SOCIAL FACTORS ON THE COURSE OF SCHIZOPHRENIA

Transcription

1 UNIVERSITY OF MEDICINE AND PHARMACY OF CRAIOVA SOCIAL FACTORS ON THE COURSE OF SCHIZOPHRENIA PhD THESIS ABSTRACT SCIENTIFIC COORDINATOR: Prof. Dragoş MARINESCU MD, PhD PhD CANDIDATE: Mihail Cristian PÎRLOG CRAIOVA

2 TABLE OF CONTENTS INTRODUCTION... 3 METHODS... 4 Working Hypothesis... 4 Objectives Data sources... 4 Registered indicators... 4 Working tools... 4 Study lot N= Statistical tools... 5 RESULTS... 5 DISCUSSIONS... 5 Social-demographics correlations... 6 Clinical-sociometric correlations... 6 CONCLUSIONS... 9 SELECTIVE REFERENCES Keywords: social stress, social cognition, stigma, social and personal disabilities 2

3 INTRODUCTION Schizophrenia is a major psychiatric disorder with a well defined neurobiological support, which affects the entire personality of the individual, manifesting itself through a combination of abnormalities of thought, perception and alterations of social behavior. A major public health problem, this disease has similar clinical symptoms throughout the world, regardless of the social, cultural and economic development of the country or nation [1], but it is still unknown etiology in full, being able to talk about combination of factors: genetic (higher rates of incidence in families of patients than in the general population, rates can reach up to 50% in families where both parents are schizophrenic and 60% to 84% in cases where one of monozygotic twins diagnosed with schizophrenia) [2], biochemical factors (biochemical imbalance in the brain for dopamine and norepinephrine, which leads to changes in the channels of transmission of electrical impulses), biological and psychosocial factors (pre-and perinatal complications, medical conditions, psychotraumatic events, limited social support, poverty, belonging to disadvantaged social classes, urban residence, migration), the abuse of psychoactive substances. Psychosocial vulnerability for schizophrenia led to the development of a descriptive model of stress-vulnerability correlation, which belong to the most important roles of genetic and environmental factors as triggers of disease and development disorder itself, including the duration of antipsychotic therapy, relapses and negative effects of social stress, substance abuse, low coping capacity and social-economic losses. Action of psychosocial factors in the development of schizophrenia was confirmed by neurobiological and neuroimaging studies, the action of stress factors leading to increased glucocorticoid release by the hypothalamic-pituitary-axis hyperactivity, which in the long run lead to hippocampal volume reduction being considered one of important biological markers of unfavorable development of schizophrenia. [3] On the other hand, one of the features of schizophrenia, impaired social function manifested by social isolation, the lack of insight and initiative, altered judgement and deficiencies in emotional expression, is caused by damage to the prefrontal cortex and reduced structures involved in process of social cognition (amygdala, superior temporal cortex). [4] 3

4 METHODS Working hypothesis A recognized psychosocial vulnerability for developing schizophrenia, the influence of environmental factors on the development of social and familial schizophrenic patients characterized by a marked impairment of social functioning (social isolation, lack of awareness of the disease, abnormal thinking and reasoning, affective-emotional and social cognition alteration) generated a complex pattern of risk factors, their correct assesment may lead to better compliance and adherence to treatment. By identifying and assessing the impact of this category of factors, emphasizing the correlations between clinical and descriptive elements and social life indicators can create the preconditions to improve the development of schizophrenia. Objectives 1. Identification of social risk factors present at schizophrenic patients and their families during the course of the disease; 2. Determining the evolutionary peculiarities depending on the weight of psychosocial factors and highlight the role of these factors on disease progression. Retrospective-prospective clinical study of patients diagnosed with schizophrenia and hospitalized in Craiova Mental Health Center between July 1, June 30, Data sources: observation charts and books for dispensary in Craiova Mental Health Center; results of psychological examinations in Craiova Mental Health Center. Registered indicators: socio-demographic indicators (age, sex, area of residence, marital status, educational level, employment status), clinical indicators (family history and presence of psychotraumatical events, personal pathological history, diagnostic classification, nature of onset, age at onset, duration of the disease, the number of admissions to the Mental Health Center in the last 5 years, agressive behavior, suicidal behavior and suicidal ideation, alcohol consumption, smoking, level of social adjustment, global status at discharge, class of antipsychotic drugs used in treatment during hospitalization), indicators of social functioning (scores obtained by applying the working tools). Working tools: Social Stress Indicators; Personal and Social Performance Scale; Involvement Evaluation Questionnaire; Burden Assessment Scale; WHOQOL BREF; Study lot N=81 After applying the inclusion and exclusion criteria, there was constitued the study lot N=81 patients diagnosed with schizophrenia and hospitalized in Craiova Mental Health Center within 5 years (July 1, June 30, 2012). 4

