E-Book, Englisch, Band Vol. 5, 94 Seiten
E-Book, Englisch, Band Vol. 5, 94 Seiten
Reihe: Advances in Psychotherapy - Evidence-Based Practice
ISBN: 978-1-61334-504-7
Verlag: Hogrefe Verlag
Format: EPUB
Kopierschutz: Wasserzeichen (»Systemvoraussetzungen)
The new edition of this highly acclaimed volume provides a fully updated and comprehensive account of the psychopathology, clinical assessment, and treatment of schizophrenia spectrum disorders. It emphasizes functional assessment and modern psychological treatment and rehabilitation methods, which continue to be under-used despite overwhelming evidence that they improve outcomes. The compact and easy-to-read text provides both experienced practitioners and students with an evidencebased guide incorporating the major developments of the last decade: the new diagnostic criteria of the DSM-5, introducing the schizophrenia spectrum and neurodevelopmental disorders, the further evolution of recovery as central to treatment and rehabilitation, advances in understanding the psychopathology of schizophrenia, and the proliferation of psychological and psychosocial modalities for treatment and rehabilitation.
Zielgruppe
Clinical psychologists, psychiatrists, psychotherapists, and
counselors, as well as students.
Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
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Description
1.1 Terminology
1.1.1 Schizophrenia as a Mental Health Policy Construct Schizophrenia refers to a type of severe and disabling mental illness that affects between .5% and 1.5% of the population worldwide, with a current global prevalence calculated at over 20 million people. It is typically first recognized in late adolescence or early adulthood, and is often associated with lifelong disability, especially when appropriate services are not provided. It has been estimated that as many as ten percent of all disabled persons in the US are diagnosed with schizophrenia. Schizophrenia is a specific psychiatric diagnosis, but for the purposes of social policy and healthcare administration it is often grouped together with schizoaffective disorder, bipolar disorder, severe chronic depression, and sometimes other conditions. Such grouping is convenient because treatment and service needs are similar within the group. The diagnoses usually grouped with schizophrenia have in common an onset in late adolescence or adulthood, an episodic course (periods of better and poorer functioning), a high risk of severe disability, and in most cases (traditionally) a lifelong need for treatment and support services. Psychiatric Disability Psychiatric disability resulting from schizophrenia extends to multiple domains of personal and social functioning. People with the diagnosis are vulnerable to institutionalization, to being found legally incompetent and requiring a guardian, and to needing assisted living situations. As a group they have very high unemployment and poor quality of life. The economic costs of schizophrenia, including direct treatment costs and lost productivity, are enormous (Insel, 2008), among the highest of all health conditions, ranking with cancer and heart disease. The diagnosis accounts for 75% of all mental health expenditures and approximately 40% of all Medicaid reimbursements, although the greatest part of the economic burden comes not from treatment but from the disability, i.e., from the lost productivity of those affected (Insel, 2008). Serious Mental Illness The term serious mental illness (SMI) has been in use for several decades, especially in federal mental health policy, to refer to schizophrenia and the other diagnoses with which it is usually grouped. However, in recent years the |2|meaning of SMI has generalized to include less disabling conditions, sometimes virtually any psychiatric diagnosis (Satel & Torrey, 2016). This would not be a problem if the criteria were sensitive to the actual, measurable degree of disability, but in practice expansion of the meaning of SMI directs resources away from those in most need. This issue is related to the so-called practice of “cherry picking,” strategically selecting healthcare clients to optimize corporate or individual profits. It is a matter of ongoing concern and debate in the healthcare industry and the mental health policy communities. The Schizophrenia Spectrum Schizophrenia spectrum is also used as a group term, although its specific meaning is variable. In the recently issued fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (American Psychiatric Association, 2013), “Schizophrenia Spectrum,” is a sub-family that includes schizophrenia and related diagnoses under the major heading “Schizophrenia Spectrum and Other Psychotic Disorders.” DSM-5 also includes schizotypal personality disorder in its definition of the schizophrenia spectrum, even though it is placed under the major heading “Personality Disorders.” In the scientific literature, “schizophrenia spectrum” is used more broadly, in recognition of the indistinct boundaries of “schizophrenia” as a diagnostic category, the multiple causes and expressions of psychopathology related by common genes, symptoms and other features, and commonalities in treatment. Schizotypal traits and other developmental vulnerabilities are considered part of the schizophrenia spectrum whether or not they meet diagnostic criteria for any disorder. For the purposes of this book, the scientific usage of “schizophrenia spectrum” provides a better reflection of its meaning than the DSM usage. Psychosis Psychosis is a clinical term that has significant policy implications as well. It is not a diagnosis, but is closely associated with schizophrenia and related diagnoses, sometimes collectively termed psychotic disorders. Psychosis is a state often loosely described as detachment from reality, expressed as specific psychiatric symptoms including hallucinations, delusions (expression of unrealistic or bizarre beliefs), disruption of coherent thought and language, and affect inappropriate to the situation (e.g., euphoria in the face of deteriorating personal circumstances, extreme anger without a discernable cause). Sometimes affective symptoms may have associated psychotic features, e.g., if depressed mood is accompanied by delusions of guilt. In such cases the psychotic features are said to be mood-congruent. Psychosis may be continuous or episodic and is highly variable in quality and severity across individuals and within individuals over time. The presence of psychosis in any clinical picture is indicative of increased morbidity, risk, and disability. Even in the general population, the presence of psychotic symptoms is associated with greater social disability (Rossler et al., 2015) and an increased risk for violent behavior (Silverstein, Del Pozzo, Roché, Boyle, & Miskimen, 2015). Unfortunately, mental health policies, regulations, and practices often fail to recognize and manage the highly variable and episodic nature of psychosis and the individual differences this creates. |3|Treatment Refractory Schizophrenia It may seem curious that the term treatment refractory appears in a discussion of policy terminology. In fact, the concept behind the term has a pervasive influence on policy and in organization and administration of mental health services. Applied in mental health in the context of severe, disabling disorders, treatment refractory means refractory to drug treatment, specifically to treatment with first-generation antipsychotic drugs (see Section 4.1.2). There is no scientific rationale for distinguishing a group based on response to drugs, much less on response to a specific sub-family of drugs. There are, however, commercial and economic reasons to make the distinction, but these are not typically reasons that serve the best interests of consumers. For example, this distinction is often used to support the use of cheaper post-patent medications, to promote prescription of newer, more profitable drugs, or to promote the interests of the medical services industry. Arguably “treatment refractory schizophrenia” is a terminological relic of the deinstitionalization era, the 1970s and 1980s, when the population of psychiatric institutions was dramatically reduced. Policy during that era showed a naïve (in retrospect) expectation that antipsychotic drugs would enable people discharged from the psychiatric institutions to function normally in their communities. Being “refractory” in this context could render the community inaccessible to the person so labeled. Most people with schizophrenia spectrum disorders are “refractory” to some degree, in the sense that very few people experience complete remission of all aspects of the disorder from drug treatment alone. Most people who are “refractory” to first-generation antipsychotics are responsive to a range of psychological treatments and social interventions, some to a very extensive degree (Newbill, Paul, Menditto, Springer, & Mehta, 2011; Paul & Lentz, 1977; Silverstein et al., 2006; Spaulding, Johnson, Nolting, & Collins, 2012). 1.1.2 Schizophrenia as a Psychiatric Diagnosis The modern diagnosis of schizophrenia has its origins in the work of Emil Kraepelin, who named it dementia praecox, “early dementia.” In the early 20th century the Swiss psychiatrist Eugen Bleuler introduced the term “schizophrenia” as he challenged the presumptions underlying Kraepelin’s “dementia praecox.” “Dementia” is inappropriate, Bleuler argued, because many people recover in ways inconsistent with an irreversible progressive brain disease. Bleuler also argued that the extensive individual differences between people with the same diagnosis suggest that it is not a single disorder, but a group of similar but distinct disorders. He argued...
