Exam #3 Flashcards
(160 cards)
1
Q
Cognition and Psychiatric Disabilities:
A
- Cognitive impairment is common and may be a core feature of the disorder.
- Normal aging also potentially impairs cognition.
*Some conditions affect executive function, such as ADHD, schizophrenia, or bipolar disorder. - Depression: decision making and concentration; often only during acute phase of illness.
- ADHD: attention, executive functioning, inhibitory control deficit
- Schizophrenia: attention, memory, learning, problem solving
- OCD: difficulty switching attention, perseverating
2
Q
Components of Cognition:
A
- Attention: effective allocation of resources; involves taking in information, interpreting, act, reassess effects
- Memory: includes basic, complex, automatic…
- Executive Function: requires a level of awareness and conscious effort, higher order skills
3
Q
efficiently using cognitive resources to take in the information needed to complete a task
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Attention
4
Q
Automatic (auto pilot) versus Controlled Processing:
A
(more complex or novel tasks requiring more focused attention)
5
Q
ability to sort out and focus on certain stimuli
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Selective Attention
6
Q
ability for multi tasking; avoid if the client has attention issues vs doing one task at a time well
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Divided Attention
7
Q
sustained attention; may lead to fatigue
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Vigilance
8
Q
Cognitive Interventions:
A
- Automatic Processing: simple tasks and provide opportunities for repeated practice
Selective Attention: remove irrelevant stimuli; enhance important information; use visual cues - Divided Attention: try to separate tasks; try to make 1 automatic; practice multi tasking
- Vigilance: incorporate breaks; schedule difficulty tasks during preferred time of day
- Memory: chunk relevant bits of information; create mnemonics and memory aids
- Concept Formation/Categorization: provide a cue sheet; provide real world experiences
- Problem Solving: provide and practice strategies; try to eliminate common problems
- Decision Making: limit options; teach strategies
8: Metacognition: create questions for client to ask themselves before a task; self evaluate
9
Q
one of the most basic cognitive functions and used for most functioning
A
Memory
10
Q
Types of memory:
A
Somatic
Episodic
Procedural
Short-term
Long-term
Working
11
Q
memory for facts; tends to be created and forgotten rather easily; strategies may be used to improve retention; Deep Processing (finding meaning in facts) = improved memory
A
Somatic memory
12
Q
memory for events that have happened to you; organized temporally
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Episodic Memory
13
Q
memory about how to do something; takes longer to create; more implicit (unconscious); OT often assists clients in gaining new procedural memories; repeated practice
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Procedural Memory
14
Q
memory that is held for only seconds or minutes; if not rehearsed, these memories are lost in 20 seconds; Miller (1956) - humans have capacity for about 7 items (plus or minus 2)
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Short-term memory
15
Q
memory that is the accumulation of information throughout a lifetime
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Long- term memory
16
Q
memory that involves “working with” short term memory while processing to complete a task
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Working Memory
17
Q
Executive Function: higher order cognitive skills-
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- Concept Formation & Categorization
- Schemas:
- Scripts:
- Problem Solving:
- Decision Making:
- Metacognition:
18
Q
concepts are the basic units of knowledge; they establish order to one’s knowledge base; may be concrete or abstract; concepts are grouped into categories; this knowledge is important for much of daily functioning; most is implicit
A
Concept Formation & Categorization
19
Q
mental representations of concepts
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Schemas
20
Q
type of schema that describes a sequence of events; OT can help client create scripts to complete complex tasks
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Scripts
21
Q
mental process to accomplish goals; follows a predicted series of steps
A
Problem-solving
22
Q
research shows that people use certain strategies to make decisions quickly, but these can be prone to errors (eg: it worked last time; I know a person who did that)
A
Decision - making
23
Q
cognition about cognition; awareness of what you do and do not know; an important regulatory function to match your abilities with the task at hand
A
Metacognition
24
Q
Assessment of Performance skills: Cognition
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Test of Everyday Attention: includes 8 everyday tasks
Multiple Errands Test: measure of executive functioning that takes place in a mall
Dynamic Lowenstein OT Cognitive Assessment (LOTCA): 20 tasks to assess various cognitive functions
Executive Function Performance Test (EFPT): performance based and standardized; evolved from the Kitchen Task Assessment
Toglia’s Dynamic Interactional Approach: includes a Contextual Memory Test and Toglia Category Assessment
Allen Cognitive Level Screen (ACLS-5): leather lacing task standardized to predict functioning in DLS
Continuous Performance Test: for individuals with dementia; involves 7 everyday activities
Do-Eat: performance-based assessment for children aged 5-8; intended to administer in natural environment like a kitchen or at school, but can be adapted for the clinic
25
Intervention: Models and Techniques
1. Cognitive remediation
2. Dynamic interactional approach
3. Cognitive adaptation
4. Cognitive orientation to daily occupational performance (CO-OP)
5. Cognitive disabilities Model & Reconsidered
6. Errorless Learning
26
improving or restoring skills for occupational participation; is based on neuroplasticity (the brain’s ability to adapt; now known to persist throughout life)
Cognitive remediation
27
considers the interaction of person, activity and environment; focus is on functional information processing capacity of the client and self-monitoring
Dynamic interactional approach
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adapting the environment or the task for cognitive impairments
Cognitive adaptation
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a problem-solving strategy for motor-based skills; 4 step strategy [Goal-Plan-Do-Check]
Cognitive orientation to daily occupational performance (CO-OP)
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initially based on the idea that cognitive remediation is not possible for some clients, so focus is on adaptation and the environment; the Reconsidered model is focused on clients with dementia
Cognitive disabilities Model & Reconsidered
