Psychiatric Diagnosis in Homeless Persons: Challenges and Strategies
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Transcript of Psychiatric Diagnosis in Homeless Persons: Challenges and Strategies
Psychiatric Diagnosis in Homeless Persons: Challenges and Strategies
International Street Medicine Conference
October 22, 2010
“One thing only I know and that is I know nothing.”
- Socrates
Co-founding Variables
• Limitations of psychiatry!
• Substance abuse and withdrawal
• Emotional and physical trauma
• Medical illnesses
• Neurological illnesses
• Multiple diagnoses
• Multiple providers, multiple short-term agency stays
Co-founding Variables (cont.)
• Complexities of symptom presentation• Effects of homelessness on psychiatric
symptomso Hygiene o Sleepo Fatigueo Threat to safetyo Demoralizationo Maladaptive coping skills
Co-founding Variables (cont.)
• Complexities of childhood historyo Abuseo Losso Deprivationo Instability
• Lack of work-up beyond interview and mental status exam
• Pressure to diagnose o Colleagueso Need of diagnosis for disability and housing
Strategies
• First step, engagement
• Modification of the evaluation processo Brief, casual encounters
oMonths to years
o Open-ended, neutral questions
Strategies (cont.)
• Observation is key
o Groomingo Odd or unusual clothingo Abnormal mouth or finger movementso Movementso Evidence of auditory hallucinations o Belongingso Locationo Company or isolation
Strategies (cont.)
• Voices-differential diagnosiso Schizophrenia
oMania
o PTSD
o Personality disorders
o Cultural
Strategies (cont.)
• “Organic”o First, rule out delirium • Inattention• Disorientation• Memory• Visual hallucinations• Combative behavior• Alcoholic hallucinations
Strategies (cont.)
Strategies (cont.)
o Psychiatric diagnosis vs. “organic” (cont.)• CAUSES
Brain injury Liver failure Drug intoxication Hypothyroidism Subdural hematoma Chronic alcohol abuse Alzheimer or other dementia B12 deficiency Renal disease Hypocalcemia Hyponatremia
DIFFERENTIAL DIAGNOSIS-BIPOLAR DISORDER
• Schizophrenia• Schizoaffective disorder• Personality disorder• PTSD• Anxiety disorder• Substance Abuse• Medication side effects• Neurological disease• Depression
Bipolar Disorder
• Zimmerman study-Brown University, 2008 82 out-patients
o 40% of people over-diagnosed with bipolar disorder met criteria for borderline personality disorder
• Muzina study-Cleveland Clinic, 2008o 100 patients admitted to mood disorder clinic-o 60% of those diagnosed with bipolar disorder did not meet
criteria for bipolar disorder
• Why over-diagnosis?• Dangers of over-diagnosis
Personality Disorder
• 12% of general population
• Often co-morbid with Axis I disorder
• Patterns of inflexible and maladaptive personality traits and behaviors that cause subjective distress
• Not bad character but rather serious psychiatric condition defined by failures in social role functioning
BIPOLAR vs. BORDERLINE PERSONALITY DISORDER
• Bipolar--episodic--distinct period of unequivocal change, uncharacteristic of the person when they are not symptomatic
• BPD--lability and impulsivity enduring pattern
• Bipolar-decreased need for sleep• BPD-often no sleep problems
BIPOLAR vs. BORDERLINE PERSONALITY DISORDER (cont’)
• BPD-quick response to intervention -distorted self image -feelings of emptiness
• Bipolar disorder-family history of Bipolar disorder -inflated self-esteem
Personality Disorder (cont.)
• Why recognize and treat? o Social implications
o Exacerbations of symptoms of Axis I
o Interfers with relationship of provider and patient
o Treatment works!
Neuropsychological Evaluation
• Known brain disorder
• Known risk factor for brain disorder
• No known risk factors but brain disorder suspected
Neuropsychological Evaluation (cont.)
• Uses
o Nature and severity of cognitive, behavioral and emotional problems
o Potential for independent living
o Foundation for treatment planning
PSYCHOLOGICAL TESTING
• IQ• Personality tests• MMPI hypochondriasis hysteria depression paranoia psychasthenia schizophrenia mania
•
Rating Scales
• Verify diagnosis
• Assess severity
• Measurement of psychiatric conditions in different points of time
• Determination of effectiveness of treatment
Alliance Building
• Consistent presence• Proceed at clients’ pace• Instill hope• Extend traditional boundaries• Focus on long-term goals• Remember engagement is not a linear
process
Alliance Building (cont.)
• Don’t give up on anyone• Team effort• Don’t insist that client acknowledges the mental
illness• Try to get person to take medications to make
them feel better• Accept clients’ explanations for not feeling well• Relationship first, treatment second
SUMMARY
• Psych. diagnosis of homeless person is more challenging that the non-homeless person
• Don’t take a “carried” diagnosis at face value.
• No definite Axis I does not mean that client is not very ill.
SUMMARY
• Clarify diagnosis by psychological testing, neuropsychological testing, scales, substance abuse history, old records, watching and waiting.
• Engage, engage, engage.