Solving POMDPs by Searching the Space of Finite Policies Nicolas Meuleau , Kee-Eung Kim , Leslie Pack Kaelbling and Anthony R. Cassandra Computer Science Dept, Box 1910, Brown University, Providence, RI 02912-1210 Abstract storeable in a finite machine). Knowing that any policyis representable as a (possibly infinite) state automaton,the first constraint we would want to impose on
UntitledYour Guide to Mental Health and ABI is part of a series of information products about acquired brain injury (ABI) produced by a joint committee of brain injury organisations with the support and assistance of the Department of Human Services, Victoria. To obtain further copies of this booklet or more information on ABI, contact Headway Victoria (telephone: (03) 9482 2955 or toll-free:
1800 817 964 or visit its website www.headwayvictoria.org.au). If you require a language interpreter to speak to Headway Victoria on your behalf contact: Translating and Interpreting Service (telephone: 131 450). This service is free of charge.
BrainLink (formerly Brain Foundation Victoria)
Department of Human Services
Associate Professor Mal Hopwood
The Journey Place for Living and Learning Inc.
The information in this booklet is of a general nature. Headway Victoria, BrainLink and arbias do not
accept responsibility for actions taken, or not taken, as a result of any interpretation of the contents of this publication.
2006 Headway Victoria, BrainLink, arbias. All rights reserved. Community organisations and individuals may copy parts of this booklet for non-profi t purposes, as long as the original meaning is maintained and there is acknowledgement of the author of the publication. No graphics elements on any page of this publication may be used, copied, or distributed separately from Common Mental Health Problems
There is strong evidence to suggest that people with an acquired brain
injury (ABI) have a signifi cant chance of developing some form of mental health problem. The complexity of dealing with a mental health issue on top of an ABI can compound stress levels for everyone involved, especially if the problem goes undiagnosed or untreated. Mental health conditions can be hard to detect amid the effects of an ABI and can dramatically hinder a person’s ability to function well. Some disorders, such as lack of impulse control, can lead to behavioural problems, which in turn can cause further social isolation. At worst, severe depression or psychosis can present a risk to life.
This booklet is designed to give you a basic understanding of the problems and symptoms a person with ABI may encounter. The better informed and aware you are of these conditions, the more likely it will be that appropriate diagnosis and treatment will occur, enhancing the person’s life and that of their family and support network.
In this booklet, we describe: > Common mental health problems after ABI
> Typical symptoms
> Treatment options
> How to get help
For more detailed information on ABI, ask for a copy of the Changed Lives Brain Injury Information Kit from Headway Victoria
(telephone: (03) 9482 2955 or toll-free: 1800 817 964).
Y O U R G U I D E T O M E N T A L H E A LT H & A B I problems after ABIThe effects of an ABI on any individual will be varied and will be infl uenced by the nature of the ABI, the person’s characteristics before the ABI and the effectiveness of their rehabilitation after it. The most common mental health problems experienced after ABI are: > Depression
> Impulse control problems
> Substance abuse
It is also quite common for people to have more than one mental health problem, such as depression and anxiety, while others may have had conditions before their ABI that went undetected. Substance abuse (alcohol or drugs) compounds the diffi culty of dealing with mental Depression
Depression is the most common mental health problem experienced following ABI. This can be the result of damage to the physical structure of the brain, but sometimes it is a response to the challenges and changes that an ABI brings. Most people develop at least some symptoms of depression during the many challenging stages of rehabilitation and recovery, but it is the combination, strength and persistence of these feelings that determines whether it is a depression that requires treatment or not.
Symptoms include: sadness, tearfulness, low mood, persistent worrying, loss of appetite, sleep disturbance, sleeplessness, feelings of gloom, helplessness, hopelessness and loss of interest or enjoyment in once Y O U R G U I D E T O M E N T A L H E A LT H & A B I For example, a diagnosis of depression might be considered if these symptoms lasted for at least two weeks and occupied a person’s thoughts for most of the time. Studies show that approximately one in four people with ABI develop signifi cant depression. Undiagnosed, depression signifi cantly reduces a person’s chance of achieving their best level of recovery from ABI. In severe cases of depression, feelings of hopelessness may lead to thoughts of suicide. Studies also show that the risk of suicide is higher in people with ABI.
