Psychiatric and Cognitive Disorders

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Psychiatric and Cognitive Disorders
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Board Exam Review
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  1. conciousness
    state of awareness that responds to external stimuli

    disturbances are usually a result of brain pathology

    disorientation is a disturbance of orientation to person, place or time. situation is sometimes used as a 4th consideration

    delirium is an acute, reversible disorder that presents as disoriented reaction with confused lability, and distrubances in behavior; may be associated with fear and hallucinations

    confusion involves inappropriate reactions to environmental stimuli, manifested by a disordered orientation in relation to person, place, time

    sundowner syndrome: occurs late afternoon and at night in older people, often seen in individuals with dementia; characterized by drowsiness, confusion, ataxia, falling, agitation, and sometimes aggression; associated with sedation, dementia, and changes in orienting cues such as light, familiar people, and objects.
  2. attention
    ability to focus on the various aspects of an activity or experience or the ability to concentrate

    • disturbances of attention
    • distratibility istheinability to concentrate one's attention without attention being drawn to unimportant or irrelevant stimuli

    selective inattention-is blockingout those activities, objects, or concepts that produce anxiety

    hypervigilence- excessive attention and alertness that guards against potential danger.
  3. emotion
    feeling state associated with affect and mood that consists of psychological and physical components

    physiological disturbances associated with mood are frequently autonomic in nature

    • affect is the observable component of emotions
    • appropriate affect is congruent with the accompanying idea, thought, or speech
    • disturbances of affect include inconsistencies with accompanying idea, thought or speech, blunted affect is a severe lack of affect, restricted affected is reduced affect, and flat affect is absence of any affective signs of emotions; labile affect is rapid and abrupt changes in affect.

    mood is a pervasive and sustained emotion manifested by thoughts and actions.

    rapid changes in affect (lability) are usually accompanied by rapid changes in mood; called "mood swings"

    • other emotions
    • anxiety is a feeling of apprehension or worry associated with anticipation of future danger; free floating anxiety does not have a specific focus.

    fear is an anxiety that is focused on real danger.
  4. motor behavior
    behavioral and motoric expressions of impulses, drives, wishes, motivation, and cravings.

    • disturbances of motor behavior:
    • echopraxia- meaningless imitation of another person's movements
    • catatonia-immobility or rigidity
    • sterotypy-repetition of fixed behaviors (movement and speech (echolia)).
    • psychomotor agitation - excessive motor and cognitive activity, usually nonproductive and in response to inner tension
    • hyperactivity-restless,sometimes aggressive,or destructive activity often associated with brain pathology
    • psychomotor retardation-decreased or slowed motor and cognitive activity
    • aggressions(forceful,agry or destructive speech or behavior)
    • acting out is the phyiscal expression of thoughts and impulses
    • akathisia-state of restlessness characterized by an urgent need for movement,usually as a side effect of meduication
    • ataxia-irregularity or failure or muscle coordination upon movememt.
  5. Thought
    Thinking is a goal-directed reasoned flow of ideas and associations (when thinking follows a logical sequence it is considered normal)

    • disturbances in form of thought include:
    • circumstantiality- speech that is delayed in reaching the point and contains excessive or irrelevant details

    tangentiality-abrubt changing of focus to a loosely associated topic

    perseveration-persistent focus on a previous topic or behavior after a new topic/bx has been introduced

    flight of ideas refers to rapid shifts in thoughts from one idea to another

    thought blocking is the interruption of a thought process before it is carried through to completion

    loosening of associations- the logical progression of thoughts were seemingly unrelated and unconnected ideas from one subject to the next.

    • disturbances in content of thought
    • delusions- false beliefs about external reality without an appropriate stimulus that can be explained by the individual's intelligence or cultural background

    compulsions are a need to act on specific impulses to relieve associated anxiety

    obsessions constitute a persistent thought or feeling that cannot be eliminated by logical thinking

    concrete thinking is characterized by actual things, events and immediate experience; inability to think abstractly.
  6. speech
    expression of ideas, thoughts, and feelings through language

    • disturbances in speech:
    • pressured speech is rapid and increased in amount
    • poverty of speech is limited amount
    • poverty of content is adequate amound but conveys little information due to vagueness
    • nonspontaneous speech- responses that are given ony when spoken to directly
    • stuttering consists of repetieion or prolongation of sounds or syllables
    • perseveration is continued, perisistent repetition of a word or phrase

    • disturbances in word output
    • expressive aphasia(brocas) is a disturbance in which the individual knows what they want to say but cannot say it

    receptive aphasia(wernickes)- an organic loss of the individuals ability to comprehend what has been saidto him/her

    nominal aphasia- inability to name objects

    global aphasia-involves all forms of aphasia.
  7. Perception
    process of interpreting sensory information recieved from the environment

