Predictors of Functional
Outcome Among
Adolescents and YOllng
Adults With Psychotic
Disorders
Alexis D. Henry, Wendy J. Coster
Key Words: affective disorders • occupational
therapy in psychiatry • schizophrenia
Adolescents and young adults who experience the onset ofa
psychotic disorder often demonstmte major disruptions in
occupational and socialfunctioning. Yet, certain persons
appear to be at a greater risk for impairedfUnctioning
after an episode ofpsychosis than others. This review ofthe
psychiatric research literature on outcomes in psychotic disorders identifies several variables predictive ofoccupational and socialfunctioning amongyoung persons with both
affective and nonaffective psychoses. Variables predictive of
fUnctional outcomes include diagnosis, symptom severity,
duration ofomet ofsymptoms, age ofonset ofsymptoms,
gender, stressful life events, premorbidfimctioning, and
social supports. A modelfor conceptualizing the relationships ofthese variables to functioning is presented, and the
implications for occupational therapy practice and research
are discussed.
Alexis D. Henry, SeD, OTRlL, is Research Assisranr Professor,
Depanmenc of Psychiarry, Cenrer for Psychosocial and
Forensic Services Research, Universiry of Massachusens
Medical Cenrer, 55 Lake Avenue Nonh, Worcesrer,
Massachusem 06155.
Wendy J. Cosrer, PhD. OTRlL, FAOTA, is Associare Professor,
Depanmenr of Occuparional Therapy, Sargenr College of
Allied Health Professions, Bosron University, Boston,
Massach lIserrs.
ThiJ article was acceptedfOr publication july 8, 1995.
oth affective and non affective psychotic disorders
often have their onset during adolescence or
young adulthood (DeLisi, 1992; Kaplan, Sadock,
& Grebb, 1994; McGlashan, 1988). It is during adolescence and young adulthood that expectations for independence and self-sufficiency in occupational and social
role performance increase. The onset of a psychotic disorder often disrupts a person's ability to perform competently in occupational and social roles, thus adolescents
with psychotic disorders are appropriate candidates for
occupational therapy intervention, Given that psychotic
disorders sometimes have a chronic course and that the
accompanying functional disruptions can be longstanding, it would be particularly meaningful for occupational
therapists to be able to identify who, at onset, is at greatest risk for occupational and social role dysfunction in
bOth the short and long term. However, little attention
has been paid to questions such as this within the occupational therapy literature.
This article presents a review of psychiatric research
literature concerned with outcomes in psychotic disorders.
The review discusses morbid and premorbid predictors of
social and occupational functioning among adolescents
and young adults with psychotic disorders, particularly
those with a first episode of psychosis. Additionally, this
article presents a model explaining the nature of the
relationship of these predictor variables to social and occupational dysfunction. Implications of the model for
occupational therapy practice and research with this vulnerable population are discussed.
B
Psychosis and Psychotic Disorders
Psychosis, which can be manifested as a disturbance of
thought organization, thought content, perception, reality testing, judgment, or any combination of these, is
characteristic of several different psychiatric disorders
(Kaplan et al., 1994). The most common major mental
disorders that can present with psychotic symptoms are
affective disorders (also called mood disorders), such as
bipolar disorder and unipolar psychotic depression; nonaffective disorders, such as schizophrenia; and schizoaffective disorder in which persons display symptoms of
both schizophrenia and an affective disorder (Kaplan et
al.,1994).
The presence of at least one episode of mania is the
facror that distinguishes bipolar disorder from unipolar
psychotic depression. Persons with mania commonly present with euphoric mood and grandiose delusions,
whereas persons with unipolar psychotic depression present with depressed mood and, generally, mood-congruent delusions such as somatic delusions or delusions of
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171
poverty (Kaplan et al., 1994).
Persons with schizophrenia most commonly present
with bizarre delusions or hallucinations or both and often
self-report measures are sometimes used. Most studies
report acceptable interrater or test-retest reliability or
both of baseline and outcome measures.
evidence a formal thought disorder, with loose associa-
Outcome in outcomes research in psychiatry has, at
tions, tangentiality, or neologisms. These florid symptoms of schizophrenia are often referred to as positive
symptoms (Andreasen & Olsen, 1982). Negative symptoms of schizophrenia are those that reflect a deficit state,
including flat or blunted affect, poverty of speech, lack of
motivation, anhedonia, poor grooming, social withdrawal, and cognitive deficits (Andreasen & Olsen, 1982).
