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Psychotropic Medications and
Diagnoses in Social Services
Misty Harding, MS, LCMFT
Director Youth Services
Salvation Army Wichita
Welcome and Introductions
• Welcome
• Housekeeping
• Introductions
• Information is a guideline
– DO NOT DIAGNOSE UNLESS YOU ARE
QUALIFIED AND THE PERSON IS YOUR
PATIENT
– Updated with DSM-5 information
THE BRAIN AS A CHEMICAL
REACTION
Brain Chemical Reactions
• Neurons
• Synapses
• Neurotransmitters
– Serotonin
– Adrenalin
• Uptake
• Reuptake
Neurons
Neurons
Medication as Chemical Balance
• SSRI
– Prozac, Welbutrin, Lexapro, Paxil
• Anti-psychotic
– Thorazine, Haldol, Clozaril,
Risperdal
• MAOI
– MonoAmine Oxidase
– Mebanazine, Octamoxin,
Phenelzine
• TriCyclics
– Imipramine, Loratadine
(antihistamine)
• Stimulant/Non-stimulant (focus)
• Other (Mood Stabilizers)
– Anti-convulsant
– Blood pressure stabilizer
– Antihistamine
DIAGNOSING and TREATING
DYSFUNCTION
Change from DSM-IV to DSM-5
• Multiaxial (DSM-IV)
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Axis
Axis
Axis
Axis
Axis
1
2
3
4
5
– clinical
– pervasive
– medical
– psychosocial
- GAF
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Sharing of symptoms
Risk factors
More NOS categories
Genetics
Comorbidity
Shared treatment response
Organized by:
• Internalizing vs externalizing
• Developmental/lifespan
• Dimensional (DSM-5)
•
considerations
Includes culture and gender
Definition of a Mental Disorder
(Per DSM-5)
• “A mental disorder is a syndrome characterized by clinically
significant disturbance in an individual’s cognition, emotion
regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes
underlying mental functioning. Mental disorders are usually
associated with significant distress or disability in social,
occupational, or other important activities. An expectable or
culturally approved response to a common stressor or loss,
such as the death of a loved one, is not a mental disorder.
Socially deviant behavior (e.g., political, religious, or sexual)
and conflicts that are primarily between the individual and
society are not mental disorders unless the deviance or
conflict results from a dysfunction in the individual, as
described above.”
Purpose of a mental disorder
diagnosis
• Determine prognosis
• Steer treatment planning
• Direct treatment
• Diagnosis does NOT always mean the
client NEEDS treatment
– Based on level of distress/impairment
– 3rd party info is highly recommended
Diagnostics
Principal Diagnosis
• Primary for clinical visit
• Causing the majority of
dysfunction
• Becomes the focus of
treatment
• More validity if based
upon measures/testing
(evidentiary)
– Some in the DSM-5
– Some require further
training
– Entire section on Culture
Provisional Diagnosis
(no more Rule Out)
• Presumptive
• Not enough info
• When the diagnosis is
based upon a specific
time frame
MENTAL HEALTH INFORMATION
• Best information comes
from;
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Client
Family
Doctor
Therapist
Pharmacist
Psychiatrist
Counselor
Case managers
• Hypochondriasis
prevention
– Dysfunction
– Issue
– Level of functioning
Common Diagnoses in Social
Services
• Dysfunction
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Bipolar Disorder
ADHD
Depression
Psychotic Disorders (Schizophrenia, Delusional)
Trauma Disorders
Substance/Chemical Abuse**
Mental Retardation/Developmental Delay**
• Personality Disorders
– Borderline
– Antisocial
Bipolar Disorder
• Per DSM IV
– “The essential feature of Bipolar I disorder
is a clinical course that is characterized by
the occurrence of one or more Manic
Episodes or Mixed Episodes. Often
individuals have also had one or more
Major Depressive Episodes.”
Bipolar Disorder
• Per DSM-5 “Bipolar and related disorders are separated
from the depressive disorders in DSM-5 and placed
between the chapters on schizophrenia spectrum and other
psychotic disorders and depressive disorders in recognition
of their place as a bridge between the two diagnostic
classes in terms of symptomatology , family history, and
genetics.
• Adds Disruptive Mood Dysregulation Disorder for clients
under 18 “who exhibit persistent irritability and frequent
episodes of extreme behavioral dyscontrol.”
Bipolar Disorder
• Possible Behavior
– Manic behavior
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Euphoric
Indiscriminate enthusiasm for sexual/interpersonal relationships
Inflated self-esteem
Alternating mood between euphoria and irritability
(complaining/hostile)
Decreased need for sleep
Speech is loud, rapid, difficult to understand (thoughts move faster
than the mouth)
Compulsive
Poor judgment
– Depression
– Anxious distress
– Significant impairment in occupation, relationships and/or
activities/energy
Bipolar Disorder
• Common medications with side effects
– Depakote (anticonvulsant)
• Shaking, nausea, drowsiness, headache
– Lamictal (anticonvulsant)
• Dizzy, drowsy, fatigue
– Lithium (salt)
• Tremors, thirst, diarrhea, vomiting
– Geodon (antipsychotic)
• Blurred vision, dry mouth, weight gain
– Anti depressants?
