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1.
Am J Psychiatry ; 154(11): 1504-13, 1997 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-9356557

RESUMO

OBJECTIVE: The study of individual psychotherapeutic approaches to the treatment of schizophrenia has yielded equivocal findings, partly because of methodologic problems. Further, the ability of psychosocial treatments to prevent psychotic relapse appears to lessen over time. The authors' goal was to develop and test a demonstrably effective individual therapy for schizophrenia. METHOD: Using a study design that addressed previous methodologic issues, the authors evaluated personal therapy specifically designed to forestall late relapse in patients with schizophrenia. They evaluated the effectiveness of personal therapy over a period of 3 years after hospital discharge among 151 patients with schizophrenia or schizoaffective disorder diagnosed according to Research Diagnostic Criteria. The patients were randomly assigned to receive either personal therapy or contrasting therapies in one of two concurrent trials. One trial studied patients who were living with family (N = 97); the other studied patients who were living independent of family (N = 54). RESULTS: All of the patients had extensive psychiatric histories, but only 44 (29%) experienced recurrent psychotic episodes over the 3-year study period, and only 27 (18%) prematurely terminated the study; most of those who left the study were in the no-personal-therapy conditions. Among patients living with family, personal therapy was more effective than family and supportive therapies in preventing psychotic and affective relapse as well as noncompliance. However, among patients living independent of family, those who received personal therapy had significantly more psychotic decompensations than did those who received supportive therapy. CONCLUSIONS: Personal therapy had a positive effect on adverse outcomes among patients who lived with family. However, personal therapy increased the rate of psychotic relapse for patients living independent of family. The application of personal therapy might best be delayed until patients have achieved symptom and residential stability.


Assuntos
Psicoterapia , Características de Residência , Esquizofrenia/terapia , Adolescente , Adulto , Antipsicóticos/uso terapêutico , Terapia Combinada , Terapia Familiar , Feminino , Habitação , Humanos , Tábuas de Vida , Masculino , Pessoa de Meia-Idade , Psicoterapia/métodos , Transtornos Psicóticos/tratamento farmacológico , Transtornos Psicóticos/psicologia , Transtornos Psicóticos/terapia , Recidiva , Projetos de Pesquisa , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Apoio Social , Análise de Sobrevida , Resultado do Tratamento
2.
Am J Psychiatry ; 154(11): 1514-24, 1997 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-9356558

RESUMO

OBJECTIVE: Previous analyses of the personal and social adjustment of outpatients with schizophrenia have either relied on the assessment of unrepresentative patients who survived without relapse or used analyses that included relapse assessments, a potential confound when different rates of relapse existed among treatment conditions. The authors' goal was to conduct a study of the effects of personal therapy on outcome that was designed to take into consideration the effects of relapse. METHOD: They evaluated the effectiveness of personal therapy over 3 years after hospital discharge among 151 patients with schizophrenia or schizoaffective disorder. The patients were randomly assigned to receive personal therapy or contrasting therapies in one of two concurrent trials. One trial included patients who were living with family (N = 97); the other included patients who were living independent of family (N = 54). Patients were assessed at 6-month intervals over 3 years of treatment on measures of personal and social adjustment; patients who relapsed and restabilized and those who did not relapse were included. RESULTS: Personal therapy had positive effects on broad components of social adjustment (role performance) but had few differential effects on symptoms, and patients receiving personal therapy remained more anxious than patients who received family or supportive therapy. For patients who were living with family, personal therapy led to better outcomes in overall performance than did the other treatments. Although family therapy had only one positive effect on patients' social adjustment, the personal adjustment (residual symptoms) of patients who received family therapy appeared to improve more than that of patients receiving personal or supportive therapy. For patients not living with family, personal therapy was more successful than supportive therapy in improving work performance and relationships out of the home. Longitudinal effects of personal therapy on symptoms were similar to those of family and supportive therapies, particularly in the first 2 years, but personal therapy effect sizes increased over time on measures of social adjustment. CONCLUSIONS: Personal therapy has pervasive effects on the social adjustment of patients with schizophrenia that are independent of relapse prevention. Supportive therapy, with or without family intervention, produces adjustment effects that peak at 12 months after discharge and plateau thereafter. However, personal therapy, a definitive psychosocial intervention, continues to improve the social adjustment of patients in the second and third years after discharge. Brief treatment would appear to be less effective than a long-term, disorder-relevant intervention for schizophrenia.


