Understanding Mental Illness: Symptoms and Approaches

THE BASICS OF MENTAL ILLNESS IN LONG TERM CARE

By: David J. Beard, MSW, LCSW and Steven C. Greenwald, MSW, ACSW, LCSW

The OBRA regulations require nursing facilities to make every possible effort to understand each resident as completely as possible. One key to such an understanding is to have basic training in the various types of mental illness that are most often seen in the long term care setting.

Practically speaking, it's important to know what to expect when you see a certain diagnosis on a resident's chart. How you approach the resident for the very first time may vary depending on the diagnosis. For instance, one might be a little more guarded when one approaches a person with schizophrenia than one with Alzheimer's disease.

The following is a basic overview of the mental illnesses that one is most likely to see in a nursing home. We hope that this foundation will stimulate you to learn more about mental illness as it affects your population.

Schizophrenic Disorders

These disorders usually consist of hallucinations, delusions, social isolation, inability to care for oneself, strange or bizarre behavior, confused conversation, socially inappropriate behavior, low motivation, poor hygiene, and suspicious nature. Proper assessment is important, because schizophrenia can often look very much like Alzheimer's disease or another dementia. For example, both can have delusions and hallucinations. The table on the back page of this newsletter illustrates some of the symptom differences between schizophrenia and dementia.

STAFF APPROACH: Patience. Staff needs to see that this is an illness. It is important that staff be consistent in approach. Be caring but firm. Medication is a primary intervention. Do not joke about the hallucinations or delusions, even light-heartedly. Do not "join in" the delusions with the resident, like one might do occasionally with a resident with dementia in order to gain compliance. Set firm limits about boundaries, such as reminding the resident when he/she is intrusive, inappropriate, or standing too close.

Major Mood Disorders

In Depression there is sadness, mental/physical slowing down, tearfulness, inability to enjoy life, rapid mood shifts, guilt, low self-esteem, poor concentration, talking of death, preoccupation with health, poor sleep, digestive problems, severe isolation, and weight loss. The severely depressed resident can be taxing to staff, who may become angry or frustrated at how "fixed" the resident's depression can be. The resident may not realize the effect he or she has on others, because the depression creates an "internal focus" on self that almost precludes seeing the environment clearly.

If a resident is not responding to counseling or psychotherapy, a psychiatric evaluation may be in order to determine which medications for depression to administer. There are many fine medications that work well in treating depression. All suicidal threats should be taken seriously and assessed for intent.

Bipolar Disorder ("manic depression") is like two alternating diseases that swing back and forth between periods of DEPRESSION and MANIA. This swing usually happens about once or twice a year. The depressive phase is similar to Major Depression. The manic phase is an extreme sense of euphoria, very irritable mood, "inability to stop", lack of sleep, grandiose delusions, inflated sense of self-esteem, pressured speech, flight of ideas, agitation, and poor judgment.

STAFF APPROACH: With depression, take the isolation seriously. Depressed people become very disconnected. Attempt to reconnect the resident to staff and peers through supportive interaction. The bi-polar resident in a manic phase can be extremely difficult. It is important to set limits to keep the resident safe. A manic resident can be exhausting. Try to learn the resident's early signs of depression or mania. If the resident suddenly becomes excessively happy (euphoric), starts to shun sleep, becomes grandiose, or seems unable to stop talking, report this immediately to nursing so that the physician can be notified.

Anxiety Disorders

There are many types of anxiety disorders, and they are very common. Generalized Anxiety Disorder, Panic Disorder, Phobias (fear of heights, public speaking, spiders, etc.), Obsessive-Compulsive Disorder, and Post Traumatic Stress Disorder are all types of anxiety disorders. Anti-anxiety medications such as Valium and Ativan are the most often prescribed psychotropic medication in the country. The basic factor with anxiety disorders is excessive, unrealistic fear.

STAFF APPROACH: Constant reassurance regarding safety and security is important. Again, try to remember that the anxious person does not choose to be this way. Help the resident with relaxation techniques such as deep breathing, progressive muscle relaxation, or recalling peaceful images, when anxious.

Do not force these residents to do the thing they fear unless they want to (i.e. do not place a claustrophobic person at a corner table in the dining room that is blocked in by other residents' wheelchairs). Constantly remind the residents that their fears are distorted and explain the true situation to them. Medication may be indicated.

Personality Disorders

These are usually fixed, problematic, life-long personality traits. Some types of personality disorders cause the resident to be very suspicious (Paranoid Personality Disorder), others cause the person to avoid contact with others (Avoidant Personality Disorder), or excessively dependent on others (Dependent Personality Disorder). Some are combative or cruel (Antisocial Personality Disorder).

In Borderline Personality Disorder the resident may develop quite intense relationships with staff, be impulsive, have mood shifts, become angry for no apparent reason, be preoccupied with abandonment, or be manipulative.

STAFF APPROACH: Don't become furious or take things personally, because they cannot help themselves. These residents have very poor self-esteem, and are scared. The latest research shows that most people with this diagnosis have experienced severe childhood physical, emotional, or sexual abuse. Persons with borderline personalities can be frustrating because they can be intensely angry, moody, manipulative, depressed, overly focused on how staff "let them down", and simply hard to manage. It's crucial to set limits firmly, but to also attend to legitimate needs.

Avoid being manipulated or pitted against other staff or residents. Be aware that they often divide people (including staff) into the "good people" or the "bad people." No one is in between. They can play staff off of each other, or manipulate other residents.

Set limits on inappropriate demands, but strongly and regularly reassure the resident that his/her legitimate demands will be taken care of. Watch for signs of depression or anxiety. Remember that any resident with a personality disorder is very likely to be exhausting or frustrating to work with because their problems are so ingrained.

In understanding the common symptoms of mental illness and effective approaches to care, staff can greatly improve these residents' feelings of security, comfort, and independence.