Patients’ and Caregivers’ Adaptation to Improvement in Schizophrenia Susan E. Mason, Susan Gingerich, Samuel G. Sins, Treatment

Ph.D. M.S.W. M.D.

of poorly

schizophrenic patients with antidepressant medication may lead to a relatively rapid increase in their level of activity, autonomy, and assertiveness. Caregivers who bad been accustomed to the patients’ more blunted affect and docile behavior mayperceive this change as

in hostility.

who

know

do

not

angerand

other

propriately

in their

bow

level

Patients to express

strongfeelings

may

alsofind

ofassertiveness

apchanges

to be

stressful. The authors illustrate these problems with case examples and suggest that psychoeducation,

regular team,

cation

contact and can

the treatment

training in communihelp both patients and adjust to the patient’s

caregivers

improved

with

condition.

Recent advances in the psychopharmacological treatment of akinetic and depressed schizophrenic and schizoaffective patients with negative symptoms have included strategies of reduced neuroleptic dosages (1 ,2), aggressive treatment with anticholinergic medications

Dr. Mason

is day

program reat Hillside Hospital, a divisionofLong Island Jewish Medical Center, P.O. Box 38, Glen Oaks, New York 11004. Dr. Sins is director of psychiatric day programs at Hillside Hospital, and Ms. Gingerich is research associate at Eastern Pennsylvania Psychiatric Institute in PhiladelphiL search

Hospital

coordinator

and

Community

the adult home director ing, the patient was

(5-7). These approaches resulted in meaningful,

manageable.

have often functional

improvement.

functioning

an increase

(3,4), and the introduction of adjunctive antidepressant medications

Psychiatry

One unforeseen result, however, has been the difficulty families and agencies sometimes have in ad justing to the relatively rapid lessening of pervasively dysfunctional symptoms in heretofore chronically ill patients. Previously docile, unobtrusive patients may become assertive, energetic, and socially engaging in a short period of time, and they may press for social gains to match their improved symptomatic status. While clinicians may be pleased with these changes, family members or other caregivers in the community may interpret them as signs of hostility or acting out that require remedial action. In this paper we present three cases that illustrate the dilemmas patients may face when quick, psychopharmacologically induced improvement disrupts a longstanding biopsychosocial status quo. Each case provides evidence that increased psychosocial intervention is needed to help patients, caregivers, and family members successfully come through a difficult period in the course of the patient’s improvement.

The

cases

Case 1. Mrs. A, a 54-year-old divorced woman with a DSM- lll-R (8) diagnosis of schizophrenia, had been living in an adult home for several years. She was known to the adult home staff for her delusional belief that people were stealing her clothes from her closet and taking her shoes from under her bed. Although her repeated complaints to

May1990

Vol.41

No.5

Generally,

were annoyconsidered she obeyed

rules, spoke in a rather meek tone, and spent agood deal oftime by herself. She was never thought of as a troublesome patient. Because Mrs. A had complained ofchronic low mood, lack of energy, and anhedonia, her treating clinician placed her on a trial of antidepressant medication, imipramine, in doses of200 mga day, in addition to her regimen of fluphenazine decanoate .2 cc aweek and benztropinc 2 mg by mouth three times a day. She felt better, her energy level increased, and her concentration improved. She felt less apathetic. In addition, she showed slightly increased overt signs of anger at persons she thought had hurt her in the past. Her paranoid delusions continued, essentially unchanged. The director of the adult home complained to the treatment team that Mrs. A was worse and needed a change in medication, specifically in the major tranquilizer. The director said that Mrs. A was acting with increasing hostility and demanding that male employees stay out of her room and that no one go through her closet. Although the treating clinician did not observe Mrs. A at the adult home, at the clinic she seemed to be less depressed than she had been before treatment with imipramine. Fortunately, in this case the treatment team was able to stay in close contact with the director ofthe adult home, to share information about the patient, and to discuss the goals of increasing Mrs. A’s energy, motivation, and autonomy. The treatment

rector

team

to develop

worked

a plan

with

the

di-

that did not

541

immediately place stringent limits on Mrs. A. As time passed, the director appeared satisfied that Mrs. A was receiving proper medication from the treatment team, and he became adjusted to her new state, but he never accepted the idea that she had improved. To the director, the patient had become worse because she was less docile and more assertive. Mrs. A, however, felt happier, better able to care for her own needs, and better able to stand up for herself and get what she wanted out of life. Case2. Mr. B, age 28, had a DSM-il-R diagnosis of schizoa.ffective disorder, depressed type. He lived with his family, although he was largely blocked off from family dynamics because he was apathetic, anergic,

and

dysphoric.

