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The University of Texas at Tyler Magazine, Fall 2009

Focus on Faculty
Restoring Lives
Dr. Dennis Combs Creates Solutions for Persons with Schizophrenia

Dr. Combs and student demonstrating eye tracker technology

Nathaniel Ayers attended the exclusive Juilliard School on scholarship, preparing for a career as a concert cellist. But he suffered a mental breakdown in his junior year. The 21-year-old dropped out of school and off the radar. Thirty years later, a newspaper reporter spotted him in downtown Los Angeles. Instead of performing in grand concert halls, Ayers was playing a badly beaten violin on the streets of Los Angeles. He was homeless and delusional.

John Nash was a mathematician gaining prominence for his groundbreaking research in game theory, algebraic geometry and nonlinear theory. But at age 31, he began to lose his grip on reality.

Nash’s progression from a mathematical mastermind to the abyss of schizophrenia was the subject of author Sylvia Nasar’s “A Beautiful Mind’’ and the 2001 film of the same name. Ayers’ descent from musical genius into the depths of the severe mental disorder became the subject of columns and a book by Los Angeles Times journalist Steve Lopez and the 2009 film “The Soloist,’’ based on the book.

Their stories have increased public awareness about the illness in recent years. But schizophrenia, a type of psychosis that often emerges during a person’s critical career-forming years, ages 18-35, has been disrupting lives throughout recorded history. Schizophrenia affects more than 3 million Americans, according to the National Institute of Mental Health. And researchers continue to study the disorder in search of ways to treat it.

Dr. Dennis Combs, an assistant professor of psychology at The University of Texas at Tyler and licensed clinical psychologist, has devoted more than 10 years to studying social cognition, paranoia and other psychological problems associated with schizophrenia. And he has collaborated with two other researchers to create Social Cognition and Interaction Training, a new intervention that is receiving international attention for improving the lives of persons with schizophrenia.

A group therapy addressing social dysfunction, SCIT has been featured by “ABC News’’ and “Psychiatric Services,’’ an American Psychiatric Association journal, as a potential best practice in rehabilitating schizophrenic patients.

Dr. Combs and his colleagues – Dr. David Penn, a professor at the University of North Carolina at Chapel Hill, and former UNC graduate student David Roberts, who is doing post-doctoral work at Yale University – hope to help schizophrenic patients worldwide through SCIT.  

The researchers are receiving calls from hospitals and clinics across the globe with an interest in the therapy. They have traveled the United States and abroad to train mental health professionals to conduct the intervention. And the SCIT training manual has been translated into different languages including Hebrew, Japanese and Korean.

“We developed the intervention because there really was nothing out there that focused on improving the social abilities of people with schizophrenia. That is why the therapy is generating so much interest. And patients have reported that their lives are much better as a result of the therapy,’’ said Dr. Combs, who gives UT Tyler students opportunities to assist in this leading-edge research.

Devastating Disorder

Schizophrenia can cause unusual thoughts or perceptions, such as hallucinations, delusions and paranoia; a loss in the ability to initiate plans, speak, express emotion or find pleasures in everyday life; and problems with attention and memory.

Researchers have determined it is a brain disease resulting from a combination of environmental and genetic factors, but they continue to search for specific causes and ways to prevent and cure it, according to NIMH. Current treatments, including medication and therapy, focus on eliminating symptoms.

Dr. Dennis CombsA Marshall native, Dr. Combs received a bachelor of arts degree in psychology at East Texas Baptist University in 1993 and a master of science in clinical psychology at UT Tyler in 1996. He went on to earn a doctorate in clinical psychology at Louisiana State University in 2002.

The professor chose schizophrenia as his main area of research because of the severity of the disorder. He had personally witnessed the disease’s devastating effects.

“Growing up, I had an aunt who was diagnosed with schizophrenia,’’ Dr. Combs said. “We used to visit her and she was always acting bizarrely. She would cover her windows and barricade herself in her house, and she just grew worse over the years. I never really understood what was wrong with her until I began learning about schizophrenia. Looking back, I believe more could have been done to help her.’’

Schizophrenia is one of the most severe mental disorders, he said, “and it’s probably the most costly of all mental disorders, including depression and bipolar disorder, in terms of what it does to people.’’

The disorder affects men and women equally and occurs at similar rates in all ethnic groups, according to NIMH.

“There’s a lot of stigma associated with schizophrenia, but these are just regular people, struggling with a condition and trying their best to cope with it,’’ Dr. Combs said.

 “Many of them were good students through high school, they had plans to go to college, but then at age 17 or 18 they became ill. Others graduated from college before their symptoms emerged. They were musicians, they were artists, writers. We’ve worked with teachers who are no longer able to teach. Schizophrenia takes away their motivation, it just takes away all their drive.’’

Although he is not familiar with Ayers’ story, Dr. Combs saw the film based on Nash’s struggles and found it to be a “really good portrayal of a schizophrenia client.’’

Nash carved out a successful career in mathematics research and was about to become a full professor when he began to slip from scientific to delusional thinking in 1959. His bout with the disorder, which included severe delusions and hallucinations, would sideline his career for the next three decades. He spent some of those years wandering the campus of Princeton University, where he had earned his doctorate and conducted breakthrough research.

Making a Difference

Dr. Combs’ studies in schizophrenia intensified at LSU, under the mentorship of Dr. Penn, who was on the faculty and conducting research in social cognition and psychosocial treatment for the disorder.

