Psychiatry of Intellectual Disability E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 881

Veröffentlichungsjahr: 2012

Beschreibung

Patients with intellectual disability (ID) can benefit from the full range of mental health services. To ensure that psychiatric assessment, diagnosis and treatment interventions are relevant and effective; individuals with ID should be evaluated and treated within the context of their developmental framework. Behavior should be viewed as a form of communication. Individuals with ID often present with behavioral symptoms complicated by limited expressive language skills and undiagnosed medical conditions. Many training programs do not include focused study of individuals with ID, despite the fact that patients with ID will be seen by virtually every mental health practitioner. In this book, the authors present a framework for competent assessment and treatment of psychiatric disorders in individuals with ID. Psychiatry of Intellectual Disability is a resource guide for psychiatrists, nurse practitioners, and other prescribers treating patients with ID. It is a supplemental text for psychiatry residents, medical students, psychology graduate students, psychotherapists, counselors, social workers, behavior support specialists and nurses. To assist the practicing clinician the book includes: * Clinical vignettes * Clinical pearls * Charts for quick reference * Issues concerning medications and poly-pharmacy * Altered diagnostic criteria specific for use with individuals with ID There are no evidence-based principles dedicated to psychotropic medication use in ID, but consensus guidelines address the high prevalence of poly-pharmacy. Altered diagnostic criteria have been published which accommodate less self-report and incorporate collateral information; this book reviews the literature on psychotropic medications, consensus guidelines, and population-specific diagnostic criteria sets. Psychiatry of Intellectual Disability also includes: * Interviewing techniques and assessment tips for all levels of communicative ability as well as for nonverbal individuals * Assessment of aggression to determine etiology and formulate a treatment plan * Overview of types of psychotherapy and suggested alterations for each to increase efficacy * Relevant legal issues for caregivers and treatment providers The detective work involved in mental health assessment of individuals with ID is challenging yet rewarding. The highest quality mental health treatment limits hospital days, improves quality of life and often allows individuals to live in the least restrictive environments. Psychiatry of Intellectual Disability is a must have resource for clinicians treating the ID population.

Leseprobe

Contents

Cover

Title Page

Copyright

Dedications

Editor Biographies

List of Contributors

List of Abbreviations

Foreword

Chapter 1: Overview

The History of Intellectual Disability and Mental Illness

The Reformers

Current Treatment Recommendations

Prevalence and Classification

Current and Proposed Diagnostic Criteria for ID

Current Trends in Nomenclature

“People First” Language

The Interface between Intellectual Disability and Mental Illness

References

Chapter 2: Psychiatric Assessment

Overview

Managing the Interview

Obtaining the History (Adapted from Levitas & Silka, 2001)

Standardized Assessment Instruments

Mental Status Examination: Modifications and Interpretation for Persons with ID

Differential Diagnosis and Diagnostic Overshadowing

Personality Factors, Personality Disorders and Substance use Issues in Persons with ID

Stressful Life Events and Exaggeration of Baseline Symptoms (Based on Hurley, 2001)

Conclusion

References

Chapter 3: Medical Assessment

Introduction

Syndrome-Specific Medical Conditions

Primary Care Evaluation and Preventive Health Planning

Making Decisions About Additional Laboratory Testing

Medication Side Effects

More Common and Less Common Conditions in the General ID Population

Organ System Review

Conclusion

References

Chapter 4: Neurologic Conditions

Introduction

Dysmorphic Features

Neurocutaneous Stigmata

Abnormal Head Circumference

Neurological “Soft Signs”

Special Features of the Neurological Examination in Patients with ID

The Management of Spasticity

Assessment and Treatment of Neuroleptic-Induced Movement Disorders

Seizure Disorders

Conclusion

References

Chapter 5: Traumatic Brain Injuries and Co-occurring Mental Illness

Introduction

Similarities and Differences between Patients with TBI as Compared with Patients with Intellectual Disability

