4/28/2014. Initial Psychiatric Diagnostic Interview. Psychiatry and ID The Diagnostic Interview. Assessment Challenges: Improving Diagnosis and DSM-V

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1 Assessment Challenges: Improving Diagnosis and DSM-V Version Year Publication Number Pages Number Conditions DSM I DSM II Research Associate Professor - Institute on Disability DSM III DSM IV DSM V 947 about same 2 Psychiatry and ID The Diagnostic Interview The Psychiatric Diagnostic Interview Evaluation Visit: 1st diagnostic appointment for mental health care It is a conversation: questions are asked of the person seeking help People with ID are disadvantaged due to limited conversational ability Initial Psychiatric Diagnostic Interview General Population Establish relationship Conversation, detailed questions & answers Evaluate overall presentation Discuss diagnosis and treatment plan ID Population Relationship with a Team Verbal ability limited 3 rd party information Atypical presentation Behavioral phenotypes Team treatment negotiation 3 4 Reason for 1 st Psychiatric Appointment Challenging Behavior Chief Complaint N= 100 each Hurley et al OPD Sep-03 SIB NIQ Mild M-P Aggression* Mood* Anxiety* Suicidality* Physical* SIB * Cognitive* Psychotic Other

and regular follow-up Careful integration of psychosocial stressors and medical conditions 7 8 What is an Instrument Instrumentation refers to printed forms specifically designed to capture useful

of the patient as well as caregivers can enhance treatment, understanding, and progress 9 10 Why is Instrumentation Not Widely Used in ID?

2 How Can We Improve Assessment? Integrating instrumentation into our assessment process Assessment of adaptive skills and neuropsychological testing and projective testing Specific tools to assess symptoms or areas, at initiation and regular follow-up Careful integration of psychosocial stressors and medical conditions 7 8 What is an Instrument Instrumentation refers to printed forms specifically designed to capture useful personal information Instruments are usually rating scales, but may be in other forms Instrumentation Advantages The quality of assessments will be enhanced when instrumentation is added Engagement of the patient as well as caregivers can enhance treatment, understanding, and progress 9 10 Why is Instrumentation Not Widely Used in ID? General psychiatric practitioners are not familiar with ID nor usefulness of instruments Instruments must be obtained - purchased & training on instrument completed Time is very limited in US for psychiatric assessment and follow-up appointments Types of Instruments in Manner of Obtaining Information Self-report: person give self-perceptions Interview: professional interviews the person Informant: a caregiver completes the instrument independently Informant interview: a professional interviews a caregiver

3 Broad Spectrum Tools- ID The Psychiatric Assessment Schedules for Adults with Developmental Disabilities (PAS-ADD ) (Moss et al., 1996, 1997) PAS-ADD Clinical Interview Reiss Screen for Maladaptive Behavior (1988) DASH-II: Diagnostic Assessment for the Severely Handicapped (Matson,1995) Developmental Behavior Checklist (Einfeld & Tongue,1995, 2002) Parent & Teacher versions Nisonger Child Behavior Rating Form (Aman et al. 1995) based on Child Behavior Checklist Instruments for Specific Area-ID Aberrant Behavior Checklist (ABC) (Aman & Singh, (1986) Behavior Problems Inventory (BPI) (Rojahn, et al. 2002) Self-Report Depression Questionnaire (Reynolds & Baker, 1988) The Fear Survey for Children With and Without Mental Retardation (FSCMR) (Ramirez & Kratochwill, 1990) Using informant rating scales Informant: How well do they know the person? Are they eager to do this work for you? Do they have the academic skills required? Did they read all the material? Is the setting within which they complete the scale quiet with no pressures? Are you available for questions? Do they know how important it is? ABC Aman & Singh 1986 Informant scale: caregiver independently completes the form Aims to capture specific behavioral symptom areas Developed on normative data from institutions and later data for group homes Widely used, over 250 published papers using the ABC Excellent psychometric properties for repeat administration ABC form has 58 items & 5 subscales Subscale Irritability Lethargy Stereotypy Hyperactivity- Noncompliance Inappropriate Speech Number Items Tyrer et al. Lancet 2008 RCT Blinded Antipsychotics Risperidone, haloperidol, and placebo in the treatment of aggressive challenging behaviour in patients with intellectual disability: a randomised controlled trial. Lancet 2008; 371: Multi-center international study Multiple measures: CGI, ABC, MOAS, quality of life, carer uplift & burden, side-effects Excluded those with psychosis, 180 pts eligible 29 Risperidone; 28 haloperiodol; 29 placebo

