Psychotic Disorders

Psychotic Disorders

Psychosis is a term that describes severe mental disturbance not a specific disorder. Many disorders have symptoms of psychosis including: Schizophrenia, Schizophreniform Disorder, Brief Psychotic Disorder, Schizoaffective Disorder, Shared Psychotic Disorder, Delusional Disorder, Psychotic Disorder Due to a General Medical Condition, Substance Induced Psychotic Disorder, and Psychotic Disorder NOS. These disorders are clinical syndromes not discrete diseases.

Most Psychotic disorders do not have clear etiology. Of course, the disorders related to medical conditions and substance withdrawal are more easily traced to a precipitating factor and are therefore more likely to be easily diagnosed.

Evaluation of persons suspected of having a psychotic disorder requires a good history and a physical examination by a physician. Generally, non-organic disorders present with disturbances in thought and emotion, while organic disorders tend to present with mental clouding, confusion, and disorientation because of some degree of delirium. This is not a hard and fast rule and in practice, there are many exceptions. The following are some characteristics that suggest the presence of an organic disorder:

1. No personal or family history of mental illness. Someone who presents with schizophrenia like psychotic symptoms will undoubtedly have some family or personal history of psychiatric treatment. This is particularly true if the subject is well into adulthood. First time psychotic breaks usually occur in early adulthood (early 20’s of men, late twenties for woman). The lack of history makes it more likely that there is some organic factor operating.

2. There is a history of serious medical illness with periodic relapses. This suggests organic etiology, especially if the subject is an elderly person.

3. There is very rapid onset. If the onset is in a few hours of days, this is a strong indicator of organic etiology. With symptoms that are not organically based, family members usually report some period of time that the client is acting “strange”.

4. The client presents with significant memory loss, confusion, disorientation, and clouding of consciousness (that may fluctuate rapidly- within hours).

Major Depression and Bipolar Disorder may have psychotic symptoms that are secondary to affective symptoms. Affective disturbance always precedes psychosis in these cases. Individuals with severe personality disorders may have brief periods of psychosis, especially at times of severe stress. Psychotic symptoms usually resolve when the environmental stressors are stabilized, either through direct psychosocial intervention or by removing the individual from the environment and placing them into a stable and safe environment such as a hospital setting. Both Pervasive Developmental Disorder NOS and Autistic Disorder may have psychotic symptoms. Again, these symptoms appear to be secondary to the developmental impairment.

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Medicaid

Medicaid, brought into effect by Title XIX of the Social Security Act, provides medical assistance for uninsured children, low-income population members, the disabled, and the elderly, as well as a large portion of long-term nursing home care. Many state Medicaid plans intitially functioned as indemnity plans; however, due to increasing health care costs and growth of Medicaid-eligible population, many Medicaid plans are now managed care plans. Medicaid is funded by both federal and state governments and is generally in the responsibility of CMS. SCHIP (State Children’s Health Insurance Program) was a result of with the 1997 Balanced Budget Act and implements a Federal agreement to match state funds for Medicaid (given a state plan for enrollment of uninsured children).

Unlike Medicare, Medicaid does provide for long-term custodial care; however, to financially qualify, a recipient must deplete his assets and income. Income and assets cannot exceed $707 per month in income with $2000 in assets, or for a couple, $942 in income with $3000 in assets (assets do not include the recipient’s home, car, personal possessions like clothing, furniture or jewelry). A Medicaid enrollee is not permitted to give away assets or income (unless they are given to a spouse, a blind or disabled child, or a trust for a blind or disabled child). If the recipient gives away assets or income, a transfer penalty (length of time during which recipient is ineligible for Medicaid) will be incurred; duration of transfer penalty is relative to amount given away.

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Traumatic Brain Injury

Patients who have suffered TBI (traumatic brain injury) should be referred for case management. Assessment, planning and implementation, and evaluation must be taken into account in determining the case management package. Factors in assessment include, but are not limited to: type of injury, risk of complications, likelihood of permanent impairment, who in the family makes the decisions, whether the patient meets criteria for the level of care, and coping ability of patient.

