Monika Dogra, Avinash Rana, Karobi Das, Ajit Avasthi

Transcription

1 An exploratory study on the effect of "Activity Scheduling" on the negative symptoms of patients with Schizophrenia in Psychiatry ward, Nehru Hospital, PGIMER, Chandigarh. Monika Dogra, Avinash Rana, Karobi Das, Ajit Avasthi Abstract : Schizophrenia is among the top ten disabling conditions worldwide for young adults. People suffering with schizophrenia suffer from a number of symptoms which can be either positive symptoms or negative symptoms. Negative symptoms represent a reduction of emotional responsiveness, motivation, socialization, speech, and movement. An exploratory study was conducted among schizophrenia patients admitted in Psychiatry ward, Nehru hospital, PGIMER, Chandigarh during the months of July-August 2008 to assess the effect of activity scheduling on these negative symptoms. A total of six patients were selected in whom individualized activity scheduling was done. Findings revealed that there was a positive effect of activity scheduling on improvement of negative symptoms when compared to another set of patients who were not following such activity schedule. Nurses can play important role for such patients by planning activities for them as they are with the patients for most of the time. Key words : Schizophrenia, Negative symptoms, Activity Scheduling. Correspondence at : Monika Dogra Khalsa College of Nursing, Khalsa College educational Society, Amritsar Introduction Schizophrenia is a common and unsolved mental health problem in the world today. It is perhaps the most enigmatic and tragic disease that psychiatrists treat, and perhaps also the most devastating as no psychological disorder is more crippling than this disorder. 1 It is characterized by disturbances in thought processes, perception, and affect that invariably results in a severe deterioration of social and 107

2 occupational functioning. It is estimated that about one percent of population is, or has been affected by this disorder world over; including India. 2 It is one of the leading causes of disability among young adults. Late adolescence and early adulthood are peak years for the onset of schizophrenia. 3,4. Its onset usually occurs early in life- adolescence or young adulthood- and often becomes a progressive and disabling condition. People suffering with schizophrenia suffer from a number of symptoms which can be either positive symptoms or negative symptoms. Positive symptoms are those symptoms that tend to reflect an excess or distor tion of normal functions like hallucinations, delusions, disorganized speech or behavior. Negative symptoms are those symptoms that tend to reflect diminution or loss of normal functions like apathy, anhedonia, alogia, avolition, affective flattening or social isolation. 5 People with schizophrenia often seem emotionally flat and unresponsive to things happening around them. They are unable to show emotion by varying their facial expressions, gestures, or tone of voice. The person may not show much response to happy or sad events, or may respond in an inappropriate way. Anhedonia is common in schizophrenia, and the current treatments are insufficient. 6 Schizophrenia may reduce people's motivation so that they are less able to work or participate in leisure activities. They may seem uninterested in everyday activities such as washing and cooking or, in extreme cases, may be unable to care for their personal hygiene or feed themselves. Indecision, negativism, and passivity may appear, mixed with sudden impulses. In extreme cases, the person may become withdrawn, agitated, or stuporous for no apparent reason. People with schizophrenia may have difficulty making and keeping friends or acquaintances; they may have few, if any, intimate relationships. Their interactions with others may be brief and superficial. In extreme cases, the person may actively avoid all social interactions 7. Some people with schizophrenia reveal a marked reduction in the amount and content of their thinking. They may only rarely speak spontaneously and may answer questions with short answers that provide no detail. In extreme cases, the person's speech is limited to short phrases such as "yes," "no," or "I don't know." For these reasons it is important 8, 9. to target inactivity early on in treatment. Studies have generally shown that negative symptoms are more stable than positive symptoms and are least likely to improve over the course of illness. 9 There is increasing empirical evidence that patients with negative symptoms can benefit from cognitive behavioral strategies like selfmonitoring, activity scheduling, graded task assignments etc. 10 The responsiveness of negative symptoms to antipsychotic medications is notably worse than that of positive symptoms Activity scheduling can be extremely useful in gradually increasing patient's activity level and in encouraging patients to interact socially. In addition as negative symptoms of schizophrenia can be extremely difficult for relatives or caregivers 108

