Definition

Dependent personality disorder is characterized by an excessive need to be taken care of or depend upon others. Persons with this disorder are typically submissive and display clinging behavior toward those from whom they fear being separated.

Dependent personality disorder is one of several personality disorders listed in the newest edition of the standard reference guide: Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-IV-TR.

Description

Persons with dependent personality disorder are docile, passive, and nonassertive. They exert a great deal of energy to please others, are self-sacrificing, and constantly attempt to elicit the approval of others. They are reluctant to express disagreement with others, and are often willing to go to abnormal lengths to win the approval of those on whom they rely. They are easily influenced and can be taken advantage of easily. This compliance and reliance upon others leads to a subtle message that someone should assume responsibility for significant areas of the patient’s life. This is often displayed as helplessness, even for completion of seemingly simple tasks.

Patients with dependent personality disorder have a low level of confidence in their own intelligence and abilities. They often have difficulty making decisions and undertaking projects on their own. They are prone to be pessimistic, self-doubting, and belittle their own accomplishments. They shy away from responsibility in occupational settings.

Affected individuals are uneasy being alone and are preoccupied with the fear of being abandoned or rejected by others. Their moods are characterized by frequent bouts of anxiety or fearfulness; generally, their demeanor is sad. Their style of thinking is naïve, uncritical, and lacks discretion.

Causes and symptoms

Causes

It is commonly thought that the development of dependence in these individuals is a result of over-involvement and intrusive behavior by their primary caretakers. Caretakers may foster dependence in the child to meet their own dependency needs, and may reward extreme loyalty but reject attempts the child makes towards independence. Families of those with dependent personality disorder are often do not express their emotions and are controlling; they demonstrate poorly defined relational roles within the family unit.

Individuals with dependent personality disorder often have been socially humiliated by others in their developmental years. They may carry significant doubts about their abilities to perform tasks, take on new responsibilities, and generally function independently of others. This reinforces their suspicions that they are incapable of living autonomously. In response to these feelings, they portray a helplessness that elicits caregiving behavior from some people in their lives.

Symptoms

DSM-IV-TRspecifies eight diagnostic criteria for dependent personality disorder. Individuals with this disorder:

• Have difficulty making common decisions. These individuals typically need an excessive amount of advice and reassurance before they can make even simple decisions, such as the clothing to wear on a given day.
• Need others to assume responsibility for them. Because they view themselves as incapable of being autonomous, they withdraw from adult responsibilities by acting passive and helpless. They allow others to take the initiative for many areas of their life. Adults with this disorder typically depend on a parent or spouse to make major decisions for them, such as where to work, to live, or with whom to be friends.
• Have difficulty expressing disagreement with others. Disagreeing with others is often viewed as too risky. It might sever the support or approval of those they upon whom they depend. They are often overly agreeable, as they fear alienating other people.
• Have difficulty initiating or doing things on their own. They lack self-confidence and believe they need help to begin or sustain tasks. They often present themselves as inept and unable to understand or accomplish the task at hand.
• Go to excessive lengths to obtain support or nurturing from others. They may even volunteer to do unpleasant tasks if they believe that doing so will evoke a positive response from others. They may subject themselves to great personal sacrifice or tolerate physical, verbal, or sexual abuse in their quest to get what they believe they need from others.
• Feel helpless when alone. Because they feel incapable of caring for themselves, they experience significant anxiety when alone. To avoid being alone, they may be with people in whom they have little interest.
• Quickly seek a new relationship when a previous one ends. When a marriage, dating, or other close relationship ends, there is typically an urgency to find a new relationship that will provide the support of the former relationship.
• Are preoccupied with fears of being left to take care of themselves. Their greatest fear is to be left alone and to be responsible for themselves. Even as adults, their dependence upon others may appear childlike.

Demographics

Dependent personality disorder should rarely, if ever, be diagnosed in children or adolescents because of their dependence on others because of their age and developmental limitations.

Diagnosis

Age and cultural factors should be considered in diagnosing dependent personality disorder. Certain cultural norms suggest a submissive, polite, or dependent posture in relating to the opposite sex, or authority figures. Dependent personality disorder should only be diagnosed when it meets the above criteria and is clearly outside one’s cultural norms.

The diagnosis of dependent personality disorder is based on a clinical interview to assess symptomatic behavior. Other assessment tools helpful in confirming the diagnosis of dependent personality disorder include:

• Minnesota Multiphasic Personality Inventory (MMPI-2)
• Millon Clinical Multi-axial Inventory (MCMI-II)
• Rorschach Psychodiagnostic Test
• Thematic Appreception Test(TAT)

For a person to be diagnosed with dependent personality disorder, at least five of the eight symptoms described above must be the present, and these symptoms must begin by early adulthood and be evident in a variety of contexts.

The diagnosis of dependent personality disorder must be distinguished from borderline personality disorder, as there are common characteristics. Borderline personality disorder is characterized by fear of abandonment, as well, but with feelings of emptiness and rage. In contrast, the dependent personality responds to this fear of abandonment with submissiveness, and searches for a replacement relationship to maintain dependency.

Likewise, persons with histrionic personality disorder have a strong need for reassurance and approval, and may appear childlike in their clinging behavior. Histrionics are characterized by a gregarious demeanor and make active demands for attention, whereas dependents respond with docile and self-deprecating behavior.

The avoidant personality disorder can also be confused with dependent personality disorder. Both are characterized by feelings of inadequacy, an oversensitivity to criticism, and a frequent need for assurance. However, patients with avoidant personality disorder typically have such an intense fear of rejection that they will instinctively withdraw until they are certain of acceptance. People with dependent personality disorder, in contrast, actually seek out contact with others because they need the approval of others.

Treatments

The general goal of treatment of dependent personality disorder is to increase the individual’s sense of autonomy and ability to function independently.

Psychodynamically oriented therapies

A long-term approach to psychodynamic treatment can be successful, but may lead to heightened dependencies and difficult separation in the therapeutic relationship over time. The preferred approach is a time-limited treatment plan consisting of a predetermined number of sessions. This has been proved to facilitate the exploration process of dependency issues more effectively than long-term therapy in most patients.

Cognitive-behavioral therapy

Cognitive-behavioral approaches attempt to increase the affected person’s ability to act independently of others, improve their self-esteem, and enhance the quality of their interpersonal relationships. Often, patients will play an active role in setting goals. Methods often used in cognitive-behavioral therapy(CBT) include assertiveness and social skills training to help reduce reliance on others, including the therapist.

Interpersonal therapy

Treatment using an interpersonal approach can be useful because the individual is usually receptive to treatment and seeks help with interpersonal relationships. The therapist would help the patient explore their long-standing patterns of interacting with others, and understand how these have contributed to dependency issues. The goal is to show the patient the high price they pay for this dependency, and to help them develop healthier alternatives. Assertiveness training and learning to identify feelings is often used to improve interpersonal behavior.

Group therapy

When a person is highly motivated to see growth, a more interactive therapeutic group can be successful in helping him/her to explore passive-dependent behavior. If the individual is socially reluctant or impaired in his/her assertiveness, decision-making, or negotiation, a supportive decision-making group would be more appropriate. Time-limited assertiveness-training groups with clearly defined goals have been proven to be effective.

Family and marital therapy

Individuals with dependent personality disorder are usually brought to therapy by their parents. They are often young adults who are struggling with neurotic or psychotic symptoms. The goal of family therapy is often to untangle the enmeshed family relationships, which usually elicits considerable resistance by most family members unless all are in therapy.

Marital therapy can be productive in helping couples reduce the anxiety of both partners who seek and meet dependency needs that arise in the relationship.

Medications

Individuals with dependent personality disorder can experience anxiety and depressive disorders as well. In these cases, it may occasionally prove useful to use antidepressants or anti-anxiety agents. Unless the anxiety or depression is considered worthy of a primary diagnosis, medications are generally not recommended for treatment of the dependency issues or the anxiety or depressive responses. Persons with dependent personality disorder may become overly dependent on any medication used.

Prognosis

The general prognosis for individuals with dependent personality disorder is good. Most people with this disorder have had a supportive relationship with at least one parent. This enables them to engage in treatment to varying degrees and to explore the source of their dependent behavior. If persons who enter treatment can learn to become more autonomous, improved functioning can be expected.

Prevention

Since dependent personality disorder originates in the patient’s family, the only known preventive measure is a nurturing, emotionally stimulating, and expressive caregiving environment.

Definition

Denial is the refusal to acknowledge the existence or severity of unpleasant external realities or internal thoughts and feelings.

Theory of denial

In psychology, denial is a concept originating with the psychodynamic theories of Sigmund Freud. According to Freud, three mental dynamics, or motivating forces, influence human behavior: the id, ego, and superego. The id consists of basic survival instincts and what Freud believed to be the two dominant human drives: sex and aggression. If the id were the only influence on behavior, humans would exclusively seek to increase pleasure, decrease pain, and achieve immediate gratification of desires. The ego consists of logical and rational thinking. It enables humans to analyze the realistic risks and benefits of a situation, to tolerate some pain for future profit, and to consider alternatives to the impulse-driven behavior of the id. The superego consists of moralistic standards and forms the basis of the conscience. Although the superego is essential to a sense of right and wrong, it can also include extreme, unrealistic ideas about what one should and should not do.

These three forces all have different goals (id, pleasure; ego, reality; superego, morality) and continually strive for dominance, resulting in internal conflict. This conflict produces anxiety. The ego, which functions as a mediator between the two extremes of the id and the superego, attempts to reduce this anxiety by using defense mechanisms. Defense mechanisms are indirect ways of dealing or coping with anxiety, such as explaining problems away or blaming others for problems. Denial is one of many defense mechanisms. It entails ignoring or refusing to believe an unpleasant reality. Defense mechanisms protect one’s psychological wellbeing in traumatic situations, or in any situation that produces anxiety or conflict. However, they do not resolve the anxiety-producing situation and, if overused, can lead to psychological disorders. Although Freud’s model of the id, ego, and superego is not emphasized by most psychologists today, defense mechanisms are still regarded as potentially maladaptive behavioral patterns that may lead to psychological disorders.

