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Physical activity as an adjunct treatment for schizophrenia and related psychotic disorders: A systematic.. Holowachuk, Brad 2008

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Physical activity as an adjunct treatment for schizophrenia and related psychotic disorders: A systematic review Brad Holowachuk Erin Hvidston Andrea Mitchell Rachel Richards Melissa Richmond Supervisor: Dr. Darlene Redenbach Outline • Introduction • Methods • Results & Discussion • Conclusion Introduction • Schizophrenia: − severe psychiatric illness −median incidence 15.2 per 100, 000; male>female (McGrath et al., 2004) − onset adolescence (Andreasen, 1995) − features: • cognitive, sensori-perceptual, motor, and emotional disturbances; reality distortion Psychiatric Profile of Schizophrenia • Positive and negative symptoms (Andreasen, 1995) • Depression and anxiety also prevalent (Goodwin et al., 2003; Siris et al., 2001) • Variability in clinical presentation(Andreasen, 1995) • Decline in psychosocial, behavioural, and occupational functioning Positive Negative delusions hallucinations thought disorganization catatonia affective flattening loss of pleasure/interest de-motivation social withdrawal psychomotor dysfunction Treatment of Schizophrenia • primarily anti-psychotic medication (Brenner et al., 1992) • side-effects: − sedation − weight-gain/obesity − metabolic and cardiovascular disorders − motor disturbances (Freedman, 2003; Schultz et al., 2007) • 5 - 25% respond poorly requiring alternate therapies (Brenner et al., 1992; Patterson and Leeuwenkamp, 2008) Complications of Treatment 1) Comorbidity • Medication and lifestyle factors 2) Psychiatric Relapse • poor therapeutic response (Brenner et al., 1992) • factors influencing non-adherence (Robinson et al., 2002; Stanniland and Taylor, 2000; Valenstein et al., 2004) • substance abuse (Addington and Addington, 1997; Cantor- Graae et al., 2001;Hambrecht and Hafner, 1996; Schultz et al., 2007) • stress (Gispen-de Wied, 2000; Schultz et al., 2007) Social and Economic Sequelae • Comorbidity and relapses experienced by patients lead to: ↓ patient participation in society ↑ economical and social costs for families and the health care system (Lauber et al., 2005; Wong and Van Tol, 2003) • Need to identify adjunct treatments to mitigate such complications Exercise as Adjunct Treatment • reduces stress levels in healthy adults (Wijndaele et al., 2007) • helps reduce symptoms of clinical depression     (Babyak et al., 2000; Lawlor and Hopker, 2001) −effect equivalent to cognitive therapy −decreases relapse rates • helps reduce symptoms of clinical anxiety (Petruzzello et al., 1991) • reduces medical comorbidity in persons with schizophrenia (Skinar et al., 2005; Faulkner et al., 2003) Exercise as Adjunct Treatment • Insufficient evidence concerning the effects of exercise on psychiatric and psychological outcomes in schizophrenia Exercise as Adjunct Treatment •Systematic reviews on this topic: −Contain only physiological outcomes (Faulkner et al., 2003) −Contain few and methodologically weak studies (Bradshaw et al., 2005) −Embed exercise within a broader category of treatments (Crawford-Walker et al., 2005) −Current protocol includes only RCTs (Campbell and Foxcroft, 2003); a significant limitation since majority of research is quasi-experimental (Faulkner & Biddle, 1999) Overall Impression • Need to determine whether exercise can influence psychiatric and psychological outcomes in schizophrenia as demonstrated for other clinical populations (Babyak et al., 2000; Lawlor and Hopker, 2001; Petruzzello et al., 1991) • Evidence to support exercise as an adjunct treatment may produce: − more comprehensive therapy − better adherence Æ reducing relapse − ↑ therapeutic effectiveness Systematic Review Statement • To systematically assess the effects of physical activity on psychological and psychiatric outcomes in persons with schizophrenia and related psychotic disorders Definitions and Format • Physical activity is inclusive of exercise, and is defined as, “bodily movement that is produced by the contraction of skeletal muscle and that substantially increases energy expenditure” (Whaley, 2006) • This review was conducted in accordance with the National Health Service Centre for Reviews and Dissemination (2001) CRD Report 4. Methods Methods • Eligibility Criteria • Search Strategy • Study Selection • Quality Assessment • Data Extraction • Data Synthesis Eligibility Criteria • Subject Characteristics – Persons with schizophrenia or related psychotic disorders (schizoaffective, schizophreniform, and bipolar disorder with psychotic features) – Subjects with concurrent brain pathology, major depression and psychoses were excluded Eligibility Criteria • Intervention − Physical activity in isolation or concurrent with other interventions (e.g. cognitive therapy) −All other regular maintenance treatment included (e.g. medications) Eligibility Criteria • Outcomes – Psychiatric and psychological outcome measures – Studies reporting only physical/physiological outcomes were excluded –Outcome measures with no reliability/validity were excluded Eligibility Criteria • Study characteristics − Peer reviewed, quantitative studies − 1960 to present day − Published and grey literature − French and English and foreign language abstracts with sufficient data Search Strategy • Four fold strategy − Electronic database search − Hand search − Reference search − Author contact Study Selection • Independently conducted by two reviewers • Reviewers were blinded to authors’ names • Level of agreement was recorded • Disagreements mediated by a third reviewer • Inter-rater agreement at full text stage was ‘excellent’ (Landis and Koch, 1977) − κ =0.93 Quality Assessment • Two measures used to assess methodological quality − Bradshaw et al. (2005) adaptation − Jadad et al. (1996) • Pilot tested by three reviewers on literature concerning exercise and depression • QA of included studies conducted by two independent reviewers • Protocol for agreement/disagreement followed as described in study selection Data Extraction • Forms created and pilot tested by two reviewers • Data extracted independently then compared and compiled Data Synthesis • Descriptive synthesis planned due to expected heterogeneity of included studies Description of Studies Description of Studies • Subjects • Study Design • Interventions • Outcome Measures • Other Description of Studies • Description of studies − 271 abstracts consistent with eligibility criteria − 67 full text articles − 59 available in French or English (5 in foreign languages, 3 unavailable in print) − 15 met eligibility criteria for review Description of Studies • Subjects – 400 subjects • 209 males • 113 females • 78 unknown –Mean age of 35.7 years (2 studies did not provide age data) – 9 of 15 studies used standardized diagnostic criteria – 9 studies in USA; 1 in each of Canada, Scotland, Israel, India and Spain Description of Studies • Study Design – 4 RCTs, 9 quasi experimental designs, 1 case series, 1 case study – 4 completed in an inpatient hospital setting, 8 in an outpatient setting, 1 took place in the community, 1 occurred in a mixed inpatient/outpatient setting – Duration of studies ranged from 4 weeks to 10 years with follow up phases as long as 2 years Description of Interventions • RCTs (n=4) − Treadmill walking vs. non-exercise (Beebe et al., 2005) − Physical exercise vs. relaxation (Canarvis, 1996) − Yoga therapy vs. physical exercise therapy (Duraiswamy et al., 2007) −Holistic treatment vs. social skills treatment (Lukoff et al., 2007) Description of Interventions • Quasi experimental studies (n=9) − Walking vs. treatment as usual (Ball et al., 2001) − Recreational games and skills (Bergman et al., 1993) − Fitness training (Centorrino et al., 2006) − Aerobic exercise (Fuller, 1990; Jorgensen, 1986) − Outdoor adventure vs. treatment as usual (Kelley et al., 1997) − Running vs. waiting to run, random activities, meditation, new meditation (Levin, 1983) − Active vs. passive therapeutic recreation (Morris et al., 1999) − Exercise vs. standard care (Torres-Carbajo et al., 2005) Description of Interventions • Case series (n=1) −Aerobic exercise on a stationary bike (Pelham and Campagna, 1991) • Case study (n=1) −Weight training (Adams, 1995) Description of Studies • Outcome Measures − 36 outcome measures identified • Psychiatric (anxiety, depression, clinical severity, psychomotor symptoms, relapse rate) • Psychological (behavioural scales, self concept, self efficacy, self image, quality of life, and functioning) −Outcome measures divided into 12 categories based on