Assessment of Function in Schizophrenia: Challenges & Opportunities

Mamdouh EL-Adl MBBCh, MSc, MRCPsych Consultant Psychiatrist

Overview
I. Schizophrenia & Function. II. Challenges III. Social Behaviour: S. Function, S. Cognition & S. Skills. IV. Assessment of Function, Why?
- Aim of healthcare - Health of the Nation - Modern NHS

V. Assessment Scales: GAF, SOFAS, HoNOS, PSP. VI. Conclusion

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I. Schizophrenia & Social Function

Schizophrenia & Function

Impairment of social function (SF) is a central feature of Schizophrenia. Early studies focused on global aspects of social functioning & overt behaviours e.g. eye contact & conversation skills1. Recently emphasis shifted to cognitive processes believed to underlie social behaviour i.e. social cognition.
1.Bellack AS, Morrison RL, Wixted JT & Mueser KT (1990). An analysis of social competence in Schizophrenia. Brit J Psychiatry, 156,809-818

Consequences of social impairment in Schizophrenia

Early onset of illness: late adolescence or early adulthood. Affects multiple domains of function. Devastating effect on the development & maintenance of key social relationships. Severe impairment across multiple areas of role functioning e.g. friendships, work, marriage,.
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Cognition1
Cognitive impairment and neuropsychological deficits have been shown to be linked to functional status.
Less is known about the cognitive and functional changes over time.
1. Matza, L.S., Buchanan, R., Purdon, S., Brewster-Jordan, J., Zhao, Y., Revicki, D.A. (2006). Measuring changes in functional status among patients with schizophrenia: The link with cognitive impairment [Electronic version]. Schizophrenia Bulletin, 32(4), 666-678. 7

The Treatment Course of Schizophrenia1

Early intervention tends to lead to better outcomes and higher functioning. Early diagnosis and stabilization on treatment are likely to be associated better the long term prognosis. Medication compliance is directly related to reduced risk of relapse

1. NIMH http://www.nimh.nih.gov/healthinformation/index.cfm 8

Schizophrenia & Social Function

Early Onset

Affects Development

Affects Multiple Domains

Devastating effect on development & Maintenance of key social relationships

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II. Challenges

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A few challenges
To understand more about social cognition & social functioning (SF) in Schizophrenia To have sound SF outcome measures. Adaptation & validation of outcome measures for use in atrisk & early psychosis populations.
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III. Social Behaviour!

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Levels of Social behaviour

The following represent different levels of Social behaviour: I. Social Functioning (SF). II. Social Cognition (SC). III. Social Skills (SS).

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Social Functioning
A broad multidimensional construct. Implies the overall performance across everyday domains1 e.g. - independent living. - employment. - interpersonal relationship - recreation. Social functioning, community functioning & social competence can be used interchangeably.

1. Green MF (1996): What are the functional consequences of neurocognitive deficits in Schizophrenia? Am J Psychiatry,153(3),321330

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Social function

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Social Function

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Social Cognition (SC)

SC: mental operations underlying social interactions. A specialised domain of cognition developed to solve social & adaptive problems & can be differentiated from non-SC (Penn et al, 1997). . The retrieval of knowledge relevant to conversation requires an adequate LT verbal memory. To send appropriate response, one must possess cognitive flexibility. Such Neurocognitive abilities (attention, working + verbal memory & executive functions) are impaired in Schizophrenia (Goldberg et al,1987; . , Ne 1991).

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Social skills (SS) - 1

Refers to cognitive, verbal & nonverbal behaviours necessary to engage in positive interpersonal interactions. A continuum ranging from: basic molecular to complex molar skills. Molecular skills: discrete observable behaviours e.g. eye contact, tone of voice. Molar skills result from smooth integration of molecular skills e.g. initiating a conversation.
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Social skills (SS) - 2

Numerous models proposed e.g. Sequential 3 process deposit model: 1. Perception: social information/cues received. 2. Processed: interpretation of cues, retrieval of relevant knowledge from memory & response generation/selection. 3. Sending: response is sent with the aid of verbal & non-verbal skills e.g. verbal fluency, tone, gestures & eye contact.
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Social Skills in Schizophrenia

3-process model: 1. Perception: receiving & recognition. 2. Processing: generate/select a response 3. Sending: verbal & non-verbal.

