Building Your Mental Health ToolboxChristina O’Neill MSW

Common Psychiatric Symptoms

Common Psychiatric Diagnosis

Commonly Used Medications

Quick Guide to Suicide Assessment

Case Management tools

Common Psychiatric Symptoms(Identifying What You Are Seeing)

Psychosis: collection of symptoms that make it difficult for a person to connect with reality. Can include positive symptoms such as delusions, hallucinations, disorganized speech/ behavior or negative symptoms such as catatonic behavior, psychomotor retardation, lack of speech, social withdrawal.  

Delusions: belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument. 

Hallucinations: an experience involving the apparent perception of something not present; they can be auditory, visual or sensory. Audio hallucinations will sometime consist of “voices” and they can have a command component in which they might instruct the person to do something.  

Mania: (or hypomania- similar behavior lasting shorter amount of time and usually not as extreme). Inflated self-esteem/ grandiose thinking, decrease need for sleep/ flight of ideas/ pressured talking/ distractibility/excessive involvement in pleasurable activities with potential for negative outcome.Additional Symptoms can include: Extreme Agitation/ Irritability, Disorganization, Ideas of reference, Tic’s/ Repetitive behaviors, Poor impulse control, Self Harm, Paranoid Thinking

Common Psychiatric DiagnosisPsychiatric diagnosis are made by observing a collection of symptoms- these definitions are not meant to be all inclusive as there are many exceptions to the rules- these are simply meant to

give you a basic understanding of the diagnosis

Bipolar: Mood Disorder characterized by having episodes of mania, hypomania, depression or combination of both (mania and depression). Episodes of severe mania can resemble a psychotic state. Subtypes: Bipolar I (1 or more manic episode- sometimes with a depressive episode) and Bipolar II (1 or more depressive episode and at least 1 hypomanic episode).

Major Depression: Depressed mood, episode lasts more than 2 weeks, disruptive to lifestyle (diminished pleasure, sleep/ eating disturbances, diminished capacity to concentrate or think).

Schizophrenia: Psychotic disorder characterized by having episodes lasting a significant period of time (1 month or more untreated) of delusions/ hallucinations/ disorganized speech or behavior. Schizophrenia can also manifest with negative symptoms to include cationic behavior, delayed speech/ actions, flat affect. Subtypes include paranoid, disorganized, and catatonic.

Common Psychiatric Diagnosis (continued)

Schizoaffective disorder: Schizophrenic type psychotic features are present for a significant amount of time (1 month or more untreated) concurrent to manic, major depressive or hypomanic episodes.

Generalized Anxiety Disorder: Excessive anxiety or worry that is hard to control (occurs more days than not for at least 6 months) that cause significant disturbance in ones functioning and include some of the following symptoms: restless / on edge feelings, easily fatigued, difficult concentrating, irritability, muscle tension, sleep disturbance.

Personality disorders: Enduring patterns of inner experiences and behaviors that deviate from the social norm that are pervasive/ inflexible over a length of time that lead to distress or impairment. Main Subtypes include: Borderline, Antisocial, Narcissistic, Dependent, Histrionic, Paranoid, Obsessive- Compulsive, Avoidant, Schizotypal (cognitive/ perceptual distortions, eccentric behavior), Schizoid (detachment from social relationships, restricted range of emotion).

Commonly Used Medications for Psychiatric Symptoms

(Most of medications listed by brand name for easy recognition instead of generic name)

 

Antipsychotics/ Neuroleptics: Zyprexa, Seroquel, Risperdal, Haldol, Geodon, Clozaril (also called -clozapine -not to be confused with clonazepam/Klonopin), Abilify, Latuda, Invega, Saphris.

Antidepressants: Zoloft, Prozac, Celexa, Paxil, Wellbutrin, Effexor, Cymbalta, Remeron, Viibryd, Lexapro, Amitriptyline, trazadone

Mood Stabilizers: Depakote, Tegretol, Lithium, Neurontin, Lamicatal, Trileptal

*ADHD: (these will test positive on UA) Vyvance, Concerta, Adderall, Ritalin, Strattera

*Benzodiazepines: (these will test positive on UA) Ativan (Lorazepam), Klonopin (clonazepam), Valium (Diazapam), Xanax (alprazolam), Librium

Non Benzodiazepine Anxiety Meds: Vistaril (antihistamine), Propranolol, Inderal, Atenolol (beta blockers/ blood pressure meds)

Alcohol Abuse: Campral, Naltrexone, Antibuse

Heroin/Opiate abuse: Suboxone, methadone

Things to remember:

Medication is meant to treat the symptoms, not the diagnosis, so different meds could be used for different reasons.

