Issues of Dual Diagnosis: Developmental Disabilities and Mental Illness

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Issues of Dual Diagnosis Developmental
Disabilities and Mental Illness

• Cath Burns, Ph.D.
• Barbara Noordsij, APRN, ND, PMHNP-BC

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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

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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

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Mental Retardation Incidence

• 1 3 of general population
• 1.5 time more common in boys than in girls
• Causes 25 have known biologic causes

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Prevalence of Mental Disorder in Adult Population
(NIMH)

• Anxiety disorders
• ADHD
• Autism
• Eating Disorders
• Mood Disorders
• Personality Disorders
• Schizophrenia

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Prevalence of Mental Disorder in Adults (NIMH)
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Prevalence in Children (NIMH)
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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)

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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

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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.

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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

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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 Aspergers
• 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)

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Etiology?
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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

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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

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Many causes of mental retardation have associated
Psychiatric Phenotypes associated with the
disorders
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Some Neurogenic Disorders with a associated
psychiatric phenotype

• Velocardiofacial sndrome
• Fragile X
• Down Syndrome
• Prader-willi syndrome
• Turners syndrome
• Sex chromosone aneuploidy

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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.

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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,
  repetetive sterotyped movements, pronounced gaze
  aversion and social anxiety.

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Downs 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

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Klinefelters 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

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Activity

• Talk case load

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How are Co-morbid Conditions Diagnosed?

• Special considerations
• Mental retardation may make diagnoses of other
  psychiatric disorders more challenging

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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

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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)

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Interview

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

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Consider

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

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4 Factors Affecting Presentation Sovner (1986)

• Intellectual Distortion
• Psychosocial masking
• Cognitive disintegration
• Baseline exaggeration

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Intellectual distortion

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

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Psychosocial masking

• Limited social experiences can influence the
  content of psychiatric symptoms
• example - mania presents as I can drive a car
• Silka Hauser, 1997)

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Cognitive disintegration

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

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Baseline exaggeration

• Increase in severity or frequency of chronic or
  maladaptive behavior after onset of psychiatric
  illness
• (comments on onset)
• Silka Hauser, 1997)

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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

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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)

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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

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Differential Diagnosis

• Distinguishing between diseases of similar
  character by comparing their signs and symptoms
• Usually involves some sort of decision tree

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Of course

• Match treatment to presenting symptom.but be
  sure you know the cause of the symptom

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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

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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!

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DD and Behavioral Disturbances SIB

• Self-Injurious Behavior (SIB) 8 14 of
  institutionalized population
• More common with IQ lt 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

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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.

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Differentiating Autism and Child onset
Schizophrenia

• Clinicians experienced with Autism and
  Schizophrenia are helpful to symptom
  differentiation
• Rapaport et al,2009
• (strategy- follow along)

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

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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 others 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.

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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

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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)

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Examples DD and Mood Disorders

• Major Depression
• Bipolar Disorder
• Dysthymic Disorder
• Higher instance of stupor and mutism in
  depression
• Bipolar disorders more common
• Can be related to specific stressors (e.g., loss
  of caregiver, change of surroundings,
  hospitalization, etc.)
• Mixed states with features of mania and
  depression, schizoaffective psychoses, psychotic
  responses to cute stress, and rapid-cycling
  bipolar disorder all appear to be more common in
  MR than non-MR
• Treatment Medication, activities to engage
  individual and exercise, groups for skill
  development
• Case Study This client had originally presented
  for treatment in elementary school. He was not
  referred until his Senior year in high school.
• -- Co-morbid diagnoses
• -- Schizoaffective Disorder
• -- Mild Mental Retardation
• -- Obsessive compulsive Disorder

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Examples DD and Psychotic Disorders

• Classical clinical features present (e.g., with
  schizophrenia) that tend to be florid but banal
• Active psychoses tend to occur at younger age and
  reflect limited social skills and experiences of
  the individual
• Mixed states more common with MR population than
  with non-MR
• Treatment Medication behavior therapies
  family support and treatment therapeutic case
  management
• Case study This client was referred in
  elementary school in about 2nd grade
• She had many difficulties in school and school
  was largely responsible for her entering the
  system of care.

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Approaches to Treatment Therapeutic Case
Management

• Coordinate services
• schools, community organizations, extended family
  and supports, other service providers and
  treatment providers
• Education
• Regarding diagnosis, long term needs
• Supports for families, expand if possible

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Crowley (2008)

• This study looked at the benefit of
  psycho-educational groups for people with
  psychosis and mild intellectual disability.
• Measures of knowledge and self esteem were
  completed pre and post group.
• Participants were able to understand the concepts
  of psychosis the need for medication and the role
  of stress and early signs of relapse. This
  approach may be helpful.

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Approaches to Treatment Behavioral Therapies

• Goal 1. Stabilize problem behaviors. Identify
  behaviors that cause the most harm and distress
  from the client and familys perspectives.
• Goal 2 Increase skills and promote prosocial
  and adaptive behaviors that will promote maximum
  independence
• Goal 3 Apply and practice across environments
• ? Teach at school
• ? Generalize to home
• Goal 4 Develop plans based upon principles of
  positive behavior support
• Goal 5 Plan for crises
• Pure behavioral models do not attend to internal
  emotional states of the individual.

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Approaches to Treatment Caveat

• There is a lack of randomized controlled trials
  (RCTs) investigating effectiveness of
  psychotherapeutic models (psychodynamic,
  cognitive behavioral, and cognitive approaches)
• Even less so are available for children
• In general, all agree that effectiveness
  decreases with decreasing IQ

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Approaches to Treatment Psychodynamic Models

• Focuses upon transference and counter
  transference within the therapeutic relationship
  to investigate the internal world of the client.
• Predominately case study and/or anecdotal
• Limited support benefits may have resulted to
  humanistic/person-centered counseling techniques

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Approaches to Treatment Cognitive Behavioral
Therapies (CBT) to Address Skill Deficits

• Dominant modality in treatment today
• Effective with
• Panic disorder - Phobias
• Promoting social behaviors - Depression
• Anxiety - Parent stress
• Anger management - Self-management
• Social problem solving - Self-Instruction
  training
• Social skills development
• Generally coupled with relaxation techniques,
  education, planned practice and generalization
  efforts

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Approaches to Treatment CBT to address
Cognitive Distortions

• Assess for ability to
• Distinguish between antecedent events and
  associated cognitions and emotions
• Recognize that cognitions mediate the effects of
  events on emotions
• Willingness to engage in collaborative
  empiricism to question the accuracy of cognitive
  distortion
• Reliability of self-reports
• Depression, anxiety, anger, and sex offences

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Overall Treatment Planning

• Include community caregivers and staff
• Develop specific treatment plans that can be
  accomplished in a specific amount of time
  avoiding treatments that cant be implemented in
  the broader community
• Take into account variables consistency versus
  change in environment, levels of supervision
  available, possible stressors, and behavioral
  management strategies
• Use therapy and activity groups to bring out the
  persons capacity for learning and participation