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individuals with some dx have trouble learning new information and impaired ability to self-monitor; tasks are adapted for success and repeated practice for success
Errorless Learning
32
Cognitive beliefs:
1. OTPF client factor—Individuals’ beliefs about themselves and the world affect occupational performance
2. Assumptions about cognitive beliefs (from psychiatry, psychology, learning theories)
*Levels of beliefs: there are surface-level and deeper-level/core beliefs
* Core beliefs can be entrenched, global, rigid, and hard to change
* Beliefs are key factors that influence how we perceive, appraise, and attach meaning to experiences
* Beliefs develop early in childhood and throughout adulthood
* Beliefs affect the experience of the environment, and the environment affects beliefs (dynamic interaction/feedback loop)
33
Cognitive beliefs and psychiatric conditions:
1. Depression
2. Anxiety
3. Eating Disorders
4.Substance use disorders
5. Schizophrenia
34
includes a negative view of self, the world, the future
Depression
35
leads to biased processing of information; intrusive thoughts; assigning self blame due to cognitive distortion
Anxiety
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include distortions of body image and of self worth; eating or not eating behaviors may be used to manage feelings of distress
Eating Disorders
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often include distorted beliefs about the effects of substances (I need/deserve this to help me cope; I can handle this; not a problem)
Substance use disorders
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it has been found that those with negative symptoms have a higher incidence of defeatist beliefs
Schizophrenia
39
Cognitive Beliefs and mental health:
1. Evidence indicates that CBT is effective for Depression, Anxiety D/O, Eating D/O, Bipolar D/O, PTSD; limited effectiveness for schizophrenia [EBP Table 21-2 p. 307]
2. Stigma and self stigma beliefs may be barriers for recovery
3. Assessment of Cognitive Beliefs
40
Intervention of Cognitive Beliefs:
1. Cognitive restructuring with CBT methods
*Beck’s Cognitive Therapy
- Socratic questioning and guided discovery: encouraging individuals to examine and reevaluate dysfunctional beliefs and consider more adaptive ways of believing/viewing situations
- Thought records: worksheets to help the client consider and reevaluate automatic thoughts
- TIC-TOC methods: Task Interfering Cognitions versus Task Oriented Cognitions
- Self-talk and affirmations: encouraging positive self talk and the use of affirmations
2. Coordinated Anxiety Learning and Management (CALM): computer guided program to manage anxiety [https://www.c4tbh.org/program-review/coordinated-anxiety-learning-management-calm/]
3. Ellis’ Rational Emotive Behavior Therapy: Activating Event, Belief, Consequents
4. Behavior /Learning –oriented CBT Methods
*Behavioral experiments: create opportunities to test beliefs and adapt them
*Behavioral Activation and Activity Scheduling: creating lists and schedules and sticking to them
* Self-Monitoring: attending to one’s beliefs, emotions, and behaviors
5. Self-efficacy beliefs and performance
* Mastery experiences: involves skill training in performance areas that need improving
* Vicarious experience, social modeling, social persuasion: learning by watching others
6. Other Educational/Learning Methods
* Psychoeducation: teaching information and skills
* Homework: practicing new skills or response patterns
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Other info re CBT:
1. Metacognitive demands of CBT
* Requires ability to self-reflect, differentiate, evaluate and grasp effects on feelings and behavior. Temporary or permanent difficulty/limitation can impact success.
2. Culture, cognitive beliefs and CBT
* Most research has focused on European American perspectives/assumptions
* Acculturation—learn about client language, support and participation to understand cultural definitions of what makes belief rational or irrational /appropriate/norms/change strategies for accuracy and best results
42
a restriction in voluntary motor action due to change in brain structure or function”
Cognitive Disability
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Functional Cognition:
* “Structural capacities of the brain
* What a person pays attention to
* Meanings the brain attaches to information
* Motor and verbal behavioral output
* Contextual elements that influence performance
* Activity demands that comprise performance
* Person’s values /interests that motivate performance
* Feedback from performance in context”
44
Theoretical Development (Cognitive Disabilities):
* Disability can be temporary or residual
* Cognition is a hierarchy
* Assessment is based on this hierarchy
* Function = deductive reasoning
* Dysfunction = impairment of sensorimotor processing in the brain resulting in an inhibited ability to perform new learning
45
Cognitive Levels:
Level 1 Automatic actions
Level 2 Postural actions
Level 3 Manual actions
Level 4 Goal-directed actions
Level 5 Exploratory actions
Level 6 Planned actions
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Level 1: Automatic actions
* Attends to internal processes/reflexive
* Attention less than one minute
* Observe feeding/eating
* Disability: arousal
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Level 2: Postural actions
* Attends to self-initiated repetitive body movement
* Attention up to 20 minutes
* Driven by physical comfort
* Basic rote exercise group
* Disability: self (body) focused
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Level 3: Manual actions
* Attends to tactile cues
* Repetitive actions with familiar schemes
* Decreased awareness of cause-effect
* Attends 30 + minutes
* Needs set up and checking of results re: hygiene and safety awareness
* Disability: step v. goal-directed
49
Level 4: Goal-directed actions
* Attends to visual cues, familiar schemes
* Difficulty with new learning
* Decreased tolerance of change
* Attends up to one hour
* Needs daily assistance to remove dangerous objects/problem solve
* Disability: Familiar actions only
50
Level 5: Exploratory actions
* Lack of planning
* Overt trial and error problem solving
* Impulsive decision making
* Socially egocentric
* Needs supervision of new learning to avoid unfavorable effects/safety issues
* Disability: social consequences
51
Level 6: Planned actions
* Capable of covert trial and error problem solving
* Ability to pre-plan
* Realistic goal setting ability
* Corrects errors by formulating a plan of action
* Uses symbolic cues
* No disability
52
Lower Cognitive Level Test (LCL):
Used to help determine if a client is Level 2 or Level 3
Consists of a task where the client follows a clapping pattern modeled by the therapist (3 claps, approx. 1 clap per sec). If client is able to imitate, they are probably Level 3 (where they can benefit from interactive group intervention)
53
ACLS-5
Screening instrument for people within 3.0-5.8 range
Quick, inexpensive, portable and safe
Designed for use by those with training in use of cognitive disabilities model.
