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The third leading cause of loss of healthy years of life are mental health disorders which disrupt individuals' capacity to participate and function in society. Classifying individuals using the ICF framework can show the breadth and complexity of ICF to portray holistically functioning and well-being. Schizophrenia is a chronic neuropsychiatric disorder that affects approximately 25 million people globally (WHO, 2002). The symptoms of schizophrenia which are defined as negative and positive, are predominantly disturbances or impairments of mental function and associated with difficulty performing general and higher-order cognitive tasks such as attention, insight, judgment, abstract thinking, problem solving, comprehension, and the retention of complex verbal and non-verbal material. While both positive and negative symptoms affect quality of life, negative symptoms are the most debilitating and chronic (Juckel & Morosini, 2008). A multidisciplinary treatment approach for schizophrenia integrates psychopathologic symptoms, patient's characteristics, and the family's experience to offer a comprehensive continuum of care (Dassori, Chiles, & Swenson-Britt, 2000). A significant challenge in achieving this comprehensive approach has been a lack of a universal, workable framework to document and interpret the complex personal and environmental factors in order to understand a client's function abilities and disabilities. Ewert and colleagues (2004) wrote that the ICF model allows mental health care practitioners "to describe the whole health experience including environmental factors (p.22).
In the following section, we present three hypothetical profiles of young males with schizophrenia and organize them using the ICF framework.
The following case studies are descriptions of three 24-year-old males with a diagnosis of disorganized type schizophrenia. At 19 years old, each was admitted to a psychiatric hospital in an acute psychotic state with positive symptoms including extremely disorganized thinking, incoherent speech, and delusions of reference and broadcasting. They have each intermittently discontinued their medication, and been readmitted to the hospital with acute psychosis. The case studies are not a commentary on social, justice, or healthcare systems in the US, Canada or India.
Jason lives in Boston, Mass., graduated from high school through an alternative program and he is unemployed.
In the past, Jason worked sporadically on construction sites, but he has not been able to keep a job. Medicaid covers Jason's healthcare, but his contact with his healthcare providers is sporadic.
After his first admission to hospital, Dave received services from the provincial early intervention for psychosis (EIP) program, which focuses on the transitional and health needs of youth and young adults with early psychosis. He is financially and emotionally dependent on his retired parents, and mother organizes his daily routines. An extended family friend organized his arranged marriage, and the engagement was celebrated in a public ceremony. Hypothetically, these three young men's schizophrenia has followed the same course, but their life experiences of navigating life with the disorder have been distinctly different.
Since cognitive impairment significantly affects activities and participation for persons with disorganized schizophrenia, we choose to focus on the mental functions domain of the ICF body function and structure components. Due to an inability to interpret social cues and recognize emotional content in social interactions, disrupted development of interpersonal skills that are involved in forming and maintaining social relationships and difficulty with conversing due to poverty of thought and disorganized thinking. Openness and Optimism – emotionally inexpressive, lacks mental agility so new situations can cause stress. Confidence and self-concept, which are undermined by lack of success in age related tasks such as higher education and the discrepancy between ability and performance. Severe impairment- Negative symptom of schizophrenia include low energy levels, apathy, difficulty imitating activities, intrinsic motivation to engage in activities low.
Reduced attention in all areas, difficulty concentrating on tasks, easily distracted by external and internal stimuli.
Higher level functions leads to difficulties in discriminating between and evaluating different options, identifying, analyzing and integrating incongruent or conflicting information into solution, all of which affects problem-solving skills, making choice and organizing self.
Poor insight is associated with poor functional outcomes for individuals with schizophrenia.
Confusion due to poor ability to interpret communication (non-verbal and social cues) can cause distress or contribute to social isolation. Most neuro-pathological studies consistently report findings of abnormalities of the limbic forebrain, (especially the amygdala and the hippocampus), and the basal ganglia (including the caudate, nucleus accumbens, and olfactory tubercle).
Studies report evidence of enlarged ventricles (more common in males) and enlarged cortical sulci in large number of people with schizophrenia at the onset of illness. There is a hypothesis that the dopamine systems of the brain are over active in schizophrenia. Performance fluctuates due to negative symptoms such as motivation to take care of his personal environment. Poor self-regulation of emotions such as anger and aggression cause him to manage conflict situation poorly. With support system and rehabilitative services such as psycho-education and assertiveness community training Dave has developed adaptive skills to handle some stressor.
