Course:RSOT513/2010W2/psychotic

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Schizophrenia

Despite that schizophrenia's etymology is from the Greek for “split mind”, it should not be confused with split personality disorder.[1] Schizophrenia is a complex mental illness that renders it difficult for individuals to distinguish between real and fictitious experiences, think logically and have socially appropriate emotional and behavioural responses.[2] Schizophrenia is a type of psychotic mental disorder and presents with hallucinations, delusions, and disorganized thinking.[2] Schizophrenia puts a substantial burden on an individual as it interferes with the person's everyday life, both socially and personally.

Prevalence and Etiology

Prevalence

A systematic review of 188 epidemiological studies showed that the point and lifetime prevalence values of schizophrenia are 4.6 and 4.0 per 1,000 persons, respectively.[3] Meta-analysis indicated lifetime morbid risk as 7.2%[3], which runs counter to the 1.1% figure often quoted in literature.[1] No significant difference was found in prevalence between males and females, nor between urban, rural, and mixed populations.[3]

The average age of onset of schizophrenia is 18 for men and 25 for women[1], and generally develops in late adolescence and early adulthood.[1][3] People with schizophrenia have abnormalities in their brain’s structure and function due to atypical neurodevelopment.[3][4] These abnormalities occur before the individual exhibits any observable symptoms of the disorder.[3]

Etiology

No single, equivocal cause of schizophrenia has been identified. Schizophrenia appears to be the result of multiple causes including genetics, perinatal factors, and environmental and psychological stressors. Studies on maternal twins have shown heritability rates of up to 40% or more.[1] The increased likelihood of schizophrenia among relatives of diagnosed individuals has been extensively documented in family, twin, and adoption studies.[5] Vulnerability to the illness has also been attributed to disruptions in normal fetal development due to gestational hypoxia and maternal malnutrition, stress, and infection.[1][3][4] People with schizophrenia are more likely to be born in the winter or spring months, which corresponds to the annual flu season, reinforcing the notion that maternal infections contribute to the vulnerability of schizophrenia development.[3] Furthermore, in critical periods of brain development, such as adolescence, stressful events[3], trauma and drug use[1][4] may trigger the incidence of schizophrenia in a vulnerable individual. Environmentally, the incidence rate of schizophrenia increases when a person grows up in an urban setting in comparison to a rural setting.[4]

Signs and Symptoms

Schizophrenia seems to have a sudden unexplained onset, but once a diagnosis is made, families and friends admit they have noticed prior behavioral changes. Some of the early warning signs are changes in hygiene, dress, facial expression, speech, and interaction.[2] In addition, problems with social functioning such as hypoactive or hyperactive, euphoric or depressed mood, disturbances in sexual behavior, complaints about the body, obsessiveness, guilt, unpredictable or odd behavior, suspicion, anxiety, and fearfulness may be noted.[2]

The symptoms of schizophrenia are divided into positive and negative categories. The positive symptoms reflect alterations of reality such as delusions, hallucinations, disordered speech, or grossly disorganized behavior.[6] Negative symptoms present as a lack of normal behaviors, such as flat or blunted emotional expressiveness, alogia (very little speech), and avolition (lack of ability to initiate or persist in goal-directed activities).[6]

Diagnostic Criteria (DSM IV-TR)

There are no diagnostic tests for schizophrenia and therefore a diagnosis must be made based on the client's history. In North America the criteria used for diagnoses is found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - IV - TR.[6] An individual must meet this criteria to be diagnosed as a person with schizophrenia. The criteria of the DSM IV-TR is as follows:[6]

  • A. Characteristic symptoms: two (or more) of the following, each present for a significant portion of time during a one-month period.
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Grossly disorganized or catatonic behavior
    • Negative symptoms (e.g., affective flattening, alogia, or avolition)

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices are conversing with each other.

