Search

Background and objectives In most countries worldwide, general adult psychiatrists look after the mental health of adults with intellectual disabilities (ID) without appropriate specialist training in the field. It is, therefore, necessary to develop a practice guideline to help these clinicians to assess and diagnose psychiatric disorders in adults with ID. Methods We have developed an evidence and consensus-based practice guideline for the assessment and diagnosis of major functional psychiatric disorders in adults with ID. Several senior psychiatrists from different European countries formed a guideline development group who assessed the evidence gathered from a systematic literature search to produce the guideline. Results Adults with ID develop the same psychiatric disorders as their non-ID counterparts. The overall rate of major functional psychiatric disorders such as schizophrenia, depressive disorder, bipolar disorder, and anxiety disorders seems to be somewhere between 14.4-22.4%. However, if a wider definition of psychopathology and mental ill-health is considered including depressive and anxiety symptoms, behaviours of concern, and other neurodevelopmental disorders such as autism spectrum disorder the rate becomes much higher than that in the general population. The risk factors for psychiatric disorders seem similar in both the ID and the non-ID populations. However certain risk factors such as genetic burden, certain comorbidities, psychosocial adversities, and reduced coping capacity are more prevalent among adults with ID. Conclusion This guideline describes how the main symptoms of major psychiatric disorders may manifest differently in adults with ID and provides recommendations as to how to address these issues in day-to-day clinical practice.

Psychiatrische stoornissen worden behandeld binnen de GGZ. Dit blijkt niet zo vanzelfsprekend voor patienten die op zwakbegaafd niveau functioneren en psychische klachten of een psychiatrische stoornis hebben. Wanneer zij in behandeling zijn bij de GGZ wordt de zwakbegaafdheid niet altijd herkend en/of krijgen zij dientengevolge niet altijd de meest passende behandeling aangeboden. Daarbij bestaat er veel onduidelijkheid over de vraag waar deze patienten behandeld kunnen worden: in de reguliere GGZ, in gespecialiseerde centra, in de VGZ? In dit hoofdstuk beschrijven wij de verwijslijnen en bespreken we wenselijke aanpassingen in de organisatie van de reguliere GGZ om aldaar een deel van deze patientenpopulatie goede zorg te kunnen bieden.

Purpose In The Netherlands, curative mental health care and supportive care for people with an intellectual disability (ID) are organised in separate domains. Prevalence of mental health problems is known to be high among people with borderline intellectual functioning (BIF) or mild intellectual disabilities (MID). By contrast, according to recent findings, prevalence of BIF and MID is high among patients in mental health care (17.5–58 per cent). In The Netherlands, a new quality standard of care (QSOC) on mental health care for people with BIF or MID is developed. It is designed to supplement existing guidelines on mental health care so that they can be used appropriately in people with BIF or MID and meant for use in both mental health care organisations (MHCO) as in organisations for ID care. To a large extent, the QSOC should describe the existing practice. This paper aims to discuss these issues. Design/methodology/approach To assess the existing practice in current mental health care for people with BIF or MID in The Netherlands, the authors examined the views and accessibility of MHCO on the mental health care for patients with and IQ Findings The authors found there is a clear awareness of the high prevalence of BIF and MID among large Dutch MHCO. Dutch MHCO estimate the prevalence of BIF and MID among their patients to be around 30 per cent. Nonetheless, most MCHO surveyed (76 per cent) indicated they do not routinely estimate or measure IQ among their patients and 53 per cent of MHCO indicated not having knowledge and expertise on the dual diagnoses of mental health problems and BIF or MID. Fitting in with the new QSOC most of the MHCO (59 per cent) agreed on the statement in the survey that professionals should be able to treat patients with BIF or ID and all but one of the MHCO stated to have some form of collaboration with an institute for ID care. Originality/value The authors concluded there is a clear awareness of the high prevalence of BIF and MID among large Dutch MHCO. The new QSOC on mental health care for people with BIF or MID can help improve accessibility and quality of mental health care for these patients.

Psychiatric disorders are three times more common in people with an intellectual disability (ID) in comparison to the general population. Still, for a long time the diagnosis and treatment of menta...