Due to cognitive difficulties, the tasks and activities demands of complex meals require significant supervision. Family relationship strained, Jason is combative when psychotic and has a history of family aggression. Family supportive, but behaviors associated with illness have caused stress within family relationships. Is motivated to complete his technical diploma, but currently taken time off due to his relapse. Supportive employment and training provided through social services (early intervention program).
Supportive employment with family However, health status and lack of education and provocation skills prevent him from succeeding in open employment. Lack of discretionary income combined with mental functions impairment such as avolition limits socializing and leisure pursuits. Environmental factors are quantified using a positive and negative scale to indicate the extent to which environment acts as a facilitator or barrier. Group home and housing available and likely to be accessed during the discharge or transitional care planning process. Access to early intervention program and early intervention reduces hopelessness and stigmatization.
A recent article featured in The New York Times underscored how diagnostic profiling of mental illness is influenced by the dominant forces of western medicine, yet cross-cultural beliefs, attitudes, and support systems attributed to mental illnesses vary vastly across the globe (Watters, 2010). Importantly, the bi--directionality of the relationships among the components of the ICF (Figure 2) guides health care practitioners to examine how a person's function in one domain influences other domains within the same component or other components such as domains within activity and participation (Stucki et al., 2002). One, we identify the domains of the activity and participation component that are affected by Jason, Dave, and Deepak's mental structure and function impairments and determine the extent to which these impairments explain their functioning and disabilities. Two, using the ICF, the health care practitioner can explain Jason, Deepak, and Dave dysfunction in performance and the discrepancy between performance and capacity in relation to personal and environmental factors.
Specifically, an examination of Deepak's environmental support and relationships domain illustrates how the ICF framework can assist a practitioner to explain a person's performance beyond the body structure and function impairments.
The absence of social welfare benefits in India means that Deepak cannot live without his family's support and if it was not available, he might reside in a state funded institution although he has the capacity to live in the community. We see the interaction of the ICF components domains coalesces in Deepak his mother's need to 'care' for her him by structuring his routines. Third, when the ICF is considered as an integrated whole, it can be used to determine therapy needs, rehabilitation goals, the environmental facilitators that support function, and measure change to assess the effectiveness of pharmacological and therapy interventions.
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Many people suffering toe nail fungus won’t go to the beach or pool because of their feet. Mental health disorders also diminish their quality of life, economic status, and well-being (World Health Organization, 2002). The term disability is widely misperceived as a reflection of an illness or a person's medical diagnosis, whereas in reality human beings accomplish their life roles through the interaction of the body's anatomical structures and physiological and psychological function, the environment, personal factors and their participation in activities. Functioning is defined conceptually as the integrity of body functions and body structures to perform tasks (activity) in life situations (participation). These are the psycho-physiological functions that encompass thought, intellect, information processing, emotions, and behaviors, all of which are critical to daily functioning. This article illustrates the applicability of the ICF framework using the Mental Function domain to explicate the roles of impairment of a body function and structures associated with a mental health disorder, and demonstrate how personal and environmental factors play an integral role in a person's functioning and disability, which is observed in person's activity and participation components.


There are five distinctive sub-types that share some similar symptoms and to some extent, all individuals with schizophrenia, have poor psychosocial adjustment, acute psychotic episodes, and functional and occupational disabilities (Rossler, Salize, van Os, Riecher-Rossler, 2005). Positive symptoms are associated mostly with acute psychoses and are the symptoms most often portrayed in the media as characteristic of schizophrenia. The difficulties in recognizing and expressing emotions non-verbally, comprehending and interpreting facial expressions and using nuanced tone and pace to express emotions when speaking are correlated significantly with decreased occupational functioning (Matthew & Barch, 2010). Furthermore, the overarching principles of the ICF are congruent with the philosophy and approaches of psychiatric rehabilitation models that focus on achieving functioning through overcoming disabling impairments at the activity and participation level or through adaptation of environments to support functioning rather than symptom reduction (Reed et al., 2009). The figure below illustrates the key domains within the ICF components that are critical to organizing information pertinent to schizophrenia. These profiles have been developed based on review of global literature on schizophrenia including cultural, socio-economic, and health care systems pertinent to the respective regions.
They each live in a different part of the world (US, Canada, and India), are from middle-class families, and share a similar clinical history. For example, they described that they believed random events had special significance, such as the TV news having special messages exclusively for them, and that others could hear their thoughts.
These episodes of psychosis have been associated with further deterioration in functioning.
