Modern Approaches to the Treatment of Schizophrenia and Other Psychotic Disorders

Suvremeni pristupi liječenju psihotičnih poremećaja stavljaju naglasak na ishod bolesti (postizanje oporavka i najbolje moguće kvalitete života oboljelih). Smjernice za liječenje shizofrenije i drugih psihotičnih poremećaja važan su „alat“ koji psihijatrima, ali i drugim stručnjacima u području mentalnog zdravlja, omogućuju primjenu terapijskih postupaka temeljenih na znanstvenim i stručnim dokazima. Smjernice ne osiguravaju „univerzalni“ model liječenja bolesnika, već predstavljaju neobvezujuću stručnu preporuku. Pristup liječenju bolesnika prvenstveno mora biti individualiziran iz čega proizlazi da pojedini terapijski postupci neće u potpunosti moći slijediti dane preporuke smjernica. Uz brojne smjernice eminentnih stranih psihijatrijskih udruženja, instituta, organizacija i stručnjaka, u našoj državi raspolažemo i nacionalnim smjernicama koje se odnose na farmakološko i psihosocijalno liječenje odraslih bolesnika sa psihotičnim poremećajima. Hrvatske smjernice za liječenje shizofrenije i drugih psihotičnih poremećaja donose preporuke farmakološkog liječenja bolesnika i obuhvaćaju područja: stanja klinički visokog rizika i prodromalne faze psihotičnog poremećaja, akutna faza – prva/ponovljena psihotična epizoda, farmakoterapija, relaps nakon prve epizode shizofrenije i drugih psihotičnih poremećaja, faza stabilizacije, faza održavanja – faza sprječavanja relapsa, terapijska rezistencija i liječenje shizofrenije i drugih psihotičnih poremećaja tijekom planiranja trudnoće, u trudnoći i dojenju. Smjernice za psihosocijalne postupke – psihički poremećaji sa psihozom i shizofrenija – odnose se na psihosocijalne metode liječenja i obuhvaćaju područja nespecifičnih i specifičnih psihosocijalnih postupaka i principa te izbora terapijske sredine i organizacije liječenja.Modern approaches to the treatment of psychotic disorders aim for the most favourable outcome of the disease (achieving recovery and the best possible quality of life for patients). Guidelines for the treatment of schizophrenia and other psychotic disorders are an important “tool” that enable psychiatrists, as well as other experts in the field of mental health, to apply therapeutic procedures based on scientific and professional evidence. The guidelines do not provide a “universal” model of patient treatment but are rather a non-binding professional recommendation. The approach to patient treatment must primarily be individualized, and consequently certain therapeutic procedures will not fully follow the recommended guidelines. In addition to numerous guidelines from renowned psychiatric associations, institutes, organizations, and experts, we also have national guidelines related to the pharmacological and psychosocial treatment of adult patients with psychotic disorders. The Croatian guidelines for the treatment of schizophrenia and other psychotic disorders provide recommendations for the pharmacological treatment of patients in the following areas: clinical high-risk and prodromal phases of a psychotic disorder, acute phase - first/repeated psychotic episode, pharmacotherapy, relapse after the first schizophrenic episode and other psychotic disorders, stabilization phase, maintenance phase – relapse prevention phase, therapeutic resistance and treatment of schizophrenia and other psychotic disorders during pregnancy planning, pregnancy itself, and breastfeeding. Guidelines for psychosocial procedures - mental disorders with psychosis and schizophrenia, refer to psychosocial methods of treatment and include non-specific and specific psychosocial procedures and principles, as well as the choice of therapeutic environment and organization of treatment

