1. 1. UNIVERSITI TEKNOLOGI MARA (UiTM) AZIMAH BINTI HASSAN 940507-02-5320 DIPLOMA IN OCCUPATIONAL THERAPY
2. 2. DEFINITION OF SCHIZOPHRENIFORM Schizophreniform is short-term type of schizophrenia that alters individuals perception, thoughts, affect and behavior. Involves symptoms that are present for less than six months. When symptoms persist longer than six months, the diagnosis is typically changed to schizophrenia. Retrieved from www.psychcentral.com
3. 3. EPIDEMIOLOGY AGE RELATED DEMOGRAPHICS - According to DSM IV, the onset occurs between the late teens and mid 30s SEX-RELATED DEMOGRAPHICS - The prevalence is equally in men and women - The onset is later in men than women In men, between the ages of 18 and 24. In women, between the ages of 24 and 35. RACE-RELATED DEMOGRAPHICS - No racial differences in the prevalence of schizophrenia have been positively identified
4. 4. ETIOLOGY The etiology and pathogenesis of schizophrenia is idiopathic, but it could be: Biochemical factor Genetic factor Environmental factor
5. 5. PATHOPHYSIOLOGY Increased ventricular size Changes in the hippocampusAnatomic abnormalities Glutaminergic dysfunction Serotonin abnormalities Neurotransmitter system abnormality Over-activation of immune system Metabolic disturbance (insulin resistance) Inflammation and immune function
6. 6. SYMPTOMS OF SCHIZOPHRENIA POSITIVE SYMPTOMS Hallucinations Delusions Disorganized speech Behavioural disturbances NEGATIVE SYMPTOMS Absence of normal cognition Alogia Avolition Anhedonia Social isolation
7. 7. SYMPTOMS OF SCHIZOPHRENIA COGNITIVE DYSFUNCTION Attention Memory Executive functions MOOD SYMPTOMS Seems cheerful or sad without obvious reasons
8. 8. DEMOGRAPHIC DATA Name : Mrs R Address : Kampung Permatang Saga, Kepala Batas Age : 34 Years Old Sex : Female Race : Malay Religion : Islam Marital Status : Married Job : Direct selling in health products Date of Onset : 06/12/2014 @ 4.45pm Date of Admission : 08/12/2014 @ 5.00pm Date of Referral : 28/12/2014 @3.30pm Reason of Referral : Return to work (work training) Diagnosis : Schizophreniform disorder
9. 9. PERSONAL HISTORY Pre-Morbid History Works as saleswoman in health care products Able to socialize with her neighbours and business partners Able to engage in leisure activity such as surfing Internet Able to do household activity such as washing clothes, kitchen preparation Post-Morbid History Social withdrawal (keep herself in room) Disorganized speech & thought Mood Disorder Unemployed
10. 10. CASE HISTORY Admitted to psychiatric ward at 5.00pm on 8th of December 2014 Brought to casualty by her husband and younger brother The patient's symptoms at the onset of his illness included auditory hallucinations of angels voice, suspiciousness, ideas of reference and hostility, and moderately severe conceptual disorganization. Patient tried to kill her son by throwing him into the well Claimed that she heard fireflies told that her child is influenced by Satan
11. 11. MEDICAL HISTORY Admitted to psychiatric ward HSAH at 4.45 pm on 6th of December 2014 Used Form 3 - certificate of involuntary admission - allows the patient to be held for two weeks - the patient must be notified with a Form 30 Used Form 4 - certificate of renewal , valid for 1 month, must be notified with Form 30
12. 12. MEDICAL HISTORY Previously had been to Hospital Kepala Batas to get treatment as her wrist injured due to suicide attempt Had been prescribed with atypical antipsychotics; - Olanzapine 20mg - Clozapine 5mg Had been responsive to Artane 2 mg as she experienced moderate extrapyramidal syndrome (EPS) after 10 days of hospitalization
13. 13. EDUCATION HISTORY Attended primary school (Standard 1 Standard 6) at SK Lahar Kepar Attended secondary school ( Form 1 Form 5) at SMK Dato Onn Attended university in Diploma level at UiTM Arau
14. 14. WORK HISTORY previous work as tuition teacher past 7 years past 4 months she works in direct selling business appeared obsessed with direct selling wanted to learn more about religious phrases that being used onto the material that she sell (VKAN products: socks, underwear)
15. 15. SOCIAL HISTORY Patient spent her time by browsing and chatting in Facebook about IS and Jews Frequently spend too much time online until she experienced sleep disorder and always argue with her husband Sometimes met her business partners and often return home at midnight
16. 16. FAMILY HISTORY + 65y/o (passed away) 61y/o 38y/o (pt 34y/o ) 28y/o 26y/o 22y/o Patient is second from five siblings One of her family members is having mental illness (schizophrenia) Stayed with her husband and 2 kids, her mother and 2 younger brothers
