OT MH Practice Midterm

Schizophrenia

A psychotic disorder with 3 clusters of symptoms

1. psychotic/positive symptoms

2. Negative symptoms

3. Cognitive symptoms

Means “split mind”

DSM-5 Diagnostic Criteria of Schizophrenia

Two or more of the following symptoms (present for significant part of a month)
▪ Hallucinations
▪ Delusions
▪ Disorganized speech
▪ Disorganized or catatonic behavior
▪ Negative symptoms
o Condition persists for 6 months
o Impaired functioning At least one!

Psychosis

A disconnection from reality

Hallucinations

Delusions

Hallucinations

Distortion in perception

Auditory: Hearing sounds that aren’t real (voices, music, footsteps,commands)
o Visual: Seeing things that aren’t real (people, shapes, lights)
o Tactile: Feeling touch or movement that isn’t real (bugs crawling on skin, organs moving)
o Gustatory: Strange or unpleasant tastes (metallic)
o Olfactory: Experiencing smells that aren’t real

Delusions

Distortion in thought/false beliefs

Culturally situation

Persecutory: Paranoid beliefs (being targeted, followed, or threatened)
o Erotomanic: Unfounded beliefs about love (someone else is in love with them)
o Grandiose: Inflated sense of self (special powers, fame, God)
o Somatic: Something is wrong with the body (missing organs, being pregnant)

Thought Disorder

Disorganized thinking and speech

Tangential speech: Not following a clear train of thought
o Loose associations: Lack of connection between ideas, moving quickly between ideas
o Neologisms: Newly coined word that is meaningless to others
o Echolalia: Repetition of words or phrases said by others
o Magical thinking: More fleeting and flexible than delusions
o Concrete thinking: Difficulty with abstraction, takes things literally

Negative Symptoms: Scizophrenia

Alogia

Flat affect

Avolition

Asociality

Anhedonia

Alogia

Reduced amt of speech, impoverished content, limited spontaneity

Flat affect

Reduced intensity of emotional expression

Avolition

Difficulty initiating and carrying out goal directed behavior

Asociality

withdrawal or avoidance of social contact

Cognitive Impairment

NOT a diagnostic criteria but a core feature

Domains: processing speed, executive function, memory, sociaal cognition

Schizoaffective Disorder

Combination og psychotic + mood disorder

Must meet DSM-5 criteria for both schizophrenia AND depressive or manic episode

Mood disturbance must be present for majority of time of illness

Positive Experiences of Psychosis

Voices of encouragement

Identity and deeper meaning

Spirituality

Symptom or strength?

Etiology

Genetic Factors

Prenatal factors

Structural and functional neuroanatomical differences

Dopamine hypothesis

Environmental factors

Diathesis Stress Model

Also called the stress vulnerability model

Suggests that schizophrenia results from

1. a biological predisposition to schizophrenia and

2. 2. environmental stressors that triggers the onset of illness

Prevalence and Course

0.3-0.7% of population

Most commonly diagnosed in early 20s

The course and prognosis of schizophrenia is widely variable
o Symptoms
o Functioning
o Self-perceived wellbeing

Prodromal period

The period of time after the onset of symptoms but before diagnostic criteria
is met is called the prodromal period (can last for weeks or months)
o Early intervention during this period can reduce long-term disability and
impairment
o Oftentimes seen first through a change in cognition

Adaptive paranoia

Health suspicion that develops from experiences of racism and racial profiling

Impact on Occupational Performance: Cognitive Impairments

Information Processing

Executive Function

Social Cognition

Memory

Memory Cognitive Impairments: Schizophrenia

Short-term memory generally impacted less
o Difficulty with working memory (manipulating and processing information)
and episodic memory (remembering past events)
o Impairment in verbal fluency (retrieving verbal information)

Schizophrenia: Health and Wellness Impact

Associated with higher rates of morbidity and mortality

Life expectancy may be reduced by decades

Obesity

Smoking

Oral Health

Schizophrenia Medication: Antipsychotics

Most effective in reducing symptoms

1st Generation - Dopamine antagonists

2nd Generation - serotonin-dopamine antagonists

Side Effects: sedation, sun sensitivity, dry mouth, blurred vision, weight gain, orthostatic hypotension, movement disorders, clozaril (decreased WBC)

