nisonger institute 2020 - combined slides...5/7/2020 3 nisonger institute 2020: idd psychiatry best...

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Stephen Ruedrich M.D.

L. Douglas Lenkoski Professor, and

Vice Chair of Psychiatry

Case Western Reserve University

School of Medicine

Cleveland Ohio

May 8, 2020

Nisonger Institute 2020: IDD Psychiatry Best Practices

Pharmacologic and Non-Pharmacologic Treatment of Persons with IDD and Co-occurring Mental Illness

and/or Behavioral Challenges


Disclosures: Dr. Ruedrich has:

Previous research support from Pfizer and Cyberonics

Current research support from the Alana Foundation and the Alzheimer’s Association

None will have any direct or indirect bearing on today’s presentation


Additional disclosures: Dr. Ruedrich:

Will start out evidence-based, and then will likely drift into consensus-based treatment, and may ultimately veer off into wild speculation

Seems to love the Bolding Function a bit too much

May have a serious counting obsession


Question:

What is the best psychotropic

medication to treat a person with an

intellectual disability?

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Question:

What is the best psychotropic medication to treat a person with an intellectual disability?

Answer:

The one (or more) that is/are appropriate for his/her psychiatric diagnosis(es)

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Outline:

Importance of psychiatric diagnosisMedical condition(s) vs. psychiatric illness?

Disease vs. SymptomPast/Present/Future of IDD psychopharm.

Treatment of behavioral disorders?WPA Guidelines

A word or two about side effectsConclusion

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IMPORTANCE OF PSYCHIATRIC DIAGNOSIS

Antipsychotic Medications are:

Used extensively to treat aggression in persons with ID

30-50% of all psychotropics used in persons with ID

However, prevalence of psychotic disorders only 3-5%

(Tsiouris JA, JIDR 2009)

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In a Norwegian community sample of 116 adults with ID:

43% were taking psychotropic medication

32% were taking antipsychotic medication

Only 27% of those on psychotropics had a psychiatric diagnosis

(Baasland & Engedal, Tidsskr Nor Laegeforen, 2009)

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Today, psychotropic treatment of persons with ID should start with making an accurate diagnosis

Once a diagnosis is made, psychotropic treatment can usually proceed as it would for a person without ID:

Antipsychotics for psychosisAntidepressants for depressionSSRI’s for OCDMood stabilizers for bipolar illnessStimulants for ADHD, etc.

(Ruedrich, 2016)

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However, almost no psychopharmacologic literature describes the treatment of specific psychiatric illnesses:

depression bipolar illnessOCDADHD

in persons with intellectual disabilities

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PubMed Search:

Drug treatment of persons with ID 4779

Psychotropic drug treatment of persons with ID 1463

Psychotropic drug treatment

of psychiatric disorders in persons with ID 1316

Psychotropic drug treatment

of specific psychiatric disorders in persons with ID 57

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The reason is, as we know:

Accurate psychiatric diagnosis in personswith intellectual and developmental disability

IS DIFFICULT

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DIAGNOSTIC SYSTEMS IN PSYCHIATRY

Most reports of psychiatric disorders in persons with ID have utilized one of two mainstream diagnostic systems available:

– Diagnostic and Statistical Manual of Mental Disorders (DSM)– International Classification of Diseases (ICD) – Most current versions:

• DSM-5 (2013)• ICD-10 (1992) (APA, 2013; WHO, 1992)

– However, neither system is universally applicable to individuals with ID, particularly those with limited verbal communication abilities, and/or more severe/profound ID (Fletcher, et al., 2007).

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DIAGNOSTIC SYSTEMS IN PSYCHIATRY

Two additional diagnostic manuals have been recently proffered to address this difficulty:

– Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities/Mental Retardation (DC-LD) (RCP, 2001)

– Diagnostic Manual for Intellectual Disabilities (DM-ID 2007; DM-ID-2, 2016, NADD Press)

– The DC-LD has undergone significant field testing, (52 field investigators; over 700 patients), demonstrating acceptable validity and reliability (Cooper et al., 2003).

– The DM-ID has not yet been field tested, although an initial clinician survey (63 clinicians, 845 patients) expressed significant satisfaction (Fletcher et al., 2009).

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Diagnostic Criteria for Psychiatric Disorders for use with Adults with Learning Disabilities/Mental Retardation (DC-LD)

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OP48. DC-LD: Diagnostic criteria for psychiatric disorders for use

with adults with learning disabilities/mental retardation

Price: £20.00 Published: Apr 2001

DC-LD is a new classification system providing operationalised

diagnostic criteria for psychiatric disorders, intended for use

with adults with moderate to profound learning disabilities. It

also be used in conjunction with the ICD-10 and DSM-IV

manuals in a complementary way, when working with adults

with mild learning disabilities. DC-LD was developed by a

working party convened on behalf of the Faculty for the

Psychiatry of Learning Disability of the Royal College of

Psychiatrists and the Penrose Society.

