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

5. 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

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

7. 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

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

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

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

11. 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

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 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

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? o Social implications o Exacerbations of symptoms of Axis I o Interfers with relationship of provider and patient o 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 o Nature and severity of cognitive, behavioral and emotional problems o Potential for independent living o 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.