    • distrubances in perception include:
    • hallucinations are a false sensory perceptions that are not in response to an external stimuli

    illusions are misperceptions or mininterpretations of real sensory events

    • disturbances associated with cognitive disorders
    • agnosia-inability to unserstand and interepret the significance of sensory input (visual agnosia is the inability to recognize people and objects)

    astereognosis- inability to identify objects through touch

    apraxia- inability to carry out specific motor tasks in the absence of sensroy or motor impairment

    adiadochokinesia- inability to perform radidly alternating movements

    disturbances associated with conversion and dissociative phenomena; disturbances in response to repressed material and involvement of physical sx and distortions that are not under voluntary control or associated with physical disorder

    depersonalization- subjective sensation of unreality about oneself or the environment

    derealization is a subjective sense that the environment is not real

    fugue is a state of serious depersonalization, oftern involving travel or relocation, in which the individual takes on a new identity with amnesia for the old identity.

    dissociate identity disorder- appearance that and indiviausl has developed two or more distinct personalities

    dissociation involves the separation of a group of mental or behavioral processes from the res of the person's psychic activity. (may involve separating an idea from its emotional tone)
  8. memory
    process where what has been experienced or learned is registered and stored, can be retained to varying degrees, and can be recalled at will.

    levels of memory

    • immediate memory- ability to recall material within seconds or minutes  (short term)
    • recent memory- ability to recall events of past few days
    • recent past memory- recall events of the past few months
    • remote memory- ability to recall events of the distant past (long term memory)
    • procedural memory- automatic sequence of behavior such as a conditioned response
    • declarative memory- recall specific to consciously learned facts,such as school subjects
    • semantic memory- knowing the meanings of words and ability to classify information
    • episodic memory- knowledge of ones personal experiences
    • prospective memory- capacity to remember to carry out actions in the future, such as knowing youhave appointments scheduled, to turn off the stove and to pay bills on time (**important to live safely and indepently)

    • disturbances of memory
    • amnesia- inability to recall past experiences or personal identity (may be caused by organic or emotional dysfunction)
    • retrograde amnesia- inability to remember events that occurred prior to precipitating  event.
  9. DSM IV
    Axis I - clinical disorders and other conditions that may be the focus of treatment (major depressive disorder, exacerbation of schizophrenia)

    Axis II- Intellecutual disabilites and personality disorders

    Axis III -general medical conditions

    Axis IV- Pshychosocial and environmental stresors/problems

    • Axis V- GAF
    • low scores indicate liklihood to cause harm to self or others, score of 100-91 indicates superior functioning
  10. psychotic disorders
    schizophrenia
    • diagnositic criteria
    • CRITERION A:
    • 2 or more of the following symptoms
    • delusions, hallucinations, disorganzied speech, positive symptoms, negative symptoms

    • CRITERION B:
    • distrubance in one or more areas of function such as work, intrapersonal relationships, or self care

    • CRITERION C:
    • continuoys signs of illness for 6 months including at least one month of symptoms that meet criterion A

    • Positive symptoms:
    • are the excess or distortions of normal function

    • NEgagtive symptoms:
    • represent a loss or absence of function
    • restricted emotion(flattening affect)
    • difficulty experiencing pleasure(adhedonia)
    • decreased thought and speech (Alogia)
    • lack of energy (anergia) and initiative (often misinterpreted as lack of motivation)
    • inability to relate to others

    paranoid type- characterized by preoccupation with one or more delusions of persucution or gandeur (auditory hallucinations are most common and negative symptoms are not common)

    disorganized type- regression desmonstrating primitive, disinhibited, and disorganized behavior

    catatonic type-characterized by severe disturbances in motor behavior

    undifferentiated type- for those not fitting in other categories

    residual type- when sx are present but do not reach complete set of diagnostic criteria

    • 50% recover and live independently
    • 25% lead satisfying lives with ongoing supports
    • other 25% not good prognosis
  11. Pscychotic disorders
    Schizophreniform disorder- meets the criteria for schizophrenia but episodes last between 1 and 6 months.

    schizoaffective disorder- person has uninterrupted period of illness which at sometime there is a major depressive period, a manic episode, or a mixed episode with symptoms that meet criterion A for schizophrenia

    delusional disorder- individual's predominant symptoms are nonbizarre delusions with the absence of other crtierion A symptoms.

    Brief Psychotic disorder: individual experiences at least one day but less than one month with 1+ criterion A symptoms resulting from severe psychosocial stress
  12. psychotic disorders impact on function
    many individuals with pyschotic disorders demonstrate deficits in cognitive-perceptual and social interaction skills that affect all areas of function

    deficits of sensory processing can make interaction with environment difficult and frightening

    can have difficulty with exhibiting socially appropriate behaviors, and having effective/meaningful conversations

    cognitive function impairments and difficulty with performance of basic skills interfere with all areas of occupation.
  13. psychotic disorders
    symptom managment
    treatment consists of use of anti-psychotic medications and prosuceas vision of a structured supportive environment.