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Social behaviour

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Social Skills
cognitive, verbal & non-verbal behaviours necessary to engage in a positive interpersonal interactions

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Social Skills

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IV. Assessment of Function

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Why assess?
A. Aim of healthcare. B. Health of the nation strategy C. Modern NHS: - Foundation trusts. - Payment by results.

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A. Aim of healthcare (1)

To improve or maintain the overall functional capacity and general health of the patients1.

1.Jenkinson C & McGee H: Patient assessed outcomes: Measuring Health Status & Quality of Life. In Assessment & Evaluation of Health & Medical Care, a methods text. Edited by Chris Jenkins (2002):6484.

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A. Aim of health Care (2)

Historically medical care has concentrated on: - Diagnosis & treatment1 - Intervention was based on traditional clinical, radiological & lab. measures2. - Evaluation of medical treatment has relied on morbidity & mortality. This approach tended to overlook global functioning, well being & quality of life i.e. outcome measures did not always reflect those of patients3,4.
1.Wasson J, Keller A, Rubenstein L, Hays R, Nelson E, Johnson D & The Dartmouth Primary Care COOP Project (1992): Benefits & obstacles of health status assessment in ambulatory settings: the clinicians point of view. 2.Albrecht G (1994) Subjective health assessment, in C Jenkinson (ed.): Measuring health & medical outcomes. London UCL Press 3.Blazer D & Houpt J (1979) Perception of the poor in the healthy older adult, Journal of the Am Geriatrics Society, 27:330 4 4.Jenkinson C (1994a) Measuring Health & Medical Outcomes: an overview, in C Jenkinson (ed.) measuring health & medical outcomes. London: UCL Press

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A. Aim of health Care (3)

Over the past few decades there has been - gradual shift from this approach. - incorporation of patients based data into evaluation of care The recognition of patients view as central to monitoring & evaluation of care has led to development of numerous approaches to measure the function & subjective well being.
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B. Health of the nation strategy

(DOH,1992)

3 targets for improving mental health: 1. To improve health & social functioning (H&SF) of mentally ill people. 2. Suicide rates in general. 3. Suicide rates in related to mental illness

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R.C.Psychiatrists Research Unit (CRU) - 1

CRU received fund to develop a set of scales to measure H & S F, to be used routinely by mental health clinicians. Health & Social gain for mentally ill covers several concepts: 1. improvement in mental, physical & social functioning > what is expected without intervention. 2. maintenance of an optimal functional state by preventing, slowing &/or mitigating deterioration.
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R.C.Psychiatrists Research Unit (CRU) - 2

The context of this development assumed that: 1. The new instrument would be usable across the whole range of contacts between patients & clinicians at a reasonable cost. 2. An eventual national system for data collection (of adequate quality & sensitivity).

Wing JK, Curtis RH & Beevor AS (1996): HoNOS: report on Research & Development, July 1993 Dec 1995, College Research Unit, Executive summary:1-8.

