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February 02 2015

Article Review: Schizophrenia and Personality Disordered Patients’ Adherence to Music Therapy (Hannibal, N., et al., 2012)

Author Susan Vaught Categories Continuing Education, Current Interns, Mental Health and Wellness, Resources for Interns 0 Comments

 

 

Introduction
The researchers believe that music therapy can be used to effectively treat schizophrenia, depression, and personality disorders. When utilizing both a psychodynamic and relational approach to treatment, music therapy can be used to create the necessary conditions for psychological change and support. The techniques used are both active and receptive: 1) active techniques include making music and/or musical improvisation, such as musical composition (e.g., song writing) or musical performance; 2) receptive techniques include listening and responding to music.

 

Music therapy is the most common treatment modality for schizophrenia and personality disorders in Denmark. Music therapy has been demonstrated to improve global assessment of functioning, depression, anxiety, and symptoms of psychosis. Improvements can be seen within 12 sessions; however, large effect sizes can be seen after 16-51 sessions.  In this study, the researchers investigated treatment adherence for music therapy for both treatment groups (schizophrenia and personality disorders).  They were examining two components: 1) general treatment adherence between the two groups; and, 2) factors that could predict treatment adherence. Treatment adherence was defined as staying in treatment during the length of time that was agreed upon. Rates of dropout / discontinuation was used to assess lack of treatment adherence.

 

Materials and Methods
The researcher examined medical records of 27 patients that began music therapy treatment in 2005-2006 across three psychiatric centers in Denmark in this one year follow up study. The following data was collected: demographic variables, psychiatric variables, and therapeutic variables (e.g., prior therapeutic experiences, concurrent therapeutic experiences, etc.). Of the 27 participants, 10 were diagnosed with Schizophrenia and 17 with a Personality Disorder. Of the 27 participants, 12 were male and 15 were female. Participant ages ranged from 19-59; the mean age was 30. Of the 27 participants, 22 were receiving medication at onset of  the study; by the conclusion of the study, 24 were receiving medication. 20 of the participants received group music therapy sessions, while 7 received individual sessions. The majority (24/27) of the participants received music therapy in an outpatient setting.

 

Results
Of the 27 total participants, only three dropped out. Participants in the Schizophrenia category had a 90 % adherence rate; those in the Personality Disorder category had an 87 % adherence rate. The average number of sessions was 18.  The researchers were unable to determine any identifying predictors for adherence (e.g., diagnosis, sex, age, etc.).

 

Discussion
This study was a naturalistic follow up study examining the adherence rates for music treatment of participants diagnosed with Schizophrenia and participants diagnosed with a Personality Disorder. The findings yielded from this research suggest that patients with Schizophrenia and Personality Disorders can adhere to music therapy treatment. This finding is a contrast from previous research, which indicated that similar patient populations had a low treatment adherence rate when in a music therapy group. The researchers cite the development of a therapeutic alliance between client and clinician as a process that is integral to a successful treatment outcome. Based on the results from the present study, it can be inferred that it is possible to build a strong therapeutic alliance despite severity of illness (as the participants in the current study had severe psychotic and non-psychotic issues).

 

A limitation of the current study is the low sample size (N = 27). Due to a dropout rate of only three, it is difficult to draw inferences based on demographic, diagnostic, or therapeutic variables. Further, the researchers did not provide data regarding demographic data for those that dropped out, data regarding comorbidity amongst the participants, or data regarding what type of personality disorder a participant had been diagnosed with. Regardless, the present study demonstrates that patients with a primary diagnosis of either Schizophrenia or a Personality Disorder can adhere to music therapy, and it should be viewed as a viable treatment modality for these populations. This can lead the way for further research studies in which a larger number of patients with Schizophrenia and/or Personality Disorders can be assessed.

 

Hannibal, N., Pedersen, I., Hestb, T., Rensen, T., and Rgensen, P.  (2012).  Schizophrenia and personality disorder patients’ adherence to music therapy. Nord J Psychiatry, 66, p. 376-379.

 

Faisal Roberts, MA
WKPIC Doctoral Intern

 

 

 

April 04 2014

Article Summary of Risk Factors for Violence in Psychosis: Systematic Review and Meta-Regression Analysis of 110 Studies

Author Susan Vaught Categories Blog, Continuing Education, Current Interns, General Information, Resources for Interns, Uncategorized 0 Comments

 

 

Witt, van Dorn, and Fazel (2013) noted many inconsistencies and varying emphases in the current literature on the association of violence and psychosis. This led the researchers to perform a meta-analyses of the current literature base, essentially combining all current studies on violence risk and psychosis into one helpful summary. The authors noted this task is important to the field for several reasons. First, combining and analyzing this information would hopefully help to develop evidence-based approaches to risk assessment. Next, this information can help focus treatment with relevant populations to the most pertinent risk factors, while simultaneously enhancing protective factors. Finally, consolidating this information can help clinicians and researchers better understand why certain individuals with psychosis have a higher risk of violence.

