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Introduction – Learning Disability Psychiatry . Dr Michelle Beaumont SPR to Professor Read. Aims. Introduction Assessment LD specific issues Psychiatric Disorders Legal issues Physical issues. Introduction. History Epidemiology Aetiology . Picture 1. History. From this….

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Introduction learning disability psychiatry l.jpg

Introduction – Learning DisabilityPsychiatry

Dr Michelle Beaumont

SPR to Professor Read


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Aims

  • Introduction

  • Assessment

  • LD specific issues

  • Psychiatric Disorders

  • Legal issues

  • Physical issues


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Introduction

  • History

  • Epidemiology

  • Aetiology






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Valuing People 2001

  • Principles

    • Rights - equal

    • Independent living

    • Control

    • Inclusion

  • Practice

    • LD register

    • Health Education factor

    • Health Action Plans

    • Housing

    • Employment



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Epidemiology

  • 210,000 Severe & Profound LD

    • 65,000 children & young people

    • 120,000 working age

    • 25,000 older people

  • 1.2 million Mild / Moderate LD

Valuing People 2001


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Epidemiology continued…

  • Institute for Health Research at Lancaster University 2004

    • 985,000 with LD

    • 224,000 known to social services

    • 761,000 mild / moderate LD maybe unknown

  • Emerson & Hatton total adults with LD

    • increase by 8 % - 868,000 by 2011

    • Increase by 14 % - 908,000 by 2021


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Epidemiology continued...

  • 5% live home of own

  • 30% residential care home

    • Significant proportion miles away from family

  • 1 in 10 (known to SS) employment

  • Significant number live with elderly carers

Valuing People Now: A New 3 year strategy for people with LD






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Aetiology

  • Primary disorders with direct effects

    • Syndromes

  • Primary disorders with secondary effects

    • Inborn error metabolism

      • PKU

      • TS

  • Secondary disorders

    • Antenatal

      • Neural tube defects

      • Infection – syphillis, CMV, rubella

    • Perinatal

      • Hypoxia

      • Infection

      • Trauma

      • Abuse / accident

    • Postnatal

      • Nutrition

      • Trauma

      • Infection

      • Encephalopathies

      • Metabolic





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Assessment considerations

  • LD criteria

  • Informants / Carers

  • Communication

  • Assessment

  • Risks


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Learning Disability Definition

  • Global impairment of intellectual functioning > diminished ability to adapt to daily demands. (IQ below 70).

  • Significant deficits / impairments in adaptive behaviours & social functioning.

  • Onset in development period (<18)

ICD - 10


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LD - Indicators

  • Special school

  • Statement (can be behavioural)

  • Educational support

    NOT

  • Asperger’s

  • Dyslexia / Specific learning difficulty

  • Normal education

  • GCSEs

  • Drive car


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AssessmentInformants / Carers

  • Key worker / family

  • Key knowledge

  • Aid to compliance

  • Stress


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Communication

  • Simple language with short sentences

  • Avoid jargon and negatives

  • Give concrete examples and avoid abstract ideas

  • Be aware literal meanings & use humour cautiously

  • Sign language /pictures. Consider interpreter

  • Check comprehension



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Consideration

  • Compliance

  • System

  • Capacity / Best interests




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Assessment

  • Psychiatric Assessment with carer (known x years)

    • Presenting Compliant

    • History of presenting compliant

      • Change

      • Illness / pain

    • Developmental history

    • Skills

    • Social history

      • Support

      • Day care

      • Benefits

      • Other peers

    • Forensic

      • Forensic issues

    • Past Psychiatric History

    • Past Medical History

    • Medications / Allergies


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AssessmentMSE

  • Appearance & behaviour

  • Agitation

  • Eye contact

  • Mood

  • Speech

    • Understanding

  • Thoughts.

