Schizophrenia And Related Disorders

Schizophrenia and related disorders An occupational therapy perspective

Introduction • Schizophrenia is one of a number of conditions (often called psychoses) characterised by: • A loss of contact with reality, usually including: • Delusions • Hallucinations

• Activity 1 • From your preparatory reading, define hallucinations and delusions – giving examples if possible • What other things might lead to similar symptoms to 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)

Pre-morbid artwork

•Subsequently, his 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 premorbid 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 presentation

Full symptoms not developed

Prodromal phase

Residual phase No further episodes (20% of those developing symptoms)

Active phase Never fully recover (10% of those developing 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 then I lost that life” • Five chapters: 1.

I remember when I was normal

2.

It’s like your computer crashes

3.

Coasting through life

4.

Try to remake that life as best you can

5.

Finally, I can move on

• Using handout #2 (p.467 of this article): • Summarise the key implications of this study for practice • Discuss how you might identify what stage in the journey an individual is at • Brainstorm different occupations that might be appropriate at each

Quality of life with schizophrenia (Lalibert-Rudman et al, 2000)

• Seven major factors: • Activity

• These factors relate to three overall themes:

• Social interaction

• Managing time

• Time

• Connecting and belonging

• Being “normal” • Disclosure • Finances • Management of illness

• Making choices and maintaining control

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):217232. •

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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. •

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Accessed online at