    • psychopharmacology
    • traditional antipsychotic mediacations such as Thorazine, Prolixin, Haldol, and Navane.
    • side effects-dry mouth, blurry vision, photosensitivity, constipation, orthostatic hypotension, Parkinsonism, dystonia (impaired tonicity), akathisia (restless), and cardiovascular disorders

    • complications  may include
    • neuroleptic malignant syndrome- autonomic emergency leading to incnreased BP,tachycadia, sweating, convulsions, coma

    tardive dyskinesia- neurological disorder resulting from longterm or high dose use of antipsychotic meds characterized by abnormal, involuntary, irregular movement of the head, limbs and trunk

    neuroleptic-induced Parkinsonism- disorder that presents with stiffness,cog-wheel rigidity,shuffling gait, shuffling gait,stooped posture, and drooling,regular tremors maybe present

    • atypical antipsychotics
    • (Clozaril,Resperdal, Zyprexe, Seroquel, Geodon..)
    • Side effects vary with the medications
  14. diagnostic specific considerations for OT
    when working with a person who has a psychotic disorder who has disorganized thinking-- communicate with simple, clear and concrete statements

    Provide consistent, external structure to organize the individuals thinking, environment, and daily activities.

    Provision of supports and tools to aid in recovery is essestial
  15. Mood Disorders
    diagnosed based on the incidence of manic, hypomanic, major depressive, and mixed episodes (Treatment and interventions will vary with shifts in mood and the symptoms experienced by the person)

    Diagnositic criteria for specific mood disorders:

    Major depressive disorder: one+ depressive episodes, may be single or recurrent episodes

    Bipolar I disorder: one+ manic episodes that may be combined with depressive espisodes

    Bipolar II disorder: one or more major depressive episodes; must be at least one hypomanic episode; no hx of a manic episode

    • other mood disorder diagnoses-
    • dysthymia: categorized by at least two years of a depressed mood most days, with depressive symptoms that are not severe enough to meet MDD

    cyclothymic disorder- characterized by at least two years with numerous periods of  hypomanic and depressive symptoms that do not meet the criteria for a manic episode or a major depressive episode
  16. Manic episode
    distinct period abnormally and persistently elevated, expansive, or irritable mood lasting at least one week

    • during this period, three or more sx are present
    • inflated self-esteem or grandiosity
    • decreased need for sleep
    • more talkative than usual or pressured speech
    • flight of ideas or feeling that thoughts are racing
    • distractibility
    • increase in goal-directed activity or pscyhomotor agitation
    • excessive involvement in pleasurable activities that have a high potential for painful consequences.

    • behaviors associated with manic episode
    • treatment resistance resulting from failure to recognize illness; suggestive or flamboyant dress; gambling, promiscuity, excessive spending of giving things away; irritability, assaultive or suicidal behavior


    • impact on function
    • lack of inhibition may lead to excessive spending, impulsive travel, flamboyant or promiscuous dress, and/or behavior

    individual may be euphoric in the early phase,but may later become labile, threatening and assaultive

    poor judgement can lead to dangerous situations, poor self care, problems in relationships and decreased or irresponsible work behaviors

    sleeping schedules will likely be impacted

    substance abused incidence risk increases

    • symptom management-
    • anyipsychotics
    • mood stabilizing medications
    • Lithium- side effects include excessive thirst, tremors, excessive urination, weight gain, nausea, diarrhea, and cognitive impairment--important to monitor blood levels

    anticonvulsants- side effects include dizziness, drowsiness, ataxia, weight gain and sedation

    • diagnositic considerations for OT
    • limit setting to set and improve boundaries, reduce individual's fears of losing control, increase participation in the intervention process and promote safety

    engagement in activities that provide structure and the opportunity to release excess energy in a positive and therapeutic manner

    periods between episodes should be used to educate the individual and family on symptom management.
  17. Major Depressive Episode
    • diagnositic criteria
    • two week period of depressed mood or loss of interest or pleasure
    • Five or more of the following symptoms
    • depressed mood most of the day
    • weight changes
    • insomnia/hypersomnia
    • phscyomotor retardation/agitation
    • fatigue,loss of energy
    • feelings of worthlessness or guilt
    • diminished ability to concentrate/make decisions
    • recurrent thoughts of death/suicide, or suicide attempt

    • behaviors associated with depressive episode
    • irritability, anxiety, phobias, and obsessive thinking
    • difficulties in social interactions, relationships and sexual functioning
    • self destructive behavior including suicide and substance abuse
    • Maybe manifested as somatic complaints
    • may  be increased use of medical services

    • impact on function
    • individuals are often tearful, brooding and isolative
    • anxiety leads to health concerns about physical health, complaints of pain, and alcohol abuse
    • hopelessness, lack of energy and slow thought processing lead to limited interest in activity and difficulty performing tasks in all areas of occupation.

    • symptom management
    • Antidepressant medications

    • Selective Seratonin Reuptake Inhibitors(SSRIs)
    • side effects include nausea,headache, sexual dysfunction, and insomnia

    Other medications

    ***Most effective treatment involves antidepressant medications and psychotherapy

    CBT- efective for those who demonstrate self awareness and intact congtitive skills

    ECT- very effective and treatment of choisce for those who have been unresponsive to trials on medications and other interventions.

