Mental Health Flashcards
Mood disorders
spectrum of disturbances from very low (depression) to very high (mania)
Major categories:
- Major depressive disorder (MDD)
- Bipolar disorders (BPD)
Other disorders:
- substance induced
- medical condition induced
MDD and Dysthymic Disorders (unipolar disorder)
Requires one major depressive episode followed by at least 2 weeks of severe functional impairment
Dysthymic - sad most of the time
NOT situational depression
Seasonal depression can turn into MDD if it stays around for a long time because it will cause chemical changes in the brain.
Bipolar disorders
Involve at least one depressive episode followed by elevated mood
Symptoms of MDD
- sadness
- hopelessness
- guilt
- irritability
- poor concentration and decision making
- anhedonia: inability to feel pleasure
- altered sleep
- fatigue
- impaired memory or cognition
- thoughts of death or suicide
Symptoms of BPD
- grandiosity
- persistent elevated mood
- little need for sleep
- babbling or excessive talking
- flights of fancy
- easily distracted
- impulsive, dangerous activity
- excessively goal directed - won’t give up
Types of BPD
BPD I: manic and depressive episodes - very high to very low
BPD II: similar to BPD I but major depressive episode then hypomania instead of mania
Cyclothmic: hypomanic episodes with depression symptoms (milder than I or II)
Clinical symptoms associated with mood disorders
- affect
- anhedonia
- avolition
- dysphoria
- euphoric
- flight of ideas
- grandiosity
- hypomania
- psychomotor agitation
- psychomotor retardation
- psychosis
affect
display of emotions (facial expressions), flat-animated
anhedonia
lack of interest in something that was previously enjoyed
avolition
lack of drive, no goals
dysphoria
depressed or negative state
euphoria
exaggerated feeling of elation
flight of ideas
disconnected, changing thoughts
grandiosity
inflated idea of self
hypomania
elevated mood, but less than mania
psychomotor agitation
fidgeting, pacing, wiggling
psychomotor retardation
slow or frozen
psychosis
delusions or hallucinations without insight
Suicidal ideation
can occur with MDD and BPD
- feelings of helplessness or hopelessness
- decrease in personal hygiene
- vocalizing death wish
- risky behaviors
- social withdrawal
- saying goodbye
- suicide note, plan, or previous attempt
- believing their situation will never change or they are doomed
Etiology of mood disorders
complex mixture of factors
- genetics
- biologic
*neurotransmitters
*endocrine system
- drugs
- stress
- cognitive vulnerability
- trauma
- negative coping styles
* big piece of OT is teaching good coping skills
Incidence and prevalence of mood disorders
Up to 16% of US population will be diagnosed as MDD
5% with BPD
Women diagnosed more than men.
Lower socioeconomic groups –> lower treatment adherence
Situational depression can cause MDD
All levels of society are affected
Diagnosis of MDD
At least one major depressive episode
Interference with function
At least 5 symptoms in a 2 week period
Diagnosis of BPD
At least one manic, depressed, or mixed episode
With manic as the dominant trait
Change in function
Pharmacologic intervention for MDD
Antidepressants-regulate neurotransmitters, specifically serotonin and norepinephrine
- Vilazodone (Viibryd)
- Citalopram (Celexa)
- Sertraline (Zoloft)
- Fluoxetine (Prozac Weekly, Prozac)
- Trazodone (Desyrel)
- Escitalopram (Lexapro)
- Paroxetine (Paxil, Paxil CR)
- Venlafaxine (Effexor, Effexor XR)
Side effects: nausea, headache, sexual dysfunction, dry mouth, blurred vision, general sedation
Pharmacologic intervention for BPD
Acute vs Maintenance treatment
Lithium (Lithobid)- most common mood stabilizer
- Valproic acid (Depakene)
- Divalproex sodium (Depakote)
- Carbamazepine (Tegretol, Equetro, others)
- Lamotrigine (Lamictal)
Side effects: weight gain, sedation, skin rash, blurred vision, sun sensitivity
Poor adherence, why?
