Exam #2 Flashcards
Why Do We Need to Know about Psychopharmacology?:
- Biopsychosocial illnesses: interaction of physical and emotional contributions
- Evidence-based practice: illness management
- Provides important context regarding the client:
* Adherence with treatment
* Side effects; including sharing with the team
* Misperceptions or lack of information about their meds
*OT often assistswith medication management education
one of the first used antipsychotics in psychiatry in the 1950’s, developed as a “tranquilizer
Thorazine
What are the First Generation/Typical Low potency Antipsychotic Medications?
Thorazine
What are the First Generation/Typical High potency Antipsychotic Medications?
Haldol and Prolixin
Typical Antipsychotics: Low Potency AnticholinergicSide Effects:
- Weight gain
- Sedation
- Dry mouth
- Dizziness/confusion
- Tachycardia
- Tardive Dyskinesia: jerky movements, lip-smacking
Typical Antipsychotics: High Potency Side Effects = Acute Extrapyramidal Symptoms (EPS):
- Akathisia (movement, inner restlessness)
- Dystonia (spasms, typically of neck muscles)
- Tremor (non-intention)
- Akinesia
- Bradykinesia- (shuffling gait, drooling, flat affect, stiffness of extremities)
- Muscle Rigidity
This happens when patients are on multiple psychotic medications (e.g., severe muscle rigidity)
Neuroleptic Malignant Syndrome (NMS)
Second Generation/Atypical Antipsychotic Medications
Clozaril
Risperdal
Zyprexa
clients must receive blood workevery week; other effects includesedation, anticholinergic effects, weight gain,orthostatic hypotension
Clozaril
Mood Stabilizers Diagnoses:
- Bipolar I
- Bipolar II
- Cyclothymia
Mood Stabilizers Functions:
- Treat mania
- Treat depression
- Maintain a stable mood
Anticonvulsants/Anti Seizure Medications:
- Depakote
- Tegretol
- Lamictal
Antidepressants “Tricyclic Antidepressants” (TCA)
Anafril and Elavil
Selective Serotonin Reuptake Inhibitors (SSRI):
- Paxil
- Celexa
- Zoloft
- Prozac
- Lexipro
SSRI Indications:
Major Depression
Obsessive-Compulsive Disorder
Panic Disorder
PTSD
Bulimia Nervosa
Premenstrual Dysphoria
Monoamine Oxidase Inhibitors (MAOI):
Nardil and Marplan
Benzodiazepines:
Xanax
Klonopin
Valium
Ativan
Electroconvulsive Therapy (ECT)Indications
Brief electrical stimulation to the brain while the patient is unconscious; generates a seizure; may be unilateral or bilateral (more effective); 8-12 sessions are typical
Indicated for: Bipolar or Depression not responding to medications
Placebo/Nocebo and Belief Effects:
- Placebo: an inert substance or treatmentthatimproves performance
- Nocebo: a negative response based on beliefs (eg: side effects)
- Belief Effects: specific knowledge changes beliefs aboutoutcomes (eg: food, drugs, behaviors
Placebo Effects:
- Placebo effect varies across individuals
- Placebo effect has received a negative connotation that limits its application as a treatment
- Placebos have their greatest impact on the subjective experience of disease (pain,distress), leading to a logical application in mental health
Application of the Placebo Effect in Clinical Practice
- Even the act of seeking treatment may give a sense of empowerment/agency and lead to some relief
- The therapeutic presence of the practitioner may provide support and comfort
- The context (professionalism of the office and the clinician) may support confidence in healing
- A thorough evaluation has been found to influence confidence in healing
- Messaging of the doctor (you will be better soon)
- Placebos can be effective even when the pt knows it is that!