5 Statistical tools Data processing was performed with Microsoft Excel, along with the XLSTAT suite for MS Excel and the secondary processing of data, calculation of basic statistical parameters and their graphic representation was performed using Pivot Tables commands, Functions, Statistics, Chart and Data Analysis module of Excel. Complex statistical tests (Chi square, Fisher exact, Student and ANOVA) were performed with XLSTAT module commands or using SPSS. RESULTS In the study lot, the gender distribution shows a predominance of females (59.26%) compared to men (40.74%), the average age being 45.36±8.50 years. The urban residence predominated (85.18%), with a relatively equal distribution for membership of a couple (married 48.15%, remarried 1.23%, cohabiting 1.23%) compared to those not involved in such social relationships (divorced 12.35%, unmarried 35.80%), with a high significant statistically distribution (p=0.005). Within the study lot, there dominated the patients with an average educational level (49.38%) and not engaged on the labor market (92.59%). There is a high incidence of paranoid schizophrenia (74.09%) with insidious onset (67.90%) in the third decade of life (20-24 years 24.70%; years %) and an average time of disease progression 18.96±8.97 years. An aggressive behavior was present at 69.14%, while suicidal behavior was not an important characteristics of the study lot (7.40%). The family history was predominantly insignificant (67.90%), as well as somatic comorbidities (53.09%); smoking (24.69%) and alcohol (37.03) were assessed as behavioral manifestations with potentially to worsening mental and somatic condition of the subject. In our study lot, there were predominant the patients that in the last 5 years of disease progression has 2 admissions (60.50%), and most of them showed a poor level of functioning and social integration (95.06%) and stationary state upon the last hospital discharge (54.32%). PSP scores show the social integration of the patient, his social skills and ability to live an independent life, the average score of 37.22±8.75, being near the limit of the range of light and most severe social-personal disabilities. Social Stress Indicators revealed an average score of 99.89±18.24 specific for intense social stress, and the burden assessed to caregivers by BAS resulted in an average score of 51.22±8.17 significant for intensely felt. IEQ score (96.44±14.32) reveals an intense involvement in patient care, but also a more intense level of social stress in caregivers than in patients (SSI ±12.45) 5

6 DISCUSSIONS The large amount of numerical values obtained and the complexity of the domains evaluated through the scales used led to the need for the statistical evaluation of possible differences between the results of the working tools based on the gender of the patients in the study lot. The recorded data showed a Gaussian distribution, allowing the use of Student t test. By calculating the average values obtained, there were not obtained any significant differences (with one exception), concluding that it was correct to use the same tools for male and female patiens, without additional correction indices. The validity and reliability of the tests used were highlighted by the significant correlation of raw scores (Pearson coefficients highly significant). Social-demographics correlations The study of the correlation between the gender of the patients in the study lot and other elements that have characterized the clinical and social functioning outcomes led to statistically significant connections between gender and age at onset (p=0.018) and gender IV Domain WHOQOL-BREF (p=0.023), while the area of residence showed a significant association (p=0.025) with the average scores obtained from the third subscale of SSI (assessing the presence and impact of major psychotraumatic events) in caregivers. The educational level of the patients was significantly correlated with the average scores obtained in the III Domain (social relations) WHOQOL-BREF (p=0.016) and the scores average of the SSI subscale which evaluates chronic stress in caregivers (p=0.050). There is an association between the age of the onset and the occupational status of the patients with high statistical significance (p=0.013), as is between the average scores of PSP and the occupational status of patients in the study lot (p=0.016) with higher scores, that are corresponding to medium - light shortcomings in personal and social performance for patients engaged in productive activities. The marital status of patients was associated with the average scores of SSI acute social stress subscale, applied both to patients (p=0.028) and carers (p=0.034). Clinical-sociometric correlations Age at onset was one of the independent variables used in the statistical analysis to highlight the influence of the social factors on patients, being identified a highly significant correlation (p~0) between the age at onset and the diagnostic classification, early onset occurring mostly for paranoid schizophrenia, which involves mainly behavioral events and social cognition and theory of mind deficit. The typology of onset was significantly correlated 6

