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Introduction – Learning Disability Psychiatry Dr Michelle Beaumont SPR to Professor Read.

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Presentation on theme: "Introduction – Learning Disability Psychiatry Dr Michelle Beaumont SPR to Professor Read."— Presentation transcript:

1 Introduction – Learning Disability Psychiatry Dr Michelle Beaumont SPR to Professor Read

2 Aims  Introduction  Assessment  LD specific issues  Psychiatric Disorders  Legal issues  Physical issues

3 Introduction  History  Epidemiology  Aetiology

4 Picture 1

5 History

6 From this…

7 To this….

8 Valuing People 2001  Principles  Rights - equal  Independent living  Control  Inclusion Practice LD register Health Education factor Health Action Plans Housing Employment

9 Epidemiology

10  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

11 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

12 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

13 Picture 2

14 Aetiology

15 IQ Distribution Curve

16 Aetiology

17  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

18 Severity of LD IQ score ranges Approximate Functional Equivalent Mental Age Percentage of total population affected Associated Features Notes Mild (80-85% of LD population) Communication skills may be mildly affected, some level of independence “Sub cultural” or “cultural familial” Moderate (10% of total LD) Severe (3-4% of LD) <9-6 <6 -0.5% combining moderate & Severe -Receptive language> expressive -Dependent -High rates of epilepsy physical /sensory impairment As disability becomes more severe, the number of specific organic pathology increases. Profound ( 1-2 % of LD ) <20<30.05Highly dependent Distinction from severe LD has doubtful value LD levels

19 Picture 3

20 Assessment

21 Assessment considerations  LD criteria  Informants / Carers  Communication  Assessment  Risks

22 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

23 LD - Indicators  Special school  Statement (can be behavioural)  Educational support NOT  Asperger’s  Dyslexia / Specific learning difficulty  Normal education  GCSEs  Drive car

24 Assessment Informants / Carers  Key worker / family  Key knowledge  Aid to compliance  Stress

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26 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

27 Accessible information

28 Consideration  Compliance  System  Capacity / Best interests

29 Picture 5

30 Psychiatric Assessment

31 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

32 AssessmentMSEAssessmentMSE  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

33 Assessment  Day care reports  Family  Monitoring charts  Other assessments  Social issues  Safeguarding issues

34 Risks  Aggression / violence  Neglect  Abuse from others  Abuse to others  DSH  Suicide  Domestic

35 Assessment  Multi Professional Team working  CMN  SALT  OT  Physiotherapy  Psychology  Care managers  Teachers

36 Treatment  Medication  Research/ evidence poor  Extrapolated from general adult psychiatry  If use off license medication should indicate  Reduced doses & slow titration

37 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,

38 Treatment  Review effect  Side effects

39 Picture 4

40 LD Specific issues  Challenging Behaviour  Behavioural phenotypes  Autism

41 Challenging Behaviour

42 Challenging behaviour  % 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)

43 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

44 Challenging behaviour  Management  monitoring,  boundary setting,  evaluation of environment,  medication may be indicated  MDT

45 Picture 6

46 Behavioural Phenotypes

47 Behavioral Phenotypes  Known (usually genetic) disorder is associated  Pattern behaviour  Personality characteristics  Psychiatric symptoms  Eg

48 Fragile X  Testicular enlargement  Large head circumference  Long & prominent ears  High arched palate  Connective tissue disorder  Lax joints  flat feet  Mitral valve prolapse

49 Fragile X cont..  Mild - moderate LD  Flattening trajectory learning over childhood  Abstract reasoning  Visuo-motor & spatial deficits  Strengths verbal & adaptive behaviour  % have autism

50 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

51 Picture 7

52 Autism Pervasive developmental disorder

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54 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.”