Factors to be taken into account in planning include, but are not limited to: correct allocation of health care resources, coordination of benefits with various health care plans, determining appropriate level of care, identification/obtaining of available services, plans for movement through various levels to least restrictive level of care, plans for respite if necessary, home modifications, plans for continuing medical, transportation and psychological needs of patient and family members, and life care planning.

Questions to be asked in the evaluation component include, but are not limited to: Is the patient still progressing towards her/his goals at the maximum level of functioning? Is the setting the least restrictive setting possible? Are health care services being used effectively and efficiently? Are all the services for which the patient is eligible being offered? How is the family unit coping with the new situation? Is there depression or substance abuse present? Are there medical complications and is the family managing the complex medical needs?

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Orthopedic Disorders

ORTHOPEDIC DISORDERS

Some common orthopedic terms include: abduction (the movement of a body part away from the midline), adduction (movement of a body part toward the midline), dorsiflexion (movement upward of the hand or foot), extension (movement of the joint ), flexion (bending the joint so its angle is lessened), hyperextension (an extension beyond what is normal), inversion (movement of the ankle forward) pronation (movement so as to place the palm facing down), rotation (movement of one bone turning on another), torsion (moving the bone on its axis) and valgus (causing outward turning of the foot and varus (causing inward turning of the foot).

The following are common orthopedic disorders. Rotator cuff tendonitis, caused by repeated overuse, diagnosed by sign of impingement, x-ray, MRI w/o tear and treated with rest, ICE/Heat, NSAIDs and cortisone injections. Acromioclavicular (AC) joint inflammation caused by repetitive overhead activity, diagnosed by impingement sign, X-ray and MRI, is treated by rest, heat/ice, NSAIDs, cortisone injection and arthroscopic depression. Adhesive capsulitis (AC Frozen shoulder) caused by no shoulder movement due to pain, diagnosed by a physical exam, is treated by ROM Exercises, pain management and manipulation under anesthesia. Ligament disorders range from anterior cruciate, to posterior cruciate, to median cruciate, to lateral cruciate (tears), diagnosed by physical exam, joint effusion, decreased ROM, edema, tests, X-ray and MRI, are treated by splint w/PT, reconstruction, repair (meniscus) and sometimes surgery.

Other orthopedic injuries include meniscus tear, hip fracture, ankle sprain, arthritis of joint, and various other fractures.

The Case Management process entails case selection, assessment, planning and implementation, and evaluation. The selection process considers:
a) does pain exceed injury
b) does disability exceed what is expected
c) will patient be out of work for over 4-6 weeks
d) is surgery recommended
e) in hip surgery cases, is the client over 70
f) is diabetes present?

Assessment considers:
a) history of injury
b) medical treatment to date
c)current diagnosis
d) treatment plan & recommendations
e)is the patient treating with an appropriate provider
f) is the treatment plan appropriate
g) is the patient improving
h)level of pain
i) presence of complications and more.

Planning and implementation consider a second opinion if appropriate, see to it that there is appropriate treatment for any medical conditions that may cause complications, coordinate the return to work of the patient, coordinate the return to PT or OT if needed, and ensure that there is a timely movement through the rehab process.

The evaluation component asks whether the patient is progressing in rehab, if the recovery is as expected, if complications are being avoided, if the effects of concurrent medical conditions are minimized, whether the treatment plan and provider are appropriate, and is the patient coping with functional changes, among other things.

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Classifying Jobs

Physical demands of a job are described from the more demanding jobs that require strength for lifting to less physically demanding jobs that require skills such as seeing. Physical conditions vary from quiet indoor jobs with no extremes of temperature to noisy outdoor jobs with extremes of temperature, moisture, vibrations, and work hazards. Specific vocational preparation is symbolized by numbers ranging from 1 (short demonstration only) to 9 (10 years or more of training/education).

The Office of Employment Statistics rates skill levels in 3 categories:

unskilled (svp is 1-2)
semi-skilled (svp 3-6) and
skilled (svp 7-9).



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