They are composite individuals with predominant patterns and experiences of individuals with schizophrenia as reported in research and survivor narrative. Instead, the cross-cultural perspective illustrates the universality and utility of the ICF. During a recent incident, the police responded to a disturbance at his parent's home where they found him incoherent, resulting in an assault of one of the officers. At present, he receives Supplementary Security Income of approximately $650.00 per month, and his brother and parents sometimes help him financially. When he becomes psychotic or his positive symptoms increase, he typically goes to an emergency or walk-in health care centre. He completed high school, but his illness has interfered with him successfully pursuing tertiary education.
Through the EIP, he continues to receive services such as case management, supported education and occupational therapy, outpatient psychiatric follow-up, and the opportunity to attend a peer support group. He is attempting to continue with his education by studying part-time through a community based non-profit academic upgrading program in order to transition to college. His parents continue to be involved in his life, but at times, his relationship with them is strained. He completed his high school and began a computer science program at the Indian Institute of Technology.
He attends a part-time Diploma program at a Technical College for computer studies and his brother pays his tuition. However, the bride's family called off the wedding after two-years because of Deepak's illness and family history of mental illness.
The ICF framework can provide an explanatory model that documents and interprets their lives with schizophrenia in order to understand their disabilities and plan individualized interventions.
We assume all three young men have the same psychopathology and mental function involvement.
It is assumed that they are stabilized with medication and are primarily presenting with chronic negative symptoms of schizophrenia.
Only selected Activities, Participation, and Environmental and Personal Factors are included to illustrate how the ICF can identify and explain function and disabilities.
Mild impairment in judgment and insight can result in refusal of medication, awareness, and understanding of one's behavior and its affect on outcomes and relationships with others. Most such studies have been consistent in finding loss of temporal lobe volume and loss of temporal lobe gray matter volume. This hypothesis is related to effectiveness of medications that block dopamine brain receptors and reduce psychotic symptoms. The barrier scale range is -0 (No barrier) to -4 (Complete barrier) and scale for the environment as facilitator has a range from + 1 ( No facilitator) to +4 Complete facilitator). Therefore, viewing mental illness solely based on an individual's psychiatric profile is shortsighted and a pitfall that mental health professionals must avoid. For example, Jason's mental functions, such as his ability to self-regulate his emotions and judge appropriate emotions for situations, affect his performance and capacity in activities and in his participation. The constructs of capacity and performance theoretically are well established within the ICF framework. In developing countries such as India, families have predominantly taken the primary lead in the care of individuals with mental illness (Murthy, 2003), and the implications of this cultural phenomenon has been researched from both positive and negative perspectives. Other barriers in this context might be the stigmatization of mental illness within his social environment.
This facilitates dependency and negates societal expectations for him to function as a 24-year-old man.
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In recognition of the overwhelming cost and suffering associated with mental illness that reaches beyond psychopathology, there has been a shift to measuring the outcomes of mental health interventions in terms of quality of psychosocial functioning and life, rather than the remission of symptoms (Juckel et al., 2008b). The World Health Organization – ICF framework represents these components and domains and their respective interactions to determine an individual's function and disability. Disability refers to a negative outcome of a health condition or disorder that compromises an individual's integrity to participate in life situations (WHO, 2001a). Likewise, activity and participation are the product of mental functions, while interaction of mental functions and contextual factors, support and shape, the relationships, attitudes, and access to service systems that influence the participation of people with mental illness.
However, the subtypes also vary in the clinical presentation, treatment responses, course, and prognosis (APA, 2000). The goal is to demonstrate how the framework assists a healthcare practitioner to interpret performance, personal and environment factors, and the interaction between the domains to represent the uniqueness of each person. As is the pattern with disorganized schizophrenia, they have negative symptoms that are debilitating and significantly affect psychosocial and occupational functioning. Since he cannot afford to live independently, and his identified place of residence is his parents' home.
Therefore, his care lacks continuity, such as a case manager and psychiatrist who monitors his medication and care. His work history is erratic and he has worked mostly in manual warehouse jobs packing boxes and loading trucks as well as a few cleaning maintenance contracts.
Dave is reluctant to accept his diagnosis and due to his lack of insight, he periodically stops his medication and discontinues his EIP services.
His attendance is inconsistent, is impatient with his Learning Coach, and his progress is limited. His family attends a family support–psycho-education group run by the schizophrenia fellowship, a nonprofit consumer organization. During his first year, Deepak had his second psychotic episode, which he attributes to the intensity of his studies, and stress of his parents' overly high expectations.
