What is schizophrenia?
Schizophrenia is characterized by disturbances in thought and verbal behavior, perception, mood, motor behavior, and relationship to the external world.
According to the world (mental) health report 2001, about 24 million people worldwide suffer from schizophrenia.
Clinical Features –
- Thoughts and speech Disorders-
- Autistic thinking (Self centered)
- Incomprehensive speech (No logical relationship between speech)
- Thought blocking (sudden interruption of speech)
- Echolalia (repetition of words)
- Delusions (false unshakable belief).
- Disorder of perception –
Hallucination (perception without stimuli) is common in schizophrenia. Auditory hallucinations are more common and visual hallucinations are less common.
- Disorder of Affect –
- emotional blunting,
- Anhedonia (unable to experience pleasure).
- Disorder of Motor behavior-
- Decrease in psychomotor activity (slow response)
- Increased psychomotor activity (excitement, aggressiveness, and restlessness)
- Stereotypical movement (repetitive strange movements)
- Affected self care, and poor grooming.
- Negative symptoms-
- Decreased attention,
- Lack of initiation,
- Social withdrawal,
- Lack of speech output.
- Other features related to occupational therapy –
- Decreased functioning in work, social relationship, and self-care.
- Decreased self identity or self-esteem.
- Absence of Insight (into the illness).
- Poor social judgment.
Types of Schizophrenia –
- Paranoid schizophrenia-
- Delusions of persecution, reference, grandeur, control
- The hallucinations usually have a persecutory content
- No disturbances of affect, speech and motor behavior
- Progressive course.
- Frequent remission and relapses.
- Hebephrenic (Disorganized) schizophrenia
- Marked thought disorder, severe loosening of associations.
- Emotional disturbances, poor self care & hygiene, impaired social & occupational functioning.
- It has one of the worst prognoses among the varies subtypes.
- Catatonic schizophrenia
Catatonic (cata: disturbed and tonic: tone) schizophrenia is characterized by a marked disturbance of motor behavior:
a). Excited catatonia- increase in psychomotor activity, increase in speech production.
b). Stuporous catatonia- extreme retardation of psychomotor function, Akinesis (no movement), Bizarre posturing, rigidity (rigid posture).
c). Catatonia alternating between excitement and stupor- this is very common. The features of both excited and stuporous catatonia are alternately present.
- Residual Schizophrenia-
The symptoms are general but we can only call it residual after at least first episode of schizophrenia.
- Undifferentiated schizophrenia-
This is very common type of schizophrenia and is diagnosed either.
a). When features of no subtype are fully present or
b). When features of more than 1 subtype are exhibited.
- Simple schizophrenia-
This subtype is most difficult to diagnose.
- It has very insidious and progressive course
- Negative symptoms are present like social withdrawal, loss of initiative and drive & wandering aimlessly
- Delusions and hallucinations are usually absent
- Prognosis is usually very poor.
Role of occupational therapy in schizophrenia –
Occupational therapist deals with the schizophrenics and the main role of an occupational therapist is to improve self-care, self-esteem/self-concept, social interaction, vocational and leisure activity.
Occupational therapy Intervention –
Schizophrenic person is not able to deal effectively with needs, drives & inhibiting factor on an adult level.
Basic personality structures-
- Poorly defined self-concept.
- Has difficulty in thinking in abstract.
- Not able to develop his own standards and values.
- Sense of rejection- insecure, feels unloved, unwanted.
- Excessive fear of hostility.
- To be loved & accepted
- To feel himself as an individual
- To have satisfying interpersonal relationship.
Occupational Therapy goals for schizophrenic Patients-
- To improve contact with reality
- To strengthen ego boundaries
- To provide an outlet for hostility
- To decrease dependency needs
- To raise patients own standards and values
- To improve motor/perceptual abilities
- To improve self care.
Characteristic behavior relevant to Occupational Therapy.:-
- Inadequate performance- impaired judgment, disorganization
- Hostility- negativity, aggression
- Childlike behavior- dependent, demanding
- Desocialization- expectation of rejection, withdrawal
- Pathological affective response- apathy, exaggerated response & inappropriate response
Specific application of Occupational Therapy :-
- Interpersonal relationship-growth & development-
- Support the patient in developing a concept of himself as a person with rights, needs and a sense of personal identification and worth.
