Mental Health Made Simple ?

1. Mental HealthMade Simple ? Simple Factoids From Doc Ty

2. Why? • 1993 Those with Severe Mental Illness discharged to the street by government • 60-85% have mental health issues • Misunderstood, stigmatized, ignored • Interesting Fact: The Human Brain can rewire past damaged areas

3. Diagnosis Wheel(Gathering the Story)

4. Diagnosis Flow • Syndromes are ID • Wide Range of diagnosis are created • One is chosen to move forward on • Comorbid diagnoses and arrange in order of importance • Check up with a formulation • Reevaluate as new data emerges

5. DSM-IV-TR • The Diagnostic Statistical Manual Fourth Edition, Text Revision produced by the American Psychiatric Association • DSM-V due 2013 • 1 of 2 International Benchmarks for Diagnosis

6. Assessments FYI • Clinicians use codified assessment tools • Behavioural • Weschler Intelligence Scales • Weschler Memory Scales • Minnesota Multiphasic Personality Inventory (MMPI) • Millon Clinical Multiaxial Inventory • California Psychological Inventory • Rorschach • Thematic Apperception Test • Neuropsychological Impairment

7. Behavioural • Focuses on preceding events/resulting consequences as an understanding factor. • Typical includes: measures of behaviour (overt/covert); antecedents (internal/external); conditions surrounding behaviour; and consequences • Validity: Challenging because of a moving matrix dependent on clinician or team, need definitions to truly understand results.

8. Weschler Intelligence Scales • Provides 3 IQ: Full scale; Verbal; Performance • Main thrust: Accuracy in predicting future behaviour, long-term predictions however fall short. • Bias towards logical thought patterns; middle to upper-class Caucasian demographics. • Norms may not be applicable to other cultures; lower socio-economic stratas; Enormity of calculations lends to higher end false results due to clinician error.

9. Weschler Memory Scales • Core component of any thought cognitive assessment. • Diagnosis of: depression, anxiety, schizophrenia, head injuries, stroke, learning disabilities, and neurotoxic exposure stipulate memory complaints. • Administration time is upwards to 42 mins.

10. MMPI • Standardized questionnaire • Provides wide range of self-description scores • Quantitative Measure of emotional adjustments and attitude towards test taking. • Areas: General health, occupational interests, preoccupations, morale, phobias, and educational problems. • Moderate levels of stability and internal consistency, high overlap with the different scales, • Bias: Gender, Age, Socio-economics, demographics, race, place of residence, intelligence and education are all variables that if not properly taken into account can skewer results or produce false results. • Used to screen individuals for high stress or sensitive jobs (i.e. air traffic controller) • Primarily Axis I

11. Millon Clinical Multiaxial Inventory (MCMI) • Self-report assessment much like MMPI (personality, emotional adjustment and attitude towards test taking), is one of few that focuses on personality disorders. • Current one is 175 items, separated into 28 scales in these categories: Modifying Indices, Clinical Personality Patterns, Severe Personality Pathology, Clinical Syndromes, and severe syndromes. • Driving Theory: Millon believed in polarity (active-passive, self-other, and pleasure-pain) by ranking these can see if the person is typical or non-typical on the personality spectrum. • Individual’s age, gender and ethnicity should be taken into account, and separate scoring norms have been developed to mitigate false results. • Primarily Axis II

12. California Psychology Inventory (CPI) • Primarily for young adults with society avg. reading level of Gr. 4 • Focused on “Folk Concepts” (culturally relevant), translated into 40 languages. • Focuses on typical population and interpersonal behaviours. • Assess enduring interpersonal personality characteristics in a typical population. • 20 Scales under general domains: • Observable, interpersonal style, & orientation (i.e. Sociability, social presence) • Internal normative orientation & values (i.e. responsibility, self-control) • Aspects of Cognitive intellectual functioning (i.e.achievement via conformance, intellectual efficiency) • Measures of role and personal style (i.e flexibility, psychological-Mindedness)

13. Rorschach • 10 inkblots given systematically, individual’s responses tracked to uncover the structure of the personality. • 3 General Categories: location (area of inkblot they focused on); determinants (specific properties of blot used in responses); content of response. • Excellent at bypassing an individual’s cognitive inhibitions. • Challenges: Subjective nature, results need to be checked/re-checked,

14. Thematic Apperception Test (TAT) • Method of revealing dominant drives, emotions, sentiments, complexes and conflicts of personality. • 20 pictures in which individual is asked to make up a story: what is happening, thoughts/feelings of characters, events that led up to picture, outcome of event. • 2 sessions, given sequence of cards, upwards 2 hrs to administer, • Qualitative not quantitative analysis • Up to Clinician Intuitive Clinical Judgment does not allow for universal standards, those who like say works well, those who detract says does not work. • Best results when apart of a battery of tests • Requires for best results a specialized/trained administrator

15. Neuropsychological Impairment • A battery of tests • Individual presents outside of test parameters can create a false negative (or positive) • Types: • Visuocontructive Abilities • Mental Activity • Memory and Learning • Verbal Functions and Academic Skills • Motor Performance • Executive Functions • Emotional Status • P.518 (Table 12.1)

16. Clinical Disorders Axis I • Other Conditions that May be a Focus of Clinical Attention

17. Axis II • Personality Disorders • Mental Retardation

18. Axis III • General Medical Conditions (ICD-9-CM coded)-medical conditions that may cause Mental Disorders. • Infectious/Parasitic (001-139) • Neoplasm (140-239) • Endocrine, nutritional, & Metabolic, Immunity (240-279) • blood & blood forming organs (320-389) • Circulatory system (390-459) • Respiratory (460-519) • Digestive Systems (520-579) • Genitourinary System (580-629) • Complications in pregnancy, childbirth, and the pueperium (630-676) • Skin and subcutaneous tissue (680-709) • Musculoskeletal System and connective tissue (710-739) • Congenital Anomalies (740-759) • Certain conditions originating in Perinatal Period (760-779) • Symptoms, Signs, and Ill defined Conditions (780-799) • Injury and Poisoning (800-999)

19. Axis IV Psychosocial/ Environmental Problems -Used to report factors that may affect diagnosis for Axis I/II Problems with: • Primary Support Group (Family. e.g.: death, health issues; abuse) • Related to Social Environment (e.g.: racism, retirement, death of friend) • Educational (e.g.: school environment, literacy) • Occupational (e.g.: un/underemployed; stressful work schedule) • Housing (e.g.: homelessness; safety) • Economic (e.g.: insufficient governmental supports; insufficient Income) • Access to health services (e.g.: inadequate, transportation, insurance) • Legal (e.g.: judicial involvement – perpetrator or victim) • Other (e.g.: disasters; war; famine; hostility; discord with professional supports; lack of governmental supports).

20. Axis V Global Assessment of Functioning Can they Function in Society? • The G.A.F. scale is a rating scale of 0 to 100 that is used over the time span an individual is receiving treatment to determine functionality. • Functioning impeded by physical or environmental limitations is not assessed. • These are averaged for the Axis V total and in brackets it is stated when score was e.g. (current), (at discharge) (highest level past year).

21. Example of DSM-IV Multiaxial Evaluation form Example 1: (p.35 DSM-IV-TR) Axis I: 296.23 Major Depressive Disorder, Single episode, Severe without Psychotic Features 305.00 Alcohol Abuse Axis II: 301.6 Dependent Personality Disorder Frequent use of denial Axis III: None Axis IV: Threat of Job Loss Axis V: GAF = 35 (current)

22. Psychopharmacology • Work with a Pharmacist and consistent Pharmacy.

23. Questions • Any questions? • Any Comments?