    • Diagnostic specific considerations
    • provision of a safe environment and the  management of behaviors that threaten the safety and well being of the individual are a paramount
    • individuals must be closely monitored for self destructive and/or suicidal behavior; most dangerous time may be when the depression begins to lift and the person becomes mobilized
  18. other subtypes
    mixed episode- criteria are met for both a manic episode and a major depressive episode for at least one week.

    hypo-manic episode- symptoms are the same as for a manic episodes but they are not severe enough ( last < 1 week) to cause marked impairment in social or occupational function or to require hospitalization
  19. Substance Related disorders
    diagnosed based upon the taking of a drug of abuse, the side-effectsof medications, and/or esposure to toxins

    substance related disorders are catergorized into two groups

    substance use disorder- include dependence and abuse

    subtance-induced disoreders include intoxication, withdrawl, and substance-induced anxiety, affective and psychotic disorders
  20. Substance disorders
    • SUBSTANCE DEPENDENCE
    • evidence of tolerance and withdrawl
    • individuals continue to use the substance despite serious consequences

    • SUBSTANCE ABUSE
    • Continued use despite serious consequences

    • impact on function
    • dependent on the type of substance used and on whether the individual is abusing or dependent on it

    • results of disorders of use:
    • disinterest and inability to care for self and others
    • difficulty with and loss of personal relationships
    • inability to be productive and/or social pursuits that do not involve substance use
    • involvement in the legal system
    • **Prolonged use may lead to severe physical, cognitive and psychiatric problems and can result in death.


    • medical management
    • medication to help the individual refrain from substance use can be provided
    • medical management is typically supplemental with psychotherapy and support groups
    • methadone clinics are widely accepted

    • diagnostic specific considerations
    • due to the presence of "learned survival skills" the individul's abilities may be overestimated

    individual's identification of the reasons for substance abuse is important to address during the eval process

    development of skills to cope with life stressors without substance abuse is critical to live without substance (communication and social skills, skills to engage productively in work, education and other productive activities; skills to use leisure time appropriately)

    lifelong patterns of denial, resistance, and other defensive behaviors can make treatment challenging and difficult
  21. anxiety disorders
    anxiety disorders inlcude a range of disorders that include episodic periods of intense anxiety to chronic periods of lower anxiety

    anxiety- internal sense of apprehension and psychological distress. may or may not have a specific focus.
  22. panic attacks and agoraphobia
    • panic attacks are symptoms of anxiety; discrete periods of intense fear or discomfort, in which four or more symptoms are present:
    • palpitations
    • sweating
    • trembling or shaking
    • sensations of SOB
    • feelings of choking
    • chest pain/discomfort
    • nausea or abdominal stress
    • feeling dizzy, unsteady, lightheades, or faint
    • derealization or depersonalization
    • fear of losing control
    • fear of dying
    • paresthesias
    • chillls or hot flashes

    • agoraphobia- associated with panic attacks
    • anxiety about being in places or situations from which escape may be difficult or embarrassing,or in which help may not be available if needed; situations are endured or avoided with anxiety about having a panic attack
  23. specific anxiety disorders
    panic disorder- recurrent panic attacks followed by at least once concern for recurrence

    specific phobia- clinically significant anxiety from a specific object or situation leading to avoidant behavior

    social phobia- clinically significant anxiety from certain types of social or performance situations leading to avoidance

    • obsessive-compulsive disorder:
    • obsessions are recurrent and persistent thoughts,images,impulses that are disturbing, intrusive and inappropriate
    • compulsions- repetitive behaviors that the person is driven to perform to reduce anxiety or prevent a dreaded event or situation.
    • obsessions and compulsions are time consuming and distressing despite the individuals awareness of their irrationality.

    • PTSD
    • persistent re-experiencing (more than one month) of an extremely traumatic event that produces symptoms of increased arousal; results in avoidance of stimuli associated with the traumatic event

    Acute stress disorder- similar to PTSD but it immediately follows an event

    Generalized anxiety disorder- consists of 6 months of persistent and excessive unfocused anxiety and worry.

    **The degree of impact varies with the severity and type of anxiety disorder; reactions can vary from temporary discomfort to severely avoidant and paralyzing behaviors.

    • Symptom management-
    • psychotherapy to explore psychodynamic issues
    • CBT to develop skills to manage symptoms
    • several types of medications can help to manage symptoms

    • diagnostic specific considerations-
    • skills training and use of congitive behavioral appraches may reduce avoidant behavior
    • developing relaxation and stress management may decrease the incidence and severity of symptoms
    • providing graded activities designed to promote self-efficacy may increase self-confidence, motivation and participation
    • systematic dessensitaization has been found to work well to diminish anxiety related to specific fears through the use of imagery and relaxation and then contact with the image or actual object.
  24. Personality Disorders
    • Evidence of characteristics and patterns of inner experience and behavior that deviate markedly from the culturally accepted norms in cognition, affect, impulse control and interpersonal relating.
    • behavior must be infelxible and maladaptive across a broad range of personal and social situations
    • must be evidence of onset in late childhood or adolescence