Although there has been controversy about whether
schizoaffective disorder is an atypical schizophrenia or an
atypical affective disorder, it is considered a unique diagnostic entity (American Psychiatric Association [APA],
1994; Harrow & Grossman, 1984; Williams & McGlashan, 1987). Persons who meet DSM-IV criteria (APA,
1994) for schizoaffective disorder must experience both
an episode during which they evidence some symptoms
of schizophrenia concurrently with either mania or major
depression and an episode during which they evidence
symptoms of psychosis without any prominent mood
symptoms.
times, been operationalized with the use of a global, overall rating of the subject's functioning. Global measures of
outcome, such as the Global Assessment of Functioning
Scale (APA, 1994), consider both the subject's functioning in a variety of occupational domains and the severity
of any psychiatric symptoms that may be present. However, most researchers in psychiatric disorders agree that a
global approach to measuring outcome is limited in that
it masks the subject's strengrhs or weaknesses relative to
different areas. For example, although work or social
functioning have some degree of relatedness to psychiatric symptomatology, they are not perfectly correlated
with it. In general, a multidimensional approach to follow-up data collection is most appropriate.
Most studies of psychotic disorders take a multidimensional approach and separate outcome into distinct
variables. These variables have included overall duration
of rehospitalization during the follow-up period, symptom severity for specified periods, quality and quantity of
social relationships, quality and quantity of occupational
functioning, quality of self-care or the ability to meet
needs, and life satisfaction (Carpenter, Bartko, Strauss, &
Hawk, 1978; Gossett, Barnhart, Lewis, & Phillips, 1977;
Harrow, Goldberg, Grossman, & Meltzer, 1990; Keller et
al., 1987; Rosen, Rosenthal, Dunner, & Fieve, 1983;
Strauss & Carpenter, 1972; Tohen, Waternaux, &
Tsuang, 1990). It seems obvious that multidimensional
baseline data also should be collected in outcome studies
because variables like past employment or social relationships tend to be the best predictors of their respective
outcomes (Strauss & Carpenter, 1974). However, surprisingly, baseline data regarding social and occupational
functioning are sometimes missing in studies where the
purpose is to describe the outcome of specific psychotic
disorders.
Outcome studies vary in terms of the length of the follow-up period, ranging from very short term (6 months) to
very long term (30 years to 40 years). Consideration should
be given to the length of the follow-up period when evaluating the findings of outcome studies because functional
status can either improve or deteriorate over time,
depending on diagnosis and other variables.
Interpretation of outcome studies in psychotic disorders conducted before the 1980s is hampered by two
major limitations. First, before the 1980s, most of the
comprehensive outcome studies of persons with psychotic
conditions have been conducted with patients with schiz-
Method and Measurement in Outcome Studies
Since Kraepelin (1921) first divided psychosis into dementia praecox (schizophrenia) and manic-depression,
many studies have addressed the prediction of outcome in
psychotic disorders. Predictive studies are longitudinal in
design, with subjects either retrospectively or prospectively
compared against themselves. Retrospective outcome
studies rely heavily on clinical records or on subjects' or
family members' recollections as sources of baseline data
regarding the premorbid or morbid phases of the disorder because subjects are usually identified after they have
left the clinical setting. Both of these sources can be
problematic in terms of completeness, accuracy, and reliability. It is generally agreed that prospective studies are
methodologically superior because subjects are identified
at a point, usually during hospitalization, when baseline
data can be collected systematically. Subjects are then followed for later outcome evaluation (Harrow & Grossman, 1984).
The most common method used to collect both
baseline and follow-up data is subject (or family member) interview. Trained interviewers generally summarize
interview data with the use of numeric rating scales. For
example, an interviewer who questions a subject regarding work functioning in the past year might rate the subject on a scale of 0 (no useful work) to 4 (employed continuously). In addition to interviews, paper-and-pencil
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March 1996, Volume 50, Number 3
ophrenia. Since then, however, changes in diagnostic
practices suggest that these cohorts probably included
subjects who would not be diagnosed with schizophrenia
with current criteria but rather with some other psychotic disorder such as bipolar disorder or unipolar psychotic
depression (APA, 1994). Thus, the relevance of the results
of early outcome studies for specific groups of patients is
unclear given the uncertain validity of diagnosis. Not surprisingly, these early studies found specific schizophrenic
symptoms and diagnosis to be relatively poor predictors
of outcomes such as occupational and social functioning,
quality of life, and current symptomatology (Carpenter
et aI., 1978; Hawk, Carpenter, & Strauss, 1975; Strauss
& Carpenter, 1972, 1974).
A second limitation of early outcome srudies of psychosis is that, generally, they involved cohortS of subjects
who have had both a first episode and multiple episodes.
Until recently, relatively little research has focused exclusively on following subjects experiencing a first episode of
psychosis. Affective and non affective psychotic disorders
can have a chronic course in many persons, and it is generally agreed that the impact of chronicity on social and
occupational functioning is substantial (Keller, Lavori,
Lewis, & Klerman, 1983; Strauss & Carpenter, 1974).
