Effective treatment of schizophrenia requires a patient-centered approach

Recognition of how people with schizophrenia interact and cope with their experiences is necessary for effective treatment, said Giovanni Stanghellini, Professor of Dynamic Psychology and Psychopathology, Chieti University, Italy in a lively, thought-stimulating workshop at EPA 2018.

Recovery requires not only the reduction of acute symptoms but also a change in the individual’s attitude with respect to his or her basic abnormal phenomena, explained Professor Stanghellini.

At-risk mental states signal a risk of imminent psychosis

At-risk mental states describes a variable set of clinical presentations carrying a heightened risk for developing more severe psychopathology, particularly within the psychotic spectrum, said Andrea Raballo, Associate Professor of Psychopathology and Development, Trondheim, Norway. They are typically accompanied by a profound modification of the subjective experience. For example, a patient might be unable to drive a car.

Examples of such experiences are described by patients as “as if parts of my brain awoke,” “my senses were sharpened,” “I became fascinated by little, insignificant things.” These drive a self-generating circuit of “deep meaning.” Subjectivity is the core.

Psychiatrists treat disease, but patients want their illness treated

Patients with schizophrenia present with an illness when the disease affects their social and personal function, said Dinesh Bhugra, Professor of Mental Health and Cultural Diversity, King’s College, London. Psychiatrists treat disease, but patients want their illness treated so they can function at work, home and socially.

The unconscious mind of patients is interpreted through sociocultural influences

Professor Bhugra emphasized the need to work with patients empathically, and explained how the unconscious mind of patients is interpreted through sociocultural influences. In this way, a disease is converted into a patient-centered illness. The sociocultural construction creates the illness experience and impacts symptoms and healing.

The message from all speakers at the workshop was that it is more important to consider an individual’s experience of their illness rather than focus on their behavior, said Professor Stanghellini.

Otto Doerr-Zegers, Professor of Psychiatry, University of Chile, Chile, clarified this distinction using auditory hallucinations as an example: the symptom is “hearing voices;” the experience is “being spoken to.”

The focus should shift from the experiential to how the patient makes sense of his or her experiences

An abnormal self-presence, an impaired perspective in which thoughts become objects, and phenomenality characterized by constant introspection and ”living in the head,” are the domains of abnormal self-experience, said Professor Stanghellini.

The focus for psychiatrists should then be to shift from the experiential to how the patient makes sense of his or her experiences, he said. That is, the meaning they give to them and how they respond to them. The schizophrenic phenotype results from the experience plus the individual’s understanding or interpretation of the experience.

The person-centered dialectical model of schizophrenia provides a framework for understanding many phenotypes

Recognizing subtle differences in the patient’s experience enables a more effective differential diagnosis

The person-centered dialectical (PCD) model of schizophrenia adds ”personhood” to the notion of “selfhood.” Personhood is more comprehensive than selfhood, said Professor Stanghellini. Selfhood is the basic vulnerability and disordered self.

Personhood makes sense of the experience and depends on an individual’s emotional tone and interpretation of the experience:

  • emotional tones include detachment, apathy, anxiety, depression, dysphoria, despair, and exultation;
  • interpretation of the experience is influenced by education, values and beliefs, and may be nonexistent or rudimentary, real-life based (e.g., “I’ve been poisoned”) or metaphysical.

The principal clinical implication of the PCD is the development of a two-tier descriptive system that includes phenomenal assessment of disordered selfhood and appraisal of personal background. Recognition of these subtle differences in the patient’s experience enables a more effective differential diagnosis, said Professor Stanghellini.

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