Complexity and Problematics of Psychosis - Essay Example

PSYCHOSIS PSHYCOSIS: COMPLEXITY AND PROBLEMATICS The psychotic disorders are the most severe and disabling of all mental illnesses. The most common cause of psychosis is schizophrenia, which is categorized as a non-affective psychotic disorder in order to distinguish it from affective psychotic disorders, such as bipolar disorder or major depression with psychotic features (American Psychiatric Association, 1994). Schizophrenia typically emerges in late adolescence or early adulthood, and is characterized by an array of distressing and impairing symptoms, including "positive symptoms" (i.e., hallucinations, delusions), "negative symptoms" (e.g., affective flattening, avolition, and alogia), disorganized thought, speech, and behavior, general cognitive impairments (e.g., attention, memory, executive functioning), and social/occupational dysfunction (Mueser & McGurk, 2004). In the United States alone, schizophrenia currently afflicts more than two million people and has a lifetime prevalence of 1%, with 200,000 new cases diagnosed each year (Cornblatt, Green, & Walker, 1999). Individuals with schizophrenia progress through a series of phases, reflecting changing signs and symptoms as the illness progresses over time. The "premorbid phase" represents the time period prior to onset of the illness, and there is compelling research documenting the presence of early cognitive, social, and motor impairments in many people that later develop schizophrenia (Walker, Kestler, Bollini, & Hochman, 2004). This phase is particularly meaningful because the level of premorbid functioning is a strong predictor of treatment response and long-term outcome in people with schizophrenia and other psychotic disorders (Malla et al., 2004). The "prodromal phase" represents the period prior to the emergence of frank psychotic symptoms. This stage of the illness is characterized by increasing cognitive dysfunction, affective disturbance, and behavioural changes (e.g., social isolation), as well as a deterioration in role functioning (i.e., performance at school or work). Depression is common during this phase, as are negative symptoms, restlessness, anxiety, and irritability. Further, the individual may report unusual perceptual experiences and beliefs, and/or behave in an odd or eccentric manner (Hfner, Lffler, Maurer, Hambrecht, & an der Heiden, 1999). The duration of the prodromal phase varies widely; on average it lasts approximately two years, but it can range from several days to as long as five years in some individuals (Hfner et al., 1999). The emergence of florid psychotic symptoms (e.g., hallucinations, delusions) marks the beginning of the "active (or acute) phase." During this time, psychotic symptoms, disorganized thought processes, and behavioral disturbances are most severe, and acute hospitalization is often required to manage symptoms and ensure the safety of the individual and/or others (ORYGEN Youth Health, 2004). Following remission of acute symptoms, individuals enter the "residual (or recovery) phase," in which attenuated positive and/or negative symptoms may be present, and cognitive difficulties and/or social functioning deficits often persist (Hill, Schuepbach, Herbener, Keshavan, & Sweeney, 2004). This phase can last for years, and its duration varies significantly among individuals. The level of clinical stability during this phase is highly variable and relapse prevention is a key goal of treatment (EPPIC, 2001). With respect to long-term course, psychotic disorders are generally associated with a broad heterogeneity in outcomes (Harrison et al., 2001). Among all the psychotic disorders, schizophrenia appears to be the most pernicious. Schizophrenia is, on average, associated with a worse long-term outcome than other major mental illnesses, including major affective disorders and severe personality disorders (McGlashan, 1988). Harrison et al. (2001) state that schizophrenia is best seen developmentally as an episodic disorder, with a minority of individuals achieving complete recovery (i.e., no residual symptoms and/or functional deficits, no need for ongoing treatment). Indeed, long-term follow-up studies reveal that schizophrenia tends to be a chronic and frequently debilitating disorder, with a large proportion of individuals experiencing multiple relapses and persistent social and occupational impairments over the course of their lifetime (Harrison et al., 2001; McGlashan, 1988). In addition to symptomatic and functional impairments, schizophrenia is also associated with increased rates of suicide, infectious disease and other physical illnesses, substance abuse and dependence, homelessness and/or dangerous living conditions, victimization, and psychiatric comorbidities such as depression, anxiety, and post-traumatic stress disorder (PTSD) (e.g., Harrison et al., 2001; McGlashan, 1988). Schizophrenia has been included among the world's top ten most disabling medical conditions (Murray & Lopez, 1996) and is therefore associated with high societal costs. In the early 1990s, the total direct (e.g., hospitalizations, medication) and indirect (e.g., lost wages) costs of treating schizophrenia in the United States were estimated between $32.5 billion and $65 billion (Knapp, Mangalore, & Simon, 2004). Healthcare analysts have estimated