Examples of denial

Death is a common occasion for denial. When someone learns of the sudden, unexpected death of a loved one, at first he or she may not be able to accept the reality of this loss. The initial denial protects that person from the emotional shock and intense grief that often accompanies news of death. Chronic or terminal illnesses also encourage denial. People with such illnesses may think, “It’s not so bad; I’ll get over it,” and refuse to make any lifestyle changes.

Denial can also apply to internal thoughts and feelings. For instance, some children are taught that anger is wrong in any situation. As adults, if these individuals experience feelings of anger, they are likely to deny their feelings to others. Cultural standards and expectations can encourage denial of subjective experience. Men who belong to cultures with extreme notions of masculinity may view fear as a sign of weakness and deny internal feelings of fear. The Chinese culture is thought to discourage the acknowledgment of mental illness, resulting in individuals denying their psychological symptoms and often developing physical symptoms instead.

Certain personality disorders tend to be characterized by denial more than others. For example, those with narcissistic personality disorder deny information that suggests they are not perfect. Antisocial behavior is characterized by denial of the harm done to others (such as with sexual offenders or substance abusers).

Denial can also be exhibited on a large scale— among groups, cultures, or even nations. Lucy Bregman gives an example of national denial of imminent mortality in the 1950s: school children participated in drills in which they hid under desks in preparation for atomic attacks. Another example of large-scale denial is the recent assertion by some that the World War II Holocaust never occurred.

Treatment of denial

Denial is treated differently in different types of therapy. In psychoanalytic therapy, denial is regarded as an obstacle to progress that must eventually be confronted and interpreted. Timing is important, however. Psychoanalytic therapists wait until clients appear emotionally ready or have some degree of insight into their problems before confronting them. In the humanistic and existential therapies, denial is considered the framework by which clients understand their world. Not directly confronting denial, therapists assist clients in exploring their world view and considering alternative ways of being. In cognitive-behavioral therapies, denial is not regarded as an important phenomenon. Rather, denial would suggest that an individual has not learned the appropriate behaviors to cope with a stressful situation. Therapists assist individuals in examining their current thoughts and behaviors and devising strategic ways to make changes.

Traditional treatment programs for substance abuse and other addictions view denial as a central theme. Such programs teach that in order to overcome addiction, one must admit to being an alcoholic or addict. Those who are unable to accept such labels are informed they are in denial. Even when the labels are accepted, individuals are still considered to be in denial if they do not acknowledge the severity of their addictions. From this perspective, progress cannot be made until individuals recognize the extent of their denial and work toward acceptance. However, there is much controversy in the field of addictions regarding the role of denial and how it should be addressed. Traditional programs stress direct confrontation. Other professionals do not insist on the acceptance of labels. They believe that denial should be worked through more subtly, empathically focusing on the personal reasons surrounding denial and seeking to strengthen the desire to change. This subtle form of addressing denial is known as motivational enhancement therapy, and can be used with other types of disorders as well.

Definition

Dementia is not a specific disorder or disease. It is a syndrome (group of symptoms) associated with a progressive loss of memory and other intellectual functions that is serious enough to interfere with performing the tasks of daily life. Dementia can occur to anyone at any age from an injury or from oxygen deprivation, although it is most commonly associated with aging. It is the leading cause of institutionalization of older adults.

Description

The definition of dementia has become more inclusive over the past several decades. Whereas earlier descriptions of dementia emphasized memory loss, the last three editions of the professional’s diagnostic handbook, Diagnostic and Statistical Manual of Mental Disorders(also known as the DSM) define dementia as an overall decline in intellectual function, including difficulties with language, simple calculations, planning and judgment, and motor (muscular movement) skills as well as loss of memory. Although dementia is not caused by aging itself— most researchers regard it as resulting from injuries, infections, brain diseases, tumors, or other disorders— it is quite common in older people. The prevalence of dementia increases rapidly with age; it doubles every five years after age 60. Dementia affects only 1% of people aged 60–64 but 30%–50% of those older than 85. About four to five million persons in the United States are affected by dementia as of 2002. Surveys indicate that dementia is the condition most feared by older adults in the United States.

Causes and symptoms

Causes

Dementia can be caused by nearly forty different diseases and conditions, ranging from dietary deficiencies and metabolic disorders to head injuries and inherited diseases. The possible causes of dementia can be categorized as follows:

• Primary dementia. These dementias are characterized by damage to or wasting away of the brain tissue itself. They include Alzheimer’s disease(AD), frontal lobe dementia (FLD), and Pick’s disease. FLD is dementia caused by a disorder (usually genetic) that affects the front portion of the brain, and Pick’s disease is a rare type of primary dementia that is characterized by a progressive loss of social skills, language, and memory, leading to personality changes and sometimes loss of moral judgment.
• Multi-infarct dementia (MID). Sometimes called vascular dementia, this type is caused by blood clots in the small blood vessels of the brain. When the clots cut off the blood supply to the brain tissue, the brain cells are damaged and may die. (An infarct is an area of dead tissue caused by obstruction of the circulation.)
• Lewy body dementia. Lewy bodies are areas of injury found on damaged nerve cells in certain parts of the brain. They are associated with Alzheimer’s and Parkinson’s disease, but researchers do not yet know whether dementia with Lewy bodies is a distinct type of dementia or a variation of Alzheimer’s or Parkinson’s disease.
• Dementia related to alcoholism or exposure to heavy metals (arsenic, antimony, bismuth).
• Dementia related to infectious diseases. These infections may be caused by viruses (HIV, viral encephalitis); spirochetes (Lyme disease, syphilis); or prions (Creutzfeldt-Jakob disease). Spirochetes are certain kinds of bacteria, and prions are protein particles that lack nucleic acid.
• Dementia related to abnormalities in the structure of the brain. These may include a buildup of spinal fluid in the brain (hydrocephalus); tumors; or blood collecting beneath the membrane that covers the brain (subdural hematoma).

Dementia may also be associated with depression, low levels of thyroid hormone, or niacin or vitamin B ₁₂deficiency. Dementia related to these conditions is often reversible.

Genetic factors in dementia

Genetic factors play a role in several types of dementia, but the importance of these factors in the development of the dementia varies considerably. Alzheimer’s disease (AD) is known, for example, to have an autosomal (non-sex-related) dominant pattern in most early-onset cases as well as in some late-onset cases, and to show different degrees of penetrance (frequency of expression) in late-life cases. Moreover, researchers have not yet discovered how the genes associated with dementia interact with other risk factors to produce or trigger the dementia. One non-genetic risk factor presently being investigated is toxic substances in the environment.

EARLY-ONSET ALZHEIMER’S DISEASE. In early-onset AD, which accounts for 2%–7% of cases of AD, the symptoms develop before age 60. It is usually caused by an inherited genetic mutation. Early-onset AD is also associated with Down syndrome, in that persons with trisomy 21 (three forms of human chromosome 21 instead of a pair) often develop early-onset AD.

LATE-ONSET ALZHEIMER’S DISEASE. Recent research indicates that late-onset Alzheimer’s disease is a polygenic disorder; that is, its development is influenced by more than one gene. It has been known since 1993 that a specific form of a gene (the APOE gene) on human chromosome 19 is a genetic risk factor for late-onset AD. In 1998 researchers at the University of Pittsburgh reported on another gene that controls the production of bleomycin hydrolase (BH) as a second genetic risk factor that acts independently of the APOE gene. In December 2000, three separate research studies reported that a gene on chromosome 10 that may affect the processing of a protein (called amyloid-beta protein) is also involved in the development of late-onset AD. When this protein is not properly broken down, a starchy substance builds up in the brains of people with AD to form the plaques that are characteristic of the disease.

MULTI-INFARCT DEMENTIA (MID). While the chief risk factors for MID are high blood pressure, advanced age, and male sex, there is an inherited form of MID called CADASIL, which stands for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. CADASIL can cause psychiatric disturbances and severe headaches as well as dementia.

FRONTAL LOBE DEMENTIAS. Researchers think that between 25% and 50% of cases of frontal lobe dementia involve genetic factors. Pick’s dementia appears to have a much smaller genetic component than FLD. It is not yet known what other risk factors combine with inherited traits to influence the development of frontal lobe dementias.

FAMILIAL BRITISH DEMENTIA (FBD). FBD is a rare autosomal dominant disorder that was first reported in the 1940s in a large British family extending over nine generations. FBD resembles Alzheimer’s in that the patient develops a progressive dementia related to amyloid deposits in the brain. In 1999, a mutated gene that produces the amyloid responsible for FBD was discovered on human chromosome 13. Studies of this mutation may yield further clues to the development of Alzheimer’s disease as well as FBD itself.

CREUTZFELDT-JAKOB DISEASE. Although Creutzfeldt-Jakob disease is caused by a prion, researchers think that 5%–15% of cases may have a genetic component.

Symptoms

The fourth edition, text revised version of the DSMwas published in 2000, and is known as DSM-IV-TR. DSM-IV-TRidentifies certain symptoms as criteria that must be met for a patient to be diagnosed with dementia. One criterion is significant weakening of the patient’s memory with regard to learning new information as well as recalling previously learned information. In addition, the patient must be found to have one or more of the following disturbances:

• Aphasia. Aphasia refers to loss of language function. A person with dementia may use vague words like “it” or “thing” often because he or she can’t recall the exact name of an object; the affected person may echo what other people say, or repeat a word or phrase over and over. People in the later stages of dementia may stop speaking at all.
• Apraxia. Apraxia refers to loss of the ability to perform intentional movements even though the person is not paralyzed, has not lost the sense of touch, and knows what he or she is trying to do. For example, a patient with apraxia may stop brushing their teeth, or have trouble tying their shoelaces.
• Agnosia. Agnosia refers to loss of the ability to recognize objects even though the person’s sight and sense of touch are normal. People with severe agnosia may fail to recognize family members or even their own face reflected in a mirror.
• Problems with abstract thinking and complex behavior. This criterion refers to the loss of the ability to make plans, carry out the steps of a task in the proper order, make appropriate decisions, evaluate situations, show good judgment, etc. For example, a patient might light a stove burner under a saucepan before putting food or water in the pan, or be unable to record checks and balance their checkbook.

