LD PD national issues NFH Oct 06 Sylvia Carpenter

People with Learning Disabilities and Personality Disorder the national picture : 

People with Learning Disabilities and Personality Disorder the national picture Dr Sylvia Carpenter, Consultant Psychiatrist for people with LD, Bristol Tracy Cox, Lead Nurse Specialist, LD Services, Bristol

Background: 

Background Clinical emergence Literature search Local survey National survey Workshop

Themes: 

Themes Diagnosis Treatment and Management Crisis Management A quality service Current national situation Current local situation The Way Forward

Diagnosis of PD in LD: 

Diagnosis of PD in LD Resistance and reluctance Validity Overlap with LD Blurring of boundaries between PD, behavioural and psychiatric disorders Stigma and Prejudice Exclusion and Barriers

Diagnosis of PD in LD cont’d: 

Diagnosis of PD in LD cont’d Clinical Usefulness: Shorthand description of symptom clusters Informs care plan Provides some indication to prognosis Enables long term plans for support andamp; care

Diagnosis of PD in LDcont’d: 

Diagnosis of PD in LDcont’d Clinical Usefulness cont’d: …and without consensus diagnostic criteria it is difficult to compare clinical practice, services and research findings (DC-LD)

Diagnosis of PD in LDcont’d: 

Diagnosis of PD in LDcont’d Assessment and clinical presentation ICD-10 (International Classification of Diseases) DSM lV (Diagnostic and Statistical Manual of Mental Disorders) DC-LD: age 21 + schizoid, dependent and anxious avoidant –n.r. suggests ‘PD unspecified’ initially Diagnosis in severe /profound LD is unlikely

Diagnosis of PD in LDcont’d: 

Diagnosis of PD in LDcont’d Assessment tools Structured Assessment of Personality (SAP) EZ Personality Questionnaire (EZPQ) Reiss Screen Psychopathology Inventory for Mentally Retarded Adults Temporal Lobe Personality Behaviour Scale

Diagnosis of PD in LDcont’d: 

Diagnosis of PD in LDcont’d …however Very limited use of assessments tools Uncertainty over PD as primary or secondary diagnosis Interface with Psychoses (differential diagnosis) Mostly diagnosed in mild and moderate LD behavioural presentation in severe LD IQ 70 - 80

Management / TreatmentKey Themes: 

Management / Treatment Key Themes Complex and difficult (don’t do well) Staff polarisation and burnt out teams Treating (treatability) or managing Motivation difficulties

Management / TreatmentKey Themes cont’d: 

Management / Treatment Key Themes cont’d Early intervention Role of medication Role of other therapies (group/indiv) Risk assessments and management Relapse prevention

Crisis ‘Management’: 

Crisis ‘Management’ Usually sudden Aandamp;T revolving door or beds +/- available / appropriate MH bed +/- available / appropriate Out of county transfer: costly, away from family and friends Services post discharge?

A quality service for people with LD and PD: 

A quality service for people with LD and PD Early detection and intervention (Child and Adolescent services) Seamless handover from adolescent services (Transition strategy)

A quality service for people with LD and PDcont’d: 

A quality service for people with LD and PDcont’d Staff taking ownership, interested Understanding narrative, early experiences and attachment issues Building trusting relationship - long term Good communication - consistency Boundaries and structure

A quality service for people with LD and PDcont’d: 

A quality service for people with LD and PDcont’d Staff need Training: basic knowledge for all specialist knowledge for some keeping up to date Support: systemic approach individual around spec. client Interdisciplinary - Holistic view Networking

A quality service for people with LD and PDcont’d: 

A quality service for people with LD and PDcont’d CARE PATHWAYS with Contingencies for long term support Ongoing Risk assessment with relapse prevention Enhanced CPA Use of legislation: MHA Guardianship POVA

A quality service for people with LD and PDcont’d: 

A quality service for people with LD and PDcont’d Prevent crises through: Long term support (interdisciplinary) ‘Home treatment Teams’ ‘Safe Haven’ local units flexible for IP, DP All agencies ‘on board’ = ROBUST BACK UP

A quality service for people with LD and PDcont’d: 

A quality service for people with LD and PDcont’d In crisis: communication !!! and quick response local units / secure and flexible local medium secure units …with seamless re-integration

In Summary:: 

In Summary: What we think is needed: Staff motivated, trained and supported Local units flexible and appropriate Local medium secure units for few Commissioners supportive of above

The local Scene: 

The local Scene …and now

Home office Psychopathy Programme for DSPD: 

Home office Psychopathy Programme for DSPD Two analyses of the violence related treatment needs of psychopaths A comparison of the social and thinking (socio-cognitive) skills of violent psychopaths and violent non-psychopaths An investigation of the effectiveness of accredited cognitive skills programmes with psychopathic offenders An in-depth study of motivation in psychopathic offenders The development of an evidence based competency framework for staff working with psychopaths The development of a ‘neuro-cognitive’ test battery Several studies exploring factors undermining interventions with psychopaths