Psychotropic Medications and Diagnoses in Social Services

1. Psychotropic Medications and Diagnoses in Social Services Misty Harding, MS, LCMFT Director Youth Services Salvation Army Wichita

2. Welcome and Introductions • Welcome • Housekeeping • Introductions • Information is a guideline • DO NOT DIAGNOSE UNLESS YOU ARE QUALIFIED AND THE PERSON IS YOUR PATIENT • Updated with DSM-5 information

3. THE BRAIN AS A CHEMICAL REACTION

4. Brain Chemical Reactions • Neurons • Synapses • Neurotransmitters • Serotonin • Adrenalin • Uptake • Reuptake

5. Neurons

6. Neurons

7. Medication as Chemical Balance • SSRI • Prozac, Welbutrin, Lexapro, Paxil • Anti-psychotic • Thorazine, Haldol, Clozaril, Risperdal • MAOI • MonoAmine Oxidase • Mebanazine, Octamoxin, Phenelzine • TriCyclics • Imipramine, Loratadine (antihistamine) • Stimulant/Non-stimulant (focus) • Other (Mood Stabilizers) • Anti-convulsant • Blood pressure stabilizer • Antihistamine

8. DIAGNOSING and TREATING DYSFUNCTION

9. Change from DSM-IV to DSM-5 • Multiaxial (DSM-IV) • Axis 1 – clinical • Axis 2 – pervasive • Axis 3 – medical • Axis 4 – psychosocial • Axis 5 - GAF • Dimensional (DSM-5) • Sharing of symptoms • Risk factors • More NOS categories • Genetics • Comorbidity • Shared treatment response • Organized by: • Internalizing vs externalizing • Developmental/lifespan considerations • Includes culture and gender factors

10. Definition of a Mental Disorder (Per DSM-5) • “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

11. Purpose of a mental disorder diagnosis • Determine prognosis • Steer treatment planning • Direct treatment • Diagnosis does NOT always mean the client NEEDS treatment • Based on level of distress/impairment • 3rd party info is highly recommended

12. Diagnostics Principal Diagnosis Provisional Diagnosis (no more Rule Out) Presumptive Not enough info When the diagnosis is based upon a specific time frame • Primary for clinical visit • Causing the majority of dysfunction • Becomes the focus of treatment • More validity if based upon measures/testing (evidentiary) • Some in the DSM-5 • Some require further training • Entire section on Culture assessment

13. MENTAL HEALTH INFORMATION • Best information comes from; • Client • Family • Doctor • Therapist • Pharmacist • Psychiatrist • Counselor • Case managers • Hypochondriasis prevention • Dysfunction • Issue • Level of functioning

14. Common Diagnoses in Social Services • Dysfunction • Bipolar Disorder • ADHD • Depression • Psychotic Disorders (Schizophrenia, Delusional) • Trauma Disorders • Substance/Chemical Abuse** • Mental Retardation/Developmental Delay** • Personality Disorders • Borderline • Antisocial

15. Bipolar Disorder • Per DSM IV • “The essential feature of Bipolar I disorder is a clinical course that is characterized by the occurrence of one or more Manic Episodes or Mixed Episodes. Often individuals have also had one or more Major Depressive Episodes.”

16. Bipolar Disorder • Per DSM-5 “Bipolar and related disorders are separated from the depressive disorders in DSM-5 and placed between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology , family history, and genetics. • Adds Disruptive Mood Dysregulation Disorder for clients under 18 “who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol.”

17. Bipolar Disorder • Possible Behavior • Manic behavior • Euphoric • Indiscriminate enthusiasm for sexual/interpersonal relationships • Inflated self-esteem • Alternating mood between euphoria and irritability (complaining/hostile) • Decreased need for sleep • Speech is loud, rapid, difficult to understand (thoughts move faster than the mouth) • Compulsive • Poor judgment • Depression • Anxious distress • Significant impairment in occupation, relationships and/or activities/energy

18. Bipolar Disorder • Common medications with side effects • Depakote (anticonvulsant) • Shaking, nausea, drowsiness, headache • Lamictal (anticonvulsant) • Dizzy, drowsy, fatigue • Lithium (salt) • Tremors, thirst, diarrhea, vomiting • Geodon (antipsychotic) • Blurred vision, dry mouth, weight gain • Anti depressants? • Takes away depression • Leaves mania

19. ADD/ADHD • Per DSM-IV • “The essential feature of Attention-Deficit/Hyperactivity Disorder is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development… There must be clear evidence of interference with developmentally appropriate social, academic, or occupational functioning.”

