Psychiatry study note. Suicide Assessment Learning Outcome: - Relevance for Occupational Therapists? Historical and cultural factors Reasons for suicide: Depression, BMD (bipolar mood disorder), BPD ( bipolar personality disorders) , psychosis, substances Emotional distress/psychic pain, sadness, anger, anxiety, shame, isolation Loss of hope Revenge/Anger/Protest/Self sacrifice Hallucinations/Delusions Intra-personal and Inter-personal Altruistic: “My family will be better off if I'm dead” “Rational Suicide” Assisted Suicide Adolescents: Denial of death, “All or nothing” thinking, Impulsivity Suicidal - Feelings? Thoughts Intentions/ Plans Actions, Past , Recent and Current Stressful for therapist, recognise possible negative countertransference: Malice vs Aversion Ambivalence/Mixed feelings - Suffering vs Anger Help vs Death Suicide Challenge “Manipulation” vs Help Seeking Dependence vs Independence Impulsive or Planned Reasons why people don’t talk about suicide - Shame/embarrassment Stigma Taboo Fear of being labelled mentally ill Fear of being made to stay in hospital Don't want intervention/help Lack of feeling of trust and understanding from clinician Why talk about suicide? - Reduces the risk of suicide Builds trust and cooperation between client and therapist Helps client to engage cognitively with difficult emotions Enables risk assessment and management planning When and how to discuss suicide - Always (don't avoid, won't “give client the idea.”) On cue, follow the cues in the client’s conversation Use plain language (not vague or euphemisms) Build trust—non-judgemental listening Normalise--- a counselling technique Phase in—from, “Does life worthwhile to you?” to, “Do you think you want to kill yourself?” “Did you think of a method to kill yourself?” Stick with it, come back to it, get to the bottom of it Avoid an inadvertent suicide challenge Suicide Risk Assessment “ SAD PERSONS” - Sex Age Depression Previous attempt Ethanol use Rational thinking, loss of it Social supports, lacking Organised Plan No Spouse Sickness No Hope Scale - No Motivation for Life/Hope Overt Change in Clinical Condition Hostile Interpersonal Environment Out of Hospital Recently Personality Factors Excuses for dying “CASE” Chronological Assessment pf suicide events ( S C Shea) - Presenting events Recent events Past events Immediate events Care Needs - Continuity: Therapeutic relationship can be protective, schedule follow up with yourself as soon as is necessary according to the risk Build therapeutic relationship, hear the story Arrange family/caregiver supervision as needed Involve MDT (diagnostic assessment and therapies/social work) Follow up, Realistic hope not empty reassurance Psychiatric assessment, treatment, admission- voluntary or involuntary Therapists care needs - Most therapists working in mental health will have to deal with suicide amongst their clients at some stage of their career. Suicide of a client is stressful to the therapist. Therapist usually try their best to prevent suicide, but many suicides are not preventable. Self-reflection is needed around themes of perfectionism or “rescue fantasies”. Countertransference difficulties should be managed via clinical supervision. Therapist’s own therapy will be helpful. Eating Disorders Learning outcomes: - Introduction Classification Epidemiology Aetiology Clinical Features & Complications Co-morbidity Management Course and prognosis Legal and Ethical Issues Eating disorders are: - Common Often complex and challenging Can be lethal Often missed Can be treated effectively Essential features are - Abnormal eating behavior Disturbed perception of body size / weight Distinguished from abnormal eating behavior / weight associated with - General Medical Conditions Other Psychiatric Disorders Classification-DSM 5 - Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge Eating Disorder Other “eating disorders” - Obesity Pica (eating non-food items) Rumination (regurgitating and re-eating) “Bigorexia” – Muscle dysmorphic disorder “Orthorexia” – Fastidious healthy diet Epidemiology - Predominantly adolescents / young adults Female > Male SA data is sparse Anorexia Nervosa relatively rare (0.1 - 0.5%) Bulimia more common (1 – 4%) Sociocultural factors - Value placed on slimness Apparent increasing incidence in black S Africans Role of media Occur in societies where food is plentiful Aetiology - - - Biopsychosocial Model Complex range of causes Biological o Genetics o ?shared with other Psych disorders eg Depression / OCD o Neurochemical / Endocrine factors. Psychological Factors o Attachment issues o Disturbed self-concept / identity o Issues with autonomy and control o Perfectionism / Obsessiveness Social / Cultural Factors o Value attached to slimness, achievement, autonomy o Role models / Media pressure o Social change / Globalisation o Professional risk factors Clinical features - - - - - Anorexia Nervosa is an eating disorder characterized by self-starvation o Person’s weight is 85% or less of normal weight (BMI < 17.5) o Person has an intense fear of gaining weight o Person has a distorted sense of their body shape (body image) o Amenorrhoea (in females) o Fatigue / Cold intolerance / Lanugo hair Two types of anorexia nervosa: o Restricting type loses weight by severely limiting the amount of food consumed o Binge-eating/Purging type engages in binges (large amount of food consumed) following by purging (vomiting or use of laxatives) Bulimia nervosa involves episodes of rapid overeating followed by compensatory behaviour o A binge is defined as eating an excessive amount of food within two hours o Compensatory Behaviour refers to Purging (vomiting, laxative abuse), fasting or excessive exercise Bulimia also involves a fear of gaining weight Subtypes o Purging o Non-Purging (eg excessive exercise) Binge Eating Disorder involves o Recurrent binges (once a week for at least 3 months) o Lack of control during the binge episode o Associated emotional distress - Binge Eating Disorder does not involve o Loss of weight o Compensatory behaviors of purging Co-morbidity - Common Restricting anorexia – Anxiety Disorders / Cluster-C PD Bulimia and Binge/Purging anorexia – Mood Disorders / Cluster-B PD Risk of suicide / DSH Substance Abuse incl laxatives Medical complications - - Restricting Anorexia o Amenorrhea / infertility o Abdominal pain / bloating / constipation o Cardiac arrhythmias o Dehydration / electrolyte imbalance o Hormonal disturbance o Renal failure Binging / Purging o Laxative damage to the heart o Parotid enlargement o Peptic ulcer / esophageal tears o Dental erosions o Gastric rupture o Knuckle abrasions Management - - - Biopsychosocial Multidisciplinary Team incl OT / Dietician In-patient or Out-patient Involve family / collaborative approach Go slow / go cautiously Biological o Medical / Nutritional assessment o Medical derangements often corrected by restoration of normal eating o Full psychiatric assessment / exclude co-morbidities o SSRI’s (eg Fluoxetine) and Benzo’s Psychological o Therapeutic alliance o CBT – address underlying cognitive distortions and correct pathological eating behaviors o Interpersonal therapy – some evidence o Need to manage usual poor insight and resistance to change o In-patient therapeutic milieus / groups o Encompass broader context – family, social networks Psychological (contd) - o o o o o o Social o o Family work a key aspect Address enmeshments Enabling behaviors Possible past abuse Maintaining healthy eating Relapse prevention Support / advocacy Reshape societal values Course and prognosis - - - Tend to be chronic Slow, stepwise improvements Dramatic change can be counter-therapeutic Usually out-patient setting Admit if o Worsening health o Rapid weight loss o Emotional / cognitive decline o Suicidal ideation o Inadequate supports at home Most respond positively to treatment Vital to make early diagnosis and commence treatment promptly Adolescents o 50-70% recover o 20% improve o 10-20% have chronic disturbance Mortality o 10-15% Anorexia patients o High rates of suicide Legal and Ethical issues - Confidentiality and consent in adolescents Poor insight and resistance to treatment may require involuntary care Conflicts of interests when working with families may require independent mediation Countertransference / MDT team dynamics End of life issues Conclusion - Eating disorders are common Associated with significant morbidity and mortality Not necessary to be overwhelmed / pessimistic - If treated early prognosis is surprisingly good Important to adopt a collaborative approach with patients and their families Chronic Pain Types of pain - Idiopathic Nociceptive Neuropathic Mixed Acute Pain - short duration, abrupt onset universal understandable in terms of a response to a harmful stimulus single cause biomedical model appropriate accurate diagnosis and prognosis more easily treatable Chronic Pain - persists beyond the time expected for resolution, gradual onset not universal less understandable in terms of a response to a stimulus multifactorial biomedical model inadequate diagnosis and prognosis uncertain less easily treatable Mechanisms of transition Conceptual issues - physical or psychological sensation or experience pathological or physiological a problem in itself or a symptom with a cause no biological markers nor objective measures metaphors Definitions of pain - - “Pain is that sensory experience evoked by stimuli that injure or threaten to destroy tissue” “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage….pain is always subjective…activity induced in the nociceptor and nociceptor pathways by a noxious stimulus is not pain.” “Pain is a multidimensional phenomenon involving sensory, affective, motivational, environmental, and cognitive components.” “The expression of human suffering in physical form, or in the idiom of medical symptomatology.” A model for acute pain? - straight through, direct transmission intensity proportional to the stimulus implication: patient passive, controlled by the stimulus treatment: removal of stimulus, interruption of pathways results (chronic pain): disappointing, pain returns, new pains emerge A Ratiep ceremony - Iraqi, Indonesian origins A rite within the Islamic mystical tradition of sufism Cutting and piercing without evidence of injury No evidence of pain No evidence of trance, or dissociated states: “not mind over matter, but an expression of faith” and the transcendence of the soul A practical approach to medically unexplained symptoms or symptoms out of proportion to known underlying pathology. - undetermined general medical condition depressive spectrum disorders somatoform disorders factitious disorders malingering - psychotic disorders Somatoform disorders/ Somatic symptom disorders - Physical symptoms suggest a general medical condition Not fully explained by general medical condition, direct effects of psychoactive substances, or another mental disorder Cause significant distress or impairment of social occupational and other areas of functioning Symptoms not intentionally produced, or under voluntary control Somatic symptom disorders - PAIN: disproportionate, vaguely described in emotional terminology, constant or deteriorating, resistant to treatment, with other symptoms in other systems PATIENT: anxious, depressed, angry, helpless, somatic conviction, personal history of abuse, family history of pain. PSYCHOSOCIAL CONTEXT: acute and/or enduring stressors Depressive spectrum disorders - BIOLOGICAL: sleep, appetite, sexual interest, energy, pain COGNITIVE: hopelessness, worthlessness, guilt AFFECTIVE: depression, anxiety, irritability BEHAVIOURAL: apathy, agitation, withdrawal Factitious disorders malingering - Factitious disorders: the intentional production for symptoms for an internal need Malingering: the intentional production of symptoms for an external incentive (“nothing wrong”…> “all in the mind”…> “not real”…> malingering > anger / breakdown of therapeutic alliance) Aetiological formulations of pain Biological Psychological Social Medical Predisposing Genetic Lack of care in early childhood/abuse Family history of illness Precipitating Injury at work Traumatic/stressful event/loss Response of others/employer Culture of modern medicine Medical responses/ investigations Perpetuating Immobility/obesity Fear/anger Disability grants/ compensation claims/ reinforcement by others Focus on somatic symptoms/neglect of psychosocial factors Levels of Iatrogenesis - What we do: inappropriate investigations > inappropriate surgery > harm What we say: “there is nothing wrong” > implication of malingering > mistrust > entrenchment / escalation of symptoms What we think (dualist paradigm): no evidence of GMC > “all in the mind” > no problem (in terms of reductive biomedical paradigm) > symptoms dismissed Paradigm shifts A practical guide to management - prevent (symptom entrenchment/iatrogenic harm) acknowledge promote identify perpetuating physical, psychological and social factors explain (integrating biological and psychosocial factors) negotiate appropriate goals cognitive behavioural strategies / appropriate medication monitor / review Key points - Pain a subjective, multidimensional experience Not simply psychological or physical Pain response is not proportional to stimulus: augmenting, modulating and perpetuating factors intervene. Treatment multifactorial, multidisciplinary Rehabilitation / coping more appropriate than notions of cure. Introduction to mental heal care of people with intellectual disability. Case study :“Dominque” - - She lives with her elderly parents in Fish Hoek. The parents describe a change in her behaviour for the past month with temper tantrums, swearing, restlessness at night, crying and refusing to go to a weekly social and OT activity group that she usually attends. Prior to this she had been excited to go to this group, saying that one of the facilitators is in love with her. Questions - 1. What could be the matter? ( Differential Diagnosis) 2.Which health professionals should be involved? 3. How should her parents respond to her report of her romantic interest? 4. Dominique’s parents hear of her ID diagnosis when she is 2 years old. What counselling help might they need ? What is intellectual disability? Intellectual Disability (ID) or Intellectual Developmental Disorder - Impaired intellectual function Impaired adaptive function Onset in developmental period (before 18 years) Developmental focus/ environmental focus. Causes of ID - Prenatal Perinatal Postnatal Toxins Infections (Especially Meningitis and HIV) Trauma Genetic - nonspecific (familial) o Chromosomal o X linked o specific gene Effects of ID/Response to ID - Individual Family Society: o Health o Education o Social services DSM 5 Intellectual Disability (intellectual Developmental Disorder) Diagnostic Criteria - - Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three criteria must be met: o A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing. o B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community. o C. Onset of intellectual and adaptive deficits during the developmental period. Intellectual function / Adaptive function - IQ tests Verbal Non-verbal Vinelands adaptive behaviour scale Degrees of severity of ID: Prevalence Rates - DSM 4 links severity of ID with IQ scores Mild --IQ 50-55 to 70 2-3% of population Moderate --IQ 35-40 to 50-55 4 per 1000 Severe --IQ 20-25 to 35-40 1 per 1000 Profound --IQ below 20-25 Mild ID • • • • • • • Moderate ID • • • • • • • • Severe ID • • • • • • • Profound ID • • • • • IQ 50-55 to 70 Mental age 7-10 years 85 % of people with ID have mild ID Educable (can be literate – may attain up to Grade 6) and be socially competent, but may need support in times of stress Develop social and communication skills in preschool and usually have minimal sensorimotor impairment ID usually only picked up at the start of formal schooling Cause of ID often not known in this group IQ 35-40 to 50-55 Mental age 5-7 years 10% of people with ID ‘Trainable’ – can acquire vocational skills and work in unskilled or semiskilled protected environments Acquire communication skills during childhood Can attend to personal care with moderate supervision Unlikely to progress beyond grade 2 Need to live in supervised settings IQ 20-25 to 35-40 Mental age 3-5 years 3-4% of those with ID Little speech during childhood but may learn to talk May acquire some self-help skills (brushing teeth, washing, dressing, toileting, eating with utensils etc) May learn to count and sight read a few words Need to live in fully supervised settings IQ below 20-25 Mental age 3 years and below 1-2% of those with ID Show profound or considerable impairments in sensorimotor functioning in early childhood Will struggle with basic activities of daily living Important Syndromes - Down Syndrome Fragile X Syndrome Prader-Willi Syndrome Tuberous Sclerosis 22q Deletion Syndrome/VCF Synd. Foetal Alcohol Syndrome TB Meningitis Behavioural Phenotypes - Foetal Alcohol Syndrome Down Syndrome Fragile X syndrome and sex chromosome syndromes 22q Deletion Syndrome/Velo-cardio-facial Syndrome Prader-Willi Syndrome Tuberous sclerosis TB Meningitis? Down Syndrome 1. 2. 3. 4. 5. 6. Fragile X Syndrome 1. 2. 3. 4. 5. Prader-Willi Syndrome • • • Physical Phenotype Behavioural Phenotype Co-morbidity: - Medical - Psychiatric Velo-cardio-facial/22q11.2 Deletion Syndrome • • • Microdeletion at 22q11.2 site 1 in 3000 births Cardiac, palatial, facial malformations, hypoparathyriodism, thymic hypoplasia, urinary system abnormalities, haematological problems Language and motor delays in children, autistic traits 40% have ID Behavioural phenotype: -poor social skills, psychotic disorder (20-30% and 1-2% of people with schizophrenia) Bipolar disorder (60%), ADHD (36%) Mutation on the X chromosome at the fragile site Incidence 1 in 2200 Mild to severe ID Physical phenotype Behavioural phenotype and neurological abnormalities 6. Females usually less impaired • • • Tuberous sclerosis complex • • • • • • Foetal Alcohol Syndrome Variants Range Intellectual Disability Physical phenotype Development and behavioral phenotype Associated medical problems Incidence • • • • Spontaneous mutation (70%) or autosomal dominant (30%) 1 in 5800 births Characteristic facial skin lesion may be present Multisystem involvement, 80% have epilepsy, 50% have ID, 40-50% have ASD and 30-50% have ADHD and many have anxiety and mood related disorders. Brain or renal tumours can cause medical crises. Medication with mTOR inhibitors is being researched Physical features Cognitive and learning problems. Behavioural problems Social/health care costs Response of the family/ effect on the family Family - - Loss: o Grief o Guilt o Shame Ambivalence: if not dealt with leads to adverse emotional environments and care giver burnout Counselling and professional support needs Recognizing ambivalence - - Parents and families usually have to deal with ambivalent feelings towards disabled children including anger, guilt, shame or even disgust or hatred together with their ordinary feelings of love and care. The negative emotions may be disavowed but could be expressed in overprotection or stiltedness in their interactions or in feelings of stress or exhaustion. Caregivers and health-care staff face a similar mix of positive and negative emotional reactions to being with or working with disabled people. Awareness of these reactions is needed in order to avoid “burnout” and to maximise clinical effectiveness. Family Grief - Parents and families also face a kind of grief when they become aware that their baby cannot fulfill their hopes and dreams and they might feel guilty about their disappointment. Role of health professionals - - Psychological support for parents can enable them to provide the best possible nurturing environment. All healthcare professionals, not just psychologists or psychiatrists, should express explicit respect for the mixed feelings and disappointment families are likely to experience. Parents need reassurance of availability of comprehensive ongoing services and they need to be given hope that their child’s development can be supported. Effects on the individual - Self esteem Stigma and discrimination Hardship, vulnerability and risk of exploitation Medical/Neurological comorbidity Psychiatric comorbidity Self -Concept in the context of ID - Most people with ID are aware, to a greater or lesser degree, of their disability, which affects self esteem. Self esteem is also affected by failures in various areas like education or social and occupational achievement. Secondary Disability - An additional limitation or an exacerbation of a primary physical, cognitive or psychological disability caused by experiences relating to the primary disorder This may be self imposed or develop in the context of lowered expectations on the part of important people in the subject’s life Defensive behavioural characteristics not intrinsic to the condition. These challenging behaviours develop over time as a function of a poor fit between the person and his environment. Stigma - - Potential to subsume identity and individuality o “I am a (…)” instead of o “I am affected by or suffer from (…) but I am person in my own right.” Set of negative expectations associated with a devalued subgroup or category. Like prejudice. Stigma can cause worse suffering than the primary condition. Anticipated stigma Self-stigma Enacted stigma Management of stigma - - Therapeutic encounters are likely to confirm or disconfirm the patient’s anticipated stigma or self stigmatizing thoughts – hence stigma should be attended to in all clinical activities whatever the presenting problems Treat patients with dignity and respect Make no assumptions- allow the patient to make a fresh impression without being influenced by previous diagnoses or assessments Promote maximum collaboration and autonomy Focus on individual disability/mastery and avoid use of technical or diagnostic terms which can categorize or label Advocate for patients’ rights and rights to treatment Stigma Venn Diagram Comorbid Psychiatric Disorders - - Reasons for high comorbidity rates: o Coping ability/stress/adverse events/adverse environments/vulnerability to abuse o Behavioural phenotypes o Diagnostic issues and Diagnostic Overshadowing Higher incidence ASD, ADHD and Disruptive Disorders, Psychotic Disorders, Mood disorders and Anxiety Disorder are common Can have any psychiatric disorder as in the general population, but may be harder to diagnose Medical/neurological comorbidity - Syndrome specific vulnerabilities Epilepsy Sensory deficits Cerebral palsy Response from society - Rights in the Context of Vulnerability? Human rights of people with intellectual disability (1) - Declaration on the Human Rights of Mentally Retarded Persons: “The mentally retarded person has, to the maximum degree of feasibility, the same rights as other human beings”. General Assembly of the United Nations 1971 Human rights of people with intellectual disability (2) - Autonomy Participation Normalization –including relationships Protected environments Rehabilitative services Impairment, Disability and Handicap - Impairment: Loss of psychological, anatomical or physiological function or structure (e.g. impairment in cognition) Disability: Loss of functional skill as the result of an impairment Handicap: Inability to fulfill a normal role in society as a result of a disability Influence of environment on disability: Impairments can be handicapping or not depending on how the environment is structured. Environments can be adapted to suit