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Diagnostic Manual for Intellectual Disabilities (DM-ID)

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Diagnostic Manual – Intellectual Disability (DM-ID)

The NADD, in association with the APA, developed a Manual that is designed to be an adaptation of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Grounded in evidence based methods and supported by the expert-consensus model, the DM-ID offers a broad examination of the topic, including a description of each disorder, a summary of the DSM-IV-TR diagnostic criteria, a review of the literature and research, and an evaluation of the strength of evidence, a discussion of the etiology and pathogenesis of the disorders, and adaptations of the diagnostic criteria

www.dmid.org

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Diagnostic Manual-Intellectual Disability-2

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The DM-ID-2 provides state-of-the-art information concerning mental disorders in persons with intellectual disabilities. Grounded in evidence based methods and supported by the expert-consensus model, DM-ID-2 offers a broad examination of the issues involved in applying diagnostic criteria for psychiatric disorders to persons with intellectual disabilities. The DM-ID-2 is an essential resource for every clinician who works with individuals with a dual diagnosis (IDD/MI).

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FULL STOP!

Before we can proceed with discussion of accurate psychiatric diagnosis, and

psychiatric treatment (both pharmacologic and non-pharmacologic), we need to

make sure that our patient’s symptoms and illness is psychiatric in nature

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MEDICAL ISSUES can present as behavioral changes

Persons with ID may have difficulty, or may be

completely unable to report any kind of medical

discomfort or distress. They may act out their

discomfort, so that the first person to observe or

learn of some change in status may be a direct carer,

family member, or behavioral specialist.

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Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices

Medical issues commonly presenting as behavioral problems:

Pain from any source• Dental• Arthritis• Headache (migraine)• Abdominal • Menstrual-related

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Medical issues commonly presenting as behavioral problems:

Sensory issues:• Visual deficits• Hearing loss• Hypersensitivities

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Medical issues commonly presenting

as behavioral problems:GI disease (Celiac disease) Seizures

Vitamin deficiency Sleep apnea

Cervical neck disease Diabetes

Urinary tract infections Thyroid illness

Allergies

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Medical issues commonly presenting

as behavioral problems:

Medication side effects

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So, in any individual with ID and behavioral problems:

before the clinician can try to differentiate a psychiatric disorder from a behavioral problem; there must be an investigation for the presence of a medical illness, presenting in a behavioral manner.

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Treating Diseases vs. Treating Symptoms

Analogy: Using HEADACHE as an EXAMPLE

Headache is a common presenting symptom for a variety of neuropsychiatric diseases (migraine, subarachnoid bleed, meningitis, trauma, stress, sinus infection, many others)

Treating the symptom (headache) from all of the above etiologies with acetominophen will bring relief to only a few.

Identifying the disease (etiology), and applying more specific treatment of the etiology, will often also relieve the symptom

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Treating Diseases vs. Treating Symptoms

Unfortunately, the state of current practice with many persons with intellectual disabilities and

behavioral or emotional difficulties today is often that of symptomatic treatment alone, in the absence of a reliably-identified psychiatric

illness

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ONE MORE PROBLEM:Historically, very few medications,

(psychotropic or otherwise), have been developed for, or tested in,

persons with ID

In the development of new drugs, the Food and Drug Administration (FDA),

typically and specifically excludes four groupsof individuals in the testing phases

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Nisonger Institute 2020: IDD Psychiatry Best Practices Nisonger Institute 2020: IDD Psychiatry Best Practices

EXCLUDED CLASSES ????

1.

2.

3.

4.

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1. Children

2.

3.

4.

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1. Children

2. Elderly

3.

4.

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1. Children

2. Elderly

3. Women of child-bearing age

4.

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EXCLUDED CLASSES:

1. Children

2. Elderly

3. Women of child-bearing age

4. Persons with ID/DD

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Perhaps as a result, there are few

psychopharmacology studiesmeeting contemporary scientific standards

(double-blind, placebo-controlled, random assignment, standardized measures),

which areeither disease-based, or symptom-based

(illness vs. behavioral problem)in persons with ID

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Nisonger Institute 2020: IDD Psychiatry Best PracticesSo…..what is the evidence for psychopharmacologic

treatment of persons with IDD?

The Past………psychotropic agents were used somewhat indiscriminately in persons with IDD, with little or no attention to psychiatric diagnosis, usually to treat behavior such as aggression, SIB, or rituals.