  • B. Social/occupational dysfunction. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset.
  • C. Duration. Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A.
  • D. Schizoaffective and mood disorder exclusion. Schizoaffective and mood disorders are the two main differential diagnoses of schizophrenia. Schizoaffective disorder and mood disorder psychotic features are ruled out because either (a) no major depressive, manic or mixed episodes have occurred concurrently with the active-phase symptoms; or (b) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active residual periods.
  • E. Substance/general medical condition exclusion. The disturbance is not due to the direct physiologic effects of a substance or a general medical condition.
  • F. Relationship to a pervasive developmental disorder. If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Differential Diagnosis

The issue with relying on diagnostic criteria, rather than laboratory testing for diagnosis, is there are other conditions which present themselves in similar ways to schizophrenia. The differential diagnosis requires the assessor to distinguish schizophrenia from, most commonly, bipolar disorder, schizoaffective disorder and brief psychotic disorder.[7] In order to differentiate these disorders from schizophrenia, one needs to determine the intensity of mood alterations and duration of psychotic episodes presented by the client.[7] Other disorders that may have similar representations are obsessive compulsive disorder, post-traumatic stress disorder, drug induced psychoses, and schizoid personality disorder.[7] In order to discern schizophrenia from these illnesses, the assessor needs to collect an appropriate, thorough medical and social history of the client to determine if there are other causative factors for the client's symptoms.[7]

Occupational Therapy and Schizophrenia

It is evident that schizophrenia creates a significant impact on the daily life of individuals. The profession of occupational therapy (OT) aims to enable individuals with schizophrenia to regain their ability to function in their daily lives as independently as possible. In order to organize practice, occupational therapists look at the activities people engage in as self-care, productivity and leisure.

Self-Care

The Canadian Association of Occupational Therapy (CAOT) defines self-care activities as “occupations for looking after the self” (p. 37).[8] These occupations consist of various activities required for personal maintenance and include: activities of daily living (ADLs) such as personal hygiene and grooming, bathing, dressing, eating, mobility, sleep and rest, and bowel and bladder management; and instrumental activities of daily living (IADLs) such as health, home and financial maintenance, meal preparation, shopping, and community mobility.[9] Individuals with schizophrenia often experience deficits in many self-care activities, thereby limiting their ability to live independently.[10]

Implications of Schizophrenia to Self-Care

  • Initial signs and symptoms of schizophrenia include negative changes in hygiene and dress.[11][12]
  • Individuals show deficits in performing IADLs.[13][11]
  • Weight gain is a common side effect of antipsychotic medications[12][14][15] and is also related to poor nutrition and decreased physical activity.[15] Studies have shown that individuals with schizophrenia spend the majority of their time participating in passive activities.[16][17]
  • “Self-care” activities that are detrimental to personal health, such as smoking, are common in this population.[17]
  • Suboptimal medication adherence is also common.[12][13][18] Atchison et al.[12] state that treatment with medication is “complicated because of the cognitive deficits in schizophrenia” (p. 83). Adherence may also be related to the side effects of the medications, which manifest quickly, whereas the therapeutic effects may take longer to emerge.[15] Other factors include patient support, therapeutic relationships, insight, and, attitudes toward medication.[18]
  • Avolition, a negative symptom of schizophrenia, significantly affects performance in self-care activities.

The individual’s deficits in self-care activities may be further exacerbated by sensorimotor, cognitive, and psychosocial symptoms.

