39May/June2011Volume14Number3 The NADD BULLETIN TheDiagnosticManual-Intellectual Disability(DM-ID):ImprovingtheDiagnosis ofPsychopathologyinIndividualswith IntellectualDisability RozemarijnStaal,DoctoralCandidate,WrightStateUniversity The American Psychiatric Association (APA, 2000) cites the prevalence rate for Mental Re- tardation,nowreferredtoasintellectualdisabil- ity(ID),asapproximately1%ofthepopulation. StudiesreporttheprevalenceratesofIDtorange between 1% and 3% of the general population. Thesedifferingfindingsaremorethanlikelydue tovariationinthedefinitionandmethodusedto obtainthediagnosisandthepopulationstudied (Fletcher,Loschen,Stavrakaki,&First,2007b). Prevalence rates of ID may also vary because training in academic, social, adaptive, and vo- cational skills can influence the applicability of thediagnosisoveraperson’slifetime.TheIndi- viduals with Disabilities Education Act of 1997 set forth the standard that diagnosis should be determinedbasedonacombinationofcognitive, adaptive, or achievement measures, as well as clinical observation (Oakland, Mpofu, Glasgow, &Jumel,2003).Thedifficultyliesinthefactthat toolselectionisuptothediscretionoftheclini- cian,andthereislittleguidanceortrainingwith regard to which measures are most appropriate tomakeadiagnosisofIDbasedontheindividu- al’sleveloffunctioning. Prevalence rates for co-morbidity of mental illness and ID in population studies range from 10%-39%forchildrenandadults,makingmen- tal illness three to five times more common in personswithIDthaninpersonswithoutID(Re- udrich, 2010; Sevin, Bowers-Stephens, & Craf- ton, 2003). Other data suggest that the use of specializedassessmenttoolsforpersonswithID results in higher rates of co-morbid psychiatric disabilities. For example, Cooper, Smley, Mor- rison,Williamson,andAllan(2007)conducteda large population study and found that by using theDiagnosticCriteriaforPsychiatricDisorders for Use with Adults with Learning Disabilities/ Mental Retardation (DC-LD), a diagnostic tool designedtodiagnosepsychopathologyinindivid- ualswithIDthatcomplimentstheInternational Classification of Diseases – 10 th Edition (ICD- 10),morethantwicethenumberofpersonswere identifiedwithaco-morbidmentalillness(35%) compared to the number identified by the ICD- 10andtheDSM-IV,whicharebothstandarddi- agnostic tools. Other factors that may influence whetherornotapsychiatricdisorderisfoundin individualswithIDcanbedependentontheage andgenderoftheindividual,thelevelofexperi- encetheexaminerhaswithindividualswithID, the setting in which the individual resides, and thetreatmentalreadyinplace(Sturmey,2007). AccuracyofDiagnosisofPsychopathology inIndividualswithID Asignificantamountofresearch(e.g.,Gustafs- son&Sonnander,2004;Reiss,1990,1994;Reis, Levitan, & Szysako, 1982; Rojahn, Warren, & Ohringer,1994;Sturmey,2007)indicatesthatit is difficult to make a reliable diagnosis of psy- chopathology in individuals diagnosed with ID. Thisdifficultyisdueinparttolinguisticbarriers anddifficultyseparatingsymptomsofmentalill- ness from the long-term consequences of abnor- malbraindevelopment,institutionalization,and learnedbehaviors,andthefactthatmanydiag- nostictoolsrelyonindividuals’abilitytodescribe their symptoms verbally (Moss, 2001; Moss et al.,1998).Impairmentincommunicationability makesitdifficulttodiagnoseindividualswithID becauseadiagnosismustthenbemadeontheba- sisofobservablebehaviors,changesinpatterns ofbehavior,dailylivingskills,interests,socialin- teraction,andinterpersonalrelationships,with- outrelianceonverbalinteractions(Moss,Emer- son,Bouras,&Holland,1997;Tongue,2007).In addition,theadoptionofa“cloakofcompetence,” whichreferstoaperson’sattempttohidethedis- abilityfromothers(Edgerton,1967),andacqui- escence bias, which refers to attempts to please theexaminerandanswerfalselyorinaccurately, alsofactorintotheevaluationprocess(Fletcher, Loschen,Stavrakaki,&First,2007c). In most cases, clinicians often are heavily de- pendentuponathirdpartyinformant’sreportof symptomsinordertomakeanaccuratediagno- sis.Theopinionofthesepersonsmaybeunduly influencedbytheirownpersonalityneedsandre- 40 May/June2011Volume14Number3 The NADD BULLETIN lationshipwiththeclient(Reiss,1993;Sturmey, 2007)orthethirdpartyinformantmaynothave the discrimination or language skills to report clinically relevant information accurately (Stur- mey,2007).Challengingordisruptivebehaviors alsocanbeattributedtotheIDratherthanpo- tentialpsychopathology(Reiss&Szyszko,1983). Furthermore, clinicians rarely receive adequate training to diagnose psychiatric disorders in individuals with ID (Moss et al., 1997). Reiss, Levitan,andSzysako(1982)empiricallydemon- stratedatendencytounderestimatethesignifi- cance of problematic behaviors and called this phenomenondiagnosticovershadowing.Thisre- searchfoundthatindividualswithIDwereless likelytobediagnosedwithapsychiatricdiagno- sis than those who were not diagnosed with ID when identical behavioral symptoms were pres- ent.Thatis,thecliniciansidentifiedthemental healthsymptomsaspartofthecognitivedeficit ratherthanasaseparatementalhealthdiagno- sis.Thedegreetowhichbehavioraldisturbances are representative of diagnostic symptoms such as depression and