Chelsie Miller: OT: Pathology: Dementia & Schizophrenia – Flashcards

o Memory loss in the presence of full consciousness o Impaired judgment, abstract thinking, and planning o Language impairments, difficulty with word finding, difficulty recognizing objects or people (agnosia), difficulty generating coherent speech (aphasia), or difficulty executing motor activities (apraxia) o Deterioration of emotional control, social behavior, or motivation o Personality changes, especially newly developed paranoia o Hallucinations o Depression, apathy, or withdraw from social situations o Neglecting self-care o Symptoms must be severe enough to interfere with vocational/social functioning for diagnosis. o Diagnosis requires memory deficits and at least one other factor (aphasia, apraxia, agnosia, or impaired executive functions). o Because the disease is degenerative and progressive, symptoms worsen with time, eventually impairing autonomic functions controlled by the brain, causing death. o Symptoms usually progress in stages and typically begin with an increase in forgetfulness (of information that is so familiar that it should not be forgotten), decreased judgment, and a loss of initiative or interest. Symptoms then progress to word finding problems, confusion, inability to recognize friends and family, and wandering behavior. In the final stages of dementia, the individual loses sensory, motor, and cognitive abilities, cannot understand words (but can respond to touch), is unable to care for themselves, and has difficulty eating and swallowing. (Bonder, 2010; Gitlin & Earlan, 2011; Seligman et al., 2001)

o Dementia is caused by various diseases and conditions that result in damage to brain cells. o 2 types 1. Primary (Irreversible) Dementia is caused by the following: -Alzheimer's Disease (AD)-number 1 cause of dementia, accounting for half of all cases; caused by death of neurons, which results in brain shrinkage -Malformation of the hippocampus occurs (contributing to memory problems, as this is the storage of memory in the brain). The frontal and temporal lobes shrink as a result of the death of neurons. As neurons die, connections between neurons can no longer be made, which results in the characteristic cognitive and motor decline. Ventricles in the brain also enlarge due to neuron death. -Low levels of the neurotransmitter acetylcholine are fond in patients with AD, which may contribute to memory loss. Some current drugs focus on targeting this neurotransmitter, to slow the progression/onset of the disease. -Neurofibrillary tangles (groups of proteins) and beta amyloid plaques accumulate in the brain. These confirm the diagnosis of AD in autopsy, as this is the only way to definitively diagnosis the condition. However, diagnosis is currently made using brain scans and the elimination of all other possibilities through other types of physical and psychological testing. -The early-onset type of AD has a genetic link. It is also higher among those with a chromosomal abnormality (such as Down Syndrome). This suggests a biologic cause of AD. Such findings are not as strong in the late-onset type. -Women are at higher risk of developing AD. -Vascular Dementia-caused by small strokes that deprive certain brain areas of oxygen, which damages brain cells; second most common cause of dementia -Unusual reflexes and movement abnormalities are present. -Lewy Body Disease, Multiple Sclerosis, Huntington's Disease, Parkinson's Disease, Down Syndrome, and Brain infections can all cause irreversible dementia also. 2. Secondary (Reversible) Dementia is caused by the following: -Changes in blood sugar, sodium, and calcium, and B12 vitamin levels -Brain tumors -Chronic alcohol use -Side effects of certain medications -These cause symptoms which can look identical to those of primary dementia. o Dementia normally occurs in late adulthood. Its prevalence is high among those who are 65+, and jumps even higher in those 85+. o Dementia affects over 5 million Americans, and 27.7 million people worldwide. This number is projected to jump drastically within the next 2-3 decades because much of the world's population will be in the age range of late adulthood (because of the aging of the baby boomers), which is where dementia is most commonly found, as well as longer life expectancies allowing more people to live to this life stage. (Bonder, 2010; Coleman et al., 2005; Gitlin & Earland, 2011; Seligman et al., 2001)