17. 17. SUBJECTIVE ASSESSMENT (done through observation on 29 December 2014) appeared hygiene and properly attired with hospital attire has adequate eye contact able to cooperate during interview and group activity sessions (needs prompting)
18. 18. General Appearance Neat and tidy with hospital attire Hygiene Behaviour Anhedonia Inappropriate behaviour ; raised voice when being asked during interview Mood Irritable and upset Speech Coherence and fluency Sometimes appeared irrelevant Thought Preoccupied , obsession, persecutory delusion , Perception Auditory hallucination Cognitive Orientation : able to state person, place and time correctly Attention and concentration : able to attend and sustain group activity until the end with prompting Short term memory: able to retrieve games rule Long term memory : able to recall her previous history Insight Good MENTAL STATE EXAMINATION (MSE)
19. 19. OBJECTIVE ASSESSMENT (done through standardized assessments on 29 December 2014) Mini Mental State Examination (MMSE) Functional Ability Assessment (FAA) Depression Anxiety And Stress Scale ( DASS ) Threshold Assessment Grid ( TAG )
20. 20. DOMAIN COMMENT SCORE ORIENTATION Year, date, day, month = Client able to state season. Place = Client recognize and know where she is. 5/5 5/5 REGISTRATION Client can names 3 different object (bed, apple, shoe) in the first trial 3/3 ATTENTION & CALCULATION Client need to calculate 100 - 3 for 5 times. Client able to answer ( 94 only ) 2/5 RECALL Client able to recall 3 objects correctly. 3/3 LANGUAGE Able to name object (pencil & watch). Able to repeat Tidak mungkin dan tidak mustahil. Able to follow instruction given ambil kertas dengan tangan kanan, lipat dua dan letakkan di atas lantai. Client able to read tutup mata anda and follow what it said. Client able to make a sentence. Client able to copy picture exactly. 2/2 1/1 3/3 1/1 1/1 1/1 TOTAL SCORE Interpretation, : mild to moderate cognitive impairment. 27/30 ( Source : www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf )
21. 21. A. LIVING SKILL SCORE COMMENTS Dressing 1 Independent in dressing Eating 1 Behavior is socially appropriate Grooming/ Hygiene 1 Independent in all areas Domestic Skills 1 Independent in all areas Time Management 1 Able to balance time with priorities (leisure, work and rest) Money Management 1 Independent in all areas (recognize money, assess change ,use of banking facilities, budget for lifestyle) B. TASK ORGANISATION SCORE COMMENTS Attention Span 1 Attends the task for more than 30 minutes Problem Solving 1 Solve problems independently Decision Making 1 Make decisions independently Frustration Tolerance 1 Deals with simple and complex tasks independently Memory Functioning 1 Independent in all areas Good short term and long term memory (according to MSE) Verbal Instructions 1 Follows all verbal instructions independently Learning Ability 1 Learns simple and complex task without difficulties
22. 22. D. MOTOR TASK SCORE COMMENTS Balance 1 Balance allows independent functioning ( sitting, walking, standing ) Coordination 1 Intermittent VM, FM, GM. C. PERSONAL / INTERPERSONAL ABILITIES SCORE COMMENTS Communication Skills 3 Difficulties in 2 areas- initiation, voice tone Good eye contact, listening and body language Social Skills 2 Intermittent difficulties in 1 area poor social interaction Passivity 1 Independent assertive functioning Aggressions 2 Communicates aggression in some situations Self Control 1 Regulates behavior appropriately to all situations Self Concept 1 Difficulties in 2 area self confidence, role expectation Reality Orientation 1 Independent in identifying Managing Stress 2 Can deal with minor stresses, occasinally not able to deal with major stresses Initiative 1 Functioning allow independence
23. 23. DEPRESSION ANXIETY AND STRESS SCALE ( DASS) Depression Anxiety Stress Total Scoring 6 5 17 Interpretation 0-9 0-7 15-18 Normal Normal Mild RESULT : ( Source : Manual For DASS, 2nd Ed (Sydney), Psychological Foundation, retrieved from www.psy.unsw.edu.au/groups )
24. 24. THRESHOLD ASSESSMENT GRID ( TAG ) Domains None Mild Moderate Severe Very severe Safety Intentional self harm / Unintentional self harm / Risk Risk of others / Risk to others / Needs and disabilities Survival / Psychological / Social / TOTAL 3 3 1 (source : www.iop.kcl.uk/prism/tag)
25. 25. CANSAS DOMAIN SCORE Accommodation 0 Food 0 Looking after home 0 Self-care 0 Daytime activities 0 Physical health 0 Psychotic symptom 2 (auditory hallucination, paranoid delusion, and obsession) Information of condition and treatment 0 Psychological distress 2 (she feels distress when people do not believe her thought) Safety to self 2 (used to injure her wrist due to suicide attempt) Safety to others 2 (used to throw her son into the well due to homicidal attempt) Alcohol 0
