All right, it's right after one so we will go ahead and get started. Welcome to understanding dual diagnosis with Kim Shantz. My name is Danielle Daly.
I'm the professional development coordinator here with the Illinois Crisis Prevention Network. I'm just going to go over a few housekeeping things, and then let Kim take over for her presentation. We will run from one o'clock to two 30 today. Please take a look at our website, icpn.org.
You can find all of our upcoming trainings. You can also review some of our past trainings that have been recorded. We do have a training next week on grieving.
We also have the start of a series on positive psychology that'll that's posted on the website right now. That is starting November 15th. We will add additional.
webinars to that series here in the next few weeks. But please go take a look at that and join our mailing list so that you can be the first to know about our upcoming training opportunities. Everyone, your cameras are disabled, you're muted, obviously use that chat box featured down below throughout the course of the webinar today to ask questions, provide comments, resources, anything of that sort.
You can also use that Q&A for questions also. Continuing education certificates, please give me about 14 days to get those out to everyone. They will come to the email address that you registered with.
So by clicking on the link, you are accounted for today. So please give me about 14 days on those. If for some reason you do not receive those after that 14-day time period, please reach out to me. My email address is the first letter of my first name and then my last name.
So ddailyathope.us. I will put that in the chat box as well so that you guys have access to that. And you can obviously email me with any other concerns that you may have regarding trainings.
I think that is all that I have. Kim, if you want to go ahead and get started. All right.
Thank you so much, Danielle. We always appreciate all your help. You do a fantastic job with this series. So we appreciate you getting us off to a good start. Thank you, Kim.
And I want to welcome everybody. And I do want to just say right up front that this is a... a live version and it's a repeat of the one that we hosted last month.
So if you were joined, if you had joined us last month and you want to click off, I totally understand so that you don't have to sit through it again. But this is a repeat of the one that we did last month. However, it is a topic that you can never learn enough about. So if you want to hear it again, feel free to stay on. I am going to ask you to use the chat box a little bit and I'll try to monitor that and go back and forth.
But I do have a few questions as we're moving along, and I just want to find out how people are feeling about working with people with dual diagnosis. So if we want to start out with that, if you could just put one or two words to describe your experience of working with people who are duly diagnosed. And you can, once again, you can put that in the chat box. It can be difficult. Interesting and challenging.
I like that one. Always interesting. Complex and contradictory. That's a good way to confusing.
Underserved for sure. Absolutely never dull. Yes.
No two days are alike. Yep. Changing daily, mixed emotions, rewarding and challenging.
Exciting and wonderful. Yep. Those are great answers.
Thank you so much. Overwhelming. Yep.
Yeah, we're talking about interactions with the law and with the criminal justice system that can be very difficult as well, especially when we're advocating for the people that we serve. All right. Well, thank you for those words.
I think that truly does capture, you know, my experience as well of having done this for over 25 years serving people with who are duly diagnosed. And it is a passion. It's something that I thoroughly enjoy. And it is like people who are duly diagnosed who might engage in challenging behaviors are just a joy to work with. Right.
They can be the most appreciative and joyful and, you know, nicest people ever to work with until they're not, you know, until they're really struggling. And then we have the privilege of working with them to try to figure out what's going on. and get them the services and the supports that they need, you know, to continue to live those full and abundant lives.
So that is what we're going to talk a little bit about today. I really like the fact that a lot of people are talking about advocating for the people that we're serving and yes, helping people understand that that really does coexist, people with a dual diagnosis and people with an intellectual disability. All right.
So today we are going to talk a little bit about that, the history of dual diagnosis. We're going to talk about a primary care fact sheet and then talk a lot about what does specific disorders look like and how do we make sure that we have an accurate diagnosis. I did. I didn't.
I apologize. I didn't necessarily start out by introducing myself. I am the director of the ICPN. I share that responsibility with Amy Burke statewide.
We have six teams for ICPN. I'm assuming most of you are very familiar with us, given the fact that you're joining us for this webinar today. I've been in the field for over 25 years.
Like I said, I'm from Trinity Services. I've. Worked within our psychosocial rehab program, serving people with dual diagnosis as a therapist, running groups. I was director of one of those programs for a while, moved into the role of deputy director of the behavioral health, serving people in both residential solo group homes and in our day programs for a daily diagnosed. And then about 13 years switched over here to being the director of ICPN.
But like I said, it truly is a passion to work with people who are daily diagnosed. And so I'm really happy to be here today. All right. Let's see. Now we're not advancing.
Before I was advancing too fast. Now I'm not. All right.
So the other dual diagnosis, as many of you know, when we talk about dual diagnosis, oftentimes people think about people who have a substance use disorder and a mental illness. The people that we work with are known, you know, that group of people, the other dual diagnosis, meaning that they have an intellectual or developmental disability and a psychiatric disorder. Okay, so the other dual diagnosis.
It's always important to clarify for everybody that having an intellectual or developmental disorder does not equal having a mental illness. They are two very separate things. And that's, once again, why it's important to talk about this.
So a little bit about the history of dual diagnosis. Going way back to 1876, there is actually at that time in history, the mentality that people could be, you know, they could go to school, that they could learn. So the American Association on Mental Deficiency recommended schooling.
So at least people were getting some services and they were learning and people were interacting with them and they were doing some things. Unfortunately, about the time of like 1908, when psychoanalysis was introduced in the U.S., people decided that people with intellectual and developmental disabilities did not fit into that model and that they would not benefit from therapy and that they could not participate in treatment. So we kind of went into that long history of institutionalization where, you know, I'm sure many of you.
most of you know the history, right? Where when a child was born with an intellectual developmental disability, people were literally urged to send their child to an institution, kind of forget about them. You know, you've seen the Willowbrook videos and videos of other historic institutions where people were getting no services whatsoever. Okay.
And so Manasseh was a famous psychiatrist from the East Coast, and he termed that as the tragic interlude, right? from the 1900s to the 1960s where nothing was happening for the people that we serve. Okay. And when we think about that, that is not that long ago, right? I was born in 62. This is that, you know, that was right there.
So at that time, treatment teams did not include psychiatrists and first-generation antipsychotics were not made available to the people that we serve. Okay. How many of you serve people with active psychotic disorders? probably most of you, right?
That's why you're here. Now think about people you're serving who have schizophrenia. And back then that first generation antipsychotic was Thorazine and they did not make it available to the people that we serve. And if you've ever seen a person with a psychotic disorder who is not properly medicated, you just want to, yeah, it's not a good experience. I don't even know how to put words to it, right?
You feel so sorry for them in terms of what you can see the total conflict in what they're... what they're experiencing internally and externally. So think about that.
It was not that long ago that medications were not made available to the people that were serving. Okay. All right. We can blame a lot of that on Freud.
So things did finally start to move forward. So between 1960 and 1970, that concept of dual diagnosis was coined by Dr. Manasolino. Okay. Also during that time, they started to do some studies and found that psychotherapy actually was helpful for people with that dual diagnosis. So things started to move in the right direction.
Yet it wasn't until 1981 when people started to actually publish stuff for providers of people who were duly diagnosed, right? So at that point, the Psychiatric Aspects of Mental Retardation newsletter started to come on the scene. And then in 1982, the National Association for Dual Diagnosis was founded. They also refer to that as NAD, or sometimes you'll hear N-A-D-D.
Dr. Manasalina was actually a founder of NAD and was very active in NAD for many, many years. And it is a wonderful organization. I encourage all of you to go online to look it up. They have yearly conferences. They have state conferences.
