Vulnerability to Psychosocial Disability in Psychosis
Psychosis, or a psychotic episode, is characterized by a distorted perception of reality that is often exacerbated by hallucinations or delusions.
Psychosis, or a psychotic episode, is characterized by a distorted perception of reality that is often exacerbated by hallucinations or delusions. Figures from the United States suggest that 4.2% of adults have a serious mental illness of some kind,1 and between 0.25% and 0.64% of these people have schizophrenia or a related psychotic disorder.2 Symptoms associated with psychotic disorders can be disruptive and distressing and can have an impact on many areas of an individual's life, including relationships with friends, family, and work colleagues. People with psychosis are at high risk for psychosocial disability.
What is psychosocial disability?
Psychosocial disability is the term used to describe the social consequences that often result from mental health issues. In particular, individuals experiencing psychosocial disability can find it difficult to interact with the world in which they live.3 Psychosocial disability may have an impact on communication, learning, and social relationships, hindering a person's ability to take part in work and education, set life goals and plans, and partake in social and cultural activities. Any social difficulties can be worsened by stigma and society's sometimes negative attitudes toward people with mental health problems.4
Psychosocial disability is not to be confused with psychiatric disability, a term that relates to the impairments associated with a psychiatric condition, although it is thought that rates of psychosocial disability are most commonly seen in those who have been diagnosed with psychotic disorders such as schizophrenia and schizoaffective disorder.5
What is the link between psychosocial disability and psychosis?
What links psychosocial disability and psychosis? Primarily, in psychosis there are several clinical markers that may predict psychosocial disability, including:
- Onset of psychosis at an early age
- Poor cognitive function
- Periods of untreated psychosis
In addition to these markers, males are also more at risk for psychosocial disability in psychosis.6
Conversely, social factors such as marginalization, deprivation, and unemployment have been recognized as being associated with an increased risk for psychosis developing. However, the presence of these risk factors does not make psychosis inevitable. “Many young people who have psychosocial difficulties, who also show early signs of psychosis, may never go on to [have a disorder] fully develop,” offered Dr Sian Lowri Griffiths, Research Associate and Teaching Fellow at the University of Birmingham, United Kingdom. “Psychosocial difficulties may be experienced by many young people, and not just those [in whom psychosis] later develops,” she added.
Intervention and prevention
Interventions such as supported employment, social skills training, cognitive behavioral therapy for psychosis, and supported accommodation have all been found to help individuals deal with psychosocial disability,7 but the effectiveness of these interventions is often dependent on how proactive the patient is. “Supported employment interventions, such as individual placement support, have shown success in helping people return to employment,” says Dr Griffiths. “However, this is more likely to be successful in those who are motivated to seek employment.”
For those who lack motivation, or who have more severe and longstanding psychosocial difficulties, a more intensive program might be required to address the complexity of their needs.5 For example, the National Health Service in England has set standards for Early Intervention in Psychosis services, which includes a choice of pharmacologic and psychological interventions, as well as access to healthy lifestyle programs, career-focused education programs, and cognitive behavioral therapy.8
The timing of any intervention is also important. Psychosocial disability often begins to develop prior to the formal onset of a disorder and diagnosis, and therefore early intervention is required to make sure psychosocial disability is not a long-term issue.6 Mental Health Australia has conducted a series of workshops on psychosocial disability, and as a result of the input of stakeholders involved, several recommendations were made in relation to the identification of people who experience psychosocial disability and the importance of early intervention. Services such as hospitals, general practitioners, and drug and alcohol services will need to work together to identify people in need, but it is agreed that the criteria for identifying these individuals is not currently consistent and therefore needs to be addressed.9
For those who do not have psychosocial disability or psychosis, but who are at high risk, Dr Griffiths believes it is important not to medicalize the disability. She also advocates that interventions be offered early and made available in a neutral place outside the health service, thus avoiding potentially medicalizing psychosocial disadvantage. “If someone is unemployed, for example, this doesn't necessarily mean there is a problem,” she says. “Also, not everyone who has difficulties with their day-to-day functioning will later [have] psychosis.”
Where next for those working within the field of psychosocial disability and psychosis? Some key points on which to focus when devising future strategies to support those vulnerable to psychosocial disability include:
- Regardless of whether psychosis develops, psychosocial disability affects many young people. Those with “not in employment, education or training” status are classed as high-risk for psychosocial disability, and preventative interventions could be targeted at this population.
- Untreated psychosocial disability can have an adverse impact on health outcomes, and because these difficulties often appear prior to the formal onset of a mental health condition, it is important that efforts be made to identify both the psychosocial disability and the mental health condition as early as possible to avoid entrenchment of impairments.
It has been acknowledged that early intervention in relation to the clinical aspects of mental health is more developed than early interventions related to the social aspects of mental illness.7 Current early intervention services do not appear to fully understand or address social disability, and therefore a review of these approaches and the development of new strategies would be beneficial. The National Health Service England guidance on Early Intervention in Psychosis supports this; the period from onset of psychosis to beginning of treatment affects long-term health outcomes significantly.9 Therefore, the quicker a well-rounded program that addresses all aspects of psychosis — including psychosocial disability — can be implemented, the better.
- National Institute of Mental Health. Mental Illness. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788. Updated November 2017. Accessed December 4, 2018.
- National Institute of Mental Health. Schizophrenia. https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml. Updated May 2018. Accessed December 4, 2018.
- Centers for Disease Control and Prevention. Disability Overview. https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html. Updated August 1, 2017. Accessed December 4, 2018.
- Iseselo MK, Kajula, L, Yahya-Malima, KI. The psychosocial problems of families caring for relatives with mental illnesses and their coping strategies: a qualitative urban based study in Dar es Salaam, Tanzania.BMC Psychiatry. 2016;16:146.
- Harvey C, Brophy L, Parsons S, Moeller-Saxone, K, Grigg, M, Siskind D. People living with psychosocial disability: rehabilitation and recovery-informed service provision within the second Australian national survey of psychosis.Aust N Z J Psychiatry. 2016;50(6), 534-–547.
- Griffiths SL, Wood SJ, Birchwood M. Vulnerability to psychosocial disability in psychosis.Epidemiol Psychiatr Sci. 2018;1-6.
- Hayes L, Brophy L, Harvey C, Herrman H, Killackey E, Tellez JJ. Effective, evidence-based psychosocial interventions suitable for early intervention in the National Disability Insurance Scheme (NDIS): promoting psychosocial functioning and recovery. https://www.mindaustralia.org.au/sites/default/files/publications/Effective_evidence_based_psychosocial_interventions_full_report.pdf. September 2016. Accessed December 4, 2018.
- NHS England (2016). Implementing the Early Intervention in Psychosis and Waiting Time Standard: Guidance. https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/04/eip-guidance.pdf. April 2016. Accessed December 4, 2018.
- Mental Health Australia (2018). National Disability Insurance Scheme: Psychosocial Disability Pathway. https://mhaustralia.org/sites/default/files/docs/ndis_psychosocial_pathway_consultation_project_-_final_report_-_may_2018.pdf. May 2018. Accessed December 4, 2018.