Aportaciones de la investigación respecto al tratamiento psicosocial y familiar de pacientes con esquizofrenia

• Autores: Marcela Valencia, Horacio Quiroga, María Luisa Rascón Gasca
• Localización: Salud mental, ISSN 0185-3325, Vol. 26, Nº. 5, 2003, págs. 1-18
• Idioma: español
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• Resumen
  • español

    Este trabajo tiene como objetivo presentar las principales aportaciones terapéuticas y de investigación realizadas desde 1979 al 2003, en el Instituto Nacional de Psiquiatría Ramón de la Fuente, antes Instituto Mexicano de Psiquiatría, en donde se aplicaron diversas formas de tratamiento psicosocial a pacientes con esquizofrenia, así como el tratamiento familiar correspondiente, dirigido a las familias de estos pacientes.

    La esquizofrenia es una enfermedad que se caracteriza por la presencia de sintomatología psicótica, y también porque incapacita al paciente de manera considerable, alterando su funcionamiento psicosocial y familiar. Se ha considerado que el tratamiento integral actual de la esquizofrenia, debe considerar por lo menos cuatro aspectos fundamentales: 1.-el tratamiento farmacológico, 2.-el tratamiento psicosocial, 3.-la terapia familiar, y 4.-el manejo del paciente en la comunidad.

    Respecto al componente psicosocial, se han identificado áreas específicas en las cuales los pacientes tienen dificultades para tener un desempeño de roles efectivo y satisfactorio en cuanto a su funcionamiento psicosocial. Estas áreas incapacitan a los pacientes a desarrollar actividades que tienen que ver con aspectos ocupacionales, manejo de dinero, relaciones sociales, vínculos de pareja y relaciones familiares. Los tratamientos psicosociales desarrollados a nivel internacional han demostrado su efectividad terapéutica ya que mejoran el funcionamiento psicosocial, ayudan a reducir las recaídas y rehospitalizaciones y a tener un funcionamiento comunitario más satisfactorio para el paciente.

    En este trabajo se presenta la implementación de diversas modalidades de tratamiento psicosocial llevadas a cabo en varios grupos de pacientes esquizofrénicos: el trabajo con pacientes agudos hospitalizados tuvo cuatro semanas de duración, en pacientes crónicos hospitalizados, el tratamiento fue de dos años, en pacientes crónicos manejados en la Consulta Externa, el tratamiento se aplicó en tres ocasiones, cada una con un año de intervención, y en el último grupo se compararon tres modalidades de intervención: el tratamiento integral, la musicoterapia y el tratamiento psicosocial, durante seis meses de intervención respectivamente. En todos los casos se utilizaron referentemente técnicas terapéuticas grupales y también individuales cuando lo requería el paciente, trabajando en las sesiones la problemática psicosocial de los pacientes, teniendo siempre como denominador común el tratamiento farmacológico en todos los grupos de pacientes.

    En términos metodológicos, en la mayoría de las modalidades se utilizaron grupos experimentales y controles, evaluando a los pacientes antes y después de las intervenciones por medio de instrumentos de investigación. Se encontró que los tratamientos psicosociales son efectivos cuando se combinan con el tratamiento farmacológico ya que los pacientes presentaron mejorías clínicas considerables, así como en su funcionamiento psicosocial, en el funcionamiento global (síntomas y actividad psicológica, social y laboral),un menor porcentaje de recaídas y rehospitalizaciones, un mayor cumplimiento con los medicamentos antipsicóticos y un mayor nivel de adherencia terapéutica, en comparación con los pacientes controles que recibieron únicamente el tratamiento farmacológico y se mantuvieron estables a lo largo del tratamiento, sin obtener los logros a nivel psicosocial, demostrados por los pacientes experimentales. Los resultados obtenidos coinciden con lo encontrado a nivel internacional, en el sentido que los tratamientos psicosociales aplicados en México también han demostrado su efectividad.