This year, their conference is in December in Nashville. December 15th to the 18th, all the speakers speak on dual diagnosis. Wonderful. They also have a publishing house.
You can order resources online at NADD. But once again, this is not until 1982. By this time, some of you might have been born. One of the things that was often overlooked, and many of you know of Reese, I'm sure. He did a lot of work with people who are diagnosed.
He did the Reese scales. But he really coined the term diagnostic overshadowing. And this is the concept that symptoms or behaviors that are due to a mental illness are attributed to a person's intellectual or developmental disability. Okay. So for example, if a person is isolated because they have the negative symptoms of schizophrenia, they might just say, well, that's because they have an intellectual disability, right?
That's because they can't talk. Um, it's because of their, you know, so everything is attributed to their intellectual disability and nothing is attributed to their mental illness. Okay. And this goes for other things as well.
This also goes for medical conditions. So you might have a person with down syndrome who goes down to the ground and he refuses to come back up and a person, you know, unfortunately the stigma stigma might kick in and it might be, well, you know, he, he flops and he doesn't want to get up. He's just, you know, just leave him be, but maybe his knee hurts.
Maybe something happened, right? Maybe he's in pain. And.
We overlook that possibility because we're just attributing it to Down syndrome as opposed to the possibility of there being a physical condition. So obviously, this can happen quite a bit for people with an intellectual or developmental disability and a mental illness. You know, there is the assumption that people with IDD can't experience depression, especially people in the severe range. you know, but yes, they absolutely can. So people are not always looking for those, for those symptoms that might be affecting that person.
All right. So some interesting studies were done. And once again, this is 1996. So not really that far back, but let's look at this for a second. When they polled psychiatrists, they asked. about working with people who are newly diagnosed.
67% agreed that antipsychotics are overused to control aggression. And we'll be talking about that quite a bit. 86% support the proposition that people with IDD do not receive a good standard of psychiatric care. This is people within their own profession. 90% agreed that specialized units provide higher levels of services.
And over 30% preferred not to work with people with an intellectual or developmental disability. Okay. And I'm sure you've all experienced that, right? It's so difficult to find good psychiatric care for people with intellectual and developmental disabilities. And here we have in 1996, 30% of the psychiatrists reporting that they would prefer not to work with the people that we serve.
Look at that also, that 90% agree that specialized units provide a higher level of services. We all know those are pretty much non-existent, right? There are some hospitals, River Edge up north here, you know, does have a specialized DD unit, but that's really about... the only one in the state of Illinois. And there's a couple in Indiana, there's a couple attached to universities who might also do research and training and stuff like that, but there's very few.
Yet 90% of the psychiatrists think that that's a necessity, yet it has not come to fruition. So this is 1996. Let's fast forward to 2007, 11 years later. Where are we at then?
75% are agreeing that antipsychotics are overused. 68% agree that people with DD receive a relatively poor standard of care. 85% agree that specialized services should be available.
But now we're up to 58% reporting that they prefer not to treat adults with IDD. Okay. So you kind of get that feeling, you know, you start to understand why it might be so difficult for us to find good psychiatrists. And that's definitely one of the purposes of this training as we're moving forward and talking about. understanding dual diagnosis and what does it look like and how, why it's important to have an accurate diagnosis because it's on us to bring this to the psychiatrists that are serving the people that we support.
Right. So hopefully you'll, you'll come away with some things today that you can share with providers. A couple more important facts about people who are diagnosed.
Now, sadly, this is from 2005 and I have not been able to find anything that's more updated. But the numbers still hold true if you look at the national core indicators and you look at some of the other studies. Canada does actually a lot of research on people who are daily diagnosed, and these numbers are consistent.
So what do we know? That intellectual disability is common in the general population, 1%, 85% function in the mild range of intellectual disability. Why is that important?
Because... when a person has a mental illness and they're not always making the best choices or understanding the consequences of their behavior or they're reacting to the symptoms, they might come up with ways to deal with it that are not safe or not, you know, not safe to those around them either. And people in that mild range can often make plans.
They can, you know, think things out, but they don't usually understand the consequences of their, of what they're doing. So 85%. Serious mental illness is common in this population, anywhere from 30 to 60 percent. Our referrals in Illinois here for SST, we do track this, and over 85 percent each year are duly diagnosed. So the referrals that we're receiving where the main reasons for referral are physical aggression, verbal aggression, elopement, property destruction, and self-interest behavior, and they can be referred for more than one.
85% of those people are dually diagnosed. So those numbers really do hold up. And anxiety, depression, and psychosis are common in people with IDD.
Always important to know that, to remember that. Another thing to remember is that substance abuse is as common in young people with mild ID as in other people. I think often we only think about people that we're serving being addicted to nicotine or caffeine.
And yet out there, you know, in the world, it is just as likely that they are addicted to other substances as it is for a person without an IP. OK, this one's important to environmental stressors can produce new psychiatric symptoms. We all know that, right?
But take a second to think about the people that we serve who are duly diagnosed and all the environmental stressors that they encounter on a daily basis. Right. I mean, the reality is even just living in a solo group home or an ICF or in a large setting right there is going to expose them to environmental stressors every single day.
OK, a day program is going to expose them to those environmental stressors. Right. And it doesn't matter if it's a two person, a four person, an eight person or an ICF or an SODC.
Living with other people that you don't, you know, they themselves might be struggling. You've got different staff coming in all the time. There's a staffing shortage. Sometimes you don't know who will be coming in.
You might be very anxious about, you know, having a preferred staff come in. It could be loud. It could be there could be a lot of light, a lot of motion.
There's so many different things. Right. And that can produce new.
psychiatric symptoms. So you see that revolving door, right, that pattern of how a person might just be constantly triggered. Accurate assessment of psychiatric problems requires comprehensive medical, psychiatric, and behavioral evaluation, right? So anytime before we jump to any different diagnosis or, you know, we need to really be ruling out medical first, you know. Is this person experiencing a medical crisis that looks like a psychiatric crisis?
What's the number one thing? UTIs, right? How often have you served a person who just suddenly is just kind of talking kind of crazy and you're like, wow, where did this come from? And they're really struggling. And they appear to be delusional.
And you might be thinking, oh, we got to get them in the psychiatrist or they need to be hospitalized, where truly it is a UTI that is causing all those symptoms. So. you know, there's other things as well. We have found over time that people who have a history of having a shunt because they had hydrocephalus, those sometimes those shunts can get blocked, you know.
So one of the things that we'll look for in historical documentation is, did they have a shunt? Is that shunt blocked? Is that what's causing what appears to be, you know, psychiatric symptoms?
So we, you know, medical conditions, right? If a person's experiencing chronic pain and it's not being addressed, that can cause depression or anxiety. So you get the picture, but we want to make sure that we're always rolling out that medical first, right? And then looking at the psychiatric and the behavioral evaluation.
What behaviors is this person engaging in? Once again, are they responding to something internal and that's why they've been so aggressive or are they, you know, experiencing... internal pain that they're not able to tact and tell you about just gonna check the chat real quick no problem about being late we're just glad you're here all right a few more things um behavioral management is always preferable to psychotropic medications we always want to make sure that this that people are on the least amount of psychotropic medications as well and that's something that the sodc's do a beautiful job with people are always on the least amount and doing well at the lower rate of medications. So many times when we get referrals for SST, the person is literally on like three or four different antipsychotics. They might be on a whole bunch of anti-epileptic medications, anti-seizure meds.