7 with the disease duration (p=0.007), age at which it ocurred (p=0.007) and the level of the burden experienced by the caregiver expressed by BAS scores (p=0.021). It is observed the increase of the average age at which the insidious onset of the disease (27.3±7.792 years) occurred, compared with the reactive onset (22.6±6.5 years). In sociological terms, this correlation may be associated with stigma in schizophrenic families, specialized examinations being delayed for fear of possible rejection from the social micro- and macrogroup, both for the patient and the other family members. These hyperprotective measures and the presence of excessive emotional expression are considered risk factors for the disease, but also for the social functioning of the patient, after diagnosis. [5] The statistically significant high correlation (p=0.001) identified between alcohol consumption and the age of onset is surprising; onset at a young age being predominantly associated with the lack of alcohol, while onset schizophrenia at adulthood has a direct correlation with occasional use. Alcohol consumption was also significantly associated (p=0.039) with the average scores obtained on the SSI III subscale, that assess the impact of major psychotraumatical events experienced by the patient during his/her lifetime. It is noted that there is a concomitant increase of scores obtained by applying the scale and quantity of alcohol consumed, highlighting the direct relationship between psychostress and the use (or misuse) of substances present in schizophrenia. [6] The presence of aggression in schizophrenia is considered a marker of treatment failure, public perception of the threat posed by schizophrenic patient becoming one of the main obstacles in establishing a therapeutic alliance between the patient - psychiatrist the family (caregivers) the community. [7] The results obtained were highly significant from the statistical perspective (p~0) for the association between aggression and social and personal performance (PSP), high scores indicating a better social functioning being directly related to the absence of aggressive behavior, between the level of perception and the interpretation of psychotraumatical events experienced by the patient (SSI III subscale) and the presence of violent behavior (p=0.018); and between the presence of aggression and the large number of admissions in Craiova Mental Health Center (p=0.018) respectively high levels of burden and stress to carers (p=0.049). An important element of our research was studying the correlation between the social adaptation, assessed on two levels: positive and weak. After the statistical verification through the ANOVA test, there were identified a number of significant and highly significant correlation from the statistical perspective: for high scores PSP, corresponding to a lack of social and personal performance minimum (p~0) with SSI high scores (intense social stress), 7

8 the chronic stress felt by the patient (SSI II subscale) and the impact that the psychotraumatical events which they experienced in life had on their subsequent evolution (SSI III subscale) (p=0.008), as well as with the BAS and IEQ scores; there was noticed a high intensity of burden for the caregivers (p=0.002) and a higher level of involvement in this activity (p=0.002), while the schizophrenic patient shows social disruption, especially expressed by the relative loss of independence. [8] The influence of social factors on the course of schizophrenia risk could be outlined by the analysis of correlations between the number of hospitalizations in the last 5 years in the Craiova Mental Health Center, as an indicator of quality of development, and scores of tools, all analysis performed by ANOVA test. (Table 1) Tabel 1 Correlation between the number of hospitalizations and scores of working tools Number of hospitalizations p ANOVA Parameter average WHOQOL std. dev WHOQOL Domain II WHOQOL Domain IV SSI I Subscale (Patient) SSI (Caregivers) SSI I Subscale (Caregivers) SSI II Subscale (Caregivers) BAS average std. dev average std. dev average std. dev average std. dev average std. dev average std. dev average std. dev < < < IEQ average std. dev The discharge status is an important clinical and evolving indicator of the effectiveness of the therapeutic strategy adopted and the patient's ability for social reintegration and it was highly significantly correlated (p~0) with PSP high scores and positive self-assessment of physical health (WHOQOL Domain I) (p=0,026). This set of significant statistical correlations is extremely important, demonstrating the influence that social stress elements (financial problems, family, social, professional) have on the patient s evolution, even in the outpatient, representing the genuine risk factors for unfavorable evolution. The constant evaluation of the stress levels may be an argument to establish a therapeutic relationship based on adherence to treatment, ensuring to the practitioner the 8

9 successful therapy and to the patient a high quality remission and adequate social functioning. [9] The chronic social stress in caregivers is highly significantly correlated (p~0) with aggravated condition upon discharge, highlighting the negative perception of the social disability of patients with schizophrenia, at the level of the social group. The negative effects are highlighted by significant connections between the high scores on BAS and the aggravated condition upon discharge (p=0.026), and the correlation between the IEQ high scores and the incomplete remission upon discharge (p=0.001) - data confirmed in specialized literature. [10] (Table 2) Table 2 Correlations between the patient condition upon discharge and working tools scores Condition at discharge Improved Stationary Aggravating p ANOVA Parameter average PSP 0,000 std. dev WHOQOL Domain I SSI (Patient) SSI II Subscale (Patient) SSI III Subscale (Patient) SSI (Caregivers) SSI II Subscale (Caregivers) BAS IEQ average std. dev ,026 average std. dev ,046 average std. dev ,037 average std. dev ,015 average std. dev ,002 average std. dev ,000 average std. dev ,026 average std. dev ,001 CONCLUSIONS 1. N=81 study lot showed a higher frequency of about 1.5 times for women (59.26%) than for men (40.74%), predominance of urban residence (85.18%) and years (23.45%), and years (22.22%) age groups. 2. The dominant educational level was in secondary education (49.38%), with significant unemployment (92.59% retired or social assistance) and highly significant distribution (p<0.01) according to marital status (50.61% married or involved in a relationship). 3. The paranoid schizophrenia was the most common form of diagnosis (74.09%) with onset at younger age (p~0) and a significant batch distribution by gender and diagnosis (p <0.01). 9

