1. PSYCHOLOGY and PSYCHIATRY : C OMPLEMENTARY AND A DDITIVE by John Snowdon Old age psychiatrist, Sydney Deakin Management Centre, Geelong November 1-3, 2007 CONFERENCE OF THE AUSTRALIAN PSYCHOLOGICAL SOCIETY Psychology & Ageing Interest Group

2. 2 1)Self-esteem. What do we think of each other? 2)How well do clinical psychologists and psychiatrists work together? 3)Management of BPSD. 4)Researching and intervening in cases of severe domestic squalor. 5)Training of psychiatrists and clinical psychologists – together? COMPLEMENTARY and ADDITIVE

3. 3 The last Choice: Preemptive Suicide in Advanced Age. Greenwood: Greenwich CT. PRADO C.G. (1998)

4. 4 The primary reasons why (we deduced) 210 people killed themselves 37 40 13 37 40 13 21 9 6 3 3119 1117 28 9

5. 5 ISSUES TO DISCUSS Understandable? Rational? To whom? Do some personality characteristics make it difficult to tolerate disability, loss, insults, pain, diminished self-regard ? Are some suicides altruistic (re burden) ? Euthanasia -- understandable? Rational?

6. 6 THE SELF-ESTEEM OF OLDER PEOPLE What have they retained? What do they feel good about? Integrity versus Despair. Do regrets affect self-esteem? Adapting.

7. 7 ABRAMOWITZ & PLACENTINI (2006): Psychologists and psychiatrists “hold different conceptual, treatment and research approaches”. Psychologists are trained to conceptualise and treat mental health disorders at the level of individual thinking and behavioural patterns, exploring the impact of environmental factors on those patterns. Training of psychologists is typically achieved through extensive didactic training with a strong emphasis on the theoretical underpinnings, research methods & empirical findings. (Clinical Psychology: Science & Practice, 13, 292-6)

8. 8 In contrast, “the zeitgeist in psychiatric training programs is a neurobiological approach…” “Psychiatric residency & fellowship training is significantly more applied & experiential in nature and provides notably less emphasis on the non- biological aspects of normal development and mental illness”. Differences “have the potential to lead to clashes within mixed departments” but can also “lead to synergistic advances”. ABRAMOWITZ & PLACENTINI (2006) (North Carolina)

9. 9 Referred to a child anxiety training clinic, where psychology interns & child psychiatry fellows work together under supervision of both psychiatry and psychology faculty. The interdisciplinary training model familiarises each group of trainees with the assessment & treatment approaches typically espoused by the other discipline and fosters appreciation for the unique strengths characterizing each group’s background, training and competencies. ABRAMOWITZ & PLACENTINI (2006)

10. 10 Additional tensions:  Psychiatrists given higher status within medical settings.  Psychiatrists can conduct physical examinations, prescribe medication and admit patients to hospital.  Psychiatrists typically command higher salaries.  Psychiatrists often have control of leadership positions. ABRAMOWITZ & PLACENTINI (2006)

11. 11 Photo of HANS EYSENCK

12. 12 CLINICAL PSYCHOLOGISTSPSYCHIATRISTS Psychotherapy, CBT Behaviour therapyDiagnosis, investigation & treatment of medical illnesses (including the dementias) Behaviour programmes (e.g. BPSD) Expertise in pharmacology Neuropsychological assessmentsPrevention of medical disease Leading (for example):  Substance abuse programs  Rehabilitation programs Leading (for example):  Inpatient treatment programs  Rehabilitation programs Advising in medical wards & residential care Consulting & advising on medical wards and residential care

13. BPSD ( CHALLENGING BEHAVIOUR) Behaviour that is considered dangerous, harmful, distressing or disturbing to the person or others. Includes physical aggression, screaming, restlessness, agitation, sexual disinhibition, cursing & shadowing – though context & the response of others determine how challenging they are.

14. 14 OPIE, DOYLE & O’CONNOR ‘Challenging behaviours in nursing home residents with dementia: a randomised controlled trial of multidisciplinary interventions’. INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, 2002, 17, 6-13. A team (psychiatrist, psychologist & nurses) assessed & recommended management for 99 BPSD residents. Early compared to late intervention. Consultancies were viewed as effective.

15. 15 BEHAVIOURAL PROBLEMS IN NURSING HOMES  In the same way as in cases of depression, staff in nursing homes need to recognise and describe behavioural problems, looking at what seemed to cause them. What were the triggers? Why now, and what’s it mean? What seems to settle the problem?  The team (not just the individual) can then work on a solution, which might be environmental – but could be treatment of constipation or UTI or depression, or maybe medication to settle distress, or control delusional beliefs….. Etc.

16. 16 SURVEY Most nursing homes have few or no staff who have had training in mental disorder assessment &/or management UK reports 10 to 20% of nurses in more specialised facilities have had such training

17. 17 RATING SCALES  NPI  Cohen-Mansfield Agitation Inventory  Behave-AD etc.

