Hi, everyone. Can you hear me? All right. So welcome to Session ID 1383, Demystifying Personality Disorders in Individuals with Intellectual Disability. Hopefully, you're all at the right place here. So I'm going to go ahead and introduce my colleagues, my panel here. So Dr. Julie Gentile is professor and chair at Wright State University in Dayton, Michigan. We've got Dr. Jesse Cannella, who is actually a recent graduate of Wright State School of Medicine. And he's about to embark on his training at Indiana University in psychiatry, pediatrics, and child and adolescent psychiatry. And then we've got Dr. Jeff Gennay, who is the residency training director at Beaumont Health in Michigan. And he also serves as the chief medical officer of Easter Seals in Michigan. So hello, I'm Dr. Neetha Bhatt. I am an associate professor at Wright State University. And I also work as a staff psychiatrist at the State Hospital in Columbus, Ohio. So before we get started, I did want to kind of put a plug in for our caucus, the ID caucus, Caucus for Psychiatrists Treating Persons with Intellectual Disabilities. That caucus takes place on Monday from 1 to 2 at the Marriott Marquis in Pacific Ave. And so our chairperson is Dr. Mark Houser. Dr. Gentile is the co-chair, and I'm the secretary. Dr. Gentile and I recently came aboard this team, and we're really excited to hopefully help invigorate, and hopefully we'll be able to meet more regularly, maybe throughout the year through Zoom or WebEx. You know, we all, I think so many of us are in this room, right, because we have a passion about caring for individuals with intellectual disability. And, you know, this meeting we have on Monday is just such a great opportunity for us to make connections and share some of our stories and hopefully figure out ways to help our patients even more. And so I've actually posted a WebEx link on our caucus message board in case you have some colleagues that maybe weren't able to join us in San Francisco or maybe you're stuck in your hotel room or whatever. So that's also an option. So please do feel free to share that with some of your colleagues and others. You know, our real desire, like I mentioned, is to increase caucus activity. You know, perhaps we'll do quarterly meetings, that sort of thing. If you aren't already a caucus member, you can easily do that on your APA account. And if anyone wants help doing that, I'm happy to kind of walk you through that at the end of the session. So, great. As far as disclosures, we have no relevant financial interests to disclose. I do just want to say Dr. Gentile is actually the co-author of the DMID II, but she receives no royalties from the sales of this book. So let's just, today we, you know, let's talk about our objectives for today. So we really want to be able to help psychiatrists and other providers recognize presentations of personality disorders in folks and individuals with intellectual disability. The criteria for personality disorders are all, you know, potentially altered in this population. There's quite a significant overlap between ID itself and personality disorders. So a lot of care has to be taken when making diagnoses. Patients with ID, of course, live in a culture where certain things are acceptable that might not be acceptable in individuals without intellectual disability. For example, being dependent on others. So both ID and certain personality disorders can be associated with other characteristics, you know, behavioral dysregulation, including self-harm, impulsivity, intense anger, those sorts of things. So when diagnosing personality disorders, we really want to consider the cultural context of ID and what's considered acceptable developmentally. So for example, difficulty with empathy, right, should be considered. The ability to imagine and perceive other people's feelings represents a developmental milestone. We will also discuss some evidence-based practices for the management of comorbid personality disorders in ID. And then we'll also discuss different resources and care team roles to help assist taking care of these individuals and managing them. So without further ado, I will hand it over to Dr. Gentile. Please get us started. Thank you so much, Dr. Bott. Welcome, everyone. It's great to be with you. Really, I just want to give you an overview to begin with, and then we're going to talk about some salient points. The other speakers are going to be expanding on borderline personality disorder and antisocial personality disorder in the ID patient population. So really, we want to think about this patient population as having co-occurring conditions. Sometimes we'll call them multi-system youth or multi-system adults. And so it's really common for them to be involved in multiple systems and to be sort of intimately involved with the healthcare system and the mental health system. So they may be hospitalized multiple times. They may be called high flyers or frequent flyers, for example. And really, it's important to make sure that they have wraparound systems in place at the time of transitions in particular. Before we start, I want to talk about the systems in Ohio that we have in place. We really decided years ago that patients who have co-occurring conditions really need multiple systems in place. And we came up with a couple ideas. This actually dates, this is our 20th year, dates back to 2003. And we're so fortunate to have funding from our state departments. We have the State Department of Developmental Disabilities and the State Department of Mental Health and Addiction Services. I know that it's rare when I talk to my colleagues at the national level that we are able to meet with the directors of these programs and with the governor's office on a regular basis and ask for funding for specific resources so that we can expand the resources and make sure that they're well suited and they're adapted to better treat individuals with intellectual disability. So we have the Coordinating Center of Excellence in Mental Illness and Intellectual Disability, or MIID. And we have funding from both of the state departments, which we're really grateful for. In exchange for funding the programs, of course, they sometimes will give us parameters or protocols to follow, and they'll often have us collect data, specifically with regard to numbers, emergency department visits, hospitalizations, institutionalization, and developmental centers. We still have developmental centers in Ohio. We have six. This has really been condensed from 11 or 12 years ago. We used to have about 1,400 individuals who were really just institutionalized long-term for years. And they didn't dispose of the developmental centers, but they really have morphed into sort of a consultation system now. So we can have patients there 30, 60, 90, 120 days, for example. And yes, there will be some... Oh, let's just move forward. Okay, I'm not touching anything. No, you didn't do anything. Okay. So really we wanted to get people out into the community in the least restrictive environment, but we also realized that there's a need for the developmental centers at the consultation level, and so that's what we've been doing. So with the Coordinating Center of Excellence, we had this administrative paradigm with three parts. So we had educational programs were all academics, and so that was sort of a perfect fit. So we really went around the state. At that time, this was pre-virtual work, and we would increase awareness, and we would train individuals. And then the second piece was teams. We thought that we should have statewide resources, but we should also have local resources. And really the important thing is to have a leader at the county level so that there's a person that is making decisions about triage and screening. Can you still hear me okay? Okay, perfect. So really, when you have statewide resources, what we don't want to have happen is to have 50 or 100 individuals come from the big cities in a state, because we have smaller, less populated counties that have less infrastructure, and they have less funding. And so we really want to reach out to them. So as we went from county to county in our travels, we asked each community to identify a team leader and to have a dual diagnosis team, which consisted of individuals from the mental health side and individuals from the intellectual disability side. So these came in really handy, because when you're trying to discharge people from state hospitals or you're trying to place people with the right resources, you can call that team lead. They can be that point person. They also make really good decisions about whether someone can stay locally and just access local resources versus when does someone need a statewide resource. So these are just some of our stats. And as of this March, we started the telepsychiatry project in 2012, and so we currently