    El tratamiento que recibieron los familiares estuvo conformado por dos elementos:1 º el psicoeducativo y 2 º el terapéutico. Se inició con un taller psicoeducativo multifamiliar que se dividió en dos partes, la primera consistió en la presentación de temas específicos relacionados con la enfermedad, expuestos por especialistas del equipo con un total de 12 sesiones educativas. Posteriormente, en una segunda parte, en grupos más reducidos se retomaban los temas de las sesiones y se favoreció el manejo de las emociones que la información despertaba en cada familiar y la solución de problemas. Al mismo tiempo se llevó a cabo la terapia unifamiliar, en donde se trabajó la problemática específica de cada familia y su paciente, aproximadamente 5 sesiones, fundamentalmente en cuanto a los límites, la jerarquía y la centralidad, así como el establecimiento de redes de apoyo ara favorecer una mejor evolución de la enfermedad centrada en aspectos comunicacionales, interaccionales y estructurales.

    Los resultados del estudio de los efectos de la intervención en los familiares, se evaluaron mediante diferentes indicadores, respecto a la carga familiar se observaron respuestas en las cargas: Emocional, económica, física y social, destacando mejoría principalmente en la ¿carga subjetiva emocional¿ de los familiares después de recibir el tratamiento.

    En cuanto a la expresión emocional el nivel alto se presentó con más frecuencia, resaltó el componente de sobreinvolucramiento, compuesto por aspectos de sobre protección y autosacrificio, al término del tratamiento se encontraron diferencias en el componente de sobreinvolucramiento y en la EE global. Se encontró asociación entre la expresión emocional alta, un pobre funcionamiento y la conducta sintomática del paciente. Los familiares que expresaron EE alta, reportaron mayor autodescuido, irritabilidad, violencia y aislamiento por parte de su pariente enfermo.

    Con respecto a la psicopatología secundaria encontrada en el familiar, se observó que más de tres cuartas relacionan el padecer algún trastorno físico o emocional con la aparición de la esquizofrenia en su pariente, es importante mencionar que de dos familiares uno presentó algún trastorno psiquiátrico, cifra muy superior a la reportada para la oblación general. En cuanto al tipo de diagnóstico se encontró similitud con lo descrito en otras oblaciones, en donde los trastornos depresivos destacan en primer lugar, seguidos por la dependencia al alcohol. Los mejores predictores de la psicopatología en los familiares por medio del uso de la regresión logística fueron: la conducta sintomática del paciente (síntomas positivos y negativos),el número de recaídas con hospitalización y el número de años de evolución de la enfermedad del paciente. R2:. 423; F:7. 102; p > .001.