Overview of TBI: Definitions, Classification and Epidemiology

Common Mental Health Presentations Following TBI

Patients with Traumatic Brain Injuries and Co-occurring Mental Illness

Assessment and Treatment Options

Conclusion

References

Chapter 6: Interviewing Techniques

Introduction

Levels of Intellectual Disability

Expressive and Receptive Language Skills: Disparity

Setting the Stage for the Interview

Cognitive Processes in the Context of Developmental Framework and How this can Affect the History

Intellectual Distortion, Psychological Masking, Cognitive Disintegration, Baseline Exaggeration

Formal Mental Status Examination

Mild ID and Concrete Operations: Interpreting Mental Status Examination Findings

Moderate ID and the Preoperational Stage: Interpreting Mental Status Examination Findings

Individuals with Severe/Profound ID (Nonverbal Communication): Interpreting the Mental Status Examination

Personality Traits that can Influence Interview Behavior

Three Disorders with Syndrome-Specific Language and Communication Strengths and Weaknesses

Useful Guidelines for Speaking with Patients with ID

Perseveration

Subvocalizations

Acquiescence

Decreased Attention Span

Serial Order Effects/Last Choice Responses

Memory Issues

Responsiveness

Social Skills

The Role of Open-Ended Questions

Medical Problems

Sensory Deficits

Sensory Hypersensitivity

Assistive Devices

Expressed Emotion

Cultural Awareness and Sensitivity

Attitude of the Interviewer

Interviewing the Victim, Witness or Suspect with ID (see also Chapter 15)

Conclusion

References

Chapter 7: Mood Disorders

Introduction

Major Depressive Disorder in ID

Bipolar Disorder in ID

Conclusions

References

Chapter 8: Anxiety Disorders

Introduction

Prevalence Rates of Anxiety Disorders

Presentation of Anxiety Disorders in the ID Population

Panic Disorder

Obsessive Compulsive Disorder (OCD)

Post-Traumatic Stress Disorder (PTSD)

Generalized Anxiety Disorder (GAD)

Treatment: Pharmacologic Interventions and Psychotherapy

Summary

References

Chapter 9: Psychotic Disorders

Historical Perspective

Prevalence

Diagnosis

Encountering the Push for Medication

Differentiating Problem Behaviors from Psychotic Illnesses

Differentiating Self-Stimulation from Psychotic Illness

Exclusion from Scientific Literature

Diagnostic Manual-Intellectual Disability (DM-ID)

Schizophrenia

Schizophreniform Disorder

Schizoaffective Disorder

Delusional Disorder

Brief Psychotic Disorder

Shared Psychotic Disorder (Folie à Deux)

Psychotic Disorder Due to a General Medical Condition

Substance-Induced Psychotic Disorder

Psychotic Disorder not Otherwise Specified

Treatment of Psychotic Disorders

Summary

References

Chapter 10: Personality Disorders

Introduction

Prevalence

Assessment

Issues Regarding Personality Disorder Diagnosis in Persons with ID

Borderline Personality Disorder

Histrionic Personality Disorder

Antisocial Personality Disorder

Principles of Treatment for Personality Disorders

Conclusion

References

Chapter 11: Aggression

Introduction

Prevalence Rates: Review of the Available Evidence

Correlates of Aggression in Persons with ID

Auto-aggression (Self-Injurious Behavior)

Comorbidity

Cognitive Processes

Mood and Anxiety Disorders and Aggression

Psychotic Disorders and Aggression

Syndromes Associated with SIB

Static and Dynamic Risk Factors for Aggression

Life Transitions and Aggression

The Biopsychosocial Model

Multimodal Model of Assessment

Emergency Assessment of Aggression in the Person with ID

Comprehensive Ongoing Assessment and Management of Aggression in Community and Residential Settings

Non-Pharmacological Intervention Strategies for Aggression

Pharmacologic Interventions for the Treatment of Aggression

Summary: A Comprehensive Approach to the Chief Complaint of Aggression – Detective Work and Problem Solving

Conclusion

References

Chapter 12: Psychotropic Medications

Introduction

Historical Review of Psychotropic Medication Guidelines

Non-Pharmacological Interventions

Reasons for Pharmacological Intervention

General Principles for the Use of Antipsychotic Medications in the ID Population

Anticonvulsants and Mood Stabilizers

Antidepressants and Anxiolytics

Expert Consensus Guidelines and Other Documents by Prescribing Authorities

References

Chapter 13: Psychotherapy

Introduction

Issues Related to the Presence of ID

Examples of Treatment Approaches

Barriers to Treatment

Communication Issues

Issues Relating to Learning and Memory

Types of Psychotherapy

Psychotherapy Topics and the ID Population

Summary

References

Chapter 14: Behavioral Assessment and Interventions

Introduction

Behavioral Assessment

Behavior Versus Psychiatric Problem

Behavioral Intervention

Antecedent Control

Focus on Consequences

Training, Implementation and Monitoring of Behavior Support Plans

Coordination of Behavior Support Services with other Interventions

Keys to Successful Coordination

References

Chapter 15: Legal Issues for Treatment Providers and Evaluators

Introduction

Part I Law Related to the Mental Health treatment of Persons with Intellectual Disability

Part II Legal Questions Requiring Evaluation of Persons with Intellectual Disability

Conclusion

References

Chapter 16: Syndromes of Intellectual Disability

Introduction

Down Syndrome

Williams Syndrome

Fetal Alcohol Spectrum Disorder

Fragile X Syndrome

Autism Spectrum Disorders

Summary

References

Index

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Dedications

Dr. Gentile would like to dedicate this book to her husband John for his extraordinary love and support; to her daughters Sarah and Jess and her son-in-law Sayre for being sources of inspiration and pride every day; and to her parents Charlie (RIP) and Patricia, who always believed the sky was the limit. She would like to thank her patients with intellectual disability, and the people who stand with them, for being true survivors.

Dr. Gillig would like to dedicate this book to the memory of Uncle Al Petre, Peter Reilly and Patty Whibbs, childhood friends with intellectual disabilities. We had some good times.

Editor Biographies

Julie P. Gentile,M.D. (jen-TILL-ee) is Associate Professor of Psychiatry at the Boonshoft School of Medicine, Wright State University, Dayton, Ohio and the Project Director/Primary Investigator for Ohio's Coordinating Center of Excellence in Mental Illness/Intellectual Disability. She has been the Professor of Dual Diagnosis for the Ohio Department of Mental Health, the Ohio Department of Developmental Disability and the Ohio Developmental Disabilities Council since 2003, and the Medical Director for both the Montgomery County Board of Developmental Disabilities Mental Health Program and Consumer Advocacy Model (treating patients with traumatic brain injury, substance use, and mental illness). Dr. Gentile has evaluated more than 2,000 individuals with co-occurring mental illness and intellectual disability. She is the recipient of the American Psychiatric Association's Frank J. Menolascino Award for Excellence in Psychiatric Services for Developmental Disabilities, the Excellence in Contributions to Clinical Practice Award from the National Association for the Dually Diagnosed, and she is a member of Alpha Omega Alpha Medical Honor Society. She is a recipient of the Faculty Mentor Award, the Golden Apple Teaching Award, the Career Achievement Award, the Outstanding Achievement in Medical Education and Research Award of the Academy of Medicine, and the Nancy Roeske Award in Medical Education from the American Psychiatric Association. Dr. Gentile has been awarded more than $3,000,000 in grants and contracts to support her work in dual diagnosis since 2003. She is the Director of Medical Student Mental Health Services at Wright State University, is a member of the editorial board for the journal Innovations in Clinical Neuroscience and has published articles and book chapters on various topics in the area of co-occurring mental illness/intellectual disability.

