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Mamdouh EL-Adl MBBCh, MSc, MRCPsych Consultant Psychiatrist
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
I. Schizophrenia & Social Function
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 skills1. • 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
• Severe impairment across multiple areas of role functioning e.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.g.…. friendships. marriage. work. 6 .
Purdon. Matza. • Less is known about the cognitive and functional changes over time. R..A.Cognition1 • Cognitive impairment and neuropsychological deficits have been shown to be linked to functional status. Zhao.. 7 .. Measuring changes in functional status among patients with schizophrenia: The link with cognitive impairment [Electronic version].. Revicki. J. (2006). Y. 32(4).. S. 1. 666-678. L.S. Schizophrenia Bulletin. Brewster-Jordan. Buchanan. D.
NIMH http://www.cfm 8 .nimh.nih.The Treatment Course of Schizophrenia1 • 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.gov/healthinformation/index.
Schizophrenia & Social Function Early Onset Affects Development Affects Multiple Domains Devastating effect on development & Maintenance of key social relationships 9 .
II. Challenges 10 .
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. 11 .
Social Behaviour! 12 .III.
Social Skills (SS). Social Functioning (SF). III.Levels of Social behaviour The following represent different levels of Social behaviour: I. II. Social Cognition (SC). 13 .
. . • Implies the overall performance across everyday domains1 e. Green MF (1996): What are the functional consequences of neurocognitive deficits in Schizophrenia? Am J Psychiatry.interpersonal relationship . 1.g. community functioning & social competence can be used interchangeably.153(3).employment. .independent living.Social Functioning • A broad multidimensional construct. • Social functioning.recreation.321–330 14 .
Social function 15 .
Social Function 16 .
1997).1987. • The retrieval of knowledge relevant to conversation requires an adequate LT verbal memory. working + verbal memory & executive functions) are impaired in Schizophrenia (Goldberg et al. .Social Cognition (SC) • SC: mental operations underlying social interactions. • Such Neurocognitive abilities (attention. 17 . A specialised domain of cognition developed to solve social & adaptive problems & can be differentiated from non-SC (Penn et al. one must possess cognitive flexibility. • To send appropriate response. Ne 1991). . .
1 • Refers to cognitive.g. eye contact. initiating a conversation.Social skills (SS) . verbal & nonverbal behaviours necessary to engage in positive interpersonal interactions. 18 . • Molar skills result from smooth integration of molecular skills e. • Molecular skills: discrete observable behaviours e. tone of voice. • A continuum ranging from: basic molecular to complex molar skills.g.
gestures & eye contact. Sequential 3 process deposit model: 1. Processed: interpretation of cues. 19 . Perception: social information/cues received.Social skills (SS) .2 Numerous models proposed e.g. tone.g. 3. retrieval of relevant knowledge from memory & response generation/selection. verbal fluency. Sending: response is sent with the aid of verbal & non-verbal skills e. 2.
20 . Processing: generate/select a response 3.Social Skills in Schizophrenia 3-process model: 1. Sending: verbal & non-verbal. 2. Perception: receiving & recognition.
Social behaviour 21 .
Social Skills cognitive. verbal & non-verbal behaviours necessary to engage in a positive interpersonal interactions 22 .
Social Skills 23 .
IV. Assessment of Function 24 .
Health of the nation strategy C. Modern NHS: . Aim of healthcare. B.Foundation trusts.Payment by results. .Why assess? A. 25 .
1. In Assessment & Evaluation of Health & Medical Care.A. a methods text. Aim of healthcare (1) To improve or maintain the overall functional capacity and general health of the patients1. Edited by Chris Jenkins (2002):64–84.Jenkinson C & McGee H: Patient assessed outcomes: Measuring Health Status & Quality of Life. 26 .
) measuring health & medical outcomes. London: UCL Press 27 . Johnson D & The Dartmouth Primary Care COOP Project (1992): Benefits & obstacles of health status assessment in ambulatory settings: the clinician’s point of view. Journal of the Am Geriatrics Society. Hays R.4.Intervention was based on traditional clinical.A. Nelson E. 27:330 –4 4. outcome measures did not always reflect those of patients3.): Measuring health & medical outcomes. in C Jenkinson (ed.Blazer D & Houpt J (1979) Perception of the poor in the healthy older adult.e. London UCL Press 3. Keller A. 2. Aim of health Care (2) • Historically medical care has concentrated on: . measures2. Rubenstein L.Diagnosis & treatment1 . in C Jenkinson (ed. 1. well being & quality of life i.Jenkinson C (1994a) Measuring Health & Medical Outcomes: an overview.Albrecht G (1994) Subjective health assessment.Wasson J.Evaluation of medical treatment has relied on morbidity & mortality. . • This approach tended to overlook global functioning. radiological & lab.
incorporation of patients’ based data into evaluation of care • The recognition of patient’s view as central to monitoring & evaluation of care has led to development of numerous approaches to measure the function & subjective well being.A. 28 . Aim of health Care (3) • Over the past few decades there has been .gradual shift from this approach. .