The Present…….studies focused on the treatment of specific psychiatric disorders, dependent on the validity of the diagnostic process?

The Future………drug-treatments of ID-related disorders with known etiology (behavioral phenotype)

(Ruedrich, 2016)

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The Past………psychotropic agents were used somewhat indiscriminately in persons with IDD, with little or no attention to psychiatric diagnosis, usually to treat behavior such as aggression, SIB, or rituals.

First/second generation antipsychotics for aggression and SIB

Mood stabilizers/anticonvulsants for aggression or SIB

Antidepressants for anxiety, or rituals/repetitive behaviors

Beta-blockers for aggression and impulse dyscontrol

Opiate antagonists for SIB

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The Present Rx of specific psychiatric disorders

In ADHD in children with IDD, stimulants (amphetamine, MPH, atomoxetine) appear to work, less robust response

(Aman et al., 2008)

In anxiety disorders, no RCTs in persons with IDD (King, 2007)

In psychotic disorders, no RCTs in persons with IDD since the 1980’s (De Leon et al., 2009)

In mood disorders, no RCTs in persons with IDD (Antonacci & Attiah, 2008)

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Question:

Are there any psychotropic

medications with a specific FDA-

approved indication in persons with

IDD and co-occurring

psychiatric/behavioral disorders?

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Currently only two psychotropicmedications with a FDA-approved indication

in the area of ID:

Risperidone and Aripiprazole are approved for the treatment of irritability

associated with Autism Spectrum Disorderin children and adolescents

“Irritability” is defined as aggression, SIB, tantrums and mood liability

(Ghanizadeh et al., 2014)42

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As a result,

an extreme view

would be that any other use

of psychotropic medication

in persons with ID

would be considered

“Off-Label” use

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The Future………drug-treatments of psychiatric disorders in persons with IDD of known etiology. This is known as a

BEHAVIORAL PHENOTYPE

Observation that a particular genetic etiology of ID is often associated with, or predictive of, a specific developmental and behavioral course

Or, that the genetic etiology determines (statistically) the psychopathology (and psychiatric diagnoses) seen

(Dykens 1995)

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The Future………drug-treatments of psychiatric disorders in persons with IDD of known etiology.

Do the typical treatments for Alzheimer’s dementia (cholinomimetics and memantine) help in persons with Down syndrome and dementia? (Costa & Scott-McKean, 2013)

ADHD in persons with Fragile X syndrome responds to stimulants. Social anxiety may respond to antidepressants

(Rueda, et al., 2009)

MPH effective for ADHD in children with VCFS (Green, et al., 2011)

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The Future………drug-treatments of psychiatricdisorders in persons with IDD of known etiology.

Stimulants and topiramate not effective for weight gain in persons with Prader-Willi syndrome (Harris, 2006)

No RCT’s in Fetal Alcohol Spectrum Disorder, Williams Syndrome (Doig et al., 2008)

In Autism Spectrum Disorders, stimulants help ADHD, and melatonin helps sleep disorders, but SSRI’s have been disappointing in anxiety, OCD, and repetitive movement disorders (Posey, et al., 2007)

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So, when we are not able to confidently arrive at a psychiatric diagnosis, is it acceptable to utilize psychotropic medications to address behavioral problems/symptoms in persons with IDD?

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Alternate title for todays presentation:

“Confessions of a Serial Polypharmacist”

How many are prescribers?

How many practice occasional or serial polypharmacy?

How many are occasionally or regularly uncomfortable with his/her current polypharmacy practice?

How many have a formal policy/program/template/mechanism to address polypharmacy?

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In 2007-2008, the Journal of Intellectual Disability Research (JIDR) published a series of papers which reviewed the main classes of psychotropic medications re their efficacy for behavioral problems in persons with ID

“The effectiveness of (fill in drug class here) for the management of behaviour problems in adults with intellectual disability: A systemic review

(Deb et al., JIDR 2008)

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Orienting Slide:

When the Food and Drug Administration

approves a new drug for a particular

clinical indication, how many subjects

(patients) must have been studied?

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FDA-approved antipsychotics; numbers of patients reported, in double-

blind, placebo-controlled trials:

Risperidone (Risperdal)

160+513+1356+246+365 = 2640

Olanzapine (Zyprexa)

149+ 253+326 = 728

Ziprasidone (Geodon)

139+302+419+200+294 = 1354

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JIDR REVIEW: MOOD STABILIZERS in IDD

Only 7 studies were found:Two controlled trials of lithium (N=74)One controlled trial of carbamazepine (N=10)One retrospective case series with lithium (N=66)One prospective case series with valproate (N=28)One retrospective case series with valproate (N=28)One retrospective case series with topiramate (N=22)

Conclusion:“Some” support for the use of mood stabilizers for mgmt of behavioral problems in adults with ID.”

“However, because of methodological difficulties,…. interpret with caution.”

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JIDR REVIEW: ANTIDEPRESSANTS in IDD

10 studies were found:One randomized controlled trial of clomipramine (N=10)Two cohort studies of fluoxetine (N=35)Two open trials of fluoxetine (N=30)Two prospective case series of fluvoxamine (N=74)One prospective case series of paroxetine (N=15)One retrospective uncontrolled study of paroxetine (N=14)One retrospective uncontrolled trial of both paroxetine and fluoxetine (N=33)

Conclusion:“Existing evidence on the use of antidepressants for the

management of behaviour problems in adults with ID is scant”The small clomipramine trial was positive“Responses to SSRIs were varied,…some clearly

favourable,….some negative….some both positive and negative outcomes.”

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JIDR REVIEW: ANTIPSYCHOTICS in IDD

9 studies were found:One randomized controlled trial of risperidone (N=39)Two prospective case series of risperidone (N=50)One prospective case series of quetiapine (N=15)One prospective case series with fluphenazine (N=12)One case crossover series with zuclopentixol & haloperidol (N=34)Two retrospective case series with clozapine (N=41)One retrospective case series with olanzapine (N=20)

Conclusion:“The evidence available at present for the effectiveness of antipsychotic

medication in the management of behaviour problems among adultswith ID is primarily based on case series.

For adults, only two RCTs (one includes children) are available. There are at least four good quality RCTs involving children with ID

w/wo autism, showing effectiveness of risperidone.”

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World Psychiatric Association Guidelines

Problem Behaviour in Adults with ID: International Guide for Using Medication

(WPA SPID September 2008 Guidelines)

“To provide advice to people who are considering the prescription of medication to manage problem behaviour among adults with ID.”“Guide neither recommends nor refutes the use of medication.”“Decision must be taken after careful consideration of all the possible benefits and potential risks.”“Problem behaviour” is “socially unacceptable behaviour that causes distress, harm or disadvantage to the person, or to other people or property, and requires intervention.”

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World Psychiatric Association GuidelinesGENERAL PRINCIPLES

Assessment and formulation

Identify the underlying cause

Assessment of causes and consequences of behavior

Input from family/caregivers and multi-disciplines

Formulation should be made even in absence of diagnosis

Input from person with ID and families/caregivers

Multidisciplinary input

Monitoring the effectiveness of intervention

Monitoring possible adverse effects

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World Psychiatric Association GuidelinesGENERAL PRINCIPLES

Revisit and re-evaluate the formulation at regular intervals

Prescribing should be part of broad person-centered care plan

Plan should be communicated clearly to the person/family

Need an assessment of capacity to give informed consent

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MAIN RECOMMENDATIONS

Use medications only within best interest of the person

All non-medication options should have been considered

Take into account cost-effectiveness

What worked before, and what did not?

If previous interventions caused AE, should be noted

Availability and non-availability of services/therapies

Local/national protocols and guidelines should be followed

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ONCE DECISION TO PRESCRIBE IS MADE:

Ensure appropriate PE and investigation

Blood tests and EKGs at regular intervals

Clarify to person/family if drug use is off-label

ID a key person to ensure appropriate administration

Provide person/family with copy of treatment plan

Have objective way to assess outcomes including AE

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ONCE DECISION TO PRESCRIBE IS MADE:

Arrange appropriate follow-up assessmentsOne medication at a timeUse within recommended dosesDoses above recommended only exceptional casesStart low and titrate slowlyLowest required dose, for the minimum time necessaryConsideration for withdrawing medication ongoing

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World Psychiatric Association GuidelinesADVERSE EVENTS

No quality evidence to support or refute that persons with ID area at greater risk for AE (* new research)

Discuss with person/family any common and serious AE

Advise what action to take for a serious AE

All AE should be recorded properly

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CHOICE OF MEDICATION

Not possible to recommend specific medication Once prescribed, evaluate risk-benefit profile regularlyConsideration of reduction/withdrawal should be ongoingShould be a relapse management planBe aware of the withdrawal effect of certain medicationsAlways consider non-medication based interventionsLack of studies of combinations of medicationsNot possible to recommend any combinationObservational studies suggest reduction in polypharmacy improves

behaviour and quality of life

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ADD-ON MEDICATION

If ineffective, reassessIf continuing the first medication, reasons for two must be recordedUse of two from same class is not recommendedIf combination effective, try to withdraw or reduce the first medicationAlways consider a non-medication interventionTry to return to monotherapy as soon as possibleAvoid using two medications for the same indicationUse more than two medications only in exceptional circumstancesTry to secure another clinician’s opinion in that case.Use of > three medications is difficult to justify, except in epilepsy