    • personality disorders are grouped in cluseters according to their impact
    • CLuster A(paranoid, schizoid, schizotypal; often percieved as odd and eccentric)

    Cluster B (antisocial, boderline, histrionic, and narcissitic; often percieved as dramatic, emotional, and erratic)

    Cluster C (avoidant, dependent, obsessive-compulsive and those NOS; often percieved as anxious or fearful)
  25. specific personality disorders
    • paranoid personality disorder- persons with this disorder are cahracterized by long standing suspiciousness and mistrust of people in general.
    • they refuse responsibility for their own feelings and assign responsibility for them to others
    • they can appear hostile, irritable, and angry

    • schizoid personality disorder
    • freequently diagnosed in individuals who display a llifelong pattern of social withdrawl
    • their discomfot with human interaction,their introversion, and their bland, constrictierd affect are noteworthy
    • persons with schizoid personality disorder are often seen by others as eccentric, isolated, or lonely

    • schizotypal
    • persons with this disorder appear odd or strange in their thinking and behavior to those who come in contact with them
    • magical thinking, peculiar ideas,ideas of reference, illusions and derealization are part of this indivudal's everyday world

    antisocial personality disorder-characterized by continual antisocial or criminal acts; inability to conform to societal norms; no regard to the safety or feelings of others and lack remorse

    • borderline personality disorder
    • experience extraordinarily unstable affect, mood, behaviors, relationships, and self-image; fear of real or imaginary abandonment leads to frantic measures to avoid it; reccurrent self-destructive or self-mutilating behavior; majority of patients have a hx of trauma.

    • histrionic personality disorder
    • characterized by colorful, dramatic, extroverted behavior in excitable, emotional persons

    avoidant personality disorder- persons with this disorder show an extreme sensitivty to rejection,which may lead toasociallywithdrawn life; want companionship but consider themself unworthy.

    • dependent personality disorder
    • persons with this disorder subordinate their own needs to those of others and need others to assume responsibility for major ares in their lives; lack self-confidence, may experience discomfort when alone

    obsessive compulsive- characterized by emotional constriction, orderliness, perseveration, stubbornness and indecisiveness; pattern of perfectionism and inflexibility

    • personality disorders(NOS)
    • passive aggressive
    • depressive
    • sadomasochisitis
    • sadistic


    ***impact on function depends on the severity and type of personality disorder


    psychotherapy and medications may reduce symptomalogy

    dialectic behavioral therapy (DBT) has demonstrated success with borderline personality disorder.

    • Diagnostic specific considerations
    • assistance to the individual to identify issues may increase commitment to treatment

    CBT can increase function and coping skills and may decrease symptomology.
  26. delirium, dementia, and amnestic and other cognitive disorders
    conditions for which the primary symptoms are cogntive deficits

    • delirium-
    • disturbance of consciousness (awareness of environment)with a decreased ability to attend)
    • change from previous cognition or perception

    • dementia
    • disturbances of memory and multiple cognitive deficits (aphasia, apraxia, agnosia, disturbance of executive functioning); often includes personality changes; leads to functional problems; Alzheimers and vascular dementia account for 75% of all cases;mental confusion due to reversible causes must be ruled out.

    • amnesic disorders
    • difficulty with memory only, but sufficient to cause functional problems
    • causes (CVA,MS,Korsakoffs syndrome, alcholic black outs, ECT, TBI, transient global amnesia)

    • impact onfunction
    • degree of impact varies according to nature and severity of symptoms; intervention could range from educating on compensatory strategies to total care

    • symptom managame
    • differential diagnosis to ensure that symptoms are not peudeodementia due to a reversible cause; medications to slow the decline of cognitive function; attempts to mitigate symptoms where possible

    • dignostic specific considerations
    • maintenance and QOL through activity adaptation and environmental modifications should be a focus
    • familyeducation

    • Reisburg's Stages for Dementia
    • Stage 1-no disbailty noted
    • Stage2- the person complains about forgetting normal age-related information (location of keys, wallet, etc.)
    • Stage 3- beginning signs and deficits are noted in this stage(I in ADL, can utilis compensation as an adaptation, recongise challenging situations to avoid)
    • Stage4- deficits are noted in all IADL
    • Stage 50- cannot function independently
    • Stage 6- cannot perform ADL without cues
    • Stage 7- person can be in a vegetative state. usually bedbound and unable to respond verbally or nonverbally to commands
  27. Eating Disorders

    Anorexia Nervosa
    • Diagnostic criteria
    • Refusal to maintain body weight at or above normal weight for age and height, or failure to make expected weight gain during a period of growth leading to a body weight of less than 85% of expected
    • intense fear of gaining weight or becoming  fat, even though underweight
    • disturbance in the way which one's body weight or shape is experienced (denial of seriousness of the current low body weight even when hospitalized or gravely ill.
    • amenorrhea- absence of at least three consecutive menstrual cycles
    • anorexia includes a food restrictive type and a binge eating/purging type