Some antipsychotic meds are used in low doses for anxiety and sleep.

Some of the mood stabilizers are also seizure medications.

* Most will show up positive on Drug UA’s

Quick Guide to Suicide Assessment Risk Factors (in no way all-inclusive)

*Mental health diagnosis*

Age (45 years or older)

Sex (men more lethal/ women more often)

Substance use/ *Alcohol*

*Impulsive*

*Significant depression*

Financial woes

Hopelessness

*Family hx of suicide*

*Prior attempts*

*Recent loss/ separation*

Stressors

Access to weapons

Lack of insight

High anxiety

Trauma

*Lack of social support*

Chronic illness

*Recent hospitalization*

*Command hallucinations*

Questions to ask: Goal is to assess for low/ moderate/ imminent risk of suicide- if there is imminent risk send

person to an emergency room/ crisis clinic for evaluation.

  Assess for Ideation: (to get the conversation started) Are you having suicidal thoughts? (Ask for specifics, how long, what kind, plan

specific or generalized wish to not exist?).

For how long? Have these thoughts increased in frequency or intensity?

Are they fleeting thoughts/ intrusive thoughts/ chronic thoughts/ daydream thoughts?

How do the thoughts make you feel? (Scared, angry, calm, happy, peaceful?)

What do you have to live for? (What are the barriers to suicide? Religion/ family/ job…)

 

Asses for Plan: (If the answer to all three is YES-send to hospital/clinic)

Do you have a plan/ What is your plan? (Ask specifics if they have them- how, where, date/ time, with what)

Access to plan? (Do they have pills/ garage/ weapon/ etc.?)

Does plan have lethal intent?

Other factors/ Questions to consider: (if you still need more facts to make a decision on client’s safety risk)

Command Hallucinations? (voices telling them to hurt self- very dangerous)

History of suicide in family?

Prior attempts? (Is this episode different than prior attempts? How/ why?)

Poor impulse control? (alcohol/ bipolar/ young age/ personality disorder)

Recent change in affect? (used to be depressed now happy, used to be happy now hopeless)

Too calm? (Often very calm after they have made final decision)

Unable to talk about future?

Lacks working alliance with treatment team/ assessor/ clinician. Won’t tell you what’s going on.

Won’t contract to be safe/ safety plan (see ideas below)?

Did they tell anyone? What support systems do they have?

Fears of any consequences?

Chronic self-punishment/ self-criticalness/ self-dislike/ self-worthlessness thoughts?

Have they made arrangements for after their suicide?

Suicide scale: 1=lowest 10=highest (ask them where they are on a scale 1-10. gives idea how intense thoughts are)

What Next? Safety Planning/ Contract to be Safe (not all inclusive/ just some ideas)

Have client make a list of four support people. (Identifying people that they can reach out to / contact before they take any action). Can any of these people stay with you today/ tonight/ next few days?

 

Create a list of five things you can do to soothe and distract yourself from suicidal/ self-injurious thoughts/ feelings. How can you stay safe? What can help keep you busy for next few days to get through this part? (Coping skills and activities)

List at least 4 positive or strength based self-talk statements that you can use when difficult feeling arise. List four things you have to stay alive for (my child, my dog, my church, etc).

List 2 goals for the upcoming day/week/month/year. (Future orientated).

Take Action Steps: Contract to tell someone before you harm self. Have someone else help distribute your meds. Remove dangerous objects from home. Stay with family/ friend.

Provide client crisis line numbers, nearest hospital if they become unsafe later, therapy references.

Case Management: Looking at the Big Picture When Working

with Mental Health Clients

Community Safety vs Perfect Compliance

Primary goal is to interact with supervision staff in a meaningful way

Failure to Comply often results in the defendant either being in community with no supervision (active warrant situation) or taking a jail bed (bad for client/ expense for jail).

Leveling the Playing Field What are barriers to compliance (resources/ understanding/ability)

Make expectations realistic and manageable (look at strengths and limitations)

Case Management ToolsSolution Focused approach concentrating on motivation and

goal setting vs problem behaviors and arrest

Techniques: (AND SOME EXAMPLES)

Move one step at a time, small steps can lead to big changes.

Create a non threatening positive environment

Homework assignments: impulse control techniques, breathing exercises

Removing the mystery: go to court room while empty, explain what happens next

Give tips for deescalating/ interacting with public or police

Meet them where they are at: look for other successful areas of their lives to parallel/ set realistic goals.

If something is working do more of it/ if not working do something different

Exception to the problem: “I see you made it to court today on time- how did you organize your morning different than usual?”

Understanding Motivation: You must have had a good reason for doing this- can you tell me about it?