have 87 of the 88 counties in Ohio engaged in the project, and we have about 2,400 patients. So really what we're asking counties to do is refer patients who have the most complex needs to the state project and then take care of the remainder of the patients locally. So these are just some of the stats that we collect for the state agencies, and we report to them quarterly. We're so fortunate to have no wait lists and no referrals denied. The grant funding allows us to do that. We do all Medicaid, Medicare, and indigent patient populations. And so if we want to spend more time with the patients, then what Medicaid allows, I think currently in Ohio it's 40 minutes for intake, and it's about 18 or 20 minutes for a follow-up. And that often is not long enough for us to fully assess the patient, and so we typically have 60 or 90 minute intake, and we do 30 minute follow-ups. This is just a map that shows where we have children engaged, where we have adults engaged, and most of the counties are actually both age groups. There's one county yet to be engaged, and that is in southeast Ohio. We also do second opinion assessments. We do about 100 per year, and that's for all 88 counties, and that's for all age groups. So when we think about personality disorders, just as a brief review, and I won't read this slide to you, but we're talking about individuals thinking, feeling, and behaving. And really when you think about impulse control and effective modulation, learning from previous experiences, some of the individuals with intellectual and developmental disorders will have difficulty in some of these areas. And so we want to take that into account when you're assessing and diagnosing individuals. And also part of that personality disorder description will be to be able to evaluate the interpersonal, social, legal, and professional behavior of self. So these are just some nuances I wanted to mention with regard to personality disorders and ID. Cluster A, and we won't read through these, but remember with cluster A that in persons with ID, some of these symptoms can overlap with symptoms of autism spectrum disorder when you think about developing relationships with others and reading others, for example. Cluster B, we want to really pay attention to that poor impulse control and that emotional instability, because that can certainly cross over into both of those circles of PD and ID. And cluster C, we want to be very careful about dependent disorder, because individuals with ID will inherently have real, realistic dependency needs. So these are just some comments from the DMID. If you haven't heard of this textbook, it's been really, really helpful for us. It's the Diagnostic Manual for Intellectual Disabilities, second edition. And it really is a cooperation between the American Psychiatric Association and the NADD or the National Association for the Duly Diagnosed. So it's a collaboration between the two national and international agencies. And so what we did was we reviewed literature on every category of the DSM-5, and then we looked at the criterion sets to see if any of them need to be adapted to be a better fit for individuals with ID. And so these are just some sort of key takeaway points for you. Real needs for support, for example. There are often expressive language skill barriers or linguistic and cognitive limitations. We also know that there's a higher prevalence of mental illness within the specialized patient population versus the general population. And sometimes when individuals have developmental delays, then you will also find that there could be some immaturity in how they're navigating their communities or their relationships. I think there's the other factor within this realm is also how integrated are they in their community and how socialized were they, for example, during those important developmental years. And then, of course, do we have reliable diagnostic instruments that have been normed for intellectual disability? In most cases, that's going to be a no, unfortunately. Hopefully, we'll get there. So about 90 to 95 percent of our patients will be referred to us or will self-refer for some type of aggression. And that could be property destruction, sexual aggression, verbal aggression. And so what we want to do really is it's our task to determine the ideology of that behavior change and what the patient is trying to communicate to us as an individual. It could be because there's limited expressive language skills or limited speech. It could be an expression of physical or some kind of medical condition that's been untreated or undertreated or undiagnosed. And that's really common. In one of the pieces of literature I found from the University of Colorado, there were in a clinic for ID, 85 percent of the individuals have some form of untreated or undertreated medical condition. And so really making sure that that individual is linked with a primary care physician and has an expanded lab panel is very important to identify those medical conditions. When we think about trauma-informed approaches, which should be universal precautions for this patient population, just remember that of course individuals, there'll be some that can exhibit manipulation and lying and stealing. But if they're exhibiting manipulation, remember that at some point, at least ask the question, at some point in the past was that person not in control or powerless over a situation? Is that where the manipulation stemmed from? If they're lying, is it possible that at some point in the past that it was not safe to tell the truth? And if they're stealing at some point in the past, is it possible that they didn't have their primary needs taken care of? And so they were either surviving or they were helping others to survive. And in particular, your mid-40s and older individuals who may have been in an institutional setting at some point. And I'm not saying all institutional settings fall in that category, I'm just saying that I have had patients in the past that have had traumatic experiences. Also, with regard to exhibiting changes in behavior that are not conducive to relationships or don't fit well in the community, we really want to be asking, how was this person during developmental years, were they encouraged to identify their emotions and to express them in a healthy way to others? A lot of my patients will say, well, I can't, I shouldn't cry, my mom tells me not to cry, my mom tells me to ignore that, ignore people when they taunt me, when they tease me, when they call me names. And so when they're telling me these stories in my office, I always want to take that into account, that everyone needs and deserves to identify their emotions and to communicate those effectively and in a healthy way to others. So emotions are not problems, they're actually signals, and we should talk about them. So this is just, I thought this was helpful to me, it's just sort of a summary, this is from the Royal College of Psychiatrists, and so it was a test question, but the answer is all of the above, and the higher age threshold, so think about, should we stick to those thresholds that are denoted in the DSM-5, or should we take into account that this person has developmental differences, and should we use 22, 23, 24, for example, as a potential cutoff. Schizoid, dependent and avoidant personality disorders are not highly recommended, so use extra caution with those, they may not be a good fit for most individuals with ID. And initial diagnosis, if it's the first appointment, if you're just getting to know the patient. Royal College of Psychiatrists recommend that you use an unspecified or sort of a category that may be changed over time or part of a differential that will be, you'll zone in and be more accurate down the road. And these are clinical pearls. So we wanna really focus on reducing risk, you know, harm reduction, safe environments. A lot of our staff that are spending most of the time with our patients are our DSPs or our direct support professionals. A lot of them want and need more education and more training. A lot of them don't have the support that they need. There's a high turnover, they have, they're typically underpaid and they're overworked. We wanna really spend time with the DSPs and the services and supports administrators or family members, the direct care staff, and make sure that they have the information that they need to properly care for individuals with co-occurring needs. Consistency, of course, it's easier said than done, but we want to be talking as a team and the staff across shifts and across environments should be in constant communication with clear behavioral goals. And so these are just some clinical pearls, reducing staff turnover. We have increased the hourly pay rate for our staff, our direct staff in Ohio, and I think that has helped. We still have too high of a