Paulette Marie Gillig, M.D., Ph.D. is Professor of Psychiatry at the Boonshoft School of Medicine, Wright State University, Dayton, Ohio and on the Faculty of the Graduate School. She has been Ohio Department of Mental Health Professor of Rural and Underserved Populations since 1998, is listed in Best Doctors in America, Who's Who in America, Who's Who in the World, is Distinguished Fellow of the American Psychiatric Association and is a member of Alpha Omega Alpha Medical Honor Society. She also is a member of the Society of Neuroscience and the Russell DeJong Society. She is a recipient of the Faculty Mentor Award and the Golden Apple Teaching Award, the Outstanding Achievement in Medical Education and Research Award of the Academy of Medicine, and the Nancy Roeske Award in Medical Education from the American Psychiatric Association. Dr. Gillig has published three books and over 60 articles and book chapters in the several areas of Community (Public) Psychiatry, Psychotherapy, and the Interface between Psychiatry and Neurology. She is the Section Editor for the journal Innovations in Clinical Neuroscience. She has completed residencies in both neurology and in psychiatry and she also holds a doctorate in Social Psychology in the area of cognitive processes. She is the past Area 4 representative to the American Association of Community Psychiatrists and Chair of the Training Committee. She was the Chair of the Committee on Minorities and Under-represented Groups for the Ohio Psychiatric Association, and a member of the Committee on Poverty and Homelessness of the American Psychiatric Association.

List of Contributors

Betsey A. Benson, PhD

Associate Professor, The Ohio State University, Columbus, Ohio, USA

Kelly M. Blankenship, MD

Assistant Professor, Indiana University, Indianapolis, Indiana, USA

Allison E. Cowan, MD

Assistant Professor, Wright State University, Dayton, Ohio, USA

Jeannette Cox, JD

Associate Professor, University of Dayton School of Law, Dayton, Ohio, USA

Gretchen N. Foley, MD

Assistant Professor, Wright State University, Dayton, Ohio, USA

Julie P. Gentile, MD

Associate Professor, Wright State University, Dayton, Ohio, USA

Paulette Marie Gillig, MD, PhD

Professor, Wright State University, Dayton, Ohio, USA

Carroll S. Jackson, LISW-S

Montgomery County Board of Developmental Disabilities, Dayton, Ohio, USA

Christopher T. Manetta, DO

Kirtland Air Force Base Medical Facility, Kirtland AFB, New Mexico, USA

Michelle A. Monro, DO

Edwards Air Force Base Medical Facility, Edwards AFB, California, USA

Ann K. Morrison, MD

Associate Professor, Wright State University, Dayton, Ohio, USA

Richard Sanders, MD

Associate Professor, Wright State University, Dayton, Ohio, USA

Christina G. Weston, MD

Associate Professor, Wright State University, Dayton, Ohio, USA

List of Abbreviations

AOCaltered consciousnessAPDantisocial personality disorderARNDalcohol related neurodevelopmental disorderBDbipolar disorderBPDborderline personality disorderBPSbiopsychosocialCBTcognitive behavioral therapyCDCCenter for Disease ControlCTcomputerized tomographyDBTdialectical behavior therapyDC LDDiagnostic Criteria – Learning DisordersDM-IDDiagnostic Manual – Intellectual DisabilityDSDown syndromeDSM-IV-TRDiagnostic and Statistical Manual, Fourth Edition Text RevisionDZdizygoticEDemergency departmentEEGelectroencephalogramEKGelectrocardiogramEPSextrapyramidal side effectsFAEfetal alcohol effectsFASfetal alcohol syndromeFASDfetal alcohol syndrome disordersFGAfirst generation antipsychoticFMR1Fragile X Mental Retardation 1 geneFXSFragile X syndromeFXTASFragile X tremor ataxia syndromeGABAgamma Aminobutyric acidGADgeneralized anxiety disorderGCSGlasgow Coma ScaleGMCgeneral medication conditionHPDhistrionic personality disorderIDintellectual disabilityIQintelligence quotientLDlearning disorderLOCloss of consciousnessMDDmajor depressive disorderMImotivational interviewingMRImagnetic resonance imagingMZmonozygoticNADDNational Association for the Dually DiagnosedNOSnot otherwise specifiedOCDobsessive compulsive disorderODDoppositional defiant disorderPDpersonality disorderPDDpervasive developmental disorderpFASpartial fetal alcohol syndromePTApost-traumatic amnesiaPTSDpost-traumatic stress disorderPWSPrader-Willi syndromeSAPStructured Assessment of PersonalitySGAsecond generation antipsychoticSIBself-injurious behaviorSPsupportive therapySSIsupplemental security incomeSSDIsocial security disability incomeSSRIselective serotonin reuptake inhibitorTBItraumatic brain injuryWSWilliams syndrome

