DSM and the Family - class notes

DSM and the FAMILY

Psychiatric Assessment

Class September 22, 2010

Most people are used to the interpretive interviews – insight oriented interview – i.e. looking for causality

-psychiatric interview – look for diagnosis/symptoms – it describes/observes

Insight-oriented vs. Symptom- oriented interview

Insight oriented interview

• Interpretative approach
• Goal - attempts to explain signs, symptoms and behaviour
• Some element of the cause of problem or behaviour.

Insight-oriented vs. Symptom- oriented interview

Psychiatric: purpose is to make a DSM IV diagnosis and decide on a treatment plan

Psychiatric interview always includes the Mental Status Examination.

Insight-oriented vs. Symptom- oriented interview

Psychiatric Assessment

• Descriptive approach: - ask for details
• Observe patient’s behaviour
• Motivate he(she) to describe problems in detail.

NOTE: Much overlap in type of questions asked

-you can move from one kind of interview to another as needed, i.e. if you have something special come up.

Strategies for Rapport

Put client at ease.

Be aware many people are ashamed at having to ask for help – especially people with anxieties/phobias –those are people who are particularly ashamed

• Introduce yourself. Ask him or her for name and correct pronunciation. If there is a problem of whether to use first or last name, ask.
• With clients who are too anxious, psychotic or dependent, you might skip this step.
• Recognize verbal and non-verbal signs:

Locomotor – territorial sign – how he/she comes into your office or react when you move into his/her space. Timid? Intrusive?

Psychomotor behaviour: avoids eye contact, puts feet on your desk

Emotions: from posture, gestures, tone of voice, tears

Verbal – vocabulary and metaphors and USE in your replies

E.G. Visual: “I see no light at the end of the tunnel”

Ask: “Since when did things look so dark”

• Respond to signs.

These signs usually hit you all at once. Might just want to observe for a while but keep monitoring or respond in kind

Territorial signs:

• Timidity – invite to come closer and sit down
• Intrusiveness: why don’t you sit down over there and we can talk more comfortably

Emotional signs – smiling, raising head, nodding

Research (Siegman and Pope l970)

interviewers who picked up on client’s emotional signals elicited in 8/10 cases spontaneous self-disclosures – more than 3 in 30 minutes.

Non-responders to emotional signals – a self-disclosures in 6/27 cases

Strategies for Rapport

Use language and level of language the client understands.

Strategies for Rapport

Assess the suffering.

Find the Suffering and Show Compassion

“The point from which you can set the clients emotions free is his point of suffering”

Link client’s feeling to the chief complaint.

i.e. “How does that make you feel?”

NOTE: Make sure you get a feeling, not a thought

It is always more important to allow a client to ventilate feelings that get facts at the beginning.

• Respond with empathy

Try and be genuine, spontaneous and accurate in your responses.

If you have difficulty feeling empathy, don’t express it.

Eg. Whinging clients

• Can get difficult clients:

T: “I heard you say you were apprehensive about coming here”

C: “You heard right damm it, that’s what I said”

OR

T: “It sounds to me you were pretty upset when you….

C: “(sarcastically) Really? It sounds to you…..? you’re just playing the therapist. I know that spiel – I’ve talked to too many therapists

Assess Insight – i.e. how the client sees the problem – no insight – doesn’t see his part as a problem

• Become an ally and try to see the client’s point of view.
• Insight refers to the client’s view of the problem.
• Insight may be full, partial, or no insight - in order to split off the sick client.
• You use the gap between his(her) insight to judge the client’s reality testing

• If you misjudge insight, your rapport will dissolve rapidly

Strategies for Rapport

Levels of insight. Important in a psychiatric setting

Full insight – aware of problem

Partial insight. Client recognizes something is wrong, blames it on external events. - paranoid patients

No insight –

eg. In couple therapy. “My wife sent me

-no insight – think hospitalization [i.e. if the issue]

Full insight

• These clients are found typically in psychiatric outpatient settings or as your clients
• explain nature of interview
• discuss treatment.. Watch for distortions from a clinically depressed patient.

E.g. My work is terrible, my lover, wife, husband, family don’t love me etc. Everything looks black to a depressed person, all data is given through a dark and negative lens.

Split off the sick

For the delusional patient with no insight, offer the safety and protection of the hospital. Offer supportive counselling to support system.

With the husband with no insight, ask how his wife’s problem affects him.

• Try and establish a goal commensurate with insight

à“You may not think your drinking is a problem but if your wife does, maybe we could look at that”

Strategies for Rapport: Therapist Roles

Balance roles

• Empathic listener – too much empathy is too much of a problem
• Expert
• Authority

Empathic Listener

Puts client at ease, sensitive to suffering and expresses compassion.

Problem: can become too lenient like a permissive mother with a spoilt child

Eg. Paula – on telephone re: breakup of engagement

T (1) Oh, you poor dear, you must be feeling terrible

T (2) Sounds like you got cold feet

Expert

• Shows expertise, establish onself as a professional
• Shows knowledge
• Stimulates curiosity eg. Options
• Deals with distrust
• Problem: may ride the high road of infallibility or appear aloof – it is the client who suffers the consequences, not me.

Authority

Establishes authority and takes responsibility for the client’s welfare

eg. Psychiatric referral for a depressed patient

eg. Referral to Emergency Room for suicidal patient.

Problem: wants the client’s respect, insists upon being in control

Clues to awareness of authoritarian stance:

• Client opposes you and becomes reluctant
• Client grins and makes undermining remarks
• Client contradicts you
• Client becomes very obedient
• Client becomes uncomfortable and monosyllabic
• Client becomes anxious and insecure

Strategies for Rapport: Client Roles

Carrier of a Problem

• Sees him/herself as only temporarily in difficulties.
• Only wants expert advice
• Rapport is easy

The Sufferer

• Flooded with problems, demands may become overwhelming and unbearable
• Wants comfort, sympathy and understanding, not advice and expertise
• Includes clients with chronic depression, personality disorders

The V.I.P.

• Expects preferred treatment, entitled to attention any time of the day or night
• Can be grossly familiar
• Search for the best in the field
• Role can be adopted by anyone from the least privileged to most successful

Strategies for Rapport
Role Interaction

Rapport is achieved when client and therapist balance roles and act accordingly

If the client attacks you, do not accept the role he has assigned to you as a victim of his/her aggression. Step aside and try to assess the reasons for the aggression then accept these reasons as legitimate concerns of the client

àDON’T RESPOND WITH DEFENSIVENESS OR COUNTERATTACKS

Good interviewer switches between roles according to needs of client.

This is related to

• Freud’s concept of transference – distorts perception, perceives others in roles or even forces them to adopt certain roles. Helps understand client-therapist relationship
• Berne’s simplification: parent/adult/child.

Psychiatric interview

-demographics education – best predictor of prognosis

• gender
• marital status
• occupation

• Good interviewer switches between roles according to needs of client.
• Related to Freud’s concept of transference – distorts perception, perceives others in roles or even forces them to adopt certain roles. Helps understand client-therapist relationship
• Berne’s simplification: parent/adult/child.
• STRUCTURE
  PSYCHIATRIC INTERVIEW
• Identification

• Age
• gender
• marital status,
• occupation,
• living arrangements

STRUCTURE PSYCHIATRIC INTERVIEW

• Research has shown that demographic indicators describing past behaviours such as education, marital status and employment can be better predictors of future functioning than personality tests or clinical judgements (Dawes, 1994; Mischel, 1968).
• Employment/Education
• An individual’s work and education is an essential source of data, not only to socioeconomic status but also to the client’s functioning and self-concept.
• Living Environment
• This component describes the physical environment of the client; housing, neighbourhood, transportation, and work environment, important data in determining client’s needs and in planning intervention.
• Chief complaint
• Essential part of interview, make diagnosis based on it.
• “How did you come to be at the hospital?”
• “What is your main problem right now?”
• or (little insight)
• “Why did other people think you should talk to me?”
• Chief Complaint
• In client’s own words
• If client won’t speak, use information from family member, case notes etc.
• Plus duration of problem.
• Chief Complaint
• Clarification of chief complaint may take time.
• A psychiatrist tries to focus the interview so the clarification of the chief complaint does not take more than 15 minutes in an hour long interview

• Often have to take charge and be directive
• Chief Complaint

• If the chief complaint is depression , use DSM IV criteria for depression and ask questions about them SIGECAPS

• Chief Complaint
• If you find the client is somewhat bizarre and you suspect the client may be psychotic, ask about
• ideas of reference: people talking about you on radio, TV in the street
• Odd mental experiences – feelings of unreality,
• Voices: get as many details as possible: inside or outside head, how often, what did they say, what was the patient’s reaction etc.
• Hallucinations: auditory, visual, olfactory, delusions
• NOTE: These are described in detail under the Mental Status Examination section
• History of complaint/problem(s)

begin when the client last was feeling relatively well

• quality of onset of symptoms (insidious vs abrupt)
• how symptoms developed.

If patient has Psychiatric history dating back several years, HPI [history of presenting illness] begins with most recent change from relative wellness to illness.

• If patient is vague or unreliable, HPI includes information from collateral sources, eg. Family, ER staff etc.
• State who came with or brought client.
• Previous psychiatric history and treatment:
• Dates and location of admissions or out-patient treatments
• Psychotherapy
• Untreated conditions eg. Suicide attempts.
• Ask about medications.
• Past Medical History
• Hospitalisations and diagnosis
• Non-psychiatric medication
• Family History and Personal History
• In a standard psychiatric history – 15 minutes - therefore you can only get the grossest details . always described in chronological order in your assessment
• could be vital especially the presence of a family history of mental illness or psychiatric difficulties
• Family History and Personal History
• As much as possible about childhood
• happy or not
• was client an average student
• friends
• teen years
• when did he/she have a girlfriend or boyfriend for the first time
• Family History and Personal History
• With older patient, work and marriage history
• Social Functioning
• Some indication of client’s best functioning during the past year. This gives a good indication of the person’s range of functioning

-see powerpoint

CLASS, SEPT 29^TH, 2010

mental status exam:

-cross-sectional view of the client: it is a system for documenting what you observe in the client

-Susan Lucas model in the book

-there is no analysis of the observations, nor professional opinion

1) appearance: do they look healthy? you may inquire about presentation i.e. very thin, (query: might think anorexia or medical problem), level of alertness (altered by substances? ETOH (code for alcoholism)

2) Speech: how does client speak? Rapid/slow =Manic/depression? Describe the observed speech

3. Emotions: describe the observed moods/behaviours. distinguish between mood and affect

mood: how they feel most of the time (might have to make assumption based on posture…)

affect: the way they show themselves (might say "I am so depressed" but appears smiling).

are the two congruent?