o The prognosis for any type of primary dementia is considered to be poor, as existing brain damage is irreversible, and progression is inevitable. -Management rather than treatment is the goal of medical intervention, as there is no cure for dementia. -Medications can be used to delay the onset and progression of the dementia in some cases. -For patients with AD and Lewy Body disease, cholinesterase inhibitors (which increase the amount of the neurotransmitter acetylcholine in the brain) slow the rate of decline and improve memory function in some patients. For patients with Alzheimer's disease, a newer medication, which prevents the buildup of chemicals thought to contribute to memory loss, has been developed. -Treatment for vascular dementia includes controlling risk factors for stokes (high blood pressure and cholesterol). -Cognitive behavioral therapy may be beneficial in reducing the distress caused by the dementia on both the patient and the caregiver. o The prognosis for secondary dementia is quite good. After the underlying cause is treated, symptoms of the dementia usually fade away, depending on the underlying condition. This is not the case for dementia related to long-term alcohol abuse, as the existing damage remains, but after treatment of the underlying cause, the dementia stabilizes. (Bonder, 2010; Coleman et al., 2005)

o All performance areas are negatively impacted by dementia. They include: -ADL's, IADL's, Rest and Sleep, Education, Work, Leisure/Play o Basic body functions become difficult, and death will ensue from the dementia. o Dementia is a progressive disease, which starts out affecting the brain, then moves to affecting all autonomic functions controlled by the brain. o Progression often occurs in phases, each of which gets progressively worse. Personality changes often occur, and the individual may have to be placed in a long-term care facility. o Decreased activity levels lead to muscle atrophy, which increases the potential for unsafe mobility, increasing the risk for falls and injuries. Decreased activity levels also reduce executive functioning of all systems, causing things like constipation, depression, agitation, increased confusion, and wandering. o Recent memory fades before long-term memory, so the individual is often not oriented to person, place, time, or space. o Quality of life is severely negatively impacted, as ability to function deteriorates in all areas. -Individuals lose the ability to engage in anything that was once meaningful to them. They withdraw from society because they cannot remember who people are or who they are. Nothing seems familiar. This can lead to frustration, which further negatively impacts quality of life. (Bonder, 2010; Miller & Butin, 2000; Seligman et al., 2001)

o OT should focus on maximizing quality of life so that the person can receive as much enjoyment as possible from their time that is left. o It is important to understand who the person was before the onset of the disease, what they liked to do, their interests, values, and preferences, as these will all contribute to individualizing therapeutic intervention so that routines can be made as familiar as possible and the individual can be provided with the opportunities to engage in activities that can provide a sense of meaning in their lives. o ADL's often become a focus of therapy, as these individuals lose the ability to care for themselves. o Engage these individuals in exercise and mentally stimulating activities for as long as is possible, as these can increase well-being while decreasing cognitive loss. o Use creative activities (crafts, etc.) to maintain positive feelings of satisfaction and quality of life for as long as possible. o Simplify and adapt the environment for safety and participation (for as long as is possible); educate the person and their family on the disease process. o Optimize remaining abilities and maximize remaining capacities to give the individual a sense of meaning and quality of life. o Community-based occupational therapy (provided in the home) was found to improve daily functioning in people with dementia. Both patient and their caregivers were more competent and had better outcomes than those who did not receive OT. Participants and their caregivers learned to prioritize activities that they wanted to improve. OT's provided home and environmental modifications. Both the persons with dementia and their caregivers were taught to use the compensatory and environmental strategies. Caregivers were trained in supervision, problem-solving, and coping strategies. (Bonder, 2010; Graff et al., 2006)

