Research into the therapeutic potential of aerobic exercise has proven fruitful over the past few years; however, no true experimental research undertakings have investigated the psychological benefits of aerobic exercise with schizophrenic semi-acute in-patients. The main objective of this thesis was to seek out evidence for the possibility that aerobic (submaximal long duration) exercise could be considered an adjunct treatment for hospitalised schizophrenic in-patients. In order to accomplish this objective the effects of a 45-minute walking programme, completed three days a week, for five weeks, was investigated. Various areas of mental health were explored in search of evidence of the therapeutic potential of aerobic exercise. These areas included, amongst other things: transfer and discharge rates, improvements in mood levels - Beck Depression Inventory-II (BDI-II; Beck, Steer, and Brown, 1996) Xhosa version; decreasing of anxiety levels (Beck Anxiety Inventory (BAI; Beck and Steer, 1993), Xhosa version); improved Global Assessment of Functioning (GAF; DSM-IV), Scale Scores; and decreases in the number of symptoms patients exhibited. 22 schizophrenic inpatients were randomly selected for this study and randomly assigned to either an aerobic (long duration submaximal) treatment group or (primarily anaerobic) control group. Results revealed that statistical significance could not be found in any of the treatment group's t-test results; despite the treatment group generally bordering on significance more so than the control group. Out of the five variables studied (Positive Symptoms, Negative Symptoms, BAI, BDI-II, and GAF Scale) three variables (Negative Symptoms, BDI-II, and GAF Scale) in the treatment group bordered more on significance than did the control group. Thus three (60 %) out of the five areas studied revealed that the treatment group had more significant results. This suggests an overall impression that the treatment group responded slightly better. The Researcher recommended that aerobic exercise therapy be considered a treatment protocol in psychiatric institutions and offered further suggestions pertaining to the effective implementation of these programmes. Included in these recommendations were motivational strategies and warnings about the possible negative effects of exercise therapy. A supplemental goal of this thesis was to explore all of the previously offered theoretical psychological mechanisms of positive mental change; and to seek out evidence, for or against these forces. Participants were given pre- and post- treatment quantitative interviews; as well as, qualitative posttreatment interviews where their phenomenological responses were analysed to seek out evidence of these mechanisms. Evidence of various causative factors was found and a new theoretical mechanism was proposed in this thesis.

Thesis (DMed (Psychiatry))--University of Stellenbosch, 2007. / This study reports on the effect of seminar education by studying changes in knowledge, attitude and behaviour to haloperidol prescribing patterns of psychiatrists who In summary, this study demonstrated a direct relationship between seminar attendance and changes to selected minimum effective haloperidol dose and duration of treatment. However, seminar attendance did not appear to be a significant factor in changes to antipsychotic class used for treatment and changes in optimal effective haloperidol dose: rather a change in the level of “background” knowledge of participants was most likely responsible. This study also found individual participant characteristic differences in those who did change treatment duration and minimum effective dose. In conclusion, this study showed that the successful integration of international treatment recommendations into daily psychiatric practise could be facilitated by the use of appropriate educational seminars. Not all attendees benefit i.e. “learn”, but those needing to “learn” most do - i.e. those who need to change their prescribing habits most to meet internationally accepted guidelines. The peer exposure provided allows a format for informed discussion and the practise of evidence-based medicine. The judicious use of such seminars should result in better treatment options and outcomes for patients.attended evidence-based schizophrenia seminars presented by the Lundbeck Institute in Denmark. The objectives of the study were two-fold. Firstly, it set out to determine whether changes actually occurred in the post-seminar haloperidol prescribing behaviour of participants. This was done by analysing changes in choice of optimal haloperidol dose (both in acute treatment i.e. most effective dose and maintenance treatment i.e. minimum effective dose), selected duration of treatment (for first- and multi-episode schizophrenia patients) and drug-class used (conventional versus new generation antipsychotic). The study then investigated whether these changes (if they occurred) could be ascribed wholly or in part to the effect of schizophrenia seminar attendance, or whether other factors e.g. scientific progress over time in understanding schizophrenia and its treatment (“background” knowledge) and differences between participant datasets studied (only paired pre- and post-seminar data were used in this study) also played a role. Secondly, it attempted to identify factors predictive of seminar participants changing their haloperidol prescribing behaviour post-seminar i.e. what were the factors that predisposed some attendees to change their prescribing behaviour? This was done by analysing the effect that pre-seminar prescribing behaviour, participant nationality, patient caseload, work experience and workplace environment had on post-seminar behaviour. Results show that changes did occur in post-seminar haloperidol prescribing behaviour, but that they were not always due to an effect of seminar attendance. Only the changes in the minimum effective haloperidol dose and duration of treatment for first- and multi-episode schizophrenia patients could validly be ascribed to the effects of schizophrenia seminar attendance. Furthermore, multivariate analysis of the factors relating to these changes found that a participant was most likely to change their selected minimum effective haloperidol dose to be more in line with internationally accepted standards if they i) selected above the target dose pre-seminar, ii) had a relatively low caseload comprised mainly of schizophrenia patients and iii) came from either Greece, Germany, Britain, Spain, Italy or some other Eastern European country. The single most important factor related to changes in duration of treatment was found to be pre-seminar behaviour: respondents below the recommended duration of treatment increased their duration of treatment significantly.