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WITHDRAWING MEDICATION

Studies show that in a proportion of cases, medications can be withdrawn

Withdraw one medication at a timeWithdraw medications slowlyIf necessary, allow time after withdrawing one to withdraw another

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A few words about Side Effects (SE)

First Generation Antipsychotics (FGA): Extrapyramidal

(EPSE) (dystonia, Parkinsonism, akathisia, tardive

dyskinesia)

Second Generation Antipsychotics (SGA): EPSE, plus

metabolic syndrome (weight gain, insulin resistance,

type 2 diabetes, hyperlipidemia)

HHHHHHHHHHHHH65


A few words about Side Effects (SE)

* Comparison of movement side effects of antipsychotics

9013 patients with IDD vs 34242 without (total of 149K patient years).

Movement disorder in 275/10K in IDD group.

Movement disorder in 248/10K in those w/o IDD.

Incidence of any movement side effect was signif. greater in those with IDD, with Parkinsonism and akathisia showing the greatest difference.

NMS was three times greater in subjects with IDD.

Findings were not due to differences in the % of FGA vs SGA.

CONCLUSION:

“Provides evidence to substantiate the long-held assumption that people with IDD are more susceptible to movement side effects of antipsychotic drugs.”

(Sheehan et al., BMJ Open 2017)

HHHHHHHHHHHHH

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A few more words about Side Effects (SE)

FGA/SGA, and SSRI’s and TCA’s: EKG QTc prolongation

FGA/SGA, and TCA’s (and perhaps SSRI’s): Lower seizure threshold

Anticonvulsant mood stabilizers: Electrolyte imbalance, ataxia, sedation, liver toxicity, rash

FGA/SGA, TCA: anticholinergic toxicity (dry mouth, constipation, urinary retention, blurry vision)

HHHHHHHHHHHHH

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A few more words about Side Effects (SE)

Persons with IDD have difficulty identifying and communicating any SE, so clinicians must have more suspicion, and a better-than-usual methodology for identifying and quantifying SE

Several rating scales (AIMS, MEDS, MOSES) have been developed to assess for and quantify SE

(Matson & Mahan, 2010)

HHHHHHHHHHHHH68


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CONCLUSIONPersons with ID can and do suffer from the entire range of psychiatric

illness

Psychiatric illness in persons with ID is common, but often difficult to

diagnose

As a result, treatment approaches in persons with ID is often symptom-

based, rather than syndrome or etiology-based

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CONCLUSION

Behavioral problems often co-exist with psychiatric illness

Psychotropic medications should be only one part of combined treatment, also utilizing behavioral, psychotherapeutic, and psychosocial treatments

When utilized, psychotropic medications should preferentially be used to treat specific psychiatric disorders, rather than to treat symptoms.

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CONCLUSION

When psychotropic medications are utilized, for psychiatric disorders, and/or behavioral problems, follow the WPA Guidelines, incorporating

systematic assessmentmultidisciplinary participationinformed consentregular monitoring for response and side effects

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THANK YOU!

QUESTIONS?

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REFERENCES:

Aman, et al, C/A Clinics of North America , 2008Antonacci & Attiah, Psych Quarterly, 2008Baasland & Engedal, Tidsskr Nor Laegeforen, 2009Cooper et al., JIDR, 2003 Costa & Scott-McKean, CNS Drugs, 2013De Leon, et al., Res in DD, 2009)Deb, et al., JIDR, 2007-2008Deb, et al., WPA-SPID Guidelines 2008Doig, et al., J Chid/Adolescent Psychopharm, 2008Fletcher, et al., J Clin Psychiatry, 2009Fletcher, et al., DM-ID 2, NADD Press, 2016 Fletcher, et al., DM-ID, NADD Press, 2007Ghanizadeh, et al., Child Psych and Human Dev, 2014Green, et al., J Child/Adolescent Psychopharm, 2011Harris, Intellectual Disability, 2006King, Psychopharmacology, in Psychiatric and Behavioral Disorders in IDD (Bouras & Holt, eds.) 2007Matson & Mahan, Res in ID, 2010Posey, et al., Biol Psych, 2007Royal College of Psychiatrists, DC-LD, 2001Rueda, et al., BMC Neurology 2009Ruedrich, Psychopharmacology, in Psychiatric and Behavioral Disorders in IDD (Hemmings & Bouras,

eds.) 2016Sheehan et al., BMJ Open, 2017Tsiouris, JIDR, 2009

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• Presentation materials are available from the event webpage: http://go.osu.edu/ni2020