- Has been used recreationally with a high potential for abuse and addiction; very similar to PCP (fencyclidine, Angel Dust)
- Currently being investigated for use with depression, and PTSD; positive effects sometimes called “miraculous”
- May produce long-term changes in the brain
Ketamine
- Naturally occurring psychedelic derived from fungi
- Structurally related to Seratonin
- A recent study found that it is very effective in the treatment of major depression when administered with clinical supervision
Psilocybin (Psychedelic Mushrooms)
Categorization per DSM-5
“Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment
Enduring pattern across four areas:
- thinking
2.Feeling - Interpersonal relationships
4.Impulse control
Specific personality disorders: Cluster A odd and eccentric
Paranoid
Schizoid
Schizotypal
Specific personality disorders: Cluster B dramatic/emotional/erratic
Antisocial
Borderline
Histrionic
narcissistic
Specific personality disorders: Cluster C avoidant/dependent/O-C
Avoidant
Dependent
Obsessive-compulsive
Etiology of personality disorders:
Biological and environmental components
* Genetic predisposition
*Biology-temperament
* Early childhood experiences-adverse experiences, caregiver response
Personality disorders impact on occupational performance:
Cognition
* Distortion
* Black-and-white thinking
* Distrustful/suspicious
* Idealizing/devaluing
Emotional modulation
* Affectivity-extreme degree and persistent emotional intensity–overwhelmed
Coping
* Impulse control-over of under control
Social participation
* Significant interpersonal problems
- A pervasive pattern of disregarding and violating the rights of others
- Hostility, aggression, deceit, and manipulation
- Inflated and arrogant self-appraisal
- Poor impulse control without considering consequences
- Reckless disregard for well well-being of others
- Lack empathy
- Behavior may have led to arrests/incarceration etc.
Antisocial personality disorder
- A pervasive pattern of instability of interpersonal relationships, self-image and affect, along with low impulse control
- Often in crisis and frequent engagement in self-harm or suicidal attempts.
- Strong perception of attachment and rejection, perceived abandonment and then anger, impulsive self-harm or actions without regard to consequences to self or others
- Black and white thinking—all good or bad and change readily
- May develop dissociative, psychosis-like symptoms during acute stress
Borderline personality disorder
Interventions for personality disorders:
- CBT
- Anger management
- DBT refer also to Ch Emotion and regulation notes
- Mindfulness meditation
- Family psychoeducation
- Peer support programs
- Re-entry programs for the criminal justice system
Dialectical Behavior Therapy:
- Theory: some people over-respond to emotional stimuli—more easily aroused and take longer to return to baseline. This is due to a biological vulnerability and invalidating environment. (Linehan, U of WA)
- Chronic invalidation made it challenging for a person to develop healthy coping skills
- Need specialized training as many referred for DBT are treated for suicidality, self-harm, and reduced impulse control
- Indiv therapy w trained therapist and group skills training (OT involved in latter)
Dialectical Behavior Therapy:
*Fundamentals of DBT:
Core mindfulness
Distress tolerance
Emotional regulation
Interpersonal effectiveness
- Two core intervention strategies:
Validation
Problem-solving
Dialectical Behavior Therapy:
Three stages of treatment:
1. Trust building is critical and paramount. Focus on suicidal and self-destructive behavior and the skills needed to address them
2. Focus on PTSD
3. Focus on self-concept and individual life goals
Clients often remain in stage one
Evolutionary/adaptive mind-body reaction that arises from individual intuitive appraisal of a situation based on past experiences and current goals
Emotion
Modal Model of Emotions:
Recursive process between person and environment/situation four phases of transactional sequence:
1. Situation
2. Attention
3. Appraisal
4. Response
Effort to be aware of and effectively manage emotional states, that is an essential skill for effective occupational performance
Emotional regulation