3 to cope with; involving patient's family network in therapy in some way can be helpful. They may assist in activity scheduling strategies and may welcome advice and information on the nature and management of negative symptoms. 13 There was no such activity scheduling done by nurses for schizophrenia patients in our settings, though there were some common activities like Morning Prayer and exercises. Since the nurses spend lot of time with these patients, they can make it a quality time. It may be beneficial for the patients to involve them in some activities which might help in relieving distress of the patient and the caregivers owing to their symptomatology. Hence the present study was conducted with the following objectives in view. Objective To assess the effect of 'Activity scheduling' on the negative symptoms of the patients with schizophrenia in Psychiatry ward, Nehru hospital, PGIMER, Chandigarh. Materials and Methods An exploratory research design was adopted to study the effect of activity scheduling on the negative symptoms of schizophrenia. The study was conducted in the Psychiatry ward of Nehru hospital, PGIMER, Chandigarh. PGIMER is a central government owned autonomous institute. Nehru hospital with 1400 beds is attached to the institute providing indoor health care facilities. Psychiatry ward is located on third floor of Cobalt-block of Nehru hospital. Patients with all types of mental illnesses are admitted in the ward for treatment. The study was conducted on six patients with schizophrenia. In order to strengthen the study, a control group consisting of similar number of cases was also selected, who were previously admitted in the ward, to compare them with the patients in case study group. They were compared for a period of two weeks after baseline. Prior to data collection guidelines to develop activity schedule and a structured activity schedule was developed. Data was collected after seeking written permission for conducting the study from the Head of the Department of Psychiatry ward. Nursing sister in charge of the ward was informed about the purpose of the study. Before the intervention, baseline assessment of the negative symptoms was obtained by using positive and negative syndrome scale (PANSS rating scale) in consensus with the treating doctor of the patient. After the baseline assessment, individualized activity schedules were made as per the prepared guidelines and implemented on a daily basis. After that negative symptoms of the patients were assessed every week on the same scale. Collected data was analyzed and some of the findings are presented here. Results Six subjects who met the inclusion criteria were enrolled in the study. All of them followed the individualized activity schedule for the time period till they were not discharged. Since their ward stay period varied from two weeks to five weeks, they were compared for only two weeks with the control group. 109

4 The score of negative symptoms of one of the patient is presented below. Similar analysis was done for all the six patients and all showed improvement in the negative symptoms. Figure 1 : Week wise Negative Symptom score of case-1 Figure1 depicts improvement in negative symptom score of case-1 from baseline to week-5. Score was 31/49 at baseline which improved to 23/49 after following activity schedule for consecutive five weeks. 49 Negative symptom score Baseline Week1 Week2 Week3 Week4 Week5 Figure 2 : Week wise participation of case-1 in Activity Schedule Score Weeks 1 Weeks 2 Weeks 3 Weeks 4 Weeks 5 110

5 Figure-2 depicts participation of case- 1 in the activities as per her activity schedule. Patient's participation in most of the activities was average in initial two weeks, though she needed continuous motivation and persuasion for following activities. Later on her par ticipation in the activities showed fluctuations due to her continuous complaints of restlessness and she developed fever also, which further reduced her par ticipation in activities. Her negative symptom score showed little improvement thereafter (from 27/49 in first week to 23/49 after five weeks). Table 1 depicts the week wise improvement in negative symptoms of all six patients. All the six patients showed improvement in the negative symptoms from baseline to week 1 to week 2. Table 1 : Weekly negative symptom scores of six case study patients PANSS score Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Baseline Week Week Then this data was compared with another set of six patients which was matched with the case study group (with respect to gender, age, medications received, duration of illness and their negative symptom scores at baseline, week I and week II.) in order to see whether the fall in the negative symptoms was actually due to activity scheduling or due to some other factors. Table 2 : Negative Symptom Scores' comparative distribution between two study groups PANSS score Case study group Control group Mean±S.D Median Mean±S.D Median p-value Baseline 28.50± ± Week ± ± Week ± ± Table 2 depicts that when median scores of case study Vs. control group was compared with respect to negative symptoms at three points of time (at baseline, week I and week II), it was observed that both the groups were found to be comparable as there was statistically no significant difference on applying Mann Whitney U-test (p-value 0.06, 0.23, 0.75 respectively). 111

6 Table 3 : Overall trend in Negative Symptom scores in two study groups using nonparametric Friedman repeated measure test. Score p- value Overall trend in negative symptom score Interaction of negative symptom score trends in two study groups Table 3 highlights the statistical analysis of overall trend in Negative Symptom scores from baseline to week II as well as interaction of Negative Symptom scores' trends in two study groups using non-parametric Friedman repeated measure test. The results in the table clearly indicate that Negative Symptom scores (mean ± SD) showed significant overall downward trend from baseline (23.67±8.26) to week I (19.08±6.97) and then week II (15.25±7.01) (P-value <.0001). On further analyzing the trends for Negative Symptom scores in two study groups; the above analysis demonstrates that there also was significant interaction between two study groups. That is- two study groups differed statistically in their decrease in Negative Symptom scores over 3 time periods (P-value 0.028). ie., baseline, week I and week II. Table 4 : Pairwise comparison of negative symptom scores in two study groups Score PANSS p-value Negative symptom score Baseline to week Week 1 to week Negative symptom score Baseline to week Interaction between two study groups Week 1 to week Table 4 depicts the Pairwise comparisons which further decompose the changes in overall as well as individual trends of Negative Symptom scores in two study groups. The change of overall Negative Symptom scores from baseline (23.67±8.26) to week I(19.08±6.97) was highly significant(p-value 0.002) and from week I to then week II (15.25±7.01)was again highly significant statistically(p-value <.0001). However, trends of Negative Symptom scores in two study groups were similar-that is both groups showed similar decrease in Negative Symptom scores from baseline to week I ( P-value 0.15) while fall in Negative Symptom scores was marginally significantly more fall in Case study group than control groups(p-value 0.076). 112

