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 symptoms o Hygiene o Sleep o Fatigue o Threat to safety o Demoralization o Maladaptive coping skills

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

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

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

Strategies (cont.) Voices-differential diagnosis o Schizophrenia o Mania 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.) “Organic” (cont.) o Psychiatric diagnosis vs. “organic” Inattention Memory impairment Depression/irritability/ moodiness

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, out-patients o 40% of people over-diagnosed with bipolar disorder met criteria for borderline personality disorder Muzina study-Cleveland Clinic, 2008 o 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.