THE LEARNING DISABILITY PSYCHIATRY SERVICE

1. THE LEARNING DISABILITY PSYCHIATRY SERVICE • Dr John Russell • Locum Consultant Psychiatrist

2. Aim • To try and give a ‘flavour’ of what I do • Background • Assessment • Mental illness & 2 cases • Treatments • The future

3. History • 1913 Mental Deficiency Act • “Idiot, imbecile and feeble-minded” • 1960 MHA (Scotland) • “Mental deficiency” • 1984 MHA (Scotland) • “Mental disorder = mental illness or mental handicap” • Mental Handicap - “A state of arrested or incomplete development of mind” • Learning / Intellectual Disability • Institutional care

4. Definition of Learning Disability • Reduced ability to understand new or complex information • Difficulty in learning new skills • May not be able to cope independently • IQ < 70 not sufficient on its own; social functioning must also be impaired. • Onset < 18 • “General” population IQ 80-120

5. Common causes of LD • GENETIC • Chromosomal abnormalities • Genetic abnormalities • Inborn Errors of Metabolism • NON - GENETIC • Ante/Peri/Post-natal • Nutritional / Toxic / Anoxia / Infection (maternal / child) / Trauma / Rhesus incompatibility • Most causes not known

6. Why is there a speciality of Psychiatry for those with LD? • Higher incidence of psychiatric disorders in those with LD • More severe the LD - higher prevalence of psychiatric disorder. • “Difficulties in describing internal world” • Presentation of mental illness different, often because of problems with communication and understanding • Special training for Psychiatrists • Multidisciplinary working

7. What are the problems in those with LD? • Communication difficulties • Medical / physical problems - (e.g. epilepsy) • Behavioural problems -often ‘challenging’ • Are these a manifestation of a treatable medical or psychiatric condition, or psychological reactions to environmental or interpersonal stress?

8. Assessment • HISTORY • Depends on verbal communication and ability to describe ‘internal world’ (feeling, thoughts, emotions) • 3rd party information important • Alternative methods of communication

9. 1. Exclude physical illness • Pain • Infection (ear, chest, UTI, teeth) • Constipation • Side effects etc. • Investigations - e.g. Thyroid function • Exclude epilepsy: • 1/3 of those with LD • Complicated (pre/peri/post/ictal)

10. 2. Has something changed in the environment? • ‘Challenging behaviour’ does not imply person is mentally ill - what is it telling us? • Can be caused by change of staff/co-sharer/ accommodation/routine etc • MDT assessment: • Behavioural analysis - ABC’s • Predisposing/Precipitating/Perpetuating factors • Behavioural Mx - e.g. reward systems

11. 3. Is there an underlying mental health problem? What are the mental health problems? (ICD10) • Organic & reversible (e.g. hypothyroidism) • Schizophrenia • Schizo-affective disorder • Affective disorder • ‘Neurotic, stress-related and somatoform disorders’ • Personality disorders • Pervasive Developmental Disorders - Autism

12. Definitions • Symptoms of mental illness and how they can present in someone with a LD • 2 Cases

13. Schizophrenia • Definition: • ‘characterised by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Clear consciousness and intellectual capacity are usually maintained’. • Types - paranoid, hebephrenia, catatonia, residual • Paranoia - persecutory, grandiose, jealousyCatatonia - increases muscle tone at rest, abolished by voluntary activity

14. Definitions • Delusion: ‘A false, unshakeable idea or belief, out of keeping with the patient’s educational, cultural & social background; it is held with extraordinary conviction and subjective certainty’ • Hallucination: A perception which arises in the absence of any external stimulus • Blunting of affect: Usual modulation of mood is lost; patient lacks warmth, but doesn’t convey the lowering of affect seen in severely depressed patients

15. “First Rank (positive) Symptoms” • Disorders of thought possession 1. Thought insertion/withdrawal 2. Thought broadcast • Passivity phenomena 3. Emotions (‘made feelings’) 4. Impulses (‘made impulses’) 5. Sensations (‘made sensations’) 6. Acts…under some outside influence

16. 1st Rank…. • Auditory hallucinations in which the person hears: 7. His/her own thoughts echoed out aloud 8. Two or more people discussing or arguing about him/her in the 3rd person (“now he is drinking tea”) 9. Voices that form a running commentary on his/her behaviour • A particular kind of delusional perception: 10. A normal perception that is then interpreted with delusional meaning

17. Negative Symptoms: • Social withdrawal • Apathy • Paucity of speech • Blunting of affect • Social drift (not due to medication/depression)

18. Psychosis in LD • Diagnosis difficult - difficulties in describing ‘internal world’ • Positive (hallucinations & delusions) and negative symptoms • Behaviours - ‘paranoia’, aggression, changes in energy, volition, social interaction, mood… • Clear consciousness

19. Depression • Core symptoms for at least 2 weeks: • Depressed mood • Loss of interest (anhedonia) • Reduced energy levels • 3 core plus some/all of following: • Reduced concentration • Reduced self esteem & confidence • Ideas of guilt & worthlessness • Bleak view of future • Suicidal/self harm thoughts • Disturbed diminished sleep • Reduced libido

20. Depression in LD • Biological/somatic symptoms: • appetite reduced • weight loss • sleep disruption • reduced concentration • compulsive behaviours etc • Agitation • Withdrawal • Apathy • Grief reactions and bereavement

21. Mania • Elevation of mood • For at least several days on end • Increased energy and activity • Marked feelings of wellbeing • Physical & mental efficiency • Increased sociability, talkativeness, overfamiliarity, increased sexual energy • Decreased need for sleep • ‘Irritability, conceit and boorish behaviour may replace euphoric sociability’

22. Hypomania / Mania in LD • Elevation of mood • Increased energy & activity • Increased sociability • Disinhibition • Reduced sleep • Irritability/aggression

23. VIOLENCE REMEMBER - IF YOU FEEL THREATENED BY A PATIENT/CLIENT, TAKE HEED OF THIS AND ACT ACCORDINGLY TO KEEP SELF SAFE

24. Neurotic, stress-related and somatoform disorders • Phobias • Anxiety • OCD • Social Problems • PTSD (abuse)

25. Pervasive Developmental Disorders • Autism / Asperger Syndrome • Starts < age 3 • ‘Triad of Impairment’: • 1 Problems with communication2 Problems with reciprocal social interaction3 Restricted, repetitive, stereotyped behaviours, interests and activities. • e.g. “Rain man”, eye contact, date of birth • Structure, Routine & Predictability

26. Treatments for mental illness • Biological / psychological / social • Medications: • Same as “general” population - anti-psychotics, anti-depressants, anxiolytics, sedatives, mood stabilisers (Prescribe seclusion/time out) • Start at lower doses - more prone to side effects • Side-effects: (BNF) • Dry mouth & oro-buccal dyskinesias (EPSE’s)

27. Other / alternative therapies? • Psychological therapies • (e.g. cognitive behavioural therapy) • Psychotherapy (Art Therapy, Music Therapy) • Homeopathy • Herbal - St John’s Wort • Massage/aromatherapy etc.

28. The Future • New diagnostic categories (DC-LD) • New medications/therapies • New Mental Health Act • Adults with Incapacity (Scotland) Act 2001 • ‘The same as you?’ Scottish Executive 2000 • A review of services for people with learning disabilities • All long-stay hospitals for people with LD to close by 2005 (?). • Small number of assessment/ Rx beds

29. And finally.. • Challenging and rewarding times ahead!