الفهرس 
A Glance at schizophrenia
RecoveryOnly 14 pages are availabe for public view
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Abstract
Schizophrenia is a devastating psychiatric disorder affecting about 0.5–1.2% of the population worldwide. This mysterious disorder is characterized by heterogeneous clinical symptoms, such as delusions, hallucinations, affective flattening, social withdrawal, and disorganized behavior. More recently neurocognitive impairments and decreased community functioning have also been recognized as core features of schizophrenia.
Schizophrenia constitutes one of the highest disease burdens globally. The disorder causes profound disruptions in individuals’ functioning including independent living skills, social relationship, scholastic and occupational domains.
At present, definitions of outcome include both maintained symptomatic remission and appropriate functioning in a conceptual framework that targets patient‘s recovery as the ultimate goal.
The concept of remission in schizophrenia, as proposed by the Remission in Schizophrenia Working group (RSWG), has been widely accepted and utilized in scientific research since 2005. According to this approach, remission of schizophrenia is defined as: A state in which patients have experienced an improvement in symptoms to the extent that any remaining symptoms are of such low intensity that they no longer interfere significantly with behavior and are below the threshold typically utilized in justifying a diagnosis of schizophrenia.
Recovery has recently come to be regarded as the new vision for mental health services. Recovery can be viewed as both an outcome and a process. Frese et al. describe recovery from schizophrenia as a concept that has evolved over the past century or so, from an initially extremely pessimistic view to one where at least some degree of recovery is increasingly the expectation.
The model of functional recovery surpasses the traditional medical model of symptomatic remission to include the realization of meaningful roles in the community. Thus, ―real-life‖ community functioning is an increasingly important treatment target for schizophrenia.
However, the assessment of functioning is a complicated issue, since there is no consensus on evaluating functioning in schizophrenia and it is unclear what constitutes ―appropriate functioning‖.
Unfortunately, full functional recovery is rarely attained and even less frequently maintained, even after symptoms have remitted. Profound impairments remain obstacles for patients suffering from schizophrenia even after clinical stabilization in the domains of occupational and academic achievement, interpersonal relationships, and independent living.
The search for outcome predictors for schizophrenia is as old as the field of psychiatry. However, despite a wealth of large, longitudinal studies into prognostic factors, only very few clinically useful outcome predictors have been identified Identification of specific predictors of outcome would have considerable benefits in clinical practice. Since predictors are synonymous with risk and resilience factors, they might provide a better understanding of the underlying pathophysiology of the illness. Also some predictors are modifiable, so they may provide specific treatment targets.
In addition to genetic/biological factors that contribute to a poor outcome, there are many other patient-centered factors that contribute substantially. These include poorer cognitive skills, longer duration of untreated psychosis, less continuity of treatment, substance abuse, family over involvement with high expressed emotion, higher vulnerability to trait anxiety, poorer developmental achievements prior to becoming ill and other important developmental variables, as well as unexpected, unpredictable life events. Predictors of remission can be considered relevant for the overall outcome of schizophrenia
Most studies that link cognitive deficits to functional outcome in schizophrenia support the notion that neurocognitive function predicts social and occupational function. Moreover, cognitive function has been found to be a better predictor of functional outcome than symptom levels. Therefore, interventions to improve cognitive function also have the capacity to improve quality of life and social and occupational outcomes.
Outcome of schizophrenia still is an under researched area in Egypt. This study is one of the few comprehensive evaluations of outcome of schizophrenia in Egypt.
The aim of our work was to find out the clinical and functional outcome in a group of Egyptian patients with schizophrenia and to give a highlight on cognitive functions in this group of patients as well as investigating possible factors that would determine the outcome.
We hypothesized that patients with schizophrenia who achieved symptom remission would have a better outcome in terms of clinical status, psychosocial functioning, quality of life and cognition.
A total number of 93 Egyptian patients diagnosed with schizophrenia according to DSM-IV diagnostic criteria; and who were previously admitted at the Institute of Psychiatry, Ain Shams University Hospitals and were following at the general adult outpatient clinics, were recruited through one year duration where their clinical records were examined to provide a reliable retrospective data about their previous hospitalization and a cross-sectional assessment was done to determine their symptomatic and functional remission as well as their cognitive functions and quality of life with emphasis on possible predictors of outcome.
