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Support clients with mental health and AOD diagnosis Mental illness and mental health 2 Predisposing factors of mental illness and substance use disorders 7 Factors that influence the onset of mental illness and substance abuse disorders 9 Signs and indicators of mental illness 10 Assessing a person with a dual diagnosis 18 Screening clients for a dual diagnosis condition 24 Impact of a dual diagnosis 31 The Mental Health Act 34 Summary 36 Additional resources 42 Glossary 43 1 2003_309_001 Mental illness and mental health When you think of mental illness what do you think of? Ask five people in your own family or social network what they consider mental illness to be and you will probably get a range of responses. So let’s see what people think of when they hear the words ‘mental illness’. Activity 1: Mental illness 1 Ask five people you know what they understand or consider mental illness to be and write down the responses here. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 2 Now that you have completed this task, which of the above responses is closest to what you consider mental illness to be? _____________________________________________________________________ _____________________________________________________________________ 3 Now put together a definition of what you consider mental illness to be. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 2 2003_309_001 Feedback 1 You may have got a range of responses to this task, and that is understandable. In any discussion of mental illness it is worth trying to understand what mental health is, in order to better understand the context of mental illness. Mental illness may be defined as a set of behavioural or psychological responses that interfere with or inhibit a person’s ability to comfortably or effectively meet human needs and function within a society. The American Psychiatric Association’s definition of mental illness or mental disorder is: A clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (some sort of painful symptom) or disability (ie impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (APA, 1994) It is estimated by the National Association of Mental Health that 40% of the population will seek psychiatric treatment at some point in their lives. It is also estimated that one in every five people will develop a diagnosable mental illness. Few families in Australia will be untouched by mental illness, be it mild to extreme. Determining just how many people in our community have mental illness is one of the purposes of the field of epidemiology. Epidemiology is the study of patterns of disease in the population. Key terms used with this discipline are: incidence prevalence. Incidence refers to new cases of a condition that occurs during a specified period of time, say the last twelve months. Prevalence refers to all cases of a disease, both new and existing cases. The estimate of people living with mental disorders (epidemiology) has changed over time due to changes in the definitions and diagnosis of mental health and mental illness. In the early 1950s the rates of mental illness estimated by epidemiologists in the USA were far higher than today’s estimates. When more restrictive definitions that reflected a more contemporary view about mental illness were used, the rates of mental disorders dropped. Instead of classifying anyone with signs and symptoms as being mentally ill, more recent practice has been to identify people as mentally ill if they have a cluster of signs and symptoms that, when combined together, impairs a persons ability to function. Research confirms that people with a mental illness are more likely to have a substance use disorder than people who do not have a mental illness. It has also been argued by researchers that people who have a substance use 3 2003_309_001 disorder are more likely to have a psychiatric illness. The relationship between mental health disorders and substance use is quite complex. People who have both a mental illness and a substance use disorder are all very different from each other. They may present with a range of disorders that may vary in severity and intensity. Information collected from the National Survey of Mental Health and Wellbeing of Adults in Australia confirmed that men and women have similar rates of mental illness but the types of disorders differed. Men, for example, are twice as likely to have a substance use disorder whereas women have higher rates of anxiety. A mental illness or mental disorder is more commonly understood as a diagnosable illness that significantly interferes with a person’s cognitive, emotional and social abilities. So, what then is mental health? Activity 2: Mental health 1 When we use the term mental health what do we mean? _____________________________________________________________________ _____________________________________________________________________ 2 Ask five people you know what they consider mental health to be and write down a summary of their responses below. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 2 You could argue that mental health is the opposite of mental illness but that would be incorrect. A definition of mental health from Australian Health Ministers (1992) is: The capacity of individuals within groups and the environment to interact with one another in ways that promote subjective wellbeing, optimal development and the use of mental abilities (cognitive, affective and relational) and achievement of individuals and collective goals consistent with justice. 4 2003_309_001 There is no universally accepted definition for mental health. People who work in the community services and health industry (CSHI) tend to agree that mental health is a positive state in which a person is responsible, displays self-awareness, is self-directive, is reasonably worry free and can cope with day to day tensions. When a person is able to carry out their role in society and their behaviour is appropriate to the environment, that person will be referred to as being ‘mentally healthy’. It can be argued that an individual who is mentally healthy can function comfortably within society, is accepted within a group and generally satisfied with their achievements. Mental health and mental illness are not polar opposites but need to be thought of as points along a continuum. Activity 3: A description of mental health Now in your own words describe what you consider mental health to be. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 3 So what is mental health? It is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people and the ability to adapt to change and cope with adversity. It is indispensable to personal wellbeing, family and interpersonal relationships and to be able to contribute to the community or society. It is the springboard of thinking and communications skills, learning, emotional growth, resilience and self-esteem. What it means to be mentally healthy is subject to many different interpretations, and rooted in value judgements that may vary across cultures. So how does mental illness differ from mental health? 5 2003_309_001 As we have discussed above, mental illness is the term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterised by alterations in thinking, mood and behaviour associated with distress and/or impaired functioning. Examples of disorders that are characterised by alterations in thinking, mood and behaviour are as follows: A condition called Alzheimer’s disease (a type of senility) exemplifies a mental disorder largely marked by alterations in thinking. Depression exemplifies a mental disorder marked by alterations in mood. Attention deficit disorder (ADD) exemplifies a mental disorder largely marked by alterations in behaviour (overactivity) and/or thinking (inability to concentrate). Alterations in thinking, mood and behaviour contributes to a host of problems such as client distress, impaired ability to function and cope, or heightened risk of death, pain, disability, or loss of freedom. Concepts of mental health and mental illness are defined, to some extent, according to the beliefs and values of the society in which the person lives. When a person is able to carry out their role in society and/or their behaviours are adaptive to the environment, we may agree that the person is ‘mentally healthy’. Such individuals may function comfortably within society, may be accepted within a group and are generally satisfied with their achievements. These last two sentences may sound somewhat subjective and can be easily challenged. Next we’ll tease out some issues that make the difference between mental health and mental illness a little blurry. 6 2003_309_001 Predisposing factors of mental illness and substance use disorders Over the past 15 years researchers have identified increasing numbers of people in our society who have and are developing comorbid (mental health and substance use disorders, otherwise referred to as a dual diagnosis condition). The question that often gets asked is: have these two conditions always existed side by side and it has only been recently that the links have been made, or have there been other changes and influences in society that has impacted upon this growing concern? Activity 4: The increase in dual diagnosis What do you think may be some of the reasons why we are seeing more and more people in our society with both mental health and substance use disorders? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7 2003_309_001 Feedback 4 Some of the reasons proposed to answer this question were put forward by two researchers (Smith and Hucker) in the 1990s. Their study was focused at the level of serious mental illness and highlighted that some of the reasons why there has been an increase in substance use disorders in people with psychiatric illness are as follows: Many people are using substances to self-medicate away their psychological pain. Some of the side effects of the medication prescribed for mental illness may cause people to self-medicate a range of legal and illegal drugs. It may be a way to increase social interaction between people. It may be a way of gaining acceptance and entry to certain subcultures. It may be a way of coping with some of the disabilities of mental illness such as poverty and isolation. In addition to these points there are now more people with serious mental illness living in the community compared to those who were once residing in psychiatric institutions. This, in itself, exposes many people to substanceusing cultures. In addition, many researchers argue that there has been an increase in social acceptability and use of substances, many of which contribute to higher levels of mental health disorders. Activity 5: Is dual diagnosis on the increase? As a student it is important for you to try and tease out this question. Do you think that the combination of mental illness and substance use disorders (dual diagnosis) is increasing, or that we are just more aware of this problem, as a society? Give this question some thought and write down your response here. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 8 2003_309_001 Feedback 5 We do know that there has been a steady rise in the use of drugs in our society. Australian statistics confirm that the proportion of young people using cannabis, inhalants, hallucinogens and narcotics has increased over the past 15 years. Research undertaken by Rutter and Smith (1995) suggested that there is an increasing trend of mental health disorders in young people. It is also possible that due to a heightened level of interest and awareness of dual diagnosis over the past 15 years that people who are treating mental illness are now more aware of, and looking for, any evidence of this problem in their clients/patients. So the question does not have a clear answer. Many mental health clinicians claim that dual diagnosis is to be anticipated when a person’s mental health is out of balance for whatever reason. The difficulty is being able to tease out whether the mental illness leads to the substance use disorder or the substance use leads to the mental illness. Factors that influence the onset of mental illness and substance abuse disorders What are the reasons why people develop a mental illness/substance use disorder? One way to look at this complex question is to examine the three major factors that influence mental health. These factors are: 1 Biological factors Biological factors include genetic predisposition; physical health; neuroanatomy and physiology. 2 Psychological factors Psychological factors include nurturing during childhood; parent, child and sibling interactions; intelligence; self-concept; skills; talents; creativity and emotional development. 3 Socio-cultural factors Socio-cultural factors include family stability; child rearing patterns; economic resources; housing; religious beliefs and values. 9 2003_309_001 Signs and indicators of mental illness Activity 6: Mental health conditions Brainstorm as many mental health conditions that you can think of that would indicate mental illness. Start with some of the major conditions, for example: schizophrenia. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 6 There are many diagnosable mental health conditions. One of the most recognised guides to mental health conditions is the Diagnostic and Statistical Manual of Mental Disorders (DSM). You might have identified: psychotic disorders serious mental illness such as schizophrenia organic disorders anxiety disorders mood disorders such as depression and bipolar disorder substance abuse disorders anxiety disorder such as post-traumatic stress disorder, panic disorder, and phobias personality disorders. 10 2003_309_001 Activity 7: Manifestations of mental illness As identified in the last activity there are a number mental health disorders, but how do they present? What are some of the more common signs and symptoms of mental illness? List what you consider to be some of the signs and symptoms of mental illness. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 7 People that experience any of the diagnosable mental health disorders may present with a variety of symptoms that may include the following: inappropriate or extreme anxiety disturbances of thought and perception altered mood states change in thinking patterns or cognitive dysfunction. Many of these symptoms may be specific to a particular diagnosis or cultural influence. For example, the symptoms of psychosis, being disturbances of thought and perception, are most commonly associated with schizophrenia. We have identified the broad range of symptoms associated with mental illness. Now we are going to look at these symptoms in more detail. 11 2003_309_001 Activity 8: Anxiety How would you explain what ‘anxiety’ is to a person from another culture who is unfamiliar with this term? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 8 Anxiety is one of the most readily accessible and easily understood of the major symptoms of mental disorders. We all experience anxiety in many forms throughout the course of performing various activities or participating in events. It may often take the form of intense fear experienced in response to an immediately threatening experience, such as narrowly avoiding a traffic accident. Experiences such as this are typically accompanied by strong emotional responses of fear and dread as well as physical signs of anxiety such as rapid heart rate and perspiration. Some of the more common symptoms of anxiety include: feelings of fear or dread trembling, restlessness and muscle tension rapid heart rate (tachycardia) light headedness or dizziness perspiration cold hands and feet shortness of breath. 12 2003_309_001 Activity 9: Psychosis When you hear the term ‘psychosis’ or someone is referred to as being ‘psychotic’ what do you think of? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 9 Disturbances of perception and thought processes fall into a broad category of symptoms referred to as psychosis. Psychosis is often described as being out of touch with reality. Like anxiety, psychotic symptoms may occur in a wide range of mental disorders. They are most characteristically associated with the condition called schizophrenia, but psychotic symptoms can also occur in severe mood disorders and in relation to excess use of drugs such as amphetamines and cannabis. People who have a psychotic disorder may experience a range of symptoms including hallucinations and delusions. Activity 10: Hallucinations If a person is said to be ‘hallucinating’ what do you understand by this term? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 13 2003_309_001 Feedback 10 We all experience the world though the senses of hearing, smell, touch, taste and sight. At times, people who experience hallucinations may experience distortions of reality in the way they hear and see things that do not actually exist in reality. An example might be someone who hears voices that no one else can hear, or sees people or images that other people do not see. Hallucinations are distortions of reality. The person who is experiencing an hallucination has no awareness that the world is different for other people. Cartoon of a woman staring in the mirror and seeing psychedelic patterns swirling around her head. Activity 11: Delusions What do you understand a ‘delusion’ to be? A delusion is one of the more common symptoms of mental illness that may be seen in people with a serious mental illness and in people who have been abusing psychoactive drugs such as amphetamines and cannabis for prolonged periods of time. In your own words define what you understand a delusion to be. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 14 2003_309_001 Feedback 11 You may often hear in conversation someone being called ‘delusional’ but this may bear little relationship to the group of symptoms of a serious mental illness resulting from disordered interpretation of information. A delusion is a false belief that an individual believes to be true despite evidence to the contrary. A common example is paranoia, whereby a person may have delusional beliefs that they are being followed and are fearful that they may be harmed. Symptoms associated with psychotic mental illness Some of the more common acute symptoms of a psychotic mental illness such schizophrenia include: hallucinations delusions disorganised thought and behaviours illogical thoughts concrete thoughts inability to experience pleasure poor motivation and initiative. Activity 12: Disturbances in mood Most of us have a fairly good understanding of what is meant by ‘mood’. If someone says to you that you are in a bad mood, we can acknowledge that we might not be feeling very happy. When you think about a disturbance of mood, what do think of? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 15 2003_309_001 Feedback 12 Being happy or sad, elated or flat is sometimes quite difficult to describe or put into clear words. The expression of mood may also have many cultural differences. Some cultures may not show overt expressions of happiness and sadness. Disturbances of mood are often seen and experienced as a sustained feeling of sadness or sustained elevation of mood. As with anxiety and psychosis, disturbances of mood may occur in a variety of different ways attached to many different types of mental disorders. The disorder most commonly associated with persistent sadness is major depression, while the condition associated with sustained elevation or fluctuation of mood is bipolar disorder (where the person may experience both mania and depression at different times). Symptoms associated with depression persistent sadness or despair insomnia (inability to sleep) decreased appetite all physical motor functions slowed down an inability to experience pleasure naturally irritability apathy, poor motivation and social withdrawal hopelessness poor self-esteem suicidal thoughts and possibly actions Symptoms associated with mania persistently elevated or euphoric mood inappropriately high self-esteem (grandiosity) decreased sleep physical agitation racing thoughts and distractibility poor judgement and poor impulse control rapid or pressured speech. 