that the costs of treating schizophrenia are typically between 1.5-3% of a country's total national healthcare expenditures (Knapp et al., 2004). Further, a significant proportion of the costs associated with schizophrenia can be attributed to the high rates of relapse and re- hospitalization (Knapp et al., 2004). Indeed, it is believed that at least 50% of the costs associated with treating schizophrenia could be saved through better relapse prevention efforts (Wasylenki, 1994). DEVELOPMENTAL COURSE OF PSYCHOSIS The majority of individuals who succumb to schizophrenia and other psychotic disorders manifest prodromal signs of behavioral disturbance (Larsen, McGlashan, Johannessan, & Vibe-Hansen, 1996). These signs usually begin in early adolescence and become progressively worse as the individual approaches young adulthood (Cornblatt, Lencz & Obuchowski, 2002). It is estimated that at least 70% of preschizophrenic people manifest behavioral dysfunction during adolescence (Cannon, et al., 1999), with many showing schizotypal signs, such as social withdrawal and thought abnormalities, deficits in memory and executive function, and neurological soft signs (Neumann & Walker, 2003). It is assumed that the heightened risk associated with this developmental period results in part, from neuromaturational processes that trigger the behavioural manifestation of latent vulnerability (i.e., adolescence is characterized by normative increases in Cortisol that down-stream augment dopamine activity and substantial synaptic pruning that may place more strain on constitutionally vulnerable or innervated circuits and structures). The prodromal period represents both a viable point for intervention, and a developmental period with high potential to shed light on the etiology of schizophrenia. Because schizotypal signs are a common manifestation of the schizophrenia prodrome (Cornblatt, Lencz, & Obuchowski, 2002), research in this area has accelerated in recent years. THE NEED FOR EARLY INTERVENTION IN PSYCHOSIS In an effort to improve the long-term outcome for individuals with schizophrenia and related psychotic disorders, research over the last two decades has increasingly focused on early identification and intervention for psychosis (e.g., Malla & Norman, 2002; McGlashan, 1998). An initial impetus for this movement was the recognition of several failures in the standard treatment of early psychosis, such as long delays in the provision of effective treatment, traumatic and demoralizing initial treatment experiences, minimal engagement of patients with the healthcare system, and poor continuity of care (Edwards & McGorry, 2002). It was widely acknowledged that current methods of treatment for individuals with recent-onset psychosis were inadequate and possibly even harmful, and there was increasing speculation that more effective intervention strategies tailored to this specific phase of the illness may result in decreased morbidity and mortality over the long-term (McGlashan & Johannessen, 1996). This approach has been bolstered by several critical findings. DURATION OF UNTREATED PSYCHOSIS AND OUTCOMES Most studies have found that the sooner that antipsychotic treatment is initiated after the emergence of active psychosis, the better the clinical outcome. Indeed, most studies find that a shorter duration of untreated psychosis (DUP ) is associated with shorter times to remission, higher rates of remission, and/or higher levels of remission (i.e., greater reduction in symptoms), even after controlling for other factors such as premorbid functioning, age of onset, or gender (Black et al., 2001). Further, this effect may be strongest in patients with a DUP of less than six months (Carbone, Harrigan, McGorry, Curry, & Elkins, 1999). The evidence supporting a relationship between DUP and long-term outcome is more equivocal. Several recent studies have reported a significant relationship between shorter DUP and better long-term outcome, in terms of both symptomatic and functional status (Bottlender et al., 2003). Other researchers, however, have failed to find such an association (Barnes et al., 2000; Craig et al., 2000). It should be noted that, even in studies detecting a significant relationship, DUP has only been found to explain a limited amount of variance with respect to long-term outcome. Thus, some researchers have attributed negative findings in this area to methodological factors such as small sample sizes and limited statistical power (Harrigan et al., 2003). While more research is needed to clarify the relationship between DUP and long-term outcome, treatment delays currently represent a significant public health concern, as mean DUP tends to be one year or more (Judge, Perkins, Nieri, & Penn, 2005). In addition to potential clinical damage and accumulating morbidity, extended DUP is often associated with increased risks of self- harm, aggressive behavior, family distress, substance abuse, and victimization. Thus, reducing delays in the provision of effective treatment for early psychosis has the potential for improving outcomes on many levels. Most research on psychotic disorders has found that the greatest amount of clinical and psychosocial deterioration occurs within the first five years of the onset of the illness (Harrison et al., 2001; McGlashan, 1988, 1998; McGlashan & Johannessen, 1996). There