All subjects involved in the study were subjected to:
1. Semi-structured clinical interview for full history taking including socio-demographic and relevant clinical data.
2. Arabic version of Structured Clinical Interview for DSM-IV Axis I (SCID I).
3. Positive and Negative Syndrome Scale (PANSS).
4. GAF (Global assessment of functioning).5. CGI (clinical global impression) scale.
6. Arabic version of Quality of life scale (QLS).
7. Arabic version of the Social Functioning Questionnaire (SFQ).
8. Wisconsin Card Sorting Test (computerized version).
All data gathered were recorded, tabulated and transferred on statistical package for social sciences (SPSS) Version 16, using personal computer and the suitable statistical parameters were used.
The main findings of this study were:
Regarding symptomatic remission, 37.6% of patients had achieved remission severity criteria whereas 62.4% failed to fulfill the criteria for remission.
Regarding functional remission, our results revealed that 32 (34.4%) of the study sample reached functional remission while 61(65.6%) failed to achieve functional remission.
When comparing symptomatic remitters and non-remitters as regards functional remission we found a high significant difference where 71.4% of symptomatic remitters achieved functional remission compared to only 12% in non-remitters.
Regarding overall outcome, our results revealed that 25 (27%) of the study sample achieved both symptomatic and functional remission indicating good outcome compared to 68 (73%) who either achieved symptomatic or functional remission alone or failed to meet both and were considered as a poor outcome.
When studying the socio-demographic and clinical characteristics of outcome groups, No statistical significance was detected in the 2 groups except for marital status where 44% of the good outcome group were single compared to 62% of the poor outcome with p-value (0.04*). Also (60%) of the good outcome group were employed in relation to only (23.5%) in poor outcome group with high statistical significance.
Also a statistical significant difference was obtained between outcome groups as regards substance use, where 25 (36.8%) of those in the poor outcome group used substances on regular basis compared to only 3 (12%) in the good outcome group.
Moreover a statistical significant difference was found between outcome groups regarding previous suicidal attempts where only (12%) of the good outcome had previous suicidal attempts compared to (34%) in the poor outcome group. Also our results revealed a statistical significant difference between groups in terms of drug compliance as (60%) of the good outcome group had good compliance compared to only (31%) in the poor outcome group.
In the contrary no significant difference was found between outcome groups regarding age at onset, DUP, number of hospitalizations, brain synchronization therapy, the type of antipsychotic received and depot injection.
We studied quality of life by QLS in different outcome groups and our results came to demonstrate a high statistical significant difference on all items of quality of life among outcome groups with [mean (±SD)] for total scores: [85, ±11]in the good outcome group and [48, ±22] in the poor outcome group
When examining cognitive functions there was no significant difference on WCST subscales; namely perseverative responses and perseverative errors, when comparing between outcome groups, yet highly significant differences were found in terms of categories completed and conceptual level response subscales which indicate deficits in conceptual skills, executive functions and set shifting.
When applying binary logistic regression to detect possible predictors of outcome, results appeared to be that lower score on lack of judgment or insight item of PANSS, greater categories completed on WCST were found to be significant predictors of good outcome. On the other hand substance use, previous suicidal attempts, symptom severity upon hospital discharge and conceptual level response on WCST were not considered as significant predictors of good outcome.
We concluded by the end of this study that symptomatic recovery seems to be a good indicator of better functioning and better quality of life. However, this does not necessarily mean that remitted patients have an ―adequate‖ quality of life or adequate functioning level especially social skills domain.
Also our findings revealed that a significant proportion of patients showed either symptomatic or functional improvement, but rarely fulfilled both symptomatic and functional remission criteria simultaneously.Moreover, we concluded that patients with better insight and better cognitive functions were able to develop and maintain both symptomatic and functional recovery compared to those having lack of insight and cognitive affection that were less likely to have a good outcome at both the symptomatic and functional level.
Based on our findings, we recommend replication of this study on larger sample size and in a prospective design, so that some insignificant correlations may prove to be significant.
Finally, we are hopeful that pharmacological and psychosocial treatments as well as vocational rehabilitation programs would be developed in order to positively affect outcome in patients with schizophrenia.