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A study was done on Physical Therapy and working with patients with Schizophrenia.   The analysis resulted in 3 main themes: (1) barriers—factors that complicate or obstruct physical activity, (2) reward—the motivation for physical activity, and (3) helpful strategies.

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Patients with schizophrenia have a substantially increased risk of cardiovascular disease and premature death compared with the general population. High prevalence of an unhealthy lifestyle contributes to the increased risk in these patients. Patients with schizophrenia are often physically inactive, and there is limited knowledge on the factors, such as barriers and incentives, that can influence physical activity in this patient group.

The aim was to study the perception and experience of barriers to and incentives for physical activity in daily living in patients with schizophrenia, as reported by the patients themselves.

An explorative study applying conventional qualitative content analysis was conducted.

A purposeful sample of 20 patients with schizophrenia or schizoaffective disorder (13 men, 7 women; 22-63 years of age) registered at 3 psychiatric outpatient clinics in Sweden were interviewed using semistructured interviews.

The analysis resulted in 3 main themes: (1) barriers-factors that complicate or obstruct physical activity, (2) reward-the motivation for physical activity, and (3) helpful strategies.

The results may not reflect important factors related to physical activity in older patients (>65 years of age), newly diagnosed patients, or inpatients.

In accordance with patients' perceptions, there may be biopsychosocial determinants of physical activity behavior that are unique for this group of patients. Future studies should investigate whether physical activity interventions for patients with schizophrenia benefit from individual analyses of barriers and reward for physical activity in combination with the use of tailored strategies such as personal support and activity planning.

Schizophrenia 1 is a serious and lifelong mental disorder. Current etiological theories suggest that it is both a developmental and a progressive brain disease. 2 Lifetime risk is below 1% worldwide, and schizophrenia affects 24 million people around the world. Symptoms are described as positive (additions to normal behavior) and negative (deficits, loss of functions). Positive symptoms are, for example, hallucinations, delusions, and disorganized speech and thinking. Hallucinations can be tactile, auditory, and visual, or they affect taste and smell. Negative symptoms include loss of important functions such as motivation (avolition), poverty of speech (alogia), difficulties in experiencing pleasure (anhedonia), loss of emotions and emotional withdrawal, and lack of a desire to form relationships (social isolation). 1

Schizophrenia can result in a profound disruption of several fundamental human abilities such as cognition, memory, language, thoughts, emotion, perception, and the sense of self. Schizophrenia leads to varying degrees of cognitive, behavioral, social, and occupational dysfunctions. 1 Active psychosis is ranked as the third most disabling health condition by severity. 3 Some patients recover and can function well in society, but approximately three-fourths have ongoing disability with relapses. 4 Comorbid disorders such as depression and anxiety are common. 5 In addition, patients with schizophrenia report discrimination and stigma in society and in somatic and psychiatric health care. 6 This "second illness" is the social label attached to the disorder. 6 Not perceiving oneself (or not being perceived by others) as "normal" can make it more difficult to connect with others and achieve a sense of belonging. 7 If friends, neighbors, and colleagues turn away, there is a loss of social interactions, and the result may be loneliness. 6 "Striving for a normal life" was identified as the core category when patients with schizophrenia were interviewed about what they needed to improve their well-being. 8 The main treatment strategy is to prevent relapses with the use of antipsychotic medication, but psychological, social, and vocational rehabilitation are equally important. 9

The effects of chronic medical illness in patients with severe mental illness have been well documented over the years. 10 The occurrence of metabolic syndrome is 2-fold to 3-fold higher in patients with schizophrenia compared with population data. 11 It is associated with a 2-fold to 3-fold increase in cardiovascular mortality and a 2-fold increase in all-cause mortality. 12 Patients with schizophrenia die 12 to 15 years prematurely, mainly because of ischemic heart disease and cancer. 13 The decreased life expectancy is related to risk factors for cardiovascular disease such as obesity, smoking, and an unhealthy and sedentary lifestyle. 9, 11, 14

Physical activity is currently defined as all body movements caused by the contraction of skeletal muscles and resulting in higher energy expenditure. 15 Exercise is the subset of activities that are planned and structured. 15 A systematic meta-analysis of cohort studies with follow-ups ranging from 4 to 20 years and including more than 880,000 participants, showed that physical activity was associated with a marked decrease in cardiovascular (30%-40%) and all-cause mortality (28%-37%), even after adjusting for other relevant risk factors. 16 There is strong evidence of a reduction of mortality in physically active people compared with sedentary people. 17 There is further evidence of positive effects of physical activity on mental health and health-related quality of life in healthy populations 18 and in different patient populations. 19 There is some evidence of positive effects of physical activity on psychological well-being, cognitive functioning, negative symptoms, and health-related quality of life and in patients with schizophrenia. 20

However, only a minority of patients with schizophrenia are physically active according to the minimum recommendations (ie, 30 minutes of moderate-intensity physical activity at least 5 days per week), 15, 21 and there is limited evidence regarding effective physical activity interventions in this patient group. 22, 23 As reported by some investigators, there are significant problems with high attrition in physical activity interventions for patients with schizophrenia. 24 There are some reports on factors that hinder or encourage physical activity in patients with serious mental illness, 25 but when this study was planned, there were no publications specifically on patients with schizophrenia. 26 How patients with schizophrenia perceive barriers to and incentives for physical activity may provide important insights to be used clinically as well as in future intervention research. The aim was to study perception of barriers to and incentives for physical activity in daily living in patients with schizophrenia as reported by the patients themselves.

Method

Design

This was an explorative study applying conventional qualitative content analysis 27 in accordance with the constructs and procedures described by Graneheim and Lundman. 28

Participants

A purposeful sample of 21 patients with schizophrenia 1 (n=19) or schizoaffective disorder 1 (n=2) was included, all registered at 3 psychiatric outpatient clinics in 3 mid-sized towns in Sweden. One interview with a patient with schizophrenia was lost due to technical problems with the recording device; thus, the final sample consisted of 20 informants ( Tabs. 1 and 2). Of these, 13 (65%) were men and 7 (35%) were women. Inclusion criteria were a Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), diagnosis of schizophrenia 1 or schizoaffective disorder for at least 1 year according to the patient record, older than 20 years of age, and being able to participate in an interview conducted in Swedish. Patients with bipolar or delusional disorders were excluded.

Procedure

A contact person at each center was responsible for the inclusion of informants, together with the first author. Information about the study was given to the staff at each clinic. The patients were given verbal and written information by the staff during a face-to-face meeting or by telephone. Written informed consent was obtained during the interview by the first author or by the staff prior to the interview. The interviews were carried out between October 2010 and January 2011 at a psychiatric outpatient clinic (n=18) or in the informants' home (n=2).

Data Collection

An interview guide ( Figure) with semistructured questions was used during the one-on-one interviews (first author). The interview guide was tested on one informant, and the pilot interview was included in the analysis because only minor changes were made. The recordings (Olympus Digital Voice Recorder DS-2400, Olympus Imaging American Inc, Center Valley, Pennsylvania) lasted between 35 and 106 minutes (median=49). Directly following the interview, the patients filled out a questionnaire regarding demographic background variables (from the Swedish version of the Structured Clinical Interview for Symptoms of Remission [SCI-SR]) 29 and questions about current living habits (from the Swedish national guidelines for methods used in the prevention of disease). 30 When needed, these forms were filled out with the assistance of the interviewer. Current height and weight were obtained by the interviewer directly following the interview (n=18) or taken from the patient record (n=2). Details on current medication and diagnosis were obtained from the patient records by the staff. Sampling was stopped when a preliminary evaluation suggested that adding more informants would not elicit any fundamentally new information regarding the categories (ie, information not already provided by previous participants). This procedure was considered acceptable, although saturation on every aspect of the analysis was not systematically evaluated.

Data Analysis

Trustworthiness

We strived to capture a variety of experiences by heterogeneity among participants regarding their illness, social situation, level of physical activity, and sex in order to increase credibility and transferability. Even though we did not succeed in recruiting an equal number of women and men, the rich variation in the data suggests that the sampling procedure was relevant. When facing informants who were predominantly silent or answered questions with few words, it was necessary to make rather extensive use of follow-up questions and to formulate questions that could be answered in a few words. Generally, in qualitative studies, informants who can provide rich verbal descriptions in response to a few open-ended questions are preferred, but applied to patients with schizophrenia, this approach would generate a very limited sample with a subsequent low transferability. Participants' background characteristics are presented in Tables 1 and 2, which makes it possible for the reader to evaluate the extent to which the findings can be transferable to another sample.