OT Intervention Approaches

Cognitive Remediation

Cognitive Adaptation

Social Skills Training

Permanent Supportive Housing

ADL and IADL training

Obsessive Compulsive Disorder

Involuntary and unwanted obsessions and compulsions that are distressing, consume more than 1 hr a day, and impair functioning

Common Themes: contamination, symmetry, forbidden thoughts, harm

May result in avoidant behaviors and/or habits and routines that interfere with daily functioning

Cycle of Obsessive Thoughts and Compulsive Behaviors in OCD

Obsessive thought → compulsive behavior → anxiety relieved → reinforcement of the behavior → another obsessive thought → more behaviors required to relieve anxiety

Body Dysmorphic Disorder

Preoccupation with perceived flaws or defects in one’s physical appearance that are not apparent or significant to others
o Consumes 3-8 hours per day

• Excessive, repetitive behaviors including seeking reassurance about appearance, compulsive skin picking, excessive lifting weights, using anabolic steroids, and having cosmetic surgical procedures

• Can impact social participation

Hoarding Disorder

Persistent difficulty discarding or parting with possessions regardless of value resulting in an accumulation of clutter that interferes with functionality of the environment
o Collecting = systematic and organized
o Hoarding = disorganized, excessive clutter that interferes with ability to use living spaces

Trichotillomania

Repetitive pulling out of one’s own hair

• Bald spots, thinning hair, skin issues

• GI issues if ingested

Excoriation Disorder

Recurrent skin picking

Usually associated with anxiety or boredom, causes distress and/or embarrassment

Frequently co-occurs with anxiety and/or depression

More common in women

Etiology

Genetics:

Strong familial links

Close relatives of a person with OCD have a 5x higher chance of having OCD

Neuroanatomy:

Frontal cortex involvement

Brain differences in OCD can change over time

Neurochemical:

Involves multiple neurotransmitter systems (serotonin, dopamine, and glutamate)

Cognitive and Psychological:

Self perpetuating cycel of obsessions and compulsions

Environmental: NO specific environmental causes, BUT infections and stressful or traumatic life events may increase the risk

Prevalence: Obsessive Disorders

OCD has prevalence rate of 2-3%

Average age onset: 19-20 → almost always before 35

Females more commonly affected

Cultural beliefs, religious practices, and family roles should be considered when assessing/treating

Impact on Occupational Performance: Obsessive Disorders

Cognitive: executive functioning impairments

Psychosocial: decreased social and community participation, disrupted relationships due to → time spent engaged in obsessive thinking, compulsive acts interfering w task completion, avoiding situations that may trigger symptoms

Medication and Medical Treatment: Obsessive Disorders

SSRIs

ECT most effective for people w comorbid depressions

Repetitive transcranial electromagnetic stimulation (rTMS)

Deep Brain Stimulation (DBS)

OT Intervention Approaches: Obsessive Disorders

Cognitive Adaptation

Cognitive Behavioral

Community Clutter and Hoarding Toolkit

Motivational Interviewing

Cognitive Disabilities Model

Developed by Occupational Therapist Claudia Allen
▪ Referred to as the Allen Cognitive levels
▪ Identifies levels by remaining abilities
▪ Developed Allen Cognitive Lacing Screen (ACLS), Allen
Diagnostic Model (ADM) and Routine Task Inventory- Expanded (RTI-E)
▪ From this theory two other OTs have expanded work
▪ Kim Warchol- Best-Abilities Care Model
▪ Teepa Snow - the Positive Approach to Care

Theory of Retrogenesis

Developed by Barry Reisberg, M.D.
▪ Hypothesis that development occurs in reverse
▪ “First in-Last Out”
▪ Compares stages to developmental stages or ages
▪ Global Deterioration Scale (GDS) and Functional Assessment Staging Tool (FAST)

Person Centered Care Approach

Developed by Thomas Kitwood, Ph.D.
▪ Person as the focal point of caregiving
▪ Care is focused on
▪ Quality of life
▪ Well-being
▪ Dignity
Core Values include: Choice, Dignity, Respect, Purposeful living, Self-determination