16 2003_309_001 Activity 13: Disturbances of thinking or cognition Can you think of some conditions and behaviours that may impact upon our ability to think clearly? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 13 Cognitive function refers to the general ability to organise, process and recall information. There are many functions commonly associated with cognition such as the ability to execute complex sequences of tasks. Disturbances of thinking or cognitive function may be seen in a number of disorders: Progressive deterioration of cognitive function is referred to as dementia. Dementia may be caused by a number of specific conditions including Alzheimer’s disease and Alcohol Related Brain Damage (ARBD). Impairment of cognitive function may also occur in other mental disorders such as depression. Changes in someone’s capacity to think and process information frequently occurs as a result of a host of chemical, metabolic and infectious diseases that can exert an influence on the brain. The consequences of cognitive impairment can vary from short-term memory loss to not being able to access longer-term memories. Attention, concentration and higher intellectual functions can be impaired, as the underlying disease process becomes worse. Language difficulties range from having problems finding words to complete inability to comprehend or use language altogether. 17 2003_309_001 Assessing a person with a dual diagnosis In this section we are going to look at some of the more common mental illness presentations and how to recognise them. When we talk of dual diagnosis (for example, having a person present with depression and heavy drinking) it is often difficult to know what comes first. Is it the depression that has led the person to heavy drinking? Or is it that, due to drinking too much, problems have arisen such as getting fired from their job, relationship breakdown and so on, and so the person has become depressed? At times the picture may be unclear and confusing. An example might be a young man with schizophrenia who smokes a lot of dope and re-experiences psychotic symptoms. This is an example of a drug-induced psychosis. Another example might be an alcoholic who drinks because she feels depressed and shows signs of delirium when withdrawing from this drug. The challenge is not only developing an awareness of the relationship between mental illness and substance use disorders but to try and tease out the relationships between the two. Prevalence studies estimate that that between 30% and 80% of clients in community and institutional treatment settings have coexisting mental health and substance use disorders. Many studies, including one conducted in the USA by Robins and Regier (1991), found that almost a third of people who had a mental health disorder had experienced a substance use disorder at some point. Studies also confirmed that a third of people with an alcohol disorder had experienced a mental health disorder. The Australian National Survey of Mental Health and Wellbeing (1998) reported that approximately half of females and a quarter of males with a substance use disorder met the criteria for a mental health disorder. 18 2003_309_001 Activity 14: Substance use disorder What do you understand the condition ‘substance use disorder’ to be? In your own words try and tease out a definition. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 14 One way to describe this disorder is to look at the interrelationship of factors associated with problematic substance use. This model contains three components: Diagram of three overlapping circles and each circle is labelled: problems of intoxication; problems of regular use; and problems of dependence. These three components can exist as distinct entities but can also interconnect to further compound the outcomes associated with substance use. In Australia, The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the classification system used within the Drug and Alcohol and Mental Health areas. There are three components inclusive of substance intoxication, substance misuse and substance dependence, as follows, that are described by this classification system: 19 2003_309_001 1 The criterion for substance intoxication is defined as the development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance. 2 The criterion for substance misuse is defined as a maladaptive pattern of substance use leading to a clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home recurrent substance use in situations in which it is physically hazardous recurrent substance use leading to legal problems (eg arrests for substance-related disorderly conduct) 3 continued substance use due to having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg arguments with the spouse about consequences of intoxication, or physical fights). The criterion for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: Tolerance, as defined by either of the following – a need for markedly increased amounts of the substance to achieve intoxication or the desired effect – markedly diminished effect with continued use of the same amount of the drug. Withdrawal, as manifested by either of the following – the characteristic withdrawal syndrome for the substance – the same (or closely related) substance is taken to relieve or avoid a withdrawal syndrome – the substance is often taken in larger amounts or over longer periods of time than was intended – there is a persistent desire or unsuccessful efforts to cut down or control substance use – a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects – important social, occupational or recreational activities are given up or reduced because of substance use – the substance use is continued despite the knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or made worse by the substance. 20 2003_309_001 Activity 15: Drug-induced psychosis There are a number of drugs that, when used to excess, may bring on symptoms of a psychotic illness. In the space below identify some of the more common drugs that may lead the user to experience a psychosis. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 15 Drugs that may cause or bring on psychosis include substances from the stimulant drug group. These include methamphetamine, ‘ice’ and other psycho-stimulants. Marijuana, when used excessively, is another drug that has the effect of bringing on psychotic symptoms. It is also worth mentioning that some people, when withdrawing from alcohol, may experience hallucinations and delusions—key symptoms of psychosis. 21 2003_309_001 Activity 16: Issues to consider in dual diagnosis What are some of the broad areas that come to mind in terms of assessing a client who you suspect may have mental illness and substance use disorders? What sorts of things would you be looking at? Eg cognitive functions, anxiety … Complete this mind map. Mind map with the words dual diagnosis in the centre. 22 2003_309_001 Feedback 16 When looking for or assessing a person for a dual diagnosis there are many different symptoms and behaviours that can be identified. A completed mind map that shows the following symptoms of behaviours associated with dual diagnosis: anxiety, behaviour change, delirium, withdrawal from drugs, cognitive functions, hallucinations, substance use patterns, deppession, delusions, psychosis. 23 2003_309_001 Screening clients for a dual diagnosis condition How would you go about assessing a client who you suspected of having a dual diagnosis? What questions would you ask them? What would you be looking for in terms of their presenting signs and symptoms? This is a difficult task as it does require teasing out issues like whether the client has a psychotic disorder, or has an organic disorder (described later), anxiety disorder or depressive disorder. Let’s look at the screening process that may tease out the issues specific to clients with psychotic disorders. Clients with psychotic disorders The term psychosis is used to refer to a range of psychiatric conditions where there has been some loss of contact with reality. Some points to note: Psychosis has many causes and can be associated with a number of conditions including schizophrenia, bipolar affective disorder, delirium, drug intoxication or drug withdrawal, major depression or head injury. Psychosis is not an uncommon condition, and is most likely to occur in young adults. Many people who experience a psychotic illness make a full recovery. Presenting clients Clients with psychotic symptoms may present with: an acute onset of psychotic symptoms, that is, the symptoms occur very quickly over a short period of time a reoccurrence of an existing psychotic illness such as schizophrenia side-effects of medication problems associated with the abuse of alcohol or other drugs a depressed mood or a background of psychotic illness. Symptoms of psychosis Some of the symptoms of psychosis include: Disorganised thinking—an inability to concentrate, to remember and to be able to follow a conversation. Sentences are unclear and make very little sense. The thinking of a person with a psychotic illness is difficult and clients may have blocked thoughts, or their thoughts are too fast or too slow, or may not be linked together appropriately. 24 2003_309_001 Delusions may be present which are fixed, false beliefs that cannot be challenged by logical argument or by reasoning with the person. Hallucinations may also be present. These are false perceptions which occur in the absence of any external stimuli. All the senses may be involved but most often hallucinations are auditory with the client stating that they hear voices in their head. Changed feelings include changes in mood that may be seen as flat, extreme or inappropriate emotions. Changes in behaviour inclusive of inappropriate, disorganised or bizarre actions. Activity 17: Screening of clients who may have a psychotic illness In trying to identify features of psychosis, what would you look for? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 17 A person with a psychotic disorder may have the following features: Appearance: They may look perplexed, angry, dishevelled, have poor personal hygiene, and be dressed inappropriately or in a bizarre manner. Behaviour: Their behaviour maybe agitated, restless, inappropriate or strange; staring at one place in a room, head turning or gesturing in the absence of any stimuli, the eyes following something that is not observable to other people; mumbling or conversing with unseen person(s). 25 2003_309_001 Verbal cues: Such a person may have difficulties in following or responding to questions; the responses of the person may make no sense or the person may give too much information that is irrelevant or provide no information at all. Clients who may have an organic brain disorder Activity 18: Identifying clients who may have an organic brain disorder An organic brain disorder is a mental disorder in which intellectual or emotional functioning, or both, are impaired due to some sort of pathology (disease or disorder) or dysfunction of the brain. An example of an organic disorder is delirium. In trying to identify features of an organic brain disorder in a client, what would you look for? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 18 A person with an organic brain disorder (specifically delirium) may have the following features: Delirium: This disorder is a collection of signs and symptoms indicative of Acute Brain Failure. There are many causes of delirium, though the symptoms are similar and characterised by alteration in the client’s level of consciousness, and there are significant alterations in the way the person thinks, judges, reasons, and plans. It usually has a sudden onset with a brief and fluctuating course and may improve rapidly when the causative factor is identified and eliminated. It is a common disorder in the elderly and in people with Alzheimer’s. There are many causes of delirium including drug intoxication and withdrawal (from alcohol and prescribed medications), metabolic and 26 2003_309_001 nutritional imbalances, infections and fevers, neurological disorders such as brain tumours, and even the stress of a change in the person’s surroundings can trigger delirium. Symptoms of delirium Some of the features of delirium include: disturbance of cognition (in the way a person thinks, judges, reasons, and plans). There may be some level of change with regard to the level of consciousness, attention and recent memory delusions may be present perceptual distortions and hallucinations may be present disturbances in activity seen as over or under-activity disturbance of sleep and a worsening of symptoms at night emotional disturbances including anxiety, fear, irritability and depression may be present. Screening of clients who may have delirium A person with delirium may have the following features: Appearance: The client may look perplexed, apprehensive or fearful, dishevelled or unkempt, inappropriately dressed and may have signs of a physical illness. Behaviour: They may be agitated, restless, extremely slow and inactive, repetitive purposeless movements, gait disturbance (leans to one side when walking or sitting); appear to respond to auditory hallucinations or to be observing unseen objects or people or picking at unseen things on clothes or the skin. Verbal cues: A person with delirium may have difficulty in speaking or following questions. Answers may not make sense and clients often respond in a repetitive manner. 