CLINICAL HANDBOOK OF SCHIZOPHRENIA - PART 3 doc

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Wiersma, D., Wanderling, J., Dragomirecka, E., Ganev, K., Harrison, G., an der Heiden, et al. (2000). Social disability in schizophrenia: Its development and prediction over 15 years in incidence co - horts in six European centres. Psychological Medicine, 30, 1155–1167. World Health Organization. (1973). The International Pilot Study of Schizophrenia (Vol. 1). Geneva: Author. Young, A. S., Nuechterlein, K. H., Mintz, J., Ventura, J., Gitlin, M., & Liberman, R. P. (1998). Sui - cidal ideation and suicide attempts in recent-onset schizophrenia. Schizophrenia Bulletin, 24, 629–634. 11. Course and Outcome 113 PART II ASSESSMENT AND DIAGNOSIS CHAPTER 12 DIAGNOSTIC INTERVIEWING ABRAHAM RUDNICK DAVID ROE Schizophrenia, which is considered the most severe psychiatric disorder, is character- ized by many impairments, such as psychosis and apathy, cognitive deficits and comorbid symptoms, as well as disrupted functioning and behavioral problems. Diagnostic inter- viewing is the “gold standard” for establishing a psychiatric diagnosis. In this chapter, we review diagnostic interviewing strategies for what are currently considered to be the char- acteristic symptoms of schizophrenia, recognizing that diagnostic criteria may change (as they have in the past). Current classifications—hence, diagnostic criteria—of schizophrenia are based pri - marily on the work of Kraepelin, who focused on the deteriorating course of the illness (which he termed dementia praecox), and Bleuler, who emphasized the core symptoms of the disorder as difficulties in thinking consistently and concisely (loose associations); re - striction in range of emotional expression, and emotional expression that is incongruent with the content of speech or thought (flat and inappropriate affect, respectively); loss of goal-directed behavior (ambivalence); and retreat into an inner world (autism). The two current major classification systems in psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2000) and the Interna - tional Classification of Diseases (ICD; World Health Organization, 1992) both specify that the diagnosis of schizophrenia is based on the presence of characteristic symptoms, the absence of others, and psychosocial difficulties that persist over a significant period of time. Symptoms must be present in the absence of general medical or so-called “organic” conditions (e.g., substance abuse, neurological disorders such as Huntington’s disease, and more) that could lead to a similar clinical presentation. The characteristic symptoms of schizophrenia are divided into positive and negative symptoms, although cognitive impairments and perhaps some comorbid symptoms may be core deficits of schizophrenia as well (American Psychiatric Association, 2000). Positive symptoms refer to the presence of perceptual experiences, thoughts, and be - haviors that are ordinarily absent in individuals without a psychiatric illness. The typical 117 positive symptoms are hallucinations (primarily hearing, but also tactile feelings, seeing, tasting, or smelling in the absence of environmental stimuli), delusions (false or patently absurd beliefs that are not shared by others in the person’s environment), and disorgani - zation of thought and behavior (disconnected thoughts and strange or apparently pur - poseless behavior). Some positive symptoms are considered highly specific, such as first- rank symptoms (e.g., delusions of thought insertion and auditory hallucinations with a running commentary), and perhaps even pathognomonic (i.e., inappropriate affect). For many people with schizophrenia, positive symptoms fluctuate in their intensity over time and are episodic in nature, with approximately 20–40% experiencing persistent positive symptoms (Curson, Patel, Liddle, & Barnes, 1988). Of note is that the term psychosis usually addresses delusions and hallucinations (Rudnick, 1997). Negative symptoms are the opposite of positive symptoms, in that they are defined by the absence of behaviors, cognitions, and emotions ordinarily present in persons with - out psychiatric disorders. Common examples of negative symptoms include flat affect, avolition (lack of motivation to perform tasks), and alogia (diminished amount or con - tent of speech). All of these negative symptoms are relatively common in schizophrenia, and they tend to be stable over time. Furthermore, negative symptoms have a particularly disruptive impact on the ability of people with schizophrenia to engage and to function socially, and to sustain independent living. The diagnosis of schizophrenia, according to DSM-IV-TR (American Psychiatric As- sociation, 2000), which is the most current diagnostic system in psychiatry, requires the following criteria: (a) two or more characteristic symptoms, each present for a significant portion of time during a 1-month period (or less if successfully treated); (b) social/occu- pational dysfunction; (c) persistence of the disturbance for at least 6 months, of which at least 1 month must fully meet criterion a (active-phase symptoms). The other criteria ex- clude other psychiatric disorders, particularly schizoaffective disorder, mood disorders, substance use disorders, general medical condition, and pervasive developmental disor- ders (unless delusions and hallucinations