Psychiatry of Learning Disability

AMHP Training22nd October 2009

Dr Mark Lovell

(Original talk- Dr Carmody)

Terminology

Learning Disability [psychiatry of]

Learning Difficulties

Mental Handicap

Mental Retardation

Intellectual Impairment/Disability

[Developmental Neuropsychiatry]

Definitions

Impairment: Fault in an organ or body system

Disability: Loss of function which is normal for humans

Handicap: Social disadvantage resulting from the above

Historical Perspectives1970sHospital Scandals – Ely Enquiry 1969 1971 White Paper – ‘Better Services’ Normalisation/Hospital resettlementCommunity Learning Disability Teams

1980sCare in the communityResettlement continuesDisability rights/patient advocacy

1990sMansell Report – Challenging BehaviourReed Report/Health of the Nation/CPA etc.Signposts for Success – DoH (1998):

Improving access to general health servicesNeed for specialist health services (mental illness,

challenging behaviour/forensic, older people, epilepsy, sensory disabilities, physical disabilities)

NSF (National Service Framework) – MH (1999)

2000sValuing People – White Paper (2001)“Bournewood”Cornwall Report (2006)Mental Capacity Act (2005) Phased introduction 2007.

Classification

ICD-10

Mental Retardation

DSM IV

4 essential components according to ICD-10 & DSM-IV:

1. Significantly subaverage general intellectual functioning (i.e. IQ < 70)

2. Significant deficits or impairments in adaptive behaviours (reading, writing, numeracy, communication, mobility, self-care, domestic, decision-making skills etc)

3. Significant deficits or impairments in social functioning (maintenance of health and safety, support seeking, socialisation, inter-personal, work, leisure skills etc)

4. Onset during the developmental period (i.e. before 18 years old)

Mild Mental Retardation Generally acquire language

Generally achieve independence in self-care and in some practical and domestic skills

Some develop literacy skills

Some potentially capable of unskilled or semi-skilled manual labour

Usually accompanied by social and emotional immaturity

IQ range 50 – 69

Includes previous categories of feeble-mindedness, mild mental subnormality, mild oligophrenia and morons.

Moderate Mental Retardation Approx. 50% never develop speech

Slow speech development and achievement

Usually require supervision throughout life

A small proportion develop literacy skills

May do simple practical work if carefully supervised

Independent living rarely achieved

Usually can engage in simple social interactions

IQ usually 35 – 49

Organic aetiology and epilepsy very common

Includes imbecility, moderate mental subnormality and moderate oligophrenia

Severe Mental Retardation

Features usually similar to moderate mental retardation but more severe

Most don’t develop speech

No literacy skills

Do not progress to independent living

Usually associated with marked motor impairment with significant damage or maldevelopment of the CNS and epilepsy

IQ usually 20 – 34

Includes severe mental subnormality and severe oligophrenia

Profound Mental Retardation Profoundly handicapped

Ability to understand or comply with requests/instructions very limited

Usually physically disabled with severely restricted mobility; incontinent

No verbal communication

No ability to care for own basic needs, require constant total care

IQ generally under 20

Organic aetiology identified in most cases, epilepsy very common

Features of pervasive developmental disorders are also common

Includes idiocy, profound mental subnormality and profound oligophrenia

Multiaxial Classification (DSM-IV, 1995)

LD severity; behaviour problems

Associated medical conditions

Associated psychiatric conditions; personality disorder

Global assessment of psychosocial disability

Associated abnormal psychosocial situations

DC-LD (Royal College of Psychiatrists, 2001)

Diagnostic criteria for adults with learning disabilities/mental retardation

Axis I – severity of learning disabilityAxis II – Causes of learning disabilityAxis III – Psychiatric disorders

Level A – Developmental DisordersLevel B – Psychiatric IllnessLevel C – Personality DisordersLevel D – Problem Behaviours

Challenging behaviour (Emerson et al 1988)

“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.”

