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Presenter: Margo Siegel, MA, LMSW, PLLC MAER Annual Conference: Livonia, Michigan April 28th, 2017 All presentations are subject to bias and/or selective process. This presentation included • No matter how much I think I know; someone always knows more. • This presentation respects confidentiality and generalities; (not all people……) • This presentation was derived from research findings, years of work experience, academic training and personal observations. (Richard Harris, LICSW, NASW: Rhode Island) • The AGE at which vision loss occurred The DEGREE of vision loss** (Spectrum) The COPING strategies learned and utilized Preconceived NOTIONS of blindness The individual’s PERSONALITY before the loss ATTITUDES of family/friends/medical staff Societal values or MISCONCEPTIONS (Tuttle & Tuttle, 2004) Clarification: • Those born blind (congenital) • Those who lost vision after early childhood • Those having some residual vision (low-vision); perhaps (e.g., progressive eye disease ) • Those who have additional exceptionalities besides blindness (e.g., DHH) • Those who lost vision due to trauma (e.g., car accident, war injury) (Tuttle & Tuttle, 2004) Concerns: Socialization (e.g., eye contact, social cues, facial expression; development of peer relationships/acceptance) Emotional (e.g., attachment, frustration, anger, behaviors) Educational growth/developmental (e.g., slower pace with developmental milestones in early childhood; lower academic expectations not appropriate, but present at times) (Fox, 2012) Concerns: Loss of: (e.g., employment/income, reading printed materials, driving ability, independence, change in daily activities, decrease in social life) Older adults/Seniors (e.g., additional health issues, death of spouse, cognitive changes, dependence on others) Military (e.g., ocular injury, traumatic brain injury, war trauma) (Fox, 2012) Found in both children and adults; however they sometimes present differently. Depression Anxiety PTSD Grief/Loss Social Withdrawal (Fox, 2012) “People suffering from vision loss are twice as likely to suffer from depression as the general population.” (Ascher, 2014) “By far the most common psychological comorbidity of vision loss is depression. Depression interferes with a person’s ability to function; and yet in too many cases, depression related to vision loss goes untreated.” (Fox, 2012) “Anxiety related to the anticipation of future vision loss/blindness in addition to phobic anxieties, such as fear of open spaces, traveling in crowded areas, and being left alone.” (Fox, 2012) “Loss of vision is one of the most feared results of aging.” (www.uniteforsight.org) Diagnostic and Statistical Manual of Mental Disorders (Located under Trauma and Stressor-Related Disorders section) Adjustment disorder is a stress-related, short-term, nonpsychotic disturbance. The discomfort, distress, turmoil, and anguish to the patient are significant, and the consequences (e.g., suicidal potential) are extremely important. (Frank, 2016) The specific DSM-5 diagnostic criteria for adjustment disorder are as follows: • Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors within 3 months of the onset of the stressor(s) plus either or both of (1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or (2) significant impairment in social, occupational, or other areas of functioning. • The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder. • The symptoms do not represent normal bereavement • After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months. • The following 6 specifiers are used to identify subtypes of adjustment disorder: • • • • • • With depressed mood With anxious mood With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance or emotions and conduct Unspecified (American Psychiatric Association, DSM-5, 2013) As the term adjustment disorder implies, symptoms develop when the person is responding to a particular event or situation, for example a loss, a problem in a close relationship, an unwanted move, a disappointment, or a failure. Characteristic symptoms include the following: Low mood Sadness/Tearfulness Worry Anxiety Insomnia Poor concentration Anger, disruptive behavior Other typical manifestations - Loss of self esteem, hopelessness, feeling trapped, having no good options, and feeling isolated or cut off from others (Frank, 2016) Additionally, children and adolescents with adjustment disorder commonly exhibit the following: Depressed/irritable mood Sleep disturbances Poor performance in school Challenging behaviors ** Isolation/withdrawal /suicidal ideation (especially with teenagers) (Frank, 2016) Clarification: Examples: ongoing, daily temper tantrums; yelling, screaming, hitting, throwing objects, disrespect of authority figures Interferes with learning/academics Disrupts daily life at home and in the community (at least 2 environments) Sometimes causes harm to others or self Sometimes causes damage to materials or belongings (AFB, Brooks, 2017) 5-YEAR OLD CHILD Additional Considerations: Vision loss highest among those >65 yrs. and increasing; expected to double in next 25 yrs. Diagnosis of the following eye conditions: AMD (age-related macular degeneration), glaucoma, diabetic retinopathy ** Comorbidity-two or more health conditions present simultaneously (e.g., sensory: DHH; cognitive: Alzheimer’s; physical: Diabetes, hip/bone fractures) (Fox, 2012) Age-related Macular Degeneration (AMD): 30% of people with AMD will experience depression within a few months of their second eye becoming affected; and anxiety related to the anticipation of this progressive vision loss (Fox, 