Family work with patients suffering from schizophrenia: the impact of training on psychiatric nurses' attitude and knowledge.

The effectiveness of family work with patients suffering from schizophrenia is well established. However, so far working with families has been carried out by highly skilled research workers. It is argued that training should be carried out to disseminate skills so that family work can be carried out routinely in clinical settings. This paper reports the impact of two pilot studies on psychiatric nurses. It was found that the trainees gained in knowledge about schizophrenia and schizophrenia family work. Furthermore, their attitudes and beliefs about schizophrenia and schizophrenia family work changed in the desired direction. The results suggest that it is possible to teach psychiatric nurses an effective model of family work for patients with schizophrenia.

Educating relatives of schizophrenic patients.

An education programme given to relatives of schizophrenic patients in the context of other social interventions is described. The findings show that although relatives remember relatively little one month after receiving the education, it is an important intervention. Several reasons are suggested, one of which is that education is a somewhat neutral but engaging beginning to the therapeutic relationship. At the later nine months follow up several positive changes in relatives' attitude were shown.

The Present State Examination Change Rating Scale.

The development and use of a new psychiatric symptom change scale based on the Present State Examination (PSE)--the PSE Change Rating Scale--is described. The advantages of the PSE are retained (the extensive glossary, the diagnostic facility and the standardised interview technique) while improving its sensitivity to change and decreasing its administration time. The scale has been designed to prevent feedback of results and 'halo' effects: it has proved highly reliable in use across raters with different backgrounds and experience. The scale has been used to monitor drug effects on clinical state across a variety of diagnoses and examples of its use are given.

Emotional attitudes and direct communication in the families of schizophrenics: a cross-national replication.

To examine how the measure of expressed emotion relates to family life, 30 relatives of schizophrenic patients were assessed for EE and then observed in ten-minute discussions with the patients. It was found that high-EE relatives express more negative emotional statements than low-EE relatives when face-to-face with the patient; they also talk more rapidly, and this speech rate is correlated with the patient speech rate. Whereas low-EE relatives expressed few criticisms or intrusive statements, high-EE over-involved relatives were more intrusive, and high-EE critical relatives were more critical as well as more intrusive in direct interaction. These findings emphasise the importance of understanding divergent EE sub-styles and the complementary behaviour of patients. The findings of an earlier Los Angeles study were replicated.

The response of untreated chronic schizophrenics to haloperidol and haloperidol decanoate.

A group of 13 untreated schizophrenic patients was collected over two and a half years. They were prescribed a standard regime of oral haloperidol, and where possible were transferred to haloperidol decanoate depot injections when their clinical condition stabilised. The progress of their symptoms was monitored weekly with a modification of the Present State Examination called the PSE Change Rating Scale. The ratings demonstrated a surprisingly good response to neuroleptic treatment in these chronic patients. Ten out of the 13 reached an arbitrary criterion of improvement with respect to psychotic symptoms, and in six patients these disappeared entirely. The reasons why the patients remained untreated for so long are considered, and include vagrancy, living with high Expressed Emotion relatives, and neglect in the community.

Prevention of relapse of schizophrenia by social and pharmacological treatments.

Even when schizophrenic patients are maintained on long-acting neuroleptics in the community, about one-third relapse over a period of 1-2 years. Relapse on medication is associated with acute stress in the form of life events and chronic stress in the form of the emotional atmosphere in the patient's home. The noxious elements in the emotional atmosphere have been identified as criticism, hostility, and overinvolvement by the relatives. Strategies are discussed for reducing the level of these emotions and their effect on the patients. A preliminary report is given on the progress of a controlled trial of social intervention with patients at high risk of relapse.

Patterns of emotional response in relatives of schizophrenic patients.

In an attempt to understand better the ways in which relatives' expressed emotion (EE) interacts with the patient's behavior to influence patterns of relapse, the correlates of EE have been examined. Four characteristics that tend to distinguish relatives who show high criticism and/or marked emotional overinvolvement from those who do not have been identified. These concern the relative's emotional reaction to the illness, views as to its legitimacy, level of tolerance/expectations, and level of intrusiveness with regard to the patient.

Bodily reactions to people and events in schizophrenics.

Schizophrenic patients were tested on psychophysiologic measures within their homes and in the laboratory. Sweat gland activity and heart rate changes when patients encounter novel situations such as life events, together with the home atmosphere generated by a critical or overinvolved relative, confirmed objectively the importance of previous social measures of these factors in determining relapse. Drug effects were also found to be modified by these social factors. Environmental and socially induced changes found in the home were undetectable in the laboratory situation.

Schizo-affective psychosis: definitions and incidence.

Eight definitions of schizo-affective psychosis have been compared in a sample of psychotic first admissions. Their mutual concordance is very low (mean 0.19) showing that there is very poor agreement about the meaning of the term 'schizo-affective' at present. Ten patients (4.5% of admissions and 8% of psychotic admissions within the age group studied) satisfied 3 definitions, a figure which demonstrates the numerical importance of this group of unclassified mental disorders.

Developments in family treatment of schizophrenia.

For the treatment of families of schizophrenics the following issues are discussed: (1) Is there any evidence that families cause schizophrenia? (2) Is it useful to consider the family as a system? (3) What is the aim of family therapy? (4) Does family therapy work for any kind of family? (5) Does family therapy work for families of schizophrenics? The conclusion is reached that systems theory can be applied successfully to some families when the patient suffers from certain conditions.

Prognostic implications of six alternative definitions of schizophrenia.