exist, in which case schizophrenia can be diag- nosed in conjunction with pervasive developmental disorders). There are various sub- types of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual [American Psychiatric Association, 2000]), but their validity is not well estab - lished, and a patient can present with more than one of them over time. INTERVIEWING STRATEGIES The current most widely accepted approach for diagnostic interviewing in psychiatric as - sessment is the use of structured interviews. The main advantage of structured interviews is that they provide a standardized approach for gathering information, which increases the (interrater) reliability of the assessment. Another advantage is that they provide guidelines for determining whether a specific symptom exists or not. On the downside, to benefit fully from the advantages of structured interviews, a fair amount of training, as well as ongoing fidelity evaluation, is required. A comprehensive assessment interview should commence with evaluation of basic characteristics of the disorder, followed by fre - quently associated features and common comorbid diagnoses. In the following section we focus on interviewing strategies for assessing characteristic symptoms of schizophrenia, recognizing that various assessment instruments can support a given interviewing strat - egy. A wide range of assessment instruments, divided primarily into self-report and inter - view-based instruments, have been developed to evaluate the existence and severity of 118 II. ASSESSMENT AND DIAGNOSIS psychiatric symptoms. The Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995) is the most widely used diagnostic assessment instru - ment in the United States for research studies with persons who have psychiatric disabili - ties. Psychiatric rating scales based on semistructured interviews have also been devel - oped to provide a useful, reliable measure of the wide range of psychiatric symptoms commonly present in people with psychiatric disorders. These scales typically contain from 1–50 or so specifically defined items, each rated on a 5- to 7-point severity scale. Some interview-based scales have been developed to measure the full range of psychiatric symptoms, such as the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) and the Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Fiszbein, 1987), whereas other interview-based scales have been designed to tap specific dimensions, such as the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1982). The same classification holds true for self-report scales. Interview-based psychiatric rating scales typically assess a combination of symptoms elicited through direct questioning and symptoms or signs observed in the course of the interview, as well as symptoms elicited by collateral history taking (from caregivers and clinical documentation). For example, in the BPRS, depression is rated by asking ques - tions such as “What has your mood been lately?” and “Have you been feeling down?”. Ratings of mannerisms and posturing, on the other hand, are based on the behavioral ob - servations of the interviewer. Psychiatric symptom scores can either be added up for an overall index of symptom severity, or summarized in subscale scores corresponding to symptom dimensions, such as negative, positive, and comorbid (affective and other) symptoms. INTERVIEWING GUIDELINES Psychiatric diagnosis involves use of generic clinical assessment skills, such as combining open-ended and close-ended questions, as well as specialized skills needed to address challenges associated with psychiatric impairments. In this section we discuss guidelines for interviewing people with schizophrenia, focusing on particular challenges to inter - viewing, and highlighting clinical communication skills in particular. Guideline 1: Preinterview “Baggage” Some challenges to interviewing may begin even before the interviewee has actually at - tended the interview or met the interviewers. These may be related to the interviewees’ feelings, expectations, and concerns generated perhaps by past experience. For instance, even before coming to the interview, the interviewee may feel threatened, expect to be harshly judged and criticized, and be concerned about the possible consequences of the interview. Such preinterview feelings may manifest themselves in a range of different ways. For example, an interviewee who is feeling threatened may be very guarded or may be aggressive as a response to his or her perceived threat. Similarly, an interviewee who expects to be harshly judged may be hesitant and reluctant to interact or even hostile and antagonistic toward the interviewer. Finally, an interviewee who is concerned with the consequences of the interview might be busy trying to guess how he or she might “best” respond to questions asked by the interviewer, which would seriously threaten the valid - ity of the information elicited. Because the effectiveness and quality of all interviews depend on rapport, a starting point for the interviewer meeting an interviewee with features described earlier would be 12. Diagnostic Interviewing 119 to develop empathy and understanding of the potential origins of the interviewee’s “bag - gage.” This may include recognizing that the interviewee may have been in several clini - cal settings and situations in the past