The problem with identifying depression is that it can be hard to isolate the symptoms from those considered to be ‘normal’ consequences of having an ABI, such as loss of motivation and fatigue. Those who are most susceptible to depression after ABI include: > People with frontal lobe brain damage
> Anyone with a personal or family history of depression
> People not aware of – or not accepting of – how their ABI affects
Anxiety becomes a problem if the person experiences excessive feelings of worry, fear or apprehension, which may be accompanied by physical symptoms, such as a racing heart, butterfl ies in the stomach, rapid breathing, sweating or shaking. Mild and infrequent anxiety is very common after an ABI, but if the level of anxiety hinders a person’s ability to function, they may need help.
Generalised anxiety following ABI is usually perceived by the person or those around them as excessive worrying over minor matters. There is a tendency to have an exaggerated focus on the negative outcomes of Y O U R G U I D E T O M E N T A L H E A LT H & A B I Some people worry so much about the effects of their ABI that instead of working through the issues, anxiety reduces their ability to function even further. For example, someone with memory problems may worry so much about missing appointments that they literal y exhaust their ability to concentrate, increasing the likelihood of missing appointments!This type of anxiety is frequently associated with feelings of tension and symptoms, such as muscular tension and headaches.
A panic attack is when a person suffers a severe episode of anxiety that occurs out of the blue. The feelings can be so intense – pounding heart, uncontrollable fear, sweating – that the person feels like they are going to die or are “going crazy”. The attacks typically reach full severity very quickly and can last from 15 to 30 minutes.
If they occur several times a day, the person may begin to withdraw from social contact, trying to avoid situations that they believe will trigger the episodes.
Social anxiety involves an unrealistic fear of social situations, such as meeting new people or talking or eating in front of others. The person may worry excessively that others will fi nd them embarrassing or awkward, to the point that they begin to avoid all contact with people. Maintaining social contacts is a common problem for many people with ABI. A person needs to make a signifi cant effort to build networks if they are to minimise isolation and anxiety. Carers and family can offer vital support and encouragement in this area.
Post Traumatic Stress Disorder (PTSD)
PTSD is caused by the experience of a severe traumatic event, often a life-threatening one to self or others, which is then re-experienced in the form of nightmares or daytime fl ashbacks. Any reminder of that event may trigger an episode, which can lead to the person avoiding all activities or places associated with that event. As a consequence, the person’s lifestyle may become very restricted.
Y O U R G U I D E T O M E N T A L H E A LT H & A B I Psychosis
A psychosis is a mental disorder in which a person’s ability to determine reality, to reason and to make sound judgements becomes disturbed. Classic symptoms are hallucinations and delusions.
Hallucinations: Hallucinations are when a person has a perceptual
experience (sees, hears, smells something) that is not there. The classic example of this is “hearing voices” when no one is actually talking.
Delusions: Delusions are fi xed, false beliefs that cannot be reasoned
with and that are not part of a person’s usual belief system. A common delusion is the belief that you are being pursued by someone or something or that your life is under threat. The person with psychosis has no awareness or insight that this experience is abnormal, which is very distressing not only for them, but for those who care for them.
Recent studies show that one in 20 people with ABI are at risk of developing a psychosis. Delusions can lead to serious behavioural problems that become extremely challenging for everyone involved. A person suffering from delusions may have diffi culty in social situations or participating in rehabilitation and activity programs.
Impulse Control Disorder
Impulse Control Disorder is sometimes referred to as Frontal Lobe Syndrome. Before an ABI, a person is general y able to inhibit certain impulses, such as open displays of aggressive or sexual behaviour. After an ABI, some people lose the ability to control these urges and act without thinking. Impulse Control Disorder lands people in all sorts of trouble when their actions are embarrassing or offensive to others. Sometimes it can be as simple as speaking without thinking, but occasional y it may be more serious, involving verbal or physical aggression or sexually inappropriate comments or touching.
Challenging behaviours, such as overt aggression, are common after ABI, but diagnosing Impulse Control Disorder usually requires an in-depth behavioural assessment. This may involve several members of the health care team, including a neuropsychologist who can determine which areas of the brain are damaged and what behaviours Y O U R G U I D E T O M E N T A L H E A LT H & A B I Substance abuse
Substance abuse is generally defi ned as a dependence on the use of drugs or alcohol that leads to negative physical, behavioural and social consequences. Substances can include nicotine, caffeine, prescribed medications, alcohol, cannabis and street drugs.