Prevalence of Psychiatric Disorder in PLD

Accepted that it is increased

- Rutter’s Isle of Wight Study (1970)

Less agreement about actual prevalence rates

- Major disorder 8 – 15%

- Minor Disorder > 50%

Dual Diagnosis

Co-existence of LD and psychiatric disorder

Diagnostic Overshadowing

Phenomenon whereby the presence of LD reduces the diagnostic significance of an accompanying behaviour problem – so that it is seen as part of the LD per se and not a psychiatric disorder

Autistic Spectrum Disorder

Autistic continuum – Wing (1988)Triad of impairments - social interaction

- communication (language)- imagination

+ a narrow, repetitive range of activities - simple- complex

Range of intellectual ability and linguistic skillsImportance of early diagnosis and intervention

EpidemiologyPrevalence varies according to diagnostic methods and criteria 2 – 36/10 000

AetiologyA neurodevelopmental disorder with an organic basis

ASD and LD65 – 88% or people with ASD have LD (Gillberg, 1995)40% of PLD (adults) show autistic traits (Bhaumik et al, 1997)

as level of LD often associated with behaviour disorder

Pathway to Specialist Learning Disability Services

Rarely self-referralsMinority from GP directly

Relies on:1. Carers noticing a change in PLD2. Carers bringing PLD to notice of ‘others’3. ‘others’ specialist services

Problems:1. Certain behaviours picked up and acted upon earlier2. Changes in staffing can mean long-term changes are not picked up3. Referral may occur because of change in carer > change in PLDDependent on carers/GP/others attitude to, or knowledge about, specialist services

Vulnerability Factors for Emotional Disorders

Biological1. Brain damage2. Vision/hearing impairments3. Physical illness/disabilities4. Genetic/familial conditions5. Drugs/alcohol abuse6. Medication/physical treatments

Psychological7. Personality development8. Deprivation/abuse9. Separations/losses10. Other life events11. Positive/negative learning experiences12. Self-insight/self-esteem

Social13. Attitude/expectations14. Support/relationships15. Inappropriate environments/services16. Under/over stimulation17. Valued/stigmatised role/role models18. Financial/legal disadvantage

Family19. Diagnostic/bereavement issues20. Life cycle transitions/crises21. ‘Letting go’22. Social/community networks23. Stress/adaptation to disabilities24. Relationships/resources

Psychiatric Assessment

History and mental statePhysical examination/investigationsFurther history - GP

- School records- Social services

Further information - Family- Professional carers- Any other informant

Wider differential diagnosisDefinitive diagnosis may only be made - over longer period

- following treatment trial

Psychiatric InterviewMild LD v Moderate/Severe LD

ContextSource of/reason for referralService users perception of visit/assessment & therapistParticipants in interview & structure

StructureNeed for flexibilityImportance of time with patient aloneInclude time for setting up monitoring mechanisms with staff etc

HistoryCover same elements as standard historyFamily historyDevelopmental historyEducational/employment historyPerception of learning disabilityLevel of functioning - include how makes needs known/social communication

- level of understandingSocial history - support network

- relationshipsMedical history

Surgery (epilepsy)

ECT

Drugs

Psychotherapy - supportive - behavioural - CBT - psychodynamic

Social

Management

Remember to treat –

(Psychiatric Bulletin September 1998)

All treatment approaches can be used

Drug Treatment “The evidence for prescribing in LD is very deficient” (APT, p 472)

i.e. everything has been tried for everything!

Neuroleptics - used in both diagnosed psychiatric disorder and behaviour disorder- most traditional neuroleptics have been used- atypicals probably now first choice- adverse effects, inc NMS, particular problem- start with lower doses (cf. elderly)

Antidepressants - also used for depression and behaviour disorder- Clomipramine/SSRIs - stereotypies

- SIB- aggression

Lithium - used for behaviour problems as well as a mood stabiliser

Anticonvulsants - carbamazepine, valproate and new AEDs- Used for aggression, bipolar affective disorder, rapid cycling mood disorder

Others - Beta blockers- Methylphenidate- Opiate antagonists- Acetylcholinesterase inhibitors- Benzodiazepines (epilepsy)

Drug treatment (cont…)

If drug treatment is for behaviour disorder: Use as part of overall management package,

including behavioural management

Monitor very closely and have an exit strategy

Consider for drug reduction programme

Ref: Fraser (1999) Psychopharmacology and people with learning disability. Advances in Psychiatric Treatment, 5, pp 471-77

Pitfalls…

Eye Contact Idiosyncrasies Social skills Shyness Over-gregarious Over-friendly Imaginary friends Interpretation of events Dysarthria

Believing stories Fantasy Concreteness Time scales/lines Disorientation (normal) Communicating/

’befriending’ Energy Disinhibition