Download focus on functioning - Todd Finnerty, Psy.D.

When Will I Get Better?
Prognostic Factors
Related to
Mood Disorders
Todd Finnerty, Psy.D.
PsychContinuingEd.com
OPA 2010
“It may be a
matter of
weeks,
or a matter of
years”
My main goals
• To encourage researchers to look at this
question
• To encourage practitioners to focus on
these issues
Why assess for
severity and
prognosis?
?
• Select Interventions
• Identify potential roadblocks
• Predict the course of treatment
Expectations
• The clinical course of depression is “highly
variable”
• Depressive episodes may often improve
relatively quickly.
• Two people who are diagnosed with
depression may not appear the same
A Tale of Two
Clients
• Client #1
(fewer factors)
• Client #2
(more factors )
Client Number One
•
•
•
•
20 something male
In the psych unit overnight
Resistant to discussing feelings
Had made a suicide-related statement in
an e-mail
• Denied suicidal ideation, denied
psychosis, denied a history of depression
or anxiety
Client Number One (cont.)
• The psychiatrist felt there was “no serious
intent when he made the suicidal
statement. It appears to be more an act of
frustration. He was counseled about the
need to act responsibly…”
• There was no diagnosis at discharge, no
medications prescribed.
Client Number Two
• 20 something male
• In the psych unit overnight
• Resistant to discussing feelings
• Based on the client and collateral
contacts:
Client Number Two (cont.)
• Very early onset of psych difficulties
(childhood)
• Also diagnosed w/ depression and
selective mutism in the 8th grade
• Comorbidity: History of depression,
anxiety, learning and speech difficulties
Client Number Two (still cont.)
• Hx of failed treatments/recurrent problems
• Hx of interpersonal problems and a
perception of poor social support
• Potentially negative and angry view
towards others and the world.
We’re still on Client #2
• Suicidal and homicidal ideation
(planning/intent?)
• He owns knives and firearms
• Possible hx of psychotic symptoms/
paranoid delusions
Does Client #1
have less
severity and a
better prognosis
than #2?
Less severity or…
…did we just have
less information?
Client 1 &
Client 2 are
the same
person
and I quote…
“no serious intent when he
made the suicidal statement.
It appears to be more an act
of frustration. He was
counseled about the need to
act responsibly…”
What
happened?
Would we have thought
the same thing?
An Imperfect
Science
Can the
science and
practice be
improved
upon?
Good
Fair
Guarded
Poor
Specific Factors:
Physiological
Cognitive
Clinical
“Physiological” factors
• Ex: potential “biomarkers;” lab testsfactors linked to vascular disease; genetic
testing; sleep EEG/brain waves
• Most “physiological” research studies are
generally designed to predict medication
response
• Hx of conflicting findings
• Currently have limited utility in your office
Still waiting for the flying car
• Don’t ignore co-occurrence
with physical concerns
(ex: pain)
which will significantly
impact prognosis.
“Cognitive” Factors
• Psychomotor slowing- vegetative sxs
• Executive Functioning
– Controlling yourself
– Managing emotions
– Sustaining attention and effort
Predictive of worse clinical, social and
occupational outcomes in mood disorders.
What does this mean for
someone with a
comorbid ADHD, LD or
language disorder?
(+ mood dysregulation?)
Some specific “Clinical” factors
•
•
•
•
•
•
•
Overall Severity and comorbidity
The nature of onset
A chronic or recurrent course
Prior failed and intensive treatments
Suicidal intent
Interpersonal concerns
Stable “trait” factors
Determining Overall Severity
• Clinical impressions
• Screeners such as the Beck scales, PHQs
• As easy as Mild, Moderate and Severe?
The “middle ground”
may have the best
prognosis- both in
terms of severity
and age of onset***
The nature of onset
• Age of first episode
• Quick vs more gradual
• Patterns of decompensation/deterioration
– Ex: “the downward spiral”
Chronicity
We want to know where the
client has been to help
determine where they are
going.
Those who do not learn from
history…
DSM-5 ETA 5/2013
Is a diagnosis of “Dysthymic Disorder”
necessarily less severe than a diagnosis
of “Major Depressive Disorder?”
-A dx may not always communicate px
-Potentially longer tx and more longterm impairment when chronic
regardless of the dx.
A proposed new Chronic
Depression diagnosis
• Chronic Depressive Disorder?
• Dysthymic disorder and chronic MDD
combined for DSM-5?
• See dysthymic disorder at dsm5.org
Caution:
• Client #1 had no chronic history
• Relying on self report alone can lead to
dichotomies like Client #1 & Client #2
being the same person
• You are counseled to use self report
“responsibly”
•What can we do?
Focus on the Fundamentals
• The “devil” is in the details (follow up)
– Frequency, Intensity, Duration
• Ex: A one minute, one-time panic attack vs
regular, prolonged attacks.
Symptoms do not equal
Severity
(focus on functioning)
Focus on Functioning
• All symptoms are not created equally
• The same symptoms do not effect different
people in the same ways
• We all live in “different worlds”
No Man is an Island
• What type of assistance/ accommodations
allows them to function the way they do?
• Can someone’s environment swing their
prognosis one way or the other?
• Social support (!)
Case Example
The apparent functioning of an
anxious and depressed
person with a supportive
significant other vs one
without that support.
How would they appear if
they were both thrown in
an environment without
those supports?
Involve others
• Is it “taboo” to get collateral information
from family/significant others in treatment?
• Can involving others in an individual’s
treatment help them perceive social
support?
• Did collateral reports make a difference in
our client #1 vs client #2 scenario?