Some of them might be for mood stabilization, but they might be for seizures, but they're on so many that they're actually canceling one another out, right? So medications are blocking the receptors while the other meds are trying to get into the receptors. There's so many things that can go on. The other thing that happens a lot is that people get put on a lot of medications, but not always at the right dose. They might be put on low doses, but a low dose of Seroquel might not be as effective as the actual, you know, as the maximum dose.
But at the lower dose, they're still getting all the side effects of those medications, but none of the benefits. That's one of the things our pharmacist, Garrett McCann, would always tell us, you know, all the side effects and none of the benefits when you don't have people at therapeutic care. doses of medications. Okay.
So, but we want to always make sure that those medications are last resort. We've tried everything behavioral first. Obviously antipsychotic medications have limited benefits for behavioral problems. You know, if it's truly something else that's going on, it's not going to stop anything. And the last point here, antihistamines produce significant confusion.
I've seen a real decrease in the use of Benadryl over the past years, but it is something to pay attention to that if you have a person who just seems to have confusion and it's not making sense, make sure you're looking at their medications and if they are on any antihistamines, okay, especially this time of year. A lot of medical problems, once again, diagnostic overshadowing, 19% are actually missed in people with IDD. And then chronic pain is common, over 25%, but often under-recognized, 61%.
So another point to always think about, is this person experiencing pain? Do they know how to ask for a PRN medication? Do they have the ability to ask for a PRN medication?
Do they even know it's available to them? You know, those are all very important things to look at. You know, you and I can go into our person, get an ibuprofen anytime we have a headache or even an allergy medicine, right? We can take our Allegro.
We can take our stuff, you know, for sneezing a lot. People we serve don't have that luxury, literally, right? So here it's saying 61% of the people have unrecognized pain that they're experiencing and that it's common and over 25%.
And yet they might not have those PRNs available to them because they don't know how to ask for them or they're not offered to them. So we've been kind of talking about this a little, you know, all the way around, but let's look at this in order. Why is it important to have an accurate diagnosis? Because we want an appropriate medication regime. We don't want somebody on too many medications.
One of the medications that we found people to really struggle with is Thorazine. We had a lot of people, we've received a lot of referrals over the years that are very interesting because one of them, I'll never forget one man named Jay. He had literally almost like lost the ability to walk.
He was drooling a lot. He couldn't feed himself anymore. He was in a hospital. Provider really didn't think they're going to be able to serve him anymore, but just because his needs had far exceeded what they were capable of providing in the cell.
So when we went back and we really reviewed his medications and we did a medical consult on Jay, because we thought it really was medical, our medical consultant, Dr. Tyler, actually picked up on the fact that they had discontinued Thorazine. um immediately prior to this decline occurring and what that did was unmask a lot of the um eps type things so he was having a lot of a movement disorder uh symptoms of a movement movement disorder so bad that he really was not able to function anymore and what they had to do was actually put him back on a low dose of thorazine to let him gain those skills back again and be able to you know have a improve the quality of his life literally you Um, we've had other people who have had to come off of clausural because of blood work that came back bad. And once that person comes off clausural, sometimes it's very difficult for them to stabilize psychiatrically. You know, sometimes Invego does not work the same way that clausural will for a person. Um, so, you know, we always want to be making sure that we're, that person's on an appropriate medication regime that is effective for them without it being too much, too little.
We want to pay attention to that. And An accurate diagnosis for a person with a mental illness also helps us know what to expect, right? If we're serving a person who has bipolar disorder and perhaps they're new to our services and when they come in, they're actually pretty stable or maybe just hypomanic, but then suddenly with all the psychosocial stressors, environmental stressors, they become manic, right? Or they go through a depressive phase.
If we know this coming in, we'll know what to expect and we're going to know how to serve that person. and how to support them when they do start to experience more symptoms of their mental illness. It also fosters empathy from caregivers, right? If you're serving a person who has, you know, let's just say depression, and the result of that depression is anger. And so they can, they just seem like they're just always agitated, and they're not always nice.
Or they have schizophrenia, and they're experiencing those negative symptoms, and therefore they're not, you know, they're really withdrawn. Sometimes it can be difficult for caregivers to feel connected to people, but when they understand that this is a function of a person's mental illness and we're able to help caregivers understand that, it does foster empathy and it does improve relationships. It should always inform an accurate diagnosis, clinical and behavioral intervention planning and implementation, right? It should be right there in the middle, person-centered planning. And then it also helps to guide the training for families and staff, you know.
We need to train staff how to work with a person who's hypomanic, who's manic, perhaps differently than a person who's experiencing depression. You know, right. Those are they can be two very different things. Right. If a person's experiencing, you know, maybe they have a personality disorder and we need to help them understand how to work with a person with borderline personality disorder.
Once again, that's much different. So it should always guide our training. So before we move on, let's talk a second about hospitalization for people that you're serving.
Just a couple words in the chat box. What is that experience like when you've had to try to seek hospitalization for somebody that you're serving? Hard. Stressful.
That's a long wait time. Yeah. Frustrating. Yeah.
And potent. I agree. Almost impossible.
No openings. What are some other things? And you can put that in the chat box. What are some things that they tell you when they don't hospitalize the person? What are the reasons that they usually give for not admitting a person that you're serving?
Too high, too low functioning, that they have a developmental disorder. Their ID, yeah, their ID makes it. You just don't want to deal with them.
That's a hard one to hear, right? Not medically stable. We can't meet their needs. Not psychotic enough.
Don't meet the criteria, no openings. Yeah. Doesn't meet criteria.
Okay. Those are great. Yeah. So it sounds like a lot of you are having the same experience, right? That when you have a person who's experiencing a mental health crisis and you take them to the hospital, this would be that diagnostic overshadowing, right?
The hospital is focusing on the person's intellectual disability and they're making the assumption that this person isn't going to benefit from treatment, but what is treatment in the hospital? It's stabilization. And that could be medication or it could just be, you know, making, keeping this person safe, right?
Because they, the criteria is a danger to self or others as a result of their mental illness. And we need, this is where I think accurate diagnosis and having this knowledge about dual diagnosis can be helpful when we go to the hospital and we're advocating for the people that we serve by really asserting that note. this person has, is depressed. They have major depression. They have major depressive disorder.
They are considering taking their life. They're making, you know, they're making suicidal ideations. They're verbalizing them.
You're right. They can't necessarily tell you what their plan is right now, but the reality is that they might do something even more lethal, not understanding the outcome and they might do it on accident, right? They might actually walk in front of a car. not realizing that the car isn't going to be able to stop in time, or they might cut themselves, not realizing how much damage it really could do.
So, you know, but once again, it goes back to the fact that they're experiencing depression and they are feeling like they don't want to live anymore. Or a person who is hearing voices, right? How many times have you taken a person to the hospital because they've just engaged in physical, I'm sorry, in, well, physical aggression obviously is the number one, right?
That why we present at the hospital, but sometimes it's property disruption. you know, and if you have a person who's experiencing voices, right, they have a lot of internal stimuli and that is just really ramping them up because they're so overwhelmed by all this. And what do they do?
Sometimes they literally tear up their room or they tear up their house, you know, their, one of their housemates rooms or the living room. And so you bring them to the hospital and you might say, they just tore up the house and they'll be like, well, there's nothing we can do about that. That's behavioral.
No, it was because they were experiencing psychiatric symptoms that they didn't know how to deal with. because they have an intellectual disability, but we don't want to focus on that in the moment. The fact is they have a mental illness that they're responding to, and that's why they're engaging in these behaviors now.