Interpret and use data as part of a comprehensive evaluation process within the scope of practice act
Administer according to standard process, comprised of verbal directions, demonstration, and specific cues to encourage task performance.
54
ACLS-5
Set up leather lacing materials according to directions.
Seating arrangement
Person factors: rapport, background, aids
Have client complete three stitches specifically according to directions:
1. Running stitches
2. Whip stitches
3. Single cordovan stitches
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ACLS-5
* Scoring process based on trained observation of pattern of behavior and performance. Assign highest score based on observations.
* Challenging levels 4.2-4.4
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Treatment/Intervention for ACLS-5:
1. Groups
- Observe and monitor acute symptoms in task env
- Activity focus
- Performance modes
*Task equivalence
*Interval scale 0.0-0.8
2. Individual consultation
- Assist with discharge planning
- Safety
- Bx. Mgmt.
57
an umbrella term that includes a continuum from the most severe disorders to mild symptoms of differing duration and intensity
Mental ill health
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collectively all diagnosable mental disorders or health conditions that are characterized by alterations in thinking, mood or behavior associated with distress and/or impaired functioning. Typically used to refer to disorders that greatly impact functioning, such as bipolar or schizophrenia.
Mental illness
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typically used to refer to more common issues, such as anxiety or depression, which may be less severe and shorter duration.
Mental health problem
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A state of well-being in which the individual realizes his or her own abilities, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community
Mental health
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Mental Health Continuum:
Two Separate Continua
* Mental Health: from Languishing to Complete Mental Health and Flourishing
* Mental Illness: from presence to absence of mental illness
* The absence of mental illness does not imply the presence of mental health and the absence of mental health does not imply the presence of mental illness
* “U.S. strategy for mental health must simultaneously (a) continue to seek to prevent and treat cases of mental illness and (b) seek to understand how to promote flourishing in individuals otherwise free of mental illness but not mentally healthy”
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Model for OT Services:
Public health model of OT services to promote mental health and prevention and intervention for mental ill health in children and youth
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Model for OT Services: 3 Tiers
Tier 1: universal services, for all children with/without disability
Tier 2: targeted interventions for at-risk children and youth
Tier 3: intensive interventions for those with identified challenges
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Model for OT Services: OT process in this model involves
* Awareness (increase knowledge base)
* Appraisal (evaluate, observe)
* Action (intervention)
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Prevalence:
* 21.8% of US children aged 3-17 have 1 or more of the common mental health conditions (Child and Adolescent Psychiatric Clinics of North America, 2022)
* 10-20% of children and adolescents experience mental disorders/mental illness worldwide
* 50% of all lifetime mental illnesses begin by age 14 (WHO, 2016).
*Consequences of untreated MI:
- Suicide
- School failure
- Juvenile/criminal justice involvement
- Increased healthcare utilization
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Biological Risk factors of Mental Health:
1. Injury, infection, exposure to toxins, such as lead or mercury
2. Complications at birth, low birth weight, prenatal exposure (SA)
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Psychosocial Risk factors of Mental Health:
* Temperament - person's nature, especially as it permanently affects their behavior.
* Shy and reluctant to engage, try new things, be away from the parent, inflexibility, low positive mood, poor concentration
* Chronic illness/disability
* Trauma
* Low self-esteem
* Life event (divorce of parents, death of loved one)
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Environmental/Societal Risk factors of Mental Health:
1. Poverty, homelessness
2. Poor access to healthcare
3. Neighborhood violence and crime
4. Trauma
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Genetic Risk factors of Mental Health:
1. Parent/parents with mental illness, especially depression
2. Twenty to fifty percent of children and adolescents with depression have a history of depression in their family
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Unique Features of Child and Adolescent Mental Health:
Diagnosis:
1. Co-morbidity more common
*Depression & Anxiety; Anxiety & Substance Abuse; Depression & Substance Abuse; Conduct Disorder & Substance Abuse; Conduct Disorder & Mood Disorder
* Present differently at different ages and many disorders share common symptoms
2.Developmental Approach
3. Family Assessment
4. School Reports
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Role of Development:
Assess: Assess relative to typical and cultural norms
Focus: Focus of this course is school-aged 5-18
Address: Pediatrics course will address 0-4
Biological/physical/motor
Cognitive
Psychological/Emotional/Social
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Child development:
* Remember typical K-12 developmental tasks
1. Emotional/social
Developing self-identity
Learning how to function in the social world
2. Cognitive
Structure and consistency
Therapeutic boundaries and limit setting
3. Motor
Realistic expectations for sitting and attending
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Child development:
1. K-through elementary school (ages 5-11)
- Time of exploration: sexual energy present but channeled into intellectual pursuits and social interactions.
- Important stage for the development of social/comm skills & self-confidence
2. Adolescence mid-high school (ages 11-20+)
- Improvements in attention, memory, processing speed, organization
- Development of meta cognition, abstract thinking, and insight
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Evaluating Children and Adolescents:
1. Varying maturational patterns
2. Contextual and environmental factors
* Young Children pre-Kindergarten
- Unstructured observation of play
* Elementary-adolescent school aged children
- Attention approximately 30 minutes
- Clarify reason for meeting
- Games/play
- Difficulty with chronology of events
- Rate feelings
- May be reluctant to reveal problem
areas
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Evaluating Children and Adolescents:
Adolescents
* There is a complex process of genetic, biological, psychological and environmental factors that influence development of problem in living or disease process.
* Trust is paramount
- See alone, or first if with parents
- Confidentiality important but clarify safety reporting
* Language is crucial
- Careful with jargon
- May use open-ended questions if no intellectual disability
* Withhold judgment
- Careful of own biases
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Assessment:
Interview:
COPM: used as young as 7 years old
COSA: Child Occupational Self-Assessment
Adolescent Role Assessment
Vineland Adaptive Behavior Scale
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Assessment:
Survey Instruments:
1. Sensory Profile (birth-14 years old)
2. Harter Pictorial Self-Concept Tool (7 -18 years old)
3. Piers Harris Childrens Self-Concept Scale (7-18 years old)
4. Individual Protective Factors Index (IPFI) (10-16 years old)
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Continuum of Specialty Mental Health Care:
* Inpatient
* Community-based care - Philosophy of “wraparound care”
* PHP/IOP
* School-based services
* In-school or After- school program
* In-home care
* Residential Treatment Center (RTC)
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Wraparound services:
1. Philosophy of care 10 principles/four core assumptions (Erdman, 2019, p. 692)
2. Youth with multidimensional complex needs
3. Phases of Care coordination—now moving toward stages:
- Engagement
- Planning
- Implementation
- Transition
- Tools
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Core Principles of Wraparound Approach:
* Destructive behavior usually driven by unmet needs
* The greatest unmet need for many w destructive behavior is loneliness
* Receiving a service does not necessarily mean that needs are being met
* It is harder to institutionalize new ideas than people
81
Ten Principles of Wraparound Process:
* Family voice and choice
* Team based/community based/outcome based (3 of 10)
* Natural supports
* Collaboration
* Culturally competent
* Individualized
* Strengths based
* Persistence
82
School Mental Health:
1.“approaches that expand to encompass health promotion, prevention, positive youth development and school wide approaches” (Bazyk, 2019, p. 810)
2. Public health approach—population, strengths-based approach:
- Tier One: Universal, whole school health promotion
- Tier Two: Prevention services for at-risk students
- Tier Three: Intensive, individual services for youth with Mental Health Diagnoses
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Mental Health Continuum for Children &Youth:
1. Positive mental health vs mental ill-health
2. Continuum services varying intensity/duration
3. 20% children ages 9-17 meet criteria diagnosable behavioral/emotional disorder; substance abuse most common, then anxiety, then depression.
4. Students with disabilities have higher risk
5. Initial symptoms cross diagnoses: accuracy time & consistent reporting
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Occupational Therapy :
* Participation in school occupations
* Positive emotions and mental health
* Occupational enrichment
* Integrated services-natural environment (Bazyk, 2019, p. 816)
- Comfortable cafeteria
- Refreshing recess
* Classroom interventions (Bazyk, 2019, p. 817)
- Zones of regulation
- ALERT program
- Drive thru menus
85
Evidence-Based Strategies to Improve Mental Health:
* Participation in enjoyable activities
* Using personal strengths
* Having friends
* Thinking optimistically
* Performing acts of kindness and
* Expressing gratitude
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Mental Health Promotion Efforts:
* creating supportive environments
* reducing stigma and discrimination
* supporting social and emotional learning (SEL) of all children and youth
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Attention Deficit Hyperactivity Disorder [ADHD]:
* Most common neurobehavioral condition; chronic condition
* Symptoms: early onset, poor persistence, move from one activity to next without completion, disorganization, poor regulation, excessive activity.
* Symptoms in two settings = reduced quality of occupational performance and functioning
* Three sub-types:
- Primarily inattentive
- Primarily hyperactive-impulsive
- Combined (most common)
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ADHD:
* Effects across the lifespan—especially seen in school/work
* Genetic, biological, and environmental risk factors
* 5% of population, more males
* Occupational performance:
- Executive function
- Sensory motor
- ADL/IADL/Daily routine
- Family interactions
- Academic functions
- Social/leisure participation
- Work
89
Intervention for ADHD:
* Medications: Stimulants/Non-stimulant medications
* Medication alone not successful. Strongest outcome medication and treatment
* Interventions
- Dynamic Interaction Approach
- Cognitive Orientation to Daily Occupational
- Performance (COOP)
- Dunn Model of Sensory Processing
- School Mental Health
- Supported Education
- Play Based Intervention
- Parental Involvement
90
Disruptive, Impulse Control, & Conduct Disorders:
* Functional difficulty with self-control of emotions and behaviors that conflict with social norms of conduct.