3. Health of the nation strategy (DOH.1992) 3 targets for improving mental health: 1. 2.B. To improve health & social functioning (H&SF) of mentally ill people. ↓Suicide rates in general. ↓Suicide rates in related to mental illness 29 .
maintenance of an optimal functional state by preventing. 2.R. 30 .C. improvement in mental. to be used routinely by mental health clinicians. • Health & Social gain for mentally ill covers several concepts: 1.Psychiatrists Research Unit (CRU) . slowing &/or mitigating deterioration. physical & social functioning > what is expected without intervention.1 • CRU received fund to develop a set of scales to measure H & S F.
Curtis RH & Beevor AS (1996): HoNOS: report on Research & Development.Psychiatrists Research Unit (CRU) . An eventual national system for data collection (of adequate quality & sensitivity). The new instrument would be usable across the whole range of contacts between patients & clinicians at a reasonable cost. Executive summary:1-8. College Research Unit. 31 . 2. Wing JK.R.2 The context of this development assumed that: 1.C. July 1993 –Dec 1995.
MacEwan GW & Honer WG 2004:25-29 2. 5. vocational. However functional recovery (e.31:381-400 3. Med Arch 1999. Can J Psychiatry 2001. Van Mastrigt S. Psychol med 2001. Schizophrenia is an area of major importance in future research as these symptoms affect patient’s functional recovery6.E. interpersonal) remains a major challenge4. Assessment in Best Care in Early Psychosis Intervention edited by Ehmann T. 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.g. social.Perkins DO & Liebermann JA.Norman RM. The pharmacological treatment of the early phase of FEP in youths. Mala AK.5. Pharmacological management in Best Care in Early Psychosis Intervention edited by Ehmann T.Cullberg J.Addington J.46:803-9.3. Hutchinson J. Anderson J.Early Intervention • Assessment of function & its rate of change in FEP should be established1. MacEwan GW & Honer WG 2004:241-47 32 .53:167-70 6. 1.106:358-64 4. Addington D. Storm V.Walter G. • Improving treatment for negative & cognitive symptoms in F. Pathways to care: help seeking behaviour in FEP. Acta Psychiatr Scand 2002. Wiltshire C.Ehmann T &Hanson L. • Recovery from psychotic symptoms is common after FEP (75 – 90% achieving remission one year after treatment)2. Duration of untreated psychosis: a critical examintion of the concept & its importance.
Early & Effective Intervention ↓Symptoms “Short & Long Term” Positive Negative Affective Cognitive Sustained Adherence to Treatment ↑Healthy Behaviour improved Performance Personal Social Integration Productivity 33 .
Assessment of function in Clinical Practice 34 .
• Assessment of function is influenced by socio-cultural. 35 . • Interpret patient’s performance with consideration to baseline & socio-cultural factors.Assessment of function in Clinical Practice • Asking patient about functioning is likely to be less sensitive than asking about Psychotic Symptoms.
IV. views. II. Family/carer: Observation.Information gathering I. Patient: Self reporting. III. Combination of the above: preferred. 36 . Clinician/team assessment.
likely to be affected by patient’s literacy & understanding of symptoms. Allows access to patient’s views.Advantage: 1. .Disadvantages: 1. patient may minimise/exaggerate impact of illness on his/her function. 37 . 3. 2. 2. possible inconsistency over time. Positive effect on therapeutic relationship.Patient Self reported assessment .
possible inconsistency over time. Longer period of observation. 3.Family/Carer .Disadvantages: 1. 38 . . Fosters working in partnership. Carers may minimise/exaggerate impact of illness on function.Advantage: 1. 2. 2. likely to be affected by carer’s literacy & understanding of symptoms.
2. 4. Looking for subtle changes in function.Clinician (s) Taking a multidimensional approach: 1. Assess function at every visit/contact. 39 . 3. Observation: likely to be objective. Gathering corroborative information.
Assessment Tools 40 .V.