criteria assessed Description of Studies • Other −Attrition −Adverse events −Health screen −Compensation Results • Methodological Quality • Bradshaw et al. (2005): • mean = 56% (range of 35-82%) • n=4 < 50%, n=9 50-75%, n=2 > 75% • Items with low scores presented in discussion • ‘substantial’ agreement (κ=0.71) (Landis and Koch, 1977) • Jadad et al. (1996): • mean= 0.80  (range of  0 - 2) • lack of double blinding and random assignment • attrition underreported • ‘substantial’ agreement (κ =0.73) (Landis and Koch, 1977) Grading of Evidence • Cochrane Musculoskeletal Group (2006) method of grading − Silver • Small sample sizes • Limited blinding of assessors • No blinding of subjects to intervention Results & Discussion Results & Discussion Outline • 1 – Results & Discussion of Outcomes • 2 – Limitations • 3 – Recommendations Results of Outcomes • Anxiety and Depression • Behaviour • Global Psychiatric Symptom Severity • Locus of Control • Pain • Psychomotor • Quality of Life and Functioning • Relapse Rate • Self Concept and Self Efficacy • Self Image • Symptoms of Schizophrenia • Trust and Cooperation Outcome: Anxiety & Depression • 7 studies • RCTs - Anxiety −Holistic health vs. social skills training found no significant differences between groups (Lukoff et al., 1986) − Physical activity vs. relaxation found no between group differences but significant within group reductions (Canarvis, 1996) Outcome: Anxiety & Depression • Quasi Experimental −adventure group had significant decreases in anxiety and depression compared with controls (Kelley et al., 1997) −aerobic exercise group had significant decreases in anxiety and depression compared with controls (Levin, 1983) − 2 additional studies using aerobic interventions reported improvements, but not significant between-group differences (Jorgensen, 1986; Ball et al., 2001) Outcome: Anxiety & Depression • Case series −general trend of a reduction in depression (Pelham and Campagana, 1991) Outcome: Anxiety & Depression • Most studies demonstrated decreases in symptoms • Underlying cause may be due to co-existing condition and not symptoms of schizophrenia • Future research should consider focusing on symptoms specific to schizophrenia Outcomes: Global Symptom Severity − 8 studies − RCTs • no between, but significant within- group improvements in overall psychiatric status for both holistic and social skills groups (Lukoff et al., 1986) Outcomes: Global Symptom Severity • Quasi experimental studies − significant between-group difference showing decreases in Somatization and Hostility for aerobic exercise condition (Jorgensen, 1986) − significant between-group difference with reduced Interpersonal sensitivity and Hostility in outdoor adventure condition (Kelley et al., 1997) − no significant between-group differences; significant within-group reductions in Obsession/Compulsion, and Phobic Anxiety for aerobic exercise condition (Levin, 1983) − no significant differences (Ball et al., 2001; Bergman et al., 1993; Centorrino et al., 2006) Outcomes: Global Symptom Severity • Case Series −general trend of increasing improvements over time with structured exercise (Pelham and Campagna, 1991) Outcomes: Global Symptom Severity • Few significant between-group differences • Significant change within groups • Results may indicate clinical significance Outcomes: Relapse Rate • 2 studies • 1 RCT found no significant differences between holistic health and social skills intervention (Lukoff et al., 1986) • 1 quasi experimental study found significantly fewer relapses for the exercise group compared to the control group (Torres-Carbajo et al., 2005) Outcomes: Relapse Rate • Not often examined • Economic / social impact on family and health care system indicates this measure should be addressed in future studies Outcomes: Quality of Life & Functioning • 2 studies • Yoga therapy (YT) had significant improvement in QOL and functioning compared with physical training (PT) (Duraiswamy et al., 2007) • Within-group differences were found for functional measures in both YT and PT • 1 study found no effect of exercise on QOL (Centorrino et al., 2006) Outcomes: Quality of Life & Functioning • Yoga shown to increase QOL and functioning • Due to self-reflective nature of yoga? Outcomes: Symptoms of Schizophrenia • 7 studies − 1 RCT found significant reduction in