To enhance the reader's evaluation of the different steps in the data analysis, an example of the data analysis procedure is given in Table 3. Representative quotations from the transcribed text are presented in the " Results" section to illustrate the themes. One problem related to dependability was difficulties during transcription to hear what some of the informants said on the recordings. Several of the informants had problems with social interaction; they were sitting slightly turned away from the interviewer, made no eye contact, and were speaking in a low voice or with unclear articulation. In order to minimize errors in the transcripts that could lead to false inferences, 32 the first author listened to half of the recordings and made corrections in the transcripts when possible. A commonly used method to increase trustworthiness in qualitative studies is to actively involve the participants in reading the transcripts or reviewing the results (confirmability). This method was not used in the present study because a majority of patients with schizophrenia (70% or more) have cognitive dysfunction, including difficulties in attention, concentration, memory, language, and executive function. 33

Dialogue with subsequent agreement between co-researchers (researcher triangulation) was one of the major methods to increase trustworthiness in this study.28 The 3 authors' combined clinical and research experience was considered to be complementary and of importance to the analysis. All authors are registered physical therapists. The interviewer (C.R.) has more than 20 years of experience from clinical work in psychiatric outpatient health care including treatment of patients with schizophrenia. This long experience of meeting patients with different psychiatric diagnoses from a physical therapist's point of view shaped the way the interviews were carried out. The second author's (C.M.'s) research area has been primarily in social sciences, and her knowledge in research with a qualitative method was especially important during the data analysis. The third author (P.Å.) has a focus on research in the field of behavioral medicine, an interdisciplinary field concerned with the integration of behavioral, psychosocial, and biomedical science in prevention, treatment, and rehabilitation.

Role of the Funding Source

This research was financially supported by the Faculty of Medicine, Uppsala University, and the Regional Research Council in Uppsala-Örebro region.

Results

The analysis resulted in 3 main themes, 11 categories, and 41 subcategories (Tab. 4).

Compulsion, paranoia, and voices

Difficulties initiating activity

Satisfaction with inactivity

Difficulties in social situations

Loneliness

Overweight and obesity

Other somatic disease

Immediate negative outcomes

Pain

Feeling mentally worse afterward

Lack of positive feelings

Negative expectations

Fear of failure

Little faith in one's own ability

Lack of motivation and time

Misconceptions

Opinions and ideas about physical activity

Body perception

Difficulties handling information from or about the body

Difficulties buying good shoes

Difficulties during the winter

Lack of resources

Poor finances

Lack of equipment or access to facilities

Increased self-confidence

Feelings of freedom and independence

More alert and active

Positive expectations

Something to look forward to

Symptom reduction

Avoid the negative consequences of inactivity

To look good

Enjoyable recollections

Positive self-talk

Firm decisions

Mental images

Personal support

Other people take the initiative

Personal instructions

Having someone to tell

Continuity

Activity planning

Avoid stress

Scheduled times

A personal choice of activity

Theme 1: Barriers-Factors That Complicate or Obstruct Physical Activity

In this theme, 6 categories and 21 subcategories were identified.

Symptoms of illness and disease

Feeling mentally unwell with depressive mood and anxiety or panic attacks were commonly mentioned obstacles to physical activity. When feeling "well," however, it was much easier to accomplish things. "Everything depends on how I feel. So if there's a day when I'm feeling well, then it's clear that I'll do it that time. But then it falls through if I'm feeling bad the next week." (P11) In order to function well in daily life and to prevent them from feeling mentally unwell, the informants considered antipsychotic medication necessary, despite the negative effects of increased appetite and weight gain. Simply leaving home for a walk can take several hours for patients with a comorbid compulsion disorder. A paranoid fear of losing clothes or other possessions made it difficult for some informants to participate in activities at training centers. Patients hearing voices reported that these "others" could have opinions about their physical activity (eg, telling them to stay at home, not go for walks, or not get their heart rate up). "Much of it is that the illness, the paranoia, as I imagine it...those who are pursuing me...want me to stay at home with my mother. And not be out running somewhere else. They are even against me taking this walk on Sunday morning." (P7)

Difficulties in initiating activities and a tendency to postpone activities were other common obstacles. "Today I should have gone out for a walk. Now, I've been stupid. Why didn't I do it today? Then, I don't feel so good the day after when I didn't go out for a walk. It will be later, yes, I shall do it-only later. And so nothing happens." (P12) "Yes, it can be difficult for me to get down to doing something. And then I need someone to give me a push. It might be that I am anxious or something. I get stuck in my thoughts somehow, I can't do something.... I brood too much.... But it is not always like that." (P3)

Being tired most of the time was another obstacle. Not getting enough sleep was a problem for the few who were working, as they had to get up early even after staying up late. Some informants simply enjoyed lying in bed most of the day, planning to do things but not actually doing anything. Feelings of not fitting in when visiting a gym, fear of meeting new people, not feeling comfortable in groups, or not knowing how to keep a conversation going made it difficult for several informants to participate in physical activity. Some were indeed lonely and had few or no friends with whom to share activities. Being overweight or obese made it difficult and tiring to move around. Being obese and perspiring a lot was the reason why some informants did not go for walks during the summer. Somatic disorders such as lung disease could make breathing difficult when walking uphill, or intestinal disease could deter them from taking walks because of the need to stay close to restrooms.

Immediate negative outcomes

Pain conditions reduced physical activity for some of the informants. This outcome included difficulties walking because of leg pain and pain from using outdated training programs without considering the possibility of modifying the program or seeking help to do so. Some informants reported pain due to doing too much in the beginning. "Well, I walked about 45 minutes a day, and then my legs hurt so much I had to rest for 2 to 3 days. I think it was because 45 minutes in one go was too much. I have never walked so much before." (P12) Not feeling mentally well right after the training sessions was reported as an obstacle by one informant. Lack of positive feelings was an obstacle for another informant.

Negative expectations

Some informants were hesitant to initiate regular physical activity in fear of not getting results, which could make them feel dissatisfied with themselves. "If I go on with it without any results, then I'm only going to make myself unhappy because I'm not succeeding, and then I will feel worse and then...well, it's like I am protecting myself from feeling bad, as I see it." (P11) Several informants expressed low faith in their ability to become more physically active or maintain physical activity for longer periods of time. Because it had not worked before, they felt it would not work in the future. Being lazy, lacking motivation and time, and having other priorities were other obstacles. Some informants were hesitant to initiate physical activity, claiming it becomes boring after a while and, therefore, there is no point in starting at all.

Misconceptions

The analysis revealed several misconceptions about physical activity (eg, the opinion that only intensive exercise was meaningful, whereas light activities such as cycling or taking short walks were pointless from a health perspective). "I understand that the little I do actually has no effect. Such short sessions are pointless, so little. They should be long sessions, I'm sure. If you swim, it ought to be a kilometer, but right now I can't swim more than 25 to 30 m." (P9) "I used to cycle earlier. But you don't get any exercise from that either. It's so easy and all, to get around." (P16) Other examples of misconceptions were: there is no point in horseback riding because it is the horse that gets the exercise and not the rider, it is too late to exercise after 50 years of age, and you have to lose weight before you can become more physically active.

Body perception

The analysis showed that informants had difficulties interpreting information from their bodies (eg, What does it feel like when your heart beats faster?). Pain conditions were rather common, but several informants had vague ideas about what part of the body the pain was related to or where the pain came from. "I notice that it is painful if I walk too much. And I don't know if it is my foot. And when I exercise, it is painful here, too, extremely painful. I don't know what it is." (P19) There were difficulties understanding diagnoses and treatments related to the body (eg, understanding the reasons for taking heart medicine or going through knee surgery). The descriptions of somatic conditions and treatments were generally vague and unspecific.

Several informants had problems buying proper shoes for walking and for the winter season. Struggling with chafing, blisters, and foot pain for months, or having only a single pair of summer shoes made it difficult to take walks during the winter. Some were always in a hurry when in a shoe store because of feeling uncomfortable. "Yes, if I had good shoes and my feet didn't hurt, perhaps I would take up those Sunday walks again. I'm always in so much of a hurry when I'm buying shoes; I have to get it over with as quickly as possible. I don't feel comfortable doing it. I go to the cheapest shoe store and buy the cheapest shoes, and as quickly as possible." (P6) Several informants markedly reduced their physical activity during the winter season (in the region, approximately 5 months) because of fear of falling, not wanting to go out when it was cold and dark, or not wanting to use warm winter clothing. Several informants lacked knowledge about equipment that could be helpful in order to move in a safe way on snow or icy streets. "I fell last winter. I was on my way to the garbage disposal and hit my hip and shoulder really hard. I was terrified; I thought I had broken my hip. It can really make you afraid when you have fallen like that. And then it is easy to avoid going out, you could say." (P18)

Lack of resources

The few informants who were working had a much better financial situation compared with those without a job. "So one big reason I don't go to gymnastics, which is fun, is my financial situation, of course. I immediately run into financial problems; there's the cost of the season ticket, and then I also need trainers, which cost a thousand kronor." (P7) Some were spending too much money on gambling or were eating in restaurants most days of the week, which, in turn, made it difficult to afford the clothing needed for physical activity or to pay for a gym membership. A few informants mentioned that the gym was located too far away or that the training sessions were at the wrong time of day. Others wanted to go bicycling, but their bike had been stolen or was broken, and they had not thought about repairing it.