Thesis (PhD (Psychiatry))--University of Stellenbosch, 2011. / ENGLISH ABSTRACT: Contemporary research has confirmed the presence of cognitive deficits as a core feature of schizophrenia that has a definite and adverse impact on functional outcome. Cognitive functioning can be improved by psychopharmacological intervention, with evidence supporting the superiority of second generation antipsychotics over their first generation predecessors. Despite evidence that cognitive impairment contributes to medication non-adherence and that depot antipsychotics are able to enhance treatment compliance whilst decreasing relapse rates, depot preparations remain less frequently prescribed than their oral counterparts, especially in patients with first episode psychosis (FEP). The aims of this study were primarily to investigate cognitive deficits in patients with FEP, and to then describe the response of these impairments to treatment with a very low dose flupenthixol decanoate. This was a prospective, non-randomized, single arm, open-label, longitudinal study of 58 participants with FEP treated according to a fixed protocol over a period of 12 months. There was a wash-out phase of up to seven days during which all psychotropic medications were discontinued. There was an initial treatment period of one week with oral flupenthixol 1mg/day, after which flupenthixol decanoate was initiated at 10mg intramuscular depot injection every fortnight. Dose increases, in cases of poor or inadequate response, were allowed at 6-weekly intervals and in increments of 10mg per injection, up to a maximum of 30mg per fortnight. The principal findings of the study were as follows: The majority of participants were markedly ill, with significant cognitive impairment at baseline. There was a discrepancy between subjectively reported, and objectively measured, cognitive impairment. The majority of the participants responded to, and achieved remission, on a very low dose of flupenthixol decanoate (22.48 ± 0.47mg/month). The majority of symptomatic and cognitive improvement occurred between baseline and three months, with response leveling out at six months. Social cognition did not improve significantly over time, whereas functional outcome and quality of life did improve with treatment. Flupenthixol decanoate was well tolerated and side-effects were of a mild and transient nature. This study reconfirms that the majority of individuals with FEP experience significant cognitive impairment at baseline. It also suggests that these impairments can be successfully treated with a very low dose of flupenthixol decanoate. The use of depot flupenthixol decanoate ensures sustained treatment delivery, thereby decreasing the risk for relapse. This holds the promise of improved long-term functional outcome for those suffering with psychotic illness. / AFRIKAANSE OPSOMMING: Onlangse navorsing het kognitiewe inkorting identifiseer as een van die kern simptoomkomplekse van skisofrenie, met toenemende bewyse vir die duidelike en ongunstige impak hiervan op funksionele uitkoms. Kognitiewe funksionering kan deur psigofarmakologiese ingrepe verbeter word. Onlangse literatuur toon dat die tweede generasie antipsigotika relatief meer effektief is as hulle eerste generasie voorgangers. Ondanks bewyse vir die negatiewe impak van kognitiewe inkorting op behandelingsinskiklikheid, én data wat daarop wys dat die gebruik van langwerkende intramuskulere (depot) antipsigotika inskiklikheid verbeter en periodes van simptoom-terugval voorkom, word dié preparate steeds minder gereeld as hulle orale eweknieë voorgeskryf, veral by pasiënte met 'n eerste episode psigose (FEP). Die doel van hierdie studie was om kognitiewe probleme by pasiënte met FEP te beskryf, en ook om die respons hiervan op behandeling met 'n baie lae dosis flupentiksol dekanoaat, te ondersoek. Die studie was 'n prospektiewe, nie-ewekansige, enkel middel, oop studie van 58 deelnemers met FEP, wat oor „n tydperk van 12 maande volgens 'n spesifieke protokol behandel is. Daar was 'n uitwas periode van 7 dae, waartydens alle psigotrope medikasie gestaak is. Hierna is behandeling met orale flupentiksol 1mg/dag begin vir een week, waarna flupentiksol dekanoaat geinisieer is teen 10mg intramuskulêr elke 2de