Cognitive
  • Cognitive deficits affect problem solving, executive functioning and memory.[12][11][15] According to Atchinson et al.[12], “memory deficits as a result of schizophrenia affect daily occupations” (p. 72).
  • Frequently, individuals also experience chronic fatigue[12][11][15] and sedation is a common side effect of anti-psychotic medications[12][14] This fatigue, in turn, affects cognition.
  • According to Sadock and Sadock[15], “cognitive impairment is a better predictor of level of function than is the severity of psychotic symptoms” (p. 485).
Sensorimotor
  • Sensorimotor deficits include hallucinations[12][11], sensory integration dysfunction[11], slow information processing[11], and poor gross[11] and fine motor skills.[15]
  • Tardive dyskinesia, a common side effect of medication[12][14], may play a significant role in self-care engagement[11][15] and affect an individual’s ability to walk, talk, eat, and breathe.[15] According to Atchinson et al.[12], the effects of this constant, involuntary movement on “performance in activities of daily living…can disturb patients enough for them to refuse to take medications” (p. 84).
Psychosocial
  • Individuals with schizophrenia often have social interaction deficits[12][19] such as poor communication skills[11] and Yilmaz et al.[19] identify the importance of “cooperating with professionals and/or people close to them to enable [them]… to manage their daily life” (p. 163). Thus, social skill deficits may hinder their ability to create the personal and professional relationships that are essential for the successful engagement of many self-care occupations.

Occupational Therapy Intervention for Self-Care

While a combination of medication and other treatments is most effective[15], medications should be started first and once the individual is stable, other treatments can be effectively introduced.[20] Some treatments that can effect change in self-care performance include: Assertive Community Treatment (ACT), psychosocial therapy, and Cognitive-Behavioural Therapy (CBT).

Assertive Community Treatment: ACT involves case management and active treatment providing support in activities of daily living as well as productivity and leisure occupations.[20] Atchinson et al.[12] state: “life-skills training, such as money management, meal preparation, and transportation, can produce positive results when done in the natural environment where activities occur” (p. 85).

Psychosocial Therapy: The goal is to enable individuals to develop the necessary skills for independent living[15], such as cooking, shopping, money management, and using public transportation.[11] Additionally, social skills training could include the use of role-play[11] to increase social abilities, self-sufficiency and practical skills.[15][20]

Cognitive Behavioural Therapy: The goal is to change behaviour and increase memory, attention, and executive function.[20] A therapist may employ CBT interventions to address self-care activities such as personal hygiene and dressing. Reed et al.[11] suggest that encouraging appropriate habits and establishing a reward system for maintaining hygiene could be effective for individuals with schizophrenia.

Productivity

The CAOT defines productivity as “occupations that make a social or economic contribution” (p.37).[8] These occupations include paid or volunteer work, attending school, taking care of a household and parenting. Most of the literature around productivity and people with schizophrenia is geared toward obtaining paid employment. Literature shows that up to 75% of people with schizophrenia remain unemployed despite expressing the desire to work.[21] Many variables contribute to individuals with schizophrenia experiencing difficulty with finding paid employment, such as personal and environmental factors.[22]

Implications of Schizophrenia to Productivity

Barriers Related To Personal Factors
  • Due to the age of onset, many individuals with schizophrenia may not have had a job before the onset of schizophrenia, or lack the necessary work skill development to gain employment.[11] Work experience prior to the onset of illness is a reliable predictive factor in regards to potential for returning to the workforce.[21]
  • Specific cognitive deficits that hinder employment acquisition include selective attention, short-term memory, long-term memory, executive functioning, and verbal fluency.[21] A number of studies attribute the difficulties with gaining employment to negative symptoms; few studies attribute the difficulties to positive symptoms.[21]
  • Fluctuation of personal factors leads to inconsistent abilities to perform tasks, which may hinder an individual with schizophrenia’s successful engagement in and/or motivation to undertake new productivity roles.[11]
Barriers Related To Environmental Factors
  • Economy and job market fluctuations affect employment acquisition of people with schizophrenia.[22]
  • The stigma surrounding mental illness may make it challenging for individuals to gain employment despite having the necessary abilities to perform job tasks successfully.[22]
  • Health and disability policies in many countries, which provide support for people with disabilities, may provide incentives to remain unemployed.[22]