    Most commonly begins in the mid teens

    • behavior characteristics
    • individuals often exhibit obsessive/compulsive behavior, depression, anxiety, rigidity, perfectionism and poor sexual adjustment
  28. Eating Disorders
    Bulimia Nervosa
    • recurrent episodes of binge eating defined as lack of control over discrete periods of excessive eating of an abnormally large amount of food.
    • purging type includes recurrent, inappropriate compensatory behaviors in order to prevent weight gain (self-induced vomiting, use of laxative/diuretics, fasting, excessive exercising)
    • binge eating/purging happen at least 2x/wk on average for three months
    • disturbance does not occur exclusively during episodes of anorexia nervosa

    Onset is typical in adolescence or early adulthood

    • behvaioral charateristics
    • individuals are often obsessed with their appearance and attractiveness to the opposite sex
    • likely to be sexually active and maintain a normal weight
  29. Eating Disorders
    NOS
    Includes several types

    Binge eating disorder (BED)- one that will be most commonly seen in OT practice due to co-morbidities caused by obesity that will result from this disorder (i.e. diabetes)

    Recurrent episodes of bing eating until uncomfortably full without purging (eating is more rapid than typical and is often initiated when not hungry and/or alone due to embarrassment about the food being consumed.
  30. Impact of ED on function
    • ADL such as self-care, eating and feeding can be severely disrupted
    • IADL such as shopping for clothing an good, meal prep and clean up and health management can be significantly affected
    • work skills can be intact unless food-restricting behaviors and/or medical problems interfere with work performance or prevocational skill development (focus on weight control may interfere with other things)
    • leisure skills can be intact unless affected by food restricting behaviors and/or medical complications (activities may focus on appearance vs meaning; exercise done for fun in the past may now be done excessively)
    • social participating may be impacted by the excessive use of food restricting behaviors and the need to maintain secrecy about behaviors and feelings of shame, guilt, embarrassment or depression about atypical eating habits.
  31. Symptom management for ED
    • use of antidepressant meds may be used in anorexia but more effective for those with bulimia
    • antipsychotics can also be used to improve distorted thinking
    • treatment of esultingmedical conditions
    • usually treatment occurins in outpatient or daycare programs
    • hospitalization may be necessary if person has medical diffiuclties is suicidal and cannot take care of themselves
    • Behavioral programs designed around a privileging system are often used (consistency among staff is crucial)

    • diagnostic considerations for OT
    • building of trust is essential to effective intervention dur to secrecy, guilt, anger, resistance, and ego fragilty
    • OT must be honest, supportive, and gently confrontational when indicated
    • eval ind intervention must include identification of socio emotional needs the eating disorder has fulfilled for the person so health promoting alternative can be explored and developed (non food related areas of interest should be pursued to promote a reality-based body image)
    • education about nutritioinal food management and development of healthy leisure time are key
  32. Disorders usually first diagnosed in infancy, childhood or adolescence
    • Oppositional Defiant Disorder
    • negativisitc, hostile and defiant behaviors that result in a functional impairment

    • Conduct Disorder
    • Disregard for the rights of others leading to affgression toward people and animals, destruction of property, deceitfulness, theft or serious violation of rules

    • Disruptive Behavior DisorerNOS
    • Children who do not meet the criteria for the other disorders, however display significant functional impairment and conduct and oppositional behaviors are present
    •  **oppositional defiant disorder is the most likely to turn into a conduct disorder if aggression is prominent

    • impact on functions
    • children with disruptive behavior disorders have difficulty at school and with the formation of healthy and social and familial relationships
    • difficulties within the family affect everyone on their role performance

    • symptom management
    • behavioral techniques are the most effective forms of intervention with adolescents
    • identificactions of other disorders (i.e. ADHD, learning disorders, substance use, depression) is important
    • uses of antipsychotics, antidepressants, and mood stabilizers may be helpful
    • consistency among team members is essential

    • Diagnostic specific considerations of OT
    • Contributing disorders (ADHD, mood disorders, learning disorders, etc.) andtheir effect on performance skills and areas of occupation must be evaluated and addressed in intervention
    • Child's goals, stressors, and family and social relationships should be considered
    • Skill development may improve emotional adjustment
    • behavioral approaches must be consistent through out all programming
    • therapist should help teachers and families understand more about the child's condition to develop strategies for behavior management.
  33. Pervasive Development Disorders/Autism Spectrum Disorders
    Etiology-organic brain pathology; may or may not be seen with other disorders

    • diagnostic characteristics
    • presences of at least 6 items (2 or more from section 1 and at least one from 2 and 3)
    • (1)impaired social interaction and in most cases cognitive disabilities
    • a. impaired nonverbal behaviors (poor eye contact, impaired attachment behavior, anxiety with changes in typical routines)
    • b.difficulty relating to others and forming relationships at an age appropriate level
    • c. lack of spontaneous social seeking behavioral interactions with others and lack of awareness of others who are seeking interactions
    • d. lack of social reciprocation due to decreased ability to infer feelings and intentions of others