turnover rate. These are just yet losses after losses for our patients. They get attached to people. Some of them have been abandoned by biological family members. And so this can be just one trauma after the next. And then clear consequences and giving a patient a means of self-control. So building skills in our patients with relaxation techniques and some things that they can do themselves, maybe listen to music and going to be by themselves, but other things that they can go to someone and effectively ask for support or help, a phone call, et cetera. So these are just some do's and don'ts. We want to remember that we want to use medications wisely, but we don't want to treat personality disorders with solely medications. We want to make sure that we are treating disorders with psychotherapy because that, of course, is evidence-based and it's going to be the most successful intervention. And we do want to consider borderline antisocial and other personality disorders, but we also want to make sure that we follow that biopsychosocial developmental, that paradigm, so that we are not missing medical conditions and ruling out the medical conditions first. So given the nature of ID to be that dependency issue, we don't want to forget that. They're likely to experience delayed development. Individuals with previous experience in institutional settings, they may have adapted to institutional life, and therein, remember that those defense mechanisms are going to be very solid and very cemented in, and so they're going to take a long time to change. And then the DMID-2 authors, they suggest that if individuals are in the mild-moderate range, we should be considering personality disorders. If they're in the severe and profound range of ID, then they may not have sufficiently developed personalities that will give us a reliable diagnosis of personality disorders. And these are my references, and our slides will be available to you, and I will now pass it on to Dr. Cannella. Hi. They should help. Hi, thank you, Dr. Gentile. So I will be discussing borderline personality disorder, specifically in patients with intellectual disability, about the diagnosis, assessment, and management of BPD in these patients. So just as a quick overview, echoing some of the points of Dr. Gentile, it's important to remember, again, our qualifications and developmental background for these patients before diagnosing any personality disorder, including BPD or other cluster B personality disorders. Again, considering an age over 23, rather than the standard age of 18, and typically avoiding this diagnosis in patients with severe to profound intellectual disability. Of note, assessment tools may be very difficult in assessing for borderline personality disorder. Multiphasic personality inventory, or the MMPI. The Minnesota, or sorry, the Minnesota Multiphasic Personality Inventory, my apologies, along with other standard tests can be very complicated in this population, both due to attention, as well as cognitive ability. These personality tests often require there be significant recall, significant memory skills, and appropriate emotional responses, which may not be capable in these patients. And when working with these patients, knowing their baseline function is also very important. Collateral data really becomes a prominent source of information. Again, as our assessment tools are lacking, and there are very few assessment tools specifically for the population with intellectual disability. So when we're talking about the presentation of borderline personality disorder, in the general population, there's often significant overlap with other comorbid psychiatric conditions, including substance use disorders of all kinds, mood disorders, eating disorders, PTSD, ADHD, as well as other personality disorders, and specifically antisocial personality disorder, or other cluster B personality disorders, or symptoms. But of note, borderline personality disorder in the general public can be, and is associated with any person with a neurocognitive dysfunction, not exclusively patients with ID. In the population specifically with ID, PPD does very commonly present along with mood disorders. And of note, these symptoms may overlap or coexist, including mood changes and pulsivity. And again, collateral data really becomes our cornerstone of diagnosing and differentiating these conditions. So specifically in patients with neuroabnormalities, we think of borderline personality disorder as really a process that occurs over life, often beginning with parental struggles, frequently parental struggles with grief, parental struggles with raising the patient with ID, along with other social determinants of health, eventually becoming into a complicated or dysfunctional attachment, both with the caregiver and for the patient himself, and ultimately inadequate validation of the child, or of the patient, making them more prone to personality disorder. BPD-related self-injury, likewise, is greater with any sort of neurocognitive defects or dysfunction, again, relating to lack of impulse control, lack of emotional management, and similarly, this pathophysiology that makes them more prone to development of personality disorders. Specifically, trauma in the developmental years is strongly associated with numerous negative outcomes, including impacts on self-esteem, self-image, again, attachment styles and relationships, and just simply the ability to process situations or process emotions, and thus process attachments and relationships in adulthood. This then leads to more of the borderline personality presentation of difficulty finding and maintaining these healthy relationships throughout life, both with caregivers, friends, and romantic relationships, and ultimately, frequently fear of abandonment. So the DSM-5 criteria for borderline personality disorder has not changed in the DSM-5-TR, and I will not go through the details, but again, there's a pervasive pattern of these interpersonal relationships and affects with marked impulsivity starting at age 18, but again, recommended age 22 to 23, or diagnosed, rather, at age 22 or 23 in the population with ID, along with five of these traits. Again, most commonly, fears of abandonment, unstable relationships, difficulty with identity, self-mutilating behavior, and chronic feelings of emptiness. So it becomes much more complicated when we're discussing patients with intellectual disability, as Dr. Gentile mentioned, because many of these symptoms and traits simply overlap with what is expected of a patient with any neurocognitive defects or with intellectual disability. In BPD, our common largest characteristics become these unstable relationships, self-image and impulsivity, but as we know in patients with intellectual disability, self-injurious behavior is quite common, impulsivity and affect availability are also very common. So the difficulty and the cornerstone of assessment really comes to figuring out where this overlap differentiates and where we can specifically, truly diagnose a personality disorder in this population. So the DMID-2, along with Project AIR, and separately the DSM-5, all emphasize looking for these additional characteristics and symptoms, rather than, as mentioned, typical symptoms of the BPD. So self-injurious, often attention-seeking behavior, along with self-injurious behavior that is not specifically self-mutilation, as that is more common in all patients with ID. Patterns of idealization and devaluation coexisting with splitting-type behaviors, patterns of manipulation and perceived victimization, again, these chronic feelings of emptiness or unstable identity, overreactions to stimuli that are more than simply affect availability, specifically abuse of caretakers and peers, as well as non-goal-oriented disruptions. This becomes further complicated when many practitioners or counselors will misinterpret these as simply their neurocognitive defects and lack of maturity or lack of emotional regulation, but it is important, again, to note that these can and do occur in any patient with ID or patient with neurocognitive disability, and so they should be interpreted in the context of their emotional maturity and cognitive ability, but should not be simply attributed to that. So when we're thinking about these patients and their relationships, they frequently, from early childhood, will have chaotic relationships existing through adulthood and through much of their life, and these chaotic relationships will frequently lead to significant emotional turmoil and emotional panic and, ultimately, subsequent ED visits, often relating to lack of appropriate emotional assessment on the first part or PCP assessment, similarly leading to chronic suicidal ideation and suicidal attempts, and both conscious and unconscious medical attention-seeking, leading to very high community resource