Dual Diagnosis:A Brief Overview

Psychiatric Disorders in Mentally Retarded Adults

same range of behavioral and emotional problems as non-disabled adults

Overshadowing

MENTAL RETARDATION IS NOT MENTAL ILLNESS

Rates of Psychiatric Disorders in Mentally Retarded Adults

Higher for adults than for children under age 10 Higher rates in mild vs. severe mental retardation Equal rates for men and women Equal rates for different cultural groups Studies show rates 4 – 6 times higher than in non-

disabled population

Difficulties specific to some individuals with mental retardation

difficulties with verbal expression/ nonverbal

Difficulties understanding their own emotional responses

Suffering in silence – the person who does not act out emotional distress

What is Wrong?

People who are higher functioning (and verbal) can usually answer this question – the standard way to investigate emotional problems

Decreases in intelligence = diminished ability to express problems verbally

Emotional expression is shown in behavior

Detective Work

Use of intuition and hunches

Detectives on behalf of our consumers

Communicating with Behavior

Externally directed behaviors

aggression

irritability

disorganized speech

Internally directed behaviors

depression

stress/nervousness

withdrawal

Internal behaviors – difficult to detect External behaviors –difficult to interpret

Negative behaviors serve a function: Attempt to communicate Expression of frustration Attention seeking (or communication about the need

for more attention) Accomplish consumer’s goals

Sorting It All Out

Gather information while consumer is stable Baseline data – observations of typical behavior Family history – interviews with family members

Observe changes Triggers Feelings Goal of behavior Symptom picture

Baseline Data

Aspects to consider: Eye contact Response to social contact Speed of response (rapid or slow) Typical mood (happy, sad, moody?) Tone of voice Body language -- physical stance Usual interests or pastimes

Family History

Obtain a family history of mental health issues Ask about:

Depression Alcoholism or strict abstinence Manic depression Stress / anxiety/ nervous breakdowns Odd personality traits Domestic violence

Observing Change

Rule out medical causes Look for triggers – changes in routine, unusual

events Ask consumer about feelings Ask yourself what the person is accomplishing

with this behavior Observe their behavior for symptoms

Diagnosis

It is an inexact way of categorizing people

Useful as a method of communicating with other professionals a way to explore your hunches, to provide yourself

with direction

Arriving at a diagnosis

Work from a big perspective toward details begins with hunches

Work from details toward an overview begins with observation

The Big Perspective

Ask yourself general questions:

Is he/she not making sense (more so than usual?) Is the person stressed? Anxious? Nervous? Does he/she seem blue, irritable, moody? Did the person just experience an event that would

have been traumatizing?

Working with intuition

Rely on your intuition as a guide Do extra reading :

Diagnostic and Statistical Manual for Mental Disorders- Fourth Edition, Text Revision (DSM-IV-TR)

Observation of behavior

Work from the perspective of changes you observe in your consumer

Use baseline data as a comparison to see how behavior has changed

Consult DSM-IV-TR

Overview: Disordered Thinking

General question: is this person not making sense? (more so than usual)

Schizophrenia: a disorder characterized by distortions of reality

Schizophrenia

Symptoms:

Positive: excess or distortion of functions – hallucinations and delusions

Negative: absence of normal functioning or severely restricted functioning– empty replies, lack of movement, flat tone of voice

Common symptoms of schizophrenia

POSITIVE SYMPTOMS: EXCESS

Delusions: erroneous beliefs – incorrect interpretations of experiences

Hallucinations: seeing or hearing things that aren’t there (voices are perceived as other than the person’s thoughts)

Common symptoms of schizophrenia

NEGATIVE SYMPTOMS: ABSENCE

Flat affect flat tone of voice immobile face poor eye contact

Brief, empty replies

Inability to continue goal-directed behavior Sitting for long periods of time Loss of interest in activities

Clues

Inappropriate laughter (for no apparent reason) Seems to be responding to something you can’t

see or hear Starring/ not responding Confusion, disorientation Seems to shift in an out of “being present” Always wears clothing that covers up the head

(hat, hooded sweatshirt) Speech doesn’t make sense/ incoherent

Clues (continued)

Tangential speech (goes off on tangents) Erratic behavior Excessive mistrust/paranoia Rigid postures Intuitive clue: How did we get here (in this

conversation)?

Treatment

Usually medications: newer meds are called “atypical antipsychotics” – they affect more neurotransmitter systems

Risperdal Zyprexa Closaril Seroquel Geodon Abilify

Overview: Mood Problems

General question: does this person seem blue, irritable, moody, wild, unstoppable?

Bipolar Disorder: a disorder of mood characterized by shifts between mania and depression, with periods of normalcy

Bipolar Disorder: (formerly Manic-depression)

Symptoms: Inflated self-esteem or grandiosity (I am God) Decreased need for sleep Pressured speech or more talkative than usual Flight of ideas/racing thoughts Distractible Increase in goal-directed activity Excessive involvement in risk-taking activities

Clues (to mania)

Irritability and anger Increased agitation Shouting, yelling, screaming Silly behavior Belief that one can do anything (superman complex) Boundless energy Decreased need for sleep Non-stop talking Easily distracted Increase in sexual behavior Shopping sprees Intuitive clue: your own exhaustion in person’s company

Treatment

Usually medications such as Depakote and Neurontin.

Lithium is still used and appropriate

Use of antidepressants can precipitate a manic attack

Major Depressive Disorder

Symptoms: tearfulness sad appearance loss of interest in usual activities lethargy disturbances in sleep and eating patterns thoughts of death or suicide

Clues

Decreased talking Regression in skills Poor self-care; lack of concern for self-care Increase in self-injurious behavior Talk about suicide; plans; giving away possessions Increased agitation or pacing Always putting oneself down; low self worth Negativity Over-eating or loss of appetite Exhaustion Constantly sleeping or unable to sleep

Treatment

Talk therapy or play therapy

Art, music, dance therapy

EXERCISE

Medications (usually the SSRIs)

Stress Disorders

General question: does the person seem stressed, jumpy, nervous?

Anxiety Disorders: a group of disorders that are characterized by an increase in overall nervousness – this can be very hard to detect in persons with mental retardation.

Anxiety Disorders

Symptoms: vary, depending upon the specific disorder

Disorders included in this category: Panic disorder Agoraphobia Social anxiety disorder Phobias Obsessive compulsive disorder PTSD Generalized anxiety disorder

Clues

Social avoidance Withdrawal Escalation of behaviors in new settings Insistence on sameness in environment Signs of autonomic arousal: “fight or flight” syndrome Restlessness Easily fatigued Trouble concentrating Muscle tension Problems with sleep

Treatment

Medications: SSRIs such as Paxil, Buspar, Benzodiazepines (addictive)

Relaxation techniques – deep breathing

Walking or other aerobic exercises

Removal of stressor

Fight or Flight Response

Dilated pupils Increased heart rate Dry mouth Tightening of muscles Increased need to urinate Increase in sweat – sweaty palms Increased adrenalin leads to tremors, shakiness

Panic Attack

Heart palpitations Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea of abdominal distress

Panic Attack (continued)

Feeling dizzy, unsteady, lightheaded or faint Feelings of unreality or detachment Fear of losing control or going crazy Fear of dying Numbness or tingling sensations Chills or hot flushes

Deep breathing will quickly bring these symptoms under control within a couple of minutes

Response to Trauma

General question: did the person just experience a traumatic event? (either as victim or witness)

Post-traumatic Stress Disorder (PTSD): an anxiety disorder that develops following a traumatic event, which includes a reliving of the event. The person vacillates between numbness and panic.

PTSD – cycling between feeling overwhelmed and feeling numb

Trauma is constantly relived Memories, nightmares, flashbacks Physiological reactivity

Avoidance of associations Avoidance of reminders Loss of memory Blunted feelings

Increased arousal Sleep difficulties Outbursts of anger hypervigilance

Clues

Hypervigilance (scans environment for danger, even in safe situations)

Easily startled by sudden noises Difficulties with sleep – nightmares Weight gain – not accounted for by diet or medication Avoidance of locations, people and things Nervous, on edge, jumpy, signs of anxiety Inappropriate sexual behaviors (as a consequence of

sexual abuse)

Treatment

Return to normal as soon as possible Art/movement therapy Group therapy for survivors of trauma Body work/relaxation techniques Psychotherapy Medications to address anxiety or depression

Thank You