Non‐pharmacologic Interventions for Individuals

with IDDAllison Cowan, MD

Associate Professor

Ohio’s Telepsychiatry project for ID

Disclosures

• I have no conflicts of interest, industry or pharmaceutical sponsorship

• Access Ohio Mental Health Center

• Montgomery County Board of Developmental Disabilities

• Coleman Professional Services

• Ohio Department of Mental Health and Addiction Services

• Ohio Department of Developmental Disabilities

• Ohio’s Telepsychiatry Project for Intellectual Disabilities

• All cases presented are de‐identified composites and contain fabricated components with no one, single person described

Autism Spectrum Disorders

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Treatment—ASD

• Treat co‐occurring disorders

• Early intervention

• Applied behavior analysis (ABA)

• Social skills groups

• Cognitive Behavior Therapy (CBT)

• Mindfulness‐based intervention (MBI)

White et al., 2018; Hampton & Kaiser et al., 2016

Treatment—ASD

Modifications

• Increased use of structure

• Increased use of visual materials

• Concrete examples and language

• More psychoeducation on emotions and anxiety

• Flexible length of sessions—suited to the patient’s needs

White et al., 2018

Treatment—ASD

• Occupational Therapy

• Sensory accommodations

• Always take care to evaluate for risk of abuse or neglect

• Treat co‐occurring disorders

ASD—Case • Mr. A is in his mid‐20’s. He has been brought to his outpatient psychiatrist for self‐injury.

• SIB is hitting both ears with both fists.

• What else do we want to know?

• No ear infections. BMs regular

• Ibuprofen/acetaminophen does not seem to help.

• Oh, WHEN does it happen?

• When that one housemate nags at him? Nah, too easy!

• With disrupted routine, noisy surroundings, annoying housemates

Neurocognitive Disorders

Dementia• Aim to improve cognition, enhance well‐being, and improve quality of life

• Reinforcement schedules

• Behavioral activation• Psychoeducational group for housemates

• Dementia‐informed environment

• Music‐oriented therapy groups

• Life story work

MacDonald and Summers, 2020

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Dementia‐informed environment

Over‐stimulated by too many signs and notices

Unable to see things like handrails and toilet seats if they’re they same color as the surroundings

Shadows or dark stripes in flooring as a change of level and try to step over them

Think shiny floors are wet and slippery

Waller and Masterson, 2015

Dementia‐informed environment

• Cognitive stimulation with meaningful activities

• Familiarity

• Photographs, memory boxes, but also traditional crockery and cutlery

• Wayfinding

• Signage with text and pictures

• Accent colors

• ID of beds, bedrooms, and social spaces

• Visibility

• Orientation

• Large clocks, natural light, artwork that reflect the seasons, outside spaces

Waller and Masterson, 2015

Dementia—Case

• Ms. B was brought to the psychiatrist but couldn’t make it into the office!

• She had been noted to be crying much more and staring into space while lying in bed. She wasn’t interested in her favorite tv show.

• What do we want to know?

• Is she depressed? Right. Her family doctor had started her on sertraline to no effect. Then cross tapered to mirtazapine. NOTHING.

• How could we address her dementia after we made reasonably sure it’s not something else?

Psychotic Disorders

Treatment—Psychotic Disorders

• Standard of care is antipsychotic medication

• Hallucinations

• Typically hearing and seeing things that aren’t there

• Remember: they can seem real to the person

• Hallucinations vs self‐talk

Biological

Psychological

Social

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• Music, headphones

• Television, movies, video games

• White noise machine at night

• Use gentle, leading questions as a reminder the voices aren’t real

• Formalized psychotherapy for hallucinations (CBTp)

ANTIPSYCHOTICS ARE THE TREATMENT FOR PSYCHOTIC DISORDERS Hayward et al., 2020


• Delusions• Defined as fixed, false beliefs

• Talk; don’t argue

ANTIPSYCHOTICS ARE THE TREATMENT FOR PSYCHOTIC DISORDERS

Psychotic Disorders

• Negative symptoms• Blunting of affect• Poverty of speech and though

• Apathy• Anhedonia• Lack of motivation• Lack of social interest

• Inattention to social input


• Cognitive Behavioral Therapy

• Motivational Interviewing

• Supportive Psychotherapy

• Case Management

• Vocational Rehabilitation

• ACT (Assertive Community Treatment

Mueser et al., 2013


• Family psychoeducation

• Supported living

• Social skills groups

• Habilitation activities

• Work as able (remember psychotic disorders can have significant impact on cognitive function)

• Scheduling

• Encouraging routine health care given risks of premature mortality

ANTIPSYCHOTICS ARE THE TREATMENT FOR PSYCHOTIC DISORDERS

Case—Ms. C

• Ms. C reports that the voices are better and that people aren’t bothering her as much with gang‐stalking as they were before. When asked, she says, “I’m fine.” Her family is concerned. She doesn’t do the things she likes anymore—like watching reality TV.