Occupational Therapy Intervention for Productivity

It is well established that a biopsychosocial approach is the preferred method for enabling people diagnosed with schizophrenia to attain gainful employment.[21] The schizophrenia Patient Outcomes Research Team found that individuals with schizophrenia who desire employment should be offered supportive employment.[23] This should include “individually tailored job development, rapid job search, availability of ongoing job supports, and integration of vocational and mental health services” (p.51).[23] Supported employment is now known as the single best predictor of successful employment for individuals with schizophrenia, despite numerous studies that seek to identify patient characteristics as primary predictors of employment outcomes.[22] Other OT interventions often used to help increase productivity in this population include:

  • Skills training involves building interpersonal skills, social interaction skills, independent living skills, and job acquisition skills.[23][11] Instruction is behaviour-based and can include role modelling, rehearsal, corrective feedback, and positive reinforcement. Skills training should be specific to the target environment and has been shown to improve worksite interpersonal skills.[23]
  • Cognitive remediation is used in conjunction with supported employment programs and can improve cognitive functioning, decrease depression over the short term and improve outcomes related to maintaining employment.[24]
  • Peer-support and peer-directed services, which include: sharing lived experiences, role modelling, stigma reduction, and removal of potential employment barriers.[23]
  • Family intervention, which includes: illness education, crisis intervention, emotional support and training for coping with symptoms have been shown to improve functional and vocational status.[23]
  • Pre-vocational programs are well suited to lower-functioning individuals and services include: graded structured tasks, positive reinforcement, corrective feedback, and homework assignments. These programs have been attributed with facilitating quicker integration into paid work and eliciting a 9.89% decrease in general symptoms and a 14.73% decrease in negative symptoms.[21]

OT interventions targeted at enabling individuals with schizophrenia to develop meaningful productivity roles are important to incorporate into therapeutic plans. Clients can benefit from a worker role as it improves social integration, enhances self-image, provides avenues to create normalized peer-relationships, and can increase income.[25] Employment can bring a sense of meaning to life and lowers the risk of alienation, apathy, substance abuse, and isolation.[25] Some clinicians and family members worry that people with schizophrenia may be under too much stress if they pursue work, but this has not been proven true.[25] On the contrary, working is a natural adult activity that greatly contributes to a person’s identity. Through the continual implementation of evidence-based programs that are client centred, such as supported employment, productivity can greatly improve the quality of life for people living with schizophrenia.[25]

Leisure

The CAOT defines leisure as “occupations for enjoyment [that include] socializing, creative expressions, outdoor activities, games and sports” (p. 37).[8] Leisure activities can improve the quality of life experienced by an individual with schizophrenia by improving self-esteem, encouraging expression, and increasing relaxation. They can also aid in the development of transferable skills, stimulation of cognition, improvement of social skills, and participation in physical activity.[26]

Implications of Schizophrenia to Leisure

  • Hallucinations and delusions may be consuming, cause anxiety and prevent the client from engaging in leisure activities.[27]
  • The client may have decreased ability to initiate and find pleasure and satisfaction in activity due to negative symptoms such as anhedonia, avolition, and inattention.[28] Activities that require attention, routines, organization and competition may overwhelm the individual with schizophrenia and cause them to withdraw from leisure pursuits with such demands.[28]
  • Both negative and positive symptoms may interfere with social functioning in the long and short-term. They can significantly affect the quality of friendships, interests, and activities; and force an individual to avoid social leisure opportunities.[29] Social anxiety has been found to be one of the most prominent barriers to participation in physical activity.[27]
  • Low income may be a barrier to engagement in activities for individuals who have difficulty finding or maintaining stable work.[28]
  • Anti-psychotic medications commonly cause weight gain and subsequent negative body image for people with schizophrenia. Both of these factors have been identified as major barriers to participation in leisure occupations of a physical nature.[27]

Occupational Therapy Intervention

The focus of treatment for clients with schizophrenia should be to improve quality of life, especially core components such as “managing time, connecting and belonging, and making choices and maintaining control”.[30] Meaningful leisure activities are valuable tools for enhancing quality of life, and can be used to construct satisfying and pleasurable rehabilitation for clients “with chronic psychosis”.[31]