Theme 2: Reward-The Motivation for Being Physically Active

A total of 2 categories and 9 subcategories were identified in this theme.

Immediate positive outcomes

Being physically active was related to increased joie de vivre and feelings of happiness and joy. "You feel better afterwards, you feel lighter, your breathing is better. It's a bit like yoga, like meditation. You feel better quite simply. You kind of fly in here." (P19) Taking walks was considered relaxing and calming to the mind. Outdoor walks were essential to experience nature and the changing seasons, which, in turn, stimulated thoughts and conversations. Accomplishing things gave the informants a feeling of being content and pleased with themselves. Being physically active reduced feelings of worthlessness related to inactivity. "It (walking) has been good for my self-confidence-to feel that my body endures despite everything." (P2) Having extra stamina when needed felt good (eg, when running for the bus or wanting to take a walk uphill). Physical activity was related to feelings of freedom and independence. "Just going for a walk gives you an incredible sense of freedom, and you feel good. You feel free when you are walking." (P15) "I actually become more independent...that you have a sense of being independent, that you can decide for yourself what you are going to do." (P6) Being physically active was an important way to increase alertness and was considered a means to achieve more during the day. "I'm more wide awake and everything if I exercise more and eat well. More alert, if you like, and achieve more during the day." (P12)

Positive expectations

Physical activity was a means to make life richer and more stimulating as well as something to look forward to. It was used to alleviate pain conditions, anxiety, and bad mood and could make the voices disappear. "Fresh air is good for you if you feel bad and the like. If I'm suffering from anxiety and go out in the fresh air, it can help me feel a little better." (P3) "I think that exercise does you good, and I think that it is fun, too. You look forward to going to the gym and everything. Yes, perhaps the voices disappear then and other such nonsense." (P13) Physical activity could prevent outbursts of anger, becoming psychotic, and smashing things at home. Another motivation for being physically active was to avoid feeling bad about yourself for not doing what you had decided to do. The informants stressed that their mood and thinking deteriorated if they didn't go out or if they became more passive. Body pain and stiffness increased. Physical inactivity was associated with more conflicts and irritation from family members. Some informants knew from personal experience that it was possible to lose weight as a result of increased physical activity. To lose weight in order to look good was a motivating factor. "I want a nice body and all that, but it is a little hard sometimes. I want to look good. It is the muscles, and then you want to get rid of the paunch, too." (P3) All but one of the informants described in positive words how they used to be more physically active when younger and before getting sick; they were jogging, dancing, swimming, or going to the gym. Some informants had been successful in sports such as basketball or ice hockey. There was a desire to be physically active in the same way they used to be but no longer were able to.

Theme 3: Helpful Strategies

In this theme, 3 categories and 11 subcategories were identified.

Mental preparation

The informants stressed the importance of understanding that your health deteriorates if you are obese and physically inactive. "It's that you begin to understand that your health deteriorates if you are fat. It's not good to be obese when you're going on fifty. So it is a warning and self-insight that you want to live longer." (P4) The informants stressed that it requires "a period of positive talking about it" (P17) before you can make the necessary commitment. It is helpful to be positive and self-confident, telling yourself that it has worked before and will work again. Words were described as powerful tools that can be used to maintain physical activity even when it is no longer enjoyable. It was important to have a positive attitude instead of a negative attitude toward yourself, to visualize what could be achieved rather than focusing on what had not been achieved during the day. Making a firm decision before starting was considered important. "I believe I can succeed if I really make a decision. You have to be mentally and spiritually determined. All this about eating healthily and going for power walks...it feels like I'm standing there and hesitating a little, I haven't made the decision yet, that really fundamental decision." (P18)

Personal support

Most informants were positive to health care staff making suggestions about physical activity, although the informants stressed the importance of being treated with respect to avoid making them feel they are under surveillance. "It helps if someone else suggests something. Goes with you. If you are depressed and don't take these initiatives, but have someone who gives you a push, then it suddenly feels like fun." (P4) Some informants described that it was helpful if someone was accompanying them (eg, to the gym), guiding them. The informants stressed that it was important to have someone to share with and that it was encouraging and helpful to get positive and affirmative response from others. "The only thing they need to do, in fact, is that I should have someone to tell when I have done these things. I have been able to tell my mother after I have been to the gym. She doesn't say anything in particular, but it's nice to have someone to tell." (P9) Some informants considered group participation helpful. "Breaking patterns from my side. And it was easier to do when you could talk to others in the group. You sort of exchanged 'this is what I did' and 'this is what I think' and 'I think this.'" (P4) Other informants preferred support from one other person or a staff member. Having the same staff over longer periods of time makes it possible to get to know and connect with each other. This continuity was especially important for those informants where the health care professionals were the only people they met on a regular basis.

Activity planning

Stress was described as an obstacle for physical activity. It was necessary to avoid too many activities during the week or day in order not to feel stressed when preparing for physical activity. "Yes, it is a procedure (before getting out). If I am stressed...it doesn't work out so well." (P8) For some, not being stressed by too many activities meant having a maximum of one activity per day or taking one walk per week. Several informants stressed the importance of structure and having fixed schedules for physical activity. This structure was helpful because of difficulties initiating activities, and "once you begin to take it easy, it is hard to break out of it." (P2) Practical tips for physical activity were: having a destination for your walk, walking instead of taking the bus, getting off the bus a few stops in advance and walking the remaining distance, and listening to music while walking. Outdoor walks and light-intensity activity were preferred by the majority of the informants, but not all. Several informants stressed the importance of being cautious in the beginning, not doing too much initially, and avoiding strenuous exercise because the body could not tolerate it. Others remarked that it had to be fun and that it was important to find an activity that you enjoyed. Besides walking, there was a variety of preferred activities, including swimming, aerobics, cycling, playing tennis, skiing, and going to the gym or yoga classes. Some informants preferred home training programs. The informants were quite clear about whether they preferred physical activity by themselves, together with a friend, or in a group. "I think it is better to take walks alone because you can walk in your own pace." (P10)

Discussion

Three major themes mirrored patients' self-perceived affordances for physical activity: barriers, reward, and helpful strategies. Barriers to and benefits of physical activity have been investigated in the general population, 34 in older adults, 35 in patients with somatic disorders, 36 in patient groups with a mixture of psychiatric diagnoses, 21, 25 and in a recent study on older patients with schizophrenia. 37 Some of the previous findings are congruent with the results from the present study-for example, identifying barriers such as mental illness symptoms, fatigue, and overweight 21, 25, 34, 37 and benefits such as increased well-being and incentives such as health concerns. 34- 35, 37 The present study adds some additional findings of interest specifically related to patients with schizophrenia.

Lack of motivation (amotivation) is considered one of the primary exercise barriers for people with schizophrenia. 38 A number of studies have documented problems recruiting and retaining patients with schizophrenia in interventions studies due to low motivation. 39- 41 In our study, several of the informants talked about the importance of motivation. Motivation was related to the reward the informants associated with physical activity-the immediate positive outcomes (eg, increased well-being, activity, and self-confidence) and the positive expectations (eg, have something to look forward to, symptom reduction). Several of the informants in our study appeared to be aware of the health risks related to physical inactivity and overweight and wanted to avoid the negative consequences of inactivity. A recent publication on the staff perspective on physical activity in older patients with schizophrenia 42 showed that the staff considered motivation an important factor to consider but that it was rare for patients to be intrinsically motivated for physical activity. In contrast to that study, our results suggest that the informants were clear about their personal motivation for physical activity.

Even though the majority of the informants reported positive feelings toward physical activity, there were a number of barriers to overcome. In effect, some informants reported that they simply refrained from physical activity because of the obstacles involved. As reported in previous research, 25, 26, 42 some of the key barriers were related to schizophrenia symptoms, such as feeling mentally unwell, having difficulties initiating activities, or hearing voices with a negative attitude toward physical activity. The results show that symptoms are a major barrier to physical activity but that physical activity also can be used to reduce symptoms. 25, 26 This finding has been reported in other studies as well. 37, 42

Some of the informants experienced problems with a variety of pain conditions that made it difficult to be physically active. Others had difficulties buying shoes that fit their feet and, therefore, had shoe-induced pain. The results point to the need to specifically ask patients with schizophrenia about pain conditions, to help patients interpret sensory information from the body, and to assist them in seeking appropriate medical examination and treatment. A physical examination by a physical therapist may be part of the multidisciplinary care for patients with schizophrenia.22

Taking antipsychotic medication regularly was considered helpful because it made informants feel better, and when you feel better, it is easier to be physically active. This result is not congruent with previous reports, where antipsychotic medication has been referred to mainly as a barrier to physical activity. 25, 26, 42 A possible explanation may be that during the past decade, new antipsychotics with fewer motor side effects have been developed compared with the first-generation agents. 9 On the other hand, the new antipsychotics also tend to induce a high incidence of metabolic side effects and weight gain, which are barriers to physical activity. 9, 25

Limitations

This study explored variation in the perception of barriers, incentives, and strategies for physical activity in a sample of patients with schizophrenia living in 3 different cities in Sweden. In an international perspective, availability of medical and psychosocial treatments for patients with schizophrenia varies among countries. 52, 53 Therefore, the results may not reflect important factors related to physical activity in patients with schizophrenia living in countries with a more limited health care or social security system.

