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Introduction – Learning Disability

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					Introduction – Learning Disability
                       Psychiatry
                       Dr Michelle Beaumont
                       SPR to Professor Read
Aims
   Introduction
   Assessment
   LD specific issues
   Psychiatric Disorders
   Legal issues
   Physical issues
Introduction
   History
   Epidemiology
   Aetiology
Picture 1
History
From this…
To this….
Valuing People 2001
   Principles
       Rights - equal       •Practice

                                  •LD register
       Independent living
                                  •Health Education factor

                                  •Health Action Plans
       Control
                                  •Housing

       Inclusion                 •Employment
Epidemiology
Epidemiology


   210,000 Severe & Profound LD

       65,000 children & young people
       120,000 working age
       25,000 older people


   1.2 million Mild / Moderate LD
                                         Valuing People 2001
Epidemiology continued…
   Institute for Health Research at Lancaster University
    2004
       985,000 with LD
       224,000 known to social services
       761,000 mild / moderate LD maybe unknown


   Emerson & Hatton total adults with LD
       increase by 8 % - 868,000 by 2011
       Increase by 14 % - 908,000 by 2021
Epidemiology continued...

   5% live home of own

   30% residential care home
       Significant proportion miles away from family


   1 in 10 (known to SS) employment

   Significant number live with elderly carers

                  Valuing People Now: A New 3 year strategy for people with LD
Picture 2
Aetiology
IQ Distribution Curve
Aetiology
Aetiology
   Primary disorders with direct effects
       Syndromes
   Primary disorders with secondary effects
       Inborn error metabolism
           PKU
           TS
   Secondary disorders
       Antenatal
           Neural tube defects
           Infection – syphillis, CMV, rubella
       Perinatal
           Hypoxia
           Infection
           Trauma
           Abuse / accident
       Postnatal
           Nutrition
           Trauma
           Infection
           Encephalopathies
           Metabolic
LD levels
    Severity of LD    IQ score   Approximate   Percentage of   Associated         Notes
                      ranges     Functional    total           Features
                                 Equivalent    population
                                 Mental Age    affected




    Mild              69-50      12-9          1.5-2 9         Communication      “Sub cultural”
    (80-85% of LD                                              skills may be      or “cultural
    population)                                                mildly affected,   familial”
                                                               some level of
                                                               independence
    Moderate          49-35      <9-6          -0.5%           -Receptive         As disability
    (10% of total                              combining        language>         becomes more
    LD)                                        moderate &      expressive         severe, the
                                               Severe          -Dependent         number of
                                                               -High rates of     specific organic
                                                               epilepsy           pathology
    Severe            34 -19     <6                            physical           increases.
    (3-4% of LD)                                               /sensory
                                                               impairment
    Profound          <20        <3            0.05            Highly             Distinction
    ( 1-2 % of LD )                                            dependent          from severe LD
                                                                                  has doubtful
                                                                                  value
Picture 3
Assessment
Assessment considerations
    LD criteria

    Informants / Carers

    Communication

    Assessment

    Risks
Learning Disability
Definition

   Global impairment of intellectual functioning > diminished
    ability to adapt to daily demands. (IQ below 70).

   Significant deficits / impairments in adaptive behaviours &
    social functioning.

   Onset in development period (<18)



                                                ICD - 10
LD - Indicators
   Special school
   Statement (can be behavioural)
   Educational support

NOT
 Asperger’s
 Dyslexia / Specific learning difficulty
 Normal education
 GCSEs
 Drive car
Assessment
Informants / Carers

    Key worker / family

    Key knowledge

    Aid to compliance

    Stress
Communication
   Simple language with short sentences

   Avoid jargon and negatives

   Give concrete examples and avoid abstract ideas

   Be aware literal meanings & use humour cautiously

   Sign language /pictures. Consider interpreter

   Check comprehension
Accessible information
Consideration

   Compliance



   System



   Capacity / Best interests
Picture 5
Psychiatric Assessment
Assessment

    Psychiatric Assessment with carer (known x years)
        Presenting Compliant
        History of presenting compliant
            Change
            Illness / pain
        Developmental history
        Skills
        Social history
            Support
            Day care
            Benefits
            Other peers
        Forensic
            Forensic issues
        Past Psychiatric History
        Past Medical History
        Medications / Allergies
   Appearance & behaviour
   Agitation
   Eye contact
   Mood
   Speech
       Understanding
   Thoughts.
       Less guilt / suicidal ideas – cognitive level
       Delusions. Basic
       Hallucinations
       Suicidal ideation
       Harm to others
   Insight
       Illness / not
       Medication
       Capacity
           Best interests
Assessment
   Day care reports

   Family

   Monitoring charts

   Other assessments

   Social issues
       Safeguarding issues
Risks
   Aggression / violence
   Neglect
   Abuse from others
   Abuse to others
   DSH
   Suicide
   Domestic
Assessment
    Multi Professional Team working

        CMN
        SALT
        OT
        Physiotherapy
        Psychology
        Care managers
        Teachers
Treatment
   Medication

       Research/ evidence poor

       Extrapolated from general adult psychiatry

       If use off license medication should indicate

       Reduced doses & slow titration
Treatment
    Side effects
        Reduced ability to communicate

        Reduced ability to not comply

        Increased risk of

            Neuroleptic Malignant Syndrome
            Tardive Dyskinesia
            Other
                Confusion
                Constipation
                Weight gain
                Medication interactions,
Treatment
   Review effect

   Side effects
Picture 4
LD Specific issues

    Challenging Behaviour

    Behavioural phenotypes

    Autism
Challenging Behaviour
Challenging behaviour
   10-15 % of LD use services
   Most common reason for referral to psychiatrist

   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.
                                       Emerson et al (1988)
Challenging behaviour

   Can present as part of specific psychiatric disorder or
    independently

   Need to exclude mental / physical illness

   May be due to lack of appreciation of social norms.

   Serious impact on accessing services / quality of life

   Carers
Challenging behaviour
   Management

       monitoring,
       boundary setting,
       evaluation of environment,
       medication may be indicated

   MDT
Picture 6
Behavioural Phenotypes
Behavioral Phenotypes
   Known (usually genetic) disorder is associated
       Pattern behaviour
       Personality characteristics
       Psychiatric symptoms


   Eg
Fragile X

   Testicular enlargement
   Large head circumference
   Long & prominent ears
   High arched palate
   Connective tissue disorder
       Lax joints
       flat feet
       Mitral valve prolapse
Fragile X cont..
   Mild - moderate LD
   Flattening trajectory learning over childhood
   Abstract reasoning
   Visuo-motor & spatial deficits
   Strengths verbal & adaptive behaviour

   5 - 46 % have autism
Fragile X characteristics
   Social avoidance
   Gaze aversion
   Shy rather than autistic indifference
   Fast garbled speech
   Litanic pitch
   Anxious interest in speech
   Hyperactivity
   Impulsiveness
   Distractible
   Wrist biting
Picture 7
                    Autism

Pervasive developmental disorder
Temple Grandin




 “My hearing is like having a hearing aid with the volume
      control stuck on “super loud”. It is like an open
   microphone that picks up everything. I have 2 choices:
  turn the mike on & get deluged by sound, or shut it off.”
Autism
   Usually coexists with significant LD
   Apparent before 3
   4/10 000
   M>F
   Increased in certain conditions
       TS, rubella
Wing
   Continuum
   Triad of impairments
         Social relationships
             Lack empathy
             Interest in others
         Language
             Expressive > receptive
             Abnormal prosody. Echolalia. Pronounal reversal. 3rd person
             Literal meaning
         Imagination restriction
             Routines. Novelty > catastrophic rage.
             Unusual interests
Autism continued..
•       Sensory
    •     Abnormalities Perceptions
             Heightened / Reduced
             Pain
             Inability distinguish signal from noise
             Ignore strong stimuli but notice small thread
    •     Time / space abnormalities
             > preoccupation with routines & intolerance of delay
         Motor
             Tone
                 Posture
             Stereotypies
             Mannerisms
Autism & Mental illness
    Psychosis
          Self talk
          General demenour
          Across all situations
          paranoia
    Depression
          Atypical
          Self harm
          Increased withdrawal
Treatments
   Behavioural assessment & management

   Key
       structure,
       predictability,
       Communication
           Social stories
           Intensive interaction
           Visual diaries
           Communication boards


   Aim reduce arousal
If environmental fail/ risks high
   Medications
       Antidepressants
           SSRI: citalopram
       Antipsychotics
           Atypical: risperidone, olanzapine
       PRN medications
           Benzodiazepines: lorazepam
           Atypical antipsychotics: risperidone
           NEED PROTOCOL
   Set targets for assessment of efficacy of medication
   Monitor risks / side effects
       Bloods, ECG, Weight & BP
Picture 8
Psychiatric Disorders
Psychiatric Disorders