Psychosocial Rehabilitation methods may be informed by CBT and social learning frameworks in order to address the symptoms that impinge on an individual’s participation in leisure activities. Evidence supports the efficacy of CBT in decreasing the severity of positive and negative symptoms.[23] Engagement in meaningful leisure activities can further help individuals cope with positive symptoms by diverting their attention from hallucinations and delusions, and by fostering a sense of personal accomplishment and mastery.[30]

Negative symptoms can have a huge impact on occupational functioning and can be addressed through skill training and leisure activities with structure, clear expectations, and specific goals.[30] Expressive and sensory activities (including art, drama, crafting, yoga, relaxation, and martial arts) can be used therapeutically, to develop skills and interests, and to provide outlets for emotional and creative expression.[30] Both yoga therapy and physical exercise (walking, jogging, and calisthenics) have been used successfully with clients with schizophrenia. One study reports that over a four month time period, clients participating in both yoga and exercise groups demonstrated improved quality of life scores, decreased negative and positive symptoms, and increased social and occupational function.[32]

Group leisure activities in inpatient, outpatient, and community centre settings are common in OT, and can effectively improve social skills.[30] The therapist may educate the client on no or low-cost leisure activities offered through the community (community centres, walking, or church activities), which accommodate financial constraints that could be faced by individuals in this population due to unemployment.[28]

Social dysfunction is a key consideration in OT interventions, as individuals may withdraw from leisure activities because of anxiety, fear of humiliation and discrimination.[27] Social skills training programs for individuals and groups have shown to be successful in recovery, and may additionally increase a client’s functioning in the broader community.[29] Critical components of social skills training programs based on the principles of the social learning approach include modeling, role-playing, coaching, shaping, and generalization of skills to life outside of therapy.[29] CBT methods can enable a client to develop the behaviours and skills necessary for engagement in desired leisure occupations. Other techniques can help the client monitor and change the negative thoughts that impede participation, and reinforce desired thoughts and behaviours.[33]

Weight gain is a common side effect of anti-psychotic medications and may be a significant barrier to participation in leisure occupations.[27] The occupational therapist is instrumental in weight management interventions and educates clients about exercise, helps clients identify barriers to exercise, promotes the benefits of exercise and encourages participation in physical activity programs.[27] Also, factors such as decreased motivation, lack of initiative, and diminished physical fitness can affect an individual’s participation in leisure activities.[34] Structured group exercise programs may provide the “structure, encouragement, and purpose” that participants with schizophrenia need to participate in physical activity.[27] Group exercise programs can also offer clients support from peers with similar mental health issues.[27]