DSM-IV-TRalso specifies that these disturbances must be severe enough to cause problems in the person’s daily life, and that they must represent a decline from a previously higher level of functioning.

In addition to the changes in cognitive functioning, the symptoms of dementia may also include personality changes and emotional instability. Patients with dementia sometimes become mildly paranoid because their loss of short-term memory leads them to think that mislaid items have been stolen. About 25% of patients with dementia develop a significant degree of paranoia, that is, generalized suspiciousness or specific delusions of persecution. Mood swings, anxiety, and irritability or anger are also frequent occurrences, particularly when patients with dementia are in situations that force them to recognize the extent of their impairment.

The following sections describe the signs and symptoms that are used to differentiate among the various types of dementia during a diagnostic evaluation.

ALZHEIMER’S DISEASE. Dementia related to AD often progresses slowly; it may be accompanied by irritability, wide mood swings, and personality changes in the early stage. Many patients, however, retain their normal degree of sociability in the early stages of Alzheimer’s. In second-stage AD, the patient typically gets lost easily, is completely disoriented with regard to time and space, and may become angry, uncooperative, or aggressive. Patients in second-stage AD are at high risk for falls and other accidents. In final-stage AD, the patient is completely bedridden, has lost control over bowel and bladder functions, and may be unable to swallow or eat. The risk of seizures increases as the patient progresses from early to end-stage Alzheimer’s. Death usually results from an infection or from malnutrition.

 

MULTI-INFARCT DEMENTIA. In MID, the symptoms are more likely to occur after age 70. In the early stages, the patient retains his or her personality more fully than a patient with AD. Another distinctive feature of this type of dementia is that it often progresses in a stepwise fashion; that is, the patient shows rapid changes in functioning, then remains at a plateau for a while rather than showing a continuous decline. The symptoms of MID may also have a “patchy” quality; that is, some of the patient’s mental functions may be severely affected while others are relatively undamaged. Other symptoms of MID include exaggerated reflexes, an abnormal gait (manner of walking), loss of bladder or bowel control, and inappropriate laughing or crying.

DEMENTIA WITH LEWY BODIES. This type of dementia may combine some features of AD, such as severe memory loss and confusion, with certain symptoms associated with Parkinson’s disease, including stiff muscles, a shuffling gait, and trembling or shaking of the hands. Visual hallucinations may be one of the first symptoms of dementia with Lewy bodies.

FRONTAL LOBE DEMENTIAS. The frontal lobe dementias are gradual in onset. Pick’s dementia is most likely to develop in persons between 40 and 60, while FLD typically begins before the age of 65. The first symptoms of the frontal lobe dementias often include socially inappropriate behavior (rude remarks, sexual acting-out, disregard of personal hygiene, etc.). Patients are also often obsessed with eating and may put non-food items in their mouths as well as making frequent sucking or smacking noises. In the later stages of frontal lobe dementia or Pick’s disease, the patient may develop muscle weakness, twitching, and delusions or hallucinations.

CREUTZFELDT-JAKOB DISEASE. The dementia associated with Creutzfeldt-Jakob disease occurs most often in persons between 40 and 60. It is typically preceded by a period of several weeks in which the patient complains of unusual fatigue, anxiety, loss of appetite, or difficulty concentrating. This type of dementia also usually progresses much more rapidly than other dementias, frequently over a span of a few months.

Description

A delusion is a belief that is clearly false and that indicates an abnormality in the affected person’s content of thought. The false belief is not accounted for by the person’s cultural or religious background or his or her level of intelligence. The key feature of a delusion is the degree to which the person is convinced that the belief is true. A person with a delusion will hold firmly to the belief regardless of evidence to the contrary. Delusions can be difficult to distinguish from overvalued ideas, which are unreasonable ideas that a person holds, but the affected person has at least some level of doubt as to its truthfulness. A person with a delusion is absolutely convinced that the delusion is real.

Delusions are a symptom of either a medical, neurological, or mental disorder. Delusions may be present in any of the following mental disorders:

• psychotic disorders, or disorders in which the affected person has a diminished or distorted sense of reality and cannot distinguish the real from the unreal, including schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, shared psychotic disorder, brief psychotic disorder, and substance-induced psychotic disorder
• bipolar disorder
• major depressive disorder with psychotic features
• delirium
• dementia

Overvalued ideas may be present in anorexia nervosa, obsessive-compulsive disorder, body dysmorphic disorder, or hypochondriasis.

Types

Delusions are categorized as either bizarre or non-bizarre and as either mood-congruent or mood-incongruent. A bizarre delusion is a delusion that is very strange and completely implausible for the person’s culture; an example of a bizarre delusion would be that aliens have removed the affected person’s brain. A non-bizarre delusion is one whose content is definitely mistaken, but is at least possible; an example may be that the affected person mistakenly believes that he or she is under constant police surveillance. A mood-congruent delusion is any delusion whose content is consistent with either a depressive or manic state; for example, a depressed person may believe that the world is ending, or a person in a manic state (a state in which the person feels compelled to take on new projects, has a lot of energy, and needs little sleep) believes that he or she has special talents or abilities, or is a famous person. A mood-incongruent delusion is any delusion whose content is not consistent with either a depressed or manic state or is mood-neutral. An example is a depressed person who believes that thoughts are being inserted into his or her mind from some outside force, person, or group of people, and these thoughts are not recognized as the person’s own thoughts (called “thought insertion”).

In addition to these categories, delusions are often categorized according to theme. Although delusions can have any theme, certain themes are more common. Some of the more common delusion themes are:

• Delusion of control: This is a false belief that another person, group of people, or external force controls one’s thoughts, feelings, impulses, or behavior. A person may describe, for instance, the experience that aliens actually make him or her move in certain ways and that the person affected has no control over the bodily movements. Thought broadcasting (the false belief that the affected person’s thoughts are heard aloud), thought insertion, and thought withdrawal (the belief that an outside force, person, or group of people is removing or extracting a person’s thoughts) are also examples of delusions of control.
• Nihilistic delusion: A delusion whose theme centers on the nonexistence of self or parts of self, others, or the world. A person with this type of delusion may have the false belief that the world is ending.
• Delusional jealousy (or delusion of infidelity): A person with this delusion falsely believes that his or her spouse or lover is having an affair. This delusion stems from pathological jealousy and the person often gathers “evidence” and confronts the spouse about the nonexistent affair.
• Delusion of guilt or sin (or delusion of self-accusation): This is a false feeling of remorse or guilt of delusional intensity. A person may, for example, believe that he or she has committed some horrible crime and should be punished severely. Another example is a person who is convinced that he or she is responsible for some disaster (such as fire, flood, or earthquake) with which there can be no possible connection.
• Delusion of mind being read: The false belief that other people can know one’s thoughts. This is different from thought broadcasting in that the person does not believe that his or her thoughts are heard aloud.
• Delusion of reference: The person falsely believes that insignificant remarks, events, or objects in one’s environment have personal meaning or significance. For instance, a person may believe that he or she is receiving special messages from the news anchorperson on television. Usually the meaning assigned to these events is negative, but the “messages” can also have a grandiose quality.
• Erotomania: A delusion in which one believes that another person, usually someone of higher status, is in love with him or her. It is common for individuals with this type of delusion to attempt to contact the other person (through phone calls, letters, gifts, and sometimes stalking).
• Grandiose delusion: An individual exaggerates his or her sense of self-importance and is convinced that he or she has special powers, talents, or abilities. Sometimes, the individual may actually believe that he or she is a famous person (for example, a rock star or Christ). More commonly, a person with this delusion believes he or she has accomplished some great achievement for which they have not received sufficient recognition.
• Persecutory delusions: These are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals. Sometimes the delusion is isolated and fragmented (such as the false belief that co-workers are harassing), but sometimes are well-organized belief systems involving a complex set of delusions (“systematized delusions”). A person with a set of persecutory delusions may be believe, for example, that he or she is being followed by government organizations because the “persecuted” person has been falsely identified as a spy. These systems of beliefs can be so broad and complex that they can explain everything that happens to the person.
• Religious delusion: Any delusion with a religious or spiritual content. These may be combined with other delusions, such as grandiose delusions (the belief that the affected person was chosen by God, for example), delusions of control, or delusions of guilt. Beliefs that would be considered normal for an individual’s religious or cultural background are not delusions.
• Somatic delusion: A delusion whose content pertains to bodily functioning, bodily sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or changed. An example of a somatic delusion would be a person who believes that his or her body is infested with parasites.

Delusions of control, nihilistic delusions, and thought broadcasting, thought insertion, and thought withdrawal are usually considered bizarre delusions. Most persecutory, somatic, grandiose, and religious delusions, as well as most delusions of jealousy, delusions of mind being read, and delusions of guilt would be considered non-bizarre.

Definition

Delusional disorder is characterized by the presence of recurrent, persistent non-bizarre delusions.

Delusions are irrational beliefs, held with a high level of conviction, that are highly resistant to change even when the delusional person is exposed to forms of proof that contradict the belief. Non-bizarre delusions are considered to be plausible; that is, there is a possibility that what the person believes to be true could actually occur a small proportion of the time. Conversely, bizarre delusions focus on matters that would be impossible in reality. For example, a non-bizarre delusion might be the belief that one’s activities are constantly under observation by federal law enforcement or intelligence agencies, which actually does occur for a small number of people. By contrast, a man who believes he is pregnant with German Shepherd puppies holds a belief that could never come to pass in reality. Also, for beliefs to be considered delusional, the content or themes of the beliefs must be uncommon in the person’s culture or religion. Generally, in delusional disorder, these mistaken beliefs are organized into a consistent world-view that is logical other than being based on an improbable foundation.