Studies that follow subjects with first-episode psychosis
are best able to control for the impact of chronicity in
identifYing factors predictive of good versus poor functioning on outcome (Tohen, Waternaux, Tsuang, &
Hunt, 1990).
Despite the limitations of these early studies, some of
their findings continue to hold up among more recent
studies. In particular, more recen t studies continue to
point to the considerably poorer outcome among persons
with nonaffective psychoses compared with persons with
affective psychoses and to the imponance of premorbid
functioning in predicting functioning on outcome (e.g.,
Beiser et al., 1994; Tsuang & Coryell, 1993).
Predictors of Outcome in Psychotic Disorders
Symptom Severity Diagnosis, and Duration ofOnset
In studies of adolescents and young adults hospitalized
for psychiatric disorders, severity of symptomatology at
the index hospitalization (i.e., the point of entry into the
study) has been shown to con·elate with social and occupational functioning at follow-up. Persons with psychosis
are generally considered to have a more severe degree of
psychiatric symptomatology than those without psychosis (Kaplan et al., 1994). In general, studies of adolescents and young adults suggest that persons who present
with psychosis (either affective or non affective) during
the index hospitalization tend to function more poorly at
both short-term and long-term follow-up than persons
without psychosis (e.g., Gossett et aI., 1977; Rosen et al.,
1983; Strober, Lampert, Schmidt, & Morrell, 1993; Weiner, Weiner, & Fishman, 1979). Persons with nonaffective psychoses such as schizophrenia consistently have
been found to have poorer outcomes (e.g., poorer social
and occupational functioning or greater symptom severity)
than those with affective psychoses (e.g., Cawthron, James,
Dell, & Seagroatt, 1994; Kettering, Harrow, Grossman,
& Meltzer, 1987; McClellan, Werry, & Ham, 1993; Moiler et aI., 1988; Tsuang & Coryell, 1993). Recent studies
of persons who have had a first episode of schizophrenia
suggest that outcome is poor, even among the subjects
with first-episode psychosis (e.g., Erickson, Beiser, Iacono,
Fleming, & Lin, 1989; Shtasel et al., 1992). However,
some studies have reported that there may be a subgroup
of persons with first-episode schizophrenia who demonstrate fewer negative symptoms and who have comparatively good functional outcome (Ganguli & Brar, 1992;
Shtasel et al., 1992). It has been suggested that negative
symptoms (e.g., Hat affect, social withdrawal) may be
more strongly related to social and occupational functioning than positive symptoms such as hallucinations and
delusions (Andreasen & Olsen, 1982; Fenton & McGlashan, 1994; Shtasel et aI., 1992).
Not all persons with affective disorders present with
psychosis; however, persons with bipolar disorder are
much more likely to present with psychosis than those
with depression. Psychosis has been reported in approximately 70% to 75% of persons with bipolar disorder
(Harrow et al., 1990; Tohen, Waternaux, & Tsuang,
1990), whereas it is estimated that only 25% of persons
with major depression have psychosis (Coryell, Pfohl, &
Zimmerman, 1984). Of note, follow-up studies of adolescents and young adults with major depression and
without a history of mania have found that a significant
number of the subjects with psychosis later developed
bipolar disorder. An initial presentation of psychotic
depression during adolescence or young adulthood may,
for some persons, be the first episode of a bipolar disorder (Strober & Carlson, 1982; Strober et al., 1993).
Among both persons with bipolar disorder and persons with depression, the presence of psychosis has been
reported to be associated with poorer functional outcome
(Coryell, Endicott, & Keller, 1990; Harrow et aI., 1990;
Henry, 1989; Rosen et aI., 1983; Tohen, Waternaux, &
Tsuang, 1990). Even when symptoms have remitted, persons with psychotic affective disorders continue to demonstrate functional deficits, especially in short-term follow-up studies (Dion, Tohen, Anthony, & Waternaux,
1988; Henry, 1989). However, some data suggest that
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differences in funccional outcome between persons with
psychotic versus nonpsychotic affective disorders may
diminish over time, with funccioning among persons
with psychotic affective disorders improving over the
long term (e.g., COlyell, Lavori, Endicott, Keller, & VanEerdewegh, 1984; Coryell & Tsuang, 1982; Strober et
aI., 1993; Tohen, Waternaux, & Tsuang, 1990).
Studies of functional outcome among persons with
schizoaffective disorder report mixed results. Some studies have suggested that persons with schizoaffective disorder tend to have outcomes more similar to schizophrenia
than to affective disorders (Coryell et aI., 1984; Williams
& McGlashan, 1987). However, in a review of outcome
studies of this disorder, Harrow and Grossman (1984)
suggested that although outcome of schizoaffective disorder is generally poorer than that of affeccive disorder, it is
generally better than outcome of schizophrenia. These
somewhat contradictory findings may be attributable to
the length of the follow-up period. There is some suggestion that functional outcomes for persons with schizoaffective disorders parallel those of affective disorders in the
short term but begin to more closely resemble schizophrenia in the long term (Tsuang & Coryell, 1993; Williams & McGlashan, 1987).