symptoms for yoga group as compared with physical training; and significant within- group reductions for both (Duraiswamy et al., 2007) − 1 RCT demonstrated significant within-group reductions for both holistic health and social skills groups (Lukoff et al., 1986) − 1 RCT found clinical significance (Beebe et al., 2005) − 3 quasi experimental studies showed no change (Ball et al., 2001; Centorrino et al., 2006; Fuller, 1990), and 1 case study found an increase in symptoms (Adams, 1995) Outcomes: Symptoms of Schizophrenia • Between-group and within-group significance • Results may indicate clinical significance • Subtype analyses concerning diagnosis may allow increased sensitivity of findings Outcomes: Other • Outcomes not as readily addressed: − Self-efficacy / concept − Self-image − Locus of control − Pain − Psychomotor − Behavioural − Trust and co-operation • Should be considered as future studies emphasize a more holistic treatment approach Results & Discussion Outline • 1 – Results &Discussion of Outcomes • 2 – Limitations • 3 – Recommendations Limitations: Breadth of Literature • Main focus is on physiological outcomes −Cardiovascular fitness −Weight loss • Literature on psychological outcomes is generally lacking Limitations: Heterogeneity • Study design − Ranged from RCTs to case study −Majority quasi-experimental • Population characteristics − Research setting, diagnosis, sample size, medications • Intervention − Standardization: design and supervision − Follow up Limitations: Methodological Quality • Generally poor • Highlighted in “Recommendations” section Limitations: Summary • Further limitations imposed by inclusion criteria • Limitations compounded to create bias • Attempts to mitigate bias: − Standardized guideline for review − Inclusion of various forms of literature Discussion Outline • 1 – Results & Discussion of Outcomes • 2 – Limitations • 3 – Recommendations −Diagnostic Criteria − Sample Size − Physical Activity Criteria − Follow Up −Other Methodological Issue: Diagnostic Criteria • Methodological Issues: −Standardized diagnostic criteria not used / reported by many studies −Subtypes often not classified −Lack of criteria weakens credibility of the study Recommendations: Diagnostic Criteria • Recommendations: −Utilize standardized diagnostic criteria (e.g. DSM) − Include subtype diagnoses to account for various presentations Strengthens causal relationship between physical activity and symptoms of schizophrenia Methodological Issue: Sample Size Methodological Issues: −Consistently small sample sizes −No power calculations Recommendations: − Perform power calculations when appropriate − Increase sample size when possible Improves ability to detect change Methodological Issue: Physical Activity Criteria Methodological Issue: − Few studies included interventions designed and supervised by qualified personnel Recommendations: − Follow standardized criteria (e.g. ACSM) and ensure supervision Allows for comparison between physical activity interventions and increases the credibility of the results Methodological Issue: Follow Up Methodological Issue: − Few studies demonstrated appropriate follow up Recommendation: Perform follow up within a time frame in which physical activity effects are maintained Methodological Issue: Other • Subject selection − Randomization vs. convenience sampling • Baseline comparison − Undetected between subject variability • Medication standardization − Chlorpromazine equivalents as covariate • Attrition − Underreported and misreported • Adverse effects / events − Underreported Summary of Recommendations • Standardized diagnostic criteria • Adequate sample size • Standardized physical activity interventions • Design / supervision for physical activity interventions • Subtype analyses by diagnostic category • Appropriate follow up • Consider sampling methods, baseline data collection, medication standardization, attrition reporting and adverse events. Conclusion • Results not sufficient to indicate that physical activity can produce a significant change in outcomes • There is, however, suggested clinical relevance for many of the findings Conclusion • Given that physical activity is beneficial to overall health and mental well being, it may be considered a useful adjunct treatment. • Using improved methodological standards, future research may result in a higher level of evidence and thus may more clearly demonstrate the role of physical activity as an adjunct to psychological and psychiatric treatment. • This review provides a compendium upon which future research can be based. Acknowledgements Special thanks to: • Dr. Darlene Redenbach • Dr. Angela Busch • Charlotte Beck • Melissa Canarvis, Kathi Fuller, Dr. Cathy Jorgensen, and Dr. Stephen Levin • Physiotherapist Inge Kreuzer and recreational therapist Donna Beniusis of Riverview Hospital in Coquitlam B.C. References Adams, L., 1995. How exercise can help people with mental health problems. Nursing Times. 