Other interventions for MDD and BPD
Electroconvulsive therapy (ECT)
- “shock” therapy
- Historically used
- Resistant to pharmacologic intervention
- Now used in conjunction with anesthesia
*Induces a seizure, not sure how it works
- Risks
* Memory loss
* Death
Repetitive Transcranial Magnetic Stimulation (rTMS)
- Fewer side effects
- Doesn’t require sedation
- Side effects
* Tingling in face
* Light headed
* Headaches
* Mania
How do mood disorders affect occupations?
ADLS
- Basic hygiene
- Maintaining routines
- Taking meds
IADLS
- Budgets
- Childcare
- Paying rent
Health Management
- Poor outcomes without support
- Weight gain
Education
- Less likely to get a degree or complete training
Work
- Less likely to work outside the home
Play, Leisure, Social Participation
Difficulty maintaining relationships
Schizophrenia spectrum and psychotic disorders causes
Chronic and lifelong disorder
- 21 million people world wide
- Less than 1% of the population but rising
Genetic link
Alteration in Neurotransmitters
- Dopamine
Brain Structure
- Smaller hippocampus, amygdala and thalamus
- Larger lateral ventricle volume
Prenatal and Birth Complications
- O2 loss
- Infections and drugs
Trauma
Urban vs rural settings
Substance Use
Positive (easier to see) symptoms and sighs of schizophrenia spectrum and psychotic disorders
Delusions
Hallucinations
Disorganized speech
Abnormal motor behavior
Types of delusions
Persecutory: Out to get me
Referential: That song is about me
Somatic: I have cancer
Grandiose: I am Elvis’ child
Erotomatic: Beyoncé loves me
Religious: I am the favorite
Nihilistic: The world is going to end
Hallucinations
Auditory, visual, tactile, gustatory or olfactory
Disorganized speech
Tangential thoughts-barely related
Loose association-not on topic
Incoherence (word salad)- no sense at all
Abnormal motor behavior
Catatonic, rigidity
Agitation
Odd or silly
Mimicking
Echolalia – repeat something they heard over and over
Negative (harder to detect) symptoms and sighs of schizophrenia spectrum and psychotic disorders
Diminished Emotional Expression (affect is flat)
Avolition-lack of motivation to do something with an end goal
Alogia-diminished speech output
Anhedonia-lack of ability to experience pleasure
Asociality-lack of socialization
Anosognosia-no insight or awareness of the disease
Diagnosis and prognosis for schizophrenia spectrum and psychotic disorders
No single test or assessment
Usually follows a “psychotic break,” usually in late adolescence or early adulthood
- Two Positive or negative symptoms
- Which includes delusions, hallucinations or disorganized speech
- For 6 months
- Impact to at least one major life area of occupation
Stages of Schizophrenia spectrum and psychotic disorders
- Premorbid: no or few symptoms
- Prodromal: subtle symptoms, mild cognitive decline but doesn’t meet the criteria
- Syndromal: worsening of symptoms, functional decline, FORMAL diagnosis
- With treatment 60-80% respond and go into remission or partial remission
- Others progress
- Up to 30% are treatment resistant and often end up hospitalized
*Intervention is predominantly medication based - Progressive: individuals who relapse repeatedly
- Chronic or residual: continual decline but less than syndromal
Treatment for Schizophrenia spectrum and psychotic disorders
Pharmacological
- Most common
- Severe side effects
- Typicals: been around for 20 years; patients will start with these; acute extrapyramidal side effects (EPS)
* Tremors, psychomotor slowing, pill rolling (roll fingers as if there’s a pill between them)
- Atypicals: weight gain, sexual dysfunction, cardiac issues, dry mouth
* Clozapine: lowers white blood cell levels to the point that pt will almost end up with leukemia
Neuromodulation
- Electric shock (ECT) and magnetic therapies (TMS)
OT:
A mind busy and occupied can help create a better outcome
Psychosocial
CBT-Cognitive Behavioral Therapy
- Self monitoring
- Coping skills
- Requires insight
Self Management programs
- Similar to CBT, includes goal setting and planning
Skills Training
- Role modeling, goals setting, rehearsal, practice
Cognitive Rehabilitation
- Focus on rehabilitation of the cognitive deficits (symptomatic)
* Memory, attention
Family Psychoeducation
- The key
- If they don’t have this and no services are available, they are doomed.
