PHINOJ K ABRAHAMI I N D M O T S T U D E N T

A L L I N D I A I N S T I T U T E O F P H Y S I C A L M E D I C I N E & R E H A B I L I T A T I O N ,

( A I I P M & R ) M U M B A I

Wellness program for Anxiety & Depression

2OverviewDefinition of Key TermsClinical DepressionClinical AnxietyImpact of Depression & Anxiety on Human

life: OT PerspectiveWellness Program for Depression &

Anxiety

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Definitions of Key Terms

FearFear – is a response to a known, external,

definite, or non conflictual threat.

AnxietyAnxiety – is a response to threat that is

unknown, internal, vague, or conflictual.The main psychological difference b/w the 2 emotional

response is the suddenness of fear and the insidiousness of anxiety.

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Key Terms Cont…

Depression Is an emotion charecterized

by “sadness,” crying, withdrawal from others, and feeling of in adequacy.

Intro to Psycho 7th edn, CT Morgan 1993

Resulting from a past experience

5Key Terms Cont…

Present ?

Avoidable ?

Yes No

Yes No

DANGER

Fear (meeting a Snake)

Anxiety(hearing hissing sound of Snake )

Depression(I will not escape from the Snake)

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Key Terms Cont…

Anxiety

Fear

DepressionPTSD

Future

Present

Past

Anxiety

Fear

DepressionPTSD

7Key Terms Cont…

Stress

Stress is a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.

Richard S Lazarus This depends on how a person perceives, thinks, and

acts on external events or internal drives. Stressors: the situation/events which cause stress.

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Cont…

Clinical Depression

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Definition of Depression: DSM-IV-TR

Major depressive episodes: Affective disorders characterized by “sad” feelings & persistent problems in other areas of life.

Intro to Psycho 7th edn, CT Morgan 1993

A major depressive disorder occurs without a history of a manic, mixed, or hypo manic episode.

DSM-IV: one of the following must be present for at least two weeks:

Depressed mood Lack of pleasure (anhedonia)

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Definitions

Other symptoms:Feelings of overwhelming sadness and/or fearBlunt affectLack of pleasureWeight gain or lossDisturbed sleep patternsPsychomotor agitation nearly every dayFatigue, mental or physical.

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Cont.. Intense feelings of guilt, nervousness, helplessness,

hopelessness, isolation or anxiety

Cognitive problems: concentrating, keeping focus, poor

memory

Recurrent thoughts of death

Suicide attempt or a specific plan for committing suicide

A total of five symptoms must be present to diagnose a major

depressive disorder

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Some Facts & Figures About Depression

Nearly 5-10% of persons in a community at a given time are in need of help for depression.

As much as 8-20% of persons carry the risk of developing depression during their lifetime.

The average age of the onset of major depression in between 20 and 40 years.

Women have higher rates of depression than men. Marital status: depression more common in persons

without close IP relationship / among Divorced single person

Race or ethnicity does not influence the prevalence of depression Ref : Conquering Depression: You can get out of the blues WHO

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Causes 1. Life experiences & Environmental Stress

“Stressful life events more often precede first, rather than subsequent, episodes of mood disorders”

Life event most often associated with development of depression is losing a parent before age 11.

The environmental Stressor most often associated with the episode of depression is the loss of Spouse.

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Causes Cont…

2. Personality Factors

No single personality trait or type uniquely predispose a person to depression

Person with certain personality disorder like OCD, histrionic & borderline – may be at grater risk.

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Causes Cont…

•High frequencies of unpleasant un rewarding events

•Less hope & energy in activities / Social Interactions

• This, make them less rewarding to be around

• Thus others tends to avoid depressed people

• This deepens their depression

3. Social Interaction

16Causes Cont…4. Biological factors & Depression

There are four main biological factors that can increase a persons risk for depression Genetic factors Biochemical factors Alterations in hormonal regulation Sleep abnormalities.

