CHP 10 mental health

emotion v affect v mood

• emotion: feeling state associated with affect and mood that consists of psychological and physical components

  • free-floating anxiety: pervasive anxiety that does not have specific focus

  • fear: anxiety focused on real danger

• affect: observable component of emotion

  • appropriate affect is consistent/congruent with idea, thought, or speech

  • blunted affect: severe lack of affect; unable to change

  • flat affect: absence of affective signs of emotion

  • labile: rapidly changes

• mood: pervasive and sustained emotion manifested by thoughts and actions (elation, anger, depression)

levels of memory

• immediate: ability to recall material within seconds or mins (STM)

• recent: ability to recall events of past few days (working)

• recent past: recall events of past few months

• remote: ability to recall events of distant past (LTM)

• procedural: automatic sequence of behavior (conditioned response)

• declarative: recall specific consciously learned facts, such as school subjects

• semantic: knowing meaning of words and being able to classify info

• episodic: knowledge of one’s personal experience

• prospective: capacity to remember to carry out actions in future

motor behavior

• behavioral and motoric expressions of impulses, drives, wishes, motivations, and cravings

• disturbances:

  • echopraxia (meaningless imitation of other persons movements); catatonia, stereotypy, hyperactivity, ataxia, etc.

attention v consciousness v perception v thought

• attention: ability to remain focused on various aspects of activity or experience; able to concentrate

• consciousness: state of awareness that responds to external stimuli

• perception: process of interpreting sensory information received from environment

  • sensory disturbances = hallucinations, depersonalization, agnosia, apraxia, etc.

• thought: goal-directed reasoned flow of ideas and associations

  • flight of ideas, perseveration, thought blocking, loosening of associations, compulsions, delusions

mental status screeners

• mini mental

• short portable mental

• Montreal Cognitive (MoCA)

• saint louis university mental status (SLUMS)

schizophrenia

• criteria

  • A: presence of two or more sx:

    • delusions (+)

    • hallucinations (+)

    • disorganized speech (+)

    • grossly disorganized or catatonic behavior (+)

    • negative sx:

      • flat affect, anhedonia, alogia (dec speech and thoughts); anergia (decr energy); inability to relate to others

  • B: disturbances in one or more areas of fxn (work, social relationships, self-care, etc.)

  • C: ongoing signs of illness for 6 mos including at least 1mo of A sx

• specifiers: further describes illness and experience

  • frequency of condition (episodes), current status, continuous, unspecified, catatonia, severity

• onset & prognosis:

  • onset btw early adolescence and early 30s

  • recovery possible w/intervention

    • complete or sufficient recovery for indp and happy life (50%)

    • happy life w/ongoing support (25%)

    • declining and poor outcomes (25%)

schizoaffective disorder

• person has uninterrupted period of illness during which…

  • major depressive or manic episode concurrent with positive or negative schizophrenia sx

schizophreniform disorder

• meets criteria for schizophrenia BUT

  • episode lasts more than 1mo but less than 6mos required for schizophrenia diagnosis

delusional disorder

• presence of one or more delusions for duration of one month or longer

• criteria for schizophrenia has not been met

brief psychotic disorder

• A: presence of one or more sensory, behavioral, cognitive, or psychomotor sx

  • delusions, hallucinations, disorganization of speech/behavior, catatonia

• B: sx range from one day to one month followed by complete resolution of sx and return to PLOF

psychopharmacology

• first generation antipsychotic (typical)

  • thorazine, prolixin, haldol, navane, etc

  • side effects: dry mouth, blurry vision, constipation, parkinsonism, dystonia, akathisia, orthostatic hypotension, photosensitivity (use sunscreen)

  • complications:

    • neuroleptic malignant syndrome: autonomic emergency leading to incr BP, tachycardia, sweating, convulsions, and coma

    • tardive dyskinesia: neurologic disorder leading to abnormal, involuntary, irregular movements of head, limbs, and trunk often slow, rhythmic, automatic, stereotyped

    • neuroleptic-induced parkinsonism (pseudo-parkinsons): muscle stiffness, cog-wheel rigidity, shuffling, stooped posture, drooling, tremors

• second generation antipsychotics (atypical)

  • clozaril, risperdal, zyprexa, abilify, invega

  • side effects: vary w/each med; may include dry mouth, blurry vision, sedation, dizziness, hypotension, insomnia, confusion

    • 2nd gen is generally less problematic than 1st and more commonly used

• OT implications: should know that when on medications, side effects may impact performance (blurry vision!! orthostatic hypotension, dizziness)

bipolar disorder

• types & criteria:

  • bipolar I

    • one or more manic episodes

    • may be combined w/hypomanic or major depressive episodes

  • bipolar II

    • one or more major depressive episodes

    • must be at least one hypomanic episode

    • no hx of manic episode

  • cyclothymic: several periods of hypomanic and depressive sx (does not meet criteria) lasting at least 2yrs

• onset & prognosis:

  • onset at 25yrs; can start early childhood or late 40s/50s

  • prognosis decreases w/severity & frequency of diagnosis

  • early intervention crucial, medication management crucial

manic episode

• criteria

  • at least 3 sx must persist for period of at least one week

    • mood uncharacteristically and consistently elevated or irritable

    • increase in targeted, goal-directed behavior or restless, purposeless behaviors (psychomotor agitation)

    • inflated self-esteem or thoughts of grandeur

    • decreased need for sleep

    • pressured or quick speech

    • risky behavior, pleasure seeking behaviors

  • sx cause marked impairments to daily fxn or require hospitalization to prevent harm

  • behaviors seen: tx resistance, suggestive dressing, gambling, promiscuity, poor financial decisions, irritable, assaultive

• sx management:

  • mood stabilizing meds (lithium!! = eskalith, lithobid)

    • side effects: excessive thirst, tremors, excessive urination, weight gain, nausea, diarrhea, cog impairment,

      • monitor for lithium toxicity!!

  • anticonvulsants

    • depakote, tegretol, neurotin

    • side effects: drowsiness, ataxia, weight gain, sedation

  • antipsychotics

    • zyprexa, seroquel, risperdal

major depressive episode

• criteria

  • five or more sx must be present for at least 2wks

    • depressed mood or notable loss of interest most of day (MUST be sx)

    • sig fluctuations in weight (appetite changes)

    • insomnia or hypersomnia

    • slowed thinking, restless, psychomotor agitation

    • fatigue, loss of energy (anergia)

    • altered mood or self-perception (worthless, inadequate, guilt)

    • decr ability to concentrate

    • recurrent suicidal thoughts

  • behaviors seen: irritable, anxiety, difficulties with social/sexual interactions, self-destructive, somatic complaints, incr use of medical services

  • sx sig enough to cause fxnal disruption

• sx management

  • antidepressants (SSRIs, SNRIs, etc.)

  • CBT, electroconvulsive therapy (ECT)

antidepressants

• selective serotonin reuptake inhibitors (SSRIs) (most commonly used)

  • prozac, zoloft, paxil, celexa, lexapro

  • side effects: nausea, headache, sexual dysfunction, insomnia, disturbed balance, orthostatic hypotension, cardio sx

• tricyclics (rarely used)

  • elavil, tofranil, norpramin

  • side effects: dry mouth, blurred vision, sedation, anticholinergic effects, orthostatic hypotension

• selective norepinephrine or serotonin and norepinephrine inhibitors (SNRIs)

  • effexor, cymbalta

  • side effects: vary but may be HTN, anxiety, dizziness, sedation, nervousness, weight gain, nausea, sweating

• atypical antidepressants

  • wellbutrin & remeron

  • side effects: similar to SSRIs and SNRIs

• monoamine oxidase inhibitors (MAOIs)

  • nardil, parnate

  • side effects: weight gain, hypotension, insomnia, liver damage

  • dietary restrictions! avoid foods with tyramine > cause HTN crisis (stop med if experienced)

  • requires strict adherence to contraindications (dietary, OTC meds can cause severe side effects)

hypomanic episode

• sx are same as for manic episode BUT not severe enough

  • EX: last for four days rather than 1 week

depressive disorders

• share common presentation of sad, sometimes irritable mood + cognitive and physical health changes affecting fxnal ability

• types & criteria

  • major depressive disorder

    • presence of one or more depressive episodes

  • persistent depressive disorder (dysthymia)

    • at least 2yrs of depressed mood, most days, w/depressive sx

    • major depressive disorder criteria may be continuously present for 2yrs

  • disruptive mood dysregulation disorder (DMDD)

    • temper outbursts including

      • severe and recurrent verbal or behavioral episodes

      • inconsistent w/expectations for developmental level

      • outburst considered over-reaction

    • diagnosis btw 6-18yrs old

  • premenstrual dysphoric disorder

    • marked affective lability, irritability/anger, depressive sx, depressed mood, anxiety

• onset

  • onset varies and can occur at any age

    • major depressive disorder > 32yrs

    • DMDD btw 6-18yrs

substance-related disorders

• continued use of alcohol, tobacco, marijuana, or medications not prescribed despite significant disruption to meaningful activities

  • common to involve abuse of multiple substances

  • all segments of society are potentially vulnerable = all occupations can be affected

• USA in a national drug crisis (opioid use!)