anxiety rather than ID has beenthesubjectofdebate,especiallyinindividu- alsfunctioningintheprofoundandsevererange ofID(Fletcheretal.,2007c). Sovner (1986) identified four factors that rep- resent the main difficulties in examination and interpretationduringtheclinicalinterviewthat influence selection of diagnoses, namely base- line exaggeration, intellectual distortion, psy- chosocialmasking,andcognitivedisintegration. Baseline exaggeration refers to the increase in frequencyandintensityofpre-existingmaladap- tive behavior during the course of a psychiatric diagnosis. For example, there could be an in- creaseindestructiveoraggressivebehaviordue totheimpactofstress.Intellectualdistortionre- fers to the misinterpretation of unusual speech or thought processes due to poor cognitive or communicationskills.IndividualswithIDthink very concretely and could affirm that they hear voices, because of a belief that the question re- ferstohearingactualvoicesintheirlivingenvi- ronment, even though the question is meant to refertohearingimaginaryvoices.Psychosocial maskingreferstotheeffectofclinicalpresenta- tionduetotheindividual’sdevelopmentaldelay, creating difficulty identifying the features and targetsymptomsofpsychopathology.Inamanic individual with moderate ID, for example, it is possiblethatgrandiositymightleadtheindivid- ualtobelievethatheorsheiscapableofaskill that is beyond the person’s capability. Finally, cognitive disintegration refers to the misinter- pretationofapatient’sextremereactiontostress duetoalackofcognitivereservetocopewithan illness,whichmayleadtheindividualtobecome grossly disorganized and express psychotic-like symptomswhenexperiencingamentaldisorder. Thepresenceofthosesymptomsdoesnotneces- sarily mean that the individual should be diag- nosed as psychotic, however, because the indi- vidual’sreactiontostressmustbetakenintoac- countpriortomakingadiagnosis(Sovner,1986). Itisclinicallychallengingtomakeadiagnosisof psychopathology in individuals with ID (Poind- exter,1996).Thereisstillcontroversysurround- ingthediagnosisofID,becauseitchallengesthe dominantbiomedicalmodelofdisabilitywithits heterogeneous nature and multiple or unknown etiology.Thiscontroversyisparticularlysalient whenitcomestomakingadiagnosisofmildID (Sturmey,2007). LimitationsoftheDSMSystem. MostcliniciansusethecriteriaofeithertheDi- agnostic Manual of Mental Disorders or the In- ternational Classification of Diseases to make a psychiatricdiagnosisinindividualswithID.The systemofdiagnosingpresentedbytheDiagnos- ticandStatisticalManualreliesonself-reported signsandsymptomstomakeadiagnosis,which research has shown is increasingly problematic asintellectualfunctioningleveldecreases(Rush &Frances,2000).Fletcheretal.(2009)conclud- ed that the Diagnostic and Statistical Manual doesnotadequatelyaddress“theissuesofprob- lembehaviors,behavioralphenotypes,inclusion ofintellectuallycomplexitemswithincategories, orthepathoplasticeffectthatIDhasonthepsy- chopathology that presents within categories,” meaningtheinfluencethatIDhasonshapingthe waythatthementalillnessisexpressed(p.968). Dykens (1995) defines a behavioral phenotype from a clinical perspective as “…a heightened probability that people with a given syndrome willexhibitbehavioralordevelopmentalsequel- ae relative to others without the syndrome” (p. 523). The American Psychiatric Association’s DSMwasdesignedtoidentifysymptomsinpro- totypical clients as seen in the general clinical population(Poindexter,1996),andthisdiagnos- ticsystemisnotdesignedtotakeintoconsider- ationtheintellectualandpsychosocialdeficitsof individuals with ID. Categorical, dimensional, andetiologicalframeworksshouldbeintegrated in view of the complexities of making a psychi- atric diagnosis in individuals with ID, meaning that ID must be included in the calculus of se- lectingadiagnosis(Barnhill,2003).Theapplica- 41 May/June2011Volume14Number3 The NADD BULLETIN bilityoftraditionalDSMcriteriaforindividuals diagnosedwithIDhasbeenquestioned,andthe applicability of this diagnostic system becomes increasinglysuspectastheseverityoftheIDin- creases(e.g.,Fletcheretal.,2009;Rush&Fran- ces,2000;Sturmey,1995). The Diagnostic Manual – Intellectual Dis- ability (DM-ID): A Clinical Guide for Diag- nosis of Mental Disorders in Person’s with IntellectualDisability The National Association for the Dually Di- agnosed developed The Diagnostic Manual –In- tellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Person’s with Intellectual Disability (Fletcher, Loschen, Stavrakaki, & First, 2007a) in association with the American Psychiatric Association in an at- tempt to improve the accuracy of psychiatric diagnoses in individuals with ID. The DM-ID incorporates all the major diagnostic categories definedinDSM-IV-TR,isdesignedwithadevel- opmentalperspectivetohelpcliniciansrecognize symptomprofilesinadultsandchildrenwithID, and provides clear examples of how symptom presentationscanbeinterpreted.Inaddition,it providesinformationthatwillhelpcliniciansdif- ferentiate behavioral problems from psychiatric disorders.Whenapplicable,theDM-IDadapted the diagnostic criteria of DSM-IV-TR with the use of an empirically-based approach, to assist