Speech and Language Therapy intervention in schizophrenia: a case study

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Speech and Language Therapy intervention in
schizophrenia a case study

• Dr Shelagh Brumfitt
• Dr Judy Clegg
• Human Communication Sciences, University of
  Sheffield

Academic Clinical Psychiatry, University of
Sheffield Dr Randolph Parks Professor Peter
Woodruff
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Adult psychiatric disorders speech and language

• Speech and language abnormalities are common in
  adult psychiatric disorders
• In schizophrenia, speech and language
  abnormalities are an important diagnostic feature
  and can include poverty of speech, poverty of
  content of speech, pressure of speech,
  perseveration, echolalia and blocking
• Speech and language abnormalities can
  significantly interfere with effective
  communication and therefore treatment and
  management in the psychiatric setting

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Speech and language therapy (SLT)

• SLT in adult psychiatric disorders is not well
  documented
• Given the significant communication difficulties
  arising from the speech and language
  abnormalities, there is a clinical need for SLT
• SLT has the potential to facilitate effective
  treatment and management and to reduce social
  barriers
• However, the nature of the speech and language
  abnormalities in adult psychiatric disorders does
  complicate the rationale, i.e., are they
  treatable independently of the psychiatric
  disorder or does traditional pharmacological
  management treat the whole disorder including the
  speech and language abnormalities?

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A case study

• Background
• 53 year old adult male (PQ) with a diagnosis of
  schizophrenia and concurrent depressive episode
• Chronic history 11 psychiatric inpatient
  admissions from the age of 17 years
• Diagnosed with epilepsy at the age of 14 years
  and remained on anti-convulsive medication since
  this time
• Left school at 16 years with 3 RSAs, worked till
  27 years of age with no further employment
• Living independently with support from adult
  mental health services

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A case study

• This admission
• 2 year history of severe psychotic and affective
  symptoms
• Positive psychotic symptoms and negative
  cognitions
• Diagnosis paranoid schizophrenia with a
  concurrent depressive episode

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PQ Speech and language profile

• Poverty of speech eg monosyllabic responses
• Extreme anxiety in all communicative situations
• Increasing withdrawal and social isolation

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PQ Speech and language profile

• Formal assessment showed
• No specific difficulties in comprehension or
  expression
• No specific semantic or pragmatic difficulties
• No evidence of aphasia, no history of TBI,
  fluency disorder or other developmental or
  acquired disorder
• Neuropsychological assessment showed
• Adequate attention, concentration, verbal memory,
  verbal naming and visuo-spatial processing

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An example

• Dr Hello PQ, please come in and sit down. Do
  you know everyone here?
• PQ Nods his head to indicate yes
• Dr So how have you been getting on this week?
• PQ Okay (pause of 4 seconds)
• Dr I gather the medication has been causing
  excess salivation, has it been happening a lot?
• PQ Bit of salivation occasionally (pause of 6
  seconds)
• Dr When does this happen?
• PQ Possibly at night (pause of 8 seconds)
• Dr Do you feel less anxious now than when you
  first came?
• PQ About the same (pause of 3 seconds)
• Dr Can you tell me a bit more? Are you feeling
  less anxious than you were?
• PQ Could be a bit better(pause of 3 seconds)
  slightly(pause 4 seconds) possibly

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The intervention

• Two phases of intervention which aimed to
• Increase PQs verbal communication
• Reduce PQs anxiety in communicative situations
• Increase PQs awareness of his own communication
  skills

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The intervention

• Baselines
• VASES (Brumfitt Sheeran 1999)
• S24 (Andrews Cutler 1974)
• Written self description (Kelly 1955)
• Transcripts of PQs interviews in ward rounds
• Communication Anxiety Scale (CAS)
• Pharmacological treatment and other therapeutic
  activities were ongoing

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Communication Anxiety Scale

• Very Anxious Intolerable
• calm but can cope anxiety
• 1..2..3.4.5..6..7..8..9..10