• Takes away depression
• Leaves mania
ADD/ADHD
• Per DSM-IV
– “The essential feature of AttentionDeficit/Hyperactivity Disorder is a persistent pattern
of inattention and/or hyperactivity-impulsivity that is
more frequent and severe than is typically observed
in individuals at a comparable level of
development… There must be clear evidence of
interference with developmentally appropriate
social, academic, or occupational functioning.”
ADHD
• Per DSM-5 “The essential feature of
attention-deficit/hyperactivity disorder
(ADHD) is a persistent pattern of
inattention and/or hyperactivity that
interferes with functioning, or
development.”
ADD/ADHD
• Possible Behavior
– Careless mistakes, lack attention to detail
– Move from one task to another quickly, without
finishing
– Disorganized
– Fidgetiness, squirming, running, climbing
– Difficulty with leisure
– Impatient
– Marked impairment in two settings; home, work,
school
ADD/ADHD
• Common medications with side effects
– Stimulants
• Adderall, Concerta, Focalin
• Weight loss, sleep problems, jittery
– Non-stimulants
• Straterra, Intuniv, Kapvay (new)
• Nausea, vomiting, constipation, headache
Depression
• Per DSM-IV
– “The essential feature of Major Depressive Disorder is
a clinical course that is characterized by one or more
Major Depressive Episodes without a history of Manic,
Mixed, or Hypo-manic Episodes.” “The essential
feature of a Major Depressive Episode is a period of at
least 2 weeks during which there is either depressed
mood or the loss of interest or pleasure in nearly all
activities.”
Major Depressive Disorder
• Per DSM-5 “Unlike in DSM-IV, this chapter
‘Depressive Disorders’ has been separated from
the previous chapter ‘Bipolar and Related
Disorders.’ The common feature of all of these
disorders is the presence of sad, empty, or
irritable mood, accompanied by somatic and
cognitive changes that significantly affect the
individual’s capacity to function. What differs
among them are issues of duration, timing, or
presumed etiology.”
Depression
• Possible Behavior
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Irritability
Changes in appetite or weight
Changes in sleep patterns
Loss of energy/fatigue
Feelings of guilt, worthlessness, and/or having “no”
feelings
Recurrent thoughts of death or suicidal
thoughts/plans and/or attempts
Anxious
Body aches/pains
Loss of pleasure in previously pleasurable activities
Depression
• Common medications with side effects
• SSRI
– Prozac, Welbutrin, Lexapro, Paxil
– Non addictive but cannot be stopped abruptly,
weight change, decline in sexual function
• Anti-psychotic
– Thorazine, Haldol, Clozaril, Risperdal
– Weight gain, high cholesterol, increased risk
of diabetes
Psychotic Disorders
• Per DSM-IV
– These disorders “are all characterized by having
psychotic symptoms as the defining feature…The term
psychotic has historically received a number of
different definitions, none of which has achieved
universal acceptance. The narrowest definition of
psychotic is restricted to delusions or prominent
hallucinations, with the hallucinations occurring in the
absence of insight into their pathological
nature…Finally the term has been defined conceptually
as a loss of ego boundaries or a gross impairment in
reality testing.”
Psychotic Disorders
• Per DSM – 5 Key Features that Define the
Psychotic Disorders
– Delusions
– Hallucinations
– Disorganized thinking (speech)
– Grossly disorganized or abnormal motor
behavior
– Negative symptoms
Psychotic Disorders
• Disorders
– Schizophrenia – more than 6 months
• Paranoid
• Disorganized
• Catatonic
• Undifferentiated (not paranoid, disorganized, or catatonic)
• Residual (not meeting all criteria – mostly flat)
– Schizophreniform – 1 to 6 months
– Schizoaffective – Depression and/or mania with
schizophrenia
– Delusional Disorder – nonbizarre delusion for at least
1 month
– Brief psychotic Disorder – “nervous break down” with
return to normal
– Folie a Deux – shared delusion/psychotic disorder
Psychotic Disorders
• Possible Behaviors
– Smiling/laughing/silly faces without appropriate
stimuli
– Loss of all interest/pleasure
– Delusional beliefs
– Pacing/rocking or immobility
– Confusion/Disorientation
– Loss of reality
– Differing reality
– Ritualistic/odd mannerisms
– 10% successfully commit suicide
– Common for use of substances esp: nicotine
Psychotic Disorders
• Common medications and side effects
– Neuroleptics “take the neuron”
• Thorazine, Haldol, Prolixine, Navane
• Tremors, involuntary movements, muscle rigidity,
spasms
– Atypical antipsychotics
• Clozaril – decrease in white blood cells
• Abilify, Geodon, Risperdal – weight gain, increased
blood sugar and cholesterol
Trauma Disorders
• Neuropsychosocial Development
– The more a brain system is used, the more it changes and morphs
to reflect how it’s activated (development/memory/learning)
– From the moment of first trauma, neurodevelopment is impacted
• New experience ALWAYS filtered through old experience for
context and understanding
