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Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness. Cath Burns, Ph.D. Barbara Noordsij, APRN, ND, PMHNP-BC . Outline. Definitions Incidence and prevalence Etiology of dual diagnosis Issues of Co-morbidity Assessment and differential diagnosis Treatment approaches

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issues of dual diagnosis developmental disabilities and mental illness

Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness

Cath Burns, Ph.D.

Barbara Noordsij, APRN, ND, PMHNP-BC

outline
Outline

Definitions

Incidence and prevalence

Etiology of dual diagnosis

Issues of Co-morbidity

Assessment and differential diagnosis

Treatment approaches

Examples of common co-morbid conditions

Applied activities sprinkled throughout

mental retardation
Mental Retardation

Significantly sub-average intellectual functioning (an IQ of approximately 70 or below)

Commensurate deficits or impairments in adaptive functioning

Onset before age 18

mental retardation incidence
Mental Retardation – Incidence

1 – 3% of general population

1.5 time more common in boys than in girls

Causes: 25% have known biologic causes

prevalence of mental disorder in adult population nimh
Prevalence of Mental Disorder in Adult Population (NIMH)

Anxiety disorders

ADHD

Autism

Eating Disorders

Mood Disorders

Personality Disorders

Schizophrenia

incidence of psychiatric disorders in mr population
Incidence of Psychiatric Disorders in MR Population

40 – 70% of individuals have diagnosable psychiatric disorders

Manifestations of MR may overshadow symptoms associated with a mental illness

Most types of psychiatric disorders are also found in the MR population

Increased incidence of Anxiety and Affective Disorders across whole MR spectrum

More Schizophrenia spectrum disorders in those with mild developmental disabilities

Existence of behavior disorder is negatively correlated with IQ (e.g., repetitive, self-stimulating, nonfunctional motor behavior, SIB and Pica)

co morbidity the norm
Co-Morbidity – the Norm!
  • Our clients more often than not have a two or more diagnoses in addition to MR
  • In a clinic sample of ADHD youth
    • 87% had one co-morbid condition
    • 67% had tow or more (Kadesjo & Gillberg, 2001)
  • Multiple disorders lead to more frequent mental health referrals
lundby 2009 cohort study 1947 1997
Lundby (2009) cohort Study (1947-1997)

Dual diagnosis was more prevalent in Mild intellectual disability than in moderate intellectual disability.

No subject with severe ID was diagnosed with a mental disorder.

lundby continued
Lundby continued

Cummulative incidence for any mental disorder was 44 %

Mood disorders 11.5%

Anxiety disorders 11.5%

Schizophrenia and other psychotic disoders 8%

Mental NOS due to general medical condition 8%

Dementia 3.8%

Alcohol abuse 1.9%

co morbidity and asd
Co-morbidity and ASD
  • Emerging area of study
  • Levy, et al. (2010)
    • 2,568 children with ASD
    • 10% had 1 or more co-occurring psychiatric diagnoses
    • 83% had non-ASD developmental diagnosis
  • Matson & Nebel-Schwalm (2005)
    • Mood disorders – 2% of ASD  30% with Asperger’s
    • Fears and phobias
    • Anxiety and Obsessions
      • Anxiety present in children with ASD
      • Debate re: whether OCD can be separated from ASD Dx – stereotypic behavior?
  • Psychosis and ASD (covered later)
etiology across population
Etiology across population?

Cumulative effects of risk

Biochemical abnormalities associated with specific Disability

Prenatal exposure to teratogens increases risk

Increased risk with specific conditions (epilepsy, developmental language disorders, sensory impairments)

MOST CASES – complex interaction among biological (including genetic), environmental and psychosocial factors

etiology in dd population
Etiology in DD Population?
  • Associated with a wide range of neurological, social, psychological issues
  • Personality risk factors: impaired cognition, organic brain damage, communication problems, physical disabilities, family psychopathology, psychosocial factors
  • Singly or in combination, individuals with DD are highly vulnerable
  • Specific chromosomal abnormalities also predispose to mental illness
slide17
Many causes of mental retardation have associated “Psychiatric Phenotypes” associated with the disorders
some neurogenic disorders with a associated psychiatric phenotype
Some Neurogenic Disorders with a associated psychiatric phenotype
  • Velocardiofacialsndrome
  • Fragile X
  • Down Syndrome
  • Prader-willi syndrome
  • Turner’s syndrome
  • Sex chromosoneaneuploidy
velocardiofacial syndrome vcfs also known as 22q11 2 deletion syndrome
Velocardiofacial syndrome VCFS also known as 22Q11.2 deletion syndrome
  • Has highly significant behavioral effects in childhood and is the single most common known genetic risk factor for schizophrenia.
  • Associated with multiple medical and cognitive disabilities.
  • These patients may present with serious psychiatric concerns.
fragile x cgg repeat expansion mutation on the fmr1 gene
Fragile XCGG repeat expansion mutation on the FMR1 gene
  • By school age boys who have FXS show aberrant speech patterns with rapid speech rate, poor intelligibility, dyspraxia, perseverative speech and impaired pragmatics.
  • The psychiatric and behavioral phenotype is hyperactivity , distractibility, irritability, repetetivesterotyped movements, pronounced gaze aversion and social anxiety.
down s syndrome
Down’s syndrome
  • Commonly children with DS are cheerful and friendly, however 20-40% have behavior problems such as aggression, attention problems
  • Adults may present with depression and dementia symptoms ; early onset dementia is more common in this population
klinefelter s syndrome the male karyotype has and abnormal addition of and x chromosone xxy
Klinefelter’s syndrome the male karyotype has and abnormal addition of and x chromosone (XXY)
  • Higher rates of psychiatric symptoms
  • Including psychotic disorders
  • Autistic features such as avoidant eye contact, restricted affect, rigid patterns of play and social deficits
  • MRI studies showed asymmetry in frontal lobes in men with KS
activity
Activity
  • Talk case load
how are co morbid conditions diagnosed
How are Co-morbid Conditions Diagnosed?

Special considerations

Mental retardation may make diagnoses of other psychiatric disorders more challenging

signs of intellectual disability
Signs of Intellectual Disability
  • Infants and children with ID do not reach developmental milestones within expected May include cognitive delays, problems with short term memory
  • Difficulties with social rules
  • Difficulty with problem solving
  • Difficulty with using logic
  • Difficulty with cause and effect relationships
things to consider in evaluation
Things to consider in evaluation
  • Talk to the patient, receptive skills may exceed expressive skills
  • Pay attention to developmental level of the client
  • Avoid leading questions
  • Observe non verbal interactions
  • (example of play)
interview
Interview
  • Course of changes in client symptoms need to be assessed
  • Recent changes in life situation
  • Time frame of changes
consider
Consider
  • Effects or untoward effects of medications.
  • Medications can cause psychotic symptoms, toxic reactions, delerium which can look like a comorbid illness
4 factors affecting presentation sovner 1986
4 Factors Affecting Presentation Sovner (1986)

Intellectual Distortion

Psychosocial masking

Cognitive disintegration

Baseline exaggeration

intellectual distortion
Intellectual distortion
  • Emotional symptoms are difficult to elicit because of deficits in abstract thinking and in receptive and expressive language skills
  • (Silka & Hauser, 1997)
psychosocial masking
Psychosocial masking
  • Limited social experiences can influence the content of psychiatric symptoms
  • example - mania presents as “I can drive a car”
  • Silka & Hauser, 1997)
cognitive disintegration
Cognitive disintegration
  • Decreased ability to tolerate stress, leading to anxiety induced decompensation (maybe misinterpreted as psychosis) (Silka & Hauser, 1997)
baseline exaggeration
Baseline exaggeration
  • Increase in severity or frequency of chronic or maladaptive behavior after onset of psychiatric illness
  • (comments on “onset”)
  • Silka & Hauser, 1997)
elements of assessment
Elements of Assessment
  • Clinical interview with psychiatric history
    • Developmental history
    • Physical disabilities (e.g.,. Epilepsy)
    • Current social functioning, social circumstances
    • Level of MR and its etiology
    • Family history of mental illness
  • Include information re: behavioral changes
    • Sleep disturbance, loss of appetite, weight loss, lack of interest, deterioration of social skills, bizarre behavior, and any other deviations from usual behavior)
    • Information on premorbid functioning and personality
    • Less subjective complaints or information from client increases need to rely upon objective data
    • Direct observations
  • Physical examination
elements of assessment continued
Elements of Assessment (continued)
  • Cognitive and adaptive assessments
  • Diagnostic rating scales specific to MR
    • Psychopathology Inventory for Mentally Retarded Adults (PIMRA; Senatgore, et al., 1985)
    • Reiss Screen for Maladaptive Behavior (Reiss, 1988)
    • Diagnostic Assessment for the Severely Handicapped Scale (DASH; Matson, 1991)
    • Psychiatric Assessment of Adults with Developmental Disability (PAS-ADD
    • Developmental Behavior Checklist (Einfeld & Tonge, 1995)
questions to guide diagnostic inquiry
Questions to guide diagnostic inquiry:

How do the symptoms wax and wane?

Define the core symptoms of the primary disorder (e.g., MR, ASD, etc.) and

Use multiple investigators

differential diagnosis
Differential Diagnosis
  • “Distinguishing between diseases of similar character by comparing their signs and symptoms”
  • Usually involves some sort of “decision tree”
of course
Of course…
  • Match treatment to presenting symptom….but be sure you know the cause of the symptom
psychiatric disorders in childhood and adolescence in mr population
Psychiatric Disorders in Childhood and Adolescence in MR Population
  • Largely unstudied
  • ADHD – significant behavioral and emotional problems in early adolescents – different trajectory compared to non-MR peers (Aman, et al, 1996)
  • Depression, Separation anxiety, ODD, RAD, CD and disturbances of personality – related to early emotional development
  • Theory that MR affects early attachments
dd and behavioral disturbances
DD and Behavioral Disturbances
  • Behaviors in and of themselves may not indicate an underlying psychiatric disorder
  • Behaviors that are abnormal in a typical-peer may be developmentally appropriate to the mental age of your client
  • Given this, the ICD 9/10 and the DSM IVR may not be the best fit for the DD population!
dd and behavioral disturbances sib
DD and Behavioral Disturbances: SIB
  • Self-Injurious Behavior (SIB): 8 – 14% of institutionalized population
  • More common with IQ < 50
  • Ages: 10 – 30 years with peak at about 15
  • Related to genetic and organic disturbances; adverse environmental and developmental conditions
  • Particular psychiatric disorders (e.g., depression) may elicit SIB
hemmings 2008
Hemmings (2008)

Clinical predictors of severe behavioral problems in people with intellectual disabilities who were referred to a mental health services.

Co-morbid schizophrenia and personality disorders predicted the presence of severe behavioral problems.

Anxiety predicted the absence of severe problems.

differentiating autism and child onset schizophrenia
Differentiating Autism and Child onset Schizophrenia

Clinicians experienced with Autism and Schizophrenia are helpful to symptom differentiation

Rapaport et al,2009

(strategy- “follow along”)

slide46

COS in PDD vs. Non PDD Samples

Rapoport, Chavez, Greenstein, Addington, & Gogtay (2008)

dd and specific disorders
DD and Specific Disorders
  • Given lack of research, much of what will be presented comes from adult literature
  • Child psychopathology and DD is an emerging field
examples dd and oppositional defiant and conduct disorders
Examples – DD and Oppositional Defiant and Conduct Disorders

ODD – patter of negative, hostile and defiant behavior lasting for 6 months

CD – pattern of behavior in which other’s rights are violated, norms are ignored, or rules are broken for at least 12 months

Often associated with ADHD and trauma

Treatment – behavior therapies; family support and treatment; coordination across all environments; psycho-education; and medication

In general clients with intellectual disabilities may appear to be oppositional

Really a cognitive impairment

Others around youth assume (incorrectly) behavior is oppositional and/ or the child has developed these behaviors to escape from activities that are overwhelming.

examples dd and impulse control disorders
Examples – DD and Impulse Control Disorders

Intermittent Explosive Disorder

Trichotillomania

Sexual behaviors, masturbation

Treatment – medication; behavior therapies; family support and training

Shopping: Case example: 43 year old

examples dd and anxiety disorders
Examples – DD and Anxiety Disorders

Generalized Anxiety Disorders, Panic Disorder, Social Phobia, Obsessive Compulsive Disorder, PTSD

Present with similar presentation to non-DD population

Adults have fears similar to those of children matched for mental age (e.g., separation, natural events, injury, animals)

Treatment: Medication; behavior therapies and psychotherapy if individual is able to participate

Untreated or symptoms of Anxiety disorders, in individuals with developmental disabilities may impact functioning.

It is important to explore treatment for these issues even those these clients may not be as “difficult”

Examples…. (community care home)

examples dd and mood disorders
Examples – DD and Mood Disorders

Major Depression

Bipolar Disorder

Dysthymic Disorder

Higher instance of stupor and mutism in depression

Bipolar disorders more common

Can be related to specific stressors (e.g., loss of caregiver, change of surroundings, hospitalization, etc.)

Mixed states with features of mania and depression, schizoaffective psychoses, psychotic responses to cute stress, and rapid-cycling bipolar disorder all appear to be more common in MR than non-MR

Treatment: Medication, activities to engage individual and exercise, groups for skill development

Case Study: This client had originally presented for treatment in elementary school. He was not referred until his Senior year in high school.

-- Co-morbid diagnoses:

-- Schizoaffective Disorder

-- Mild Mental Retardation

-- Obsessive compulsive Disorder

examples dd and psychotic disorders
Examples – DD and Psychotic Disorders

Classical clinical features present (e.g., with schizophrenia) that tend to be “florid but banal”

Active psychoses tend to occur at younger age and reflect limited social skills and experiences of the individual

Mixed states more common with MR population than with non-MR

Treatment: Medication; behavior therapies; family support and treatment; therapeutic case management

Case study: This client was referred in elementary school in about 2nd grade…

She had many difficulties in school and school was largely responsible for her entering the system of care.

approaches to treatment therapeutic case management
Approaches to Treatment – Therapeutic Case Management

Coordinate services

schools, community organizations, extended family and supports, other service providers and treatment providers

Education

Regarding diagnosis, long term needs…

Supports for families, expand if possible

crowley 2008
Crowley (2008)

This study looked at the benefit of psycho-educational groups for people with psychosis and mild intellectual disability.

Measures of knowledge and self esteem were completed pre and post group.

Participants were able to understand the concepts of psychosis the need for medication and the role of stress and early signs of relapse. This approach may be helpful.

approaches to treatment behavioral therapies
Approaches to Treatment – Behavioral Therapies

Goal 1. Stabilize problem behaviors. Identify behaviors that cause the most harm and distress from the client and family’s perspectives.

Goal 2: Increase skills and promote prosocial and adaptive behaviors that will promote maximum independence

Goal 3: Apply and practice across environments

 Teach at school

 Generalize to home

Goal 4: Develop plans based upon principles of positive behavior support

Goal 5: Plan for crises

Pure behavioral models do not attend to internal emotional states of the individual.

approaches to treatment caveat
Approaches to Treatment – Caveat
  • There is a lack of randomized controlled trials (RCT’s) investigating effectiveness of psychotherapeutic models (psychodynamic, cognitive behavioral, and cognitive approaches)
  • Even less so are available for children
  • In general, all agree that effectiveness decreases with decreasing IQ
approaches to treatment psychodynamic models
Approaches to Treatment – Psychodynamic Models

Focuses upon transference and counter transference within the therapeutic relationship to investigate the internal world of the client.

Predominately case study and/or anecdotal

Limited support – benefits may have resulted to humanistic/person-centered counseling techniques

approaches to treatment cognitive behavioral therapies cbt to address skill deficits
Approaches to Treatment – Cognitive Behavioral Therapies (CBT) to Address Skill Deficits

Dominant modality in treatment today

Effective with:

Panic disorder - Phobias

Promoting social behaviors - Depression

Anxiety - Parent stress

Anger management - Self-management

Social problem solving - Self-Instruction training

Social skills development

Generally coupled with relaxation techniques, education, planned practice and generalization efforts

approaches to treatment cbt to address cognitive distortions
Approaches to Treatment: CBT to address Cognitive Distortions
  • Assess for ability to
    • Distinguish between antecedent events and associated cognitions and emotions
    • Recognize that cognitions mediate the effects of events on emotions
    • Willingness to engage in “collaborative empiricism” to question the accuracy of cognitive distortion
  • Reliability of self-reports
  • Depression, anxiety, anger, and sex offences
overall treatment planning
Overall Treatment Planning

Include community caregivers and staff

Develop specific treatment plans that can be accomplished in a specific amount of time avoiding treatments that can’t be implemented in the broader community

Take into account variables: consistency versus change in environment, levels of supervision available, possible stressors, and behavioral management strategies

Use therapy and activity groups to bring out the person’s capacity for learning and participation