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Early Intervention
Assessment of function & its rate of change in FEP should be established1. Recovery from psychotic symptoms is common after FEP (75 90% achieving remission one year after treatment)2,3. However functional recovery (e.g. social, vocational, interpersonal) remains a major challenge4,5. Improving treatment for negative & cognitive symptoms in F.E. Schizophrenia is an area of major importance in future research as these symptoms affect patients functional recovery6.
1.Ehmann T &Hanson L. Assessment in Best Care in Early Psychosis Intervention edited by Ehmann T, MacEwan GW & Honer WG 2004:25-29 2.Norman RM, Mala AK, Duration of untreated psychosis: a critical examintion of the concept & its importance. Psychol med 2001;31:381-400 3.Addington J, Van Mastrigt S, Hutchinson J, Addington D. Pathways to care: help seeking behaviour in FEP. Acta Psychiatr Scand 2002;106:358-64 4.Walter G, Wiltshire C, Anderson J, Storm V. The pharmacological treatment of the early phase of FEP in youths. Can J Psychiatry 2001;46:803-9. 5.Cullberg J. Integrating intensive psychosocial therapy & low dose medical treatment in a total material of first episode psychotic patients compared to treatment as usual: a 3 year follow-up. Med Arch 1999;53:167-70 6.Perkins DO & Liebermann JA. Pharmacological management in Best Care in Early Psychosis Intervention edited by Ehmann T, MacEwan GW & Honer WG 2004:241-47

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Early & Effective Intervention

Symptoms Short & Long Term Positive Negative Affective Cognitive Sustained Adherence to Treatment

Healthy Behaviour
improved Performance Personal Social Integration Productivity

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Assessment of function in Clinical Practice

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Assessment of function in Clinical Practice

Asking patient about functioning is likely to be less sensitive than asking about Psychotic Symptoms. Assessment of function is influenced by socio-cultural. Interpret patients performance with consideration to baseline & socio-cultural factors.

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Information gathering
I. Patient: Self reporting. II. Family/carer: Observation, views. III. Clinician/team assessment. IV. Combination of the above: preferred.

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Patient
Self reported assessment - Advantage: 1. Allows access to patients views. 2. Positive effect on therapeutic relationship. - Disadvantages: 1. patient may minimise/exaggerate impact of illness on his/her function. 2. likely to be affected by patients literacy & understanding of symptoms. 3. possible inconsistency over time.
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Family/Carer
- Advantage: 1. Longer period of observation. 2. Fosters working in partnership. - Disadvantages: 1. Carers may minimise/exaggerate impact of illness on function. 2. likely to be affected by carers literacy & understanding of symptoms. 3. possible inconsistency over time.
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Clinician (s)
Taking a multidimensional approach: 1. Observation: likely to be objective. 2. Gathering corroborative information. 3. Assess function at every visit/contact. 4. Looking for subtle changes in function.

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V. Assessment Tools

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Assessments of Function
1.GAF: Global Assessment of Function. 2.SOFAS: Social & Occupational Functioning Assessment Scale. 3.HoNOS: Health of the Nation Outcome Scale 3.PSP: Personal & Social Performance Scale.

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GAF
Overall assessment of Social, Occupational & Psychological functioning (Axis V). Criticism: 1. Does not include physical or environmental limitations. 2. Not a pure measure of individuals ability to function as it incorporates symptom severity e.g. L41 50 for serious symptoms (e.g. suicidal ideation, severe obsessive rituals, shoplifting). Hence DSM-IV-TR includes SOFAS*.
*First, M & Tasman, A (2004) DSM-IV-TR, Mental Disorders: Diagnosis, Etiology & Treatment, Wiley. Diagnosis:1-49.

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SOFAS
Assesses Social & Occupational Function separate from Psychological symptoms Impairment due to general medical conditions are rated. Can be used to track progress in rehabilitation settings.

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PSP
Clearly identified anchor points. 4 domains of social & occupational functioning*

*Morosini, P., Magliano, L., Brambilla, L., Ugolini, S., Pioli, R. (2000). Development, reliability and acceptability 0f a new version of the DSM-IV social and occupational scales (SOFAS) to assess routine social functioning. Acta Psychiatrica Scandinavica, 101(4), 323-329.

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Introduction to PSP

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PSP
Developed as a measure of personal and social functioning of patients with psychiatric disorders1 First published in 2000 in an effort to develop a more valid and reliable version of the SOFAS2 Quick & reliable when administered by trained mental health professionals1 SIPSP: structured Interview to increase raters reliability & validity.