use. So when we're managing patients with BPD and coexisting intellectual disability, it's important to thus have a multidisciplinary, very stable team for treatment. Inconsistently, it will lead to disruptions with the staff and staff emotions, staff assessments of the patients and the therapeutic environment, as well as disruptions from the patient themselves and miscommunication, making it very important, again, to have a cohesive and well-trained staff from all levels, as well as allocation of resources, specifically towards consistent and effective interventions, which may differentiate by patient. Treatment goals really, thus, specifically in therapy, focus on addressing their fear of abandonment, as well as addressing their unstable moods, intense anger, and self-harming behavior, and really helping them to live in a mature, stable environment. Behavioral management is very important for these patients, with psychotherapy really being the main line or being the gold standard. But DBT and IPT, specifically, are also very positive interventions for psychotherapy in these patients, as really addressing relationships and emotional regulation is the keystone. Importantly, however, DBT and IPT will likely need to be adjusted versus typical protocols and may be significantly less formal than the true protocols to appropriately manage these patients. So we do have a case study of a real patient with coexisting BPD and intellectual disability. So Jay is a 27-year-old female with she, her pronouns, and presented to the ED, saying that, I just want to die, just leave me alone so I can kill myself. She was already well-known to the hospital due to frequent visits, frequent, very similar visits. When the doctor asked what's going on, Jay begrudgingly said that she got into a fistfight with one of her staff members after the staff member refused to drive her to visit her boyfriend. The doctor said, but I thought she was your favorite staff. Well, not anymore. Before the fight, Jay had tried to break into her locked medication box and was discovered to be yelling about taking all her medications and yelling about attempting suicide. And Jay reports that she was just so mad that I blacked out. I don't remember what I said. I'm depressed because my boyfriend didn't call me and didn't answer his phone. So her psychiatric history is mild ID, which was diagnosed early in childhood in school, borderline personality disorder, major depression, PTSD, and recurrent SI. Of note, she's had eight previous hospitalizations for SI and auditory hallucinations of the wind calling my name. But she's typically admitted, stabilized and discharged within two days. She has no known substance use history and does live alone but with assisted care. She was raised in a single family household with her mother, but a strong history of abuse growing up. She currently has multiple boyfriends and is in constant conflict with each one. She frequently dumps her boyfriends due to suspected, although unverified cheating. And she has no female friends at all because she reportedly can't trust them not to steal her boyfriend or boyfriends. She believes that people often talk behind her back and are trying to hurt her or out to get her. So an outpatient follow-up, Jay says that she didn't even know why she made a fuss but was terrified that her boyfriend was cheating, again, just because he hadn't returned her call. She was tearful and sobbing through the exam, but when her case manager asked if getting a coke would help, Jay immediately stopped crying and very happily said that would be great. So pharmacological intervention, again, is not meant to treat borderline personality disorder directly or the personality disorder or personality traits directly, but is important for frequent comorbid and often severe coexisting diagnoses. So for her MDD and PTSD specifically, she's taking sertraline, luspiron for anxiety, and of note, bipolar disorder was carefully ruled out, although these symptoms may sometimes be misinterpreted in the setting of BPD. She does, however, have a normal sleep pattern and her affective instability is very strongly associated with external stimuli rather than actual mood changes or mood episodes, such as intense fears that her boyfriend was cheating, leading to suicidal attempts or suicidal ideation, and intense sadness followed by immediate happiness and joy after potentially receiving a coke. So again, the treatment team is importantly multidisciplinary and will include a therapist, behavioral support specialist, as well as case management and habilitation specialists. With her habilitation specialist, Jay is receiving good progress at employment placement. And then in therapy, again, multidisciplinary and from different lenses, she's in weekly group therapy for anger management issues and for managing some of these more intense emotions with fellow peers, women's group therapy for her relationship issues and her fear of other women, fear of cheating, discomfort with other females, and then individual weekly therapy with the primary goal of talking about her feelings and actually voicing her feelings rather than acting on them impulsively, as well as learning, again, anger management techniques and specifically recognizing her emotions. In therapy, she's making slow progress, but progress. So this was a pretty classic case, again, illustrating a number of the above points for these coexisting diagnoses and really emphasizes the importance of a multidisciplinary but consistent treatment team. As significant overlap, again, exists with ID and BPD. Comorbid diagnosis is important as the management team and rehabilitation and specialists, as well as specific therapy will potentially differ and potentially make this patient more available to resources and thus really needs to focus, again, on this self-injurious, attention-seeking behavior, manipulation and splitting, overreaction to stimuli, caretaker abuse, and then, again, this non-goal-oriented disruption. These are my references, and I will turn it over to Dr. Ginnett. Thank you. Thank you, Dr. Cannella. So I'm gonna talk a little bit about antisocial personality disorder. And this is very rare in intellectual disabilities, but antisocial traits or criminal behaviors might often be common, so we're gonna talk about all of those things in general. But any time I'm talking about violence in people with mental illness, sorry, are you guys hearing an echo? Is it really loud? Okay, I'm gonna push this away. Is that better? Okay. So any time we're talking about violence in people with mental disorders, I think it's important to recognize that, one, most of violence in the population is not perpetrated by people without mental illness. And even when people have mental disorders, the violence is often not directly attributable to those mental disorders. And this is, I think, everyone here probably understands that, but I think this is very difficult sometimes for the general population to wrap their minds around. I do lots of news interviews, and frequently this has happened after mass shootings or other things. And oftentimes there's just, the interviewer is asking questions based on the premise that violent people must be crazy, that they must, oh boy. Now it's happening to me. So I think this is something that is important for us to mention frequently and often, especially when we're teaching students or when we're doing news interviews or when we're just talking to the general population. It's also important to recognize that individuals with mental disorders are much more likely to be the victims of violence than the perpetrators of violence. All right, I'll get off my soapbox and move on. All right, so intellectual disability, intellectual developmental disabilities. Are those a risk factor for criminal behavior? I'm throwing out to you all. What do you guys think? Is it a risk factor? I'm seeing some reserved head nods, a few head shakes. Anyone wanna just shout out anything of what you're thinking? All right. I heard a yes, okay. So I'm seeing a lot of mixtures. I worked for a while in a mental facility in a prison in Barcelona. You see way more people than you would expect with intellectual disability. What I wonder is why are they there? Maybe there's a bias and put them in prison. Great, so he said that he's worked at a prison and he saw a lot more people there, or high levels of people there with IDD, but he wonders why is there perhaps a bias? And so that's great. So yes, just to your point. And you'll notice some of these studies are old and that's because there's just limited studies out there. But at least this study said that about four to 10% of the prison population was made up of people with IDD. And that's compared to two to 3% of the general population having intellectual disabilities. So certainly the prevalence is higher. Then the question