Social Skills Training
- Like CBT or skills training just focus on Social Skills
- Important in early diagnosis
Importance of Early Intervention
Delusional disorder
- 1 or more delusions for more than one month
- No other symptoms
Brief Psychotic Disorder
- Just like Schizophrenia but lasts 1 day to 1 month
- Sometimes drug or disease induced
Schizophreniform Disorder
- “Pre-Schizo”
- Symptoms last 1-6 months
Schizoaffective Disorder
- Same symptoms plus a major episode of depression or mania
- Function is not always affected
- Hallucinations are present
Other psychotic disorders
- Delusional Disorder
- Brief Psychotic Disorder
- Schizophreniform Disorder
- Schizoaffective Disorder
- Substance or Medication Induced
- Due to another medical disorder
- UTI: strong urine odor, dark urine
- become septic
How do Schizophrenia spectrum and psychotic disorders impact occupations?
- Stigma of the disease “crazy”
- Depends on the environment, what factors
- Response to meds
- ADLs: may not be dressing or eating depending on the level
- IADLS: may not be paying bills
- Health Management
- Rest and Sleep
- Under education
- Under employed
- Social and Leisure
Anxiety disorder common features
Fear
- Emotional response
- Autonomic arousal
- Escape behaviors
Anxiety
- Causations or avoiding behavior
- Muscle tension
- Active preparation for danger
6 months or longer with impact to functional domains
Types of anxiety disorders
- General Anxiety
- Obsessive-compulsive and related disorders
- Trauma and stress related disorders
Types of general anxiety disorders
- Panic Disorders
- Specific Phobias
- Social Anxiety Disorder
- Agoraphobia
- Generalized Anxiety Disorder
- Separation Anxiety
- Selective Mutism
Panic disorders
Recurrent, unexpected panic attacks, fear and anxiety
1 attack within the previous month, with at least one month of
- Worry
- Additional panic attacks
- “Heart attack” or “going crazy”
- Avoiding behavior
Specific phobias
Intense, irrational fear of something
Provokes instant fear and anxiety that is out of proportion
Last at least 6 months, often have more than one
- Situational Phobias: more common in adulthood
- Natural Environment Phobias-common in childhood
- Blood or Injection Phobias
- Animal Phobias: more common in adulthood
- Other Phobias
Social Anxiety Disorder
- Speaking
- Performing
- Anxiety and over judgement of one’s performance in a social setting
Vs Shy??
Agoraphobia
Not just a fear of leaving the house, but also comes with excessive anxiety and panic
- Public transportation
- Open spaces
- Enclosed spaces
- Crowds
- Alone outside of the home
Generalized Anxiety Disorder
- Excessive worry and anxiety for at least 6 months without a cause
- Worry about everything
Separation Anxiety
6 months in adults, 4 months in children
At least 3 of the following symptoms:
- Anxiety about the possibility of separation
- Wish to stay close for fear of death
- Worry that some thing bad is going to happen to them to keep them from the other person
- Refusal to go out alone
- Excessive fear of being home alone
- Refusal to spend the night away
- Recurring nightmares of separation
- Physical reactions to being separated-hysteria, vomiting, shaking
Selective Mutism
Must have all 5
- Won’t speak in certain situations
- Failure to speak is impacting function (school)
- The failure to speak continues after 1 month in the situation
- There are no language deficits
- Not due to another diagnosis (autism) or communication disorder
Etiology and prevalence of anxiety disorders
40 million people in the US at least 1 x per year
- Women more than men
- Panic Disorders: women more than men, diagnosed early 20’s
- Phobias: most common mental disorder in US, usually start at age 7
Likely biological or neurochemical component
Psychosocial factors
- Trauma
* Divorce, death
- Abuse
- Conditioning
* Food, war etc.