27 2003_309_001 Activity 19: What sort of things could you ask a person with delirium? In trying to gauge the extent of the condition, what questions would you consider asking the client? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 19 It may be difficult to ask a person with delirium any questions, though depending upon the severity of their delirium the following are appropriate: How are you feeling at the moment? What are the times that you feel at your worse? Are your thoughts all mixed up? How long have you felt like this? Can you tell me the day, date and month? Have you felt that people are against you or trying to harm you? Have you had any strange experiences? Have you had any problems with your physical health? Do you see, hear, smell or feel things that you believe other people do not? 28 2003_309_001 Screening of clients who may have an anxiety disorder Anxiety is an uncomfortable feeling of apprehension and, in small doses, is not uncommon. It is when anxiety starts to affect daily living that an anxiety disorder is said to be present. The symptoms of anxiety include: restlessness and agitation muscle tension, aches and pains fast and rapid heart rate with occasional palpitations sweating and dry mouth dizziness and headaches irritability and sleep disturbances difficulty in concentrating feelings of fearfulness inability to cope. People with anxiety may experience both physical and psychological symptoms. Organic brain conditions and drug and alcohol misuse (taking and withdrawing off some substances) are also associated with the development of symptoms of anxiety. Clients presenting An anxious person may present with: Panic symptoms that are characterised by shortness of breath, overbreathing (hyperventilating), palpitations, chest tightness, lightheadedness, tremors, sweating, nausea, tingling in the hands and feet, and fear that the person is having a heart attack. There may be physical symptoms such as a headache, upset stomach, dizziness and fatigue. Symptoms of both depression and anxiety may coexist. Thoughts of suicide and self-harm may be present. 29 2003_309_001 Clients who may have a depressive disorder Cartoon of a woman looking sad and alone. Activity 20: Symptoms of depression In trying to identify some of the symptoms of depression, what would you look for? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback 20 Depression is a very common mental illness and may be seen in people with a physical illness, chronic pain, disability, psychological distress and people who use and abuse drugs. There are quite a few symptoms of depression that include: a low mood a change in appetite and weight—some people do not feel hungry while others eat more and put on weight there may be a loss of experiencing pleasurable things a loss of energy and motivation to do things poor concentration and recent memory sleep disturbances—difficulty getting off to sleep and frequent waking agitation or feeling really slowed down feelings of guilt, hopelessness and worthlessness suicidal ideas may be present physical aches and pains. 30 2003_309_001 Impact of a dual diagnosis Activity 21: Peter Consider the following scenario. Peter is a 24 year-old man who has had a long history of depression and substance abuse. He consumes large quantities of alcohol on a daily basis and experiences the following symptoms of depression: a very low mood most of the time no appetite poorly motivated to do things poor concentration experiences severe sleep disturbances feels agitated most of the time has marked feelings of guilt and hopelessness. How do you think this combination of depression and a substance abuse disorder may impact on the life of this person? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 31 2003_309_001 Feedback 21 It is likely that Peter has quite a chaotic life. Did you consider the difficulty for him to be able to maintain permanent and stable employment, a healthy relationship, financial stability, his ability to undertake study, and so on? There may also be social issues and health-related issues. The abuse of alcohol may make Peter feel less depressed, though he may be consuming so much alcohol that if he stops he may go into a physical withdrawal. It is difficult to gauge what the impact of these two disorders must be like for Peter. We can try and put ourselves in the shoes of someone like Peter and ask what it may be like. What about the impact of this dual diagnosis condition on family and friends? Every corner of Peter’s life will be impacted upon by depression and alcohol abuse whilst the two conditions remain acute and untreated. Activity 22: Sandra Consider the following scenario. Sandra is a single mother of two young children. Since the age of 21 she has been in and out of the local psychiatric unit on about four occasions due to experiencing psychotic symptoms associated with schizophrenia. Most of the time Sandra is symptom-free when she takes her medication and stays away from smoking marijuana. She finds it a battle just to do some of the basic day to day tasks, so she uses marijuana as a sort of ‘pick me up’. She is aware of the risks of smoking dope in terms of her mental illness becoming more pronounced, but she says that she wants to ‘experience pleasure and zone out for a while.’ Sandra is an accountant who works part-time as her two children are not yet at school. Her mother lives close and helps out with the children. What do you think the impact of the abuse of marijuana and Sandra’s schizophrenic illness might be on her life? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 32 2003_309_001 Feedback 22 It appears that the use of marijuana combined with Sandra’s mental illness has some devastating consequences. Let’s not look at how to fix the situation but reflect upon the overall impact of not only the schizophrenic illness but also the substance use disorder. The impact is quite significant. Not only does Sandra become quite ill, experiencing a range of psychotic symptoms, but her capacity to care for her children and undertake work are seriously compromised. Income that is vital to financial independence is in jeopardy. The relationship with her children is disturbed, as is her capacity to care for them without some sort of external assistance or supervision. Legal problems might also cloud the picture, be they behaviours that Sandra engages in when she is unwell, to loosing her capacity to voluntarily accept treatment for a psychotic condition. She may find herself admitted to a psychiatric unit and placed under the control of the Mental Health Act. The impact of a dual diagnosis for a person such as Sandra is quite devastating. Her whole world will be impacted upon and it is unlikely that any corner is left untouched. Apart from the short-term physical, social, emotional and spiritual impact of a dual diagnosis, there is the longer-term scars of the illness. It may be that people close to Sandra treat her differently and are always on the lookout for signs of her illness. 33 2003_309_001 The Mental Health Act The Mental Health Act is a law that governs the care and treatment of people in NSW who experience a mental illness or mental disorder. (Mental Health Act Guide Book, NSW Institute of Psychiatry, 1998). The underlying philosophy of the Act is to ensure the best possible treatment and care for people with a mental illness. The Mental Health Act states that those who are mentally ill or disordered are to receive the best possible care and treatment in the least restrictive environment, so that any restriction on their liberty or interference with their rights, dignity and selfrespect is kept to a minimum. The Mental Health Act provides a number of ways that allow a person to be transported to a hospital for psychiatric assessment, where that person is not capable or refuses to give consent. The use of the Mental Health Act does not automatically imply that the person will be admitted to an inpatient psychiatric unit. It includes Section 21 and Section 22 that make up Schedule 2 and Section 24. Schedule 2 Schedule 2 is made up of two parts (Sections 21 and 22). It involves an assessment by a medical practitioner (Part 1, Section 21) and police assistance to transport the person to an appropriate facility (Part 2, Section 22). Section 21 A person may be taken and detained in a hospital when he/she has been assessed by the medical practitioner who has formed the opinion that the person is either ‘mentally ill’ or ‘mentally disordered’ and cannot be treated or cared for outside of an inpatient psychiatric facility. Section 22 A medical practitioner who has completed a Schedule 2 under Section 21 may request the assistance of the police in taking the person to hospital. 34 2003_309_001 Section 24 This gives the police broad power to take a person who appears to be mentally disturbed to a hospital for assessment. The police do not need a warrant and may apprehend the person in any place, either public or private. The police are required under the Act to wait until the person has been assessed. There will be occasions where someone with a dual diagnosis may be forcibly apprehended against their will and taken to a hospital for assessment. The impact of being taken against one’s wishes may be quite devastating for the individual, family and friends but the outcome of not having the legal authority of the Mental Health Act would be potentially catastrophic. 35 2003_309_001 Summary From the outset of this topic it was important that we acknowledged that a substance use disorder and mental illness are both diseases. We considered that people who experience a dual diagnosis are ill and do not have the capacity to click their fingers and stop being psychotic or stop abusing drugs without some significant input from, in the most part, health professionals. You explored your understanding of mental illness and mental health. Highlighted was the fact that mental health and mental illness mean different things to different people. Mental illness conditions were described and examined from anxiety disorders and depression to schizophrenia. We explored the question of why some people develop a mental illness and a substance use disorder. In doing so we looked at some of the signs and indicators of mental illness in our society and some of the more common symptoms and behaviours that may be experienced or observed. Identification and assessment of a person with a dual diagnosis is a skill that community services and health industry (CSHI) workers need to master. We also looked at some of the presenting symptoms and behaviours that might feature when assessing for dual diagnosis. Lastly, we looked at the impact that dual diagnosis has on the lives of people living with these illnesses. Working through some scenarios it becomes clear that it is difficult for an observer to fully comprehend and understand the impact a mental illness and a substance use disorder has on the lives of people trapped with this combined illness. 36 2003_309_001 Check your progress 1 What do you understand to be the similarities and differences between mental health and mental illness? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 2 Here are two clients with mental health problems: Paul has been living with a mental illness for the past 10 years. He has been in and out of hospitals and it has only been in the past year that he has been able to get back to work and be in a stable relationship. Tom is experiencing quite a serious bout of depression following the breakdown of his marriage. In terms of mental health, who may be less ill? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 37 2003_309_001 3 Identify some of the reasons why people may develop a mental illness and substance use disorder. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4 Identify some of the more common signs and indicators of psychosis. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5 Identify some of the more common signs and indicators of depression. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 38 2003_309_001 6 If you suspected that a client has an anxiety disorder and substance use disorder, what would you be looking for? _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Feedback: Check your progress 1 Mental health is: a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people and the ability to adapt to change and cope with adversity. It is indispensable to personal wellbeing, family and interpersonal relationships and being able to contribute to community or society. It is the springboard of thinking and communications skills, learning, emotional growth, resilience and self-esteem. What it means to be mentally healthy is subject to many different interpretations that are rooted in value judgements that may vary across cultures. Mental illness is: the term that refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterised by alterations in thinking, mood and behaviour associated with distress and/or impaired functioning. Examples of disorders that are characterised by alterations in thinking, mood and behaviour are as follows: A condition called Alzheimer’s disease (a type of senility) that exemplifies a mental disorder largely marked by alterations in mood, especially thinking. Depression exemplifies a mental disorder marked by alterations in mood. Attention deficit disorder (ADD) exemplifies a mental disorder largely marked by alterations in behaviour (overactivity) and/or thinking (inability to concentrate). 39 2003_309_001 Alterations in thinking, mood and behaviour contribute to a host of problems such as client distress, impaired ability to function and cope, or heightened risk of death, pain, disability, or loss of freedom. 2 This question is quite difficult to answer. Concepts of mental health and mental illness are defined, to some extent, according to the beliefs and values of the society within which the person lives in. When a person is able to carry out his or her role in society and/or his or her behaviours are adaptive to the environment, we may say that the person is ‘mentally healthy’. Such individuals may function comfortably within society, may be accepted within a group and are generally satisfied with their achievements. 3 There are three major factors that influence why some people may develop a mental illness and substance use disorder. Biological factors: Biological factors include genetic predisposition; physical health; neuroanatomy and physiology. Psychological factors: Psychological factors include nurturing during childhood; parent, child and sibling interactions; intelligence; self-concept; skills; talents; creativity and emotional development. Socio-cultural factors: Socio-cultural factors include family stability; child rearing patterns; economic resources; housing; religious beliefs and values. 4 5 Some of the signs and symptoms of a person with a psychotic illness may include the presence of: hallucinations delusions disorganised thought and behaviours illogical thoughts concrete thoughts inability to experience pleasure poor motivation and initiative. Some of the common signs and symptoms of depression include: persistent sadness or despair insomnia (inability to sleep) decreased appetite all physical motor functions slowed down an inability to experience pleasure naturally irritability apathy, poor motivation and social withdrawal 40 2003_309_001 6 hopelessness poor self esteem suicidal thoughts and possibly actions. The types of questions that may help to tease out an anxiety disorder and substance use disorder are: Do you feel restless and agitated? Have you any muscle tension, aches and pains? Do you experience a rapid heart rate? Do you experience sweating, a dry mouth, dizziness and headaches? Do you suffer from irritability and sleep disturbances, difficulty in concentrating and feelings of fearfulness? Are you concerned about your ability to cope? Are you using alcohol or other drugs and, if so, what are you using and how often? 41 2003_309_001 Additional resources Books American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn), (DSM1V), Washington DC Australian Health Ministers (1992) National Mental Health Plan Australian Government Printing Service, Canberra Hall W, Teesson M, Lynskey M, and Degenhardt L (1998) ‘The prevalance in the past year of substance use and ICD-10 substance use disorders in Australian adults; Findings from the Australian National Survey of Mental Health and Wellbeing’ Technical Report No.63, National Drug and Alcohol Research Centre Mental Health Act Guide Book (1998) NSW Institute of Psychiatry ‘National Survey of Mental Health and Wellbeing of Adults in Australia’ (1997) Australian Bureau of Statistics Robins L and Reiger D (eds) (1991) Psychiatric Disorders in America: The Epidemiology Catchment Area Study New York, Free Press Smith J and Hucker S (1994) ‘Schizophrenia and Substance Abuse’ British Journal of Psychiatry 165 Videos Drug Use and Misuse (1998) Lidnja Davis What’s Your Poison (1999) Geoffrey Burchfield Using the Internet Australian Drug Foundation (ADF): www.adf.org.au Alcohol and Drug Foundation: www.adfq.org 42 2003_309_001 Glossary Affect a subjective feeling or emotional tone often accompanied by bodily expressions noticeable to others Anxiety an unpleasant feeling of fear and apprehension accompanied by increased physical symptom arousal Delirium a state of great mental confusion in which consciousness is clouded, attention cannot be sustained, and the stream of thought and speech is incoherent; the person is probably disoriented, emotionally erratic, restless or lethargic, and often has illusions, delusions, and hallucinations Delusion a fixed, false belief that a person is experiencing and believes to be real; a person cannot be talked out of their delusional belief Depression an emotional state marked by great sadness and apprehension; feelings of worthlessness and guilt; withdrawal from others; loss of sleep, appetite, and sexual desire, or interest and pleasure in usual activities; and either lethargy or agitation Hallucination a sensory perception that has the compelling sense of reality but that occurs without any external stimulation; most commonly involves the hearing of voices; other less common experiences can include seeing, feeling, tasting, or smelling things which, to the person are real, but are not actually there Schizophrenia a group of psychotic disorders characterised by major disturbances in thought, emotion and behaviour; disordered thinking in which ideas are not logically related; faulty perception and attention; bizarre disturbances in motor activity; flat or inappropriate emotion; reduced tolerance to stress of interpersonal relations Tolerance a reduced sensitivity to a drug by the body; as a result of regular and repeated doses of the drug, the body becomes used to or tolerant to the drug, thus higher doses are required for the person to experience the desired drug effects 43 2003_309_001