THE FIRST EPISODE SCHIZOPHRENIA: THE IMPORTANCE OF EARLY DETECTION OF ILLNESS WHAT DO SOCIAL WORKERS NEED TO KNOW

Shizofrenija je kronična duševna bolest, klinički sindrom karakteriziran specifičnim psihičkim i ponašajnim simptomima, značajnim individualnim varijacijama kliničke slike, odgovora na terapiju i tijeka bolesti te često prisutnim značajnim padom funkcionalnih kapaciteta bolesnika na svim planovima – osobnom, obiteljskom, radnom i socijalnom. Suvremeni koncepti sagledavanja shizofrenije kao neurodegenerativnog procesa impliciraju neophodnost razvoja specifičnih ranih intervencija usmjerenih na što raniju detekciju bolesti i provođenje adekvatnih i sveobuhvatnih farmakoloških, psihoterapijskih i psihosocijalnih terapijskih intervencija. Iz navedenog proizlazi i rastući interes struke za prodromalnu fazu bolesti i prvu epizodu shizofrenije pri čemu se naglasak stavlja na ishod bolesti (postizanje simptomatske i funkcionalne remisije i što bolji potpuni oporavak bolesnika). Ciljevi ranog otkrivanja psihotičnih poremećaja, uključujući i shizofreniju, i ranih intervencija su reducirati i/ili prevenirati progresiju i/ili pogoršanje psihotičnih simptoma/sindroma, neurobioloških i neuropatoloških oštećenja, sekundarnog psihijatrijskog i somatskog morbiditeta, deterioracije općeg funkcioniranja i razvojnih potencijala bolesnika, individualnog i obiteljskog stresnog iskustva, stigmatizacije bolesnika i njegove okoline, recidiva bolesti te reducirati troškove vezane uz liječenje i radnu nesposobnost oboljelog. Ovo složeno područje zahtijeva kontinuirano stručno i znanstveno multidisciplinarno istraživanje i djelovanje u čemu aktivnosti socijalnih radnika imaju značajnu ulogu, a s ciljem što učinkovitije redukcije neurotoksičnih, psihotoksičnih i sociotoksičnih posljedica shizofrenog procesa.Schizophrenia is mental disorder, clinical syndrome characterized by specific mental and behavioral symptoms, significant individual variations in clinical presentation, therapy response and course of disorder, with often present a significant decline in functional capacity of patients in all plans – personal, family, social and occupational. Modern concepts of schizophrenia as neurodegenerative process, imply the necessity of development of a specific early interventions aimed at the early detection of disease and implementation of adequate and comprehensive pharmacological, psychotherapeutic and psychosocial therapeutic interventions. Because of this increasing professional interest is oriented toward the prodromal phase and first episode of schizophrenia with the focus on disease outcome (achievement of symptomatic and functional remission and a better compete recovery) The aims of detection and diagnosis of first onset psychosis, including schizophrenia, are to reduce and/or prevent progression and/or worsening of symptom/syndrome; neurobiological changes and neuropathology; psychiatric and somatic comorbidity; deterioration of functioning and personal potentials; individual and family¨s experience of trauma; stigma; relapse of the disease; and to reduce costs to the community including inability for work. This complex field requires continuous multidisciplinary scientific and professional approach, in which the activities of social workers has a significant role, aimed at the effective reduction of neurotoxic, psychotoxic and sociotoxic consequences of schizophrenia

