The Diagnostic Manual for the Mentally Ill and Intellectually Disabled

By Robert Fletcher, Earl Loschen, Chrissoula Stavrakaki, and Michael First

Reviewed by Marie Hartwell-Walker, Ed.D.
June 17, 2008

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Here is an example excerpted from Chapter 27 of the text (written by panel chairs Andrew Levitas, M.D. and Anne D. Hurley, Ph.D.):

Adjustment Disorder

DSM-IV_TR Criteria

Adaptation of Criteria for Individuals with Mild to Moderate ID

Adaptation of Criteria for Individuals with Severe to Profound ID

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

No Adaptation

Note: Stressors in the lives of persons with Mild/Moderate ID can include any need for an increase in autonomous functioning (move to a new home or away from family, loss or change status of important caregiver, promotion to educational, vocational or residential placement beyond one’s level of comfort, onset of illness).

No Adaptation

These symptoms or behaviors are clinically significant as evidenced by either of the following:

Marked distress that is in excess of what would be expected from exposure to the stressor

significant impairment in social or behavioral functioning.

B. Anxiety and depression may manifest in persons with Mild/Moderate ID as they would in persons without ID, but also as clinging, apparent loss of skills, withdrawal, or irritability.

Distress in excess of the individual’s known baseline of distress responses.

Impairment compared to baseline functioning

B. Anxiety and depression may manifest in persons with Mild/Moderate ID as they would in persons without ID, but also as clinging, apparent loss of skills, withdrawal, or irritability, aggression,. Self-injury, destructiveness, and loss of earlier compliance with routines of care.

1. Distress in excess of the individual’s known baseline of distress responses.

2.Impairment compared to baseline functioning

The stress-related disturbance does not met the criteria for another specific Axis I disorder and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder

C. A Clear history of a stressor and the differences from previous patterns seen in pre-existing Axis I and Axis II disorders must be noted.

C. A Clear history of a stressor and the differences from previous patterns seen in pre-existing Axis I and Axis II disorders must be noted. Assessment must be made for such disorders, as they may not have been diagnosed prior to the current mental health contact. It should not be assumed from the limited behavioral repertoire that exacerbation of symptoms of Severe/Profound ID do not merit diagnosis of an Adjustment Disorder despite clear relation to a stressor.

D. The symptoms do not represent bereavement.

D. In many persons with Moderate ID, bereavement may take the form of anger and irritability, with resulting disturbance of conduct; in this situation, Adjustment Disorder with Disturbance of Conduct, or Adjustment Disorder with Mixed Disturbance of Emotion sand Conduct should be diagnosed, as the phenomena of normal bereavement may be significantly surpassed. In addition, loss of housemates, friends, favored staff, and even routines may be causes of grief.

In persons with Severe/Profound ID, bereavement may take the form of anger and irritability, with resulting disturbance of conduct; in this situation, Adjustment Disorder with Disturbance of Conduct, or Adjustment Disorder with Mixed Disturbance of Emotion sand Conduct should be diagnosed, as the phenomena of normal bereavement may be significantly surpassed. Bereavement may occur in response to loss, not only by death, but also due to promotion, retirement, or transfer of important caregivers. In addition, loss of housemates, friends, favored staff, and even routines my be causes of grief.

Chapters 2 and 3 are of particular interest and importance. Chapter 2 describes effective assessment and diagnostic procedures, providing guidance about useful types of information to be gathered from different people. There is a checklist for historical data as well as an overview of the medical issues that should be addressed before considering a mental health diagnosis.

Chapter 3 lists the behavioral phenotypes and associated mental health disorders of twelve of the most common genetic disorders, including Down, Angelman , Fragile X and Fetal Alcohol syndromes. Simple-to-read charts highlight the differences between childhood and adulthood that are explained at length within the chapter.

A companion volume, DM-ID: A Clinical Guide for Diagnosis of Mental Disorders in Persons with Intellectual Disability, is an abridged version of the textbook. It is intended to be clinically useful as a more rapid reference for practicing clinicians.

Twenty percent of the typical population will deal with a mental illness at some point in their lifetimes. Depending on the study, people with ID have been found to be two to four times at risk. The reasons are many and complex, from the essential fact that having a cognitive disability in a non-accepting world can be traumatizing in itself to the terrible reality that more than 80 percent of intellectually disabled women are or have been sexually abused.

Intellectually disabled people with mental illnesses may present substantially different symptoms, and many clinicians do not see enough people with ID to develop needed expertise. As a result, people with a dual diagnosis of intellectual disabilities and mental illness continue to be misdiagnosed and often do not get adequate treatment. The DM-ID provides an organized approach for recognizing mental illness in an often underserved and misunderstood population. More accurate diagnosis should lead to more effective treatment.