trying to tip the untippable!

w1-11 + 13 now:)

explain the interaction between biological vulnerability, stress level and individual’s response in the stress vulnerability model

biological determines the threshold. when stress level stays below the threshold, individuals react in a elastic homeostatic way; when the stress level exceeds this threshold, individuals experience psychopathological episode. when the stress level drops back to below the threshold, the episode ends and the individual returns to pre-episode state.

vulnerability-stress-protective factors model of mental illness

• goal

• types of protective factors

• components of clinical progress and outcomes

goal: build up protective factors and shift the balance from disability towards recovery

types of protective factors: personal attributes & environmental factors

clinical progress and outcomes: symptoms & relapses, social functioning, cognitive impairment, QoL

medium for remediation and overcoming of disabilities in psychological rehab + aim + examples

• skills training

  • remediate disabilities in social, family, and vocational functioning + learn to react with stressful env

  • e.g. social skills/ pre-vocational/ relaxation skills/ life skills/ emotional regulation training

• environmental support

  • reduce potential stressors + compensate for disabilities

  • e.g. family support program, ICCMW, transitional housing, peer support, supported employment

• societal rehab initiatives

  • change the system the the MI patient has to function in + promote occupational justice (reduce stigma)

  • e.g. equal opportunities in employment

define personal journey

rediscovery of self in the process of learning to live with an illness

4 focuses of recovery

journey, meaning, striving to achieve, transformation

characteristics of recovery

• unique and individual

• non-linear

• gradual

• recovery without cure

• without professional intervention

CHIME framework + examples

• connectedness (relationships/ community/ social support)

• hope and optimism (belief in recovery/ aspirations/ positive thinking/ motivation)

• identity (+ve self-identity/ overcoming stigma)

• meaning (meaningful goals/ life/ roles/ meaning in mental health experience)

• empowerment (sense of control/ taking personal responsibility/ focusing on strengths)

framework of recovery

• stages of recovery (change model)

• process (CHIME)

• characteristics of journey

explain the stages of recovery + OT role

transtheoretical stages of change model

OR

moratorium (confusion/ withdrawal)

awareness (hope)

preparation (evaluate strengths and weaknesses)

rebuilding (positive identity/ goals/ empowerment)

growth (resilience)

domains of recovery

• clinical

• personal (hope/ resilience/ personal goals/ identity)

• social (social participation/ roles/ inclusion/ contribution)

• functional (skills/ adjustment/ adaptations)

types of strengths

• talents & skills

• personal attributes (e.g. good memory)

• interests/ aspirations

• environmental strengths

strength Ax

current strengths → aspirations and goals → past resources (used before)

how identification of strengths supports mental health recovery?

i just guess

• identify strengths → promotes commitment and motivation + focus on the +ve aspects in life → hope and optimism (CHIME)

• strength Ax → identify meaningful goals and aspirations → meaning (CHIME)

• identify strengths → utilize them to achieve goals → regain sense of empowerment (CHIME)

  • empowerment + strength-based = ROP

purpose of OT Ax and evaluation

therapist

• answer specific (referral) questions

• continuous documentation progress

• set ST and LT recovery goals

patient

• motivation on rehab

domains of OT to be assessed + examples of components of each domains + example of Ax)

• pattern of occupation - occupational questionnaire (routine)/ role checklist (role)

• Motivation of occupation - Interest checklist (interest)

• communication and interaction skills - ACIS (e.g. non-verbal/ conversational skills)

• motor (energy/ coordination) and processing (knowledge/ problem solving) skills - AMPS

OT process

group process (Cole’s 7 steps group)

1. introduction

2. activity

3. sharing

4. processing

5. generalizing

6. application

7. summary

group roles (good/ bad)

task roles (8) (good)

• coordinator/ elaborator/ orienter (CEO)

• procedural technician

• info seeker/ giver

• opinion seeker/ giver

• initiator-contributor

• recorder

building and maintenance roles (good) (4)

• harmonizer

• compromiser

• gatekeeper (ensure everyone participates)

• follower

individual roles (6)

• play boy/girl

• blocker

• aggressor

• recognition seeker

• self confessor

• dominator

group leaders responsibilities + qualities

• motivate the group (encourage participation/ enthusiasm) - confidence

• set limit/ rules (limit inappropriate behaviours) - authority

• establish therapeutic communication (build trust and rapport/ understand feelings) - attentiveness/ empathy

purpose of OT group intervention

• social context for training

• mutual support

• social learning (observational)

• connect with others → new roles (social recovery)

• resources consideration

(target all types of recovery + any timing in recovery process)

definition of social skills

interacting with others in social situations appropriately and effectively

• appropriate: x violate social expectations/ values/ norms

• effectively: achieved the intention of the social interaction

components of social skills

conversational

• verbal (e.g. tone/ choice of wordings/ continuation of dialogue)

• non-verbal (e.g. facial expressions/ gestures)

assertiveness

• between submissive and aggressive

• express moods

• say no

• ask for help from others

structure of group SST

explanation

demonstration

role play (behavioural rehearsal, repetition, modeling)

immediate concrete, encouraging and corrective feedback (+ve reinforcement, shaping)

HW to promote generalization

social learning theory: 4 factors affecting social learning (did not appear in ppt but appeared in PP)

attention

retention

reproduction

motivation

approaches of SST

shaping and +ve reinforcement (token/ social reinforcement)

errorless learning

• immediate cues and prompts to minimize errors → do not need to unlearn mistakes and no frustration

• esp for schiz patients with low procedural/ implicit learning capacity

• requires detailed analysis of the behavioural task to be learned and precision teaching techniques

• breakdown task into behavioural components → sequential teaching, start with easiest and smallest behavioural component → successfully display desired behaviour for at least 10 times → move on to next

• demonstrate (role model) → prompts and reinforcement → desired response → repetition and fading

relationship between social skills and MI

• biological vulnerability of depression and schizophrenia

• poor social skills causes depression and depression leads to poor social skills

• poor social skills → unable to express their needs/ themselves → more likely to develop schiz

definition of social cognition & components

mental process that underlies social interaction, including perception, interpretation and response towards others’ dispositions, behaviours and intentions

• social cognition deficit: emotion and social perception/ theory-of-mind

• social cognitive bias: jumping to conclusion/ attributional style (internal vs external/ global vs specific/ temporary vs permanent)

significance of social cognition in functioning

• better explain variance in functional outcome than neurocognition

• mediator between neurocognition and functioning

structure/ process of SCIT

1. recognizing emotions and understanding social cognition

2. addressing social cognitive bias and thinking

3. integration/ application

how does SCIT improve functioning & what are the ways to improve effectiveness of SCIT

it causes neuroplastic changes in social brain

effectiveness

• target wider range of social cognition domains instead of just one

• combine it with cognitive remediation (CR)

significance of life skills training in MI

schiz patients tend to have functional deficits in life skills

structure of life skills training for ADL/ IADL

1. introduction

2. video tape + QnA review

3. identify resources used + ways to obtain them

4. suggest alternative resources + evaluate pros and cons

5. role-play to re-enact the scenario in video tape

6. rehearse the skills in real-life with limited support from trainer

7. independently use the skills in everyday life 

effectiveness of life skills training

meal prep and cooking → improve cognitive fx and independence

grocery shopping → improve IADL skills + EF

concepts of IMR (5-2-9)

5 strategies

• psychoeducation for MI & Tx

• behavioural tailoring for medication adherence → optimal mental state

• relapse prevention plan (identify warning signs + empowerment)

• social skills training → more social support

• coping skills training

2 models

• state of change

• stress & vulnerability model

  

9 curriculum

• practical facts about MI

• building social support

• getting needs met in mental health system

• coping with stress

• coping with problems and symtoms

• Tx strategies and stress-vulnerability model

• reducing relapse

• managing medication

• recovery strategies (set goals/ awareness of recovery)

• (HLS/ substance use)

process/ structure of IMR

1. informal socializing

2. review prev session

3. review HW

4. FU on goals

5. set agenda

6. teach new stuff and practice

7. HW

8. summary

(target the whole process of recovery)

nature of attention

• selective and limited → constantly filter unnecessary info to avoid overload (x multitask but switch tasks)

