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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