- The patient needs to feel that he can be accepted- giving him accepting environment, accept patient as he/she is.
- Adjust to patient’s tempo- speak & move as slowly as necessary for patient, avoid upsetting him by sudden speech or action.
- Allow him/her enough time to perform necessary action & help him/her to get ready.
- Facilitate communication for patient- be sensitive to use nonverbal communications, try to talk to patient at his/her functioning level and if appropriate use his/her words.
- Avoid over talkativeness, demanding or authoritative manner.
- The patient should be encouraged and supported in his/her attempts at the more independent function.
- Characteristic of suitable activities for schizophrenia-
Those providing opportunities for actual or symbolic gratification or oral or anal need in accordance with the degree of regression.
a) Oral needs gratification activities – eating, biting, sucking, chewing, blowing, etc. e.g.-
- Preparing and eating food
- Looking and collecting pictures of food.
- Blowing soap bubble, gum, musical instrument.
b) Anal needs gratification activities- handling excretory substitute, retentive activities, etc. e.g.-
- Gardening, preparing soil, potting.
- Washing & scrubbing clothes, corridors, dishes, vehicles, etc.
- Collecting garbage, trash, stamps etc.
- Activities providing opportunities for improvement in sensory, perception and motor coordination through the use of-
- Gross muscle activities.
- Rhythm marching, clapping.
- Activities providing opportunities for appropriate dependency which may be gradually abandoned as patient matures-
- Permitting extensive guidance and assistance.
- Requiring minimal patient initiative and planning, avoiding decisions beyond capacity of the patient.
- Activities providing opportunities for development of self concept, ego strength, sense of personal worth and own standard of value-
- Establish a sense of personal identity- personalized project for own use.
- Foster ego growth- self care, personal grooming – insure successful endeavor within current capacity.
- Encourage & respect the patient’s expression of his feeling and ideas relative to activities.
- Activities encouraging the constructive release of hostility-
- Initially use non aggressive activities. As the patient can tolerate it, then introduce aggressive activities, e.g. hammering, woodwork.
- Activities providing opportunity for reality testing and the experience of shared reality-
- Use activities which offer a maximum of reality contact.
- Activities which provide opportunity for agreement on the nature of reality.
- Activities providing opportunity for patients to experience a sense of belonging-
- Sharing common experience and feelings
- Contributing a particular skill useful to the group.
- Activities providing opportunity for social interaction-
a) Symbolic expression of feelings.
b) An achievement which results in the expression of favorable comment.
- Increasing give-and-take relationship.
- Sharing tools
- Taking turns
- Helping others
- Group projects.
Psychosocial treatment & rehabilitation
Education of the patient and especially the family regarding the nature of illness, its course and treatment.
It helps in establishing a good therapeutic relationship with the patient and family
- Individual psychotherapy- it is usually supportive in nature. Rarely psychoanalytically oriented psychotherapy is used.
- Group psychotherapy- particularly aimed at teaching:-
- Problem solving
- Communication skills.
OT approach within group psychotherapy-
- Using a supportive approach:- its function is to strengthen the ego defense mechanism. For this verbal methods or arts media are used.
- Using an Exploratory approach:- various stages in the group are
- Forming- initiation of group.
- Storming- testing out of boundaries.
- Norming- group cohesion develops with emerging norms & growth of mutual support.
- Performing- realization of working groups where possibilities for solving difficulties emerge
- Group Therapy
Organizing an explorative group:- the pattern of events is as follows-
- Introduction- it allows the questions and used to set the climate of the group.
- Participation time- the main activity is carried out.
- Individual’s explanation of work.
- Group interaction- discussion refers to the work done & its significance for individual and group.
- Summary- where main points are drawn together with acknowledgements of work done in group.
Activities used in exploratory approach are:-
- Self portrait– to develop accurate self concept.
- Cooking/Eating– to satisfy the oral needs.
- Cleaning/Collecting– to satisfy the anal needs.
- Woodwork– for expression of hostility.
- Structured sports– for development of perception of self movements & others.
- Discussion group– to encourage shared reality.