26. 26. Drug 0 Company 0 (patient has partner) Intimate relationship 0 (patient has married) Sexual expression 0 (patient claims that she has no problem) Child care 1 (patients children are taking care by her mother) Basic education 0 (able to read, write and understand Bahasa Malaysia) Telephone 0 (patient able to to use handphone ; make calls and send instant messages) Transport 1 (patient able to use public transport) Money 0 (patient able to budget her money) Benefits 0 (patient has no problem in financial assistance) Spiritual 2 (patient believes that her son is influenced by Satan and makes attempt to kill him)
27. 27. OCCUPATIONAL THERAPY DOMAIN
28. 28. Activity of daily living (ADL) Personal hygiene : Patient able to look after her self care independently Instrumental activity of daily living ( IADL ) Meal preparation and clean up : Patient able to perform domestic skill independently Money management : Patient able to use banking facilities ATM and manage budget for lifestyle independently Time management : Patient spends too much time online and often return home at midnight Education Patient attends to university until diploma level AREAS OF OCCUPATION
29. 29. Rest and sleep Patient unable to balance her biological clock until she had sleep disorder Work Patient works as saleswoman in health products Leisure Leisure exploration Patient likes to cook and trying new recipes Leisure participation Patient spends her leisure with cooking and taking her children for a walk Social participation Patient lacks of social participation with others as she exhibits inappropriate behaviour and often raise her voice when something is wrong
30. 30. CLIENT FACTORS Mental functions Attention patient able to attend the activity with prompting Memory able to retrieve short and long term memory (according to FAA ) Perception presence of auditory hallucination Emotional unable to cope during stress (according to DASS ) Experience of self and time has poor self esteem, self concept Sensory functions and pain No problem Neuromusculoskeletal and movement related functions Gait pattern shuffling type walking due to medication Balance and coordination good balance & coordination (according to FAA). Good control of voluntary and involuntary movement able to do activities involving crossing the midline, bilateral movement, and gross-motor control. Good in endurance patient not easily fatigue when performing exercise (during warm up and group activity). Cardiovascular, hematological, immunological, respiratory functions No problem
31. 31. Voice and speech functions No problem Digestive, metabolic, endocrine and system functions No problem Genitourinary and reproductive functions No problem Skin and related structure functions No problem BODY STRUCTURE CATEGORIES No Problem VALUES, BELIEFS AND SPIRITUALITY Patient believed that she was spied by the Jews and they had made attempt to kill her
32. 32. Sensory perceptual skills Patient presents with auditory hallucination Motor and praxis skills Has no problems in motor skills, able to initiate the activity Emotional regulation skills According to DASS, patient has mild stress with no depressed and anxiety Cognitive skills Attention and concentration : able to attend and sustain the activity until the end Memory functioning : retrieval of short and long term memory independently Problems solving : able to provide solution for situation given independently Decision making : able to prompt with prompting Orientation : able to state person, time, place independently Follow verbal instruction : able to follow verbal instructions in Malay language Communication and social skills Communication skill: able to speak and understand Malay language Social skill : lack of social interaction with inappropriate tone voice PERFORMANCE SKILLS
33. 33. PERFORMANCE PATTERNS CLIENTS PATTERNS EXPLAINATION ROLES Patient unable to perform her roles as a mother and a saleswoman as her symptoms become severe (auditory hallucination, paranoid) ROUTINES Patient wakes up and take a bath at 6.30 am Patient participates in rehab programs during daytimes Patient takes her meals at consistent time Patient takes her bath before dinner and sleeps at 10pm HABITS Patient always make dua before she enters rehab department RITUALS Patient always perform her rituals at particular time . She does praying and fasting