So, you know, we really using the diagnostic criteria that we're going to talk about in a few minutes and getting that petition, right? You can get, ask the ER for a petition, or you can actually get one on the state of Illinois website, a petition certificate for psychiatric hospitalization. and sitting down and writing down everything that's happened in the last 24 to 48 hours that makes this person a danger to suffer others. But while you're writing that, making sure you're focusing on the symptoms of the mental illness that this person has been displaying. Now, I realized down, especially in our Southern region, I know there's very few beds and that they really, a lot of hospitals really do hold to that criteria that the person, if they have an intellectual disability, they can't admit them.
That's really not true. That's not written anywhere. We've been having so many conversations with people about like, where does the ADA come in and all this, right?
I mean, a person with an intellectual disability, even if they're in the moderate range, they still have the right to have psychiatric services. And if that needs to be inpatient, it needs to be inpatient, right? Hopefully more places will consider, you know, opening dual diagnosis unit and treating people in a specialized unit to get the care they really need.
You know, sometimes it really is about... knowing a bunch of hospitals that will admit, even if they're far away, it sounds bad, but you know, if this person only needs hospitalization, maybe someone from the Southern region, and it happens a lot, you know, needs to get into River Edge Hospital or, you know, other hospitals where we know they will admit. I do know the southern region has a more difficult time with this too, because in the northern region, we have managed care.
So Medicaid managed care has been implemented. A lot of people are switched over to that. And therefore, a person with Medicaid can be admitted to a freestanding psych hospital.
If a person only has Medicaid, they actually cannot be admitted to a freestanding psych hospital. the hospital has to be attached to a medical facility for Medicaid to be used for those services. So sometimes that comes into play too, but people don't necessarily explain that to the provider or to the person who's trying to hospitalize. Because if that's it, then let's see, does the person have Medicare? So going to the hospital with even that information, or do they have managed care or do they have insurance through their parents?
Maybe they don't have Medicaid, but sadly, a lot of decisions about psych hospitalizations are made based on a person having Medicaid or not. And there are ways around that. So I'm taking a little bit of a left turn there, but I think it's just important, right? Because when we're talking about people who are duly diagnosed, the reality is that there are times when there might be the need for a hospitalization because of their symptoms that make them a danger to suffer others. And yet we all know that that is a very difficult process.
So having that information going to the hospital is, is, is essential. All right. So things to consider for the people that we're serving, right?
Medication side effects. We talked about this a little bit, right? They can, you know, if the person's on too many medications and they don't need them, all of them, think about what it must feel like for a person to have such a dry mouth all the time that they're now engaging in polydipsia and you have a whole new problem, right? If they're doing, they're charging people to get to water.
We have a lot of people who might experience dystonia. We served a woman who literally her eyes just kept rolling up into her head. You know, the dystonia was so bad. And until we were able to bring her down off of some of those psychotropics, you know, she had to take a lot of actually antihistamines. Benadryl is often used for that.
You know, so think about the medication side effects that the people you're serving might be experiencing, which might be therefore increasing some of those problem behaviors that you're also, you know, learning how to navigate. So lethargy, you know, constipation, gastro upset, headaches, itching, you know, dry skin. There's a lot of different ones. We also need to consider the life circumstances.
We know that most of the people that we've served have experienced trauma, right? And we'll talk about that a little bit in terms of PTSD. But life circumstances, definitely history, family history.
So many things come into play here in terms of their mental illness. We also always want to think about their physical development versus their emotional development. So if we're serving a young man who has a mental illness and, you know, they're 23 and it's very difficult to tell that they have an intellectual disability, but their emotional development is still around the 12-year-old range.
We need to make sure that we're accounting for the fact that he may be making a lot of choices based on his biological age, his chronological age, you know, but not really. prepared for all that comes with that, you know, in terms of his emotional development, right? And then once again, you throw in a mental illness like anxiety or something to that, and it's going to make those decisions a lot more difficult.
The lack of ability to communicate symptoms. And this could be even for a person who's highly, highly verbal, you know, some people can say very nonchalantly, you know, those voices in my head, you know, I was running a group one time and I literally, and it was a social skills group. And I said to the group, okay, all right, let's kind of review why are social skills so important?
And one of the people literally raised their hand and said, that way we can talk to those voices in our head, you know? And I love that because where a person without an intellectual disability might actually hide those types of symptoms, right? Because they're embarrassed.
The people that we serve are often right there and telling you what's going on. So we do need to make sure that there is that lack of ability. but also to listen to what they are saying. And that might give you insight to what they're experiencing internally. That inability to detect emotions.
You know, we might be able to say, I'm really blue. I'm not feeling like myself. I'm a little, I'm down.
But a person might find that hard to do. So we need to learn how to help them put into words the things that they're experiencing. Impaired knowledge of social norms.
So what we might, you know, we kind of understand those. Sometimes people don't. And then the lack of education and understanding of symptoms.
You and I might actually experience something and be like, hmm, I'm really anxious. I wonder if I'm, you know, maybe I need some help. And that might not be possible for the people that we're working with. All right. There's that lack of assertiveness, right?
If they have a history of not getting their wants and needs met, they might not be able to say, I think I need some help. I'm struggling. So we want to always watch for that, too.
Impulsivity. If you or I are experiencing an urge to hurt ourselves or to take out our anger or our anxiety on another person you know a lot of times if we're anxious we'll snap at people and stuff like that we can curb that right we can kind of stop that but people we serve can't um so sometimes a person that's why i think sometimes people who are dilly diagnosed can uh be more challenging to serve right because they've got all this stuff going on but they don't have literally the basic skills to know how to navigate the world of their dual diagnosis um and then of course that fear of not responding to their wants and needs so oftentimes they won't share So things to consider. Their history, a person's history is so important.
A person is not their mental illness. And I want to make sure you know that I'm not saying that that's what it is. A person is not their diagnosis.
A person is not their mental illness. However, it is still really important that you look at their history, right? And that you know that a lot of times we'll get a referral for a person who literally has 10 different diagnoses on their face sheet.
And it's... a little confusing, right? Because it could be schizophrenia and schizoaffective disorder and major depression and bipolar.
And so it's like a little bit of everything where really they probably could have shored that up a little bit, but then you all of a sudden start to see some personality disorders thrown in there, or you might see intermittent explosive disorder where really it could be impulsivity from a different mental illness. And it can be very, very overwhelming for the provider, for the psychiatrist, for anybody else, right? Because we just don't know it.
So knowing history is important. to be able to go through and kind of get all that information before a current diagnosis is reviewed, right? On the flip side of that, you might have a person who has a history of an anxiety disorder, but when you started to serve them, they were actually doing well in that moment.
And it's not until you go back to the paperwork when they start to struggle again, that you find out that this is actually, you know, can be very serious for this person, that that anxiety could then turn into depression and, you know, be bad. Know a person's history. Really make sure you pay attention to that.
Institutional behaviors are learned behaviors, right? So if a person has a history of being in, you know, children's residential in the past or other large congregate settings, sometimes hoarding behaviors might start to pop up, right? They're very protective of items. They might not ask what they need because everything kind of came to them, you know, on a tray and they don't.
they didn't have that opportunity to ask for a specific food or a specific, you know, drink and stuff like that. And so we might think that there's different skills that they've lost over time, but it could just be that, you know, they're, they're learning how to live in a different type of setting. And then of course, abandonment issues, right? They might try to test new relationships at every turn because they're so used to people not being consistent in their lives.