91 (36)  37-39. Addington, J., Addington, D., 1997. Substance abuse and cognitive functioning in schizophrenia. J Psychiatry Neurosci. 22 (2) 99-104. Andreasen, N.C., 1995. Symptoms, signs, and diagnosis of schizophrenia. Lancet. 346 (8973) 477-81. Babyak, M., Blumenthal, J.A., Herman, S., Khatri, P., Doraiswamy, M., Moore, K., Craighead, E., Baldewicz, T.T., Krishnan, K.R., 2000. Exercise treatment for major depression: Maintenance of therapeutic benefit at 10 months. Psychosomatic Medicine. 62 633-638. Ball, M. P., Coons, V. B., Buchanan, R. W., 2001. A program for treating olanzapine-related weight gain. Psychiatric Services. 52 (7) 967-969. Beebe, L. H., Tian, L., Morris, N., Goodwin, A., Allen, S. S., Kuldau, J., 2005. Effects of exercise on mental and physical health parameters of persons with schizophrenia. Issues in Mental Health Nursing. 26 (6) 661-676. Bergman, U., Hutzler, Y., Stein, D., Avidan, G., Wozner, Y., 1993. Therapeutic physical activity for adolescents in a closed psychiatric ward. Issues in Special Education & Rehabilitation. 8 (2) 41-54. Bradshaw, T., Lovell, K., Harris, N., 2005. Healthy living interventions and schizophrenia: a systematic review. Journal of Advanced Nursing. 49 (6) 634-654. Brenner, H.D., Hodel, B., Roder, V., Corrigan, P., 1992. Treatment of cognitive dysfunctions and behavioural deficits in schizophrenia: integrated psychological therapy. Schizophr Bull. 18 (1) 21-6. Campbell, P., Foxcroft, D., 2003. Exercise therapy for schizophrenia (Protocol). Cochrane Database of Systematic Reviews. Issue 4 Art. No.: CD004412. DOI: 10.1002/14651858.CD004412. Canarvis, M., 1996. Effectiveness of relaxation as compared to physical exercise in anxiety reduction for individuals with chronic schizophrenia. M.S., D'Youville College. Cantor-Graae, E., Nordstrom, L.E., McNeil, T.F., 2001. Substance abuse in schizophrenia: a review of the literature and a study of correlates in Sweden. Schizophr. Res. 48 (1) 69-82. Centorrino, F., Wurtman, J. J., Duca, K. A., Fellman, V. H., Fogarty, K. V., Berry, J. M., Guay, D.M., Romeling, M., Kidwell, J., Cincotta, S.L., Baldessarini, R. J., 2006. Weight loss in overweight patients maintained on atypical antipsychotic agents. International journal of obesity. 30 (6) 1011-1016. Cochrane Musculoskeletal Group, 2006. Developing a systematic review [Online].  Available from Crawford-Walker, C.J., King, A., Chan, S., 2005. Distraction techniques for schizophrenia. Cochrane Database of Systematic Reviews. Issue 1. Art. No.:CD004717. DOI: 10.1002/14651858.CD004717.pub2. Duraiswamy, G., Thirthalli, J., Nagendra, H. R., Gangadhar, B. N., 2007. Yoga therapy as an add-on treatment in the management of patients with schizophrenia - A randomized controlled trial. Acta Psychiatrica Scandinavica. 116 (3) 226-232. Faulkner, G., Biddle, S., 1999. Exercise as an adjunct treatment for schizophrenia: A review of the literature. J of Mental Health. 8 (5) 441-457. References Faulkner, G., Soundy, A.A., Lloyd, K., 2003. Schizophrenia and weight management: a systematic review of interventions to control weight. Acta Psychiatr Scand. 108 324-332. Freedman, R., 2003. Schizophrenia. New England Journal of Medicine. 349 (18) 1738-49. Fuller, K., 1990. Antecedent aerobic exercise training with schizophrenic outpatients. Masters dissertation, Western Michigan University. Gispen-de Wied, C.C., 2000. Stress in schizophrenia: an integrative view.  European Journal of Pharmacology. 405 (1) 375-384. Goodwin, R.D., Amador, X.F., Malaspina, D., Yale, S.A., Goetz, R.R., Gorman, J.M., 2003. Anxiety and substance use comorbidity among inpatients with schizophrenia. Schizophr. Res. 61 89-95. Hambrecht, H., Hafner, H., 1996. Substance abuse and the onset of schizophrenia. Biology of Psychiatry. 