ability levels and adapted to optimize development and learning of skills. This refers to both the physical conditions as well as the functional skills required of an individual. Rehabilitative services and healthcare - Multidisciplinary team Examples of multidisciplinary work in ID services - - Medical/psychiatric- Medical comorbidity, Psychiatric diagnoses, Psychopharmacology, counselling Psychology- Psychotherapy, family therapy, parent counselling, Psychometric assessments Occupational Therapy- Functional assessments, behavioural assessments, stimulation plans, communication assistance, liaison with special schools, parenting skills, social skills, appropriate sexual behaviour, work assessments Speech therapist- verbal skills, drooling, swallowing problems Social work- Family support, liaison with community services, accessing gov. grants, housing, custody, adoption and fostering Physiotherapy- Mobility, balance, coordination, seating, posture, exercise therapy, weight loss Nurses- Parenting skills, basic skills- toileting, eating, dressing, inpatient care and observation Dietician- neurological eating issues, fussy eating , weight loss. Case: Abduraghman 5 Yr - - - - Referred from Red Cross Hosp. to LH ID Outpatients with problems of tantrums, hyperactivity, not talking. Lives with 8 yr old brother and mother in Wendy House in yard of mother’s family. Mother unemployed. Premature birth. Delayed motor milestones. Delayed speech. Unilateral hearing loss. Not yet toilet trained. CT scan indicated hydrocephalus and a ventriculo-peritoneal shunt was inserted. Abduraghman has a big head but is not dysmorphic. He is hyperactive, friendly but does not speak. Mother is tearful. She wakes at 3 am in fear. She is tired, irritable and sometimes spanks the patient. She says she is at the end of her tether. The brother is well behaved and cooperative. He tries to comfort mother if she cries. Stress factors: Father was murdered 4 months ago- shot by men known to the family at 3 am outside the door. The family relocated to mother’s family home- overcrowding. There is a poor relationship between mother and her siblings and no involvement from late father’s family. Task: Consider possible diagnoses for each family member and assign tasks to multidisciplinary team members to manage the case. Practical Approach to Behaviour Change 1.Check for physical illness 2. Check for side effects of medication 3. Address environmental problems and self efficacy issues - Provide emotional warmth, care and respect - Improve communication - Increase autonomy, self-determination and self-help skills 4. Check for psychiatric illness and treat using - Bio-Psycho-Social model 5. Consider possible behavioural phenotypes 6. Apply Behaviour modification techniques Functional analysis- positive and negative re-enforcers -Consistent consequences -Time Out and restitution Summary - Concept of ID Degrees of severity of ID Causes of ID /Syndromes associated with ID Developmentally Friendly Environments Effects of ID and the response of the Individual, Family and Society Human Rights and people with ID Psychiatric and Medical Comorbidity Practical Approach To Behaviour Change HIV and Mental Health Aim: To reduce Morbidity and Mortality Associated with HIV infection and co-morbid mental disorders: 1. Minimizing Disorders / Behaviour that lead to HIV acquisition 2. Ensuring early HIV testing and engagement in care by reducing stigma / mental disorders 3. Reducing the incidence, prevalence and severity of Mental Disorders in PLWHA, to ensure ART adherence 4. Addressing secondary / tertiary prevention in Mental Disorders and HAND, through support, rehabilitation and addressing co-morbidities Notes: - Knowledge and awareness of the impact of mental disorders in persons living with HIV is critical to several key health outcomes. Firstly, we know that HIV is usually acquired through some form of risky behaviour. The majority of infections occur either through sexual intercourse of some kind or through infected needles during intra-venous drug use. Far fewer infections these days occur through mother to child transmission (otherwise known as vertical transmission), but the original infection of the mother would have been through sexual intercourse. Any behaviour or mental health condition that leads to diminished ability to make good judgements, decrease risk or negotiate interaction, could lead to infection. The second reason to deal with mental disorders in the context of HIV, is to reduce barriers to HIV testing and care engagement. These barriers are often due to stigma and shame associated with acquiring or having HIV. A third reason is to reduce the development and impact of mental disorders when they do occur. Effective treatment of a mental disorder in a person living with HIV might have a significant impact on health behaviour such as adherence, and retention in care. Lastly, when mental disorders are present, we want to be able to reduce the impact on quality of life, and try to ensure that systems are in place to improve symptoms, improve function, and improve coping. Assumptions 1. You know what a “mental disorder” is (and a “phenomenon”) 2. You know that Mental Disorders (aka Psychiatric Disorders or in this case Neuropsychiatric Disorders) can have multiple causes / aetiologies 3. You know that Mental Disorders have an impact on function and quality of life 4. You that HIV is an infectious agent, chronic, affects the immune system and multiple organs, is treatable but not curable at this point Notes: - Before we proceed, I want to ensure that you have covered certain material which you will need to develop a full understanding of this topic. Specifically, I am going to assume that you know what a mental disorder is. And within that, what a behavioural, psychological, or emotional phenomenon is. I am also going to assume that you have received lectures on several of the mental disorders, and that you appreciate that any mental disorder may arise in someone for different and multiple reasons. I am further going to assume that I don’t need to convince you that when a mental disorder is present- in fact to properly diagnose a mental disorder- some degree of functional impairment and/or significant clinical distress must be present. And then in terms of HIV itself, I am going to assume that you are relatively well informed. In this regard, you will know that HIV is an infectious agent which impacts the human immune system, and through that, is a multi-organ disease. But is is also treatable through anti-retrovirals, although not curbale. State of the HIV Epidemic: SA - We live in the global epicentre of HIV infection. But fortunately it is an evolving epidemic. Southern and Eastern Africa carry more than half of the global burden of persons living with HIV. We also have the largest anti-retroviral program in the world, with over 70% of persons accessing therapy. We do however, also have ongoing infections, with many of these occurring in younger women. So while the epidemic is being limited by reduced numbers of new cases, the overall number of persons living with HIV rises, as life expectancy increases. The Care Cascade: SA - The World Health Organisation has been promoting its 90-90-90 goals for some time. A newer set of goals, namely 95-95-95 has more recently been proposed. The first 90 refers to 90% of individuals knowing their HIV status. This does not take people who have been tested but refuse to believe the result into account. The second 90 refers to 90% of people accessing care and initiated on anti-retroviral therapy. This is the 72% I referred to in the previous slide so the treatment gap is 18%. Why do people who know their status not take treatment? In many cases the answer is through a mental disorder or psychological barrier. The last 90 refers to 90% of people taking ART who are virally suppressed. The gap between this and those initiating ART is about 7%. And again, much of this gap is explained through mental disorders, but also through structural barriers such as treatment and clinic access, distances to clinics, and migration. HIV and Stigma - One of the main barriers to HIV testing and care engagement has been identified as stigma. Stigma refers to the experience of being marked, dirty or perceived negatively through having HIV. Stigma may be external, of others express stigma towards you, or internal, if you feel or think badly of yourself. The HIV stigma index includes 7 questions, listed on the right, first developed in 2005 by Dr Olive Shisana and colleagues. The index has been used in several national HIV prevalence surveys. In the 2012 survey, we showed that a third of people reported at least some form of stigma towards others. In the wide southern and eastern African region, 32% of people endorsed the idea that they would not purchase vegetables from a shopkeeper known to be living with HIV. These stigmatizing attitudes lead to barriers in people testing and access care. Mental Illness and Stigma - In the same way, many people hold stigmatizing attitudes towards people living with a mental disorder. You might have your own reaction to these slides. You may consider people who inject drugs or drink excessively to be dirty, foolish, and weak-minded. Those who cry or feel depressed might be weak or unable to cope. While those who report psychotic symptoms are crazy, mad, or not be associated with. All of these attitudes, which exist even in healthcare providers, are incorrect, and lead to persons living with mental illness to experience shame and stigma, and not seek help. Why is mental Health and Behaviour so Important in HIV prevention and care - - HIV is ACQUIRED by means of BEHAVIOUR o Unprotected heterosexual concurrent intercourse o Unprotected other intercourse o Drug use (needles, sharing) >HIV care engagement (testing, pill-taking) is mediated mainly by BEHAVIOUR >HIV INFECTS the brain, and AFFECTS the brain Notes: - People often think about HIV in terms of numbers, data, graphs and figures, But these seldom do justice to the critical human and behavioural element to care pathways. All aspects of HIV: its acquisiting, testing, care engagement, and adherence, rely on a persons knowledge of their condition, of the risks of HIV, awareness of ART and its effects, and how to communicate when they are having difficulties. In South Africa, the majority of persons living with HIV are poor, live in peri-urban settings, and rely on state services, public transport, and limited job opportunities. Bio-psycho-social determinants of mental/neuropsychiatric disorders Notes: - So at this point, we move to talking more directly about HIV and mental disorders, or Neuropsychiatric Disorders. I have made the assumption that you (a) know what a mental disorder is, and (b) that you are aware that mental disorders can have different causes and aetiologies. A person’s genetic make-up and early life experiences are a significant determinant of many mental disorders, even those that develop later in life. On top of this, people experience what are known as psycho-social stressor, such as relationship or job losses. Then, they live in a general context, often of deprivation- where education is lower quality, housing is limited and crowded. In more recent times, the experience of COVID and restrictions, with job losses, are an added stress. All of these factors, some weighing more than others, may cause a mental disorder to arise in a person. Notes: - In someone living with HIV, you then add in the infectious agent, which we now know might invade and infect brain cells. Persons with HIV often endure additional hardships, as they experience further losses and bereavements, the stigma of living with HIV, and the additional burden of living with a chronic disease and its impact. This places persons living with HIV generally at greater risk of developing a mental disorder, than someone in the general population. What is the relationship between HIV and Mental disorders? - Infection with HIV may lead to several biological effects on the brain and related functions. It may cause direct neuro-inflammation, immuno-compromise may lead to secondary infections and tumours, and then there is the stress of living with HIV, as I mentioned in the previous slide. People living with mental disorders may develop poor judgement and insight as a result of the condition. They may make poor decisions, some of which might result in risky behaviour such as unprotected sexual intercourse. People with related cognitive problems may not only be forgetful, but also not plan their daily activities such as clinic visits. This may lead to poor adherence and missed clinic visits. And so you can see how HIV may cause or aggravate a mental disorder, while having a mental disorder may place a person at risk of HIV (if they don’t have it), or of coping poorly with HIV care, if they do. Untreated NeuroHIV causes HIV encephalitis. - This slide is to illustrate the neurological effects of HIV on the brain in someone who is not taking ART, and is immuno-compromised. HIV has widely infected the brain but mainly int the subcortical areas- this includes the regions below the grey rim of tissue on the outside, to the edge of the dark ventricular system. The white areas represent inflammation of the white matter. In this case, the frontal lobes (top part) and occipital lobes (bottom part) are mainly involved. Prevalence of Psychiatric Disorders in PLWHA - These are data from the early 2000’s- so before ART became widely available in South Africa. The pink columns represent prevalence data for HIV samples- the HCSUS in the USA and the HSRC from South Africa- and the columns on the right are general population surveys. You will notice significantly higher rates of major depression and also minor depression when it was measured. Also high rates of anxiety, although less in South Africa. PTSD was not reported on, and then alcohol use disorders which are actually very prevalent in many population surveys. Note that there were some difference in how the diagnostic information was obtained and this may affect the prevalence data. (Neuro) Psychiatric disorders and DSM-V - Criterion A: Characteristics of the syndrome [e.g. low mood plus others] Criterion B: Clinical distress or social / occupational dysfunction [e.g. cant work] Criterion C: Other psychiatric disorder exclusion [e.g. dementia] Criterion D: Substance use / General Medical condition exclusion [e.g. drinks] Notes: - Just to remind you of the DSM5 approach to psychiatric disorders. The presence of a symptom or phenomenon, together with distress or impairment is needed to make a diagnosis. The presence of another psychiatric disorder, or an organic cause changes the diagnosis. For example, if someone had major depression and HIV infection, you would diagnose a Depressive Disorder due to HIV infection, rather than saying purely “major depressive disorder”. The implication is that HIV is the cause of the depression, and it treated, the condition would resolve. In reality, this is not necessarily the case, and many persons living with HIV are effectively treated, but remain depressed for psycho-social (and perhaps even genetic) reasons. Neuropsychiatric syndromes/disorders in HIV - Depressive disorders: mild to severe; MDD vs adjustment disorders Stress and Anxiety Disorders Substance and Alcohol Use Disorders Severe Mental Illness: Psychotic disorders and AIDS Mania Neurocognitive disorders (including dementia and delirium): 15-20% Anti-retroviral induced disorders: “at least ONE moderate or severe side effect Efavirenz in 35%” Depression in HIV - Depression= a syndrome of low mood, anhedonia, thoughts of death and other neurovegetative Sx Common throughout course of disease: lifetime prevalence MDD in HIV 20% to 2x higher than general population Effects: Poor adherence, poor quality of life and accelerated HIV disease Nodal points: Dx, bereavements, stage 4 Suicidality: Thoughts of dying, desire to die, intent to die, planning: 9% in TBH ARV clinic; 35x risk in AIDS (New York) Notes: - Depression is a syndrome of low mood and anhedonia, with a range of other vegetative and cognitive symptoms. It is highly prevalent in persons with HIV, and is thought to occur at a lifetime rate of 12-20% of persons with HIV. There are points in time when stressors may predispose to depression: at diagnosis and disclosure, when illness is experienced, or losses occur. Suicide is a symptom of depression but does not occur exclusively within depression. It is a phenomenon that has proven very difficult to predict, let alone prevent. Nonetheless, the active identification and treatment of all mental disorders is a good start to suicide prevention. Other risk factors include isolation, shame, alcohol abuse and chronic pain. Depressive Disorders: The continuum in HIV - Depression does not occur in discrete lumps, of either symptom number, symptom severity or duration. The DSM uses somewhat arbitrary symptom number and duration cut-offs to describe major vs minor depression. In reality, people develop negative emotions, feel miserable, rejected or hopeless for varying periods of time. Sometimes persistent symptoms lead to disorders by virtue of their long duration and impact on functioning. One must not forget very common adjustment disorders, dysthymia and minor depression- thought to occur in about 25% of persons with HIV in their lifetime. Adjustment and Anxiety Disorders: The Response to “stress” - Humans have a very diverse response to stress, and specifically a single major stressor. When the stress involves a specific event with a strong element of threat to life or self, accompanied by an emotional reaction, the acute stress disorder may develop. This will usually resolve in days to weeks, depending on whether the threat persists or has been removed. An example would be a rapist who lives in the same road, vs a serious car accident that happened once. Some people will go on to develop post-traumatic stress, where the memory and its related emotional content, continue to intrude into awareness in an unwanted way. This may be associated with hyperarousal as the person continues to feel threatened, and avoidance of the situation or places where the threat may have occurred. In South Africa, about 50% of women report a sexual trauma and a significant proportion of those will have both HIV infection and PTSD. Adjustment disorders are generall associated with mood or anxiety symptoms, and follow a psycho-social stressor, typically a loss or change. Examples for people living with HIV include receiving the diagnosis, developing illnesses, job losses, or bereavements. Many people with adjustment disorders will recover spontaneously, when the stressor abates, but some will require counselling or even antidepressant treatment. - This slide illustrates what happens to people starting anti-retrovirals and after 6 months. In the top bar chart, you will see that people with alcohol and substance abuse problems when they start ART- in blue around 38%- tend to still struggle after 6 months of ART, with about 18% still using. So alcohol and drug use among people with HIV would be a good screening and intervention target at baseline. The picture with psychological distress, using the Kessler10 scale is slightly different. In this case, about 24% of people report significant distress when the start treatment, but only about 8% remain distressed after 6 months. It is likely that once they take ART, feel better, and become accustomed to living with HIV, their symptoms improve. So full-scale screening for distress at ART initiation may not be a cost-effective strategy. Alcohol ( and substance Abuse) - The impact of alcohol use disorders on the HIV care cascade is marked. In this diagram it can be seen that alcohol has an impact on several areas of the cascade. In africa, there is an unusually high prevalence of binge-drinking (at 25%) compared to other regions. Data on how drinkers engage in care is mixed. Globally drinkers are very often poorly adherentRehana Kader published a cross-sectional study of 1500 South Africans which showed that Hazardous or harmful alcohol use …predicted missing and stopping ARVs which, in turn, was associated with a decrease in CD4 counts and more rapid HIV-disease progression and poorer health outcomes in people living with HIV/AIDS. It is also clear that drinking is associated with a 57% higher risk of HIV risk behaviour. Alcohol abuse in HIV: “ I cant drink AND take my ARVs”: interactive toxicity - TBH ID clinic- 10% alchohol dependent GSH ID clinic 2007- 40% alcohol use disorder Effect on adherence, risk behaviours, liver, TB Identify: ask, CAGE, AUDIT Establish stage of change Evaluate for other psychiatric problems Motivate to change Support and/or refer Notes: - One of the challenges of alcohol abuse in HIV clinic settings is the link between binge drinking and missing ART doses, especially over weekends. In the past, messages given by counselors include the idea that alcohol and ART don’t mix. What they meant was : “if you drink you will probably forget to take your pills”; what patients heard was : “I cant mix alcohol with ARVs… so I will drink this weekend and take the pills during the week.”. It becomes important to screen for alcohol use disorder, and there are several tools you can use to do so, including the CAGE questions, or the AUDIT tool. Establishing whether your patient is motivated to stop drinking is key to whether you engage actively and refer them to counseling services. People not ready to stop will still benefit from non-judgemental messaging that alcohol can be harmful and that the clinician will assist them in recovery. HIV and severe mental illness ( SMI) - Increased prevalence / incidence of HIV in those with pre-existing, severe mental illness >Evidence for deterioration, treatment-resistance, increased side-effects to medication >“double stigma” Notes: - When we speak about severe mental illnesses, we usually talk about the psychotic disorders, such as schizophrenia and bipolar disorder. The word “severe” describes a condition that is often chronic, prone to relapse, may require admission to hospital, and has a significant impact on function and quality of life. What is known about the relationship between SMI and HIV, is that people with SMI are at increased risk of acquiring HIV, probably because they exhibit poor judgment when it comes to decisions around safe sex. People with SMI and who have HIV may struggle with daily ART adherence, and until fairly recently, clinicians were reluctant to prescribe ART to them. HIV- Associated Psychosis - >5% of late-stage, usually in association with HIV-D Small percentage occurring earlier Fluctuating level of consciousness; multiple hallucinations; mixed mood Manic picture also common Very sensitive to medication Usually do well on CART Notes: - People with SMI and HIV may develop severe immuno-compromise due to poor adherence, or non-engagement in care. These people will develop a syndrome of neuroHIV called HIVpsychosis. It is different to the psychosis of schizophrenia, because it resembles the syndrome of someone with a chronic delirium. They will display changes in awareness over hours to days; hallucinations may come and go; mood symptoms may also change over time and they may sometimes display manic symptoms. This is a different picture to schizophrenia, where the psychosis is stable over time and does not change unless treated. Persons with HIV psychosis need urgent anti-retroviral treatment, and they will usually improve over 6 weeks. They sometimes also need a course