PSYCHOLOGY and PSYCHIATRY: COMPLEMENTARY AND ADDITIVE

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PSYCHOLOGY and PSYCHIATRY COMPLEMENTARY AND
ADDITIVE
CONFERENCE OF THE AUSTRALIAN PSYCHOLOGICAL
SOCIETY Psychology Ageing Interest Group
Deakin Management Centre, Geelong November 1-3,
2007

• by
• John Snowdon
• Old age psychiatrist, Sydney

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COMPLEMENTARY and ADDITIVE

• Self-esteem. What do we think of each other?
• How well do clinical psychologists and
  psychiatrists work together?
• Management of BPSD.
• Researching and intervening in cases of severe
  domestic squalor.
• Training of psychiatrists and clinical
  psychologists together?

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PRADO C.G. (1998)

• The last Choice Preemptive Suicide in Advanced
  Age.
• Greenwood Greenwich CT.

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The primary reasons why (we deduced) 210 people
killed themselves
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ISSUES TO DISCUSS

• Understandable? Rational? To whom?
• Do some personality characteristics make it
  difficult to tolerate disability, loss, insults,
  pain, diminished self-regard ?
• Are some suicides altruistic (re burden) ?
• Euthanasia -- understandable? Rational?

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THE SELF-ESTEEM OF OLDER PEOPLE

• What have they retained?
• What do they feel good about?
• Integrity versus Despair.
• Do regrets affect self-esteem?
• Adapting.

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ABRAMOWITZ PLACENTINI (2006)

• Psychologists and psychiatrists hold different
  conceptual, treatment and research approaches.
• Psychologists are trained to conceptualise and
  treat mental health disorders at the level of
  individual thinking and behavioural patterns,
  exploring the impact of environmental factors on
  those patterns.
• Training of psychologists is typically achieved
  through extensive didactic training with a strong
  emphasis on the theoretical underpinnings,
  research methods empirical findings.

(Clinical Psychology Science Practice, 13,
292-6)
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ABRAMOWITZ PLACENTINI (2006)(North Carolina)

• In contrast, the zeitgeist in psychiatric
  training programs is a neurobiological approach
• Psychiatric residency fellowship training is
  significantly more applied experiential in
  nature and provides notably less emphasis on the
  non-biological aspects of normal development and
  mental illness.
• Differences have the potential to lead to
  clashes within mixed departments but can also
  lead to synergistic advances.

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ABRAMOWITZ PLACENTINI (2006)

• Referred to a child anxiety training clinic,
  where psychology interns child psychiatry
  fellows work together under supervision of both
  psychiatry and psychology faculty.
• The interdisciplinary training model familiarises
  each group of trainees with the assessment
  treatment approaches typically espoused by the
  other discipline and fosters appreciation for the
  unique strengths characterizing each groups
  background, training and competencies.

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ABRAMOWITZ PLACENTINI (2006)

• Additional tensions
• Psychiatrists given higher status within medical
  settings.
• Psychiatrists can conduct physical examinations,
  prescribe medication and admit patients to
  hospital.
• Psychiatrists typically command higher salaries.
• Psychiatrists often have control of leadership
  positions.

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Photo of HANS EYSENCK
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BPSD(CHALLENGING BEHAVIOUR)

• Behaviour that is considered dangerous, harmful,
  distressing or disturbing to the person or
  others.
• Includes physical aggression, screaming,
  restlessness, agitation, sexual disinhibition,
  cursing shadowing though context the
  response of others determine how challenging they
  are.

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OPIE, DOYLE OCONNOR

• Challenging behaviours in nursing home residents
  with dementia a randomised controlled trial of
  multidisciplinary interventions.
• INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY,
• 2002, 17, 6-13.

A team (psychiatrist, psychologist nurses)
assessed recommended management for 99 BPSD
residents. Early compared to late intervention.
Consultancies were viewed as effective.
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BEHAVIOURAL PROBLEMS IN NURSING HOMES

• In the same way as in cases of depression, staff
  in nursing homes need to recognise and describe
  behavioural problems, looking at what seemed to
  cause them. What were the triggers? Why now,
  and whats it mean? What seems to settle the
  problem?
• The team (not just the individual) can then work
  on a solution, which might be environmental but
  could be treatment of constipation or UTI or
  depression, or maybe medication to settle
  distress, or control delusional beliefs.. Etc.

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SURVEY

• Most nursing homes have few or no staff who have
  had training in mental disorder assessment /or
  management
• UK reports 10 to 20 of nurses in more
  specialised facilities have had such training

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RATING SCALES

• NPI
• Cohen-Mansfield Agitation Inventory
• Behave-AD
• etc.