7 Figure 3 : Trends of fall in negative symptoms in both study groups Mean Negative Symptom Scores Activity scheduling Case study group Control Group Baseline Week I Negative Symptom Scores Week II Table 5 : Significance of fall in Negative Symptom scores by using Paired samples Wilcoxon Signed Ranks test PANSS score Case study group Control group Mean± S.D p-value Mean± S.D p-value Baseline- week ± ± Week 1- week ± ± Table 5 shows significance of fall in Negative Symptom scores between two successive time points in cases as well as controls using Wilcoxon Signed Ranks tests for paired data. The table shows that mean(±sd) fall in Negative Symptom scores in case study group from baseline to Week I was 6.33(±5.39) (P-value 0.027) and from week I to week II was 5.33(±2.88)(P-value 0.027). In the control group, the mean (±SD) fall in Negative Symptom scores from baseline to Week I was 2.88 (±1.17) (P-value 0.027) and from week I to week II was 2.33(±2.34) (P-value 0.078). 113

8 The fall in negative symptoms may be slightly more in cases than controls from baseline to week first despite large 6.33 difference as compared to 2.88 in controls but it is clearly more in case study group from week 1 to week 2 as shown by lower SD values of negative symptom scores (2.88 from 5.39). Discussion The findings of the study indicate that activity scheduling does have impact on the negative symptoms of the patients with schizophrenia. There is increasing empirical evidence that patients with negative symptoms can benefit from cognitive behavioral strategies like self- monitoring, activity scheduling, graded task assignments etc14. Results of the present study also show that there was improvement in the negative symptoms of the cases following activity schedule. Few studies concluded that cognitive behavior therapy as an adjunct to antipsychotic medication increased the chances of reducing symptoms as compared to medication alone. 15. The present study also suggested the role of activity scheduling as an adjunct to antipsychotic medication in reducing the negative symptoms. It could be concluded that both groups showed decrease in Negative Symptom scores from baseline to week I and then from week I to week II. There was no significant difference in the decrease in negative symptoms of both the groups from baseline to week I but it is clearly more in case study group from week 1 to week 2 as shown by lower SD values of negative symptom scores (2.88 from 5.39). It could be due to effect size i.e. small sample size and also that the patients were in active phase of illness, therefore activity scheduling could not bring much effect on the negative symptoms. Activity scheduling would have been more effective in the stabilized phase of illness. Therefore it is recommended to replicate similar study on a larger sample with assessment of its effect on other significant outcome variables as quality of life, general satisfaction measures, keeping the patient occupied and engaged, instead of depending only on the PANSS rating scale. It is also recommended to incorporate activity scheduling in the daily assignment of the nursing staff. References 1. Townsend MC. Psychiatric and mental health nursing: concept of care in evidence- based practice. I edition. Jaypee Brothers Medical Publishers 2007: Schultz SH, North SW, Shields CG. Schizophrenia: a review. American Family Physician 2007; 75 (12): Tamminga CA, Buchanan RW, Gold JM. The role of negative symptoms and cognitive dysfunction in schizophrenia outcome. International Clinical Psychopharmacology.1998; 3: Miller DD. Schizophrenia: its etiology and impact. Pharmacotherapy 1996; 16: Stuart GW, Michele T. Principles and practice of nursing. Mosby Inc 2005; first Indian edition: Sadock B and Kaplan. Comprehensive textbook of psychiatry. Volume I. Williams and Wilkins; 5th edition 1998:

9 7. Wolf DH. Anhedonia in schizophrenia. Current Psychiatry Report 2006; 8(4): Rector Neil A, Beck Aaron T. Cognitive Therapy for Schizophrenia: From Conceptualization to Intervention. Canadian Journal of Psychiatry 2002; 47(1): Haddock G, Peter DS. Cognitive Behavioral Interventions with psychotic disorders. EVHS 1996: Rober ts G. Enabling Recovery: Principles and Practice of Rehabilitation Psychiatry. RCP psychiatry publication 2006: Tollefson GD, Sanger TM. Negative symptoms: A path analytic approach to a double blind placebo and HPL controlled clinical trial with olanzapine. American journal of psychiatry 1997; 154: Meltzer HY, Casey DE, Garver DL, Marder SR, Masand PS, Miller D. Assessing the effects of atypical antipsychotics on negative symptoms. Journal of clinical psychology 1998; 59: Roberts G. Enabling Recovery: Principles and Practice of Rehabilitation Psychiatry. RCP psychiatry publication 2006: Haringe CM, Zahniser JH. Empirical correction of seven myths about schizophrenia with implications for treatment. Acta psychiatry Scandia 1994; 90: Zimmerson G, Favrod J, Trien VH, Pomini V. The effect of cognitive behavioral treatment on the symptoms of schizophrenia spectrum disorders: a Meta analysis. Schizophrenia news 2005; 77: