Mental Illness in the Elderly
CNA Specialty Course
Capital Community College
Spring 2008
Dr. Linda A. Barile
Overview of Mental Illness
Class 1
Anxiety Disorder (Neurotic)
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Generalized Anxiety Disorder
Obsessive Compulsive Disease
Phobia
Panic Disorder
Depression – Exogenous
PTSD
Anxiety Disorder (Neurotic)
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Judgment – Good
Orientation – Good
Memory – Good
Affect – Anxiety, Depression
Cognitions – Reality based
Personality Disorders
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Borderline
Antisocial
Personality Disorders
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Judgment – poor, mistakes over & over
Orientation – good
Memory – good
Affect – Anger
Anxiety & Depression Underlying
Cognitions – may have brief Psychotic
episodes
Personality Disorders
(ANTISOCIAL) (DSMIV)
a. Inability to delay gratification
b. Inability to conform to norms of society
c. Seeks pleasure
Personality Disorders
(ANTISOCIAL) (DSMIV)
d. Lacks satisfying, fulfilling,
interpersonal relationships - egocentric
e. Lacks capacity for concern over others
f. Does not feel guilt, no conscience,
remorse or shame
Personality Disorders
(ANTISOCIAL) (DSMIV)
g. Impulsive-irresponsible-rebelliousinsincere-lying
h. Charming
i. Does not learn from mistakes- unable
to handle criticism
Personality Disorders
(ANTISOCIAL) (DSMIV)
j. Impaired judgment and repeated
failures
k. Irritability, aggressiveness
l. Denial, rationalization, projection as
defenses
Personality Disorders
(BORDERLINE) (DSMIV)
a. Identity disturbance
b. Physically self-damaging acts
c. Unstable affect
Personality Disorders
(BORDERLINE) (DSMIV)
d. Chronic feeling of emptiness / boredom
e. Lack of tolerance for being alone
f. Intense, unstable relationships
Personality Disorders
(BORDERLINE) (DSMIV)
g. Impulsivity, unpredictability
h. Inappropriate or intense anger
Psychotic
(Hallucinations, Delusions, Bizarre Behavior)
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Schizophrenia
Bipolar
Depression – Endogenous, Comes from
within Family History
Psychotic
(Hallucinations, Delusions, Bizarre Behavior)
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Judgment – poor
Orientation – may not be affected
Memory – unremarkable
Affect
Schizophrenia – flat
Bipolar – Manic or Depressed
Depression – sad
Cognitions – Hallucinations, Delusions
Organic
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Dementia
Chronic
No known cause
Irreversible
Example - Alzheimer's
Organic
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Delirium
Acute
Know cause
Reversible
Example - DT’s
Organic
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Judgment – poor
Orientation – poor
Memory – poor for recent events
Affect – Labile
Cognitions – Hallucinations/Delusions
Special Category
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Anorexia/Bulimia
Addiction
Abuse
Levels of Anxiety
Mild Moderate
Ability
1) Attend
2) Listen
3) Concentrate
4) Learn
Levels of Anxiety
Severe Panic
Ability
1) Cannot function
2) Can’t problem solve, make decision,
choice etc.
Obsessive/Compulsive
a. Obsessive: painful idea, recurrent,
persistent thoughts
b. Compulsive: behavior or acts i.e.
repetitive, ritualistic physical acts
c. Disproportionate degree of anxiety
d. Repression of conflict
Obsessive/Compulsive
e. Knows thoughts and behavior is
senseless but cannot control itInterferes with functioning
f. Has conflict and guilt
g. Behavior relieves tension
h. Dependency, self-defeating behavior,
low self esteem, inadequacy, inferiority
Obsessive/Compulsive
i. Inability to make decisions based on
anxiety about failure - ambivalence strives for perfection
j. Defense mechanisms:
Obsessive - reaction formation,
displacement
Compulsive - undoing
k. Depression may be underlying
Overview of Mental Illness
Class 2
Phobias
a. Anxiety is bound up in fear of a
particular object or situation - Avoid
dreaded object
b. Feared object symbolizes underlying
conflict
c. Fear is not subject to conscious control
Phobias
d. Defense mechanism of displacement
e. Fear is recognized as unreasonable but
has a major effect on the person's life
f. May be a learned behavior
Powerlessness Related To
Depression
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Theories of Depression
Biological – serotonin deficiency
Psychological
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Aggression turned inward
Crisis: precipitating event, perception, coping,
supports
Cognitive: depressive thoughts cause depression
feelings and behavior
Learned helplessness: same symptoms of
depression
Sociological: family and society
Powerlessness Related To
Depression
a. Affect or Mood
1.Hopeless, helpless, discouraged
2.Inability to experience pleasure
3.Negative feelings about self (guilt, low selfesteem), others, and the world
4.Anxiety, agitation, anger turned inward
(psychomotor agitation/retardation),
monosyllabic speech
Powerlessness Related To
Depression
b. Thoughts
Slow, worried, preoccupied thoughts
(psychomotor retardation)
2. Unable to make decisions
3. Concern with physical health
4. Possible hallucinations, delusions if
psychotic
5. Thoughts of death or suicide
1.
Powerlessness Related To
Depression
c. Behavior
1. Passivity dependence
2. Social isolation; lacks initiative
Powerlessness Related To
Depression
d. Physical Problems
1. Loss of appetite, insomnia or excessive
sleeping, constipation, loss of sex drive
Powerlessness Related To
Depression
e. Basic problem - inability to express
anger (defense: introjections - anger
turned inward).
If anger or hostility is expressed before
client is able, he will feel increasing
guilt and possibly be suicidal.
Suicide
a. Depression, low self esteem
b. Hopelessness, Helpless
c. Guilt
d. Ambivalence
Suicide
e. Anger turned inward (introjection)- Help
patient deal with anger in constructive
manner
f. High in men, 50 years and older, with high
stress such as divorce or loss of job and
g. Specific plan. Suicide is one of the leading
causes of death in adolescents and the elderly
Bipolar (Manic Phase)
Emotional manifestation
(affect or mood)
1. Elated, euphoric, hyperirritability
2. Happy, playful
3. Grandiose
Bipolar
Cognitive manifestations
(thought processes)
1. Rapid and pressured
2. Positive
3. Hypercritical and blames others
4. Flight of ideas
Bipolar
Behavioral Manifestations
1. Domineering
2. Wants independence - dislikes
restrictions or restraints
Bipolar
Physical manifestations
1. Hyperactivity
2. Not easily fatigued
3. Appetite is variable
4. Hypersexual
5. Insomnia
6. Impairment of personal hygiene
Schizophrenia
Signs and Symptoms
Affect or Mood
a. Severe or panic anxiety
b. Sensitive to feelings of others
c. Flat or inappropriate Affect
d. Ambivalence
e. Low self-esteem, insecurity
Schizophrenia
Signs and Symptoms
Thoughts or Cognition
a. Thought disorder
b. Lack of trust
c. Lack of sense of self - Lack of ego structure
d. Autism- disordered communicationextreme withdrawal into non-reality
Schizophrenia
Signs and Symptoms
Thoughts or Cognition
e. Loose Associations
f. Hallucinations/delusions, ideas of reference
g. Neologism, word salad, echolalia
Schizophrenia
Signs and Symptoms
Behavior
a. Isolation from others, withdrawal
b. Introversion
c. Disturbance in previous level of functioning
or goal directed behavior
d. Disturbance in body image and self-concept
Schizophrenia
Signs and Symptoms
Symptoms of Schizophrenia
Positive Symptoms
a. Hallucinations
b. Delusions
c. Bizarre behavior
d. Loose associations
Schizophrenia
Signs and Symptoms
Symptoms of Schizophrenia
Negative Symptoms - of depression
a. Slowed thought
b. Diminished spontaneity
c. Flat affect - loss of drive
d. Apathy
Schizophrenia
Signs and symptoms
Symptoms of Schizophrenia
Negative Symptoms - of depression
a. Attention concentration difficulty
b. Few words
c. Withdrawal
d. Not able to experience pleasure
Addiction
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Basic Problem
Physical and psychological addiction with tolerance
and or withdrawal
Withdrawal from alcohol
8-24 hrs-anxiety, nervousness, irritability, upset
stomach
12-48 hrs-agitation, temp 100 or above, pulse 100 or
above, BP>
Alcoholic hallucinations (well lighted room to
prevent shadows)
3-5 days-convulsions, coma, death
Addiction
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Heroin withdrawal-every bone in body
aches, vomiting, dilated pupils,
diarrhea
Cocaine-when on Cocaine looks like
bipolar in manic stage-withdrawal is
depression
Dynamics of Anger
Class 3
Dynamics of Anger
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Analyze the dynamics of anger and
hostility
Topics
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Recognize one’s own response to anger
and hostility
Dynamics of anger and hostility
Role of anger in depression, suicide
Dynamics of Anger
Identify theories and precipitating factors to
anger and conflict situations
Topics
Theories of Anger:
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Biological
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Psychological
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Social, cultural and spiritual
Precipitating factors
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Threats
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Loss
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Unmet expectations
Dynamics of Anger
Discuss anger management and stress management
Topics
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Anger Management
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Bodily skills
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Mental skills
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Thinking skills
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Empathy training
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Explanatory Style
1. Thoughts, feelings, behaviors
2. Commitment, challenge and control
3. Optimism vs. pessimism
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Stress cycle and breaking the cycle
Dealing withDifficult
Behaviors
Class 4
Hallucinations
Identify strategies to deal withhallucinations
Strategies
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Relaxation or meditation
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Keep a record of when you hear the voices – date, time
place
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Talk to others, talk on the phone, write a letter –don’t
have to talk about your voices
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Use Aversion Self Therapy-snap a rubber band,
imagine something unpleasant
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Tell the so called voices to go away – dismiss them
Hallucinations
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Take care of your physical health-eating,
sleeping, vitamins, exercise
Tune out the voices
Use music, television etc. Use headphones
Avoid alcohol or illegal drugs, over the counter
drugs and caffeine
Talk to yourself – view your voices as your
own thoughts
Hallucinations
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Challenge what the voices are telling you
Use thought stopping and tell the voices to stop-then
think of something pleasant
Use time out if being with others make the voices
worse
Use earplugs in one ear
Use positive self-talk
Use distraction-housework, gardening, sports event,
reading, change your environment
Use your own voice – humming, singing, counting,
positive mantra, reading out load
Hallucinations
Role Play dealing with difficult behaviors
Caregiver Interventions
Hallucinations/Delusions
1. Do not argue, challenge or reason. Do not taste food if patient
thinks it is poison. Do not indicate non-verbal agreement.
2. Delusions are defenses against underlying feelings, themes and
needs. Delusions reflect sense of vulnerability. Meet the need
the delusion serves.
3. Make empathic comments-"It must be frightening"-address
feelings and content.
4. State simply that you do not hear voices. Ask what the "so
called" voices or "voices you say you hear" are saying.
5. Provide distraction or competition for voices while actively
hallucinating.
6. Provide extra support and stay with patient (use supportive
approach with schizophrenia).
7. Ask what the so-called voices were saying - do not question at
great length giving status to voices.
STRESS MANAGEMENT
Class 5
Stress Cycle
Event
Perception
Fight, Flight,
Freeze
Relaxation
Thoughts
Positive Coping
Visualization
Anger Cycle
Justification
Anger
Depression
Somaticizing
Compromise
Threat
Loss
Change
Unmet
Expectations
Helpless/
Powerless
Anxiety
6 Determinants as to Whether
You Will Feel Stress
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Control
Challenge
Commitment
Powerlessness
Choices
Ownership
Values
Home
&
Family
Work
&
Money
Health
&
Sanity
Fun
Spirituality
Communication
Class 6
Communication
Models of Interpersonal Behavior
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Communication model – Communication is
the process by which information is exchanged
between two or more persons.
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Transactional model – the study of the
communication or transactions that take place
between people and of the sometimes
unconscious and destructive ways (games) that
people relate to each other.
Communication
Models of Interpersonal Behavior
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Human needs – emphasizes that all humans have the
same basic needs and that these needs are what
motivate a person’s behavior. Maslow described five
basic categories of needs: physiological, safety, love
and belonging esteem needs, and self-actualization.
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Values model – values are important because like
needs they affect interpersonal behavior. Values of
health care professionals might be as follows: helping
others, independence, equality, authority etc.
Communication
Interpersonal Communication Skills
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Empathy – Ability to sense the other person's world as if it were
your own
Respect – a feeling of high regard, honor or esteem for another
person
Genuineness- authentic, honest, true, forthright,
Immediacy – dealing with the here and now
Concreteness – the what, when, where, how but not why. The
ability to be specific
Confrontation – pointing out discrepancies between thoughts,
feelings and behaviors. The act of presenting differing
observations. Sharing that behaviors are discrepant is an act of
confrontation.
Assertion
Empathy
Definition: Ability to sense the other person's
world as if it were your own. Aware of the
other person's feelings and reflect
understanding back to the person. (e.g.
"You feel _____ because.")
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Skills Necessary
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Attending - Offering Self
Listening – Silence
Observing - Non-Verbal
Responding - Reflecting
Respect (warmth, non-judgmental)
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Positive Regard
Definition: Accepting another without
conditions or judgments - caring for the
person and believing in his ability
Blocks to Respect
a.
False Reassurance
b.
Agreeing/Disagreeing
c.
Giving Advice or Opinion
d.
Challenging
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Defending
Concreteness
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Restating technique, seeking clarification,
genuineness
a. Questioning - who, what, where, SELDOM WHY
b. Open vs. closed questioning (open is preferable)
c. Double questions - to be avoided
d.Bombarding questions - to be avoided
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Summarizing Technique
Confrontation - giving immediate feedback
Priorities in Limit Setting
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Destructive
Disorganized
Deviant
Withdrawn
Dependent Behaviors
Reality Orientation
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Definition: Techniques for providing
basic, current information to a person
having memory loss, confusion, and
time-place disorientation