Transcript Psychiatric Diagnosis in Homeless Persons: Challenges and

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
symptoms
o Hygiene
o Sleep
o Fatigue
o Threat to safety
o Demoralization
o Maladaptive coping skills
Co-founding Variables (cont.)
• Complexities of childhood history
o Abuse
o Loss
o Deprivation
o Instability
• Lack of work-up beyond interview and mental
status exam
• Pressure to diagnose
o Colleagues
o Need of diagnosis for disability and housing
Strategies
• First step, engagement
• Modification of the evaluation process
o Brief, casual encounters
o Months to years
o Open-ended, neutral questions
Strategies (cont.)
• Observation is key
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Grooming
Odd or unusual clothing
Abnormal mouth or finger movements
Movements
Evidence of auditory hallucinations
Belongings
Location
Company or isolation
Strategies (cont.)
• Voices-differential diagnosis
o Schizophrenia
o Mania
o PTSD
o Personality disorders
o Cultural
Strategies (cont.)
• “Organic”
o First, rule out delirium
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Inattention
Disorientation
Memory
Visual hallucinations
Combative behavior
Alcoholic hallucinations
Strategies (cont.)
• “Organic” (cont.)
o Psychiatric diagnosis
vs. “organic”
• Inattention
• Memory impairment
• Depression/irritability/
moodiness
Strategies (cont.)
o Psychiatric diagnosis vs. “organic” (cont.)
• CAUSES
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Brain injury
Liver failure
Drug intoxication
Hypothyroidism
Subdural hematoma
Chronic alcohol abuse
Alzheimer or other dementia
B12 deficiency
Renal disease
Hypocalcemia
Hyponatremia
DIFFERENTIAL DIAGNOSISBIPOLAR DISORDER
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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, 2008
o 100 patients admitted to mood disorder clinico 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
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Rating Scales
• Verify diagnosis
• Assess severity
• Measurement of psychiatric conditions in
different points of time
• Determination of effectiveness of treatment
Alliance Building
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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.