of anti-psychotic treatment, although they are sensitive to the extra-pyramidal side effects. Neurocognitive disorders in HIV - “Neurocognition” describes brain processes such as attention, language, learning and perceptual motor integration- as well the speed and efficiency of these processes Neurocognitive Impairment (NCI) common in HIV HIV infects + affects the sub-cortical structures and related circuits Notes: - Because HIV often does infect the brain, and when it is untreated, causes a widespread inflammation of the subcortical brain tissue, a neurocognitive disorder may develop. Neurocognitive refers to aspect of brain function that involve attention, thinking, language and memory. In untreated HIV, especially when people are immunosuppressed with low CD4 counts, neurocognitive impairment might occur in 1/3 to ½ of people with HIV. In untreated HIV, it is the sub-cortical white matter and deep grey nuclei that are affected. HIV-Associated Dementia ( HAD) - Usually presents late in HIV, but may be the first stage 4 defining illness 15% pre-CART; <5% on CART Essential to exclude other opportunistic CNS disorders eg. TBM; CNS lymphoma; cryptococcal meningitis Subcortical dementia: Triad of motor, cognitive and behavioural signs Notes: - HIV dementia is the most severe form of neurocognitive disorder in HIV. It is associated with severe functional impairment. In untreated HIV, it is reported to occur in 15-20% of clinic populations. In South Africa, this was prior to 2006 when ART become widely used. While we still have people not accessing care, or taking ART, it remains a problem. Once people take ART and become virally suppressed, the prevalence drops to under 5%. Nowadays it is rare to see people on effective ART with significant HIV dementia. Mild forms of impairment probably are more common, and may be the result of brain damage occurring before a person started treatment- what we call a “legacy effect”. The impact if HIV-associated neuropsychiatric disorders - Mental or Neuropsychiatric Disorders in persons with HIV may exert a marked impact at the individual and community level. The presence of psychiatric symptoms is often associated with impairments of neurocognition, as well as other aspects of social and cognitive function, such as judgement, motivation and persistence. These are usually NOT reported by patients and are hard to measure, but they DO result in significant loss of function. In the real world, these impairments may lead to a persons inability to seek work or hold down a job; manage complex tasks such as pay bills or draw money; count out and remember to take pills; and manage all the home tasks we take for granted. Impact of HIV-Ass NCI on everyday functioning - These data were published by Dr Heaton in 2004. They illustrate how people with HIV who suffer from a neurocognitive disorder have significant struggles performing a range of activities of daily living. More than half of people with a neurocognitive disorder have these challenges. Self-reported impairment – Lawton ADL - Many of our patients do not drive, use bank accounts, sign work contracts, play the piano or use computers: floor effect Many patients under-report impairment We use blunt instruments A combination of self-report, collateral report and lab-based is the gold standard Functional problems only come to light under conditions of non-adherence Notes: - Self-reported tools such as the Lawton Activities of Daily Living may guide clinicians in asking the right questions. On their own, though, these tools are blunt, and may not provide the detail needed to establish the presence of functional impairment. Many of the people we see with HIV in our services do not drive or have a bank account. Many of the tasks tapped by the tools are not relevant to our setting. In addition, patients will often not have insight or will under-report their impairment for various reasons. Sometimes it is because they are ashamed, or because a relative has taken over those functions. We will often need to interview relatives to obtain informant information, or to observe how people function in clinics or labs to be able to report on the degree of impairment. Summary - HIV infects the brain in almost all pts Clinical effects of neuroHIV detectable in >60% if untreated ART access reduces the impact of neuroHIV but not common mental disorders Psychiatric disorders are common in PWH Treatment is usually effective and can minimize adverse outcomes Adverse outcomes: poor adherence, death, poor function/QoL, distress- viz the 90-90-90. Overview of child and Adolescent Psychiatry Outline - - - What is Child & Adolescent Psychiatry How is it different from Adult/General Psychiatry? o Developmental Perspective o Environmental factors Snapshots on: o ADHD o ODD/Conduct Disorder General principles of assessment & management in an MDT What is child and adolescent psychiatry (CAP) - CAP is a medical discipline that deals broadly with mental health promotion, prevention, diagnosis, treatment, and rehabilitation (+ recovery) of mental illnesses. CAP diagnose and treat a diverse spectrum of psychiatric disorders that are usually first diagnosed in infancy, childhood and adolescence, links paediatrics with psychiatry Registered sub speciality of psychiatry Importance of CAP - In SA 40% of total population are minors = 20 million Prevalence of psychiatric disorders is 17% = 3.4 mil Present differently to adults Less than 60 HPCSA registered child and adolescent psychiatrists in SA, very few specialized CAMHS services, clustering in big cities, no Child & Adolescent Mental Health government policies in place countrywide Key aspects - - The diagnostic process is the foundation of effective treatment CAMH assessment differs considerably from other types of assessment in medicine: o distinctive developmental aspect in the mental state examination of children/adolescents o Assessing an individual within systems (family, community, environment) o Use of observation, interview, interaction, play, collateral reports, often over a number of sessions Be clear about your aims and role in the assessment General considerations - Children grow and develop. o Expectations about what is “normal”and what might be “a problem” vary according to stage of development o The capacity to understand, reflect and participate in decision making and treatment evolves with age Distinctive aspects of CAMH assessment - Referral is typically by someone other than patient There are rarely simple blood tests or other investigations leading to a diagnosis. Various (often conflicting) sources of information have to be integrated by a skilled clinician The Basic Aims - A good therapeutic relationship Reason for referral (Why now? Whose problem is it?) Main complaint Current individual functioning Developmental functioning Family functioning Mental state Formulate/communicate clinical formulation Clarify focus of treatment (risks/benefits) Be time efficient The Basics: SIRSE - Symptoms Impact Risk Factors Strengths Explanations N.B. While we often focus on the symptoms first it can be useful to start by exploring nonproblem areas (esp. in externalizing disorders) The basic building blocks - - Parent and child interview o Seeing parents and child together o Seeing parents alone o Seeing the child alone Mental state examination Medical history and physical examination Information from others (e.g, teachers) Rating scales and psychometric assessment Conscious promotion of positive early relationship to promote lifelong health - Influenced by Family, Community, Culture First 3 Years: critical window of brain development Boys more sensitiv to toxic stress Erikson: healthy development across childhood occurs within the context of healthy family relationships and cultural context Bowlby: Attachment Theory: primary caregiving relationships lay the foundation for social and emotional development Ainsworth: sensitive and consistent caregivers have securly attached infants Winnicott: “holding” the child, both physically and in mind, facilitating early emotional regulation - - - - - IMH coined in 1970 by Selma Fraiberg: early infant observation/interaction, strengthening relationships between parents and children in vulnerable families “Ghosts in the Nursery: intergenerational transmission of trauma and attachment disorders Lieberman: encouraging positive caregiving experiences to help parents overcome trauma Stern “Motherhood constellation “ – transitioning into motherhood Charles Zeanah “Handbook of IMH and DC:0-3 Fonagy “Reflective Functioning” – the ability to recognize mental states of one’s self and others influences attachment Connection: Early Life experiences and lifelong health Cultural context: holding spoiling, community where you need to toughen up, resilience, other ways to soothe Age group prone to NAI Epigenetics: gene/environment interaction, investigating the molecular mechanisms (such as DNA methylation and histone acetylation) that affect gene expression without altering DNA sequence Rats whose mothers showed increased licking showed less exaggerated stress responses later in life and the expression of mother pup interaction is passed on to the next generation Positive stress, tolerable stress, toxic stress, context of buffering Prolonged toxic stress without buffer leads to changes in the neuronal architecture of the brain (amygdala, hippocampus and PFC) affecting, memory, learning, executive functining (hyperactivation of amygdala, less top down control), more anxiety, mood swings, impaired memory, inhibition of contextual learning, discrimination, what is dangerous, what is safe Stress induced changes in the architecture of different regions of the developing brain can have potentially permanent effects on the range of important functions, such as regulating stress physiology, learning new skills and developing the capacity to make healthy adaptations to future adversity. Toxic stress includes alterations in ummune function and increases inflammatory markers associated woth porr health outcomes: CVD, viral hepatitis, liver cancer, asthma, chronic obstructive pulmonary disease, autoimmune diseases, poor dental health and depression o Early experiences are built in to our bodies o Significant adversity can produce physiological disruptions or biological memories that undermine the development of the body’s stress response and affect the developing brain, cardiovascular systm, immune system and metabolic regulatory controls o These physiological disruptions can persist far into adulthood Teenager - Social and cultural context, experiences, reactions influence as well Adolescent brain - Frontal lobes are not fully connected “Is this a good idea? What is the consequence of this action? “sluggish” connections between nerve cells and brain centres (myelin↓) Insight requires a fully connected frontal lobe The brain resembles that of an adult by age 25 years Imaging Studies - Different parts of the cortex mature at different rates Areas involved in basic functioning mature first: processing of sensory information and motor movements Areas responsible for top-down control (controlling impulses, planning ahead) are among the last to mature Family - Composition Structure Functioning Support Stressors Peer relationship and school - Opportunity for self discovery and development that improves resilience and well being. Peer support is important for children and adolescents o - ↓sense of isolation, identity through group cohesion o - Learning new coping strategies o - Influencing social environment positively o - Enlarging the perception of what is normal o - Adopting alternative perspectives School and peers - The primary “occupation” of childhood and adolescence is going to school. Large proportion of time spent at school and with peers. Appropriateness