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Causes – Psychological Theories

1. Psychodynamic Theory According to this theory “depression is resulting from an

overly demanding super ego – one that sets standard too high for the person to live up to – and from early loss of attachment figures” Un realistic/achievable Goals – Edward Bibring Depressed people have lived for their lives for some one else

(principle, ideal, institution / individual) – Silvano Arieti Parents fails to give the child a positive sense of self esteem &

self cohesion – Heinz Kohut (Self Psychological Theory) Traumatic childhood events – Johm Bowlby Child victimized by a tormenting parent. – Edith Jacobson

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Causes – Psychological Theories Cont…

2. Cognitive theory According to this theory depression results from

“specific cognitive distortions present in person susceptible to depression”

AARON BECK suggest a cognitive triad of depression that consists of Views about self – a negative self respect About the environment – a tendency to experience

the world as hostile & demanding About the future – the expectation of suffering &

failure.

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Causes – Psychological Theories Cont…

3. Behavioral Theory Learned Helplessness : this theory connects depressive

phenomena to the experience of uncontrollable life events.

EX: Dog exposed to repetitive electric shocks from which they could not escape Reacted initially Then they reminded passively

According to Behavioral theory “Dog learned that outcomes were independent of response” so they had Cognitive Motivational deficit – not attempted to escape Emotional deficit – decreased reactivity.

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Causes – Psychological Theories Cont…

Behavioral Theory cont…

In human depression, Uncontrollable stress events produce loss of self

esteem.Behavioral theory stresses that “improvement

of depression is dependent on the patients learning a sense of control & mastery of environment”

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Types of Depressive Disorders

Major Depressive Disorder

Dysthymic Disorder

Minor Depressive disorder

Recurent Brief Depressive disorders

Full Unipolar Spectrum.

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Depression; It’s not only a state of mind.

Emotional Symptoms Include: Physical Symptoms Include:

Sadness Vague aches and painsLoss of interest or pleasure HeadacheOverwhelmed Sleep disturbances

Anxiety Fatigue

Diminished ability to think or concentrate, indecisiveness Back pain

Excessive or inappropriate guilt Significant change in appetite resulting in weight loss or gain

Symptoms of Depression

Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. 2000:345-356,489.

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Depression – The Physical Presentation

In primary care, physical symptoms are often the chief complaint in depressed patients

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1

Reference: Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

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The Importance of Emotional and Physical Symptoms

• 76% of compliant depressed patients with lingering symptoms of depression relapsed within 10 months

94% of depressed patients who experienced lingering symptoms had mild to moderate physical symptoms1

Reference: Paykel ES, et al. Psychol Med. 1995;25:1171-1180.

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Complications

Alcohol abuse Substance abuse Anxiety Heart disease and other medical conditions Work or school problems Family conflicts Relationship difficulties Social isolation Suicide

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Clinical Anxiety Disorders

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Anxiety DisordersA condition characterized by extreme, chronic anxiety

that disturbs mood, thought, behavior and/or physiological activity. www.psychiatric-disorders.com

Anxiety Disorders: DSM-IV-TR Panic Disorder Agoraphobia Social Phobia Specific Phobia Obessive Compulsive Disorder Generalized Anxiety Disorder (GAD) The most commonly diagnosed Separationa Anxiety Disorder

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Diagnosis

To better differentiate between GAD and other anxiety or depressive disorders, 4 “first rank” and at least 1 “second rank” symptoms are needed

First Inability to relax, restlessness Fatigueability Exaggerated startle response Muscle tension

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Diagnosis Cont…

First Cont… Sleep disturbances Difficulty in concentrating Irritability

Second Nausea or abdominal complaints Dry mouth Tachycardia Tremor

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Epidemiology

Incidence & Prevalance National prevalence rates of Anxiety Neurosis

Median 18.5 ; Mode 11-70 Indian Journal of Community Medicine

Vol. 26, No. 4 (2001-10 - 2001-12)

Sex Women : 30.5 % life time prevalence Men : 19.2 % life prevalence

National Co-morbidity Study, USA

31Anxiety FactsMost common mental illness in the U.S. with 19 million

of the adult (ages 18-54) U.S. population affected. Anxiety is highly treatable (up to 90% of cases), but only

one-third of those who suffer from it receive treatmentPeople with an anxiety disorder are three-to-five times

more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers.

Depression often accompanies anxiety disorders Ref: 2003 Anxiety Disorders Association of America

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Common CausesThere is no one cause for anxiety disorders. Several

factors can play a role Genetics Brain biochemistry Overactive "fight or flight" response

Can be caused by too much stress Life circumstances/experiances Personality

People who have low self-esteem and poor coping skills may be more prone

Certain drugs In very rare cases, a tumor of the adrenal gland

(pheochromocytoma) may be the cause of anxiety.