– Ability to bond and show empathy is directly related to early life
relationships
– Trauma creates stimulitic arousal (heart rate, brain stimulus,
breathing)
– High arousal creates dissociation (check out)
– Effects all levels of development including intelligence, mental
health, and physical growth
Trauma Disorders
• Per DSM-5 “Trauma and
stressor-related disorders
include disorders in which
exposure to a traumatic
or stressful event is listed
explicityly as a diagnostic
criterion…close
relationship between
these diagnoses and
disorders…anxiety
disorders, obsessivecompulsive…and
dissociative disorders”
• Diagnoses
– Reactive Attachment
Disorder (withdraw)
– Disinhibited Social
Engagement Disorder
– Posttraumatic Stress
Disorder
– Acute Stress Disorder
– Adjustment Disorder
– Other Specified Traumaand Stressor-Related
Disorder
– Unspecified Trauma-and
Stressor-Related Disorder
Trauma Disorders
• Possible Behaviors
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Anxiety
Fear
Feeling “numb”
Dysphoria
Anger
Aggression
Dissociation
Flashbacks
• Medication
– Only two approved for
treatment of PTSD
• Paxil
• Zoloft
– Other(s) may be used
to treat accompanying
symptoms
• Sleeping meds
• Antipsychotics
• Other antidepressants
Personality Disorder
• Per DSM-IV
– “A Personality Disorder is an enduring pattern of inner
experience and behavior that deviates markedly from the
expectations of the individual’s culture, is pervasive and
inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or
impairment.”
Personality Disorder
• Per DSM – 5 – Alternative approach to
diagnosing – Section III – Page 761
– General criteria for Personality Disorder
• Impairment in personality functioning
• One or more pathological personality traits
• Personality impairments are relatively inflexible and
pervasive
• Impairments are stable and traced back to adolescence or
young adult hood
• Not better explained by another mental disorder
• Not attributed to a substance or medical condition
• Not normal for development or sociocultural environment
Personality Disorder
• Possible Behaviors
– Borderline Personality Disorder – “is a pattern of instability in
interpersonal relationships, self-image, and affects, and marked
impulsivity.”
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Avoids real or perceived abandonment
Unstable relationships (push/pull)
Unstable self-image
Suicidal/self-harm
Intense moods and anger problems
Paranoid and/or dissociative
– Antisocial Personality Disorder – “is a pattern of disregard for, and
violation of, the rights of others.” Commonly referred to as
“psychopath,” or “sociopath.”
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Deceitful, manipulative
Impulsive, failure to plan
Irritable/aggressive
Reckless disregard of safety for self and others
Irresponsible
Lacks remorse
Prior to age 18,may have diagnosis of ODD, Conduct DO or Disruptive DO
Personality Disorder
• Common medication and side effects
– Borderline
• Anti depressants
• Mood stabilizers
• Anti psychotics
– Antisocial
• Rarely seek treatment
• Lack insight and motivation
• Anger and high frustration
Suicide Risk is HIGH in Social
Services
• “Suicidal behavior is seen in the context of a
•
variety of mental disorders, most commonly
bipolar disorder, major depressive disorder,
schizophrenia, schizoaffective disorder, anxiety
disorders…substance use disorders…borderline
personality disorder, antisocial personality
disorder, eating disorders, and adjustment
disorders. It is rarely manifested by individuals
with no discernible pathology…”
Chaos and disruption are common in SS and
exacerbate feelings of hopelessness
Suicidal Ideation
Ideation
• Thoughts
• How to kill oneself
• Most do not attempt when
•
having these thoughts
Some may make suicide
attempts
– Some deliberately planned
to fail or be discovered
– Some carefully planned to
succeed
– According to a Finnish study,
over one fifth of people who
actually died by suicide had
discussed their aim with a
doctor or other health care
professional during their last
session
Self-harm
• Repeated self inflicted
injury
• Shallow but painful
• Surface injury
• With purpose
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Reduce tension
Reduce anxiety
Self punishment
Resolve interpersonal conflict
Immediate sense of relief
Addictive qualities
NOT A SUICIDE ATTEMPT
NOR EVIDENCE OF SUICIDAL
IDEATION
INFORMATION IS A WEAPON OR A
TOOL?
• Knowledge
• NOT for diagnosing (unless qualified
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•
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to do so)
NOT for providing psychotherapy
(unless qualified to do so)
NOT for medication management
Best tool is referring and
communication
• Do not take mental illness
lightly
• **Cultural diversity and
faith/mental illness
Questions?
• Misty A. Harding, MS, LCMFT
• Director of Youth Services; Residential
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and Foster Care
Wichita City Command/Koch Center
350 N. Market
Wichita, KS 67202
316-263-2769 x 181
[email protected]