• tend to wander → unhappiness → default mode of network → rumination

window of tolerance theory

in your window of tolerance ~ below the threshold of stress-vulnerability mode

above threshold → hypo/ hyperarousal

definition of body-mind intervention

• therapeutic approach focusing on harnessing the power of mind

• interaction between brain, mind, body, behaviours → use the mind to promote physical funcitoning and health

definition of mindfulness

awareness that emerges from intentionally paying attention to things as they are non-judgmentally in the present

types of body-mind intervention + examples

• physical (e.g. progressive muscle relaxation/ acupuncture/ diaphragmatic breathing)

• psychological (e.g. meditation/ mindfulness/ music therapy)

• combined (e.g. dance therapy, yoga, qigong, baduanjin, taichi)

types of mindfulness

• non-secular (religious)

• secular

• mindfulness based program (MBP) - e.g. MBSR program/ MBCT

axioms of mindfulness in MBP

• attention (to present moment + internal & external experiences)

• intention (e.g. improving well-being)

• action (integrate into daily activities)

• attitude (compassion/ kindness/ curiosity)

definitions + examples of formal and informal mindfulness practice 

formal: specific time + regular basis + devoted solely for cultivating mindfulness

• breathing practice

• anchoring practice

• mindful stretching practice

• mindful walking practice

• body scan practice

• sitting practice

informal: integrate into daily activities + mindfulness attitudes

• sitting

• walking

• running

• eating

• washing hands

• bathing, etc

neuropsychology (parts of brain/ nerve/ system) of mindfulness

parasympathetic system + vagus nerve (CN X)

attention control (sustained attention)

• activation: ACC, dlPFC

emotional regulation

• activation: dlPFC, vlPFC, insula

• deactivation: amygdala

self awareness (noticing and decentering from rumination)

• activation: PFC

• deactivate: PCC

function of vagus nerve

• control bp, slow HR

• regulate resp. rate

• stimulate digestion (stomach/ intestines motility and secretion)

• swallowing, gag reflex etc.

psychological mechanism and effects of mindfulness

• enables us to skillfully react to life experiences

• create space between stimuli and reaction

• shift from driven-doing mode (constantly comparing progress to your own goals while nth can be done) → rumination) to being mode (accept + allow)

+ve effects of MBP

• MBCT: QoL, reduce depression Sx, relapse recurrence

• MBSR: QoL, anxiety, reduce stress

difference between adverse reaction and side effects

adverse reaction: unwanted events caused by treatment

side effects: unwanted events caused by effective treatment

source of adverse effects of MBP

program, participant, teacher/ clinician factors

define stigma

• negative/ discriminative attitudes

• happens when society degrades/ loses respect for someone w/ discrediting attributes → marginalization

components of stigma + define

• stereotype - making inference/ categorizing info according to people’s assignment to a particular group (for quick adaptive response/ simplification of social info) (+ve/ -ve)

• prejudice - negative affective attitudes towards a particular stereotyped group

• discrimination - enacted prejudice as a negative reaction towards a particular group

types of stigma + impacts

institutional

• systemic stigma → unintentional/ intentional limitations of opportunities for PIR

public

• public + media: media representation/ public discrimination → decreased help-seeking behaviour/ low awareness and discussion of mental health

• courtesy: stigma towards people in relation to PIR → alienation/ burden/ conceal relationship/ distress

• professional: medical/ social service providers → distress of PIR/ adverse experience

self

• low self esteem and self efficacy

• social isolation/ ostracism

• poor QoL

models of stigma

• stage model (awareness → agreement → apply/ self-concurrence → harm (low self efficacy/ self esteem)

• model of personal response (stigma → group identification → perception of legitimacy → contingency of self worth → righteous anger & empowerment/ low self esteem and efficacy/ indifference)

consequences of stigma

direct: avoidance of anticipated stigma → refused to seek psy help

indirect: reduced insight in the benefits of Tx and focus on -ve aspects of tx → non-compliance

intervention to combat stigma + details

personal empowerment

• encourage people they can achieve

disclosure

• stages: social avoidance → secrecy → selected disclosure → indiscriminant disclosure → broadcasting (be proud and educate people)

