Learning Disability LD Dr Sam Baldwin Consultant Psychiatrist learning disabilities, Dundee

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Learning
Disability(LD) Dr Sam
BaldwinConsultant Psychiatrist (learning
disabilities, Dundee)
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Stigma

• Idiot
• Imbecile MHA
• Feeble Minded 1929
• Moron
• Mental Subnormality
• Mental Deficiency MHA 1960
• Mental Handicap ICD 9
• Mental Impairment MHA 1984
• Mental Retardation
• Learning Disabilities

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Definition

• A condition of arrested or incomplete
  development of the mind, which is especially
  characterised by impairment of skills manifested
  during the developmental period, which contribute
  to the overall level of intelligence i.e.
  cognitive, language, motor and social abilities
• ICD 10

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How to recognise LD

• Limited intellect (IQlt70, school support / exams)
• Impaired life skills due to limited intellect
  (work, family, hygiene, cooking, managing money)
• Deficits present from childhood (lt18)

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ButBe cautious with IQ

• Lower than expected IQ can be due to
• Lack of schooling
• Physical/Emotional abuse in childhood
• Mental illness
• Tiredness
• Physical illness
• Drugs impairing concentration

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• Around 2.5 of the population will have an IQ of
  less than 70
• Only about 50 of those are identified

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Classification

• Borderline IQ 70
• Mild IQ 69-50
• Moderate IQ 49-35
• Severe IQ 34-20
• Profound IQ lt 20

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General principles

• Learning disabled people will continue to grow
  and develop given an appropriate environment
• Learning disabled people are worthy of all the
  dignity and rights of any citizen
• Concept of learning through risk taking and the
  avoidance of over-protection
• The availability of everyday, normal conditions
  of life
• The availability of generic environments and
  services

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LD - Some associated factors

• Epilepsy
• Mental Illness
• Substance Misuse
• Physical Disability
• Sensory problems
• Autistic Spectrum Disorder
• Sexual Abuse
• Family Dysfunction
• Different Appearance
• Poor employment prospects
• Low expectation of success
• Stigma

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The Tayside LD Team

• GP
• Social Work
• Care managers
• Social care officers
• Care Providers
• Health
• Nursing
• Psychiatry
• Psychology
• SALT
• Physiotherapy
• Occupational Therapy
• Art/Music Therapy

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LD Psychiatry In Tayside

• Much wider remit than general adult psychiatry
• Any mental disorder or challenging behaviour (CB)
• Community Teams for Angus, Perth and Dundee
• Tayside Behavioural Support and Intervention Team
• Inpatient Units (used to 800 at Strathmartine
  Hospital)
• Learning Disability Assessment Unit, Carseview
  (10)
• Behavioural Support and Intervention Unit,
  Strathmartine (6)
• Forensic locked ward, Strathmartine (10)
• Forensic Open Ward, Strathmartine (8)

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How to suck eggs

• People with more severe LD present with
  behavioural changes not symptoms
• Carer who knows them well is crucial
• Give adequate time for the interview
• Make questions simple
• Only ask one thing at a time
• Do not use complicated medical language
• Explain what you are doing
• Check their understanding
• If they dont offer an answer, ask if it is ok to
  ask their parent/ carer about them, but offer the
  chance butt in

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In your clinic

• Often its impossible to be sure whats going on
  - the carer started last week, your patient is
  non-verbal, and they wont let you examine or
  investigate them!
• Get as clear a picture as you can and bear in
  mind
• Epilepsy (25 overall but 50 profound LD)
• Specific syndromes e.g. Downs and Alzheimers
• May have very high pain thresholds
• Consider
• Physical illness (GP rule out as far as possible)
• Environmental changes
• Psychiatric illness

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LD Psychiatry

• If in doubt, refer to the team or ring up for
  advice.
• Mental illness and CB is all about baseline
  shift.
• Often presents with problem behaviours rather
  than classical symptoms
• Commonly associated with physical disorder
• Family history makes a diagnosis more likely
• Mental illness in LD
• More common
• Harder to diagnose
• More treatment resistant
• More sensitive to psychotropic medication
  (antipsychotics and epilepsy)
• But treated in more or less the same way as
  mainstream

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Schizophrenia

• Diagnosis technically depends on identification
  of one of the following
• -Third person auditory hallucinations.
• -Hallucinatory voices from some part of the
  body.
• -Impossible / fantastic delusions.
• -Delusional percept or Passivity phenomenon.
• At least two of the following should also be
  present
• -Mood incongruent delusions/Hallucinations.
• -Disordered form of thought.
• -Catatonic symptoms and Negative symptoms.

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Schizophrenia

• Lifetime prevalence of Schizophrenia in L.D is 3
  compared to 1 in general population.
• Diagnostic difficulty in those with limited
  communication skills.
• Significant proportion of those with more severe
  L.D undiagnosed.

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Schizophrenia

• May present in a variety of ways in L.D.
• Change in behaviour
• Aggression
• social withdrawal
• speaking to themselves or to other person when
  nobody is there
• pointing at things, picking or swiping at things
  which others cannot see.
• Such changes can have a variety of explanations

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Schizophrenia

• Quality of psychotic symptoms may differ from
  general population.
• People with L.D may be more compliant, and
  possibly talked out of any delusional beliefs.
• Better indicator of delusional belief is a
  repeatedly stated false belief or one returned to
  voluntarily. Same applies to hallucinations.
• Content of delusions and hallucinations is
  developmentally appropriate.

