Presentation on theme: "Psychiatric evaluation of patients with dual upset Professor Iqbal Singh."— Presentation transcript:
Psychiatric evaluation of patients with dual upset Professor Iqbal Singh
Mental disorder as defined in ICD- 10 Clinically significant conditions characterised by alterations in thinking, mood (emotions), or behaviour associated with personal distress and/or impaired functioning. Mental and behavioural disorders are not just variations within the range of “normal”, but are clearly abnormal or pathological phenomena.
DSM-1V Contains broadly similar definitions There are similar concepts such as change from the pre-morbid functioning, personal distress, patterns of symptoms, recognizable courses of illnesses and exclusion of culturally acceptable deviations
The concept of mental disorder in people with learning disabilities presents several challenges Diagnosis must be made in a person whose behaviour is already restricted and unusual This difficulty is reflected in a number of potential problems such as intellectual distortion, psychosocial masking, cognitive disintegration, baseline exaggeration, diagnostic overshadowing, etc.
Mental disorder in learning disabilities: the second challenge In making a diagnosis many subjective judgements concerning the significance of changes in behaviour are made, e.g. Value system of the carer Undetected physical illness Accuracy of third party reporting Tolerance of third party for deviant behaviour
Mental disorder in learning disabilities: the third challenge Most mental health referrals are typically initiated by the clients themselves, unlike in learning disabled clients where referral is made by distressed relatives or carers
Some common problems in making psychiatric diagnoses in people with learning disabilities (1) Intellectual distortion: concrete thinking & impaired communication result in poor communication about their own experience Psychosocial masking: impoverished social skills & life experiences result in unsophisticated presentation of a disorder, or misdiagnosis of unusual behaviour as a psychiatric disorder
Some common problems (2) Cognitive disintegration: bizarre behaviour is presented in response to minor stressors that could be misdiagnosed as a psychiatric disorder Baseline exaggeration: prior to the onset of a disorder there are high levels of unusual behaviours, making it difficult to recognize the onset of a new disorder
Some common problems (3) Misdiagnosis of developmentally appropriate phenomenon: developmentally appropriate behaviours that are unusual for the client’s chronological age are misdiagnosed as a psychiatric disorder Passing: people with LD learn to cover up disability and pass for normal Diagnostic overshadowing: unusual behaviour is erroneously ascribed to LD, rather than a true mental disorder
Relationship between learning disability and mental illness Mental illness learning disability Learning disability mental illness Underlying pathology causing learning disability and mental illness
PIMRA: scoring Each item scored yes or no 75% of items must be completed for a valid result to be obtained
Other assessment instruments ABC: Aberrant Behaviour Checklist. 58 items, each scored on a 4-point scale DASH: Diagnostic Assessment for Severely Handicapped scale PAS-ADD: Psychiatric Assessment Schedule for Adults with Developmental Disabilities checklist DC-LD
Multimodal Assessment for Mental Health Problems in People with Learning Disabilities (1) This is an ideal way to assess mental health needs of people with learning disabilities as otherwise the histories of these people remain fragmented. The following are the steps in the model:
Multimodal Assessment (2) 1. Referral 2. Screening phase 3. The assessment process 1. Venue 2. Who should be there? 3. Brief screen 4. Inter-disciplinary assessment 4. Clinical interview 1. Full history/observation 2. Psychiatric examination 3. Investigations
Depression (1) Overall psychiatric morbidity is 3 times higher in people with LD than in general populations and depression is no exception. Symptoms for mild LD: Tearfulness Diurnal variations in mood Loss of energy Loss of interest Low self-esteem
Depression (2) Symptoms for moderate LD: Social isolation Self-injurious behaviour Weight loss Symptoms for severe LD: Screaming Aggression Self-injurious behaviour
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