    • (2) Difficulty with communication
    • a. lack of initiation, reflections,development of spoken language or alternative means for communication
    • b. if speech is developed, difficulty in initiating or engaging in conversation and lack of appropriate context
    • c. stereotyped echolalia and/or used of indiscernable language
    • d. lack of spontaneous pretend play

    • (3)Repetitive and sterotyped behaviors and movements in one or more of the following
    • a. ritualistic nonfunctional routines,preoccupation
    • b. rigid observance of nonfunctional routines or behavioral patterns
    • c. repetitive motor actions (flapping and wiggling of fingers, head banging, rocking of the body
    • d. restrictive fixation on parts of a whole object (wheel of a car)

    prior to three years of age, delay or impairment in social interaction and/or language and/or play (symbolic or imaginative

    • not better described by Rett's Syndrome
    • difficulty with sensory processing and perception; difficulty in modulation of stimuli at various levels

    • common associated behaviors include unanticipated mood swings, temper tantrums, lack of ability to focus, insomnia
    • common and enuresis

    deficits tend to be more severe in verbal sequencing and abstraction versus abilities in visuospatial and rote memory skills (calcation and musical abilities)
  34. Asperger's Disorder
    • Etiology is unknown
    • Diagnostic Crtieria:
    • difficulty in social interaction
    • restricted interests and behaviors
    • characterized by clumsiness
    • delayed developmental milestones
    • differentiated from autism by adequate language and the level of social interaction and engagement in activities with others
  35. Rett's Syndrome
    • etiology is unknown
    • deterioration occurs after a period of normal development (thought to be attributed to genetic metabolic disorder)
    • occurs morein girls (1 in 10000)

    • Diagnositc characteristics and seqaulae:
    • deterioration of language, receptive and expressive communication skills and social skills may plateau
    • motoredeterioration is characterized by a loss of purposeful hand movements with the development of stereotypical movements such as hand wringing, licking,biting and slapping of fingers
    • muscle tone becomes hypotonic and then progresses to spasticity and then rigidity resulting in ataxic, uncoordinated and stiff gait
    • muscles wasting can make these children prone to scoliosis an eventually necessitate the use of a wheelchair
    • breathing patterns become irregular, marked by hyperventilation, apnea, and holding of breath
    • regression occurs in cognition and praxis
    • EEGs are abnormal and seizures are common
  36. Pervasive development disorder, unspecified
    • disorders are similar with the other impairments
    • impairments evident in social interaction, communication, motor behavior, interests and activities
  37. symptom management
    medications depending on symptoms (i.e. seizure medication, for muscle deterioration, to increase alertness, and to modulate behaviors)

    • Diagnostiespecific considerations
    • Evaluate developmental and functional levels
    • develop sensrimotor,social interaction, vocational readiness, and community participation skills relevant to the child's level
    • Provide sensory integrative interventions, if indicated
    • train in AT and augmentative communication if applicable
    • provide adaptive positioning equipmentto facilitate function
    • collaborate withthefamily andthe team
  38. Reactive Attachment Disorder (RAD)
    • exact cause is unknown
    • Early poor experiences with initial caregivers and/or pathogenic care may contribute to the disorder

    • indicators of pathogenic care:
    • persistent disregard of childs basic emotional need, or basic physical needs, repeated changes of primary caregiver or a succession of caregivers prevents establishment of a stable, appropriate attachments

    • onset begins before 5 years of age
    • ***high risk of prevalence for toddlers  and children in foster care and those with frequently changing caregivers

    • Two types of RAD
    • Inhibited Type
    • persistent failure to initiate or respond in developmentally appropriate fashion to most social interactions
    • Interactions are excessively inhibited,hypervigilant, or highly ambivalent and contradictory in nature

    • Disinhibited Type
    • Characterized by indiscriminate sociability with inability to exhibit appropriate selective attachments
    • Demonstrated by excessive familiarity with relative strangers or lack of selectivity

    • Impact on function
    • Children with RAD exhibit challenging behaviors that can include:
    • high need to be in control
    • frequent lying
    • affectionate and overly related with strangers
    • frequent episodes of hoarding or gorging on food
    • denial of responsibility
    • projecting blame for their actions on others

    • Diagnositic specific considerations
    • Close and on going collaboration with the child's family facilitates successful outcomes
    • actively involve parentsintreatment
    • assist children to form a more secure sense of self
    • limit child's exposure to multiple caregivers
    • provides levels of structure and consistency
  39. Attention deficit hyperactivity disorder (ADHD)
    etiology unknown (suggested contributing factors include genetics, nuerological factors, neurochemical dysfunction, and psychosocial factors

    • DSM-IV delineates 3 subtypes:
    • predominantly inattentive type
    • predominantly hyperactive-impulse type
    • combined type

    **symptoms are often noted during the toddler years, but it is advised to not make a diagnosis in early childhood years; often made in early elementary years when behavior interferes with adjustment to school.