His

family

was concerned about his positive symptoms (auditory hallucinations and

delusional

grandiosity)

and

was

pered and irritable. clinician felt that work on expressing appropriate

Mr. B’s treating Mr. B needed to anger in a more

manner

but sawMr.

B as

much improved overall and better able to be responsible for himself. Mr. B himself was increasingly bothered by headaches that made him feel irritable and frustrated. The headaches, which had been a longstanding complaint, had not become more painful, but Mr. B felt less tolcrant of them. He was nevertheless more satisfied by his own behavior in general and felt that his mood self-respect had improved.

accepting ofhis role as the identified patient. After irnipraminc 1 50 mg a day was added to Mr. B’s standing dose offluphenazine decanoate .85 cc a week and benztropine 2 mg by mouth three times a day, Mr. B’s mood improved, his energy increased, and he began to assert himself. His manner of self-assertion seemed understandable to the treatment team, but his mother cornplained that his symptoms were worsening. On one occasion, Mr. B was riding in a car with his mother and his brother, who was a drug abuser. The brother, who was driving, became angry at his mother and threatened to drive the car offthe road, possibly killing her. Mr. B grabbed the steering wheel and somehow convinced the brother to stop. Then Mr. B punched his brother in the face. Subsequently, Mr. B refused to lend his car to his brother, although previously he had allowed his brother to use the car at will and had also paid for any damages and traffic violations that occurred when the brother was driving the car. Family members were dissatisfied with Mr. B’s behavior, which they viewed as overly aggressive. His mother described him as short-tern-

Her treating clinician placed her on a trial of irnipramine, which was eventually built up to 300 mg a day, in conjunction with her continuing dose of fluphenazine decanoate .17 cc a week and benztropine 2 mg by mouth three times a day. Her mood, energy level, and concentration improved, as did her self-esteem and anxiety level. She gradually discontinued abusing amphetamines and was soon able to get a job. After two months on her optimal dose of irnipramine, Ms. C cornplained that her mother, her boyfriend, and his mother all found her to be overly assertive and angry much ofthe time. They said, according to the patient, that she argued, demanded her own way, and generally “wasn’t the same person they used to know.” Ms. C stated that although she had previously been timid, she now felt better able to cxpress her wishes and opinions. For example, she had strenuously objected to her boyfriend’s New Year’s Eve plans, which included his mother but not Ms. C’s mother, and she was eventually able to obtain an invitation for her mother.

542

May

Vol. 41

No.

medication

5

Ms. C’s boyfriend her, stating that her

had

caused

her

to pro-

yoke a multitude of arguments. He said he would have nothing to do with her unless she stopped her current medication regimen. The treatment team was initially surprised at the boyfriend’s reaction. They had viewed Ms. C as less depressed and appropriately able to express her wants and needs. An indication of her new assertiveness was Ms. C’s request for more time with her clinicians.

and

Case 3. Ms. C, a 32-year-old woman with a DSM-I1I-R diagnosis of schizoaffective disorder, lived at home with her mother and drugabusing brother. She herself abused amphetamines an average of three times a week. She had not worked for nine years and was continually ruminating about her uncertain future with her boyfriend. She suffered from depressed mood and low self-esteem and had an abnormally high level of anxiety.

1990

Eventually, broke up with

The

treatment

team

gladly

granted this request, considering it a sign ofimproved health. Eventually, Ms. C and her boyfriend met together with the treatment team clinicians and discussed Ms. C’s newly assertive behavior. At the meeting, her boyfriend readily perceived that Ms. C’s improved mood

and

increased

energy

and

assertiveness were preferable to her previous docility caused by depression, and their relationship resumed. Discussion The adaptation port

system

of the patient’s to relatively

sup-

rapid

im-

provement in the patient has received little attention in the literature to date. Early writers, who approached the issue from a psychosocial

perspective,

focused

chodynamic

influences

velopment

and

on psy-

on the de-

maintenance

of

schizophrenia(9, 10). Some theorists proposed that parents who blur age and

generational

boundaries

create

inappropriate behavior that promotes schizophrenia in their offspring(9). In these families, dysfunctional patterns of interaction were maintained under a facade of wellbeing, a phenomenon that has been labeled “pseudo-mutuality” (10). Recent studies of accommodation of schizophrenic patients by families and agencies have dealt with the effects of deinstitutionalization. This literature suggests that the burden

experienced

by primary

care-

givers of outpatients with schizophrenia ( 1 1-14) varies in degree depending on the nature ofthe caregivers’ support systems (1 5) and the patient’s most prominent symptoms (16,17).

