Disability in

schizophrenia
Dr Sandeep Raj K
 Disability
Inability to perform as expected in the
socio-economic and cultural context

A limitation of function secondary to a

disorder of a specific organ or body
system.
 Disability
Disordered or deficient functioning in the social
roles and domains (work, family, social group,
etc) regarded as normal in that society, the
family or social group or by the person affected
[WHO 1988]
Eg. Poor self care, social role , family role,
vocational competence, interpersonal
relationships
 Impairment
Loss of structure or function
Any loss or abnormality of psychological,
physiological, or anatomical structure or
function [WHO]
Symptoms of mental illness
Eg. Delusions, hallucinations, negative
symptoms
 Handicap
Disadvantage in competitions along with
others
Reflects the interaction between the
disability on one hand and both the
disabled person and his or her
architectural, attitudinal, social and legal
environment on the other
Eg. Job interviews, transport, money
management etc
 Disability in schizophrenia
Disability due to psychiatric disorders
began to receive widespread attention
after the report of “global burden of
diseases” (Murray et al 1996)
Schizophrenia along with major
depression, alchol use, bipolar affective
disorders, OCD is one of the 10 major
causes of disability. (Andrew et al 1998)
 Disability in schizophrenia
The last two decades has seen major
research in this field.
Schizophrenia starts usually at young age
and frequently associated with
deterioration
Have multiple psychological and physical
disability.
 Disability in schizophrenia
More in patients with continues and
deteriorating course.
High prevalence of unemployment, social
isolation, homelessness and dependency
Stigma
 Disability in schizophrenia
Disability in developed countries 41%
developing countries 15%
India  18% (varghese et al 1989)
Rural and urban have same behavior and
social role disability (Murthy et al 1992)
Early age of onset, poor premorbid
functioning indicate greater disability
(Thara, Joseph 1995)
 Disability in schizophrenia
Dynamic

Difficult to quantify

Invisible

Problem in convincing others

 Causes of disability
Positive symptom
- Hallucinations
- Delusions
- Thought interference
- Agitation
Negative symptoms
- Amotivation
- Apathy
 Causes of disability
Cognitive impairments
- Attention and concentration
- Impairment of judgment
- Concrete thinking
Co-morbidities
- Anxiety disorders OCD,
- Substance abuse
 Causes of disability
Side effects of antipsychotics
- Weight gain
- Drowsiness
- Neurological
- Metabolic
Lack of community based rehabilitation
- Revolving door phenomena
- Institutionalization
Stigma
 Disabilities
Poor socialization
Poor communication
Not able to do any job
Poor role performance
Poor personal hygiene
Poor interpersonal relationships.
 Handicaps
Unemployment
Poor housing
Lack of leisure activity
Loss of social support
 Management
Assessment
Prioritization
Program planning
Short term goals
Long term goals
Implementation
Follow-up
 Assessment
Road map of journey from acute exacerbation to
recovery
Pinpoints the areas of intervention and provides
a baseline its monitoring
Helps in certifying
Numerous scales available
No single scale is complete
Eg: symptomatology PANSS, BPRS
disability DAS, IDEAS
Disability Assessment Scale
Released by WHO
Has 6 domains namely
- Understanding & communicating
- Getting around
- Self care
- Getting along with people
- Life activities (Household and work)
- Participation in Society
 IDEAS
Indian Disability Evaluation Assessment
Schedule
Adapted from WHO-DAS
Brief
No need for training
Accepted by Ministry GOI
Modified version of IDEAS based on PWD Act
1995
Has four domains
- Self care,
- Interpersonal activities ( social relationships),
- Communication and understanding,
- Work ( Employment, Housework, Education)
 Scores
0- No disability (none, absent, negligible)
1- Mild disability (slight, low)
2- Moderate disability (medium, fair)
3- Severe disability (high, extreme)
4- Profound disability (totally cannot do)

Total score:
Add scores of the 4 items and obtain a total score
 Duration of Illness (DOI)

DOI < 2 years: scores to be added is 1

DOI 2-5 years: add 2

DOI 6-10 years: add 3

DOI >10 years: add 4

 Global disability
Total disability score + DOI score =
Global disability
Percentages:
0- No disability = 0%
1-6 Mild disability = <40%
7-13 Moderate disability = 40-70%
14-19 Severe disability = 71-99%
20 Profound disability = 100%
Cut off for welfare measures = 40%
 Prioritization

Needs of patient

Needs of the Family

Felt needs

Expressed needs

Assessed needs
 Short term goals
Cast in daily, weekly or monthly time frames.
Work as stepping stones or subgoals
Better if endorsed by patient or family members
or care givers
Eg :
Disruptive behavior Work behavior
Active symptoms Medication management
Negative symptoms Interpersonal
relationships
 Long term goals
Cast in monthly or yearly time frame
Should be comprehensive
Should facilitate
social, interpersonal, familial, financial,
recreational, medical or psychiatric, ADL’s,
independent living skills, vocational,
educational, spiritual, and housing or
residential.
 Pharmacological
Medicines never teach new skills but it
helps by removing the barrier for the
learning process
Significantly improve the symptomatology
Double edged sword
 Pharmacological

Side effects itself can cause disability

Newer antipsychotics are better
Dose to be adjusted according to the
clinical condition
 Psychosocial
Behavioral techniques for teaching skills-
- Shaping
- Modeling
- Coaching
- Prompting
- Over correction
Contingency Management
- Token economy
 Psychosocial

Attention enhancing skills

- Grain sorting
- Color cancellation etc

Activity scheduling
- patient and family should prepare
 Follow up
Ensure regular follow ups
Assessment to be done to assess
progress
Medication dose adjustment to be done
Booster sessions involving psychosocial
rehabilitation
 Role of family
Family plays an important role
Expressed emotion influences disability
Expectations have to be assessed
Psycho education to be done
Crisis intervention
Family support systems to be assessed
and established
 Role of community
Acceptance by the community influences
disability
Awareness will reduce stigma
Use of community resources is helpful
Community based rehabilitation helps in
deinstitutionalization
Its cost effective
To be educated about early warning signs
and side effect profile
 Conclusion
The past few decades has seen
tremendous improvement in health care
reducing mortality which in turn has
increased disability burden
An integrated multidisciplinary, tailor made
intervention strategy is the need of the day
Community participation, use of
community resources is necessary for
better outcome
Thank you