In addition to giving evidence of a cluster of interrelated non-bizarre delusions, persons with delusional disorder experience hallucinations far less frequently than do individuals with schizophrenia or schizoaffective disorder.

Description

Unlike most other psychotic disorders, the person with delusional disorder typically does not appear obviously odd, strange or peculiar during periods of active illness. Yet the person might make unusual choices in day-to-day life because of the delusional beliefs. Expanding on the previous example, people who believe they are under government observation might seem typical in most ways but could refuse to have a telephone or use credit cards in order to make it harder for “those Federal agents” to monitor purchases and conversations. Most mental health professionals would concur that until the person with delusional disorder discusses the areas of life affected by the delusions, it would be difficult to distinguish the sufferer from members of the general public who are not psychiatrically disturbed. Another distinction of delusional disorder compared with other psychotic disorders is that hallucinations are either absent or occur infrequently.

The person with delusional disorder may or may not come to the attention of mental health providers. Typically, while delusional disorder sufferers may be distressed about the delusional “reality,” they may not have the insight to see that anything is wrong with the way they are thinking or functioning. Regarding the earlier example, those suffering delusion might state that the only thing wrong or upsetting in their lives is that the government is spying, and if the surveillance would cease, so would the problems. Similarly, the people suffering the disorder attribute any obstacles or problems in functioning to the delusional reality, separating it from their internal control. Furthermore, whether unable to get a good job or maintain a romantic relationship, the difficulties would be blamed on “government interference” rather than on their own failures or omissions. Unless the form of the delusions causes illegal behavior, somehow affects an ability to work, or otherwise deal with daily activities, the delusional disorder sufferer may adapt well enough to navigate life without coming to clinical attention. When people with delusional disorder decide to seek mental health care, the motivation for getting treatment is usually to decrease the negative emotions of depression, fearfulness, rage, or constant worry caused by living under the cloud of delusional beliefs, not to change the unusual thoughts themselves.

Forms of delusional disorder

An important aspect of delusional disorder is the identification of the form of delusion from which a person suffers. The most common form of delusional disorder is the persecutory or paranoid subtype, in which the patients are certain that others are striving to harm them.

In the erotomanic form of delusional disorder, the primary delusional belief is that some important person is secretly in love with the sufferer. The erotomanic type is more common in women than men. Erotomanic delusions may prompt stalking the love object and even violence against the beloved or those viewed as potential romantic rivals.

The grandiose subtype of delusional disorder involves the conviction of one’s importance and uniqueness, and takes a variety of forms: believing that one has a distinguished role, has some remarkable connections with important persons, or enjoys some extraordinary powers or abilities.

In the somatic subtype, there is excessive concern and irrational ideas about bodily functioning, which may include worries regarding infestation with parasites or insects, imagined physical deformity, or a conviction that one is emitting a foul stench when there is no problematic odor.

The form of disorder most associated with violent behavior, usually between romantic partners, is the jealous subtype of delusional disorder. Patients are firmly convinced of the infidelity of a spouse or partner, despite contrary evidence and based on minimal data (like a messy bedspread or more cigarettes than usual in an ashtray, for instance). Delusional jealousy sufferers may gather scraps of conjectured “evidence,” and may try to constrict their partners’ activities or confine them to home. Delusional disorder cases involving aggression and injury toward others have been most associated with this subtype.

Delusion and other disorders

Even though the main characteristic of delusional disorder is a noticeable system of delusional beliefs, delusions may occur in the course of a large number of other psychiatric disorders. Delusions are often observed in persons with other psychotic disorders such as schizophrenia and schizoaffective disorder. In addition to occurring in the psychotic disorders, delusions also may be evident as part of a response to physical, medical conditions (such as brain injury or brain tumors), or reactions to ingestion of a drug.

Delusions also occur in the dementias, which are syndromes wherein psychiatric symptoms and memory loss result from deterioration of brain tissue. Because delusions can be shown as part of many illnesses, the diagnosis of delusional disorder is partially conducted by process of elimination. If the delusions are not accompanied by persistent, recurring hallucinations, then schizophrenia and schizoaffective disorder are not appropriate diagnoses. If the delusions are not accompanied by memory loss, then dementia is ruled out. If there is no physical illness or injury or other active biological cause (such as drug ingestion or drug withdrawal), then the delusions cannot be attributed to a general medical problem or drug-related causes. If delusions are the most obvious and pervasive symptom, without hallucinations, medical causation, drug influences or memory loss, then delusional disorder is the most appropriate categorization.

Because delusions occur in many different disorders, some clinician-researchers have argued that there is little usefulness in focusing on what diagnosis the person has been given. Those who ascribe to this view believe it is more important to focus on the symptom of delusional thinking, and find ways to have an effect on delusions, whether they occur in delusional disorder or schizophrenia or schizoaffective disorder. The majority of psychotherapy techniques used in delusional disorder come from symptom-focused (as opposed to diagnosis-focused) researcher-practitioners.

Causes and symptoms

Causes

Because clear identification of delusional disorder has traditionally been challenging, scientists have conducted far less research relating to the disorder than studies for schizophrenia or mood disorders. Still, some theories of causation have developed, which fall into several categories.

GENETIC OR BIOLOGICAL. Close relatives of persons with delusional disorder have increased rates of delusional disorder and paranoid personality traits. They do not have higher rates of schizophrenia, schizoaffective disorder or mood disorder compared to relatives of non-delusional persons. Increased incidence of these psychiatric disorders in individuals closely genetically related to persons with delusional disorder suggest that there is a genetic component to the disorder. Furthermore, a number of studies comparing activity of different regions of the brain in delusional and non-delusional research participants yielded data about differences in the functioning of the brains between members of the two groups. These differences in brain activity suggest that persons neurologically with delusions tend to react as if threatening conditions are consistently present. Non-delusional persons only show such patterns under certain kinds of conditions where the interpretation of being threatened is more accurate. With both brain activity evidence and family heritability evidence, a strong chance exists that there is a biological aspect to delusional disorder.

DYSFUNCTIONAL COGNITIVE PROCESSING. An elaborate term for thinking is “cognitive processing.” Delusions may arise from distorted ways people have of explaining life to themselves. The most prominent cognitive problems involve the manner in which delusion sufferers develop conclusions both about other people, and about causation of unusual perceptions or negative events. Studies examining how people with delusions develop theories about reality show that the subjects have ideas which which they tend to reach an inference based on less information than most people use. This “jumping to conclusions” bias can lead to delusional interpretations of ordinary events. For example, developing flu-like symptoms coinciding with the week new neighbors move in might lead to the conclusion, “the new neighbors are poisoning me.” The conclusion is drawn without considering alternative explanations—catching an illness from a relative with the flu, that a virus seems to be going around at work, or that the tuna salad from lunch at the deli may have been spoiled. Additional research shows that persons prone to delusions “read” people differently than non-delusional individuals do. Whether they do so more accurately or particularly poorly is a matter of controversy. Delusional persons develop interpretations about how others view them that are distorted. They tend to view life as a continuing series of threatening events. When these two aspects of thought co-occur, a tendency to develop delusions about others wishing to do them harm is likely.

MOTIVATED OR DEFENSIVE DELUSIONS. Some predisposed persons might suffer the onset of an ongoing delusional disorder when coping with life and maintaining high self-esteem becomes a significant challenge. In order to preserve a positive view of oneself, a person views others as the cause of personal difficulties that may occur. This can then become an ingrained pattern of thought.

Symptoms

The criteria that define delusional disorder are furnished in the Diagnostic and Statistical Manual of Mental DisordersFourth Edition Text Revision, or DSM-IV-TR, published by the American Psychiatric Association. The criteria for delusional disorder are as follows:

• non-bizarre delusions which have been present for at least one month
• absence of obviously odd or bizarre behavior
• absence of hallucinations, or hallucinations that only occur infrequently in comparison to other psychotic disorders
• no memory loss, medical illness or drug or alcohol-related effects are associated with the development of delusions

Demographics

The base rate of delusional disorder in adults is unclear. The prevalence is estimated at 0.025-0.03%, lower than the rates for schizophrenia (1%). Delusional disorder may account for 1–2% of admissions to inpatient psychiatric hospitals. Age at onset ranges from 18–90 years, with a mean age of 40 years. More females than males (overall) suffer from delusional disorder, especially the late onset form that is observed in the elderly.

Diagnosis

Client interviews focused on obtaining information about the sufferer’s life situation and past history aid in identification of delusional disorder. With the client’s permission, the clinician obtains details from earlier medical records, and engages in thorough discussion with the client’s immediate family—helpful measures in determining whether delusions are present. The clinician may use a semi-structured interview called a mental status examination to assess the patient’s concentration, memory, understanding the individual’s situation and logical thinking. The mental status examination is intended to reveal peculiar thought processes in the patient. The Peters Delusion Inventory (PDI) is a psychological test that focuses on identifying and understanding delusional thinking; but its use is more common in research than in clinical practice.

Even using the DSM-IV-TRcriteria listed above, classification of delusional disorder is relatively subjective. The criteria “non-bizarre” and “resistant to change” and “not culturally accepted” are all subject to very individual interpretations. They create variability in how professionals diagnose the illness. The utility of diagnosing the syndrome rather than focusing on successful treatment of delusion in any form of illness is debated in the medical community. Some researchers further contend that delusional disorder, currently classified as a psychotic disorder, is actually a variation of depression and might respond better to antidepressants or therapy more similar to that utilized for depression. Also, the meaning and implications of “culturally accepted” can create problems. The cultural relativity of “delusions,”—most evident where the beliefs shown are typical of the person’s subculture or religion yet would be viewed as strange or delusional by the dominant culture—can force complex choices to be made in diagnosis and treatment. An example could be that of a Haitian immigrant to the United States who believed in voodoo. If that person became aggressive toward neighbors issuing curses or hexes, believing that death is imminent at the hands of those neighbors, a question arises. The belief is typical of the individual’s subculture, so the issue is whether it should be diagnosed or treated. If it were to be treated, whether the remedy should come through Western medicine, or be conducted through voodoo shamanistic treatment is the problem to be solved.