o The primary goal of rehabilitation is to enable people to achieve their optimal level of function. This thinking is very applicable to the population of dementia, but has not been utilized in this population very often because of the degenerative and progressive nature of the disease. Compensatory, habilitative, non-pharmacologic approaches can be used to modify behaviors or the physical/social environments to help individuals cope with dementia and to continue to engage in everyday activities for as long as possible. o The focus is on strengths and preserved capabilities. o New learning impairments are characteristic of dementia. However, procedural memory capacities are the last to be affected by dementia, which means that procedural memory is not impacted by such learning impairments especially in the early to moderate phases of dementia. Therefore, it has been proposed that these individuals can learn using procedural memory, which is the most enduring memory. Practicing a procedural skill (such as brushing teeth) can allow the person to learn the skill (in procedural memory). o Rehabilitative strategies that can be used to facilitate such compensatory learning include: modifying environments, simplifying tasks, establishing structure and routine, practicing concrete tasks through repetition, giving task-specific training, using hands-on teaching techniques, using cueing and communication effectively, and educating family/caregivers. o Behavioral symptoms common in dementia can be reduced using these techniques as well. The key is to provide simple tasks and environments that are as stress and frustration free as possible, so that the individual can familiarize their routines. (Gitlin & Earland, 2011)

o A study from the University of Pittsburgh found that walking about six miles a week seems to protect against brain shrinkage, which in turn may slow the progression of cognitive decline. -Because brain shrinkage is correlated with dementia, it is possible that reducing shrinkage may help to prevent dementia. -This study supports the findings of previous research findings, which suggest that physical activity may be the best measure that one can take to prevent dementia. -Increased blood flow to the brain may keep it healthy and rid it of toxins, better protecting it against dementia. -Because walking is the most common physical activity that older adults engage in, implementing this strategy as a precautionary measure would be good for their overall health. o Under current investigation by the Alzheimer's Research Foundation are the effects of Vitamin E (an antioxidant), estrogen, and ant-inflammatory drugs in the prevention of AD. Only time will tell if these prove to be successful. (Fisher Center for Alzheimer's Research Foundation, 2011; Simon, 2010)

o Caregiving of a person with dementia usually falls on the spouse if one is married and their spouse is not deceased. If there is no spouse, then the role of caregiver usually falls on the eldest daughter. Often, daughter-in laws take on the responsibility as well. Family of some sort usually acts as the caregiver for as long as possible, as we all feel obligated to care for our family members. o Caregivers engage in management activities with the patient, which are concrete, specific daily activities with which the caregiver carries out with the patient to promote comfort, efficiency, and safety for both persons involved. These include things like helping the person to bathe without frustration. o Caregivers also engage in coping skills, which are ways of adapting to challenging situations in both the human and physical environment. These increase success with management activities. These include things like understanding the caregiver role, knowing the progression of the disease, and utilizing stress reduction techniques. o Being a caregiver for an individual with dementia is a full-time position that comes with many emotions. It can be very frustrating for the caregiver, and can be a source of both emotional and financial stress. (Mannion, 2008; Miller & Butin, 2000)

o Because of the many demands of caring for an individual with dementia, caregivers' lives are often out of occupational balance. Most of their time is spent with the person who has dementia. Their social and leisure participation suffer. Also, they may need to reduce their engagement in paid work or quit their job all together because of the time and energy that their role as a caregiver demands. They often neglect caring for themselves and their needs, as the demands of their role as a caregiver surpass those of all other roles. Because of the significant impact of caregiving on an individual's life, occupational therapy is often needed for the caregiver, as well as the patient. o The caregiver often experiences physical health problems from the strain that is involved in the caring process. They are headaches, nervousness, insomnia, weight loss/gain, unusual drowsiness, depression, anxiety, and caregiver distress. It has been shown that the level of distress and depression in the caregiver is related to the behavior of the individual with dementia. This means that the overall well-being of both individuals affects the disease process. o A COPE program was developed to be used with caregivers and their relatives with dementia. It addressed the needs of the caregiver, as well as the needs of the individual with dementia. -A problem solving group was used with the caregivers alone. The purpose of the group was to carry over strategies learned in the group into the home environment. Also, one hour each week was spent with the caregivers and their relatives pursuing an activity that was targeted to promote a successful experience. The activities cohered with past interests and identified strengths and deficits in components of performance. The purpose of the COPE group was to enable the caregiver to facilitate their relatives' participation in meaningful activities. Occupational therapy has the ability to improve the quality of life for both the caregiver and the patient with dementia, while fostering a bond between the two individuals. o Help caregivers cope with emerging deficits and give them emotional support. -Arrange for community services to relieve the caregiver as much as possible. Respite is a key to preventing caregiver burnout. Caring for an individual with dementia is a progressive process. As the disease worsens, the amount of care needed increases and intensifies. This can lead to caregiver frustration and can impact the behavior of the individual with dementia. -Help the caregiver make an informed decision about nursing home placement if/when the time comes that they can no longer provide care for their loved one. (Bonder, 2010; Coleman et al., 2005; Mannion, 2008; Miller & Butin, 2000)

