Psychiatric evaluation of patients with dual upset

1. Psychiatric evaluation of patients with dual upset Professor Iqbal Singh

2. Mental disorder as defined in ICD-10 • Clinically significant conditions characterised by alterations in thinking, mood (emotions), or behaviour associated with personal distress and/or impaired functioning. • Mental and behavioural disorders are not just variations within the range of “normal”, but are clearly abnormal or pathological phenomena.

3. DSM-1V • Contains broadly similar definitions • There are similar concepts such as change from the pre-morbid functioning, personal distress, patterns of symptoms, recognizable courses of illnesses and exclusion of culturally acceptable deviations

4. The concept of mental disorder in people with learning disabilities presents several challenges • Diagnosis must be made in a person whose behaviour is already restricted and unusual • This difficulty is reflected in a number of potential problems such as intellectual distortion, psychosocial masking, cognitive disintegration, baseline exaggeration, diagnostic overshadowing, etc.

5. Mental disorder in learning disabilities: the second challenge • In making a diagnosis many subjective judgements concerning the significance of changes in behaviour are made, e.g. • Value system of the carer • Undetected physical illness • Accuracy of third party reporting • Tolerance of third party for deviant behaviour

6. Mental disorder in learning disabilities: the third challenge • Most mental health referrals are typically initiated by the clients themselves, unlike in learning disabled clients where referral is made by distressed relatives or carers

7. Some common problems in making psychiatric diagnoses in people with learning disabilities (1) • Intellectual distortion: concrete thinking & impaired communication result in poor communication about their own experience • Psychosocial masking: impoverished social skills & life experiences result in unsophisticated presentation of a disorder, or misdiagnosis of unusual behaviour as a psychiatric disorder

8. Some common problems (2) • Cognitive disintegration: bizarre behaviour is presented in response to minor stressors that could be misdiagnosed as a psychiatric disorder • Baseline exaggeration: prior to the onset of a disorder there are high levels of unusual behaviours, making it difficult to recognize the onset of a new disorder

9. Some common problems (3) • Misdiagnosis of developmentally appropriate phenomenon: developmentally appropriate behaviours that are unusual for the client’s chronological age are misdiagnosed as a psychiatric disorder • Passing: people with LD learn to cover up disability and pass for normal • Diagnostic overshadowing: unusual behaviour is erroneously ascribed to LD, rather than a true mental disorder

10. Relationship between learning disability and mental illness • Mental illness g learning disability • Learning disability g mental illness • Underlying pathology causing learning disability and mental illness

11. PIMRA: drawn from DSM-III • Informant version • Self report version • 58 items • 8 sub-scales • Schizophrenia • Affective disorder • Psychosexual disorder • Adjustment disorder • Anxiety disorder • Somatoform disorder • Personality disorder • Inappropriate adjustment

12. PIMRA: scoring • Each item scored yes or no • 75% of items must be completed for a valid result to be obtained

13. Other assessment instruments • ABC: Aberrant Behaviour Checklist. 58 items, each scored on a 4-point scale • DASH: Diagnostic Assessment for Severely Handicapped scale • PAS-ADD: Psychiatric Assessment Schedule for Adults with Developmental Disabilities checklist • DC-LD

14. Multimodal Assessment for Mental Health Problems in People with Learning Disabilities (1) • This is an ideal way to assess mental health needs of people with learning disabilities as otherwise the histories of these people remain fragmented. The following are the steps in the model:

15. Multimodal Assessment (2) • Referral • Screening phase • The assessment process • Venue • Who should be there? • Brief screen • Inter-disciplinary assessment • Clinical interview • Full history/observation • Psychiatric examination • Investigations

16. Depression (1) • Overall psychiatric morbidity is 3 times higher in people with LD than in general populations and depression is no exception. • Symptoms for mild LD: • Tearfulness • Diurnal variations in mood • Loss of energy • Loss of interest • Low self-esteem

17. Depression (2) • Symptoms for moderate LD: • Social isolation • Self-injurious behaviour • Weight loss • Symptoms for severe LD: • Screaming • Aggression • Self-injurious behaviour