After being stabilized with medication, Deepak returned home and received outpatient services at a local hospital. Deepak relapsed soon after, and was admitted to the Hospital supported by the National Mental Health Program. The framework conceptually explains their performance relative to their activities and participation by identifying the domains affected and recognizing the interaction of environmental and personal factors and body structure and functions that contribute to their disabilities or support their functioning. We then show using the ICF, the differences in functioning and the respective disabilities of each young man can be explained by examining their environmental (socio-economic and cultural) and personal factors. The intention is not to provide an exhaustive list of the domains that might be affected in a person with disorganized schizophrenia. The ICF framework is helpful in that it enables the health care professional to conceptualize the disability associated with schizophrenia on three levels: the body, the person's actions, and the context.
His difficulties with executive cognitive functions affect his ability to make sound judgments, problem-solve, and consider consequences, all of which contribute to his limited functioning. However the delineation in practice may be debatable owing to the subjectivity between the client and the practitioner. Deepak's cultural family centered values and middle class status of his parents and brother facilitates his functioning by providing housing and financial support. His family is reluctant to have his mental illness known which leads them limit his social interactions to family gatherings and therefore his opportunities to develop social skills and form relationships outside the family are limited. Her actions might be interpreted as a response to her experiences with her brother and a sense of culpability for his disorder because mental illness exists in her family.
Hence, it is through the structure of the ICF that a health care practitioner can fully comprehend Deepak's disabilities and functioning.
Even though people with schizophrenia seek to reduce their positive symptoms, the essence of their mental health is their participation in everyday activities, social relationships, employment, and having safe secure housing (Mueser, 2006). The international classification of functioning, disability, and health and its application to cognitive disorders. The role of the "International classification of functioning, disability and health, ICF" in the description and classification of mental disorders. Factors associated with prodromal progression of schizophrenia that influence the course of the illness.
The assessment of disability in patients with psychotic disorders: An application of the ICIDH-2. Identification of the most common patient problems in patients with chronic conditions using the ICF checklist.
The new approach: psychosocial functioning as a necessary outcome criterion for therapeutic success in schizophrenia. Validation of the personal and social performance (PSP) scale in a German sample of acutely ill patients with schizophrenia.
Work status and chronic low back pain: Exploring the International Classification of Functioning, Disability, and Health. Current issues in schizophrenia: Overview of patient acceptability, functioning capacity, and quality of life. The Illness Management and Recovery Program: Rationale, development, and preliminary findings. Family interventions and empowerment as an approach to enhance mental health resources in developing countries.
How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Implementing the ICF in a psychiatric rehabilitation setting for people with serious mental illness in the Lombardy region of Italy.


Mental health in the workplace: Using the ICF to model the prospective associations between symptoms, activities, participation and environmental factors. Schizophrenic patients' quality of life – association with coping, locus of control, subjective well-being, satisfaction and patient-judged caregiver burden. Measurement of problems in activities and participation in patients with anxiety, depression, and schizophrenia using the ICF checklist. The international classification of functioning, disability, and health: A new tool for understanding disability and health. Functioning description according to the ICF model in chronic back pain: Disablement appears even more complex with deceasing symptom specificity.
The ingredients fight nail fungus into your bloodstream quickly for a truly fast, effective, and side effect free symptom relief. This article uses three case studies of individuals with mental health disorders to demonstrate the applicability of the International Classification of Functioning, Disability, and Health (ICF) as a conceptual framework and a classification system. Using a bio-psychosocial perspective with a uniform framework and language the ICF can be used to describe health and health-related states concerning human functioning and the restrictions in activities and participation due to impairments in body structures and functions. In conceptualizing functioning and disability in this way, the ICF construes the relationships among the components of the body, environment, and personal domains as bidirectional (Stucki, Ewert, & Cieza, 2002). For example, the predominant characteristics that distinguish paranoid-type schizophrenia are delusions that are persistent false beliefs about persecution or mistreatment, and auditory hallucinations. The effects of negative symptoms are additionally debilitating because there is little evidence of effective treatment for these symptoms (Erhart, Marder, & Carpenter, 2006).
Each diagnosed with schizophrenia of the disorganized type was prescribed a new generation anti-psychotic medication called Respirodone and discharged from the hospital into the care of their parents (APA, 2000). A source of information for Jason's profile was the National Alliance on Mental Illness 2009 national survey.
