Exam 3: Mental Health Diagnoses

MH diagnoses, schizophrenia, ACLS-5, DBT/CBT/MI, harm reduction/abstinence, treatment settings, general tips working w/ TAY

Bipolar & Related Disorders: Manic Episode

• distinct period of abnormally and persistently elevated, expansive, or irritable mood

• abnormally and persistently goal-directed activity or energy

• lasting ~1 week

• severely impacts functioning 

Bipolar & Related Disorders: Hypomanic Episode

• Less intense than mania

• Duration: ~4 consecutive days; less impact on functioning

Bipolar & Related Disorders: Bipolar I

• must have manic episodes

• common: hypomanic & major depressive episodes

Bipolar & Related Disorders: Bipolar II

• must have hypomanic & major depressive episode

• excludes manic episodes

Major Depressive Disorder (5 or more of the following):

• Depressed mood

• Loss of interest/pleasure

• Unintended and significant weight fluctuations

• Insomnia/hypersomnia

• Psychomotor agitation or retardation

• Fatigue

• Feelings of worthlessness

• Difficulty thinking

• Recurrent thoughts of death

Generalized Anxiety Disorder: Excessive anxiety & worry majority of days for 6 months about a variety of things; difficult to control the worry

3 or more of:

• Restlessness

• Easily fatigued

• Difficulty concentrating

• Irritability

• Muscle tension

• Sleep disturbance

Social Anxiety Disorder: fear/anxiety out of proportion in frequency and/or duration to the actual situation

• Persistent for ~6 months

• Social situations avoided/endured with fear

• Fear of showing anxiety symptoms and being embarrassed/humiliated

• Fear or anxiety about social situations 

• Experience persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others

• Exposure to the feared situation invariably provokes anxiety, which may take the form of a situationally bound or situationally pre-disposed Panic Attack

• Experience significant distress or impairment that interferes with his or her ordinary routine in social settings, at work or school, or during other everyday activities

• Unlike in DSM-IV, which requires that the individual recognize that his or her response is excessive or unreasonable, the DSM5 criteria shift that judgment to the clinician. 

Trauma & Stressor-Related Disorders: PTSD

Exposure to actual or threatened death, serious injury, or sexual violence in one of the following ways:

• Direct experience

• Witnessing it

• Learning that it occurred to a close family member/friend

• Experiencing repeated or extreme exposure to aversive details of the traumatic event (police officers, first responders, etc.)

Trauma & Stressor-Related Disorders: PTSD (Presence of ~1 of…)

• Recurrent, intrusive, depressing memories

• Recurrent & distressing dreams

• Dissociative reactions/flashbacks

• Intense or prolonged psychological distress from triggers

• Physiological reactions to triggers

• Persistent avoidance of triggers (memories, thoughts, people, places, objects)

• Negative alterations in cognition and mood as a result of the event.

• Marked alterations in arousal, reactivity

• Lasts at least 1 month

Trauma & Stressor-Related Disorders: PTSD - Negative alterations in cognition and mood as a result of the event. Presence of at least 2 of the following:

• Loss of memory of parts of traumatic event

• Persistent & exaggerated negative beliefs

• Persistent, distorted cognitions about the cause of consequence of traumatic event

• Persistent negative emotional state

• Diminished interest/participation in activities

• Feelings of detachment from others

• Persistent inability to experience positive emotions

Trauma & Stressor-Related Disorders: PTSD - Marked alterations in arousal and reactivity. Presence of at least 2 of the following:

• Irritable behavior / angry outbursts

• Reckless and self-destructive behavior

• Hypervigilance

• Exaggerated startle response

• Problems with concentration

• Sleep disturbance

Trauma & Stressor-Related Disorders - Adjustment Disorder

Development of emotional or behavioral symptoms in response to a stressor (within 3 months of onset of stressor)

• Clinically significant due to marked distress that’s out of proportion and/or results in a significant impairment in functioning

Feeding & Eating Disorders: Binge eating 🍔

Recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances

• Episodes marked by feelings of lack of control associated with marked distress and occurs on average

• at least 1x a week over 3 months

Feeding & Eating Disorders: Anorexia Nervosa ❌

Self-imposed Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health

• Intense fear of gaining weight or becoming fat, even when significantly underweight

• Disturbance about body weight or shape, undue influence of body  weight or shape on self-evaluation, or denial of the seriousness of current low body weight

Feeding & Eating Disorders: Bulimia nervosa 🤮

Frequent episodes of binge eating followed by behaviors such as:

• self-induced vomiting to avoid weight gain

• Must engage in behavior at least once per week

Disruptive, Impulse Control, Conduct Disorders: be careful with?

Racial biases, presumed cause of behavior can lead to discriminatory behavior towards clients

• Many implications within the criminal justice system.

Disruptive, Impulse Control, Conduct Disorders: Conduct Disorder

Behavior that violates either the rights of others or major societal norms. Clinical precursor to antisocial personality disorder.

