CLINICAL HANDBOOK OF SCHIZOPHRENIA

208 IV. PSYCHOSOCIAL TREATMENTdisinhibition; (3) a combination of these. Apathy is characterized by poverty of speechand movement, and the inability to initiate and follow through on behavioral sequences.Someone with apathetic behavior is likely to have difficulty initiating each step in amultistep task. Obviously, for such a person, a task with many steps is unlikely to be initiatedor, if initiated, will not likely be completed. Disinhibition is characterized bydistractibility and behavior that is highly driven by cues in the environment. An individualwith disinhibited behavior may start a task but become easily distracted and not completeit. A person with mixed behavior will have trouble both in initiating tasks and innot becoming distracted during the performance of tasks once they have been initiated.Prior to participating in CAT, patients receive a comprehensive assessment of cognitivefunctioning, including tests of psychomotor speed, attention, memory, and problemsolving. Behavior is rated with the Frontal Systems Behavior Scale (Grace & Malloy,2002), an instrument that assesses apathy and disinhibition as observed during the performanceof everyday tasks. In addition, the person’s ability to perform basic and higherlevel daily activities is measured with a variety of performance-based assessments and behavioralobservation. Finally, there is an assessment of the patient’s environment, whichexamines whether the individual has items that are necessary to perform everyday tasks(soap, toothpaste, bug spray), where those items are placed (e.g., a toothbrush in a bottomdresser drawer is not likely to be used), and whether there are any safety hazards thatneed immediate attention (exposed electrical wires). Moreover, the assessment examinesthe availability of public transportation and whether supportive family members orfriends are available for assistance.Interventions in CAT are based on two dimensions: (1) level of impairment in executivefunctions (as determined by scores on a set of cognitive tests) and (2) whether theovert behavior of the individual is characterized more by apathy, disinhibition, or a combinationof these styles. The poorer a person’s executive functioning, the greater the needfor high levels of structure and more obviously placed environmental cues. Those withsomewhat better executive functioning need less structure and more subtle cues. Behaviorscharacterized by apathy can be altered by providing prompts and cues to initiate eachstep in a sequenced task. Examples of environmental alterations for apathetic behaviorinclude utilizing checklists for tasks that involve complex behavioral sequencing, placingsigns and equipment for daily activities directly in front of the patient (e.g., placing toothbrushand toothpaste in a basket directly attached to bathroom mirror), and utilizinglabels and electronic devices (tape recorders) to cue and sequence behavior. Individualswith disinhibited behavior respond well to the removal of distracting stimuli and to redirection.For disinhibited behavior, supplies are organized to minimize inappropriate use.For example, outfits with one shirt, one pair of pants, and so forth, are placed in individualboxes in the closet to prevent the patient from putting on multiple layers of clothing.Differently colored bins for sorting laundry can prevent patients from mixing clean andsoiled clothing. Individuals with mixed behavior (apathy and disinhibition) are offered acombination of these strategies.Assessment results yield one of six CAT classifications for which interventions can betargeted. CAT classifications are presented in Table 21.1, along with problems that maybe observed and possible interventions for impairments in dressing. Figure 21.1 illustratesthree approaches for problems in dressing, one for each behavioral type, for individualswith poorer executive functioning.Once an individual’s CAT classification has been determined, strategies for specificfunctional problems (dental hygiene, laundry, leisure activity) are chosen from a series oftables. These basic strategies are then altered for strengths or weaknesses (relative toother outpatients with schizophrenia) in the areas of attention, memory, and fine motor