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Causes – Psychological Theories

1. Psychoanalytic Theories Sigmund Freud distinguished two types of anxiety:

I. Traumatic – arising from the person being overwhelmed by stressors

II. Neurotic – anticipation of negative consequences that activates defensive processes

2. Behavioural Theory Postulate that anxiety, is a conditioned response to

a specific stimulus.

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Causes – Psychological Theories Cont…

3. Existential Theories “…. Person experience feeling of living in a purposeless

universe“

4. Charles D. Spielberger’s State–Trait Anxiety Inventory (STAI) State Anxiety : Anxious personality Trait Anxiety : momentary anxiety to a stimulus

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SymptomsAnxiety is an emotion often accompanied by

various physical symptoms, including: Twitching or trembling Muscle tension Headaches Sweating Dry mouth Difficulty swallowing Abdominal pain (may be the only symptom of stress

especially in a child)

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Additional Symptoms

Dizziness Rapid or irregular heart rate Rapid breathing Diarrhea or frequent need to urinate Fatigue Irritability, including loss of your temper Sleeping difficulties and nightmares Decreased concentration Sexual problems

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Recent Studies‘Freedom From Fear’ conducted a survey among 410 attendees during National Anxiety Disorders Screening Day on May 7, 2003. The results :

An increase in physical aches and pains is directly attributed to anxiety disorders and depression

60% of the respondents with undiagnosed medical conditions said that on days when they feel anxious or depressed, there is a moderate (41%) to severe (19%) change in their physical symptoms or aches and pains.

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Recent Studies Cont…

These physical symptoms or aches and pains include Backaches (13%) Vague aches and pains (14%) Headaches (14%), Digestive pain (11%) Dizziness (8%).

50% of respondents with diagnosed medical conditions, such as arthritis, migraines, diabetes, heart and respiratory diseases, reported that on days when they feel anxious or depressed, there is a moderate (38%) to severe (12%) change in their physical symptoms or aches and pains.

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Complication

Emotional Complication risk for depression Substance Abuse

Physical Complications Heart disease, and high blood pressure Sudden death from a heart attack or cardiac event. Gastrointestinal disorders Migraine and tension headaches Obesity as well as anorexia.

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Vulnerable PeopleStudents

Symptoms of anxiety and symptoms of depression were prevalent in medical students (43% and 14%, respectively) and in humanities students (52% and 12%, respectively).

International Journal of Social Psychiatry, Vol. 54, No. 6, 494-501 (2008)

Main Causes: Improper Time management, Stress, Personal Demands, body image perception & acceptance, un healthy Competition etc..

Job losers & Job seekers A 2002 study at the University of Michigan found “that secondary

stressors of job loss such as financial strain and loss of personal control are the true culprits that lead to depression. The study also found that elevated levels of depression ‘may reduce the likelihood of reemployment.’”

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Cont…Among workers

In Unorganized sectors out of 457 million workers in India, 395 million (93%) are employed in

the unorganized sectors like construction, agriculture, weaving and fishing and contribute to about 60% of national income.

About 7 % of the total work force is employed in the formal or organized sector

Suicides epidemic is high in this sector. In Organized Sector

Anxiety & Depression is because of Excessive Job demand Problems related to payment Un safe Job environment Job Dissatisfaction / Loosing Interest

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Cont…Among Elderly

Prevalence of depression 19.8%. The elderly living in a nuclear family system were 4.3

times more likely to suffer from depression than those living in a joint family system

BMC Psychiatry 2007, 7:57doi:10.1186/1471-244X-7-57

Common causes: Changes within the family Chronic pain and illness Difficulty getting around Frustration with memory loss Loss of a spouse or close friend

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Cont…Among People with Chronic Disabilities

The rate for depression occurring with other medical illnesses is quite high: Heart attack: 40%-65% Coronary artery disease (without heart attack): 18%-20% Parkinson’s disease: 40% Multiple sclerosis: 40% Stroke: 10%-27% Cancer: 25% Diabetes: 25% www.cchs.net/health/health-info/docs/2200/2282.asp?index=9288