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OF NORWEGIAN RESIDENTS SHOWING CMAI BEHAVIOUR
gtONCE PER WEEK(Testad, Aasland Aarsland, IJGP
2007, 22, 916-921)

• Repetitious sentences/questions 31
• Cursing/verbal aggression 25
• Complaining
  25
• Constant requests for attention 24
• Pacing
  23
• Screaming
  15
• Making strange noises 13
• Grabbing
  13
• Hitting
  9.6
• Scratching
  5
• Physical sexual advances 2.4
• Negativism
  22
• 17 other behaviours
  1.8 to 14.4

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NUMBER () OUT OF 2445 RESIDENTS WHO MANIFESTED
PROBLEM BEHAVIOURS FOR MUCH OF THE TIME
Snowdon et al, 1996
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• An enthusiastic, committed, positive thinking
  clinical psychologist can contribute so much to a
  catchment area (integrated community and
  hospital) old age psychiatry service.

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MODELS OF PROVISION OF PSYCHIATRIC SERVICES

• Visiting psychiatrist. Responds to referral of a
  specific patient. No subsequent care unless
  called back.
• Consultation-liaison. Sees patient and staff.
  Education. May have designated nurse in n.h. to
  coordinate referrals.
• Multidisciplinary team approach. Team of n.h.
  and/or visiting staff, e.g. nurses, social
  worker, psychologist. Old age psychiatry teams
  can do it if adequately resourced.
• Nurse-centred approach. Back-up by psychiatrist.
• Telepsychiatry.

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WHEN TO REFER, AND TO WHOM

• Recognise theres a problem.
• Intervention.
• G.P. staff try alternatives.
• Referral. Who to? Depends on whos available,
  and whats the main problem.
• IF BEHAVIOURAL
• ? psychologist, nurse-specialist,
• Behavioural Support Unit
• or old age psychiatry team
• IF DEPRESSED, PARANOID, SEVERELY AGITATED
• psychiatrist ( supporting team)
• Ideally, the team already liaises educates!

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A model for interventions in cases of BPSD

• If a residents behaviour doesnt settle with
  usual treatment provided by n.h. GP
• Refer to specialist for consultation, assessment,
  short-term intervention.
• May need more intensive treatment in situ.
  Special care top-up funds to broker additional
  services. Behavioural Assessment and
  Intervention Service BAsIS teams
• Transfer to special assessment/care/treatment
  unit. Weeks to months.
• Few need the Neuro-behavioural unit. Physically
  violent, may be younger big. Maybe 20 beds per
  600,000 elderly in NSW.

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Bird et al (2002, report to Australian
Government)

• Individualised, primarily psychosocial approaches
  in nursing homes.
• They argued that the impact of the behaviour
  (rather than the behaviour itself) determines
  whether it is a problem.
• It is possible to treat such cases in situ,
• without hospitalisation.

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Squalor data-base (Central Sydney)

• All those referred to the Central Sydney (Eastern
  Sector) old age psychiatry team because they were
  deemed to be living in squalor were rated on the
• LIVING CONDITIONS RATING SCALE
• (Samios K, 1996. RANZCP. Unpublished)
• This scale was used by Halliday et al (2000)
• in a community study of people who live in
  squalor.
• (Lancet, 355, 882-886)

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13-item Living Conditions Rating Scale (interior)
Reliability rated by Halliday Snowdon while
developing a new scale (to be published)
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Central Sydney (Eastern sector) old age
psychiatry data-base of people assessed as living
in unclean accommodation, referred Jan 1, 2000
to Sept.30, 2007
Raters of LCRS (of 14) stated whether they
regarded the squalor as moderate or severe
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SEVERE DOMESTIC SQUALOR

• Cooney and Hamid (1995) referred to
• a reclusive elderly person living alone in a
  dilapidated filthy house. The home is cluttered
  with rubbish and infested with vermin. Excrement
  and decomposing food are strewn around the floors
  and the stench emanating is unbearable to all but
  the occupant, who is blissfully unconcerned by
  the situation.

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SEVERE DOMESTIC SQUALOR

• Descriptions of cases can largely be grouped
  into
• those where accumulation of useless items and
  articles had obstructed proper care of a persons
  living conditions, and
• those where filth and refuse had accumulated
  because of failure to get rid of them.

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SEVERE DOMESTIC SQUALOR

• Environmental uncleanliness (and often associated
  personal uncleanliness)
• and, to a varying extent,
• Lack of concern about their living conditions
• Social withdrawal
• Hostile attitudes
• Stubborn refusal of help

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INTERVENTIONSJohn Snowdon, Ajit Shah and Graeme
Halliday(International Psychogeriatrics 2007,
19, 37-51)

• Reports suggest that agencies worldwide are
  generally uncoordinated and consequently
  inefficient when trying to intervene and help in
  cases of squalor. Insufficient attention,
  resources and research have been committed to
  improving our understanding and interventions.

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FROST GROSS (1993)

• The hoarding of possessions.
• Behaviour Research and Therapy, 31, 367-381.
• Most theories which mention hoarding do so in
  the context of obsessive compulsive disorders.
  Hoarding is clearly related to obsessional
  thinking and to compulsive behaviors.

CHIU, CHONG LAU (2003)
Exploratory study of hoarding behaviour in Hong
Kong. Hong Kong Journal of Psychiatry, 13,
23-30. Over half the subjects had gt90 of the
dwelling covered by hoarded items, but only one
subject was diagnosed as having OCD.
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Not all those who self-neglectand not all those
who hoardlive in severe domestic squalor

• Some people neglect (seem not to care about)
  cleanliness of themselves, their dependants or
  their homes and dont get rid of rubbish (e.g.
  some with dementia, schizophrenia, alcoholism).
  Some are physically or cognitively unable to take
  action.
• Excessive or inappropriate collecting (and
  especially failure to discard) may lead to
  difficulty in cleaning.

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IT IS LIKELY THAT THOSE WHO LIVE IN SEVERE
DOMESTIC SQUALOR START DOING SO BECAUSE OF A
COMPLEX INTERPLAY OF TRIGGERS AND
VULNERABILITIES1. Obsessive compulsions and
indecisiveness may be largely to blame in some
cases. 2. In others, accumulation of refuse
and useless items is attributable to apathy and
impaired executive function, resulting from brain
disease or mental disorder. Lack of impulse
control could be contributory. There is limited
but growing evidence that frontal lobe
dysfunction is a major factor.
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Aspects of collectionism, self-neglect and
severe domestic squalor

• Organised and systematic collecting
• Compulsive acquisition with little attempt to
  resist (items may be of value, collected
  systematically but to excess)
• Hoarding acquisition of, and failure to discard
  possessions of limited use or value
• Accumulation of rubbish

• Neglect personal care and home cleanliness
• Neglect basic health needs (including
  medication)
• Neglect social needs
• Fail to eat/drink enough
• Poor care of finances
• Fail to protect self from financial or sexual
  abuse

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LCRS ratings of hoarding clutter
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Prevalence/incidence

• The population of persons aged 65 living outside
  aged care facilities in Central Sydney (Eastern
  sector) is about 18,000. A referral rate of 140
  subjects aged 65 in 7.75 years an incidence of
  1 per 1000.
• The incidence of cases of people 65 living in
  moderate/severe squalor 0.7 per 1000
• These are cases referred to an old age psychiatry
  service the number of non-referred cases can
  only be guessed. Some were referred but refused
  to see us.
• Because over half of those referred are found to
  be still at home after one year, the prevalence
  of people aged 65 living in domestic squalor is
  estimated at over 2 per 1000, and of those living
  in moderate or severe domestic squalor at about
  1.5 per 1000.

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Contents of September 07 BJ Clin Psychol

• CBT counselling for chronic fatigue.
• Subtypes of borderline personality disorder a
  latent class analysis.
• The Depression Anxiety Stress Scales in depressed
  clinical samples.
• The structure of PTSD symptoms.
• Beliefs about depression coping strategies.
• Trauma stimuli in people with schizophrenia.
• Emotion and tension in females with borderline
  personality disorder.
• Wisconsin Card Sorting Test in schizophrenia.

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Contents of BJ Med Psychol, December 2001

• CBT of delusional disorder.
• OCD phenomenology, help-seeking, treatment.
• Shame-based guilt-based PTSD.
• Effect of dissociation at encoding on intrusive
  memories.
• Mediation of depression by perceptions of defeat
  entrapment.
• Affective states associated with bingeing
  purging.
• Attachment in anorexia nervosa.

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CONCLUSIONS

• Good reason for clinical psychologists and old
  age psychiatrists to respect and work well with
  each other.
• Clinical psychologists have much to offer, if
  only we could attract them into our services.
• What about training psychiatrists and
  psychologists together for at least part of their
  training.