Emotional Regulation:
- Regulation can occur, before, during, or after emotion occurs
- Presents physically
- Developmental
- Neurophysiological
Emotion regulation: Neurophysiology
- Mind-body phenomenon largely regulated by the nervous and endocrine systems
- Response to threat and negative emotion:
* Hyper-arousal triggers release of hormones that are felt by bodily changes (examples p. 387)
* Prepares body for taking in more info to take appropriate action
*Affected by SNS flight or fight (sympathetic)
* PNS braking effect (parasympathetic)
* Amygdala
* Limbic system
* Prefrontal cortex
Neurophysiology continued:
- Vagal nerve and PNS
- Neuroplasticity enables new learning and strengthening of capacity at any age
- Limbic system
* Amygdala
* Hippocampus
* Prefrontal cortex
Development of emotion regulation:
- Learned in the context of primary relationships
* Safe, secure, soothed - Learn to tolerate distress as develop
- Biological and environmental factors impact emotion regulation
* Trait anxiety and impulsivity
* Biological vulnerability predisposes to dysregulation
* Emotional abuse, neglect, loss of caregiver consistency, chronic mis-attunement
* Cultural influences
Emotional dysregulation and psychiatric disorders:
- Borderline personality disorder
* Self-injury without suicide; affective instability - Depression
* Tend to avoid/suppress; rumination - Anxiety
* Emotion and SNS overactivation pervade lives and cause insomnia - Substance abuse
*Used as a means to control impulses/numb/avoid - Bipolar disorder
* Behavioral approach system (BAS) impairment–rewards - Disruptive behavior disorders
* BAS impairment leads to seeking larger reinforcement—increased risk-taking
Assessment of Emotion Regulation:
- Observation
- Survey instruments
- Informed by:
* Client self-knowledge
* Skill deficit
* Emotional inhibition
* Environmental constraints
Interventions for emotional dysregulation:
- Dialectical behavior therapy (DBT)
* Cognitive behavioral approach that is mindfulness-based
* Combines individual psychotherapy with psychosocial skills training
* Initially w parasuicidal BPD now expanded to other populations
* Treatment:
- Validates client’s current emotional behavior and functional state while promoting change in skills, behavior, or thinking (dialectic aspect—two contradictory approaches—acceptance and asking for change)
Interventions for Emotional Dysregulation Continued:
- Mindfulness-based OT
* Advanced training in Mindfulness-Based Stress Reduction (MBSR)
- Body awareness practice
- Opening to and expanding awareness
- Mindful movement during ADL - Caregiver interventions
- Anger management
* Coping Power Program
* Small group problem-solving
Emotional Regulation Coping Skills:
- 3 major categories of coping skills
1. Behavioral strategies – some type of action to manage stress; ex. confront person, engage in physical activity
2. Avoidance strategies – methods of staying away from stress; ex. withdrawal, distraction, using substances
3. Cognitive strategies – efforts to analyze the situation to fully understand the threat or challenge
International Classification of Function (ICF of WHO, 2002)
- shift from impairment to supporting participation in context
- shift from medical to social/community models of care
Loss:
- Loss can be sudden, gradual, permanent, total or anticipated
- There can be age-related changes in function which are experienced as losses
- People can lose external objects such as their home
- Loss of health affects people’s engagement in occupations/relationships/valued roles
- Limited participation in activities that bring pleasure or a sense of achievement
- Altered body image
- Caregivers often lose parts of themselves to the role of caregiver
Implications:
Isolation
Pain
Body image
Relational intimacy
Cognition
Grief and bereavement:
- Complex–Cognitive, emotional, physical, social, behavioral, and spiritual reaction to personal loss—is an emotional reaction
- All grief theories describe patterns of shock, and acute mourning, followed by resolution. Appears to have stages, but non-linear, and is interactive
- Bereavement psychological process of letting go
- Mourning behavioral action and integration of grief and bereavement
Response to illness:
