Family Intervention in First Episode Psychosis

23_Psychosis_154 28/5/04 12:48 pm Page 215 1 2 23 3 4 5 Family Intervention in First Episode Psychosis 6 7 William R McFarlane 8 9 10 11 12 13 14 15 16 17 Introduction placeable and remarkably effective contributors 18 to the treatment and rehabilitation process. Among all medical disorders, schizophrenia is 19 one of the most costly and most severe, creating 20 nearly continuous disability for a lifetime in the Mutually reinforcing biological and 21 social processes 22 great majority of cases. It is a devastating disorder 23 for families, who often assume major care-taking The prodromal and early psychosis 24 and psychological burdens secondary to the func- phases 25 tional deficits that this and other psychotic disor- Studies of first episode psychosis, document that 26 ders impose. The functional disability that is the average time between onset of psychotic 27 particularly devastating in schizophrenia appears symptoms and the initiation of treatment is one 28 to be secondary to the negative symptoms that to two years, depending on the study.1 Frequency 29 usually begin prior to the psychotic symptoms, and severity of recurrence may be increased by 30 often persist despite treatment and usually get exposure to periods of untreated psychosis and 31 worse with time and with each subsequent decreased by effective treatment.2,3 The earlier 32 episode. These deficit symptoms are often the one provides treatment, the more effective is that 33 most burdensome for family members, because treatment, the better the prognosis, and the less 34 they usually do not identify them as part of the the functional deficit, perhaps preventing the per- 35 disorder but they nevertheless find themselves sistent residual deficits common in these disor- 36 supporting the affected member to compensate ders. Early identification of those with active 37 for those deficits. The reactions many family symptoms allows initiation of state-of-the-art treat- 38 members have to the emerging symptoms often ment that can continue for as long as the person 39 become one of the stressors that have a negative remains vulnerable. 40 influence on those symptoms, longer-term out- While the scientific evidence is increasingly 41 comes and degree of disability. This chapter strong that the major psychotic disorders are 42 describes the interaction of family and biological based in genetic or developmental defects involv- 43 processes and a powerful treatment method that ing brain function, there is also abundant evid- 44 has been shown to reverse these negative ence that the final development of psychotic 45 processes and help family members become irre- symptoms is the result of psychosocial stress. The 23_Psychosis_154 28/5/04 12:48 pm Page 216 216 BEST CARE IN EARLY PSYCHOSIS INTERVENTION 1 stress-diathesis or stress-vulnerability model pro- meta-analysis, Bebbington and Kuipers cite the 2 vides a widely accepted, empirically supported overwhelming evidence from 25 studies repre- 3 and useful framework for describing the relation- senting 1346 patients in 12 different countries for 4 ships among provoking agents (stressors), vulner- a predictive relationship between high levels of 5 ability and symptom formation (diathesis), and expressed emotion and relapse of schizophrenia 6 outcome.4 Thus, a genetically or developmentally and bipolar disorder.6 Inclusive reciprocal models 7 vulnerable person with a low tolerance for stress have been proposed to increase the accuracy of 8 may experience a first episode of psychotic illness the construct.7 For example, Strachan et al.,8 and 9 following exposure to excessive internally or Goldstein et al.,9 found that expressed emotion 10 externally generated stimulation. This principle among key relatives is a reflection of transactional 11 underlies the Biosocial Hypothesis (see box). processes between the patient and family, sup- 12 porting the conclusion that family functioning is 13 affected by aspects of the illness, as well as the Major psychotic disorders are the result of 14 converse. the continual interaction of specific biologic 15 Attribution—relatives’ beliefs about the causes disorders of the brain with specific 16 psychosocial and other environmental of illness-related behavior—is also associated with 17 factors. expressed emotion. Relatives described as critical 18 or hostile misperceive the patient as somehow 19 responsible for unpleasant, symptomatic behav- 20 Psychosocial factors are usually the proximal ior, whereas more accepting relatives see identical 21 causes of relapse in established cases and in the behaviors as characteristic of the illness itself.10 22 initial psychotic episode. The treatment described This is an especially acute risk in the prodromal 23 here is based on a simple and now plausible phase and in the first episode, during which 24 theory: the first episode occurs in a biologically symptoms and deficits often develop slowly, 25 vulnerable individual in an already evolving dis- appearing to reflect personality or behavioral 26 order in which the