* Oppositional Defiant Disorder
* Intermittent Explosive Disorder
* Conduct Disorder
* Antisocial Personality Disorder
* Pyromania
* Kleptomania
91
Disruptive, Impulse Control and Conduct Disorders:
* Frequent co-morbidity
* Etiology
1. Genetics/Neurobiology
- Low responsivity in amygdala and reduced connectivity to prefrontal cortex
- Parenting: negativity, harsh discipline including corporal punishment, permissiveness
2. Environment
- Classroom management
- Trauma, neglect
- Poor sleep, increased caffeine ingestion
- Lack of emotional intelligence limits development of self regulation
* Prevalence/gender: males
* Culture: bias present
92
Conduct Disorder: Impact on Occupational Performance:
1. Impulsivity, irritability, disruption, fixation
- Struggle to focus, identify daily needs, and meet demands, prioritize
2. ADL/IADL/Sleep/habits/routines
3. Academics and employment-unpredictable and with expectations of performance
- Social and sensory strategies
93
Oppositional Defiant Disorder (ODD):
* Enduring pattern of negativistic, hostile, and defiant behaviors in the absence of serious violations of the rights of others/social norms.
* Typically begins by age 8 but always but no later than adolescence
* More prevalent w boys before puberty but equal prevalence after puberty
* High co-morbidity w ADHD, mood or anxiety disorders
* Symptoms:
- easily loses temper
- argues with adults
- actively refuses to comply with adult
- requests and rules
- deliberately does things to annoy others
- blames others for mistakes and misbehavior
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Interventions for ODD:
* Medications: Antipsychotics, Lithium, * Anticonvulsants
* Anger management
* CO-OP
* Dunn Sensory Processing
* Zones of Regulation
* Sensory Rooms
* Mindfulness
* Re-entry Programs
* School Mental Health
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Anxiety Disorders:
1. Separation Anxiety
2. Post Traumatic Stress Disorder (PTSD)
3. Obsessive Compulsive Disorder (OCD)
96
Anxiety Disorders:
* Often develop in the context of changing demands for adaptation
* Panic disorder commonly initiated in teens
* Anxiety disorders in youth can remit by adulthood (40% +)
* Impact: school refusal, social refusal, excessive worry, sleep disturbances, for OCD may have repetitive behaviors such as hair pulling or skin picking
97
Anxiety Disorder Interventions:
1. Decrease environmental pressure
2. Expressive activities to explore fears and makes sense
3. Problem solving strategies
4. CBT
5. Relaxation training
6. Trauma informed care
98
Mood disorders in children and youth:
* Depression may present differently based on age/development of child.
* Can be irritable mood as opposed to “depressed mood” for adults, otherwise same symptoms
* At risk groups LGBTQ or anyone feeling marginalized
* Potential negative effects on function: social, academic, future
99
Depression Interventions:
1. Respect the energy deficit
2. Focus on establishing routines
3. self-concept- positive experience each session
4. Structured decision-making, not open-ended questions
5. Provide opportunities for some decision making
6. Shorter time periods for interventions at first
100
Bipolar Disorder:
* Often begins with depressive episode in adolescence
* Somewhat controversial in pre-adolescence
* High co-morbidity
* Potential for suicide risk
* Risk factors:
- Family history
- Earlier age of Dx and presentation with
psychotic features
- Manic symptoms with antidepressant meds
100
Bipolar Disorder: Strategies and Interventions:
* Set limits but do not engage in arguments
* Ignore comments about superior skills, gently encourage engagement in task
* Simple structured tasks to improve attention
* Decrease sensory stimuli
* Explore sensory strategies to manage mood and energy
* Develop routines and structure in daily schedule
* Support low-risk environments during recovery such as clubs, non-competitive activities
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Eating Disorders:
1. Risk factors
- Biology
- Environment
- Psychosocial
2. Protective factors
- Personal
- Family
- Social context
3. Co-morbidity - 89% have co-morbidity
102
Eating Disorders Intervention:
* Family-centered appears to be superior for younger patients
* Individual/family/group therapies
* CBT
* Family systems therapy
* Approach to re-feeding
* Support developmental tasks
103
Description of Eating Disorders:
* Disorders of mind and body
* Characterized by intense fear of being fat
* Leading to obsessive quest for thinness
* Difficulty with identity and competence results in impaired motivation to participate in adaptive activities of daily life
* ED provides meaning, purpose and satisfaction
* Challenging and complex etiology
104
Etiology of Eating Disorders:
1. Predisposing Factors: Individual personality & temperament; biology/role of serotonin; family functioning & dynamics; social pressure; cultural norms
2. Precipitating Factors: body dissatisfaction, losses, increased demands, trauma
3. Perpetuating Factors: eating disturbance may initially be rewarded by others and is reinforcing; cognitive distortions are accelerated by the effects of restricting and fasting; the person seems themselves as strong and in control
4. Protective Factors:
- Individual: autonomy, self-assertion, self-esteem, stress management
- Family: support , appropriate concern with weight
- Social: supportive environment, accepting of body differences, provides opportunities to grow and develop, spirituality
105
Eating Disorders: Co-Morbidity and Risk Factors:
* 89% of young women who meet criteria for ED demonstrate co-morbidity, usually with depression (Lewinsohn, et al, 2000)
* Other common co-morbidity = anxiety
* Family/parent history of ED
* Family/parent Pre-occupation with weight
* Acculturation is significant risk factor for Hispanic females
* Risk associated with transitions to adolescence and young adulthood
* Life events- lengthy separation /lack of attachment
106
Anorexia: Epidemiology:
* Present in .5 to 1% of adolescent females
* Occurs 10-20 X more in females
* Range of onset age 14-25
* Increasingly seen in younger females, adolescent males, and women in mid-life
* Developed countries
107
Anorexia Characteristics::
1. Individual does not maintain minimally normal weight; intense fear of gaining weight; significantly misinterpret their body and its shape; are obsessed with food and thinness.