- Research has shown that most people adapt (are resilient) to the demands of their environment/change, even when the circumstances are overwhelming
- Coping behavior supports people during stressful circumstances because it diminishes psychological distress
- Coping is a step in adapting to change
- People who experience loss and grief have different coping skills to “get through the day”
Appraisal Focused Coping:
- Minimize or deny the existence of a disability to protect themselves from the stress
- May involve reframing circumstances once they are understood
- Compare their circumstances to others
- Reframe their experience “a gift”
- Development of compassion and awareness that help them to help themselves and others
Problem-focused Coping:
- Emphasizes the practical aspects of a situation
- Person learns the facts about the situation
- After collecting information, problem-focused coping leads to action
Emotion-Focused Coping:
- Involves the emotions associated with the critical situation
- Controlling the environment and exposure to stressful activities
- Emotional discharge involves the release of feelings
- Resigned acceptance is accepting the reality of the situation; nothing can change it
Examples: Childhood disability:
- Development
- At each milestone the child and family must re-adjust to the challenges of the disability
- Parents must continually advocate for the child
- Much interaction with specialists
- Siblings
*.May feel the need to make up for loss- May feel neglected
- Alienation
- School children with disabilities are at an increased risk of being socially rejected and feeling isolated
- Relationships with peers and adults in the school environment produce frustrations, a lower self-concept and loneliness
- Social alienation increases the risk of leaving school
accepting the reality of the situation; nothing can change it
resigned acceptance
Challenges: chronic illness or disability
- Physical pain may be a daily life experience
- Unpleasant side effects of medications
- Loss of relational intimacy
- Cognitive demands of managing the condition
- Frequent hospitalization/exacerbation of symptoms
* Isolation
* Lack of privacy
* Interruption of routines and habits
* Disruption of accustomed roles
* Dependency on others to meet physical needs
* Loss of identity accompanies loss of roles
* Risk and uncertainty of intervention
Response : Acute Onset Disabling Conditions
- Vigilance, Becoming Engulfed
- Occurs at the initial point of injury
- Continues until the person surrenders care to another ER/ADM
- Disruption
- Feel like they are “in a fog”
- Significant others provide a safe haven/ orienting force in a chaotic environment
- Usually in an ICU/acute care
- Confronting and Regrouping
- Improvement in reality orientation; Implications of injury begin to be recognized
- Support of others to provide encouragement
- Merging the Old and New
- Test limits of newly altered bodies
- Learn what they can / cannot do
- Stage marked by frustration; Life goals have to be revised
(Pendleton, & Schultz-Krohn, 2005)
Factors that promote positive adaptation:
Coping
Social support
Gaining knowledge
Positive role performance
Resilience
Therapist Roles:
- Interpreter
- Guide
- Resource
- Model
- Be available to talk to the client and family: education, support, advocacy
- Understand that the client may not be at the stage where you want him/her to be
- Don’t make “everything about doing and nothing about being”
Neurocognitive disorders (NCD) in DSM 5:
acquired syndrome of the brain that affects:
Cognition/thinking/memory
Disrupts perception, info processing, problem-solving, sequencing, judgment, naming objects, mood/affect, writing/calculating and other ADL/IADL necessary to daily life.
Is progressive
Behavioral difficulties emerge as agitation, aggression and altered sleep/wake cycles
Alzheimer’s is most common type.
Major and mild
Effects on cognitive domains for mild and major NCD:
Complex attention
Executive function
Learning and memory
Language
Perceptual motor
Social cognition
Onset of Neurocognitive disorders:
Young= before 65
Most= post 65, including Alzheimer’s
Many causes in early to mid-life re tumors, vit deficiency, mid-life Huntington’s, Parkinson’s.