Does the mood change over the interview? is it excessive? is it labile?

In our assessments, Joan wants us to distinguish between mood and affect.

Is mood blunt [does it stop?]/flat [ongoing but pretty empty]?

Thought process: process is the music, and content is the words

Is the thought:

• Circumstantial? Does it go in circles? Does it have no direction?
• Preservative? Do they repeat continually, and forcefully?
• Tangential: sort of speaking about the subject but not really central to the point. Thoughts are unrelated but
• Loose association or flight of ideas [exaggerated loose of ideas]
• Thought blocking – speech is haled and then picked up later. Thoughts/ideas being interrupted by intrusive thoughts or “blank screen”
• Neologisms: patient coins a new words which may have a special meaning for him
• Clanging: choosing words by sound and not by meaning

Affective/psychosis is usually associated with thought problems. The severe ones are usually schizophrenia

Content

• Persecutory delusions
• Ideas of reference – people on TV are talking about me to persecutory delusions. Therefore some people hide their psychosis by not watching TV.
• Delusions of passivity
• Ideas of influence
• Thought broadcasting – everyone thinks my thoughts
• Thought withdrawal – people stealing my ideas
• Thought insertion: someone put thoughts into my head
• Delusions of self-condemnation – I am guilty so I must condemn myself forever
• Delusions with expansive trends: Jerusalem syndrome
• Delusions with somatic delusions

-Delusions are often indicators of a functional psychotic disorder

-Observing ego – is essential in the process of making the ego-syntonic to ego-dystonic

Obsessive thought or compulsive behaviours? If so describe in the mental status exam, MSE. Obsessions are ego-syntonic but out of control

Compulsions are actions which are uncontrollable [checking doors/washing hands]

Is the person phobic? Does the person have panic attack with phobia? Does it come before or after the phobia? Is there avoidance behaviours?

Suicide: thoughts/action/plan

Homicide: thought/action/plan

Often, suicidal ideation occurs in depression

Is there a ruminating thing? A thought preoccupying the person? Describe…

Sensory stuff:

• Auditory
• Sight
• Tactile
• Olfactory
• Gustatory
• Illusions [real object being distorted by person]/hallucinations [solely stemming from in the person’s head] – describe which sense is being distorted. Ask whether its male or female voices? Do you recognize the voices? What do they say? Important question “is it inside or outside your head” – pseudo-hallucination are what the person conceives as inside the person’s head. Auditory hallucination is most common in psychosis. Visual hallucination is common after drugs/organic conditions. Olfactory =common in neurological disorder. Tactile hallucinations = common in substance-use withdrawal

Mental capacities:

• Oriented x 3 – Time/place/name
• Intelligence: average? Above/below?
• Is concentration levels ok?
• Remote/recent memory – test = serial 7s =subtract in 7s. remember 3 objects after 10 minutes. Drawing: people w/ dementia cannot draw a clock
• Does judgment appear impaired? If so, tell why you have observed.
• Appropriate sense of self-worth? If not, on what do you base your observations on
• Does person understand consequences?
• Insight?
• Stage 1 = full insight
• Stage 2 = stopped hallucination but person still thought they were real
• Stage 3 = experienced recently – patient does not want to talk about them = usually medication compliance issues
• Stage 4 =Talk about them hallucinations
• Stage 5 = Act on hallucination

Attitude to interviewer

Describe…

Do they respond to empathy? Capable of it?

Does their attitude change throughout the interview?

In MSE:

• 5 axis of Provisional diagnosis
• Differential diagnosis
• r/o = rule out. So X r/o Y means that I think he has x, but it could be Y
• Investigation – i.e. to find out which diagnosis it is
• Treatment plan

OCTOBER 6, 2010 – DEMENTIAS

Delirium come in bursts, is acute, is psychotic-like, usually organic

In dementias, one has to rule out depression and hearing loss, which might appear similar to dementia.

MMSE stands for Mini-Mental Status Exam

Family therapy with dementias: possible themes:

• helping the family care for the client.
• Helping process the guilt of relief after death after the dementia degeneration
• Seeking resolution about a loved one who cannot fully truly be communicative/functional anymore

cultural implications of dementias:

• some cultures (i.e. less urban/individualistic) do not require the family to constantly watch over the dementia sufferer as all the village know the person and know what to do if the person is wandering (i.e. Turkey)
• many people expect that care provider will “fix” the client

Alzheimer’s has no cure, but some symptom alleviation

Alzheimer ‘s: 7% early onset (before age 65). Early onset is very rapid 5-20 years live expectancy, but usually 7-10 years.

October 13^th, 2010

Untangling the mind – the movie

-initially, psychiatric facilities were horrifically overcrowded, with no realy therapeutic road-map.

-when people discovered medication (dr. Leeman) which helped mental illness (1950s), psychiatry became much more humane – it was really sucky before that

Tartive dyskenesia – after many years of anti-psychotic medication, you get Parkinson-like motor symptom

-some claim that medication is form of social control

-many clients using medication complain of side-effects, i.e. tiredness/fatigue/sloppiness

Stimulation is hard for schizophrenics… so many would like to retreat/withdraw/be alone, in order to reduce stimulation

-only a 1/3 of identical twins both have schizophrenia. One theory is that it is genetic predisposition and some virus which affects the brain

-electroconvulsive treatment (ECT) often works quite well for some psychosis/depressions which are medically resistant/ but it is not really know how/why it works.

-some medication are developed with time –i.e. less side effects, more attuned

OCTOBER 20, 2010

Axis 1 – schizophrenia

-you learn a lot about the disease through talking to the family

• Schizophrenia is a brain disease that affects many mental functions such as:
• thinking
• five senses
• judgment
• feelings
• behaviour
• Schizophrenia is NOT a split or multiple personality

Schizophrenia:

• Positive Symptoms
• Delusions: persecutory, religious, grandiose, somatic – persist and are not fleeing thought
• Hallucinations: auditory, olfactory, visual, gustatory, tactile
• Examples:
• the person feels persecuted (delusions of persecution)
• that he/she is God (religious delusions)
• that he/she is the central figure in everything going on around him/her (delusions of reference)
• A sensory perception which does not come from the outside, but is due to a faulty message in the brain
• People may believe that it is something real and exterior
• Examples:
• Hearing hallucinations (auditory)
• Smelling hallucinations (olfactory)
• Touching hallucinations (tactile)
• Seeing hallucinations (visual)
• Asked teenagers who avoid television/internet because they think in self-referential ways
• Negative Symptoms
• Low energy (anergia) - Loss of ability to become enthusiastic over some things, lack of interest in surroundings
• Loss of interest (anhedonia) - Loss of ability to experience pleasure or express emotion
• Withdrawal - Lack of interest in social surroundings (for example: staying in a room alone for extended periods of time, avoiding friends)
• Flat or blunted affect - limited or no facial expression, poor eye contact; gestures aren't used during communication
• Poverty of thought (alogia) - General slowing of thought and difficulty generating ideas
• Disorganization
• Good question: can he make a meal for himself
• Many patients think or communicate less logically than do people normally
• Thoughts and speech are disorganized
• Behaviour may be disorganized
• Examples:
• Wandering in the streets
• Laughing alone
• Other symptoms include:
• Depression
• Suicidal thoughts
• Anxiety
• Somatic (physical) concerns
• Lack of insight and understanding of the illness
• Difficulty concentrating

Frequency of schizophrenia

• 1 person in every 100 is at risk during their lifetime regardless of race, sex and environment
• World-wide
• In upper-middle class, under-diagnosing due to doctors not wanting to tell the family

Age when it typically starts

• Usually starts in late teens and twenties
• Illness start a bit earlier in men than women
• Peak Age
• Men 23
• Woman 27 –i.e. after 1^st baby. Positive symptoms disappear during pregnancy

-anti-depressive medication will increase psychosis when there is a psychotic subtext [that’s why some commit suicide on anti-depressive medication.] if anti-depression medication increases psychosis, move to anti-psychotic medication!

Causes of schizophrenia

• Specific causes have not been identified
• Genetics: inherited change or a new change in the genes
• Other possible causes:
• complications during pregnancy, birth
• problem during infancy
• viruses
• Many factors are known to be contributory:
• Genetic vulnerability
• Neurodevelopmental abnormalities due to a variety of causes (i.e., the way the brain develops)
• Other factors, such as stress, that exist in conjunction with biological vulnerability
• Genetics: If you are:
• Part of the general population - Approximate Risk- 1 in 100 (1%)
• A brother, sister or parent of Someone who has schizophrenia -Approximate Risk 1 in 10 (10%)
• The child of parents who both have Schizophrenia - Approximate Risk -2 in 5 (40%)
• An identical twin of someone who has Schizophrenia -Approximate Risk -2 in 5 (40%)

Brain Change

• Changes in how the brain develops (neurodevelopmental problems)
• Changes in brain chemicals (neurotransmitters)
• Dopamine
• Serotonin
• Others

Stress-vulnerability model -(Zubin & Spring, 1977)

• Likelihood of illness depends on biological vulnerability and environmental stress
• Determines how medication and psychosocial interventions contribute to treatment and rehabilitation
• Stress-vulnerability model suggests that treatment and rehabilitation success depends on:
• reducing the person's biological vulnerability to symptoms (treating the neurochemical imbalance)
• reducing or modifying the effect of the stress to which the person is exposed (such as daily events; avoiding alcohol and illegal drugs)
• improving skills for coping with stress
• effectiveness of social support given by family, friends and other caregivers

possible triggers

• stopping treatment
• Stress (life events, daily hassles)
• Expressed emotions (EE) such as hostility, criticism, emotional over-involvement
• Alcohol, drugs (another type of stress

What does not cause schizophrenia

• Schizophrenia is NOT caused by:
• Family upbringing
• Poor diet
• Problems with other people

àimportant to work on the family around guilt

Relapse rates and long-term outlook

• Relapse Rates % at 2 years –research of
• With medication and adequate psychosocial Intervention (family psychoeducation and Social skills training)………................................................0 - 20% àBEST COMBINATION!
• With medication only………………………….15 - 40%
• Without medication……………………………60 - 80%
• Why try and prevent relapse? Because relapse and full recovery to pre-relapse levels of function is not that possible! First 5 years are the hardest, and then there is a levelling off. Some rare cases have a spontaneous recovery

Psychosocial interventions

• Work best with medication
• Individuals who are educated about their illness are less likely to relapse
• Includes:
• case management
• psychoeducation for family and patients
• skills training (such as social, vocational, life skills and problem solving)
• other interventions - e.g. stress management

case management

• Designed to assist the severely, chronically mentally ill in maximizing their use of existing resources, thereby increasing their independence and quality of life
• Should be defined within the context of client needs and community resources
• Includes:
• Identification and outreach
• Individual assessment
• Service Planning
• Linkage with requisite services
• Monitoring service delivery
• Advocacy

Medication

• Essential
• Controls symptoms of psychosis
• Better for positive symptoms.
• Reduces further vulnerability
• Available by mouth (oral) or by injection

Injections

• used for long-term management
• help improve compliance
• Reduces symptoms such as hallucinations and delusions
• Prevents recurrence or symptoms
• May work on a number of different chemicals in the brain.
• Most antipsychotics affect the dopamine system which produces a brain chemical
• Newer antispychotic drugs may affect other chemical messenger systems such as serotonin
• Antipsychotic medication is not addictive

Medication Choice & Dosage

• Goals
• Achieve the best symptomatic relief and the least side effect
• Use lowest possible dose
• Considerations
• Every patient reacts differently to medications
• It may be necessary to try different medications before the right one is found

Common Medications

Brand Name Generic Name

• Clopixol * Zauclopenthixol
• Clozaril Clozapine
• Fuanxol * Flupenthixol
• Haldol * Haloperidol
• Largactil * Chlorpromazine
• Loxapac * Loxapine
• Mellaril Thioridazine
• Moditen * Flupehzazine HCL
• Nozinan Methotrimeprazine
• Orap Pimozide
• Resperdal Risperidone
• Stelazine Trifluoperazine
• Trilafon * Perphenazine
• Zyprexa Olanzapine

* Also available in injectable form (by injection)

Medication Treatment

• Antipsychotic medication should be taken:
• As long as there are positive or negative symptoms
• As long as there is a significant risk of relapse, even though acute symptoms are no longer present

• Recommendations
• After 1 episode: Medication for at least 1-2 years
• After 2 or more episodes: Continuous medication. Unless the patient has been symptom free for at least 5 years
• Follow-up required even when not on any medication
• Early Intervention
• The best treatment is continuous medication at the lowest possible dose
• If treatment is stated early:
• nearly 90% recover from their psychosis
• long-term outcome improves significantly

Medication compliance

• Patients
• Often do not acknowledge illness
• Start to feel better, and no longer feel a need for medication
• Experience troublesome and unpleasant side effects
• Believe some societal views that antispychotic medications will rob them of their real personality
• Want to test their strengths in battling schizophrenia alone.

-neurotransmitter reuptake of dopamine is the neural issue behind schizophrenia. Must of medications focus on balancing the dopamine levels- when redefined as a biological process, as opposed to a “going crazy” attribution, this often makes it easier for client and family to accept – and therefore, it increases compliance [sort of like a psychoeducational]. When stopping the medication, some of it stays in the fatty tissue, so therefore, relapse is only there after 4 months. Some fear that medication will “rob” person of his personality!

Medication side-effects

Some accidentally attribute the symptoms of the illness to the side-effects of the medication!

Common side effects include:

• Most side effects occur early in treatment
• Remedy
• reduce dose
• change medication
• treat side effects directly
• Treatment should not be stopped automatically because of side effects
• Some of the problem that patients often think are side effects (fatigue, lack of energy, depression,
• etc.) may in fact be symptoms
• Treatment is a balance between benefit and risk.
• Problems with movement
• acute dystonia (muscle spasms)
• akathisia (restlesness)
• parkinsonism (rigidity, shaking, slowing of movements)
• Tardive dyskinesia (abnormal involuntary movements) 15-20% risk with long-term neuroleptic therapy Newer anti-psychotics may pose less of a risk.
• Blurred vision, difficulty urinating
• Difficulty remembering or concentrating
• Drowsiness and lethargy
• Dry mouth
• Constipation
• Menstrual irregularities
• Sexual dysfunction
• Low blood pressure
• Sensitivity to sunlight (sunburn) àthey need hats!!!!
• Weight gain –i.e. common in zyprexa

Consequences of substance abuse

-dual diagnosis is common in younger schizophrenia – schizophrenia + substance use – often marijuana

• Symptoms increase
• Depressive symptoms
• Disruptive behaviour
• Aggressive/assaultive behaviour
• Poor self-care
• Housing instability
• Treatment non-compliance
• Increased use of other substances
• Increased rates of hospitalization
• Poverty

Common early warning signs

Mood and behavior:

• increased tension and nervousness
• depression
• feeling worthless
• loss of interest in things
• changes in sleep
• changes in appetite

Thinking and perception

• Deceased concentration
• Decreased memory
• Feelings of persecution
• Feeling of being ridiculed
• Feeling of being talked about
• Religious preoccupations (previously non-existent)
• Hearing voices
• Seeing things

Long term effects

Result of many complex and dynamic factors such as:

• the person
• his/her vulnerabilities
• the environment
• individual decisions made by the person
• timing of treatment
• comprehensive nature of the treatment provided.

The Patient's role in Treatment

• Stay with treatment
• Stay with medication
• Not use drugs or alcohol
• Manage general health issues (hygiene, diet, etc.)

Psychosocial treatment and families

• Family members are important partners within the treatment team
• Families must be as informed as the individual who has the illness. Education about the illness helps all family members cope with the illness
• In addition to psychoeducation, some families will require specific interventions and support to assist them in coping with their relative's illness and to equip them with the necessary skills.

Future prospects

• With antipsychotic medication treatment:
• 75% of patients improve considerably
• 25% respond poorly and still have positive and negative symptoms
• New and promising antipsychotics are in development for patients responding poorly to existing therapies.

-neurotransmitter reuptake of dopamine is the neural issue behind schizophrenia. Must of medications focus on balancing the dopamine levels- when redefined as a biological process, as opposed to a “going crazy” attribution, this often makes it easier for client and family to accept – and therefore, it increases compliance [sort of like a psychoeducational]. When stopping the medication, some of it stays in the fatty tissues, so therefore, relapse is only there after 4 months. Some fear that medication will “rob” person of his personality!

Dual diagnosis – means two major diagnosis

October 27^th, 2010

-coping mechanisms of family members care-givers improve with social support

-case management system tries to improve continuity o f care

Limitations

-might try to replace rather than support the family – i.e. interfere with the relationship of the sick relative and family

-face-to-face meeting with case management is correlated with less satisfaction with the care

àneed to integrate the case-management and

Massively important: Grieving:

-people is an essential first step to adjustment to diagnosis

àmust come to term with shattered dreams and hopes

-unlike loss of child, this grief is chronic, due to the problem being there continuously. Denial of illness often takes a long time and gets in the way of realistic treatment plan set by case-management

-self-awareness is physically difficult for the client to accept

-initial denial may be helpful to prevent overwhelming the individual and family

àeventually, the denial will be detrimental, if the person/family in treatment

-family may be the first to acknowledge the illness and start the grieving process… then the treatment plan can start addressing the client’s denial.

-family is integral to the work with the client. Family is more statistically reliable than standardized test. Patients are not reliable in self-report og function. Family is often the only source of information about the negative symptoms. Negative symptoms may be subtle and easily attributed to other causes – i.e. adjustment/personality. Family may be better at identifying the positive symptoms. Patient can hide the positive symptoms in front of psychiatrist, but not when family is there, due to the family being part of the emotional system being present.

schizophrenia – illness of thinking

lifecycle

Diagnosis of mental illness during late adolescence – the patient may need more support during a time when the normative thing would be increased autonomy. Clinician o help family balance schizophrenic’s autonomy and necessary massive support

Confidentiality: impractical to mental illness. Family members often complain that they are used as sources of information but given information to help support the family. No verdict on the matter, and this matter needs to be negotiated, with the help of MFT person. Psychotic patient often initially refuse, but agree to family help with time on medication. Relationship with all family members is key to the MFT helping on this one. i.e. support group/psychoeducational referrals are helpful.

November 3^rd, 2010 – bipolar

Manic episodes

• Abnormally persistently elevated mood
• Decreased sleep
• Increased talking, rapid thoughts
• Increased goal directed and pleasure full activities

Depressive episodes

• Depressed mood, crying, low self-esteem, guilt
• Low energy, sleep disturbance, appetite disturbance
• Suicidal thoughts

CAUSAL HYPOTHESES

• Genetic factors
• Neurotransmitter dysregulation
• Neuroendocrine dysregulation
• Life events;
• More often precede first rather than subsequent episodes of mood disorders
• Loss of a parent before age 11
• Loss of a spouse

RISK FACTORS

• 1-2% of the general population
• Equal in men and women
• 25% of children with one parent with Bipolar illness
• 50-75% of children if both parents are affected
• Age of onset: 30 years old
• Classification
• Severity: eg. mild, moderate
• Severity with psychotic features
• Severity without psychotic features
• In partial remission
• Pattern of Episodes: - i.e. With or without full inter episodic recovery

- With rapid cycling

Bipolar Disorder and its Cousins

Extreme depression

• Totally withdrawn, doesn't talk
• Unable to eat, respond
• Suicidal or too depressed to harm self
• Hears voices of guilt, doom
• Hospitalization needed

Severe depression

• Needs prodding to function
• Serious sleep disorder
• Weight loss or gain
• Suicidal ideas
• Very withdrawn
• Feels guilt, self-hate, paranoia
• May need hospitalization

Moderate depression

• Loss of energy, interest, movement, desire to work
• Disturbed sleep, appetite, ability to function
• Withdrawn
• Desire to stay in bed
• Life not worthwhile

Mild depression

• Feels unsure, unfocused slowed down
• Lack of energy, optimism, pleasure desire, sexual interest
• Crying spells

Normal mood

Mild Elation

• Feels wonderful, confident, perceptive, creative
• Increased interest in travel, business, projects, sex, religion, spending money

Moderate Elation

• Excessive confidence, activity, talking, thinking travel, sex, irritability, controlling, spending money
• Decreased eating, caution, sleep (4-6 hours / night)

Severe Elation

• Very rapid talking, thinking
• Very little eating, sleeping, control
• Unusual ideas, behaviour
• Religious fervor
• Hostile
• May need to be hospitalized

Extreme Elation

• Restless/hyper
• Hostile/violent
• Nonstop talking
• Paranoid
• Hears voices
• Incoherent
• Can't function
• Elated or wild
• Little or no: eating, sleeping, control, organization
• Hospitalize

Difference between Bipolar I and Bipolar II

• Bipolar I – one or more manic episodes
• May also have depressive episodes
• Bipolar II - one or more depressive episodes whose symptoms cause significant distress in social, occupational or other areas of functioning
• Must have at least one hypomanic episode

• Bipolar I : more emphasis on mania
• Bipolar II: more emphasis on depressive symptoms

-Person has chronic fluctuating moods (for at least two years)

-These mood swings do not meet the criteria for either major depression or mania

Differential Diagnosis

• Schizophrenia – does not return to social functioning
• Schizoaffective disorder
• Unipolar depression
• Temporal lobe episodes
• Stimulant abuse: may produce period of manic behaviour followed by depression during withdrawal
• Alcohol or sedative abuse: may produce period of depression followed by “mania” during withdrawal delirium
• Brief reactive psychosis due to a very stressful life event

-medication: anti-psychosis for mania, and anti-depressive for depressive – lithium/tegratol/epival are mood stabilizers to keep mood within normal intensity

Prognosis

• The natural course of manic-depressive illness is to have increasing number and severity of episodes as the patients gets older
• Drugs used to stabilize and prevent mood swings (lithium, carbamazepine, and valproate) decrease the number and severity of episodes but do not necessarily abolish them
• The disorder appears to be lifelong, and therefore often requires lifelong treatment.