week. Dosisverhogings, in geval van onvoldoende respons, was toelaatbaar met 6-weeklikse tussenposes, in inkremente van 10mg per inspuiting, tot 'n maksimum van 30mg elke 2de week. Die vernaamste bevindinge van die studie was soos volg: Die meerderheid van die deelnemers was ernstig siek, met beduidende kognitiewe inkorting tydens basislyn evaluasie. Daar was 'n verskil tussen subjektief-gerapporteerde en objektief-meetbare kognitiewe inkorting. Die meerderheid van die deelnemers het goed reageer op behandeling en het ook remissie op 'n baie lae dosis flupentiksol dekanoaat (22.48 ± 0.47mg/maand), bereik. Die meerderheid van simptomatiese en kognitiewe verbetering het plaasgevind binne die eerste 3 maande, met afplatting in die tempo en hoeveelheid van verbetering vanaf 6 maande. Sosiale kognisie het nie beduidend gedurende die studieperiode verbeter nie. Funksionele uitkoms en lewenskwailiteit van deelnemers het ook met behandeling verbeter. Flupentiksol dekanoaat is goed verdra en die newe-effekte, indien dit teenwoordig was, was van ligte graad en verbygaande aard. Hierdie studie herbevestig dat individue met FEP beduidende kognitiewe inkorting by basislyn ervaar, maar dat hierdie inkortings effektief met 'n baie lae dosis van flupentiksol dekanoaat behandel kan word. Die gebruik van depot flupentiksol is 'n suksesvolle manier om volgehoue behandeling te verseker en sodoende die risiko vir terugvalle te verminder. Dit verstewig dus die hoop op beter langtermyn funksionering vir persone met psigotiese siektes.

Thesis (PhD)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Prospective, longitudinal clinical studies in first-episode schizophrenia have become relatively commonplace over the past two decades or more and have provided a wealth of useful information regarding the clinical presentation, treatment, course and outcome of the illness. However, there remain several unanswered questions. The majority of the studies have been conducted in upper income countries using often costly medication with heterogeneous samples. While the overall outcome of patients showed some progress, there is room for improvement yet. The overall aim of the dissertation was to study the clinical, biological and functional aspects of outcome in first episode schizophrenia in a resource constrained setting. We conducted a prospective, non-comparative, longitudinal study over 12 months assessing the efficacy and tolerability of a cost effective, long-acting injectable antipsychotic (LAI; flupenthixol decanoate) combined with an assertive monitoring program (AMP) among first-episode schizophrenia patients. Efficacy was measured by examining rates of response, remission and relapse, as well as quality of life and social and occupational functioning. Tolerability of our intervention was assessed by measuring extrapyramidal symptoms, and weight and metabolic changes. We also examined the evolution of treatment refractoriness by studying the rates of non-response, and other associated predictor and outcome features. We found high rates of acceptance and adherence to the LAI and AMP. Seventy percent of our patients completed the 12 months of treatment. Treatment response was achieved by 82% of the participants and 60% achieved remission. Although 19% of our patients relapsed, the majority of the relapses were mild and did not require hospitalisation. Patients experienced significant quality of life and social and occupational functioning improvements. We found mild rates of extrapyramidal effects, present in only a third of our cohort. The majority of the extrapyramidal effects were treated with anticholinergics or propranolol. Only 3% of our patients developed transient dyskinesia over the duration of the study. However, our cohort gained considerable weight, with statistically significant increases in BMI (p< .0001) and waist circumference (p=0.0006). Our cohort also experienced significant deleterious changes to their lipid profiles. Of particular concern was the increase in triglycerides (p=0.03) and a significant decrease in high density lipoprotein (p=0.005) leading to a 91% increase in the triglyceride/high density lipoprotein ratio. With regards to emerging treatment refractoriness, 12% of our patients met our pre-defined criteria