THE FIRST EPISODE SCHIZOPHRENIA: THE IMPORTANCE OF EARLY DETECTION OF ILLNESS WHAT DO SOCIAL WORKERS NEED TO KNOW

Shizofrenija je kronična duševna bolest, klinički sindrom karakteriziran specifičnim psihičkim i ponašajnim simptomima, značajnim individualnim varijacijama kliničke slike, odgovora na terapiju i tijeka bolesti te često prisutnim značajnim padom funkcionalnih kapaciteta bolesnika na svim planovima – osobnom, obiteljskom, radnom i socijalnom. Suvremeni koncepti sagledavanja shizofrenije kao neurodegenerativnog procesa impliciraju neophodnost razvoja specifičnih ranih intervencija usmjerenih na što raniju detekciju bolesti i provođenje adekvatnih i sveobuhvatnih farmakoloških, psihoterapijskih i psihosocijalnih terapijskih intervencija. Iz navedenog proizlazi i rastući interes struke za prodromalnu fazu bolesti i prvu epizodu shizofrenije pri čemu se naglasak stavlja na ishod bolesti (postizanje simptomatske i funkcionalne remisije i što bolji potpuni oporavak bolesnika). Ciljevi ranog otkrivanja psihotičnih poremećaja, uključujući i shizofreniju, i ranih intervencija su reducirati i/ili prevenirati progresiju i/ili pogoršanje psihotičnih simptoma/sindroma, neurobioloških i neuropatoloških oštećenja, sekundarnog psihijatrijskog i somatskog morbiditeta, deterioracije općeg funkcioniranja i razvojnih potencijala bolesnika, individualnog i obiteljskog stresnog iskustva, stigmatizacije bolesnika i njegove okoline, recidiva bolesti te reducirati troškove vezane uz liječenje i radnu nesposobnost oboljelog. Ovo složeno područje zahtijeva kontinuirano stručno i znanstveno multidisciplinarno istraživanje i djelovanje u čemu aktivnosti socijalnih radnika imaju značajnu ulogu, a s ciljem što učinkovitije redukcije neurotoksičnih, psihotoksičnih i sociotoksičnih posljedica shizofrenog procesa.Schizophrenia is mental disorder, clinical syndrome characterized by specific mental and behavioral symptoms, significant individual variations in clinical presentation, therapy response and course of disorder, with often present a significant decline in functional capacity of patients in all plans – personal, family, social and occupational. Modern concepts of schizophrenia as neurodegenerative process, imply the necessity of development of a specific early interventions aimed at the early detection of disease and implementation of adequate and comprehensive pharmacological, psychotherapeutic and psychosocial therapeutic interventions. Because of this increasing professional interest is oriented toward the prodromal phase and first episode of schizophrenia with the focus on disease outcome (achievement of symptomatic and functional remission and a better compete recovery) The aims of detection and diagnosis of first onset psychosis, including schizophrenia, are to reduce and/or prevent progression and/or worsening of symptom/syndrome; neurobiological changes and neuropathology; psychiatric and somatic comorbidity; deterioration of functioning and personal potentials; individual and family¨s experience of trauma; stigma; relapse of the disease; and to reduce costs to the community including inability for work. This complex field requires continuous multidisciplinary scientific and professional approach, in which the activities of social workers has a significant role, aimed at the effective reduction of neurotoxic, psychotoxic and sociotoxic consequences of schizophrenia

Modern Approaches to the Treatment of Schizophrenia and Other Psychotic Disorders

Suvremeni pristupi liječenju psihotičnih poremećaja stavljaju naglasak na ishod bolesti (postizanje oporavka i najbolje moguće kvalitete života oboljelih). Smjernice za liječenje shizofrenije i drugih psihotičnih poremećaja važan su „alat“ koji psihijatrima, ali i drugim stručnjacima u području mentalnog zdravlja, omogućuju primjenu terapijskih postupaka temeljenih na znanstvenim i stručnim dokazima. Smjernice ne osiguravaju „univerzalni“ model liječenja bolesnika, već predstavljaju neobvezujuću stručnu preporuku. Pristup liječenju bolesnika prvenstveno mora biti individualiziran iz čega proizlazi da pojedini terapijski postupci neće u potpunosti moći slijediti dane preporuke smjernica. Uz brojne smjernice eminentnih stranih psihijatrijskih udruženja, instituta, organizacija i stručnjaka, u našoj državi raspolažemo i nacionalnim smjernicama koje se odnose na farmakološko i psihosocijalno liječenje odraslih bolesnika sa psihotičnim poremećajima. Hrvatske smjernice za liječenje shizofrenije i drugih psihotičnih poremećaja donose preporuke farmakološkog liječenja bolesnika i obuhvaćaju područja: stanja klinički visokog rizika i prodromalne faze psihotičnog poremećaja, akutna faza – prva/ponovljena psihotična epizoda, farmakoterapija, relaps nakon prve epizode shizofrenije i drugih psihotičnih poremećaja, faza stabilizacije, faza održavanja – faza sprječavanja relapsa, terapijska rezistencija i liječenje shizofrenije i drugih psihotičnih poremećaja tijekom planiranja trudnoće, u trudnoći i dojenju. Smjernice za psihosocijalne postupke – psihički poremećaji sa psihozom i shizofrenija – odnose se na psihosocijalne metode liječenja i obuhvaćaju područja nespecifičnih i specifičnih psihosocijalnih postupaka i principa te izbora terapijske sredine i organizacije liječenja.Modern approaches to the treatment of psychotic disorders aim for the most favourable outcome of the disease (achieving recovery and the best possible quality of life for patients). Guidelines for the treatment of schizophrenia and other psychotic disorders are an important “tool” that enable psychiatrists, as well as other experts in the field of mental health, to apply therapeutic procedures based on scientific and professional evidence. The guidelines do not provide a “universal” model of patient treatment but are rather a non-binding professional recommendation. The approach to patient treatment must primarily be individualized, and consequently certain therapeutic procedures will not fully follow the recommended guidelines. In addition to numerous guidelines from renowned psychiatric associations, institutes, organizations, and experts, we also have national guidelines related to the pharmacological and psychosocial treatment of adult patients with psychotic disorders. The Croatian guidelines for the treatment of schizophrenia and other psychotic disorders provide recommendations for the pharmacological treatment of patients in the following areas: clinical high-risk and prodromal phases of a psychotic disorder, acute phase - first/repeated psychotic episode, pharmacotherapy, relapse after the first schizophrenic episode and other psychotic disorders, stabilization phase, maintenance phase – relapse prevention phase, therapeutic resistance and treatment of schizophrenia and other psychotic disorders during pregnancy planning, pregnancy itself, and breastfeeding. Guidelines for psychosocial procedures - mental disorders with psychosis and schizophrenia, refer to psychosocial methods of treatment and include non-specific and specific psychosocial procedures and principles, as well as the choice of therapeutic environment and organization of treatment

