McDD Guidance by Understanding Dr. Gerard J. Nijhof • Orthopedagogue / clinical psychologist • Master and PhD, Free University Amsterdam • Current occupation at Amsta, Amsterdam, department for people with intellectual disabilities • [email protected] McDD Multiple complex Developmental Disorder Contents Case: Pierre McDD: symptoms McDD and Autism: differences and similarities McDD and Schizophrenia Treatment Case: Pierre Pierre - 1 • • • • Pierre is a boy of 18 years old. Very anxious, he wants to stay at home. Sometimes he is flooded with fear and panic. Often he is in a good mood, but this can rapidly change into a state of high irritation. • He fears people who (in his fantasy) ‘have a gun. behind their back’, he avoids other people. Pierre - 2 • He doesn’t have friends – ‘friends do not understand what is really happening’. • He doesn’t understand the nature of social interactions very well. • For him his ‘men with guns’ fantasy is a reality. • He thinks he is the only person who can save his family. Pierre - 3 • Pierre has to learn how to handle - his mood swings - his anxiety - his fantasies • When he can master his mood swings, anxiety and fantasies, his outlook is much better. Classification • McDD: no separate DSM-IV entry; • McDD is classified as PDD-NOS most of the time. Symptoms McDD: developmental disorder. Symptoms - three different groups: 1. Regulation of affective state 2. Social behaviour and sensitivity 3. Cognitive processing 1. Regulation of affective state Regulation of affective state - 1 • Intense generalised anxiety, diffuse tension, or irritability. • Unusual fears an phobias that are peculiar in content or intensity. • Recurrent panic episodes, extremely frightened, or flooded with anxiety. Regulation of affective state - 2 • Episodes of behavioural disorganisation or regression - with immature and primitive behaviour (sometimes self injurious), lasting from minutes to days. • High amount of mood swings, often out of line with a certain cause. • High frequency of idiosyncratic anxiety. reactions. This means anxiety reactions which are strange, bizarre and very individual. 2. Social behaviour and sensitivity Social behaviour - 1 • • • • • Impairments in sensitivity to social signals Impairments in social reciprocity. Social disinterest. Detachment, no emotional involvement. Avoidance or withdrawal of social engagement, particularly with adults. Social behaviour - 2 • Attachments may seem friendly and cooperative, but are very superficial, aimed primarily on receiving material needs. • Inability to initiate or maintain peer relations, leading to isolation. • Disturbed attachments displaying high degrees of ambivalence, particularly to adults (parents / caregivers). This is manifested by clinging, overly controlling and wanting behaviour. Social behaviour - 3 • ‘Shifting’ or aggressive behaviour. Oppositional behaviour towards parents, teachers and therapists. • Profound limitations in empathy. • Profound limitations to ‘read’ or understand others thoughts and feelings. 3. Cognitive processing (thinking disorder) Cognitive processing, thinking disorders - 1 • Thought problems out of proportion with mental age. • Irrationality, sudden intrusions on normal thought processes. • Magical thinking. • Neologisms (new words) or nonsense words, often repeated over and over again. • Bizarre ideas, intentional or non intentional, without worrying what others think of it. Cognitive processing, thinking disorders - 2 • Very typical: confusion between reality and fantasy. • Perplexity, easily being confused. Trouble with understanding social processes and keeping one’s thoughts straight. • Delusions (something a person believes to be true because they want it to be true, when it is actually not true). Cognitive processing, thinking disorders - 3 • Fantasies of omnipotence. Thinking they can do the impossible. • Paranoid preoccupations (i.e. ‘everybody is looking at me’). • Over engagement with fantasy figures. • Grandiose fantasies (i.e. having special powers). McDD and Autism Differences and similarities McDD and Autism - 1 • McDD: characterized by anxiety and reactions to anxiety (= affective part of the disorder). • Autism: shows a perseverative way of thinking and acting. • McDD: rapid mood swings and extreme reactions (sudden temper tantrums). • Autism: this is less recognizable. McDD and Autism - 2 Both Autism and McDD are characterized by many