that he or she perceived as threatening (e.g., being interviewed at a teaching hospital in front of trainees who were all strangers), that he or she was indeed judged harshly (e.g., for discontinuing medication against medical advice or using substances), or suffered from perceived consequences of previous interviews (e.g., forced interventions or involuntarily hospitalization). In addition, the interviewer may use his or her clinical skills to help the interviewee feel more comfortable and at ease by expressing concern and empathy, and reacting to the interviewee and his or her story in a nonjudgmental manner. It is often useful in such cases not to ignore the “elephant in the room” but rather to focus first on the interviewee’s immediate feelings and address the discomfort that he or she might be feeling (“I have a sense that you are not feeling very comfortable. I was wondering if you might be willing to share how you are feeling right now”). In addition to addressing the interpersonal context, there are several practi - cal ways in which the interviewer might be able to help the interviewee feel more at ease. Examples include introducing him- or herself, describing what to expect in terms of the format of the interview (its nature, rationale, and length) and what will follow. The inter - viewer should offer the interviewee the option to ask questions and to have his or her concerns addressed before proceeding. Forming a collaborative atmosphere in which the interviewee is viewed as an active participant rather than a passive subject of an interview is important. In addition, respecting the interviewee’s style and pacing oneself to better match his or her tempo gradually increase the interviewee’s trust and participation. Finally, when the interviewee is uncomfortable, it is particularly useful to start the actual interview with a “warm-up” phase that includes easy-to-answer, factual questions to help the interviewee gradually become more at ease. As the interviewee feels more comfort- able, follow-up questions can be particularly helpful in gathering more information about particular areas of significance. Guideline 2: Lack of Insight into Illness Because the interview usually takes place in a clinical setting (outpatient clinic or hospi - tal), a typical early question is “What brought you here?” or “How did you come to be in the hospital?”. These questions are meant to provide a neutral stimulus to encourage the interviewee to reveal the sequence of events that preceded the current situation. One po - tential challenge is that the interviewee may lack insight into his or her behaviors, experi - ences or beliefs that impacted the events preceding the interview. The interviewee may deny having a problem (“I do not know. Everything was just fine”) or believe that what led to being treated is not his or her problem (“They [family] wanted me taken away, be - cause they needed the room in the house”), or that he or she has a problem but not a mental problem (“I was feeling weak, but they wanted me to go to the psychiatrist”). These various degrees and styles reflecting a lack of insight are common among people with schizophrenia and present a potential obstacle for the interviewer seeking to obtain an overview of the current episode and psychiatric history. Although it may be frustrating for the interviewer, it is not useful to be confronta - tional or to repeat the question with the hope that the interviewee will eventually “gain insight.” It is important instead to acknowledge the potential value in the information collected rather than to get angry or anxious about failing to elicit the “required” infor - mation. There are a number of reasons why information collected “even” with an inter - viewee who seems to have limited insight into his or her condition may be of value: First, discrepancies between the perceptions of interviewees and mental health providers may 120 II. ASSESSMENT AND DIAGNOSIS not always indicate lack of insight (Roe, Leriya, & Fennig, 2001). Second, even if the in - terviewee clearly lacks insight, it is clinically useful to explore and to understand how he or she perceives and experiences different events (Roe & Kravetz, 2003). In addition, lack of insight may in some cases serve as a defense against the threat to self posed by the ill - ness, and its social and personal meaning (Roe & Davidson, 2005). Thus, acknowledging the clinical value of the interviewee’s report, even if it is not concurrent with one’s own, may help the interviewer to convey genuine respect for the interviewee’s views rather than to become impatient, angry, or confrontational regarding the interviewee’s “lack of in - sight.” Guideline 3: Challenges of the Extremes: The Guarded and the Suggestible Interviewee The validity of the information collected may be seriously compromised in the extreme case of a particularly guarded or suggestible interviewee. At one extreme, the guarded in - terviewee may not reveal much information, particularly in relation to symptoms. Be - cause clinical assessment in psychiatry is dependent to a great degree on self-report, inter - views with guarded interviewees may create the false impression that they experience fewer symptoms than they actually do. At the other extreme are the suggestible interview - ees, who are easily influenced by the interviewer’s questions and “convinced” that