THE LEARNING DISABILITY PSYCHIATRY SERVICE
Dr John Russell Locum Consultant Psychiatrist
To try and give a „flavour‟ of what I do Background Assessment Mental illness & 2 cases Treatments The future
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
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
Common causes of LD
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
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
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?
Depends on verbal communication and ability to describe „internal world‟ (feeling, thoughts, emotions) 3rd party information important Alternative methods of communication
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)
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
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
Definitions Symptoms of mental illness and how they can present in someone with a LD 2 Cases
„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, jealousy Catatonia - increases muscle tone at rest, abolished by voluntary activity
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
“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
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
Social withdrawal Apathy Paucity of speech Blunting of affect Social drift (not due to medication/depression)
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
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
Depression in LD
– – – – – appetite reduced weight loss sleep disruption reduced concentration compulsive behaviours etc
Agitation Withdrawal Apathy Grief reactions and bereavement
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‟
Hypomania / Mania in LD
Elevation of mood
Increased energy & activity
Reduced sleep Irritability/aggression
REMEMBER - IF YOU FEEL THREATENED BY A PATIENT/CLIENT, TAKE HEED OF THIS AND ACT ACCORDINGLY TO KEEP SELF SAFE
Neurotic, stress-related and somatoform disorders
Phobias Anxiety OCD Social Problems PTSD (abuse)
Pervasive Developmental Disorders
Autism / Asperger Syndrome Starts < age 3 „Triad of Impairment‟:
1 2 3 Problems with communication Problems with reciprocal social interaction Restricted, repetitive, stereotyped behaviours, interests and activities.
e.g. “Rain man”, eye contact, date of birth
Structure, Routine & Predictability
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)
Other / alternative therapies?
Psychological therapies (e.g. cognitive behavioural therapy) Psychotherapy (Art Therapy, Music Therapy)
Herbal - St John‟s Wort
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
and rewarding times ahead!