  • English

    The objective of the present study is to describe the principal therapeutic and research contributions developed during 1979 and the year 2003, at the National Institute of Psychiatry Ramón de la Fuente, former Mexican Institute of Psychiatry. Several psychosocial treatment approaches were applied to different groups of schizophrenic patients, as well as family therapy to the their relatives. Schizophrenia is an illness characterized by psychotic symptoms, some of them known as positive symptoms such as: hallucinations, delusions, disorganized speech, and also negative symptoms such as: affective flattering, alogia or avoition. Psychotic symptoms may lead the patient to loose contact with reality, specially if he is not using antipsychotic medication. Since the illness usually begins in late adolescence or early adulthood, the learning of psychosocial role performance is interrupted resulting in a decline of psychosocial functioning with catastrophic consequences for the patient, several areas of psychosocial functioning remain affected such as: work, income, social relations, love relationships, and also the family system is affected, the relatives have to manage not only the economic consequences but also the impact of the illnes. As a result, the management of schizophrenia should include not only the psychotic symptoms, but also the impairments and the disabilities of the illness. Within this frame work, the present treatment of schizophrenia should consider four important components: 1.- pharmacological treatment, 2.- psychosocial treatment, 3.- family treatment, 4.-the management of the patient in the community. The initiation of psychosocial treatments for schizophrenia is almost parallel, or immediately after the appearance of neuroleptic medication, which occured early in the 1950´s. Patiens recluded in mental hospitals, started to use neuroleptic medication and as a consequence there was a reduction in psychotic symtomatology. Patients were released to the community, in some cases they returned to live with their relatives, in other cases, some alternatives were developed in the community such as: halfway houses, day care centers, partial hospitalisation services, and therapeutic communities. By the time patients were living in the community, they began to present several psychosocial problems, most of them related to the impairments of the illness. They had difficulties for maintaining a job and as a consequence they had no income; therefore, they had economic dependence upon their families or otherwise they needed economic support from certain social agencies in the community. They also had difficulties for initiating and maintaining social interactions, their social network was very much reduced and as a consequence the possibility of having long and lasting love relationships was limited. Within this framework certain specific areas where schizophrenic patients have psychosocial problems have been identified. The evidence indicates that psychosocial functioning is not satisfactory for the patient in the community. Patients, not only have to battle with the symptoms of the illness, since it has been established that in order to reduce the symptoms, they need to take antipsychotic medication. They also have to deal with the impairments, and disabilities arising from the illness, that affect their psychosocial functioning, and therefore they need psychosocial treatment. In developed countries, psychosocial treatments for schizophrenic patients have become an important and necessary component in mental health services, psychiatric hospitals, and specially in Schizophrenia Clinics. Psychosocial treatments have been validated as effective in providing psychosocial coping skills, improving community psychosocial functioning, reducing relapse rate, increasing compliance with the prescribed medication, and usually obtaining an acceptable degree of therapeutic adherence. Psychosocial treatments can not be used as a substitute of pharmacological treatment, neither as the only treatment of choice. It has been established and recommended that the most convenient perspective to treat schizophrenic patients is always using the combination of pharmacological and psychosocial treatment. Psychosocial interventions can be used beneficially in conjunction with antipsychotic medication and the combination may actually have an additive or synergistic effect. In this article, several models of psychosocial treatment are presented that were carried out in different groups of schizophrenic patients at the National Institute of Psychiatry in Mexico City. One model was utilized on acute psychotic hospitalised patients, during four weeks of treatment. Another model was implemented on chronic hospitalised schizophrenic patients, during two years of treatment. Another type of psychosocial treatment was carried out on three different occasions on non-hospitalised schizophrenic patients, on each occasion the duration of every treatment was of one year. Finally, another study was carried out, comparing three modalities of interventions: integrated treatment, music therapy, and psychosocial treatment, during six months. In all psychosocial models, group therapy techniques were utilized and in some cases, individual therapy was provided, when needed. Therapy sessions were utilized as an space for the patients to talk about their psychosocial problems. In all groups, the basic component was the use of prescribed antipsychotic medication, as the first approach to treatment. The clinical procedure for allocating the patients to the interventions group´s consisted in determining and verifying the schizophrenia diagnosis, and the use of antipsychotic medication. Once the patients were clinically stabilized, they were allocated to the treatment groups. The scientific method consisted of using quasi-experimental and experimental designs including experimental and control groups. Patients of all groups were assessed at the beginning and at the end of each intervention, considering variables such as: symtomatology, psychosocial functioning, global functioning, compliance with antipsychotic medication, relapse, rehospitalization, therapeutic non-compliance and adherence. The results show that psychosocial treatments can be very effective when combined with antipsychotic medication, in comparison with the use of pharmacotherapy alone. Patients improved clinically and psychosocially in the following aspects: symtomatology, psychosocial functioning, global functioning (symptoms and psychological activities), they presented a lower relapse frequency and rehospitalization rate, a higher antipsychotic medication compliance, a reduced rate of therapeutic noncompliance and a higher degree of adherence. Control patients, who received exclusively pharmacological treatment, remained stabilized in their psychotic symtomatology, but they did not improved in any of the psychosocial variables. It can be concluded that the conjunction of pharmacological and psychosocial treatments, show beneficial effects for the patients; therefore, it should be considered as an important therapeutic alternative in the treatment of schizophrenia. The schizophrenia is one of the mental disorders in where old difficulties in the family environment are introduced; the negative effect of the illness, in the majority of the cases, it relapse basically in who they suffer it and in who they live together with the sick person, the clinical characteristics of this illness generate a great number of negative situations like difficulty in the family relationships, impoverishment in the quality of life, social isolation that interferes in the labor operation, scholar and in the own home; the one which increases the level of stress already existent, being converted in an additional factor of anguish, so much for the patient like for their family, coming to be considered like precipitant of relapses, of exacerbation of symptoms and of rehospitalization, the family plays a fundamental paper when she are pretended to improve the level of global operation of the patient, their quality of life and their addiction to the treatment. The treatment that they received the relatives was conformed by two element: 1º the psychoeducation and 2º the therapeutic. Psychoeducation was begun multifamily that divided in two parts, the senior with a shop it consisted in the presentation of specific related topics with the illness, exposed for specialists of the team with a total of 12 educational sessions. Subsequently, in a second part, in more reduced groups recombine the topics of the sessions and he was favored the handling of the emotions that the information woke up in each relative and the solution of problems. To the same time the therapy was carried out unfamiliar, in where I am worked the specific problem of each family and their patient, approximately 5 sessions, fundamentally as for the limits, the hierarchy and the centrality, as well as the establishment of nets of support in order to favor a better evolution of the illness centered in looks communicative, interaccional and structural.

