Socially Inappropriate Behaviour in People With First Episode Psychosis: A Caregivers' Perspective
Condition: First Episode Psychosis
MeSH terms: Psychotic Disorders; Mental Disorders
Study type: Observational

Summary: 
      Social impairment is one of the core symptoms in first episode psychosis (FEP). Despite
      negative symptoms and social cognition impairment found in patient suffering from FEP,
      clinicians occasionally identified socially inappropriate behaviours (SIB) after onset and
      stabilization of psychotic disorder. It is also uncommon that some caregivers often complain
      about their relatives with psychosis of embarrassing and immature behaviour. SIB mainly
      observed in form of excessive emotional expression, childish behaviour and regressive
      behaviour. There is limited research focusing on this inadequate behavioural pattern in
      patient with first episode psychosis recently. It was worth investigating this phenomenon and
      gain more understanding in other comorbidity symptoms and caregiving distress arisen from
      this. Psychometric tests and validated assessment tools are well-developed for measuring
      positive symptoms, negative symptoms, neurocognitive deficits and social cognition impairment
      in schizophrenic patients but none of them is useful specifically for assessing SIB, and not
      to mention, from carer's perspective. It could be an obstacle for clinicians to investigate
      the phenomena of the prevalence and the impact on family in real life without any validated
      assessment tools or questionnaires. This qualitative study aims to identify the SIB in
      patients with FEP and to explore the caregiving experience and distress. Hopefully, this
      study may help designing a questionnaire for future exploration on this topic.
    

Detailed description: 
      Study Design

      This study will be conducted in descriptive qualitative design. Descriptive qualitative
      design is an eclectic and pragmatic approach. It presents comprehensive summaries of a
      phenomenon or events in everyday language. It studies a phenomenon to discover patterns and
      themes about life events intensely. Meanings of the data provided by informants should be
      kept as much as possible in any interpretation of the researcher. It helps to in-depth
      understand the experiences of caring individuals with first episode psychosis in Hong Kong.
      It also allows them to express their observed socially inappropriate behaviors and perceived
      burdens and coping strategies in their own words. It allows researches to focus on
      discovering the experiences and gaining insights from informants regarding a poorly
      understood phenomenon and develop questionnaires or interventions.

      Sampling

      Purposive sampling will be employed in this study. Purposive sampling allows rich and
      in-depth data collection as researcher purposely selecting subjects who are judged to be
      suitable in the population or particularly knowledgeable about the issues under study. It is
      particular well suited to this study as it provides a systematic way of exploring the full
      picture of the observed phenomenon. Using homogeneous purposive sampling can ensure selecting
      samples for having a shared characteristic or set of characteristics and focusing on one
      specific subgroup in which all the sample members are similar in a particular level or
      hierarchy.

      The subjects will be recruited from Alice Ho Miu Ling Nethersole Hospital (AHNH) and North
      District Hospital (NDH) psychiatric specialist out-patient clinic. The psychiatrists working
      in Early Assessment Services for Young People with psychosis (EASY) team will refer the
      suitable Chinese cases after granted the agreement from potential subjects. The Inclusion
      criteria framed all target subjects were Hong Kong primary caregivers whose offspring was
      primary diagnosed of schizophrenic spectrum disorder with social inappropriate behavior after
      onset of illness. The patient should be under active care by EASY team. The cases of bipolar
      affective disorder and drug induced psychosis should be excluded from the study. In addition,
      the cases of active substance abuse and presenting active psychotic symptoms were also not
      suitable for the study.

      Study Population Description

      Socially inappropriate behavior was occasionally identified by clinicians in patient with
      first episode psychosis. SIB was mainly observed as social inappropriate affectionate
      behavior, childish behavior and regressive behavior. Clinicians observed some patient became
      excessively dependent on family members and displayed intimate physical contact towards
      family members. Such socially inappropriate behaviors may explain by frontal lobe dysfunction
      or deficits in theory of mind.

      Socially inappropriate behaviour, as well as social disinhibition, is defined as
      inappropriate behaviours in term of verbal, physical or sexual acts which reflect a loss of
      inhibition or an inability to conform to social or cultural behavioural norms. The broad
      definition of SIB is regarded as physical actions with intimate or sexual behaviours which
      acting impulsively in motor and verbal expression. Also, SIB is also descried as a
      behavioural syndrome characterized by immaturity and insensitivity towards others. Research
      study showed SIB could be assumed to result from deficits in theory of mind as patient failed
      to understanding of other's mind and perspective. Various psychiatric and neurologic
      disorders are notable for further developing of socially inappropriate behaviours. Frontal
      lobe dysfunction, frontal lobe lesions, traumatic brain injury, Tourette's syndrome and
      frontotemporal dementia were found correlated to the development of socially inappropriate
      behaviours. The affected patients are unable to correctly identify moral transgressions or
      having impairment in judgement in their actual behaviours, excessive emotionally based acts
      and sexual misbehaviours.

