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Understanding Dual Diagnosis

In the past, clinicians believed that individuals with developmental disabilities were unlikely to be affected by psychiatric conditions. Many felt that developmental disabilities prevented people from understanding and responding to life situations in ways that would produce a psychiatric disorder. Over time, it has become increasingly clear that this is not the case. People with developmental disabilities are at as much risk, or more, than the general population for developing psychiatric conditions. The recognition that individuals with developmental disabilities can also be affected by specific psychiatric conditions is referred to as the dual diagnosis concept; individuals who have both a developmental disability and a psychiatric disorder are referred to as being dually diagnosed.

Accurate diagnosis of psychiatric conditions in people with developmental disabilities is especially difficult. Often, individuals may not be able to express themselves verbally, making it difficult to learn how they feel or how they experience the world. The person may have difficulty identifying feelings or may not be able to remember a sequence of events. Reports by others who know the person may be inconsistent or conflicting. For example, one family member may feel that the individual is incapacitated and unable to get out of bed, while another believes that the person is being stubborn or resistant.

The person's cognitive disability may also make it hard to recognize psychiatric symptoms. For example, a person who cannot speak may simply hit his or her head when hearing voices. Similarly, the only clue we may have that someone is depressed may be that she sits with her head hanging down and avoids eye contact. One can also see from these examples that these changes in behavior may be caused by a variety of things other than psychiatric difficulties. Medical problems, in particular, often cause behaviors that look like psychiatric symptoms in people with developmental disabilities. Hitting one's head may indicate that the person has a sinus infection; looking away may be due to problems with vision or headaches.

An additional problem in determining psychiatric diagnosis is the presence of tranquilizing medications, such as Mellaril, Haldol, Risperdal, or Zyprexa. Many individuals may have been prescribed these drugs in order to control aggressive or disruptive behaviors. Unfortunately, these medications may mask the symptoms of certain psychiatric disorders, making accurate diagnosis and treatment impossible. In some instances, sedative medications can make certain psychiatric disorders worse. For example, a person who is depressed may be irritable and aggressive. Tranquilizing medications will often decrease the aggression; however, these medications are likely to make the depression worse. For this reason, it is often important to reduce medications to evaluate the person's diagnosis, especially if the person has been on the medication for a long time.

Accurate psychiatric diagnosis is essential to ensure that individuals receive the right treatments and have the best quality of life possible. Inaccurate diagnosis or incomplete evaluation carries a significant risk, and may lead to a number of negative consequences. One such consequence is that the person may not receive the treatment that he or she needs. Untreated psychiatric conditions may interfere with the person's ability to work, socialize, or take care of him or herself. He or she may not be able to be as independent or may not be able to enjoy as many activities. Untreated psychiatric conditions can also sometimes worsen over time, and the person may lose skills that he or she has worked hard to develop.

Another risk associated with inaccurate psychiatric diagnosis is that the person may receive the wrong treatment. The person may be treated with unnecessary medications, or may be prescribed the wrong type of medication. Important treatments, such as psychotherapy, relaxation training, group therapies, and biofeedback may be overlooked. These errors in treatment reduce the chances for recovery and expose the person to unnecessary risks associated with medication side effects. While these risks may seem small, it is important to keep in mind that there is no such thing as a "safe" medication. All medications can have very serious, sometimes lethal, side effects. This is especially true of tranquilizing medications, which can cause permanent neurological problems if they are used over a long period of time.

An Approach to Improving the Accuracy of Psychiatric Diagnosis

  1. Know when to obtain consultation. In the normal course of life, people often experience changes in behavior, changes in mood, problems with concentration, anxiety, or unusual perceptions. The person's sleep, appetite, or health habits may also be affected at these times. Usually these difficulties are due to stressors or significant events in the person's life and they will improve as the person adjusts to the situation. However, if these changes persist for several weeks and become severe enough to affect the person's quality of life, we need to consider whether further medical and psychiatric evaluation are needed.

  2. Begin with a thorough medical evaluation. Medical problems often present with behavior change, psychiatric symptoms, or cognitive problems. The person who is ill may be more aggressive to others or engage in more self-injurious behaviors. He or she may cry, cling to staff, or appear anxious and depressed. The person may suddenly be unable to bathe or dress, or may appear more forgetful and confused. In all cases where a person has had a significant change in behavior or mental status, it is essential to explore whether medical or dental illness may be causing the distress. Keep in mind that people with developmental disabilities frequently have other conditions that affect their mental health, such as seizures, sleep disorders, or hypothyroidism. Physical disabilities and immobility may contribute to pain and discomfort. Problems with vision or hearing may make people more anxious or confused. People are often also on medications that cause psychiatric side effects, such as Phenobarbital and other anticonvulsants, steroids, and blood pressure medications. Even if psychiatric treatment is later required, it is important that the underlying causes for the disorder have been thoroughly addressed. Keep records of all medical treatment, laboratory studies, and medications, so that these are available whenever the person receives medical attention.