Treatments

Delusional disorder treatment often involves atypical(also callednovelornewer-generation) antipsychotic medications, which can be effective in some patients. Risperidone(Risperdal), quetiapine(Seroquel), and olanzapine(Zyprexa) are all examples of atypical or novel antipsychotic medications. If agitationoccurs, a number of different antipsychotics can be used to conclude the outbreak of acute agitation. Agitation, a state of frantic activity experienced concurrently with anger or exaggerated fearfulness, increases the risk that the client will endanger self or others. To decrease anxiety and slow behavior in emergency situations where agitation is a factor, an injection of haloperidol(Haldol) is often given usually in combination with other medications (often lorazepam, also known as Ativan). Agitation in delusional disorder is a typical response to severe or harsh confrontation when dealing with the existence of the delusions. It can also be a result of blocking the individual from performing inappropriate actions the client views as urgent in light of the delusional reality. A novel antipsychotic is generally given orally on a daily basis for ongoing treatment meant for long-term effect on the symptoms. Response to antipsychotics in delusional disorder seems to follow the “rule of thirds,” in which about one-third of patients respond somewhat positively, one-third show little change, and one-third worsen or are unable to comply.

Cognitive therapy has shown promise as an emerging treatment for delusions. The cognitive therapist tries to capitalize on any doubt the individual has about the delusions; then attempts to develop a joint effort with the sufferer to generate alternative explanations, assisting the client in checking the evidence. This examination proceeds in favor of the various explanations. Much of the work is done by use of empathy, asking hypothetical questions in a form of therapeutic Socratic dialogue—a process that follows a basic question and answer format, figuring out what is known and unknown before reaching a logical conclusion. Combining pharmacotherapy with cognitive therapy integrates both treating the possible underlying biological problems and decreasing the symptoms with psychotherapy.

Prognosis

Evidence collected to date indicates about 10% of cases will show some improvement of delusional symptoms though irrational beliefs may remain; 33–50% may show complete remission; and, in 30–40% of cases there will be persistent non-improving symptoms. The prognosis for clients with delusional disorder is largely related to the level of conviction regarding the delusions and the openness the person has for allowing information that contradicts the delusion.

Prevention

Little work has been done thus far regarding prevention of the disorder. Effective means of prevention have not been identified.

Definition

Delirium is a medical condition characterized by a vascillating general disorientation, which is accompanied by cognitive impairment, mood shift, self-awareness, and inability to attend (the inability to focus and maintain attention). The change occurs over a short period of time— hours to days— and the disturbance in consciousness fluctuates throughout the day.

Description

The word delirium comes from the Latin delirare. In its Latin form, the word means to become crazy or to rave. A phrase often used to describe delirium is “clouding of consciousness,” meaning the person has a diminished awareness of their surroundings. While the delirium is active, the person tends to fade into and out of lucidity, meaning that he or she will sometimes appear to know what’s going on, and at other times, may show disorientation to time, place, person, or situation. It appears that the longer the delirium goes untreated, the more progressive the disorientation becomes. It usually begins with disorientation to time, during which a patient will declare it to be morning, even though it may be late night. Later, the person may state that he or she is in a different place rather than at home or in a hospital bed. Still later, the patient may not recognize loved ones, close friends, or relatives, or may insist that a visitor is someone else altogether. Finally, the patient may not recognize the reason for his/her hospitalization and might accuse staff or others of some covert reason for his/her hospitalization (see example below). In fact, this waxing and waning of consciousness is often worse at the end of a day, a phenomenon known as “sundowning.”

A delirious patient will have a difficult time with most mental operations. Due to the fact that the patient is unable to attend consistently to his environment, he/she can become disoriented. Nevertheless, disorientation and memory loss are not essential to the diagnosis of delirium; the inability to focus and maintain attention, however, is essential to rendering a correct diagnosis. Left unchecked, delirium tends to transition from inattention to increased levels of lethargy, leading to torpor, stupor, and coma. In its other form, delirious patients become agitated and almost hypervigilant, with their sleep-wake cycle dramatically altered, fluctuating between great guardedness and hypersomnia(excessive drowsiness) during the day and wakefulness during the night. Delirious patients can also experience hallucinations of the visual, auditory, or tactile type. In such cases, the patient will see things others cannot see, hear things others cannot hear, and/or feel things that others cannot, such as feeling as though his or her skin is crawling. In short, the extremes of delirium range from the appearance of simple confusion and apathy to the anxious, agitated, and hyperactive type, with some patients experiencing both ends of the spectrum during a single episode. It is imperative that a quick evaluation occur if delirium is suspected, because it can lead to death.

Causes and symptoms

Causes

While the symptoms of delirium are numerous and varied, the causes of delirium fall into four basic categories: metabolic, toxic, structural, and infectious. Stated another way, the bases of delirium may be medical, chemical, surgical, or neurological. Many metabolic disorders, such as hypothyroidism, hyperthyroidism, hypokalemia, anoxia, etc. can cause delirium. For example, hypothyroidism (the thyroid gland emits reduced levels of thyroid hormones) brings about a change in emotional responsiveness, which can appear similar to depressive symptoms and cause a state of delirium. Other metabolic sources of delirium involve the dysfunction of the pituitary gland, pancreas, adrenal glands, and parathyroid glands. It should be noted that when a metabolic imbalance goes unattended, the brain may suffer irreparable damage.

One of the most frequent causes of delirium in the elderly is overmedication. The use of medications such as tricyclic antidepressants and antiparkinsonian medications can bring about an anticholinergic toxicity and subsequent delirium. In addition to the anticholinergic drugs, other drugs that can be the source of a delirium are:

• anticonvulsants, used to treat epilepsy
• antihypertensives, used to treat high blood pressure
• cardiac glycosides, such as Digoxin, used to treat heart failure
• cimetidine, used to reduce the production of stomach aciddisulfiram, used in the treatment of alcoholism
• insulin, used to treat diabetes
• opiates, used to treat pain
• phencyclidine (PCP), used originally as an anesthetic, but later removed from the market, now only produced and used illicitly
• salicylates, basically found in aspirin
• steroids, sometimes used to prevent muscle wasting in bedridden or other immobile patients

Additionally, systemic poisoning by chemicals or compounds such as carbon monoxide, lead, mercury, or other industrial chemicals can be the source of delirium.

Just as the ingestion of certain drugs may cause delirium in some patients, the withdrawal of drugs can also cause it. Alcohol is the most widely used and most well known of these drugs whose withdrawal symptoms may include delirium. Delirium onset from the abstinence of alcohol in a chronic user can begin within three days of cessation of drinking. The term delirium tremens is used to describe this form of delirium. The resulting symptoms of this delirium are similar in nature to other delirious states, but may be preceded by clear-headed auditory hallucinations. In other words, the delirium has not begun, but the patient may experience auditory hallucinations. Delirium tremens follow and can have ominous consequences with as many as 15% dying.

Some of the structural causes of delirium include vascular blockage, subdural hematoma, and brain tumors. Any of these can damage the brain, through oxygen deprivation or direct insult, and cause delirium. Some patients become delirious following surgery. This can be due to any of several factors, such as: effects of anesthesia, infections, or a metabolic imbalance.

Infectious diseases can also cause delirium. Commonly diagnosed diseases such as urinary tract infections, pneumonia, or fever from a viral infection can induce delirium. Additionally, diseases of the liver, kidney, lungs, and cardiovascular system can cause delirium. Finally, an infection, specific to the brain, can cause delirium. Even a deficiency of thiamin (vitamin B1) can be a trigger for delirium.

Symptoms

Symptoms of delirium include a confused state of mind accompanied by poor attention, impaired recent memory, irritability, inappropriate behavior (such as the use of vulgar language, despite lack of a history of such behavior), and anxiety and fearfulness. In some cases, the person can appear to be psychotic, fostering illusions, delusions, hallucinations, and/or paranoia. In other cases, the patient may simply appear to be withdrawn and apathetic. In still other cases, the patient may become agitated and restless, unable to remain in bed, and feel a strong need to pace the floor.

A few examples of people affected by delirium follow:

• One gentleman, who had already been in the hospital for three days, when asked if he knew where he was, stated the correct city and hospital. He immediately followed this by saying, “but I started out in Dallas, Texas this morning.” The hospital location was some 1,800 miles from Dallas, Texas, and as previously indicated, he had been in the same hospital for three days.
• In another case, an elderly gentleman was placed in a private room that had a wonderful large mural on one wall. The mural was that of a forest scene—no animals or people, only trees and sunlight. His chief complaint at various points during the day was that evil people were watching him from behind the trees in the forest scene.
• An elderly woman had to be subdued while attempting to flee from the hospital, because she was convinced that she had been brought there so surgeons could harvest her organs. Despite the lack of surgical scars or incisions, she insisted that she had been taken to the basement of the hospital the previous night and a surgeon had removed one of her kidneys.

Demographics

Delirium occurs most frequently in the elderly and the young, but can occur in anyone at any age. Of persons over 65 who are brought to the hospital for a general medical condition, roughly 10% show signs of delirium at admission. It is suspected that another 10%-15% may develop delirium while in the hospital. There appears to be no gender difference—delirium seems to affect males and females equally.

Diagnosis

Whether or not delirium is diagnosed in a patient depends on the type manifest. If the case is an elderly, postoperative patient who appears quiet and apathetic, the condition may go undiagnosed. However, if the patient presents with the agitated, uncooperative type of delirium, it will certainly be noticed. In any case, where there is sudden onset of a confused state accompanied by a behavioral change, delirium should be considered. This is not intended to imply that such a diagnosis will be made easily.