4 Tyrer et al. Lancet 2008 results on ABC drug wk.1 wk.4 wk.12 placebo risperidone haloperidol Tyrer et al Lancet Median scores on the Modified Overt Aggression Scale for 12 weeks ABC 25 yo Bipolar Disorder ABC 23 yo Male ADHD Subscale # Items-Max Day Staff Family Subscale # Items-Max Day Staff Family Irritability 15 (45) Irritability 15 (45) Lethargy 16 (48) 5 11 Lethargy 16 (48) 1 2 Stereotypy 7 (21) 3 0 Stereotypy 7 (21) 0 0 Hyperactivity- Noncompliance 16 (48) Inappropriate Speech 4 (12) 1 1 Hyperactivity- Noncompliance 16 (48) Inappropriate Speech 4 (12) 0 0 The Fear Survey for Children With and Without Mental Retardation (FSCMR) (Ramirez & Kratochwill, 1990) Ramirez & Kratchowill (1990) used the FSSC-R as a model to develop a novel self-report measure administered orally to children. Ramirez & Lukenbill (1997) FS for Adults with Mental Retardation Administered verbally to individual Individual and examiner establish a fear word yes-no-a little afraid-a lot afraid 87 items The Fear Survey for Children With and Without Mental Retardation (FSCMR) (Ramirez & Kratochwill, 1990) Y N L A 17. Somebody breaking into your home somebody coming into your house through the door or window when you do not want them to come in. Y N L A 18. Being sick - when your body feels bad, like when you have a bad cold and you have to stay in bed. Y N L A 19. Having an accident, like cutting yourself on broken glass or burning yourself on the stove - hurting yourself on something all of a sudden, when you didn't know that it was going to happen

5 Better Assessment of Cognitive Abilities For any patient, we must understand their cognitive strengths and weaknesses, in addition to other abilities to cope with life, e.g. educational background For people with intellectual disability, a psychiatric assessment should be cause to initiate a neuropsychological assessment, as one might treating possible dementia in a geriatric population We Judge Others Based on Verbal Abilities For people with ID, we may over or underestimate their true cognitive abilities how much they understand of what we are saying People with ID can often respond in a way that is not clear, and we assume we are understood We must always take care to speak slowly, carefully, using simple words, and check for meaning*** WISC-III age 12 composite scores NVLD Verbal Comprehension Index 80 9% Perceptual Organization Index 69 2% Working Memory Index 62 1% Processing Speed Index 67 1% Rey-Osterrieth Figure Child Copy (photo source: Wikipedia) copy 10% immediately recall <1% delayed recall <1% Down syndrome 43 yo F ref: obsessive about laundry job-? ALZ WAIS-R VIQ 51 PIQ 54 Digit Span 2 digits PP Vocab T 2yrs 8 months DTVMI 4 yrs 9 months DAP 3-5 Passed memory testing well including portions Rivermead Behavioural Memory Test Down syndrome 43 yo F ABS Res & Community Independ F 5 yr 6 Mos Phys Dev 7-6 Economic 6-6 Language below 3 Numbers Time 5-9 Domestic 8-9 Self Dir 4 Responsibility 8-6 Socializ

6 DSM Axis System Axis I: major psychiatric diagnoses Axis II: personality disorders and ID Axis III: medical conditions Axis IV: psychosocial stressors Axis V: GAF DSM Axis System Example Axis I: ADHD; OCD Axis II: Mild ID Axis III: GERD; scoliosis; sleep apnea; HTN Axis IV: death of mother; change residence; loss day new day service Axis V: DSM-V Ended Axis System Often clumsy, but demanded integrated documentation of thinking re: possible disorders, medical conditions, and psychosocial stressors relevant to the diagnostic process For people with ID, stressors are often not recognized or understood, as most people with ID cannot articulate their difficulties We must insist that a thorough assessment of stresses be included in thinking Stress They moved my bowl DSM-IV Stressors DM-ID Adaptations Axis IV DSM-IV-TR Category and Examples Suggested General Considerations for ID Primary Support Group Social Environment Occupation-Education Housing Economic Access to Health Care Legal System and Crime Other Primary support group involves family and partners, as well as issues of death, divorce, abuse, discord with other family members Social environment: loss of friend, living alone, discrimination, life-cycle stresses such as retirement Long-term relationships with peers, staff and support personnel, and housemates apply to this category. Living independently can be a particular stressor; discrimination is a severe and persistent condition for people with disabilities; stresses in changes in services and lack of available state services apply to this category