• promote empowerment + reduce self-stigma/ worry and concerns of secrecy

• hierarchy

1. psychoeducation about MI/ challenge -ve beiefs and self stigma

2. CBT (change dysfunctional beliefs/ stigma) or MI (encourage Tx compliance)

3. SST (navigation of relationship)

4. goals (formulate and guide them to attain)

5. round-up

define SMI

mental, behavioural or emotional disorder that causes serious functional impairment substantially interfering with or limiting life activities

symptoms of schizophrenia

+ve

• hallucinations - sensory experience w/o external input (mostly auditory)

• delusion - misinterpretation of reality (mostly delusions of grandeur and persecutions)

-ve

• apathy/ avolition - asociality/ anhedonia/ avolition (due to lack of anticipatory pleasure

• diminished expression (blunted affect/ alogia)

cognitive

• social cognition (social and emotional perception/ theory of mind/ attributional styles)

• neurocognition (processing speed/ attention/ EF/ prospective memory/ verbal learning/ visual memory/ WM)

concept of anticipatory pleasure

• → avolition

• inability to anticipate pleasure in achieving or pursuing goals

• reward processing disturbances: reward prediction/ learning deficit, inaccurate/ maladaptive internal value representation (e.g. sense of achievement/ social recognition)

major phases of symptoms development of schiz

prodromal: deteriorating functioning, last for few days to years

active: fluctuating, active and prominent psychotic symptoms

residual: psychotic symptoms subsides and less active; -ve and cog Sx remains stable and still exist, +ve Sx remission

Mx of schizophrenia

pharmacological: antipsychotics (x response well → clozapine as last resort; attack WBC)

psychosocial: individual CBT/ family intervention

employment: supported employment

education: pre-vocational training/ educational activities

routinely record daytime activities in their care plan + occupational outcomes

major groups of mood disorder

depression only

• unipolar depression

• dysthymic depression (milder)

mania + depression

• bipolar I: manic + depression

• bipolar II: hypomania + depression

• cyclothymia

Sx of manic and hypomanic episodes

mood Sx

• elevated, expansive or irritable mood

Cog Sx

• distractibility

• sense of grandiosity

• racing thoughts

behavioural sx

• pressure speech

• decreased need for sleep

• talkativeness

• psychomotor agitation

• excessive involvement in pleasurable yet foolish activities

neurobiological predispositions of bipolar disorder

dysregulation of norepinephrine and dopamine systems in the brain

Mx of BD

pharmacological: antipsychotics/ mood stabilizers

psychological: CBT/ interpersonal therapy/ behavioural couples therapy

EBP OT interventions for SMI

• CR

• CBT

• supported employment (w/ SST & CR)

• supported education

• occupational based interventions

focus: valued life roles and occupations

definition of NEAR

neuropsychiatric educational approach to cognitive remediation

• highly individualized learning

• group based Tx of cognitive remediation

• promote intrinsic motivation through

  • personalized: tasks suit their cognitive needs + interest

  • contextualized tasks: related to real-life + practical → more motivated

  • learner control: control pace and choose activities → engaging

structure of NEAR

• group size: 6-8 people

• at least 2 sessions per week (1-1.5 hrs each)

• ¾ cognitive activities; ¼ bridging group

• computer- assisted cognitive training (~3 activities)

• bridging group

  • naming cognitive skills: discuss the cognitive skills used in daily activities → metacognitive knowledge and awareness

  • metacognitive group: discuss CR software and the cognitive problems that it addresses → enhance metacognition regulation

metacognition type and level (Cella et al)

knowledge 1: knows cognitive operation is necessary for doing everyday tasks

knowledge 2: knows the cognitive skills needed for the tasks

knowledge 3: know the impact/ diff associated with the cognitive deficit/ operation

regulation 1: x adjust/ compensate for cognitive deficits

regulation 2: can anticipate demand + limited planning and adaptations

regulation 3: can adapt with planning regularly + adjust according to feedback

how to increase effectiveness of NEAR

• w/ psychiatric rehab

• w/ practice and drills + strategy coaching

types of intervention in CR

strategy (skills e.g. chunking)/ remediation (change ext factors)/ aids (add external facilitator)

Ax for SMI + function (brief)