34. 34. CONTEXT AND ENVIRONMENT Cultural Patient always greet staffs when she enters rehab department Patient always shake hands before return to ward Personal Patient is a 34 year s old woman with diploma level Patient has 2 children Temporal Previous work as a tuition teacher and saleswoman Currently patient is unemployed At the age of 35, patient supposes to strive hard in her career, enjoys great family time while having good relationship with family members. Virtual Patient uses Facebook account to discuss about current news of Islam with the preachers Contact her business partners through instant messages and call Physical Patients usual environments are at psychiatric ward and her house Patient stays in her fully furnished house which is near to hospital Social Patient able to socialize with other patients by providing prompting
35. 35. ACTIVITY DEMANDS (MEAL PREPARATION)
36. 36. Tools and materials Knife, can opener, bowl, spoons, plates, chopping board Space demands Washing place sink Sandwich making place - large, open spaces with adequate lighting. Social demands The place must be clean as hygiene is important in our community Able to follow sequence of making the sandwich. Able to share the objects and materials with others. Sequencing and timing STEPS : PREPARATION : - Therapist choose a menu for patient (sardine sandwich) - Patient list down the ingredients needed and choose all the ingredients and utensil for meal preparation MAKING SANDWICH : - Open sardine can with can opener and pour into the bowl - Peel and chop onion into small pieces and put it into the bowl filled with sardine - Prepare 2 plates, one for main serving purpose and another one for putting the bread - Take a slice of bread , and spread the well-mix sardine onto the bread and serve it onto the main plate SERVING - Patient set up the table by placing plate, cutlery and glass for breakfast CLEAN UP - After finish eating, therapist instruct patient to clean dining and preparation table with the utensils - Patient washes and wipes the dishes
37. 37. Required actions and performance skill able to estimate quantity of materials needed for meal preparation able to follow instruction on meal preparation need good fine motor skills. need good eye hand coordination. Required body functions frustration toleration emotional stability and consciousness Required body structures both upper limbs (fingers, wrist, arms )
38. 38. PATIENTS ASSETS Patient is adhering to medication Patient has good moral support from her family Patient is compliance and motivated to treatment Patient has being identified with specific interest in cooking and meal preparation
39. 39. PROBLEMS IDENTIFICATION Patient exhibits the presence of psychotic symptoms Patient lacks of communication skills (inappropriate voice tone) Patient lacks of social skills (self-imposed isolation) Patient lacks of motivation due to avolition
40. 40. FORMULATING AIMS SHORT TERM GOAL To reduce psychotic symptoms through physical fitness activity To promote communication skills through social skill training To facilitate social skills through To enhance self motivation through LONG TERM GOAL To maintain ADL and leisure independently To facilitate work return through work training
41. 41. MODELS Recovery Model Recovering from a mental illness requires a commitment to wellness, a commitment to see a life beyond the impact of mental illness ( Glover , 2007 ) Believe in her ability to recover Work as though recovery is always a reality Provide environments that support patients recovery efforts Dont stand in the way of her recovery process ( Glover, 2007 )
42. 42. FRAME OF REFERENCE PSYCHOEDUCATION APPROACH - To promote patients knowledge of and insight into her illness and enable her to cope effectively thereby improving prognosis - Evidence suggests that psycho educational approaches are useful as part of treatment programs for people with schizophrenia (compliance with medication improved, decreased relapse and readmission rates, had positive effect on persons well-being, treatment brief and inexpensive) (Pekkala and Merinder,2000)
43. 43. REHABILITATION APPROACH - Rehabilitation describes the restoration of functioning physical, mental and health - Psychosocial rehabilitation refers more specifically to the restoration of psychological and social functioning, and is frequently used in the context of mental illness (King et al, 2007) Based on 2 core principles that people are: Motivated to achieve independence and self-confidence through competence and mastery Are capable of learning and adapting to meet their needs and achieve their goals
44. 44. COGNITIVE BEHAVIOURAL APPROACH Cognitive behavior therapy has been found in controlled studies to be affective form treatment for schizophrenia and depression problem. Cognitive approach for schizophrenia focused on the clinical observation that psychotic symptom often seems to result from negative patterns of thinking and behaving. ( Jacqueline, 1993)