is, is that because people with IDD are more likely to commit crimes or are they more likely to be arrested or are they more likely to be charged? Are they more likely to be convicted? And probably there's some truth on all levels there. We know that people with IDD are more likely to confess whether they did the crime or not. They're more likely to be impoverished and perhaps have less resources to hire attorneys and those sorts of things. However, there's also some evidence to suggest that people with IDD are more likely to commit violent offenses even aside from arrest and conviction stats. And so, but it's also possible, sorry, this is starting to do it to me too. Let's see. So it's possible that, so that increased rate of violent crime isn't directly attributable to IDD itself but perhaps a lot of mediating variables such as increased rates of trauma among people with IDD, lower education, unemployment, housing instability. All of those things are correlated with IDD and they're correlated with criminality. I think it's important to talk about sex offenders as well because this is something that comes up frequently. We do know from this study in 2010 that 31% of convicted sex offenders had developmental disabilities. So that could include IDD or autism. And we know that there's been several studies, there's a lot of literature connecting IDD and sex offenders. We know that pedophilia just in general is associated with low IQ, with intellectual immaturity. And we also know that people with IDD actually have higher phallometric responses to younger children than other sex offenders do. If you're not familiar with penile plasmography, also known as the pecker checker, these are sensors that are placed on someone's penis. They look at pictures of adult males and adult females, adolescent males and females and pre-adolescent males and females and they detect engorgement. And so this is a way of assessing pedophilic disorder. And we see this. So other risk factors for sex offenders that also are higher prevalent in IDD than the general population is higher rates of sexual trauma. We know most survivors of sexual trauma will not go on to be abusers themselves, but many abusers have a history of sexual trauma as well. And being offenders, especially linked with earlier victimization. So again, we have some mediating variables that may increase the risk of IDD being associated with sex offenders. And we also just know, I know anecdotally from seeing cases that oftentimes perhaps because of social rejection from peers of their chronological age, that perhaps adults with IDD are spending more time with people of the same developmental age as them, kids. And sometimes because of a lack of understanding or a lack of social awareness or a lack of understanding the wrongfulness, they may engage in sexual behaviors. And so it's really important that we are aware of this and that caregivers, group homes, and us, we're making sure that we are keeping our patients safe, but also the people around them safe and make sure there's proper supervision. So there's a lot of evidence out there linking IDD with trauma. We know that 16% of people with IDD have a diagnosis of PTSD. This is a point prevalence, which the point prevalence of PTSD in the general population is somewhere between four and 5%. So this is four or five times higher than that, or three, four times higher than that. And we also know that when people have a trauma and they have a lower IQ, that that is associated with increased risk of developing PTSD after the trauma and often associated with a worse severity of PTSD. People with developmental disabilities are two times more likely of experience child abuse, to four times more likely to have been a victim of a crime. And we know that many people with IDD have spent time in institutions. This is an old stat from 1986, but we know that there is risk of abuse in institutions. And so for all of these reasons, I think trauma seems to be the biggest risk factor, the biggest mediating variable that links IDD with criminal behavior. And I think it's why it's so important, like Dr. Gentile said, that just universally we are having trauma-informed approaches to our care with our patients and making sure we're addressing the trauma. It's very frequent that therapists, other mental health professionals, might not even assess for trauma in the first place, or if they do, it ends up on the chart and no one ever addresses it. It's very common to think, well, that was a long time ago, they never bring it up, but it must not be a big deal. Frequently, it is a big deal. And maybe they're not bringing it up, one, because of language deficits and difficulty bringing it up, two, because they've been in trouble for telling the truth before, as Dr. Gentile said, or three, avoidance is a characteristic symptom of PTSD. And so we wanna make sure we are assessing for trauma and addressing trauma regularly. These are general risk factors for violence. They do not specifically apply to IDD, but Andrew's study suggested the big four violence risk factors, antisocial personality, which we'll talk a bit about in a minute, cognitions that are antisocial, being around antisocial people, and then family and marital stressors. And then the moderate four, which are related to substance use and social determinants of health. And as you look at these, you can see that a lot of these things are very common among people with IDD. And they may, again, be mediating variables and increasing criminal behavior. There are also things that we can do something about. For a lot of these things, if we're making sure people have proper supervision, hopefully we can limit their interaction with antisocial companions. Perhaps we can limit their ability to get substances. We can help with employment and providing meaningful and purposeful activities in people's lives. We can help provide supported education and recreational activities, and hopefully lower violence risk. So this kind of summarizes a lot of the things I was just mentioning. We have risks that are indirectly due to trauma vulnerability that is higher in people with IDD. And hopefully we can do a better job of ensuring there's good supervision, there's good support. We can make sure we assess and treat trauma and PTSD. We also, there's risks directly related to intellectual disabilities. So the mood and behavioral dysregulation that we've talked about. Just misinterpreting rules, not understanding rules right for wrong. Well, everyone else is doing this, so it must not be wrong. It was on the internet, so it must not be wrong. Sometimes that concrete thinking can make it difficult. Empathy deficits. So I'll talk a bit more about this in a few minutes, but there's sometimes this idea of mind blindness, particularly among people with autism, and not recognizing that someone else is frightened by certain behavior. And so they're misreading the cues, and that may cause problems. It reminds me, I had a patient when I worked at the state hospital who had mild IDD and was found not guilty by reason of insanity for stalking. And in his mind, he was short, he was thin, he was not scary. So when he was texting, Facebooking, Instagramming girls constantly, all day, every day for years, he was like, and they would say, you're scaring me, stop, you're scaring me. He would say, but I'm not scary. And he just did not conceptualize it, and unfortunately, he did not have the support and supervision he needed. So he was left at home alone pretty much 24-7 to his own devices, literally, and was eventually found NGRI for stalking, as I said. Which, stalking, by definition, at least in Michigan, is defined by the emotional response of the victim, feeling terrorized, feeling frightened, and even though that was not his intent, he was just trying to make friends and have a girlfriend. And if you have social cognition issues, and you're trying to use maybe movies and television as a template for how to get a significant other, that's probably a bad thing to do, because if you've watched any rom-com, often there's a lot of stalking-type behaviors that happen. Going to people's homes and throwing pebbles at their window and holding up a boombox and stuff, that's the kind of thing in real life might get you arrested, right? Unless you're a really good-looking Hollywood actor or actress, then maybe it'd be okay, but. All right. So, and I'm not gonna talk a ton about this, but I think everybody should be aware of criminal diversion approaches, of trying to divert people with mental disorders away from the criminal justice system and towards treatment and towards getting help. One of those models is the sequential intercept model, this idea that intercept zero is like the community, community mental health, intercept one is law enforcement at the time of arrest, where are they brought? There's, and as you go down the intercepts, are mental health courts involved? Are substance use courts involved? Do we use mental health treatment as a condition of probation or parole? Those sorts of things. So I think these are things we can do to try to address the bias that a member of the audience was talking about before and try to get people towards treatment. And fortunately, studies of use of the sequential intercept model show better outcomes, less recidivism and less costliness in the long term as well. Wow, it went forward on its own when it was supposed to. That's amazing. Okay, so we heard earlier some comparing and contrasting of borderline personality and IDD. So I throw it out to you. What do the two conditions have in common? What overlaps? Shout it out. Empathy deficits perhaps, okay. What else? I'm sorry? Maybe emotional instability, okay. What else? Impulsivity. Impulsivity, yeah. I think I heard that from a few people. Great, what about what do they have in common? How do you distinguish them from each other? Is there a difference in what maybe drives the impulsivity in one versus the other, or the empathy deficits, or anything else for that matter? Well, we're gonna, oh, yeah, sorry. Internal versus external. Internal versus external, like motivation? Yeah. Lighting would be more internal than, or lighting would be more external. Okay, all right. So there is, as I said earlier, antisocial personality disorder is not commonly diagnosed in people with IDD. However, 10 to 20% of people with IDD exhibit antisocial behaviors. And as Dr. Gentile mentioned earlier, a lot of the referrals that IDD clinics get are often for agitation, aggression, irritability, those sorts of things, right? There are common risk factors that both share, some of which we've already talked about, you know, the trauma, poverty, those sorts of things. And there's a common course, childhood onset, antisocial personality disorder, by definition, you must meet criteria for conduct disorder before the age of 15. It's the only personality disorder that has a requirement like that. We know that about 1 3rd of people with conduct disorder grow up to have antisocial personality disorder, which means that 2 3rds of the majority grow out of it. That's the general population. There aren't any studies that, to my knowledge, that assess that specifically in IDD. But also we see, you know, developmental delays that are very common, perhaps because of some of those common risk factors, things like trauma, those sorts of things. You may have heard, like, the triad of psychopathy, you know, bedwetting, fire setting, and cruelty to animals. So, you know, late bedwetting is a very common thing that we see in people with developmental delays as well. And they're pervasive, right? If someone, all of a sudden, if you're seeing an adult and you get this history, and all of a sudden they started having criminal behavior at age 25, at age 30, I would be thinking about other things besides antisocial personality disorder. Probably the first thing that would come to mind is was there a trauma, what's going on? Or was there a change in supervision? Was there recently a death of a caregiver? Did they recently move group homes? Something like that. But generally, IDD and antisocial personality disorder, not generally, by definition, they start in childhood. So to compare and contrast, I put asterisks here by all of the things, by the nine antisocial criteria in DSM-5, you have to have three of these criteria to meet the diagnosis of antisocial personality disorder in addition to, like I said, having conduct disorder prior to age 15. So we see frequently academic dysfunction in both. And oftentimes, on average, people with antisocial personality disorder do have lower IQs, but a lot of times the dysfunction may not be because of intellectual problems, but maybe because of lack of effort, because of getting in trouble and sorts of other things. We see social dysfunction in both. We see immaturity and lack of intimacy and rule breaking that might drive that social dysfunction. However, oftentimes with IDD, it may be driven more by poor social communication, oddness that is kind of off-putting to people, whereas with antisocial personality disorder, a lot of times it's gonna be driven more by lack of respect or not conforming to social norms, right? And while I'm on this topic, I think it's worth saying, I mean, just the way I kind of personally look at personality disorders, I think of them as being a state of arrested development. If you look at kids and teenagers, almost, not almost, probably all of us met criteria for various personality disorders as we were growing up, which is why we generally don't want to diagnose them until they're pervasive and in adulthood, right? Teenagers are often moody and mercurial and may present as having borderline personality. Kids are often narcissistic. My dad can beat up your dad and those sorts of things. So these things, we have to take that in mind with people with intellectual disabilities. They may, because of developmental delays, they may also be in a state of arrested development and have similar mindsets. When I think of antisocial personality disorder, a lot of times people automatically think of violence, but most people with antisocial personality are not violent. The characteristic issue is that they don't, they are antisocial, they are against society, they do not conform to social norms. So that could include not having relationships, not having a job, kind of having parasitic lifestyles where they use other people for sex and money and a place to stay. And some of those things could look very similar for people with IDD, who are dependent on other people, who have a hard time with empathy, so they're only thinking of themselves. But we wanna look not just at the manifest content, but try to look at the underlying drives and motivations that are leading to that, and that may help us distinguish antisocial from IDD. Irresponsibility, aggression, we talked about. Oftentimes, as Dr. Gentile said, aggression is a means of communication. This is driven by a lack of maybe communication skills. I can't, I don't have the skills to say, I'm angry, you pissed me off, I really wanna do that now. And so maybe that's communicated behaviorally through punching, kicking, breaking things. And by problem-solving deficits of how to achieve your goals. Whereas people with antisocial personality disorder, generally, that aggression is driven by self-promotion. I'm gonna use this to intimidate you to do what I want, and I just don't care about your rights and your feelings. Impulsivity, similarly, impulsivity is often very reactive in IDD, often driven by invalidating environments, or it's just a lack of socialization, a lack of operant conditioning that existed in their childhoods and adulthoods of positively reinforcing good behaviors and those sorts of things. I recall a patient I saw, an outpatient. She was about 30 years old. She lived with her parents, she had moderate IDD. She was mostly non-verbal, except when she would hit her mother and say, now, candy, now, candy, now. And then her mother would take out candy and give it to her. And so I talked a lot with them about, we're positively reinforcing negative behaviors. And that's a hard conversation to have, because it's a lot easier for me to say that than to live it, what that mother's living through, and it's often is gonna evoke defensiveness in the parents who are just doing the best they can, right? But we try to work to change some of the approaches and to maybe say, maybe we can reinforce please. Maybe if she said please, you give her the candy, even if she hit you, maybe, to start with. And then maybe you don't get the candy if you hit. You only get the candy if you don't hit. You know, those sorts of things. And try to gradually, step-wise, change that behavior. And so, again, that's driven by this reactivity and by sometimes us, as clinicians or caregivers, reinforcing the negative behavior, as opposed to an antisocial personality disorder. A lot of times, impulsivity is just thrill-seeking. It's just, we know that physiologically, a lot of times, people with antisocial personality disorder have low resting heart rates, and sometimes you'll even hear psychopaths describe they only feel alive when they're being violent, or when they're driving a motorcycle really fast, or doing things that are thrill-seeking. So it's a different motivation. I mentioned earlier that we're gonna talk about empathy. So I like to think about, there's a lot of different ways to classify empathy and think about empathy, but one that I like, and that I think is helpful here, is cognitive empathy versus emotional empathy. And so, people with antisocial personality disorder generally lack emotional empathy. They have cognitive empathy. Often, they're actually quite