As discussed in the " Method " section, a commonly used method in qualitative research to improve trustworthiness is to actively involve the participants in reading transcripts or reviewing the results. However, reading long texts may be a problem for patients with schizophrenia. Trustworthiness in the study could have been further improved by using a modified form of a participant check of the transcripts and the results. The study was conducted in an outpatient setting, and the results may not reflect the experiences of patients receiving treatment in mental hospitals.

The question of how to secure variation in perceptions of the concept under investigation is central in qualitative research. 54 However, it is not evident that more variation is captured by increasing the number of participants sharing a certain characteristic if we do not know that variation in this characteristic is related to variation in the central concept. Hence, we do not know if our results would have been different if more people with, for example, a body mass index below 25 kg/m ² had been included. Because patients who are newly diagnosed and older patients (>65 years of age) were not included in the study, the results may suffer from lack of variation depending on these characteristics.

Future Research

The results from the present study suggest some important new areas (eg, difficulties in body perception) that need to be considered when planning physical activity interventions for patients with schizophrenia in research and in the clinic. The effects of body awareness therapy and other physical therapy interventions on body perception, self-esteem, and cognitive function in patients with schizophrenia need further evaluation. 22, 55 Additionally, the results imply the need to develop a new patient-specific measure of physical activity self-efficacy that considers the unique barriers patients with schizophrenia meet in relation to being physically active. The importance of physical activity self-efficacy beliefs in patients with schizophrenia should be further investigated with a patient-specific measure. Furthermore, there is a need for well-designed randomized controlled trials examining the effects of physical activity interventions for patients with schizophrenia. Our results could be transferred to hypotheses about biopsychosocial determinants of physical activity behavior, possibly unique for people with schizophrenia. If corroborated, they support the development of integrated behavioral medicine and physical therapy interventions. Future studies should evaluate if consideration of the barriers, benefits, and strategies explored in this study enhances the effects of such interventions.

In conclusion, this study explored the patient perspective on physical activity in patients with schizophrenia. In accordance with patients' perceptions, there may be biopsychosocial determinants of physical activity behavior that are unique for this group of patients. Future studies should investigate whether physical activity interventions for patients with schizophrenia benefit from individual analyses of barriers and reward for physical activity in combination with the use of tailored strategies such as personal support and activity planning.

As one informant summarized:

If you are going to manage, you need balance in life. Help from the outside and rules...routines that you are to see someone or participate in an ordered activity. Because you probably don't manage on your own. You need external help and to work with motivation and goals. And realize that it is important for your health, you want to live long, and life...is a chance you get. (P4)

An overview of the results was presented as a poster/abstract at the 12th International Congress of Behavioral Medicine; August 29-September 1, 2012; Budapest, Hungary.

Ethical approval for this study was provided by the Regional Ethical Review Board in Uppsala, Sweden (Dnr 2010/264).

This research was financially supported by the Faculty of Medicine, Uppsala University, and the Regional Research Council in Uppsala-Örebro region.

References

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Barriers, Benefits, and Strategies for Physical Activity in Patients With Schizophrenia | Physical Therapy | Oxford Academic

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BackgroundPatients with schizophrenia have a substantially increased risk of cardiovascular disease and premature death compared with the general population. High prevalence of an unhealthy lifestyle contributes to the increased risk in these patients.

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Learning proper social skills will help people living with Schizophrenia to lead a more extrovert lifestyle

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https://www.healthlinkbc.ca/health-topics/aa48198

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https://www.healthlinkbc.ca/health-topics/aa48198 Is it an emergency? If you or someone in your care has chest pains, difficulty breathing, or severe bleeding, it could be a life-threatening emergency. Call 9-1-1 or the local emergency number immediately. If you are concerned about a possible poisoning or exposure to a toxic substance, call Poison Control now at 1-800-567-8911.

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First hand account from a person living with Schizophrenia.

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I went to another day program and that helped me quite a bit. I was in that for four months and they taught me how to live on a budget and banking techniques and social assertiveness techniques and I found that very helpful because that gave me a reason to get up in the morning, even though I couldn't work I could go to this day program.

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First hand account from people living with Schizophrenia.

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High prevalence of childhood trauma in patients with schizophrenia spectrum and affective disorder

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High prevalence of childhood trauma in patients with schizophrenia spectrum and affective disorder

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High prevalence of childhood trauma in patients with schizophrenia

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Abstract

Introduction

The term childhood trauma has been used to capture a range of severe adverse experiences, including sexual, physical, and emotional abuse, and neglect. A recent survey in the United Kingdom estimated the prevalence of childhood sexual abuse at around 11% and physical abuse at around 24%. 1 In the United States, estimates tend to be higher. 2 The adverse long-term consequences of childhood sexual and physical abuse have been well documented and include increased risk of adult depression, 3 personality disorders, 4, 5 suicide, 6, 7 posttraumatic stress disorder (PTSD), 8 and drug and alcohol dependence. 9 It is possible, moreover, that specific forms of abuse are linked to particular disorders. For example, sexual abuse shows strong correlations with later depression 3 and borderline personality disorder 4 and physical abuse with antisocial personality disorder. 10, 11

This review is concerned with the question of whether childhood trauma increases the risk for adult psychosis or, more specifically, schizophrenia. Our aim is to provide an overview of the most relevant and robust research and, from this, to highlight a number of conceptual and methodological issues that need to be taken into account in future research.

A Gathering Storm

Interest in this issue has reemerged in recent years and has coalesced around a recent review article by Read et al, 12 in which the authors claim that the evidence shows: "child abuse is a causal factor for psychosis and 'schizophrenia.'"(p330) This led one UK psychologist and journalist to write of this review as providing "tectonic plate-shifting evidence." 13 Are these claims warranted?

The Prevalence of Childhood Trauma in Clinical Populations

It is necessary to begin on a critical note. The overall impression created by the review of Read et al 12 is that there is a wealth of evidence suggestive of a causal relationship between childhood trauma and psychosis. For example, Read et al 12 produce weighted averages for females and males of reported child sexual abuse (48% females, 28% males), incest (29% females, 7% males), and child physical abuse (48% females, 50% males) from 51 studies of psychiatric inpatients and of outpatients when half or more were diagnosed with a psychotic illness. In terms of understanding the relationship between childhood trauma and psychosis, however, these estimates are misleading.

Of the 51 studies included, 8 are of children and adolescent samples, 14 are of inpatient or ex-inpatient samples, in which only a minority, if any, have a diagnosis of psychosis, and 9 are of outpatient samples in which over 50% have a diagnosis of psychosis. In other words, 31 of the 51 studies are of diagnostically heterogeneous samples in which the numbers with a psychotic disorder are often unclear. Read et al 12 reason that this is acceptable because, they claim, the prevalence of childhood trauma in those with a psychotic disorder is likely to be higher than in other groups.(p334) However, when the weighted prevalences are recalculated, using only those studies ( n = 20) in which all subjects were diagnosed with a psychotic mental illness, the estimates reduce for all but one form of abuse (sexual abuse in males, which remains the same) (see table 1).

This analysis notwithstanding, there remain doubts about whether calculating a weighted prevalence from even this more restricted list of studies is meaningful. Combining data to produce a single estimate of prevalence carries an implicit assumption that the samples and the measures of exposure across the studies are comparable. However, the samples used in these studies were invariably small, highly selected and heterogeneous, and the definitions and measures of abuse varied widely. Furthermore, all but 2 of these studies 14, 15 was of chronic samples, such that, even if the rates of childhood trauma were higher than in comparable population samples, this may reflect the impact of abuse on illness severity and chronicity or the presence of comorbid affective, substance use, personality, or post-traumatic stress disorders, all of which have been linked to earlier abuse and all of which are common in those with a psychotic mental illness. 16 In a recent study, for example, of 124 outpatients with a diagnosis of schizophrenia, Scheller-Gelkey et al 17 report a 37% prevalence of sexual abuse in those with a comorbid substance misuse problem compared with 16% in those with no substance misuse problem.

Population-Based Studies

This critical note aside, in recent years, there has been a small number of large population-based studies that provide data more relevant to this question, 5, 18-21 and these are summarized in table 2.

Study Design

Sample

Measure of Childhood Trauma

Measure of Outcome

Number Exposed

Number With Outcome

Measure of Effect

Spataro et al5(Australia)

Prospective cohort

1612 children (1327 female, 285 male) who had been sexually abused; 3 139 745 population controls.