In addition to the diagnosis and the severity of the
symptoms associated with the diagnosis, the duration of
the onset of the symptoms has been found to be predictive of functional outcome. Onset is generally defined as
the length of time between first evidence of psychiatric
symptoms, usually psychotic symptoms, and first hospitalization or treatment (Flaum, Andreasen, & Arndt,
1992; Haas & Sweeney, 1992). Several studies of adolescent and young adult subjeccs experiencing both first and
mul tiple episodes of psychosis suggest that duration of
onset of psychiatric symptoms predicts both short-term
and long-term outcome. Persons with a rapid, more
acute onset of symptoms tend to function better at outcome (and have a reduced risk for relapse) than those
with a more gradual, insidious onset (e.g., Flaum et aI.,
1992; Johnstone, MacMillan, Frith, Benn, & Crow,
1990; Rabiner, Wegner, & Kane, 1986; Shtasel et al.,
1992, Tohen et aI., 1992). In essence, chronicity predicts
chronicity. Patients who have been chronically ill are likely to have continued difficulty functioning and to have
poorer functional outcomes than patients who have been
ill for only a short period. It may be that psychosis has a
deteriorating effect on functioning, so persons who have
been symptomatic for longer periods have greater difficulty overcoming the effects of psychosis.
Age ofOnset
Most studies of schizophrenia suggest that an early age of
onset is a prediccor of poor outcome. Studies of persons
with a first episode of schizophrenia point to the beginning of a decline in functioning during adolescence and
young adulthood and an earlier age of onset as a predictor of rehospitalization, chronicity, and poorer social and
occupational functioning at follow-up (e.g., Eaton et aI.,
1992; Moller, von Zerssen, Werner-Eilert, & WuschnerStockheim, 1982; Shtasel et aI., 1992). Among persons
with first-episode schizophrenia, an earlier age of onset
has been associated with poor or an insidious decline in
premorbid functioning, whereas a later age of onset has
been associated with good premorbid functioning (Haas
& Sweeney, 1992).
Among affective psychoses, findings regarding the
relationship between age of onset and functioning at follow-up are equivocal. A prospeccive 18-month follow-up
of persons with first-episode affective psychosis found
that younger subjects functioned more poorly at outcome
than the older persons (Erickson et aI., 1989). Similarly,
Rosen and colleagues (1983) conducted a retrospective 5year follow-up of subjects with bipolar disorder with and
without psychosis and found that the subjects with psychosis were considerably younger at first treatment and
that a younger age at first treatment was related to poorer
global functioning at follow-up. However, McGlashan
(1988) conducted a long-term OS-year) follow-up study
comparing adolescent-onset with adult-onset mania and
found that although the adolescent subjects presented
with more psychotic symptoms and greater chronicity at
baseline, at follow-up, they were functioning as well as or
better than the subjects with adult-onset mania. Tohen
and colleagues' recent studies with varying follow-up periods (6 months and 4 years) did not find any relationship
between age of onset and functioning at follow-up among
persons with bipolar disorder (Tohen, Waternaux, & Tsuang, 1990; Tohen, Waternaux, Tsuang, & Hunt, 1990;
Tohen et aI., 1992).
Few studies have examined the relationship between
age of onset and functional outcomes among persons
with psychotic depression (A. J. Rothschild, personal
communication, 1994). In their 6-month follow-up of
subjects with first-episode psychosis, Tohen and colleagues (1992) found that the subjeccs with psychotic
depression under the age of 40 were at a significantly
greater risk for not recovering functionally at 6 months
than the subjects over the age of 40, although the sample
was very small (n = 15). As previously described, some
studies suggest that persons who present with psychotic
depression during adolescence or young adulthood have
an increased likelihood of later developing bipolar disorder (Strober & Carlson, 1982; Strober et aI., 1993).
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March 1996, Volume 50, Number 3
Gender
Srudies of schizophrenia consistently include more male
than female subjects. Although some have questioned
whether this trend reflects a methodological bias among
researchers (Wahl & Hunter, 1992), recent studies of
first-episode schizophrenia suggest that the disorder may
be both less severe and less common in women, particularly among young women (Iacono & Beiser, 1992). Men
with schizophrenia tend to have an earlier age of onset,
demonstrate more negative symptoms, show greater intellecrual deterioration, and have poorer premorbid functioning than women (Beiser et al., 1994; Bilder et al.,
1992; Childers & Harding, 1990; Faraone, Chen, Goldstein, & Tsuang, 1994; Haas & Sweeney, 1992; Salokangas & Stengard, 1990). In addition, men generally demonstrate poorer functioning on outcome and are more likely
to be chronically ill (Beiser et al., 1994; Kastrup, 1987;
Klinge, Piggott, Knitter, & O'Donnell, 1986; McGlashan
& Bardenstein, 1990). Although not all srudies of outcome in schizophrenia have found a gender effect, rarely
have men been shown to have a more favorable outcome
than women (Angermeyer, Kuhn, & Goldstein, 1990).