Schizophrenic

Hospital

and Community

patients

who

Psychiatry

display

positive

thought

symptoms

disorders,

such

as

hallucinations,

and delusions, are more likely to be accepted by spouses than are patients with negative symptoms, such as lack of energy or motivation and poor impulse control ( 1 7). Schizophrenic

patients

are

also

lack skills for socially pression

of anger

thought

appropriate

and

to

cx-

family.

In general, about illness

educating

the causes and and establishing

how

the

more

to manage

specific

issue

improving

of

schizo-

phreiiic patients who show increased energy and assertive behavior has not been adequately addressed.

In the clinic

cases

staff

we presented,

perceived

that

tients had improved, but members or other caregivers share these perceptions. In the adult home staff initially understand the pected outcomes

objectives of the

the the

pa-

family did not case 1, did not

and change

cxin

the patient’s pharmacological treatment, leading to conflict with the treatment staff. Such conflicts are not only unpleasant; they can facilitate splitting by patients to the detriment ofprogress in recovery. In case 2, the family was unable to cope with the patient’s newly gained assertiveness. In situations like this one, violence may result if other family members besides the patient lack impulse

members ness

control

have

used

as a central

part

and ifthe

family

the patient’s of their

ill-

adaptaCase 3 il-

tion to their own problems. lustrated the problems that result when the patient, caregivers, and treatment team hold diverse perceptions ofwhat constitutes healthy behavior and when a patient seems forced to choose between pleasing significant others and taking helpful medication.

Patients

who

are

cx-

pected to make such choices undoubtedly experience harmful stress. As the cases show, some patients

Hospital

and Community

Psychiatry

ful and unpleasant,

and caregivers. Recent research has shown the positive effects of systematically including families and significant others in the treatment of schizophrenia (18,23,25-28). The most successfulofthese efforts teach patients and families about the illness and suggest coping strategies. It is likely that psychoeducation would have helped the patients and caregivers described here. The goals would have been to increase patients’ and caregivers’ understanding of schizophrenia, depression, and negative symptoms and to foster an appreciation of specific pharmacological effects. Additional goals would be to develop realistic expectations of the recovery process, to provide support to patients and caregivers, and to improve communication with the treatment team.

particularly

expressed in ways that flicts. Family members givers may be unsettled

derstand mental

the illness.

ness

behaviors

clinical

if

and may

course of not know

are part

of the ill-

are not,

indicate condition

haviors

ofanger

involved in the and do not Un-

nature They

and which

ifit is

lead to conand careby a change

expression

they have not been patient’s treatment

which

families

course of the open dia-

logues between families and mental health professionals improve family attitudes toward patient care (192 1). Still,

medication and to help family members and other caregivers cope with the stresses associated with the patient’s increased level of energy.

in the patient’s

for effectively

coping with anxiety and stress (16,18), deficits that contribute to the social burden experienced by the patient’s

who experience an increase in energy also experience an increase in anger and assertiveness. Although having more energy is a positive outcome, to most people anger is stress-

or which

be-

improvement in and which are har-

bingers ofrelapse. Indeed, expressions ofanger have often been noted to be proximal correlates ofpsychot-

ic relapse

(22),

and family

members

and caregivers may have learned to be frightened by these signs, which they may understandably seek to

suppress. Exhausted, ized by their

confused, attempts

ordemoralto cope (23,

24), family members and caregivers often may not be able to deal with changes without help. With great ef-

fort,

they may have

satisfactory that they

are

achieved

but stable reluctant

an un-

equilibrium to disrupt.

Their past experiences of destabilization in their environment resuiting

from

changes

in the patient’s

behavior may have been bitter. In such a setting, both the patient and caregivers

may have avoided a full range offeelings

cx-

in

Psychoeducation

Regular givers

contact

and

for patients

between

the treatment

careteam.