ADRD and Cognition: Dementia

NOT a specific disease
▪ Overall term covering a wide range of specific medical
conditions
▪ General term for a loss of ‘thinking abilities’ severe enough to interfere with daily life

Classifications

Reversible

• Major Depression

• Stroke

• Traumatic Brain Injury (TBI)

• Normal pressure hydrocephalus

• Medication side effects

Irreversible

• Alzheimer’s Disease (AD)

• Vascular Dementia (Multi-Infarct Dementia)

• Lewy Body Dementia

• Frontotemporal Dementia

Alzheimer’s Disease

Most common type of Dementia; accounts for 60-80%
▪ A progressive neurodegenerative disease
▪ No known cure
▪ Two abnormal structures
▪ Plaques-protein beta-amyloid build in the spaces
▪ Tangles- protein tau build in cells

Characterized by loss of function → loss of independence in daily life activities

Progression is in a continual slope

Vascular Dementia( Multi-infarct Dementia)

Commonly occurs with Alzheimer’s

Only around 5-10% occurs alone

More common in men

Causes blocked or reduced blood flow causing oxygen deprivation

Memory loss may or may not be a significant symptom
▪ Impaired planning and judgement, uncontrolled emotion, decreased attention span, impaired social skills and difficulty with word finding
▪ Progression is in a step pattern

Lewy Body Dementia

3rd most common cause of dementia

Deposits of alpha-synuclein proteins inside a neuron

Hallucinations, mostly visual

Trouble w visual info

Parkinsonian movement features

Confusion and alertness that varies significantly

Frontotemporal Dementia (FTD)

Nerve cell damage in frontal and temporal lopes

Causes by 1. Tau and 2. TDP4-3

Used to be referred to as Pick’s disease

Frontotemporal Dementia

Behavior variant frontotemporal dementia (bvFTD)

• Personality changes, conduct, judgement, empathy

• 50s and 60s, can be seen as early as 20s

Primary Progressive Aphasias (PPA)

• speaking, writing comprehensions

• Normally midlife

Disturbances of motor

Additional Types of Dementia

Korsakoff Syndrome: deficiency in thiamine (B-1)
▪ Most common cause is alcohol abuse
Parkinson’s Disease dementia:
▪ Early on tremors, shakiness, shuffling, stiff movements
▪ As brain changes spread often affect mental functions
Huntington’s Disease:
▪ Single defective gene on chromosome 4
▪ Uncontrolled movement of arms, legs, head, face,
▪ Decline in memory, concentration, judgement, ability to plan and organize
Mixed Dementia

Components of Function

Sensory

Emotional

Physical

Cognitive

Cognitive Components

Memory

Attention

Problem Solving

Sequencing

4 Types of Memory

Short Term

Long Term

Procedural

Working

Working Memory

Considered an executive function

Retaining information for a brief period of time while then manipulating that information
▪ Helps the brain organize info for storage

Attention

The act of carefully thinking about, listening, to or watching someone or something
▪ Level of alertness: Selective, Divided, Switching, and Sustained

Problem Solving

Ability to recognize and problem and then formulate and implement solutions
▪ Components include:
▪ Recognizing problem
▪ Identify the source of the problem
▪ Devise a solution to the problem
▪ Carry out that solution to correct problem
▪ Assess effectiveness

Best Ability to Function

Comes from the Allen Cognitive Levels
▪ Each level is described by the remaining abilities
▪ These abilities are what provides us with the 'just right challenge'
▪ Matching task complexity with cognitive ability
▪ Is written in % of cognitive assistance

We can think it terms of developmental age
▪ We do not want to speak of a person as 'acting like a 2 year old"
▪ The intention is to help facilitate understanding of remaining abilities

Allen Cognitive Levels

1 through 6, with 1 being the most severe

Level 1: Allen Cognitive Levels

Dementia Stage: End Stage, Severe
▪ Developmental Age: 0-12 months/infant
▪ BATF: Total Cognitive Assistance
▪ GDS: 7

Likely bed bound, mute, and requires total care
▪ Perceptual awareness 14" from face; monocular vision
▪ Can still feel love and experience relationships
▪ Primary remaining abilities
▪ Response to sensory stimuli
▪ Swallow
▪ Vocalize
▪ Partial ROM

