Frontline Initiative Dual Diagnosis

Psychiatric disabilities and Intellectual or developmental disabilities


Robert Fletcher DSW is the Founder and CEO of NADD

A reality that all Direct Support Professionals (DSPs) face is that many individuals they support who have intellectual or developmental disabilities (I/DD) may also have psychiatric disabilities. This combination of disabilities is commonly referred to as a “dual diagnosis.” However, this is not always fully recognized and appreciated by support teams.

 Appreciating the reality of dual diagnoses is critical. An individual’s behavior may be attributed to his or her I/DD and written off as such. Too often this hap­pens when a person shows signs of an underlying mental health issue.

It is estimated that more than one million people in the United States have a dual diagnosis of I/DD and mental illness. According to NADD, the rate of mental illness among people with I/DD is three-to-four times greater than the general population. Many pro­fessionals estimate that approxi­mately one-third of people with I/DD have a psychiatric disability.

The higher incidence rate of psychiatric disorders among individuals with I/DD — particu­larly anxiety and mood disorders, described below — is attributed to a variety of factors including bio­logical and social. Individuals with I/DD may have coexisting central nervous dysfunction and medical problems, and they may take a va­riety of medications that influence the body’s basic chemistry. They are also subjected to increased stress and negative social condi­tions. They suffer abuse more frequently than other people. They often have inadequate social sup­ports and, given societal attitudes, may experience low self-esteem.

The most common types of psychiatric disorders experienced by individuals with I/DD are:

Anxiety disorders — a group of disorders characterized by excessive fears or nervousness or frequent physical complaints that have no medical basis (so­matic complaints) and interfere with functioning. Panic attacks, obsessive-compulsive behavior, phobias (irrational fears) and post traumatic stress disorder (PTSD) are types of anxiety dis­orders.

Bipolar disorder — a mood disorder, also known as manic-depressive illness, that causes extreme shifts in mood. A person with bipolar disorder may cycle between periods of mania (extreme levels of energy and overconfidence that may lead to reckless behavior) and depression, but also have normal moods. The length of a manic or depressed cycle may be days or months.

Major depression — also a mood disorder that affects the mind, body and innermost feel­ings of an individual. Everyone feels down from time to time; it is a natural response to particu­lar life events. But with major depression, however, the symp­toms are severe or long lasting. Symptoms can include sad or irritable mood; loss of interest in activities once enjoyed; signifi­cant changes in appetite, sleep­ing patterns and activity level; feelings of emptiness or hope­lessness; difficulty concentrating and thoughts of death.

Individuals with I/DD may also have psychotic disorders, such as schizophrenia. The major symptom of these disorders is psychosis, or delusions and hallucinations. Delusions are false beliefs that impair a person’s functioning. One example of a delusion is a person believing that someone is trying to hurt him or her when there is no tangible evidence of this. Another example is a person believing that he or she is somebody else, such as the President. Hallucina­tions are false perceptions. They can be visual (seeing things that aren’t there), auditory (hearing), olfactory (smelling), tactile (feeling sensations on your skin that aren’t really there, such as a person feeling bugs crawling on him or her), or taste. Unlike anxiety and mood disorders, the incidence of psychotic disorders among people with I/DD is believed to be the same as that for the general population.

Individuals with I/DD may also have personality disorders. These are patterns of dysfunctional be­havior that present as personality traits. They may also have adjust­ment disorders. These are de­scribed as an inability to cope with or adjust to a particular source of stress.

The issue of dual diagnoses is not new. It has just become more visible as people with I/DD have emerged from the shadows of institutions. Taking their right­ful place in the community with their fellow citizens, they and their advocates, families, clinicians and direct support professionals have demanded that attention be paid to needs that they share with people who do not have I/DD, in­cluding mental health needs. And like individuals who do not have I/DD, their mental health needs can be addressed through appro­priate professional interventions. These may include psychopharma­cology (medications), psychother­apy, behavior management, social skills training, residential supports and crisis intervention services.

An excellent resource on this matter is The Dual Diagnosis Primer: A Training Manual for Family Members, Case Managers, Advocates, Guardians and Direct Support Professionals, published by NADD .