is compelling evidence that much of this deterioration takes place during the prodromal phase, before the emergence of active psychosis (e.g., Hfner et al., 1999). In addition, the active disease process appears to level off, or "plateau," after about five years in most individuals (McGlashan, 1988; McGlashan & Johannessen, 1996). Indeed, in long-term follow-up studies of individuals with schizophrenia, early (i.e., two-year) outcome has been the best predictor of long-term (i.e., 15-year) outcome (Harrison et al., 2001). These data, taken together with research on DUP, strongly suggest that pharmacological and psychosocial treatment delivered early in the course of psychosis is likely to have a stronger impact than comparable treatment delivered at later stages of the illness. RELAPSE IN EARLY PSYCHOSIS AND TREATMENT RESISTANCE There is a very high risk of relapse following resolution of the first acute episode of psychosis. Across a variety of studies, relapse rates range from 15-50% within the first year after an initial episode, 30-70% within the first two years (McGlashan & Johannessen, 1996), and up to 80-85% within the first five years (Wiersma et al., 1998). In general, the risk of relapse in early psychosis is significantly higher following medication discontinuation (Bradford, Perkins, & Lieberman, 2003). Relapse can be extremely traumatic for an individual with respect to clinical and psychosocial trajectory, and can evoke feelings of hopelessness, despair, and lack of control over one's illness (Birchwood, 2003). In addition, there is evidence suggesting that treatment resistance may develop over time with each subsequent relapse (Wiersma et al., 1998). Lieberman (1999) reports that only 10-15% of patients are treatmentresistant at the onset of illness, but that 30-60% eventually become treatment-resistant over time. The time to remission tends to increase with each subsequent relapse in many patients, as does the likelihood of incomplete recovery. These findings are consistent with research reporting progressive neuroanatomical and neuropsychological changes in at least a subset of patients with schizophrenia beginning with the first episode (e.g., Lieberman, 1999). Most of this neurobiological deterioration appears to occur within the first five years following illness onset, consistent with clinical observations (Lieberman, 1999). Further, these progressive brain changes are most likely to be found in patients with a poor long-term outcome, characterized by persistent negative symptoms and significant functional impairments (Ho et al., 2003). Given these findings, some researchers have postulated that schizophrenia is, in part, a neurodegenerative disease, and that periods of untreated active psychosis may be neurotoxic, leading to progressive deterioration and reduced capacity to respond to treatment (Lieberman, 1999). Other researchers have acknowledged the presence of significant neuroanatomical abnormalities and neuropsychological dysfunction as early as the first episode, but have not detected progressive, irreversible changes in most patients. They have argued against a "neurodegenerative" explanation of schizophrenia, and in favor of a "neurodevelopmental" explanation, which links the disease to early (pre- and perinatal) and/or late (peri-adolescent) abnormalities in brain development (Ho et al., 2003). There have been recent efforts to bring these models together, with proponents of such a unitary approach suggesting that the pathophysiology of schizophrenia maybest be explained as a combination of both neurodevelopmental abnormalities as well as neurodegenerative processes in at least a subset of individuals (Lieberman, 1999). Despite discrepant find ings regarding underlying neurobiological processes, it is clear that sustained and targeted intervention in early psychosis is essential in order to facilitate recovery from the first episode, reduce the risk of relapse and re-hospitalization (and associa ted societal costs), minimize personal suffering/trauma and psychosocial deterioration, and maximize therapeutic engagement during this critical period in the course of the illness (McGlashan & Johannessen, 1996). PSYCHOSIS AND PSYCHOSOCIAL TREATMENT The previous part of the paper indicates that pharmacotherapy is necessary but not sufficient in the effective management of early psychosis, especially with respect to preventing relapse, facilitating psychological adjustment, and assuring functional recovery. Consequently, there has been growing interest in employing adjunctive psychosocial interventions in early psychosis to address these and other areas of concern for individuals recovering from a first episode (Spencer et al., 2001). Indeed, psychosocial interventions are now recommended as a best practice in the management of first episode psychosis (McGorry et al., 2003). There has been a surge of research on psychosocial interventions in early psychosis over the last 15 years, and published results have been promising (Malla, Norman, & Joober, 2005). In general, the literature on psychosocial interventions for first episode psychosis can be conceptualized as constituting two broad categories: 1) studies evaluating comprehensive (i.e., multi-element) interventions, which typically include community outreach/early detection efforts (to reduce DUP), in- and