Social Support
=
muy importante
Interpersonal factors
Some people behave in ways which “create”
negative interpersonal experiences even
when not depressed
“Stress-generating behaviors”
-their interpersonal problem
solving difficulties lead to conflict
Interpersonal Factors
• Negative feedback-seeking
– People with negative opinions of themselves
may try to convince others of their
“worthlessness.”
– People may “look for” and sometimes obtain
interpersonal rejection
Excessive Reassurance
Seeking
• Significant others may start out comforting,
but proceed to annoyed and potentially
rejecting
• An eventual negative effect on perceived
social support?
Excessive Reassurance
Seeking:
By the way, how is my
presentation so far?
Are you sure it’s not running
a little long?
They probably can’t hear me
in the back
I do tend to mumble…
…are you sure you can hear
me?
you’re just saying that…
…I drive you crazy don’t I?
I’d like to avoid any
interpersonal conflict
• Low assertiveness
• Avoidance and social withdrawal
Interpersonal Problems
• These problems are often
found in individuals with
chronic and recurrent
depression
Comorbidity
“Perhaps the most important severity indicator”
What type of disorder is
comorbid in as high as 50%
of people w/ Major
Depressive Disorder?
Anxiety
• Yerkes-Dodson: arousal is
only good for performance up
to a point.
• Comorbid anxiety usually
predicts worse psychosocial
outcomes
Psychotic symptoms
• Mood Congruent:
–Do they occur with an
elevated mood or
depressive mood w/
depressive/ manic
themes?
Mania and hypomania
• Bipolar I: possibly briefer but “more
severe” episodes of depression than MDD.
• Subthreshold manic/hypomanic sxs may
not cause much functional impairment
(euphoria, irritability, overactivity)
– However, they may predict a longer course
and poor pattern of response to
antidepressants if comorbid with MDD.
Substance Use
• Usually significant improvement within
approx 30 days w/ abstinence if
substance-induced
• Otherwise “just say low” when it comes to
prognosis for improvement w/ comorbid
substance use and another disorder.
relatively stable tendencies
Some Overlapping Concepts:
• Schemas/Automatic thoughts
– Irrational, “Bitter Beliefs”
• “Cognitive Vulnerabilities”
– Ex: Hopelessness; negative attitudes,
rumination
• Personality Disorder/personality traits
– Ex: Neuroticism/Negative Emotionality
‘cause we’ve got… Personality
• Usual mood dominated by dejection,
gloominess, cheerlessness, joylessness…
• Beliefs of inadequacy, worthlessness
• Critical, blaming, derogatory towards self
• Brooding, given to worry
• Negative, critical, judgmental to others
• Pessimistic
• Prone to feeling guilty, remorseful
We can be agnostic as to “why”
Mix of Nature & Nurture; early experiences
They’re often noticeable by the early
teenage years in some individuals
Gender differences develop
about the same time as in
depression.
Personality Impacts Depression
• risk for onset of an episode and
recurrence/relapse of future
episodes
• risk for treatment resistance and a
longer course of treatment
• poor functioning
• Increased comorbidity
Treatment Outcomes
• The more of these factors you have,
the more likely you are to have poor
treatment outcomes
• Many of these may also potentially
relate to a risk for…
Suicide.
These factors may also relate to
Suicide
• Plus: Extent of suicidal
intent/planning
• identifying with and
time spent dwelling on
themes of death
disability
The more these factors
interfere with daily
functioning and predict a
chronic course the more
likely they are to lead to
“disability”
Can Secondary Gain
create a barrier to
successful treatment?
Do you share the same
treatment goals?
Case Example
Younger gentleman in a nursing home with
back problems
– Went home every day
– Didn’t receive much nursing home assistance
– Came back in time to not be discharged
because…
…his Dr. said it would increase his chances of
getting benefits if he were still in the nursing home.
…it may not be “malingering”
Secondary gain can
potentially impact prognosis
in a negative fashion
File Review Consultant Bias
• DOCUMENTATION
I didn’t sign up
for a
“lecture” on
documentation!
Bait & Switch?
• Another case
example of client #1
vs Client #2
Client #2 has a severe
mental illness
Client #1’s progress
notes look like this…
“Pt seen
doing OK
RTC
3 mo”
We can fit over 4 years of treatment
on 3 PowerPoint slides
…As expected
Client #1 and Client #2 are
the same person…
…with enough limitations
that they would qualify for
disability based on their
severe mental illness.
(apparently
“doing ok” is a
relative term)
Brevity = valor?
• Will things you write in your
notes “hurt” your client?
• Possibly depending on your
definition of “hurt”
• No one says write everything
down
• You are not
protecting yourself
or your client by
leaving out
important details.
When you are aware of
factors related to prognosis
and/or severity…
Write them down
Write this down…
• Disability
• Medical Necessity
• Legal/ethical
(“S.O.S.”)
• Continuity of care
Factors Related to Prognosis
• Doom
• Gloom
»and…
Resilience
We also have strength
Reminders
• Symptoms do not equal Severity
(focus on functioning)
• The “devil” is in the details
(follow up)
• Frequency, Intensity, Duration
• No man is an Island
• History may repeat itself.
Review
•
•
•
•
•
Chronicity and recurrence
# of failed and intensive treatments
Comorbidity/Co-occurrence
Suicidal intent & preoccupation w/ death
The “middle ground” of severity and age of
onset may have the best prognosis.
• Stable “personality” characteristics can
prolong the course of treatment & create
risk of recurrence
Clinical Judgment
• Predictions based solely on the
self-report of a single individual
will only take us so far
– Ex: client #1 vs client #2
• We should continue to improve
the process of integrating
multiple types of information to
increase accuracy.
Thank you!
materials @
ToddFinnerty.com