they have experienced symptoms they may never have had, and may therefore be assessed as more symptomatic than they are in actuality. Regardless of which extreme a person repre- sents, the information collected through the interview may not reflect his or her condition in a valid manner. There are a number of possible solutions to these issues. First, the interviewer can be explicit about the value of eliciting the most valid information and its importance in help- ing to generate the most beneficial and tailored treatment plan. Second, he or she can gently explore whether the interviewee has understood the questions. Third, once the in- terviewer identifies such a tendency, he or she should be particularly careful about asking leading questions that imply to the interviewee that there is a “right” answer (which would motivate the guarded interviewee to deny having the symptom, and the suggestible interviewee to become convinced that he or she has it). Finally, it is important that the interviewer use his or her judgment and clinical skills to evaluate whether other sources (including observations within the interview) are in concurrence with the interviewee’s self-report. Guideline 4: Assessing Symptoms Many of the reviewed challenges in collecting reliable information during an interview are intensified when an interviewer tries to elicit information about symptoms. These chal - lenges make it particularly difficult to achieve the primary goal of a diagnostic interview— to assess the interviewee’s symptoms in a reliable manner. In the absence of laboratory test markers and indicators, psychiatric diagnosis depends heavily on self-report, which is subject to many distortions (although it may provide valuable information on subjective experience). Fortunately, the interview’s inherent limitations are also its strength: The complex process and data gathering that get in the way of generating a diagnostic hypothesis may also facilitate it. For instance, by evaluating the content and logical flow of the inter - viewee’s verbalization, the interviewer may be able to learn about the presence of symp - toms such as hallucinations and thought disorganization (e.g., loose associations, 12. Diagnostic Interviewing 121 circumstantiality, and thought blocking). Although delusions may at times be readily as - sessed because of the interviewee’s preoccupation with the theme or idea, at other times engagement in lengthier discussions is required before the interviewee begins to reveal much about his or her delusional ideas. In addition, observing the interviewee’s behavior and affective expressivity during the interview can help the interviewer detect symptoms such as constricted or inappropriate affect. Finally, the interviewer may ask him- or her - self whether he or she is losing track of the point the interviewee is trying to make, which can serve as a useful cue to consideration of different symptoms, such as tangential speech or derailing. Guideline 5: Symptoms Getting in the Way During some interviews, the characteristic symptoms of schizophrenia make it difficult to secure sufficient and sound information, for example, when the interviewee is actively hallucinating or delusional; displaying disorganized thought or behavior; and presenting severe negative symptoms, cognitive impairments, or comorbid symptoms such as anxi - ety. Common effects of these symptoms and impairments are distractions that disrupt the flow of the interview and hinder collaboration. There are various ways to address such disruptions. One way is to break up the in - terview into smaller parts to accommodate the person’s short attention span. This can in- volve taking more frequent rest breaks or conducting the interview over a few days. This approach can also be used within the interview by breaking questions down into smaller ones, so that the person can more easily retain and process them. Finally, it is also often useful to explain the benefits of the interview and provide token rewards, so that the per- son participates as fully as possible in the interview. Guideline 6: Beyond Isolated Symptoms: The Importance of the Context Another challenge may be a lack of sufficient information on the personal or cultural context within which the diagnostic information may be meaningfully understood. This may occur in transcultural situations, in which the interviewer is not versed in the inter - viewee’s language and culture. Because the interviewer functions as a yardstick to some degree to evaluate the interviewee’s beliefs, it is imperative that he or she be familiar with, or at least be sure to assess, the interviewee’s general and health beliefs in relation to those of the culture to which the person belongs. To understand the personal context it is useful to explore how symptoms relate to various domains of a person’s life. To gather such information, it is important that the interviewer ask about a range of other contexts, including work, living, leisure, and so - cial relationships, to try to identify the often complex mutual influences between these contexts and symptoms. Another important aspect of the context is its longitudinal course (e.g., time of onset of the first psychotic episode), which may have an impact on the developmental abilities of the interviewee (e.g., educational level and interpersonal experiences). The interviewer should also be sensitive to paranoia or to a traumatic his - tory on the part of the interviewee that may disrupt the interview, and use appropriate communication skills to build trust. For instance, the interviewer should fully disclose the possible risks and expected benefits of the interview, give the interviewee as much control as possible over the interview (e.g., by asking open-ended questions and invit - ing the person to tell his or her life story), use empathic verbalizations, and more. Last but not least, the interviewer should be sensitive to the interviewee’s cultural (and spiri - 122 II. ASSESSMENT AND DIAGNOSIS [...]