Dave Atkinson Consultant Nurse
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'in short, herein lies the difference between
retarded persons and madmen:
madmen put the wrong ideas together and so make
erroneous propositions, but argue and reason rightly
from them: but retarded persons make few or no
propositions and scarcely argue at all‘
Locke 18th Century cited in Szymanski, 1994
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In some ways nothing much:
 Subjective experiences...
 Normal reactions to life’s stresses...
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But:
 Increased prevalence of disorders
 Atypical presentations complicate assessment /
diagnosis
 Complex co-morbidities
 Treatment may be more complex
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Mental Health - successful performance of
mental functions, resulting in productive activities,
fulfilling relationships... and the ability to adapt to
change and cope with adversity.
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Mental health needs are needs that must be met
in order to avoid / alleviate mental disorders
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Mental Disorders - health conditions
characterized by alterations in thinking, mood,
and/or behaviour associated with distress and/or
impaired functioning.
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800,000 adults with LD in England – 180,000
known to services – where are the others??
25-40% prevalence of mental health
problems amongst adults – cf 16% general
popn.
36% prevalence of mental health problems
amongst children and young people (cf 8%
general popn)
 Young people with MH problems are 33x more
likely to be on the Autistic spectrum
3x prevalence schizophrenia
 Major mood disorders 6.6% cf 2% general popn.
 OCD 3.5% cf 1% general popn.
 ADHD - 12% of adults with mild LD reported to have
cf 4% general popn.
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Dementia 21.6% cf 5.7% post 65yrs (higher in DS).
 Generalised Anxiety Disorder reported at around
3.8% similar to general popn.
 Eating disorders: anorexia and bulimia very rare
(why??). But pica, binge eating disorder etc...
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Biological
Psychological
Social
Brain damage
Self insight
Increased exposure to
adverse life events
Sensory impairments
Poor self image
Lower socio economic groups
Physical health problems /
chronic pain
Poor coping mechanisms
Discrimination / abuse
Genetic conditions
Bereavement & loss
Reduced social networks
Medication side effects
History and expectation of
failure - learned helplessness
Transitions
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Sovner’s (1986) Confounding Variables:
 Intellectual distortion – the difficulty an
individual has in communicating their internal
feelings due to decreased intellect and
impaired language ability.
 Psychosocial masking –impoverished social
skills and life experiences lead to psychiatric
symptoms less rich in content, compared to a
non disabled person.
 Cognitive Disintegration – the lowered
threshold for anxiety to become overwhelming
thereby disorganising cognitive function
further. E.g. transient breaks in reality testing.
 Baseline exaggeration – the increase in
disturbed behaviours that may occur as a
result of superimposition of a mental disorder.
The increase in baseline symptoms is
ascribed to a fluctuation s a result of learning
disability.
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Diagnostic Overshadowing (Reiss 1982, 83)
 The presence of a learning disability reduces the
diagnostic significance of an accompanying behaviour
problem – easier to call it CB
Reiss et al. (1982).
Case description of debilitating fear presented to 2 groups of psychologists. Group 1
told IQ was 60, Group 2 told IQ was 102. Both groups asked to diagnose and
recommend interventions.
Individual with learning disability less likely to be diagnosed with phobia and have
treatment recommended.
The presence of the LD overshadowed the presence of behaviour indicative of
psychopathology. (Similar subsequent findings for SCZ and PD).
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Reliance upon carers – training, nature of relationship and
previous labels may colour attitude and affect the validity /
reliability of information.
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Classification issues related to both ICD 10 and DSM IV for
this client group.
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Acquiescence
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Reduced attention span affecting MSE’s
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Negative experiences of interviews may colour performance
within MSE
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Developmental issues – cognitive, moral, ego defence
mechanisms
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Physical Co morbidity
 Classic Study (Ryan & Sunada 1997)
▪ 1135 subjects with LD referred for mental health
assessment over a 6 year period
▪ All were previously presumed to be medically well
▪ All were meticulously medically evaluated
▪ Screening assessment for all
▪ Expanded assessment based on clinical status
 Results
▪ 75% suffered 1 or more medical problem, almost all
previously undiagnosed or undertreated
▪ Most commonly discovered conditions:
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Epilepsy
Hypothyroidism
Tourette’s
GI reflux
Chronic pain
Arthritis
Anaemia
Stroke
Etc…
- 46%
- 13%
- 12%
- 10%
-9%
- 5%
- 3%
- 3%
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Social Interventions & Relapse prevention:
Having one’s various needs recognised and met
Improving physical health
Feeling secure and safe from harm
Being given choice and control over one’s life
Developing assertiveness and communication
skills
 Having employment and meaningful daytime
activities
 Having responsibility – recognising achievements
 Being supported in a person centred way
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Psychological Therapies
 Need to be modified in light of communication
and cognitive profile
 Evidence / expert opinion supports use of:
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Psychodynamic psychotherapy
Systemic therapy
Counselling
Behavioural Interventions
CBT
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Psychotropic Medication Issues:
 Full range of medications used.
 Efficacy unclear - LD popn. usually excluded from clinical trials
 Positive responses to ‘atypical antispsychotics’ at a low anxiolytic
dosage
 Higher prevalence of side effects
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Adverse effects at lower dosages
Higher proportion of atypical responses
Adverse effects can occur following lower dosages given for briefer periods
Lack of subjective reporting makes side effects difficult to spot
Akathisia – the most overlooked side effect in LD – often taken to be CB
 Polypharmacy often inevitable due to medication to treat physical
morbidity
 Often prescribed for CB outside of ICD diagnosis…
 Consent / best interests dilemmas
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Governance:
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Research
Information
User experience
Audit
Risk
Education & cpd
Workforce issues
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Observation & screening tools
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Listen to your service users
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Use terms appropriately (No lay
terms!!)
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Understand how symptoms and
signs may be distorted in the
LD popn.
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Facilitate access to specialists
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Help specialists make sense of
LD
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Holistic formulation
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Care Coordination
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Deliver interventions
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Develop support workers