Level 1 Care Approaches

Provide meaningful sensory stimuli
▪ Provide stimuli directly in front of person
▪ Gain person’s trust and agreement
▪ Promote movement
▪ Caregiver Knowledge
▪ Contractures
▪ Skin break down
▪ Aspiration
▪ Weight loss

Level 2: Allen Cognitive

Dementia Stage: Late stage
▪ Developmental Age: 12-18 months
▪ BATF: Maximum Cognitive Assistance
▪ GDS: 6-7

Gross motor movements
▪ Mobility
▪ Simple communication
▪ Possible self-feeding and drinking
▪ Perceptual awareness 23" from face; monocular field

Level 2 Care Approaches

Wait for a response
▪ Use verbal, visual, and tactile cues to gain attention and assist in processing directions
▪ Gain the person's trust and agreement
▪ Caregiver Knowledge
▪ Effective communication and engagement
▪ Hospice/ end stage complications
▪ Safety/fall prevention
▪ Promotion of movement
▪ Swallowing

Level 3: Allen Cognitive

Dementia Stage: Middle stage
▪ Developmental Age: 8 months – 3 years
▪ BATF: Moderate Cognitive Assistance- except feeding
which is minimal
▪ GDS: 6

Uses hands to pick up and manipulate familiar objects
▪ Eye hand coordination
▪ Notices effects of actions on objects
▪ Follows one step directions with cues
▪ Perceptual awareness is to elbow/knees; binocular vision
▪ Significant range of abilities; represented on a continuum
of high and low

Level 3 Care Approaches

Use verbal, visual, and tactile cues to gain attention and assist in processing directions
▪ Break activity into one step parts and cue at each step
▪ Use familiar objects to access procedural memory
▪ Gain the person's trust and agreement
▪ Caregiver Knowledge
▪ Effective communication and engagement
▪ Knowing level of assist; avoiding excess disability
▪ Avoidance of behaviors
▪ Safety/fall prevention accommodations

Level 4 Care Approaches

Set out or make supplies visible
▪ Provide assist for problem solving
▪ Establish and maintain a daily routine
▪ Gain the person's trust and agreement
▪ Caregiver Knowledge
▪ Prevent excess disability by promoting use of abilities
▪ Promote effective communication
▪ Safe environment

Level 4: Allen Cognitive

Dementia Stage: Early stage
▪ Developmental Age: 4 years – 10/12 years
▪ BATF: Minimum Cognitive Assistance- except feeding
which is supervision
▪ GDS: 4-5

Goal directed in simple, familiar activities
▪ Follows routines- very dependent on these
▪ Some new learning
▪ Some simple problem solving
▪ Perceptual awareness egocentric; binocular vision

Significant range of abilities; represented on continuum

Level 5: Allen Cognitive

Dementia Stage: Mild Cognitive Impairment
▪ Developmental Age: Teens to early 20s
▪ BATF: Independent to supervision depending on task
▪ GDS: 2-3

Follows simple written instructions
▪ Understands primary effects of actions; may not understand secondary
▪ Ability to learn through trial and error
▪ Beginning to have lapses in judgement, memory, attention, may show impulsivity
▪ Perceptual awareness beginning egocentric; tunnel vision

Level 5 Care Approaches

Compensatory strategies
▪ Gain the person's trust and agreement

Caregiver Knowledge
▪ Potential safety hazards
▪ Establish medication routine/compliance
▪ Walker training

Level 6: Allen Cognitive

Dementia Stage: No dementia
▪ Developmental Age: 25+ years
▪ BATF: Independent
▪ GDS: 1

The exchange of information
▪ 'Behavior' is communication
▪ Expressive
▪ Speech
▪ Body language
▪ Facial expression
▪ Receptive
▪ Comprehending message from other

Communication Approaches

Processing

• speak in short sentences

• wait for response

• visuals

Memory

• use nouns/avoid pronouns

• avoid reality checks “remember?”