Diagnosis for anxiety disorders
Meet the specific criteria for each condition
Treatment for anxiety disorders
Medications
- Benzo’s (addictive)
- Side effects
Names like:
Zoloft, Lexapro, Prozac, konini, Xanax
OT:
- Sensory Integration
- CBT
- Mindfulness
- Metacognition
- Exercise
- Nutrition
- Systematic Desensitization (heavy exposure therapy)
* Virtual exposure
- Relaxation Training
- Deep breathing
- Visualization
- Family and Group Therapy
- Yoga
- Energy Work: working out, free weights, riding a horse
- Meditation
Neurocognitive Disorders (NCD)
Neurocognitive disability resulting from an underlying neurological cause
Delirium
- Short term disorientation or psychosis
- Can be brought on by high fever and UTI
Hypoactive (stunned), Hyperactive (agitated) or Mixed
Diagnosis: many assessments MMSE
Prognosis: resolves with the issue
Types of NCD
Mild
Major (also called dimentia)
Mild NCD
One or more declines in:
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual motor
- Social cognition
Modest decline that requires compensatory strategies and accommodations
- May or may not turn into Major NCD
Major NCD
Significant decline in one or more of the above areas
Interferes with independence in every day activities
Diseases that can lead to NCD
Alzheimer’s
Frontotemporal Lobe Degeneration (formally called Pick Disease)
Lewy Body Disease
Vascular
Traumatic Brain Injury
Substance Induced
Human Immunodeficiency Virus
Cause of Alzheimer’s Disease
No clear cause
- Family history
- Mutation of chromosome or gene
- High cholesterol, BP
- Insulin Resistant Diabetes
- Decrease in neurotransmitters
Diagnosing Alzheimer’s
Rule out other causes
MRI and PET scans (60-90%)
BIO markers: Amyloid Betadeposits in brain, Hyperphosphorylation of protein, and neuroinflammation of glial cells
5.8 Million Americans, risk increases as we age
Stages of Alzheimer’s
Frontotemporal Disease
Formally called pick disease
Behavioral Variant
- Loss of sympathy, apathy or inertia
- Compulsive/ritual behavior
- Extreme behavioral changes
- Decline in social cognition and executive ability
Language Variant
- Decline in language
* Speech production
* Word finding
* Object naming
* Grammar
* Comprehension
Both retain learning, memory and perceptual motor skills
Diagnosis
- Behavior changes/legal issues/firings-as early as 40
- CT or MRI
* Atrophy
* Quick decline, quicker death
Lewy body disease
Abnormal deposits of alpha-synuclein protein called Lewy bodies
- Blocks dopamine and acetylcholine
Onset is 50’s, more men than women
2nd most common cause of dementia
Changes in attention, emotions, movement and sleep
Hallucinations
Learning difficulty, memory later
Misdiagnosed as Alzheimer’s or Parkinson’s
Vascular dimentia
Due to decreased vascular supply
- Other types ruled out
- Not as aggressive
CVA, Vascular Disease, other
Traumatic Brain Injury
Evident on MRI
Substance induced NCD
Mild to major
Alcohol abuse causes cortical thinning
Meth causes microhemorrhages
Human Immunodeficiency Virus NCD
Mild to major
No other explanations
Diagnosing NCD
- Decline in one or more cognitive domains
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual motor abilities
- Social cognition - Occupational Impairment
- Not delirium
- Not something else
Intervention for NCD
Assure appropriate diagnosis
Psychoeducation of patient and family is key in association with medical management.
Manage behavior and cognitive decline
- Routines, adaptations, reactions of others
Promoting ADLS
Caregiver support
Pharmacology
Types of Obsessive Compulsive Disorders (OCD) and related disorders (OCRD)
Obsessive Compulsive Disorder (OCD)
Body Dysmorphic Disorder (BDD)
Hoarding disorder
Hair-pulling disorder
Skin picking disorder
Obsessive compulsive disorder
Fear of harm/checking disorders
Sexual/religious thoughts
Contamination concerns/washing rituals
Symmetry/ordering behaviors
Causes of OCD and related disorders
Genetic variations
Environmental factors
Physical damage to the brain
Psychosocial Trauma
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus)
- Don’t know why or who is more likely to get it
- comes after a strep infection
Diagnosing OCD and related disorders
Pt’s may go a long time before diagnosis
Self report of the repetitive or obsessive thoughts
Management or Intervention
- Complex
- Pharmacological
* Anxiety meds
- Psychotherapy
- Occupational therapy
- Cognitive Behavioral Therapy (CBT)
A lot of the same interventions as addicts.