2. Gross distortion of body image
3. Intense fear of gaining weight, even though underweight
4. Unrelenting pursuit of thinness—vigorous, ritualistic, obsessive exercise
5. Cognitive perceptual disturbances—”fat” despite evidence to the contrary
6. Global “all or none” thinking”
7. High co-morbidity:
- Depression (65%)
- Social phobia (34%)
- Obsessive-compulsive d/o (26%)
108
Anorexia Characteristics (continued):
* Typically does not self-refer; presents with a medical problem, not anorexia (eg: laxative seeking, amenorrhea)
* Often characterized as perfectionists and overachievers who appear to be in control
* Unusual eating habits are common
- Obsessed with food and cooking/preparation
- Ritualistic
109
Anorexia: Subtypes
1. Restricting type
- Non-binge eating behavior
- Often have obsessive-compulsive traits with
food and other matters
2. Binge-eating/Purge type
- Develops in up to 50% of those with initial
restrictive type
- Likely associated with impulse control
issues
110
Anorexia: Physical Complications:
Related to weight loss:
- Loss of muscle tone and muscle mass
- Cardiac – bradycardia and risk of heart failure
- Gastrointestinal - gastric emptying abnormalities, causing bloating, and vomiting, decreased bowel motility
- Reproductive - amenorrhea
- Dermatologic – brittle nails and hair; hair loss; lanugo; dry, rough skin
- Skeletal – Osteopenia, osteoporosis
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Bulimia:
1. Shares fear of fatness with those with anorexia, but appears of normal weight, but with the presence of recurrent bingeing and purging or other unhealthy compensating behaviors.
2. Bingeing involves rapid consumption of uncommonly large amounts of food
3. Purging involves a frenetic attempt to rid the body of the food (usually vomiting, laxatives, exercise, fasting)
4. More prevalent than anorexia
5. Significantly more common in females, peak age of onset 16-18
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Bulimia: Clinical Features:
* Recurrent episodes of binge eating, followed by recurrent inappropriate compensatory behavior to prevent weight gain, often completed in secrecy and resulting in guilt and shame
* Severity based on number of inappropriate episodes of compensation/week—mild, moderate, severe
* Self-evaluation unduly influenced by body shape and weight.
* Associated with poor impulse control & co-occurring mood disorders
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Purging: Health Complications:
* Metabolic – electrolyte imbalance
* Cardiac-hypokalemia from vomiting (low potassium)
* Gastrointestinal – esophageal lesions and damage, chronic constipation
* Dental – discolored/damaged teeth, swollen salivary glands
* Neuropsychiatric – possible seizures
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Course of Illness/Prognosis:
Anorexia: Course is variable
- Early intervention can improve prognosis
- This condition has the highest mortality rate of any psychiatric condition
Bulimia: Course is variable
- Depends in part on the severity of purging sequelae and early response of CBT
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Treatment for Eating Disorders:
* Inpatient indicated to counteract effects of starvation, or with other acute presentation
* Lab values
* Individual and/or Group Psychotherapy
- Cognitive behavioral therapy (CBT)
- Interpersonal Therapy (IPT)
* Family therapy
* Occupational therapy
* Nutritional counseling
* Pharmacotherapy
- Antidepressants (SSRI) or other medications re co-morbidities
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Impact on Occupational Participation:
* Overvaluation of weight, shape, and their control
* Mood intolerance
* Core low self-esteem
* Perfectionism
* Interpersonal problems
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Occupational Performance and Eating Disorders:
* Eating skills
* Meal preparation skills
* ILS and role functioning
* Social, communication and assertiveness skills
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Cognitive Behavioral Therapy and Bulimia (EBP):
* Addresses self checking behavior
* Addresses inability to tolerate intense moods—negative and sometimes positive
- Often a trigger for binge eating, self induced vomiting or excessive exercise
* Control of bulimia linked to dysfunctional system of evaluating self worth
- Judges self by eating habits, body shape or weight and ability to control them.
- Sees self as being at fault for not being able to meet rigid self, imposed rules related to food intake rather than judging the standards as too harsh.