for non-response. Non-responders were younger and at baseline showed more prominent disorganised symptoms, poorer social and occupational functioning, poorer quality of life for psychological, social and environmental domains, more prominent neurological soft signs (NSS), and lower BMI. At endpoint the non-responders were characterised by higher levels of symptomatology in all domains; poorer functional outcome, poorer quality of life and greater cognitive impairments. They also had more prominent NSS and a lower BMI. The strongest predictors of non-response were prominent baseline NSS and poor early (7 weeks) treatment response. In conclusion, the combination of an LAI with an AMP may be an effective and safe intervention in firstepisode schizophrenia, and may be particularly suitable for resource-constrained settings. The risk of weight gain and metabolic syndrome associated with antipsychotic treatment in first-episode schizophrenia are not restricted to second generation antipsychotics and low-potency first-generation antipsychotics. Ensuring effective treatment for first episode schizophrenia patients is a global problem, and likely to be under-recognised in LMICs. / AFRIKAANSE OPSOMMING: Oor die afgelope twee dekades het toenemend meer longitudinale kliniese studies, wat eerste episode skisofrenie bestudeer, die lig gesien. Die studies het ‘n magdom van waardevolle inligtng oor die kliniese voorkoms, behandeling, verloop en uitkomste van die siekte opgelewer. Die meerderheid van die studies is egter in hoë inkomste ontwikkelde lande gedoen met pasiënte wat duur medikasie gebruik en hoofsaaklik in heterogene steekproewe. Alhoewel dit blyk uit hierdie studies dat daar oor die algemeen vordering gemaak word ten opsigte van die behandeling van pasiënte is daar steeds ‘n gebrek aan voldoende inligting oor die onderwerp veral in minder gegoede, ontwikkelende lande. Die oorhoofse doel van hierdie proefskrif is om binne ‘n hulpbron beperkte konteks die kliniese, biologiese en funksionele aspekte van pasiënt -uitkomste in eerste episode skisofrenie te ondersoek. Ons het ‘n longitudinale studie gedoen waarin ons die effektiwiteit en toleransie van ‘n enkele antipsigotiese medikasie vir 12 maande nagevors het. Die medikasie wat ons ondersoek het, is flupenthixol decanoate en word deur ‘n inspuiting gegee en die medikasie word dan geleidelik deur die liggaam geabsorbeer. As deel van die behandeling het ons pasiënte ook streng gemonitor. Ons het die effektiwiteit van die behandeling gemeet nagelang van hoe pasiënte reageer op die behandeling, hoeveel pasiënte in remissie gaan en terugval, en ook pasiënte se kwaliteit van lewe en hulle sosiale en beroepsfunksionering. Ons het toleransie gemeet nagelang van pasiënte se gewig en metaboliese verandering sowel as die voorkoms van medikasie geïnduseerde newe-effekte. Verder het ons pasiënte wat nie op medikasie gereageer het nie ondersoek sowel as die aspekte wat moontlik hiernee verband hou. Ons het bevind dat die meerderheid van pasiënte hulle medikasie getrou geneem het en ook die streng monitering aanvaar het. Sewentig persent van die pasiënte het hulle 12 maande behandeling voltooi, 82% het op die medikasie gereageer en 60% het in remissie ingegaan. Alhoewel 19% van die pasiënte teruggeval het, was dit nie so ernstig dat ons hulle moes hospitaliseer nie. Pasiënte het beduidende verbetering ten opsigte van hulle kwaliteit van lewe en sosiale en beroepsfunksionering getoon. Ons het slegs ‘n gematigde mate van medikasie geïnduseerde newe-effekte opgemerk en alleenlik by ‘n derde van die kohort. In die meerderheid van gevalle het ons die newe-effekte met anticholinergics of propranolol behandel. Slegs 3% van die pasiënte het gedurende die verloop van 12 maande die kondisie transient dyskinesia ontwikkel. Ongelukkig het ons kohort geweldig baie gewig opgetel en die toename in pasiënte se BMI (p< .0001) en middellyf omtrek (p=0.0006) was statisties beduidend. Ons het ook bevind dat veranderinge in ons kohort se lipied profiele kommerwekkend is veral as in ag geneem word dat die toename in trigliseriede (p = 0,03) en die beduidende afname in die hoë digtheid lipoproteïen (p = 0,005) gelei het tot ‘n 91% verhoging in trigliseriede: hoë digtheid lipoproteïen verhouding.