Some researchers, however, have found that the gender
effect diminishes over a very long-term follow-up period
(Childers & Harding, 1990). Similar findings of poorer
functional outcome among men have been reported in
persons with bipolar disorder (Erickson et al., 1989;
Harrow et al., 1990; Tohen et al., 1992; Tohen, Waternaux, Tsuang, & Hunt, 1990). Although both nonpsychotic and psychotic depression are more common in
women, reporrs of gender differences in functional outcome are not found (A. J. Rothschild, personal communication, 1994; Coryell, Keller, Lavori, & Endicott, 1990).
StressfUl Lift Events
Several authors have suggested that stressful, independent
life events (those that are not a result of symptomatology
or personal behavior) may have a role as triggers for both
the onset and the relapse of schizophrenic, bipolar, or
depressive episodes, particularly when the event(s) OCCutS
within 3 weeks to 4 weeks of onset or relapse (Ellicott,
Hammen, Gitlin, Brown, & Jamison, 1990; Nuechterlein et al., 1992). However, the relationship of precipitating stressful life events (those that occur before the onset
of a first episode of psychosis) to social and occupational
functioning after the first episode has not been well
researched. Some au thors have suggested that clearly
identifiable precipitants to a psychotic episode predict a
more positive functional outcome (Moller et al., 1982;
Opjordsmoen, 1991), whereas others did not find such a
relationship (Strauss & Carpenter, 1974).
It seems paradoxical that stressors trigger the onset of
either an initial or relapse episode and yet predict a better
outcome from that episode. However, there is some evidence that stressful life events are associated with an acute
as opposed to a more insidious onset of symptoms (Billings & Moos, 1984). The previously healthy person who
appears to become acutely symptomatic in response to a
major stressor generally has a history of better premorbid
functioning (also a predictor of better outcome) than the
person who has had a slower, insidious onset of symptoms
that is often accompanied by a deterioration in functioning over time. A person experiencing a relapse of symptoms is likely to experience some impairment in functioning, although a brief symptomatic relapse secondary to a
life stressor may have only limited functional consequences. However, repeated psychotic relapses, triggered
by repeated stressors, can result in substantial, relatively
longstanding impairments in occupational and social
functioning. Thus, stressful life events may predict poor
ourcome in persons with chronic illness. A critical factor
in the relationship between life events and symptomatic
relapse and functioning may be the person's capacity to
cope with stress, which is addressed in the next section.
Premorbid Functioning and Social Supports
When the data are collected, premorbid occupational and
social functioning are among the best predictors of occupational and social functioning on outcome. Srudies of
bOth affective and nonaffective psychoses point to a history of good premorbid functioning as being one of the
most consistent predictors of good functioning in both
short-term and long-term follow-up. Premorbid functioning predicts functioning on outcome for bom persons who
are acurely ill and persons who are chronically ill (Beiser et
aI., 1994; McGlashan, 1986; Williams & McGlashan,
1987). However, good premorbid functioning, particularly
among persons with chronic schizophrenia, seems to lose
its protective effect against later deterioration over me very
long term as instirutionalization, personality deterioration,
and long-term medication use take their toll (McGlashan,
1986). Good premorbid functioning is generally associated
with a more acute and a later age of onset of first psychosis (Haas & Sweeney, 1992). In addition, good premorbid functioning has been found to be associated with
an absence of negative symptoms (Andreasen & Olsen,
1982). Among persons with psychotic disorders, aspects
of premorbid functioning that have been shown to predict functional outcomes include duration of work history, quality of work performance, and occupational level;
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scholastic achievement and educational level; social adjustment, social skills, and social relationships, including
marital status and heterosexual relationships; number of
creasingly important as outcome variables in follow-up
studies of psychotic disorders (Erickson, et aI., 1989;
Johnstone et aI., 1990; Strauss & Carpenter, 1974). The
friends and involvement with friends; and range of interests and activity involvement (e.g., Beiser et aI., 1994;
Dejong, Giel, Sloof[, & Wiersma, 1985; Erickson et aI.,
1989; Harrow, Westermeyer, Silverstein, Strauss, &
Cohler, 1986; Johnstone et aI., 1990; McGlashan, 1986;
Moller et aI., 1988; Rabiner et aI., 1986).