40 (11) 1155-1163. Jadad, A.R., Moore, R.A., Carroll, D., Jenkinson, C., Reynolds, D.J.M., Gavaghan, D.J., McQuay, H.J., 1996. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Controlled Clinical Trials. 17 1-12. Jorgensen, C., 1986. Aerobic conditioning in the therapeutic treatment of chronic schizophrenia. Educat.D., Northern Arizona University. Kelley, M. P., Coursey, R. D., Selby, P. M. (1997). Therapeutic adventures outdoors: A demonstration of benefits for people with mental illness. Psychiatric Rehabilitation Journal. 20 (4) 61-73. Landis, J.R., & Koch, G.G., 1977. The measurement of observer agreement for categorical data. Biometric. 33 159. Lawlor, D.A., Hopker, S.W., 2001. The effectiveness of exercise as an intervention in the management of depression: Systematic review and meta- regression analysis of randomised controlled trials. BMJ. 322  763-767. Lauber, C., Keller, C., Eichenberger, A., Rossler, W., 2005. Family burden during exacerbation of schizophrenia: Quantification and determinants of additional costs. International Journal of Social Psychiatry.51 (3) 259-264. Levin, S., 1983. The effects of a ten-week jogging program as an adjunctive treatment for patients in a social rehabilitation clinic. US: ProQuest Information & Learning. Lukoff, D., Wallace, C. J., Liberman, R. P., Burke, K., 1986. A holistic program for chronic schizophrenic patients. Schizophrenia bulletin, 12 (2) 274- 282. McGrath, J., Saha, S., Welham, J., Saadi, O.E., MacCauley, C., Chant, D., 2004. A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status an methodology. BMC Med.  2 13. Morris, D., Card, J., Menditto, A., 1999. Active and passive therapeutic recreation activities: A comparison of appropriate behaviors of individual with schizophrenia. Therapeutic Recreation Journal, 33 (4) 275-286. Patterson, T.L., Leeuwenkamp, O.R., 2008. Adjunctive psychosocial therapies for the treatment of schizophrenia. Schizophr. Res. 100 108-119. References Pelham, T. W., Campagna, P. D., 1991. Benefits of exercise in psychiatric rehabilitation of persons with schizophrenia. Canadian Journal of Rehabilitation. 4 (3) 159-168. Petruzzello, S.J., Landers, D.M., Hartfield, B.D., Kubitz, K.A., Salazar, W., 1991. A meta-analysis on the anxiety-reducing effects of acute and chronic exercise. Sports Medicine.  11 143-182. Robinson, D.G., Woerner, M.G., Alvir, J.M.J., bilder, R.M., Hinrichsen, G.A., Lieberman, J.A., 2002. Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder. Schizophr. Res. 57 209-219. Schultz, S.H., North, S.W., Shields, C.G., 2007. Schizophrenia: a review. American Family Physician. 5 (12) 1821-1830. Siris, S.G., Addington, D., Azorin, J.M., Falloon, I.R., Gerlach, J., Hirsch, S.R., 2001. Depression in schizophrenia: recognition and management in the USA. Schizophr. Res. 47 (2-3) 185-197. Skinar, G.S., Huxley, N.A., Hutchinson, D.S., Menniger, E., Glew, P., 2005. The role of a fitness intervention on people with serious psychiatric disabilities. Psychiatric Rehabilitation Journal. 29 (2) 122-127. Stanniland, C., Taylor, D., 2000. Tolerability of atypical antipsychotics. Drug Safety. 22 195-214. Torres-Carbajo, A., Olivares, J. M., Merino, H., Vázquez, H., Díaz, A., Cruz, E., 2005.  Efficacy and effectiveness of an exercise program as community support for schizophrenic patients. American Journal of Recreation Therapy. 4 (3) 41-47. Valenstein, M., Blow, F.C., Copeland, L.A., McCarthy, J.F., Zeber, J.E., Omon, L., Bingham, R., Stavenger, T., 2004. Poor antipsychotic adherence among patients with schizophrenia: medications and patient factors. Schizophr. Bull. 30 (2) 255-264. Whaley, M.H., editor, 2006. American college of sports medicine guidelines for exercise testing and prescription, seventh ed. Lippincott Williams & Wilkins, Philadelphia. Wijndaele, K., Matton. L., Duvigneaud, N., Lefevre, J., De Bourdeaudhuij, I., Duquet, W., Thomis, M., Philippaerts, R.M., 2007. Association between leisure time physical activity and stress, social support and coping: A cluster-analytic approach. Psychology of Sport and Exercise. 8 (4) 425- 440. Wong, A.H.C, Van Tol, H.H.M., 2003. Schizophrenia, from phenomenology to neurobiology. Neuroscience and Biobehavioural Reviews. 27 (3) 269- 306. THANK YOU!


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