Foreword

The field of Intellectual Disabilities (ID) is expanding along many fronts. Over the last 20 years, community-based placement has come to replace large residential facilities in many states. This transformation accompanied changes in treatment models, especially the legal and ideological shifts away from custodial to more active treatment programs. During this era, increased demands for community programs required a major restructuring of services to deal with many of our most complicated and difficult to treat patients. Adequate staffing and integration of complex services needs proved to be one of our greatest challenges- especially the gaps between availability and access to quality care and sociocultural-bound beliefs and values that might hinder utilization by the target population.

In part, availability and access to adequate care is often limited by maldistribution of qualified professionals, fragmentation of health care systems and persistent problems merging mental health and intellectual disability services. These are especially thorny issues since many of these individuals have either major problems with co-existing medical/neurological disorders, severe challenging behaviors or mental disorders. When specialized services are not available, any combination of these variables may overwhelm community programs and in many situations circumstances may jeopardize community placement. These challenging individuals seriously tax community resources and as a result finish up with multiple psychotropic medications or with an excessive reliance on acute hospitalization. In many cases these individuals end up in a pattern of revolving door admissions to mental health facilities. As a result, we are in the midst of a second psycho-pharmacological revolution; this one is generated by the increased overuse of polypharmacy that is due in part to limited clinical and behavioral management resources.

Over 25 years ago, the idea that individuals with ID might also be at risk for psychiatric disorders was clouded by many layers of diagnostic overshadowing. In addition, it became apparent that many individuals with ID did not fit either the standard psychiatric models of etiology or descriptive phenomenology, and therefore required modifications in the standard psychiatric evaluation and assessment. In the mid 1980s, the National Association for the Dually Diagnosed in the US attempted to remedy this confusing situation by providing direct training and educational programs designed for clinicians and direct care personnel in the field. In 2007, this Association published the Diagnostic Manual-Intellectual Disabilities. This two-volume edition modified and adapted the already existing DSM-IV-TR diagnostic criteria (American Psychiatric Association, 2000). These modifications, along with the ICD-based Diagnostic Criteria-Learning Disability already available, promoted a modified descriptive and categorical classification system for the field of dual diagnosis. The DM-ID provided a starting place for improvements in clinical treatment using evidence and best practice-based diagnostic criteria.

This book edited by Drs. Gentile and Gillig is grounded in our growing understanding of the complex neurodevelopmental and biopsychosocial substrates for challenging behaviors and mental disorders. The authors provide abundant evidence for the value of criteria-based diagnosis and treatment planning founded on scientific evidence and our growing integration of genetics, behavioral neurosciences and neuropharmacology with psychosocial/behavioral therapies. Our biggest challenge is to keep our assessment and treatment approaches in step with the rapidly changing scientific evidence. One example of this problem is the difficulty we all face dealing with the rapid pace of change in our understanding of neurobiology of major psychiatric disorders. We now confront molecular genetics, intracellular mechanisms that are replacing our previous reliance on neurotransmitter models, behavioral neuropharmacology and genomics of drug metabolism and mechanisms of action, developmental changes that point to gene-environmental and epigenetic interactions rather than our older over-simplified models of nature versus nurture, neuro-endocrinological and neuro-immunological factors that influence brain function and psychopathology. If this isn't enough, we confront a second conundrum-dealing with the clinical heterogeneity and complex developmental neurobiology of ID.