In general, premorbid measures of functioning are
the best predictors of their respective outcome measures;
that is, premorbid occupational (work) functioning best
predicts occupational functioning on outcome, and premorbid social functioning best predicts social functioning on outcome. However, there is evidence that social
functioning predicts not just its corresponding outcome,
but other outcome variables as well. Having friends, the
capacity for involvement with friends, and the capacity
to recruit these social supports when under stress are particularly relevant. The recruitment of social supports is
one coping skill that may moderate the negative effects of
stressful life events for persons with psychotic disorders
(Lukoff, Snyder, Ventura, & Nuechterlein, 1984). The
composition and quality of the relationships in the social
support network are important factors in the prediction
of outcome. Several studies have reported that persons
whose social networks were composed primarily of
friends, neighbors, and others who are not kin tended to
demonstrate better occupational functioning and to
experience better symptomatic recovery and lower relapse
rates than those whose social networks were composed
primarily of relatives (Erickson et aI., 1989; Garrison,
1978; Lukoff et aI., 1984; Randolph & Escobar's study
[as cited in Lukoff et aI., 1984]).
Most of the research examining family member involvement in the course of psychotic disorders has focused
on persons with schizophrenia and the construct of
expressed emotion. Expressed emotion refers, in part, to
the level of criticism, emotional overinvolvement, and hostility directed toward patients by the family members, typically spouses and parents (Vaughn & Leff, 1976).
Research data have indicated that persons whose families
are high in expressed emotion are at greater risk for relapse
than persons whose families are low in expressed emotion
(Lukoff et aI., 1984). So a social network composed primarily of relatives might be more toxic if the family is high
in expressed emotion, and such a family would be considered to be a source of stress rather than of support.
data suggest that each of the variables discussed in this
review contributes something to the prediction of who
will function well after a first episode of psychosis and
who will not. A useful framework for conceptualizing the
nature of the relationship of these variables to each other
and to functioning can be found in a model for prevention of psychopathology proposed by Albee (1984) and
adapted by Gartner and Riessman (1982). The model
suggests the following equation for explaining dysfunction:
Discussion
Occupational and social functioning have become in-
Occuparional/social dysruncrion = Constitutional vulnerabilities + stress
Competence + coping skills + !'ocial suppon
Variables in both the numerator and the denominator have been identified in this review as predictors of
outcome in psychotic disorders. The term constitutional
vulnerabilities implies factors that are related to neurochemical, developmental, or genetic makeup and, among
the variables discussed here, includes diagnosis and diagnosis-related variables (i.e., symptom severity, duration of
onset), age of onset, and gender (F1or-Henry, 1990; Murray, O'Cailaghan, Castle, & Lewis, 1992). The variables
in the numerator-constitutional vulnerabilities and
stress-can be thought of as primary causes of occupational and social dysfunction. The variables in the denominator~ompetence, coping skills (i.e., good premorbid
functioning), and social support-are factors that moderate the impact of primary causes on dysfunction. Thus, a
person who has a history of relative competence and good
coping skills along with good social supportS could be
expected to experience less dysfunction than a person
with a history of relative incompetence, poor coping
skills, and an inadequate support system, even if constitutional vulnerabilities and stress are similar for the two persons. Support for this model can be found elsewhere in
the literature on outcomes in psychosis (e.g., Nuechterlein
etal., 1992).
Albee's (1984) equation for dysfunction helps explain
why premorbid functioning is a consistent predictor of
functional outcomes. For a person with good premorbid
functioning, the initial episode of a psychotic disorder
might have less severe functional consequences. Furthermore, competence, coping skills, and social supports
might be protective mechanisms that allow the person to
better tolerate repeated episodes of a psychotic disorder
with less functional deterioration. The equation also helps
explain why adolescents and young adults with psychotic
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disorders appear particularly vulnerable to occupational
and social dysfunction. A younger person who develops a
psychotic disorder has had less time and therefore fewer
opportunities to develop the skills (i.e., competence and
coping skills) that may moderate the negative effects of
psychosis, and their ability to develop these skills in the
future may be compromised by the psychosis. Donahue
and Lieberman (1992) have found relationships between
measures of social competence and age of onset of psychosis among male and female subjects. The subjects
with a later age of onset of a psychotic disorder evidenced
better current social competence. Donahue and Lieberman speculate that the onset of psychosis interferes with
the development of social competence.
Implications for Occupational Therapy Practice
and Research
This review of the psychiatric research literature and the
equation for dysfunction, as presented in this article,
point to a definitive role for occupational therapy with
adolescents and young adults with psychotic disorders.