1. Morosini, P., Magliano, L., Brambilla, L., Ugolini, S., Pioli, R. (2000). Development, reliability and acceptability of a new version of the DSM-IV social and occupational scales (SOFAS) to assess routine social functioning. Acta Psychiatrica Scandinavica, 101(4), 323-329.

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Clinicians Responsibilities
To obtain the most accurate information on functioning: The individual administering the scale should:
Be experienced in treatment of psychiatric disorders Remain consistent for a given patient at all visits

Consider information obtained from other health care professionals and/or family members regarding patients functioning Follow SIPSP Guide & PSP Scoring Guidelines
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Interviewing Techniques
Approach to patient Establishing rapport Knowledge
Introduce self and explain scale/intent of interview Maintain appropriate eye contact, listen to patient Summarize patients responses to clarify and confirm Show appropriate affective response to patient

Interview style

Emphasize appropriate time-frame Qualify duration and frequency of behaviors

Reference patients previous responses as necessary Broaden/narrow area of inquiry as needed Reference previous responses

Keep notes from the last visit

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Structured Interview
PSP Domains
a) Self-care b) Socially useful activities c) Personal & social relationships d) Disturbing and aggressive behavior

Within each domain determine the frequency of:

Patient independence with tasks
Verbal reminders required Physical assistance required Independently With verbal prompting With physical assistance

Frequency of tasks completed

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PSP: Scoring
Four domains
a) Self-care b) Socially useful activities c) Personal & social relationships d) Disturbing and aggressive behavior

Scoring range: 0-100

Divided into 10 equal intervals Scores of 71-100 represent a mild to little/no difficulty Scores of 31-70 represent manifest to marked difficulty Scores of 1-30 represent severe degrees of difficulty Score of 0 represents insufficient information.
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Domain Components Defined

Self-care
Bathing/Showering Washing hair Brushing teeth Changing clothes Taking medication Eating

Personal & social relationships

Partner, family and/or friends Support system outside of treatment

Socially useful activities

Work or school Household chores Volunteer work or group activities

Disturbing and aggressive behavior

Speaking too loudly, cursing, verbal threats Breaking or throwing objects, fighting Making threats to harm self or others
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Scoring Table
Absent a) Self-care b) Socially useful activities, including work and study Mild Manifest Marked Severe Very Severe

c) Personal and social relationships

d) Disturbing and aggressive behaviors Self-care: Bathing, changing clothes, brushing teeth, washing hair, eating Socially useful activities: includes work or school, attending a treatment program Personal and social relationships: Getting along with others, isolative behaviors Disturbing and aggressive behaviors: Easily irritated or angered, inappropriate behavior, verbal arguments, cursing, threatening physical harm to others, throwing objects, intentionally breaking things, punching walls or furniture, physical fights, 52 physical harm to self or others

Scoring Guide for the PSP

Absent Mild Manifest Marked Severe Very Severe
3 OF 3
100-81

1 OR MORE
80-71

1 OR MORE
70-61

DOMAINS a,b,c

ONLY 1 OF 3 IS MARKED
60-51

2 OF 3 MARKED OR 1 SEVERE AND 0 MARKED

50-41

50-41

50-41

1 OF 2
40-31

1
40-31

2 OF 3
30-21

3 OF 3
20-11

10-6

3 OF 3

5-1

NO

OR
60-51

NO
50-41

OR
20-11

DOMAIN d

80-71

AND
100-81

OR
70-61

OR
50-41

OR
40-31

OR
30-21 10-6 5-1

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Conclusion
Assessment of function is very important for patients, carers, clinicians & commissioners. Functional Assessment Scales (FASs) are useful tools. Interpretation of patients performance has to consider baseline level & socio-cultural factors. Adaptation & validation of FASs for use in atrisk & early psychosis populations is needed.
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Thank You

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It is now time for food Enjoy your meal

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