Psychiatric Rehabilitation

1. Psychiatric Rehabilitation Medical & Psychosocial Aspects of Disability RCS 6080 October 3, 2006

2. Diagnosis and psychiatric disability • Should be conducted by a trained diagnostician • Includes an interview, record review and possibly some psychological testing. • It should be “functional” • In rehabilitation, the diagnosis should provide useful insight into the person’s problem • It should also allow for proper services. • Psychiatric diagnoses are frequently stigmatizing and care should be made when discussing diagnosis with the client and others.

3. Mental Illness and Rehabilitation • Wide variety of psychiatric disorders • VR disability coding system is out of date • Psychotic disorders • Psychoneurotic disorders • Character disorders • More current use is the DSM-IV-TR

4. Multiaxial Assessment: Axis I • Clinical disorders & other conditions that may be a focus of clinical attention Delirium, dementia and other cognitive disorders Mental disorders due to a general medical condition Substance-related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Factitious disorders Dissociative disorders Sexual and gender identity disorders Eating disorders Sleep disorders Impulse-Control Disorders NOS Adjustment disorders Other conditions

5. Multiaxial Assessment: Axis II • Personality Disorders and Mental Retardation • Personality Disorders organized in clusters: • Cluster A – Paranoid PD Schizoid PD, Schizotypal PD • Cluster B - Antisocial SP, Borderline PD, Histrionic PD, Narcissistic PD • Cluster C – Avoidant PD, Dependent PD, Obsessive-Compulsive PD, PD NOS • Mental Retardation – to be discussed in class on Developmental Disabilities

6. Multiaxial Assessment • Axis III – General Medical Conditions such as diabetes, heart condition, low back pain, or any other medical problems • Axis IV – Psychosocial and Environmental Problems – such as suicidal ideation without plan, marital discord, legal or financial problems etc. • Axis V – Global Assessment of Functioning (GAF)

7. GAF scale • Considers the psychological, social and occupational functioning on a 0-100 hypothetical mental-illness continuum (does not include impairment due to physical or environmental limitations) • Low numbers implies poor functioning – suicidal gestures, inability to maintain personal hygiene, frankly psychotic, etc • High numbers implies good functioning – has lots of friends, sought out by others, satisfied with life – few if any symptoms.

8. Sample Diagnostic table Axis I: 309.28 Adjustment Disorder with mixed anxiety and depressed mood. V61.21 Sexual Abuse of Child 296.23 R/O Major Depressive Disorder, Single Episode, Severe without Psychotic Features. 315.9 R/O Learning Disorder NOS Axis II: 799.9 Deferred, Passive-Aggressive traits noted Axis III: Type II diabetes – Insulin dependent Axis IV: Psychosocial Environmental Problems: problem with primary support group in social environment Also Occupational, Economic and Legal Problems Axis V: GAF – 50, Serious symptoms such as suicidal ideation and serious impairment in social functioning.

9. When is a Psychiatric Disorder significant in the VR system? • Does the psychiatric disorder severely restrict the daily functioning of the client? • Is the psychiatric disorder persistent in nature? • What is the likelihood that the individual will respond favorably to VR services. • Some examples of these disorders are: • Schizophrenia, residual type • Substance/Alcohol Dependence, in remission • Bipolar I Disorder

10. VR & Psychiatric Disorders • A psychiatric disorder may be significant to the VR system when it is the result of another condition: • PTSD following a serious, violent injury (i.e. gunshot or auto accident) • Depression or Adjustment disorder following a major disease, SCI, or TBI

11. Psychotic Disorders • Schizophrenia • Several subtypes: paranoid, disorganized, catatonic, undifferentiated, & residual • Involves severe cognitive impairments, social isolation • Positive symptoms can also include delusions and hallucinations.

12. Schizophrenia • Etiology: • Unknown, some genetic and behavioral factors • Age of onset: • Usually occurs during late adolescence to early adulthood. Onset is rare outside of this age range. • Other demographics: • Apparently it occurs in all ethnic groups, genders (onset seems to be a little earlier with males than females), socio-economic classes • Course of disease: • Some people have only one such psychotic episode; others have many episodes during a lifetime, but lead relatively normal lives during the interim periods. However, the individual with “chronic” schizophrenia, or a continuous or recurring pattern of illness, often does not fully recover normal functioning and typically requires long-term treatment, generally including medication, to control the symptoms.

13. Symptoms • Positive Symptoms • Hallucinations • Delusions • Disorganized thoughts and behaviors • Loose or illogical thoughts • Agitation • Negative Symptoms • Flat or blunted affect • Concrete thoughts • Anhedonia (inability to experience pleasure) • Poor motivation, spontaneity, and initiative

14. Symptoms • Distorted perceptions of reality • Hallucinations • Delusions • Disordered thinking • Emotional expression • Normal vs. Abnormal

15. Co-morbidity Issues • Violence? • Substance Abuse • Nicotine • Suicide

16. Schizophrenia - Treatment • Psychopharmicological Treatment • Necessary for stabilization of acute cases • Compliance • Side effects • Duration of psychotropic treatment • Psychosocial Treatment • Rehabilitation • Individual psychotherapy • Family Education • Self-Help Groups

17. Schizoaffective Disorder • Similar to schizophrenia, but also includes a major mood episode. • Less common that schizophrenia • Treatment similar to schizophrenia, but may also include mood stabilizing medications such as Valproic Acid or Lithium.