20. ADHD • Per DSM-5 “The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity that interferes with functioning, or development.”

21. ADD/ADHD • Possible Behavior • Careless mistakes, lack attention to detail • Move from one task to another quickly, without finishing • Disorganized • Fidgetiness, squirming, running, climbing • Difficulty with leisure • Impatient • Marked impairment in two settings; home, work, school

22. ADD/ADHD • Common medications with side effects • Stimulants • Adderall, Concerta, Focalin • Weight loss, sleep problems, jittery • Non-stimulants • Straterra, Intuniv, Kapvay (new) • Nausea, vomiting, constipation, headache

23. Depression • Per DSM-IV • “The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypo-manic Episodes.” “The essential feature of a Major Depressive Episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities.”

24. Major Depressive Disorder • Per DSM-5 “Unlike in DSM-IV, this chapter ‘Depressive Disorders’ has been separated from the previous chapter ‘Bipolar and Related Disorders.’ The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. What differs among them are issues of duration, timing, or presumed etiology.”

25. Depression • Possible Behavior • Irritability • Changes in appetite or weight • Changes in sleep patterns • Loss of energy/fatigue • Feelings of guilt, worthlessness, and/or having “no” feelings • Recurrent thoughts of death or suicidal thoughts/plans and/or attempts • Anxious • Body aches/pains • Loss of pleasure in previously pleasurable activities

26. Depression • Common medications with side effects • SSRI • Prozac, Welbutrin, Lexapro, Paxil • Non addictive but cannot be stopped abruptly, weight change, decline in sexual function • Anti-psychotic • Thorazine, Haldol, Clozaril, Risperdal • Weight gain, high cholesterol, increased risk of diabetes

27. Psychotic Disorders • Per DSM-IV • These disorders “are all characterized by having psychotic symptoms as the defining feature…The term psychotic has historically received a number of different definitions, none of which has achieved universal acceptance. The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature…Finally the term has been defined conceptually as a loss of ego boundaries or a gross impairment in reality testing.”

28. Psychotic Disorders • Per DSM – 5 Key Features that Define the Psychotic Disorders • Delusions • Hallucinations • Disorganized thinking (speech) • Grossly disorganized or abnormal motor behavior • Negative symptoms

29. Psychotic Disorders • Disorders • Schizophrenia – more than 6 months • Paranoid • Disorganized • Catatonic • Undifferentiated (not paranoid, disorganized, or catatonic) • Residual (not meeting all criteria – mostly flat) • Schizophreniform – 1 to 6 months • Schizoaffective – Depression and/or mania with schizophrenia • Delusional Disorder – nonbizarre delusion for at least 1 month • Brief psychotic Disorder – “nervous break down” with return to normal • Folie a Deux – shared delusion/psychotic disorder

30. Psychotic Disorders • Possible Behaviors • Smiling/laughing/silly faces without appropriate stimuli • Loss of all interest/pleasure • Delusional beliefs • Pacing/rocking or immobility • Confusion/Disorientation • Loss of reality • Differing reality • Ritualistic/odd mannerisms • 10% successfully commit suicide • Common for use of substances esp: nicotine

31. Psychotic Disorders • Common medications and side effects • Neuroleptics “take the neuron” • Thorazine, Haldol, Prolixine, Navane • Tremors, involuntary movements, muscle rigidity, spasms • Atypical antipsychotics • Clozaril – decrease in white blood cells • Abilify, Geodon, Risperdal – weight gain, increased blood sugar and cholesterol