cliniciansinmoreaccuratelydiagnosingmental disordersinindividualswithID.Theauthorsof theDM-IDintendedittobeusedinconjunction withtheexistingcriteriaofDSM-IV-TR(Fletch- er,Loschen,Stavrakaki,&First,2007c). The DM-ID criteria for diagnosis are divided into three categories for applicability for indi- viduals with Mild through Profound, Mild/Mod- erate, and Severe/Profound levels of ID. Mental illnessesandsubtypesforwhichadaptedcriteria fromDSM-IV-TRhavebeenadoptedforindivid- ualswithIDincludeMajorDepressiveEpisode, HypomanicEpisode,GeneralizedAnxietyDisor- der, Obsessive Compulsive Order, Somatization Disorder,FactitiousDisorder,DissociativeIden- tity Disorder, Intermittent Explosive Disorder, AdjustmentDisorder,andAntisocialPersonality Disorder. The DM-ID provides suggestions on how the DSM criteria should be interpreted or appliedtoindividualswithID. DSM-IV-TR criteria are adapted by adding symptomequivalents,omittingsymptoms,chang- ing the symptom count or modifying symptom duration, and modifying the age requirements inordertomeetcriteria.Insomeinstances,the DM-IDstatesthatcertaindiagnosticcriteriado not apply. In addition, the DM-ID provides ex- planatorynotesregardingassessmentandevalu- ationmethodstoassistcliniciansinrecognizing thecommonbehaviorsofintellectualdisabilities, as well as differentiating behavioral problems frompsychiatricdisorders.TheDM-IDalsopro- vides clear examples that assist diagnosticians inapplyingthemodifiedcriteria(Fletcher,2008; Fletcher, Loschen, Stravrakiki, & First, 2007c). The following examples of adaptations of DSM- IV-TRcriteriawereprovidedataconferencethat includedalectureregardingtheclinicalutilityof theDM-ID(Fletcher,2008). An example where the DM-ID changed both the count and symptom equivalent in order for individualswithIDtomeetDSM-IV-TRcriteria can be found in the criteria for Major Depres- siveEpisode.DSM-IV-TRcriteriastate:“Fiveor moreofthefollowingsymptomshavebeenpres- entduringthesame2-weekperiodandrepresent achangefrompreviousfunctioning.Atleastone ofthesymptomsiseither(1)depressedmoodor (2) loss of interest or pleasure” (APA, 2000, p. 356). The DM-ID modifies these criteria as fol- lows:“Fourormoresymptomshavebeenpresent during the same 2-week period and represent a changefrompreviousfunctioning.Atleastoneof thesymptomspresentneedstobe(1)depressed mood, (2) loss of interest or pleasure or (3) irri- tablemood”(Fletcher,2008,p.15). An example where the DM-ID has omitted symptoms in order to meet DSM-IV-TR criteria canbefoundwhenlookingatObsessiveCompul- siveDisorder.DSM-IV-TRcriteriaforObsessive CompulsiveDisorderstate:“thepersonattempts toignoreorsuppresssuchthoughts,impulsesor images, or to neutralize them with some other thoughtoraction”(APA,2000,p.462).TheDM- IDhasomittedsymptomsinorderforindividuals with ID to meet DSM-IV-TR criteria for Obses- sive Compulsive Disorder. For example, for in- dividuals with mild or moderate ID, the DM-ID criteriastate:“Theperson’sattemptstoignoreor suppressthoughtsmaynotbepossibletodeter- mine due to cognitive and communicative defi- cits”(Fletcher,2008,p.15). An example where the DM-ID has modified the symptom duration can be found when look- ingatIntermittentExplosiveDisorder.DSM-IV- TR criteria for Intermittent Explosive Disorder include “Several discrete episodes of failure to resistaggressiveimpulsesthatresultinserious assaultiveactsordestructionofproperty”(APA, 2000,p.667).TheDM-IDadaptedthecriteriafor thisdiagnosisformildtoprofoundIDandstates: 42 May/June2011Volume14Number3 The NADD BULLETIN “Frequent episodes that last for at least two months of failure to resist aggressive impulses thatresultinseriousassaultiveactsordestruc- tionofproperty”(Fletcher,2008,p.16). AnexamplewheretheDM-IDhasmodifiedthe agerequirementinordertomeetdiagnosticcri- teriacanbefoundwhenlookingatSpecificPho- bia.TheDSM-IV-TRcriteriaforSpecificPhobia include: “In individuals under the age 18 years, the duration is at least 6 months” (APA, 2000, p. 449). In the DM-ID, the criteria have been adaptedforseveretoprofoundIDandstate:“In individuals under age 18 years and people with ID,thedurationisatleast6months”(Fletcher, 2008,p.16).Forindividualswithmildtomoder- ate ID the DSM-IV-TR criteria were not modi- fied. Conclusion The difficulty with making an accurate diag- nosis of psychopathology in individuals with ID liesinthefactthatthereisno“goldstandard”or expert consensus that has established the best practiceinthefieldthatshouldbeusedtoobtain anaccuratediagnosis.WhiletheDM-IDisavail- able as a supplemental diagnostic tool, and re- searchintotheclinicalutilityhasindicatedthat it is a valuable resource for clinicians, as of yet noresearchhasevaluatedthevalidityofadding the DM-ID criteria to the traditional diagnostic system, because this resource is relatively new. FurtherresearchintothevalidityoftheDM-ID that demonstrates improved psychiatric diag- nostic accuracy for individuals diagnosed with IDmayleadtotheuseofthistoolasastandard inclinicalpracticeandconsequentlyleadtothe establishmentofamuchneeded“goldstandard” whenitcomesdiagnosingpsychopathologyinin- dividualswithIDandimprovementintreatment outcomesforthispopulation. References American Psychiatric Association. (2000). Di- agnostic and statistical manual of mental disorders(4thed.