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Substance Abuse:
* Does not reach the level of tolerance or withdrawal
* but consistently results in negative consequences
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development of reversible substance-specific syndrome due to ingestion of a substance
substance intoxication
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Substance dependence:
* considered more serious
* key feature is continued use of substance in the face of major life disruptions, such as losing a job or marital status due to negative effects of substance use
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development of substance-specific problematic behavioral change with physiologic and cognitive components due to cessation/reduction in heavy/prolonged use of substance
substance withdrawal
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Substance Use Disorders - Negative pattern of behavior across four areas:
Impaired control
Social impairment
Risky use
Pharmacological criteria
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Substance-related classes
Alcohol
Caffeine
Tobacco
Cannabis
Hallucinogens
Inhalants
Opioids
CNS depressants
Stimulants
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Features of Substance-related disorders:
* More sedating substances produce significant depressive symptoms during intoxication and anxiety during withdrawal
* More stimulating substances associated with substance-induced psychosis; anxiety during intoxication and substance-induced depression during withdrawal
* Both types produce sleep and sexual disturbances
* COD= co-occurring disorders
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Etiology of Substance-Related Disorders:
1. Neurobiological: Some may process and experience in a way that leads to compulsive use
2. Psychological and environmental
* Personality traits-impulsivity, sensation seeking
* Poverty
* Trauma exposure
* Social endorsement for SA
3. Sociocultural influences
Gender/spiritual coping/employment/ethnicity
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Substance-Related Disorders Impact on occupational performance:
ADL/IADL
Rest/sleep
Education/work
Play/leisure
Social participation
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Interventions for Substance-Related Disorders:
1. Medication-assisted treatments
2. Integrated approach
CBT
Motivational interviewing
SBIRT
DBT
Mindfulness meditation
Re-entry programs
Spiritual participation
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Three Medications Approved for Alcohol Dependence in US:
1. Naltrexone: opiate antagonist; don’t feel the rush with alcohol/don’t get the relaxed, good feeling; not used for those who haven’t stopped drinking
2. Acamprosate (Campral): Believed to help regulate the brain of chronic drinkers; Doesn’t stop withdrawal symptoms; can help cravings; most effective once stopped drinking
3. Disulfiram (Antabuse): Produces unpleasant reactions when alcohol consumed
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Medications for Drug Use/Abuse:
1. Methadone: Reduces withdrawal symptoms but doesn’t cause the high associated with heroin; Controversial—” addictive” but does not produce negative effects of opiates (the physical and psychological highs and lows due to changes in opiate level in the blood)
2. Buprenorphine: Reduces craving & withdrawal symptoms; Can block the effects of other opioids; Can be addictive and needs tapered if discontinued; use of alcohol, sedatives, and tranquilizers while taking this drug may cause overdose and death
3. Suboxone (contains Buprenorphine & Naloxone): Similar to just buprenorphine but has the added benefit of less addiction and less risk of misuse by injection due to naloxone
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Naloxone:
OT is one of the professions designated for training and administration of Naloxone
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Motivational Interviewing Strategies:
1. Express empathy – important for the client to know they are accepted, i.e. “change is hard”
2. Develop discrepancy – call attention to the discrepancy between current behaviors and the person’s goals and values
3. Roll with resistance – avoid argument and don’t oppose the client's resistance; acknowledge ambivalence
4. Support self-efficacy – express your belief that the client can be successful; they must make change, can’t be made for them
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Motivational Interviewing:
1. Highly influenced by the Transtheoretical Model
2. Fundamental approaches include:
*Collaboration – therapist and client are partners
*Evocation – drawing on the client to identify their own goals and values toward change
*Autonomy – the client has the capacity for self-direction and makes their own choices
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What is involved in SUD treatment?
1. Intervention
*Confrontation to break through denial
2. Detoxification
*Biological –may or may not need medical supervision
3. Rehabilitation
Three components
a. Continued efforts to increase/ maintain motivation for abstinence
b. Help person adjust to life without substance
c. Relapse prevention
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Barriers to Treatment:
No health coverage
Not ready: Denial/minimization/rationalization/blame
Able to handle w/o treatment
Transportation
Neighbors may form negative opinions
No programs available
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Alcohol:
-Most widely abused substance
-Intoxication .08% blood alcohol level (definition varies by state)
-Chronic abuse damages organs, esp. liver and brain
-Withdrawal can be life-threatening
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Alcohol Use Disorder Epidemiology:
1. Variable course with remissions and relapse
2. Co-occurring medical problems common
3. High Co-morbidity with other conditions
*Antisocial personality disorder
*Major Depressive Disorder
*Anxiety disorders
*Suicide risk
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Inhalants:
* Cheap, legal, easily accessible.
* Intoxication resembles “drunken” bx without the odor of alcohol.
* Ex. Aerosols, glue, shoe polish, paint thinners, felt-tip markers
* Treatment is symptomatic
* Most effects are reversible, but if chronic, can cause dementia
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Cannabis:
*Most widely used illicit drug in the U.S.
* Many states approved for medicinal or recreational use.
* Produces disinhibition, anxiety, agitation, impaired judgment, temporal slowing
*Chronic use can produce serious paranoid ideation and depersonalization
*Tolerance can develop--withdrawal includes mild insomnia, anxiety, and restlessness
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Stimulants (Cocaine)
1. High potential for abuse as it produces very intense craving
2. Creates psychological rather than physical dependence.
3. Produces euphoria, increased energy and insomnia, hypervigilance, grandiose beliefs/actions, paranoid ideation, hallucinations
4. Many medical complications from use: nasal inflammation, infection, non-hemorrhagic cerebral infarctions, tachycardia, arrhythmias.
5. Those who inject = potential for HIV/AIDS and/or Hepatitis
6. More likely to exhibit poor judgment/impulsivity when using, such as unsafe sex
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Stimulants (Amphetamines):
* Ex. Dexedrine, Ritalin, Adderall
* “Designer amphetamines” crank, ice, meth, speed, MDEA, STP, XTC
* Heavy use leads to dysphoria, irritability, hostility, insomnia, sometimes paranoia, and delusion.
* Amphetamine psychosis can last for several weeks.