3 or more symptoms must be present in the past 12 months with one symptom having been present in the past 6 months…

• Aggression to people or animals

• Destruction of property

• Deceitfulness or theft

• Serious violation of rules

Disruptive, Impulse Control, Conduct Disorders: Oppositional Defiant Disorder

At least 4 of the following for less than 6 months…

• Angry/irritable mood: often loses temper, easily annoyed, angry and resentful

• Vindictiveness: spiteful at least 2x in last month

• Argumentative/defiant behavior: often argues w/ authorities, actively defies requests from authority, deliberately annoys others, puts blame on others for own actions

Personality Disorders: General

Individual has ways of thinking & feeling about oneself and others that significantly and adversely affect how they function in many parts of their lives

• 3 clusters

  • A = appear odd or eccentric (paranoid, schizoid, or schizotypal personality disorder)

  • B = dramatic, emotional, erratic (antisocial, borderline, histrionic, narcissistic) 

  • C = anxious or fearful (avoidant, dependent, obsessive-compulsive)

• Must express a pattern of thought & behavior significantly different from their culture in at least 2 areas that started in adolescence: cognition, affectivity, interpersonal functioning, impulse control

• Must lead to “clinically significant distress or impairment in social, occupational, or other important areas of functioning”

Personality Disorders: Borderline Personality Disorder

Pervasive pattern of instability in interpersonal relationships, self-image and emotions.

• Must include >5 of the following:

  • Frantic efforts to avoid real or imagined abandonment

  • Pattern of unstable and intense relationships that alternate between idealization and devaluation

  • Significant and persistent unstable self-image

  • Impulsivity in > 2 areas that are potentially self-damaging (sex, substance abuse, spending, etc.)

  • Recurrent suicidal/ self-mutilating behavior

  • Mood instability (lability)

  • Chronic feelings of emptiness

  • Inappropriate, intense anger / difficulties controlling anger

  • Transient, stress-related paranoid ideation or severe dissociative symptoms

• People with borderline personality disorder are also usually very impulsive, oftentimes demonstrating self-injurious behaviors (risky sexual behaviors, cutting, suicide attempts).

• Occurs in most by early adulthood. The unstable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability(fluctuations in mood, sometimes in a quick manner) in a person’s emotions and feelings. People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.

Suicide risk assessment process: Step 1 - Be clear about confidentiality and reporting obligations

When client expresses suicidal ideation, take it seriously and remind them of your professional boundaries before continuing the conversation, so that they can make an informed decision on whether they want to continue the conversation

Suicide risk assessment process: Step 2 - Determine the risk

Use a screening assessment to determine immediate risk of suicide. (The Columbia Protocol aka C-SSRS)

• Stay calm and listen. Be direct in your questions and do not beat around the bush

Suicide risk assessment process: Step 3 - Based on the risk, take associated actions.

IF HIGH RISK:

• “Now that I am aware of your need, we will need to contact the crisis line”

  • Call for immediate help (911 or 988) and stay with the client until help arrives.

  • *You can ask client if they would like to be the one to call (you would have to be present), or they would like you to be the one to call

C-SSRS: Step 1

Have you wished you were dead or wished you could go to sleep and not wake up?

C-SSRS: Step 2

Have you actually had any thoughts about killing yourself?

• If YES to 2, ask questions 3, 4, 5, 6

• If NO, skip to question 6 (which you always ask regardless.)

C-SSRS: Step 3

Have you been thinking about how you might do this?

C-SSRS: Step 4 = High Risk

Have you had these thoughts and some intention on of acting on them?

C-SSRS: Step 5 = High Risk

Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?

C-SSRS: Step 6 = Lifetime OR High Risk (past 3 months)

“Have you done anything, started to do anything, or prepared to do anything to end your life?”

• EX: took pills, tried shooting or cutting self, obtained gun, gave away valuables, wrote a will/suicide note

• If yes, was this within the past 3 months?

C-SSRS: Last Steps

• If YES to 2 or 3: seek behavioral healthcare for further evaluation

• If YES to 4, 5, 6: Get immediate help. Call or text 988, 911, or go to emergency room. STAY with them until they can get evaluated

Utilization of a safety plan: What to know

• The safety plan is NOT created in an active suicidal crisis. 

• Instead, it is created as a preventative tool for clients at risk of suicide.

• The safety plan is a tool for clients to use when they have suicidal thoughts or are in distress. It provides clients with ways to manage their crisis and stay safe.

Utilization of a safety plan: What’s in a safety plan?

A list of resources/strategies that can be followed when the client feels a suicidal crisis coming on

• Step 1: Warning signs that a suicidal crisis may be developing

• Step 2: internal coping strategies (relaxation/distraction techniques that can be done SOLO)

• Step 3: People and social settings that provide distraction

• Step 4: People whom I can ask for help (ADULTS ONLY!)

• Step 5: Professionals or agencies that can be contacted during a crisis

• Step 6: Making the environment safe

  • Try as hard as you can to have adults lock up/remove weapons from the home, ideally ASAP!

Utilization of a safety plan: Principles to creating a safety plan

• Confidentiality.

  • Make sure the client understands rights and limitations of confidentiality.

