RIJKSUNIVERSITEIT GRONINGEN BOTTOM-UP REHABILITATION IN SCHIZOPHRENIA

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1 RIJKSUNIVERSITEIT GRONINGEN BOTTOM-UP REHABILITATION IN SCHIZOPHRENIA Proefschrift ter verkrijging van het doctoraat in de Geneeskunde aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus Dr. F. van der Woude in het openbaar te verdedigen op woensdag 24 januari 1996 des namiddags te 4.00 uur door Martinus Theodoor Appelo geboren op 20 juni 1962 te Zwartsluis

2 Promotores: Prof. dr. R.J. van den Bosch Prof. dr. P.M.G. Emmelkamp Referenten: Dr. M. van der Gaag Dr. C.J. Slooff

3 It ain't what you do it's the way that you do it (Bananarama)

4 Photograph cover: Chris Kliphuis Druk: Stichting Drukkerij Regenboog, Groningen (1995) ISBN:

5 Acknowledgement. This study was part of the Schizophrenia Rehabilitation Research Group Groningen/Assen (SRRG), a cooperation of the Psychiatric Hospital 'Licht en Kracht' in Assen, and the departments of Clinical Psychiatry and Clinical Psychology of the University of Groningen. The study has been realized thanks to the financial support by the Dutch Praeventiefonds. Without the 'executive control' by Frank Woonings, Jan Willem Louwerens and Wim Appelo, the stress related to finishing this study, would have exceeded my 'treshold'.

6 Contents. Introduction. 3 1 Schizophrenia and rehabilitation Schizophrenia Theoretical starting points A special note on negative symptoms The concept of rehabilitation Schizophrenia and rehabilitation: the state of the art Information processing and schizophrenia Introduction A cognitive model for skills acquisition Cognitive disturbances in chronic schizophrenia Cognitive disturbances and symptoms Methodological tactics in rehabilitation Introduction Behaviour therapeutic tactics in rehabilitation Tactics at the declarative stage Tactics for knowledge compilation Tactics for production tuning General tactics for professionals Towards a pilot-study Pilot-study: cognitive and social skills training Introduction Cognitive training in schizophrenia Content of the combination-training Method of the pilot-study Subjects Assessment Results of the combination-training General impression Results Conclusions and implications. 37

7 5 Selection of instruments for rehabilitation research Introduction Operationalization of theoretical starting points Cognitive functions Coping-style Social skills General functioning Symptoms Demographics Selection of variables A bottom-up rehabilitation programme Introduction Content of the rehabilitation programme Subdivisions at the first and second stage Subdivisions at the first stage Subdivisions at the second stage The meaning of the programme Content of the control conditions Methods Aims of the study Subjects Assessment Assessment of syndromes of schizophrenia Design and procedure Hypotheses and questions Hypothesis on the effect of the programme The additional value of cognitive skills training Predictors of successful rehabilitation Statistical procedures Results Introduction Correlations at the first assessment Do drop-outs differ from non-drop-outs? The results of the programme Results on cognitive organization Results on problem oriented coping. 84

8 8.4.3 Results on social skills Results on general functioning Results on reality distortion Results on accommodation Results on daily activities Conclusion The additional value of cognitive skills training Conclusion Predictors of successful rehabilitation Stability of CPT-d' Predicting improvement Conclusion Discussion Introduction How to improve rehabilitation in schizophrenia? Bottom-up or top-down rehabilitation? The reduction of profound reality distortion The establishment of problem oriented coping The role of society Methodological considerations for further research Summary and conclusion: schizophrenia and selfcontrol. 109 Samenvatting. 111 References. 119 Appendix. 133

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