o Driving is a form of autonomy and independence. No one is ever happy when they are no longer allowed to drive due to any reason. Often, in late adulthood, individuals lose their privilege to drive due to health related reasons. Persons with dementia fall into this category. It is difficult for health care professionals to determine when to take an individual with dementia's drivers license. Due to the progressive nature of the disease, it is clear that these individuals need to be reassessed often to determine whether or not they should be driving, but there is no specified protocol as to what interval to use for assessment/reassessment. A study was conducted to develop criteria for driver assessment referral and to explore the value of routine reassessment for drivers with dementia. o This study found that standard OT driver assessment and reassessment can be used to detect change in ability to drive in persons with dementia. It was found that individuals should be assessed upon diagnosis, as there is a low pass rate (indicating that these persons should not be driving just after receiving a dementia diagnosis), then reassessed after six months, due to a strong change in driving performance. o People with dementia should have the opportunity to drive for longer if it is safe to do so (as this may contribute to feelings of independence, well-being, and contribute to quality of life), and OT driver assessors can play an important role in allowing them to do so. (Lovell & Russell, 2005)

o To be diagnosed, an individual must present with two or more of the following symptoms within the most recent one month period, with symptoms persisting for at least six months. -Delusions: false beliefs, unrelated to how the person feels, that persist against all evidence presented against them; disturb thought in both form and content -Grandeur: belief that one is especially important ( belief that one is God, Satan, Jesus, the Pope, or anyone who is of great importance in society) -Control: belief that their thoughts and behaviors are being controlled by an outside force (that aliens have taken over their brain and are making them do certain things) -Persecution: belief that a person or group is out to get them ( belief that the Mafia has a hit out on them) -Somatic: unverified belief that something is wrong with their body (that they have stomach cancer because they feel queasy despite all negative tests) -Ideas of reference: belief that events or people have a special significance for them (Oprah is sending them personal messages through her show) -Hallucinations: false sensory perceptions which seem real despite the fact that there is no external stimuli producing the perception -Most often auditory -These happen within the brain. -Disorganized speech or behavior: shifts from one topic/movement to another without any apparent connection -Catatonic symptoms: decrease in movement; an individual may appear to be frozen -Often exhibit waxy rigidity, in which, when moved into a position (even a very uncomfortable one), they will remain in that position until an outside force moves them again. -They may also appear to be mute or completely unresponsive. o These are all positive symptoms, which means that something is present that should not be there. -Negative symptoms: these are things that are not present but should be present -Avolition: extreme lack of energy or interest in activities -Flat affect: body language/facial expression is unresponsive to stimuli - Algoia: major decrease in speech (often one word answers with long pauses in between) o Sense of self is also impaired. These individuals have an inability to separate themselves from others or from the environment. o Schizophrenia is a mental disorder that makes it hard to distinguish between real and unreal experiences, think logically, have normal emotional responses, and behave in socially appropriate manners. o Schizophrenia is one of the few disorders that are defined relative to function. To be diagnosed, functional level must be below the highest level previously achieved in one or more areas of one's life. o Symptoms occur in 3 predictable phases: 1. Prodromal Phase: function begins to deteriorate; they withdraw from friends and family, and work, self-care, and leisure activities suffer. They no longer take care of themselves. 2. Active Phase: delusions and hallucinations are present, as well as other psychotic symptoms. This phase may occur spontaneously or as a result of stress (positive or negative). 3. Residual Phase: this is similar to the prodromal phase, in that function is below the highest levels ever achieved and the individual isolates themselves from others. Functional difficulties remain, especially in work, self-care, and leisure, but symptoms are much less severe than they are in the active phase. oThe individual is not always actively psychotic. Schizophrenia may occur in an episodic pattern, as a continuous state, or (as is least common) as one single episode in a person's life. oSuicidal thoughts are common. (Bonder, 2010; MayoClinic Staff, 2010; PubMed Health, 2010; Seligman et al., 2001)

