Transcript Psychiatric disorders in adults with Learning Disabilities

Psychiatric disorders in adults with Learning
Disabilities
detection and management
Dr Vesna Jordanova
Consultant Psychiatrist
Learning Disability
A life long condition
 Impairment in development of brain
functions that affect cognitive abilities and
emotions
 Criteria for a learning disability:

– IQ below 70
– Impairments in functioning
– Onset in infancy

A learning disability is not a mental health problem
Prevalence
Mental health problems - between 10% and 20% of
people with learning disabilities
 But research suggests that some people may go
undiagnosed
Some figures appear much higher, but they tend to
include people with challenging behaviour - which is
not a mental health problem

Confidential Inquiry into premature
deaths of people with learning
disabilities
 22%
of people with LD were under 50
when they died, compared with 9% of
people without LD
 Women with LD die 20 years sooner,
than those without LD
 Men with LD die on average 13 years
younger
Most common reasons of death
 delays
or problems with diagnosis or
treatment
 two-fifths of people with LD died
from causes amenable to good
quality healthcare
Learning Disability
 Global
impairment of intellect (IQ <
70 equal to 2.5% of population)
 Acquired before age 18
(developmental period)
 Social / Occupational impairment
 AKA Mental retardation (old, but still
in ICD-10)
 AKA Intellectual disability (new)
Learning Disability
 Prevalence
> Men
 2.5% predicted by IQ distribution,
but actual LD probably lower
 Mainly Mild LD (50-70 IQ est)
 Moderate LD: IQ around 35-50
 Severe LD: IQ < 35 (but not
meaningful at this point)
Learning Disability: Causes
CNS Insult (e.g. Hypoxia, infection)
 Specific Genetics:

– Trisomy 21 most common genetic cause
– Fragile X most common inherited cause
(triplicate repeat on X chromosome)
– Many others: incl many micro deletions,
trisomys, sex chromosome abnormalities
– XXY, XO have, on average, slightly lower IQ,
but not normally in LD range. (Possibly XYY
too).
Learning Disability: Mental Health
 Schizophrenia
Probably 3%
Incidence
 BAD 1.5%, possibly more
 Most mental illness believed to be
increased in prevalence (up to x3) in
LD
 Anorexia less common (but overall
eating disorders more common)
Schizophrenia and Learning Disabilities
Higher prevalence:
– Approximately 1% of general population
– Approximately 3% of learning disability
population
 On average earlier onset:
– General population - 26.8 years
– Learning disability population - 22.5 years

Learning Disability: Mental Health
 Prognosis
probably worse:
particularly studied in schizophrenia,
more insidious and malign.
 Some specific associations with
Trisomy 21
– Depression
– Dementia (of Alzheimer's type), early
onset.
Vicious Cycle of Social Exclusion
Lower
Self-Esteem
Increased
Levels of
Isolation
Reduced
Opportunities
Mental
Health
Problem
Stigma
Discrimination
Schizophrenia and Learning Disabilities
 Diagnosis
of Schizophrenia relies on language
based criteria
 People with LD often unable to communicate
complex experiences
 Delusions in people with LD
– may be less complex
- delusions are drawn from the person’s
more limited field of experience
 Hallucinations
in people with learning
disabilities:
– may express their hallucinations in broad
terms without details
– may not be able to explain further when
asked specifics
Schizophrenia and Learning Disabilities
Symptoms may be atypical
 Other symptoms in people with mild to moderate
learning disabilities:
– social withdrawal
– fearfulness
– sleep disturbance
– simple delusions and hallucinations

Behaviours in people with learning
disabilities that may be mistaken for
schizophrenia:
 May
invent their own words due to:
– not knowing the appropriate word
– autistic neologisms – “pet” words
– having a limited vocabulary
Schizophrenia and Learning Disabilities
 May
still have child-like beliefs, which have
been perpetuated by family or carers
 Fantasy worlds
 May be aloof
 May be uncommunicative
Mood Disorders and Learning
Disability
Presentation in people with learning
disabilities:
Relatively easier to diagnose than schizophrenia due
to the biological and behavioural changes - even in
people with severe learning disabilities
 Prevalent in 1-6% of the LD population