... comprehensive measure of the community functioning of severely and persistently mentally ill individuals Schizophrenia Bulletin, 26 (3) , 631 –658 Ware, J E., Jr., & Sherbourne, C D (1992) The MOS 36 -Item Short-Form Health Survey (SF -3 6 ): I Conceptual framework and item selection Medical Care, 30 (6), 4 73 4 83 C H A P TE R 15 TREATMENT PLANNING ALEXANDER L MILLER DAWN I VELLIGAN Much of this chapter is devoted... Life, Social Competence, and Behavioral Problems) of the client’s community functioning in the past 3 6 months  139 Self-rated SF -3 6 (Ware Global & Sherbourne, measure 1992) 15–60 minutes CAN (Phelan et al., 1995) Comprehensive Self-rated and measure clinician-rated 60 minutes for the CASIG-SR and 45 minutes for the CASIG-I 20 30 minutes 15 30 minutes 15 30 minutes 10–20 minutes Multiple European studies... therefore, they may be difficult to interpret in a clinical context The BASIS -3 2 is more often used for assessing large groups of clients and determining their clinical and social functioning than for specific treatment purposes Short Form 36 -Item General Health Survey The Short Form 36 -Item General Health Survey (SF -3 6 ; Ware & Sherbourne, 1992) assesses eight areas of health, including physical functioning,... illustrates aware- TABLE 15.1 Treatment Plan Example Start date Expected goal achievement Responsible Contact person information date Problem Intervention(s) Measure Goal Psychosis Drug A Brief Positive Symptom Scale Reduction 2-1 4-0 7 to no more than mild symptoms 5-1 0-0 7 Dr Jones 55 5-5 555 Days in hospital per year Reduction 1-1 5-0 7 of > 50% compared to prior year 4-1 4-0 7 Ms Smith 12 3- 4 567 Repeated Assertive... health center clients Journal of Traumatic Stress, 12, 25 39 World Health Organization (1992) International classification of diseases (ICD-10) (10th ed.) Geneva: Author C H A P TE R 13 ASSESSMENT OF CO-OCCURRING DISORDERS KAREN WOHLHEITER LISA DIXON This chapter covers the assessment of a range of disorders that commonly co-occur with schizophrenia These include use and abuse of different substances,... Perceptions of barriers to employment, coping efficacy, and career search efficacy in people with mental health problems Journal of Career Assessment, 12(4), 460–478 Donahoe, C P., Carer, M J., Bloem, W D., Leff, G L., Laasi, N., & Wallace, C J (1990) Assessment of Interpersonal Problem Solving Skills Psychiatry, 53, 32 9 33 9 Fisher, A G (19 93) The assessment of IADL motor skills: An application of many-faceted... Journal of Psychiatry, 155, 232 – 238 Rosenberg, S D., Swanson, J W., Wolford, G L., Osher, F C., Swartz, M S., Essock, S M., et al (20 03) The five-site health and risk study of blood-borne infections among persons with severe mental illness Psychiatric Services, 54, 827– 835 Sallis, J F., Pinski, R B., Grossman, R M., Patterson, T L., & Nader, P R (1998) The development of self-efficacy scales for health-related... clients living in the community Large-scale health surveys; not specific to serious mental illness Multiple large-scale studies Validated with large range of clients Length of administration Validated CASIG (Wallace Comprehensive Self-Report measure (CASIG-SR) et al., 2001) and Informant (CASIG-I) versions Comprehensive Clinician-rated measure Self-rated BASIS -3 2 (Eisen Global et al., 1994) measure... recognition of the important role that mental health professionals assume in the diagnosis and management of co-occurring somatic disorders has required that mental health practitioners perform routine monitoring and assessment of such disorders Assessment of co-occurring addiction and somatic disorders often requires two types of approaches The first approach involves asking the patient a series of questions... Research, 3, 2 83 292 Selzer, M L (1971) The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument American Journal of Psychiatry, 127, 16 53 1658 Selzer, M L., Vinokur, A., & Rooijen, L (1975) A self-administered Short Michigan Alcoholism Screening Test (SMAST) Journal of Studies on Alcohol, 36 , 117–126 Skinner, H A (1982) The Drug Abuse Screening Test Addictive Behaviors, 7(4), 36 3 37 1 . Medicine, 32 , 130 1– 130 7. Opjordsmoen, S. (1991). Long-term clinical outcome of schizophrenia with special reference to gen - der differences. Acta Psychiatrica Scandinavica, 83, 30 7 31 3. Palmer,. from those of the in - terviewer. Guideline 7: Differential Diagnosis The symptoms of schizophrenia often overlap with those of many other psychiatric disor - ders; thus, the presence of other. recent-onset schizophrenia. Schizophrenia Bulletin, 24, 629– 634 . 11. Course and Outcome 1 13 PART II ASSESSMENT AND DIAGNOSIS CHAPTER 12 DIAGNOSTIC INTERVIEWING ABRAHAM RUDNICK DAVID ROE Schizophrenia,