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The intervention

• Phase 1 and 2 25 sessions of approximately 45
  minutes
• Side room of an inpatient ward
• Traditional speech and language therapy
  activities (Johnson and Wintgens, 2001)
• Rationale starting with easy structured
  communication tasks and moving through a
  hierarchy of stages where the tasks increased in
  demand
• Phase 1 desensitisation to verbal
  communication, relaxation and increasing
  awareness of own communication

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The intervention

• Phase 2 communicating factual information and
  engaging in shared tasks requiring verbal
  communication
• Stages incorporated into the phases PQ rated
  his anxiety within that stage using the CAS and
  when decreased to a comfortable level PQ
  progressed onto the next stage
• Generalisation to other activities encouraged but
  not formally documented, e.g., occupational
  therapy
• Use of video for watching self, identifying
  behaviours

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Results

• From Phase 1
• Could give factual information about self
• Could tolerate sitting in sessions
• Reduction of hand wringing or foot tapping
• Increase in verbal communication
• Both SLT and PQ agreed that these changes had
  taken place

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Results

• Phase 2
• Could engage in conversation about self in
  general way i.e. books read, everyday events
• Unable to talk about personal life difficulties
• Could use emotional words e.g. reticent
  relaxed
• Staff reported more able to initiate and return
  greetings etc
• Could watch video of self and make observations

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Outcomes
Comparison of PQs pre and post intervention
scores

CAS self rated where 10 was intolerable anxiety,
5 anxious but able to cope and 0 as very calm
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Post intervention transcript (part of)

• Dr Hello PQ, come on in and have a seat
• PQ Okay, thank you, hello
• Dr You had some leave this week, how did it go?
• PQ Better than I thought (pause of 3 seconds)
• Dr Where did you go?
• PQ Went to X (name of location) to stay with my
  sister Mary
• Dr When did you go?
• PQ My sister Sally, she and her husband took me
  down in the car and brought me back last week
• Dr What did you do there?
• PQ Went out for a walk, went out for some
  visits, did some reading in the garden, did a lot
  of reading actually (pause of 2 seconds)
• Dr Okay, are you happy for the plans for the
  discharge next week?
• PQ Yes (pause of 2 seconds)
• Dr Is Tuesday going to be better than the
  Monday?
• PQ Why Tuesday? Why has it changed?

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Challenges

• There are many challenges
• Using relevant and appropriate measures as pre
  and post intervention measures
• Establishing reliable and consistent baselines of
  communicative behaviour
• Measuring small changes in communicative
  behaviour at a conversational level
• Measuring effects of SLT intervention
  independently of other interventions ethical
  implications of this

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In conclusion

• Intervention was partially successful
• Spontaneous speech increased
• Developed more appropriate social communication
  skills
• Negative attitude to communication remained
  unchanged even though his self evaluative status
  changed
• PQ had a good level of insight into himself and
  his situation which certainly facilitated the
  intervention
• Need to question the specific effects of the SLT
  intervention in light of the pharmacological
  intervention and other therapeutic activities
• Need to consider how to measure SLT intervention
  to analyse efficacy

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References

• ANDREWS, G. and CUTLER, J., 1974, Stuttering
  therapy the relation between changes in symptom
  level and attitudes. Journal of Speech and
  Hearing Disorders, 39, 312-319.
• BRUMFITT, S.M. and SHEERAN, P., 1999, The
  development and validation of the Visual Analogue
  Self Esteem Scale. British Journal of Clinical
  Psychology, 38, 387-400.
• BRUMFITT, S.M. and SHEERAN, P., 1999, VASES
  Visual Analogue Self-Esteem Scale, (Winslow Press
  Ltd).
• CORCORAN, R. and FRITH, C.D., 1996,
  Conversational conduct and the symptoms of
  schizophrenia. Cognitive Neuropsychiatry, 1,
  105-318.
• CORCORAN, R., MERCER, G. and FRITH, C.D., 1995,
  Schizophrenia, symptomatology and social
  inference Investigating theory of mind in
  people with schizophrenia. Schizophrenia
  Research, 17, 5-13.
• KELLY, G., 1955, The Psychology of Personal
  Constructs, (New York. Norton).
• JOHNSON, M WINTGENS, 2001 The selective mutism
  resources manual. (Oxon UK Speech mark
  Publishing)