o The cause of schizophrenia is not fully known or understood. o Genetic predisposition: first degree relatives have a 10x higher risk for developing the disease o Environmental factors (especially psychosocial stressors) are important for triggering the occurrence of the disease in predisposed individuals. -Stress -Maladjusted family relationships, poor parenting, and family dysfunction -Childhood trauma contributes to the development of the disorder o Genetic + Environmental factors lead to the development of schizophrenia o Prenatal exposure to infection, season of birth, and complications during pregnancy/birth have all been hypothesized as contributing to the development of the disorder. If an infection or extreme maternal stress presents within a specific critical period of prenatal development, then it is more likely that the child will have schizophrenia. Environmental influences are important even before birth. o Dopamine transmission in the brain: Individuals with schizophrenia have more dopamine D2 receptors than those without the disorder. Therefore, dopamine is too active in their systems. -Antipsychotic drugs block the activity of dopamine, thus reducing symptoms. -Drugs that increase dopamine activity can create psychosis, as is found in those with schizophrenia. -Movement abnormalities are often present in those who are not being treated for the disorder. These movement abnormalities are similar to those that are associated with excessive dopamine activity. o About 1% of the population is diagnosed with schizophrenia o More common in men because men have higher levels of dopamine, especially in the basal ganglia o Typical onset is in adolescence or early adulthood, but childhood behavior can illustrate a precursor to the development of the disorder. Onset rarely occurs in later in life than this. -Onset is usually later and is more mild among women. -The childhood form is the most severe and chronic. -The late onset form is almost always seen with a previous psychiatric diagnosis. o Older paternal age, as well as taking psychoactive drugs during adolescence or young adulthood have been identified as risk factors for developing schizophrenia. (Bonder, 2010; MayoClinic Staff, 2010; PubMed Health, 2010; Seligman et al., 2001)

o Variable o Relapse rate is high without medication. o Individuals need to be medicated for long periods of time, but they often stop taking their medications as they begin to feel a little better, thinking that they no longer need the medicine. o If onset is in childhood, then prognosis is worse because the course of the disease is more severe. o Prognosis worsens with the accumulation of hospital admissions. Predictors of prognosis also include age, duration of disorder, marital status, gender, and education level. Better outcome is predicted by older age, being married, being female, and higher pre-morbid autonomy in living arrangements. -A recent study found that a significant proportion of first-episode patients with schizophrenia achieve moderate long-term outcomes, with global functioning stabilizing more often than deteriorating. However, the stabilization is often at a level that is below the highest level ever achieved by the individual. This is the case in most industrialized countries. o Subtype may impact prognosis, as those with paranoid schizophrenia appear to have the most favorable outcomes. o Combined drug treatment and psychotherapy are related to better outcomes. (Abdel-Baki et al., 2011; Bonder, 2010)

o This is one of the most disabling psychiatric conditions. Its diagnosis is based on severe functional impairments. This means that performance in all areas of occupation is very negatively affected. o Social, vocational, leisure, self-care, ADL's and IADL's are markedly affected, resulting in a global picture of disability. The degree of impairment depends on the severity, phase, and type. o During the prodromal and residual phases, functional impairments outweigh psychotic symptoms. In the active phase, functional impairments peak, along with psychotic symptoms, lack of motivation, social withdraw, and self-care deficits. o These individuals often lack motivation prior to the disorder, which results in even more social isolation after onset. o These individuals often have problems keeping jobs, as their motivation, self-care, and interruptions in thought are not conducive to meeting the demands of full-time traditional employment. With supportive work environments with low stress levels and considerate bosses, these individuals may be able to hold jobs. During the active phase, it is almost impossible for individuals to work, and they may need to take a great deal of personal time off before they can return to work after the active phase subsides. o Hospitalization may be necessary during the active phase for stabilization and support. o Habits suffer because of the cyclic nature of the disorder. It is very difficult for these individuals to construct and maintain daily routines. -There is very poor cooperation with medication schedules, which leads to relapses of the active phase. o After the deinstitutionalization movement in the US, many with schizophrenia became homeless. Such individuals often lack the support and medication that they need and continue to suffer from the debilitating effects of their disorder. (Bonder, 2010; PubMed Health, 2010)