A pilot study performed in Ontario, Canada, reported promising results about the benefits of an adventure recreation program for younger clients with psychosis.[34] Improvements in self-esteem, motivation, and sense of accomplishment were noted in the participants, who engaged in weekly activities (including kayaking, rock climbing, and bowling) with the support of an interdisciplinary health team (including OT). Participants also felt a sense of belonging to a group.[34] This study holds important implications for future directions of rehabilitation programs for people with schizophrenia.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Picchioni, M. M., & Murray R. M. (2007). Schizophrenia. British Medical Journal, 335(7610), 91-95.
  2. ↑ 2.0 2.1 2.2 2.3 Teske, Y. R. (2007). Schizophrenia. In B. J. Atchison & D. K. Dirette (Eds.), Conditions in occupational therapy (pp. 67-89). Philadelphia, PA: Lippincott Williams & Wilkins.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 McGrath, J., Saha, S., Chant D., & Welham J. (2008). Schizophrenia: A concise overview of incidence, prevalence, and mortality. Epidemiological Reviews, 30, 67–76.
  4. ↑ 4.0 4.1 4.2 4.3 Os J. V., & Kapur S. (2009). Schizophrenia. The Lancet, 374(9690), 635-645.
  5. ↑ Craddock, N., O’Donovan, M. C., & Owen, M. J. (2005). The genetics of schizophrenia and bipolar disorder: dissecting psychosis. Journal of Medical Genetics, 42(3), 193-204.
  6. ↑ 6.0 6.1 6.2 6.3 Butcher, J. N., Mineka, S., & Hooley, J. M. (2004). Abnormal psychology. Boston, MA: Pearson.
  7. ↑ 7.0 7.1 7.2 7.3 Swierzewski, S. J. (2007). Schizophrenia diagnosis. Retrieved from http://www.mentalhealthchannel.net/schizophrenia/diagnosis.shtml
  8. ↑ 8.0 8.1 8.2 Townsend, S. (Ed.) (2002). Enabling occupation: An occupational therapy perspective (revised ed.). Ottawa, ON: CAOT Publications ACE.
  9. ↑ James, A. B. (2009). Activities of daily living and instrumental activities of daily living. In E. B. Crepeau, E. S. Cohn and B. A. Boyt Schell (Eds.), Willard and Spackman’s Occupational Therapy (11th ed) (pp. 538-578). Baltimore, MD: Lippincott, Williams and Wilkins.
  10. ↑ Stefanopoulou, E., Lafuente, A. R., Fonseca, A. S., Keegan, S., Vishnick, C. and Huxley, A. (2011). Global assessment of psychosocial functioning and predictors of outcome in schizophrenia. International Journal of Psychiatry in Clinical Practice, 15(1), 62–68. doi:10.3109/13651501.2010.519035
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 Reed, K. L. (2001). Quick reference to occupational therapy (2nd ed.). Houston, TX: Pro-ed.
  12. ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 12.12 Atchinson, B. J., & Dirette, D. K. (2007). Conditions in occupational therapy: Effect on occupational function (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins.
  13. ↑ 13.0 13.1 Neistadt, M. E. (2000). Occupational therapy evaluation for adults: A pocket guide. Baltimore, MD: Lippincott, Williams & Wilkins.
  14. ↑ 14.0 14.1 14.2 Hahn, R. K., Albers, L. J. & Reist, C. (2010). Psychiatry: 2010 edition. Blue Jay, CA: Current Clinical Strategies.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 Sadock, B. J. & Sadock, V. A. (2007). Synopsis of psychiatry (10th ed). Philadelphia, PA: Lippincott, Williams and Wilkins.
  16. ↑ Minato, M. & Zemke, R. (2004). Time use of people with schizophrenia living in the community. Occupational Therapy International, 11(3), 177-191. doi:10.1002/oti.205
  17. ↑ 17.0 17.1 Bejerholm, U. & Eklund, M. (2004). Time use and occupational performance among persons with schizophrenia. Occupational Therapy and Mental Health, 20(1), 27-47. doi:10.1300/J004v20n01_02
  18. ↑ 18.0 18.1 Kikkert, M. J., Schene, A. H., Koeter, M. W. J., Robson, D., Born, A., Helm, H., Nose, M., Goss, C., Thornicroft, G., & Gray, R. J. (2006). Medication adherence in schizophrenia: Exploring patients', carers' and professionals' views. Schizophrenia Bulletin, 32(4), 786-794.