CFNA (chinese functional needs Ax)

• self-care

• community living skills

• → community independence

CWPP (chinese work personality profile)

• work functioning/ job suitability

C-LASER

• work readiness

setting that are suitable for applying NEAR and what can NEAR improve

any setting (out/ in patient/ supportive housing facilities)

improve attention, processing speed, immediate learning and memory, delayed verbal memory

*x improve physical fitness/ medical adherence

theoretical background and bases of family intervention

• relapse rate is lower if lived in resident setting than those with family

• based in systemic approach (context & environment matter)

• dynamic relationship b/t symptoms and the interpersonal context in which the symptoms occur

• family = system, made of complex relationship b/t members and the world outside → causes symptoms (i.e. structure/ belief/ pattern of family = perpetuating factors)

• Sx reduced change in family and increases the predictability → homeostasis (e.g. PIR becomes the shared project that allows the family to escape from old problems)

explain the concept of EE

expressed emotion

• measures the family env

• high EE (criticism/ hostility/ emotional over-involvement) → high relapse rate of schiz/ mood disorder)

• low EE (low levels of emotion/ empathy/ calm and respectful/ positive

hooley’s controllability model

family beliefs about PIR ability to control Sx and behaviours → emotional responses → controlling actions

• underlying belief (Pt should control their Sx/ problem)

• attributional staff (assign responsibility to patient)

• utility belief (use criticism/ EOI as means to reduce Sx even if they are ineffective → -ve affective and behavioural responses → high EE)

• criticism/ hostility = think patient should take responsibility to control her illness

• EOI = think Pt do not have the ability to control Sx/ problem

types of interaction pattern of high EE

pursuer distancer

conflict avoidance

high conflict

over/ under functioning

→ high EE leads to problem maintaining functional interaction pattern among family members

impacts of high/ low EE

• high relapse rate for SMI

• intensify delusions

• criticizing remarks increases -ve Sx

• EOI increases +ve Sx

• warmth/ +ve improves overall social functioning

camberwell family interview schedule

• gold standard measure of EE

• interview key relatives w/o pt

items

• criticism (dislike/ hatred/ dissatisfaction about the patient expressed by tone of voice; high EE: >=7 )

• hostility (general + extensive expressed emotional towards the patient rather than their function; high EE: >=1)

• EOI (exaggerated emotional reaction/ excessive protective, defensive, limiting, controlling attitudes and behaviour against the status of the patient; high EE: >=3)

• positive remarks

• warmth (expressed empathy)

FMSS/ RAI

five-minute speech sample

high EE

• CRIT (-ve initial statement/ -ve relationship rating/ >=1 criticism)

• EOI (self-sacrificing/ overprotectiveness, emotional displays, >=2 ratings of excessive detail about the past, expressions of love for pt, excessive praise of pt)

relative assessment interview

• bg info

• chronicity of illness

• irritability

• financial/ chores

• interests and social activities of relatives

• current prob + Sx

impacts of poor insight into MI

• poor medication adherence

• impaired vocational functioning → should consider interventions of improving insights (e.g. psychoedu) when prescribing vocational rehab

• x correlates with social skills

approaches of intervention to improve insights

clinical insight: educate pt of MI (e.g. psychoedu)

cognitive insights: improve understanding of experience by targeting thinking style (e.g. CBT/ metacognitive therapy)

behavioural changes: engage more in Tx (e.g. MI)

interventions for insight Mx

behavioural changes

MERIT metacognitive reflection and insight therapy (stimulate 4 elements of metacog: self-reflectivity/ understanding other’s mind/ decentration/ mastery)

key family recovery stages

1. recognition of problem

2. clearer recognition/ confirmation, hoping for cure

3. accept the chronicity of illness

4. accept MI, reclaim own life

basis/ goal of family psychoeducation

• based on stress-vulnerability model

• partnering w/ PIR and family to support recovery

• create optimal env for recovery

• help family develop skills and knowledge to assist recovery + avoid past eteological dysfx