2012) Glaucoma: no symptoms occur initially until significant damage to vision has occurred causing people to suffer shock/trauma with the reality of the situation; then possibly leading to adjustment disorders (CNIB) Diabetic Mellitus: Adjustment Disorder with depressive mood in this disease presents with an increase in hyperglycemic episodes and increased vascular complications (retinopathy); patients not motivated to continue with ongoing laser treatments or follow-up care due to their depressed symptoms which may contribute to the increase in vision loss/blindness. (Fox, 2012) At times normal age-related changes in vision and hearing may be confused with abnormal sensory changes which may lead to misdiagnosis or misunderstanding of a person’s level of functioning. An older individual with vision problems may act timid, hesitant or confused especially in a new situation/surroundings. Just as an older person with hearing loss may miss the nuances of conversations and appear confused. Both of these experiences if misunderstood may lead to feelings of isolation, disappointment and frustration for the individual. (Crews & Campbell, 2003) Approaches that may be helpful include the following: Psychodynamic psychotherapy (Talk Therapy) Cognitive-behavioral therapy (CBT) Family and group therapies (SolutionFocused) Support groups specific to the stressor (Frank, 2016) Learning to adapt and cope with new and uninvited circumstances Working with a professional in a safe, trusting and non-judgmental therapeutic environment Working through challenges and grasping the idea that there is a balance between continuing to be independent and being able to ask for assistance when necessary Being in a relationship where a psychotherapist encourages the “person-centered” approach which gives the individual responsibility for exploring his/her own inner wisdom and potential for positive change (Delany, 2017) Because adjustment disorder tends to be time-limited, brief rather than long-term psychotherapy is often sufficient. The goals of brief therapy typically include: To analyze the stressors affecting the patient and determine whether they can be eliminated or minimized (problem solving) To clarify and interpret the meaning the patient gives to the stressor To reframe the meaning of the stressor(e.g., negative to positive) To illuminate the concerns and conflicts the patient experiences To identify a means of reducing the stressor To maximize the patient’s coping skills (emotional selfregulation, avoidance of maladaptive coping, especially substance misuse) To help patients gain perspective on the stressor, establish relationships, mobilize support, and manage themselves and the stressor (Frank, 2016) YOUNG ADULT Phase One: Trauma Hearing initial news of vision loss from medical staff “What hit me?” Phase Two: Shock and Denial “This is not happening to me, or Why Me?” “Mental numbness” Belief of unrealistic miracle will bring vision back Phase Three: Mourning and Withdrawal Sadness, anger, outbursts, isolation from others Feelings of inadequacy; low self-esteem Phase Four: Succumbing and Depression “I can’t” Resentment, frustration, hostility, negativism Despair, discouragement, disinterest, distress, disenchantment Phase Five: Reassessment and Reaffirmation “Life is not over” The “turning point” in coping “I am the same person as before my vision loss. I may have to do things differently. I can do it.” Phase Six: Coping and Mobilization Emphasis on strengths, abilities, etc. Positive attitude, more confident Open to trying new skills/techniques/adaptations Phase Seven: Self-Acceptance and Self-Esteem “I like me.” Accepting strengths with limitations, assets, selfapproval No longer questioning, “IF ONLY” (Tuttle & Tuttle, 2004) SENIOR ADULT CHILD, ADULT ? HOPE “Sometimes life can be unfair. We cannot stop bad things from happening; we can only choose how we will respond to them.” (Delaney, 2017) WHAT DID YOU LEARN TODAY? Ascher, M. (2014 May 3). Vision Loss and Mental Health: The Hidden Connection. Retrieved from https://www.pennmedicine.org/news American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Arlington, VA: APA. Brooks, C. (2017). Behavioral Issues in Children with Visual Impairments and Blindness: A Guide for Parents. Retrieved from https://www.afb.org Chronic Illness and Disability. Retrieved from http://www.goodtherapy.org Crews, J. & Campbell, V. (2004). Vision Impairment and Hearing Loss Among Community-Dwelling Older Americans: Implications for Health and Functioning. American Journal of Public Health, 94 (45), 823-829. Delany, J. (2017). The Benefits of Psychotherapy. Retrieved from https://www.fightingblindness.ie/support/ Eger, E. (2004 Nov. 1). Helping Patients Cope with Vision Loss. Retrieved from http://www.optometricmanagment.com Fox, S. (2012 Oct. 29). Visual Impairment: Understanding the Psychosocial Impact. Retrieved from http://www.medscape.com Frank, J. (2016 Nov. 1). Adjustment Disorders. Retrieved from http://emedicine.medscape.com Module 10: Eye Disease and Mental Health. Retrieved from: http://www.uniteforsight.org/community Sacks, S., Kekelis, L., & Gaylord-Ross, R. (1997) The Development of Social Skills by Blind and Visually Impaired Students. New York, NY: AFB Press. Sullivan, G. (2000). Helen Keller. New York, NY: Scholastic Inc. Publisher. Tuttle, D. & Tuttle, N. (2004). Self-Esteem and Adjusting with Blindness, 3rd. Ed. Springfield, IL: Charles C. Thomas Publish. Wahl, H. (2013). The Psychological Challenge o of Late-Life Vision Impairment: Concepts, Findings, and Practical Implications. Journal of Ophthalmology, Vol. 2013, Article ID 278135, 11 pages.