of educational placement and adequacy to meet a particular child’s needs. Society - - National standpoints o Society’s views about childhood o e.g., “Children should be seen and not head” Legal o Children’s Act, MHCA, Child Justice Act Community o Community instability/violence/basic needs o Cultural and religious practices Principles of Assessment/Diagnostic Formulation: Aetiological Factors - Bio-psycho-social model o Biological factors include: - Temperament - Genetic predisposition - General medical conditions - Substances Biological factors- Temperament - - - A way of responding to the environment o Inborn o Patterned o Stable (?) An aspect of personality concerned with emotional dispositions and reactions and their speed and intensity; the term often is used to refer to the prevailing mood or mood pattern of a person. Tomas and Chess criteria o Activity level o Rhythmicity (regularity)- sleeping/eating etc o Approach/withdrawal o Adaptability o Threshold of responsiveness o Intensity of reaction o Quality of mood o Distractibility o Attention span and persistence o Easy/ difficult/ slow-to-warm-up temperaments o Goodness of fit Biological factors- General Medical Conditions - Chronic hunger/ illness with fatigue and irritability Sensory disorders – impaired hearing and vision etc - Anxiety-provoking illness: cardiac, respiratory ‘Disfiguring’ conditions: fear, anger Endocrine disorders CNS disorders: e.g., delirium, seizure disorders Substance/medication- induced disorders Aetiological factors - Psycho-social factors o Failure to negotiate developmental stages properly o Psychosocial stressors o Parental psychopathology Psycho-social stressors - Unmet basic needs? Food, shelter, contact Community instability/ violence Inappropriate/inadequate educational system Abuse (physical, sexual or emotional) Loss of attachment figures/parental conflict Chaotic household/inconsistent discipline Under/ Over-stimulated/ uncontainment Psychosocial factors-parental psychopathology - Inappropriate expectation o Ignorance/ cognitive impairment Personality pathology : especially Cluster B Substance abuse Mood disorders Anxiety disorders Psychosis The role of occupational therapy in child and adolescent psychiatry - Occupational Therapy is defined as the process that engages the child or adolescent in activity (occupation) to improve his/her physical, psychological & social well being & to help him/her cope more effectively with everyday life consisting of school, play/leisure & activities of daily living. Role of OT: - - A core belief of Occupational Therapy in Child and Adolescent Mental Health Services (CAMHS) is engaging the parent or child in meaningful & relevant occupation to overcome the effects of mental health difficulties (Mee & Sumison, British Journal of Occupational Therapy, 2001). CAMHS Occupational Therapy services can be provided to care giver or child in two ways: direct intervention & indirect intervention. Direct: individually or in groups (activity based, skills based etc. – evaluate, facilitate, restore, maintain abilities) often with other MDT members (psychology, speech) Indirect: consultation with caregivers, teachers, other professionals Notes: o o a Parent Group on strategies to promote your child’s occupational performance at home Occupational Therapy programme to support your child’s occupational performance at school Examples: - Clumsiness/Poor coordination Sensory Processing Difficulties Slow to learn basic self-care skills Poor organisational skills Lack of structured daily routine Poor use of leisure time Maladaptive occupational performance Poor life skills Poor concentration; poor attention; poor impulse control. Parent – Child Attachment difficulties CAMHS Occupational Therapy Interventions - 1:1 intervention with caregiver or child to address function & occupational performance difficulties. Attachment Intervention Group Interventions eg ‘Move & Play Group’; ‘Chill Out Group’; ‘Stop,Think & Do Group’ Tic/ADHD/OCD/Anger Management Group Parent Group – Strategies to support daily living skills at home (ADHD) Teacher Education – Strategies to support educational needs at school (ADHD) Psychoeducation Groups with Adolescents eg Graffitti Group; Teenage Girls Activity Group Teenage Life Skills Group School Visits to provide education & programmes to teachers Case Vignette - - - Chad is a 6 year old boy presenting with severe temper tantrums, anger outburst, hitting his little sister if she annoys him, screaming matches if not getting his will. Pre School complains he never sits still, does not listen to instructions, is messy, does not complete his work. Mom noted he dislikes certain textures in his food, refuses shoes, wears shorts and T- shirts only even if cold. Chad struggles to fall asleep at night and often demands to sleep in his parents bed, he is petrified to be forgotten being picked up on time from pre school. He hoards food under his bed and is wetting his bed at time. His father is often angry with his hyperactive and destructive behaviour and gives him hidings. Diagnosis - Chad is seen by CAMHS and diagnosed with o ADHD o Separation Anxiety Disorder o Sensory Processing Disorder o Parent Child Relational Difficulties, Sibling Rivalry o Early Attachment Difficulties Management - - Chad is started on a low dose of Ritalin to improve concentration, impulsivity and hyperactivity, but he remains anxious, still throws tantrums, has sensory issues and a very strained relationship with his parents who struggle to parent him effectively. He is referred to OT OT referral - What further information, assessments do you need? What skills does Chad need to learn? What skills do his parents need to learn? What skills do his teachers need to learn? How do you explain to them what he needs? How do you address his sensory difficulties? How do you address his tantrums? How do you address his sleep difficulties? How do you address his difficulties with his sister, parents, other children and teachers at school? Snapshots of Psychiatric Disorders - Attention Deficit Hyperactivity Disorder (ADHD) Oppositional Defiant Disorder (ODD), Conduct Disorder (CD) ADHD - Persistent pattern of Inattention and/or Higher levels of impulsivity/ hyperactivity That interferes with functioning or development More than expected for someone of that age and developmental level Differential Diagnosis Treatment - Parent Counselling & Training OT, school adaptations & educational concessions - Behaviour therapy If over 6 years: medication with stimulants (or alternatives) Oppositional Defiant Disorder - - Pattern of o Negativistic o Hostile o defiant behaviour At least since 6 months 1) often loses temper 2) Argues with adults 3) Defies or refuses adult requests 4) Annoys people 5) Blames others 6) Easily annoyed by others 7) Angry and resentful 8) Spiteful and vindictive Differential diagnosis - Adjustment Disorder ADHD Cognitive Disorder Intellectual Disability Progress into conduct disorder (esp. if comorbidity with ADHD), substance abuse Learning Difficulties Mood Disorder Management - Family Intervention Child Management Skills Conduct Disorder - A repetitive and persistent pattern of violating basic rights of others and/or age-appropriate societal norms or rules, including: Aggression to people and animals (e.g., bullying, threatening, fighting, using a weapon) Destruction of property (e.g., deliberate fire setting) Deceitfulness or theft (e.g., “conning” others, shoplifting, breaking into others’ property) Serious violations of rules (e.g., running away, truancy, staying out at night without permission) Childhood onset vs Adolescent onset types Mild, moderate, severe Limited pro-social emotions (lack of remorse, callous/ lack of empathy, unconcerned about performance,, shallow affect) Comorbidities - ADHD Depression - Anxiety Disorders Substance use disorder – bidirectional relationship 25% of girls and 40% of boys eventually develop antisocial personality disorder, which is highly comorbid with substance use disorders (Zocccolillo, 1996) Developmental course - Life-course persistent vs Adolescence-limited Those with early onset have: lower IQ more attentional and impulsivity problems poorer neuropsychological test scores greater peer difficulties and are more likely to come from adverse family circumstances (Moffitt, 2001). Poorer outcomes in terms of violence, mental health, substance abuse, work and family life (Moffitt, 2002). Those with later onset are more likely to become delinquent in response to social influences. Treatment options - Family Interventions Peer Group Therapy Anger Management Training Vocational Training Cognitive Behaviour Therapy (Problem Solving Skills, Communication Skills etc.) Treat comorbidities (anxiety, depression, substance use, learning difficulties etc.) Involve Social Services, Diversion Services Management plan The role of the OT in a Multidisciplinary team - Assessments & interventions (sensorimotor integration, motor abilities) Support developmental play Social skills/life skills training/Study skills Affiliated therapy: art, movement Group/individual/parent work Improving adaptive functioning Behaviour management General principles - Use a holistic approach Child is viewed within his or her context Multidisciplinary team assessments – OT assessments are important Multimodal interventions, including individual and/or group OT interventions Evidence based practice Summary - - What does THIS behaviour in THIS child at THIS time mean? o Normal/environment/parent/GMC/psychopathology? If there is a disorder: o Use of multimodal interventions is important i.e. non-pharmacologic and pharmacologic interventions Referral to specialist Child and Adolescent Mental Health Services (CAMHS) when warranted. AN INTRODUCTION TO AUTISM- Print lecture powerpoint because it is all photos. Trauma and stressor related disorders - Group of disorders which follow on a stressful / traumatic experience This exposure is captured explicitly as a diagnostic criterion ie. a clear aetiological connection is made with that life-experience DSM-5 - Reactive Attachment Disorder Disinhibited Social Engagement Disorder Post-Traumatic Stress Disorder Acute Stress Disorder Adjustment Disorder PTSD - A psychiatric disorder that arises in response to a stressful event or situation Exceptionally threatening or catastrophic eg natural disaster, physical assault, rape, torture Common, but often missed Locally relevant due to endemic violence, crime, social adversity, HIV History of PTSD - 19th Century-Hysterical neurosis WWI - “Shell Shock”( ammunition shells) WWII -Traumatic Neurosis 1960’s - Vietnam War - Rape Crisis centres Formal Diagnosis-DSM III (1980) Traumas - War Violence (esp torture/interpersonal) Sexual or Physical Assault Natural disasters Terrorism Medical - Life threatening illness - Medical procedures Severe accidental injuries ( MVA, Burns) Core Features - Exposure to Traumatic Event Threat of Serious Injury/Death Intense Fear, Helplessness, Horror Not all Develop PTSD Not purely dependent on severity Subjective Response more important Diagnostic criteria - Persistent Re-experiencing o -Recurrent Thoughts/Dreams - o Flashbacks/Reliving Experiences Marked Avoidance( conversations, places, memories) Increased Arousal (hyper vigilance, poor sleep, anxiety, heightened startle response) Negative Cognitions and Mood (Shame, self-blame, withdrawal from others, loss of interest) Significant Distress/Impairment Duration < 1 Month : Acute Stress Disorder (ASD) Duration > 1 Month : PTSD Chronic PTSD and Delayed Onset PTSD Clinical Features may Include o Anger/Aggression o Poor Impulse Control o Shame/Self-blame/Survivor Guilt o Depression o Substance Abuse Subtypes - Type I - “one sudden blow” o Classical DSM-5 symptoms Type II- Complex PTSD o Multiple, long