Mental Health Issues in Psychiatry of

Intellectual Disability

Dr. Tareq GhaniIntellectual Disability

Bawnmore, Brothers of Charity, Limerick

Mental Illness & Life

Introduction

“You treat a disease, you win, you lose. You treat a person, I

guarantee you’ll win, no matter what the outcome”.

-Patch Adams (1998)

Mental Illness & Intellectual Disability

•People with ID are at least as susceptible to mental health problems as the rest of society

•Often times, their problems remain undetected because the symptoms can be lost amongst the various other behaviors which they may exhibit

•Thus, its essential to be as aware as possible of potential mental health problems and to get them assessed and treated with minimum delay

What is Mental Illness?

The essential feature of mental illness is a clinically recognizable set of symptoms or behaviors,

Usually associated with distress and interference in personal functioning

Psychiatric Conditions Common In Persons With Intellectual Disability

• Non-Affective Psychotic Disorders

• Affective Psychotic Disorders

• OCD

• Dementia

Non-Affective Psychotic Disorders

• Includes:

• Schizophrenia

• Persistent delusional disorders

• Acute and Transient Psychotic Disorders

• Persistent Hallucinatory Disorders

Schizophrenia

• A chronic and severe mental disorder that affects how a person thinks, feels, and behaves

• People with schizophrenia may seem like they have partially or completely lost touch with reality.

• Although not as common as other mental disorders, the symptoms can be very disabling.

Signs and Symptoms•Start between ages 16 and 30. In rare cases, children have

schizophrenia too

•Fall into three categories: • Positive • Negative• Cognitive

Positive Symptoms

• People with positive symptoms may “lose touch” with some aspects of reality

• Symptoms include:• Hallucinations: Auditory or Visual• Delusions: fixed belief that is clearly false

• Can range from bizarre to realistic

• Disorganized/Bizarre Speech or Behaviour • represents a noticeable change from individual’s typical functioning

Negative Symptoms • Associated with disruptions to normal emotions and behaviours

• Symptoms include:• “Flat affect” (reduced expression of emotions via facial expression or

voice tone)• Reduced feelings of pleasure in everyday life• Difficulty beginning and sustaining activities• Reduced speaking

Cognitive Symptoms • For some patients, the cognitive symptoms of schizophrenia are subtle,

but for others, they are more severe and patients may notice changes in their memory or other aspects of thinking

• Symptoms include:• Poor “executive functioning” (the ability to understand information and

use it to make decisions)• Trouble focusing or paying attention• Problems with “working memory” (the ability to use information

immediately after learning it)

What is a Delusion?

False beliefs, that are held to a firm unshakeable extent

Types Of Delusions Erotomanic Type: Delusionsthat another person, usually of higher status, is in love with the individual

Somatic Type: Delusions that the person has some physical defect or general medical condition

Grandiose Type: Delusions of inflated worth, power, knowledge, identity or special relationship to a deity of famous person• Jealous Type: Delusions that individual’s

sexual partner is unfaithful • Persecutory Type: Delusions that the

person (or someone to whom the • person is close) is being malevolently

treated in some way

Mixed Type: Delusions characteristic of more than one of the above types but no one theme predominates

Unspecified Type: persecutory and jealous types are most common and Erotomanic and somatic types are most unusual

Psychosis In People With Intellectual Disabilities

• Key component of psychosis is based on internal experiences and their description

• Cannot reliably diagnose in people who are non-verbal and/or those with low-Moderate/Severe/Profound ID

• Higher prevalence in ID than in general population: • 1-3% vs. 2-4.4% (2005)

What’s Different Among People With Id?

Delusions:

• More likely to be mundane in nature

• May include new avoidance or new fears

• Irrational beliefs not expressed before

• Glaring with intense anger at strangers or previously liked others

• Sudden medication refusal

What’s Different Among People With Id?

Hallucinations:

• Auditory most common (voices)

• Similar to rate in general population but people with ID are more likely to report symptoms

• More likely to observe interaction with hallucinations

• May include agitation or SIB in response to hallucinations

• May see covering of eyes or ears to ‘block out’ hallucinations

• May include sniffing the air, as if smelling something not smelt by others

Symptoms Not Indicative Of Psychosis

• There are some symptoms which, although sometimes dramatic in presentation, are almost never indications of psychosis.

• Volitional self talk and self answering• Shouts and screeches are almost always vocal tics• Symptoms which are modelled by others and are very clearly being copied.• Gestures that the person can start and stop at will or when asked to start and

stop.• Gestures and vocalizations which have been explicitly taught to the person

What Do Some People With Psychosis Go Through?

• http://www.youtube.com/watch?v=SN1GCoVzxGg

Affective Disorder: Depression

Depression may be easily misdiagnosed or under-diagnosed

Depression • Symptoms to observe for:

• Failure to maintain the persons usual mood state through the day• Irritability • Reduced level of tolerance• Physical or verbal aggression in response to minor things that the person

would usually tolerate • Loss of interest or pleasure in previously enjoyed activities• OR Social Withdrawal• OR Reduction of self-care • OR Reduction in quantity of speech

Depression

•What to consider before we even think its depression?

• Drug Induced

• Hypothyroidism

• Other physical causes

Drug Induced Causes

High-dose caffeine or ephedrine

nervousness , panic-like symptoms ,

frank psychosis , or mania

NSAIDs (i.e. Ibuprofen)

elicit depressive symptoms and

paranoia in patients with prior psychiatric

diagnosis

Other common causes • Neurological Disorders

• Multiple Sclerosis• Brain tumours.• Complex partial seizures• Strokes

• Endocrine Disease/Metabolic abnormalities• Hypo/hyperthyroidism, Adrenal hypofunction • Hyperparathyroidism• Hyponatraemia• Hypokalaemia

Depression (Additional Features)

• Additional symptoms :

• Loss of energy

• Increased reassurance-seeking behaviour, anxiety or fearfulness

• Increased tearfulness

• Increase in somatic symptoms/physical complains , preoccupation with physical

illness, repeatedly showing different parts of the body for the carer to check

• Poor concentration or increased indecisiveness

• Onset of sleep disturbance

Affective Disorder: Manic Episode

Manic Episode • Symptoms to observe for:

• Abnormally elevated, expansive or irritable mood (physical or verbal aggression)

• Over-activity, increased energy

• Increased talkativeness or vocalization

• Flight of ideas

• Inappropriate social behaviour – engaging in non-sexual bodily functions in public, over-familiarity, intrusiveness)

• Reduced sleep

• Increased self-esteem

• Reduced concentration

• Reckless behaviour – excessive spending, giving away belongings

• Increased libido

Manic Episode

•Before considering a diagnosis of manic disorder, think of:

• Drug-induced causes (i.e. Steroids)

• Hyperthyroidism

Mixed-affective State

• Rapid alteration of symptoms that would meet the criteria for both depressive

episode and manic episode and changes every few minutes to hours

• Must be present nearly every day for at least two weeks

Dementia

Dementia

•What to consider before thinking Dementia: • Rule out depression • Rule out hypothyroidism, infection, folate and B12 deficiency• Assess for hearing impairment, visual impairment

• cataract or conditions such as keratoconus is common in individuals with Down’s syndrome

• Rule out malignancy such as leukaemia, joint problems of neck, knee or hip and sleep apnoea

Drugs and Pseudo-dementia

Down Syndrome and Dementia

How often to monitor?

• The frequency of prospective monitoring for dementia should be

matched to the rising risk with age.

• For example, the baseline assessment should take place at 30

years; then every two years for those in their 40s; and annually

for those aged 50 and over.

Impact of Life Events

• People with intellectual disabilities in their middle age can face a number of life events such as loss of a parent or long-term carer, moving away from home or loss of day activities.

• In some individuals, the impact of life events may lead to a regressive state with apparent loss of skills.

• Changes in routine such as new structure to day opportunities or changes in support staff can cause profound reactions in an individual with intellectual disabilities leading to functional decline and a dementia- like presentation.

Epilepsy in Persons with Intellectual Disability

The prevalence rate of epilepsy amongst people with learning disabilities

(IQ<70) has been reported as 26% (Kerr et al. 2009), compared to prevalence

rates for the general population of 0.4%-1% (Chadwick, 1994)

Implications of Epilepsy in Persons with Intellectual Disability

• Not only is epilepsy more common in those with ID than in the rest of the population: it tends to have a worse prognosis, with lower rates of seizure freedom.

• There is a high rate of multiple antiepileptic drug use, incurring more side-effects

• Adults with ID and epilepsy have high rates of morbidity and mortality,

including sudden unexplained death in epilepsy (SUDEP)

Physical Health

• Management of weight

• Management of pain

• Management of sleep

• Management of epilepsy

• Management of medication

What Can I Do To Help?

• Help with record keeping and monitoring of symptoms and bring these documents to the treating professionals.

• Think about how you’ve successfully coped with stress, and try to teach/encourage them to do the same.

• Know that change takes time, and appreciate small steps and successes.

• Praise the person for any small steps they make and remind them of this if/when they get down.

• Make a ‘brag book’ so they can look at it often

Other Strategies That Can Help

• Do not argue or try to reason with the person about the validity of hallucinations/delusions Instead, remain supportive, listen to their concerns, and identify how that might make you feel if you had that experience.

• Offer suggestions for how to deal with that feeling (ex., fear, sadness, anger, etc.)

• Offer safe distractions and soothing alternatives to help de-escalate the person and redirect their attention

More That You Can Do

• Remind the person of strategies that have worked for them in the past (a few hours ago, yesterday, last week, last month…).

• Pointing out their successes can be helpful.

• Physical exercise can be helpful.

• Learn and practice proper sleep hygiene and nutrition

• Encourage them to avoid substance use/abuse

• Minimize known stressors in the environment whenever possible

SELF-CARE IS IMPORTANT TOO

If you are feeling stressed, get support for yourself!

Don’t try to handle everything on your own.

 "You'll never find any gold if you don't go looking' for it”