Medication

• Lithium
• Salt
• 7-10 days for effect
• blood tests ; concentration in blood .8 - 1.5 therapeutic window
• side effects: toxicity - diarrhea, nausea, dehydration,
• problem with overdose
• failure rate of 20-30% not universally effective
• Carbamazepine (Tegretol)
• Valproic Acid (Depakote)

Medication Dilemmas

• Anti-Psychotics
• swing to depression
• Anti-Depressants
• swing into mania

Treatment: Psychological

• Focus on acceptance of illness
• Family psychoeducation

November 10^th, 2010 - depressed

General Issues

• The term “depression” can mean many different things. Therefore, when patients say they are “depressed”, it is important to ask, “What do you mean by ‘depressed’?
• The term “depression” can refer to any of the following:
• Major affective disorder
• Depression secondary to some medical cause
• Adjustment disorder with depressed mood
• Dysthymia (minor, chronic depression)
• Brief reactive depression
• Grief
• Bereavement
• Chronic emptiness of borderline personality disorder
• A component of schizoaffective disorder
• Boredom

àit is the Most Common Mental Health Disorder

• Poorly understood by public – can’t just snap out of it.
• Left unchecked, depression at work can manifest itself as alcoholism, absenteeism, injury and even physical illness.
• Royal Bank 31% of short-term absenteeism is related to mental illness and addiction
• Most Common Mental Health Disorder
• Harvard University project - #1 source of lost workdays in developed countries by 2020
• Cost $60 billion in US and Canada per year in lost productivity. (Gazette – 7/8/2000)
• Screening in 6 sites in Montreal of 500 people – more than 40% showed symptoms of depression and one-third had not previously sought help for their condition (Gazette – 8/14/2000)

Strategies for Evaluating Depression

• Step One: consider medical causes
• Cancer (22%)
• Brain tumour, hypothyroidism, Multiple
• sclerosis (6-57%)
• Parkinson’s disease (40%)
• Step Two: Consider adjustment disorder
• Assess psychosocial problems
• Decide if suitable for some type of psychotherapy or counseling
• Step Three: Consider the possibility of a major depression
• Refer for treatment with medication

DEFINITION/IDENTIFICTION

• Major depression used to be called endogenous depression
• Major depression is defined by the presence of specific symptoms
• There is no biological marker for major depression although its diagnosis implied an underlying psychobiological disorder
• Criteria required for diagnosis of major depression
• At least one of the following: depressed or discouraged mood or loss of interest and pleasure must be present continuously for at least 2 weeks.
• It is useful to ask if client is discouraged since many people deny being “depressed” because it is considered a sign of weakness and involves some stigma – could be a gender issue
• The depressive symptoms cannot be a result of some medical cause.

SIGECAPS

5 of the following symptoms present continuously over the past two weeks

• Sleep - Depressed clients may have classical early morning awakening but also may have trouble initiating or maintaining sleep. Ask the client “Has there been a change in your usual sleep pattern?”
• Interest – anhedonia the inability to get pleasure from or find interest in activities. Ask, “When you were last feeling well, what sort of things did you do to enjoy yourself? Are you doing those things now, and do you enjoy them?”
• Energy - fatigue
• guilt
• Concentration - depression is usually thought of as a mood disorder; however, it is also a cognitive disorder.
• When the cognitive impairment is prominent, especially in the elderly, clinicians often misdiagnose the problem as dementia.
• Memory difficulty associated with depression is sometimes called pseudodementia
• Appetite: Depressed patients typically have impaired appetite (which may result in weight loss); however, increased appetite (and weight gain) is also possible
• Psychomotor agitation or retardation is a behavioural expression of depression. Clinicians may observe hand wringing, restless pacing, or withdrawal and slowed movements. Cannot talk, cannot walk [need wheelchair].
• Suicidal ideation
• It is crucial to ask about suicidal ideation as part of every depression evaluation because clients may not volunteer this information.
• It may be helpful to pursue this topic by an escalating series of questions
• Clients acknowledging suicidal ideation and plan should be considered a serious suicide threat.
• Arrangements should be made for the client’s safety

DEFINITION/IDENTIFICTION

• Some standardized psychological tests can be helpful
• Beck’s depression scale.
• David Burns has developed a simplified version.

PREVALENCE

• The community prevalence of major depression is 3% to 5%
• The lifetime risk is 3% to 12% for men and 20% to 25% for women
• The risk is higher for those with a first-degree relative with major depression, bipolar disorder, or alcoholism.
• Prevalence of major depression goes up dramatically in patients with medical illness
• The prevalence of major depression in the elderly
• community prevalence of 3% to 5%
• Nursing home prevalence 15% to 20%

RECOGNITION

• In physicians’ primary care practice, recognition of major depression is about 50%.
• Reasons for low recognition include the following:
• Patient reluctance to acknowledge symptoms
• Predominant symptoms may mislead the clinician
• Fatigue may be seen as a medical problem
• Sleep difficulty may be seen as primary
• Cognitive symptoms are seen as dementia
• Somatic symptoms seen as medical
• Chronic pain seen as medical
• Functional disability seen as inevitable in elderly
• Depression seen as a normal reaction

CRITERIA SPECIFIC TO MEN (Pollack, 1998)

• Increased withdrawal from relationships
• Overinvolvment with work activities: May reach a level of obsessional concern, masked by comments about “stress” (burnout)
• Denial of pain
• Increasingly rigid demands for autonomy
• Avoiding the help of others: The “I can do it myself” syndrome
• Shift in the interest level of sexual encounters: May be either a decrease or an increase (differentiate from mania
• Increase in intensity or frequency of angry outbursts
• New or renewed interest in psychoactive substance self-administration: To create self-numbing tension relief states without classic dissociative mechanisms
• A denial of any sadness and an inability to cry
• Harsh self-criticism: Often focusing on failures in the arenas of provider and/or protector
• Impulsive plans to have loved ones cared for in case of patient’s death or disability: “The wife and/or kids only need me for the money.”
• Depleted or impulsive mood

Precipitating factors or events

• Rejection in a significant relationship
• Loss of employment or other role status
• Narcissistic wounding
• Third-party coercion (employer, partner, spouse) – being told that you are depressed – others might notice your mood more.
• Paranoia and increased interpersonal sensitivity (assess for risk of stalking)

DIFFERENTIAL DIAGNOSIS

• Major depression with psychotic symptoms
• increases risk of suicide
• Uncovering questions – Have you had any disturbing thoughts about your body = gets at somatic delusions
• psychotic symptoms occur only with the depression
• Schizoaffective disorder: psychotic symptoms also occur separately. Sometimes very difficult to distinguish from psychotic depression
• Bipolar affective disorder with depression
• Depression secondary to a medical cause
• Adjustment disorder with depressed mood
• symptoms do not meet full criteria for major depression
• occur in relation to some stress
• last less than 6 months
• Bereavement – associated with the death of a close relationship. Duration of bereavement may be culturally determined; a problem to diagnose depression before the prescribed bereavement period is over. àthis is on the V codes of DSM
• Dysthymia; chronic depressive symptoms that do not become severe enough to meet criteria for major depression, present for at least 2 years.
• Borderline personality disorder with chronic emptiness, depressed mood and suicidal ideation
• Seasonal affective Disorder.
• Temporal relationship between the onset (or remission) of a mood disorder and a particular period of the year.
• Typically the illness begins in autumn or spring. Carbohydrate craving and weight gain are often associated.
• Sleep disturbance is usually hypersomnia.

COMORBIDITY

• A symptom of some major Axis I disorders: e.g. bipolar, schizoaffective disorder
• Panic disorder and major depression - anywhere from 30% to 70%
• Substance Abuse disorders - nearly half of alcohol/drug patients have a history of major depression (Miller, Klamen, Hafmann & Flaherty, 1990)
• Maybe relatively uncommon to find a major depressive disorder without finding other psychiatric problems

PROGNOSIS

• Left untreated, episodes of major depression usually last about 6 to 9 months.
• Some cases of major depression are episodic and recurrent
• Some cases become chronic and may last for years
• Without treatment, major depression is a serious illness that affects quality of life to the same extent as chronic medical illnesses. In addition, there is a definite increased risk of suicide.
• Treatment has a significant positive effect, with more that 70% of major depression responding to adequate trials of medication.

TREATMENT

• Three forms of effective treatment for major depression are
• Psychotherapy –i.e. Cognitive Therapy
• antidepressant medication
• ECT
• Medication or psychotherapy?
• Patients whose symptoms interfere with participation in talking therapy should start with medication first
• Patients with milder symptoms who seem willing to talk about their problems hold be started with psychotherapy, reserving medication for an inadequate response
• Between the two extremes, the two treatments can be used conjointly
• Medication treats symptoms, therapy treats problems
• Common Medications:
• Trycyclics
• SSRI”s Selective serotonin re-uptake inhibitors: Paxil, Prozac
• Wellbutin
• Effexor – serotonin and norepenephrine
• Serzone – popular lately, no sexual side effects
• MAO inhibitors. Nardil
• Systemic Therapy for Depression (Beach, 2003)

-Marital and parenting interventions may have the potential to help reduce depressive symptoms and the interpersonal problems that often occur concurrently with depression

• Marital distress may be maintaining the problem
• Depressed patients report considerable distress and difficulty in parenting relationships. Parent training may be a useful point of intervention to break into a stress-generation process for some depressed individuals.
• Parent training effectiveness with depressed clients needs to be adapted – some direct attention needs to be given to cognitive symptoms of depression (Sanders and McFarland, 2000)
• Guidelines:
• Depressed individuals who report substantial difficulties in marital and/or parenting relationships and indicate that current depression followed these problems.
• Initial focus on these problems (marital therapy or parent training) may produce positive outcomes compared to individual focus only.
• when depressed individuals report no or mild marital distress and little parenting difficult, involve the spouse or other family members as adjuncts. “you may not be part of the problem, but you do want to be part of the solution”.
• Focus on strengthening support system
• Depressed individuals who report substantial relationship problems that emerged only after depressive episode
• Initial focus on either on the individual and his or her symptoms of depression.
• Concurrent focus on relationship may be beneficial.
• Important rule of thumb: If any treatment for depression within 4 – 6 weeks of treatment, regardless of modality, refer to another empirically supported treatment.
• Physical Aggression between Partners and Depression
• Wife’s depression strongly related to low level physical aggression within couple during conflict
• NOT TRUE OF HUSBANDS. Husband’s depression is unrelated to wife’s violence

New Treatment

• RTMS -Repeated Transcranial Magnetic Stimulation
• Developed from MRI researchers who noticed improvement – would go in a scanner for a while and felt better
• Now being tested in clinical trials for depression and for auditory hallucinations – mostly in Germany
• Counter indication: Patients with seizure disorders

November 17^th, 2010 - suicide

-Reality of suicide: any person who truly wants to end his or her life, other than a very young child or a completely incapacitated adult, will find a way to do so. You may wish to change that, you may try to change it, you may believe you have changed it, but you may fail. That is a fact.

“Must accept reality but there is a great deal that you can do, should do and can learn to do.” (Susan Lukas)

Facts

-Suicide is completed by over 30,000 Americans each year and is the 9th leading overall cause of death, second among youth. (National Center for Health Statistics, 1998)

• 5th cause among ages 25-45
• 3rd cause among ages 15-24
• 5th cause among ages 5-14
• for every completed suicide 50-200 attempts made

-Must evaluate suicidal risk as part of Mental Status Examination

-A high percentage of patients who commit suicide visit their primary care physicians in the prior few months.

Risk factors

• Chronic medical illness
• Suicide is almost twice as high among cancer patients and significantly elevated among AIDS patients.
• Heomodialysis patients
• Patients with dt’s and respiratory diseases
• Old age – especially white elderly males: 8 – 15 times as great as rates for women of the same age. Recent death of a spouse a prominent risk factor.
• Male sex: women try more frequently, men succeed. At all ages, for all races, men commit suicide at three to five times the rate a women.
• Recent major mental illness:
• Major depression (50%) ,
• Chronic alcoholism (20%)
• Schizophrenia (10%)
• Borderline personality (5-15% )
• Previous suicide attempts (present in 30% to 40% of cases)
• Suicidal ideation (communicated in 60% of cases)
• Risk is increased in situations of recent major loss or bereavement, diagnosis of illness, intense work frustration, and feelings of hopelessness, helplessness, isolation, and humiliation.
• Risk is increased if there is a family history of suicide (through mechanisms of guilt and/or identification.)
• In the person with a family history of suicide, dangerous times are holidays and anniversaries of the death.
• Visits to MD’s – about 50% have since a MD within the past month
• Panic attacks (20% of people with panic disorder)
• Poor sleep
• Unemployment
• Unmarried.

MYTHS

-A person who is thinking about killing him/herself will never tell anyone.

- The fact is that they will verbally say:

• “I wish I were dead”
• “What difference will it make if I fail an exam?
• “What do you suppose it is like to be dead?”
• Anger: “He will be sorry when I am dead”

The fact is that there are nonverbal as well– giving away possessions, cutting off the phone. Making an attempt

-If you talk about suicide, that will put the idea into the person’s mind and he/she will kill him/herself.

àthe fact is that: TALKING ABOUT SUICIDE MAKES IT LESS LIKELY THE PERSON WILL KILL HIM/HERSELF

Interview protocol for Evaluating Suicidal Ideation

• “you have said you are depressed; could you tell me what that is like for you?
• “Are there times you feel like crying?”
• “When you feel that way, what sort of thoughts go through your mind?”
• “Do you ever get to the point where you feel that if this is the way things are, that it is no worth going on?”
• “Have you gone so far as to think of taking your own life?”
• “Have you made any plan?”
• “Do you have the means to carry out such a plan?”
• “Is there anything that would prevent you from carrying out the plan?”

NOTE:

(Harvey G.) I say things like: “You are coming here with problems and distress, and although I am not sensing that they’ll overwhelm you, are there times when it seems hopeless, when you feel you’d be better off dead?”

Obviously if the answer is yes, you get more specific. Even when the answer is no, I still ask, “There never have been such moments?”

A great many persons will answer yes to this second question.

Interview protocol for Evaluating Suicidal Ideation (Lukas)

• When did she last have a thought about killing herself?
• How often does she think about killing herself?
• How comforting do these thought seem to her?
• Has She made a previous suicide attempt?
• Does she now have a plan to kill herself?
• Can she carry out a plan?
• Worrisome Signs
• Unusual calmness may be a worrisome sign in a severely agitated and depressed person since it might signal a resolve to end it.
• Sudden divestment of valued assets
• Bizarre communications that hint or overtly bid someone goodbye
• Worrisome Signs
• Behaviour that is self endangering. Many kinds of reckless or dangerous behaviours
• driving too fast, drinking and driving
• using large quantities of drugs, especially cocaine and heroin.

ASSESSMENT OF SUICIDE RISK IN MEN (COCHRAN & RABINOVITCH, 2000)

• Severity or level of depression
• Based on diagnostic criteria
• Patient-rated severity and level of distress
• Proximal risk factors
• Acute intoxication
• Isolation
• Psychosis, delusional thinking
• Relationship or job loss, failure experiences
• Acute anxiety, restlessness, agitation
• Medical Illness
• Presence and intensity of suicidal ideation
• Presence and specificity of suicide plan
• Access to means to commit suicide
• Firearms
• Ropes for hanging
• Combustion engine and enclosed garage
• Prescription medications
• Capacity for self-control and containment of depression
• previous suicide attempt
• willingness to work with therapist to manage depression
• Specific suicidal intent
• patient-rated level of intent to follow through
• indirect evidence (“Put affairs in order”, giving away valued possessions, notes)
• Exacerbating conditions or circumstances
• anger as predominant affect
• hopelessness
• Protective factors available or accessible
• social support – family, work, school, neighbours
• cooperation with therapist in planning for safety
• psychiatric consultation

MANAGEMENT

• Depends on the context in which clinician is functioning
• Assessment context
• specification of level of risk
• immediate short term strategies to contain emergent suicide danger
• Treatment context
• analysis of the level of suicide risk is balanced with the strength of the therapeutic alliance
• active decision making with client whether risk is best managed in an outpatient or inpatient context.

MANAGEMENT: Common factors

• Therapeutic interventions to increase tolerance of depressive and painful affect – helps decrease intrusive and burdensome nature of severe depression
• With men, education-orientated interventions can be helpful – to undo negative effect of male gender socialization – i.e. sadness and display of depressive affect as not masculine and undesirable.
• Strategies designed to limit access to means of committing suicide.
• Direct questioning.
• Offer to hold a weapon or arrange with someone to do so.
• If client gets into a power struggle with the clinician – a signal that suicidality cannot be handled in an outpatient context.
• Clinician addresses other aspects of danger related to risk e.g. acute intoxication, active psychosis
• Clinician increases environmental support systems. Identification of supportive people in the client’s life will help reduce risk.
• Bolster therapeutic alliance
• increase frequency of sessions,
• no-suicide agreements or contracts,
• check-in phone calls, E-mail.
• NOTE: Inability of client to co-operate indicates high risk

Management of suicide risk in Men

• Countertransference Issues
• Therapist internalized gender-role values
• Threats to the therapeutic alliance
• Temptation to debate philosophical issues around suicide. Debating issues with the man patient will serve no useful purpose and may exacerbate feelings of disconnection and isolation

FAMILY TREATMENT (MacFarlane, 2001)

• Antecedents normally either invisible to family members or misinterpreted by them
• Initial focus on a safety plan for the client.
• Treatment based on a psychosocial model of the development of depression
• Step 1. Perception of sustained goal frustration
• Step 2. Feeling of loss of control in important areas
• Step 3. Disengagement from incentives and corresponding belief that responding will not make a difference.
• Step 4. Appearance of depression symptoms, starting with withdrawal, rumination, and progressing to physical symptoms
• To sustain a positive mood, the perception of current, or anticipated, positive events must be greater than current, or anticipated, negative events
• The job of therapy is to increase the ratio of positive events and recognition, relative to negative events and recognition (e.g. criticism) in the lives of depressed individuals.
• Increasing the positive ratio leads to self-esteem which leads to help and adaptive performance.

TWO IMPORTANT PRINCIPLES

• Successful performance is a powerful anti-depressant.
• Self-esteem flows from positive social recognition.

TREATMENT GOALS

• Establish safety, personal competence and successful performance on the part of the suicidal family member
• Healthy family functioning
• Focus on the present and future rather than past
• Based on solution -focused therapies (Beck, 1979; Lewinshom,1984)
• i.e. Therapy should be brief, people are not pathological and clients can change rapidly .

Acute Stage

• Opening communication - listening to gain understanding
• Evaluation of suicidal risk and previous attempts: Continum
• (1) suicide ideation but no intent
• (2) intent but no plan
• (3) the presence of a plan
• (4) the presence of a plan and the available means.
• Safety evaluation
• Means
• need for one-to-one monitoring
• destablilizing influences
• alcohol,
• exploitive friends,
• internet material on means
• Assess possible referral networks
• Suicidal member may have to be closely monitored if she/he continues to have suicidal ideation and a plan is present

Comprehensive Assessment Stage

• Suicide risk (on-going monitoring)
• Psychometric assessment of level of depression (monitor) e.g. Beck Depression Inventory (1987)
• Within-family communication patterns
• Family members' respective views of key issues affecting primary client
• Comprehensive Assessment Stage
• Primary client's perception of personal problems
• Level of functioning of primary client
• Faulty beliefs of primary client
• Personal goals of primary client
• NOTE: The miracle question can help activate problem-solving skills, help client to see life without the problem.

Intervention

• Primarily Educational
• Role of Unconditional Family Support
• Mood-Driven Performance and Cognitive Biases
• Intervention
• Reciprocal Behavioural Agreements.
• All members of a family have an age-appropriate right to have other family member do what they have committed themselves to.
• Must be reciprocal. "You do this for me and I'll agree to do that for you."
• Action Steps
• Ground rules for family meetings
• Translating Complaints into Requests
• Reciprocal Behavioural Agreements
• Reversing the Direction of Aversive Interactions.
• Family members have a long memory for slights
• Daily Structure for Primary Client
• Pleasant Event Schedule for Primary Client

November 24, 2010

INTRODUCTION

Definition of anxiety: Fear without a cause

Anxiety become a problem when it:

• Interferes with adaptive behaviour
• Causes physical symptoms
• Exceeds a tolerable level

PANIC DISORDER

Definition: presence of (or history) of panic attacks that do not have an underlying medical etiology (e.g. cardiovascular, asthma, COPD, neurological disorders).

-Severe anxiety that comes on suddenly and characterized by somatic and psychological symptoms:

• Respiratory: chest pressure, choking sighing
• Cardiovascular: tachycardia, palpitations, chest pains, faintness
• Autonomic: dry mouth, sweating, headaches, hot flashes
• Musculoskeletal: aches, pains, twitching, stiffness, fatigue
• Genitourinary: frequency, urgency, sexual dysfunction, menstrual problems
• Gastronintestinal: swallowing, abdominal pain, nausea, irritable bowel
• Neurologial: dizziness, numbness/tingling, visual disturbance, weakness, tremor

Panic attacks may be the result of other medical or psychiatric conditions

Agoraphobia – often a part of panic disorder. Client becomes fearful of having an attack and wants to stay in a safe place.

DSM Panic Disorder Criteria

• Recurrent panic attacks with worry about recurrence or consequences
• Panic attack is defined as a discrete period of intense fear or discomfort, starting abruptly and reaching a peak within 10 minutes, with physical symptoms such as the following:
• Palpitations, tachycardia
• Sweating
• Shaking or trembling
• Shortness of breath
• Choking
• Chest pain/discomfort
• Nausea, abdominal distress
• Dizziness, faintness
• Feeling unreal or detached from oneself
• Fear of “going crazy”
• Fear of dying
• Paresthesias
• Chills or hot flashes

PANIC DISORDER

Prevalence of Panic Attacks

1 to 2% of general population: Incidence highest in young women in early 20’s: 40% onset after age 30

tend to cluster in medical practices

genetic component

Course and Prognosis

• Episodic: may emerge, disappear and re-emerge years later
• Do not underestimate the impact of panic disorder
• symptoms are often frightening and disabling
• secondary substance abuse is not uncommon
• in severe cases, there is an association with suicide

Assessment

• “Are you a Worrier?”
• ‘Have you ever had a panic or anxiety attack?”
• panic attack is a sudden rush of fear and nervousness in which your heart pounds, you get short of breath and you are afraid you are going to lose control or even die. Has this ever happened to you?”
• When did you last have one of these attacks? Can you describe that attack for me? What were you doing when it started? How did it make you feel and how long did it last”?
• When you have these attacks, do you notice any of the following symptoms: sweating, shaking, tingling in your hands or lips, shortness of breath, your heart pounding, chest pain, nausea or a feeling you are going to go crazy or die?”
• “Do you have any special fears such as of insects or flying?”

Phobias

An irrational fear that interferes with normal behaviour

3 major groups

• Agoraphobia without panic disorder
• sShould be considered with reclusive clients
• Social Phobia: specific (public speaking) or general fears of being with people, manifested by extreme anxiety in these contexts.
• Simple phobia: fear of snakes, heights, crossing bridges, darkness, flying and needles.

Treatment

Very responsive to psychopharmacology:

• Benzodiazepines: e.g. Xanex, Rivotril
• Antidepressants: e.g. Imipramine, SSRI’s (Prozac)

Cognitive-behavioural Therapy (CBT)

• Identification of the irrational thoughts and erroneous core beliefs that trigger panic.
• Cognitive restructuring: decatastrophize catastrophic thoughts, examine realistic consequences of a perceived negative event, and probability of negative event occurring.
• Exposure exercises (imaged, in vivo, or both) designed to reduce avoidant behaviour (e.g. agoraphobia)
• Physiological sensations: Taught control of breathing during anxiety.

-sometime psychoanalytic work is important but cannot be completed before the CBT component.

Interpersonal Component.

-enlisting a spouse as cotherapist can enhance CBT.

Help client understand syndrome, conduct exposure and breathing exercises outside therapy

Relationship communication enhanced.

Obsessive-Compulsive Disorder

Obsessions: recurrent and persistent ideas, thoughts impulses, or images that are experiences as intrusive and inappropriate and cause marked anxiety or distress

Examples: may include fears of contamination, personally unacceptable sexual thoughts, obsessions with a need for symmetry or exactness, hoarding or saving obsessions, obsessions with violent or aggressive images or behaviours, or a fear that harm will come to others.

Compulsions:

-repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession, or according to rules than must be applied rigidly.

Aimed at preventing or reducing distress and anxiety or preventing some dreaded event or situation, but the behaviours are either clearly excessive or are not connected in a realistic way with what they are designed to prevent.

Compulsions Examples:

• Ritual hand washing or cleaning to avoid contamination
• Ritual checking of locks, stove burners, and water faucets to avoid feared disasters such as fire burglary, and flood
• Ritual hoarding or collecting of items to reduce a fear of items being needed and not available
• Ritual ordering and arranging of items.
• Rituals involving repeated touching of objects, rituals of avoidance such as not stepping on cracks, and ritual counting are also common.

Interfere significantly with everyday functioning , provoke considerable emotional distress. Examples; sitting in chairs, using the telephone and eating can be disrupted for fear of contamination.

Assessment

-“Do you have symptoms of obsessive-compulsive disorder such as needing to wash your hands all the time because you feel dirty, constantly checking things or having annoying thoughts pop into your ear?”

NOTE: May not reveal OCD behaviours unless specifically asked

Prevalence

2% in general population

Genetic link: higher incidence in first degree relatives

Prognosis

Tends to be a chronic disorder although some people seem to have periods of remission

Recovery takes place in about 50% of patients

→more utilization of mental health facilities, disability pensions, depression, general anxiety disorder.

-“Dying with embarrassment” – a self-help book for social phobia

December 1^st, 2010 -Anxiety Disorders II - Joan Keefler, Ph.D.

OCD: Family impact

• Members experience stress
• become involved in avoidant behaviours and compulsions to relieve the sufferer’s fears and anxieties
• Research confirms family involvement and distress in 25% - 50% of cases of OCD.
• Examples:
• 23 female barricaded herself in living room, used cans in which to urinate → vile odour in the house.
• Husband with severe hoarding → family confined to a single room for years. Enraged when wife objected. Overflow into neighbours → legal action.

OCD: Family Etiology

• Family response can aggravate or support treatment efforts.
• Family impatience, protection and accommodating behaviours predictive of relapse (Steketee & Foa, 1985) –too much accommodating to OCD is bad!
• Family High EE leads to relapse (Emmelkamp, Kloek & Blaauw, 1992)
• Conflictual marriage leads to relapse (Hafner, 1982)

OCD: Family Treatment Research

• Symptoms may serve interpersonal functions in conflictual relationships. Clear improvement in marital relationship when spouse involved in treatment (Hafner, 1988, 1992)
• OCD: Family Treatment Research
• 60% decrease in OCD symptoms from spouse assisted exposure/response treatment (Thornicroft et al, 1991)
• Sig. decrease in symptoms from multiple-family behavioural treatment (MFBT) (Van Noppen et al, 1997)

OCD: Family Treatment Research

• Marital and family therapy without behavioural treatment does not help reduce OCD symptoms. Go for behaviours before dynamics!
• Optimal Treatment Model is Multi-disciplinary

OCD: Behavioural approach

• Cognitive-Behavioural Therapy (CBT) most effective approach

• Behavioural element exposure/response (EX/RP) help in 83% of cases short term and 76% of cases two years later (Kozak and Foa, 1997)
• EX/RP: clients expose themselves to feared stimulus oring situation (cleaning toilet, washing themselves, checking locks)

• Theory “Repeated, prolonged exposure to feared thoughts and situations provides information that disconfirms mistaken associations and evaluations held by the patients, and thereby promotes habituation” -this can change the synapse circuits. Family members’ role is to do the in-vivo calm
• In vivo exposure and response prevention – most effective.
• Imagined exposure alone or systematic desensitization not found to be particularly helpful

• Relaxation training not effective without in vivo exposure. – useful to control anxiety during response prevention.
• OCD: Behavioural approach
• 90 minutes of exposure usually needed for reduction of anxiety to take place

• Exposure tasks are assigned based on hierarchy of gradually increasing levels of anxiety and difficulty. Start with the easy.

OCD: Cognitive Approach

• Most OCD clients already think behaviours/thoughts are erroneous. Most know that their thoughts are ego-dystonic

• MacFarlance suggests self-talk developed by Padesky and Greenberger, 1995 that reinforces client’s ability to cope with anxiety during exposure. E.g.
• “Relax, breathe, Nothing bad will happen.”
• “What is the worst thing that could happen if I don’t ……. “
• Other therapists suggest distracting thoughts during exposure

• Family member can act as a co-therapist during exposure exercise eg. – remind client that anxiety will not last forever, support in walking away, in breathing exercises etc.
• Core beliefs of clients should be explored - eg. If they do not do everything perfectly, they will not be loved

OCD: Biological Approach

• Evidence for biological basis – runs in families
• Connection to serotonin.
• Medical and pharmacological treatment important. E.g. anti-depressants: tricyclics, SSRI’s

OCD: Systemic Approach

• Macfarlance suggests using a postmodern social constructionist and narrative approach
• Offer information or interpretations in a tentative way that respects the client’s right to reject the therapists’ constructions if they do not seem to fit or are not found useful.
• (Psychodynamic roots not acknowledged by post modern theorists)

OCD: Systemic Approach

• White and Epston (1990) – externalizing the problem.
• Explore how the problem has controlled client and family, build on previously ignored experiences of strength and competence,
• weave into a new narrative.
• Old core beliefs can be replaced with new stories;

OCD: Systemic Approach

• Example of Core Beliefs
• Policeman’s obsessions with unlocked doors, burners left on - the result of his professional experience with disastrous results
• Example of Psychodynamic roots of names reminiscent of something anxiety provoking → Couple Therapy

Post Traumatic Stress Disorder

• Definition
• Recurrent anxiety precipitated by an exposure to or memory of some past traumatic situation
• Stressors causing PTSD are severe and outside the range of normal experience
• (e.g. rape, combat, assault, traffic accidents).

DSM Criteria: PTSD

• History of a traumatic experience
• the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury or threat to the physical integrity of self or others
• the person’s response involved intense fear, helplessness in horror.
• NOTE: in children this may be expressed instead by disorganized or agitated behaviour.
• Re-experience of the traumatic event by:
• Intrusive memories
• Disturbing dreams. NOTE: in children, frightening dreams without recognizable content.
• Act or feel as if the traumatic event was recurring, a sense of reliving the experience: e.g. “Flashbacks”
• Psychological or physical distress as a result of reminders of the event
• Persistent avoidance of things associated with the trauma (people and thoughts) Can include:
• inability to recall important aspects of the event
• feeling of detachment or estrangement from others
• restricted range of affect
• sense of a foreshortened future
• Symptoms including:
• Sleep problems
• Irritability
• Trouble concentrating
• Hypervigilence
• Startle responses

Post Traumatic Stress Disorder

• Likelihood of developing disorder may increase as the intensity of and physical proximity to the stressor increase.
• Symptoms usually begin within first 3 months after the trauma but there may be a delay of months even years.
• Stimuli associated with the trauma are persistently avoided –person makes deliberate efforts to avoid
• thoughts, feelings or conversations about the traumatic event
• Activities, situations or people who arouse recollections of it
• Associated Features of PTSD
• Guilt feelings of having survive while others did not
• Phobic avoidance may interfere with job, marital satisfaction and/or other interpersonal relationships
• Feelings of ineffectiveness, shame, despair or hopelessness

Associated Features of PTSD

• Impaired affect regulation
• Dissociative symptoms
• Social withdrawal
• Loss of previous belief systems

Post Traumatic Stress Disorder

• Cultural Factors – may occur more often in immigrants from areas of social and political unrest
• Age Factors
• In children reliving of the event may occur in repetitive play - eg. car crash →crashing cars in play
• Children- physical symptoms headaches, stomach aches

Assessment

“Do you have painful memories or dreams of a terrible experience?

Prevalence

• 1% of the general population – higher in people who have been exposed to extremely traumatic life experiences. War, rape, catastrophes
• PTSD: Risk Factors
• People in occupations in which they are exposed to trauma. Police, Firemen, Soldiers
• People reporting mental illness in their family members were at heightened risk for exposure to trauma (Breslau et al., 1991).
• The more psychologically prepared victims were (e.g., knowing about torture methods, being aware that torture often followed arrest, being trained in stoicism techniques), the less severe were their torture-related PTSD symptoms (Başolu et al., 1997)

PTSD: Risk Factors

• People who are already suffering from anxiety or mood disorders family history of these disorders (Breslau et al., 1991).
• Childhood Sexual abuse (Nishith, Mechanic, & Resick, 2000)
• Childhood physical abuse (Breslau, Chilcoat, Kessler, & Davis, 1999)
• Retrospective reports of instability in one's family during childhood (King, King, Foy, & Gudanowski, 1996).
• Lower intelligence was associated with greater with greater severity of PTSD symptoms among Vietnam veterans even after controlling for the extent of combat exposure (McNally and Shin,1995)
• PTSD: Risk Factors
• IQ was the best predictor of resilience against PTSD among inner-city children and adolescents to trauma exposed to trauma (Silva et al.,2000)
• High IQ also predictive of resilience for soldiers in Viet Nam and Israel.

Post Traumatic Stress Disorder

Treatment Controversy

• Rapid Eye Movement Desensitization
• Early intervention with crisis counselling
• NOTE: Lately, a panel of the American Psychological Society has concluded that post-traumatic stress counselling is not helpful and can be actually hurtful

• Thoughful forgetting and even repression of memory and emotion may be more effective in helping people reconstruct a new life.

Critical Incident Debriefing

• (McNally, 2003)
• Following the terrorist attacks at the World Trade Center, more than 9,000 grief and crisis counselors arrived in New York City to provide aid to families, rescue workers, and others exposed to the mayhem of September 11, 2001 (Kadet, 2002).
• The assumption driving these well-intentioned efforts was that many New Yorkers were likely to develop posttraumatic stress disorder (PTSD) if they did not receive counseling soon after the trauma.
• Critical Incident Debriefing
• Sites were quickly established throughout the city to accommodate the countless numbers of people expected to seek psychological help.
• Yet few people showed up. The demand for psychological services was far less than most experts had predicted (Kadet, 2002).1
• People directly affected by the attacks—those who lost their loved ones or their jobs when the towers collapsed—were often too busy trying to put their lives back together to take time out for psychological counseling.
• when they did seek professional assistance, it was often to obtain help in practical matters (e.g., getting death certificates for insurance purposes).

• March 2003, only 643,710 people had sought help, whereas officials had expected to treat 2.5 million New Yorkers.
• May 2003, $90 million of therapy funds remained unspent
• Contrary to a widely held belief, pushing people to talk about their feelings and thoughts very soon after a trauma may not be beneficial.
• Many survivors have good support networks and may prefer to rely on their trusted confidants,
• Others may need help in activating social support because they do not have access to good support (whether because of the loss or separation from significant others, preexisting poor support, or the perception that previously trusted people do not understand their plight).
• Recent recommendations for crisis intervention programs take into account that the posttrauma environment has an important influence on recovery and urge that social support be facilitated (including by trying to increase community cohesion if an entire community is affected; ( Litz et al., 2002; Raphael & Dobson, 2001; Meichenbaum, 1994).

Post Traumatic Stress Disorder

• Acute Stress Disorder
• Milder form of PTSD
• Dissociative symptoms – numbing, detachment etc.
• No sense of foreshortened life

OTHER ANXIETY DISORDERS

• Generalized Anxiety Disorder
• Worries out of proportion to actual events
• Substance-induced Anxiety Disorder
• Social anxiety

• DSM and THE FAMILY
• Axis I: Varia
• Joan Keefler, Ph.D.
• Somatoform Disorders
• Client presents with physical symptoms that suggest a physical disorder for which there is no demonstrable underlying physical bases
• there is a strong presumption that the symptoms are linked to psychological factors
• Usually present to general practitioners, not therapists
• Somatization
• A history of physical complaints (or the belief that one is sick) beginning before age 30 and lasting for several years

• Pain in at least four different sites, 2 gastrointestinal symptoms, sexual symptom, pseudoneurological symptom – e.g. dizzy
• Tends to be chronic, can be contained, usually not cured
• Somatization
• Must be a history or at least one symptom that suggests a neurological condition e.g. Dizziness, problems with balance
• Must be a history of at least one sexual or reproductive symptom other than pain
• E.g.. Women: irregular menses
• E.g.. Men: erectile dysfunction
• Both men and women may be subject to sexual indifference
• Somatization
• Clients often describe symptoms in colourful exaggerated terms but specific factual information is often lacking
• Inconsistent historians
• Often seek treatment from several physicians concurrently
• Somatization
• Patients do not want symptom relief but rather a relationship that is comforting
• Want acknowledgement of sickness, not reassurance that nothing is physically wrong

• For physician – give regularly scheduled appointments and avoid expensive testing.
• 
  
  
  Conversion Disorder
• A loss of physical function that suggests a physical disorder but is instead, a manifestation of an unconscious conflict or problem

• Symptoms are not consciously produced.
• Conversion Disorder
• Impaired co-ordination of balance
• Paralysis
• Difficulty swallowing
• Urinary retention
• Loss of touch, pain sensation, double vision, blindness, deafness
• Seizures, convulsions
• Conversion Disorder
• Diagnosis should only be made after a thorough medical investigation
• Conversion symptoms do not conform to known anatomical pathways and physiological mechanisms – follow individual's idea of a condition

e.g. “paralysis” may involve inability to perform a particular movement or move an entire body part

Can be moved inadvertently when attention directed elsewhere.

• Conversion Disorder
• Symptoms NOT intentionally produced for some secondary gain
• Focus of treatment in 1%-3% of outpatient referrals to mental health clinics
• More common in rural populations, lower socio-economic status, less knowledge of medical and psychological conditions
• Conversion Disorder
• Onset – late childhood to early adulthood
• Onset generally acute
• Good prognosis associated with
• Acute onset
• Presence of clear identifiable stress
• Short interval between onset and treatment
• Above average intelligence
• Pain Disorder
• Pain in one or more anatomical sites is the focus of clinical presentation of sufficient severity to warrant attention

e.g. disc herniation, osteoporosis, neuralgia

• Psychological factors judged to have important role in onset, severity, exacerbation or maintenance of pain
• Causes distress, impairment in functioning
• Not intentionally produced or feigned
• Hypochondriasis
• Preoccupation with fears of having or idea that one has, a serious disease based on the person's misinterpretations of bodily symptoms
• Persists despite medical evaluation & reassurance
• Duration more than 6 months
• Body Dysmorphic Disorder
• Preoccupation with a defect in appearance
• If there is a slight physical anomaly, the person’s concern is excessive
• Preoccupation causes significant distress or impairment in functioning

? Michael Jackson

• Factitious Disorders
• Characterized by physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role
• May include fabrication of subjective complaints e.g. stomach aches, self-inflicted conditions (inject saliva into skin to produce an abscess)
• Factitious Disorders
• External incentives for sick role are absent

e.g. economic gain, avoiding legal responsibility, the draft

• Different from malingering - goal for assuming sick role is evident
• Factitious Disorders
• Often have extensive knowledge about medical procedures, hospital routines
• May eagerly undergo very invasive procedures
• After evaluation for one set of symptoms reveals no problem, will produce new symptoms
• Admissions to many different hospitals in many different cities etc.
• Dissociative Disorders
• Dissociation often involved feelings of unreality, amnesia and detachment from one’s self
• Post-traumatic defense moblized by the patient as protection from overwhelming pain and trauma
• In most severe form known as dissociative identity disorder – previously called multiple personality disorder.
• Dissociative Disorders
• Typically occurs in context of childhood physical and/or sexual abuse
• Psychogenic amnesia – loss of memory from psychological cases.
• Females in their teens
• Males in war
• Confused and puzzled during the attack
• recovery is rapid and complete
• Dissociative Disorders

Dissociative amnesia - one or more episodes

• Loss of memory, usually of important events
• Usually centred on traumatic events – accidents or unexpected bereavements
• Usually partial and selective
• Not due to PSTD or physiological effects of a substance (drugs, medication) or neurological or other general medical condition (amnesic disorder due to head trauma).
• Dissociative Disorders

Dissociative fugue

• All the features of dissociative amnesia plus purposeful travel beyond usual everyday range
• Person looks normal to outsiders
• Dissociative Disorders
• Dissociative Identity Disorder (formerly Multiple Personality Disorder)
• Presence of two or more distinct identities of personality states
• At least two of these identities or personality states recurrently take control of the person’s behaviour
• Dissociative Disorders
• Depersonalization Disorder
• Persistent or recurrent experiences of feeling detached from, as if one is an outside observer, one’s mental processes or body

e.g feeling like one is in a dream.

• Dissociative Disorders
• Dissociative stupor
• Profound diminution of absence of voluntary movement and normal responsiveness to external stimuli such as light, noise and touch
• No physical cause
• Positive evidence of psychogenic causation in form of recent stressful events or problems
• (not catatonic or depressed)
• Dissociative Disorders
• Assessment
• Often goes undetected or undiagnosed as symptoms difficult for client to describe or therapist don’t know the right questions to ask
• SICD-D (Structured Clinical Interview for DSM Dissociative Disorders)
• Interviewer asks open ended questions – can take from two to three hours
• Dissociative Disorders SICD-D
• Amnesia
• Inability to recall that a significant block of time has passed. – “gaps” in memory. If chronic – client will sometimes confabulate or use data from friends or relatives
• Dissociative Disorders SICD-D
• Depersonalization
• Experience of detachment from one’s body or self, feeling self is unreal, having out-of-body experiences, feeling detached from one’s emotions.
• Experience depersonalization within the context of ongoing, coherent dialogues with the self – difficult for patient to describe or they can become habituated
• Dissociative Disorders SICD-D
• Derealization
• Involves the sense that one’s physical and/or interpersonal environment t has lost its sense of familiarity or reality.
• Clients report that friends and relatives seem strange and unfamiliar, as may their home workplace or immediate physical environment
• Often occurs in context of flashback, in which a person re-experiences a past trauma. As a result the present feels unreal to the person.
• Dissociative Disorders SICD-D
• Identity Confusion
• A sense of uncertainty, puzzlement or conflict regarding personal identity.
• Clients who experience dissociative symptoms often express confusion as to who they really are
• Identity confusion often manifests as a intense battle for inner survival
• May occur transiently in adolescence or life crisis but in clients with dissociative disorders tends to be more chronic and distressing.
• Dissociative Disorders SICD-D
• Identity Alteration Involves objective behaviour indicating the assumption of different identities.
• the use of different names, finding possessions that one cannot remember acquiring, and possessing a skill that one cannot remember having learned
• Clients sometimes refer to themselves in the plural as “We” or Us”
• Severe identity alteration is accompanied by amnesia for events experience under alternate personality states.
• Dissociative Disorders Treatment

The Four C’s

• Comfort - Focus on self-nurturing – classic stabilization in the treatment of trauma survivors. E.g regularly scheduling time for personal comfort
• Communication - Acknowledging one’s feelings – Anger, Shame
• Cooperation. - Learn to respect feelings --Development of positive dialogue that counters negative or critical inner voice.
• Connection. - Connection to one’s past and present
• Dissociative Disorders
• Significance for Family Therapists
• Trauma victims often use dissociation as a coping mechanism. Children of alcoholics often at risk

• Will present for treatment with difficulty with intimacy, sexual dysfunction ad well as anxiety, depression and/or temper outburst which cause problems with relationships
• Symptoms of dissociation sometimes precede anxiety and panic.
• Dissociative Disorders
• If dissociative disorder remains undetected and thus untreated, couples therapy may be ineffective
• Couples or family therapy should be used on conjunction for the treatment of clients with dissociative disorder.
• Dissociative Disorders
• Case Examples JIK
• Mary - in my office, overlooking the roofs she used to help her abusive father repair – episode of dissociation (depersonalization)
• Arlene – victim of abuse by grandfather, became pregnant and had a child by him at age 12 – flashback during which she was not sure of where she was – rerealization.
• Dissociative Disorders
• James (Matthew Honeycutt)
• Referred to psychiatry from medical ward. Picked up naked from a down town hotel into which he has wandered after finding himself naked in a lane. Did not know his name but did know he was homosexual. Shortly after the Black and Blue Ball
• Pleasant, bewildered fragile young man, bright, neat and organized. Co-operative, did not like hospital. Very focused on finding out who he was.
• Dissociative Disorders
• Two incidents of recovered memory. Eating with a boyfriend in a pizza parlour and being in a metro.
• Obtained welfare for him. Welfare co-operation, Canada Immigration initially was NOT.
• Went on television, we contacted press, missing persons bureau. Matthew felt TV station seemed familiar to him.
• Homosexual community very good to him
• Dissociative Disorders
• Family after approximately two months contacted through television program.
• Family Interview: Matthew still amnesiac. Mother 99% the source of information. Sister burst into tears in response to n empathic remark and spend the interview crying in a corner.
• Mother in 50’s, Sister, Christina, age 23, Matthew, age 28. Another brother, Kevin, age 30, a lay pastor in Tennessee, fundamentalist church.
• Dissociative Disorders
• Father left family when Mathew was 10, Mathew had a breakdown and hospitalization post divorce.
• Matthew had worked for 3 years in a small TV studio – Did everything, left as he was only paid minimum wage.
• Had recently managed a UPS office in Knoxville
• Dissociative Disorders
• In previous summer, Matthew had returned home, described as depressed, did not leave home for 3 weeks.
• Refused to give away sister at wedding
• During this time Matthew’s homosexuality was revealed to mother who was very upset as homosexuality a sin in her religion
• Dissociative Disorders
• Matthew had stolen brother’s car and left (for Canada)
• Brother reported car missing.
• Family did not file missing persons report, gave away Matthew’s clothes and CD’s
• Dissociative Disorders
• Mother a simple woman, a textile worker, preferred Walt Disney films, overinvested in children.
• Matthew did not seem to fit comfortably into this family – more intelligent, homosexuality

• Referred to Clinic for Dissociation Disorders in Tennesse.
• Eating Disorders
• Anorexia Nervosa

Characterized by intense fear of gaining weight

Disturbance in body image

Denial of seriousness of weight loss

• Restricting Type – weight loss through dieting
• Binge-Eating/Purging Type
• Eating Disorders
• Bulimia Nervosa
• Binge eating and in appropriate compensatory methods to prevent weight gain.
• Must occur at least twice a week for 3 months
• Usually ashamed of and conceal eating habits
• Subtypes
• Purging
• Non-purging – fast or over-exercise
• Sleep Disorders
• Primary insomnia - sleep difficulties for at least 1 month
• Primary hypersomnia – excessive for at least 1 month
• Narcolepsy – irresistible attacks of refreshing sleep, cataplexy (loss of muscle tone), intrusive REM sleep between sleep & wakefulness
• must occur daily over period of 3 months,
• Sleep Disorders
• Breathing related sleep disorders – associated with sleep apnea
• Circadian Rhythm Sleep Disorder
• Nightmare Disorder
• Sleep Terror Disorder
• Sleepwalking Disorder
• Parasomnias – characterized by abnormal behavioural or physiological events occurring in association with sleep. Complain of unusual behaviour during sleep
• Impulse Control Disorders
• Intermittent Explosive Disorder
• Failure to resist aggressive impulses
• Kleptomania
• Stealing – individual feels release of tension
• Done without assistance from others
• Not committed to express anger or vengeance
• Often thought of being a part of obsessive-compulsive disorder, since the irresistible and uncontrollable actions are similar to the frequently excessive, unnecessary and unwanted rituals of OCD. Some individuals with kleptomania demonstrate hoarding symptoms that resemble those with OCD (Wikipedia)

• Impulse Control Disorders
• Pyromania - fire setting
• Trichtillomania - recurrent pulling out of one’s hair resulting in noticeable hair loss
• Release of tension
• No physical explanation

January 5^th, 2011 – personality disorder

-personality = persistent pattern behavior over time.

Cluster A:

• Paranoid personality disorder – blames others, hostility
• Schizoid personality disorder: reclusive/uncooperative, limited range of emotion
• Schizotypal personality disorder

Cluster B

• Antisocial personality disorder – disregard rights of others/look for advantage – lack of anxiety
• Borderline personality disorder – disorganized, acting out, emotionally labile, impulsive
• Historonic personality disorder
• Narcissistic personality disorder

Cluster C

• Avoidant personality disorder – socially inhibited, hypersensitive to criticism
• Dependant personality disorder
• Obsessive-compulsive personality disorder

Paranoid

• Suspiciousness
• Chronic injustice
• Collect injustice
• Every slight = personal rejection
• Injustice/rules
• Major preoccupation with justness & fairness
• Compulsive concern with honesty – this disguise for their concealed rage
• Shame
• Acute sense of shame
• Repeated childhood experiences of shame/humiliation
• Difficulties in apologies/accepting apologies
• Little capacity to feel guilt
• Grandiosity
• Insist that they are right
• Target of insincere flattery or praise
• Attracted to extremist groups
• “End justify the means” kind of attitude
• Report receiving recognition from some authority before earning it through achievement.
• Envy and jealousy
• Sadism/masochism
• When paranoid defenses do not work, overwhelming depression
• Unable to ask for love directly, but can only get it only though pain/self-sacrifice/humiliation
• Success is a problem
• Expect others will react with envy and jealousy [projection]
• Can accept success only if linked to an idealistic cause
• Driven to independence
• No one to counter their imagination
• Incessantly ponder along a single deviant track
• Flimsy evidence/reshape the past to fit their beliefs
• Intricate logic to justify anxiety/desires
• Invalid/unshakable beliefs
• Delusions tend to be systematic, rational and convincing
• Suspicions to supposition to imagination – gives birth to delusions
• Unable to accept faults
• Maintain self-esteem by attributing shortcomings to others
• Spotting deficiencies of others and point them out subtly/directly with pleasure
• Ready to humiliate and deprecate anyone possible
• Grudges/unforgiving of those with whom they have related in the past
• Defensive expressive behavior
• Tense and guarded
• Fixed eyes/sharp focusing
• Rarely relax
• “Paranoid stare”
• Provocative interpersonal contact
• Cognitive style suspicious
• Self-image – inviolable
• Object representation – unalterable
• Regulatory defense mechanism: projective/fantasy
• Projection helps with guilt – anything bad if of course someone else’s fault
• Mood/temperament: irascible
• Fanatic – extravagant/dismiss incongruencies
• Types:
• Malignant – power-orientation
• Obdurate – more pathological of ocpd
• Querulous
• Insular
• Success is learnt to be boastful and not adaptive accomplishment
• Words and actions of parents are different
• Parents are seductive. Parent always right and child is always wrong
• Child expects that all close relationships = abolishing independence
• Parental sadism is common