The ability of six different operational definitions of schizophrenia to identify prospectively patients whose eventual prognosis would be poor was studied using data from a six-year follow-up of a series of 134 patients with functional psychoses. All six definitions were more successful at predicting a poor symptomatic outcome than a poor social outcome. Spitzer's Research Diagnostic Criteria, Carpenter's flexible criteria, and Langfeldt's criteria predicted a poor outcome as well as the original clinical diagnoses and were considerably better than the New Haven criteria, Schneider's first rank symptoms, or the computer program Catego.

Psychiatrists' versus patients' concepts of unpleasant emotions.

A semantic differential technique was used to elicit concepts of anxiety, depression and irritability from twenty patients suffering from neurosis and ten experienced psychiatrists. It was found that psychiatrists hold concepts of these unpleasant affects that are much more differentiated than those held by patients. In particular, the psychiatrists' concepts of anxiety and depression showed a correlation of zero, whereas the patients' concepts of these affects overlapped to a considerable degree. Patients were unable to discriminate between anxiety and depression on the basis of 11 somatic symptoms, but were able to use these symptoms to distinguish anxiety and depression from irritability. The psychiatrists were in close accord with the patients over the somatic symptoms that distinguished anxiety from irritability.

Definitions of schizophrenia: concordance and prediction of outcome.

The study reports a comparison of 10 definitions of schizophrenia (Feighner's, Taylor's, Schneider's, Longfeldt's, Spitzer's, Carpenter's, Astrachan's, 2 from Forrest & Hay and Catego) in respect of their reliability, concordance and prediction of outcome. Some (including Feighner's) proved too strict, and others (including Schneider's) were weak predictors of clinical and social state. Four definitions (Spitzer's, Langfeldt's, Carpenter's and Catego) emerged as relatively effective and these also had a somewhat more satisfactory mutual concordance.

The concept of a 'case' in psychiatric population surveys.

A series of in-patients, a series of out-patients and a series of women from a general population sample, all aged under 65, and all living in the same area of south-east London, were examined using the ninth edition of the Present State Examination (PSE). An 'index of definition' (ID), based on number, type and severity of PSE symptoms, was constructed in order to define a threshold point above which sufficient information was available to allow classification into one of the functional psychoses or neuroses. The index specified 8 levels of definition of disorder; the threshold point for a 'case' lying between levels 4 and 5. The identification of 'cases' by this means in the general population series was highly concordant with global clinical judgement. When the 3 series were compared, the in-patient series contained the most definite cases, the outpatient series was intermediate, and the general population series was characterized mainly by below-threshold conditions. Disorders above the threshold point were classified using the CATEGO program. The clinical severity of the depressive disorders and anxiety states identified in this way in the 3 series was compared on the basis of symptom and syndrome profiles and PSE scores. As expected, the inpatients had the most severe, and the general population 'cases' the least severe disorders. It is suggested that the PSE-ID-CATEGO techniques can be used to help standardize certain aspects of case-finding and case-description in both referred and non-referred populations and thereby make the results of surveys more comparable.

Reliability of the PSE (ninth edition) used in a population study.

A random sample of 237 women in a south-east London area were seen by non-medical interviewers, trained to use a standard technique (the Present State Examination) to elicit and record psychiatric symptoms. Ninety-five were interviewed a second time by psychiatrists, who also rated audiotape recordings. The reproducibility of the techniques is adequate though not as high, in some respects, as that obtained from out-patient or in-patient samples. This is true at the level of symptom, syndrome, total score, and index of definition of psychiatric disorder. It is concluded that non-medical interviewers can obtain as high reproducibility as psychiatrists on most of the non-psychotic sections of the PSE if they have appropriate training. Repeatability is lower than reproducibility, partly due to fluctuations in clinical condition, partly to environmental changes between interviews, and partly to differential responses to medical and non-medical interviews. Over a short period of time, such as a week, repeatability is satisfactory.

Notions of the emotions.

The process of communication of emotional distress from patient to doctor is analysed into several components. The structure of language itself imposes certain limitations on what can be communicated. The doctor's preconceptions influence the way in which he perceives the patients' complaints. The doctor's preconceptions are bound up with his concepts of neurotic illnesses. The patient's complaints are partly determined by his concepts of emotional distress. A comparison of doctors' and patients' concepts of unpleasant emotions by means of a semantic differential technique reveals significant disparities.

A cross-national epidemiological study of mania.

An epidemiological study of the first admission rate for mania was carried out in London and Aarhus. The case registers in these two centres were used to conduct a retrospective study of case notes covering several years, and a screening procedure was used for the prospective collection of new cases over the course of one year. The annual incidence of mania was found to be virtually identical in both centres. The retrospective study gave a figure of 2-6 per 100,000 population in both Aarhus and London. But the London sample was found to contain 45 per cent of immigrants in contrast to the Aarhus sample in which only a negligible proportion were born outside Denmark. Male West Indians, in particular, were over-represented in the London sample.

The influence of family and social factors on the course of psychiatric illness. A comparison of schizophrenic and depressed neurotic patients.

This study is a replication and extension of past work carried out by Brown, Birley and Wing (1972) concerning the influence of family life on the course of schizophrenia. In the original research the index of emotion expressed by a key relative about the patient at the time of key admission proved to be the best single predictor of symptomatic relapse in the nine months after discharge from hospital. In the present study this main finding of Brown et al has been replicated for two clinically different groups of psychiatric patients. The expressed emotion of the relative again seems to be associated with relapse independently of all other social and clinical factors investigated. In addition, important additive effects between various social influences and pharmacological treatments have been revealed which make it possible to predict relapse patterns in schizophrenia with considerable precision. The patterns of these relationships with relapse are different for the two clinical groups studied, patients with schizophrenic psychosis and with depressive neurosis.