Records from Victorian Institute of Forensic Medicine of medical examinations confirming sexual abuse.

Cases registered on Victorian Psychiatric Case Register.

1612 subjects identified as having been sexually abused.

113 907 had contacts with psychiatric services (113 707 controls; 200 cases); 20 805 with a schizophrenic disorder diagnosis (20 792 [0.7%] controls; 13 [0.8%] cases).

Relative risk of schizophrenic disorder in controls vs schizophrenic disorder in cases who had been abused: RR 1.2 (0.7-2.1)

Bebbington et al18(United Kingdom)

Cross-sectional survey

8580 adults aged 16-74 recruited to the second British National Survey of Psychiatric Morbidity.

Respondents shown cards with a list of stressful life events, including sexual abuse, and asked if they had experienced any in their lifetime. Presence or absence only rated.

A 2-stage approach was adopted to assess presence of psychotic disorder: (1) Psychosis Screening Questionnaire 64 was administered to all participants; (2) those who screened positive, and a proportion who screened negative were interviewed with the SCAN. 65

2982 (3.5%) with no disorder responded positively to the question on sexual abuse; 21 (34.5%) with a probable psychotic disorder responded positively.

60 with a probable or definite psychotic disorder.

Sexual abuse vs none:Adj. ORa 2.9 (1.3-6.4)

Janssen et al19(Netherlands)

Prospective cohort

4045 adults aged 18-64 recruited to the Netherlands Mental Health and Incidence Study.

At baseline, subjects were asked about experiences of any kind of emotional, physical, psychological or sexual abuse before age 16, using a 4-item semistructured interview designed for the study. Presence or absence, and frequency of events rated.

CIDI 66 for screening followed by 2 items of the BPRS 67 and need for care assessed using CAN. 68 3 outcome groups:1. BPRS any psychosis2. BPRS pathology level psychosis3. Need-based disorder

423 (10.5%) reported childhood abuse; 260 (61.5%) were women

Psychosis outcome at follow-up:BPRS any psychosis: n = 38 (0.94%) BPRS pathology level: n = 10 (0.25%) Need-based disorder: n = 7 (0.17%)

Abuse vs no abuse:BPRS any psychosisAdj. OR b 2.5 (1.1-5.7)BPRS pathology level Adj. OR b 9.3 (2.0-43.6)Need-based disorderAdj. OR b 7.3 (1.1-49.0)

Whitfield et al20(United States)

Cross-sectional

17 337 subjects (mean age 57) recruited to the Adverse Childhood Experiences study

Self-report postal questionnaire comprising questions from other scales and studies. Presence or absence and frequency before the age of 19 were noted

A single question used to determine lifetime history of hallucinations ("Have you ever had, or do you have, hallucinations (seen, smelled, or heard things that were not really there?")).

Emotional abuse: 13%
Physical abuse: 27%
Sexual abuse: 25%

Lifetime history of hallucinations: 2%

Risk of ever having had a hallucination:
Emotional abuse:Adj. OR c 2.3 (1.8-3.0)
Physical abuse:Adj. OR c 1.7 (1.4-2.1)
Sexual abuse:Adj. OR c 1.7 (1.4-2.1)

Spauwen et al21(Germany)

Prospective cohort

2524 subjects aged 14-24 recruited to the Early Developmental Stages of Psychopathology study

Lifetime exposure to 9 traumatic events were measured at baseline using a module from the CIDI

Ratings from the 15 M-CIDI core psychosis items were used to assess presence of psychotic symptoms. Psychosis outcome was defined as "broad" (one or more psychotic symptom), "medium" (2 or more psychotic symptoms), or "narrow" (3 or more psychotic symptoms).

Any trauma n = 491 (19.5%)
Sexual abuse n = 39 (1.5%)

Psychotic symptoms broad n = 441 (17.5%); medium n = 183 (7.3%); narrow n = 85 (3.4%)

Narrow psychosis
Any trauma:Adj. OR 1.89 d (1.16-3.08)
Sexual abuse: Adj. OR d 1.55 (0.47-5.08)
Physical threat:Adj. OR d 2.14 (1.18-3.89)
Rape: Adj. OR d 2.26 (0.55-9.21)

Using data on 8580 subjects aged 16-74 from the British National Survey of Psychiatric Morbidity, Bebbington et al 18 found that those who met criteria for a definite or probable psychotic disorder ( n = 60) were over 15 times more likely to have been sexually abused at some point in their lifetime (not restricted to childhood). When the interrelationship between other negative life events and level of depression were controlled, the odds ratio was markedly reduced, though still significant (Adj. OR 2.9). However, the measure of sexual abuse was crude (a single question), no account was taken of timing, duration, or severity of abuse, and childhood and adult exposure were not distinguished.

In their analysis of data on 4045 subjects aged 18-64 drawn from the Netherlands Mental Health Survey and Incidence Study, Janssen et al 19 found that those who had experienced emotional, physical, or sexual abuse or neglect before the age of 16 were more likely to report experiencing psychotic symptoms during a 3-year follow-up period. The effect was strongest for the most severe psychosis groups and held after adjusting for a range of potential confounding variables (eg, need for care level psychosis: Adj. OR 7.3). However, the number of subjects with psychotic symptoms was very small, particularly those with the most severe symptoms ( n = 7), meaning the confidence intervals for each odds ratio were very wide, and while there was evidence that the risk of developing psychosis increased in a dose-response fashion with increasing severity of abuse, no formal test for trend across levels of abuse severity was reported. In a more recent study using a similar design, Spauwen et al, 21 using data on 2524 subjects aged 14-24 from the Early Developmental Stages of Psychopathology study, found that the experience of any lifetime trauma (from a list of 9 events, not restricted to childhood) was associated with the development of 3 or more (but not fewer) psychotic symptoms during an average follow-up period of 42 months (Adj. OR 1.9). The trauma exerting the strongest independent effect was natural catastrophe (Adj. OR 15.1) followed by physical threat (Adj. OR 2.1). The risk of developing 3 or more psychotic symptoms was elevated in those who reported sexual abuse (Adj. OR 1.6) but not significantly and by much less than in the studies by Bebbington et al 18 and Janssen et al. 19 However, as in the study by Bebbington et al, 18 the measure of trauma was relatively crude, again with no account taken of timing, duration, or severity.

In the only study in which the occurrence of sexual abuse was determined using contemporaneous records, Spataro et al 5 compared rates of subsequent hospital admissions in those who had been sexually abused before the age of 16 ( n = 1612), according to official records, with admission rates in a large population-based control sample ( n = 3 139 745). They found no association between child sexual abuse and later admission to hospital with a diagnosis of schizophrenia (relative risk 1.2). However, as the majority of cases of sexual abuse go unrecognized, meaning many cases of sexual abuse will have been included in the control sample, the potential for this study to detect a difference was limited. Further, by definition, the cases of abuse included were the subject of some form of state intervention, and this may have had protective effects on later risk of psychopathology.

In another recent large population-based study ( n = 17 337), Whitfield et al 20 found that respondents reporting a history of hallucinations were more likely to have been both physically (Adj. OR 1.7) and sexually (Adj. OR 1.7) abused during childhood. The sample size is a strength, but the study is cross-sectional and the measure of hallucinations extremely limited (ie, a single question, see table 2). Nonetheless, this is in line with findings from a number of previous (much smaller) studies, which have reported higher rates of hallucinations in patients with a psychotic illness (or in clinical populations more generally) who had experienced various forms of trauma in childhood compared with those who had not. 22-24 The evidence regarding delusions is more equivocal. Janssen et al, 19 for example, reported higher rates of both hallucinations and delusional ideation in those who had experienced childhood abuse, but others have found no association between early trauma and delusions. 16 Only a small number of studies have investigated other symptoms, such as negative symptoms, 25, 26 and no clear patterns emerge.

The findings from the recent, more robust, studies of childhood trauma are suggestive of a link with adult psychosis. However, the findings have not been altogether consistent and a number of complicating conceptual and methodological issues remain.

Conceptual and Methodological Issues

Diagnostic Conundrums

In the main, the recent studies of childhood trauma have focused on psychotic symptoms in the general population, at varying levels of severity, and whether reported associations will extend to those with symptom clusters meeting criteria for specific psychotic diagnoses remains unclear. Further, positive psychotic symptoms are reportedly common among those with a primary diagnosis of PTSD 27 (and those with dissociative symptoms 28, 29), and recent studies suggest there is a high prevalence of PTSD (much of it unrecognised) in patients with a diagnosed psychotic disorder. 30 A key issue for future research is, consequently, the question of whether any link between childhood trauma and psychosis is diagnosis specific. It may be, as Read et al 12 suggest, that Kapur's 31 notion of "psychosis-in-schizophrenia" is relevant here. That is, childhood trauma may be associated with positive psychotic symptoms in schizophrenia, and as such understanding this link may "... have more implications for understanding the occurrence of psychosis in other illnesses (eg, manic psychosis) than it does for understanding the nonpsychotic (ie, negative and cognitive) symptoms in schizophrenia."(p18) This further ties in with recent movements in cognitive psychology toward a focus on individual symptoms rather than diagnoses. 32 Disentangling these complex issues is essential if the relationship between childhood trauma and psychosis is to be fully understood.