-textrevised).Washington, DC:Author. Barnhill,J.(2003).CantheDSM-IVbesalvaged forindividualswithsevereintellectualdis- abilities?MentalHealthAspectsofDevelop- mentalDisabilities,6,567-574. Cooper,S.,Smiley,E.,Morrison,J.,Williamson, A.,&Allan,L.(2007).Mentalill-healthin adultswithintellectualdisabilities:Preva- lenceandassociatedfactors.BritishJournal ofPsychiatry,190(1),27-35. Dykens,E.(1995).Measuringbehavioralpheno- types:Provocationsfromthe“newgenetics.” American Journal on Mental Retardation, 99(5),522-532. Edgerton,R.B.(1967).Thecloakofcompetence: Stigmainthelivesofthementallyretarded. Berkeley,CA:UniversityofCaliforniaPress. Fletcher,R.J.(2008,October).Theclinicaluseful- nessoftheDiagnosticManual–Intellectual Disability(DM-ID:Atextbookofdiagnosis of mental disorders in persons with intel- lectual disability). In M. Gerhardstein & E. Comer (Co-Chairs) Putting the Pieces Together. Symposium conducted at the meetingoftheMontgomeryCountyBoard of MRDD Mental Health Supports and Services, Wright State University School ofMedicineDepartmentofPsychiatry,and Ohio’sCoordinatingCenterofExcellencein MI/ID,Dayton,Ohio. Fletcher, R. J., Havercamp, S. M., Reudrich, S. L., Benson, B. A., Barnhill, L. J., & Coo- per,S.A.(2009).Clinicalusefulnessofthe Diagnosticmanual–intellectualdisability formentaldisordersinpersonswithintel- lectualdisability:Resultsfromabrieffield survey.JournalofClinicalPsychiatry,70(7), 967–974. Fletcher,R.,Loschen,E.,Stavrakaki,C.,&First, M. (Eds.) (2007a) Diagnostic manual- intellectual disability: A clinical guide for diagnosis of mental disorders in persons with intellectual disability. Kingston, NY: NADDPress. Fletcher,R.,Loschen,E.,Stavrakaki,C.,&First, M. (2007). Intellectual disabilities. In R. Fletcher, E. Loschen, C. Stavrakaki, & M. First(Eds.),Diagnosticmanual-intellectual disability:Atextbookofdiagnosisofmental disordersinpersonswithintellectualdisabil- ity(pp.51-54).Kingston,NY:NADDPress. Fletcher,R.,Loschen,E.,Stavrakaki,C.,&First, M.(2007c).Introduction.InR.Fletcher,E. Loschen,C.Stavrakaki,&M.First(Eds.), Diagnosticmanual-intellectual disability: Atextbookofdiagnosisofmentaldisorders in persons with intellectual disability (pp. 1-10).Kingston,NY:NADDPress. Gustafsson, C., & Sonnander, K. (2004). Occur- rence of mental health problems in Swed- ishsamples of adults with intellectual dis- abilities.SocialPsychiatryandPsychiatric Epidemiology,39,448-456. Moss, S. (2001). Psychiatric disorders in adults with mental retardation. In L. Glidden (Ed.), International review of research in 43 September/October2010Volume13Number5 The NADD BULLETIN mentalretardation(pp.211-244).NewYork: AcademicPress. Moss, S., Emerson, E., Bouras, N., & Holland, A. (1997). Mental disorders and problem- aticbehavioursinpeoplewithintellectual disability: Future directions for research. JournalofIntellectualDisabilityResearch, MentalHealth,andIntellectualDisability, 41(6),440-447. Moss, S., Prosser, H., Costello, H., Simpson, N., Patel,P.,&Rowe,S.(1998).Reliabilityand validity of the PAS-ADD Checklist for de- tectingpsychiatricdisordersinadultswith intellectualdisability.JournalofIntellectual DisabilityResearch,42(2),173-183. Oakland, T., Mpofu, E., Glasgow, K., Jumel, B. (2003)Diagnosisandadministrativeinter- ventionsforstudentswithmentalretarda- tion in Australia, France, United States, and Zimbabwe 98 years after Binet’s first intelligence test. International Journal of Testing,3(1),59-75. Poindexter, A. (1996) Current trends in mental health care for persons with mental re- tardation. The Journal of Rehabilitation. Retrievedfrom:http://www.theIreelibrary.com/ Current¹trends+in+mental+health+care+for+ persons+with+mental...-a018562555. Reiss,S.(1990).Prevalenceofdualdiagnosisin community-baseddayprogramsintheChi- cagometropolitanarea.AmericanJournal onMentalRetardation,94,578-585. Reiss, S. (1993)Assessment of psychopathology inpersonswithmentalretardation.InJ.L. Matson&R.P.Barrett(Eds.),Psychopathol- ogyinthementallyretarded(2 nd ed.)(pp.17- 40).NeedhamHeights,MA;Allyn&Bacon. Reiss,S.(1994).Handbookofchallengingbehav- ior:Mentalhealthaspectsofmentalretar- dation. Worthington, OH: IDS Publishing Corporation. Reiss, S., Levitan, G. W., & Szysako, J. (1982). Emotional disturbance in mental retarda- tion: Diagnostic overshadowing. American JournalofMentalDeficiency,86,567-571 Reiss, S., & Szyszko, J. (1983). Diagnostic over- shadowing and professional experience withmentallyretardedpersons.American JournalofMentalDeficiency,87,396-402. Reudrich,S.(2010).Mentalillness.InJ.O’Hara, J.McCarthy,&N.Bouras(Eds),Intellectual disabilityandillhealth(pp.165-177).Cam- bridge,UK:CambridgeUniversityPress. Reudrich, S., & Menolascino, F.J. (1984). Dual diagnosisofmentalretardationandmental illness: An overview. In F. J. Menolascino & J.A. Stark (Eds.), Handbook of mental illnessinthementallyretarded(pp.45-81). NewYork:Plenum. Rojahn, J., Warren, V. J., & Ohringer, S. (1994) A comparison of assessment methods for depressioninmentalretardation.Journal of Autism and Developmental Disorders, 24,305-313. Rush,A.J.,&Frances,A.(Eds.).