Early Occupational Therapy Intervention for Schizophrenia

The Potential value of Early Occupational Therapy Intervention for Adults with Schizophrenia.

Introduction (approx 250 words)

In this discussion, we would stress on the importance of occupational therapy in the treatment of schizophrenia and in vocational rehabilitation of schizophrenic adults. The discussions begin with examining the causes and aetiology, prognosis and diagnosis of schizophrenia, the symptoms involved and the general outlook of the treatment. We look at stress factors, genetic vulnerability, deformities in the brain, chemical imbalance in hormones and neurotransmitters in the body, faulty neural connections, increased or decreased size of brain parts, viral infections at foetal stage and pre and post natal complications that can all contribute to schizophrenia. The clinical manifestation of the disease usually shows early onset in male adults and schizophrenia is rare in children and elderly persons. Symptoms of the disease show the presence of hallucinations, delusions, disordered and bizarre thinking, social isolation and extreme suspicion. The various types of intervention programs for treatment and care of schizophrenia are then discussed and these range from pharmacological interventions to psychotherapy such as cognitive behavioural therapy and occupational therapy, family and psychosocial interventions. The different types of interventions including psychological, occupational and clinical have been suggested by the NHS and Department of Health and the role of mental health services has been stressed. The guideline issued by the National Institute for Clinical Excellence (NICE) suggests the need for care across all stages of the disease with medical attention at the initial acute stage of the disease. Treatment of acute episodes promoting reduction of symptoms and application of tranquilizers have been identified as essential and we discuss in detail the importance of occupation and the role of occupational therapists in aiming to restore a healthy life for schizophrenics.

Chapter 1 (approx 1200 words).

1. Aetiology of schizophrenia – Several Factors

The cause of Schizophrenia has not yet been conclusively established and several causes have been proposed. The interplay of genetic, behavioural, social and physiological factors may be responsible for the onset of the condition. Changes or deformities in the brain have been held responsible for development of schizophrenia although genetic factors are also important. Schizophrenia seems to run in families and a child born in a family with history of schizophrenia is 10 times more likely to develop the disease than anyone in the general population. Multiple genes are involved in developing a predisposition for schizophrenia although prenatal difficulties like intrauterine starvation or viral infections, peri-natal complications, and various non-specific stressors, seem to influence the development of the condition. However the mechanism of genetic transmission of the disease has not yet been established. Identification of specific genes in the human genome is underway and the strongest evidence suggest chromosomes 13 and 6 are responsible for susceptibility to schizophrenia. Some evidence that schizophrenia is related to imbalance in chemical systems of the brain suggests that neurotransmitters dopamine and glutamate are linked to the onset of the disease. Neuro-imaging studies have found abnormalities in the brain structure of schizophrenics with decreased or increased size of brain parts. However these brain abnormalities are not just present in people with schizophrenia nor are they common for all schizophrenics suggesting that these abnormalities may not have definite links with the disease. The National Institute of Mental Health (NIMH) has categorised schizophrenia as a developmental disease resulting when neurons form inappropriate connections in the foetal stage of development. However these faulty connections can remain dormant and tend to affect only after puberty when changes in the brain seem to get adversely affected by these dormant faulty connections. Certain biochemical changes have been found through brain imaging techniques as preceding the onset of disease so changes in neural circuits as well as molecular changes exploring the genetic basis of brain abnormalities have all been linked as causes of schizophrenia.

Recent studies have proved that schizophrenia and other mental ailments are caused by a combination of inherited genetic factors and external environmental factors and all current theories such as the chemical imbalance theory, genetic vulnerability theory, stress and vulnerability theory and complex disease theory reach similar conclusions. The two factors – genetic vulnerability and environmental vulnerability or stress and their effects on the body and brain have been found to play important role in Schizophrenia. Excessive stress, for example can trigger the release of certain hormones and result in increased levels of cortisol in the brain. Excessive cortisol in turn destroys nerve cells in the hippocampus that are responsible for memory and coordinating daily and complex tasks.