Substance abuse is particularly problematic for people with ABI. Apart from accentuating diffi culties associated with brain damage, such as memory, self control, thinking and coordination, it can also trigger a range of other mental health symptoms, such as paranoia, psychosis and anxiety.
Levels of alcohol and substance use that might not be considered harmful for most people, can be a problem for some people with ABI. This is because the effects of alcohol can be unpredictable and dramatic on a brain that has already suffered damage. If you have concerns about ABI, substance abuse and related mental health problems, there are several organisations that may be able to assist listed under Getting Help (Alcohol and Drug Services) at the back Y O U R G U I D E T O M E N T A L H E A LT H & A B I Treatments There are three types of treatments available for people with ABI who also suffer from mental health disorders: > Medication
> Talking treatments
> Behaviour management treatment
Effective diagnosis and treatment depends on examining al the factors that could infl uence a person’s mental health. For example, the person may be going through a chal enging transition period, such as going back to work, trying to build new friendships or struggling to accept aspects of life with ABI. They may need some extra support during that time.
Or, their mental health problem could be the reason why they are not coping with these transitions. Often a combination of treatment approaches is helpful in alleviating symptoms. The following factors can have a signifi cant, positive impact on the > Team work – a coordinated, proactive health care team is vital
> Environment – treatments administered where the person
> Hospitalisation – sometimes hospital is the safest place for
> Relationships – supportive families or networks that are
well informed and well nurtured and who seek assistance > They are based on a careful assessment that examines all the
factors potentially infl uencing the situation > There is an explicit diagnosis of a mental health disorder or
evidence of symptoms that can be targeted by treatment > There are regular reviews of treatment
> Signifi cant or even partial improvements are observed on an
> Treatments are maintained appropriately to avoid recurrence
Y O U R G U I D E T O M E N T A L H E A LT H & A B I Types of medication
There are four main types of medication used to treat mental > Antidepressants – depression, anxiety
> Benzodiazepines – anxiety, sleep disorders
> Antipsychotics – psychosis
> Mood-stabilisers – depression, Impulse Control Disorder
Headway Victoria (telephone: (03) 9482 2955 or toll-free: 1800 817 964)
has an information leafl et called Medications Commonly Prescribed after a Brain Injury that provides detailed information about these medications and their side effects.
The most widely used medications in the treatment of anxiety and depression following ABI are Specifi c Serotonin Reuptake Inhibitors (SSRIs), which have names like Fluoxetine, Paroxetine and Sertraline. Once the right antidepressant and correct dose is found for each individual, it can take at least one to two weeks to have a benefi cial effect. This process of trial and error and delayed response can be very frustrating, but it’s usually worth the attempt as the chance of a positive result is in the order of 70 to 80 per cent. Regular reviews of the antidepressant treatment and good maintenance can help to reduce the risk of relapse.
The most widely used group of medications to treat anxiety and sleep problems are the benzodiazepines. You are probably familiar with some of the brand names: Valium, Serepax, Mogadon and Normison.
While benzodiazepines can be dramatically effective, health professionals prescribe them less frequently these days because some people become addicted to them quite easily.
In the case of people with ABI, use of benzodiazepines can cause an increase in behavioural issues, such as aggression. As a result, their use is generally short-term (up to eight weeks) and only in cases where Y O U R G U I D E T O M E N T A L H E A LT H & A B I Antipsychotic drugs
The major differences between the most widely used antipsychotic drugs are their availability and side effects. These drugs fall into two main classes – typical drugs and new generation drugs.
Typical: Drugs classed as typical have generally been around longer and
can be used to control a range of conditions, such as Impulse Control Disorder and severe anxiety. Some brand names are Serenace, Stelazine, Largactil and Anatensol.
New generation: New generation drugs are more expensive and are
generally used to treat specifi c conditions, such as schizophrenia. Some brand names are Risperdal, Zyprexa, Seroquel, Solian and Clozaril. They tend to have fewer side effects, and in particular, fewer movement- related side effects. This is especially relevant for people whose ABI is due to hypoxia (lack of oxygen) or hypoglycaemia (low blood-sugar levels), which means the areas of their brain that control smooth movement are likely to be damaged.
This group of medications is used to treat Impulse Control Disorder and the alternative mood states sometimes experienced after ABI or in specifi c conditions, such as Bipolar Affective Disorder. Mood states might include persistent feelings of euphoria or depression, increased energy, less need for sleep and impulsive behaviour. Some common brand names include Lithicarb and Epilim, Valpro and Tegretol. Y O U R G U I D E T O M E N T A L H E A LT H & A B I Talking treatments
The term “talking treatments” refers to regular, direct communication with a professional who works to stabilise a person’s state of mind and/or emotional balance. Treatments are usually for 50 minutes at a time and professionals may use any combination of the therapies listed below, tailoring their approach to suit the individual. Talking therapies are generally a slow process and require a solid commitment by the person to ongoing treatment.
There are various forms of psychotherapy. This one takes a problem- oriented approach where you discuss an issue with the therapist who may offer direct advice, or simply reassurance. It is usually conducted by a general practitioner, psychologist or psychiatrist and is more like having a trusted shoulder to lean on in tough times, rather than someone deeply probing into problems and trying to resolve them.
Cognitive Behavioural Therapy (CBT)
CBT is used widely for the treatment of depression and anxiety-related problems. The main aim is to identify and eliminate unhelpful and repetitive patterns of thought or action.
For example, if a person thinks in a pessimistic manner constantly, the world becomes a dismal place, which may lead to depression. Through discussion, the person learns how to identify pessimistic thinking. Through practice, the person learns how to change their behaviour to reduce or eliminate those negative thought patterns. CBT is a very useful treatment but may need to be modifi ed for someone who already has signifi cant cognitive (thinking, perceptual, judgement) problems as a result of their ABI.
Psychoanalysis works on the belief that change in behaviour only occurs when a person fully understands the reasons why they do the things they do. This therapy usually involves deep discussion of childhood, relationships and past traumatic events. It requires a high level of verbal skill and emotional insight by the participant and may not be appropriate for people who have major thinking, perceptual or communication diffi culties following their ABI.
Y O U R G U I D E T O M E N T A L H E A LT H & A B I Behavioural therapy
Behavioural therapy is an umbrella term for a range of therapies that can be used to help people who suffer Impulse Control Disorder. The basic idea is to monitor diffi cult behaviours closely in order to understand the triggers for and outcomes of those behaviours. For example, environmental factors, such as noisy or crowded rooms, might make the person more agitated. The solution might be to avoid those situations and to compensate by scheduling more enjoyable activities in less hectic environments. Or the person might experience pain when they pursue an activity they once enjoyed, which upsets them and triggers outbursts of aggression.
Y O U R G U I D E T O M E N T A L H E A LT H & A B I Getting help Given how common mental health problems are following ABI, anyone with ABI and their carers need to be aware of (and watch out for) symptoms. Should you suspect that something is occurring beyond the ‘normal’ effects of the ABI, have it checked out. In general, mental health problems do not disappear of their own accord. Even when treated, they have a tendency to reoccur and Who to see about mental health issues
If a person begins to exhibit any behaviour beyond the effects of their brain injury, discuss this new behaviour with them fi rst to see if they are aware of it. If you still have concerns, bring it up with their case manager, general practitioner or a trusted member of their health care team. Because support for ABI is the collaborative effort of a team of health care professionals, a general practitioner or case manager can help to decide which professional can best address your concerns.
If there is no case manager or general practitioner, BrainLink can refer
you for assistance (free call:1800 677 579).
When decision-making is a problem
Mental health problems, such as delusions or even depression, can muddy a person’s ability to see when their actions are damaging towards themselves or others. Also, a person’s brain injury may affect their capacity to make informed decisions or to provide informed consent about their treatment. At times like these, relatives may need to take the person’s care in hand, with or without their consent. Y O U R G U I D E T O M E N T A L H E A LT H & A B I Guardianship and administration
Sometimes, a person with an ABI needs somebody else to make decisions for them or to manage their fi nancial affairs until they are able to take over those responsibilities again. First, you need to fi nd out whether they have appointed someone, or whether there is a legal order in place such as a Power of Attorney, that allows another person to act on their behalf should they become incapacitated.
If there is diffi culty in establishing the appropriate decision-maker or there are doubts about the person’s wishes or there are differences of opinion about what course of action to take, the Victorian Civil and Administrative Tribunal (VCAT) can help by appointing an administrator or guardian, if required.
(telephone: (03) 9628 9911 or toll-free: 1800 133 055).