45. 45. Problem 1 Patient exhibits presence of psychotic symptoms Aim To reduce psychotic symptoms and provide awareness (auditory hallucination, obsessions and delusions) Intervention Technique / Modalities Cognitive Behavioural Therapy (Psychoeducation) Method Patient is placed in a comfortable and wide space area Provide briefing about psychoeducation and its purpose Educate client about patients condition Duration 15 20 minutes Rational Psychoeducation refers to the process of educating patients about their conditions and useful truths about life in general (Fischer, 2011) Precaution Activity should be conducted at a neat and wide space room Ensure patient in the state of mentally stable TREATMENT IMPLEMENTATION
46. 46. Problem 2 Patient lacks of social skills (self-imposed isolation) Aim To promote social skills through social skill training Intervention Technique / Modalities Music Therapy (Musical Chair) Method This activity must be done in a convenience environment. Therapist must select between 6 to 8 patients to perform activity. After patients selection the therapist need to give brief instruction about the activity. After patient understands the needs, the therapist can start the activity. Give a reward to the winner and get the feedback from patient. Rationale Music has nonverbal, creative and emotional qualities. These are used in therapeutic relationship to facilitate contact, socialization, self-awareness learning, self expression, communication and personal skills. Canadian Association for Music Therapy, 1994. Precaution Ensure patients safety and health requirements Ensure the location is carried out at purpose buildings or special playing fields
47. 47. Problem 3 Patient lacks of communication skills Aim To facilitate communication skills through social skill training Intervention Technique / Modalities Social Skill Training (Role play) Method Introduction : Members are welcomed, ice breaking activity Warm up : Physical exercise, verbal and non-verbal games Action : Activity begin and end with the use of music. Patient selects one of the papers , read the situation and then act based on the situation chosen. Finally, repeat the process. Wind- down : Closure activities and therapists comments Post group : Discussion and reflection Rationale Social skills training, when carried out with high intensity and sufficient duration, has been shown to improve the capacities for personal effectiveness among persons with schizophrenia, thereby facilitating social skills. Retrieved from www.chizophreniabulletin.oxfordjournals.org Precaution Aware of patients mood and behavior. Ensure the instructions given are easy for the patient to understand
48. 48. Problem 4 Patient lacks of motivation due to avolition Aim To enhance self motivation Intervention Technique / Modalities Social Skill Training (Role play) Method Introduction : Members are welcomed, ice breaking activity Warm up : Physical exercise, verbal and non-verbal games Action : Activity begin and end with the use of music. Patient selects one of the papers , read the situation and then act based on the situation chosen. Finally, repeat the process. Wind- down : Closure activities and therapists comments Post group : Discussion and reflection Rationale Social skills training, when carried out with high intensity and sufficient duration, has been shown to improve the capacities for personal effectiveness among persons with schizophrenia, thereby facilitating social skills. Retrieved from www.chizophreniabulletin.oxfordjournals.org
49. 49. Problem 5 Patient is unemployed due to hospitalization Aim To facilitate work return through domestic activity Intervention Technique / Modalities Domestic activity (cooking and food selling) Method Stage 1 Building therapeutic relationship with patient. Explore patients goals. Discuss safety issues in kitchen Stage 2 Quick cookery tasks for patient to prepare small meal Stage 3 Longer cookery tasks when patient can prepare a small meal independently, she prepares a larger meal Stage 4 Cooking independently with observation, patient prepares meal with no assistance from OT. Once mastered this, prepares main meal without assistance. Stage 6 Preparing, serving and packaging food for food selling Rationale Cooking offers opportunities to satisfy physiological needs, hunger, esteem needs if receives praise, mastery needs learning new skills, self- actualization needs or enjoyment. (Finlay ,2004 )
50. 50. REASSESSMENTS (Reassessments was carried out on 7 January 2015)
