Psychiatric Diagnosis in Homeless Persons: Challenges and Strategies

1. Psychiatric Diagnosis in Homeless Persons: Challenges and Strategies International Street Medicine Conference October 22, 2010

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

3. 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

4. Co-founding Variables (cont.) • Complexities of symptom presentation • Effects of homelessness on psychiatric symptoms • Hygiene • Sleep • Fatigue • Threat to safety • Demoralization • Maladaptive coping skills

5. Co-founding Variables (cont.) • Complexities of childhood history • Abuse • Loss • Deprivation • Instability • Lack of work-up beyond interview and mental status exam • Pressure to diagnose • Colleagues • Need of diagnosis for disability and housing

6. Strategies • First step, engagement • Modification of the evaluation process • Brief, casual encounters • Months to years • Open-ended, neutral questions

7. Strategies (cont.) • Observation is key • Grooming • Odd or unusual clothing • Abnormal mouth or finger movements • Movements • Evidence of auditory hallucinations • Belongings • Location • Company or isolation

8. Strategies (cont.) • Voices-differential diagnosis • Schizophrenia • Mania • PTSD • Personality disorders • Cultural

9. Strategies (cont.) • “Organic” • First, rule out delirium • Inattention • Disorientation • Memory • Visual hallucinations • Combative behavior • Alcoholic hallucinations

10. Strategies (cont.) • “Organic” (cont.) • Psychiatric diagnosis vs. “organic” • Inattention • Memory impairment • Depression/irritability/moodiness

11. Strategies (cont.) • 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

12. DIFFERENTIAL DIAGNOSIS-BIPOLAR DISORDER • Schizophrenia • Schizoaffective disorder • Personality disorder • PTSD • Anxiety disorder • Substance Abuse • Medication side effects • Neurological disease • Depression

13. Bipolar Disorder • Zimmerman study-Brown University, 2008 82 out-patients • 40% of people over-diagnosed with bipolar disorder met criteria for borderline personality disorder • Muzina study-Cleveland Clinic, 2008 • 100 patients admitted to mood disorder clinic- • 60% of those diagnosed with bipolar disorder did not meet criteria for bipolar disorder • Why over-diagnosis? • Dangers of over-diagnosis

14. 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

15. 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

16. 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

17. Personality Disorder (cont.) • Why recognize and treat? • Social implications • Exacerbations of symptoms of Axis I • Interfers with relationship of provider and patient • Treatment works!

18. Neuropsychological Evaluation • Known brain disorder • Known risk factor for brain disorder • No known risk factors but brain disorder suspected

19. Neuropsychological Evaluation (cont.) • Uses • Nature and severity of cognitive, behavioral and emotional problems • Potential for independent living • Foundation for treatment planning

20. PSYCHOLOGICAL TESTING • IQ • Personality tests • MMPI hypochondriasis hysteria depression paranoia psychasthenia schizophrenia mania

21. Rating Scales • Verify diagnosis • Assess severity • Measurement of psychiatric conditions in different points of time • Determination of effectiveness of treatment

22. 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

23. 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

24. 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.

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