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The NHS emphasises that much of the available research on the aetiology of schizophrenia is consistent with a ‘stress-vulnerability‘ model of the illness (Nuechterlein & Dawson, 1984 cited in NHS, 2005),a model which arguably has the greatest utility in integrating current biological,psychological and social findings. This paradigm suggests that individuals possess different levels of vulnerability to schizophrenia, which are determined by a combination of biological, social and/or psychological factors. It is proposed that vulnerability to schizophrenia will result in the development of problems only when environmental stressors are present. If the vulnerability of an individual is sufficiently high, relatively low levels of environmental stress might be sufficient to cause problems. If the vulnerability is much less, problems will develop only when higher levels of environmental stress are experienced. The model is consistent with a wide variety of putative causes of the disorder, as well as the differential relapse and readmission rates observed among people with schizophrenia (NHS report, on Schizophrenia 2005).

1.2 Clinical Presentation of Schizophrenia – Early Onset.

Schizophrenia is a disabling and chronic mental ailment and has been related to brain disorder. The disorder appears earlier in men and usually affects women later in life. The vulnerable age for the disease is late adolescence to early adulthood in most men and affects men of age 16 to 30 years and women in their late twenties to early thirties. The disease is marked by early onset and is rarely found in older men or children, although such cases of very early or late schizophrenic acute phases have been reported. The disease once affecting an individual can cripple him for a lifetime. People with schizophrenia can have delusions and hallucinations and can even be paranoid that leave them fearful, suspicious and withdrawn. They may be incomprehensible or disorganised in speech and actions and lead a life completely isolated and excluded from social interactions (Schretlen et al. 2000). In most conditions they lose contact with reality and their repeated, meaningless and sometimes withdrawn and sometimes aggressive behaviour can be frightening to other individuals. The onset of schizophrenia is marked by withdrawal and shocking changes in behaviour and is accompanied by hallucinations, delusions, paranoia and false personal beliefs and unreal experiences (WHO, 1980). Social isolation and unusual speech or thinking are found in this acute phase of the disease. Chronic schizophrenic symptoms or a continuing or recurring pattern of illness in a patient signifies the necessity for long term treatment including medication and the patient may even fail to recover normal functioning. 1% of the population has been found to have this disease and the NHS and WHO give a statistical data on schizophrenia and we will be providing here. Sometimes people with symptoms of schizophrenia may show depressive mood or bipolar disorder and in some cases individuals may be diagnosed with schizophrenia like symptoms also known as schizoaffective disorder.

1.3 Early Intervention Service – Occupational Therapy (Core Skills).

Comparing the effectiveness of skills training with occupational therapy, Liberman et al (1998) studied community functioning of outpatients with persistent forms of schizophrenia after the patients were treated with psychosocial and occupational therapy or given social skills training conducted by paraprofessionals. For the study 80 outpatients with persistent schizophrenia were randomly selected and received psychosocial occupational therapy or skills’ training for 12 hours every week for 6 months and this was followed by 18 months of case management in the community. Antipsychotic medication was also given by psychiatrists. The results of the study indicated that patients who received skills training showed greater independent living skills during a 2 year follow up of everyday community functioning. Liberman et al concluded that skills training can be effectively conducted by paraprofessionals with durability and generalization greater than that achieved by occupational therapists who provide patients with psychosocial occupational therapy.

Whitwell (2001) discuss early intervention as a strategy in the treatment of mental illness carried out by specialised and innovative projects and approaches. Early intervention approaches have grown rapidly in the last decade as it has been observed that schizophrenia reaches a peak of severity after 2-5 years of its onset and after this the disability remains the same or decreases , also known as the ‘plateau effect’ (McGlashen 1988). Most people remain untreated for the first 1 or 2 years of the onset of illness and when left untreated, the illness set out biological, psychological and social processes that add to the chronicity of the illness and the illness may actually become toxic triggering chemical changes in the brain. The ‘critical period’ hypothesis or the necessity to intervene and treat the condition early is essential for developing newer insights into the nature of the illness (Birchwood et al 1998).Early intervention is the strategy for treating psychotic illnesses during its early stages of development, involving shortening the duration of untreated psychosis and may also involve intervention even before the psychosis develops. Early intervention with flexible and assertive approach on the part of occupational therapists is important in full recovery or prevention of the disease.

Chapter 2 (approx 2500 words), To evaluate the effects of

schizophrenia on the individuals occupational performance

2.1 The Occupational Nature of Humans.

Occupation of a human being refers to the role a person plays or an activity through which a person earns money or livelihood. With the emergence of occupational science and the realisation of health benefits of occupational engagement, there is a necessity for increased research into the occupational nature of humans. Chugg and Craik (2002) argue that engaging in occupations have a positive effect on an individual’s health and sense of well being, although in schizophrenia there is a decreased volition and reduction in occupation with lowered performance. Their study focused on the influences on occupational engagement for people with schizophrenia living in a particular community. They used semi-structured interviews and qualitative analytic approach. 4 male and 4 female participants aged 23 to 49 years described their occupational engagement and the associated influences. Content analysis along with coding was used to categorise the data and four main themes on health, routine, external and internal factors emerged from the study. The specific factors identified within these themes are medication, daily schedules, family, staff, work, self concept and life challenges. The role of occupational therapists to influence clients with schizophrenia to engage more successfully in occupations has been highlighted in the study.