- The Arts Activities:–
Arts activities like music, clay work, poetry and drama provide the ways of bringing people together and exploring the self, these activities referred to as ‘projective techniques’.
- Sensory integration- Activities used by ‘King’ for the chronic non-paranoid schizophrenia. It includes-
- Standing in a circle, throwing a ball back and forth.
- Standing in a circle, kicking a ball around the circle.
- Marching to the music.
- Stepping over the ropes.
- Ducking under nets.
- Jumping over ropes a few inches off the ground.
- Passing a ball back over the head.
- Family therapy-
The family members are provided with social skills training to enhance communication and decrease intra-familial tensions.
Attempts are also made to decrease expressed emotions. The family taught to decrease expectations, emotional over involvement and hostility.
- Milieu therapy–
It includes treatment in a living, learning or working environment ranging from inpatient psychiatric unit to day care hospitals. Psychosocial Rehabilitation is used along with milieu therapy.
- Activity therapy-
It is used to develop the work habit. Graded schemes will gradually involve the patient in more active and responsible work.
Stimulation is needed, either through the activities, through contact with the therapist or the other patients.
Group activities may be used to stimulate interest & activities like gardening, industrial and domestic work.
Regular exercise is important, such as walks, dancing and simple games. Dressmaking, hairdressing, manicuring and makeup will give confidence to women patient & high standard of personal appearance for men is important, i.e. well-shaved with pressed clothes.
Training in a new vocation or retraining in a previous skill, social skills training (communication), habit training improves work habit.
- Social skill training–
It is directed at simple targets and goals, such as how to have eye contact, appropriate posture and clarity of voice.
Problem solving approach is used to motivate clients to participate, to identify the behavior required and to teach new skills
- Vocational Rehabilitation-
Functional decline in the ability to maintain paid employment can be psychologically & economically affect to the individuals with schizophrenia. As well as to his family members.
Work may mean different things to different people so definition of work, whether full- or part time, paid, voluntary or open employment or housework so that relevant program can be devised.
Therapist should have contact with employment staff and be aware of local resources, including training opportunities.
Development of general work habits is an obvious requirement.
If patient experiencing difficulties at work because of social withdrawal, then assessment of associated skills should be performed. Provide the informal conversational situations, such as coffee breaks to help them improve the working relationships between the colleagues.
Following types of schizophrenia may need special consideration because of the predominance of one or more symptoms:-
Occupational therapy in Paranoid Schizophrenia–
An onset occurs between the ages of 30-45. The paranoid patient, because of overt or covert grandiosity and suspicion finds difficulty in responding to any approach.
Satisfactory rapport may be obtained if the patient is given some position of responsibility.
Overtly expressed delusion should not be opposed and they should not be encouraged.
The patient’s attention diverted towards interesting activities unconnected with his delusions.
It is unwise to allow such patients to use dangerous tools, i.e. axes or picks, impulsiveness and suspicion may result in homicidal attacks.
Effective follow-up after discharge may present difficulties, the patient may think that contact with an occupational therapist is a prelude to further hospitalization.
Occupational therapy in Hebephrenic schizophrenia-
This illness occurring in adolescence or in early twenties. It has an insidious onset and may therefore have become well established before the patient received any treatment.
In many cases, they may never live full social lives. If rightly assessed and placed in jobs which hold interest, but do not impose strain, they may live successfully in the community for some years although the ultimate prognosis is poor.
Occupational therapy in Catatonic Schizophrenia-
This illness occurs in the twenties and early thirties. It is characterized by either stupor or excitement.
The onset is more rapid than in hebephrenia and the prognosis is better.
General principals of treatment remains same. Great care is necessary in introducing the catatonic patient to a group because his liability to impulsive behavior.
Dangerous tools are contraindicated. Where stupor is marked, physical exercise may be achieved by guided movements to music and games involving catching a beanbag or passing an object round the circle of patient in which the patient automatically performs required action.
- Clifford T. Morgan, Richard A. King. Introduction to psychology. 7th
- Niraj Ahuja. A short textbook of psychiatry. 6th
- Kaplan & saddock. Synopsis of psychiatry. 9th
- Jennifer Creek. Occupational Therapy and Mental Health: Principles, skills and practice.