Body dysmorphic
Physical appearance
Often starts in adolescence
Not due to injury
Excessive surgery, shame, failure to leave home, suicide
With anorexic pt. you ask them to draw a picture of themselves, they often draw themselves bigger than they are, when they are really skin and bones.
Hoarding disorder
Discard unnecessary possessions, clutter that interferes with life
Animal hoarding
Little insight - don’t recognize that it’s a mess
Hair pulling disorder
Trichotillomania
Pull and sometimes eat one’s hair
Skin picking disorder
Skin lesions
Amount of time picking
Triggers
Can lead to infection and amputation in diabetic patients
Symptoms of OCD and OCRD
Symptoms may occur in childhood (men more) or adulthood (women more)
Complex Trauma
Emotional Shock following a stressful or distressing event
- Can be a single event (trauma)
* PTSD
- Multiple Events (complex trauma)
* C-PTSD
Experiencing, witnessing, learning about, violence, abuse, neglect
- Especially if directed at them or a loved one
Event can be:
- Physical
- Sexual
- Emotional/psychological
- Neglect (one of the worst things that can happen; higher death and injury rates)
Often transgenerational (that’s how I was raised, so why should it be any different with my kids)
- Neglect is most dangerous
- Death
Risk factors of complex trauma
Young/single parents
Lack of education
Large number of dependents
Adults with psychiatric disorders
Unrealistic expectations for children
- Toilet training
Childhood history of abuse (80%)
Substance abuse
Lack of family support
Children with issues or disabilities (fussy babies)
Socioeconomic status
- Ability to hide it? “I don’t think poor people are more likely to abuse their children, I think wealthy people are better at being able to hide it”
Poor bonding in infancy
Nonbiologic/transient caregivers living in the home
- mom’s boyfriend who won’t stick around
Adopted and foster children
This risk factors can be cumulative
Who is abused/ who abuses?
Of cases reported 60% are neglect (social or medical), 11% are physical abuse and 7-8% are sexual abuse
Children under the age of 1
Boys and Girls about equal overall (75% of sexual abuse cases are girls)
Neglect most commonly associated with women
Sexual abuse most commonly associated with men
92% of the time it’s a parent
Women most often and Mom’s the highest group
Domains of impairment for complex trauma
There are 7 domains of impairment
1. attachment and relationship
2. thinking and learning
3. physical health: body and brain
4. behavior
5. self-concept and future orientation
6. emotional responses
7. dissociation
Diagnosis and prognosis for complex trauma
Diagnosis requires and intervention
- Interviews
- Observations: especially in how children play
- Surveys
- Standardized assessments
Prognosis
- Related to extend of exposure
- Resiliency factors
* Executive function
* Nurturing environment
* Maternal health
* Consistent and health home routines
* Understanding of the trauma (not sweeping it under the rug)
How does complex trauma impact function?
ADLS
- Bathing and hygiene
- Over or under in any area
- High stress
Toileting
- Encopresis: pooping in places you shouldn’t
- Enuresis: peeing in places you shouldn’t
* Both are often in response to sexual abuse
Feeding and Eating
- Bottle rot (dental issue; teeth and gums will rot) and poor eaters or messy
- Eating disorders: control
- Food hoarding
Sexual Activity
- Sexualized or age-inappropriate activities
- Drug and alcohol use
IADLS
- Parentifications: when the children become the parents
- Under achievers
- Academic issues
- Difficulty with own health issues
- Abnormal sleep and rest
* Night terrors
Work
- Disinterest in work
- Underemployment
- Difficulty keeping job
- Difficulty with interpersonal skills
Play and Leisure
- Lack of explorative play
- Symbolic play may imitate their environment
- Difficulty connecting with others
* Rage
* Avoidance
Social
- Isolation
- Feelings of worthlessness
- Deviant affiliations
- Persistent conflicts (emotional or physical)
- Unsafe acts
- Court involvement
- Avoiding or aggressive
Somatic Disorders
Disorders of perception
- Excessive or disproportionate thoughts and feelings and behaviors
- Disrupt life for 6 months or more
- Regardless of medical etiology
- Perception is real
Somatic Symptoms
- Associated with the senses, usually pain
- Could also be itching, dizziness, chest pain, irritable bowel
Not explained by medical or other psychologic issue
Malingering-intentional production of a problem for gain
Hypochondriasis- over attention but can be swayed
Types of somatic disorders
- Somatic Symptom disorders
- Illness Anxiety disorder
- Conversion Disorder
- Psychological factors impacting other medical conditions
- Factitious Disorders
Somatic symptom disorders
Usually a physical symptom
Headaches, chest pain, joint pain
Fixated on it
They believe it!