Wilcock (1999) claim that the relationship between occupation and health and well being of an individual is very complex and can be described in many ways. Wilcock claims that the definition of occupation that appear to appeal a wide range of people is a synthesis of doing, being and becoming. Wilcock reflects on a dynamic balance between doing and being which is central to healthy living and wellness and suggests that becoming what a person or a community is best suitable for is dependent on both the doing and the being. Doing is what Wilcock suggests, the synonym for occupation and it is not possible to envisage a world without occupation showing the importance and central role of the occupational nature of humans. Being is represented by notions such as nature and essence and encapsulates being true to ourselves and individual capacities in all that we do. Becoming adds to this an element or sense of future and holds in it the notions of transformation and self actualization. Wilcock emphasises that becoming helps in actually enabling occupation with ideas on human development, growth and potential. The occupational therapists help people to transform their lives through enabling them to do and to be through the process of becoming. Philosophically, thus doing and being are integral to becoming and to occupational therapy, process and outcomes and Wilcock suggests how best to utilize these in self growth, professional practice, student teaching and learning and help individuals to influence a social and global change for healthier lifestyles.

2.2 Occupational Deficits associated with Schizophrenia

Bejerholm et al (2004) suggest that schizophrenia is a complex disorder and has severe impacts in daily life. The human occupational pattern is considered as a product of person-occupation-environment interaction and the importance of exploring all these three factors have been stressed as essential to understand the daily occupational patterns among persons with schizophrenia. Bejerholm’s study used data obtained from 10 schizophrenic individuals and examined their time use reflecting on their daily occupations, social and geographical environments, emotional reactions and reflections on their occupational performance. The results of the study indicated stagnation in a participants’ occupational pattern and time use. The authors suggest that most activities by schizophrenics are not triggered by a facilitating environment but happen due to factors inherent in the person triggered by basic and immediate life needs or simply for the need of escaping reality and seeking social isolation. The paper suggests that occupational therapists are capable of assisting people with schizophrenia to help reshaping the environment and help them to regain roles that involved interacting with the external environment.

Breier (1998) claims that schizophrenia is characterised by cognitive deficits in several human domains and involve dysfunction in attention, information processing, memory and executive performance. These deficits are observed in family members of schizophrenics as well suggesting a heritable component in the disease. Cognitive deficits also predate the onset of schizophrenia suggesting that core components of schizophrenia are not secondary to medication side effects or to positive or negative symptoms. Cognitive abnormalities tend to predict occupational and social dysfunction is a major determinant of long term outcome. Breier points out that traditional neuroleptic drugs have been proven to be relatively infective for the deficits and atypical antipsychotic drugs may have cognitive properties. One of these antipsychotic agents, olanzapine increases norepinephrine and dopamine in prefronatal cortex and produces mediated disruption in information processing with mixed effects supporting cognitive enhancing potential. Breier points out that that some recent trails, olanzapine, risperidone and haloperidol when used in comparative trials in early phases of schizophrenia have suggested that olanzapine demonstrates superiority for a number of cognitive domains over other antipsychotic drugs. Atypical drugs are increasingly used for the treatment of schizophrenia and may play even greater roles in the future.

2.3 The Value of Occupational Performance

Occupational therapy helps in assessing and remediation of human performance deficits and closely associated with enhancing occupational performance. Occupational performance is measured as the ability to perform tasks that make it possible to carry out occupational roles in a manner appropriate to an individual’s developmental culture, stage of life, and environment. Functional performance is important to occupational therapy and is required for assessment of a person’s level of functioning and for assessing the efficacy of interventions. Occupational functioning measures can be made at various levels of complexity and occupational therapists need to measure the level at which a mentally disabled individual can work.