It is likely that he will go to prison for the assault unless he is referred to the mental health court where his condition will be taken into consideration during sentencing. His lack of insight, recurrent acute episodes, substance abuse, and marginal functioning strains his family relationships. This lack of oversight contributes to poor adherence to medication and poor follow up with outpatient and rehabilitation services. He is reluctant to move on to vocational rehabilitation services since he believes he can complete his community based academic upgrading program and obtain his Assistant Cook Extended Training (ACET) George Brown College certificate. He still has some contact with his childhood friends in the neighborhood, but mostly his parents initiate this through close family friends. There is a plan for him to be discharged into the care of his parents, unless they decide to arrange private rehabilitation services.
This multi-faceted understanding is essential for determining and monitoring effective interventions. The assignment of the ICF qualifiers is used to document the severities of impairments in body functions and structures and difficulties with activities and participations. This includes his lack of adherence to a medication regime, and his inability to maintain employment or housing.
The use of an ICF Assessment Sheet, such as the one proposed by Rauch, Cieza and Stucki (2008), allows a practitioner to clearly discern the patient's perspective and illustrate the distinctions between capacity and performance in both activities and participation. There is also his mother's relationship with him, which reflects the emotional over-involvement seen in families with a member who has schizophrenia (Marom, Munitz, Jones, Weizman, & Hermesh, 2005).
Furthermore, his family's sensibility toward mental illness is heighted society's marginalization of people with mental illness. Then they are in a position to identify the components and domains which the non-pharmacological interventions need to target in order to facilitate functioning using psychiatric rehabilitative approaches that addresses the discrepancy between performance and capacity. The ICF is a tool that enables the practitioner to reach beyond the negative focus of impairments in body functions and structures to evaluate and interpret the complexity and chaos of living with a mental illness, irrespective of setting or culture in order to offer evidence based care that will achieve mental health, reduce disabilities, and enhance function. The use of ICF enables practitioners to evaluate, and interpret chronic mental health disorders within different populations and at varying levels of disabilities and function (Ewert et al., 2004).
The ICF classification system differs to diagnostic systems, such as the International Classification of Diseases (ICD-10) and the Diagnostic and Statistical Manual for the Classification of Mental Disorders (DSM-IV TR).
To elucidate this dynamic relationship, the ICF employs two constructs: capacity and performance. This auditory perceptual disturbance includes voices people hear that tend to be hypercritical and are negative comments about the person or evoke suspicion of others. The ICF framework offers a middle ground that recognizes the bio-psychosocial dimensions of disability.
All the three young males in the case studies report that two to three years prior to their first psychotic episode, their performance at school began to deteriorate.
Jason's parents attend the family-to-family classes run by NAMI (a consumer advocacy organization), but Jason refuses to be involved with the group.
Upon the third and most recent admission to hospital, he has been identified as high risk and was registered with an assertive community outreach program. The assignment of qualifiers to code the extent of the problem is quantified on the percentage limitation within an ICF component (WHO, 2001). This is consistent with comprehensive models of treatment, namely the Assertive Community Treatment, the Psychiatric Rehabilitation Model, and the Illness Management and Recovery program, all of which aim to reduce the discrepancy between capacity and performance. His behaviors have in the past compromised relationships with his family, and periodically resulted in homelessness. In other words, in looking at the function and disability profile of the three case studies, Jason, Deepak, and Dave may conceptually have the similar capacity to execute activities in a standard environment. He has access to mental health services in a country where there are about 4000 psychiatrists for one billion people (WHO 2001b, Rangawamy & Sujit, 2009), and a supportive work environment within his extended family network. Furthermore, it directs the health care practitioners' attention to the functioning ability of a client measured by psychosocial and occupational outcomes.
The ICF classification system is applied to mental functions of the three individuals with schizophrenia who live in three different countries. Capacity is a person's ability to execute tasks in a standard environment such as the therapy setting. In paranoid schizophrenia specific mental functions such as executive thinking and expression of emotions are relatively unaffected. It organizes individual data and the findings of diverse measures to capture the multidimensionality of a person with mental illness.
They experienced difficulty concentrating, initiating activities, and frequently lost track of time because of daydreaming. Periodically, Jason lives on the street, uses homeless shelters, and has contact with a program for street youth run by a non-profit organization. He only attends immediate family gatherings, since his parents are ambivalent about his circumstances and illness and wish to keep his problems private. This is problematic since due to his poor mental function he lacks awareness to evaluate the risks of homelessness poses to his health and safety.