o OT treatment should be comprehensive with an emphasis on occupational engagement, as these individuals often lack motivation. o It is important to build on areas that are strengths and to focus therapy activities on areas that they express interest in, as areas of interest are normally few. This requires careful probing and motivation. o Social skills and life skills training is of vital importance. Help the individual to function in a variety of settings. Help them to identify meaning and quality to their life. o Work is an important intervention area, as it is hard for them to hold down jobs. Connect them with community organizations, help them find jobs, fill out applications, etc. The productivity found in a job can contribute to feelings of well-being and enhanced quality of life. o Leisure is also important to address because these individuals often have a hard time managing the unstructured time on their hands. Find healthy interests and pursue them. o Adapt tasks and their environment as is necessary to fit their level of skill/functioning. o We have a role in educating their family and employers, as well as advocating for specific needs of this client population. (Bonder, 2010)

o During the active phase, hospitalization may be necessary for safety and stabilization, as well as to ensure that the individual receives basic necessities (food, shelter, etc.) o Antipsychotic medications are the most effective treatment. They change chemical balances in the brain, which helps to control symptoms. Early antipsychotics (typical) were only effective at treating the positive symptoms of the disorder, and they had numerous, serious side effects, which dissuaded individuals from taking them on a regular basis. New antipsychotics (known as the atypicals), are more effective at treating both positive and negative symptoms, and their side effects are fewer and less severe. o Individuals taking antipsychotic medications should be placed on the lowest possible dose in order to avoid side effects. The most serious long-term side effect from taking these medications is tardive dyskinesia, in which people develop movements that they cannot control, especially around the mouth (often resembling the lip smacking and tongue movements of a frog). o Because schizophrenia is a chronic condition, individuals need to be on these medications for life. They often try to taper off their dosage or stop taking their medications all together whenever they being to feel better, which often results in a vicious cycle of symptoms, hospitalizations, and more medications. o Behavioral techniques, such as social skills training, can be used during therapy or at home to improve function socially and at work. Family treatments that combine support and education about schizophrenia help families cope. Programs that emphasize outreach and community support services can help people who lack family and social support. o Art therapy has been shown to alleviate some of the negative symptoms of schizophrenia, while providing the individuals with a sense of self-expression and motivation. It is often utilized in a group setting in order to provide the patients with social interaction, an area which their disorder makes very difficult to engage in. (Bonder, 2010; MayoClinic Staff, 2010; PubMed Health, 2010; Seligman et al., 2001)

o1. Catatonic: immobility often accompanied by mutism or catatonic excitement, in which there is motor excitation that is purposeless and not impacted by external stimuli -These individuals may sit motionless for long periods of time in positions that appear to be quite uncomfortable. They often show no acknowledgment of the outside world. -As a type of schizophrenia, this is uncommon. However, catatonic behavior may be present in other types. o 2. Disorganized: flat or inappropriate affect and disorganized behavior/speech -Conversations with these individuals are non-comprehensible. They talk, but they do not make sense to the listener. They often walk with a shuffled gait (which may aid in diagnosing this particular type). o 3. Paranoid: have well-developed delusions (usually of persecution) -They normally have auditory hallucinations and inappropriate affect. -The cause of this type is thought to be markedly different from the cause of the other types. Unlike any other type, people with paranoid schizophrenia do not show impairments on neuropsychological testing. They have better pre-morbid functioning than any other type, and their diagnosis is more stable, which leads to better long-term outcomes. o 4. Residual: occurs when the individual has psychotic symptoms but does not meet the criteria for any other type of schizophrenia. However, these individuals may have difficulty with role functioning, be socially isolated, demonstrate peculiar behavior, impaired hygiene, flat or inappropriate emotional expression, odd thinking, apathy, or unusual perceptions of experiences. o 5. Undifferentiated: these individuals do not fit into the other categories. They have poor interpersonal adjustment accompanied by some psychotic symptoms. o The DSM-IV-TR lists diagnostic criteria for each subtype of schizophrenia. o The developers of the DSM-V are considering eliminating the different sub-types of schizophrenia because individuals often present with symptoms of multiple types, making diagnosis between professionals less reliable. (Bonder, 2010; Seligman, 2001)