Younger usually due to metabolic disorders, SA, immune-mediated diseases, infectious diseases
Always differentiate co-occurring depression or delirium
Course of Neurocognitive disorders:
- Most chronic, progressive and irreversible
- Reversible NCD include:
Systemic Lupus (SLE)
Subdural hematoma
Some tumors
Hyper-hypothyroidism
Normal pressure hydrocephalus
Vit B12 and folate deficiency
Delirium
Differentiating delirium, dementia, and depression:
Attention deficit & affective lability across all but careful with other characteristics/presentation
Subtypes/etiologies of Neurocognitive disorders:
Alzheimer’s
Frontotemporal lobar degeneration
Lewy body disease
Vascular disorder
HIV
Creutzfeldt-Jakob disease
Parkinson disease
Huntington disease
Neurocognitive disorder’s Impact on occupational performance:
- Occupations that demand complex thinking and new learning
- Person may withdraw from activities that require a higher level perform
- Disease progression brings ADL challenges including dependence in bathing, toileting, feeding
- Fatigue
- Broad range of deficits in process skills due to cogn deficits
- Agnosia
- STM deficits
- Visual perceptual challenges
- Interpret visual stil
- Catastrophic reactions
- Emotional outbursts due to frustrations
Intervention approaches for Neurocognitive disorder’s:
- Interdisciplinary team
- Clinical exam/family interview/MRI/lab/neuropsych/OT/SW
Medications to enhance thinking and some to manage symptoms
Avoid anticholinergics as these exacerbate cogn impairment
- Clinical exam/family interview/MRI/lab/neuropsych/OT/SW
- Cognitive disabilities approach
- Errorless learning
- Augmentative /altern commun
- Home environment skill building
- Pet ownership
- Community arts
What is sensory processing?
- Following stimulation, the brain recognizes/classifies– translates
- Then we assign meaning to the stimulus and incorporate (assimilate) the info into what we are doing at the time
- The action that occurs can be conscious or unconscious and typically includes cognitive and motor processing.
Visual Sensory Processing:
- Lens focuses, enabling visual acuity
- Visual field, area we can see, each overlaps enabling depth perception
- Photoreceptors are receptors of this system and there are two types: one detecting movement and one for form—where and what something is
Auditory Sensory Processing:
- Location of objects and sounds, such as speech
- Input comes through waves measured by amplitude (account for loudness) and frequency (“pitch”)
- Vibration produced by waves transmitted through fluid in inner ear and hair cells, that fire nerve fibers, and also through bone conduction
Tactile Sensory Processing:
- Tactile sensory receptors on skin
- Surface and deep subcutaneous tissue –different receptors
- Surface=light-arouses to pay attention
- Deep=pressure-tells where and what one is feeling
- How respond depends on many factors
- Distal more sensitive than proximal
- Skin adaptive can habituate, less likely for weaker, intermittent stim such as routine movement in clothing
- Tactile sensitivity important for food texture preferences
Taste/Smell Sensory Processing:
- Primitive smell connects directly to the amygdala and hippocampus before going to the thalamus. Associated with emotional response and memories. Strong historical association
- Gustatory and Olfactory are chemical sensory systems and highly connected—when we taste we typically smell the food. Important for safety and unpleasant tastes.
Proprioception Sensory Processing:
- Awareness of body position in space
- Muscle spindles are receptors with info about muscle length and stretch. Golgi tendon organs provide info where the tendon meets muscle
Vestibular Sensory Processing:
- Responsible for balance through detection of position and movement of the head in space
- Receptors in semicircular canals of the inner ear
inability to modulate sensations
Over-responsivity
Under-responsivity
Sensory seeking
Sensory Modulation Disorder
Sensory processing and children with mental health conditions
ADHD
Autism spectrum disorder
Developmental trauma disorder
Sensory processing and adults with mental health conditions
- Schizophrenia and schizoaffective disorders
- Higher scores on low registration
- Mood disorders
* Sensory avoiding, sensory sensitivity, low registration w negative mood and sensation seeking w positive mood - PTSD
- All four types but extreme scores
- OCD
- More likely to startle—heightened awareness. Sensory avoiding, sensory sensitivity, low registration
Sensory Processing Assessment:
Observation
Sensory Profiles-infant through adult
Sensory Processing Measure
Highly Sensitive Person Scale
Sensory Processing Intervention:
- Ayres Sensory Integration (ASI)
- Sensory-based interventions (SBI)
- Zones of regulation
- Alert Program
- Deep pressure touch strategies
- Sensory rooms/environments
- Interventions specific to Dunn’s model of sensory processing
Dunn’s model of sensory processing:
- Four quadrants
- Sensory sensitivity
- Sensation avoiding
- Low registration
- Sensation seeking
Dunn’s model of sensory processing:
Four quadrants Threshold Response
Low registration high passive
Sensory sensitivity low passive
Sensation seeking high active
Sensation avoiding low active
Occurs when an individual experiences high neurological thresholds with passive responding strategies
- These individuals tend to miss or take longer to respond to stimuli that others notice (Brown, 2002)
- This is the person who you need to say their name 5 times before they respond
- These people may be highly flexible as they are not bothered by sensory stimuli and can typically manage distracting environments
Low registration
Low neurological thresholds with passive responding strategies
- These individuals are sensitive to stimuli, they experience discomfort caused by sensations; heightened awareness of the environment, and info to make decisions.
