MENTAL AND BEHAVIOURAL DISORDERS IN ADULTS WITH A LEARNING DISABILITY

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MENTAL AND BEHAVIOURAL DISORDERS IN ADULTS WITH A
LEARNING DISABILITY

• Dr Eileen Mc Namara
• Consultant Psychiatrist
• Hertfordshire Partnership NHS Foundation Trust

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OBJECTIVES

• EPIDEMIOLOGY
• AETIOLOGY AND RISK FACTORS
• BEHAVIOURAL PHENOTYPES
• CLINICAL FEATURES
• DIAGNOSIS
• CLASSIFICATION
• MANAGEMENT

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OBJECTIVES

• APPLY KNOWLEDGE TO CLINICAL PRACTICE
• PATIENT MANAGEMENT PROBLEMS

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LEARNING DISABILITY

• Impairment of intelligence
• Impairment of adaptive functioning
• Manifest during the developmental period

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Legal definitions

• 1983 MHA
• Mental impairment
• Severe mental impairment
• 2007 MHA
• Any disorder or disability of the mind
• Behaviour criterion retained

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Dual Diagnosis

• MENTAL ILLNESS
• LEARNING DISABILITY

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Challenging behaviour

• Culturally abnormal behaviour of such 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
  limit use of or result in the person being denied
  access to ordinary community facilities.
• Emerson 1995

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Self injurious behaviour

• The deliberate alteration or destruction of body
  tissue without conscious suicidal intent
• Favazza 1989

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Behavioural phenotype
a group of specific behaviours consistently
associated with a genetic syndrome
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EPIDEMIOLOGY

• MENTAL ILLNESS IS SIGNIFICANTLY MORE COMMON IN
  PEOPLE WITH LEARNING DISABILITIES THAN IN THE
  GENERAL POPULATION

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Methodological challenges
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Epidemiology of mental health problems in adults
with learning disability An update 2005 Vol
11 E Smiley
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Risk factors for mental illness
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Diagnostic challenges

• Intellectual distortion
• Baseline exaggeration
• Cognitive disintegration
• Misdiagnosis of developmentally appropriate
  phenomena
• Diagnostic overshadowing

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Classification
Axis I severity of ld Axis II cause of ld Axis
III psychiatric disorders Level A - E
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DC-LD

• Susan is a 37 year old lady with a severe
  learning disability Axis I due to Downs
  syndrome Axis II who has a six month history of
  obsessive compulsive disorder Axis III level B
  and long standing self injurious behaviour
  through head banging axis III level D

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Psychiatric assessment should include all aspects
of the standard psychiatric assessment as used
in the general population plus additional
considerations relevant specifically to people
with learning disabilities
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ASSESSMENT

• HISTORY
• MSE
• PHYSICAL EXAM
• COLLATERAL HISTORY
• REVIEW OLD NOTES
• MDT DISCUSSION
• INVESTIGATIONS
• DIAGNOSTIC FORMULATION

• SENSORY ASSESSMENT
• GENETIC TESTING
• EPILEPSY
• PSYCHOMETRIC TESTING
• BEHAVIOURAL ANALYSIS
• SALT
• SPECIALIST ASSESSMENT AUTISM OR DEMENTIA

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What historical information might indicate that
the person has a learning disability?
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COMMUNICATION
Context Environment Verbal communication Non
verbal Communication Sensory impairments
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ASSESSMENT AND MANAGEMENT WILL USUALLY INVOLVE
SEVERAL MEMBERS OF THE MULTIDISCIPLINARY TEAM
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Medication issues

• Evidence based prescribing
• Collaboration with multi disciplinary team
• Clearly defined goals
• Capacity to consent and 2005 Mental Capacity Act
• Provide adequate accessible information
• Beware drug interactions
• Use the lowest effective dose
• Avoid polypharmacy
• Consider compliance and safety issues
• Review regularly