Regular contacts with the treatment team increase caregivers’ opportunities to share information about changes in the patient’s symptoms and their impact on the environment. Together, caregivers and the treatment team can work to anticipate and support the changes that may result macotherapy.

from

adjustments in pharFrequent phone calls

may have been “protecting” the patient by not expressing their own dissatisfaction, and both the patient and the caregivers may have been coping with positive symptoms or may have been preoccupied with the

can supplement in-person contacts and help clarify misunderstandings before they become exaggerated. Communication training. Patients who report an increase in their expression of anger and their caregivers can benefit from communication training that suggests ways to express anger that are less likely to lead to arguments and stress. Falloon

crisis

and

pressing Patients feelings and

(18). might have held back angry because oflow self-esteem

low

energy.

ofacute

Family

illness.

members

If not

handled

well, a patient’s unexpected and rough-edged assertiveness could substantially disrupt the patient’s environment and could be countertherapeutic for the patient. Three itiated

interventions by the treatment

can be inteam

to help

patients optimize and maintain improvements resulting from advances

May

1990

Vol. 41

No.

5

others

(18,27)

outlined

five

major skills that are especially helpful for families. They are expressing positive feelings; making positive, direct, and unambiguous requests; expressing unpleasant feelings in a manner

conducive

change; attentive problem solving. could be included

to constructive

listening; Other skills as necessary.

and (28)

543

The three types of interventions would have been useful in the cases we described. IfMr. B and his family in case 2 had been involved in an ongoing psychoeducational group, they might have been better prepared for Mr. B’s change in mood and perhaps could have anticipated that he might be more assertive in his behavior.

Once

conflicts

developed,

communication training could have helped Mr. B and his family learn to express feelings in ways that are less likely result in fist fights and arguments. Learning to express positive feelings might have helped the family to keep sight ofMr. B’s irnprovements, and learning how to complain appropriately might have helped Mr. B obtain treatment for his headache pain. Ms. C and her boyfriend, described in case 3, might also have benefited from a psychoeducational group and communication skills training. The group could have provided information about her illness, the effects of medication, and the goals and intentions ofthe treatment team. With this information, her family and boyfriend might have felt more involved in and supportive of her treatment. When conflicts developed between Ms. C and her caregivers, communication skills training might have helped them express their feelings more appropriately and solve problems in a step-by-step fashion. As noted, initial contacts between the treatment team and Ms. C and her boyfriend had positive results. In case 1 , increased regular contact with Mrs. A’s treatment team would have helped the staff of the adult home understand the changes they perceived in herbehavioras her mood improved. Communication

selves and assume responsibility for their lives. One side effect of these changes, however, may be disruption of the equilibrium that has developed in the patient’s environment as an adaptation to their dysfunctional state. To help patients realize the maximum benefits of pharmacotherapy, treatment teams must be sensitive to the effect of this disruption on patients’ families and other caregivers

as well

as on

Acknowledgments This research was supported in part by National Institute of Mental Health grant MH-34309 and National Institute on Drug Abuse grant DA-05039.

References 1. Kane jM, Rifirin A, Woerner M, et at: Low-dose neuroleptic treatment of outpatient schizophrenics, I: preliminary results for relapse rates. Archives of General Psychiatry 40:893-896, 1983 2. Carpenter WTjr, Heinrichs DW, HanIon TE: A comparative trial of pharmacologic strategies in schizophrenia. journal

of

Psychiatry

sary?

antiparkinson

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A

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23.

1978

Conclusions Improvements in the pharmacological treatment ofpatients with chronic psychotic, depressed, or negative symptom states may result in advances in their capacity to care for them-

might

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7. Sins SG, Adan F, Cohen M, et at: Postpsychotic depression and negative symptoms: an investigation ofsyndromaloverlap. AmericanjournalofPsychiatry 145: 1532-1537, 1988 8. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, rev. Washington, DC, American Psychiatric Association, 1987 9. Lidz T, Fleck 5: Family studies and a theory of schizophrenia, in Schizophrenia and the Family. Edited by Lidz T, Fleck 5, Cornelson AR. New York, International Universities Press, 1965 10. Wynne L, Ryckoffl, Dayj, etal: Pseudomutuality in the family relations of

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Hospital

and Community

Psychiatry

Patients' and caregivers' adaptation to improvement in schizophrenia.

Treatment of poorly functioning schizophrenic patients with antidepressant medication may lead to a relatively rapid increase in their level of activi...
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