Frequent mental status examinations, at various times throughout the day, may be required to render a diagnosis of delirium. This is generally done using the Mini-Mental State Examination(MMSE). This abbreviated form of mental status examination begins by first assessing the patient’s ability to attend. If the patient is inattentive or in a stuporous state, further examination of mental status cannot be done. However, assuming the patient is able to respond to questions asked, the examination can proceed. The Mini-Mental State Exam assesses the areas of orientation, registration, attention and concentration, recall, language, and spatial perception. Another recently evaluated and recommended tool for use in diagnosing delirium is the Delirium Rating Scale-Revised-98. This clinician-rated, 16-item scale allows for the assessment of 13 severity items and three diagnostic items. This test has been reported as more sensitive than the MMSE at detecting delirium.

At times, the untrained observer may mistake psychotic features of delirium for another primary mental illness such as schizophrenia or a manic episode such as that associated with bipolar disorder. However, it should be noted that there are major differences between these diagnoses and delirium. In people who have schizophrenia, their odd behavior, stereotyped motor activity, or abnormal speech persists in the absence of disorientation like that seen with delirium. The schizophrenic appears alert and although his/her delusions and/or hallucinations persist, he/she could be formally tested. In contrast, the delirious patient appears hapless and disoriented, between episodes of lucidity. The delirious patient may not be testable. A manic episode could be misconstrued for agitated delirium, but consistency of elevated mood would contrast sharply to the less consistent mood of the delirious patient. Once again, delirium should always be considered when there is a rapid onset and especially when there is waxing and waning of the ability to attend and the confusion state.

Since delirium can be superimposed into a pre-existing dementia, the most often posed question, when diagnosing delirium, is whether the person might have dementia instead. Both cause disturbances of memory, but a person with dementia does not reflect the disturbance of consciousness depicted by someone with delirium. Expert history taking is a must in differentiating dementia from delirium. Dementia is insidious in nature and thus progresses slowly, while delirium begins with a sudden onset and acute symptoms. A person with dementia can appear clear-headed, but can harbor delusions not elicited during an interview. One does not see the typical fluctuation of consciousness in dementia that manifests itself in delirium. It has been stated that, as a general rule, delirium comes and goes, but dementia comes and stays. Delirium rarely lasts more than a month. Usually, by the end of that period, a patient with dementia has full-blown dementia or has died. As a final caution, the clinician must be prepared to rule out factitious disorder and malingering as possible causes for the delirium.

When a state of delirium is confirmed, the clinician is faced with the task of making the diagnosis in appropriate context to its cause. The delirium may be caused by a general medical condition. In such a case, the clinician must identify the source of the delirium within the diagnosis. For example, if the delirium is caused by liver dysfunction, wherein the liver is unable to clean the system of toxins, thereby allowing them to enter the system and so the brain, the diagnosis would be Delirium Due to Hepatic Encephalopathy. The delirium might also be caused by a substance such as alcohol. To render a diagnosis of Alcohol Intoxication Delirium, the cognitive symptoms should be more exaggerated than those found in intoxication syndrome. The delirium could also be caused by withdrawal from a substance. Continuing the alcohol theme, the diagnosis would be Alcohol Withdrawal Delirium (delirium tremens could be a feature of this diagnosis).

There may be instances in which delirium has multiple causes, such as when a patient has a head trauma and liver failure, or viral encephalitis and alcohol withdrawal. When delirium comes from multiple sources, a diagnosis of delirium precedes each medical condition that contributes. As an example, the multiple causes would be reflected as Delirium Due to Head Trauma and Delirium Due to Hepatic Encephalopathy. Finally, when delirium is the focus of clinical attention, but insufficient evidence exists to identify a specific causal factor, a diagnosis of Delirium Not Otherwise Specified is rendered. An example of this can occur in people who are exposed to sensory deprivation, such as might occur in Intensive Care Units or Cardiac Care Units where the patient is allowed no stimulation save that of the occasional member of the hospital staff.

In summary, delirium develops rapidly, has a fluctuating course involving waxing and waning lucidity, severely affects attention, must receive immediate medical attention, and is reversible in most cases.

Treatment

Treating delirium means treating the underlying illness that is its basis. This could include correcting any chemical disparities within the body, such as electrolyte imbalances, the treatment of an infection, reduction of a fever, or removal of a medication or toxin. A review of anticholinergic effects of medications administered to the patient should take place. It is suggested that sedatives and hypnotic-type medications not be used; however, despite the fact that they can sometimes contribute to delirium, in cases of agitated delirium, the use of these may be necessary. Medications that are often used to treat agitated delirium include haloperidol, thioridazine and risperidone. These can reduce the psychotic features and curb some of the volatility of the patient, but they are only treating symptoms of the delirium and not the source. Benzodiazepines (medications that slow the central nervous system to relax the patient) can also assist in controlling agitated patients, but since they can contribute to delirium, they should be used in the lowest therapeutic doses possible. The reduction and discontinuance of all psychotropic drugs should be the goal of treatment and occur as soon as possible to permit recovery and viable assessment of the patient.

Prognosis

If a quick diagnosis and treatment of delirium occurs, the condition is frequently reversible. However, if the condition goes unchecked or is treated too late, there is a high incidence of mortality or permanent brain damage associated with it. The underlying illness may respond quickly to a treatment regimen, but improvement in mental functioning may lag behind, especially in the elderly. Moreover, one study disclosed that one group of elderly survivors of delirium, at three years following hospital discharge, had a 33% higher rate of death than other patients. As a final note, delirium is a medical emergency, requiring prompt attention to avoid the potential for permanent brain damage or even death.

Definition

Deinstitutionalization is a long-term trend wherein fewer people reside as patients in mental hospitals and fewer mental health treatments are delivered in public hospitals. This trend is directly due to the process of closing public hospitals and the ensuing transfers of patients to community-based mental health services in the late twentieth century. It represents the dissipation of patients over a wider variety of health care settings and geographic areas. Deinstitutionalization also illustrates evolution in the structure, practice, experiences, and purposes of mental health care in the United States.

History

Hospital care for mental health

In the United States in the nineteenth century, hospitals were built to house and care for people with chronic illness, and mental health care was a local responsibility. As with most chronic illness, hospitalization did not always provide a cure. Individual states assumed primary responsibilities for mental hospitals beginning in 1890. In the first part of the twentieth century, while mental health treatments had very limited efficacy, many patients received custodial care in state hospitals. Custodial care refers to care in which the patient is watched and protected, but a cure is not sought.

After the founding of the National Institutes of Mental Health (NIMH), new psychiatric medications were developed and introduced into state mental hospitals beginning in 1955. These new medicines brought new hope, and helped address some of the symptoms of mental disorders.

President John F. Kennedy’s 1963 Community Mental Health Centers Act accelerated the trend toward deinstitutionalization with the establishment of a network of community mental health centers. In the 1960s, with the introduction of Medicare and Medicaid, the federal government assumed an increasing share of responsibility for the costs of mental health care. That trend continued into the 1970s with the implementation of the Supplemental Security Income program in 1974. State governments helped accelerate deinstitutionalization, especially of elderly people. In the 1960s and 1970s, state and national policies championed the need for comprehensive community mental health care, though this ideal was slowly and only partially realized.

Beginning in the 1980s, managed care systems began to review systematically the use of inpatient hospital care for mental health. Both public concerns and private health insurance policies generated financial incentives to admit fewer people to hospitals and discharge inpatients more rapidly, limit the length of patient stays, or to transfer responsibility to less costly forms of care.

Indicators and trends

Many statistical indicators show the amount of inpatient hospital care for persons with mental illness decreased during the latter half of the twentieth century, while the total volume of mental health care increased.

A patient care episode is a specific measure of the volume of care provided by an organization or system. It begins when a person visits a health care facility for treatment and ends when the person leaves the facility. In 1955, 77% of all patient care episodes in mental health organizations took place in 24-hour hospitals. By 1994, although the numbers of patient care episodes increased by more than 500%, only 26% of mental health treatment episodes were in these hospitals. The timing of this trend varied across different states and regions, but it was consistent across a variety of indicators.

The number of inpatient beds available to each group of 100,000 civilians decreased from over 200 beds in 1970 to less than 50 in 1992. The average number of patients in psychiatric hospitals decreased from over 2,000 in 1958 to about 500 in 1978. While adjusted per-capita spending on mental health rose from $16.53 in 1969 to $19.33 in 1994, the portion of funds spent on state and county mental hospitals fell from $9.11 to $4.56.

Transinstutionalization

Trends toward deinstitutionalization also reflect shifting demographics and boundaries of care. For example, decreases in inpatient mental health care can be complemented by increases in outpatient mental health care. Decreases in inpatient mental health care can also be paired with increases in other forms of care, such as social welfare, criminal justice, or nursing home care. Thus deinstitutionalization is part of a process sometimes called transinstutionalization, the transfer of institutional populations from hospitals to jails, nursing homes, and shelters.

Causes and consequences

Causes

Deinstitutionalization, originally and idealistically portrayed by advocates and consumers as a liberating, humane policy alternative to restrictive care, may also be interpreted as a series of health policy reforms that are associated with the gradual demise of mental health care dependent on large, state-supported hospitals. Deinstitutionalization is often attributed to decreased need for hospital care and to the advent of new psychiatric medicines.

Consequences

Ideally, deinstitutionalization represents more humane and liberal treatment of mental illness in community-based settings. Pragmatically, it represents a change in the scope of mental health care from longer, custodial inpatient care to shorter outpatient care.

The process of deinstitutionalization, combined with the scarcity of community-based care, is also associated with the visible problems of homelessness. Between 30-50% of homeless people in the United States are people with mental illness, and people with mental illness are disproportionate among the homeless.

Experience and adjustment

Deinstitutionalization also describes the adjustment process whereby people with illness are removed from the effects of life within institutions. Since people may become socialized to highly structured institutional environments, they often adapt their social behavior to institutional conditions. Therefore adjusting to life outside of an institution may be difficult.

