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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
Cath Burns, Ph.D.
Barbara Noordsij, APRN, ND, PMHNP-BC
Incidence and prevalence
Etiology of dual diagnosis
Issues of Co-morbidity
Assessment and differential diagnosis
Examples of common co-morbid conditions
Applied activities sprinkled throughout
Significantly sub-average intellectual functioning (an IQ of approximately 70 or below)
Commensurate deficits or impairments in adaptive functioning
Onset before age 18
1 – 3% of general population
1.5 time more common in boys than in girls
Causes: 25% have known biologic causes
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)
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.
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%
Alcohol abuse 1.9%
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
Mental retardation may make diagnoses of other psychiatric disorders more challenging
How do the symptoms wax and wane?
Define the core symptoms of the primary disorder (e.g., MR, ASD, etc.) and
Use multiple investigators
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.
Clinicians experienced with Autism and Schizophrenia are helpful to symptom differentiation
Rapaport et al,2009
(strategy- “follow along”)
Rapoport, Chavez, Greenstein, Addington, & Gogtay (2008)
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.
Intermittent Explosive Disorder
Sexual behaviors, masturbation
Treatment – medication; behavior therapies; family support and training
Shopping: Case example: 43 year old
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)
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
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.
schools, community organizations, extended family and supports, other service providers and treatment providers
Regarding diagnosis, long term needs…
Supports for families, expand if possible
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.
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.
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
Dominant modality in treatment today
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
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