* Can also lead to cardiac problems
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Opioids:
* Used for pain, cause sedation, euphoria and impaired intellectual function
* Ex. Heroin, codeine, morphine, Oxycontin, Vicodin, fentanyl
* Habit forming--must take the drug to ward off withdrawal symptoms
* Withdrawal symptoms include muscle cramping, fever, chills, diarrhea
* Treated with methadone, naltrexone, buprenorphine
* Co-morbidity due to injection—HIV, Hep C, bacterial infections
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Sedatives:
* Include benzodiazepines, sleeping medications
* Cause generalized depression of the CNS--drowsiness, respiratory depression, nausea.
* Alcohol increases the risk of abuse and overdose; an overdose is life-threatening
* Daily use for only a month can produce physical dependence.
* Withdrawal can cause seizures or psychosis and requires medically supervised detox
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Anabolic Steroids:
* Muscle building; masculinizing effects; natural male hormone (testosterone) and synthetic analog (Diabonal)
* Ingestion: oral, transdermal, intramuscular
* Used illegally to enhance physical performance
* Initially produce euphoria/hyperactivity, also increases arousal, irritability, anxiety, somatization, and depression.
* Some experience mania, psychosis, or rage.
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from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being
Trauma
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Core concept of trauma-informed care:
1. Secure attachment = trust in one’s feelings and understanding of the world
2. Insecure attachment may lead to the inability to modulate arousal and to self-regulate
3. Caregivers/caregiver relationships may be the source of trauma
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Pervasive impacts of trauma:
1. Effects may last across the lifespan
* In children, trauma can cause neurologic changes that affect affective, cognitive, social, and relationship domains
* ACE Study – Adverse Childhood Experience Study – As the ACE score increases (0-10), so does the risk for health and social problems in adulthood (physical health, mental health high-risk behaviors, etc.)
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Traumatic events:
The experience is individual and influenced by variables such as perceived degree of control during trauma, age, personality, etc.
Examples:
Emotional, sexual, and physical abuse
Violent assault, MVA, physical injuries
Neglect, betrayal, abandonment
Witnessing violence or restraint
Rape
Invasive medical or dental procedures
Natural disasters
Death or illness of close personal relationship and loss
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Trauma response:
* Triggers include sensory stimulation, actions, or thoughts related to trauma
* Difficult to modulate sensory experiences and organize behavior for an adaptive response.
* Increases hormonal secretions and subcortical and cortical responses
* Trauma is subjective – one person’s trauma is not comparable to another’s.
* Mental health consumers have a high incidence of trauma experiences, as high as 90%
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How trauma is experienced:
Heightened arousal: fight or flight
Psychological distress
Anxiety
Hyper-vigilance
Difficulty communicating
Modulation [arousal, emotions, concentration, being “present”]
Hypersensitivities
Avoidant behavior
Numbing
Self-injurious behavior
Paranoia
Risk-taking and sensory-seeking behavior
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TRAUMA INFORMED CARE:
1. Addresses the significant effects of trauma on neurobiology, psychology, and social relationships
2. Inpatient hospitalization may trigger fear and negative reactions among individuals with trauma histories
* Staff may be unaware of trauma
* Environment is strict and controlling
* Prevent further trauma by designing alternatives to chemical and physical restraint
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Models of Trauma-Informed Care:
Theraplay
Sanctuary model
Trauma Focused CBT (TF-CBT)
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Trauma-informed interventions:
Linking assessment to intervention
* Adult Attachment Scale, CANS-Trauma (MD version), Difficulties in Emotion Regulation Scale (DERS), Behavior Rating Inventory of Exec. Function 2 (BRIEF 2), Adaptive Behavior Assessment System 3rd ed (ABAS – 3)
* OT – COPM, Adolescent/Adult Sensory Profile
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OT role:
OT role: environmental modification for strategic use of sensory input on the unit or individual level.
https://dreampadsleep.com/ - more individualized
Think Recovery Model – strengths-based, empowering, hope building
Promote participation and success in occupations/ performance
Promote safety (physical and psychological)
CBT and coping, routines, building resilience
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Seclusion and restraint reduction:
1. National initiative to reduce coercive practices such as chemical and physical restraint.
2. OT Role: Tool kits for use by inpatients to self calm
* weighted blanket or vest
* relaxation music
* stress balls
* lotions/aromatherapies, etc.
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Sensory modulation and mindfulness approach in OT:
1. Therapeutic use of self
2. Evaluation
* Adolescent/ Adult Sensory Profile
3. Modalities for intervention
* Sensory strategies
* Sensory-motor activities
* Mindfulness practices
* DBT
* Environmental modifications
* Sensory diet
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Mindfulness:
1. Exercising being “in the moment” through self-awareness and self-knowledge.
2. Dialectical behavior therapy incorporates mindfulness into this EBP as well as distress tolerance, emotional regulation, and interpersonal effectiveness.
3. Yoga, tai chi, and meditation are other methods to cultivate mindfulness
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Bessel van der Kolk:
1. Psychotherapy
2. EMDR
3. Yoga
4. Theatre and movement
5. Neural feedback
6. Psychedelics
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A Balanced Lifestyle Meets 5 Basic Needs:
1. Meet basic instrumental needs necessary for sustained biological health and physical safety
2. Have rewarding and self-affirming relationships with others
3. Feel engaged, challenged, and competent
4. Create meaning and a positive personal identity
5. Organize time and energy in ways that enable the meeting of important personal goals and renewal
