Psychiatric Diagnosis in Homeless Persons: Challenges and Strategies

International Street Medicine Conference

October 22, 2010

“One thing only I know and that is I know nothing.”

- Socrates

Co-founding Variables

• Limitations of psychiatry!

• Substance abuse and withdrawal

• Emotional and physical trauma

• Medical illnesses

• Neurological illnesses

• Multiple diagnoses

• Multiple providers, multiple short-term agency stays

Co-founding Variables (cont.)

• Complexities of symptom presentation• Effects of homelessness on psychiatric

symptomso Hygiene o Sleepo Fatigueo Threat to safetyo Demoralizationo Maladaptive coping skills

Co-founding Variables (cont.)

• Complexities of childhood historyo Abuseo Losso Deprivationo Instability

• Lack of work-up beyond interview and mental status exam

• Pressure to diagnose o Colleagueso Need of diagnosis for disability and housing

Strategies

• First step, engagement

• Modification of the evaluation processo Brief, casual encounters

oMonths to years

o Open-ended, neutral questions

Strategies (cont.)

• Observation is key

o Groomingo Odd or unusual clothingo Abnormal mouth or finger movementso Movementso Evidence of auditory hallucinations o Belongingso Locationo Company or isolation

Strategies (cont.)

• Voices-differential diagnosiso Schizophrenia

oMania

o PTSD

o Personality disorders

o Cultural

Strategies (cont.)

• “Organic”o First, rule out delirium • Inattention• Disorientation• Memory• Visual hallucinations• Combative behavior• Alcoholic hallucinations

Strategies (cont.)

Strategies (cont.)

o Psychiatric diagnosis vs. “organic” (cont.)• CAUSES

Brain injury Liver failure Drug intoxication Hypothyroidism Subdural hematoma Chronic alcohol abuse Alzheimer or other dementia B12 deficiency Renal disease Hypocalcemia Hyponatremia

DIFFERENTIAL DIAGNOSIS-BIPOLAR DISORDER

• Schizophrenia• Schizoaffective disorder• Personality disorder• PTSD• Anxiety disorder• Substance Abuse• Medication side effects• Neurological disease• Depression

Bipolar Disorder

• Zimmerman study-Brown University, 2008 82 out-patients

o 40% of people over-diagnosed with bipolar disorder met criteria for borderline personality disorder

• Muzina study-Cleveland Clinic, 2008o 100 patients admitted to mood disorder clinic-o 60% of those diagnosed with bipolar disorder did not meet

criteria for bipolar disorder

• Why over-diagnosis?• Dangers of over-diagnosis

Personality Disorder

• 12% of general population

• Often co-morbid with Axis I disorder

• Patterns of inflexible and maladaptive personality traits and behaviors that cause subjective distress

• Not bad character but rather serious psychiatric condition defined by failures in social role functioning

BIPOLAR vs. BORDERLINE PERSONALITY DISORDER

• Bipolar--episodic--distinct period of unequivocal change, uncharacteristic of the person when they are not symptomatic

• BPD--lability and impulsivity enduring pattern

• Bipolar-decreased need for sleep• BPD-often no sleep problems

BIPOLAR vs. BORDERLINE PERSONALITY DISORDER (cont’)

• BPD-quick response to intervention -distorted self image -feelings of emptiness

• Bipolar disorder-family history of Bipolar disorder -inflated self-esteem

Personality Disorder (cont.)

• Why recognize and treat? o Social implications

o Exacerbations of symptoms of Axis I

o Interfers with relationship of provider and patient

o Treatment works!

Neuropsychological Evaluation

• Known brain disorder

• Known risk factor for brain disorder

• No known risk factors but brain disorder suspected

Neuropsychological Evaluation (cont.)

• Uses

o Nature and severity of cognitive, behavioral and emotional problems

o Potential for independent living

o Foundation for treatment planning

PSYCHOLOGICAL TESTING

• IQ• Personality tests• MMPI hypochondriasis hysteria depression paranoia psychasthenia schizophrenia mania

•

Rating Scales

• Verify diagnosis

• Assess severity

• Measurement of psychiatric conditions in different points of time

• Determination of effectiveness of treatment

Alliance Building

• Consistent presence• Proceed at clients’ pace• Instill hope• Extend traditional boundaries• Focus on long-term goals• Remember engagement is not a linear

process

Alliance Building (cont.)

• Don’t give up on anyone• Team effort• Don’t insist that client acknowledges the mental

illness• Try to get person to take medications to make

them feel better• Accept clients’ explanations for not feeling well• Relationship first, treatment second

SUMMARY

• Psych. diagnosis of homeless person is more challenging that the non-homeless person

• Don’t take a “carried” diagnosis at face value.

• No definite Axis I does not mean that client is not very ill.

SUMMARY

• Clarify diagnosis by psychological testing, neuropsychological testing, scales, substance abuse history, old records, watching and waiting.

• Engage, engage, engage.