51. 51. DOMAIN COMMENT SCORE ORIENTATION Year, date, day, month = Client able to state season. Place = Client recognize and know where she is. 5/5 5/5 REGISTRATION Client can names 3 different object (bed, apple, shoe) in the first trial 3/3 ATTENTION & CALCULATION Client need to calculate 100 - 3 for 5 times. Client able to give 5 answers correctly 5/5 RECALL Client able to recall 3 objects correctly. 3/3 LANGUAGE Able to name object (pencil & watch). Able to repeat Tidak mungkin dan tidak mustahil. Able to follow instruction given ambil kertas dengan tangan kanan, lipat dua dan letakkan di atas lantai. Client able to read tutup mata anda and follow what it said. Client able to make a sentence. Client able to copy picture exactly. 2/2 1/1 3/3 1/1 1/1 1/1 TOTAL SCORE Interpretation, : mild to moderate cognitive impairment. 30/30 ( Source : www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf ) S im -m S impr
52. 52. A. LIVING SKILL SCORE COMMENTS Dressing 1 Independent in dressing Eating 1 Behavior is socially appropriate Grooming/ Hygiene 1 Independent in all areas Domestic Skills 1 Independent in all areas Time Management 1 Able to balance time with priorities (leisure, work and rest) Money Management 1 Independent in all areas (recognize money, assess change ,use of banking facilities, budget for lifestyle) B. TASK ORGANISATION SCORE COMMENTS Attention Span 1 Attends the task for more than 30 minutes Problem Solving 1 Solve problems independently Decision Making 1 Make decisions independently Frustration Tolerance 1 Deals with simple and complex tasks independently Memory Functioning 1 Independent in all areas Good short term and long term memory (according to MSE) Verbal Instructions 1 Follows all verbal instructions independently Learning Ability 1 Learns simple and complex task without difficulties
53. 53. D. MOTOR TASK SCORE COMMENTS Balance 1 Balance allows independent functioning ( sitting, walking, standing ) Coordination 1 Intermittent VM, FM, GM. C. PERSONAL / INTERPERSONAL ABILITIES SCORE COMMENTS Communication Skills 1 Able to initiate conversation with normal voice tone Good eye contact, listening and body language Social Skills 1 Able to socialize with other patients independently Passivity 1 Independent assertive functioning Aggressions 1 Able to control agressions when her roomates tear her magazine Self Control 1 Regulates behavior appropriately to all situations Self Concept 1 Self confidence and role expectation have improved Reality Orientation 1 Able to identify and discriminate real thought Managing Stress 1 Able to deal with minor and major stresses Initiative 1 Functioning allow independence im im
54. 54. DEPRESSION ANXIETY AND STRESS SCALE ( DASS) Depression Anxiety Stress Total Scoring 6 5 10 Interpretation 0-9 0-7 0-14 Normal Normal Normal RESULT : ( Source : Manual For DASS, 2nd Ed (Sydney), Psychological Foundation, retrieved from www.psy.unsw.edu.au/groups ) Show improve -ment
55. 55. PROGNOSIS Medical Based on nursing report, patient is compliance with the medication Rehabilitation Based on Occupational Therapy (OT) aspect, patient prognosis is good where: Patient shows improvement in her condition (appropriate behaviour and thought) Patient able to follow and cooperate with rehab programs Patient is motivated to change her condition (volition towards work return)
56. 56. Be aware of patients mood and emotion and behavior. Do not allow to stand in front of the patient. Away from the patient if the patient is aggressive. Look for the effect of the medication. Never leave the patient alone. Prevent of patient from relapsing. Watch out for fatigue and psychosis symptoms. Aware of any sharp and dangerous objects. Avoid activity that can promote injury or dangerous to patient. Be aware of skin irritated, redness or allergic when perform activities. Make sure the instruction given are easy for the patient to understand. Use the simple and clear language. PRECAUTIONS /CONTRAINDICATIONS
57. 57. FUTURE PLAN Continues occupational therapy programme : 1. Group therapy 2. Cognitive training 3. Psycho education 4. Job placement / work training
58. 58. REFERENCES Occupational Therapy and Mental Health 3rd ed.; Creek, J.; U.S.A; Churchill L; 2002 M. Gelder, R. Mayou, J. Geddes (1999). Psychiatry. Oxford University Press. Mental Health concepts And Techniques for the Occupational Therapy Assistant 3rd ed.; Early, M.B.; U.S.A; Lippincott W&W; 2000 Reed, Kathlyn L. (1991). Quick Reference to Occupational Therapy. An Aspen Publication. Pocket Guide to Treatment in Occupational Therapy Franklin Stein, Ph.D., OTR/L, university of south Dakota,: Becky Roose, M.S. , OTR/L, Medilink, Iowa