standing traumas eg childhood sexual/physical abuse o Associated with maladaptive behaviors, other psychopathology Epidemiology - - Few local studies Globally 5-10% lifetime prevalence Women more likely than men Aftermath of single traumatic event o 8% men develop PTSD o 20% women develop PTSD Social adversity, armed conflicts, natural disasters, violent crime Cultural / Existential factors Risk Factors - Female gender Nature, severity, duration of trauma Uncontrollability / Unpredictability Sexual vs non-sexual trauma Vulnerable groups (children/elderly) Lack of Social support / Validation Migration / Refugee status Aetiology - Biopsychosocial Traumatic event primary Biological factors o Genetics – familial pattern confirmed o - - Neurochemistry Serotonin – low mood, impulsiveness Noradrenaline - hyperarousal Opiate system – numbing o Neuroendocrine – HPA axis (Cortisol) o Brain structures Limbic system / amygdala Memory related structures eg Hippocampus Prefrontal cortex Psychological Factors o Psychoanalytic – defense mechanisms o Learning Theory – role of fear based memories in entrenching patterns of feeling, thinking and behavior Social / Environmental Factors o Protective role of support/validation o Endemic violence/insecurity o Role of media o Natural causes vs human violence o Shared “meaning-making” of traumatic experiences Management - - - - - Biopsychosocial Individualised o Strengths / Vulnerabilities o Past history of traumas Trauma focused psychotherapies Medications when appropriate Social support Acute phase o Usually self-limiting o Psychological First-Aid o Supportive counseling o No place for single session debriefing PTSD o Comprehensive psych assessment o Exclude co-morbid depression, substance abuse, personality factors o CBT o Revisit traumatic cognitions o Confront traumatic memories o Challenge misinterpretations that overestimate and generalise threat o Achieve mastery over despair, helpless victimhood o Dismantle avoidance behaviors o Develop skills to cope with stressors Eye Motion Desensitisation and Reprocessing (EMDR) o Client recalls an image of an important aspect of the traumatic event o Follows repetitive side to side eye movements, sounds or taps as the image is focused on Medication o o o o o Not first line SSRI’s – evidence of benefit for all core symptoms of PTSD Delayed onset of action Sedatives / tranquilisers in short-term Mood-stabilisers / antipsychotics rarely Prevention - Crisis Intervention Screen at risk groups / Early intervention Community based interventions Community Support Life skills / Psychoeducation Child protection services Media Outcomes/Prognosis - 30% recover 40% mild ongoing symptoms 20% moderate 10% severe Ongoing / repeated traumas convey poor prognosis Co-morbid conditions esp Depression, Substance abuse, PD, Bulimia Impact on clinicians - “Contagiousness” of trauma Trauma fatigue / Burnout Need for introspection, self reflection Support - individual or group Ethical / legal concerns o Conflicts around confidentiality / child protection, military/police etc Advocacy role Conclusion - PTSD is common Often missed with potentially harmful consequences Can be treated effectively Early diagnosis / intervention needed ? Resilience - what it means for PTSD Public health / Social priority to reduce levels of trauma Culture, Language and mental health Outcomes: - Core concepts Relevance of Culture to Psychiatry Language and Interpreters Culture and the DSM-5 Locally relevant Cultural Syndromes Culturally-Sensitive Psychiatric Practice Core concepts: - - - - Culture o refers to the meanings, values and behavioural norms that are learned and transmitted in society and within its social groups. Culture powerfully influences cognition, feelings, and self concept as well as the diagnostic process and treatment decisions. Cultural Universalism o Focus on underlying generic / common factors o Seeks to explain mechanisms Cultural Relativism o Focus on specific context o Seeks to understand meanings Cultural Diversity Culture change Migration / Urbanization / Globalization Cultural choice / Multicultural identities Local historical / political context Relevance of culture to psych - - - - Culture permeates all aspects of psychiatry o Determine specific stressors o Shape symptoms and illness behavior– idioms of distress o Shape help-seeking behavior and from what sector (allopathic or alternative) o Guide meaning-making – explanatory models / illness narratives Diagnostic process o Requires sophisticated communication o Knowledge of local cultural beliefs and practices o Clinician prejudices, cultural biases o Cultural “neutrality” vs Cultural “blindness” o Culturally sensitive diagnostic instruments and systems of classification Management o Biopsychosocio(cultural) approach o Specific issues that influence treatment choices and compliance o Understand and mobilise local resilience and coping factors o Partnerships with traditional healers where appropriate Growing multilingualism Invariable need for interpreters - - - Inadequate supply means inappropriate use of unsuitable persons Common pitfalls o Ethical issues (confidentiality) o Reliability of information o Absence of subtleties crucial for psych Common errors made by interpreters o Omission o Addition o Condensation o Substitution o Blurring of roles Improving interpreted interviews o Planning / preparation o Initiating the interview – purpose, roles o Conducting the interview – seating, comfort, clarification, feedback etc o Debriefing / Discussion Culture and DSM-5 - - Largely universalistic assumptions Deals with culture in 3 ways o Cultural variations of major disorders noted in the body of the main text o An appendix listing a glossary of Cultural syndromes o A structure for a cultural formulation 5 Elements of the Cultural Formulation o Cultural identity (incl language, religion) o Cultural explanations (idioms of distress, explanatory models, help sought) o Psychosocial environment / stressors / supports – impact of cultural factors o Cultural aspects of client-therapist relationship o Overall impact of cultural factors on Mx Locally relevant cultural syndromes - - Recurrent, locale-specific patterns of disturbed emotion/behavior Do not correspond with specific DSM-5 diagnoses Often clear precipitants. Run benign course. Resolve spontaneously. None incorporated in DSM-5 list Cultural Syndromes controversial (?AN) Amafufunyane o Madness due to possession by evil spirits / sorcery o Motor agitation, aggression, bizarre behavior o Hallucinations, labile mood, poor sleep o Females > Males o DSM-5 Dissociative (trance) states o Amnesia post-recovery Ukuthwasa o Calling by ancestors to be a healer (sangoma) o Calling revealed thru’ thwasa – gift from ancestors o Feelings / fears of madness o Vivid dreams / visions / physical symptoms - - - o Social withdrawal o Emotional turmoil / self neglect o DSM-5 Schizophrenia / catatonia o Role of traditional healer Ukuphaphazela o Children with night terrors, visual hallucinations, running away o Idiom of distress – child seeing evil spirits o DSM-5 – sleep terror disorder Ukuphambane o Generic term to describe the mental disturbance caused by spirit possession o Aggression, agitation, psychotic symptoms o Seems a true Culture-Bound syndrome Isimnyama eskoli o Scholars o Headaches, blurred vision, weakness of the hands o Usually academic pressure, school based stressors o May be epidemic o DSM-5 – Conversion disorder (sensory) o Similar to Brain Fag – listed in DSM-5 as Cultural Syndrome Culturally sensitive psychiatric practice - - Culture matters! Make it explicit at all levels o Clinically o Teaching o Research o Service design Cultural sensitivity vs stereotyping. Responsiveness Enhance cultural and linguistic competence Appropriate interpreting services Engage with local cultural experts / traditional healers. Old Age Psychiatry, dementia and delirium Ageism/ Mortality fears/ Disability fears Ageism: - Prejudice or discrimination on the grounds of a person’s age Prejudicial stereotyping of older people Effects of ageing - Biological effects Psychological effects Social effects Physical effects of ageing - - - Physical problems (>70years): o •10% men and 20% women cannot use steps/stairs o •10% men and 30% women cannot walk outside o •10% men and 20% women cannot bath themselves Access to health care o getting to clinic o waiting times o public transport, minimal elderly specific services Causes of death o •Cardiovascular disease 53% o •Neoplasms 17% o •Respiratory disease 14% Psychological development - Integrity vs Despair Changing roles Search for meaning in life Social effects - Retirement Loss of income shrinking financial resources Social isolation Epidemiology, Mental Health - Depression 13,5% Anxiety 12% Dementia (severe) 5,6% Dementia (mild) 5,7% Schizophrenia 1,1% Delirium Assessment - History o Physical examination o Cognitive assessment o Functional assessment Psychiatric History: Old Age - - Main complaint: o Mood symptoms o Cognitive symptoms o Psychotic symptoms Past psychiatric history Family psychiatric history Past medical history Past surgical history Medication Allergies Substances Functional Assessment - Mobility Ability to communicate needs Ability to relate to others Ability to wash/dress self Ability to feed self Compliance with medication Control of bladder/bowels Presence of aggression/ other socially unacceptable behaviour Need for supervision Ability to prepare meals Ability to go shopping Ability to do housework Dementia, DSM definition - Significant cognitive decline in one/ more cognitive domains Interferes with independence in everyday activities Not in context of a delirium Not better explained by another mental disorder DSM 5 – 6 cognitive domains - Complex attention Executive function Language Learning and memory Perceptual-motor (visual perception, gnosis, praxis) Social cognition Types of Dementia - Alzheimer’s, Dementia with Lewy bodies, Parkinson’s disease, Huntington’s disease, prion disease Vascular /Stroke Traumatic brain injury Alcohol, Toxins, Heavy metals HIV, Neurosyphilis Hypothyoidism Vit B12 deficiency, Folic acid deficiency Alzheimer’s dementia - Memory, short term initially, progressing to long term. Language, word finding Losing things, getting lost Motor, praxis, gnosis Social, initiative, insight Early rapid, late, slowly progressing Dementia with Lewy bodies - Apathy, depression Fluctuating attention Hallucinations , visual REM sleep behaviour disturbance Sensitive to antipsychotic medication side effects, Parkinson’s features Episodes of loss of consciousness Vascular dementia - Multiple small infarctions/strokes Stepwise deterioration Motor impairments, may recover partly Variable depending on site of infarction Heart disease, Hypertension, Diabetes associated Task 1 - Your client is a 79 year old woman with mild dementia due to Alzheimer's disease. She lives alone in a block of flats which is 5 minutes walk from a Pic ‘n Pay supermarket. She has difficulty with her grocery shopping due to forgetfulness and runs out of basic supplies like milk, eggs and bread. She struggles with cooking and has lost weight. You can spend one hour a week working with her. Devise methods/interventions to help her to maintain independent living in her own home for as long as possible. Management of dementia - Treat underlying cause Medication: o Cognitive enhancers - Acetylcholine esterase inhibitors NMDA-receptor antagonists Optimise functioning o Caregiver o Patient Depression - Depressed mood Anhedonia Δ Weight Δ Sleep Psychomotor agitation/ retardation Fatigue Guilt Cognitive impairment and depression - Depression in pre-existing dementia Depression as a prodrome of dementia Depression as a risk factor for dementia Cognitive impairment as a feature of depression (‘Pseudodementia’) “Pseudodementia” Behavioural and psychological symptoms of dementia ( BPSD) - Symptoms of disturbed perception, thought content, mood or behaviour that that frequently occur in patients with dementia. BPSD, symptoms and behaviours - Delusions Hallucinations Depression Anxiety Impaired sleep Agitation Shouting Wandering Apathy Inappropriate sexual behaviour Help for BPSD carer - Psycho-education Support Respite care Medication Help for BPSD patient - Reality orientation Reminiscence therapy Validation therapy Psychomotor therapy Multisensory stimulation Cognitive stimulation therapy Aromatherapy Music therapy Environmental manipulation Behavioural management techniques Psychotherapies Medication Task 3 - Your patient has moderately severe dementia. He has aggressive episodes during which he swears at his caregivers and tries to hit them. Describe your assessment to try to discover the cause of these episodes. It turns out that his frustration is due him losing items and that he believes his caregivers are stealing from him . Describe how you would help him and his caregivers with this problem. Delirium - Conciousness: disturbance in attention and awareness Cognition: an additional disturbance in cognition Course: sudden onset, tend to fluctuate Cause: due to medical condition or substance Delirium vs psychosis - Time frame Systematised or general Orientation Hallucinations and misperceptions, visual and tactile Delirium Tremens DIMTOP - D rugs: alcohol, opiates, sedatives, steroids I nfection: pneumonia, urinary tract infection M etabolic: hyper- / hypoglycaemia, hyponatremia T rauma: head injury, cerebral haemorrhage O2: hypoxia P ain Task 2 - You are contracted to a large state run old age home which has a clinic ward or ‘sick bay’ Residents develop delirium from time to time and are then transferred to the clinic ward. Describe your plans for the layout of this area and the environment you would try to create to facilitate safe recovery for patients with delirium. Treatment of delirium - Treat underlying cause, without delay Explanation, reorientation, reassurance Quiet room Adequate lightning Infrequent staff changes OT lecture old age psch. Feedback - 1)Did the lecture help you to discover your emotional reaction to professional work with the elderly and your own attitude to getting old? 2) Did the lecture help you to become aware of common psychiatric disorders affecting the elderly and to discover the OTs role in health-care of this group? 3) Slides, learning materials 4) Class participation 5) Lecturer to class communication 6) Comments/suggestions Ethics in Psychiatry What is ethics: - What ought to be Examines ‘good / bad’, ‘right / wrong’, ‘should’, ‘justice’, ‘duty’, ‘obligation’, ‘responsibility’ Questions where a person has a choice of possible actions, none of which is entirely proscribed, and a course has to be followed Origin of “ETHICAL DILEMMAS” Moral Principles - Respect for autonomy: Respecting the decision-making capacities of autonomous persons Nonmaleficence: Avoiding the causation of harm Beneficenc: Provide benefits and balance benefits against risks Justice: Fairness in the distribution of benefits and risks Fiduciary relationship – the principal of fidelity - The trusting relationship that enables people to consign entirely their well-being to a clinician Advocate for the ‘benefit of the sick’ Subverted by conflict of interests: eg, managed care, financial incentive Some Ethical Issues - Confidentiality & Data Protection Informed Consent & Competence Coercion / Involuntary treatment and dangerousness Dual Agency / Conflict of Interest Boundary Violations Fair use of scarce resources (Justice) Confidentiality - - “Whatsoever I shall see or hear in the course of my profession… if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets” [HIPPOCRATIC OATH] “I will respect the secrets which are confided in me, even after the patient has died” [DECLARATION OF GENEVA] Rule 20 of HPC(SA) Common breaches - Telephone call in presence of others (NB: Cell Phones!!) Discussions with colleagues in social settings (‘the interesting case that I saw today…’) Greeting and chatting with patients in public or social settings Disclosure of information to family, especially in case of minors (a dilemma!!) Unguarded sources of information, such as computers and files that can be accessed by others Documentation to medical aids / managed care facilities etc Permissible breaches of confidentiality - Patient provides consent Patient is forewarned that confidentiality cannot be given (eg. Insurance examination) Emergency (to save life) To protect a third party (degree of potential harm is important) Required by law (eg. Notifiable diseases, child abuse), or to report a serious crime Court orders disclosure To protect oneself!! (eg. Patient makes false allegations etc) Information is already in public domain, eg. Before court or in the media Privacy & Privilege - Privacy is patient’s right not to have confidential information divulged by clinician to others Privilege is clinician’s right not to be forced to disclose information about patient In SA this is not an absolute right Can be forced by Court to divulge information Informed consent - Differs from ASSENT Patient given enough information to make a rational decision (including potential ill effects) Patient possesses competence Given voluntarily Allowed to refuse Competence - - Decision-making capacity’ o Capacity for understanding and communication o Capacity of reasoning and deliberation Relative concept that varies according to.. o Type of decision ( minor vs major procedures) o Time (dementia/delirium are fluctuating disorders) o Presence of assistance (eg. Lawyer) Can be breached: - Legal guardian provides consent if person is not competent Emergency Required by law (eg. Rapists that have to be tested for HIV) Court order (blood transfusion for Jehovah’s Witness child etc) Sterilization of severely handicapped individuals Dual Agency - Your primary loyalty is not to the patient/client but to a third party that is paying you Eg. Insurance company pays to have the client return to work, or requests an assessment Possible remedies: Disclosure about your role beforehand Amelioration of possible harms Conflict of interest - Clinicians primary interest is undermined by a competing secondary interest - o Eg. Use of equipment made by a company that you have shares in, It is not obvious wrongdoing that is the problem, but the appearance of impropriety o You refer a disabled client to your uncle to sell him an insurance policy Professional Boundaries - “The ‘edge’ or limit of appropriate behaviour by the psychiatrist in the clinical setting” (Gabbard 1999) To create an atmosphere of safety and predictability that facilitates the patient’s ability to use the treatment Not cold distance but a structure within which therapist can interact with warmth, empathy and spontaneity. Can depend on paradigm and context “The ‘edge’ or limit of appropriate behaviour by the psychiatrist in the clinical setting” (Gabbard 1999) To create an atmosphere of safety and predictability that facilitates the patient’s ability to use the treatment Not cold distance but a structure within which therapist can interact with warmth, empathy and spontaneity. Can depend on paradigm and context The rule of abstinence - - The therapist must refrain from obtaining personal gratification at the expense of the patient The therapist’s main source of personal satisfaction is derived from obtaining professional gratification of engaging in the therapeutic process and from the pleasure gained in helping the patient Maintain ‘therapeutic neutrality’ Avoid imposing therapist’s values on patients, or interfering in their personal lives based on therapist’s own agenda. Boundary violations - Involve transgressions that are potentially harmful to or exploitative of the patient Differentiate from Boundary Crossings that is a non-sexual boundary transgression in which the ultimate effect is positive (i.e. advances the therapy constructively) Boundary crossings can be human responses to unusual events, eg. Giving a patient a lift under dire circumstances etc. May be difficult to distringuish boundary crossing from boundary violation Types of boundary violations - SEXUAL NON-SEXUAL PHYSICAL CONTACT TIME & LOCATION FINANCIAL & BUSINESS TRANSACTION DUAL RELATIONSHIPS SELF DISCLOSURE INTERACTIONS WITH OTHERS GIFTS LANGUAGE USE Language use: - Use of first names? Explicit language Seductive terms Use of flattery Jokes?? Overfamiliarity by either Boundaries in Psychiatry History taking and MSE - Presenting Complaint Past History Life History Vulnerability factors What is behind the problem? And what is behind that? Schizophrenia - Many subtypes Many degrees of severity Outcome variable Stigmatising 4 As Affect Association Autism Associated Sx Abnormal salience/false certainty Responding to delusions Responding to paranoia Depression Mania Bipolar Mood D/O - 3 Legs of depression Losses and defence against losses Mania Sx Mood destabilising medications and drugs Antidepressant compared to placebo Counselling basics Anxiety and Trauma - GAD – worrying D/O Panic and Agoraphobia Phobias- desensitisation – motivation OCD- resistant to psychotherapy Traumatic stress- 3 Legs – counselling OT roles in PTSD treatment- avoidance Eating disorders - Irrational ideas about food and eating Perfectionism – Am I allowed to want (food)? - Importance of family therapy Personality Disorders - Borderline PD splitting in hospital setting suicidality substances prognosis professional boundaries Chronic Pain and somatisation - Book: Michael Balint- The Doctor, the Patient and his Illness—the role of the illness in the patients life. Unconscious causes of illness Skin Internal Organs Mind Child Psych and ID Psych - Importance of environments Support development- stages Attachment problems- inter-generational Reactive attachment disorders Disability- feedback loops, child to parent -parental ambivalence Display knowledge of syndrome in case questions Disruptive disorders ADHD, ODD, CD Boundaries Relationships between therapist and client - Attachment issues Borderline dynamics Like friendship, like romance? -meet in private, confidential, attention, concern, empathy, intimate details (one sided) Ethical Principle NO DUAL RELATIONSHIPS, NOW OR EVER Client’s romantic interest in Therapists - It is a common and normal occurrence but needs prompt and active management on part of therapist to resolve and is not the patient’s fault. Client becomes drawn to therapist in romantic way - Therapist’s reaction- may feel affirmed, gratified Pick up the hints- client’s comments or actions. Therapist’s actions needed to resolve the issue promptlyReflect on the hints with gentle questions-often denied. Normalise, explain, reassure, re-commit to the therapy. Avoid shame and embarrassment to client. Don’t avoid the issue. Don’t “runaway”, resolve it. Stalking - End result unresolved erotic transference. Role of shame/embarrassment experienced by client. At risk personalities Best remedy, re-establish therapeutic relationship promptly before any acting out happens Case: - - Client: “So, we’re friends right, as a friend I would like to share this or that with you.” Therapist: “We are like friends because we meet regularly, privately etc, etc but we are not like ordinary friends because we don’t meet outside of the therapy or do other things together (and if we did it could spoil the therapy.”) Maintaining a therapeutic relationship over time can be the main work of the therapy if the patient has BPD. Termination of therapy – attachment issues, rejection issues. Manage these with awareness of loss/grief that the patient is likely to experience
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