Defining and Measuring Childhood Trauma

Childhood trauma is a broad term, encompassing a range of adverse experiences. The nature, timing, severity, and duration of trauma are likely to influence its impact on future mental health. As already noted, it is possible that different forms of trauma increase risk for distinct pathological outcomes. In the studies summarized in table 2, there were notable differences in how trauma was defined and measured. This makes it difficult to directly compare these studies and indeed may explain some of the variability in the findings.

Any estimate of the impact of childhood trauma on risk of psychosis is dependent on accurate assessment of early traumatic experiences. In the absence of contemporary records, information has to be collected retrospectively. This is particularly problematic if having psychotic experiences or a psychotic disorder differentially impacts on recall compared with others, for example, because of an effort after meaning or, more rarely, delusions of abuse. Instruments have been developed and used in the study of other disorders (eg, depression), which employ a number of strategies to overcome the potential problem of recall bias (eg, use of life history calendar, use of multiple sources of information, assurances of confidentiality).3 However, this issue has not been addressed in the major studies of childhood trauma and psychosis to date and the use of relatively crude measures of traumatic experiences, as was the case in the studies discussed above, increases the risk of systematic information bias.

Mechanisms: Some Tentative Speculations

In the past, the proposition that socioenvironmental factors are of etiological importance in psychosis has been weakened by the lack of any clearly formulated mechanisms linking the two. One consequence of the recent rapid advances in the neurosciences and genetics is that we are beginning to understand how social experience across the life course interacts with genes, and impacts on biological development, to shape adult outcomes. These insights are now being used to produce biological models linking adverse social experiences, including childhood trauma, and adult psychosis.

Dopamine continues to be implicated in the etiology of psychosis, particularly in the formation of persecutory delusions due to its perceived role in the interpretation of threat-related stimuli. 33 Spauwen et al 21 have speculated that extended exposure to trauma may increase risk for psychosis through direct effects on dopamine function. There is accumulating evidence from animal studies that negative and threatening events (eg, maternal deprivation in neonatal rats, 34 "social defeat" in mice 35) can produce dopaminergic hyperactivity in the mesocorticolimbic system and that prolonged exposure to such aversive environments can lead to sensitization of this system. 36 In humans, elevated dopamine metabolism has been found in girls who have been sexually abused compared with nonabused controls. 37 This poses the intriguing question of whether early trauma increases risk of later psychosis through sensitization of the dopaminergic system. Along similar lines, Read et al 12 have suggested that early, prolonged, and severe trauma may increase risk for later psychosis through lasting effects on the hypothalamic-pituitary-adrenal (HPA) axis. There are studies that have found HPA dysregulation in abused girls 38 and in women who were physically or sexually abused in childhood. 39 Heightened sensitivity to stress has been considered a central feature of schizophrenia, 40 and recent research has found patients with a first episode of psychosis to have enlarged pituitary glands compared with normal controls, 41 independent of antipsychotic treatment. 42

It may be, moreover, that some individuals are more prone to develop psychosis following prolonged childhood trauma because of an underlying genetic susceptibility. Recent research has provided strong evidence that the impact of environmental factors on risk of adult psychopathology is mediated by an individual's genotype (eg, cannabis and catechol-o-methyltransferaze 43), and data from the Finnish adoption study 44 provides some evidence that the effect of problematic family relationships on risk of later schizophrenia is mediated by genetic risk. There are currently no reported data testing potential gene-trauma interactions in psychosis. Nevertheless, it is possible to propose, as potential candidates for interaction with childhood trauma in the etiology of psychosis, genes involved in HPA regulation 45-47 and dopamine levels in the brain. 48 Of course, at this stage, this is highly speculative.

Conclusions

The evidence that childhood trauma causes psychosis is controversial and contestable. Child abuse certainly causes prolonged suffering, and it may increase the distress experienced by those who develop a psychotic mental illness in adulthood and lead to worse outcomes. The implications of this for clinical practice require careful consideration. There is not, in our view, a large body of research supporting a causal connection, contrary to the impression gained from the review of Read et al.12 There are a modest number of recent population-based studies that suggest the risk of experiencing psychotic symptoms is increased in those exposed to early trauma. The plausibility of proposed biological mechanisms add some weight to these data. The findings from such studies, however, have not been wholly consistent, and a number of methodological limitations mean we should be cautious in overinterpreting these. That said, this issue is one that certainly merits more sustained and systematic research.

References

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Environment and Schizophrenia: Environmental Factors in Schizophrenia: Childhood Trauma-A Critical Review | Schizophrenia Bulletin | Oxford Academic

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There is renewed interest in the relationship between early childhood trauma and risk of psychosis in adulthood. There are a large number of studies of psychiatric inpatients, and of outpatients in which a majority have a psychotic disorder, that suggest the prevalence of childhood trauma in these populations is high.

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Diagnosed at a young age with Schizophrenia.  She has gone on to open
Saks Institute for Mental Health.

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Visit USC on YouTube: http://www.youtube.com/usc Learn more about the University of Southern California: http://www.usc.edu USC Gould School of Law Professor Elyn Saks was invited by Vice President Joe Biden office to share information about her lifelong illness of schizophrenia for his mental health campaign.

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Joshua shares his personal journey with honesty and openness in a new documentary film about the challenges and triumphs of mental health recovery and treatment. Watch the complete documentary at http://www.ChoicesInRecovery.com

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Submission by a young person with schizophrenia. http://www.mindyourmind.ca Download the video here http://www.megaupload.com/?d=0NUTAEFA

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Myths and beliefs around schizophrenia that influence society and infers a stigma of the illness.

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Schizophrenia is a biochemical brain disorder which affects a person’s ability to determine what is reality and what is not.  People with schizophrenia are affected by delusions (fixed false beliefs that can be terrifying to the person experiencing them), hallucinations (sensory experiences, such as hearing voices talking about them when there is no one there), social withdrawal and disturbed thinking.

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What is schizophrenia?

Schizophrenia is a mental illness that affects the way you understand and interact with the world around you.

At the beginning of an episode, people may feel that things around them seem different or strange. They may start to experience problems concentrating, thinking or communicating clearly, or taking part in their usual activities. At the height of the episode, people may experience breaks from reality called psychosis. These could be hallucinations (sensations, like voices, that aren't real) and delusions (strong beliefs that aren't true, like the belief that they have superpowers). Some people feel 'flat' or numb. They may also experience changes in mood, motivation, and the ability to complete tasks. After an episode, signs can continue for some time. People may feel restless, withdraw from others, or have a hard time concentrating.

The exact course and impact of schizophrenia is unique for each person. Some people only experience one episode in their lifetime while others experience many episodes. Some people experience periods of wellness between episodes while others may experience episodes that last a long time. Some people experience a psychotic episode without warning while others experience many early warning signs. No matter how someone experiences schizophrenia, researchers agree that early treatment can help reduce the impact of episodes in the future.

Who does it affect?

Schizophrenia can affect anyone. It usually starts to affect people in the teen years, though females often start to experience the illness a little later than males. No one knows exactly what causes schizophrenia or why it can affect people so differently. Genes, the way a person's brain develops, and life events may all play a part.

What can I do about it?

While there is no cure for schizophrenia, people can and do recover. Recovery may mean learning to reduce the impact of problems, work around challenges, or maintain wellness. Most people use some combination of the following treatments and supports.

Some people need to spend time in hospital if they experience a severe episode of psychosis. This is a time to figure out the best treatment for you and begin your journey to health. Before you leave the hospital, care providers should help you map out the service providers (like doctors, counsellors, and social workers) who will be involved in your care and support your recovery.

Medication
Medication called antipsychotics may help reduce the severity of symptoms like hallucinations and delusions, and may eliminate these symptoms all together for many people. Continuing medication after you feel well again may help reduce the risk of relapse (when symptoms come back). There are many different kinds of antipsychotics, so it may take time and patience to find the best one for you.

All medications can cause side effects-some of which can be uncomfortable or difficult. It's best to have ongoing, open conversations about medication with a doctor so that everyone understands how a medication is affecting you, what can be done, and what other options you may have.

Counselling and supports
Counselling can help with many problems like low mood, anxiety, and relationships. You can learn helpful skills like problem-solving and setting goals. There are also therapies to help reduce the impact of delusions and hallucinations. Schizophrenia can affect people's goals around education, work, and independent living. Professionals like occupational therapists and social workers can help with daily living, social skills, employment or volunteer training, and community activities. They can also connect you with community supports like home care, housing, and income assistance.

