Dual Diagnosis and Your Family Member

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Have you ever been concerned that your family member might have a psychiatric condition? This article is intended to acquaint you with some basic information about common psychiatric conditions and resources available to you in dealing with your concerns.

Throughout life, people often experience changes in how they behave and how they feel about their lives. We all, at times, have problems with concentration, anxiety, or unusual perceptions. Sleep, appetite, or health habits may also be affected. Usually these difficulties are caused by stress or significant events in a person's life, and they will improve as the person adjusts to the situation. If, however, these difficulties become severe enough to affect the person's quality of life, we need to consider whether a psychiatric condition may be the cause of the person's problems.

Psychiatric disorders are actually very common medical conditions. At any one time, about 20% of the population - one in five people - is likely to be affected by some psychiatric condition. Psychiatric disorders may be minor or severe. They can last only a short time or be persistent. The person who has a psychiatric disability is not "crazy" or hopeless. The vast majority of people who have psychiatric difficulties continue to work or go to school and have full lives. Most individuals will recover completely, and significant improvement of symptoms can be expected.

What Do We Mean by Dual Diagnosis?

People with developmental disabilities are at the same or greater risk than the general population for developing psychiatric conditions. Recognizing that individuals with developmental disabilities can also be affected by psychiatric conditions is known as the dual diagnosis concept; individuals who have both a developmental disability and a psychiatric disorder are referred to as being dually diagnosed. In the mental health field, people who have a psychiatric condition and a substance use/addictive disorder, are also described as having a dual diagnosis.

Accurately diagnosing psychiatric conditions in people with developmental disabilities is especially difficult. Often, individuals with developmental disabilities may not use words to communicate, making it difficult to learn how they feel or how they see the world around them. The person may not identify how they feel or may not remember what was going on as problems were building. Descriptions of the person's difficulties 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 the person is being stubborn or resistant.

Medical problems 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.

Another problem in diagnosing people with developmental disabilities is the use of some medications. Many individuals may take certain drugs to control aggressive or disruptive behaviors. These medications may hide symptoms of certain psychiatric disorders. In some cases, medications can make certain disorders worse. For example, a person who is depressed may be irritable and aggressive. Tranquilizers may decrease the aggression, yet are likely to make the person's depression worse. It is important to keep in mind that there is no such thing as a "safe" medication. All medications can have very serious side effects. Accurate psychiatric diagnosis is extremely important in making sure that individuals receive the right treatment and have the best quality of life possible.

Common Psychiatric Disorders

Individuals with developmental disabilities can be affected by any psychiatric disorder. The disorders described below are the most common. Most people will have some of the symptoms in these descriptions some of the time. This is normal. These experiences only become a "disorder" when they continue for weeks or months and become severe enough to interfere with a person's daily activities. Also keep in mind that, for all of these conditions, individualized treatment can be very helpful in reducing distress and negative effects on a person's life activities.

Major Depressive Disorder- Depression is one of the most common psychiatric disorders. Often it is brought on by a loss or change that is difficult for the person. The person's normal grief may not fade over time, but may become more severe and persistent.

• Individuals who are depressed feel sad, withdraw, cry, or make sobbing or moaning sounds for extended periods of time.
• They often give up activities that they used to enjoy and stop socializing with others.
• The person may say they are very tired, or may simply lie in bed, sit or lie down during normal activities, or strike out when others encourage activity.
• The person may feel guilty or worthless. People who have difficulty communicating with words may call themselves "bad" or may allow others to blame them unfairly.
• The individual who has depression will often have sleep problems. They may have insomnia or awaken in the middle of the night. Some individuals sleep too much, or spend much of the day in bed.
• Appetite is generally poor and people may lose a significant amount of weight.
• Concentration may also be affected. The person may seem more forgetful and 'just not care' about things. He or she may have problems making decisions.
• It is not unusual for people who are depressed to think about death or illness. They may express the wish to die or may think about taking their own lives.
• Individuals can also be worried, irritable, or agitated during a depressive episode. People having limited verbal communication may express this through aggressive or combative behavior.
• It is also not uncommon for people to have an increase in self-injurious behaviors, such as hitting themselves.

Panic Disorder- Panic attacks are another very common psychiatric experience. If they occur very infrequently, they may have little impact on the person's life. Frequent and severe panic attacks can be very debilitating.

• Panic attacks generally come on suddenly, peak within 10 minutes, and then gradually fade out. The attack will usually start with the person feeling anxious and afraid. These feelings then become more intense.
• The person usually has various physical symptoms, including pounding heartbeat, shortness of breath, sweating, flushing and tremor. The person may feel that he is choking or cannot swallow. Chest pains and nausea are common, sometimes making individuals fear that they are having a heart attack. The person may feel dizzy or light-headed, or may have numbness and tingling in the hands or feet.
• People often fear that they are dying during an attack, or may have a sensation of floating outside their bodies.
• They may feel that they are losing control or "going crazy".
• Individuals who do not communicate verbally may appear panicky, become combative, bolt from the situation, or desperately grasp at others.
• Panic attacks may go away quickly, within 10-15 minutes.
• For some individuals, a sense of tension, confusion, fatigue, or foreboding can last for several hours after the attack.

