Learning Objectives Mental Health 101 for supportive housing providers By the end of this training, you should be able to: Describe symptoms of Depression, Bipolar Disorder, Schizophrenia, and the more commonly seen personality disorders. Identify appropriate responses, stances, strategies and/or referrals for working with people who are living with each of these mental illnesses. Use person first language in discussing individuals with mental illness. Some perspective The continuum of mental health Nationwide 50 million Americans suffer from a mental illness in a given year. Mental Illness is more common than: Cancer, Diabetes, Heart Disease Psychiatric disorders are the #1 reason for hospital admissions nationwide. Mental illness is treatable. Contributing Factors to Mental Health Biology: Family history, chemical imbalances Life Experiences: Trauma, abuse, death Individual Factors: Self-esteem, beliefs about mental health Current Circumstances: Support systems, relationship/financial/work stress, basically life in general! Famous Individuals with MI Abraham Lincoln (Depression) Mary Todd Lincoln (Schizophrenia) Ludwig van Beethoven (Bipolar Disorder) Janet Jackson (Depression) Charles Schulz (Depression) Buzz Aldrin (Depression) Harrison Ford (Depression) Princess Diana (Depression and Eating Disorders) 1
Overview: What is Serious Mental Illness (SMI)? Biological in Origin Biological in origin (Stress Vulnerability Model) Diagnosis Chronicity Breadth of impact Severe mental illness is caused by bad parenting Cognitive Impairments What Causes Mental Illness? Biological vs. Environmental? or Nature vs. Nurture? Mental illness seems to be caused by a combination of biological & environmental factors Biological factors include genetics and brain structure Environmental factors are things that happen to and around a person (e.g., Trauma) The Stress-Vulnerability Model Three factors work together to cause the development of a disease: Vulnerability to the disease Stress (can include environmental factors) Protective factors Vulnerability is determined by a unique set of biological, psychological and social factors Stressors can trigger the onset of disease, or worsen its impact The Stress-Vulnerability Model Protective factors may offset the levels of vulnerability and stress, reducing the likelihood of a person becoming ill. Protective factors include: Community support A supportive family Coping skills Medication Ample resources for food, clothing and shelter Diagnosis Diagnoses that are considered severe mental illnesses include: Psychotic disorders such as Schizophrenia or Schizoaffective disorder Mood disorders such as manic depression (Bipolar Disorder) or Major Depression Axis II diagnoses such as Borderline Personality Disorder or Antisocial Personality Disorder 2
DSM IV Multi-Axial System Chronicity Axis I : Clinical Disorders Axis II: Personality disorders and MR Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Axis V: Global Assessment of Functioning (GAF) How long an illness lasts The duration of an SMI is usually years Some disorders are characterized by ongoing illness, and others by a series of relapses (or acute episodes) with normal functioning in between episodes. Breadth Cognitive Difficulties Associated with Serious Mental Illness: The impact an illness has on an individual s functioning and life roles In SMI, almost all major life areas/roles are affected by the disorder: Social/family Occupational/educational Leisure Self-care Income Unable to think clearly Difficulty processing information quickly Difficulty paying attention Difficulty remembering new information Difficulty thinking critically, planning, organizing and problem solving May not initiate conversations Difficulty responding to information quickly Recovery = Rebuilding Confidence Schizophrenia Cognitive Difficulties = Selfconfidence Schizophrenia is a psychotic/thought disorder Symptoms usually first appear when the person is in their late teens to early twenties Some of the symptoms of schizophrenia are hallucinations, delusions, thought disorder, flat affect, social withdrawal, and low motivation 3
Symptoms Hallucinations Positive Symptoms (excess, or distortion of normal functions): Hallucinations, delusions, and thought disorder Negative Symptoms (diminution, or loss of normal functions): Flat affect, social withdrawal, and low motivation are sometimes called negative symptoms of schizophrenia False perceptions of a sensory event, such as hearing voices when no one is speaking, or seeing something that is not there. Auditory hallucinations (hearing voices) are the most common hallucinations in schizophrenia. Some people with schizophrenia are aware that the voices they hear are not real, while others may believe that they are. Delusions Delusions Delusions are false beliefs about reality. Delusions are maintained even when there is evidence that they are not true. Delusions are maintained in spite of what almost everyone else in the culture believes. Grandeur: Beliefs in exceptional status Reference: Being watched or talked about Hypochondrical: Contracted a disease Jealousy: Partners are unfaithful Passivity: Being controlled or influenced Persecutory: Being interfered with Thought Disorder Negative Symptoms Someone with disordered thinking might: Say things that do not make sense; disorganized Change the subject very often jumping from one unrelated topic to another Not say very much at all Thought disorder is usually observed in the speech of someone rather than reported by the individual. Negative symptoms of schizophrenia, such as flat affect, lack of motivation, and asocial behavior may not seem like symptoms of mental illness. However, negative symptoms are harder to treat with medication, and people with more negative symptoms tend to have a more serious course of illness. 4