Defined experientially, deinstitutionalization allows individuals to regain freedom and empower themselves through responsible choices and actions. With the assistance of social workers and through psychiatric rehabilitation, former inpatients can adjust to everyday life outside of institutional rules and expectations. This aspect of deinstitutionalization promotes hope and recovery, ongoing debates over the best structure and process of mental health service delivery notwithstanding.

Definition

Cyclothymic disorder, also known as cyclothymia, is a relatively mild form of bipolar II disorder characterized by mood swings that may appear to be almost within the normal range of emotions. These mood swings range from mild depression, or dysthymia, to mania of low intensity, or hypomania.

Description

Cyclothymic disorder, a symptomatically mild form of bipolar II disorder, involves mood swings ranging from mild depression to mild mania. It is possible for cyclothymia to go undiagnosed, and for individuals with the disorder to be unaware that they have a treatable disease. Individuals with cyclothymia may experience episodes of low-level depression, known as dysthymia; periods of intense energy, creativity, and/or irritability, known as hypomania; or they may alternate between both mood states. Like other bipolar disorders, cyclothymia is a chronic illness characterized by mood swings that can occur as often as every day and last for several days, weeks, months, or as long as two years. Individuals with this disorder are never free of symptoms of either hypomania or mild depression for more than two months at a time.

The noted psychiatrist Emil Kraepelin first described the symptoms of cyclothymic disorder in the late nineteenth century. Kraepelin described four types of personality disorders: depressive (gloomy); manic (cheerful and uninhibited); irritable (emotionally unstable and explosive); and cyclothymic. He viewed the irritable personality as simultaneously depressive and manic, and the cyclothymic personality as alternating between depressive and manic states.

Persons with cyclothymic disorder differ in the relative proportion of depressive versus hypomanic episodes that they experience. Some individuals have more frequent depressive episodes, whereas others are more likely to feel hypomanic. Most individuals who seek help for the disorder alternate between feelings of mild depression and intense irritability. Those who feel energized and creative when they are hypomanic, and who find their emotional low periods tolerable, may never seek treatment.

Causes and symptoms

Causes

Controversy exists over whether cyclothymic disorder is truly a mood disorder in either biological or psychological terms, or whether it belongs in the class of disorders known as personality disorders. Despite this controversy, most of the evidence from biological and genetic research supports the placement of cyclothymia within the mood disorder category.

Genetic data provide strong support that cyclothymia is indeed a mood disorder. About 30% of all patients with cyclothymia have family histories of bipolar I disorder, which involves full-blown manic episodes alternating with periods of relative emotional stability. Full-blown depressive episodes are frequently, but not always, part of the picture in bipolar I disorder. Reviews of the family histories of bipolar I patients show a tendency toward illnesses that alternate across generations: bipolar I in one generation, followed by cyclothymia in the next, followed again by bipolar I in the third generation. The general prevalence of cyclothymia in families with bipolar I diagnoses is much higher than in families with other mental disorders or in the general population. It has been reported that about one-third of patients with cyclothymic disorder subsequently develop a major mood disorder.

Most psychodynamic theorists believe that the psychosocial origins of cyclothymia lie in early traumas and unmet needs dating back to the earliest stages of childhood development. Hypomania has been described as a deficiency of self-criticism and an absence of inhibitions. The patient is believed to use denial to avoid external problems and internal feelings of depression. Hypomania is also believed to be frequently triggered by profound interpersonal loss. The false feeling of euphoria (giddy or intense happiness) that arises in such instances serves as a protection against painful feelings of sadness, and even possibly anger against the lost loved one.

Symptoms

The symptoms of cyclothymic disorder are identical to those of bipolar I disorder except that they are usually less severe. It is possible, however, for the symptoms of cyclothymia to be as intense as those of bipolar I, but of shorter duration. About one-half of all patients with cyclothymic disorder have depression as their major symptom. These persons are most likely to seek help for their symptoms, especially during their depressed episodes. Other patients with cyclothymic disorder experience primarily hypomanic symptoms. They are less likely to seek help than those who suffer primarily from depression. Almost all patients with cyclothymic disorder have periods of mixed symptoms (both depression and hypomania together) during which time they are highly irritable.

Cyclothymic disorder may cause disruption in all areas of the person’s life. Many individuals with this disorder are unable to succeed in their professional or personal lives as a result of their symptoms. A few who suffer primarily from hypomanic episodes are high achievers who work long hours and require little sleep. A person’s ability to manage the symptoms of the disorder depends upon a number of personal, social, and cultural factors.

The lives of most people suffering from cyclothymic disorder are difficult. The cycles of the disorder tend to be much shorter than in bipolar I. In cyclothymic disorder, mood changes are irregular and abrupt, and can occur within hours. While there are occasional periods of normal mood, the unpredictability of the patient’s feelings and behavior creates great stress for him or her and for those who must live or work with the patient. Patients often feel that their moods are out of control. During mixed periods, when they are highly irritable, they may become involved in unprovoked arguments with family, friends, and co-workers, causing stress to all around them.

It is common for cyclothymic disorder patients to abuse alcohol and/or other drugs as a means of self-medicating. It is estimated that about 5–10% of all patients with cyclothymic disorder suffer also from substance dependence.

Demographics

Patients with cyclothymic disorder are estimated to constitute from 3–10% of all psychiatric outpatients. They may be particularly well represented among those with complaints about marital and interpersonal difficulties. In the general population, the lifetime chance of developing cyclothymic disorder is about 1%. The actual percentage of the general population with cyclothymia is probably somewhat higher, however, as many patients may not be aware that they have a treatable disease.

Cyclothymic disorder frequently coexists with borderline personality disorder, which is a severe lifelong illness characterized by emotional instability and relationship problems. An estimated 10% of outpatients and 20% of inpatients with borderline personality disorder have a coexisting diagnosis of cyclothymic disorder. The female-to-male ratio in cyclothymic disorder is approximately 3:2. It is estimated that 50%–75% of all patients develop the disorder between the ages of 15 and 25.

Diagnosis

The diagnosis of cyclothymic disorder is usually made when a person with the disorder is sufficiently disturbed by the symptoms or their consequences to seek help. While there are no laboratory tests or imaging studies that can detect the disorder as of 2002, the doctor will usually give the patient a general physical examination to rule out general medical conditions that are often associated with depressed mood. The doctor will also take a detailed medical and psychiatric history. If the patient’s history or other aspects of his or her behavior during the interview suggest the diagnosis of cyclothymic disorder, the doctor may follow up the interview with the patient by talking with friends or family members to confirm the diagnosis.

The manual used by mental health professionals to diagnose mental illnesses is called the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, also known as the DSM-IV-TR. This manual specifies six criteria that must be met for a diagnosis of cyclothymic disorder. These include:

• • Numerous episodes of hypomania and depression that are not severe enough to be considered major depression. These episodes must have lasted for at least two years.
• • During the same two-year period (one year for children and adolescents), the individual has not been free from either hypomania or mild depression for more than two months at a time.
• • No major depression, mania, or mixed (both depression and mania together) condition has been present during the first two years of the disorder.
• • The individual does not have a thought disorder such as schizophrenia or other psychotic condition.
• • The symptoms are not due to the direct effects of substance use (such as a drug of abuse or a prescribed medication) or to a medical condition.
• • The symptoms cause significant impairment in the patient’s social, occupational, family, or other important areas of life functioning.

Treatments

Biological therapy

Medication is an important component of treatment for cyclothymic disorder. A class of drugs known as antimanic medications is usually the first line of treatment for these patients. Drugs such as lithium, carbamazepine (Tegretol), and sodium valproate (Depakene), have all been reported to be effective. While antidepressant medications might be prescribed, they should be used with caution, because these patients are highly susceptible to hypomanic or full-blown manic episodes induced by antidepressants. It is estimated that 40–50% of all patients with cyclothymic disorder who are treated with antidepressants experience such episodes.

Psychosocial therapy

Psychotherapy with individuals diagnosed with cyclothymic disorder is best directed toward increasing the patient’s awareness of his or her condition and helping to develop effective coping strategies for mood swings. Often, considerable work is needed to improve the patient’s relationships with family members and workplace colleagues because of damage done to these relationships during hypomanic episodes. Because cyclothymic disorder is a lifelong condition, psychotherapy is also a long-term commitment. Working with families of cyclothymic patients can help them adjust more effectively to the patients’ mood swings as well.

Prognosis

While some patients later diagnosed with cyclothymic disorder were considered sensitive, hyperactive, or moody as children, the onset of cyclothymic disorder usually occurs gradually during the patient’s late teens or early 20s. Often school performance becomes a problem along with difficulty establishing peer relationships. Approximately one-third of all patients with cyclothymic disorder develop a major mood disorder during their lifetime, usually bipolar II disorder.

Prevention

Cyclothymic disorder appears to have a strong genetic component. It is far more common among the first-degree biological relatives of persons with bipolar I disorder than among the general population. At this time, there are no known effective preventive measures that can reduce the risk of developing cyclothymic disorder. Genetic counseling, which assists a couple in understanding their risk of producing a child with the disorder, may be of some help.

Definition

Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems. A crisis can refer to any situation in which the individual perceives a sudden loss of his or her ability to use effective problem-solving and coping skills. A number of events or circumstances can be considered a crisis: life-threatening situations, such as natural disasters (such as an earthquake or tornado), sexual assault or other criminal victimization; medical illness; mental illness; thoughts of suicide or homicide; and loss or drastic changes in relationships (death of a loved one or divorce, for example).

Purpose

Crisis intervention has several purposes. It aims to reduce the intensity of an individual’s emotional, mental, physical and behavioral reactions to a crisis. Another purpose is to help individuals return to their level of functioning before the crisis. Functioning may be improved above and beyond this by developing new coping skills and eliminating ineffective ways of coping, such as withdrawal, isolation, and substance abuse. In this way, the individual is better equipped to cope with future difficulties. Through talking about what happened, and the feelings about what happened, while developing ways to cope and solve problems, crisis intervention aims to assist the individual in recovering from the crisis and to prevent serious long-term problems from developing. Research documents positive outcomes for crisis intervention, such as decreased distress and improved problem solving.