• diagnosis ranges from mild to moderate to severe

• subtypes determined by category of drug NOT amount or pattern of use

  • EX: alcohol addiction, caffeine, tobacco, cannabis, etc.

• criteria

  • involves negative patterns of behaviors involving 11 sx across 4 areas:

    1. impaired control (using more than intended or unable to cut down even when wanting to)

    2. social impairment (unable meet role expectations)

    3. risky use (continue use despite negative outcomes)

    4. pharmacological criteria (tolerance and withdrawal)

• medical management:

  • medications!! both to help refrain from substance and reverse overdose

    • Naloxone (Narcan!); methadone (heroin replacement)

• OT: coping skills!!

gambling disorder

• criteria

  • 4 or more behaviors must be true for at least 12 mos

    • thoughts of gambling occupy mind most of day

    • multiple unsuccessful attempt to decr gambling > restless, irritable, unhappy

    • gambling incr in presence of stress

    • serious financial trouble

    • excessive gambling continues after losses

    • downplays frequency or effect of gambling to others

    • problematic and recurrent (not manic)

anxiety disorder

• common underlying elements of ALL anxiety disorders? (2)

• disorders (7)

• common underlying elements of ALL anxiety disorders:

  • excessive fear: drives response to “real or perceived imminent threat

    • “there’s a bear! use the bear spray!”

  • excessive anxiety: represents “anticipation of future threat”

    • “what if there’s a bear! let’s not go.”

• onset: often begins in childhood

• sx management: psychotherapy, CBT, medications

  • anxiolytic, antidepressants

• disorders:

  • separation anxiety: typically young children become excessively attached to another person and experience severe anxiety when separated

  • selective mutism: consistent inability to speak in social situations when expected, can speak in other situations; persist 1mo and not explained by communication disorder

  • phobia: sig anxiety from specific object or situation leading to avoidant behavior

  • social anxiety: anxiety due to social leading to avoidant behaviors

  • panic disorder: recurrent panic attacks followed by concern for recurrence

  • agoraphobia: anxiety about being in places or situations where escape is difficult or embarrassing

  • generalized anxiety disorder: 6mos or persistent and excessive unfocused anxiety and worry

panic attacks

• SYMPTOM of anxiety, not formal diagnosis

• discrete periods of intense fear or discomfort, in which 4 or more sx develop abruptly and reach peak within minutes

  • physical sx: heart palpitation, sweating, trembling, etc

  • psychological sx: de-realization, loss of control, fear of dying

  • neurological sx: paresthesia

anxiolytic medications

• xanax, valium, ativan, klonopin, serax, buspar

• side effects: drowsiness, ataxia, headache, nausea, depression, dependence

personality disorders

• persistent patterns in cognition, affect, behavior, or interpersonal functioning are experienced or expressed despite being notably different from expectations and norms of one’s culture

  • pattern in stable, inflexible, evident in wide range of situations

• Cluster A: social discomfort

  • paranoid personality disorder: long-standing suspiciousness and mistrust of people; hostile, irritable, angry

  • schizoid personality disorder: lifelong pattern of social withdrawal; discomfort w/human interaction, introversion, bland and constricted affect; eccentric, isolated, lonely

  • schizotypal personality disorder: odd or strange in thinking and behavior; magical thinking, peculiar ideas, ideas of reference, illusions, derealization

    • willy wonka

• Cluster B: dramatic, impulsive, emotional

  • antisocial personality disorder: continual antisocial or criminal acts; inability to conform to social norm; no regard for safety or feelings of others, lack remorse

  • borderline personality disorder: unstable affect, mood, behavior, relationships, and self-image; fear of abandonment, unstable relationships; self-destructive; emptiness, hx of trauma common

  • histrionic personality disorder: colorful, dramatic, extroverted behavior in excitable, emotional person; inability to maintain deep relationships; dramatic, flighty, flamboyant, cheery

