Dual Diagnosis: A Brief Overview

1. Dual Diagnosis:A Brief Overview

2. Psychiatric Disorders in Mentally Retarded Adults • same range of behavioral and emotional problems as non-disabled adults • Overshadowing • MENTAL RETARDATION IS NOT MENTAL ILLNESS

3. 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

4. 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

5. 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

6. Detective Work • Use of intuition and hunches • Detectives on behalf of our consumers

7. Externally directed behaviors aggression irritability disorganized speech Internally directed behaviors depression stress/nervousness withdrawal Communicating with Behavior

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Arriving at a diagnosis • Work from a big perspective toward details • begins with hunches • Work from details toward an overview • begins with observation

15. 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?

16. 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)

17. 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

18. Overview: Disordered Thinking General question: is this person not making sense? (more so than usual) Schizophrenia: a disorder characterized by distortions of reality

19. 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

20. 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)

21. 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

22. 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

23. 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)?

24. Treatment • Usually medications: newer meds are called “atypical antipsychotics” – they affect more neurotransmitter systems • Risperdal • Zyprexa • Closaril • Seroquel • Geodon • Abilify

25. 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

26. 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

27. 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

28. Treatment • Usually medications such as Depakote and Neurontin. • Lithium is still used and appropriate • Use of antidepressants can precipitate a manic attack

29. 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

30. 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

31. Treatment • Talk therapy or play therapy • Art, music, dance therapy • EXERCISE • Medications (usually the SSRIs)

32. 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.

33. 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

34. 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

35. Treatment • Medications: SSRIs such as Paxil, Buspar, Benzodiazepines (addictive) • Relaxation techniques – deep breathing • Walking or other aerobic exercises • Removal of stressor

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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)

42. 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

43. Thank You