Spinal Cord Injury: 22% - major depressive <2 months post injury (Krause, Bombardier and Carter, 2008), 11.4% after 1 yr. Krause et al. (2000)

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Impact of Depression & Anxiety on Human life:

OT Perspective

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Impact of Depression & Anxiety on Human life: OT Perspective“From an occupational therapy perspective, people

with depression (or anxiety) typically do not have the energy or drive to participate in the things that are important to them,”

Lisa Mahaffey, MS, OTR/L,

OT Evaluation

Model Of Human Occupation (MOHO) Gray Kielhofner

Uniform Terminology for Occupational Therapy 3ird edn

by the American Occupational Therapy Association (AOTA) 1994

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Model Of Human Occupation (MOHO)

The Model of Human occupation seeks to explain the occupational functioning of person.

It focuses on how person choose, order, and perform in everyday occupational behavior.

This model also stresses the Motivation for mastery, control, personal effectiveness & the need of persons to maintain a positive self – image.

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MOHO Conceptualize the Human being as an Open System

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MOHO : Concepts

Knowledge of Self Experience

Decision Making

Physical SocialEnvironment

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Volition

Habituation

Performance Capacity

Participation

Performance

Skill

Occupational Identity

Occupational Adaptation

Occupational Competence

Model of Human Occupation – (based on diagram by Gary Kielhofner)

MOHO : Person & Environment

Throughput Output Feedback s

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Evaluation & Intervention Process using MOHO

Evaluation Process “…. Collect and use data to help clients understand

how their personal perceptions and subjective views lead to occupational performance actions and patterns. Gary Kielhofner

Therapeutic Intervention The process of self-maintenance and change is

supported by allowing the person to participate in freely chosen occupations in therapy

Gary Kielhofner

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Case Study

The application of MOHO in the treatment of a patient with depression in Taiwan: A case study Methods:

Multiple Chinese version MOHO assessments were applied to her at initial stage. The therapeutic relationship with the patient was developed through the discussion of the results of the assessment and treatment planning.

Results:The patient obtained high scores on all symptom checklists and lower satisfaction of her lifestyle and performance initially. A set of meaningful occupations were constructed with her and the steps to apply to her life were negotiated. Before her discharge in a month, her daily living function, role performance, occupational identification and competence improved from previous state.

The MOHO is a useful theoretical base in the clinical assessment and treatment of patients with minor mental disorder.

Yun-Ling Chen et., al MOHO Center Taiwan, Nov 29, 2008

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Uniform Terminology for Occupational Therapy

According to AOTA, uniform terminology for OT is “…. indented to provide a generic outline of the domains of concerns of Occupational Therapy and is designed to created common terminology for the profession & to capture the essence of OT for succinctly others”

Domains of Concerns are, Performance Areas Performance Components Performance Contexts

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Uniform Terminology Cont…

Performance Areas Activities of Daily Living Work & productive activities Play & Leisure activities

Performance Components Sensory-motor components Cognitive Integration & Components Psychosocial Skills & Components

Performance Contexts Temporal Aspects Environmental Aspects

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Wellness Program for Depression & Anxiety

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“Every tomorrow has two handles.

We can take hold of it with the handle

of anxiety or the handle of faith.”

Henry Ward Beecher

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Wellness

Wellness is a state of optimal well-being that is oriented toward maximizing an individual’s potential.

This is a life-long processDimensions: physical,

intellectual, emotional, social, spiritual, and environmental well-being.

How? - by adapting patterns of behavior

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Wellness Program for Depression & Anxiety

Levels Intra – personal

Creative Self Coping Self Essential Self Physical Self General Feeling of Well-Being

Inter-personal Social Self

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Creative Self

Thinking. Being mentally active and open-minded. The ability to be creative and experimental. Having a sense of curiosity. The ability to apply problem-solving strategies to social conflicts.

Emotions. Being aware of or in touch with your feelings. The ability to express appropriately positive and negative feelings.

Control. Beliefs about your competence, confidence, and personal mastery. Beliefs that you can usually achieve the goals you set out for yourself.

Work. Satisfaction with your work. Feeling that your skills are used appropriately. Feeling you can manage one’s workload. Feeling a sense of job security. Feeling appreciated in the work you do.