And obviously for people with mental illness, consistency is really important. So they're going to find it a little more difficult to trust new staff or to trust you. And they're going to test that a little bit to make sure that you're going to stick with them through the curriculum. All right. You know, I'm going to let's go ahead.
We're going to move on here to talking about the DMID and talk more about specific mental illnesses and the diagnostic criteria and how that diagnostic criteria is adapted for people with intellectual disabilities. So let's go ahead and stop here. It's 1.42. Let's take an eight minute break and come back at 1.50. All right.
Thank you so much. Thank you. All right, welcome back.
Give it a second. All right, looking at the chat box real quick. Hannah, I don't think there's going to be a survey, but it will be about two weeks for your CEUs to come out.
But we always welcome feedback, so if you want to email myself or Danielle, we always love to hear what you think of our presentations and also any suggestions that you have for future ones, topics you'd like to learn about, we can work on that. Let's see. Yeah, we were not frozen. We were on break. One of the things that people said was that people have been working on their sexuality and sexual needs and it's chronically overlooked as well.
And I totally agree because that can lead to all sorts of different things. So I love that people are really paying attention to that. Somebody else was commenting that they had to travel four hours to a psychiatrist, wait in the waiting room, spend five minutes with the doctor and four hours to travel home, right?
There just needs to be so much more telehealth, quality telehealth. for situations like that because that right there can you imagine being four eight hours in the car for that what that would do if you were experiencing symptoms um yep okay so just kind of looking at all that so or new messages all right all right and yes i can provide the powerpoint of this presentation that's not a problem I will send those to Danielle and she'll send those out. So, okay.
Oh, that was Rebecca. That's he said to tell you, there isn't a lot of hospital help for people like him. Tell him we, we definitely want to work on that. We agree.
We agree. I'm glad he's got people like you to talk to. So, okay.
All right. And thank you, Angela. That was sweet. All right. So let's move on.
And once again, if you have questions, please feel free to put them in there. I'll go back to it every once in a while and see to answer those. And we will do that.
Someone just asked for some more stuff about relationships and sexuality. We'll definitely look at that as well in terms of getting somebody. What we try to do, quick side note, what we try to do at ICPN is we have so many team members, there's about 70 of us statewide at least. So we try to find different things that people.
really focus on that they excel in, that they know a lot about. And then we also develop trainings. We have that person develop a training pertaining to that topic. We have one about the complexities of grief coming up soon.
But we've also brought in outside speakers to speak on certain topics and stuff like that too. So we really do love when we get that feedback in terms of what you think would be helpful as providers in our IDD world. So, all right, moving on. So you So I am now going to talk a little bit about the DMID2. I'm hoping that some of you actually have some experience with it and heard of it.
This is what it looks like. It is an adaptation of the DSM-5 and now DSM-5-TR. So the DMID2 was developed, as was the one, the first one, by the National Association on Dual Diagnosis. So NAD actually developed this.
It was based on evidence-based methods supported by the expert consensus model, meaning that they took the criteria for different diagnoses. Like I said, they adapted it for people with IDD, but it was done by a group of psychiatrists and psychologists who are known in this field and have experience working with people with intellectual and developmental disabilities. They all reviewed it.
They came up with a consensus model that, yes, this makes sense. And then this was published. That's what I love about the National Association for Dill Diagnosis. You know, they really do wonderful projects like this. It was at a NAD conference where I first heard a psychiatrist speak who said that he never, ever prescribed any medications without data.
So his model was actually no data, no drugs. OK, so if you had data that this person was experiencing different symptoms of a potential mood disorder or something else, then he would go ahead and he would. prescribed medications, but literally no data, no drugs.
What a wonderful way to think about it. And he is one of the men that contributed to developing this book. So the other nice thing about this book is that it talks about, for those of you who are psychologists who might be doing assessments and stuff like that, it actually talks about the different, not just the adaptation of diagnostic criteria, but also different measures. that are normed for people with intellectual and developmental disabilities has a great section on genetic disorders, what that might look like in people.
You know, just those these little things all in one book that that can feel like a textbook at times, but it really is interesting when you get into it. I mean, like, you know, just want to hear about disassociative disorders and, you know, sexual dysfunction and, you know, all that kind of stuff. So we definitely recommend this.
You can get it on Amazon. So it's a little expensive, but it's worth it. Um, it's also worth it if you're doing, if you're training students, you know, it's worth it to take it to your psychiatrist and said, Hey, have you ever seen this book?
You know, um, it's really helpful. Uh, yeah. If you've got students coming in, you know, right now we have two social work students from UIC and making sure that we get this in our hands.
So they know about it, you know, they won't be here next year, but you know what, they might walk away in a year or two and meet somebody and be working as an LCSW or something and be like, Oh, I remember that book. All right. So What it does is it takes a dozen table of adapted criteria. And like you can see here, DSM-5 criteria, and then it adapts it for people with mild to moderate and then severe to profound.
So we're going to talk about a few of the common co-occurring diagnoses that we see for people. Of course, there's a lot more. I did not go into personality disorders on this one, just because that could be a whole different workshop, right? If we were to start talking about people with borderline type behaviors or antisocial stuff like that, narcissistic, whole different conversation.
So today we're going to focus on depression, schizophrenia, post-traumatic stress disorder, and intermittent explosive disorder. Okay. So let's look at the criteria for major depression for a person who does not have an intellectual disability.
It's, you know, we need five or more of the following symptoms in a two week period with at least one being. a depressed mood or loss of interest or pleasure, right? So then you get all this criteria that would be, you know, used as diagnostic criteria and you need to have five. or more with that, right? Now, when we look at major depression for a person with an intellectual disability, it changes that criteria.
So for this one, major depression diagnosis requires only four of the criteria, and it includes irritability as a diagnostic feature. So that's what's nice. It takes that diagnostic criteria and it puts it into language that you don't have to be a psychologist or a psychiatrist to understand.
So the depressed mood may be described as a sad facial expression, right? So if you have direct care staff or you have cues or you have others who might, you know, a brand new cue who doesn't have a lot of experience in there yet, you know, it's easier for them to recognize some of these signs and symptoms, right? So that depressed mood could also be the absence of a normal expression, right? So if this person tends to have flat affect, but now that expression has changed. That could be part of the diagnostic criteria.
Someone who's rarely laughing or smiling and then they're crying or they're tearful. Okay. Another irritable mood could be grouchy or having an angry facial expression, right?
So for a person with few words, it includes their nonverbal communication and presentation. Okay. Having an onset or increase in agitated behavior.
So this might be a person who sometimes... engages in physical or verbal aggression, but now we've seen an increase in that, right? Or that increase in self-injury, right? So an increase in the behavior and then an angry affect.
But it also includes, you know, stereotypies, ritualistic, repetitive behaviors may also increase during irritability. So it helps us really take a look at a person through that lens of their intellectual disability to make that decision. The person might be experiencing a diminished interest or loss of pleasure, including refusing preferred activities.
They're withdrawn. They're spending excessive time alone. They're becoming aggressive, unprompted to participate in activities that they used to enjoy. So, you know, so think about some of these, right? This could be the person that typically when there was an outing of the day program, they were the first one.
They couldn't wait to get in the van, you know, but now suddenly you're having to really encourage them to go and they don't want to go. Sadly, sometimes when a person's refusing preferred activities. You know, they'll say, oh, they just don't want the other people in the house to be able to go.