  19. ↑ 19.0 19.1 Yilmaz, M., Josephsson, S., Danermark, B., & Ivarsson, A. (2008). Participation by doing: Social interaction in everyday activities among persons with schizophrenia. Scandinavian Journal of Occupational Therapy, 15, 162-172. doi:10.1080/11038120802022102
  20. ↑ 20.0 20.1 20.2 20.3 Trudeau, G. M. (2009). Schizophrenia. In E. B. Crepeau, E. S. Cohn and B. A. Boyt Schell (Eds.), Willard and Spackman’s Occupational Therapy (11th ed) (1058-1061). Baltimore, MD: Lippincott, Williams and Wilkins.
  21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 Rouleau, S., Saint-Jean, M., Stip, E., & Fortier, P. (2009). The impact of a pre-vocational program on cognition, symptoms, and work re-integration in schizophrenia. Occupational Therapy in Mental Health, 25(1), 26-43. DOI: 10.1080/01642120802644904
  22. ↑ 22.0 22.1 22.2 22.3 22.4 Bond, G. R., & Drake, R. E. (2008). Predictors of competitive employment among patients with schizophrenia. Current Opinion in Psychiatry 21, 362-369.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 23.5 23.6 Dixon, L., Dickerson, F., Bellack, A., Bennett, M., Dickinson, D., Goldberg, R., Lehman, A., Tenhula, W., Calmes, C., Pasillas, R., Peer, J., & Kreyenbuhl, J. (2010). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements, Schizophrenia Bulletin, 36(1), 48-70.
  24. ↑ McGurk, S. R., Mueser K. T., Feldman, K., Wolfe, R., & Pascaris, A. (2007). Cognitive training for supported employment: 2-3 year outcomes of a randomized controlled trial. American Journal of Psychiatry 164, 437-441.
  25. ↑ 25.0 25.1 25.2 25.3 Warner, R. (2009). Recovery from schizophrenia and the recovery model. Current Opinion in Psychiatry, 22, 374-380.
  26. ↑ Stein, F. & Cutler, S. (2002). Psychosocial occupational therapy: A holistic approach (2nd Ed.). Clifton Park: NY.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 27.5 27.6 27.7 Johnstone, R., Nicol, K., Donaghy, M., & Lawrie, S. (2009). Barriers to uptake of physical activity in community-based patients with schizophrenia. Journal of Mental Health, 18(6), 523-532.
  28. ↑ 28.0 28.1 28.2 28.3 Teske, Y. (2000). Schizophrenia. In Hansen, R., & Atchison, B., (Ed.s) Conditions in occupational therapy (2nd Ed., pp. 54-74). Baltimore, MD: Lippincott Williams, & Wilkins.
  29. ↑ 29.0 29.1 29.2 Kern, R., Glynn, S., Horan, W., & Marder, S. (2009). Psychosocial treatments to promote functional recovery in schizophrenia. Schizophrenia Bulletin, 35(2), 347-361. DOI: 10.1093/schbul/sbnl77.
  30. ↑ 30.0 30.1 30.2 30.3 30.4 MacCrae, A. (2005) Schizophrenia. In Cara E. & MacCrae, A. (Ed.s) Psychosocial occupational therapy: A clinical practice (2nd Ed., pp. 140-161). Clifton Park, NY: Thomson Delmar Learning.
  31. ↑ Pondé, M. Peireira, C., Leal, B., & Calmon Oliveira, C. (2009). The role of leisure in the lives of psychotic patients: A qualitative study. Transcultural Psychiatry, 46(2), 328-339. DOI: 10.1177/1363461509105822.
  32. ↑ Duraiswamy, G., Thirthalli, J., Nagendra, H. R., & Gangadhar B. N. (2007). Yoga therapy as an add-on treatment in the management of patients with schizophrenia –A randomized controlled trial. Acta Psychiatrica Scandinavica, 116, 226-232. DOI: 10.1111/j.1600-0447.2007.01032.x
  33. ↑ Ikiuga, M. (2007). Psychosocial conceptual practice models in occupational therapy: Building adaptive capability. St. Louis, MI: Elsevier.
  34. ↑ 34.0 34.1 34.2 Voruganti, L. Whatham, J, Bard, E, Parker, G, Babbey, C, Ryan, J, Lee, S, & MacCrimmon, D. (2006). Going beyond: An adventure and recreation-based group intervention promotes well-being and weight loss in schizophrenia. Canadian Journal of Psychiatry, 51, 575-580.
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