A tentative model of schizophrenic psychotic episodes is presented, based on the evidence that certain characteristics of individuals may serve as vulnerability factors and that environmental stressors may precipitate psychotic periods in vulnerable individuals. Certain information-processing deficits, autonomic reactivity anomalies, and social competence and coping limitations are viewed as potential vulnerability factors. Stressors in the form of discrete life events as well as the prevailing level of social environmental stress are seen as factors that interact with preexisting vulnerability characteristics to produce vicious circles, which lead, in turn, to psychotic episodes. A distinction among stable vulnerability indicators, mediating vulnerability factors, and episode indicators is suggested to differentiate types of abnormalities that characterize individuals prone to or manifesting schizophrenic disorder. Some major areas of unresolved questions in relation to this view of schizophrenic psychotic episodes are discussed.

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A Heuristic Vulnerability/Stress Model of Schizophrenic Episodes

Background. While there is a growing body of evidence on the efficacy of psychological interventions for schizophrenia, this meta-analysis improves upon previous systematic and meta-analytical reviews by including a wider range of randomized controlled trials and providing comparisons against both standard care and other active interventions. 

Method. Literature searches identified randomized controlled trials of four types of psychological interventions: family intervention, cognitive behavioural therapy (CBT), social skills training and cognitive remediation. These were then subjected to meta-analysis on a variety of outcome measures. This paper presents results relating to the first two.

Results. Family therapy, in particular single family therapy, had clear preventative effects on the outcomes of psychotic relapse and readmission, in addition to benefits in medication compliance. CBT produced higher rates of 'important improvement' in mental state and demonstrated positive effects on continuous measures of mental state at follow-up. CBT also seems to be associated with low drop-out rates.

Conclusions. Family intervention should be offered to people with schizophrenia who are in contact with carers. CBT may be useful for those with treatment resistant symptoms. Both treatments, in particular CBT, should be further investigated in large trials across a variety of patients, in various settings. The factors mediating treatment success in these interventions should be researched.

/pdf/psychological-treatments-in-schizophrenia-i-meta-analysis-of-4uma3ynsqp.pdf

Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy

Background
People with schizophrenia from families that express high levels of criticism, hostility, or over involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive of emotions. Forms of psychosocial intervention, designed to reduce these levels of expressed emotions within families, are now widely used.

Objectives
To estimate the effects of family psychosocial interventions in community settings for people with schizophrenia or schizophrenia-like conditions compared with standard care.

Search methods
We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register (September 2008).

Selection criteria
We selected randomised or quasi-randomised studies focusing primarily on families of people with schizophrenia or schizoaffective disorder that compared community-orientated family-based psychosocial intervention with standard care.

Data collection and analysis
We independently extracted data and calculated fixed-effect relative risk (RR), the 95% confidence intervals (CI) for binary data, and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated mean differences (MD).

Main results
This 2009-10 update adds 21 additional studies, with a total of 53 randomised controlled trials included. Family intervention may decrease the frequency of relapse (n = 2981, 32 RCTs, RR 0.55 CI 0.5 to 0.6, NNT 7 CI 6 to 8), although some small but negative studies might not have been identified by the search. Family intervention may also reduce hospital admission (n = 481, 8 RCTs, RR 0.78 CI 0.6 to 1.0, NNT 8 CI 6 to 13) and encourage compliance with medication (n = 695, 10 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 6 CI 5 to 9) but it does not obviously affect the tendency of individuals/families to leave care (n = 733, 10 RCTs, RR 0.74 CI 0.5 to 1.0). Family intervention also seems to improve general social impairment and the levels of expressed emotion within the family. We did not find data to suggest that family intervention either prevents or promotes suicide.

Authors' conclusions
Family intervention may reduce the number of relapse events and hospitalisations and would therefore be of interest to people with schizophrenia, clinicians and policy makers. However, the treatment effects of these trials may be overestimated due to the poor methodological quality. Further data from trials that describe the methods of randomisation, test the blindness of the study evaluators, and implement the CONSORT guidelines would enable greater confidence in these findings.

Family intervention for schizophrenia

In recent years a set of concepts that had originated in the lexicon of the layman has come to exert a powerful influence on scientific research in epidemiology, psychology, and psychopathology. Risk, protective factors, stress, vulnerability, and coping are now a significant part of a scientific agenda aimed at understanding the nature of etiological, maintenance, and outcome factors that influence the course of adaptation and maladaptation in human behavior. In many respects, these concepts and the research they engender capture an essential component of the emergent field of developmental psychopathology (Sroufe & Rutter, 1984). They focus attention on the precursors of disordered and nondisordered outcomes and on the concomitant issue of continuity-discontinuity in behavior from childhood to adult psychopathology. They speak to issues related to the attributes of vulnerable and stress-resistant individuals, their environments, and the interactions that predict successful and unsuccessful adaptation. And finally, because they emphasize the need to identify the factors and processes associated with disorder, competence, and recovery, they can lead in time to a body of knowledge essential to the development of effective prevention strategies for containing mental disorders.

Risk, Vulnerability, and Protective Factors in Developmental Psychopathology

Twenty-five intervention studies were meta-analytically examined regarding the effect of including relatives in schizophrenia treatment. The studies investigated family intervention programs to educate relatives and help them cope better with the patient's illness. The patient's relapse rate, measured by either a significant worsening of symptoms or rehospitalization in the first years after hospitalization, served as the main study criterion. The main result of the meta-analysis was that the relapse rate can be reduced by 20 percent if relatives of schizophrenia patients are included in the treatment. If family interventions continued for longer than 3 months, the effect was particularly marked. Furthermore, different types of comprehensive family interventions have similar results. The bifocal approach, which offers psychosocial support to relatives and schizophrenia patients in addition to medical treatment, was clearly superior to the medication-only standard treatment. The effects of family interventions and comprehensive patient interventions were comparable, but the combination did not yield significantly better results than did a treatment approach, which focused on either the patient or the family. This meta-analysis indicates that psychoeducational interventions are essential to schizophrenia treatment.