“Fortunately, I was interested in schizophrenia and Dr. Penn, one of the top experts in the world of schizophrenia research, had an opening for a student assistant at the time,’’ said Dr. Combs, whose research focuses primarily on social cognition in schizophrenia and treatment and assessment of paranoia, psychosis and delusions. Dr. Combs’ interests also include cultural aspects of psychosis and cognitive behavioral therapy.

Social dysfunction is among the most debilitating aspects of schizophrenia, the professor said. Schizophrenic patients typically have problems with social cognition, or the ability to understand, perceive and interpret the intentions and dispositions of others. Social interactions can be stressful for them, causing them to become fearful, hostile or emotionally distressed.

“With these types of social challenges, it becomes very difficult for people to earn a living and function in their communities,’’ Dr. Combs said.

SCIT addresses both social cognition and social functioning in schizophrenic clients to help them function better in everyday life.

The intervention provides social skills training in the ability to perceive the emotions of others; theory of mind or the ability to understand others’ intentions or perspectives; and attributional style, the ability to assume a reasonable explanation for a positive or negative outcome in a social situation.

 “In a sense, we’re retraining their brains to be more efficient in processing social interactions,’’ Dr. Combs said of SCIT, which can work in conjunction with the client’s medication.

Conducted in one-hour weekly sessions over a six-month period, the therapy consists of three phases and involves video tapes, computerized activities, role playing and other tools that are both engaging and enlightening.

“The first seven sessions are all about emotion training, during which we’re helping them to recognize emotions,’’ the professor said.

“The second phase involves ‘figuring out situations,’ and what we do is teach them how to be better ‘social detectives.’ For instance, you set a date with someone and they don’t show up. You need to figure out why they didn’t show up, because understanding why will help you deal more adaptively with the situation. So we teach them how to get information and not jump to conclusions.

“The third phase is what we call ‘checking it out,’ in which they take everything they’ve learned and apply it to their own lives.’’

Clients in the third phase are encouraged to talk about troubling interpersonal situations. And they are walked through the process of identifying the other person’s affect, distinguishing facts from guesses, avoiding jumping to conclusions, and forming a solution or action plan.

Pilot testing of the intervention in 2007 demonstrated that SCIT improved emotion perception and theory of mind, and reduced the tendency to attribute hostile intent to others. Patients also were less likely to act out in an aggressive way.

After the pilot testing, UT Tyler and UNC received a three-year NIMH grant for $425,000 to further investigate SCIT. Dr. Combs and student research assistants in the UT Tyler Psychotic Disorders Research Laboratory are conducting randomized controlled trials to test the intervention’s effectiveness. Although the testing of SCIT will not conclude until 2010, the intervention continues to produce good results.

Dr. Combs has seen remarkable improvement in the lives of SCIT participants.

“People have returned to work after treatment. Several people we’ve worked with have returned to school. They finally felt ready to go back into a classroom and focus and be around other students. Others were able to reconnect with family members who had kind of abandoned them,’’ he said.

“Those are real-world success stories, and that’s what the field of psychology is all about. I teach my students that when they complete their education in psychology, it’s important to get out and help people. I can sit in my office and write research papers and grant proposals, but there’s much more to being a psychologist than that. Our field is about helping others,’’ said the professor, who has published more than 45 research papers.

Additional Interventions

Dr. Combs’ work to improve social cognition in schizophrenia does not end with SCIT. He has created a computerized attention shaping program to improve emotion perception by drawing attention to the face.

The professor developed the intervention after noticing schizophrenic clients in social interactions were paying little or no attention to faces, which convey important social information.

The program engages computerized prompts to draw the client’s attention to portions of the face including the eyes and mouth, which are most salient to emotional expressions. Faces conveying various emotions are displayed on the screen, and the client is asked to identify each emotion.

Dr. Combs’ research lab is equipped with state-of-the-art eye tracker technology that enables him and his student assistants to detect what parts of the face the client is viewing.

“What we’re seeing is that when they first come in, they’re looking at different parts of the face, but not the eyes and mouth. After participating in the computerized attention shaping program, they have significantly higher scores on the Face Emotion Identification Test,’’ he said.

NIMH awarded the professor a grant for $67,000 to investigate the effectiveness of the intervention. Results of his two-year investigation, published recently in the journal “Schizophrenia Research,’’ showed improvement not only in emotion perception but also in social behavior.

Dr. Combs said the attention shaping program can be integrated into SCIT and other interventions or serve as an individual rehabilitation training program for persons with schizophrenia.

Beyond his work in social cognition, Dr. Combs also conducts research in cognitive behavioral therapy for schizophrenic symptoms. The therapy teaches patients to test the reality of their thoughts, reject hallucinatory voices and shake off the apathy associated with the disorder.

The professor recently completed a book chapter with instructional guidance for practitioners on conducting the therapy. It is set to be published this year.

The Ultimate

Through self-will and the support of family and former colleagues, Nash gradually learned to resist his delusional thoughts and gain some control over his mental state. He returned to his research in mathematics in the 1990s and, in 1994, was awarded the Nobel Memorial Prize in Economic Sciences for his earlier work in game theory.

It’s the kind of success story Dr. Combs likes to hear. And it’s the kind of success he hopes will be repeated again and again, in other lives that have been disrupted by schizophrenia.

Restoring lives is the ultimate goal of his research.

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