Schizophrenia and related

disorders
An occupational therapy
perspective
 Introduction
• Schizophrenia is one • Activity 1
of a number of • From your
conditions (often preparatory reading,
called psychoses) define hallucinations
and delusions –
characterised by:
giving examples if
• A loss of contact possible
with reality, usually
• What other things
including:
might lead to similar
• Delusions
symptoms to
• Hallucinations
schizophrenia?
Gaining an understanding of
typical psychotic symptoms
 Example
• The next slide is a sample movie of a part of a
new piece of ‘virtual reality’ software
designed to help healthcare professionals
understand what psychotic symptoms are
like
• Although the movie is not the ‘full’
experience, it may still cause you distress. If
you anticipate such difficulties, or find you
become too distressed during the movie,
The Degeneration of the Psychotic Perception of
the World:
Paintings of cats by Louis Wain (1860-1939)
•Subsequently, his
Pre-morbid artwork artwork showed
evidence of his
progressive loss of
contact with reality.
•Wain began to
suffer symptoms of
very late-onset
schizophrenia at age
57. He never
recovered
•Focus particularly
on the way cats’ eyes
are seen…
 Disordered thinking
• ‘When we dream, all sorts of strange things can
happen to us, but we still believe that they’re really
happening to us. Hearing voices can be like that - a
waking dream - but something that is experienced as
real.’
• (Darton & Sharman, 2004)
• Unlike anxiety-based disorders, the symptoms
ascribed to psychotic disorders may appear to be
outside our experience. This quote, however,
suggests that our dreams may provide a means of
understanding these symptoms.
• In pairs, discuss past dreams you can remember:
• Do you recall strange beliefs, disembodied voices, strange
 Hallucinations
• What do you do?
• Your mobile phone rings. You
answer it, and a voice says,
“Careful - they’re all watching”
• When you respond to the caller,
there is silence
• You discover that the phone is
switched off
• You later find out that the
battery has run out
• Discuss in groups:
• Why do we tend to
rationalise ?
Key Features

First episode
 First-episode schizophrenia
• Three typical phases (Bonder 2004:96):
• Prodromal
• First symptoms appear, but condition may not be recognised (Ballas
2007)
• Symptoms are non-specific; and do not necessarily lead to ‘full’
schizophrenia (White et al 2006:376)
• “In essence, the prodrome is the period between the most valid
estimates of the onset of change in the person and the onset of
psychosis ” (Yung & McGorry 1996:355)
• Active
• Dominated by positive symptoms
• Phase for which diagnosis can be (retrospectively) made
• Diagnosis cannot be made until minimum criteria have been evident for 1
month (ICD-10) or even 6 months (DSM-V)
• Residual
• Active phase has passed; but similar features to prodromal phase
remain
• ***NB*** Although this is the typical pattern after first episode, some
patients appear to make a full recovery
 The prodromal phase –
handout activities
• In small groups:
• Read the case study on page 3
• From Møller and Husby’s list of prodromal features (page 2),
is there sufficient evidence available for a diagnosis of
schizophrenia here?
• How else might this girl’s presentation be explained?
• Look at the graph showing the development of
psychosis over time
• At which arrow point would you say the prodromal phase
begins?
• When would you say that the prodromal phase ends, and the
active phase begins?
The active phase – a MOHO
perspective
• In the first episode
of psychosis, what is
likely to be the effect
on a person’s:
• Occupational
competence?
• Occupational
identity?
• What are the
implications of this
for the focus of our
intervention?
 The active phase – effect on volition
• Personal causation
• Delusions such as thought insertion/ withdrawal; thought
broadcasting (involuntary); ideas of reference; and passivity are
likely to lead to a sense of loss of control (lowered personal
causation)
• In contrast, grandiose delusions may lead to inappropriately high
personal causation
• Interests
• Person may appear to have lost interest in previously valued
occupations, and may appear disinterested in other suggested
activities (anhedonia)
• However, there may be an obsessional interest in one or two
(sometimes delusionally-based) activities – examples?
• Values and goals
• Values may be confused and related to disordered thinking
• Lack of clear goals
 The active phase – effect on
• Habits
• May lose all sense of daily/weekly schedules - leading to, e.g.,
lateness for appointments; disrupted pattern of waking/sleeping;
self-neglect (missing meals, forgetting to wash/bathe/change
clothes)
• Alternatively, may develop a very fixed, limited routine of
activities, as a coping strategy
• Possible development of an opportunistic pattern of behaviour –
‘drifting’ into any activities that are around, but not tending to
initiate many independently
• Pre-occupation with one or two activities leading to impoverished
routines
• Roles
• Perception of roles may change due to delusional beliefs
• Disruption to volition and habits is likely to seriously disrupt pre-
morbid roles
The active phase – effect on performance
• Performance capacity
• Objective capacity not significantly affected during first episode
(likely to still be have the capacity to carry out pre-morbid
activities) – usually able to return to full capacity once active
symptoms ha
• Subjective capacity, however, may be significantly impaired by a
belief that they are being prevented from performing these
activities (c.f. reduced personal causation)
• Performance behaviour
• Mind, brain and body performance may all be significantly
impacted as a result of symptoms (e.g. difficulties in concentrating
due to hallucinatory experiences) and/or side-effects of
medication
• Participation
• Work, play and ADL all significantly impaired during active phase
 The active phase – effect on skills
• Perceptual-motor and process skills
• Difficulty in accurately perceiving ‘real’ experiences
• Active-phase symptoms may include perceptions of bodily control
• Abnormal movements?
• Symptoms of illness
• Side-effects of medication (Parkinsonian)