Anxiety and Learning Disabilities
Presentation of anxiety in people with
learning disabilities:
Irritability
 Difficulties getting to sleep
 Physical complaints

Principles of Assessment
Mild learning disabilities and reasonable
verbal communication skills:
– assessment is similar to the general population
 Severe learning disabilities and limited
communication skills:
– rely on changes in behaviour and the
observations of others

 Always
consider possible underlying physical
illness - this may contribute to changes in
behaviour and functioning
Assessment – Current Situation
What is the person normally like?
 What has changed?
 Possible signs and symptoms
 Recent life events

– transitions, changes in circumstances, change in staff or
routine, frequency of family contact, abuse, bereavement,
new service user

Why are you reporting this now?
LD: Assessment, Communication
 Keep
speech simple, jargon-free, one
concept at a time.
 Beware acquiesce:
– Are you happy?
– Are you sad?
– Are you Ming the Merciless?
 Beware
Yes
Yes
Yes
suggestibility:
– Are you happy or sad?
– Are you sad or happy?
Sad
Happy
LD Assessment, Communication
 (Almost)
always communicate with
PWLD first – this is the most
frequent complaint of PWLD.
 However, don’t be shy to ask an
informant for information or to help
with communication
 Visual prompts can help at time.
Things that can help in an
assessment
–
–
–
–
–
–
–
ABC charts
sleep charts
weight charts
current drug card
recent skills assessments
incident reports
seizure monitoring chart
Principles of treatment
 Multidisciplinary
 Partnership
 User
and carer involvement
 Optimal inter-professional
communication.
 The issue of valid ,informed consent.
 Assessment of capacity.
Learning Disability: treatment
Medication normally used more slowly /
cautiously (sensitivity to side effects)
 Epilepsy more common: care with
proconvulsant effect of many psychiatric
drugs (and interaction with anti
convulsants).
 Psychological therapies used, particularly
CBT
 Behavioural management
 CPA Used

Autistic Spectrum Disorders
 Qualitative
abnormalities in
reciprocal social interaction
 Communication abnormalities
 Restricted, stereotyped repetitive
interests and activities
 Pervasive
 Onset in childhood
Prevalence of ASD in the UK

The UK National Surveys of Psychiatric
Morbidity 2007
 First population-based study of adults with
autism (Brugha et al. 2009)
 prevalence of autism - 0.9%
 88.9%- male
 56.3%- unemployed
 56.9%- single
 8.5%- ICD-10 neurotic disorder
ASD: Communication and
Assessment
 Neurodevelopmental
important
history very
– Imaginative play
– Interaction with other children
– Pointing out objects
– Understanding others internal mind
(theory of mind)
– Generalised motor clumsiness
– Restricted area of interest
ASD: Communication and
Assessment
Try and interview in side room / quiet,
non distracting area (ASD = sensitive to
noise++)
 New environments usually very distressing
to ASD, bear this in mind. A trusted
support worker, family, friend, makes this
easier.
 Avoid euphemisms, and relying on nonverbal communication
 Try and keep things unambiguous, “black
and white”, concrete.

Watch out!
Misdiagnosis…
Is it….?
Obsessive Compulsive
Disorder/Personality
Or…
Autistic rituals and
need for sameness
Auditory hallucinations
Or…
Unusual sensory
experiences
Depression
Or…
Lack of emotional
expression
Bipolar disorder
Or…
Changeable mood/
over-excitability
Borderline Personality
Disorder
Or…
Emotional lability in AS
and poor theory of
mind/social skills
Autism or schizophrenia





Social isolation, lack of general interests and
slow response may be contributed to
“negative symptoms”
Communication difficulties (odd, overinclusive
speech) may be mistaken as “thought
disorder”
Incomplete/odd answers can sound like
delusions
Catatonia
Autistic behaviour can be alleviated by use of
antipsychotics
ASD in adulthood
It is a lifelong disability
 The costs of supporting adults with ASD in the UK
amount to 25 billion pounds each year (NAS
2010)
 Only 15% of people with ASD in the UK are
employed (National Audit Office 2009)
 Comorbidity in autism is associated with negative
long-term outcomes

Contact Details
Vesna Jordanova
Email: [email protected]