Attention

• Make direct eye contact

• begin with name

Behavior

• trust and agreement

Communication Difficulty

Processing requests and directions → difficulties voicing desires and needs → resembling communication of infant

Behavior is Communication

Dementia causes people to act unpredictably

People with dementia communicate through behaviors

Recognize that behavior is communication and look for the trigger

Behavior Problems Arise from

1. Pain-number one cause

2. Fear

3. Inability to express unmet need

4. Loss of sense of self

5. Inappropriate expectations from a caregiver

Behavior Management Plan Questions

Who: Who was involved in incident
▪ What: What was the behavior
▪ Where: Where did incident occur? Is there a pattern?
▪ When:When did incident occur? Is there a pattern?
▪ Why: What happened prior?
▪ How: How did you respond? Was it effective?

Behavior Problems

Resists care
Physical and verbal aggression
Anxiety
Sundowning
Transfer Trauma
Sad mood or depression
Wandering

Minimize or Prevent

Come back later
▪ Use interests
▪ Gain trust and agreement
▪ Allow for as much control as possible
▪ Reduce stressors
▪ Check for pain
▪ Help to develop relationships
▪ Minimize time left alone
▪ Listen and support
▪ Anticipate unmet needs
▪ Engage in valued activities
▪ Challenging Behavior

Therapeutic Fibbing

1. Try other tactics first
   ▪ Distraction
   ▪ Respond to the emotion rather than the behavior

2. Mix it up
   ▪ Don’t always resort to this technique - it doesn’t work with
   everyone!

3. Safety and well-being rule
   ▪ Only use when necessary to create safety, enhance QOL,
   and ensure well-being

4. Let it be
   ▪ If the client is happy and not in danger, let them stay in
   their personal reality

5. Intuition
   ▪ Do what feels right

Montessori Method

Purpose
▪ Help persons with dementia be engaged by meaningful activity
▪ Teach loved ones new ways of connecting
Principles
▪ Sense of purpose and capture interest
▪ Activities that relate the the past
▪ Invite the person to participate
▪ Offer choices (no more than 2)
▪ Talk less, demonstrate more
▪ Match their speed
▪ Engagement is success

Sensory Engagement

Visual Engagement: bright colors, familiar objects to look at

Provide for Motor Movement: active movements throughout day, fidget toys, rocking chairs, air cushion

Activate senses for task preparation: smells of food or cooking before eating, smells of shower, relaxing music to calm or favorite music to alert

Cognitive Beliefs

Convictions held as true

Influence and influenced by occupational, personal, and environmental factors

OTPs can address cognitive beliefs to positively influence occupational participation and performance

Theoretical Assumption

1. Deeply held core beliefs influence our thoughts, emotions, behavior, and
physiological arousal
2. Beliefs and their dynamic interaction with behavior, emotions, physiological states, and the environment comprise human functioning
3. Beliefs are instrumental in how we perceive, appraise, and attach meaning to information from ourselves and the environment (our beliefs are our filter)
4. Beliefs that are true or held to be true often act as self-fulfilling prophecies
5. Beliefs develop from childhood through adulthood
6. Beliefs affect relationships, group affiliations, and society, and these social contexts also affect beliefs

Levels of Beliefs

Beliefs are on a continuum of overlapping levels
o Automatic thoughts- surface level, spontaneous, flexible, situational, arise
from core beliefs
o Assumptions/rules for living- intermediate assumptions, values, conditional rules, arise from core beliefs
o Core beliefs or schemas- deepest level; templates of absolutes about self, others, or the world; rigid; global
• Exist in a dynamic feedback loop where core beliefs generate intermediate and surface level thoughts, and intermediate and surface level thoughts reinforce core beliefs

Levels of Beliefs: Feedback Loop

Surface beliefs or automatic thoughts

Intermediate beliefs: values, attitudes, and rules for living

Core beliefs or schemas: about self, world, future

Depression: Cognitive Beliefs

Cognitive triad of negative beliefs
1. Self
2. The world or environment
3. The future
o May lead to a pessimistic world-view, self-deprecation, unpleasant feelings, maladaptive behaviors

Anxiety Disorders: Cognitive Beliefs

Beliefs tend to focus on threats and catastrophic interpretations of situations
o Intolerance of Uncertainty Model
o In OCD, distorted beliefs lead to inflated responsibility for negative events and need for control
o In PTSD, distorted beliefs center around self-blame