Description

Individuals are more open to receiving help during crises. A person may have experienced the crisis within the last 24 hours or within a few weeks before seeking help. Crisis intervention is conducted in a supportive manner. The length of time for crisis intervention may range from one session to several weeks, with the average being four weeks. Crisis intervention is not sufficient for individuals with long-standing problems. Session length may range from 20 minutes to two or more hours. Crisis intervention is appropriate for children, adolescents, and younger and older adults. It can take place in a range of settings, such as hospital emergency rooms, crisis centers, counseling centers, mental health clinics, schools, correctional facilities, and other social service agencies. Local and national telephone hotlines are available to address crises related to suicide, domestic violence, sexual assault, and other concerns. They are usually available 24 hours a day, seven days a week.

Responses to crisis

A typical crisis intervention progresses through several phases. It begins with an assessment of what happened during the crisis and the individual’s responses to it. There are certain common patterns of response to most crises. An individual’s reaction to a crisis can include emotional reactions (fear, anger, guilt, grief), mental reactions (difficulty concentrating, confusion, nightmares), physical reactions (headaches, dizziness, fatigue, stomach problems), and behavioral reactions (sleep and appetite problems, isolation, restlessness). Assessment of the individual’s potential for suicide and/or homicide is also conducted. Also, information about the individual’s strengths, coping skills, and social support networks is obtained.

Education

There is an educational component to crisis intervention. It is critical for the individual to be informed about various responses to crisis and informed that he or she is having normal reactions to an abnormal situation. The individual will also be told that the responses are temporary. Although there is not a specific time that a person can expect to recover from a crisis, an individual can help recovery by engaging in the coping and problem-solving skills described below.

Coping and problem solving

Other elements of crisis intervention include helping the individual understand the crisis and their response to it as well as becoming aware of and expressing feelings, such as anger and guilt. A major focus of crisis intervention is exploring coping strategies. Strategies that the individual previously used but that have not been used to deal with the current crisis may be enhanced or bolstered. Also, new coping skills may be developed. Coping skills may include relaxation techniques and exercise to reduce body tension and stress as well as putting thoughts and feelings on paper through journal writing instead of keeping them inside. In addition, options for social support or spending time with people who provide a feeling of comfort and caring are addressed. Another central focus of crisis intervention is problem solving. This process involves thoroughly understanding the problem and the desired changes, considering alternatives for solving the problem, discussing the pros and cons of alternative solutions, selecting a solution and developing a plan to try it out, and evaluating the outcome. Cognitive therapy, which is based on the notion that thoughts can influence feelings and behavior, can be used in crisis intervention.

In the final phase of crisis intervention, the professional will review changes the individual made in order to point out that it is possible to cope with difficult life events. Continued use of the effective coping strategies that reduced distress will be encouraged. Also, assistance will be provided in making realistic plans for the future, particularly in terms of dealing with potential future crises. Signs that the individual’s condition is getting worse or “red flags” will be discussed. Information will be provided about resources for additional help should the need arise. A telephone follow-up may be arranged at some agreed-upon time in the future.

Suicide intervention

Purpose

Suicidal behavior is the most frequent mental health emergency. The goal of crisis intervention in this case is to keep the individual alive so that a stable state can be reached and alternatives to suicide can be explored. In other words, the goal is to help the individual reduce distress and survive the crisis.

Assessment

Suicide intervention begins with an assessment of how likely it is that the individual will kill himself or herself in the immediate future. This assessment has various components. The professional will evaluate whether or not the individual has a plan for how the act would be committed, how deadly the method is (shooting, overdosing), if means are available (access to weapons), and if the plan is detailed and specific versus vague. The professional will also assess the individual’s emotions, such as depression, hopelessness, hostility and anxiety. Past suicide attempts as well as completed suicides among family and friends will be assessed. The nature of any current crisis event or circumstance will be evaluated, such as loss of physical abilities because of illness or accident, unemployment, and loss of an important relationship.

Treatment plan

A written safekeeping contract may be obtained. This is a statement signed by the individual that he or she will not commit suicide, and agrees to various actions, such as notifying their clinician, family, friends, or emergency personnel, should thoughts of committing suicide again arise. This contract may also include coping strategies that the individual agrees to engage in to reduce distress. If the individual states that he or she is not able to do this, then it may be determined that medical assistance is required and voluntary or involuntary psychiatric hospitalization may be implemented. Most individuals with thoughts of suicide do not require hospitalization and respond well to outpatient treatment. Educating family and friends and seeking their support is an important aspect of suicide intervention. Individual therapy, family therapy, substance abuse treatment, and/or psychiatric medication may be recommended.

Critical incident stress debriefing and management

Definition

Critical incident stress debriefing (CISD) uses a structured, small group format to discuss a distressing crisis event. It is the best known and most widely used debriefing model. Critical incident stress management (CISM) refers to a system of interventions that includes CISD as well as other interventions, such as one-on-one crisis intervention, support groups for family and significant others, stress management education programs, and follow up programs. It was originally designed to be used with high-risk professional groups, such as emergency services, public safety, disaster response, and military personnel. It can be used with any population, including children. A trained personnel team conducts this intervention. The team usually includes professional support personnel, such as mental health professionals and clergy. In some settings, peer support personnel, such as emergency services workers, will be part of the debriefing team. It is recommended that a debriefing occur after the first 24 hours following a crisis event, but before 72 hours have passed since the incident.

Purpose

This process aims to prevent excessive emotional, mental, physical, and behavioral reactions and post-traumatic stress disorder (PTSD) from developing in response to a crisis. Its goal is to help individuals recover as quickly as possible from the stress associated with a crisis.

Phases of CISD

There are seven phases to a formal CISD.

1. 1. Introductory remarks: team sets the tone and rules for the discussion, encourages participant cooperation.
2. 2. Fact phase: participants describe what happened during the incident.
3. 3. Thought phase: participants state the first or main thoughts while going through the incident.
4. 4. Reaction phase: participants discuss the elements of the situation that were worst.
5. 5. Symptom phase: participants describe the symptoms of distress experienced during or after the incident.
6. 6. Teaching phase: team provides information and suggestions that can be used to reduce the impact of stress.
7. 7. Re-entry phase: team answers participants’ questions and makes summary comments.

Precautions

Some concern has been expressed in the research literature about the effectiveness of CISD. It is thought that as long as the provider(s) of CISD have been properly trained, the process should be helpful to individuals in distress. If untrained personnel conduct CISD, then it may result in harm to the participants. CISD is not psychotherapy or a substitute for it. It is not designed to solve all problems presented during the meeting. In some cases, a referral for follow-up assessment and/or treatment is recommended to individuals after a debriefing.

Medical crisis counseling

Medical crisis counseling is a brief intervention used to address psychological (anxiety, fear and depression) and social (family conflicts) problems related to chronic illness in the health care setting. It uses coping techniques and building social support to help patients manage the stress of being newly diagnosed with a chronic illness or suffering a worsening medical condition. It aims to help patients understand their reactions as normal responses to a stressful circumstance and to help them function better. Preliminary studies of medical crisis counseling indicate that one to four sessions may be needed. Research is also promising in terms of its effectiveness at decreasing patients’ level of distress and improving their functioning.

Definition

Crisis housing (or crisis residential services) are supervised short-term residential alternatives to hospitalization for adults with serious mental illnesses or children with serious emotional or behavioral disturbances.

Purpose

The course of most serious mental illness (such as schizophrenia, bipolar disorder, severe depression, and borderline personality disorder) is cyclical, typically characterized by periods of relative well-being, interrupted by periods of deterioration or relapse. When relapse occurs, the individual generally exhibits florid symptoms that require immediate psychiatric attention and treatment. More often than not, relapse is caused by the individual’s failure to comply with a prescribed medication regimen (not taking medication regularly, not taking the amount or dose prescribed, or not taking it all). Relapse can also be triggered during periods of great stress or can even occur spontaneously, without any marked changes in lifestyle or medication regimen. When these crises recur, the goal of treatment is to stabilize the individual as soon as possible, since research suggests that these patients are also more likely to attempt suicide.

Description

Over the past 30 years, crisis housing programs have evolved as short-term, less costly, and less restrictive residential alternatives to hospitalization. Intended to divert individuals from emergency rooms, jails, and hospitals into community-based treatment settings, they offer intensive crisis support to individuals and their families. Services include diagnosis, assessment, and treatment (including medication stabilization); rehabilitation; and links to community-based services. These programs are intended to stabilize the individual as rapidly as possible—usually between eight and 60 days—so they can return to their home or residence in the community.

Some of the earliest crisis housing programs include Soteria House and La Posada, which began in northern California in the 1970s, and the START (short-term acute residential treatment) program that began in San Diego in 1980. While programs vary from location to location, most offer acute services 24 hours a day in a small noninstitutional residential setting. Adequate structure and supervision is provided by an interdisciplinary team of professionals and other trained workers.

Beginning the day they arrive, residents help develop their own plans for recovery and continued care in the community. Patients receive state-of-the art psychopharmacological treatment and other cognitive-behavioral interventions. Residents are encouraged to play an active role in the operation of the household, including meal preparation. The home-like environment is helpful in lessening the stigma and sense of failure that often occurs when someone needs to return to an inpatient psychiatric unit.

Similarly, in the case of seriously emotionally disturbed children and adolescents, the goal of crisis housing is to avert visits to the emergency room or hospitalization by stabilizing the individual in as normal a setting as possible. Compared to these services for adults, there is typically greater emphasis placed on involving families and schools in planning for community-based care after discharge.

While the evidence base for crisis housing is comprised primarily of uncontrolled studies, evaluations of several of these programs suggest that they may provide high-quality treatment and care at a lower cost than hospitals. Crisis housing is not currently available in all communities, however.