• Collaborate and stay client-centered. 

  • Help clients identify the coping strategies and people that are meaningful TO THEM! 

• Assess the appropriate-ness of people added to the safety plan.

  • Are they available reliably? AND reachable by phone?

  • People in step 4 MUST be ADULTS!

• Remember that safety is the ultimate goal. 

  • Don’t shoot down coping strategies that you may view as unhealthy/maladaptive. If they identify “smoking weed” as an internal coping strategy, so what! As long as it distracts them from suicidal thoughts. 

Trauma definition

exposure to event (often w/ threat of emotional or physical danger) that overwhelms one usual means of coping, resulting in a sense of helplessness

Adverse childhood experiences (ACES): Traumatic events that occur before age 18. Include things like abuse, neglect, divorce of parents, etc.

LT negative outcomes in:

• Physical health

• Mental health

• Social interactions

• Behavioral health

Impacts ability to process and cope with stress. OT approach:

• develop coping strategies

• improve emotional regulation techniques

• create healthy habits and routines

Effects of trauma

• Physiological

• Altered brain processes and structures

• Increased levels of stress hormones

• Psychological: Hypervigilance

• Emotional

  • 0-60 emotional activation

  • Seemingly disproportionate emotional responses to stressors

  • Generalization of activators

• Existential: Altered meaning and beliefs of self, others, and the world

Trauma Informed Care: Realize (1)

and understand the widespread impact of trauma

Trauma Informed Care: Recognize (2) signs & symptoms of trauma

• Kindergartener bites his classmates whenever they get close to him

• Adult cries or shuts down when given constructive feedback at work

Trauma Informed Care: Respond (3) interpersonally and through policies, procedures, practices

• Make sure to only seek out information that is relevant to your role/interactions with the client

• Don’t open up something you’re not capable of closing

• Your job is not to process the emotions of the client. That is a psychotherapist’s job. 

• Physical touch/setting considerations

• Enact principles of TIC: Safety, trustworthiness & transparency, collaboration & mutuality, empowerment, voice, and choice

Trauma Informed Care: Avoid Re-traumatization actively, through universal & targeted actions

• Make sure to only seek out information that is relevant to your role/interactions with the client

• Refer out when needed: Consider scope of practice, client needs, and role of other professionals on care team

  • Supportive direction to appropriate professional

  • Warm hand off

  • Provide / connect to crisis resources when appropriate

We care about diagnoses because OTs can gather information about the client’s?

likely symptoms, prognosis, history; professional collaboration & evidence-based practices

General approach to OT treatment in MH

• Identify symptoms/areas of difficulty which occupations are impacted 

• Identify client’s goals and strengths/ resources

• Utilize activity analysis, grading, environmental modification, skill building, etc. to assist client in meeting their goals

Important MH Considerations

• Possibility of misdiagnosis

• Co-occurring disorders (comorbidity): like substance use

  • Form of self-medication

  • Comes with its own symptoms and side-effects

  • Harm-reduction approach

  • Non-judgment

  • Not the problem, but often a symptom of something else

• Psychosomatic symptoms, double-bind of diagnoses 

• Trauma, environmental/social factors, racism, prejudice, suicide

OT MH Responsibilities

• Notice warning signs, assess, support, refer out

• We can’t control their actions

• Stressful → need for self-care 

How to assess MH (OT)

• Take every reference seriously, use Columbia-Suicide Severity Rating Scale (C-SSRS) or similar tool. If yes to all, Call child crisis hotline, Inform client & supervisor, Implement safety plan, Stay with client/ on phone)

• Avoid: innuendos about suicide, “I understand”, making it about yourself, don’t process emotions, dig into trauma, or diagnose

• Do: respond calm, speak directly, focus full attention on them, go at their speed, allow for silences

OT: How to support MH

• Develop safety plan

• Reality-based treatment (DBT, CBT, MBT)

• Facilitate development of coping strategies, social and communication skills through meaningful occupations

• Develop ways to organize the external environment to decrease excess stress

• Develop ways to improve self-esteem

• Family education, and relapse/contingency management

OT: When to refer

• Scope of practice

• Crisis numbers - in phone

• Warm-lines

• Ongoing support

Application to OT - Treatment: Activity Analysis

• consideration of symptoms & context

• identification of barriers to engagement

• provision of scaffolding in activity or practice and generalization of skills through related activities/games

Application to OT - Treatment: High 5 Approach

Client is the expert, witness their experience, verbalize strengths, identify needs, summarize

Application to OT - Treatment: Coping Skills

breathing techniques, social supports, grounding techniques, preferred occupations

Application to OT - Treatment: Psychoeducation

Understanding of symptoms/impacts on life

• Normalization of experience

• Information about treatment options

• Connection to peer supports → All supporting informed decision-making

Application to OT - Treatment: Routines

Analysis of existing routines

• Psychoeducation around impact on health

• Support establishment of health-promoting routines and related skills

MH OT: DO NOT…

• process emotions, dig into trauma, or diagnose

• Specialized approaches: DBT, CBT, MI