A big part of managing schizophrenia is relapse prevention. You can learn what might trigger an episode and learn to recognize early warning signs of an episode. The goal is to learn when to seek extra supports, which may help reduce the impact or length of the episode.

Self-care is important for everyone. Small steps like eating well, getting regular exercise, building healthy sleep habits, spending time on activities you enjoy, spirituality, and connecting with loved ones can make a big difference.

Schizophrenia can leave people feeling very isolated and alone. At times, many people who experience schizophrenia feel uncomfortable around others. But many also worry about what others will think of them. The right relationships can be supportive and healing. Your support team can help you connect with support groups.

How can I help a loved one?
Supporting a loved one can be hard. It can be difficult to understand what a loved one is experiencing, and their behaviour may be confusing at times. Many people worry about their loved one's future. The good news is that schizophrenia is treatable-and love and support can go a long way. Here are some tips for helping a loved one:

Learn more about schizophrenia so you have a better idea of what to expect and how you can help.

Schizophrenia can have a big impact on people's ability to concentrate and make sense of information. Loved ones may not react to things in ways you expect or may struggle with tasks that seem simple to you. It's okay to feel frustrated, but it isn't anyone's fault.

If a loved one has trouble following conversations, choose a quiet space and speaking calmly and clearly.

It's best to avoid arguing with delusions or hallucinations. A more helpful strategy is to focus on the feelings that delusions or hallucinations bring up.

Ask your loved one how you can help. This may be a simple as helping with day-to-day tasks.

Talk about dealing with emergencies when your loved one is feeling well and decide how you can contribute. Write it down in a crisis plan and share it with your care team. This is also a good time to talk about behaviours you aren't willing to deal with.

Learn more about support services for care providers through your loved one's care team, provincial or territorial health services, or community organizations.

Depending on the barriers that your loved one experiences, planning for the future with tools like a Registered Disability Savings Plan can bring peace of mind.

Set your own boundaries, and seek support for yourself when you need it. Think about joining a support group for loved ones and seeking counselling for the entire family.

Do you need more help?

Contact a community organization like the Canadian Mental Health Association to learn more about support and resources in your area.

Founded in 1918, The Canadian Mental Health Association (CMHA) is a national charity that helps maintain and improve mental health for all Canadians. As the nation-wide leader and champion for mental health, CMHA helps people access the community resources they need to build resilience and support recovery from mental illness.

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Schizophrenia is a mystery, a puzzle with missing pieces. This complex biochemical brain disorder affects a person's ability to determine what is reality and what is not. It is as though the brain sends perceptions along the wrong path, leading to the wrong conclusion.

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Many people who are diagnosis with Schizophrenia have high intellect abilities. Although not many become Nobel Prize winners like John Nash or become a university professor like Elyn Saks, many do live a productive and meaningful life with the help of therapy, medication and strong family support.

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Early Warning Signs of Schizophrenia in Children

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Early Warning Signs of Schizophrenia in Children

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Schizophrenia is a brain disease caused by biological and chemical changes in the brain. It is an uncommon illness in children and hard to recognize in its early phases.

The behaviour of children and adolescents with schizophrenia may differ from that of adults with this illness. Child and adolescent psychiatrists look for several of the following early warning signs in youngsters with schizophrenia:

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Schizophrenia is a brain disease caused by biological and chemical changes in the brain. It is an uncommon illness in children and hard to recognize in its early phases.
The behaviour of children and adolescents with schizophrenia may differ from that of adults with this illness. Child and adolescent psychiatrists look for several of the following early warning signs in youngsters with schizophrenia:

· Trouble telling dreams from reality
· Seeing things and hearing voices which are not reality
· Confused thinking
· Vivid and bizarre thoughts and ideas
· Extreme moodiness
· Odd behaviour
· Ideas that people are "out to get them"
· Behaving like a younger child
· Severe anxiety and fearfulness
· Confusing television with reality
· Severe problems in making and keeping friends

The behaviour of children with schizophrenia may change slowly over time. For example, children who used to enjoy relationships with others may start to become more shy or withdrawn and seem to be in their own world. Sometimes youngsters will begin talking about strange fears and ideas. They may cling to parents or say things that do not make much sense. These early problems may first be noticed by the child's school teachers.

Schizophrenia is a serious illness. Early diagnosis and medical treatment are important. Children with the problems and symptoms listed above must have a complete evaluation. Usually these children need individual treatment plans involving other professionals. A combination of medication and individual therapy, family therapy, and specialized programs (school, activities, etc.) is often necessary.

Psychotropic medication can be helpful for many of the symptoms and problems identified. These medications require careful monitoring by a child and adolescent psychiatrist. Parents should ask their family physician or pediatrician to refer them to a child and adolescent psychiatrist who is specifically trained and skilled at evaluating, diagnosing and treating children with schizophrenia.

- Adapted from Dept. of Medicine, University of Michigan

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British Columbia Schizophrenia Society - Schizophrenia in Children

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Schizophrenia is a brain disease caused by biological and chemical changes in the brain. It is an uncommon illness in children and hard to recognize in its early phases. The behaviour of children and adolescents with schizophrenia may differ from that of adults with this illness.

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[Article updated on 11 September 2017]
What does 'schizophrenia' mean?
The term 'schizophrenia' was coined in 1910 by the Swiss psychiatrist Paul Eugen Bleuler, and is derived from the Greek words 'schizo' (split) and 'phren' (mind). Bleuler had intended the term to refer to the dissociation or 'loosening' of thoughts and feelings that he had found to be a prominent feature of the illness.
What does 'schizophrenia' not mean?
Many people mistakenly think of schizophrenia as a 'split personality'. Robert Louis Stevenson's fictional novel The Strange Case of Dr Jekyll and Mr Hyde did much to popularize the concept of a 'split personality', which is sometimes also referred to as ' multiple personality disorder'. Multiple personality disorder is a vanishingly condition that is totally unrelated to schizophrenia. Although schizophrenia sufferers may hear voices that they attribute to various people or have strange beliefs that seem out of keeping with their usual selves, this is not the same as having a 'split personality'. Unlike Dr Jekyll, schizophrenia sufferers do not suddenly change into a different, unrecognizable person.

The term 'schizophrenia' has led to much confusion about the nature of the illness, but Bleuler had intended it to replace the older, even more misleading term of ' dementia praecox' ('dementia of early life'). This older term had been championed by the eminent German psychiatrist Emil Kraepelin, who mistakenly believed that the illness only occurred in young people and that it inevitably led to mental deterioration. Bleuler disagreed on both counts and, in an attempt to clarify matters, changed the name of the illness to 'schizophrenia'. Bleuler believed that, contrary to mental deterioration, schizophrenia led to a heightened consciousness of memories and experiences.

It is as common as it is unfortunate to hear the adjective 'schizophrenic' being bandied about to mean 'changeable' or 'unpredictable'. This usage should be discouraged because it perpetuates people's misunderstanding of the illness and contributes to the stigmatization of schizophrenia sufferers. Even used correctly, the term 'schizophrenic' does little more than label a person according to an illness, implicitly diminishing him or her to little more than that illness. For this reason, I have dropped the term 'schizophrenic' from my books and articles in favour of 'schizophrenia sufferer'. A person is not a 'schizophrenic' any more than he or she is a 'diabetic' or suffering with toothache.
Who 'discovered' schizophrenia?
Although Kraepelin had some mistaken beliefs about the nature of schizophrenia, he was the first person to distinguish the illness from other forms of psychosis, and in particular from the 'affective psychoses' that occur in mood disorders such depression and manic-depressive illness (bipolar affective disorder). His classification of mental disorders, the Compendium der Psychiatrie, is the forerunner of the two most influential classifications of mental disorders, the International Classification of Diseases 10th Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders 4th revision (DSM-IV). Today these classifications are principally based on scientific research and expert opinion and, particularly in the case of ICD-10, on international consultation and consensus. As well as listing mental disorders, they provide operational definitions and diagnostic criteria that doctors use to reach a diagnosis of schizophrenia.

Kraepelin first isolated schizophrenia from other forms of psychosis in 1887, but this is not to say that schizophrenia-or 'dementia praecox', as he called it-had not existed long before Kraepelin's day. The oldest available description of an illness closely resembling schizophrenia can be found in the Ebers papyrus, which dates back to the Egypt of 1550 BC. And archaeological discoveries of Stone Age skulls with burr holes drilled into them (presumably to release 'evil spirits') have led to speculation that schizophrenia is as old as mankind itself.
How was schizophrenia thought of in antiquity?
In antiquity, people did not think of 'madness' (a term that they used indiscriminately for all forms of psychosis) in terms of mental illness, but in terms of divine punishment or demonic possession. Evidence for this comes from the Old Testament and most notably from the First Book of Samuel, according to which King Saul became 'mad' after neglecting his religious duties and angering God. The fact that David used to play on his harp to make Saul better suggests that, even in antiquity, people believed that psychotic illnesses could be successfully treated.