good at reading people. That's why high-functioning antisocial people often become politicians, CEOs, and used car salesmen, they're good at reading people and manipulating them, and they have that good cognitive empathy, but they don't have emotional empathy. They don't feel your pain. And so, they know if they do something wrong to you that it bothers you, they just don't care. Whereas, people with intellectual developmental disabilities often, and autism especially, often have emotional empathy, but lack cognitive empathy. So they know you're mad at them, but they don't know why. They don't understand why you're yelling, but they feel it. They feel it very deeply, maybe more deeply than the average person, which is why they can get so dysregulated when they're upset. And so, those are an important way I think we can help distinguish between these. And also, lack of remorse. Generally, I will see people with IDD, they do lack remorse afterwards. I had a colleague of mine who had been working with someone with moderate IDD and autism for years, and had a great rapport with them, and the person, I forget exactly, they were having some sort of stressor in their life, they came in very dysregulated, and they actually bit the doctor's earlobe off. And fortunately, she's okay and doing well now, but immediately after, she was kind of like shocked, the patient was shocked into remorse, and was crying and saying, I'm so sorry, and trying to hug her, and sometimes it's not that soon, sometimes it's hours or days later, but this is something you frequently see with people with IDD. They get very upset, they get emotionally dysregulated, and they get impulsive, and they act, they communicate behaviorally, and then later, when they calm down, they feel really bad about what they have done. And that's that emotional empathy again. Whereas someone with an antisocial personality, they might say they feel bad, but that might be just to manipulate you into something else. Oh, and lastly, we generally have a positive countertransference to people with IDD and antisocial personality disorder, which this is something I always try to footstomp when I'm teaching med students or residents, junior residents, because often they're like, well, that person's not antisocial, they're not a psychopath, I like them, they're really nice. Well, remember, people with antisocial personality disorder generally have good cognitive empathy, they read you, and they often use charm and manipulation to get what they want. And when that fails, then they might go to intimidation and violence. But usually, especially the higher functioning antisocial people are going to start with charm, because usually that's more effective. All right, so getting into some forensic psychiatry, most states that have not guilty by reason of insanity have some sort of wrongfulness prong, that by, so where I'm from in Michigan, as a result of a mental illness or an intellectual disability, you're not guilty by reason of insanity if, as a result of those things, or as a result of those things, you either lack substantial capacity to appreciate the nature and quality of what you've done, the wrongfulness of what you've done, or your capacity to conform your conduct to the requirements of the law. Those are the three main prongs. Every state has one, two, or three of those prongs. This is the most common across the country. And so when we think about people with IDD and how this might apply to them, there's often deficits of conceptual thinking, so they might have very concrete way of thinking about the rules. And so I've had patients with IDD who were charged with child pornography and they thought, this is on the internet, so it must be okay. Or someone told me it was okay. Or I saw my brother do this, so it must be okay. Those sorts of things. Oftentimes a lack of awareness of the outcome and social cognition. So I talked about this a little bit before, kind of that mind blindness, not reading cues, which can be a problem both with certain crimes, but where you're scaring someone and you don't know it, it can also be a problem at the time of arrest and people resisting arrest, or people acting odd and flat because they're scared, and so people interpret that as cold and callous and you don't care about what you've done, those sorts of things. And then self-absorption. So being so absorbed in what you're doing and not thinking about the people around you because of theory of mind and empathy deficits. And so this can also, often the behavior might be criminal, but the intent itself may not have been, just like the stalking case that I told you about. And frequently, especially with people with autism who have very strict routines, sometimes the drive to engage in those behaviors, compulsions, something that they're obsessed with, or something that is just part of their routine, that you can't do that. You can't go there right now. And their drive to do that thing overwhelms their ability to listen to the limit setting that's happening right now and they continue to do what they feel compelled to do. Another prong that may frequently apply to people with IDD who may be invoking the insanity defense, so their ability to conform their conduct to the law. That's very common language throughout the United States. Sometimes other languages, inability to refrain from engaging in criminal behavior, or irresistible impulse is another term that sometimes comes up. And so as we talked about, people with IDD often have mood and behavioral dysregulation, especially when they're under stress. And these things may lead to problems and lead to criminal behavior and charges even. And then as I've been saying, and we've been saying all along, those poor social and verbal skills that can often lead to problems or lead to communicating emotions or fears through criminal behaviors or dangerous behaviors. All right, so what do we do about all of this? How do we manage people who maybe have comorbid antisocial personality disorder or at least have antisocial traits? And as I said before, that's 10 to 20% of people with IDD and that's often a higher prevalence of the people who can refer to us to see them, whether we're in the hospital or outpatient. So what do we do? I'm asking you guys, what do we do? That was the main reason I came here, just get a bunch of smart people in a room to tell me what I'm supposed to do to help these people. Any thoughts? Yes. So the question was, should people with IDD be charged in juvenile court? And should their developmental age be taken into account? Personally, I have not given any thought to that question. But the first thing that sticks out in my mind is if you're tried in juvenile court, then you would think you would go to juvenile detention. And there might be safety issues there as well. So we have mental health courts. We have substance use courts. Perhaps we should have developmental disability courts. I don't know. Is anyone aware of any in the country? I'm not aware of those. I know there's lots of different specialty courts. I've never heard of a DD court. But perhaps that's something that should be considered. All right. So any thoughts? How do we help people or help the people around them or the environments around them when they have antisocial behaviors? I'm just thinking of rocks. What about some kind of animal therapy with them, like a program, like an animal therapy? I like animals more than people. So animal therapy was brought up. So I don't know about studies specifically in DD, but I do know in criminal populations in general, there are studies that show animal therapy, actually bringing animals into prisons, and even not just like once a week for animal therapy day, but actually having inmates raise animals and take care of something and be responsible for something actually reduces recidivism. So there might be that potentially could be good. At the same time, we know that sometimes people with IDD have trouble with their own ADLs. And so we would want to make sure they have enough supervision to take care of those animals too, right? Any other thoughts? I work right now on a disability residency unit. So I have like 13 patients that are mine. And the antisocial ones are the most difficult by far, right? What I've seen is that if you give them more stimulant, if you give them more activities to do, and if you, I mean, more things to do, like more labor therapy or occupational therapy. And on the other hand, if you reduce the stimulus environment, if you can give them a more contained environment, normally they go with it, right? Yeah. It's hard because that's very expensive. Yeah, so what he was saying was that you want to give proper stimulation, positive activities, things for people to do, occupational therapy, and give people activities that are hopefully pro-social and that give them a sense of meaning and