QUALITY OF LIFE OF PEOPLE WITH FIRST-EPISODE SCHIZOPHRENIA IN REMISSION AND SOCIAL WORK STUDENTS

Kvaliteta života ima bitnu ulogu u svakodnevnom životu. U ovom istraživanju, istraživala se kvaliteta života studenata i osoba oboljelih od prve epizode shizofrenije u stanju remisije. U istraživanju je bilo uključeno 50 studenata i 50 osoba oboljelih od prvih epizoda shizofrenije u stanju remisije. Procjena kvalitete života provedena je Upitnikom o kvaliteti života Svjetske zdravstvene organizacije (WHOQOL – BREF). Rezultati su pokazali da mlade osobe oboljele od prve epizode shizofrenije u remisiji u odnosu na studente socijalnog rada, procjenjuju vlastitu kvalitetu života lošijom u domeni socijalnih odnosa. Nije nađena statistički značaja razlika u domenama psihičkog zdravlja, fizičkog zdravlje i okolišne dimenzije. Rezultati ovog istraživanja potvrđuju neophodno sveobuhvatno i učinkovito liječenje i skrb za bolesnike oboljele od prvih epizoda shizofrenije pri čemu je posebno važna kvalitetna socijalna rehabilitacija.The quality of life has an important role in everyday life. In this study, the quality of life of social work students (N=50) and young people with first-episode schizophrenia (N=50) in remission was studied. The assessment of the quality of life of patients and students was conducted using the World Health Organization’s Quality of Life Questionnaire (WHOQOL-BREF). The results show that young people with first-episode schizophrenia assess their quality of life as worse in the domain of social relationsin comparison to social work students. There were no statistically significant differences in the domains of mental health, physical health, and environmental dimensions. The results confirm the necessity of a comprehensive and effective treatment and care for patients with thefirst episode of schizophrenia in which special attention should be given to quality social relations and rehabilitation

INTEGRATED SPECIALIZED EARLY-COURSE PSYCHOSIS TREATMENT SERVICES - UNIVERSITY PSYCHIATRIC HOSPITAL VRAPCE MODEL

First episode of psychosis presents a critical period in terms of numerous associated risks, but also possibilities for effective therapeutic interventions. There is a continued focus on early interventions in prodromal states and early course of frank psychosis, aimed at ensuring faster remission, reducing relapses, achieving better long-term functioning, and preventing adverse outcomes linked to untreated psychosis and chronic psychotic disorders. A number of different specialized treatment models and services exist trying to close knowledge gaps and provide clinical interventions to first-episode psychosis (FEP) patients, but there is still no generally accepted standard of care informing our every-day practice. FEP and early-course psychosis specialized treatment model developed in 2004 in University Psychiatric Hospital Vrapce rests on integration of care across different organization units and clinical presentation acuity levels and patient needs (intensive care, FEP inpatient unit, FEP outpatient services including day hospital). Such integration of FEP services allows for flexible entry point on multiple levels, earlier structuring of therapeutic alliance for those requiring inpatient care, reduction of risks associated with FEP, quicker formation of long-term treatment plans, reduction of delay in accessing specialized services, and a more coordinated diagnostic process and recruitment of FEP patient population. Detailed evaluations of outcomes and comparisons with different treatment models are necessary in order to assess strengths and weaknesses of each specific model and inform modifications to current practice models