types of proximal causes of the faults. An individual who is cognitively impaired, 27 first episode are the same as those in later denying illness, paranoid, angry, hostile, affec- 28 relapses. Those include major stresses imposed by tively labile, socially withdrawn or anhedonic will 29 role transitions and other life events, social isola- be much less available to receive the support 30 tion, family expressed emotion, conflict and exas- needed to function at an optimal level.11 If family 31 peration, separation from family of origin, and members confronted by such symptoms in a loved 32 stigma. A review of pertinent literature supports one have little formal knowledge of the illness, 33 this biosocial causal theory, yielding an interac- they are likely to respond with increased involve- 34 tive, feedback-based model for the final stages of ment, emotional intensity or criticism. One of the 35 onset, as compared to a simpler linear-causal few prospectively validated predictors of the onset 36 model. Therefore, treatments that prevent of schizophrenic psychosis in vulnerable adoles- 37 relapse by counteracting those proximal causes cents is negative affective style, an analog of EE.12 38 can ameliorate the first episode, prevent sub- 39 sequent relapse, and reduce the vulnerability to Stigma 40 developing deficit symptoms. Stigma is often associated with withdrawal of 41 social support, demoralization, and loss of self- 42 Expressed emotion (EE) esteem, and can have far-reaching effects on daily 43 High levels of criticism and emotional over- functioning, particularly at work or school. Link 44 involvement are strongly predictive of exacerba- and colleagues observed that stigma had a strong 45 tion or relapse of symptoms.5 In an extensive continuing negative impact on well-being, even 23_Psychosis_154 28/5/04 12:48 pm Page 217 FAMILY INTERVENTION IN FIRST EPISODE PSYCHOSIS 217 1 though proper diagnoses and treatment toward treatment in general, schizophrenic 2 improved symptoms and levels of functioning relapse, and quality of life.20 Availability of social 3 over time.13 Stigma affects the family as well. support to the family is associated with subjective 4 Effects include withdrawal and isolation on the burden experienced by relatives.21 Brown et al. 5 part of family members, which in turn are associ- showed that 90% of the families with high 6 ated with a decrease in social network size and expressed emotion were small in size and socially 7 emotional support, increased burden, diminished isolated.5 Social network size decreases with 8 quality of life, and exacerbations of medical disor- number of episodes, is lower than normal prior to 9 ders.14 Self-imposed stigma tends to reduce the onset and decreases during the first episode.22 10 likelihood that early signs will be addressed and 11 treatment sought and accepted, especially during Life events prior to onset 12 the first episode.15 Disruption of social networks leads to destabiliza- 13 tion and relapse. Steinberg and Durrell found 14 Communication deviance that the vast majority (nearly 80%) of first 15 Communication deviance, a measure of distracted episodes in an Australian sample occurred after 16 or vague conversational style, has been consis- separation from home and family—on entering 17 tently associated with schizophrenia. It, along with college or the military.23 Life events have been 18 family negative affective style, are the two predic- shown to be associated with, or predictive of, 19 tive factors in the onset of schizophrenic psy- relapse in schizophrenia.24 For young adults and 20 chosis in disturbed, but non-psychotic, adolescents the most potent events tend to be 21 adolescents.12 Studies have demonstrated that those that involve loss of supportive social ties, 22 communication deviance is correlated with cogni- especially separation from, or death of, family 23 tive dysfunction in relatives, which is of the same members, romantic/marital losses for women, 24 type as in patients with schizophrenia, but of and occupational disruptions for men. 25 lower severity.16 This suggests that some family 26 members have difficulty holding a focus of atten- Effects on the family of psychosis 27 tion, with important implications for treatment Because there is so much evidence that family 28 design. A child with subtle cognitive deficiencies members of patients with established psychotic 29 may learn to converse in a communication milieu disorders share subclinical forms of similar 30 that is less able to compensate and correct. These deficits and abnormalities, treatment for early 31 difficulties are not personality defects; rather they stages of psychosis must be designed to compen- 32 are manifestations of the schizophrenic diathesis sate for some of those difficulties. Those deficits 33 playing itself out in the interpersonal as well as in lead to diminished coping ability, which is 34 the neurological domain. required in abundance in order to provide a ther- 35 apeutic influence on the affected family member.

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