18. 18 % OF NORWEGIAN RESIDENTS SHOWING CMAI BEHAVIOUR >ONCE PER WEEK (Testad, Aasland & Aarsland, IJGP 2007, 22, 916-921)  Repetitious sentences/questions 31%  Cursing/verbal aggression 25%  Complaining 25%  Constant requests for attention 24%  Pacing 23%  Screaming 15%  Making strange noises 13%  Grabbing 13%  Hitting 9.6%  Scratching 5%  Physical sexual advances 2.4%  Negativism 22%   17 other behaviours 1.8% to 14.4%

19. 19 NUMBER (%) OUT OF 2445 RESIDENTS WHO MANIFESTED PROBLEM BEHAVIOURS FOR MUCH OF THE TIME Several times per hour Several times per day Pacing, wandering 81 (3.3%) 108 Complaining 14 (0.6%) 82 Cursing, verbal aggression 19 (0.8%) 100 Screaming 11 (0.5%) 43 Hitting (incl. Self) 4 (0.2%) 39 Snowdon et al, 1996

20. 20 An enthusiastic, committed, positive thinking clinical psychologist can contribute so much to a catchment area (integrated community and hospital) old age psychiatry service.

21. 21 MODELS OF PROVISION OF PSYCHIATRIC SERVICES 1)Visiting psychiatrist. Responds to referral of a specific patient. No subsequent care unless called back. 2)Consultation-liaison. Sees patient and staff. Education. May have designated nurse in n.h. to coordinate referrals. 3)Multidisciplinary team approach. Team of n.h. and/or visiting staff, e.g. nurses, social worker, psychologist. Old age psychiatry teams can do it if adequately resourced. 4)Nurse-centred approach. Back-up by psychiatrist. 5)Telepsychiatry.

22. 22 WHEN TO REFER, AND TO WHOM: 1)Recognise there’s a problem. 2)Intervention. 3)G.P. & staff try alternatives. 4)Referral. Who to? Depends on who’s available, and what’s the main problem. IF BEHAVIOURAL :  ? psychologist, nurse-specialist, Behavioural Support Unit or old age psychiatry team IF DEPRESSED, PARANOID, SEVERELY AGITATED:  psychiatrist (+ supporting team) Ideally, the team already liaises & educates!

23. 23 A model for interventions in cases of BPSD If a resident’s behaviour doesn’t settle with ‘usual’ treatment provided by n.h. & GP: 1)Refer to specialist for consultation, assessment, short-term intervention. 2)May need more intensive treatment in situ. Special care ‘top-up’ funds to broker additional services. Behavioural Assessment and Intervention Service [BAsIS teams] 3)Transfer to special assessment/care/treatment unit. Weeks to months. 4)Few need the Neuro-behavioural unit. Physically violent, may be younger & big. Maybe 20 beds per 600,000 elderly in NSW.

24. 24 Bird et al (2002, report to Australian Government)  Individualised, primarily psychosocial approaches in nursing homes.  They argued that the impact of the behaviour (rather than the behaviour itself) determines whether it is a problem. “It is possible to treat such cases in situ, without hospitalisation”.

25. 25 Squalor data-base (Central Sydney)  All those referred to the Central Sydney (Eastern Sector) old age psychiatry team because they were deemed to be living in squalor were rated on the LIVING CONDITIONS RATING SCALE (Samios K, 1996. RANZCP. Unpublished) This scale was used by Halliday et al (2000) in a community study of people who live in squalor. (Lancet, 355, 882-886)

26. 26 13-item Living Conditions Rating Scale (interior) AccessibilityFood OdourBathroom/toilet LightingDisposal of excreta Floors/carpetsHoarding WallsClutter FurnitureVermin KITCHEN:AcceptableMildly dirtyModerately dirty Filthy Reliability rated by Halliday & Snowdon while developing a new scale (to be published)

27. 27 Central Sydney (Eastern sector) old age psychiatry data- base of people assessed as living in unclean accommodation, referred Jan 1, 2000 to Sept.30, 2007 MALESFEMALESTOTAL Mild (LCRS<14, mean 9.7) or LCRS data missing 291544 Moderate (LCRS 14-27, mean 18.5) 401959 Severe (LCRS 15-33, mean 24.0) 221537 TOTAL (LCRS mean 17.7) 91 (65%) 49140 Raters of LCRS (of 14+) stated whether they regarded the squalor as moderate or severe

28. 28 SEVERE DOMESTIC SQUALOR Cooney and Hamid (1995) referred to “a reclusive elderly person living alone in a dilapidated filthy house. The home is cluttered with rubbish and infested with vermin. Excrement and decomposing food are strewn around the floors and the stench emanating is unbearable to all but the occupant, who is blissfully unconcerned by the situation.”

29. 29 SEVERE DOMESTIC SQUALOR Descriptions of cases can largely be grouped into: (1)those where accumulation of useless items and articles had obstructed proper care of a person’s living conditions, and (2)those where filth and refuse had accumulated because of failure to get rid of them.