The Effect of Family Interventions on Relapse and Rehospitalization in Schizophrenia—A Meta-analysis

\s=b\In an attempt to assess the contributory role of family factors to the development of schizophrenia-like disorders, measures of parental communication deviance and affective styles of communication were obtained for a sample of families of disturbed but nonpsychotic adolescents. Outcome was assessed five years later. Absence of a pathologic affective style was associated with a benign outcome, but neither parental variable alone allowed precise identification of the schizophrenia-spectrum cases. However, an index using a combination of both variables was statistically predictive of subsequent psychiatric status at follow-up. Thus, adolescents whose parents had both a pathologic affective style of communication and a high level of communication deviance had schizophrenia-like disorders develop in young adulthood. Adolescents of parents who had both lower levels of communication deviance and a benign affective style had offspring with healthier outcomes. (Arch Gen Psychiatry 1981;38:679-685) Disordered family relationships may be an important factor in the development of schizophrenia, but meaningful empirical evidence of the process is difficult to obtain. Most of the evidence comes from cross-sectional studies in which families with a diagnosed schizophrenic offspring are contrasted with families with psychiatrically disturbed or normal offspring. Such designs, of course, cannot separate antecedent family patterns from accom¬ modations to the presence of a psychotic offspring. We report a prospective longitudinal study of family relation¬ ships to examine whether specific disordered patterns of intrafamilial relationships antedate the actual onset of schizophrenic and schizophrenia-like symptoms in the offspring. There are several recent reviews of the cross-sectional studies.'-' Those measuring communication disorder have shown the most consistent results. In particular, the Singer and Wynne index of parental communication deviance (CD) has identified parents of schizophrenics and border¬ line schizophrenics in diverse measurement contexts.410 This index reflects an inability of the parent or parents to establish and maintain a shared focus of attention during transactions with another person. The theory maintains that the extent to which parents fail to communicate effectively reflects the extent to which the child will become confused, lost, distressed, and more vulnerable to subsequent breakdown.1 Such findings have been repli¬ cated in several cross-sectional studies, although in one study" the parental-group separation was less sharp than in the Singer-Wynne studies. The implication of these cross-sectional studies is that communication deviance (CD) may play a contributory role in the development of schizophrenia. However, before any etiological role is considered, it is necessary to demonstrate that this parental attribute is present substantially before the onset of prodromal or actual clinical features of a schizophrenic disorder. A basic goal of the present study is to determine whether parental CD does indeed antedate the onset of schizophrenia and related disorders. The subjects in our study were first studied in midadolescence, at a time when all were disturbed but when none showed any prodromal or clinical signs of schizophrenic disor¬ ders. While most of the cross-sectional studies have focused on issues of the family's potential role in the etiology of schizophrenia, Vaughn and Leff,'- building on the work of Brown et al,'3 reported that the course of the disorder may be affected by the affective tone or expressed emotion (EE) of the family environment to which the patient returns after hospitalization. Expressed emotion is a con¬ struct that includes negative attitudes directed toward the target patient, including criticism, hostility, and overinvolvement; the likelihood of relapse is greater when patients return to high-EE environments.

Parental Communication Deviance and Affective Style Predictors of Subsequent Schizophrenia Spectrum Disorders in Vulnerable Adolescents

The demand for information by relatives and the success of family intervention programs with an initial didactic component has resulted in a proliferation of educational interventions in schizophrenia. The present study assesses the impact of a single educational session on relatives of recent-onset schizophrenic patients. Results suggest that relatives who participated in family education experience an increased sense of support from the treatment team and a nearly significant tendency toward a decrease in self-blame regarding the schizophrenic illness. Despite findings in previous studies suggesting information acquisition immediately after education and retention after 6 months, the present study found no information retention after a 2-month period. After family education, relatives rated as high in expressed emotion (EE) reported a significantly increased sense of understanding of the illness and expressed increased feelings of support from the treatment team, whereas low EE relatives did not change significantly in these attitudes as a function of the educational session. Low EE relatives demonstrated more actual information about the illness and were less likely to perceive the symptoms as being done intentionally to bother them.

The Impact of Education About Schizophrenia on Relatives Varying in Expressed Emotion

• The presennnce of a pattern of parental transactional style deviance on the Thematic Apperception Test (TAT) (a significant attribute of parents of offspring with schizophrenia spectrum disorders) was used to identify a group of disturbed nonpsychotic adolescents hypothesized to be at high risk for subsequently developing schizophreniform psychopathology. Highrisk male adolescents came from two symptom groups, Withdrawn adolescents and adolescents in active family conflict, which are symptom patterns similar to the premorbid pictures of two schizophrenia subtypes. High-risk parents also tended to show transactional style deviance in direct interaction with their child and in a written statement describing their child's problem. The degree of risk was significantly related to the amount of therapy in which the family was subsequently engaged and, at a four-year follow-up, to the level of adjustment of the adolescents seen earlier in the project.

Kathryn L. West

Papers

Parental Communication Deviance and Affective Style Predictors of Subsequent Schizophrenia Spectrum Disorders in Vulnerable Adolescents

The Impact of Education About Schizophrenia on Relatives Varying in Expressed Emotion

Parental transactional style deviance as a possible indicator of risk for schizophrenia.