outpatient individual, group, and/or family therapy, and case management, in addition to pharmacological treatment, and 2) studies evaluating specific psychosocial interventions (e.g., individual cognitive behavioral therapy). RECOVERY FROM PSYCHOSIS AND ITS FACILITATORS "Recovery" from severe mental illness has been defined in different ways in recent years. Nevertheless, most definitions emphasize three broad elements of meaningful recovery: illness-management (i.e., through medication adherence, increased understanding of one's illness, and effective coping regarding symptoms, stress, and the threat of relapse), optimism and a sense of control over one's illness, and functional recovery (i.e., meaningful relationships, meaningful roles at work or school, independent living, leisure/recreation time) (Spaniol et al., 2002). There have been a number of factors identified as specific facilitators of recovery, or predictors of good outcome, in schizophrenia and early psychosis, in particular. Some of these are fixed, or unchangeable by the time an individual presents for therapy following resolution of an initial psychotic episode; however, many of these predictors are malleable and thus potential targets of treatment. Fixed facilitators of recovery include: good premorbid functioning (Malla et al., 2005), female gender, later age of illness onset, higher socioeconomic status (Spaniol et al., 2002), shorter DUP (Lieberman, Perkins et al., 2001), and a better initial response to antipsychotic medication. There are several facilitators of recovery in early psychosis that are malleable and potentially amenable to psychosocial intervention. These include basic illness-management strategies (e.g., medication adherence, relapse prevention efforts), abstinence from substance use, effective management of residual positive and negative symptoms, optimism and high self-esteem, pursuit of personally relevant goals, and good social/occupational functioning (Spaniol et al., 2002). PSYCHOSIS, DELUSIONAL STATES AND NORMAL ANOMALOUS EXPERIENCES Historically, the study of delusions was given a great deal of attention, as theorists such as Kraepelin (1971) and Bleuler (1950) spent a great deal of time organizing and classifying categories of this symptom. Bleuler (1950) proposed that delusions were a product of disturbances of affectivity and associations, and could be divided into the categories of "basic delusions" (the main set of beliefs) and "elaborative delusions" (basic beliefs extend to other areas of thinking). Schneider (1959) suggested that a delusion was not a primary disturbance of perception or sensation, but one of symbolic meaning or attribution. Since the work of these early theorists, however, delusions have not received a great deal of attention in the psychopathology literature, despite their prevalence (Winters & Neale, 1983) and their importance in the definition, diagnosis, and course of several psychiatric conditions. Not limited to schizophrenia, delusions occur in a variety of disorders, including unipolar and bipolar affective disorders, delusional disorder, substance use disorders, personality disorders (schizotypal personality disorder and transiently in borderline personality disorder), and organic psychoses (Winters & Neale, 1983). Perhaps because they occur in so many manifestations of psychopathology, they are not given primary diagnostic importance, as many researchers choose to give attention to more general syndromes or "basic processes" instead (Oltmanns & Maher, 1988, p. xi). It is quite valuable, however, to study specific symptoms of disorders as well, in that frequently, a patient's symptoms can often be more reliably identified and more meaningfully related to an individual's past experiences and social background than can a syndromal diagnosis or more microscopic psychological processes. In addition, when symptoms are not studied individually, "fascinating and important psychological phenomena are ignored" (Persons, 1986, p. 1253). Other advantages of studying specific symptoms include the avoidance of misclassification of research subjects, the ability to formulate and test hypotheses about relationships between symptoms, as well as relationships between symptoms and causes and their underlying mechanisms. Furthermore, delusions are extremely common in psychotic patients; they are one of the hallmark symptoms of schizophrenia, occurring with much more frequency than formal thought disorder (Winters & Neale, 1983). While theorists such as Bleuler (1950) have suggested that delusional ideation in schizophrenia generally subsides after five years, more recent studies have found that even with antipsychotic medication, delusions persisted over an eight-year period in 75% of psychotic subjects, and that, although delusions existed in both patients with bipolar affective disorder and schizophrenia, they were more severe, more frequently occurring, and persisted for a longer period of time in subjects with schizophrenia. Delusions also appear to play a significant role in the onset and relapse process and may also influence the process of a first psychotic break. They clearly represent a disturbing and socially disruptive symptom that often becomes quickly apparent to others in a patient's environment (Yung, et. al., 1998). 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