(2000).Treatment of psychiatric and behavioral problems in mentalretardation(SpecialIssue).Ameri- canJournalonMentalRetardation,105(3), 165-226. Sevin,J.A.,Bowers-Stephens,C.,&Crafton,C.G. (2003).Psychiatricdisordersinadolescents with developmental disabilities: Longitu- dinal data on diagnostic disagreement in 150 clients. Child Psychiatry and Human Development,34(2),147-163. Sovner, R. (1986). Limiting factors in using DSM-IIcriteriawithmentallyill/mentally retarded persons. Psychopharmacological Bulletin,22,1055-1059. Sovner, R., & Hurley,A.D. (1983). Do the men- tallyretardedsufferfromaffectiveillness? ArchivesofGeneralPsychiatry,40,61-67. Sovner,R.,&Pary,R.J.(1993)Affectivedisorders indevelopmentallydisabledpersons.InJ. L. Matson & R. P. Barrett (Eds.), Psycho- pathologyinthementallyretarded(2 nd ed.) (pp.87-148). Needham Heights, MA:Allyn &Bacon. Sturmey,P.(1995).DSM-III-Randpersonswith dual diagnosis: Conceptual issues and strategies for future research. Journal of IntellectualDisabilityResearch,39,357-364. Sturmey,P.(2007).Diagnosisofmentaldisorders in people with intellectual disabilities. In N.Bouras&G.Holt(Eds.),Psychiatricand behavioraldisordersinintellectualandde- velopmentaldisabilities(2 nd ed.)(pp.3-23). Cambridge:CambridgeUniversityPress. Tonge,B.(2007).Thepsychopathologyofchildren withintellectualdisabilities.InN.Bouras& G.Holt(Eds.),Psychiatricandbehavioural disordersinintellectualanddevelopmental disabilities(2 nd ed.)(pp.93-112).Cambridge, UK;CambridgeUniversityPress. For further information, please contact Roz- emarijnStaalatstaal.2(wright.edu. 2003). There is still controversy surrounding the diagnosis of ID. Most clinicians use the criteria of either the Diagnostic Manual of Mental Disorders or the International Classification of Diseases to make a psychiatric diagnosis in individuals with ID. Baseline exaggeration refers to the increase in frequency and intensity of pre-existing maladaptive behavior during the course of a psychiatric diagnosis. or the pathoplastic effect that ID has on the psychopathology that presents within categories. because the individual’s reaction to stress must be taken into account prior to making a diagnosis (Sovner. there could be an increase in destructive or aggressive behavior due to the impact of stress. In a manic individual with moderate ID. 1986). Fletcher et al. psychosocial masking. because it challenges the dominant biomedical model of disability with its heterogeneous nature and multiple or unknown etiology. it is possible that grandiosity might lead the individual to believe that he or she is capable of a skill that is beyond the person’s capability. Psychosocial masking refers to the effect of clinical presentation due to the individual’s developmental delay. The presence of those symptoms does not necessarily mean that the individual should be diagnosed as psychotic. especially in individuals functioning in the profound and severe range of ID (Fletcher et al. Sovner (1986) identified four factors that represent the main difficulties in examination and interpretation during the clinical interview that influence selection of diagnoses. Intellectual distortion refers to the misinterpretation of unusual speech or thought processes due to poor cognitive or communication skills. dimensional. 2000). 1993. This controversy is particularly salient when it comes to making a diagnosis of mild ID (Sturmey. 2007). (2009) concluded that the Diagnostic and Statistical Manual does not adequately address “the issues of problem behaviors. It is clinically challenging to make a diagnosis of psychopathology in individuals with ID (Poindexter.. 2007c). for example.” meaning the influence that ID has on shaping the way that the mental illness is expressed (p. 1997). 1983). Reiss. The system of diagnosing presented by the Diagnostic and Statistical Manual relies on self-reported signs and symptoms to make a diagnosis. even though the question is meant to refer to hearing imaginary voices. The degree to which behavioral disturbances are representative of diagnostic symptoms such as depression and anxiety rather than ID has been the subject of debate. The American Psychiatric Association’s DSM was designed to identify symptoms in prototypical clients as seen in the general clinical population (Poindexter. Finally. 968). Furthermore. inclusion of intellectually complex items within categories. For example.The NADD BULLETIN lationship with the client (Reiss. cognitive disintegration refers to the misinter40 pretation of a patient’s extreme reaction to stress due to a lack of cognitive reserve to cope with an illness. Sturmey. the clinicians identified the mental health symptoms as part of the cognitive deficit rather than as a separate mental health diagnosis. namely baseline exaggeration. clinicians rarely receive adequate training to diagnose psychiatric disorders in individuals with ID (Moss et al. 2007) or the third party informant may not have the discrimination or language skills to report clinically relevant information accurately (Sturmey. The applicaMay/June 2011 Volume 14 Number 3 . 523). 1996). Levitan. 