Background: to examine whether Borderline Intellectual Functioning (BIF) and Adverse Childhood Experiences independently predict adult psychiatric morbidity. Methods: we performed a secondary analysis of longitudinal data derived from the 1970 British Birth Cohort Study to examine whether BIF and Adverse Childhood Experiences independently predict adult mental distress as measured by the Malaise Inventory. Factor analysis was used to derive a proxy measure of IQ from cognitive testing at age 10 or 5. Variables that could be indicators of exposure to Adverse Childhood Experiences were identified and grouped into health related and socio-economic related adversity. Results: children with BIF were significantly more likely than their peers to have been exposed to Adverse Childhood Experiences (BIF mean 5.90, non-BIF mean 3.19; Mann-Whitney z = 31.74, p < 0.001). As adults, participants with BIF were significantly more likely to score above the cut-off on the Malaise Inventory. We found statistically significant relationships between the number of socio-economic Adverse Childhood Experiences and poorer adult psychiatric morbidity (r range 0.104-0.141, all p < 001). At all ages the indirect mediating effects of Adverse Childhood Experiences were significantly related to adult psychiatric morbidity. Conclusions: the relationship between BIF and adult psychiatric morbidity appears to be partially mediated by exposure to Adverse Childhood Experiences. Where possible, targeting Adverse Childhood Experiences through early detection, prevention and interventions may improve psychiatric morbidity in this population group., NCD-Lifespan, Fogarty/NIMH grant at the Boston Children's Hospital, Harvard Medical School; Global RD0C, Fogarty/NIMH grant at the Boston Children's Hospital, Harvard Medical School; Institut d’Assistència Sanitària, the Government of Catalunya; Mental Health Policy Unit, the Centre for Disability Research and Policy Faculty of Health Sciences, University of Sydney

Background Aggressive behaviour is prevalent in people with intellectual disabilities. To understand the aetiology, it is important to recognize factors associated with the behaviour. Method A systematic review was conducted and included studies published between January 2002 and April 2017 on the association of behavioural, psychiatric and psychosocial factors with aggressive behaviour in adults with intellectual disabilities. Results Thirty‐eight studies were included that presented associations with 11 behavioural, psychiatric and psychosocial factors. Conflicting evidence was found on the association of these factors with aggressive behaviour. Conclusions The aetiology of aggressive behaviour is specific for a certain person in a certain context and may be multifactorial. Additional research is required to identify contributing factors, to understand causal relationships and to increase knowledge on possible interaction effects of different factors.

SummaryBorderline intellectual functioning is an important and frequently unrecognised comorbid condition relevant to the diagnosis and treatment of any and all psychiatric disorders. In the DSM-IV-TR, it is defined by IQ in the 71–84 range. In DSM–5, IQ boundaries are no longer part of the classification, leaving the concept without a clear definition. This modification is one of the least highlighted changes in DSM–5. In this article we describe the history of the classification of borderline intellectual functioning. We provide information about it and on the importance of placing it in the right context and in the right place in future DSM editions and other classification systems such as the International Classification of Diseases.

Introduction In most countries, people with borderline intellectual functioning (BIF) are not considered a separate group in mental health care. There is little to no research on the impact of BIF on the presentation, nature and severity of mental health problems. The aim of the present exploratory study was to compare, in a naturalistic setting of patients referred to secondary care, symptom profiles of patients with BIF diagnosed with either major depressive disorder (MDD) or posttraumatic stress disorder (PTSD) to patients from regular mental health care (RMHC) and patients with Mild ID diagnosed with the same disorders. Methods We used a cohort of adolescent and adult outpatients (aged 16–88) with or without BIF diagnosed with a primary diagnosis MDD or PTSD. Primary outcome was the nature and severity of psychopathological symptoms assessed at baseline using the Brief Symptom Inventory. All outcomes were adjusted for gender and age. Results Results showed that BIF patients with a primary diagnosis MDD reported less severe symptoms on BSI Total and the subscales Depression, Obsession–Compulsion and Psychoticism than patients from regular mental health care (RMHC). There were no statistically significant differences in reported symptom severity on BSI Total and the different BSI subscales between BIF patients with PTSD and either patients from RMHC or patients with Mild ID. Patients Mild ID, did report significantly less severe symptoms on the subscale Depression and on the subscale Psychoticism than patients from RMHC. Discussion Since there were no other published studies into symptom profiles in patients with BIF compared to either patients with higher or lower levels of cognitive functioning, the study was mainly exploratory in nature, providing direction for future research. Results indicate that symptom profiles did not widely differ, but that there might be some characteristics unique to patients BIF separating them as a group from both patients from RMHC and patients with Mild ID.

