Learning disability psychiatry

• Background to learning disability psychiatry
• Personal perspective
• List of specialties
• Link to Learning Disability Faculty home page

Background to learning disability psychiatry

If psychiatry is sometimes referred to as the Cinderella of medical specialties, then learning disability psychiatry is the Cinderella of Cinderellas.

In the UK, a person is said to be learning disabled when their general intellectual ability (cognitive, motor, language and social) is felt to be lower than expected for someone of similar age or culture. In addition, the difficulties must originate in childhood. An intelligence quotient (IQ) of 70 which is associated with impairment in adaptive behaviour (an inability to adapt behaviour to the setting in which one lives) demarcates those with a learning disability from the general population. The level of learning disability is further subdivided into mild, moderate, severe and profound mental retardation. The aetiology of learning disability can be hereditary or acquired. In the majority of cases of mild learning disability (the largest sub group) an identifiable cause is not found.

For this group of people, already disadvantaged and stigmatised, the likelihood of mental illness is greater than for the general population and is more likely to be complicated by associated medical problems such as epilepsy, rare genetic conditions or sensory impairment. Add in communication deficits and the diagnostics of mental illness becomes more challenging, whilst arguably more important for appropriate management.

Treatment of mental illness in people with learning disability is complicated by additional physical problems and other required medication coupled with the increased sensitivity to medication of those already handicapped – clinically doses need to be lower at the outset and changes made more slowly. Add in the potential of lifespan services (cradle to grave) and you can encounter features of both child and adolescent mental health and older people’s psychiatric specialties. The recent Mental Capacity Act and the emerging recognition of autistic disorder adds further areas of interest and challenge.

For anyone who enjoys the majority of medical specialties, is intrigued by the vagaries of genetics and embryology, is fascinated by psychiatry, but likes the developmental/holistic approach utilised by children’s services and enjoys the luxury of time to consider each case, then learning disability psychiatry might just be the right specialty.

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Personal perspective - learning disability psychiatry

As a senior house officer in the nineties, I really enjoyed my old age and working age adult psychiatry but I was unprepared for the enthusiasm I developed for learning disability psychiatry. At the time one of my peers commented “If you like learning disability psychiatry, you’re not the person I thought you were”. Many years on I still reflect on that curious comment with a smile. Psychiatry is not the most glamorous of medical specialties and indeed the psychiatry of learning disability is not the most high profile of psychiatry subspecialties, but it has a great deal to offer.

Having dual trained as a specialist registrar in both learning disability and working age adult psychiatry, I now work as one of five consultants in the learning disability directorate. Community psychiatry uses all of the skills that I learned throughout my training.

What inspires me about the job is the variety of mental health challenges that keeps the week so interesting. The nature of problems managed within our service is much broader than with other psychiatric subspecialties. My typical clinic includes organic and functional psychiatric disorders, autism, challenging behaviour, behavioural phenotypes, epilepsy and of course there’s always capacity to consider. Generally, community clinics allow us to see a spectrum of people of different ages, cognitive abilities, sensory impairment and risk. Not surprisingly, issues around adult protection and offending behaviour are not infrequent themes within our population.

As a result, you need a questioning approach for accurate diagnosis and risk assessment and to appropriately consider the full range of resources and treatment options that are available. Yes, biopsychosocial assessments started here!

I work within a truly multidisciplinary community learning disability team. This allows joint working to flourish and makes the job satisfying and productive. I actually feel we make a difference to both the service user and the carers’ quality of life.

I am glad I took up the challenge to embark upon this exciting and rewarding career.

Amanda Spencer

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List of Specialties