7 Holmes and Rahe Adult and Child Stress Scales 1967 Score of 300+: At risk of illness. Score of : Risk of illness is moderate (reduced by 30% from the above risk). Score <150: Only have a slight risk of illness Available free Wikipedia Holmes Rahe Scale sample items Life event Death of a spouse 100 Divorce 73 Marital separation 65 Imprisonment 63 Death of a close family member 63 Life change units Lifestress Inventory (Bramston & Bostock, 1994 & 1995) for people with Mild ID Self-Report 30 items rate on 1-4 scale o no stress o some stress o moderate stress o great deal of stress o no response Lifestress Inventory (Bramston & Bostock, 1994) 1. Do you get to choose things that are important to you? 2. Do you get enough privacy/time to yourself? 3. Have you heard people you know arguing? 4. Do people treat you as though you are different? 5. Do people respect your rights? 6. Has someone you know been seriously ill or died? 7. Have you been getting on with your partner/girlfriend/boyfriend? The Stress Survey Schedule for Individuals with Autism and Other Pervasive Developmental Disorders, Groden Designed for people with ASD Informant instrument, 5-point rating scale o none o mild to moderate o moderate o moderate to severe o severe Assesses: Changes, Anticipation, Unpleasant, Positive, Sensory, Personal, Food Related, Social Environment, Rituals The Stress Survey Schedule for Individuals with Autism and Other Pervasive Developmental Disorders, Groden

8 The Stress Survey Schedule for Individuals with Autism and Other Pervasive Developmental Disorders, Groden Medical Genetic Assessment Medical problems cause stress, possible pain, disability, difficulties in daily functioning Behavioral phenotype advances are identifying so many conditions that are associated with psychiatric and behavioral profiles assessment by clinical genetics may be often warranted: FG syndrome and ADHD-ASD Fragile X and ADHD Down syndrome, severe MDD and Alzheimer s Bipolar Disorder DSM-V Now its own chapter Criterion A: Changes in energy and activity as well as mood and includes irritable mood Bipolar I diagnoses has been changed-no longer need to meet mania and depression criteria for full features, but instead can present with a mixed episode, depression with manic/ mania with depressed features Cooper et al. JIDR 2007 Sample of all ID in registered area interviewed individually. 4 diagnostic approaches were used with the following results identifying bipolar disorder: Clinical judgment 2.3% DSM-IV-TR 1.7% general population 0.5% Chief complaint Hurley 2008 JIDR dep (85) bipolar (70) anxiety (30)control (27) DEP BIP ANX Aggression * Anxiety ** Cognitive Depression Other behavior Physical Psychotic Self-injury Suicidality Evaluation DSM-V Bipolar 1 A: Period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goaldirected activity of energy lasting 1 week and most of the day every day. DM-ID: Tantrums, hyperactivity, laughing, seeming obsessed with preferred activities

DSM-V Bipolar dx Manic Episode criteria 3 and DM-ID: 2/3 communication problems* DSM V 3 Inflated self-esteem Grandiosity Little sleep, seems rested at all times Pressure of speech Flight of ideas

9 DSM-V Bipolar dx Manic Episode criteria 3 and DM-ID: 2/3 communication problems* DSM V 3 Inflated self-esteem Grandiosity Little sleep, seems rested at all times Pressure of speech Flight of ideas DM-ID (3/2) Can fix a TV, says he is a movie star Charts, reports of being up at night More talk, more noises? difficult with developmental delay Bipolar dx Manic Episode criteria 3 DM-ID: 2/3 communication* DSM (3/4) Distractibility Increase in goal directed activity Excessive involvement in pleasurable activities DMID-(2/3)? Working more, doing more at home? unusual, excessive walking, playing with toys, cooking when you cannot cook Ways to Improve Bipolar 1 Diagnosis ABC: excellent as irritability and hyperactivity - noncompliance would identify strong symptoms Reiss Screen: has euphoria item and other disorders for comparisons ( depression scales, psychosis scale, etc.) DASH-II: as well has mania and multiple other scales for comparison PAS-ADD: overall excellent tool Improving Bipolar 1 Diagnosis Sleep Chart Modified Overt Aggression Scale Psychological assessment with traditional instruments if appropriate: otat ororschach Conclusions DSM-V: Few additions to help with ID unless associated with developmental perspectives Still will need a need for a DM-ID and altered criteria for the Intellectual Disability population Add specialized assessment tools and have updated neuropsychological- adaptive behavior scales Because Axis system eliminated, clinicians must specially assess stressors and medical conditions without this structure

6/22/2012. Co-morbidity - when two or more conditions occur together. The two conditions may or may not be causally related.

6/22/2012. Co-morbidity - when two or more conditions occur together. The two conditions may or may not be causally related. Autism Spectrum Disorders and Co-existing Mental Health Issues By Dr. Karen Berkman Objective To present an overview of common psychiatric conditions that occur in persons with autism spectrum disorders