Assuntos
Psicoterapia , Características de Residência , Esquizofrenia/terapia , Adaptação Psicológica , Adolescente , Adulto , Terapia Familiar , Feminino , Habitação , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Escalas de Graduação Psiquiátrica/estatística & dados numéricos , Psicoterapia/métodos , Transtornos Psicóticos/psicologia , Transtornos Psicóticos/terapia , Recidiva , Projetos de Pesquisa , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Ajustamento Social , Resultado do Tratamento
3.
Arch Gen Psychiatry ; 52(1): 29, 1995 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-7811160

RESUMO

BACKGROUND: Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken. METHODS: In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks. RESULTS: For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression. CONCLUSION: Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.


Assuntos
Transtornos de Ansiedade/tratamento farmacológico , Transtorno Depressivo/tratamento farmacológico , Flufenazina/análogos & derivados , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Adolescente , Adulto , Assistência Ambulatorial , Antipsicóticos/efeitos adversos , Transtornos de Ansiedade/induzido quimicamente , Transtornos de Ansiedade/diagnóstico , Doenças dos Gânglios da Base/diagnóstico , Doenças dos Gânglios da Base/etiologia , Doenças dos Gânglios da Base/prevenção & controle , Benzotropina/análogos & derivados , Benzotropina/uso terapêutico , Transtorno Depressivo/induzido quimicamente , Transtorno Depressivo/diagnóstico , Desipramina/uso terapêutico , Diagnóstico Diferencial , Relação Dose-Resposta a Droga , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Flufenazina/uso terapêutico , Glicopirrolato/uso terapêutico , Humanos , Carbonato de Lítio/uso terapêutico , Masculino , Pessoa de Meia-Idade , Placebos , Escalas de Graduação Psiquiátrica , Fatores Sexuais
4.
Schizophr Bull ; 21(3): 379-93, 1995.
Artigo em Inglês | MEDLINE | ID: mdl-7481569

RESUMO

While the long-term care of ambulatory schizophrenia patients requires highly effective interpersonal treatment skills among clinicians, there is little evidence to support an empirically validated individual psychotherapy of schizophrenia. Personal therapy (PT) attempts to address the apparent limitations of traditional psychotherapy by modifying the "model of the person" to accommodate an underlying pathophysiology, minimizing potential iatrogenic effects of maintenance antipsychotic medication, controlling sources of environmental provocation, and extending therapy to a time when crisis management has lessened and stabilization is better ensured. By means of graduated, internal coping strategies, PT attempts to provide a growing awareness of personal vulnerability, including the "internal cues" of affect dysregulation. The goals are to increase foresight through the accurate appraisal of emotional states, their appropriate expression, and assessment of the reciprocal response of others. The strategies are supplemented by phase-specific psychoeducation and behavior therapy techniques. Practical issues in the application of this new intervention are discussed. Preliminary observations from two samples of patients, one living with and the other living independent of family, suggest differential improvement over time among PT recipients.


Assuntos
Antipsicóticos/uso terapêutico , Psicoterapia/métodos , Esquizofrenia/terapia , Psicologia do Esquizofrênico , Atividades Cotidianas/psicologia , Adolescente , Adulto , Antipsicóticos/efeitos adversos , Doença Crônica , Terapia Combinada , Intervenção em Crise , Família/psicologia , Terapia Familiar/métodos , Feminino , Humanos , Controle Interno-Externo , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Participação do Paciente , Meio Social , Resultado do Tratamento
5.
Arch Gen Psychiatry ; 45(9): 797-805, 1988 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-3415422

RESUMO

Issues regarding the side effects of antipsychotic medication and the possible contribution of the environment to dose requirements led to a two-year controlled dosage study of maintenance antipsychotic medication and familial environment among recently discharged schizophrenic patients. Seventy stable patients, living in high- or low-expressed emotion (EE) households, were randomized, double blind, to receive a standard dose of fluphenazine decanoate (average, 25 mg every two weeks) or a minimal dose representing 20% of the dose prescribed (average, 3.8 mg every two weeks). No differences in relapse were observed among dose, EE, or dose and EE. Patients in the minimal dose/high-EE condition experienced more minor but aborted episodes in year 2. Side effects were fewer on the minimal dose after one year, and low-EE patients were better adjusted than high-EE patients. Over time, minimal-dose recipients were significantly more improved in their instrumental and interpersonal role performance than were standard-dose recipients.


Assuntos
Família , Flufenazina/administração & dosagem , Esquizofrenia/tratamento farmacológico , Adulto , Relação Dose-Resposta a Droga , Emoções , Meio Ambiente , Feminino , Flufenazina/efeitos adversos , Humanos , Masculino , Recidiva , Psicologia do Esquizofrênico , Ajustamento Social
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