The WHO classifies mental impairments on a functional hierarchy and provides the initial foundation according to which occupational therapists distinguish levels of functioning for various diseases. Lower levels of impairment signify dysfunction of organs and may not be accompanied by any impairment of functional ability. For example in case of diabetes or a related illness, a dysfunction of the pancreas may not involve impairments in occupational performance. Bio-mechanical and physiological aspects of motor performance are measured with the help of devices although measurements of occupational performance are a bit more complex as they involve an appraisal of abilities which can be measured, representing component parts of occupational performance. The importance of each of the component parts or abilities for measuring occupational performance can vary from one individual to another. Disability would usually refer to the inability to perform any particular physical task although motivational issues are important as these help to overcome disabilities in a person. The highest level of impairment categorized by WHO is a handicap, in which any disability severely impairs a person from performing a social or physical role successfully. Occupational therapists seek ways in handicap patients and help them to overcome performance deficits. However handicap is more of a socially defined phenomena rather than a quantifiable impaired physical ability and not being able to fulfil a social role is a serve problem faced by mentally ill patients, especially in schizophrenia. Occupational therapists tend to restore the social and psychological involvement to an extent in schizophrenic individuals. The measurement of occupational performance needs to be understood in social and individual contexts as also in the context of individual function and development.

2.4 The Relevance of Occupation

Occupational performance can be classified into four types according to the use of occupational performance as a generic frame of reference for national medical practice, as a frame of reference for occupational therapy curricula, as a term for the use of occupational therapists to explain practice and the use of occupational therapy to develop assessment tools. The concept of occupational performance is closely associated with therapy as performance indicated purposeful activity and consisted of areas in care, work and leisure activities. Skills in areas of performance are related life space of an individual and include the cultural, social and physical environment. Occupational performance is based on learning, developmental stages of sensory integrative functioning, social functioning, psychological functioning, cognitive functioning and motor functioning.

Based on the framework for occupational performance, a consistent occupational therapy model could be developed and the Canadian Association of Occupational therapy outlined the generic conceptual framework of function for occupational therapy to be followed by clients, in work settings and in modes of practice. In general the notion of occupational performance is affirming the worth of a person as an active participant in his or her therapeutic relationship although this concept gets into difficulty for patients with severe mental ailments. The three areas of occupational performance have been described as self care, productivity and leisure activities and four performance components recognised are mental, physical, socio-cultural and spiritual. Townsend et al stated “in achieving occupational performance, each individual both influences and is influenced by his or her environment” (1997, p.71).

2.5 Early Intervention of Schizophrenia – Department of Health objectives, NHS plan and guidelines of the Mental Health National Service Framework

The NHS describes schizophrenia as a mental illness with substantial short and long term consequences for individuals, family, health and clinical services and society. One in hundred people experience schizophrenia in their lifetime with highest incidence of the disease in late teens and early 20s. People with schizophrenia suffer distress and long term disability and there is a lot of accompanied stigma and prejudice involved with the disease that can have negative effects on employment, relationships and life satisfaction. A person’s family is completely destroyed with schizophrenia and carers and family members also carry the burden of the disease and caring the person for a long time. A schizophrenic family member can be a stress to the entire family. Schizophrenia costs the NHS more than any other mental illness and consumes more than 5% of the NHS budget as it is associated with a loss of income causing serious personal, medical, social and economic problems. Stigmatization, and discrimination is associated with schizophrenia and occur in wider society and diagnosis of the disease can have serious implications for a person’s career or social life. Even within the NHS, individuals with schizophrenia can receive substandard no psychiatric care as a result of professional ignorance and prejudice. However guidelines provided by the NHS are essential for improving services and provisions for schizophrenics.

The NHS, DH and NICE guidelines for schizophrenia can be given as follows

Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care, outlines best practice for health professionals caring for individuals with schizophrenia in a range of areas, including:

• Care across all stages (for example, the importance of working in partnership with service users and carers, and offering treatment in an atmosphere of hope and optimism)
• Initiation of treatment (for example, the development of early intervention services to provide appropriate care for people with suspected or newly diagnosed schizophrenia)
• Treatment of acute episodes (for example, the use of antipsychotic drugs as part of a comprehensive package of care that addresses the individual’s clinical, emotional and social needs)
• Promoting recovery (for example, the use of psychological interventions such as cognitive behavioural therapy to prevent relapse and reduce symptoms)
• Rapid tranquillisation (for example, minimising factors that might increase need for rapid tranquillisation and outlining the principles health professionals should follow)

The guideline has been developed by the National Collaborating Centre (NCC) for Mental Health. The recommendations in the schizophrenia guideline given by the NICE (National Institute for Clinical excellence- NHS) cover

psychological treatments,

treatment with medicines, and

how best to organise mental health services in order to help people with schizophrenia.