  3. Address situational stressors that may be contributing to the problem. Stressful events in the person's life will often produce changes in mood, concentration, or behavior. The person who is unhappy with his job, roommate, or living situation may become more aggressive, irritable, or withdrawn. A person may appear confused or sad when a favorite staff member is on vacation or when family members do not come to visit as planned. Frequently, it is the residential provider who knows the person's habits best and can offer the best ideas about what might be troubling the individual. A good rule of thumb whenever you identify stressors in the person's life that might be causing challenging behaviors is: try to fix the problem, don't try to fix the person. Do what you can to change the situation or lessen the stress. Obviously, there are some situations that one cannot change, such as the death of a loved one or the closure of a person's work program. In these instances, it may be helpful to give the person reassurance, distracting activities, and extra attention to help him or her get through a difficult time.

  4. Consult with a behavioral psychologist. Sometimes individuals will learn to use certain behaviors to get things that they like or avoid things they dislike. For example, a person may learn to complain of illness to avoid going to work or may have an angry outburst in order to be offered a snack. A behavioral psychologist will identify behaviors like these and will create a plan to change the behaviors. Even if a psychiatric condition is present, behavior plans can be very effective in supporting the person's recovery. A good behavior plan will help the person learn constructive ways to communicate his or her needs and get what is desired. All the staff working with a person should be familiar with the behavior plan and do their best to implement it consistently. If this is not done, staff members can unintentionally work at cross purposes to each other, and the behaviors may get worse. A behavioral psychologist will also ask staff to collect data about the behavior. Staff will be asked to count how often a behavior occurs and to write this down on a graph or chart. It is very important that staff do their best to be as accurate and consistent as possible in recording this data, because it is the only way to know if the behavior plan and other treatments are working.

  5. Keep accurate records of hours of sleep and weight. Many psychiatric conditions are accompanied by changes in sleep patterns, appetite, and weight. To make an accurate psychiatric diagnosis, the psychiatrist will need information about how many hours the person sleeps, whether he or she awakens during the night or sleeps during the day. The psychiatrist will also want to know if there has been a change in the person's eating habits. Charting the person's nightly sleep habits and weighing the person weekly will help the psychiatrist to make a more accurate determination of the person's psychiatric needs.

  6. Bring all your records to the psychiatric appointment. As a part of the psychiatric consultation, the psychiatrist will want to review the person's medical records, laboratory studies, sleep and weight records, and behavioral data. The more information available, the better and faster the treatment. It is especially helpful to provide the information to the psychiatrist in advance, so that there is time to thoroughly review the person's records. It is also important for the person to be accompanied to the appointment by someone who knows them well and can provide information about his or her health and behavior.

  7. Use symptom checklists. The psychiatrist may ask you to chart the person's symptoms using a checklist. Some examples of symptom checklists are given at the end of this article. Checklists give a more objective description of the person's behavior and help the psychiatrist determine the diagnosis and track whether the treatment is working. They may also alert staff to symptoms that may have been overlooked. Checklists are easy to use and take very little time to complete. The person who fills out the checklist should know the person well, or several staff members can work together to make sure that the checklist reflects all of their observations about the person.

While it is clear that people who have developmental disabilities can also develop psychiatric disorders, it is often challenging to make an accurate diagnosis due to the person's cognitive disability. Family members and residential staff play critical roles in supporting a psychiatric evaluation and making sure that the person receives the best care possible. They are often most familiar with the person's daily habits and behavior, and are the ones responsible for seeing that needed information reaches the psychiatrist. They also collect all the information about sleep, appetite, behavior, and symptoms that is essential to making an accurate diagnosis and finding the best treatment. Psychiatric diagnosis and treatment is improving over time. Teamwork and coordination of services are often what makes the difference in terms of a person's recovery from a psychiatric condition.

Psychiatric Symptom Checklist - Depression
Symptom Never Infrequently Sometimes Very Often
Looks sad, cries, whimpers        
Isolates in room        
Refuses usual activities        
Avoids friends        
Has poor appetite        
Has excessive appetite        
Has a change in weight        
Can't sleep        
Sleeps too much        
Is up in the middle of the night        
Has trouble making choices        
Moves and speaks slowly        
Looks anxious        
Has trouble completing tasks        
Doesn't care about appearance        
Has a decline in grooming        
Is irritable        
Is self-injurious        
Feels guilty        
Is more forgetful        
Has trouble concentrating        
Talks about death        
Talks about suicide        

Psychiatric Symptom Checklist - Psychosis
Symptom Never Infrequently Sometimes Very Often
Listens to things others don't hear        
Looks at things that aren't there        
Appears fearful for no reason        
Makes accusations of others        
Talks or "babbles" to self        
Seems lost in own thoughts        
Can't concentrate on tasks        
Speech doesn't make sense        
Afraid others are trying to hurt him        
Neglects hygiene        
Decline in dressing/grooming        
Seems confused        
Poor appetite        
Change in sleep habits        
Talks about odd things        

Psychiatric Symptom Checklist - Mania
Symptom Never Infrequently Sometimes Very Often
Is often excited or laughing        
Is irritable        
Wants a lot of attention        
Interrupts others        
Is bossy to others        
Is more aggressive        
Exaggerates or brags        
Is more argumentative        
Speaks loudly        
Speaks rapidly        
Can't stay on topic        
Talks continuously        
Can't sit still        
Needs less sleep than usual        
Is up in the middle of the night        
In constantly on the move        
Wears bright or flashy clothes        
Spends or gives away money        
Is more sexual or flirtatious        
Takes things impulsively        

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