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Schizophrenia

• Difficult to distinguish between third person,
  second person and elementary hallucinations.
• Some positive symptoms are uncommon e.g.
  delusional perception, passivity phenomenon,
  thought echo and thought alienation.
• Thought disorder and neologisms can occur but
  should be distinguished from normal developmental
  findings.
• Negative symptoms may be seen but it may be
  difficult to determine premorbid social
  functioning and skills.

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Useful Questions

• Anything new happened?
• Any new ideas?
• Found anything new or special or strange?
• Anyone getting at /against you?
• Anyone trying to harm you?
• Received any special messages?
• Television/radio troubling you?
• Anyone talking behind your back/saying bad
  things?
• Anyone telling you to do bad things?
• Heard anyone speaking when nobody around?
• Seen anything frightening?
• Seen things other people say are not there?

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Depression

• Depressed mood.
• Loss of interest
• Loss of energy
• Reduced concentration
• Reduced self confidence
• Ideas of guilt and unworthiness
• Pessimistic view of the future
• Change in appetite
• Sleep disturbance
• Suicidal Thoughts

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Depression

• More reliant on biological than cognitive
  symptoms
• Early morning wakening
• Poor appetite and wt loss
• Poor concentration
• Withdrawn
• Not enjoying life as they used to
• Suicide less common

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Mania

• Abnormally elevated, expansive or irritable mood.
• In addition
• - Over activity
• - Pressure of speech
• - Flight of ideas
• - Dis-inhibition
• - Reduced sleep
• - Grandiosity
• - Reduced concentration
• - Reckless behaviour
• - Increased libido

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Manic Episode

• Uncommon
• Much more likely to have a mixed affective
  episode overactivity, disinhibition, agitation,
  aggression, fluctuating between weepiness and
  elation.

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Neurotic and Stress related Disorders

• Common in adults with L.D, many are undiagnosed
  and untreated.
• Long history of difficulties.
• Irritability and restlessness are common and may
  be marked which can present as aggression towards
  self/others.
• Presence and description of more complex
  cognitive phenomenon is difficult to illicit.

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Neurotic and Stress related Disorders

• May not recognise their fear to be excessive
• or unreasonable.
• May not recognise or be able to describe the
  unreasonableness of their obsessions or
  compulsions.
• Compulsions should be distinguished from
  repetitive movements.
• Diagnosis made on objective observation in
  addition to subjective description.

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Agoraphobia (less common)

• Marked fear of
• Crowds, Public places, Using public
  transport and Leaving home.
• Palpitations
• Sweating
• Trembling
• Dry mouth
• Difficulty breathing
• Chest discomfort
• Nausea
• Churning stomach (butterflies)
• Dizziness
• Hot flushes or cold chills
• Restlessness and Irritability.

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Social Phobia (less common)

• Fear in social situations
• Fear of behaving in a way that will be
  embarrassing or humiliating.
• In the feared situation, or in anticipation of
  it, one of the following should occur
• -Blushing or shaking
• -Vomiting, retching, or fear of vomiting.
• -Urgency of micturation or defecation, or
  incontinence.
• Plus general anxiety symptoms

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Generalised Anxiety Disorder(fairly common)

• Symptoms / signs should be long-standing, usually
  greater than six months.
• Anxiety is free-floating.

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Obsessive-compulsive Disorder (less common)

• Obsessions and/or compulsions at least
• 2 weeks and have following features
• Repetitive
• Intrusive
• Unpleasant and cause distress
• Resisted
• Interference with functioning.

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Eating Disorders

• Anorexia Nervosa (very uncommon)
• Bulimia Nervosa (very uncommon)
• Binge eating disorder
• Psychogenic overeating/vomiting
• Psychogenic loss of appetite
• Food faddiness/refusal
• Food rumination/regurgitation

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Eating Disorders

• Anorexia Nervosa
• BMI lt17.5
• Self induced weight loss
• Distorted body image
• Hormonal dysfunction
• Bulimia Nervosa
• Binge eating
• Self induced weight loss
• Distorted body image.

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Eating Disorders

• Association with different syndromes.
• AN and BN less common than Psychogenic
  overeating/vomiting and food faddiness /food
  refusal disorders.
• Lack of verbal communication and abstract body
  conceptualisation skills.
• Abnormal eating pattern secondary to other causes.

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Personality Disorder

• Disharmonious attitude and behaviour.
• Considerable personal distress.
• Problems in functioning.
• Delay in diagnosis.
• Huge overlap, probably not valid to talk of a
  specific PD in LD (or mainstream perhaps).

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Drug and alcohol related disorders

• On the increase
• Money
• Access
• Lack of consequences
• Physical/Psychiatric/Behavioural sequelae.

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Indicate whether you agree or disagree with these
statements

• People with a learning disability are not
  normal and should not be treated as normal
• Families should be encouraged to care for their
  disabled member as soon as possible
• It is unrealistic for a person with a learning
  disability to seek work whilst there are so many
  people unemployed
• Limited NHS resources should be directed towards
  life-saving surgery rather than the long-term
  care of people with learning disability
• The needs of people with a learning disability
  can be met only by specialist services
• People with a learning disability have the same
  needs and aspirations as others but may require
  help in meeting those needs
• Support should be available to enable people with
  a learning disability to use ordinary facilities
  in the community
• It is unfair to expect people with a learning
  disability to cope with the rigours of modern
  industrial society. They should be cared for in a
  sympathetic environment.
• Community care for people with a learning
  disability puts those individuals and others in
  society at risk
• Professionals are best placed to determine the
  lives of people with a learning disability

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Thanks