• Communication and interaction skills

• Disordered speech
• Paranoia and delusions
• Withdrawal from social situations
 The first episode and beyond
Pre-morbid
Full symptoms
presentation
not developed

Prodromal
phase

Residual
Active phase
phase

Never fully
No further recover (10%
episodes (20% of of those
those developing developing
symptoms) symptoms)
Prognosis after first episode
• Patients who never recover
will need ongoing support
from professional services
• 50% of patients relapse in less
than 2 years
• Rises to about 61% by 5 years
• “In most patients (> 60%),
schizophrenia has a
prolonged, remitting/
relapsing course with variable
inter-episode recovery; acute
relapses may occur years after
remission” (Frangou &
Kington 2004:24)
• Each relapse produces
increased levels of residual
symptoms
• Eventually, changes to brain
structures become apparent
 Living with schizophrenia: shared
narratives
(Gould et al, 2005)
• Overall theme: “And • Using handout #2
then I lost that life” (p.467 of this article):
• Five chapters: • Summarise the key
implications of this study
1. I remember when I
for practice
was normal
• Discuss how you might
2. It’s like your computer
identify what stage in the
crashes
journey an individual is
3. Coasting through life at
4. Try to remake that life • Brainstorm different
as best you can occupations that might
5. Finally, I can move on be appropriate at each
Quality of life with schizophrenia
(Lalibert-Rudman et al, 2000)

• Seven major factors: • These factors relate to

• Activity three overall themes:
• Social interaction • Managing time
• Time • Connecting and
• Being “normal” belonging
• Disclosure • Making choices and
maintaining control
• Finances
• Management of illness
As an OT, how would you structure an
intervention to ensure these themes and factors
are suitably addressed?
 Schizophrenia – a long-term
perspective
• Research is increasingly challenging the
traditional, pessimistic view of
schizophrenia as almost always chronic
and progressive. (Macrae 2005:151):
• Some studies suggest that recovery or
significant improvement may occur in
about 68% of cases (McGuire 2000)
• However, such improvement may take 2-3
decades to occur
 References
• Ballas, P (2007). Early detection of schizophrenia:
the prodrome phase.
• Accessed online at
http://www.healthcentral.com/schizophrenia/c/76/3075
(15.09.08).
• Bonder (2004). Psychopathology and Function.
Thorofare, New Jersey: SLACK Inc.
• Darton K and Sharman J (2004). Understanding
Psychotic Experiences. London: Mind.
• Available online at:
http://www.rcpsych.ac.uk/mentalhealthinformation/defi
(2.10.06).
• Frangou, S and Kington, J (2004). Schizophrenia.
Medicine 32(7):21-25.
 References
•Geanellos, R (2005). Adversity as opportunity:
living with schizophrenia and developing a resilient
self. International Journal of Mental Health Nursing
14(1):7-15.
•Gould, A; DeSouza, S; and Rebeiro-Gruhl, KL

(2005). And then I lost that life: a shared narrative of

four young men with schizophrenia. British Journal
of Occupational Therapy 68(10):467-473.
•Laliberte-Rudman, D; Yu, B; Scott, E; and

Pajouhandeh, P (2000). Exploration of the

perspectives of persons with schizophrenia
regarding quality of life. American Journal of
Occupational Therapy 54(2):137-47.
 References
•Macrae A (2005). Schizophrenia. In: E Cara and A Macrae
(Eds). Psychosocial occupational therapy: a clinical practice.
Clifton Park, New York: Thomson Delmar Learning.
•Møller, P & Husby R (2000). The initial prodrome in

schizophrenia: searching for naturalistic core dimensions of

experience and behaviour. Schizophrenia Bulletin 26(1):217-
232.
• Accessed online at
http://schizophreniabulletin.oxfordjournals.org/cgi/reprint/26/1/217
(05.10.08).
•White, T; Anjum, A; and Schulz, SC (2006). The
schizophrenia prodrome. American Journal of Psychiatry
163(3):376-380.
•Yung, AR & McGorry, PD (1996). The prodromal phase of

first-episode psychosis: past and current conceptualizations.

Schizophrenia Bulletin 22(2):353-370.
• Accessed online at