment of the early phase of FEP in youths. Can J Psychiatry 2001;46:803-9. 5.Cullberg J. Integrating intensive psychosocial therapy & low dose medical treatment in a total material of first episode psychotic patients compared to treatment as usual: a 3 year follow-up. Med Arch 1999;53:167-70 6.Perkins DO & Liebermann JA. Pharmacological management in Best Care in Early Psychosis Intervention edited by Ehmann T, MacEwan GW & Honer WG 2004:241-47

33 33 Early & Effective Intervention Symptoms Short & Long Term Positive Negative Affective Cognitive Sustained Adherence to Treatment Healthy Behaviour improved Performance Personal Social Integration Productivity

34 34 Assessment of function in Clinical Practice

35 35 Assessment of function in Clinical Practice Asking patient about functioning is likely to be less sensitive than asking about Psychotic Symptoms. Assessment of function is influenced by socio-cultural. Interpret patients performance with consideration to baseline & socio-cultural factors.

36 36 Information gathering I. Patient: Self reporting. II. Family/carer: Observation, views. III. Clinician/team assessment. IV. Combination of the above: preferred.

37 37 Patient Self reported assessment - Advantage: 1. Allows access to patients views. 2. Positive effect on therapeutic relationship. - Disadvantages: 1. patient may minimise/exaggerate impact of illness on his/her function. 2. likely to be affected by patients literacy & understanding of symptoms. 3. possible inconsistency over time.

38 38 Family/Carer - Advantage: 1. Longer period of observation. 2. Fosters working in partnership. - Disadvantages: 1. Carers may minimise/exaggerate impact of illness on function. 2. likely to be affected by carers literacy & understanding of symptoms. 3. possible inconsistency over time.

39 39 Clinician (s) Taking a multidimensional approach: 1. Observation: likely to be objective. 2. Gathering corroborative information. 3. Assess function at every visit/contact. 4. Looking for subtle changes in function.

40 40 V. Assessment Tools

41 41 Assessments of Function 1.GAF: Global Assessment of Function. 2.SOFAS: Social & Occupational Functioning Assessment Scale. 3.HoNOS: Health of the Nation Outcome Scale 3.PSP: Personal & Social Performance Scale.

42 42 GAF Overall assessment of Social, Occupational & Psychological functioning (Axis V). Criticism: 1. Does not include physical or environmental limitations. 2. Not a pure measure of individuals ability to function as it incorporates symptom severity e.g. L41 – 50 for serious symptoms (e.g. suicidal ideation, severe obsessive rituals, shoplifting). Hence DSM-IV-TR includes SOFAS*. *First, M & Tasman, A (2004) DSM-IV-TR, Mental Disorders: Diagnosis, Etiology & Treatment, Wiley. Diagnosis:1-49.

43 43 SOFAS Assesses Social & Occupational Function separate from Psychological symptoms Impairment due to general medical conditions are rated. Can be used to track progress in rehabilitation settings.

44 44 PSP Clearly identified anchor points. 4 domains of social & occupational functioning* *Morosini, P., Magliano, L., Brambilla, L., Ugolini, S., Pioli, R. (2000). Development, reliability and acceptability 0f a new version of the DSM-IV social and occupational scales (SOFAS) to assess routine social functioning. Acta Psychiatrica Scandinavica, 101(4), 323-329.

45 45 Introduction to PSP

46 46 PSP Developed as a measure of personal and social functioning of patients with psychiatric disorders 1 First published in 2000 in an effort to develop a more valid and reliable version of the SOFAS 2 Quick & reliable when administered by trained mental health professionals 1 SIPSP: structured Interview to increase raters reliability & validity. 1. Morosini, P., Magliano, L., Brambilla, L., Ugolini, S., Pioli, R. (2000). Development, reliability and acceptability of a new version of the DSM-IV social and occupational scales (SOFAS) to assess routine social functioning. Acta Psychiatrica Scandinavica, 101(4), 323-329.

47 47 Clinicians Responsibilities To obtain the most accurate information on functioning: The individual administering the scale should: –Be experienced in treatment of psychiatric disorders –Remain consistent for a given patient at all visits Consider information obtained from other health care professionals and/or family members regarding patients functioning Follow SIPSP Guide & PSP Scoring Guidelines

48 48 Interviewing Techniques Approach to patient –Introduce self and explain scale/intent of interview Establishing rapport –Maintain appropriate eye contact, listen to patient –Summarize patients responses to clarify and confirm –Show appropriate affective response to patient Knowledge –Emphasize appropriate time-frame –Qualify duration and frequency of behaviors Interview style –Reference patients previous responses as necessary –Broaden/narrow area of inquiry as needed Keep notes from the last visit –Reference previous responses

49 49 Structured Interview PSP Domains a) Self-care b) Socially useful activities c) Personal & social relationships d) Disturbing and aggressive behavior Within each domain determine the frequency of: –Patient independence with tasks Verbal reminders required Physical assistance required –Frequency of tasks completed Independently With verbal prompting With physical assistance

50 50 PSP: Scoring Four domains a) Self-care b) Socially useful activities c) Personal & social relationships d) Disturbing and aggressive behavior Scoring range: 0-100 –Divided into 10 equal intervals Scores of 71-100 represent a mild to little/no difficulty Scores of 31-70 represent manifest to marked difficulty Scores of 1-30 represent severe degrees of difficulty Score of 0 represents insufficient information.

51 51 Domain Components Defined Self-care –Bathing/Showering –Washing hair –Brushing teeth –Changing clothes –Taking medication –Eating Socially useful activities –Work or school –Household chores –Volunteer work or group activities Personal & social relationships –Partner, family and/or friends –Support system outside of treatment Disturbing and aggressive behavior –Speaking too loudly, cursing, verbal threats –Breaking or throwing objects, fighting –Making threats to harm self or others

52 52 Scoring Table Self-care: Bathing, changing clothes, brushing teeth, washing hair, eating Socially useful activities: includes work or school, attending a treatment program Personal and social relationships: Getting along with others, isolative behaviors Disturbing and aggressive behaviors: Easily irritated or angered, inappropriate behavior, verbal arguments, cursing, threatening physical harm to others, throwing objects, intentionally breaking things, punching walls or furniture, physical fights, physical harm to self or others AbsentMildManifestMarkedSevere Very Severe a) Self-care b) Socially useful activities, including work and study c) Personal and social relationships d) Disturbing and aggressive behaviors

53 53 Scoring Guide for the PSP AbsentMildManifestMarkedSevere Very Severe DOMAIN d NO 80-71 OR 70-61 OR 60-51 OR 40-31 OR 30-21 OR 20-11 AND 100-81 DOMAINS a,b,c 3 OF 3 100-81 1 OR MORE 80-71 1 OR MORE 70-61 ONLY 1 OF 3 IS MARKED 60-51 1 40-31 2 OF 3 30-21 3 OF 3 20-11 2 OF 3 MARKED OR 1 SEVERE AND 0 MARKED 50-41 10-65-1 1 OF 2 40-31 OR 50-41 NO 50-41 10-65-1 3 OF 3

54 54 Conclusion Assessment of function is very important for patients, carers, clinicians & commissioners. Functional Assessment Scales (FASs) are useful tools. Interpretation of patients performance has to consider baseline level & socio-cultural factors. Adaptation & validation of FASs for use in at–risk & early psychosis populations is needed.

55 55 Thank You

56 56 It is now time for food Enjoy your meal

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