• What would you want to know? • Medication—has it been adjusted; have other medical problems been resolved?

• Social—what else is going on

• What would you recommend?

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Bipolar Affective Disorders

Minimizing sleep disruptions

Psychoeducation

Family psychoeducation and intervention

Cognitive Behavioral Therapy

Group Therapy

Interpersonal and social rhythm therapy

Case management

Miziou et al., 2015

Case Mr. D

• Mr. D went to camp for the first time at age 25. He was reported to be up all night while there, talking a mile a minute, and trying to pass out communion (hot dog buns) in the cafeteria.

• What should we tell him?

• What supports can we provide?

• Sleep schedule

• Family psychoeducation

• MI for medication adherence

DepressionTreatment—Depression

• Psychotherapy• Cognitive Behavioral Therapy• Supportive Therapy• Psychodynamic Psychotherapy

• Acceptance and Commitment Therapy

Treatment—Depression

Clinical Pearls

• Behavioral activation

• Environmental factors

• Sleep factors

• Alcohol and drugs

• Medical considerations

• Family connections

Anxiety Disorders

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Depression—case

• Ms. E’s mother passed away last year, and Ms. E had to suddenly move into a group home. She hasn’t been enjoying the things she normally does‐‐like reality television like Big Cat Rescue.

• What are our first steps?

• Safe environment

• Staying connected with family and friends

• Acknowledge about grief and loss

• Consider PCP, referral for therapy

Treatment—Anxiety

• Psychotherapy

• Cognitive Behavioral Therapy

• Supportive Therapy

• Psychodynamic Psychotherapy

• Acceptance and Commitment Therapy

Treatment—Anxiety

• Clinical Pearls• Question‐reassurance cycle• Routine and structure• “Worry” or questions as a conversational salvo

• Too much news• Not enough news• Sleep

Case

• Mr F’s new home manager brings him to a psychiatric intake for “being forgetful.” She worries that he can’t seem to remember what they just talked about.

• What do you want to know???

• Exactly!! TELL ME MORE

• Mr F really likes his new home manager and struggles with communication, but likes to connect with others.

• Should we start a medication??

• NO!

Trauma‐Related Disorders

Trauma‐ and stressor‐related disorders

• PTSD

• Acute Stress Disorder

• Adjustment Disorder

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Treatment—PTSD

• Trauma‐focused CBT

• Cognitive Processing Therapy

• Narrative therapy

• Play therapy

• EMDR

• Psychodynamic Psychotherapy


• Prolonged Exposure

Treatment—PTSD

New Line Cinema

Trauma‐informed care

Six Key Principles

• Safety

• Trustworthiness and Transparency

• Peer Support

• Collaboration and Mutuality

• Empowerment, Voice, and Choice

• Cultural, Historical, and Gender issues

De‐Prescribing

Obsessive‐Compulsive Spectrum Disorders

OCD Spectrum Disorders

• OCD

• Body Dysmorphic Disorder

• Hoarding Disorder

• Trichotillomania

• Excoriation (Skin‐Picking) Disorder

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OCD Treatment

• CBT with exposure and response prevention

• Acceptance and commitment therapy


OCD treatment

• Clinical pearls• The point is to resist doing the compulsion

• First, just tracking it• Then, trying to not do it a little longer• Then extending that time

• Differentiating between ASD and OCPD is difficult.

• Calm, patience is helpful

• Arguing and or forbidding is not helpful

Hoarding Disorder

• Institutional experience

• CBT + home visits

• Motivational interviewing for adherence and increasing motivation for changes

• Lack of insight can be major contributing factor

• You can’t throw the stuff away. It just comes back.

Dayton Daily News, 1945

Skin‐picking Disorder

• CBT

• Response prevention

• Keeping wounds well moisturized

• Monitor for infection or spread of infection

• Keep nails short and clean

• When nail salons are open, consider a manicure**

• Remember that this can be signal anxiety—an indicator of general level of anxiety

**not actual medical advice—just a practical tip**

Insomnia

Insomnia—Treatment• CBTi

• Sleep hygiene

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Insomnia

• Safety

• Weird noises

• Too bright/too dark

• Roommate sawing logs

• Other roommate being loud

• CAFFEINE!

Personality Disorders

Personality Disorders—treatment

• Therapy!

• How much time do we have?

• PDs are long‐standing ways of behaving and seeing the world• “enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individuals’ culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”

• DM‐ID‐2 suggests modifying DMS‐5 criteria of age 18 to age 22.