Or, you know, they're just spending time alone in the room because, you know, Dan is bothering them. So that's why they're spending time alone. And it might not be that at all.
Right. So we want to be looking at this very specific criteria here. They're avoiding social interactions.
And then previously motivating objects or activities have lost their reinforcement power. Right. So for all of you with that behavioral background, you know, something maybe. maybe meeting with you was reinforcing, right?
You always want to use something that's, you know, not tangible, but, you know, sometimes we've got to use tangibles too, but something that previously that person really did find reinforcing and they really enjoyed just sitting for five minutes and that made the difference, you know, and they just have not reinforcing whatsoever. They want nothing to do with it. You know, they might've always been, a paycheck might've been very important to them.
Right. And that's why they were working so hard at their, at their. community day service program or their, you know, their program.
And now suddenly they have no desire to earn a paycheck. You know, they're not working at all. And, you know, people might come up with some explanations for that.
You know, maybe they just have nothing that they want to buy or, you know, that's, they're just being difficult or whatever, but perhaps it's depression, right? And for any of you who have experienced depression or you have a family member who's experienced depression. you know what that can feel like or look like, right?
And just how devastating and how much that really affects a person's quality of life. And yet we might not really be looking at it for people with IDD, especially with people with that more moderate to severe range, right? The nice thing about the major depression criteria is that you don't have to have a lot of words to actually meet the criteria for some of these categories where I'm not promoting a person being on too many medications.
Once again, if you've known anybody who... has experienced depression, and then they've gone on an antidepressant and you've seen the improvement in the quality of their life, you'd understand why it's so important for a person that we're serving who might be experiencing depression to have that same opportunity, right? So always be, you know, aware of that and be thinking about that as a possibility. And once again, this is where history is important, right? Maybe they haven't had a depressive episode for 10 years.
Maybe it can't, you know, it can be situational, but more difficult for them to, um, to work their way out of, you know, around grief or loss or, or different things. Right. So we want to make sure we're, we're really paying attention to that. Um, major depression with, with ID, again, changes in weight, eating in excess, obsessing about food, um, stealing food.
Right. That's not, you know, that's not going to be in your normal DSM-5s. Right. But here they're stealing food, maybe, you know, because part of their depressive, the topography for them is eating more food. And then agitated behaviors emerging around mealtimes.
And then there's actually no adaptation, which is nice, too. Right. I'll just say there's no adaptation for changes in sleep.
You know, some people might sleep more. Some people might sleep less. That's what the DSM-5s tell you. OK.
Changes in psychomotor behavior, something else that we don't always pay attention to, right? Sometimes it's that they rarely sit down, they're pacing, they're walking rapidly, they're fidgeting. You know, this could be a person that used to be able to sit calmly, but now they're just up and down and up and down and up and down. And we're just thinking that, you know, something else is going on, but maybe this is part of that change in the psychomotor behavior. Or they're...
slower movements, right? They've decreased. We talked about talking less. They're less active. Sometimes people might be termed as being non-compliant or, you know, other things.
So we want to make sure that we are paying attention to that, right? Fatigue or loss of energy. They appear tired.
They're more easily agitated when they're prompted to engage in physical activities. And then they are spending more time sitting or laying down. And you can really see where diagnostic overshadowing could come into effect here, right? And then those feelings of worthlessness, if they're identifying themselves as bad, they're expecting punishment.
We had a person that doesn't necessarily correlate directly with major depression, but we served a man who never really, didn't use a lot of words to speak, very rarely, very, very rarely. And he was also blind. And, um, we had inherited the program. And so we were just getting to know him and he would, and this is more of a trauma reaction, but I do think that there was things in his environment that could create, um, you know, depressive symptoms.
Um, so he would all of a sudden just start pacing up and down the hallway and saying, skipper, get the belt, get the belt skipper, you know, as if he was expecting punishment, you know? Um, so it was very, very sad, but you had to really listen to what he was saying. And that's what he was saying. You know, um, he was He was expecting for somebody to use the belt on him.
They'll blame themselves for problems. They have unrealistic fear that caregivers will be angry or reject them. This happens a lot, right?
When you're serving people, because direct care staff are so important to them and the people that they're working with on a daily basis are so important to them, they do have that fear at times that people are going to be angry or reject them. But when a person is experiencing depression, it can really go to a new level. So once again, being mindful of that. Excessively seeking reassurance.
Sadly, at times, a person who's excessively seeking reassurance can be frustrating for staff to work with, especially if they're always asking the same question over and over and you try to assure them and it doesn't work, it doesn't work. This is one of those things where I think psychoeducation and helping people and doing training and helping people understand the symptoms of depression, what this person might be experiencing. can really help a staff take a step back and foster that empathy, right? They're not seeking reassurance because they want your attention or because, you know, of something else. It's really a symptom of their depression that they're looking for that reassurance, right?
Okay. And then people in the severity profile range might not have the cognitive ability to, you know, meet this criteria because it might be difficult for them to show or to verbalize any of that part of the criteria. Right.
OK. Once again, that diminished ability to concentrate or make decisions. There could be reduced productivity at workshop or day program.
Once again, it might not be that they're distracted or that they don't want to be there. It could just be that they're having a difficult time. Diminished self-care skills, not completing tasks that they that they previously could. You know, sometimes we do worry about people decompensating physically and cognitively. But once again, is this also psychologically?
So watching for that. Increased agitation when they're prompted to do tasks that previously were not a problem. Memory problems that can come and go.
If you've ever had yourself been highly anxious or maybe experienced some type of depression, you know that it's difficult sometimes to recall information, right? So those memory problems can come and go sometimes. And then unexplained skill loss as well.
just like, you know, recurrent thoughts of death or suicide. They might talk more about death, frequent unrealistic physical complaints and fears of illness or death. A lot of times the people that we serve will talk about death and they'll say, my grandma died. And you're like, oh, I'm so sorry to hear that. And you know, when did this happen?
And they'll tell you like 20 years ago. But you kind of start to catch that they're really rehashing a lot of loss and thoughts of death that they, you know, from their past. And, you know, that could be another symptom. That could be another flag for us to be paying attention to. Because sometimes people we work with do talk about death quite a bit, but has the way they talk about it changed?
Something to watch for. Okay. And then those unrealistic physical complaints or fears of illness or death for themselves, right? You know, some things to consider. This is obvious, right, that mood disorders can be missed because they can look different than it might for you or I.
And then, once again, those developmental effects may account for the presenting clinical picture. And that's why the historical information is important in making a diagnosis, right? A person with depression who is 58 might present differently than a person who's 28. OK, but once again, the developmental effects might kick in and it might look totally different than either two of those ages.
So paying attention to that as well, really knowing that person's history. OK, some more things to think about that, aside from depression and bipolar mood disorders, really have not been studied with this population. um, agitation, aggression can be behavioral manifestations, not clinical symptoms, you know, not symptoms of a clinical diagnosis, right?
So it goes both ways. And that's why we really do need to pay attention. Um, is this person just agitated and acting and having, uh, engaging in aggression because they're having a hard time telling us what they want or need, or because there is too much stimulation around them, um, or because they're just, you know, they're confused or they don't know how to get what they want or need.
Or is it a symptom of the mood disorder? And, you know, so it also flips the other way, right? There's a high frequency of people with intellectual and developmental disabilities diagnosed with a mood disorder. Okay. We do know, obviously, that people with IDD have a higher incidence of mental illness.
