Schizophrenia as destitute beggars or to asylums2. Philip pineal

Schizophrenia
Is a clinical syndrome of variable, but profoundly disruptive psychopathology
that involves cognition, emotion, perception, and other aspect of behavior.  It is commonly known as ‘functional psychosis’1.
It is a chronic illness which affects the patient and the family in all
functionalities. It impairs quality of life such as employment, marriage, and
parenthood etc.

Symptoms
of schizophrenia have considered to be existed for existed for centuries.
Individuals have exhibited now described grandeur and paranoia as per the Greek
and Babylonian history. It might have been considered as evil spirits, sages,
witches, and such peoples were left as destitute beggars or to asylums2.
Philip pineal was a pioneer in field of psychiatry who dismissed the theory
that the mental illness happens because of demonic possession or a punishment
from God. Instead he theorized that mental illness was a result of extreme
exposure to social and psychological stresses, heredity and physiological
damage3.

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In
1878 Emil Kraepelin suggested the term ‘Dementia praecox’4  progressive intellectual deterioration  (dementia) of early onset (praecox), which is
now known as schizophrenia . He described four type of schizophrenia . 1)
Simple, marked by a slow social decline couple with apathy, 2) Paranoid, marked
by fear and persecutory delusions, 3) Hebephrenic, where the patient may
act  or bizarre with disorganized speech
and behavior , and 4) Catatonic , marked by poverty of movement , waxy
flexibility and fear with possible verbigeration ( obsessive repetition of
meaningless words and phrases ), echolalia and which means “splitting of the
mind”. He proposed the fundamental symptoms of the illness as 4A’s, which is
loosening of associations, affiancing , autism , and ambivalence5 .
A German psychiatrist Kurt Schneider grouped the symptoms as first rank
symptoms which are thought insertion, thought withdrawal, thought broadcasting
, voices commenting , discussing or arguing , auditable thought, made will, act
, and affect , somatic passivity or a delusional perception.

Psychosocial Problems:

Mental
illness may cause a variety of psychosocial problems such as decrease quality
of life for the patient’s family members, as well as increased social distance
for the patient and family caring for the patient. The family members who care for
the relatives with mental illness report felling stigmatized a result of their
associated with the mentally ill6.

Person
with serious mental illness often engage in behaviors that are frightening,
troublesome, disruptive, or at annoying , and many relatives are obliged to
control, manage , or tolerate these behavior 7. Thus, psychiatric
professionals often view the family members of patient and they can act as co-therapists
at home 8. The family members need to be in an optimal social and
psychological state. It is report that reduced function of one family member
contributes to the Burdon of other members and this in turn leads to other
family members assuming a critical attitude lead to the other family members
assuming a critical attitude toward the patient 9. Such criticism
can in some cases lead to a relapse to the patient’s illness or to the family
feeling overviwhelmed by the patient’s descriptive behavior. 6,10

Social
support is important for the wellbeing of the family affected mental illness. A
research finding rivals that families should assume major roles in supporting
relatives with mental illness; and collaborative plans should include
strategies to assist family members and consumers in dealing with stigma11.
There is a relationship between caregivers’ social support and stigma
associated with relative with mental illness. For example, in a study
investigating the in between stigma, depressive symptoms and coping amongst
caregivers, it was found that stigma may erode the morale of family caregiver
and result in withdrawal from potential supporters 12.

Family coping and adaption:

Coping
differs from one family to another for a variety of reason. In developing countries,
some researchers have emphasized coping as a key concept for the study of adaption
and mental health 13,14. However, the effects of age, duration
illness, living arrangements and other contextual factor on the  coping  style
of family caregiver, and on the recovery or rehabilitation of persons with
mental illness are important factor to be considers 14.

In
this case, family caregivers have to learn and understand the patient’s characteristics
and behavior. Coping with symptoms such as delusion, hallucination,
inappropriate behaviors, and violence may often require lengthy, complex, and
distressing negotiations. Over-Burdon caregivers imply less affective coping
strategies, report more frequent physical and mental health problems and use
services more often15.

Need for the study:

Schizophrenia
is a chronic psychiatric condition where hospitalization & relapse happens
often. More over the lack of knowledge among caregivers may directly or
indirectly determines the attitude of caregivers towards the patient. Also,
expressed emotion can be seen in most of the families of female diagnosed with
schizophrenia.  Keeping this in mind, the
current study try to explore how the psycho-social intervention  can increase the knowledge and further reduce
the expressed emotion among family members. Such intervention may help to
achieve a good compliance  as well as
reduce hospitalization.  Also , very few
studies have been done in the Indian setting and this would apparently through
light into it.

REVIEW AND LITERAURE

Barrowclough
et al.,16  conducted a study
that compared the effectiveness of family therapy in reducing expressed emotion
level of the families and changing their critical and negatives attitude toward
patient . The family therapy  session
were conducted at home and psycho education for schizophrenia; problem solving
skills and communication skills were given to the families and their patient.
The result of this demonstrated that the patient who did not participate in
family therapy session had much higher relapse rates than the patients who
participated in the program in the 9 and 24 months follow-up  periods. The families improved at problem
solving skills and coping strategies after the intervention program and
reported that their subjective burden was reduced.

A
study was done by king17, on Expressed emotion, family dynamics and severity
in a predictive model of social adjustment  for schizophrenia young adults . Sixty-nine
schizophrenic outpatient and 108 of their relatives participated. Relatives EE
was assessed and they were administered FACES III for perception of family
cohesion and adaptability.  Patient  as well as the relatives were interviewed at
the same time and after 9 months with Social Adjustment scale (SAS-II) and
BPRS. It was found that batter social adjustment in patients associated with
less family adaptability, and with greater emotional over involvement in
relatives. Adjustment of patient in the work role is more associated with high critical
comment from mothers. The study concluded with less aspect that high expressed
emotion is associated with batter social adjustment in schizophrenic patients.