  • narcissistic personality disorder: heightened sense of self-importance, grandiose feelings

• Cluster C: anxious and fearful

  • avoidant personality disorder: extreme sensitivity to rejection; socially withdrawn; NOT asocial; desire social interactions but consider self unworthy; chronically and extremely insecure

  • dependent personality disorder: becomes subordinate for others; disregards self; lack self-confidence; hates being alone; submissive, puppy dog

  • obsessive-compulsive personality disorder: emotional constriction, orderliness, perseverance, stubbornness, indecisiveness, perfectionism, inflexibility, NOT OCD

obsessive-compulsive disorder

• obsessions: persistent thoughts or feelings that are unwanted, intrusive, and inappropriate based on stimulus or situations

• compulsions: irresistible urges that take form of repetitive behaviors carried out in attempt to reduce anxiety or anticipated negative consequences related to obsessions

• often ritualistic, time consuming, and intrusive

body dysmorphic disorder

• person preoccupied with perceived physical flaws that are imperceptible, acceptable, or insignificant to others

hoarding disorder

• perceived need to save items and significant difficulty discarding possessions, regardless of value, need, or practicality

trichotillomania

• compulsive, irresistible desire to pull out hair

excoriation disorder

• repeated picking at own skin resulting in skin lesions

reactive attachment disorder (RAD)

• childhood filled with social neglect or instability/inconsistency of primary caregiver leading to insufficient or frequently changing care that alters nature of interactions with caregivers

  • onset before 5yrs

• characterized by

  • persistent failure to initiate or respond in developmentally appropriate fashion to most social interactions

  • interactions are excessively inhibited, hypervigilant, or highly ambivalent and contradictory in nature

• impact:

  • high need to be in control, frequent lying, overly affectionate w/strangers, hoarding or gorging on food, denial of responsibility, blaming

• tx: no effective tx identified or prognosis

  • high structure, limit caregiver exposure,

disinhibited social engagement disorder

• child initiates active interaction w/unfamiliar adults while displaying at least 2 behaviors

  • little reservation when approaching unfamiliar adults

  • overly familiar use of words or actions despite unfamiliarity

  • child willing to leave with unfamiliar adult without hesitation

• upbringing of neglect, deprivation, unreliable caregiving

• at least 9mos old

post-traumatic stress disorder

• criteria

  • exposure to threats or actual events that can result in harm by

    • personally/directly experiencing, first-hand witness, learning about events experienced by close loved ones, repeated exposure to visuals or explanations of aversive details of PTSD

  • presence of intrusion sx

    • recurrent, unwanted memories or dreams related to event

    • physical or mental exposure to event causing to believe event is reoccurring

    • marked, prolonged physiological rxn w/exposure to cues related to event

  • changes in patterns to avoid trigger

  • reminders to events have adverse rxn on cognition, memory, mind, fxn

acute distress disorder

• similar to PTSD, BUT is immediately follows event

• sx do not persist beyond 1mo

adjustment disorder

• criteria

  • clearly identifiable stressor causes onset of emotional and/or behavioral sx within 3 mos of experiencing stressor

    • sx resolve within 6mos

  • sx cause marked distress in important areas of fxn

  • sx not explained by other disorder

neurocognitive disorder

• conditions that primary sx are cognitive deficits

  • caused by various things (substance abuse, medical condition, unknown)

  • onset & prognosis:

    • increases with age; prognosis dec w/age and time of illness

• delirium: disturbance of consciousness with decreased ability to attend; covers short period of time (hours to days); fluctuates

  • causes: brain dysfunction, medication, endocrine disorders, cardiac disorders, infections, liver disorders

  • onset: 1 in 5 hospitalizations (greater for older); more severe w/old age

• major neurocognitive disorder: significant impairment in cog fxn w/marked decline from PLOF

• mild neurocognitive disorder: cognitive deficits do not interfere w/independence in everyday life

reversible causes of mental confusion

• sensory related:

  • age-related losses (hearing, vision, touch)

  • unavailable or inadequate prostheses (hearing aid, glasses, etc.)