    Several instruments were utilized: 1.- The Identification of Evaluation of the conduct of the patient SBAS 2º Ed; 2.- The Cuestionary of Evaluation of expressed emotion (CEEE); 3.Conception of the Illness. (CONENF); 4.- The Composite International Diagnostic Interview [version] 1.0. (CIDI); Global evaluation of the form of family relationship with the EEGARDSM-IV and the Cuestionary of Woman Domestic Violence (MVD). The outputs of the study of the effects of the intervention in the relatives, they were evaluated by means of several indicators, concerning the family load answers in the loads were observed: Emotional, Economical, Physics and Social, highlighting improvement mainly in the «subjective emotional load» of the relatives after receiving the treatment. As for the emotional expression the tall level was introduced with more frequency, he stood out the component of overinvolvement, compound for looks of overinvolvement and sacrificial, they to the term of the treatment met differences in the component of overinvolvement and in the global EE. He met association between the emotional tall expression, an unfortunate operation and the symptomatic conduct of the patient. The relatives that expressed tall EE, reporter old carelessness, irritability, violence and isolation per party of their sick relative. With concerning the secondary opposing psychopathology in the relative, he was observed that more than three fourth relate the suffer any physical or emotional disorder with the apparition of the schizophrenia in their relative, it is important mention that of two relatives one introduced any disorder psychical, very superior figure to the reported for the general population, as for the type of diagnosis met similitude with him described in other populations, in where the disorders depressives highlights in first place; consecutive for the dependence to the alcohol. The outputs that were gotten of this investigation are of utility for the construction of a model of treatment and study of the relatives of a sick person with schizophrenia, in order to prevent and try to resolve the necessities detected in the relatives of effective manner. Upon considering the illness of the patient on one hand and the wide range of problems related to this and for another, the presence of one or more diagnoses psychical in the responsible relative, he is of waiting for, that the evolution of both lacks a satisfactory course, unless this comorbility is detected and undertaken therapeutics, with the purpose of optimizer the evolution or the development of the illness and diminish the exacerbation of symptoms or relapses and to their time, improve the family interaction. Considering the necessity of undertaking so much integral the diagnosis like the treatment and the prevention of the illness for the family group, the sick relative, of manner the team of mental health and the community will allow to advance toward the rehabilitation of the people that they suffer this suffering