RECOGNITION OF BORDERLINE PERSONALITY DISORDER SYMPTOMS IN PARENTS WHEN THE CHILD’S WELFARE IS AT RISK: PERSPECTIVE OF EXPERTS FROM SOCIAL WELFARE CENTRES

Granični poremećaj ličnosti je učestali psihički poremećaj koji se manifestira kroz simptome afektivne nestabilnosti, impulzivnog i nekontroliranog ponašanja, poremećaj identiteta, nestabilne interpersonalne odnose i moguće pogreške u testiranju realnostiuslijed kojih osoba može imati značajnih poteškoća u osobnom, roditeljskom, obiteljskom, socijalnom i radnom funkcioniranju. U ovom radu prikazani su rezultati kvalitativnog istraživanja »Prepoznavanje simptoma graničnog poremećaja ličnosti roditelja u situacijama ugrožene dobrobiti djeteta« u kojem je sudjelovalo 12 socijalnih radnika i psihologa iz Odjela za zaštitu djece, obitelji i braka centara za socijalnu skrb na području Grada Zagreba i Zagrebačke županije. Istraživanje je provedeno metodom polustrukturiranog intervjua. U obradi podataka korištena je tematska analiza. Rezultati istraživanja pokazuju da stručnjaci u svakodnevnom radu u situacijama ugrožene dobrobiti djeteta prepoznaju različite simptome afektivne nestabilnosti, impulzivnog i nekontroliranog ponašanja, smetnji identiteta, nestabilnih i intenzivnih interpersonalnih odnosa te teškoća testiranja realnosti koje su potencijalno povezane s mogućim graničnim poremećajem ličnosti roditelja. Kao otežavajuću okolnost u radu s ovim roditeljima stručnjaci iz centara za socijalnu skrb navode poteškoće suradnje sa stručnjacima iz zdravstvenog sustava.Borderline personality disorder is a common mental disorder with the symptoms of affective instability, impulsive and uncontrolled behaviour, identity disorder, unstable interpersonal relationships, and possible reality-testing errors, due to which the affected person can experience significant difficulties in personal, parental, family, social and professional functioning. This paper presents the results of a qualitative study on the recognition of symptoms of borderline personality disorder in parents when a child’s welfare is at risk, including 12 social workers and psychologists from the Department for the Protection of Children, Family and Marriage of the social welfare centres in the City of Zagreb and Zagreb County. The research was conducted using the method of a semi-structured interview. Thematic analysis was used for data processing. The results of the research show that in their daily work, in situations when a child’s welfare is threatened, experts recognise different symptoms of affective instability, impulsive and uncontrolled behaviour, identity disorders, unstable and intensive interpersonal relationships, as well as difficulties with reality testing, which may be related to possible borderline personality disorder in parents. Experts from social welfare centres mention difficulties in cooperation with healthcare professionals as an aggravating circumstance in working with this group of parents

Characteristics of Intimate Partnership Breakups in Parents with Symptoms of Emotionally Unstable Personality Disorder