  • sensory overload or deprivation

• depression

• drug use or misuse

• infections/inflammation

• metabolic problems

  • kidney/liver disease, thyroid disorder

  • dehydration, poorly controlled diabetes

anorexia nervosa

• criteria

  • low body weight due to difficulty maintaining body weight at normal level

  • fear of gaining weight despite being underweight & perceives self as being heavier than actually are

  • alteration in self-perception of body weight

  • either food restrictive or binge eating/purging

• onset & prognosis:

  • most common in midteens

  • varied long term prognosis

bulimia nervosa

• criteria

  • ongoing binge eating of large portions and feeling inability to control consumption to avoid gaining weight

  • attempts made to avoid gaining weight through vomiting, laxatives, fasting, extreme exercise

  • self-concept defined by body proportions and size

  • sx not due to anorexia nervosa

• onset & prognosis: usually later than AN; reported higher rates of suicidal ideation than AN

• maintain normative weight

binge-eating disorder

• criteria

  • inability to control binge-eating, recurrent periods of consuming extreme amount of food in discrete situation

  • episodes may include

    • eating until painfully full or past hunger

    • eating more and at faster pace

    • experiencing guilt or depression after binge

    • solitary eating due to embarrassment

  • clinically significant distress

  • severity based on frequency of episodes

    • mild 1-3 per wk

    • extreme 12+ per wk

rumination disorder

• repeated, unintentional regurgitation of undigested or partially digested food followed by rechewing and either swallowing or spitting food

oppositional defiant disorder v conduct disorder v unspecified

• oppositional defiant disorder: negativistic, hostile, and defiant behaviors that result in functional impairment

  • begins in early childhood

  • likely to progress to conduct disorder if aggression is prominent

• conduct disorder: disregard for rights of others leading to aggression toward people and animals, destruction of property, deceitfulness, theft, or serious violations of rules

  • middle childhood through middle adolescence

  • severe conduct disorder associated w/other disorders and SUD later in life

• unspecified disruptive, impulse control, and conduct disorder: children do not meet criteria for above disorders BUT display significant functional impairments and similar behaviors

autism spectrum disorder

• five criteria with 2 essential features (symptom-specific criteria)

  1. persistent deficits in social communication and social interaction across multiple contexts (ESSENTIAL)

     • social-emotional reciprocity deficits

     • nonverbal communication behaviors used for social interaction impairments

     • deficits in developing, maintaining, and understanding relationships

  2. restricted, repetitive patterns of behavior, interests, or activities (ESSENTIAL)

     • stereotyped or repetitive motor movements, use of objects, or speech

     • insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior

     • highly restricted, fixated interests that are abnormal in intensity or focus

     • hyperreactivity or hyperreactivity to sensory experiences

  3. sx must be present in early developmental period

  4. sx cause clinically significant impairment in social, occupational, or other important areas of current functioning

  5. disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay

• etiology: organic brain pathology; hereditary link!, known genetic conditions (Rett’s)

Attention deficit hyperactivity disorder (ADHD)

• etiology: unknown but contributing factors include

  • genetics, neurologic factors, neurochemical dysfunction, psychosocial factors

• types:

  • predominantly inattentive (ADHD-I)

  • predominantly hyperactivity-impulsive (ADHD-HI)

  • combined types (ADHD-C) - MOST COMMON

    • both attention deficit and hyperactive impulsive subtypes

• criteria

  • presence of 6 or more sx in single domain or both (6mos)

    • inattention domain

    • hyperactivity domain

    • impulsivity domain

  • impairments present in two settings (school/work & home)

• onset: common in toddler to early childhood (becomes very evident at school age)

• sx management

  • medication:

    • dextroamphetamine for +3yrs old

    • methylphenidate for +6yrs old

    • side effect: loss of appetite, weight loss, disturbed sleep, slow growth

  • antidepressants, anxiolytics

intellectual developmental disorders (IDD)

• etiology: genetics, metabolic conditions, prenatal infection, maternal SU, infection, head trauma

• onset & prognosis: varied onset (before 18yrs age), lifelong disorder

  • diagnosis by IQ test but not full picture > adaptive fxn test

• criteria

  • A: deficits in general mental abilities

  • B: impairment in everyday adaptive fxn

    • conceptual skills, social skills, practical skills

  • C: onset during developmental period

• severity:

  • mild: minimal support, ADL, IADL, social, work skills for independence, intermittent support

  • moderate: independence in daily routine, support and structure for work/IADLs; moderate support for specific tasks (meal prep, public transport); supervised living required

  • severe: some communication and basic living skills; significant impairments in motor; most tasks require assistance, supervised living required

  • profound: significant impairments in motor and physical development; extensive 24/7 support; dependent for ADLs; supervised living