32. Trauma Disorders • Neuropsychosocial Development • The more a brain system is used, the more it changes and morphs to reflect how it’s activated (development/memory/learning) • From the moment of first trauma, neurodevelopment is impacted • New experience ALWAYS filtered through old experience for context and understanding • Ability to bond and show empathy is directly related to early life relationships • Trauma creates stimulitic arousal (heart rate, brain stimulus, breathing) • High arousal creates dissociation (check out) • Effects all levels of development including intelligence, mental health, and physical growth • **NMT slide***

33. Trauma Disorders • Per DSM-5 “Trauma and stressor-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicityly as a diagnostic criterion…close relationship between these diagnoses and disorders…anxiety disorders, obsessive-compulsive…and dissociative disorders” • Diagnoses • Reactive Attachment Disorder (withdraw) • Disinhibited Social Engagement Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder • Adjustment Disorder • Other Specified Trauma-and Stressor-Related Disorder • Unspecified Trauma-and Stressor-Related Disorder

34. Trauma Disorders • Possible Behaviors • Anxiety • Fear • Feeling “numb” • Dysphoria • Anger • Aggression • Dissociation • Flashbacks • Medication • Only two approved for treatment of PTSD • Paxil • Zoloft • Other(s) may be used to treat accompanying symptoms • Sleeping meds • Antipsychotics • Other antidepressants

35. Personality Disorder • Per DSM-IV • “A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”

36. Personality Disorder • Per DSM – 5 – Alternative approach to diagnosing – Section III – Page 761 • General criteria for Personality Disorder • Impairment in personality functioning • One or more pathological personality traits • Personality impairments are relatively inflexible and pervasive • Impairments are stable and traced back to adolescence or young adult hood • Not better explained by another mental disorder • Not attributed to a substance or medical condition • Not normal for development or sociocultural environment

37. Personality Disorder • Possible Behaviors • Borderline Personality Disorder – “is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.” • Avoids real or perceived abandonment • Unstable relationships (push/pull) • Unstable self-image • Suicidal/self-harm • Intense moods and anger problems • Paranoid and/or dissociative • Antisocial Personality Disorder – “is a pattern of disregard for, and violation of, the rights of others.” Commonly referred to as “psychopath,” or “sociopath.” • Deceitful, manipulative • Impulsive, failure to plan • Irritable/aggressive • Reckless disregard of safety for self and others • Irresponsible • Lacks remorse • Prior to age 18,may have diagnosis of ODD, Conduct DO or Disruptive DO

38. Personality Disorder • Common medication and side effects • Borderline • Anti depressants • Mood stabilizers • Anti psychotics • Antisocial • Rarely seek treatment • Lack insight and motivation • Anger and high frustration

39. Suicide Risk is HIGH in Social Services • “Suicidal behavior is seen in the context of a variety of mental disorders, most commonly bipolar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety disorders…substance use disorders…borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. It is rarely manifested by individuals with no discernible pathology…” • Chaos and disruption are common in SS and exacerbate feelings of hopelessness

40. Suicidal Ideation Ideation Self-harm Repeated self inflicted injury Shallow but painful Surface injury With purpose Reduce tension Reduce anxiety Self punishment Resolve interpersonal conflict Immediate sense of relief Addictive qualities NOT A SUICIDE ATTEMPT NOR EVIDENCE OF SUICIDAL IDEATION • Thoughts • How to kill oneself • Most do not attempt when having these thoughts • Some may make suicide attempts • Some deliberately planned to fail or be discovered • Some carefully planned to succeed • According to a Finnish study, over one fifth of people who actually died by suicide had discussed their aim with a doctor or other health care professional during their last session

41. INFORMATION IS A WEAPON OR A TOOL? • Knowledge • NOT for diagnosing (unless qualified to do so) • NOT for providing psychotherapy (unless qualified to do so) • NOT for medication management • Best tool is referring and communication • Do not take mental illness lightly • **Cultural diversity and faith/mental illness

42. Questions? • Misty A. Harding, MS, LCMFT • Director of Youth Services; Residential and Foster Care • Wichita City Command/Koch Center • 350 N. Market • Wichita, KS 67202 • 316-263-2769 x 181 • Misty_harding@usc.salvationarmy.org