LEARNING DISABILITY AND PSYCHIATRY

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LEARNING DISABILITY AND PSYCHIATRY

• Dr. Shosh Arbelle

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Definition of Learning Disability

• Reduced ability to understand new or complex
  information
• Difficulty in learning new skills
• May not be able to cope independently
• IQ lt 70 not sufficient on its own social
  functioning must also be impaired.
• Onset lt 18
• General population IQ 80-120

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Salient background information

• Total prevalence rate of mental health problems
  in LD is considerably higher than in the general
  population.
• 30 50 (Smiley, 2005).
• More children with complex health needs LD
  living into adulthood.
• Ageing LD population links with dementia /
  anxiety / mood disorders (Cooper, 1997).

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Common causes of LD

• GENETIC
• Chromosomal abnormalities
• Genetic abnormalities
• Inborn Errors of Metabolism
• NON - GENETIC
• Ante/Peri/Post-natal
• Nutritional / Toxic / Anoxia / Infection
  (maternal / child) / Trauma / Rhesus
  incompatibility
• Most causes not known

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Diagnostic features ICD 10 F 81.0 DSM IV 315.00

• Achievement on standardized tests is
  substantially below that expected for age,
  schooling and level of intelligence.
• The LD significantly interfere with academic
  achievement or activities on daily skills.

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Why is there a speciality of Psychiatry for those
with LD?

• Higher incidence of psychiatric disorders in
  those with LD
• More severe the LD - higher prevalence of
  psychiatric disorder.
• Difficulties in describing internal world
• Presentation of mental illness different, often
  because of problems with communication and
  understanding
• Special training for Psychiatrists
• Multidisciplinary working

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Differential Diagnosis

• Normal variations!!!
• Lack of opportunities, poor teaching
• Cultural factors
• Impaired vision or hearing
• MR
• Communication Disorders

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Associated features

• Demoralization, low self esteem, school dropout,
  poor social adjustment.
• ADHD
• MDD, Dysthymia, CD, ODD, PDD
• 20 from the above also have LD

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Complex interactions in LD
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Complex interactions in LD
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What are the problems in those with LD?

• Communication difficulties
• Medical / physical problems - (e.g. epilepsy,
  lead poisoning, FAS, Fragile X)
• Behavioral problems -often challenging
• Are these a manifestation of a treatable medical
  or psychiatric condition, or psychological
  reactions to environmental or interpersonal
  stress?

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Assessment

• HISTORY
• Depends on verbal communication and ability to
  describe internal world (feeling, thoughts,
  emotions)
• 3rd party information important
• Alternative methods of communication

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Exclude physical illness

• Pain
• Infection (ear, chest, UTI, teeth)
• Constipation
• Side effects etc.
• Investigations - e.g. Thyroid function
• Exclude epilepsy
• 1/3 of those with LD
• Complicated (pre/peri/post/ictal)

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Has something changed in the environment?

• Challenging behavior does not imply person is
  mentally ill - what is it telling us?
• Can be caused by change of staff/co-sharer/
  accommodation/routine etc
• MDT assessment
• Behavioral analysis - ABCs
• Predisposing/Precipitating/Perpetuating factors
• Behavioral Mx - e.g. reward systems

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Is there an underlying mental health problem?

• What are the mental health problems? (ICD10 DSM
  IV)
• Organic reversible (e.g. hypothyroidism)
• Schizophrenia
• Schizo-affective disorder
• Affective disorder
• Neurotic, stress-related and somatoform
  disorders
• ADHD, ODD, CD
• Pervasive Developmental Disorders - Autism

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Schizophrenia

• Definition
• characterised by fundamental and characteristic
  distortions of thinking and perception, and by
  inappropriate or blunted affect. Clear
  consciousness and intellectual capacity are
  usually maintained.
• Types - paranoid, hebephrenia, catatonia,
  residual
• Paranoia - persecutory, grandiose,
  jealousyCatatonia - increases muscle tone at
  rest, abolished by voluntary activity

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Definitions

• Delusion A false, unshakeable idea or belief,
  out of keeping with the patients educational,
  cultural social background it is held with
  extraordinary conviction and subjective
  certainty
• Hallucination A perception which arises in the
  absence of any external stimulus
• Blunting of affect Usual modulation of mood is
  lost patient lacks warmth, but doesnt convey
  the lowering of affect seen in severely depressed
  patients

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First Rank (positive) Symptoms

• Disorders of thought possession
• 1. Thought insertion/withdrawal
• 2. Thought broadcast
• Passivity phenomena
• 3. Emotions (made feelings)
• 4. Impulses (made impulses)
• 5. Sensations (made sensations)
• 6. Actsunder some outside influence

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1st Rank.

• Auditory hallucinations in which the person
  hears
• 7. His/her own thoughts echoed out aloud
• 8. Two or more people discussing or arguing
  about him/her in the 3rd person (now he is
  drinking tea)
• 9. Voices that form a running commentary on
  his/her behaviour
• A particular kind of delusional perception
• 10. A normal perception that is then interpreted
  with delusional meaning

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Negative Symptoms

• Social withdrawal
• Apathy
• Paucity of speech
• Blunting of affect
• Social drift (not due to medication/depression)

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Psychosis in LD

• Diagnosis difficult - difficulties in describing
  internal world
• Positive (hallucinations delusions) and
  negative symptoms
• Behaviors - paranoia, aggression, changes in
  energy, volition, social interaction, mood
• Clear consciousness

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Depression (Dysthymia)

• Core symptoms for at least 2 weeks
• Depressed mood
• Loss of interest (anhedonia)
• Reduced energy levels
• 3 core plus some/all of following
• Reduced concentration
• Reduced self esteem confidence
• Ideas of guilt worthlessness
• Bleak view of future
• Suicidal/self harm thoughts
• Disturbed diminished sleep
• Reduced libido

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Depression in LD

• Biological/somatic symptoms
• appetite reduced
• weight loss
• sleep disruption
• reduced concentration
• compulsive behaviors etc
• Agitation
• Withdrawal
• Apathy
• Grief reactions and bereavement

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Mania

• Elevation of mood
• For at least several days on end
• Increased energy and activity
• Marked feelings of wellbeing
• Physical mental efficiency
• Increased sociability, talkativeness, over
  familiarity, increased sexual energy
• Decreased need for sleep
• Irritability, conceit and boorish behaviour may
  replace euphoric sociability

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Hypomania / Mania in LD

• Elevation of mood
• Increased energy activity
• Increased sociability
• Disinhibition
• Reduced sleep
• Irritability/aggression

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Conduct Disorder

• Repetitive and persistent pattern of behavior in
  which the basic rights of others or social rules
  and norms are violated.
• Aggression to people or animals
• Destruction of property
• Deceitfulness, theft
• Serious violation of rules
• Clinically significant impairment

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Oppositional Defiant Disorder

• A pattern of negativistic, hostile and defiant
  behavior for at least 6 months
• Argues, loses temper, annoys people, blames
  others, angry and resentful
• Clinically significant impairment

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ADHD

• Inattention, Hyperactivity, Impulsivity
• Before age 7
• Symptoms in two or more settings
• Clinically significant impairment (social,
  academic, occupational)

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Neurotic, stress-related and somatoform disorders

• Phobias
• Anxiety
• OCD
• Social Problems
• PTSD (abuse)

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Pervasive Developmental Disorders

• Autism / Asperger Syndrome
• Starts lt age 3
• Triad of Impairment
• 1 Problems with communication2 Problems with
  reciprocal social interaction3 Restricted,
  repetitive, stereotyped behaviors,
  interests and activities.
• e.g. Rain man, eye contact, date of birth
• Structure, Routine Predictability

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Treatments for mental illness

• Biological / psychological / social
• Medications
• Same as general population -
• anti-psychotics, anti-depressants, anxiolytics,
  sedatives, mood stabilizers
• (Prescribe seclusion/time out)
• Start at lower doses - more prone to side effects

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Other / alternative therapies?

• Psychological therapies
• (e.g. cognitive behavioral therapy)
• Psychotherapy (Art Therapy, Music Therapy)

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And finally..

• Challenging and rewarding times ahead!