Given the complex nature of occupational and social
outcomes for persons with psychotic disorders, it seems
clear that for both clinical and research purposes, evaluation of the patient must be multifaceted. In addition to
an evaluation of the clinical condition, with its focus on
presenting symptomatology and the determination of an
accurate diagnosis, any comprehensive workup of a
patient presenting with a psychotic disorder (particularly
a first episode) should include a thorough evaluation of
the patient's premorbid functioning (competence and
coping skills) and of his or her environmental supports
because these data are likely to be among the most relevant for predicting functioning on outcome.
Occupational therapists are among the members of
the psychiatric treatment team who are responsible for
the collection of such data. Because occupational therapists consider functioning from a broad perspective, evaluating not only the person's capacity for work, play, and
self-care, but also his or her interests, values, and motives
that influence engagement in these occupations and the
environmental factors that support or constrain engagement, they are well qualified to elaborate on which aspects of current and premorbid functioning might be
most predictive of functioning after a psychotic episode.
Within occupational therapy, the Model of Human
Occupation (Kielhofner, 1995) and the Cognitive Disabilities Model (Allen, Earhart, & Blue, 1992) often are
used to guide evaluation of persons with psychiatric disorders. An assortment of evaluation procedures, compatible with each model, have been developed to evaluate
various aspects of functioning. These and other procedures not grounded in a specific practice model are frequently used in mental health practice (see Table I).
Although most of these measures have been subjected to
examinations of reliability, and some have been found to
discriminate between persons with and persons without
psychiatric disorders (e.g., Barris, Dickie, & Baron, 1988;
Barris et aI., 1986; Ebb, Coster, & Duncombe, 1989;
Katz, ]osman, & Steinmetz, 1988; Smyntek, Barris, &
Kielhofner, 1985), very few data exiSt regarding the predictive validity of occupational therapy evaluation procedures. Concentrating instrument development efforts on
examination of the validity of the existing measures
would allow occupational therapists to make important
contributions to outcome studies of psychiatric disorders,
particularly because in many outcome studies, evaluation
of morbid and premorbid functioning during baseline
data collection is limited.
Follow-up studies that identify consistent predictors
of functional outcome help to identi~' those persons who
are at risk for dysfunction after an episode of a psychotic
disorder. The equation for dysfunction proposed by Albee
(1984), suggests that efforts to lessen dysfunction should
be aimed at decreasing the factors in me numerator (i.e.,
constitutional vulnerabilities and stress) or increasing factors in the denominator (i.e., competence, coping skills,
and social support) or both. Certainly, psychotropic medications are an important intervention that may alter certain constitutional vulnerabilities. Research data indicate,
however, that many persons with psychotic disorders who
experience remittance of psychotic symptoms with medication continue to have impairments in occupational and
social functioning (Dion et al., 1988; Henry, 1989). For
these persons, particularly those with multiple risk factors
for poor functional outcomes (e.g., the young male
patient with poor premorbid functioning), treatment
interventions clearly should extend beyond symptom
amelioration. Less clear are the forms of intervention that
would be most beneficial in decreasing dysfunction.
The equation for dysfunction (Albee, 1984; Gartner
& Riessman, 1982) suggests that the answer lies in
strengthening competence, coping skills, and social supports, and wi thin the occupational therapy literature,
there are many descriptions of programs designed to
strengthen competence among persons with psychiatric
disorders (see Munoz in Kielhofner [1995] for a bibliography of treatment programs based on the Model of
Human Occupation). Unfortunately, very few studies in
occupational therapy have examined the effectiveness of
interventions aimed at strengthening competence among
persons with mental illness. One study examined the
The American journal ofOccupational Therapy
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177
Table 1
Some Occupational Therapy Functional Assessments Used in Mental Health Practice
Pr~ccice
Model
I\rcas of funccioning A."esscd
Assessment Tool
Underlying
Observations of behavior
Allen Cognirive Level Tesr (ACL)
CDM
Abiliry
[0
Source
learn
Allen, Earhart, and
Blue (1992)
Routine Task Inventory (RTl)
CDM
ADL
Allen er aL (J 992)
Assessment of Morar and Process Skills (AMPS)
MOHO
ivloror and process skiJls performed
while completing lADL
Fisher (1994)
Milw~uket' Evaluarion of Daily Living
Skills (MEDLS)
none specified
ADL
Leonardelli (J 988)
Kohlman Evaluarion of Living Skills (KELS)