There is little research on the subject of personality disorder (PD) in individuals with borderline intellectual functioning (BIF). Unlike in most countries, in the Netherlands, patients with BIF are eligible for specialized mental health care. This offers the unique possibility of examining the rates of PDs in patients, who in other countries are treated relatively invisibly in regular mental health care.To compare, in a naturalistic setting, the frequency of PD diagnoses in outpatients with BIF with outpatients from regular mental health care and outpatients with mild ID.We compared the rates of all DSM-IV-TR axis II PDs in outpatients with BIF (BIF group; n = 235) with rates of the same disorders in outpatients from regular mental health care (RMHC group; n = 1026) and outpatients with mild intellectual disability (ID) (mild ID group; n = 152) in a naturalistic cross-sectional anonymized medical chart review.Over half of the patients with BIF (52.8%) were diagnosed with a PD, compared with one in five in the RMHC group (19.3%) and one in three of the mild ID group (33.6%). All PD diagnoses, except for cluster A PDs and histrionic PDs, were most frequently diagnosed in the BIF group. PD NOS and borderline PD were the most frequently diagnosed PDs in BIF. The majority of PD patients had one or more comorbid axis I disorder.There is a high frequency of PD diagnoses in BIF outpatients in daily clinical practice. In anticipation of further scientific research, results suggest that PDs should not be overlooked in patients with BIF.

In the International Classification of Diseases, 10th Revision, there is no specific code for it, but in the DSM-IV-TR, as well as in DSM-5, borderline intellectual functioning is a V code that can be used to signify problems associated with subaverage intellectual performance.1–3 These patients function in between people with average or above average intelligence and people with ID. Adults with borderline intellectual functioning are believed to suffer from high rates of psychiatric disorders and rely mostly on outpatient treatment.4 In most countries they are not considered part of the ID population and are treated in the same clinics as patients without ID. However, it is unknown to what extent the mix of disorders with which they present themselves in mental health outpatient clinics differs from patients without ID. It is also unknown to what extent this mix of disorders differs from patients with lower IQs. Most studies in the general population, as well as in outpatients, did not include people with borderline intellectual functioning.5–7 This may be important, as the prevalence of mental health disorders has been reported to vary by the severity of the ID.8 Unlike most other countries, in the Netherlands, patients with borderline intellectual functioning and comorbid psychiatric disorders are eligible for the same specialist psychiatric services as patients with ID. For instance, the Dutch regional mental health care provider Rivierduinen has over 10 years of experience with 2 outpatient mental health care centres specialized in psychiatry and ID, mainly for patients with borderline intellectual functioning and mild ID, apart from outpatient clinics for people without ID. Well established referral pathways and focus on patients with borderline intellectual functioning as a separate group made referral of patients with borderline intellectual functioning and psychiatric disorders to specialized mental health care the default procedure. Using data from these 2 specialized outpatient clinics and from a general outpatient clinic of Rivierduinen operating in the same region, we were able to compare psychiatric morbidity of patients with borderline intellectual functioning with outpatients from RMHC and with outpatients with mild ID. Clinical Implications In patients with PTSD and V codes, one should extend the diagnostic process to borderline intellectual functioning as a co-existing problem. Caregivers should be aware of the possible hidden morbidity of depressive disorders in patients with borderline intellectual functioning or mild ID. Limitations Results apply only to outpatients and cannot be generalized to inpatients with more severe illness. Our study did not account for comorbidity of Axis II disorders.