Method

1

The Role of Symptomatology in the Process of
Rehabilitation Thea L. Rothmann, Jason E. Peer,
Srividya N. Iyer, Myla Browne, Anita H. Sim, A.
Jocelyn Ritchie, and William D. Spaulding
University of Nebraska-Lincoln

Introduction

Results
Severe mental illness (SMI) is increasingly
understood by examining impairments in multiple
levels of functioning (e.g., neurocognition,
sociocognition, etc.) and how they relate to each
other (Spaulding, 1997). Successful
rehabilitation programs must target multiple
levels of functioning to improve and sustain
treatment outcomes. The relationship between some
areas of functioning (e.g. neurocognition) and
rehabilitation outcomes have been extensively
researched while other areas (e.g.
symptomatology) have received less attention.
Symptoms and Outcomes. Few studies have
evaluated the impact of symptoms on the
rehabilitation process. This may be a result
of difficulties in accurately measuring these
symptoms the fact that current
conceptualizations of symptom distinctions (i.e.,
negative vs. positive symptoms) do not
adequately encompass the range of symptoms
experienced by people with SMI (Mueser, 1997)
Some studies suggest Negative symptoms
(e.g., blunted affect) Disorganized symptoms
(e.g., thought disorder) are
associated with poor treatment outcome (Addington
Addington 1999 Brekke et al. 1997).
Fluctuations in mood (e.g., depression, anxiety)
are also characteristic of SMI and may impact the
rehabilitation process (Drake et al., 1985
Penn et al., 1994). While other studies
suggest Symptoms are not predictive of social
skills training success (Smith, 1999) Symptoms
are not related to success in behaviorally-oriente
d rehabilitation programs (Corrigan et al.,
1997) Different symptom profiles may be
implicated in successful treatment outcomes
depending on how success (e.g., compliance with
treatment, improved psychosocial functioning) and
symptoms are measured. The current study
explored the relationships among symptoms,
rehabilitation noncompliance, and psychosocial
functioning over the course of treatment. It
was predicted that symptoms would serve as
reliable predictors of outcomes as measured by
compliance and overall psychosocial functioning.
Changes Over the Course of Treatment. From
admission to 6 months of treatment Significant
decrease in disorganized symptoms (p.009)
Significant improvement in psychosocial
functioning (NOSIE Total Assets, p.004) -
Significant increase in daily schedule competence
(p.002) - Increase in social interest
(p.07) - Significant decrease in motor
retardation (p.011) From 6 months of treatment
to 12 months of treatment Significant decrease
in the mean number of instances of rehabilitation
noncompliance (p.001) Relationship Between
Symptoms and Outcome Variables. Significant
correlations between symptoms at admission to
higher levels of noncompliance over the first 6
months of treatment (See Table 1) Significant
correlations between symptoms at six months
post-admission to higher levels of noncompliance
over the second 6 months of treatment (See Table
2) Rehabiliatation Noncompliance -
Significant correlations between BPRS factor
scores (Disorganization, Paranoia,
Agitation/Elation) at admission to greater
levels of noncompliance over the first 6 months
of treatment emerged (See Table 3) - The above
predictors were used in a regression model and
were able to predict levels of rehabilitation
noncompliance (See Table 4) Psychosocial
Functioning (NOSIE) - Significant correlations
between BPRS factor scores (Disorganization and
Paranoia) at admission to poorer levels of
psychosocial functioning over the first 6 months
of treatment were noted (See Table 3) - The
above predictors were used in a regression model
and were able to predict levels of psychosocial
functioning (See Table 5)

Discussion
Method
Overview. An archival database of the Community
Transition Program (CTP), a comprehensive
psychosocial rehabilitation unit for individuals
with SMI, was utilized for this study. The
database consists of neurocognitive, social
cognitive, and clinical data from a routine
assessment battery administered at admission and
every six months following admission to each
program participant. Participants. Data from
assessments administered to 72 participants at
admission and six months post-admission was used.
This sample represents a particularly severe and
treatment refractory population. All
participants were in involved in a comprehensive
psychosocial rehabilitation program. Measures.
1) The Brief Psychiatric Rating Scale (BPRS
Lukoff et al., 1986) was used to assess
symptomatology. BPRS factor scores were derived
from a previous factor analysis using a standard
principle components analysis (Spaulding, Reed,
et al., 1999) and six factors were identified
paranoid, anxiety/depression, hallucination/delusi
on, disorganized, blunted affect, and
agitation/elation. 2) The Nurse Observation Scale
for Inpatient Evaluation (NOSIE-30 Honigfeld,
Roderick, Klett, 1966) served as a measure of
psychosocial functioning. 3) The average number
of weekly instances of noncompliance with program
requirements at six months and twelve months
served as a measure of rehabilitation
noncompliance (RNC).
Results from the current study support the
hypothesis that symptoms can serve as reliable
predictors of treatment outcomes. Previous
research in this area has relied upon narrow
symptom conceptualizations (i.e., positive and
negative symptoms groupings) and varying measures
of treatment outcome success. The current study
measured treatment outcomes using an overall
measure of psychosocial functioning across
various domains as well as utilizing instances of
noncompliance with treatment as a measure of
treatment outcome. Since participation in and
adherence to ones own treatment program is
associated with better outcomes, compliance can
be viewed as one way of measuring treatment
success. In addition, this study examined a wider
range of symptoms experienced by people with
severe mental illnesses like schizophrenia and
did not use categorical diagnostic criteria as
symptom dimensions. Results suggest that higher
levels of disorganized and paranoid symptoms are
consistent predictors of higher levels of
noncompliance with treatment and poorer
psychosocial functioning. The relationship
between disorganized symptoms and poor outcomes
is consistent with previous research identifying
disorganization as related to poor functional
ability (Brekke et al., 1997). The relationship
between paranoid symptoms and poor outcomes is
somewhat inconsistent with research suggesting
that paranoid symptoms (i.e., the paranoid
subtype) are associated with better outcomes.
However, this finding is consistent with recent
research suggesting a dimensional criteria for
paranoid symptoms is a more accurate predictor of
outcomes than diagnostic subtypes (Salinas et
al., 2002). There may be key neurocognitive or
social cognitive aspects implicated in these
symptoms which result in the observed decrements
in psychosocial functioning and treatment
adherence. Future research should attempt to
identify these social cognitive and
neurocognitive aspects as potential targets for
intervention. Furthermore, future research should
address how symptom level interventions
(pharmacological or psychosocial) impact
subsequent psychosocial functioning and treatment
adherence. Since treatment noncompliance
represents a major concern for rehabilitation
providers, it is imperative that a comprehensive
understanding of the factors associated with
noncompliance be developed. The results from
this study support the need for rehabilitation
providers to consider multiple levels of
functioning, including symptomatology, to
maximize the potential for successful treatment
outcomes.
Table 4. BPRS Factor Scores at Time 1 as
Predictors of Rehabilitation Noncompliance at 6
Months Post-Admission
Table 5. BPRS Factor Scores at Time 1 as
Predictors of Psychosocial Functioning at 6
Months Post-Admission
Visit the Severe Mental Illness
Research Group website at the University of
Nebraska - Lincoln
http//www.unl.edu/psypage/smi