    • impact on function
    • infants are over-active, difficult to soothewhen crying and desmonstrate poor sleeping habits
    • defesnveness to environmental stimuli, frequent irritibility, affressive behavior, emotional lability, and fluctuating and unpredictable performance
    • difficulty with delayed gratifcation
    • deficits in perceptual motor tasks with disorders in reading, math, written experssion and general coordination resulting
    • disorders of memory or speech, thinking or hearing
    • depression secondary to frustration and difficulty with learning leading to low self-esteem and conduct disorders

    • symptom management
    • prescribed meds depend on the symptoms present
    • Stimulants
    • Antidepressants
    • Anxiolytics
    • Monitoring of medication an its impact on cognitive and psychosocial function

    • Diagnostic specific considerations
    • Behavior's impact on school, home, play/leisure, and social participation must be considered
    • environmental modifications and activity adaptations to structure the clients home andschool environements can promote function
    • training in social skills and self-management can improve adaptive behaviors
    • interventions to promote sensory modulation are emphasized
    • consultation is provided to parents, family members, teachers, and employees regarding strategies for provision of structure and expecatations
    • collaboration with IEP team
  40. Intellectual Disorders
    • Genetic conditions such as chromosomal abnormalities(Down Syndrome, Fragile X Syndrome, Prader-Willi Syndrome, Klinefelter's Syndrome
    • Metabolic consideration such as phenylketonuria,hypothyroidism, and Tay Sachs disease
    • Prenatal factors such as infections such as encephalitis,menigitis
    • Head trauma

    • DSM-IV
    • diagnosis is  based on the measurement of intelligence or IQ tests
    • individuals who scores more than two SD below the norm, or below an IQ of 70 are considered to have an intellectual disability
    • IQ of 55-69: mild intellectual disability
    • IQ of 40 to 54: Moderate intellectual disability (establishing routine daily routines and skills necessary to perform in desired occupational roles with supports and structure; will require supervised living
    • IQ  of 25 to 39: severe intellectual disability (focus placed on acquiring communciation skills and basic healeth habits; supervised living required; assistance for most tasks
    • IQ of 25 or below indicated a profound intellectual disability (assistance and ongoing supervision required for basic survival skills; significant motor functioning impairments; supervised living required)

    • Impact ondevelopment
    • varies depending on severity of intellectual disability

    • cognitive development
    • slower learning
    • shorter attention span
    • difficulty with problem solving and critical thinking
    • increased distractibility
    • difficulty generalizing information and mastering abstract thinking

    • motor development
    • slower development (hit milestones later)
    • uncoordinated appearance and movements
    • low muscle tone

    • Sensory development
    • diminished sensory modulation abilities
    • hyper or hypo sensitivity

    • language development
    • decreased ability in recalling and retrieving words
    • difficulty grasping and expressing concepts
    • dificulty with the motor aspects of creating language
    • psychosocial development

    • impaired ability to respond to social cues can results in behavioral responses (excessive shyness or aggressiveness)
    • hyperactivity and distractibility can impede psychosocial development

    • Diagnostic specific considerations for OT
    • self-determination person-centered planning within the person's capabilities
    • support and assistance  may be required to address performance skills and patterns
    • development of community and social participation
    • collaboration with the team, the family
  41. OT Mental Health Evaluation
    • determine values, interests, desired occupational roles, and self-determined goals
    • identify cognitive, perceptual, and psychosocial strengths, skills, and their ability to faciliate recovery as well as deficits
    • determination of functional problems
    • treatment history and abiltiy to engage in recovery
    • identification of coping skills, stressors, and environmental social supports


    • Role of the COTA
    • COTA can contribute to the eval process in collaboration with the OT; cannot independently evaluate or interpret results
  42. OT Mental Health Intervention
    • Focus of intervention in acute hospitalization:
    • management of behaviors that threaten the safety and well being of the individual and others
    • stabiliazation of behaviors to engage in intervention
    • engagement in activities that are "do-able" to enable success and promote reality-based thinking
    • engagement in activities to increase participation in treatment
    • develop relaxation and stress management to decrease incidence and severity of symptoms
    • developmental of skills needed to pursue desired occupational roles
    • engagement in activities to improve communication and self-expression
    • assistance with d/c planning and communication with team members


    • Focus of intervention during periods of long term hospitalization
    • development and implementation of a plan for self-determined goal achievement
    • engagement of the person in the treamtment process
    • provision ofgraded acivities to develop the skills needed for competence in ADL, IADL, social participation, lesire, school, work
    • development of relaationand stressmanamgementskills
    • continuation of assessment to determine realistic and meaningful d/c goals.
    • development of skills and external supports needed to pursue desired post-discharge occupational roles

    • Focus of intervention in community setting
    • Provison of services that facilitate recovery and assist in the maintenance of existing skills
    • assistance with the continued development of skills needed for community living, social participation and valued occupational skills
    • development of skills and supports to enable ongoing recovery
    • monitoring the individual for changing clinical personal and social needs

    • Role of OTA
    • implements intervention with supervision for the OT
    • during the implementation of intervention, the OTA informs the supervising OT of any changes in the individual's status and any other relevant information that may affect treatment.

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