Understanding Mental Illness: Symptoms
and Approaches |
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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.
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