- This person might have trouble focusing attention or noticing every detail of something, and experience discomfort in high-intensity environments
Sensory Sensitivity
Low neurological thresholds with active responding strategies
- These individuals limit exposure to sensory stimuli, by creating or choosing environments with reduced sensory input
- This is the person who might like to be alone or seem bothered in certain environments, particularly if they cannot control it. They like predictable and consistent routines
- Tend to be skilled at adapting environments to meet their needs, but also may miss information
Sensation avoiding
High neurological thresholds with active responding strategies
- These individuals enjoy sensory stimuli and they may seek out and create sensations in the environment
- This is the person who can listen to loud music while studying/working or gets bored easily
Sensory seeking
Characteristics of sensory environments:
Modalities and reasoning to guide intervention
Intensity
Amount
Repetition
Competing stimuli
Predictability
Familiarity
Speed
Contrast
Psych OT:
Coping skills
Emotion regulation
Motivation
Role performance
Stress often related to hospitalization itself, challenging diagnosis, traumatic injury, etc
coping skills
Increased anxiety, frustration, sadness, and dysregulation > less desired behaviors
emotional regulation
Anhedonia = a symptom of depression; somatic symptoms may also play a role (i.e. pain)
motivation
Decreased/no ability to engage in meaningful roles and subsequent effect on self-concept
role performance
INPATIENT ACUTE SETTING:
- Organic psychiatric illness
- Danger to themselves or others
- Evaluations, groups/1:1 treatment, discharge planning
Smart Goals:
- Making abstract concepts more concrete
- Client centeredness
Smart Gals Examples:
- Pt will ID 1-3 coping skills with MOD assist
- Pt will verbalize feelings 75% of opportunities with 50% MOD 50% MAX assist
*Pt will ID 3 strategies to manage triggers of substance abuse with MIN assist - Pt will ID 2 valued roles and strategies to improve performance with MAX assist
Games (what might I see during a turn-taking game)
impulsivity, direction following, frustration tolerance, planning
Task activities (what might I see)
initiation/motivation, time management, leisure pursuit, follow through, goal achievement, concentration
Passive activities (depending on where ppl are at)
sensory, PMR/guided imagery, interactions with Remy as a modality
COMMON PHYSICAL LIMITATIONS
Trach/ventilator, lines and tubes, decreased mobility, SCI, fatigue, pain, poor dexterity, neuro changes
COMMON PSYCH LIMITATIONS
Anxiety, demoralization, frustration, anger, impulsivity, trauma, lack of control
Comprehensive, looking at multiple areas of occupation and psychosocial barriers
EVALUATION
After each session, documenting progress toward goals
PROGRESS NOTES
Amount of progress made in which domains; recommendations if any
DISCHARGE
SERVICE LINES:
Transplant
Cancer
CSICU, MICU, SICU, and associated step-down units
Shock Trauma Center
OTHER CL PROVIDERS
Palliative
Integrative Medicine
Pastoral Care
Barriers & Challenges:
Lack of education
Stigma
Role delineation
OT at end of life
Managing caseload
Niche focus
Communication
