Psychiatric Rehabilitation

							Psychiatric Rehabilitation
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.
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   VR disability coding system is out of
    date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
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
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
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)
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.
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.
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
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
Psychotic Disorders
   Schizophrenia
       Several subtypes: paranoid, disorganized,
        catatonic, undifferentiated, & residual
       Involves severe cognitive impairments,
        social isolation
       Positive symptoms can also include
        delusions and hallucinations.
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.
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
Symptoms
   Distorted perceptions of reality
   Hallucinations
   Delusions
   Disordered thinking
   Emotional expression
   Normal vs. Abnormal
Co-morbidity Issues
   Violence?
   Substance Abuse
   Nicotine
   Suicide
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
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.
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.)
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
Mood Disorders
   Two types:
       Depressive
       Bipolar
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)
Depression: Comorbidity issues
   Alcohol or drug abuse
   Anxiety
   Somatization
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)
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
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.
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
Bipolar: Comorbidity
   Suicide
   Substance Abuse
   Impulsive disorders
Bipolar: Treatment
   Medications
       Lithium Carbonate
       Tegretol (carbamazepine)
       Depakote (Valproic Acid)
       Gabapentine
   Major problem is medication compliance
Dementia & Delirium
   What is Dementia?
   What is Delirium?
   How are they alike?
   How are they different?
Dementia: Causes
   Many reasons for Dementia
       Alzheimer’s
       Lewy bodies
       Vascular
       Parkinson’s
       Huntington’s
       Substance Abuse
       Brain Trauma
       Creutzfeldt-Jakob Disease
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.
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.
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.
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)
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.
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/
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
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_i
    s_the_Program_of_Assertive_Community_Treatment_(PACT)_.htm
   Club House Model
     http://www.fountainhouse.org/
     http://www.mhcdc.org/yaharahouse/
     http://www.iccd.org/