Course of Schizophrenia People with Schizophrenia may have difficulty with: There is no one course of schizophrenia. Some people with schizophrenia may have long periods of time where they are symptom free and only occasionally have episodes of psychosis. Some experience some symptoms most of the time. Some experience negative symptoms most of the time while only occasionally experiencing acute psychotic episodes. Ability to pay attention Ability to remember and recall information Ability to process information quickly Ability to think critically, plan, organize and problem solve Ability to initiate speech Schizophrenia: Treatment Depression Options include: Antipsychotic Medications (e.g., Haldol, Zyprexa, Seroquel) Psychotherapy Depression is a mood disorder. The most dx common among persons with serious mental illness is Major Depressive Disorder. Symptoms of a Major Depressive Episode Symptoms of a Major Depressive Episode Feeling sad or down most of the day almost every day Having less pleasure or interest in most activities Changes in weight of more than 5% of body weight within a month (gain/loss) Sleeping much more or less than usual Physical agitation or slowness Feeling worthless or excessively guilty nearly every day Diminished interest or lack of pleasure in activities Sleeping too much, or too unable to sleep Fatigue, or loss of energy Decreased ability to concentrate or make decisions Thinking about death, including suicide Some people with a major depressive disorder may also report psychotic symptoms 5
Major Depressive Disorder Severe Depression An individual is diagnosed with Major Depressive Disorder (Recurrent), when they have had two or more major depressive episodes. Major Depressive Episode (5 of more symptoms in two weeks) When depression is severe an individual may not have the desire or energy to complete activities of daily living such as going to work, grooming, or taking care of one s self. The risk of suicide also increases as the severity of depression increases. Depression: Treatment Supporting People with Depression Options include: Psychotherapy Antidepressant Medications Electroconvulsive Therapy (ECT) Alternative Therapies When others are depressed, encourage them to: Set realistic goals and set priorities. Break large tasks into small ones. Allow friends and family to support and love them. Socialize and participate in recreational activities, even as an observer. Postpone making large decisions until symptoms improve. Most importantly: Lend a friendly ear, and allow Midwest them Harm Reduction time Institute to heal. Comorbidity of Depression & Substance Use Issues Bipolar Disorder Heavy Drinking Depression (Raimo & Schuckit 1998; Swendsen, et al 2000) Depression tends to be transient Depression Heavy Drinking (Swendsen, et al 2000; Vengeliene et al 2005) Self-medication Persons diagnosed with Bipolar Disorder must have experienced at least one Manic Episode or Hypomanic Episode. Many have also experienced one or more Major Depressive Episodes (this is why persons with a Bipolar Disorder used to be called manic-depressive ). 6
Symptoms of a Manic Episode Abnormally elevated (good), or irritable mood Increased self-esteem even to the point of being grandiose Decreased need for sleep More talkative than usual Racing thoughts and jumping from topic to topic Symptoms of a Manic Episode Easily distracted Increased activity or agitation Excessive involvement in pleasurable activities that have a high chance of negative consequences, such as shopping sprees, risky sexual behavior, chaotic substance use, etc. Some also report symptoms of psychosis People with Bipolar Disorder may have difficulty with: Treatment of Bipolar Disorder Ability to pay attention Ability to remember and recall information Ability to think critically, categorize and organize information and problem solve Ability to quickly coordinate eye-hand movements Because bipolar disorder is a recurrent illness, long-term preventative treatment is strongly recommended. Most treatment strategies combine the use of medication and psychosocial therapy. Comorbidity of Bipolar Disorder & Substance Use Issues Schizoaffective Disorder There is no evidence that Bipolar Disorder is developed as a result of drinking alcohol. Schizoaffective disorder is a psychotic disorder and shares some features with schizophrenia and some features with mood disorders. There is some evidence which suggests that people with Bipolar Disorder may use alcohol to accentuate the Manic Phase or to medicate the Depressive Phase. The presence of hallucinations, delusions, and manic or depressive symptoms The timing of the mood and psychotic symptoms determines whether an individual will be diagnosed with schizoaffective disorder, or will be given two separate diagnoses of schizophrenia and a mood disorder. 7
Axis II: Personality Disorders A disorder in the inner experience and behavior of an individual (markedly different from their culture) Can affect cognition, affect, interpersonal functioning and impulse control Cannot be better accounted for as a manifestation or consequence of another mental disorder (Axis I) or due to the effects of a substance or general medical condition Axis II: Personality Disorders Cluster A (odd or eccentric disorders) Paranoid personality disorder: characterized by irrational suspicions and mistrust of others. Schizoid personality disorder: lack of interest in social relationships, seeing no point in sharing time with others, introspection. Schizotypal personality disorder: characterized by odd behavior or thinking. Axis II: Personality Disorders Cluster B (dramatic, emotional or erratic disorders) Antisocial personality disorder: a pervasive disregard for the rights of others, lack of empathy, pattern of regular criminal activity. Borderline personality disorder: extreme "black and white" thinking, instability in relationships & self-image; self-harm. Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy. Characterized by self-importance, preoccupations with fantasies, belief that they are special, sense of entitlement, and extreme levels of jealousy and arrogance. Axis II: Personality Disorders Cluster C (anxious or fearful disorders) Avoidant personality disorder: social inhibition, feelings of inadequacy, avoidance of social interaction. Dependent personality disorder: pervasive psychological dependence on other people. Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder): rigid conformity to rules, moral codes and excessive orderliness. Borderline Personality Disorder Pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity beginning in early adulthood Frantic efforts to avoid real or imagined abandonment Extremes of idealization and devaluation Unstable self image or sense of self Impulsivity (i.e. spending, sex, substance use, etc.) Recurrent suicidal behavior, gestures, threats, or self-mutilating Affective instability, reactivity of mood Chronic feelings of emptiness Inappropriate/intense anger, difficulty controlling anger Transient, stress related paranoid ideation, dissociative symptoms Antisocial Personality Disorder Pervasive pattern of disregard for and violation of the rights of others beginning in childhood or early adolescence and continues into adulthood Has previously been referred to as psychopathy or sociopathy Individual must be 18 years or older Hx of some symptoms of Conduct Disorder (aggression toward people or animals, destruction of property, deceitfulness, theft, serious violation or rules) before 15 years old 8
Comorbidity of Personality Disorders & Substance Use Issues MISA (Mental Illness and Substance Abuse) Borderline Personality Disorder and Substance Use Disorders seem to stem from common factors rather than one causing the other (Trull et al 2000). The common factors are hypothesized to be: inherited deficiencies in serotonergic functioning and deviant family environment. A third to half of those diagnosed with a serious mental illness also have problems with substance abuse. Substance use disorders are diagnosed based on the substance being used and the severity of the symptoms. Substance Abuse and SMI Stigmatization Delayed diagnosis or misdiagnosis contributes to a 50% rate of substance abuse among those with Bipolar Disorder. People who have both SMI and substance use problems: Tend to have more disability; Are less likely to stay with a course of treatment; Often have worse medication adherence, & May have physical and psychiatric complications from combining prescribed medications with other substances Only 35% of people with diagnosable mental health disorders seek treatment The single most common barrier to seeking treatment is Shame Consequences of Stigma Associated with Psychiatric Disability Impaired functioning lack of social support, low income, inadequate housing, poor health, and legal problems. Lack of social support, low income, inadequate housing, poor health and legal problems discrimination. Understanding the individual as a PERSON FIRST Person first language Is not: That mentally ill woman. A schizophrenic man. The mentally ill live here. Person first is: She has a diagnosis of major depressive disorder. A man who has schizophrenia. People with mental illness live here. 9
Term Consumer Survivor Prosumer Language and Respect How it Is Used Replaces words like patient and resident to more accurately represent a person as a consumer of services Also replaces patient and resident; represents what it is like to live with a mental illness surviving the symptoms of the illness and surviving in spite of so many barriers in society A person with a mental illness who works in psychiatric rehabilitation; is both a professional and a consumer Respectful Choose Language that Is: Reflects dignity for the individual we are describing Diagnosis vs. Disability Diagnosis is identifying what particular mental disorder an individual has. Disability is how a person s ability to function is affected by a disorder, disease, or condition. It is important to understand both! Exercise: Experiencing a Mental Illness Imagine what it might be like to actually experience some of these symptoms of mental illness: Hearing voices when no one is talking Sensory issues lights are too bright Mind wandering and difficulty concentrating Delusions i.e. believing that the TV is controlling your mind Lack of energy and motivation Imagine being told you have a mental illness and would have to take medication and live in a nursing home, possibly for the rest of your life. Disability and SMI It is the degree of disability rather than the diagnosis that determines how serious one s condition is. Any individual with schizophrenia may or may not function at the same level as an individual with depression. It depends on the particular skill deficits that each person has rather than on their diagnosis. Areas Where a Person with SMI May Be Disabled Include: Social skills Cognitive functioning Occupational skills Self-care skills Coping skills Housing availability Health skills Recreation skills Education and selfadvancement skills Transportation skills 10
The Recovery Model Qualities of Recovery A journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice, while striving to achieve his or her full potential. Recovery can occur without professional intervention; Recovery requires people who believe in and stand by the person in recovery; A recovery vision is not a function of theories about the cause of psychiatric conditions; Recovery can occur even if symptoms reoccur; Recovery changes the frequency and duration of symptoms; Qualities of Recovery Resources for Mental Health Recovery from the consequences of a psychiatric condition are often far more difficult than from the symptoms; Recovery is not linear; Recovery takes place as a series of small steps; Recovery does not mean the person was never really psychiatrically disabled; Recovery focuses on wellness not illness; Recovery should focus on consumer choice NAMI Meetings (1-800-346-4572) Peer Drop In Centers (Walk-in list provided in packet) NAMI Warm Line (Support line : 1-866-359-7953) www.mental-health-today.com (Website with every single self-help resource there is, including 12 step meetings, financial assistance for medicine and therapy, etc.) References http://documents.csh.org/documents/mi/ho usingfirst/harmreduccommodel.pdf 11