Osobe s emocionalno nestabilnom ličnosti imaju značajne poteškoće u partnerskim odnosima. Njihovi odnosi su nestabilni i burni, obilježeni nepovjerenjem, razdobljima prekidanja i mirenja, ali i visokom stopom razvoda. Prekid partnerske zajednice, zbog osjetljivosti na odbijanje i straha od napuštanja, potencijalni je okidač koji može dovesti do aktivacije postojeće emocinoalno nestabilne ličnosti roditelja, intenziviranja njegovih simptoma, a posljedično i do različitih oblika neprikladnog i manipulativnog ponašanja. Svrha ovog rada je dobiti uvid u obilježja prekida partnerskih zajednica roditelja sa simptomima emocionalno nestabilne ličnosti. U radu su prikazani rezultati kvalitativnog istraživanja obilježja prekida bračne i izvanbračne zajednice roditelja sa simptomima emocionalno nestabilne ličnosti u kojem je sudjelovalo 12 socijalnih radnika i psihologa iz Odjela za zaštitu djece, obitelji i braka centara za socijalnu skrb na području grada Zagreba i Zagrebačke županije. Istraživanje je provedeno metodom polustrukturiranog intervjua. U obradi podataka korištena je tematska analiza. Prema rezultatima istraživanja prekidi partnerske zajednice roditelja sa simptomima emocionalno nestabilne ličnosti obilježeni su visokom razinom sukoba među roditeljima, nemogućnošću postizanja sporazuma oko ostvarivanja sadržaja roditeljske skrbi, manipulativnim ponašanjem i manipulacijom djetetom, drugim roditeljem (bivšim partnerom), stručnjacima i sustavom. Najčešći oblici manipulacije su onemogućavanje susreta i druženja djeteta s drugim roditeljem i članovima njegove obitelji, ocrnjivanje drugog roditelja i članova njegove obitelji pred djetetom i stručnjacima, neutemeljene prijave protiv drugog roditelja, učestali prigovori i prijave protiv postupanja nadležnih socijalnih radnika i drugih stručnjaka.Persons with emotionally unstable personality disorder have significant difficulties in intimate partnerships. Their relationships are unstable and intense and are marked by distrust, periods of temporary breakups and reconciliation, and a high rate of divorce. Breakups are, due to sensitivity to rejection and fear of abandonment, a potential trigger that can lead to the activation of existing emotionally unstable personality disorder in the parents and increase in the intensity of their symptoms, consequently leading to different forms of inappropriate and manipulative behavior. The goal of this study was to achieve insights in the characteristics of breakups in parents with symptoms of emotionally unstable personality disorder. The present article describes the results of a qualitative study on the characteristics of dissolution of martial and non-marital partnerships of parents with symptoms of emotionally unstable personality disorder, with the participation of 12 social workers and psychologists from the Department for the Protection of Children, Family, and Marriage of social welfare centers in the area of Zagreb and Zagreb County. The study was conducted in the form of semistructured interviews. Data processing consisted of thematic analysis. According to the results of the study, breakups in parents with symptoms of emotionally unstable personality disorder are marked by a high level of conflict among the parents, inability to reach an agreement about organizing parental care, manipulative behavior, and manipulation of the child, the other parent (i.e. the ex-partner), social care professionals, and the system as a whole. The most common forms of manipulation are preventing the child from meeting and spending time with the other parent and members of their family, disparaging the other parent and members of their family in front of the child and social welfare professionals, unfounded accusations and reports against the other parents, and repeated complaints and reports against the conduct of social workers and other experts

INTEGRATED SPECIALIZED EARLY-COURSE PSYCHOSIS TREATMENT SERVICES - UNIVERSITY PSYCHIATRIC HOSPITAL VRAPCE MODEL

First episode of psychosis presents a critical period in terms of numerous associated risks, but also possibilities for effective therapeutic interventions. There is a continued focus on early interventions in prodromal states and early course of frank psychosis, aimed at ensuring faster remission, reducing relapses, achieving better long-term functioning, and preventing adverse outcomes linked to untreated psychosis and chronic psychotic disorders. A number of different specialized treatment models and services exist trying to close knowledge gaps and provide clinical interventions to first-episode psychosis (FEP) patients, but there is still no generally accepted standard of care informing our every-day practice. FEP and early-course psychosis specialized treatment model developed in 2004 in University Psychiatric Hospital Vrapce rests on integration of care across different organization units and clinical presentation acuity levels and patient needs (intensive care, FEP inpatient unit, FEP outpatient services including day hospital). Such integration of FEP services allows for flexible entry point on multiple levels, earlier structuring of therapeutic alliance for those requiring inpatient care, reduction of risks associated with FEP, quicker formation of long-term treatment plans, reduction of delay in accessing specialized services, and a more coordinated diagnostic process and recruitment of FEP patient population. Detailed evaluations of outcomes and comparisons with different treatment models are necessary in order to assess strengths and weaknesses of each specific model and inform modifications to current practice models