problems in the social realm, especially when more people are involved. McDD: it can be confusing that people with McDD sometimes function quite well in individual interaction with a doctor or a psychologist. Autism: we do not find this in the same way with autism. McDD and Autism - 3 Both in McDD and Autism there are problems with inadequate social behaviour. McDD: People with McDD can show adequate and inadequate social behaviour. This depends on the intensity of the flooding of thoughts and emotions. Autism: People with autism are continuously embarrassed in the social domain which can cause anxiety that leads to aggression. McDD and Autism - 4 McDD: For people with McDD social behaviour is restricted by interferences of - thought disorders - intensity of emotions - lack of regulation of emotions Autism: People with Autism can be characterized by having ‘theory of mind’ problems. It is one of the reasons for their restricted social functioning. Theory of mind • The ability to take into account own and others mental state in understanding and predicting behaviour. • Attributing ideas and feelings to another person and (re)acting accordingly: giving direction. • By accessing the mental processes of other persons we can predict and understand their behaviour. McDD and Autism - 5 • McDD: In general language development is normal with McDD. However communication is poor and without reciprocity. • Autism: There is more variability. • McDD: In children with McDD fantasy can be excessive and sometimes bizarre and frightening. • Autism: Children with autism have difficulties with their fantasies. Their play is poor and stereotyped. McDD and Autism - 6 Both have problems in the behavioural repertoire. • McDD: Behaviours of people with McDD are highly variable and of short duration. The thinking disorders are impressive: highly associative, illogical, not allowing for reality. • Autism: People with autism are restricted in their behavioural repertoire. It is marked by obsessions, stereotyped behaviours and restricted interests. McDD and Schizophrenia McDD and Schizophrenia - 1 • Unlike autistic children some children with McDD develop Schizophrenia in adult life. • Sometimes it is very difficult to distinguish psychotic behaviour from fantasies of omnipotence and other fantasies. • The main difference: with McDD the irrational ideas are correctable (this may be difficult). McDD and Schizophrenia - 2 • With McDD I sometimes observe episodes which I call: ‘mini psychotic moments’. • It is important to acknowledge the difference between symptoms of Autism, McDD and Schizophrenia. Treatment Treatment • Persons with McDD do need a same climate of guidance as persons with autism do. • There are special items in the treatment and guidance of persons with MCDD. • Special items: Help ego, Master of mood, Master of anxiety , Master of fantasies Treatment – 1: the Help Ego • Other persons can become a ‘help ego’ in an ongoing process of clarifying ambiguous situations, they can also be of help in regulating emotions. • This system is very vulnerable, because without a help ego offering explanation and correction life is too complicated. • A ‘help ego’ is a central element in the treatment. Treatment – 2: Master of Mood • People with McDD need help learning to regulate their emotions and mood swings. • They can be trained to perform a ritual when the emotions are too strong: - Rotating one’s body in some way - Thinking of their birthday - Softly saying: ‘I am the master of my emotions’ Treatment – 3: Master of Anxiety • Psychotherapy: therapists can help to remove the anxiety. • Therapist can try to ‘level out’ anxiety… ‘Sometimes all people are anxious. You are anxious, I am anxious. But we know that it is not necessary. You are the master of your anxiety.’ Treatment- 4: Master of Fantasies • Therapists (parents) can help to correct the ideas (fantasies). Confrontation with reality in a friendly way can help, i.e.: ‘Look, there really is no man with a gun.’ • Therapist can help to correct the grandiose fantasies. Confrontation with reality may be useful. Sometimes it is necessary to communicate that: ‘nobody is almighty, we are all normal people’. Thank you for your kind attention This lecture is based on my own experience and on the research and practical work of many colleagues. We are beginning to gain insight in the complex world of McDD, but a lot still needs to be clarified.