18. Vocational Implications • Cognitive impairments due to delusions, concrete thinking etc will hinder clients in jobs that require flexible thinking and independence. • Delusions and social withdrawal may interfere with work relationships • Denial and poor insight can lead to relapses and hospitalizations • Medication side effects can reduce functionality (blurred vision, fine motor control etc.)

19. Accommodations • Simplify the tasks • Provide some flexibility in work schedule • Allow for a self-paced workload • Have other employees discuss only work related issues at work. • Provide sufficient structure at work • Reduce distractions in work environment

20. Mood Disorders • Two types: • Depressive • Bipolar

21. Depression • Symptoms • Cognitive • Thoughts of hopelessness, futility, poor self-worth, rumination of negative thoughts • Affective • Feeling sad, unable to feel pleasure, irritability • Psychomotor/Physical • Decreased libido, energy • Sleep changes (70% less, 30% more) • Appetite changes (70 % less, 30 % more)

22. Depression: Comorbidity issues • Alcohol or drug abuse • Anxiety • Somatization

23. Depression: Risks • Suicide • 15% complete suicide • Highest risk: divorced or single male over 55 (usually white) • 20 – 25% of people with chronic illnesses have depression (i.e., diabetes, heart attack, cancer)

24. Depression: Treatment • Antidepressant Medications • SSRI’s are first line of treatment • Psychotherapy • Usually individual psychotherapy • Cognitive behavioral therapy has most evidence for efficacy of treatment. • Sometimes exercise or body awareness has been found to helpful

25. Bipolar Disorders • People with bipolar disorders cycle between depression and mania • Large swings (deep psychotic depression to high psychotic mania) or moderate swings (moderate depression to hypomania) • Mixed episodes occur when both depression and mania occur for over a week. Rapid, alternating depression and mania occur nearly every day.

26. Bipolar: Manic symptoms • Cognitive • Grandiose thinking • Loose associations • Racing thoughts • Affective • Euphoria • Irritability • Increased enthusiasm • Physical/Psychomotor • Increased activity • Decreased need for sleep • Increased libido • Pressured speech

27. Bipolar: Comorbidity • Suicide • Substance Abuse • Impulsive disorders

28. Bipolar: Treatment • Medications • Lithium Carbonate • Tegretol (carbamazepine) • Depakote (Valproic Acid) • Gabapentine • Major problem is medication compliance

29. Dementia & Delirium • What is Dementia? • What is Delirium? • How are they alike? • How are they different?

30. Dementia: Causes • Many reasons for Dementia • Alzheimer’s • Lewy bodies • Vascular • Parkinson’s • Huntington’s • Substance Abuse • Brain Trauma • Creutzfeldt-Jakob Disease

31. Dementia • Dementia is a mental disorder that affects your ability to think, speak, reason, remember and move. Many types of dementia exist. Some are progressive and permanent. That is, they get worse with time and cannot be cured. Only a few types can be treated and reversed.

32. Delirium • Is a severe but temporary state of mental confusion. It tends to be more common in older adults who have heart or lung disease, infections, poor nutrition, medication interactions or hormone disorders. • A person who experiences the sudden onset of disorientation, loss of mental skills or loss of consciousness is more likely to have delirium rather than dementia.

33. Personality Disorders • Cluster A PDs (paranoid, schizoid, & schizotypal) • People with these disorders often appear odd or eccentric. • Cluster B PDs (antisocial, borderline, histrionic, & narcissistic) • People with these disorders often appear overly dramatic, emotional or erratic • Cluster C PDs (avoidant, dependent, and obsessive-compulsive) • People with these disorders usually appear overly anxious or fearful.

34. Diagnostic traits of PDs “Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute Personality Disorders.” (DSM IV-TR p. 686)

35. DSM-IV General Diagnostic Criteria for PDs • Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. The pattern is manifested in at least two of the following areas: • Cognition, affect, interpersonal functioning, or impulse control. • The enduring pattern is inflexible and pervasive across a broad range of personal and social settings • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning • The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. • The enduring pattern is not better accounted for as a manifestation of consequence of another mental disorder • The enduring pattern is not due to direct physiological effects of substance abuse or a general medical condition.

36. Treatment of PDs • Usually very difficult and lengthy • A common treatment for Borderline PDs is Dialectical Behavior Treatment (DBT). This was developed by Marsha Linehan. For more info check: http://mentalhealth.about.com/cs/personaltydisordrs/a/dbtbrief.htm • A cognitive behavioral technique for personality disorders in general is Schema Therapy, that was developed by Jeffrey Young. For more info check: http://www.schematherapy.com/

37. Other Rehab Psych Treatments • PACT model (program of assertive community treatment) • Key features: Treatment, Rehabilitation, Support Services • For people with psychotic disorders • Club House • Self-help community based programs for people with severe mental illness

38. Links • National Institute of Mental Health http://www.nimh.nih.gov/healthinformation/index.cfm • Thresholds in Chicago, IL http://www.thresholds.org • PACT info at the National Alliance for the Mentally Ill (NAMI) http://www.nami.org/Content/ContentGroups/Programs/PACT1/What_is_the_Program_of_Assertive_Community_Treatment_(PACT)_.htm • Club House Model http://www.fountainhouse.org/ http://www.mhcdc.org/yaharahouse/ http://www.iccd.org/