The guideline concentrates on services for adults of working age with schizophrenia and not on schizophrenia in childhood or schizophrenia starting in later life .

The guideline also does not cover diagnosis and assessment tools in detail.

It outlines the kind of treatment (medicines and psychological therapy) and services are of most help to people with schizophrenia, and whether treatment should be given as an outpatient, by a community mental health team, as an inpatient or in any other mental health service. It also outlines the role of GPs in managing and treating schizophrenia.

The Specific aims of the guideline of NICE and NHS on Schizophrenia are given below:

Source: NHS report on Schizophrenia treatment and Interventions guidelines

Source: NHS, 2005

The NHS report points out that the treatment and management of schizophrenia took place in large asylums in earlier times although government policy initiated a programme to change this practice and this has been largely possible by the introduction of conventional antipsychotic drugs such as chlorpromazine, thioridazine, haloperidol. The NHS mentions several interventions methods such as pharmacological treatment, psychological interventions, service level interventions, primary-secondary care interface, physical health care, and skills training as effective for treatment and support for schizophrenic individuals. We would discuss these methods of intervention in the next chapter.

Chapter 3.

A Critical Analysis of Early Interventions used by Occupational therapists.

3.1 Psychosocial intervention

Mueser and McGurk (2004) define Schizophrenia as a mental illness that is among world’s top ten causes of long term disability. The symptoms of schizophrenia include psychosis, apathy and withdrawal, cognitive impairment and these can lead to associated problems in social and occupational functioning as also problems with self-care. They also give the percentage of affected population at 1% across different countries, cultural groups and sexes. Mueser and McGurk point out that the illness develops between the ages 16 and 30 years and persists throughout the adult’s lifetime. Reiterating that the cause of schizophrenia is largely unknown, the authors claim that genetic factors, early environmental influences and obstetric complications, social factors such as poverty can contribute to the illness. Although pathophysiological differences exist in a wide range of brain structures , no biological alterations are symptomatic or pathognomic of schizophrenia. As for intervention methods, the authors emphasize that antipsychotic medication is the mainstay for managing schizophrenia although a range of other psychosocial treatments such as family intervention, supported employment and occupational therapy, cognitive behavioural therapy for psychosis, social and skills training, teaching illness self management skills, assertive community treatment and other forms of integrated treatment for co-occurring substance abuse are equally important. In this section we would discuss several intervention methods and approaches highlighting on the three important ones including the broader category of psychosocial intervention, skills training and pharmacologic or medical treatments.

Schizophrenia is a chronic disorder that can affect an individual during the early adult years or adolescent period of life. It is usually marked by acute and sometimes frequent relapses. In acute conditions, the main treatment method is controlling the symptoms and this is done with the application and administration of antipsychotic medication, psychotherapy and counselling and a variety of other methods. Antipsychotic medication prescribed by psychiatrists is the most common form of treatment and both older typical medication as well as newer anti-psychotics are used which are usually taken by the patient once in every two to four weeks. Injections given are usually thought to improve effectiveness of medication. Newer atypical anti-psychotics are generally used for acute episodes although there is very little evidence that they prevent relapses. Talking treatments and therapies involve meetings with therapists, general support and advice on illness and some deeper analysis may also be involved. However certain types of therapies may not be effective treatments of acute symptoms although they may help in particular problems as in vocational rehabilitation or occupational therapy who are helped to learn self help skills and given vocational training or aided to get back to earlier work. Antipsychotic medication is sometimes given in combination with occupational and other types of therapy although these drugs may have many long term side effects. Typical anti psychotics were known to cause disorders in movement although the newer varieties may have other side effects such as weight gain. Talking therapies along with medication can help improve compliance with the antipsychotic medication given and increase general knowledge about the illness making patients more aware of their condition. Patients are usually treated by a team of professionals comprising of psychiatrists, occupational therapists, social workers and nurses. Community psychiatric nurses or CPNs treat outpatients and provide both therapeutic and medical help. Social workers tend to address family problems and related issues. Vocational rehabilitation is given by occupational therapists, psychiatrists give medical help and advice and clinical psychologists usually undertake psychotherapy and engage in talking cure remedial measures.

Occupational therapy is skilled treatment helping affected individuals to achieve independence in all areas of life. Occupational therapy he