2007). and this diagnostic system is not designed to take into consideration the intellectual and psychosocial deficits of individuals with ID. which research has shown is increasingly problematic as intellectual functioning level decreases (Rush & Frances. Individuals with ID think very concretely and could affirm that they hear voices. Limitations of the DSM System. That is. because of a belief that the question refers to hearing actual voices in their living environment. meaning that ID must be included in the calculus of selecting a diagnosis (Barnhill. which may lead the individual to become grossly disorganized and express psychotic-like symptoms when experiencing a mental disorder. however. and Szysako (1982) empirically demonstrated a tendency to underestimate the significance of problematic behaviors and called this phenomenon diagnostic overshadowing. Challenging or disruptive behaviors also can be attributed to the ID rather than potential psychopathology (Reiss & Szyszko. This research found that individuals with ID were less likely to be diagnosed with a psychiatric diagnosis than those who were not diagnosed with ID when identical behavioral symptoms were present. 1996). Categorical.. and etiological frameworks should be integrated in view of the complexities of making a psychiatric diagnosis in individuals with ID. behavioral phenotypes. creating difficulty identifying the features and target symptoms of psychopathology. and cognitive disintegration. Dykens (1995) defines a behavioral phenotype from a clinical perspective as “…a heightened probability that people with a given syndrome will exhibit behavioral or developmental sequelae relative to others without the syndrome” (p. intellectual distortion. to assist clinicians in more accurately diagnosing mental disorders in individuals with ID. for individuals with mild or moderate ID. changing the symptom count or modifying symptom duration. Fletcher. Generalized Anxiety Disorder.. 2008).g. 1995). & First. Stavrakaki. and the applicability of this diagnostic system becomes increasingly suspect as the severity of the ID increases (e. p. In some instances. The authors of the DM-ID intended it to be used in conjunction with the existing criteria of DSM-IV-TR (Fletcher. or to neutralize them with some other thought or action” (APA. p. Stravrakiki. the DM-ID criteria state: “The person’s attempts to ignore or suppress thoughts may not be possible to determine due to cognitive and communicative deficits” (Fletcher. Factitious Disorder. The DM-ID also provides clear examples that assist diagnosticians in applying the modified criteria (Fletcher. DSM-IVTR criteria for Intermittent Explosive Disorder include “Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property” (APA. 667).The NADD BULLETIN bility of traditional DSM criteria for individuals diagnosed with ID has been questioned. In addition. 2007a) in association with the American Psychiatric Association in an attempt to improve the accuracy of psychiatric diagnoses in individuals with ID. Rush & Frances.IV-TR have been adopted for individuals with ID include Major Depressive Episode. p. 2008. 2000. Hypomanic Episode. 2008. Loschen. the DM-ID adapted the diagnostic criteria of DSM-IV-TR with the use of an empirically-based approach. Mild/Moderate. The DM-ID criteria for diagnosis are divided into three categories for applicability for individuals with Mild through Profound. 2007c). Loschen. p. & First. 2000. p. Intermittent Explosive Disorder. 462). The DMID has omitted symptoms in order for individuals with ID to meet DSM-IV-TR criteria for Obsessive Compulsive Disorder. it provides information that will help clinicians differentiate behavioral problems from psychiatric disorders. The DM-ID adapted the criteria for this diagnosis for mild to profound ID and states: 41 . An example where the DM-ID has modified the symptom duration can be found when looking at Intermittent Explosive Disorder. The DM-ID provides suggestions on how the DSM criteria should be interpreted or applied to individuals with ID. & First. The DM-ID incorporates all the major diagnostic categories defined in DSM-IV-TR. Mental illnesses and subtypes for which adapted criteria from DSM. Somatization Disorder. Stavrakaki. 356).. and modifying the age requirements in order to meet criteria. and Severe/Profound levels of ID.15). At least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure” (APA.15). DSM-IV-TR criteria state: “Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. and Antisocial Personality Disorder. Loschen. the DM-ID provides explanatory notes regarding assessment and evaluation methods to assist clinicians in recognizing the common behaviors of intellectual disabilities. is designed with a developmental perspective to help clinicians recognize symptom profiles in adults and children with ID. 2000. The DM-ID modifies these criteria as follows: “Four or more symptoms have been present during the same 2-week period and represent a change from previous functioning. as well as differentiating behavioral problems from psychiatric disorders. At least one of the symptoms present needs to be (1) depressed mood. Fletcher et al. omitting symptoms. Adjustment Disorder. Obsessive Compulsive Order. When applicable. the May/June 2011 Volume 14 Number 3 DM-ID states that certain diagnostic criteria do not apply. impulses or images. An example where the DM-ID has omitted symptoms in order to meet DSM-IV-TR criteria can be found when looking at Obsessive Compulsive Disorder. DSM-IV-TR criteria are adapted by adding symptom equivalents. (2) loss of interest or pleasure or (3) irritable mood” (Fletcher. In addition. 