Learning Disability Psychiatry

Question 1

What is included in the subsets of mental disorder according to legislation?

Answer 1

• Mental illness
• Personality disorder
• Learning disability

Question 2

What is the ICD10 definition of learning disability?

Answer 2

A condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence i.e. cognitive, language, motor and social abilities

Question 3

What is the criteria fro learning disability?

Answer 3

1.Intellectual impairment (IQ < 70)(Wechsler)

2. Social or adaptive dysfunction (Vineland Scale)Deficit/impairment in 2 or more of the following:
   - adaptive skills: communication, self-care, home living, social skills, community use, self direction, health and safety, functional academics, leisure & work

3.Onset in the developmental period (age 18)

Question 4

What is the prevalence of learning disabilities?

Answer 4

Statistically the prevalence of people with IQ<70 should be 2.5% but the actual prevalence if 1-2% because

• Differential mortality (the more severe the degree of learning disability, the higher the mortality c.f. general population)
• The role of functioning - those with IQ<70 but no problems functioning within their environment would not be defined as having a learning disability

Question 5

How are learning disability severity classified?

Answer 5

IQ is used to classify level of LD

• Mild LD 50-69
• Moderate LD 35-49
• Severe LD 20-34
• Profound LD <20

Question 6

What is the aetiology of LD?

Answer 6

• Genetic
• Infective
• Toxic (foetal alcohol syndrome)
• Trauma (birth asphyxiation, head injury)
• Unknown for most individuals

Question 7

What genetic conditions can result in LD?

Answer 7

• Single gene: Fragile X, PKU, Retts Syndrome
• Microdeletion/duplication: DiGeorge Syndrome, Prader-Willi, Angelman syndrome
• Chromosomal abnormality: Down Syndrome

Question 8

What infective causes of LD are there?

Answer 8

Ante-natal infection
-Rubella

Post-natal infection

• Meningitis
• Encephalitis

Question 9

What common physical conditions often accompany LD?

Answer 9

• Epilepsy
• Sensory impairments
• Obesity
• Swallowing problems, reflux oesophagitis, helicobacter pylori, constipation
• Chest infections, aspiration pneumonia
• Cerebral palsy
• Joint contractures, osteoporosis
• Dermatological and dental problems

Question 10

Why is there a speciality of psychiatry for those with learning disabilities?

Answer 10

• Higher incidence of psychiatric disorders
• More severe
• May present in a broadly similar way to general population
• Can present differently, particularly those with moderate to sever LD
• Difficulties describing problems
• Communication issues
• Different baselines to general population
• Observable signs are often relied on during consultation
• Specialist training required
• MDT working

Question 11

What are the assessment areas of LD psychiatry?

Answer 11

• Aetiology of LD
• Associated biomedical conditions
• Severity of LD
• Psychiatric Disorders, their cause and consequences

Question 12

How can schizophrenia/psychosis present in LD?

Answer 12

• More prevalent 3% compared to 1% of general population
• Associated with change in personality and reduction in functional abilities
• ‘Self-talk’ is common in LD, particularly in Downs syndrome

Question 13

How can mood disorders present in LD?

Answer 13

• Increased incidence

- Less likely to complain of mood changes and noted by change in behaviour

Question 14

How can OCD present in LD?

Answer 14

• Ritualistic behaviour and obsessional themes significantly increased in LD
• Obsessions hard to describe by people with LD but compulsions more readily observed

Question 15

What is the association between LD and Autism?

Answer 15

2/3 of people with Autism will have a LD

Question 16

How can over-activity syndromes present in LD?

Answer 16

• ADHD much higher incidence
• Many severe LD children are overactive, distractible and impulsive but NOT to extent that would indicate diagnosis of ADHD

Question 17

How can challenging behaviour and self-injury present in LD?

Answer 17

• Mannerisms, head banging and rocking common with severe LD
• General trend is towards greater prevalence of problem behaviour with increasing severity of LD (but people with profound LD exhibit less outwardly)

Question 18

What is the association between LD and forensic history?

Answer 18

• Mild LD have similar rates of offending to the general population but diff profile of offending
• IQ below 70 over-represented for arson and sexual (usually exhibitionism) in prison population

Question 19

What do health professional need to do when dealing with psychiatric issues and LD?

Answer 19

• Take time and have patience
• Value what is being communicated
• Recognised non-verbal cues
• Use alternative communication strategies if necessary
• Explain things in a clear and appropriate way
• Be prepared to meet the person several times to build up rapport and trust
• Use the knowledge and support of people’s carers

Question 20

What is book beyond words?

Answer 20

• A series of picture based books that have been developed to make communicating easier for individuals
• Many people can understand pictures better than words

Question 21

What is diagnostic overshadowing?

Answer 21

Presenting symptoms are put down to their learning disability, rather than seeking another, potentially treatable cause