Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness

1. Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness Cath Burns, Ph.D. Barbara Noordsij, APRN, ND, PMHNP-BC

2. 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

3. 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

4. Mental Retardation – Incidence 1 – 3% of general population 1.5 time more common in boys than in girls Causes: 25% have known biologic causes

5. Prevalence of Mental Disorder in Adult Population (NIMH) Anxiety disorders ADHD Autism Eating Disorders Mood Disorders Personality Disorders Schizophrenia

6. Prevalence of Mental Disorder in Adults (NIMH)

7. Prevalence in Children (NIMH)

8. 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)

9. 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

10. 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.

11. 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%

12. 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)

13. Etiology?

15. 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

16. 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

17. Many causes of mental retardation have associated “Psychiatric Phenotypes” associated with the disorders

18. Some Neurogenic Disorders with a associated psychiatric phenotype • Velocardiofacialsndrome • Fragile X • Down Syndrome • Prader-willi syndrome • Turner’s syndrome • Sex chromosoneaneuploidy

19. 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.

20. 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.

21. 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

22. 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

23. Activity • Talk case load

24. How are Co-morbid Conditions Diagnosed? Special considerations Mental retardation may make diagnoses of other psychiatric disorders more challenging

25. 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

26. 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)

27. Interview • Course of changes in client symptoms need to be assessed • Recent changes in life situation • Time frame of changes

28. Consider • Effects or untoward effects of medications. • Medications can cause psychotic symptoms, toxic reactions, delerium which can look like a comorbid illness

29. 4 Factors Affecting Presentation Sovner (1986) Intellectual Distortion Psychosocial masking Cognitive disintegration Baseline exaggeration

30. Intellectual distortion • Emotional symptoms are difficult to elicit because of deficits in abstract thinking and in receptive and expressive language skills • (Silka & Hauser, 1997)

31. Psychosocial masking • Limited social experiences can influence the content of psychiatric symptoms • example - mania presents as “I can drive a car” • Silka & Hauser, 1997)

32. Cognitive disintegration • Decreased ability to tolerate stress, leading to anxiety induced decompensation (maybe misinterpreted as psychosis) (Silka & Hauser, 1997)

33. Baseline exaggeration • Increase in severity or frequency of chronic or maladaptive behavior after onset of psychiatric illness • (comments on “onset”) • Silka & Hauser, 1997)

34. 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

35. 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)

36. 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

37. Differential Diagnosis • “Distinguishing between diseases of similar character by comparing their signs and symptoms” • Usually involves some sort of “decision tree”

39. Of course… • Match treatment to presenting symptom….but be sure you know the cause of the symptom

41. 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

42. 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!

43. 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

44. 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.

45. Differentiating Autism and Child onset Schizophrenia Clinicians experienced with Autism and Schizophrenia are helpful to symptom differentiation Rapaport et al,2009 (strategy- “follow along”)

46. COS in PDD vs. Non PDD Samples Rapoport, Chavez, Greenstein, Addington, & Gogtay (2008)

47. 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

48. 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.

49. 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

50. 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)