      Research studies indicated evidence in frontal lobe dysfunction is one of the major causes of
      SIB in the pathogenesis of schizophrenic spectrum disorder. The schizophrenic patient who
      suffered from frontal lobe damage demonstrated dramatic personality change, cognitive
      impairment and negative symptoms. The frontal system damage induced specific impairment of
      deficits in various aspects especially causing impulsive acts, inappropriate activities,
      excessive emotional expressions and childish behaviours. It is commonly to find patient shown
      declining in cognitive functioning, social impairment, poor motivation, lack of
      responsibility and impaired judgement in related to frontal lobe dysfunction.

      Data Collection

      Face-to face semi-structured in-depth interview will be arranged in order to explore the
      inappropriate social behavior and caregiver stress from caregivers. The interview will be
      guided by a semi-structured interview guide which specially designed for exploring clinical
      picture of inappropriate social and affectionate behavior and caregiving distress. The
      interview guide mainly consisted of specific questions and open-ended questions that
      encourage the subjects to talk freely in relevant topics during interview. Demographic data
      was also collected in the beginning of interview. Each interview will be conducted around 60
      minutes until data saturated. The interview will be audio-taped with informed consent from
      subjects. The interview will be audio-taped and being transcribed into verbatim in text
      material for data analysis.

      Data analysis

      Data collected in the interview was audio taped and being transcribed into verbatim in text
      material for data analysis. Content analysis is used for analyzing the content of the
      collected data. It is used for analyzing the numerous findings to identify prominent themes
      and patterns among all collected data. It is commonly known as breaking down collected data
      into smaller units and grouping the similar content and concept into a sub-group with
      specific coding and naming. Phases and key words identified in the content of collected data
      which shared the common ground and meaning were interpreted and divided into related themes
      in order to disseminate the findings in category scheme. It determines the trends and
      relationship of reality by systematic coding and categorizing approach. Verbatim and related
      narrative materials were reviewed repeatedly by principal investigator in order to identify
      the underlying themes accurately and precisely.

      Ethical Consideration

      The study was governed and monitored by NTEC-CUHK Joint CREC. Potential subjects were invited
      purposively to attend the interview with full disclosure of the study. Written informed
      consent must be obtained from the subjects before the interview. The consent form clearly
      stated the essential information of study and the rights of being a research subject in
      Chinese. Subjects had freedom to refuse joining the study and answering questions from
      researchers. Subjects had the right to withdraw from the study at any time. All data and
      information collected was regarded as confidential and strictly accessible by responding
      researchers only. All data collected will be encrypted with password (electronic documents)
      and placed in safety place with double lock (written documents). All data and information
      collected in the study including audio-tape recordings and the verbatim materials will be
      destroyed after the completion of the study. This study do not involve any treatment or
      procedure differ from current treatment practice to subjects.
    

Intervention name(s): Face-to face semi-structured in-depth interview
Intervention type(s): Other
Intervention description(s): Face-to face semi-structured in-depth interview will be arranged in order to explore the inappropriate social behavior and caregiver stress from caregivers. The interview will be guided by a semi-structured interview guide which specially designed for exploring clinical picture of inappropriate social and affectionate behavior and caregiving distress. The interview guide mainly consisted of specific questions and open-ended questions that encourage the subjects to talk freely in relevant topics during interview. Demographic data was also collected in the beginning of interview. Each interview will be conducted around 60 minutes until data saturated. The interview will be audio-taped with informed consent from subjects.
Observational model: Family-Based
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        Social impairment is one of the core symptoms in first episode psychosis and a part of its
        diagnostic criteria. Social impairment not only affects families and working performance
        but also creates distress and disharmony in social interactions and relationships. Despite
        of negative symptoms and social cognitive impairment found in patient suffering from first
        episode psychosis, clinicians occasionally identified socially inappropriate affectionate
        behavior after onset of psychotic disorder. Socially inappropriate behavior was mainly
        observed as social inappropriate affectionate behavior, childish behavior and regressive
        behavior. Clinicians observed some patient became excessively dependent on family members
        and displayed intimate physical contact towards family members.
      
Keywords: Regressive behaviors; Childish behaviors; Socially Inappropriate Behaviors; Qualitative study; Schizophrenic spectrum disorder; First episode psychosis; Caregiving experience; Caregiving distress