• A VERY brief overview**

• Paranoid: paranoid

• Schizoid: detached

• Schizotypal: eccentric

• Antisocial: disregard for rules, others’ feelings

• Borderline: instability in relationships and moods with impulsivity

• Histrionic: excessive emotionality and attention‐seeking

• Narcissist: narcissist

• Dependent: **

• Obsessive‐compulsive: preoccupation with perfection, orderliness


• A VERY brief overview**

• Paranoid: paranoid

• Schizoid: detached

• Schizotypal: eccentric

• Antisocial: disregard for rules, others’ feelings

• Borderline: instability in relationships and moods with impulsivity

• Histrionic: excessive emotionality and attention‐seeking

• Narcissist: narcissist

• Dependent: dependent

• Obsessive‐compulsive: preoccupation with perfection, orderliness


• Antisocial PD• Treatment of co‐occurring substance use disorders like tobacco, alcohol, marijuana or other drugs

• Treatment of any other co‐occurring mental illness

• Coordination of team• Setting appropriate boundaries and expectations• Natural consequences—discuss with your team what will happen with involvement of law enforcement

• Safety of patient and team

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Personality Disorders—treatment • Borderline Personality

• Remember you can have BPD and other psychiatric disorders

• Medications are not the treatment of choice for BPD

• Therapy is.• Supportive psychotherapy• Dialectical Behavioral Therapy

• Group therapy• CBT

• Coordination of team—have a plan and everyone on the same page

Personality Disorder Case

• Mr G reports that he has “abandonment issues” and that he doesn’t trust people. He has an active restraining order prohibiting him from calling his ex‐girlfriend. He reports that it wasn’t fair that it was on him and not on her because she was the person who started the fight. He has fairly significant mood swings and is destructive when upset—breaking his phone, throwing dishes.

• WHAT DIAGNOSIS?

• WHAT SHOULD WE DO!?

Questions? References

• White SW, Simmons GL, Gotham KO, Conner CM, Smith IC, Beck KB, Mazefsky CA. Psychosocial treatments targeting anxiety and depression in adolescents and adults on the autism spectrum: Review of the latest research and recommended future directions. Current psychiatry reports. 2018 Oct 1;20(10):82.

• Hampton LH, Kaiser AP. Intervention effects on spoken‐language outcomes for children with autism: a systematic review and meta‐analysis. Journal of Intellectual Disability Research. 2016 May;60(5):444‐63.

• Roux AM, Anderson KA, Rast JE, Nord D, Shattuck PT. Vocational rehabilitation experiences of transition‐age youth with autism spectrum disorder across states: Prioritizing modifiable factors for research. Journal of Vocational Rehabilitation. 2018 Jan 1;49(3):309‐25.

• MacDonald S, Summers SJ. Psychosocial interventions for people with intellectual disabilities and dementia: A systematic review. Journal of Applied Research in Intellectual Disabilities. 2020 Feb 27.

• Waller S, Masterson A. Designing dementia‐friendly hospital environments. Future Hospital Journal. 2015 Feb;2(1):63.

• Mueser KT, Deavers F, Penn DL, Cassisi JE. Psychosocial treatments for schizophrenia. Annual review of clinical psychology. 2013 Mar 28;9:465‐97.

• Hayward M, Berry C, Cameron B, Arnold K, Berry K, Bremner S, Cavanagh K, Fowler D, Gage H, Greenwood K, Hazell C. Increasing access to CBT for psychosis patients: a feasibility, randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE2). Trials. 2020 Dec;21(1):1‐4.

References

• Miziou S, Tsitsipa E, Moysidou S, Karavelas V, Dimelis D, Polyzoidou V, Fountoulakis KN. Psychosocial treatment and interventions for bipolar disorder: a systematic review. Annals of general psychiatry. 2015 Dec;14(1):19.

• Mueser KT, Deavers F, Penn DL, Cassisi JE. Psychosocial treatments for schizophrenia. Annual review of clinical psychology. 2013 Mar 28;9:465‐97.

• Gentile JP, Jackson CS. Supportive psychotherapy with the dual diagnosis patient: Co‐occurring mental illness/intellectual disabilities. Psychiatry (Edgmont). 2008 Mar;5(3):49.

• Brown FJ, Hooper S. Acceptance and Commitment Therapy (ACT) with a learning disabled young person experiencing anxious and obsessive thoughts. Journal of Intellectual Disabilities. 2009 Sep;13(3):195‐201. • Presentation materials are available from the event webpage: http://go.osu.edu/ni2020

• For questions regarding Cont. Ed./certificate of attendance, please contact: [email protected]

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