assumptions of family psychoeducation

• misunderstandings of MI → conflicts and unrealistic expectations

• relatives as env protective factor

• emphasize on family strength

purposes + elements of FPE

purpose

• provide knowledge about illness

• reduce overinvolvement → improve independence of PIR

• increase tolerance of problems and reduce criticism

• improve PIR’s skills/ performance/ coping

• tackling problems arising from MI

• answering questions

• exchanging info

• coping strategies

• defusing emotions and engender optimism for future

elements

• natural course of MI

• possible etiology

• Diagnosis and prognosis

• treatment options expected outcomes

• SSx

• side effects and effects of Tx

• relapse prevention

structure of FPE

1. orientation & engagement x3

2. knowledge abt MI (w/ pt) x6

3. building strength and therapeutic family roles (w/o pt) x7

4. termination x2

mainly: illness related info + behavioral problem solving skills (stress coping & problem solving)

FPE: prescribe to whom + when + effects

• to all family in close contact with PIR (psychosis/ schiz)

• betwee 3m to 1 year period

• at least 10 planned session

• group (multiple fam)/ individual (single fam) - consider preference of family

effects

• reduction of relapse/ rehospitalization/ hospital days/ improve family understanding and well being

• no change in belief for the sytem

• reduced distress and burden in relatives

• gain knowledge

neuroendocrine factor for depression

• high secretion of cortisol

• thyroid hormone → better antidepressants effect for women

• hormones make people more responsive to antidepressants

name the biochemical systems involved in major depression

• HPA

• HPT

episodes vs disorder

episode

• anytime

• abnormally happy/ sad

• functional performance as indicator

disorder

• pattern of illness

• dx based in episodes

types of manic episode and the major difference

manic

• more severe

• last for at least one week

• impaired functioning

hypomanic

• at least 4 days

• milder

• no impairment in daily functioning

mixed

• manic + major depressive episode last for at least one week

• functional impairment

types of depressive disorder

MDD, single episode

MDD, recurrent episode

• at least 2 major depressive episode at last 2 months apart

persistent depressive disorder (dysthymic disorder)

• milder

• at least 2 years (adults); others: at last one yr

• x Sx free for more than 2 months

common intervention strategies + theories for depression

+ve psychology

• focus on well-being, resilience and recovery instead of the disease itself

• bio/ personal/ relational/ institutional/ cultural/ global dimensions of life

• 3 paths to happiness

  • pleasant life: optimal experience of +ve feelings; normal healthy life)

  • good life: optimally engaging in primary activities → sense of accomplishment

  • meaningful life: belonging and contributing to larger groups

flow theory

• flow = state of intense absorption in work/ activities that one finds pleasurable

• just right challenge (use most of our ability) → sense of accomplishment

• aims to create more flow opportunities

PERMA theory of wellbeing

• positive emotions (happiness = genetic set range + factors under voluntary control + life circumstances)

• engagement (flow)

• meaning (contribute + belong)

• accomplishment

5 ways of wellbeing (lifestyle redesign)

• be active

• keep learning

• take notice

• connect

• give

meds for anxiety

• anxiolytics

• antidepressants

OT intervention for anxiety

counselling

CBT

• panic/ avoidance/ safety behaviour/ anticipatory anxiety cycles

• knowledge (fear cycles/ misinterpretations & catastrophization)

• skills (challenge irrational fears/ beliefs)

• exposure

behavioural approach

• exposure

• desensitization

sensory modulation

• sensory over responsive → sensory defensiveness/ hyposensitivity

• sensory defensiveness → anxiety/ depression/ maladjustment

• through tactile/ proprioceptive/ deep pressure activities to reduce anxiety level

  • sensory diet: balance of arousal and tolerance + interest and needs of individuals

  • can resolve childhood abuse issues

periods with highest suicidal risks + what to ask

• start

• later remission period (fear for relapse/ got better → able to plan for suicide)

• ask if there is fomulated plan/ means for suicide

diff lev of suicidal risk

• ideation

• plan

• attempt

OT interventions to suicide

relaxation training

• progressive muscle relaxation

• breathing exercise

SST + assertiveness

expressive activities

• journal writing

• arts and crafts

education lifestyle alternations

time management

cognitive/ functional behavioral training

stages of sleep

• 4-5 sleep cycles (90-120min each)

• 2 physiological stages: REM/ NREM