    Vulnerability factors

    Diagnostic issues

    Disorders
Vulnerability for mental disorders
Mental Disorder

   Under-diagnosed

       Behavioural disorder

       Insufficient weight to symptoms

       Psychosocial masking - bland beliefs




   Consider co-morbidity e.g. physical ill health / epilepsy
Mental Disorder
       Diagnostic difficulty

           Cognitive disintegration
             Stress induced disruption of information processing can > bizarre
              behaviour & psychotic symptoms

           Baseline exaggeration
             General increase in pre-existing cognitive deficits can make
              interpretation of symptoms difficult

           Diagnostic overshadowing
             Tendency to attribute symptoms & B associated with illness to LD
Picture 9
    Schizophrenia

•   Prevalence
    •   approx 3% (Fraser & Nolan 1994) cf 1 % gen popn
•   Undetected in more severe LD - IQ < 50
   Presentation
       Depends on level of LD
           Mild & verbally able similar general popn
       Auditory hallucinations 90% (Meadows et al 1991)
       Less psychopathology
        •   Less complex delusions
        •   FTD
        •   Less likely passivity, thought echo, running commentary
Schizophrenia
   Delusions
    •   Can be talked out of - consider if repeated
    •   Wish fulfilment
    •   Content developmentally appropriate
•   Adults with severe LD
       Increased catatonic symptoms
           Consider
               Major change no significant environmental change
               Family history


   Misinterpretation of reality
Schizophrenia
   Differential Diagnosis
    •   BPAD
    •   Organic
    •   Autistic Spectrum Disorder
    •   “Brief” Reactive Psychosis
•   Consider
    •   Self talk
    •   Suggestibility & compliance
    •   Fantasy
    •   Misinterpretation of reality
Schizophrenia
Treatment
   NICE
       Antipsychotics
           NMS
           TD
           Akathisia
           Weight
           Metabolic syndrome
           Interactions -
               Medications
               Epilepsy
       PSI -
           CBT
           Family interventions
Picture 10
Affective Disorders

   Prevalence
       5-10 % major depressive disorder.
       3-8% bipolar
   Under-diagnosed especially severe LD
   Atypical presentation
   Historically thought people with LD didn’t experience
    emotions
Depressive episode
   Depressed / irritable mood and or
   Either
       Loss of interest/ pleasure in activities
       Social withdrawal
       Reduced self care
       Reduced communication
   Some of
       Lethargy, fearfulness, somatic concerns, reduced
        concentration / indecisive, increase behaviour problem,
        agitation / retardation, appetite / sleep disturbance


                                                      DC - LD
Depressive episode

   Symptoms
       Anxiety prominent
           Loss of confidence and tearfulness common
       Irritability
       Behavioural symptoms - (worsening of pre-existing)
           Self injury
           Aggression
           Screaming, temper tantrums, incontinence & Vomiting
       Hypochondriacal
       Regression i.e. loss of skills, social withdrawal
Affective disorders
Severe LD
   More biological symptoms e.g. sleep and appetite

   Regression

   Psychomotor agitation

   Catatonia and visual hallucinations more common
Affective Disorders
Differential Diagnosis

    Environmental change, loss, abuse
    Medical condition
    Drug induced
    Anxiety
    Dementia
    Behavioural disorder
    BPAD / mania (irritability / aggression, pressure of speech >
     complex verbal symptoms)
Janet
   50 year old lady
   Moderate LD
   Supported living
   Tearful.
   Lost confidence.
   Poor appetite. Weight loss.
   Withdrawn
   Reduced mobility. Abnormal gait. Falls
   Previous similar presentation 15 years ago.
MSE
   Wheel chair
   Anxious.
   Tearful
   Denial of symptoms
Suicide
   Rarely reported
   Attempted suicide rate 0.9% cf 1% gen popn (Sternlicht et
    al 1970)
   DSH more men cf women
   Mild/ borderline
   More severe LD – self harming behaviour thought be
    suicidal
Skin Picking
Helen
   Wheelchair bound limited use of arms

   Scissors

   Sink
Affective disorders
Mania/ hypomania
   4% adults with LD cyclical changes in behaviour &
    mood (Deb & Hunter 1991)

   Mixed affective & rapid cycling more common

   Rapid cycling M = F
Bipolar Affective disorder
Mania Symptoms
   Irritability > euphoria
   Grandiose ideas & delusions - simple
   P of speech > flight of ideas
   Inc / dec appetite
   Echolalia
   Crying
   Overactivity
   Social inhibitions
   Reckless Behaviour
Affective disorders
Management
   • NICE
       Antidepressants - longer for effect
       Mood stabilizers
       PSI
           Routine / structure
           CBT
           Psychotherapy
       ECT
Picture 11
Neuroses
Anxiety disorder
   Mild LD increased neuroticism cf gen popn
   GAD similar symptoms cf general popn
   Irritability & restlessness can be marked
   May not be able to avoid
   More severe LD only behavioural signs

   Co-morbidity /
       Psychiatric illnesses
       Williams syndrome part of behavioural phenotype
       ASD
Obsessive Compulsive Disorder

   Repetitive behaviour common
   Compulsive Behaviours
       3.5%-40% in mild to profound learning disabilities
   Symptoms
     Ordering compulsions most prevalent
     Thoughts/ acts not due to external source
     Not pleasurable
     May not be viewed as unreasonable
     Resistance may be minimal
     Compulsions can > aggression if prevented.
Sue
   50 year old lady with Down’s syndrome
   Living in supported living
   Carer’s problems
       Excess time to leave house – routines
       Lining up
       Aggression/ risk of injury
   No evidence anxiety on examination - with limits set
PTSD
   Increased risk of emotional, physical & sexual abuse

   Increased risk of PTSD / adjustment disorders
Anxiety disorders
   Treatment
       Treat psychiatric disorder
       NICE guidance
           SSRI
           Less frequent TCA’s
       Behavioural treatments
       Staff training
Personality Disorder

   Controversial
          Developmental delay when personality complete
          Stigma
          Individuals IQ <50


   Overlaps - behavioural phenotypes
   Poor research base
   More readily diagnosed in mild / borderline LD
   Age 21
   Avoid ICD diagnosis - schizoid, anxious, dependant
   Small number - mild LD, Antisocial PD, usually male
       persistent fire setters
       sex offences
Picture 12
Dementia
Dementia
   Increased life expectancy

•   Dementia brought forward all LD
         30yr - Downs
         10-15yr LD not Downs (Hoffman et al 1991)
Down’s Syndrome & Dementia
   “Precipitated senility” - Fraser & Mitchell 1876

   Onset from 30 onwards
           30-39 = few %
           40-49 = 10 - 25 %
           50-59 = 20 - 50 %
           60-69 = 30 - 75 %
Dementia in Downs syndrome
Clinical Features

   Atypical - personality / behaviour changes precede dementia by some years

   Maybe onset of seizures or worsening of seizures

   Middle & later course = gen popn

   Increase in myoclonic epilepsy & dysphagia

   Possibly more rapid
Dementia
   Differential

       Hypothyroidism (30% in DS)

       Medical/ iatrogenic

       Sensory impairments

       Depression / adjustment reaction
Dementia
   Assessment
       MDT

       Rating scales DSDS & Modified MMSE

       Routine screens bloods etc

       Sensory

       Neuroimaging -
           Early stage Alzheimer's - atrophy of medial temporal lobe - Normal in Downs
            syndrome
Dementia
   Treatment

       NICE
           Anti dementia medication

       Other treatments as for general dementia care

       Life story work

       Palliative care
Conclusion


    All psychiatric disorders possible
    Assessment may take longer
        Informants
        Diagnostic overshadowing
    MDT
    Treatment according to diagnosis
        Capacity / best interests
        Medication
            Small doses & slow titration
            Monitor effect / SE
Picture 13
References
   Read, S. 1997. Psychiatry in Learning Disability.
   Fraser, W. & Kerr, M. 2003. Seminars in the psychiatry of Learning
    Disabilities. Second edition. College seminar series.
   Royal College of Psychiatrists. 2001. DC- LD
   British Psychological Society / Royal College of Psychiatrists.
    2009. Dementia & People with LD
   Code of Practice. Mental Health Act 1983
   Fear, C. 2004. Essential revision notes for MRCPsych.
   Puri, B.K & Hall, A.D. Revision notes in Psychiatry.
   Valuing People Now (2007)
Good books to read

    Freaks Geeks & Asperger’s syndrome, L Jackson
    The curious incident of the dog who barked in the night,
     M.Haddon.
Questions




   Thank you

				
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