 

Six major databases were searched from their inception until December 2011. For some databases, this meant going back as far as 1960. Non-English articles were translated by qualified post-graduate students. For inclusion, diagnoses had to be assigned based on Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria, and more than 95% of study participants were aged 18 or older and diagnosed with either schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, schizotypal disorder, psychosis not otherwise specified, and bipolar disorder. It is important to note that psychoses as the result of medical conditions, substance intoxication, or substance withdrawal were excluded from the collected data. Studies were excluded if the focus was on genetic or epigenetic associations with violence, childhood violence, or offender populations. Furthermore, items were only included in the data collection process if the risk factor was included in three or more separate studies, which helped improve the validity of risk estimates. Risk factors were separated by time in that “recent” factors were those that occurred within the past year from the time of the original study, while “history of” factors were those that occurred at some point in the past, more than one year from the time of the original study. Data collected from each study may have been reported in different measurements; therefore, all collected data was converted to an odds ratio (ORs). For each factor identified, ORs, 95% confidence intervals, number of studies, the z score, number of violent participants, and total number of participants were reported.

 

A total of 110 studies that included 73 independent samples met inclusion criteria. This equated to a large number of participants (n=45,533) of whom 18.5% (8,439) were reported to be violent. Just over 85% of participants were diagnosed with schizophrenia, just under 12% were diagnosed with other psychoses, and 0.4% were diagnosed with bipolar disorder. The age of participants ranged from 21.1 to 54.3 years, with the average age of 35.8 years. The data included studies conducted in 27 countries.

 

Overall, the strongest domains associated with violence include the criminal history, substance misuse, demographic, and premorbid factors. When analysis was restricted to inpatient samples, the substance misuse domain was significantly associated with violence, but less so compared to the findings in the overall analysis. Additionally, analysis restricted to inpatient samples found the psychopathology and positive symptom domains were more strongly associated with violence, while the negative symptom, neuropsychological, demographic, premorbid, suicidality, and treatment-related domains were not significantly associated with risk of violence when compared to the overall analysis. The finding of differences in factors associated with violence among inpatient samples versus community samples could lend itself to the field developing different violence risk assessment approaches depending on whether the individual is in inpatient or outpatient treatment currently. A rather interesting finding was the association of previous suicide attempts with violence, especially considering most current and commonly used violence risk assessments do not usually include assessment of suicide. The authors speculate that history of previous suicide attempts was associated with violence, while experiencing suicidal ideation was not, because impulsivity may be a contributing factor to violence toward self and violence toward others. The authors close by identifying the most important factors to attend to during violence risk assessments: hostile behavior, poor impulse control, lack of insight, general symptom scores, recent alcohol and/or drug misuse, psychotherapy non-compliance, and medication non-compliance.

 

The major findings are described below in outline format for easy reference.

  • Demographic Factors
    • Strongly associated with violence:
      • History of being violently victimized
    • Moderately associated with violence:
      • Recent homelessness or history of homelessness
      • Male
    • Weakly associated with violence:
      • Member of ethnic minorities
      • Currently having a lower socioeconomic status
    • NOT significantly associated with violence:
      • Received no more than a primary school education
      • Received no more than a high school education
      • Lower family socioeconomic status during childhood
      • Shorter duration of education in years
      • Lacking any formal education qualifications
      • Currently living in an urban environment
      • Currently living alone
      • Unmarried
      • Widowed or divorced
      • Currently unemployed
      • Having children
      • Younger age at study enrollment in years
  • Premorbid Factors
    • Moderately associated with violence:
      • History of childhood physical or sexual abuse
      • Parental history of criminal involvement
      • Parental history of alcohol misuse
    • NOT significantly associated with violence:
      • Experienced the death of one parent during childhood
      • Experienced divorce or separation of parents during childhood
      • Raised by a single parent
  • Criminal History Factors
    • Significantly associated with violence:
      • History of assault
      • History of imprisonment for any offense
      • Recent arrest or history of arrest for any offense
      • History of conviction for a violent offense
      • History of violent behavior
      • Hostility during the study period
  • Psychopathological Factors
    • Strongly associated with violence:
      • Lack of insight
      • Poor impulse control
    • Moderately associated with violence:
      • Diagnosis of comorbid antisocial personality disorder
      • Higher total Positive and Negative Symptom Scale (PANSS) scores
    • NOT significantly associated with violence:
      • Diagnosed with bipolar disorder
      • Diagnosed with any subtype of schizophrenia
      • Diagnosed with schizoaffective disorder
      • Diagnosed with psychotic disorder not otherwise specified
      • Younger age of onset in years
  • Positive Symptom Factors
    • Associated with violence:
      • Higher positive symptom scores
    • NOT significantly associated with violence:
      • Experienced paranoid thoughts
      • Experienced delusions of any type
      • Experienced auditory hallucinations, including command auditory hallucinations
      • Acutely symptomatic
  • Negative Symptom Factors
    • NOT significantly associated with violence:
      • Higher poor attention span scores
      • Diagnosed with comorbid depression
  • Neuropsychological Factors
    • NOT significantly associated with violence:
      • Lower Full Scale IQ scores on the Wechsler Adult Intelligence Scale (WAIS)
      • Lower Performance IQ scores on the WAIS
      • Lower Verbal IQ scores on the WAIS
      • Lower scores on the Picture Completion subtest of the WAIS
      • Lower total scores on the National Adult Reading Test (NART)
      • Higher perseverative errors on the Wisconsin Card Sorting Test
  • Substance Misuse Factors
    • Strongly associated with violence:
      • History of polysubstance misuse
      • Diagnosis of comorbid substance use disorder
      • Recent substance misuse
    • Moderately associated with violence:
      • Recent or history of alcohol misuse
      • History of substance misuse
      • Recent or history of drug misuse
  • Treatment-Related Factors
    • Strongly associated with violence:
      • Psychotherapy treatment non-compliance
    • Moderately associated with violence:
      • Medication non-compliance
    • NOT significantly associated with violence:
      • Not having a prescription of antipsychotic medication of any type
      • Higher antipsychotic dosage
      • Shorter duration of antipsychotic treatment in months
      • Shorter duration of current inpatient admission in months
      • Shorter duration of current outpatient treatment in months
      • Younger age at first psychiatric inpatient admission in years
      • Greater number of previous psychiatric admissions
      • Longer duration of untreated illness in years
  • Suicide Factors
    • Moderately associated with violence:
      • History of previous suicide attempts
    • NOT significantly associated with violence:
      • History of experiencing suicidal ideation
      • History of self-harm