10 4. In N=81 study lot the average age of onset was 25.78±7.38 years, the average duration of the disease was 18.96±8.97 years, somatic comorbidities (46.91%), and the psychiatric family history (32.10%). 5. Patients in N=81 study lot showed a stationary state (54.32%) and aggravated state (12.35%) conditions upon discharge and psychosocial adaptation deficit (95.06%). The main social factors that influenced the evolution and adaptive deficit was the inability and social stress. 6. Moderate - severe social and personal inabilities (PSP) were significantly correlated with the aggressive behavior (p~0), the poor social adjustment (p~0), stationary or worsened evolution (p~0) and unemployment (p<0.05). 7. The social stress (SSI) evaluated in patients was significantly correlated with the poor social adjustement (p<0.01), educational level (p<0.05), marital status (p<0.05), alcohol consumption (p<0.05), presence of aggression (p<0.05) higher number of hospitalizations (p<0.05) and aggravated condition upon discharge (p<0.05). 8. The social stress (SSI) evaluated at caregivers was more pronounced than in patients significantly associated with the large number of relapses (p<0.01), aggravated condition upon discharge (p<0.01), rural areas of residence (p<0.05), educational level of patients (p<0.05) and poor social adaptation level (p<0.05). 9. The level of involvement in care (IEQ) was intense, being significantly influenced by the adaptive deficit of patients (p<0.01), number of hospitalizations (p<0.01) and patient's condition upon discharge (p <0.01). 10. The intense resentment of the burden (BAS), expression of negative social influence and stigmatization was significantly correlated with the adaptive deficit (p<0.01), frequent relapses (p<0.01), insidious onset of the disease (p<0.05), alcohol consumption (p<0.05), aggressive behavior (p<0.05) and low quality of remission (p<0.05). 11. The assessment of the quality of life was influenced by several clinical and socialdemographic variables: the number of readmissions (p~0), the patient's condition upon discharge (p<0.05), the patient s gender (p<0.05), educational level (p<0.05) and level of social adjustment (p<0.05). 12. The statistical significance of the data obtained confirms the importance of social risk factors in the development of schizophrenia and monitoring the level of social disability (social cognition deficit), the presence and intensity of social stress (in acute and chronic forms) both for the patient and the caregivers, the effects of stigma and emotional involving of family and the patient's quality of life can provide the necessary parts for the clinician to optimize therapeutic strategies. 10

11 SELECTIVE REFERENCES [1] Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE. Schizophrenia: manifestations, incidence, and course in different cultures a World Health Organization ten-country study. Psychol Med Monograph Suppl 1992; 20: [2] McGuffin P, Owen MJ, Farmer AE. Genetic basis of schizophrenia. Lancet 1995; 346: [3] Mueser KT, McGurk SR. Schizophrenia, Lancet 2004; 363: [4] McEwen BS. Plasticity of the hippocampus: adaptation to chronic stress and allostatic load. Ann N Y Acad Sci 2001; 933: [5] Barrash J, Tranel D, Anderson SW: Acquired personality distrubances associated with bilateral damage to the ventromedial prefrontal region. Developmental Neuropsychology, 2000, 18, [6] Wuerker AK, Haas QL, Bellack AS. Interpersonal Control and Expressed Emotion in Families of Persons With Schizophrenia: Change Over Time, Schizophrenia Bulletin, 27(4): , [7] Swofford CD, Kasckow JW, Scheller-Gilkey G, Inderbitzin LB. Substance use: a powerful predictor of relapse in schizophrenia. Schizophr Res, 1996, 20: [8] Lefley HP. Family Burden and Family Stigma in Major Mental Illness, American Psychologist, March 1989, Vol. 44, No. 3, [9] Barak Y, Aizenberg D. Clinical and psychosocial remission in schizophrenia: correlations with antipsychotic treatment, BMC Psychiatry, 2012, 12:108 doi: / x [10] Corrigan PW, Backs Edwards A, Qreen A, Lickey Thwart S, Perm DL. Prejudice, Social Distance, and Familiarity with Mental Illness, Schizophrenia Bulletin, 27(2): ,