Bipolar Disorder- Bipolar disorder, formerly called manic-depressive illness, is a condition in which the person has wide mood swings that disrupt his or her daily activities. A number of different types of bipolar disorder have been described based upon the frequency and duration of the mood swings. Episodes of mania and depressed mood may last several weeks or months, or they can occur rapidly over the course of days.

• Some people experience a combination of manic and depressive mood symptoms. Generally, the depressions associated with bipolar disorder are identical to those in major depressive disorder described above.
• Manic episodes are characterized by hyperactivity and excessively happy mood.
• The person may feel special and important, make very unrealistic plans, or believe that he owns expensive things that he does not have.
• Many people are restless; they may pace or be "on the move" all the time.
• Often the person in a manic episode has less need for sleep. She may be up in the middle of the night, rummaging in belongings or trying to get others up to socialize.
• If the person is verbal, he may speak very rapidly and change topics frequently.
• At first, the person may be hyper-productive at work. However, if the mood swing is severe, people tend to become more and more distractible and begin to lose their focus. They may jump from one activity to the next, unable to complete any task.
• Irritability is common during mania, and individuals may become more aggressive and impulsive. Occasionally, people will run away, travel, or take others' belongings.
• Sometimes a person will be more flamboyant during a manic episode, wear flashy or provocative clothing, spend excessively or give away their money.
• Sexual activity and other pleasurable activities can also be increased, and people sometimes make impulsive decisions that they later regret.

Obsessive-Compulsive Disorder- Obsessive-Compulsive Disorder (OCD) is seen in repeated upsetting thoughts (obsessions) that prompt a person to perform repetitive behaviors (compulsions) in order to reduce anxiety. Often the obsessional thoughts involve fear of a catastrophic event, such as the death of a loved one.

• Common compulsive behaviors include repetitive hand-washing, checking behaviors, turning lights on and off, ordering things, counting, or repeating phrases.
• Individuals who are able to communicate verbally may be able to recognize that their actions are not logical. For other people, one may simply observe the person engaging in repetitive behaviors.
• At times, individuals having OCD will rearrange furniture in a particular manner, hoard papers or other objects in their pockets or closet, spin around or gesture, spell words repetitively, rearrange contents of cabinets, or insist on following a very rigid schedule.
• Repetitive behaviors that are similar to OCD are also observed in other disorders such as Tourette's disorder, autistic disorder, and Down's syndrome, so that careful diagnostic assessment is essential.

Psychosis- Psychosis refers to any mental condition in which a person experiences hallucinations, incoherent thoughts, or unusual beliefs. Psychosis may be the predominant problem, as in schizophrenia, or psychotic symptoms may occur as part of other psychiatric conditions.

• Psychotic symptoms may occur for brief periods of time in response to extreme stress.
• Individuals who are unable to tell us about their experiences may be observed to react to things that others don't see.
• They may laugh to themselves or appear fearful without apparent cause.
• People may mumble to themselves or be so preoccupied with their thoughts that they are unable to concentrate on tasks in the world around them.
• Some individuals may be able to tell us that they fear someone is trying to hurt them or they may refuse food, afraid that it is poisoned.
• If people feel threatened, they may be more aggressive or defensive.
• Psychosis is often accompanied by difficulties with sleep and self-care.
• The individual may become unable to bathe or dress.
• At times, the person may be withdrawn and apathetic due to the disorganization of his or her thoughts.

Resources

If you are concerned that your family member may be experiencing symptoms of a psychiatric disorder, there are many avenues for you to get help.

• An important first step would be to record your observations. Keeping track of things you find disturbing will assist others in figuring out what is going on.
• Keep in mind that certain behaviors you observe may not be indicative of a psychiatric condition. Be open to an assessment process that does not jump to conclusions. There are many reasons why people behave the way they do.
• Share your observations with your family's primary care physician and obtain their opinion on how to approach any identified issues.
• Share your observations and concerns with your family member's service coordinator. The serv ice coordinator is responsible for addressing needs a consumer has for services and supports, including those that may involve assessment and treatment of psychiatric conditions.
• The service coordinator is there to help you address your issues of concern. For example, referrals for medical, behavioral, psychiatric, or communication evaluations may be made so that the team has current information regarding changes you have seen in your family member. The team can then pursue the course of action that appropriately addresses any identified needs related to your family member's physical and emotional well-being.
• Should the team need additional guidance in approaching the needs of your family member, they can access the resources of the regional center's Clinical Team. Each regional center has a Clinical Team that service coordinators can access for advice. This group has clinical expertise and knowledge of diagnostic and treatment resources both within the regional center and in your local area.
• Learn more. The regional center can direct you to local resources where you can expand your knowledge of psychiatric conditions. These include educational and support resources. In addition, The National Association on Dual Diagnosis has information specifically related to persons who have both developmental disabilities and psychiatric conditions.
• http://www.thenadd.org/