Witt, K., van Dorn, R., & Fazel, S. (2013). Risk factors for violence in psychosis: Systematic review and meta-regression analysis of 110 studies. PLOS One, 8(2), 1-15.

 

Danielle M. McNeill, M.S., M.A.
Doctoral Intern

 

 

February 02 2013

Virtual Realty and Schizophrena: A New Twist on Social Skills Training

Author Susan Vaught Categories Uncategorized

 

 

Social skills training is commonly used when treating an individual diagnosed with schizophrenia. However, there are disadvantages to using traditional social skills approach, particularly related to the individual’s motivation. Technology is increasingly used in the treatment of mental disorders. Studies have found Virtual Reality (VR) to be effective in the treatment of some anxiety disorders. Since the early 2000s, researchers are exploring the idea of using similar VR technology in the assessment and treatment of schizophrenia. In the domain of social skills training, VR technology could potentially improve the participant’s motivation during training. Additionally, the participant no longer has to rely on his or her imagination during social skills training as participants interact with virtual avatars to practice skills.

 

Park et al. (2011) developed a study to compare social skills training using VR role-playing (SST-VR) to traditional social skills training role-playing (SST-TR). Participants were recruited from an adult psychiatric inpatient hospital in Korea after receiving stabilization treatment for two to four weeks. Participants were randomly assigned to either the SST-VR group (n=46) or the SST-TR group (n=45). Symptom severity was assessed before and after social skills training. Both groups received 10 semiweekly sessions over the course of five weeks. Of the 10 sessions, five sessions focused on conversation skills training, three focused on assertiveness skills training, and two focused on emotional expression skills training. Sessions were conducted as 90 minute group sessions consisting of four to five participants in the group. The only difference between the two groups was the modality of role-playing. In the SST-VR group, participants interacted with virtual avatars in a virtual environment, whereas in the SST-TR group, participants interacted with therapist actors. Voice quality, nonverbal skill, and conversational properties were the primary measures assessed during training. Self-report measures of motivation and interest in the training were also assessed.

 

Park et al. (2011) found that SST-VR participants had more interest in participating in the training and had a higher attendance rate compared to the SST-TR group. The researchers found that overall social skills improved regardless of training received. However, when considering the subcategories, SST-VR participants showed a greater improvement in the conversational skills domain, whereas the SST-TR participants showed a greater improvement in the vocal and nonverbal domains. The researchers hypothesized that modeling skills demonstrated by the therapist during traditional role-playing and difficulty providing accurate feedback during VR role-playing due to the VR equipment blocking the participants’ faces led to the discrepancy in scores in certain domains. It is also important to consider the participants’ perception of the role-playing task. Individuals in the SST-VR group reported feeling less anxious and more powerful than normal when interacting with virtual avatars, which is a significant advantage over traditional role-playing.

 

Park et al. (2011) concluded that VR role-playing is unable to completely replace traditional role-playing at this time but could in the future with advances in technology.

 

Park, K., Ku, J., Choi, S., Jang, H., Park, J., Kim, S. I., & Kim, J. (2011). A virtual reality application in role-plays of social skills training for schizophrenia: A randomized, controlled trial. Psychiatry Research, 189, 166-172.

 

Danielle McNeill, M.S., M.A.
WKPIC Doctoral Intern

 

 

 

 

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