55 Autism  Usually coexists with significant LD  Apparent before 3  4/  M>F  Increased in certain conditions  TS, rubella

56 Wing  Continuum  Triad of impairments  Social relationships  Lack empathy  Interest in others  Language  Expressive > receptive  Abnormal prosody. Echolalia. Pronounal reversal. 3 rd person  Literal meaning  Imagination restriction  Routines. Novelty > catastrophic rage.  Unusual interests

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58 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

59 Autism & Mental illness  Psychosis  Self talk  General demenour  Across all situations  paranoia  Depression  Atypical  Self harm  Increased withdrawal

60 Treatments  Behavioural assessment & management  Key  structure,  predictability,  Communication  Social stories  Intensive interaction  Visual diaries  Communication boards  Aim reduce arousal

61 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

62 Picture 8

63 Psychiatric Disorders

64  Vulnerability factors  Diagnostic issues  Disorders

65 Vulnerability for mental disorders INDIVIDUAL Family Bereavement issues Life-cycle transitions / crises “Letting go” Social / community networks Stress / adaptation to disabilities Protective factors Daytime activity Structure Relationships Social Attitudes / expectations Supports / relationships Inappropriate environments / services Under / over stimulation Biological Brain Damage Vision / hearing impairments Physical illness / disabilities/ epilepsy Genetic - familial conditions Behavioural phenotypes Drugs / Alcohol abuse Medication / Physical treatments Psychological Personality Development Deprivation / abuse Separation / losses Life events Learning Experiences Self-insight / self-esteem

66 Mental Disorder  Under-diagnosed  Behavioural disorder  Insufficient weight to symptoms  Psychosocial masking - bland beliefs  Consider co-morbidity e.g. physical ill health / epilepsy

67 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

68 Picture 9

69 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

70 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

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72 Schizophrenia  Differential Diagnosis BPAD Organic Autistic Spectrum Disorder “Brief” Reactive Psychosis Consider Self talk Suggestibility & compliance Fantasy Misinterpretation of reality

73 Schizophrenia Treatment  NICE  Antipsychotics  NMS  TD  Akathisia  Weight  Metabolic syndrome  Interactions -  Medications  Epilepsy  PSI -  CBT  Family interventions

74 Picture 10

75 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

76 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

77 D epressive 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

78 Affective disorders Severe LD  More biological symptoms e.g. sleep and appetite  Regression  Psychomotor agitation  Catatonia and visual hallucinations more common

79 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)

80 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.

81 MSE  Wheel chair  Anxious.  Tearful  Denial of symptoms

82 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

83 Skin Picking

84 Helen  Wheelchair bound limited use of arms  Scissors  Sink

85 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

86 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

87 Affective disorders Management  NICE  Antidepressants - longer for effect  Mood stabilizers  PSI  Routine / structure  CBT  Psychotherapy  ECT

88 Picture 11

89 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

90 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.

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92 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

93 PTSD  Increased risk of emotional, physical & sexual abuse  Increased risk of PTSD / adjustment disorders

94 Anxiety disorders  Treatment  Treat psychiatric disorder  NICE guidance  SSRI  Less frequent TCA’s  Behavioural treatments  Staff training

95 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

96 Picture 12

97 Dementia

98  Increased life expectancy Dementia brought forward all LD  30yr - Downs  10-15yr LD not Downs (Hoffman et al 1991)

99 Down’s Syndrome & Dementia  “Precipitated senility” - Fraser & Mitchell 1876  Onset from 30 onwards  = few %  = %  = %  = %

100 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

101 Dementia  Differential  Hypothyroidism (30% in DS)  Medical/ iatrogenic  Sensory impairments  Depression / adjustment reaction

102 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

103 Dementia  Treatment  NICE  Anti dementia medication  Other treatments as for general dementia care  Life story work  Palliative care

104 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

105 Picture 13

106 References  Read, S Psychiatry in Learning Disability.  Fraser, W. & Kerr, M Seminars in the psychiatry of Learning Disabilities. Second edition. College seminar series.  Royal College of Psychiatrists DC- LD  British Psychological Society / Royal C ollege of Psychiatrists Dementia & People with LD  Code of Practice. Mental Health Act 1983  Fear, C Essential revision notes for MRCPsych.  Puri, B.K & Hall, A.D. Revision notes in Psychiatry.  Valuing People Now (2007)

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

108 Questions  Thank you


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