o Often develop substance abuse problems, which increases the relapse rate and can intensify symptoms of the schizophrenia -People with schizophrenia often smoke. This increases their risk of lung cancer dramatically when compared with the general population. -Heart disease is a common occurrence as well. It is precipitated by the chronic smoking. o Physical illness is common due to an inactive lifestyle and side effects from medications. Such illnesses are often overlooked because these people do not have access to good healthcare (especially if they are homeless or lack family/social support). o Depression, self-destructive behavior, and suicide are all risk factors for individuals with schizophrenia. Their delusions and hallucinations often lead them to harm themselves physically, some of which self-inflicted injuries may be serious enough to cause death. Their low quality of life and inability to function at an optimal level take a toll on their psychological well-being, often resulting in depression and suicidal thoughts/attempts. (MayoClinic Staff, 2010; PubMed Health, 2010)

o Individuals with schizophrenia often need a great deal of outside support, not only from professionals, but from family and friends in order to meet the demands of life. They are often unable to live alone. This means that family members must take on the role of a caregiver in many situations. Because the disorder normally develops during adolescence or early adulthood, it is very possible that these individuals have not experienced an opportunity to meet a significant other, to marry, or to have children. Therefore, their own care often falls back onto their parents. -A study was conducted to determine the effects of caring for a son with schizophrenia on mothers using an occupational therapy perspective. -The life trajectories and occupations of these women were altered to include caring. They described their experience of caring for a son with schizophrenia as entailing: initial confusion and learning about the disease and how they would need to adapt their lives to care for their sons; an evolution of the situation in their adaptation to taking on the role; an emotional state of not getting too optimistic about the recovery of their child; and a focus of their lives geared toward their son, with little time for themselves. -The most important way for caregivers to sustain satisfying lives is to pursue interests outside of caregiving, so that they can maintain quality of life and competence in other life roles. -Occupational therapy can be useful in caregiver education and providing access to community resources to alleviate some of the caregiver burden. (Chaffey & Fossey, 2004)

o There are cases in which individuals with schizophrenia cannot manage their disease on their own, do not have adequate social support, or have needs that cannot otherwise be met. This often results in such individuals becoming long-term patients at psychiatric hospitals. After living in such an institution for prolonged periods of time, it is often difficult for individuals to regain the competencies need to live outside of the walls of the facility. o Factors that have been shown to impede the discharge of such patients include advanced age (associated with physical complications and an increased frequency of negative symptoms), severe mental symptoms, and a higher rating of one's own capabilities in daily living than exists in reality (attributable to comfort level in a particular environment). These factors not only impede discharge, but contribute to the readmission of individuals back into long-term facilities if they are discharged. o This study suggests that inpatients with schizophrenia tend to view themselves as being sufficiently competent to lead their daily lives and to be satisfied with their lives within the hospital setting. o This suggests that long-term inpatients with schizophrenia may need occupational therapy interventions which provide them with a realistic image of their daily life and allow them to update their own assessments of their competence related to the skills necessary for daily life, instead of interventions that focus on daily life within the protective hospital environment alone. We must provide these patients with a clear image of their daily life after discharge (inform about available social resources) and converse with them about obstacles that they will encounter outside of the hospital (cooking, shopping, financial management, etc.) (Ishikawa & Okamura, 2008)