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Mobility Considerations 19.5.5
(i) Schizophrenia is one of the most serious forms of severe mental illness. Its lifetime prevalence is nearly 1%, its annual incidence is about 10-15 cases per 100,000 people in the population and the average general practitioner probably cares for 10-20 people with schizophrenia. Around 8% of people with schizophrenia are managed entirely by their general practitioner without referral to psychiatric services.
(ii) Contrary to continuing popular belief a person affected by schizophrenia does not have a split or multiple personality but has a general disturbance of thought processes and a disruption of the personality. The condition has profound effects not just on those affected, but also on their families and friends.
(iii) Onset in men is usually before the age of 30. In women the onset is a little later, by some four years.
(i) People with schizophrenia may demonstrate positive symptoms of psychosis such as delusions, hallucinations and thought disorder, or negative symptoms such as social withdrawal, limited and slow thought, blunted emotions, loss of initiative and the sense of enjoyment. Some people show both positive and negative features to varying extents.
(ii) People with thought disorder may complain of poor concentration or of their mind being blocked or emptied (thought block). They may stop in mid speech in a perplexed fashion with continuing incoherent and disconnected speech. They may have difficulty following a train of thought to a logical conclusion, with individual thoughts having only a very peripheral connection to each other.
(iii) Hallucinations are false perceptions in any of the senses. The person experiences a seemingly real voice or sound or smell, for example, although nothing has actually occurred. A common clinical feature of schizophrenia is that the affected person experiences voices talking about them or telling them to do something.
(iv) Delusions are false beliefs held with absolute certainty, dominating the person's mind, which have no apparent basis in reality, for example a false belief of persecution.
(v) The early stages of schizophrenia can vary considerably. A typical presentation is that a family expresses concern that a personality has changed or even makes a mistaken assumption that the causes of the observed changes are due to substance (drug) abuse. A decline in personal hygiene, depressive symptoms, loss of friends or jobs, all for no good reason, are commonly encountered. About one in ten people with severe forms of schizophrenia commit suicide, usually in the younger age groups. Although there have been some specific examples of violent attacks upon strangers, in general people with schizophrenia do not pose a danger to others.
(vi) Medication is generally effective in controlling hallucinations, delusions and thought disorder. Depot injections of long-acting drugs at two - to four - weekly intervals are useful to ensure that medication has been taken. These have to be given regularly and are likely to be needed as long-term treatment. Relief of symptoms is achieved in at least 70% of people with such treatments. However people who are receiving medication and regular supervision on at least a weekly basis by a community psychiatric nurse or other medical professional are likely to be among the most severely affected with a significant level of care needs.
(vii) Side-effects of the antipsychotic drugs used may pose particular problems, especially those adverse drug effects on movement. Parkinsonian symptoms [see Chapter 15] may occur. Sedation or depressed mood, or restlessness may also be distressing.
(i) Up to 20% of people with schizophrenia will require long term, highly dependent structured care, sometimes in a hostel with day and night staff.
(ii) About half of affected individuals can live relatively independent lives with the need for varying levels of support and care, but require continuing medication.
(iii) Around 30% make a complete recovery from a single episode of illness and are independent, usually working full time, and raising families. General indications of a good outlook are a rapid onset, a short duration of illness, evidence that the person may also be depressed, onset in middle age, and a previously good social and work record.
(i) In the past, the care of people with schizophrenia was largely hospital based. The emphasis now is on integration in the community whenever possible. This may include living in group homes or attending day centres.
(ii) Hostels or group homes vary in structure and support, from the high dependence that can provide 24 hour care to semi-independence of a supported flat with someone visiting daily or less often. Attendance at a day unit can improve personal functioning (for example, hygiene, conversation and friendships) as well as providing early detection of relapse.
(iii) Whilst it may appear that people are functioning relatively well in the community, this may be only because of the level of support being provided, and is not necessarily an indication of low care needs. Without that support some people might neglect to take care of their personal needs and omit to take medication. As a consequence without such support some could return to a severely disturbed mental state.
(iv) When the person's mental state is severely disturbed there may be risks of danger arising from forgetfulness due to poor concentration. There may also be a need for supervision to avoid danger both to the person and to others. A person with a severely disturbed mental state will usually require hospitalisation, at least initially.
(v) Risk of suicide must be considered in young people with severe forms of schizophrenia [see para 19.5.2(v)]. Here again hospitalisation is likely if there is a requirement for continuing supervision because of that risk, but the mere absence of hospital admissions should not be taken to indicate that the risk does not arise
19.5.5 Mobility Considerations
(i) People with schizophrenia will be physically able to walk unless another disability or illness limits walking ability.
(ii) In the early stages of schizophrenia there may be a need for guidance or supervision when the person walks outdoors. However this need is likely to be short lived. Similarly, the adverse effects of drugs (particularly those referred to as psychotropic drugs) which may produce muscle rigidity and symptoms of Parkinsonism [see Chapter 15] which to a certain extent can limit walking ability, are unlikely to persist for more than a few weeks. Drug treatments are available which counteract these types of side-effect. In some people long-term side effects of the psychotropic medications can persist, although not to an extent likely to affect walking ability.
(i) See outcome at paragraph 19.5.3 above.
(ii) A rapid onset of schizophrenia in middle age, without a previous history of psychological problems, may indicate that the person will respond well to treatment and not have any long term care needs. However, a more gradual onset in a younger person may indicate that the condition and its associated disabilities is likely to persist for very many years and, indeed, in some throughout life.
(iii) The prescription of long-term medication, including the use of depot injections, may be an indication that the condition has been difficult to control and that the level of care needs in the individual person are likely to be long-standing. Similarly, a high level of professional support in the community (see paragraph 19.5.4 (ii) ) is only likely to be given to those with significant ongoing disability.
(i) In many cases, people with schizophrenia may not be able to express adequately their needs on the self-reporting claim form. A factual report from the consultant psychiatrist, the community psychiatric nurse, other mental health professional, or the general practitioner should be sought to establish the level of support and care needs required. In complex cases advice may also be sought from a Medical Services doctor to assist in posing questions which will focus on particular aspects of the person's management and care needs that require clarification.