But the spirit of the Lord departed from Saul, and an evil spirit from the Lord troubled him ... And it came to pass, when the evil spirit from God was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him. -1 Samuel 16.14, 16.23 (KJV)

When did people first start thinking of schizophrenia as an illness?
In Greek mythology and the Homerian epics, madness is similarly thought of as a punishment from God-or the gods-and it is in actual fact not until the time of the Greek physician Hippocrates (460-377 BC) that mental illness first became an object of scientific speculation. Hippocrates thought that madness resulted from an imbalance of four bodily humors and that it could be cured by rebalancing these humors with such treatments as special diets, purgatives, and blood-lettings. To modern readers, Hippocrates' ideas may seem far-fetched, perhaps even on the dangerous side of eccentric, but in the fourth century BC they represented a significant advance on the idea of mental illness as a punishment from God. The Greek philosopher Aristotle (384-322 BC) and later the Roman physician Galen (129-216) expanded on Hippocrates' humoral theories and both men played an important role in establishing them as Europe's dominant medical model.

Only from the brain springs our pleasures, our feelings of happiness, laughter and jokes, our pain, our sorrows and tears ... This same organ makes us mad or confused, inspires us with fear and anxiety... -Hippocrates, The Holy Disease

It is perhaps worth noting that not everybody in antiquity invariably thought of 'madness' as a curse or an illness. In Plato's Phaedrus, the Greek philosopher Socrates (470-399 BC) says,

Madness, provided it comes as the gift of heaven, is the channel by which we receive the greatest blessings ... the men of old who gave things their names saw no disgrace or reproach in madness; otherwise they would not have connected it with the name of the noblest of arts, the art of discerning the future, and called it the manic art ... So, according to the evidence provided by our ancestors, madness is a nobler thing than sober sense ... madness comes from God, whereas sober sense is merely human.

In Ancient Rome, the physician Asclepiades and the statesman and philosopher Cicero (106-43 BC) rejected Hippocrates' humoral theories, asserting, for example, that melancholia (depression) resulted not from an excess of 'black bile' but from emotions such as rage, fear, and grief. Unfortunately, in the first century AD the influence of Asclepiades and Cicero began to decline, and the influential Roman physician Celsus reinstated the idea of madness as a punishment from the gods-an idea to be later reinforced by the rise of Christianity and the collapse of the Roman Empire.

In the Middle Ages, religion became central to cure and, alongside the mediaeval asylums such as the Bethlehem in London, some monasteries transformed themselves into centres for the treatment of mental illness. This is not to say that the humoral theories of Hippocrates had been forgotten, but merely that they had been incorporated into the prevailing Christian beliefs, and the purgatives and blood-lettings continued alongside the prayers and confession.
How did beliefs change?
The burning of the so-called heretics-often people suffering from psychotic illnesses such as schizophrenia-began in the early Renaissance and reached its peak in the fourteenth and fifteenth centuries. First published in 1563, De praestigiis daemonum (The Deception of Demons) argued that the madness of 'heretics' resulted not from divine punishment or demonic possession, but from natural causes. The Church forbade the book and accused its author, Johann Weyer, of being a sorcerer.

From the fifteenth century, scientific breakthroughs such as those of the astronomer Galileo (1564-1642) and the anatomist Vesalius (1514-1584) began challenging the authority of the Church, and the centre of attention and study gradually shifted from God to man and from the heavens to the Earth. Unfortunately, this did not immediately translate into better treatments, and Hippocrates' humoral theories persisted up to and into the eighteenth century.

Empirical thinkers such as John Locke (1632-1704) in England and Denis Diderot (1713-1784) in France challenged this status quo by arguing, very much as Cicero had done, that reason and emotions are caused by nothing more or less than sensations. Also in France, the physician Philippe Pinel (1745-1826) began regarding mental illness as the result of exposure to psychological and social stressors. A landmark in the history of psychiatry, Pinel's Medico-Philosophical Treatise on Mental Alienation or Mania called for a more humane approach to the treatment of mental illness. This so-called ' moral treatment' included respect for the person, a trusting and confiding doctor-patient relationship, decreased stimuli, routine activity, and the abandonment of old-fashioned Hippocratic treatments. At about the same time as Pinel in France, the Tukes (father and son) in England founded the York Retreat, the first institution 'for the humane care of the insane' in the British Isles.
How did beliefs evolve in the 20th century?
The founder of psychoanalysis, the Viennese psychiatrist Sigmund Freud (1856-1939), influenced much of twentieth century psychiatry. As a result of his influence, by the second half of the twentieth century the majority of psychiatrists in the USA (although not in the UK) believed that schizophrenia resulted from unconscious conflicts originating in childhood.

Since then, the advent of antipsychotic medication, advanced brain imaging, and molecular genetic studies has confirmed beyond any reasonable doubt that schizophrenia has an important biological basis. Yet it is also recognized that psychological and social stresses can play an important role in triggering episodes of illness, and that different approaches to treatment should be seen not as competing but as complementary. Thanks to this fundamental realization, the advent of antipsychotic medication, and the shift to care in the community, schizophrenia sufferers today stand a better chance than ever before of leading a healthy, productive, and fulfilling life.
What treatments were used before the advent of antipsychotic medication?
Febrile illnesses such as malaria had been observed to temper psychotic symptoms, and in the early twentieth century 'fever therapy' became a common form of treatment for schizophrenia. Psychiatrists tried to induce fevers in their patients, sometimes by means of injections of sulphur or oil. Other popular but unsatisfactory treatments included sleep therapy, gas therapy, electroconvulsive or electroshock treatment, and prefrontal leucotomy-the removal of the part of the brain that processes emotions. Sadly, many such 'treatments' were aimed more at controlling disturbed behaviour than at curing illness or alleviating suffering. In some countries, such as Germany during the Nazi era, the belief that schizophrenia resulted from a 'hereditary defect' even led to atrocious acts of forced sterilization and genocide. The first antipsychotic drug, chlorpromazine, first became available in the 1950s, and opened up an era of hope and promise for schizophrenia sufferers and their carers. Since the advent of antipsychotic drugs, the use of electroconvulsive therapy in schizophrenia has become increasingly rare. Nevertheless, it should be underlined that modern electroconvulsive therapy is a safe and humane intervention, and that it can be highly effective in the treatment of severe mood symptoms that have not responded to medication.
So, where to now?
In 1919, Kraepelin stated that 'the causes of dementia praecox are at the present time still mapped in impenetrable darkness'. Since then, greater understanding of the causes of schizophrenia has opened up multiple avenues for the prevention and treatment of the illness, and a broad range of pharmacological, psychological, and social interventions have been scientifically proven to work.

Today, schizophrenia sufferers stand a better chance than at any other time in history of leading a normal life. And thanks to the fast pace of on-going medical research, a good outcome is increasingly likely.

Neel Burton is author of Living with Schizophrenia, Growing from Depression, The Meaning of Madness, and other books.

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Article updated on 11 September 2017] What does 'schizophrenia' mean? The term 'schizophrenia' was coined in 1910 by the Swiss psychiatrist Paul Eugen Bleuler, and is derived from the Greek words 'schizo' (split) and 'phren' (mind). Bleuler had intended the term to refer to the dissociation or 'loosening' of thoughts and feelings that he had found to be a prominent feature of the illness.

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Learn More about Schizophrenia - BC Schizophrenia Society

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Learn about what is schizophrenia and schizophrenia treatment options

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Learning about what is schizophrenia is just the first step, read more about the path to mental health recovery and how to fight mental disorders stigma.

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Russell Crowe portrayed the Nobel Peace Prize Winner, John F. Nash in the movie "A Beautiful Mind."  Diagnosed with paranoid schizophrenia, suffering from delusions of voices from outer space, and in the 1960's, Nash endured insulin shock treatment that he described as "torture."

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A scene from the movie "A Beautiful Mind" (2001) in which mathematician and Nobel Prize laureate John Nash (Russel Crowe), in the Sixties, undergoes Insulin shock therapy as a treatment for schizophrenia, under the eyes of his wife Alicia (Jennifer Connelly).

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Insulin shock treatment - Described as "traumatic assaults," Austrian, Neuropsychologist named Manfred Sakel, accidentally discovered insulin shock treatments in 1928 as a way to "jolt disordered parts" back into place.

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Information for Education Assistant & Support Worker

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Information for Education Assistant & Support Worker

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From the BC Schizophrenia Society website, there is an information resource package specific for Educators in supporting students with schizophrenia.  The package contains resources such as a fact sheet for teachers to support a student with their return to school, a teachers guide video on "Reaching Out," information on supporting the family and a general overview of the disability.  http://www.bcss.org/resources/topics-by-audience/educators/2010/09/a-printable-psychosis-package-for-educators/