Koenig M, Castillo M-C, Urdapilleta I, Le Borgne P, Bouleau J-H
Laboratoire de psychopathologie et de neuropsychologie (EA 027), université Paris-8, 2, rue de La Liberté, 93526 Saint-Denis cedex, France.
Encephale. 2011 Jun;37(3):207-16. doi: 10.1016/j.encep.2010.06.002. Epub 2010 Aug 14.
The question of the course of schizophrenia relapses, is of considerable interest in different clinical and social areas such as prognosis, quality of life, therapeutic relationship, psychoeducation, rehabilitation and so on. The more the schizophrenic relapses, the higher the level of handicap. Although there is a widespread agreement that it is essential to detect early signs of relapses in order to prevent them, there still remain theoretical and methodological difficulties in identifying these signs because they are personal, heterogeneous and not always specific to psychosis. That is why the notion of "relapse signature" seems relevant by taking into account differentiated and personal assessment of early signs of relapse. This implies the consideration of the different visions of relapse given by patients, parents and caregivers.
We propose a qualitative study of the joint appraisal of patients, patients' parents and medical staff. The aim of this study is to regroup the expertises in order to further our understanding of the early signs of relapse. We assume that patients and parents are able to describe signs that are not considered as pathological symptoms, but refer to a personal manner of initiating the relapse process. This should then help in designing early intervention and provide reinforced therapeutic alliance and more positive responses to psychoeducation programs.
We have interviewed 30 subjects divided in three groups: 10 schizophrenic patients, 10 caregivers (including physicians, psychologists and nurses) and 10 parents of schizophrenics. The patients met the following criteria: patients with a diagnosis of schizophrenia (DSM IV criteria), under neuroleptic treatment, and stabilized. The mean duration of illness was 15 years. The patients as well as caregivers were recruited in two external hospital structures. All the subjects gave their written consent for this study and its methods. We did not recruit parents who were not living with their schizophrenic child or who did not see or have frequent contact with him or her for this study. We conducted a semistructured interview and analysed the transcripts of the narratives provided by our three groups on the definition of relapse and early signs of relapse. Recorded interviews were processed using the Alceste Method, a computer program of textual analysis that identifies the word patterns most frequently used by the subjects. Alceste creates classes of words using a hierarchical descending classification. The description of each class is presented in the form of a word list (with the value of the word's Chi(2) association in this class). We assessed the awareness of problems using the 8-Q.
The three groups described relapses as a distressed, even traumatic experience. This experience is shared by the patients' siblings who sometimes mention violent situations and difficulties at home. The analysis showed that each group uses a compartmentalized universe of speech. This raises the question of the communication and the sharing of information between the different groups. Parents who didn't live the relapse of their children and the caregivers gave prepsychotic or psychotic symptoms of relapse. Conversely, parents who had lived relapse(s) of their children gave nonspecific and very personalized signs of relapse (e.g., "When she relapses, our daughter eats much more cheese than usually"). The patients with a low level of awareness of his/her problem were able to describe early signs of relapse. They described mood and sleep disturbances. This is an unexpected result and calls for a debate on the need or not to have good insight in order to follow a psychoeducation program.
This study insists on the complementarity of different conceptions of all persons involved in schizophrenic relapse in order to identify as accurately as possible the "relapse signature" of patients. According to us, and in order to promote suitable subjective data to increase insight, compliance and therapeutic alliance, psychoeducation programs should rely on these personal criteria rather than propose systematic programs. Then the relapse signature could be the first step to the appropriation of the course of illness and control of psychotic symptoms by schizophrenic patients.
精神分裂症复发的病程问题在不同的临床和社会领域备受关注，如预后、生活质量、治疗关系、心理教育、康复等。精神分裂症复发次数越多，残疾程度越高。尽管人们普遍认为，为预防复发而尽早发现复发迹象至关重要，但识别这些迹象仍存在理论和方法上的困难，因为它们因人而异、各不相同，且并非总是精神疾病所特有的。这就是为什么“复发特征”这一概念似乎具有相关性，因为它考虑到了对复发早期迹象的差异化和个性化评估。这意味着要考虑患者、父母和护理人员对复发的不同看法。
我们提议对患者、患者父母和医护人员的联合评估进行定性研究。本研究的目的是整合专业知识，以加深我们对复发早期迹象的理解。我们假设患者和父母能够描述那些不被视为病理症状，但涉及复发过程起始的个人方式的迹象。这进而应有助于设计早期干预措施，并加强治疗联盟，以及对心理教育项目做出更积极的反应。
我们采访了30名受试者，分为三组：10名精神分裂症患者、10名护理人员（包括医生、心理学家和护士）以及10名精神分裂症患者的父母。患者符合以下标准：诊断为精神分裂症（DSM-IV标准），正在接受抗精神病药物治疗且病情稳定。平均病程为15年。患者和护理人员是在两家外部医院机构招募的。所有受试者均书面同意参与本研究及其方法。我们没有招募那些不与精神分裂症子女同住、或不看望或不经常与子女接触的父母参与本研究。我们进行了半结构化访谈，并分析了三组关于复发定义和复发早期迹象的叙述记录。对录制的访谈使用阿尔塞斯特方法进行处理，这是一个文本分析计算机程序，可识别受试者最常用的词型。阿尔塞斯特使用层次递减分类法创建词类。每个类别的描述以词表形式呈现（并列出该类中词的卡方关联值）。我们使用8-Q评估对问题的认知。
三组均将复发描述为一种痛苦甚至创伤性的经历。患者的兄弟姐妹也有这种经历，他们有时会提及家中的暴力情况和困难。分析表明，每组都使用一个划分开来的话语范畴。这就引发了不同组之间信息交流和共享的问题。未经历过子女复发的父母和护理人员给出了精神病发作前或精神病性的复发症状。相反，经历过子女复发的父母给出了非特异性且非常个性化的复发迹象（例如，“我们女儿复发时，吃的奶酪比平时多得多”）。对自身问题认知水平较低的患者能够描述复发的早期迹象。他们描述了情绪和睡眠障碍。这是一个意想不到的结果，引发了关于是否需要良好洞察力才能参与心理教育项目的讨论。
本研究强调参与精神分裂症复发的所有人员的不同观念的互补性，以便尽可能准确地识别患者的“复发特征”。我们认为，为了促进合适的主观数据以提高洞察力、依从性和治疗联盟，心理教育项目应依赖这些个人标准，而不是提出系统性的项目。那么，复发特征可能是精神分裂症患者了解疾病病程并控制精神病症状的第一步。
