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 disordersMental disorders due to a general medical conditionSubstance-related disordersSchizophrenia and other psychotic disordersMood disordersAnxiety disordersSomatoform disordersFactitious disordersDissociative disordersSexual and gender identity disordersEating disordersSleep disordersImpulse-Control Disorders NOSAdjustment disordersOther 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 tableAxis 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_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/