none specified
ADL
Kohlman-Thompson (J 992)
Bay Area Funcrional Performance
Evaluation (BaFPE)
none specified
Task performance and social skills
Williams and Bloomer (J 987)
ScorabJe Self-Care Evaluarion
none specified
ADL
Clark and Perers (1992)
Volitional Questionnaire
J'vIOHO
Motivation, personal causation,
de las Heras (J 993)
values, and interests
Paper-and-pencil self-report instrumenrs
IntercSt Checklisr
MOHO
Intercsts and interesr patterns
Matsutsuyu (1%9)
Role Checklisr
MOHO
Role identification and role value
Oakley, Kielhofner, Barris,
and Reichlet (1986)
Self-Assessment of Occuparional Functioning
MOHO
Self-perceprions of srrengrhs and
weaknesses in volition, habiruarion,
and performance
Baron and Currin (J 990)
Occuparional Questionnaire
MOHO
Time use patterns and beliefs
abour rime use
Smith, Kielhofner, and
Warts (J 986)
Occupational Performance History
Inrerview (OPHI)
MOHO eclectic
Past and current
adapration
Worker Role fntcrview (\VRI)
MOHO
Interviews
occup~tion,d
Kielhofner, Henry, and
Walens (1989)
Current influences on the ability
ro rew rn ro work
Velozo, Kielhofncr, and
Fisher (1990)
Assessment of Occupational Functioning (AOF)
MOHO
Current occuparional adaptation
Watts, Btollier, Bauer, and
Schmidr (J 988)
Occuparional Case Analysis Inrerview and
Raring Scale (OCAIRS)
i\'IOHO
Current occupational adaptarion
Kaplan and Kiclhofner (J 989)
Canadian Occuparional Performance
Measure (COPi\,I)
Occuparional performance
C1ient-idenrifled problem areas
in daily funCtioning
Pollock (1993)
Note, ADL = acriviries of daily living, CDM
Occupation
= Cognirive Di",hilirie,\ Model,
IADL
effectiveness of a time-limited aftercare program, which
was based on the Model of Human Occupation and
designed to promote occupational competence, for
young adults with chronic mental illness (Kielhofner &
Brinson, 1989), The results showed no significant differences between experimental and control subjects on any
of the outcome measures, although nonsignificant trends
in the data showed less recidivism and higher volition
scores among experimental subjects, Other studies have
suggested that occupational therapy interventions, specifically task-oriented or activity-oriented group interventions, may be more effective in enhancing specific types
of social and communication skills than verbal group
interventions (DeCarlo & Mann, 1985; McDermott,
1988; Schwartzberg, Howe, & McDermott, 1982),
= instrumental activities of daily living,
MOHO
= Model of Human
Findings that suggest the potential for activity-oriented group interventions to enhance social functioning
are intriguing given the apparent relationship of premorbid social competence to more positive outcomes among
young persons with psychotic disorders. However, obvious questions remain, To what extent can social competence be enhanced in adolescents and young adults
already experiencing a psychotic disorder if they previously lacked such skills? What methods are best for teaching
these skills? If they can be taught, to what extent will
these capacities act to moderate the effects of future psychotic episodes on functioning? Researchers in occupational therapy could make an important contribution to
the treatment of adolescents and young adults with psychotic disorders by concenttating research efforts on
178
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jv1arch 1996. Volume 50, Number 3
questions such as these and could make evidenr the
unique and crucial conuiburion of occupational therapy
to the psychiatric treatment team....
social funerioning, and longer-rerm outcome in DSM-Ill schizophrenia. Schizophrenia BuLletin, 16, 309-318.
Clark, E. N., & Peters, M. (1992). ScorabLe se/fcare evaLuation.
Thorofare, NJ: Slack.
Coryell, W., Endicon, J., & Keller, M. (1990). Outcome of
patients with chronic affeerive disorder: A five-yea.r follow-up. AmericanjoumaL ofPsychiany, 147, 1627-1633.
Acknowledgments
We thank linda TickJe-Degnen, PhD, OTRlL, Maureen Neistadt, SeD,
OTR/L, FAOTA, and Mark Rosenfeld, PhD, OTR/L, for theit helpful
comments on an earlier draft of this arricle. This arricle was supporred
in parr by a grant ro Sargent College of Allied Health Professions,
Bosron University, Bosron, Massachuserrs, from the U.S.
Deparrment of Health and Human Services, Division of Maternal
and Child Health Services, and was completed in parriaJ fulfillment
of the disserration requirements for the first author's degtee of Doeror
of Science, Sargent College, Bosron Universiry.
Coryell, W., Keller, M., lavori, P., & Endicon, J. (1990).
Affective syndromes, psychotic features and prognosis. Archives of
GeneraL Psychiatry, 47,651-657.
Coryell, W., Lavori, P., Endicon, J., Keller, M., VanEerdewegh,
M. (1984). Outcome in schizoaffective, psychotic and nonpsychotic
depression. Course during a six- ro 24-month follow-up. Archives of
GeneraL Psychiatry, 41, 787-791.
Coryell, W., Pfohl, B., & Zimmerman, M. (1984). The c1inicaJ
and neuroendocrine fearures of psychotic depression. JournaL ofNervousandMentaLDisease, 172,521-528.
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