Mino
and colleague18 54 patient and their families were included. The
study used a 9 months follow up after discharge and had two groups; the psycho
education group and the control group. The overall findings of the study found low
expressed emotion in psycho education group with less relapse rate was in the
psycho education group (30%) as compare to the control group (58.1%).

Rahmani
et al.,19 an interview study on the effects of group psycho
education program me on attitude toward mental illness in families of patients
with schizophrenia , with 74 families at university of medical science , Iran.
The randomly selected experimental group revived 8 continuous 90 minute 3 times
in a week psycho educational session . The result shows a significant
difference in the attitude towards mental illness before and before and after
psycho education .

Amira
alshowkan et al.,20 conduct a study on the quality of life for
people with schizophrenia, consists of 130 studies based on the literature
review of studies investigating  the
socio-result were educational and the quality of life people with schizophrenia
.  

AIM

Psychosocial
management of female living with schizophrenia and their family members.

OBJECTIVES

1)      To
improve the social support of female living with schizophrenia.

2)      To
reduce the level of express emotion of female living with schizophrenia .

 

MATERIAL
AND METHOD

STUDY
DESIGN

This
Study was hospital based experimental design without control, carried out of inpatient
department of institute of Mental health IMH, PT. B D Sharma, University of
health science of Rohtak.

The
sample will be selected  from the patient
attending psychiatry indoor services from department of psychiatry of IMH.  Thirty consecutive consenting  female patients living with schizophrenia admitted
in the hospital and meeting study criteria would be selected for the study.

All
consecutive consenting  patient meeting
the criteria for inclusion would be included in the study.  Aim to explore the psychosocial management of
social support and express emotion of the patients .

Study
sample

Selection
of sample was made on the basis of systematic random sampling technique, it was
two stage sampling. First the patients were selected through systematic
sampling, and secondly their caregivers were identified for the intervention.
30 patients fulfilling the inclusion and exclusion criteria of the study were
selected, their caregiver were approached for the consent.

 

 INCLUSION AND EXCULSION CERTERIA

Inclusion
Criteria for patients

1.      Patients
diagnosed with schizophrenia as per ICD 10 Diagnostic criteria for research.

2.     
Female

3.      Age
between 25-45 years.

 

Exclusion
criteria for patient

1.      Patient
who have history of mental Retardation.

2.      Substance  dependence.

Inclusion
criteria for the Caregiver

1)      Caregivers
who have are staying with patient from at least 6 months.

2)       Age group 18-60.

3)      Care
givers who are qualify primary education.

4)      Caregiver
who gave consent for the caregiver for the study.

Exclusion
criteria for the caregiver

1)      Caregiver
who  have score 3 or more score in
GHQ-12.

2)      Evidence
that the caregiver have any organic impairment .

 

 TOOLS                                                                                         

1.      Socio-demographic
and clinical profile data sheet. (Appendix II)

2.      General
health questioner-12.(Appendix III)

3.      Family
attitude questioner.(Appendix IV)

4.      Social
support questioner. (Appendix V)

 

1)                 
Socio demographic and clinical data
sheet

A
specially designed Performa for collecting information about socio-demographic
and clinical variables for the study sample will be prepared for the study.

2)                 
General Health Questionnire-12

The
GHQ-12 questionnaire is a well – validated instrument for the identification
and measurement of non-psychotic psychiatric disorder in community and medical
setting. The self –reported GHQ-12 consists of 12 question, each with a choice of
four response: ‘batter than usual’ or ‘same as usual’ are both scored as ‘0’,
whereas ‘less than usual’ or ‘much less than usual’ are scored as ‘1’. Using
the GHQ scoring method there is a maximum total score of 12 and a cut-off threshold
of 3 analyzed as a binary ‘yes/no’ outcome. A total score of 3 or grater has
been reported as being indicative of a psychiatric disorder.

3)                 
Family Attitude questionnaire:

The
scale developed by sheti et al., is used to assess Express Emotion (measurement
of the attitude of key-relatives toward their patient). This consists of 30
question relating to number of critical comments, hostility, dissatisfaction, and
warmth and emotional over involvement  by
a key relative toward the patient. The psychometric property of this
questionnaire is satisfactory. The questions are arranged as per the attitude
of family (positive/negative) with a 3 point scale of 2 (yes), I(indefinite), 0
(no). The score are then totaled for each answer sheet and assigned into
categories.

 

4)                 
social support questionnaire:

Social
support questionnaire (SSQ)11 is a quantitative, psychometrically
sound survey questionnaire intended to measure social support and satisfaction
with said social support from the perspective of the interviewee. Degree of
social support has been shown to influence the onset and course of certain
psychiatric disorder such as clinical depression or schizophrenia. The SSQ was
approved for public release in 1981 by Irwin sarason, Henry Levine, Robert
basham and Barbara Sarason under the University of  Washington Department of Psychology and consists
of 27 questions. Overall, the SSQ has good test-retest reliability and
convergent internal construct validity.

 

Procedure

After
getting the approval from the PG Board of department, study will be conducted
on total of 30 patients diagnosed with schizophrenia. They will be explained
the objectives of present study and a written consent will be taken from them.
Those patient match in inclusion area the scale apply  them . 
The scale are socio-demographic profiles will be recorded using the
Performa.

Further
tool of General health questionnaire for identification and measurement
fitness of caregiver. Tool for assess the express emotion Attitude
questionnaire . Tool assess for social support use social support
questionnaire.

Statically
Analysis

Appropriate
statically analysis will be done.

Reference

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