30. 30 SEVERE DOMESTIC SQUALOR  Environmental uncleanliness (and often associated personal uncleanliness) and, to a varying extent,  Lack of concern about their living conditions  Social withdrawal  Hostile attitudes  Stubborn refusal of help

31. 31

32. 32

33. 33

34. 34

35. 35

36. 36

37. 37

38. 38

39. 39

40. 40

41. 41 INTERVENTIONS John Snowdon, Ajit Shah and Graeme Halliday (International Psychogeriatrics 2007, 19, 37-51) Reports suggest that agencies worldwide are generally uncoordinated and consequently inefficient when trying to intervene and help in cases of squalor. Insufficient attention, resources and research have been committed to improving our understanding and interventions.

42. 42 FROST & GROSS (1993) The hoarding of possessions. Behaviour Research and Therapy, 31, 367-381. “Most theories which mention hoarding do so in the context of obsessive compulsive disorders”. Hoarding “is clearly related to obsessional thinking and to compulsive behaviors.” CHIU, CHONG & LAU (2003) Exploratory study of hoarding behaviour in Hong Kong. Hong Kong Journal of Psychiatry, 13, 23-30. Over half the subjects had >90% of the dwelling covered by hoarded items, but only one subject was diagnosed as having OCD.

43. Not all those who self-neglect and not all those who hoard live in severe domestic squalor Some people neglect (seem not to care about) cleanliness of themselves, their dependants or their homes and don’t get rid of rubbish (e.g. some with dementia, schizophrenia, alcoholism). Some are physically or cognitively unable to take action. Excessive or inappropriate collecting (and especially failure to discard) may lead to difficulty in cleaning.

44. IT IS LIKELY THAT THOSE WHO LIVE IN SEVERE DOMESTIC SQUALOR START DOING SO BECAUSE OF A COMPLEX INTERPLAY OF TRIGGERS AND VULNERABILITIES: 1. Obsessive compulsions and indecisiveness may be largely to blame in some cases. 2. In others, accumulation of refuse and useless items is attributable to apathy and impaired executive function, resulting from brain disease or mental disorder. Lack of impulse control could be contributory. There is limited but growing evidence that frontal lobe dysfunction is a major factor.

45. 45 Aspects of collectionism, self-neglect and severe domestic squalor  Organised and systematic collecting  Compulsive acquisition with little attempt to resist (items may be of value, collected systematically but to excess)  Hoarding: acquisition of, and failure to discard possessions of limited use or value  Accumulation of rubbish  Neglect personal care and home cleanliness  Neglect basic health needs (including medication)  Neglect social needs  Fail to eat/drink enough  Poor care of finances  Fail to protect self from financial or sexual abuse

46. 46 LCRS ratings of hoarding & clutter LCRS (3 = major degree, 2 = moderate/most rooms, 1 = minor/ some rooms) MODERATE/SEVERE (n = 88) MILD SQUALOR (n = 32) Mean hoarding (0 to 3) score 1.43 0.91 Mean clutter (0 to 3) 1.72 0.97 Hoarding score 3 Clutter score 3 n = 24 (27%) n = 26 n = 4 (13%) Hoarding score 2 Clutter score 2 n = 16 (18%) n = 27 n = 7 (22%) Hoarding score 1 n = 20 (23%) n = 3 (9%) Hoarding score 0 n = 28 (32%) n = 18 (56%)

47. 47 Prevalence/incidence The population of persons aged 65+ living outside aged care facilities in Central Sydney (Eastern sector) is about 18,000. A referral rate of 140 subjects aged 65+ in 7.75 years = an incidence of 1 per 1000. The incidence of cases of people 65+ living in moderate/severe squalor = 0.7 per 1000 These are cases referred to an old age psychiatry service; the number of non-referred cases can only be guessed. Some were referred but refused to see us. Because over half of those referred are found to be still at home after one year, the prevalence of people aged 65+ living in domestic squalor is estimated at over 2 per 1000, and of those living in moderate or severe domestic squalor at about 1.5 per 1000.

48. 48 Contents of September ’07 BJ Clin Psychol 1) CBT & counselling for chronic fatigue. 2) Subtypes of borderline personality disorder: a latent class analysis. 3) The Depression Anxiety Stress Scales in depressed clinical samples. 4) The structure of PTSD symptoms. 5) Beliefs about depression & coping strategies. 6) Trauma stimuli in people with schizophrenia. 7) Emotion and tension in females with borderline personality disorder. 8) Wisconsin Card Sorting Test in schizophrenia.

49. 49 1) CBT of delusional disorder. 2) OCD: phenomenology, help-seeking, treatment. 3) Shame-based & guilt-based PTSD. 4) Effect of dissociation at encoding on intrusive memories. 5) Mediation of depression by perceptions of defeat & entrapment. 6) Affective states associated with bingeing & purging. 7) Attachment in anorexia nervosa. Contents of BJ Med Psychol, December 2001

50. 50 CONCLUSIONS 1.Good reason for clinical psychologists and old age psychiatrists to respect and work well with each other. 2.Clinical psychologists have much to offer, if only we could attract them into our services. 3.What about training psychiatrists and psychologists together for at least part of their training.