When a person refuses to or is unable to make informed decisions and they are considered to be a risk to themselves or others due to their mental health problem, such as psychosis, severe Impulse Control Disorder or suicidal depression, they may have to be treated as an involuntary patient under the authority of the Mental Health Act. This is a very big step that is only taken when there is clear evidence that: > The person is at high risk of harming themselves or others as
a result of their mental health condition > Their condition is likely to remain the same or become worse
A request for a recommendation for compulsory treatment must be made by a mental health professional or general practitioner and must be endorsed by a psychiatrist.
When considering whether to make a request for a recommendation to invoke the Mental Health Act, the mental health workers will ask relatives, carers and health care professionals to provide very specifi c information about the person’s behaviour before any action is taken.
Y O U R G U I D E T O M E N T A L H E A LT H & A B I Information about the provisions of the Mental Health Act and the person’s rights can be obtained from the Mental Health Legal Centre
(telephone: (03) 9629 4422 or toll-free: 1800 555 887) or visit Mental health services
Referrals to publicly funded, specialist mental health services are generally made through a general practitioner or other health worker. The referral might be to an Area Mental Health Service, or in urgent cases, to a Crisis Assessment Team.
Specialist public mental health services
Clinical mental health services are managed by public hospitals and provide assessment, diagnosis and treatment to people with serious mental illness. To be eligible to use them, a person needs to be in a crisis situation or to require hospitalisation or to need support within their community setting. The services are provided on an area basis and are divided into adult mental health services, child and adolescent services and services for aged persons. Victoria also has a number of highly specialised, state-wide, mental health services. These are attached to major hospitals, such as the Neuropsychiatry Centre at the Royal Melbourne Hospital and the Brain Disorders Program Victoria (BDPV) based at Austin Health, which includes the Community Brain Disorders Assessment and Treatment Service (CBDATS). These two major hospitals provide mental health assessment, treatment and rehabilitation services as well as education and research through their programs. To fi nd out which services may be of use to you, speak with your general practitioner or case manager or your local general hospital. Getting the assistance you require may take some persistence, but CBDATS and Headway Victoria can help you to explore the options and point you Y O U R G U I D E T O M E N T A L H E A LT H & A B I Contact details for your local Area Mental Health Services are available on the Victorian Department of Human Services website: www.health.
vic.gov.au/mentalhealth or by calling the Mental Health branch on (telephone: (03) 9096 8592).
(telephone: (03) 9490 7366) or visit www.bdpv.org
Austin Health Neurobehaviour Assessment Clinic
(telephone: (03) 9496 2940)
Royal Melbourne Hospital Neuropsychiatry Centre
(telephone: (03) 9342 8750)
Private psychiatric services
Private psychiatric services are offered on a fee-for-service basis. Anyone who uses these private services will require adequate health insurance cover or need to be eligible for compensation with approved agencies, such as the Transport Accident Commission or the Victorian WorkCover Authority. Private services include in-patient and out-patient treatment but the private system does not have a crisis capacity and does not provide involuntary in-patient treatment.
There are a number of fee-for-service psychiatrists who practice outside the hospital system who have experience assisting people with an ABI. A general practitioner or case manager can help you work out whether you need to engage one and how to fi nd one.
Some other community-based disability support services may also be useful. For example, the ABI Behaviour Consultancy offers assistance in diagnosing and managing behavioural problems.
ABI Behaviour Consultancy
(telephone: (03) 9383 7176) or visit www.abibehaviour.org.au Y O U R G U I D E T O M E N T A L H E A LT H & A B I Alcohol and drug services
Regional ABI Alcohol & Drug Clinicians/Consultants
Workers with a specialist knowledge of ABI are located in key alcohol and drug services in each region. The clinical consultant at Turning Point can put you in touch with the consultant in your region and provide advice on access to specialist case management. The Turning Point website is also a great source of information about drugs and alcohol and the support services available.
(telephone: (03) 8413 8413) or visit www.turningpoint.org.au/abi/
arbias offers a range of services including specialist case management, neuropsychological assessment, accommodation, attendant care, recreation, training and secondary consultation for people with alcohol or substance-related brain injury.
(telephone: (03) 8388 1222) or visit website for fact sheets For more information
We hope this booklet has given you a basic understanding of mental health issues and a useful overview of the common symptoms and treatments a person with brain injury may encounter. We’ve listed a range of services that might assist, but if you do not have a case manager or do not know where to begin to locate an appropriate service, call us at Headway Victoria (telephone: (03) 9482 2955 or Y O U R G U I D E T O M E N T A L H E A LT H & A B I
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