    • Less guilt / suicidal ideas – cognitive level

    • Delusions. Basic

    • Hallucinations

    • Suicidal ideation

    • Harm to others

  • Insight

    • Illness / not

    • Medication

    • Capacity

      • Best interests


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Assessment

  • Day care reports

  • Family

  • Monitoring charts

  • Other assessments

  • Social issues

    • Safeguarding issues


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Risks

  • Aggression / violence

  • Neglect

  • Abuse from others

  • Abuse to others

  • DSH

  • Suicide

  • Domestic


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Assessment

  • Multi Professional Team working

    • CMN

    • SALT

    • OT

    • Physiotherapy

    • Psychology

    • Care managers

    • Teachers


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Treatment

  • Medication

    • Research/ evidence poor

    • Extrapolated from general adult psychiatry

    • If use off license medication should indicate

    • Reduced doses & slow titration


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Treatment

  • Side effects

    • Reduced ability to communicate

    • Reduced ability to not comply

    • Increased risk of

      • Neuroleptic Malignant Syndrome

      • Tardive Dyskinesia

      • Other

        • Confusion

        • Constipation

        • Weight gain

        • Medication interactions,


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Treatment

  • Review effect

  • Side effects



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LD Specific issues

  • Challenging Behaviour

  • Behavioural phenotypes

  • Autism



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Challenging behaviour

  • 10-15 % of LD use services

  • Most common reason for referral to psychiatrist

  • Behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and use of ordinary community facilities.

  • Emerson et al (1988)


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Challenging behaviour

  • Can present as part of specific psychiatric disorder or independently

  • Need to exclude mental / physical illness

  • May be due to lack of appreciation of social norms.

  • Serious impact on accessing services / quality of life

  • Carers


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Challenging behaviour

  • Management

    • monitoring,

    • boundary setting,

    • evaluation of environment,

    • medication may be indicated

  • MDT




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Behavioral Phenotypes

  • Known (usually genetic) disorder is associated

    • Pattern behaviour

    • Personality characteristics

    • Psychiatric symptoms

  • Eg


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Fragile X

  • Testicular enlargement

  • Large head circumference

  • Long & prominent ears

  • High arched palate

  • Connective tissue disorder

    • Lax joints

    • flat feet

    • Mitral valve prolapse


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Fragile X cont..

  • Mild - moderate LD

  • Flattening trajectory learning over childhood

  • Abstract reasoning

  • Visuo-motor & spatial deficits

  • Strengths verbal & adaptive behaviour

  • 5 - 46 % have autism


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Fragile X characteristics

  • Social avoidance

  • Gaze aversion

  • Shy rather than autistic indifference

  • Fast garbled speech

  • Litanic pitch

  • Anxious interest in speech

  • Hyperactivity

  • Impulsiveness

  • Distractible

  • Wrist biting



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Autism

Pervasive developmental disorder


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Temple Grandin

“My hearing is like having a hearing aid with the volume control stuck on “super loud”. It is like an open microphone that picks up everything. I have 2 choices: turn the mike on & get deluged by sound, or shut it off.”


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Autism

  • Usually coexists with significant LD

  • Apparent before 3

  • 4/10 000

  • M>F

  • Increased in certain conditions

    • TS, rubella


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Wing

  • Continuum

  • Triad of impairments

    • Social relationships

      • Lack empathy

      • Interest in others

    • Language

      • Expressive > receptive

      • Abnormal prosody. Echolalia. Pronounal reversal. 3rd person

      • Literal meaning

    • Imagination restriction

      • Routines. Novelty > catastrophic rage.

      • Unusual interests


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Autism continued..

  • Sensory

    • Abnormalities Perceptions

      • Heightened / Reduced

      • Pain

      • Inability distinguish signal from noise

      • Ignore strong stimuli but notice small thread

    • Time / space abnormalities

      • > preoccupation with routines & intolerance of delay

    • Motor

      • Tone

        • Posture

      • Stereotypies

      • Mannerisms


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Autism & Mental illness

  • Psychosis

    • Self talk

    • General demenour

    • Across all situations

    • paranoia

  • Depression

    • Atypical

    • Self harm

    • Increased withdrawal


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    Treatments

    • Behavioural assessment & management

    • Key

      • structure,

      • predictability,

      • Communication

        • Social stories

        • Intensive interaction

        • Visual diaries

        • Communication boards

    • Aim reduce arousal


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    If environmental fail/ risks high

    • Medications

      • Antidepressants

        • SSRI: citalopram

      • Antipsychotics

        • Atypical: risperidone, olanzapine

      • PRN medications

        • Benzodiazepines: lorazepam

        • Atypical antipsychotics: risperidone

        • NEED PROTOCOL

    • Set targets for assessment of efficacy of medication

    • Monitor risks / side effects

      • Bloods, ECG, Weight & BP




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    Psychiatric Disorders

    • Vulnerability factors

    • Diagnostic issues

    • Disorders



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    Mental Disorder

    • Under-diagnosed

      • Behavioural disorder

      • Insufficient weight to symptoms

      • Psychosocial masking - bland beliefs

    • Consider co-morbidity e.g. physical ill health / epilepsy


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    Mental Disorder

    • Diagnostic difficulty

      • Cognitive disintegration

        • Stress induced disruption of information processing can > bizarre behaviour & psychotic symptoms

      • Baseline exaggeration

        • General increase in pre-existing cognitive deficits can make interpretation of symptoms difficult

      • Diagnostic overshadowing

        • Tendency to attribute symptoms & B associated with illness to LD



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    Schizophrenia

    • Prevalence

      • approx 3% (Fraser & Nolan 1994) cf 1 % gen popn

    • Undetected in more severe LD - IQ < 50

    • Presentation

      • Depends on level of LD

        • Mild & verbally able similar general popn

      • Auditory hallucinations 90% (Meadows et al 1991)

      • Less psychopathology

        • Less complex delusions

        • FTD

        • Less likely passivity, thought echo, running commentary


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    Schizophrenia

    • Delusions

      • Can be talked out of - consider if repeated

      • Wish fulfilment

      • Content developmentally appropriate

    • Adults with severe LD

      • Increased catatonic symptoms

        • Consider

          • Major change no significant environmental change

          • Family history

    • Misinterpretation of reality


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    Schizophrenia

    • Differential Diagnosis

      • BPAD

      • Organic

      • Autistic Spectrum Disorder

      • “Brief” Reactive Psychosis

    • Consider

      • Self talk

      • Suggestibility & compliance

      • Fantasy

      • Misinterpretation of reality


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    SchizophreniaTreatment

    • NICE

      • Antipsychotics

        • NMS

        • TD

        • Akathisia

        • Weight

        • Metabolic syndrome

        • Interactions -

          • Medications

          • Epilepsy

      • PSI -

        • CBT

        • Family interventions



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    Affective Disorders

    • Prevalence

      • 5-10 % major depressive disorder.

      • 3-8% bipolar

    • Under-diagnosed especially severe LD

    • Atypical presentation

    • Historically thought people with LD didn’t experience emotions


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    Depressive episode

    • Depressed / irritable mood and or

    • Either

      • Loss of interest/ pleasure in activities

      • Social withdrawal

      • Reduced self care

      • Reduced communication

    • Some of

      • Lethargy, fearfulness, somatic concerns, reduced concentration / indecisive, increase behaviour problem, agitation / retardation, appetite / sleep disturbance

    DC - LD


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    Depressive episode

    • Symptoms

      • Anxiety prominent

        • Loss of confidence and tearfulness common

      • Irritability

      • Behavioural symptoms - (worsening of pre-existing)

        • Self injury

        • Aggression

        • Screaming, temper tantrums, incontinence & Vomiting

      • Hypochondriacal

      • Regression i.e. loss of skills, social withdrawal


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    Affective disordersSevere LD

    • More biological symptoms e.g. sleep and appetite

    • Regression

    • Psychomotor agitation

    • Catatonia and visual hallucinations more common


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    Affective Disorders Differential Diagnosis

    • Environmental change, loss, abuse

    • Medical condition

    • Drug induced

    • Anxiety

    • Dementia

    • Behavioural disorder

    • BPAD / mania (irritability / aggression, pressure of speech > complex verbal symptoms)


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    Janet

    • 50 year old lady

    • Moderate LD

    • Supported living

    • Tearful.

    • Lost confidence.

    • Poor appetite. Weight loss.

    • Withdrawn

    • Reduced mobility. Abnormal gait. Falls

    • Previous similar presentation 15 years ago.


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    MSE

    • Wheel chair

    • Anxious.

    • Tearful

    • Denial of symptoms


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    Suicide

    • Rarely reported

    • Attempted suicide rate 0.9% cf 1% gen popn (Sternlicht et al 1970)

    • DSH more men cf women

    • Mild/ borderline

    • More severe LD – self harming behaviour thought be suicidal



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    Helen

    • Wheelchair bound limited use of arms

    • Scissors

    • Sink


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    Affective disordersMania/ hypomania

    • 4% adults with LD cyclical changes in behaviour & mood (Deb & Hunter 1991)

    • Mixed affective & rapid cycling more common

    • Rapid cycling M = F


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    Bipolar Affective disorder Mania Symptoms

    • Irritability > euphoria

    • Grandiose ideas & delusions - simple

    • P of speech > flight of ideas

    • Inc / dec appetite

    • Echolalia

    • Crying

    • Overactivity

    • Social inhibitions

    • Reckless Behaviour


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    Affective disordersManagement

    • NICE

      • Antidepressants - longer for effect

      • Mood stabilizers

      • PSI

        • Routine / structure

        • CBT

        • Psychotherapy

      • ECT



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    Neuroses Anxiety disorder

    • Mild LD increased neuroticism cf gen popn

    • GAD similar symptoms cf general popn

    • Irritability & restlessness can be marked

    • May not be able to avoid

    • More severe LD only behavioural signs

    • Co-morbidity /

      • Psychiatric illnesses

      • Williams syndrome part of behavioural phenotype

      • ASD


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    Obsessive Compulsive Disorder

    • Repetitive behaviour common

    • Compulsive Behaviours

      • 3.5%-40% in mild to profound learning disabilities

    • Symptoms

      • Ordering compulsions most prevalent

      • Thoughts/ acts not due to external source

      • Not pleasurable

      • May not be viewed as unreasonable

      • Resistance may be minimal

      • Compulsions can > aggression if prevented.


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    Sue

    • 50 year old lady with Down’s syndrome

    • Living in supported living

    • Carer’s problems

      • Excess time to leave house – routines

      • Lining up

      • Aggression/ risk of injury

    • No evidence anxiety on examination - with limits set


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    PTSD

    • Increased risk of emotional, physical & sexual abuse

    • Increased risk of PTSD / adjustment disorders


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    Anxiety disorders

    • Treatment

      • Treat psychiatric disorder

      • NICE guidance

        • SSRI

        • Less frequent TCA’s

      • Behavioural treatments

      • Staff training


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    Personality Disorder

    • Controversial

      • Developmental delay when personality complete

      • Stigma

      • Individuals IQ <50

  • Overlaps - behavioural phenotypes

  • Poor research base

  • More readily diagnosed in mild / borderline LD

  • Age 21

  • Avoid ICD diagnosis - schizoid, anxious, dependant

  • Small number - mild LD, Antisocial PD, usually male

    • persistent fire setters

    • sex offences




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    Dementia

    • Increased life expectancy

    • Dementia brought forward all LD

      • 30yr - Downs

      • 10-15yr LD not Downs (Hoffman et al 1991)


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    Down’s Syndrome & Dementia

    • “Precipitated senility” - Fraser & Mitchell 1876

    • Onset from 30 onwards

      • 30-39 = few %

      • 40-49 = 10 - 25 %

      • 50-59 = 20 - 50 %

      • 60-69 = 30 - 75 %


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    Dementia in Downs syndrome

    Clinical Features

    • Atypical - personality / behaviour changes precede dementia by some years

    • Maybe onset of seizures or worsening of seizures

    • Middle & later course = gen popn

    • Increase in myoclonic epilepsy & dysphagia

    • Possibly more rapid


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    Dementia

    • Differential

      • Hypothyroidism (30% in DS)

      • Medical/ iatrogenic

      • Sensory impairments

      • Depression / adjustment reaction


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    Dementia

    • Assessment

      • MDT

      • Rating scales DSDS & Modified MMSE

      • Routine screens bloods etc

      • Sensory

      • Neuroimaging -

        • Early stage Alzheimer's - atrophy of medial temporal lobe - Normal in Downs syndrome


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    Dementia

    • Treatment

      • NICE

        • Anti dementia medication

      • Other treatments as for general dementia care

      • Life story work

      • Palliative care


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    Conclusion

    • All psychiatric disorders possible

    • Assessment may take longer

      • Informants

      • Diagnostic overshadowing

    • MDT

    • Treatment according to diagnosis

      • Capacity / best interests

      • Medication

        • Small doses & slow titration

        • Monitor effect / SE



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    References

    • Read, S. 1997. Psychiatry in Learning Disability.

    • Fraser, W. & Kerr, M. 2003. Seminars in the psychiatry of Learning Disabilities. Second edition. College seminar series.

    • Royal College of Psychiatrists. 2001. DC- LD

    • British Psychological Society / Royal College of Psychiatrists. 2009. Dementia & People with LD

    • Code of Practice. Mental Health Act 1983

    • Fear, C. 2004. Essential revision notes for MRCPsych.

    • Puri, B.K & Hall, A.D. Revision notes in Psychiatry.

    • Valuing People Now (2007)


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    Good books to read

    • Freaks Geeks & Asperger’s syndrome, L Jackson

    • The curious incident of the dog who barked in the night, M.Haddon.


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    Questions

    • Thank you


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