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.

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It’s called the “other” dual diagnosis. While most professionals and laypeople understand dual diagnosis to mean those who suffer from both mental illness and substance abuse, the term is also used for those with the double challenge of mental illness and mental retardation.

The intellectually disabled long have been deprived of needed treatment and even compassion because their mental illness has been seen through the lens of their disability. It was thought that people with cognitive disabilities could not possibly have mental illness, perhaps could not even have the same feelings, as the typical population. This “diagnostic overshadowing” — the tendency to let the mental retardation diagnosis block recognition of mental illness — still lingers. When a person with ID acts in uncharacteristic or even dangerous ways, it is still all too often understood as misbehavior, not as possible symptoms of an undiagnosed medical or mental illness.

The National Association for the Dually Diagnosed has published the Diagnostic Manual-Intellectual Disability (DM-ID): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability. NADD is doing much to gain recognition of dual diagnosis and to ensure that people with intellectual disabilities who present psychiatric symptoms are accurately diagnosed. Now clinicians new to the population have an authoritative resource to guide them in the assessment and treatment of the “other dual diagnosis.” For experienced clinicians, the book provides a standardized set of diagnostic criteria that will facilitate communication and inform treatment.

Developed through a cooperative effort of NADD and the American Psychiatric Association (APA), the volume was 10 years in the making. Using the DSM-IV-TR categories of mental illness, panels of experts worked to describe how symptoms are expressed by those who often can’t adequately report their experience. Each chapter was developed through consensus, using an evidence-based approach. The book was then edited by Robert J. Fletcher, D.S.W., A.C.S.W., Chief Editor, Earl Loschen, MD, Chrissoula Stavrakaki, M.D., Ph.D. and Michael First, M.D. (Dr. First also edited the DSM-IV-TR.)

Each chapter reviews the diagnostic criteria for a diagnosis as defined by the DSM-IV-TR, describes issues that are specific to how the diagnosis is expressed by people with intellectual disabilities, provides a review of relevant literature and discusses the etiology and pathogenesis of the disorder. Symptoms for the diagnosis are then arranged in three columns: Column 1 sets out the diagnostic criteria as stated in the DSM-IV-TR. Column 2 lists adapted criteria for those with mild to moderate retardation and Column 3 lists adapted criteria for those with severe to profound retardation. Often Columns 1 and 2 are much the same. Sometimes Columns 2 and 3 are collapsed. When no adaptation is needed or appropriate, it is simply stated.

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).

  1. 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).

  1. 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).

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

 

 

 

  1. Marked distress that is in excess of what would be expected from exposure to the stressor
  1. 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.

 

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

 

 

  1. 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

  1.  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.

 

  1. 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.

References

Related Article on PsychCentral.com: Mental Retardation and Mental Illness

National Association for the Dually Diagnosed

American Association on Intellectual and Developmental Disabilities (formerly named the American Association for Mental Retardation).

Gene Tests contains reviews of 175 genetic conditions that cause intellectual disabilities.

Society for the Study of Behavioural Phenotypes

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APA Reference
Hartwell-Walker, M. (2008). The Diagnostic Manual for the Mentally Ill and Intellectually Disabled. Psych Central. Retrieved on July 28, 2014, from http://psychcentral.com/lib/diagnostic-manual-intellectual-disability-dm-id-a-textbook-of-diagnosis-of-mental-disorders-in-persons-with-intellectual-disability/0001390
Scientifically Reviewed
    Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
    Published on PsychCentral.com. All rights reserved.

 

 

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