The authors of this edition focus on integrating biopsychosocial models. In keeping with the medieval position taken by Bernard of Chartres and later borrowed by Isaac Newton: we make progress “by standing on the shoulders of giants” who came before us. This book is a testament to their vision and efforts. Their challenge to us is take the new knowledge gleaned from our marvelous technical and scientific research and integrate neurosciences into a person-centered, positive support program that provides humane care. This book reminds us how we might accomplish this.

Jarrett Barnhill MD DFAPA, FAACAPUniversity of North Carolina School of Medicine

Chapter 1

Overview

Allison E. Cowan, MD, Assistant Professor, Wright State University, Dayton, Ohio

Julie P. Gentile, MD, Associate Professor, Wright State University, Dayton, Ohio

The History of Intellectual Disability and Mental Illness

The history of individuals with mental illness and intellectual disability (ID) is profoundly intertwined. Due to a lack of effective treatments, both groups have long occupied a status of “otherness” and have been relegated to the fringes of society. Individuals with ID and those with mental illness had to rely on support from the community if their families were unable or unwilling to care for them. Throughout history, such individuals have been diagnosed together as “mental defectives,” have been treated or housed in asylums and have been singled out as somehow “less than human” or less deserving of the same rights and treatment as other individuals.

In more recent times, progress has been made in returning rights, choices and lives of their own making to individuals with ID and mental illness. There remains, however, a paucity of historical writings about people with a combination of both ID and mental illness. An overview of their separate histories and the subsequent development of the concept of dual diagnosis will serve as an appropriate starting point for Psychiatry of Intellectual Disability.

In prehistory, individuals with mental illness and ID were reliant on family and social structure. The earliest treatment of mental illness was likely through shamanism, spirituality and superstition, using herbs, rituals and amulets. From observations documented in the fossil record, other techniques were found, including psychosurgery. For example, Neolithic humans used trepanation – the drilling of circular holes in the skull – to release evil spirits that were thought to cause mental illness. The practice of trepanation has been observed across varying cultures and geographical regions. For example, the Incans of Peru (Arnott et al., 2002) and the Native Americans of North America (Stone et al., 1990) performed trepanation, with most cases living long enough for the bones of the skull to heal. The great classical physicians Hippocrates and Galen used trepanation to treat phlegmatous lesions of the brain (Missios, 2007). There exists a painting by the Dutch Renaissance painter Hieronymus Bosch called “Extracting the Stone of Madness” that indicates that psychosurgery also was performed to alleviate mental illness.

The etiology of mental illness remains a mystery even now. The Judeo-Christian tradition teaches that disobedience to God will result in being cursed with madness, saying, “God will smite thee with madness” (The Holy Bible, King James Version, 1611). In the Hindu faith, a person suffering from schizophrenia would be treated by removing toxins presumed to be causing the illness in order to restore harmonious balance and mental health (Progler, 2008). Hippocrates also believed that mental illness resulted from an imbalance in the bodily humors, rather than a divine cause. He recommended that the body be allowed to restore itself, as opposed to using more invasive procedures and medicines.

Individuals with more severe intellectual or other disabilities historically did not survive into adulthood. In ancient times, infants who were considered “deformed” were often killed through what was called “exposure” (Bennett, 1923), in which the infant was abandoned outside, presumably to perish. Aristotle (Kraut, 1998) recommended, “Let there be a law against nourishing those [infants] that are deformed.” Sparta, a culture infamous for rates of infanticide, had a process wherein the infant was brought for official inspection for “defects” and was abandoned if found to be “defective.” Soranus of Ephesus, a 2nd Century C.E. physician, listed criteria that made an infant “worth rearing,” which included having a healthy mother, being full-term, crying with vigor, being perfect in all its parts and having the right size and shape (Patterson, 1985). Soranus did, however, advocate for the humane treatment of persons with mental illness, recommending rest, sympathy and reading (Scheerenberger, 1983). He wrote: