Psychiatric Rehabilitation

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Psychiatric Rehabilitation
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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 persons 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.

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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• VR disability coding system is out of date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

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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

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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

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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)

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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.

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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.

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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

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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

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Psychotic Disorders

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

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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.

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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

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Symptoms

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

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Co-morbidity Issues

• Violence?
• Substance Abuse
• Nicotine
• Suicide

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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

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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.

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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.)

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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

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Mood Disorders

• Two types
• Depressive
• Bipolar

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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)

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Depression Comorbidity issues

• Alcohol or drug abuse
• Anxiety
• Somatization

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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)

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Depression Treatment

• Antidepressant Medications
• SSRIs 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

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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.

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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

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Bipolar Comorbidity

• Suicide
• Substance Abuse
• Impulsive disorders

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Bipolar Treatment

• Medications
• Lithium Carbonate
• Tegretol (carbamazepine)
• Depakote (Valproic Acid)
• Gabapentine
• Major problem is medication compliance

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Dementia Delirium

• What is Dementia?
• What is Delirium?
• How are they alike?
• How are they different?

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Dementia Causes

• Many reasons for Dementia
• Alzheimers
• Lewy bodies
• Vascular
• Parkinsons
• Huntingtons
• Substance Abuse
• Brain Trauma
• Creutzfeldt-Jakob Disease

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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.

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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.

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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.

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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)

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DSM-IV General Diagnostic Criteria for PDs

• Enduring pattern of inner experience and behavior
  that deviates markedly from the expectations of
  the individuals 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.

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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/personalty
  disordrs/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/

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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

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Links

• National Institute of Mental Health
  http//www.nimh.nih.gov/healthinformation/index.cf
  m
• Thresholds in Chicago, IL
• http//www.thresholds.org
• PACT info at the National Alliance for the
  Mentally Ill (NAMI) http//www.nami.org/Content/Co
  ntentGroups/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/