Assessments of Function 1. 3.HoNOS: Health of the Nation Outcome Scale 3.PSP: Personal & Social Performance Scale.GAF: Global Assessment of Function. 41 . 2.SOFAS: Social & Occupational Functioning Assessment Scale.
g. Does not include physical or environmental limitations.GAF • Overall assessment of Social. *First. A (2004) DSM-IV-TR. L41 – 50 for serious symptoms (e. Occupational & Psychological functioning (Axis V). 42 . • Criticism: 1. Etiology & Treatment. severe obsessive rituals. 2. Not a pure measure of individual’s ability to function as it incorporates symptom severity e.g. Hence DSM-IV-TR includes SOFAS*. M & Tasman. Wiley. suicidal ideation. Mental Disorders: Diagnosis. Diagnosis:1-49. shoplifting).
43 . • Can be used to track progress in rehabilitation settings.SOFAS • Assesses Social & Occupational Function separate from Psychological symptoms • Impairment due to general medical conditions are rated.
101(4). Brambilla.. • 4 domains of social & occupational functioning* *Morosini. Acta Psychiatrica Scandinavica. P. L. Pioli.. 44 . (2000). S. 323-329. Magliano. Ugolini. L.. Development..PSP • Clearly identified anchor points. reliability and acceptability 0f a new version of the DSM-IV social and occupational scales (SOFAS) to assess routine social functioning. R.
Introduction to PSP 45 .
46 . P. Acta Psychiatrica Scandinavica. S. 101(4).. Morosini..PSP • Developed as a measure of personal and social functioning of patients with psychiatric disorders1 • First published in 2000 in an effort to develop a more valid and reliable version of the SOFAS2 • Quick & reliable when administered by trained mental health professionals1 • SIPSP: structured Interview to increase raters’ reliability & validity. Development.. Ugolini. L. Brambilla. Magliano. 323-329. L. reliability and acceptability of a new version of the DSM-IV social and occupational scales (SOFAS) to assess routine social functioning. R. 1.. Pioli. (2000).
Clinician’s 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 patient’s functioning • Follow SIPSP Guide & PSP Scoring Guidelines 47 .
Interviewing Techniques • Approach to patient • Establishing rapport • Knowledge – Introduce self and explain scale/intent of interview – Maintain appropriate eye contact. listen to patient – Summarize patient’s responses to clarify and confirm – Show appropriate affective response to patient • Interview style – Emphasize appropriate time-frame – Qualify duration and frequency of behaviors – Reference patient’s previous responses as necessary – Broaden/narrow area of inquiry as needed – Reference previous responses • Keep notes from the last visit 48 .
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 • Independently • With verbal prompting • With physical assistance – Frequency of tasks completed 49 .
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. 50 .
verbal threats – Breaking or throwing objects. fighting – Making threats to harm self or others 51 . cursing.Domain Components Defined • Self-care – – – – – – Bathing/Showering Washing hair Brushing teeth Changing clothes Taking medication Eating • Personal & social relationships – Partner. family and/or friends – Support system outside of treatment • Socially useful activities – Work or school – Household chores – Volunteer work or group activities • Disturbing and aggressive behavior – Speaking too loudly.
attending a treatment program Personal and social relationships: Getting along with others. physical fights. isolative behaviors Disturbing and aggressive behaviors: Easily irritated or angered. punching walls or furniture. intentionally breaking things. cursing. 52 physical harm to self or others Mild Manifest Marked Severe Very Severe . eating Socially useful activities: includes work or school. threatening physical harm to others. verbal arguments. washing hair. brushing teeth. throwing objects. changing clothes. including work and study c) Personal and social relationships d) Disturbing and aggressive behaviors • • • • Self-care: Bathing. inappropriate behavior.Scoring Table Absent a) Self-care b) Socially useful activities.
b.c ONLY 1 OF 3 IS MARKED 60-51 2 OF 3 MARKED OR 1 SEVERE AND 0 MARKED 50-41 50-41 50-41 1 OF 2 40-31 1 40-31 2 OF 3 30-21 3 OF 3 20-11 10-6 3 OF 3 5-1 NO OR 60-51 NO 50-41 OR 20-11 DOMAIN d 80-71 AND 100-81 OR 70-61 OR 50-41 OR 40-31 OR 30-21 10-6 5-1 53 .Scoring Guide for the PSP Absent Mild Manifest Marked Severe Very Severe 3 OF 3 100-81 1 OR MORE 80-71 1 OR MORE 70-61 DOMAINS a.
• Interpretation of patient’s performance has to consider baseline level & socio-cultural factors. • Functional Assessment Scales (FASs) are useful tools. 54 . • Adaptation & validation of FASs for use in at–risk & early psychosis populations is needed. carers. clinicians & commissioners.Conclusion • Assessment of function is very important for patients.
Thank You 55 .
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