So it can go all sorts of different ways. And unfortunately, there's just not enough research done to show all this, right? And then you also want to think about the effects of the mood disorder and the, I'm sorry, I totally lost my train of thought on that one. We'll just move on.
Sorry about that. All right. I know what it was.
Oftentimes we see people come up with those hybrid diagnosis, like schizoaffective disorder, right? So they're, you know, they're talking about the fact that this person has the symptoms of schizophrenia and a mood disorder. So they're kind of grouped together.
as opposed to pulling those apart. You know, so that, that to me is very interesting too, in terms of those considerations that sometimes, you know, they're, they'll just use a diagnosis to cover them both, but now you got psychotropics and you have, you know, mood stabilizers, but yeah, anyways. All right.
Let me just check here real quick. All right. Let's go back to anxiety disorders and IDD. This is one of those things that I can say working on SST.
that I feel, we feel that anxiety disorders are just missed left and right for people, right? And we know that people with autism tend to have a higher incidence of anxiety disorders. People with fetal alcohol spectrum disorders have higher incidence of anxiety disorders.
So we know that, right? We kind of know to watch for it, but we don't always treat it. And you think about for yourself. Have you ever had a panic attack or have you ever just gotten so anxious so fast that something happened and you were just flooded with, you know, adrenaline and everything else?
And, you know, you just want to jump out of your skin because you're so anxious. You know, maybe it was like to take a licensing exam or something, right? Or to whatever it could be, right? But think of a time when you've just experienced anxiety to a degree that you were uncomfortable.
Now think about a person with an intellectual disability who can't understand and make sense of that feeling of anxiety that they're experiencing, especially if they're experiencing it on a regular basis. Right. How many of you literally, maybe it was college, maybe it was another time in your life where you literally were experiencing anxiety every day. Right. Just how much that wore you down, how, how you just started to feel, you know, exhausted everything else.
Right. So once again, anxiety is just one of those things that we really do watch for. We don't want to over, you know, overdiagnosis or over-treated.
But there are ways to treat it even without medications. But once again, I just feel like it's really messed and it does lead to a lot of other problems at times for that person, including really affecting the quality of their life. So anxiety disorders, it is adapted for people as severe to profound in that it can be observed rather than subjectively described. So this is really important, right?
If you're going to the psychiatrist and he says, well, this person can't describe it to me. And you can say, well, no, but look, here's all the reports that we have from the direct care staff, from the other people in this person's life that subjectively describes. the presentation of this person with anxiety, right? It does not require that person, that criteria of the individual finds it difficult to control the worry. That's not required.
And only one of six, not one, or only one of six symptoms are required for diagnosis. So that makes a big difference, right? For people to get that diagnosis of anxiety disorder. All right. Moving on here to schizophrenia.
So this is the criteria for a person who does not have an intellectual disability, right? Two or more of the following have to be present for a one-month period. It includes delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, the negative symptoms.
We always need to be really thoughtful about what this looks like in a person with an intellectual disability. Right. It's so easy to confuse autism and schizophrenia at times. And it's also very easy to miss schizophrenia because once again, we go back to the fact that there is a higher incidence of these mental illness amongst the people we serve.
So, you know, what can delusions look like? You know, this is that person that's really telling some big stories and, you know, they're not grounded in reality. But the fact is, this is this person's reality.
And we don't want to be trying to talk a person out of a delusion, right? Because that is as concrete to them as their religious beliefs and everything else, right? So you're not going to talk a person out of their delusions. In fact, you're only going to hurt your relationship with them when you try to argue with them about their delusions. Same thing with hallucinations.
You know, they might, you know, like I said, some people can outright say, I'm hearing those voices in my head or I'm hearing voices. But other people might not know how to put words to that, right? And they might not know how to explain to us those auditory hallucinations that they might be having.
But there's other hallucinations as well, right? There's tactile hallucinations. We served a young woman who had all the negative symptoms of schizophrenia, but she had a lot of the positive ones too. So you'd often see her in the bathroom with her pants down, just rubbing her legs because she really felt like there's ants crawling on her legs. So she was having those tactile hallucinations.
And We, you know, if we hadn't walked in and realized that that was, was happening and talked to her about it, you know, like, you okay, Sarah? And, you know, it's the ants, the ants. That helped us to understand a little bit more about the hallucinations that she was experiencing. You know, like, so there's olfactory, you know, are, are they talking about smelling? I have a friend who has schizophrenia.
She does not have an intellectual disorder disorder, but she would say that before. When she knew that things were going to get bad, when she needed to go see her doctor because she would smell chocolate chip cookies baking, but yet there were none. Right. So she would start to have those olfactory hallucinations starting to trigger a break. So, you know, watching people, are they looking off into the corners?
You know, while you're talking to somebody, are they kind of squinting their eyes? You know, sometimes they'll close one eye and kind of look at you because they're they're trying to concentrate or they're seeing two of you. You know.
if they're having the visual hallucinations, right. You know, they might be seeing two of you or more, the colors might be really bright for them. Um, so, you know, they might be just with one eye, um, like I said, looking up into the corners, um, you know, um, listening to you, but then kind of responding one man we serve, um, has voices that are just very funny. Um, he'll just sit and giggle.
Um, and he's not a person who actually that's not his typical affect. He's usually very, very kind of flat and stuff like that. But when he's having auditory hallucinations, he's laughing. He's laughing at them. So this really means understanding and watching the people that we're serving, right?
To catch a lot of these symptoms that signify disorder like schizophrenia and knowing what they look like in the people that we serve, okay? Disorganized speech, sometimes that can be a difficult one, right? For us to figure out when a person might not be highly verbal to begin with, but... You know, if it's a change from their baseline or what, how they usually speak.
And now it's, you know, they're all over the place and they're, you know, they're kind of giving you work salad and stuff like that. You know, this, this can signal a problem, right? So we want to be careful of this, right? That grossly disorganized or catatonic behavior.
Um, just like for people in the, in the, um, community, you might have the person who comes out in four layers of clothing in the middle of summer. You might have that person who just, their makeup is really, really extreme. Um, you know, they, um, catatonic behaviors. We talked about Sarah.
Sarah would also have the catatonic behaviors and we'd also find her in the hallway of the day program, kind of, um, squatting and sucking her thumb and not responsive. It took us, you know, it would take a long time for her to respond to us. When we would find her like that and try to kind of bring her back.
Right. So watching those catatonic behaviors are people literally checking out for, for, you know, extended periods of time. And then of course the negative symptoms, sometimes those can be right.
That poverty of speech, poverty of the, the lack of wanting to engage in activity, right. Just not, not wanting to move. Right. Like I said, poverty of speech and then just that look.
And any of you who have been in the field long enough know the look I'm talking about, right? It's not even a flat look. It's just like, it's not like a flat effort, just like beyond that. It's kind of like the person's just kind of gone in a moment.
So we want to, you know, when we're looking at schizophrenia and IDD, and we're looking at the DMID too, this is important stuff to take back to a psychiatrist, right? Because this is really hard. So no adaptation.
However, a multidisciplinary approach is highly emphasized. Meaning... We're going to be looking at that diagnostic criteria, but we really want to make sure that everybody has ruled something out, right? That this person is not starting to show these signs of schizophrenia, you know, and it's not common that they're going to start showing them when they're 35 or 40, right?