2009. 2008. For example. 2000. DSM-IV-TR criteria for Obsessive Compulsive Disorder state: “the person attempts to ignore or suppress such thoughts. Dissociative Identity Disorder. The following examples of adaptations of DSMIV-TR criteria were provided at a conference that included a lecture regarding the clinical utility of the DM-ID (Fletcher. 2007c). and provides clear examples of how symptom presentations can be interpreted. An example where the DM-ID changed both the count and symptom equivalent in order for individuals with ID to meet DSM-IV-TR criteria can be found in the criteria for Major Depressive Episode. Sturmey. The Diagnostic Manual – Intellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Person’s with Intellectual Disability The National Association for the Dually Diagnosed developed The Diagnostic Manual –Intellectual Disability (DM-ID): A Clinical Guide for Diagnosis of Mental Disorders in Person’s with Intellectual Disability (Fletcher. (2009). Diagnostic manual-intellectual disability: A textbook of diagnosis of mental disorders in persons with intellectual disability (pp. 1-10). p. M. A. Kingston.. International review of research in May/June 2011 Volume 14 Number 3 42 . the duration is at least 6 months” (APA. Smiley. & First.. Fletcher. Intellectual disabilities. While the DM-ID is available as a supplemental diagnostic tool.. In M. Further research into the validity of the DM-ID that demonstrates improved psychiatric diagnostic accuracy for individuals diagnosed with ID may lead to the use of this tool as a standard in clinical practice and consequently lead to the establishment of a much needed “gold standard” when it comes diagnosing psychopathology in individuals with ID and improvement in treatment outcomes for this population. & First. Social Psychiatry and Psychiatric Epidemiology. 2000.16). 522-532. 27-35.. Barnhill.The NADD BULLETIN “Frequent episodes that last for at least two months of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property” (Fletcher. as of yet no research has evaluated the validity of adding the DM-ID criteria to the traditional diagnostic system. Comer (Co-Chairs) Putting the Pieces Together. Diagnostic and statistical manual of mental disorders (4th ed. Ohio. Diagnostic manual-intellectual disability: A textbook of diagnosis of mental disorders in persons with intellectual disability (pp. Kingston.. E. For individuals with mild to moderate ID the DSM-IV-TR criteria were not modified. 449).. Morrison. because this resource is relatively new. Havercamp. Introduction. Fletcher. J. C. DC: Author. The clinical usefulness of the Diagnostic Manual – Intellectual Disability (DM-ID: A textbook of diagnosis of mental disorders in persons with intellectual disability). Conclusion The difficulty with making an accurate diagnosis of psychopathology in individuals with ID lies in the fact that there is no “gold standard” or expert consensus that has established the best practice in the field that should be used to obtain an accurate diagnosis. B. Stavrakaki. Glidden (Ed. NY: NADD Press. Williamson. The DSM-IV-TR criteria for Specific Phobia include: “In individuals under the age 18 years. (2001)..). Barnhill.” American Journal on Mental Retardation. L. M. October). NY: NADD Press.).. Dykens. (2000). R. R. Journal of Clinical Psychiatry. Mental ill-health in adults with intellectual disabilities: Prevalence and associated factors.. Cooper. p. Symposium conducted at the meeting of the Montgomery County Board of MRDD Mental Health Supports and Services. (1967). C. Gerhardstein & E. & M. Gustafsson. A.. Stavrakaki.16). 190(1). M. & Cooper.. Stavrakaki. & M. (2008. In R. K. 99(5).. & Sonnander. 2008. (Eds. 2008. First (Eds. Stavrakaki. Washington. Fletcher. and research into the clinical utility has indicated that it is a valuable resource for clinicians. 39. L. The cloak of competence: Stigma in the lives of the mentally retarded. 448-456. Psychiatric disorders in adults with mental retardation. NY: NADD Press. 51-54). E. J. CA: University of California Press. the duration is at least 6 months” (Fletcher. Benson. 70(7). 6. E. Edgerton. S. First (Eds. J. S. Kingston. British Journal of Psychiatry.) (2007a) Diagnostic manualintellectual disability: A clinical guide for diagnosis of mental disorders in persons with intellectual disability. Loschen. An example where the DM-ID has modified the age requirement in order to meet diagnostic criteria can be found when looking at Specific Phobia. Can the DSM-IV be salvaged for individuals with severe intellectualdisabilities? Mental Health Aspects of Developmental Disabilities. Moss. Loschen. E. (2007). p. R. (2007). In L.. Loschen. M. J.