The continued investigation into the experiences of individuals with schizophrenia who participate in biomedical research trials is necessary in order to understand participants’ perspectives, motivations, attitudes, values, and beliefs. As important stakeholders in the clinical research process, participant feedback is significant and can help shed light on, not only their experiences, but also deepen understandings when it comes to clinical trial participants’ perceptions of informed consent and personal autonomy. Conducting ethical research demands the exploration of these issues and specifically targeting this vulnerable group helped to address a gap in the literature. This study was conducted for InSite Clinical Research and gathered data in the form of in-depth semi-structured interviews and a short survey instrument with 20 low-income adults diagnosed with schizophrenia that participate in clinical research trials. Findings indicate overall positive research experiences, with motivations aligning with previous research when it comes to trial participation including: altruism, personal benefit, access to medications, financial incentives, and psychosocial treatment. Learning about their illness and themselves, autonomy, and debriefing were also particularly important within this group. Unique to this sample were findings of friendship. Trust in the research staff was identified as a major underlying value and shaping factor impacting informed consent decisions. These conclusions have implications for recruitment and informed consent practices at InSite Clinical Research.

Spirituality in the discipline of nursing has gained popularity over the past two decades. National and provincial nursing associations and colleges expect nurses to be educated in providing spiritual health assessments and interventions in order to provide holistic nursing care. There is a paucity of research in the nursing literature on the meaning of spirituality from the perspectives of individuals who experience chronic mental illness, specifically schizophrenia. Spirituality remains an elusive construct, challenging psychiatric nurse educators, researchers and practitioners in the development of nursing curricula to guide psychiatric nursing practice. The focus of this research study was to develop a substantive theory about the experience of spirituality among individuals living with schizophrenia using grounded theory methodology in the tradition of Glaser and Strauss (1967). Forty semi-structured interviews and four focus groups were conducted with 20 participants who self-reported to be diagnosed with schizophrenia. Findings: The substantive theory "spirituality as connection" indicates that spirituality for persons living with schizophrenia involves a dialectical process in which one strives to be connected to one's spiritual self (body-mind-spirit), significant others (family, friends, G o d / Higher Power, health care professionals), community (others living with a mental illness, others who are well, a faith community, the community in which participants lived), and nature, while at the same time experiencing situations and incidents that promote disconnection from these sub-themes. Strategies used by participants to achieve connection included: taking prescribed atypical anti-psychotic medications, maintaining their health and a healthy lifestyle, use of prayer / meditation, caring for self and others, and engaging in creative activities that added meaning to their life experiences. Among the 17 factors contributing to connection, exemplars are: reconnecting with one's spirit through prayer and meditation, attending drop-in centres for persons living with a mental illness, and walking / hiking in nature. Outcomes include feeling peaceful, love, contentment, being accepted and nurtured by others. Among the 14 factors contributing to disconnection, exemplars are: the effect of the illness on relationships with other people, the stigma of being in a psychiatric ward, being unemployed, and taking typical antipsychotic medications. Outcomes include feeling powerlessness, isolation, rejection and alienation.

Thesis (MSc (Genetics))--University of Stellenbosch, 2007. / ENGLISH ABSTRACT: Rapidly expanding knowledge of the human genome allows new insight into the interaction between drugs and DNA. The heterogeneic nature of schizophrenia is known to cause different patients to display dissimilar drug responses, reflecting distinct genetic profiles. Resulting adverse side effects include tardive dyskinesia (TD), a movement disorder associated with the long-term use of antipsychotic drugs. The identification of a pharmacogenetic basis of TD may have significant clinical implications in the treatment of schizophrenia, allowing individualised prescription of antipsychotic drugs and eventual elimination of undesirable side effects. The current study focussed on a number of South African Xhosa schizophrenia patients, some of whom have been diagnosed with TD. The investigation sought to establish whether the underlying mechanism causing the disorder to manifest only in some individuals, might be attributed to differences in DNA sequences, i.e. genomic susceptibility. A number of candidate polymorphisms in the CYP and MDR1 genes were evaluated in three separate analyses. (The same approach was followed in each investigation, and only known polymorphisms were selected.) The incidences of the various variants were compared between TD and non-TD patients. In addition, potential predisposing factors, i.e. tobacco and cannabis smoking and anhedonia, were taken into consideration. These were analysed concurrently with DNA data and TD status.

Spirituality in the discipline of nursing has gained popularity over the past two decades. National and provincial nursing associations and colleges expect nurses to be educated in providing spiritual health assessments and interventions in order to provide holistic nursing care. There is a paucity of research in the nursing literature on the meaning of spirituality from the perspectives of individuals who experience chronic mental illness, specifically schizophrenia. Spirituality remains an elusive construct, challenging psychiatric nurse educators, researchers and practitioners in the development of nursing curricula to guide psychiatric nursing practice. The focus of this research study was to develop a substantive theory about the experience of spirituality among individuals living with schizophrenia using grounded theory methodology in the tradition of Glaser and Strauss (1967). Forty semi-structured interviews and four focus groups were conducted with 20 participants who self-reported to be diagnosed with schizophrenia. Findings: The substantive theory "spirituality as connection" indicates that spirituality for persons living with schizophrenia involves a dialectical process in which one strives to be connected to one's spiritual self (body-mind-spirit), significant others (family, friends, G o d / Higher Power, health care professionals), community (others living with a mental illness, others who are well, a faith community, the community in which participants lived), and nature, while at the same time experiencing situations and incidents that promote disconnection from these sub-themes. Strategies used by participants to achieve connection included: taking prescribed atypical anti-psychotic medications, maintaining their health and a healthy lifestyle, use of prayer / meditation, caring for self and others, and engaging in creative activities that added meaning to their life experiences. Among the 17 factors contributing to connection, exemplars are: reconnecting with one's spirit through prayer and meditation, attending drop-in centres for persons living with a mental illness, and walking / hiking in nature. Outcomes include feeling peaceful, love, contentment, being accepted and nurtured by others. Among the 14 factors contributing to disconnection, exemplars are: the effect of the illness on relationships with other people, the stigma of being in a psychiatric ward, being unemployed, and taking typical antipsychotic medications. Outcomes include feeling powerlessness, isolation, rejection and alienation. / Education, Faculty of / Curriculum and Pedagogy (EDCP), Department of / Graduate

The aim of this thesis is to present current trends in the treatment of schizophrenia and to mediate the experience of people with schizophrenia that are treated during hospitalization. The theoretical part consists of two chapters. The first chapter briefly characterizes schizophrenia and describes how the disease can affect the quality of life. The second chapter deals with the forms of treatment that are currently considered the most appropriate and presents how this group of patients perceives the treatment. The empirical part is based on a qualitative methodology. The study involved 9 people with the schizophrenic disease aged 19-43 years undergoing the stabilization phase of treatment during hospitalization. Data were obtained using semi-structured in-depth interviews and then analyzed by interpretive phenomenological analysis. Based on the analysis, two thematic domains were identified: the respondents' experience with treatment during hospitalization, and the respondents' experience with the interventions offered during hospitalization. The obtained results are described and also discussed with other researches dealing with similar topics. Keywords schizophrenia, treatment, perception of treatment, psychosocial intervention, quality of life

This research situates itself in the study of stigma in mental illness. In particular, the aim is to explore the potential that art making and exhibiting has in reducing stigma for those with a diagnosis of schizophrenia. The research explores one aspect (the exhibition stage) of an "art as therapy" project. The exhibiting of one’s artwork aims to counter limiting "patient" identities by allowing those labelled as psychiatric patients to extend their self-identity to an alternative identity of the "artist". However, this idea only stands strong if the artwork created is not discriminated against as "naïve art" and is accepted or at least considered for acceptance as legitimate nonprofessional artwork. This research explores the ways in which art created by inpatients with a diagnosis of schizophrenia is received by the general art-viewing public at the National Arts Festival in Grahamstown, South Africa. The study uses a discourse analytic framework to analyse the interviews of members of the public who attended the art exhibition of patient artwork. It will examine the ways in which the public construct the artworks and how they position the makers of this art across a continuum, from patient to artist. The results of this thesis have implications for rehabilitation practices for people with a diagnosis of schizophrenia particularly with regard to opportunities to "perform" alternative identities in public spaces.