They probably will be showing them, usually young men around 18, could be a little later, obviously, for people with intellectual disabilities because of the developmental component. And for women, it's usually, you know, 20s, late 20s and stuff like that, right? But we want to make sure that we're looking at that.
and looking at the whole picture, right? So that's why that multidisciplinary approach is really, really important. Self-talk is common for people with intellectual disabilities, right?
And we should not always assume that that is an extension of a psychotic disorder. And this is where it can get kind of difficult with autism versus schizophrenia and other things like that, right? If they're talking and or they're living, their world is a little bit different in terms of how they're organizing it.
but that's not, does not mean they're psychotic. The, the thing is a change in behavior should alert a clinician to the possibility of psychosis, right? So if a person has had, you know, this baseline of, you know, sometimes not making sense, you know, sometimes talking about things that other people don't know what they're discussing, but suddenly you see this big change where they're, you know, they are now start responding to all sorts of things around them that we're not seeing or hearing ourselves.
That should be. a trigger for us to start looking into things a little bit more closely, right? So it is very difficult to assess for people in the severe to profound range.
And really a person in the severe to profound range should not carry a diagnosis of schizophrenia because you really cannot endorse the diagnostic criteria necessary for this diagnosis in people with severe to profound ID. All right. So once again, you know, when talking about psychotic disorders, because, you know, these are the people that are going to be on the really intense medications, right?
The psychotropics that are really going to have some long term negative effects on their bodies. So we want to be careful, you know, understand that expressive communication is essential for diagnosis to be reached. Right. Diagnosis can be increasingly more difficult with the different degrees of ID. We just talked about that.
And then, of course, literature does not reveal a significant change in the presenting symptomology, but the length of the observation and the depth of the assessment should be really, you know, we should take time to do both to make sure that we are getting an accurate diagnosis. All right. I'm going to go a little bit faster.
I'm actually running out of time. Post-traumatic stress disorder. Let's talk about that just for a second.
Obviously, we sort of. a lot of people with trauma, like I said, the majority of people that we serve have experienced trauma, sadly, right? And so the diagnostic criteria actually is adapted very nicely for people with ID, okay? And there is more and more research being done on this, which is very nice, but there is considerable evidence that there's the likelihood of disorganized or agitated behavior is greater when people are more in that moderate, severe to profound range, right?
So they're more likely to engage in disorganized or agitated behavior. It was really interesting years ago, I was part of a FEMA Homeland Security mental health response team. So I had the opportunity to respond to Hurricane Katrina. And so I was down there, I was in Louisiana and I was in one of the medical tents because we actually supported the medical teams to make sure that the doctors and nurses and the other people, their mental health was good so that they could keep and they weren't experiencing too much trauma from what they were witnessing. But while in the tent, they asked me to come talk to a woman.
who had Down syndrome, who actually wasn't speaking. She wasn't vocal verbal in the moment. She was with her mom and she was very reserved and, you know, not talking and wouldn't interact with me. And just, you know, it was really, really sad.
Right. And the mom was just beside herself and thought that there was something medical going on with her. Did not have any insight to the fact that they were not able to evacuate for Katrina.
They actually lived through the hurricane and they lost their house. And so they lost all their belongings. And now they had been in a shelter for quite a while.
And this woman was obviously starting to exhibit signs of PTSD and depression. And yet the mom was really trying to get the nurses and doctors to figure out what was wrong with her medically. So, you know, it's those little, it's very easy to miss that kind of stuff, right? That diagnostic overshadowing comes in all the time. And PTSD is one of those times.
All right. Um, the people we serve experience many of the same symptoms and it can often look the same that we might just have more time, a more difficult time getting them to express it. So, uh, recurrent dreams, frightening dreams without specific content are more likely for people with lower developmental ages.
Um, you know, so you might have people come into you and say, I had a bad dream last night. I had a bad dream last night, you know, and that could be a sign of PTSD. We want to be aware of that. Right.
Um, they, people, uh, with moderate to severe ID have actually reenacted the trauma. So something else to be watching for is this person engaging in a behavior that looks kind of weird. You know, we've had people who didn't want to get into a van in the winter when it was snowing later to find out that they had been in a horrific crash in a van on the way to day program during a snowstorm. Right. And so they were, you know, kind of like, you know, reenacting car crashes and stuff like that.
And, you know, once again, that's where history is important, figuring out what's going on. efforts to avoid the thoughts, feelings, and conversations, right? Because people, if they had a traumatic experience with it in the past, they're not going to want to do it again. We all know this, right?
The person who doesn't want to take a shower because they were assaulted in a shower. The person who, and then they start to generalize that to all water. You know, people who have had trauma around eating and, you know, they want to always eat by themselves. They don't want to eat with other people.
You know, but we're... who are they avoiding and what they're avoiding is very important for us to watch for, right? Once again, you know, if they're experiencing that trauma, that PTSD, that diminished interest or participation in activities, isolation, and once again, that foreshortened future, it is important to know the developmental level at which the trauma occurs because the younger they are, the more difficult it is for them to adapt, right?
And then trauma does disrupt the maturing person's development. So you see, once again, you know, it is more difficult for them. Let's just go on real quick to intermittent explosive disorder. This is one that to me is very interesting because I think we see an overabundance of diagnosis of intermittent explosive disorder. And so if we look at this with the general population, this is when there's several discrete episodes of failure to resist.
So when a person is unable to resist that impulse to be aggressive. and it results in a serious assaultive act or destruction of property, right? That that aggressiveness is out of proportion to a precipitating stressor, and then the aggressive episodes are not better accounted for by something else, right? So that's how a person's going to get that diagnosis of intermittent explosive disorder. For a person with IDD, this is really important, right?
The reason I think this isn't so important is because when you're looking at packets to fill the vacancies in your agency or you're starting to get to know a person and you see intermittent explosive disorders, a lot of things immediately come to mind, right? There's even people who might say, I can't serve this person because of this diagnosis. And yet look at this diagnostic criteria from the DMID, right? That episodes last at least two months and they involve a failure to resist aggressive impulses.
Okay, so there's... impulses that occur all the time, right? And there might be some that they're able to navigate, but there might be others that they can't, right?
So, but these episodes need to be lasting like two months for them to get that. The degree of aggressiveness is grossly out of proportion to the stressor and the degree of the level of the intellectual disability. So. If I'm a person with a moderate intellectual disability and it's more difficult for me to understand consequences and to understand how the world works, it's more likely that at times I'm going to be aggressive.
But that is not grossly out of proportion to the stressor. Right. Because that makes sense.
But for this diagnosis, it has to be grossly out of proportion. Right. And once again, those aggressive episodes are not better accounted for by any other mental disorder.
OK, except if the other one is mild compared to the aggression or temporarily. unrelated to the aggression. So that was kind of a quick wrap up there.
But I think that once again, I use that example because when we are misdiagnosing the people that we serve with things like antisocial personality disorder or borderline personality disorder or intermittent explosive disorder or even schizophrenia at times, and we don't have an accurate diagnosis, the implications are huge. on so many levels for this person, whether it's medication management, what services are going to be available in the community, but also who's going to be willing to serve that person based on what's on their face sheet. So I definitely encourage all of you to take the time to learn more about dual diagnosis, to get a DMID too, start introducing it to your teams, introduce it to your psychiatrist, your psychologist, and really advocate for the people you're serving who have a dual diagnosis to get the right treatment out there. I don't know if there's any questions.
If you have any, you know, any feedback, I always appreciate that. And anything you need, feel free. I, Daniel will send out my contact information, you're more than welcome to reach out to me as well. All right. You guys have a great day.
And we'll see you soon.