Eating Disorders: Cognitive Beliefs

Distorted beliefs about self and eating

Emphasis on appearance and eating habits on self worth

Substance Use Disorders: Cognitive Beliefs

Anticipatory beliefs - expectation of reward

Relief-oriented beliefs - using will alleviate discomfort

Facilitative beliefs - permissive in spite of potential consequences

Schizophrenia: Cognitive Beliefs

Defeatist beliefs

Self stigma

Cognitive Beliefs and Stigma

Stigma is rooted in personal and public beliefs
• Experiencing stigmatized beliefs from others and/or holding stigmatizing beliefs about oneself may hinder recovery
• Restructuring beliefs about mental illness to focus on hope and the ability to live a successful, meaningful life can support recovery

Cognitive Beliefs Assessment

Structured:

Pain Self Efficacy Questionnaire

Self Efficacy Gauge

Semi-Structured:

Socratic Questioning

Dysfunctional Thought Records

TIC-TOC

ABC

Pain Self Efficacy Questionnaire

Adults with chronic pain

10 item Likert scale survey measuring confidence in ability to perform daily tasks with pain

Self Efficacy Guage

For adults with occupational performance dysfunction

27 item Likert scale survey measuring confidence to perform occupational performance tasks

Acceptance and Commitment Therapy Practice Model

Acceptance: be willing to experience difficult thoughts

Cognitive Defusion: observe your thoughts without being ruled by them

Being Present: focus on the here and now

Self as Context: notice your thoughts

Values: discover what is really important to you

Commitment: take action to pursue the important things in your life

CBT Effectiveness

Reducing anxiety

Improving mood and reducing relapse rates in bipolar disorder

Decreasing symptoms of depression

Targeting underlying pathology associated with eating disorders

Substance use treatment, particularly when combined with motivational and skill building approaches

Addressing SOME aspects of functioning in schizophrenia

CBT and OT

When using CBT (or related approaches) in OT, we should consider the relationship between cognitive beliefs and occupational participation and performance
o How do beliefs shape our participation and performance?
o How do participation and performance shape our beliefs?

CBT: Cognitive Restructuring

Socratic Questioning

Guiding Discovery

TIC_TOC

Self-Talk and Affirmations

Thought Records

Coordinated Anxiety Learning and Management (CALM)

Ellis’s Rational Emotive Behavior Therapy (REBT)

TIC-TOC

focuses on identifying and reframing cognitions that interfere with tasks (Task-interfering Cognitions → Task-Oriented Cognitions)
o Identify task-interfering cognitions (TICs)
o Identify the associated though distortions
o Reframe to task-oriented cognition (TOCs)

Thought Records

Worksheet to organize and evaluate thoughts, beliefs, and emotional responses during distress
o May help to challenge cognitive distortions

Cognitive Distortions

All or nothing

Magnifying or minimizing

Catastrophizing or fortune-telling

Mental filter

Emotionalizing or emotional reasoning

Personalizing

Coordinated Anxiety Learning and Management (CALM)

Model for treating anxiety in primary care settings

8 week computer guided program w educational videos, opportunities to practice new skills, and homework

Ellis’s Rational Emotive Behavior Therapy (REBT_

Core tenet: irrational beliefs about how things “must” and “should” be for
people to be happy actually lead them to make themselves miserable
o Participants first identify, evaluate, and challenge irrational beliefs and then restructure and replace these beliefs using a graded approach
o ABC Model
▪ Activating event
▪ Irrational beliefs
▪ Emotional and behavioral consequences

CBT: Behavior/Learning Methods

Behavioral Experiments

Behavioral Activation and Activity Scheduling

Self-Monitoring

Behavioral Experiments

Collaborative strategy where client has opportunities to test thoughts, attitudes, beliefs, and behaviors
o Involves developing a hypothesis, predicting the outcome, engaging in the behavior, evaluating results, and revising beliefs and behaviors

Behavioral Activation and Activity Scheduling

Inactivity/avoidance may result from negative beliefs
o Behavioral activation aims to increase activity, counteract avoidance behavior, increase access to positive resources
o May include activity scheduling like making a list, chart, or calendar of activities to increase commitment and engagement