Illness anxiety disorder
Fear of getting a disorder
Insist on X-Ray, MRI, Blood work
Previous illness or family illness
Hypochondriasis- over attention but can be swayed
Conversion disorder
Also called Functional Neurological Symptom Disorder or Psychogenic Disorder
Tremors, tick, dystonic movements
“cause and effect”
- begins shaking when husband gets mad and thinks she has parkinson’s
Psychological factors impacting other medical conditions
Overeating, overworking, ignoring symptoms, stress
Factitious Disorders
Knowingly report or even create false symptoms
Munchausen or Munchausen by proxy (this is intentional, malingering, not always considered a somatic disorder)
Diagnosing somatic disorders
Don’t know what causes it
- History of Trauma
- Idiopathic
Often difficult to diagnose
- Doctor shopping
More likely to occur in Women
Intervention for somatic disorders
Unnecessary and unneeded surgery and tests is common
CBT
Pain management techniques
- Imagery
- Stress management
- Family training
- Relaxation techniques
- Engagement in health Occupations
Meds
- Anxiety
- Prozac, Paxil, Zoloft, others
Impact to FUNCTION
- Impaired ADLS
- Inability to care for children
- Over attention to health management
- Rest and sleep –impaired, too much not enough
- Education-high drop out rate
- Work-unable to concentrate, do physical work or attendance issues
- Play and Leisure-same as education and work
- Social-focus on themselves and illness, withdrawal from al other
Feeding and eating disorders
Has nothing to do with the feeding process (Dysphagia)
Anorexia Nervosa
Bulimia Nervosa
Binge Eating
Pica
Rumination
Avoidant/Restrictive food intake disorder
Anorexia Nervosa
Distorted body image
Failure to maintain body weight
Fear of gaining weight
Calorie restrictors, exercise anorexia, geriatric anorexia
Atrophy, bone loss, loss of menstruation, men and women
1%-men and women, all ages, most deadly
Bulimia nervosa
Distorted body image
Binging and purging
Laxatives or diet pills
Vomiting
Issues: teeth, ulcers
young adults 1.5%, 10 x the diagnosis in women, mostly young adults and adolescents
Binge eating
Like bulimia but don’t purge or use laxatives
Leads to obesity
1.6 %, more women than men, all ages and races
Pica
Eating non foods
Chalk, ash, dirt, hair
all ages and cultures, small percentage, difficult to study, more common in southeast
Rumination
Rarest eating disorder
Like a bird
Regurgitation and reswallow
Not able to control
very rare, no real numbers
Avoidant/restrictive food intake disorder
This area is expanding
May be due to sensory issues
May severely limit the type of food
Not weight driven
- Sensory, emotional, unpleasant experience, belief
Start as perfectly normal diets
1.5-5% youth to adults
Biggest eating disorder in the US
Etiology and prevalence of eating disorders
Complex mix of:
- Cognitive, emotional, genetic, environmental, trauma and other factors
- Link to other Psychological issues
* OCD, Depression
Over 30 million people in the US
Diagnosis and intervention for eating disorders
Diagnosis
- Difficult-shame-manipulation
- For all-symptom appearance (dental issues or nutritional insufficiency)
Interventions
- Psychological
* CBT and Family based therapy
* Role of occupational therapy
How do eating disorders impact function?
ADLS and IADLS-every thing focus on food, may end of with NGT
Poor Health management
Education/Work -lower academic and work performance
Play and Leisure-over exercise, avoid places of food, impact to family and friends