-text revised). C. C. R. C. S. R. Loschen. (2004). Measuring behavioral phenotypes: Provocations from the “new genetics. S.). References American Psychiatric Association. E. Fletcher. Occurrence of mental health problems in Swedishsamples of adults with intellectual disabilities. Fletcher. S. C.. Fletcher. & First. & Allan. 567-574. Clinical usefulness of the Diagnostic manual – intellectual disability for mental disorders in persons with intellectual disability: Results from a brief field survey. Dayton. and Ohio’s Coordinating Center of Excellence in MI/ID.. (2007c). In the DM-ID. A. In R.. Reudrich. R.. Wright State University School of Medicine Department of Psychiatry. (2003). L. the criteria have been adapted for severe to profound ID and state: “In individuals under age 18 years and people with ID. Fletcher.. Berkeley. J.. Loschen. B. 967–974. Stavrakaki. (1995). E. E. 357-364. Reiss. & Rowe.-a018562555. L. Sovner. H. For further information. P. S. N. 24.)(pp. C.. In J. (2003) Diagnosis and administrative interventions for students with mental retardation in Australia. Sovner. & Frances. 578-585. Diagnosis of mental disorders in people with intellectual disabilities. please contact Rozemarijn Staal at VWDDO#ZULJKWHGX.) (pp. & Crafton. Levitan. J.The NADD BULLETIN mental retardation (pp.. 45-81). J. A. Psychiatric disorders in adolescents with developmental disabilities: Longitudinal data on diagnostic disagreement in 150 clients.D. 43 . Diagnostic overshadowing and professional experience with mentally retarded persons. Rush. Moss. Reudrich. 165-177). Sevin. S. (1994).). B. 61-67. Journal of Intellectual Disability Research... Bouras (Eds). Cambridge: Cambridge University Press. 39. Tonge. American Journal of Mental Deficiency. 165-226. Reiss. Handbook of mental illness in the mentally retarded (pp. 440-447. J. Bouras & G. Holt (Eds. (1993) Assessment of psychopathology in persons with mental retardation. Reiss. A. Reliability and validity of the PAS-ADD Checklist for detecting psychiatric disorders in adults with intellectual disability. P.) (pp. R. J.. Bouras & G. Poindexter. McCarthy. Limiting factors in using DSM-II criteria with mentally ill/ mentally retarded persons. Stark (Eds. American Journal on Mental Retardation. E.. S.. S. 567-571 Reiss. Reiss. J.. Intellectual disability and ill health (pp. Mpofu. (2003). Cambridge. J. Child Psychiatry and Human Development. R. (1996) Current trends in mental health care for persons with mental retardation. 94. 42(2). 396-402. K. Treatment of psychiatric and behavioral problems in mental retardation (Special Issue).. R. (1986). J. 305-313. Barrett (Eds. Glasgow.. MA: Allyn & Bacon.. (1984). O’Hara. DSM-III-R and persons with dual diagnosis: Conceptual issues and strategies for future research.. H. W. Dual diagnosis of mental retardation and mental September/October 2010 Volume 13 Number 5 illness: An overview. New York: Academic Press. Oakland. Reudrich.. Sturmey. Menolascino & J. (1990). J. Bowers-Stephens.). & Szysako. 1055-1059. (1982). Worthington.. 105(3). 147-163. Patel. Sturmey. (2000). Emerson. Allyn & Bacon. United States. A. (1995).. In N.. Psychopathology in the mentally retarded (2nd ed. 87. In N. Handbook of challenging behavior: Mental health aspects of mental retardation. A. S. (1998). Bouras. S. 211-244). New York: Plenum. (2007). R.. (2010). Mental Health.. N. Psychopathology in the mentally retarded (2nd ed.). Sovner. American Journal on Mental Retardation. E. Journal of Intellectual Disability Research.. 1740). Mental illness.) (pp. and Intellectual Disability.). L. P. A. & Szyszko. Do the mentally retarded suffer from affective illness? Archives of General Psychiatry. The psychopathology of children with intellectual disabilities. Costello. & Ohringer. and Zimbabwe 98 years after Binet’s first intelligence test. International Journal of Testing. J. (1997). (1993) Affective disorders in developmentally disabled persons. Psychiatric and behavioral disorders in intellectual and developmental disabilities (2nd ed. & Menolascino. Cambridge University Press. C. Psychiatric and behavioural disorders in intellectual and developmental disabilities (2nd ed. 3(1). Needham Heights. UK. Journal of Intellectual Disability Research. 41(6). G. 34(2).. Needham Heights. S. & N. Emotional disturbance in mental retardation: Diagnostic overshadowing. UK: Cambridge University Press. 93-112). Cambridge. & Pary. A. (2007). S. 59-75. Holt (Eds. 173-183. Barrett (Eds. Prosser. American Journal of Mental Deficiency. (1983). S.).).87-148). 40. 3-23). In J. S. (Eds. B. Prevalence of dual diagnosis in community-based day programs in the Chicago metropolitan area.J. Mental disorders and problematic behaviours in people with intellectual disability: Future directions for research. & Hurley. (1983). 22.. Moss. The Journal of Rehabilitation. Simpson. Jumel. Rojahn. F. V. Psychopharmacological Bulletin. Warren. OH: IDS Publishing Corporation. Matson & R. P.. 86. G. A. P. Matson & R. & Holland. S. Retrieved from: KWWS ZZZWKHIUHHOLEUDU\FRP &XUUHQWWUHQGV+in+mental+health+care+for+ persons+with+mental. In F... T. MA. In J. France. Journal of Autism and Developmental Disorders. (1994) A comparison of assessment methods for depression in mental retardation.