The differences in their actual performance is understood when the contextual aspects and personal perspectives are taken into account. These interpretations of the environmental factors further elucidated when they are viewed in relation to Deepak's personal factors and mental function impairments. It shifts the emphasis from diagnosis and symptom reduction to comprehensive interventions that address the pervasive disability. The universality of the ICF framework captures the uniqueness in functioning and disability of these individuals because each is interpreted in the context of his environmental and personal factors such as dispositions, experiences, healthcare systems, culture, economic status, and availability of resources rather, than their psychopathology and mental function impairments associated with schizophrenia.
Whereas, performance is the actual performance of a person executing tasks in his or her natural environment. In contrast, disorganized-type schizophrenia is characterized by disorganized thinking that is observed in a person's incoherent speech or impoverished thoughts and in his or her difficulty performing everyday tasks due to chronically impaired mental functions. It also provides a common language for describing the functioning of individuals with mental health disorders across various settings (Tenorio- Martinez, del Carmen Lara-Muñoz, Medina-Mora 2009). They commented that it was increasingly difficult to be around people and they participated less in their activities with friends. Ongoing research is needed to develop assessment procedures to standardize the use of the ICF qualifiers (WHO, 2001).
He does not comprehend the increased likelihood of relapse if he does not continue his medication, with the possibility of further cognitive and functional disabilities with each subsequent psychotic episode. Their participation (performance) is a product of their current environment, and personal factors, which have also been shaped by their respective environments.
However, an alternate analysis of his environmental factors reveals that some aspects of this supportive environment can be interpreted to be a barrier to him functioning at his capacity. His passivity, difficulty in initiating activities, his low energy and motivation, and poor ability to self-regulate his stress, all accentuate dependency. An analysis of a person's ICF profile assists practitioners to deduce in which domains interventions should focus. Two individuals with the same diagnosis and severity of disorder might have the same capacity to perform tasks when performing in a controlled environment, but their performance might differ significantly in their natural environment due to their personal factors and their environment's characteristics. Difficulty understanding and expressing emotions is common and this significantly disrupts social participation.
The ICF model also differentiates between the disability arising from mental health disorders and those that are due to environmental factors, including society's discrimination of persons with mental disorders (Kennedy 2006).
For the purpose of this paper, the intention of the assignment of qualifiers in this paper is not to rank the health or health related state of the three individuals, but rather, to highlight the differences in their functioning and exemplified qualifier system of the ICF components. For example, the environment affords opportunities and experiences that may have enabled them to learn social skills or develop a repertoire of healthy adaptive behavior.
There is a lack of expectations that facilitate him to participate in age related activities and be self-determining for his optimal level of functioning. Using Deepak as an exemplar, we note here that the component of personal factors, although not classified in the ICF, vitally influences the domains within the other components. For example, whether skill development is required for improvement in performance or whether changes to a person's environment could reduce the effect of impairment and enhance function or whether both strategies are required. Therefore the use of an ICF based goal-driven tool is essential for a practitioner to ascertain the effect of symptoms, personal factors, and environment, and the interaction of all three to understand Jason, Deepak and Dave's limited or disrupted performance. In this case, Deepak's temperament and personality (b1263), a domain within global mental function, and ability to deal with stress (d240), a domain within activity and participation, is significantly influenced by his family.
For example, a practitioner could use an ICF profile of Dave to determine whether he has the potential (structure and function domains) to acquire the skills to manage his medication, if yes, an evaluation would determine his activity and participation capacity for this task and assess his current performance. For example, to explain Deepak's performance, we examine environmental and personal factors, and activity and participation, impairments in structure and functions, and the interactions of these component's domains. A practitioner, while planning intervention, needs to take into account the interaction of personal factors with all the other components of the ICF. His impaired mental function, his diminished higher-level thinking, low energy, and poor thought and language function and his limited skills to cope with stressor is a personal factor.
In contrast, the lack of mental healthcare services is a significant barrier to Jason and his capacity to maintaining a medication regime and mental stability.
In viewing, the ICF profile of Dave, a practitioner would readily identify that his personal factors play a significant role in his relapses and his poor performance in his activities and participation.
Based on this, he or she might suggest psycho-educational group treatment approach, which addresses understanding and self-management of schizophrenia as an intervention such as the Assertive Community Outreach program.



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