A Brief Discussion on the International Pilot Study of Schizophrenia

I’ve been trying to make a renewed and dedicated effort to both read and write more. I’ve realized that waiting for the inspiration to strike doesn’t happen. If I want to read and write more, then I need to set aside time to cultivate the skill. It has been more difficult that I thought.

Still, this is part of that effort. And so today, I decided to review and write about my thoughts on a very important psychiatric article – The International Pilot Study of Schizophrenia: five-year follow-up findings.

Published in 1992, this article is an “oldie but goodie.” It is best known for its provocative finding that people with schizophrenia have better clinical and social outcomes in developing countries when compared with developed countries. In other words, a person with schizophrenia in Agra (India) or Ibadan (Nigeria) was significantly less ill and suffered less occupational and social impairment than someone with the same diagnosis in London (United Kingdom) or Washington, DC (United States).

As discussed in the article, one suggested explanation for this finding is incompleteness of follow-up at the sites in developing countries. However, when they further examined the data, they found that this was an unsatisfactory explanation for the results. A second suggested explanation was if a greater proportion of patients in developing countries had an acute, rapidly resolving psychosis with an inherently better prognosis. This explanation, too, was not supported upon further data modeling.

A third proposed explanation involved greater tolerance and acceptance of the behaviors displayed by people with schizophrenia by their families. This hypothesis had partial support, as a sub-study related to this project showed that patients in Chandigarh (India) who had families with low levels of Expressed Emotion had better clinical outcomes.

Low levels of Expressed Emotions are favorable; alternatively, families with high Expressed Emotion interact more frequently with negative and intense verbal exchanges. Relationships are oppositional or conflictual in nature, and interaction patterns are rigid. Conversations are marked by increased criticism, hostility, and emotional overinvolvement. As described by Amaresha & Venkatasubramanian in a 2012 article, “Researchers have positioned Expressed Emotion within the diathesis-stress model of psychopathology, characterizing it as an environmental stressor that can potentially precipitate/cause relapse of psychosis among people with a genetic vulnerability.”

However, the study concluded with a statement that an exact definition of the elements of culture and society that improve outcomes remains unclear.

There have been additional follow-up studies to this impactful article. In 2000, Hopper and Wanderling revisited this question and hypothesized that cultural factors promoting recovery may include: 1) supportive kin, 2) auspicious or alternative beliefs, 3) flexibly configured work, 4) forgiving domestic space, and 5) more socially integrated subjectivities. They also point out that, subtracting Hong Kong, the remaining sites in the “developing” group are all located within India, which simplifies the question of culture.

“The extraordinary engagement of Indian families in the course of treatment – from the initial decision to seek help, to attending to basic needs and medication adherence during hospitalization, to support afterward, including monitoring medications and functioning – is surely one of the signature features of psychiatry in that country.”


Hopper & Wanderling 2000, “Revisiting the Developed Versus Developing Country Distinction in Course and Outcome in Schizophrenia.”

I can further appreciate this finding while I was reading The Quiet Room by Lori Schiller. The Quiet Room is a biography describing one woman’s experience with schizophrenia. About midway into the book, Lori’s mother realizes that she had seen her own mother, Lori’s grandmother, display the eccentric and psychotic behaviors that Lori appeared to be experiencing. Lori underwent multiple psychiatric hospitalizations and trials of medications. Meanwhile, Lori’s grandmother, who was the daughter of a wealthy man and a housewife, did not. As a quote from the book describes, “My mother [Lori’s grandmother] was rich, and so she was allowed to be eccentric.” (Schiller & Bennett 1994, pg 82)

Lori, who faced the pressures of being a high-achieving, upper-middle class young adult, newly graduated from college, suffered greatly not just from the symptoms of psychosis but also from the loss of her place in society.

“I have lost many things: the career I might have pursued, the husband I might have married, the children I might have had.  During the years when my friends were marrying, having their babies and moving into the houses I once dreamed of living in, I have been behind locked doors.”


Schiller & Bennet 1994, The Quiet Room, pg 5

It brings to mind the pressures that society may place on its members to conform. Of course, conforming is not necessarily bad. Conforming to social norms regulates our social interactions, reduces anxiety, brings us closer to one another, and helps us feel safe. But perhaps there is a price for conformity – a price that is paid by the marginalized among us.

References

Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med. 1992 Feb;22(1):131-45.

Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. Schizophr Bull. 2000;26(4):835-46.

Amaresha AC, Venkatasubramanian G. Expressed emotion in schizophrenia: an overview. Indian J Psychol Med. 2012;34(1):12-20.

Schiller, L., & Bennett, A. The Quiet Room: A Journey Out of the Torment of Madness. New York: Warner Books. 1994.

I Am Not Sick, I Don’t Need Help

Have you ever been in denial?

Recently I have been pinching myself in disbelief. Am I really graduated from medical school? Are people actually going to start calling me “doctor?” Wow! It is terrifying, yet exciting. As a fresh graduate, I know that I still have a long road ahead of me before becoming a board-certified physician, but right now I have been feeling so incredibly blessed.

This period of time between graduation and the beginning of residency has been incredibly relaxing. I spent most of it vacationing. In April, I traveled throughout Japan for three blissful weeks. Then, I went on a scenic car trip from Texas and all the way up through New Mexico, Nevada, and Idaho to Washington State. Beautiful, isn’t it?

Driving by the Sierra Nevada © Jennifer Hsu

During these trips, I also read several books. One of these is “I Am Not Sick, I Don’t Need Help” by Xavier Amador, Ph.D., a clinical psychologist. I found it to be a quick, pleasurable read, because of the author’s concise and clear writing style. He also does a spectacular job of evoking empathy and understanding through clinical vignettes and personal stories.

If you know somebody with serious mental illness who is in “denial” and refuses to seek treatment or take medication, then this book is for you.

Dr. Amador divides this book into five parts. The first part provides information about mental illness, particularly schizophrenia. The second part describes the LEAP (listen, empathize, agree, partner) methodology that Dr. Amador developed, which has shown positive results in his work with patients and their families. The third part focuses on the feelings of betrayal and guilt that a patient and their family may feel when the patient is taken against their will to the hospital, and how to re-build trust. The fourth part discusses the value of assessing a person’s awareness of their illness and its purpose in formulating a cooperative treatment plan.

The fifth section is the most memorable of all. In it, Dr. Amador tells us about his brother Henry, who was diagnosed with schizophrenia. I could feel the love and care between the brothers, nearly palpable from the page, and I admired that he shared his brother’s story with us. It is a poignant reminder that every patient, no matter how “crazy” or psychotic, is loved by somebody. I admit that I shed some tears reading Henry’s story.

I highly recommend this book for anyone with a family member with mental illness. It is also a wonderful read for any health professionals.

Key Takeaways
  • “Denial” is the wrong term for poor insight in a person with mental illness. In patients with schizophrenia, the executive (frontal) part of the brain is often dysfunctional, resulting in a symptom called anosognosia, which is the condition in which a person with a disability seems unaware of its existence.
  • Reflective listening is listening with only one goal: to understand. It is not commenting, disagreeing, judging, or reacting in any way.
  • It is not necessary for the patient to believe that they have a mental illness. But, it is necessary for the patient and their support network (family, health provider) to work together for success. Prioritize finding common ground and collaboration, not arguing over who is “right.”
Quotes

“I can’t guarantee that LEAP will definitely eliminate medication and service refusal in the person you’re trying to help, but I can promise that if you faithfully follow the guidelines I give, they will help lower tension, increase trust, and greatly increase the likelihood that the person you are trying to help will follow your advice.” – Amador, X. Page 3.

“I have never talked anyone out of a delusion and, to my knowledge, I have never talked anyone into one either. The point is, when you’re facing someone who rigidly holds irrational beliefs, you gain nothing by disagreeing.” – Amador, X. Page 84.

“I loved Henry, and when someone you love is in pain, it is hard not to empathize. Learning to listen lead to empathy. And my empathy ultimately resulted in my brother showing a real interest in my thoughts about the illness he felt he did not have and the medications he was sure he did not need.” – Amador, X. Page 113.

More Information

Amador, X. I Am Not Sick I Don’t Need Help! How to Help Someone with Mental Illness Accept Treatment. Vida Press. Kindle Edition. 2012.

“LEAP®”; “L.E.A.P.®“;“Listen-Empathize-Agree-Partner®”; “Listen, Empathize, Agree, Partner®” and all similarly punctuated versions are registered trademarks of the LEAP Institute, are protected under the laws of the United States Patent and Trademark Office (USPTO), and may not be used without express license of the LEAP Institute.

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