Positive Humor. Being able to laugh at your own mistakes. The ability to use humor to accomplish even serious tasks.

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Coping Self

Leisure. Satisfaction with your time spent in leisure. Feeling that your skills are used appropriately.

Stress Management. On-going self-assessment of your coping resources. The ability to organize and manage resources such as time, energy, and setting limits.

Self-Worth. Accepting who and what you are, positive qualities along with imperfections. A sense of being genuine within yourself and with others.

Realistic Beliefs. Ability to process information and perceive reality accurately. The absence of persistent irrational beliefs and thoughts and need for perfection.

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Essential Self

Spirituality. Personal beliefs and behaviors practiced as part of the recognition that we are more than the material aspects of mind and body. Belief in a higher power. Hope and optimism. Practice of worship, prayer, and/or meditation; purpose in life. Compassion for others. Moral values. Transcendence (a sense of oneness with the universe).

Gender Identity. Satisfaction with and feeling supported in one’s gender. Ability to be androgynous.

Cultural Identity. Satisfaction with and feeling supported in one’s cultural identity. Cultural assimilation.

Self-Care. Taking responsibility for one’s wellness through self-care and safety habits that are preventive in nature.

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Physical Self

Nutrition. Eating a nutritionally balanced diet. Maintaining a normal weight (within 15% of the ideal).

Exercise. Engaging in sufficient physical activity through exercise or in your work to keep in good physical condition.

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General Feeling of Well-Being

Perceived Wellness. The extent to which you believe you have achieved wellness in all areas, or total wellness. Your estimate of your total wellness.

Perceived Safety. The extent to which you believe you are safe in your home, neighborhood, and community, and the extent to which you feel safe from harm by terrorists.

Context. The extent to which your wellness is influenced, in a conscious manner, by individual, institutional, and global contexts, and the extent to which you are aware of and intentional in responding positively to changes in wellness over time.

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Social Self

Friendship. Social relationships that involve a connection with others individually or in community. Having a capacity to trust others. Having empathy for others. Feeling understood by others.

Love. The ability to be intimate, trusting, self-disclosing with another. The ability to give as well as express affection with significant others and to accept others without conditions.

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Implementation of Mental Wellness Program

Among, Students Job losers & Job Seekers Employers/workers

In Organized Sectors In Un organized sectors

Elderly People People with Disabilities

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Students

Methods Creating a nurturing learning environment Identifying and assisting struggling students Counseling Promoting self-awareness Teaching skills for stress management Helping students promote personal health Activity Scheduling &Time management

Mayo Clin Proc December 2005;80(12):1613-1622

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Job Losers

OT’s can teach/advice/ impliment the following things Stick to a schedule after losing job Spend time each day looking for work. Get plenty of exercise Enjoy with family during this time of uncertainty

Take your kids to the park or go on a walk. Volunteer at your kid's school.

Seek professional help.

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Job seekersBy incorporating MOHO concepts, OT’s can do Prevocational

, Work capacity evaluation and can suggest suitable vocation for the person based on his personal factors

Aim: “Right Job for Right Person”Variables Include;

• VolitionPersonal CausationValuesInterests

• HabituationRolesHabits

• PerformanceSkills

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Employers / workers

In Organized SectorsDiscuses & find out possible solution for the

problems of employers with the employee.Suggest a Nurturing working environment

Activity Scheduling & Time managementArranging Recreational Activities like trips, sports

or cultural activitiesEncourage Meditation, Yoga, Relaxation techniques

activitiesMusic Therapy

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Employers / workers

In Un-organized Sectors

Social security

Social Support groups

Arranging Community Recreational Activities

Counseling Cells

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Elderly People

Early Screening

Social supports

Family Support

Engaging In Fruitful/Productive activities

Spend More time for Recreational activities

Relaxation techniques, Yoga, Meditation, Music Therapy

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People with Disabilities

CounselingBehavioral Technique : ModelingCBT : Biblio-therapy by reading; & Counseling, engaged in

meaningful activities Self help groups

EX: MSSI. AAAArranging Recreational Activities, Seminars, Gatherings etcPhysical Exercises programsGood NutritionSelf Management skillsRelaxation techniques, Yoga, Meditation, Music Therapy

72Thank You..