purpose. And that is, I think, an important part of treatment plans for all of our patients, whether they have IDD, antisocial, schizophrenia, anything, right? People need something to do and something that contributes positively to society and contributes positively to their sense of self-worth and a sense of industry. On the flip side, there's also negative stimulation, right? Where if we're overstimulating people with lots of noise and lots of fights on the unit and those sorts of things, we know that inpatient psych units that have a lot of programming tend to have less incident reports than those that leave people kind of their own devices for hours on end watching TV and then fighting over which show to watch. By the way, two TVs on a unit reduces violence versus one TV. Less to fight over, people can separate. So it's just important of environment. And what I'm hearing everyone saying is environmental changes, right? There's not really a whole lot of psychopharmacology that is going to solve this issue, whether it's antisocial and or IDD, right? Psychosocial interventions are important. So as I've been saying throughout this talk, just general principle, supervision is so important. And not just assuming that the supervision is good and that the supervisors understand the condition or understand operant conditioning and those sorts of things. So it's really important that we're doing education with parents, with siblings, with group home managers, with group home staff, with wherever they are to help people provide safe supervision to know the level of need that this person has, whether it's ADLs and IADLs, but also understand that where this person is developmentally, their history, what their triggers are. I remember working at Dr. Gentile's clinic when I was a resident, actually, and a patient, I was asked to go out in the parking lot because a patient would not come in. The patient was underneath their car and was crying and was scared to come in. And this had never happened. I had seen this person for several times and never had any issues. And I was trying to understand what was happening. Turns out they had watched Red Dawn the night before, not the original with Patrick Swayze, the remake with Thor. And no Swayze, no Wayze, I say. But anyways, he was afraid that there was going to be Red Army communists coming out, parachuting out of the sky, and he didn't want to go outside. And he was hiding under the car. And we talked a lot with the caregivers about movies, about that, yes, he's 22, but perhaps our movies and scary movies are appropriate for him because in his concrete thinking, he's thinking this is real. So sometimes, and it had never even occurred to them that that was a problem. He's over 18. You can see these movies, right? So providing that education, providing that education, like I said, about positive reinforcement and not positively reinforcing bad behavior, which we do a lot. And a lot of times, we don't even know we're doing it, right? Providing consistency as much as possible, this is difficult. This is difficult because we have different shifts in group homes. There's a lot of turnover in group homes. But hopefully, we can talk with the patient about that, prepare them for that, and address it. A lot of times, caregivers, their favorite caregiver is gone, and no one ever addresses it. No one talks to them about it, that it's about to happen, and no one addresses it after it happens. And it's very common to see acute change of behaviors with caregiver changes. Similarly, when a spouse dies, or sorry, a parent dies, and someone goes to a group home, they're dealing with the trauma of losing a loved one and of moving, which is stressful for all of us. And oftentimes, these things don't get addressed or talked about. Trauma-informed care, trauma-focused psychotherapies. Again, we can adapt trauma-focused therapies like cognitive processing therapy, and prolonged exposure, and EMDR, and trauma-focused CBT. And we can adapt those to people with IDD and speak at their level. Sometimes, it requires a lot more teaching upfront about what is an emotion, what is a thought, what is a behavior, rather than just kind of glossing over that and assuming they understand those labels. And sometimes, it involves shorter sessions or more frequent sessions. And there's a lot of things we can do to adapt psychotherapies and that we can encourage our teams to adapt to working with people with IDD. Pro-social conditioning. So this can be in formal social skills classes, occupational therapy that was mentioned, ABA therapy, which this is what ABA is all built upon, possibly reinforcing pro-social behaviors, like looking someone in the eye, toileting, all sorts of things. There's parent training models, such as play therapy, teaching parents to play with their kids in a way that simulates pro-social behavior. And especially in early intervention, if you do this training with parents before the ages of three, four, five, oftentimes kids with autism or developmental delays no longer meet criteria by the time they hit school age. And then there's adapted DBT models as well. So when I was in the state hospital, Center for Forensic Psychiatry in Michigan, they had recently implemented DBT treatment that was available to all of the patients, regardless of diagnosis. There are some payers that will only pay for this if someone has borderline personality disorder, but there's a lot of evidence to support DBT for a variety of disorders, mood disorders, impulse disorders, all personality disorders. And so we were offering DBT, and we had kind of three levels. We had classic DBT. We had advanced DBT for patients who had successfully completed at least two cycles of DBT. And then we had DBT, which we utilized the Julie Brown model. And so this is called the skill system. And if you get this book, it basically takes DBT and boils it down to its essence. It tries to simplify it a lot. But what we were finding was with some of our patients, even this simplified adaptive model of DBT was not successful. Sometimes it was too complicated. There was still dozens of different skills. You were supposed to think about your stress level on a 1 to 7 scale. And if it was over this number, you use these skills. And this number, you use these skills. I mean, I can't even keep all of it straight. And so when someone's in a lot of stress on the unit, I mean, it can be very difficult. So it did help. But we actually decided to create our own model, which we call DBT for all learning styles. This was something that me and our DBT team produced while I was a state employee. So we make no money off of it. It's freely available. If you Google DBT for all learning styles, you can download the whole manual for free. But what we did is I basically took the Julie Brown model, and I went through and tried to find alternatives to every single multisyllabic word in there and to every single abstract concept in there. And then we had multiple work groups coming together to try to boil things down to just a handful of basic skills and techniques that patients can use. And then we also spent a lot more time, as I mentioned earlier, teaching what is emotion, what is a thought, what is a behavior, what is a body feeling versus what is an emotion feeling, and trying to help people distinguish this. And these things are often just taken for granted that everyone knows what those things are. And frequently, people would really struggle with that. We would have to spend months really just teaching about what is being mad, what is being sad. And the other thing we did, as alluded to with the all learning styles name, is we tried to integrate, rather than this all being deaf by PowerPoint, which hopefully we're not doing to you right now, but try to do visual learning, auditory learning, and experiential learning in all of our sessions, and act things out, play games, and do things. And we found that incident reports amongst the patients dropped dramatically. And in this group, we had people with mild to moderate IDD. We had people with autism. We had people with severe residual cognitive symptoms of psychotic illnesses. We had people with TBIs. And we saw a lot of improvement with this approach. And then last and least is psychopharmacology, which I think is often our go-to too frequently. It's like what we go to when we don't know what to do. And I've seen a lot of people's aggression and irritability get better with de-prescribing rather than prescribing. I've seen lots of patients with IDD who come in. They're on two antidepressants, two antipsychotics, and two benzos, and an alpha blocker, and a beta blocker, and all of these things. And then sometimes weird things that I would never prescribe to a psychiatric patient. And sometimes what's happening is we are snowing them so much that no one could make a good rational decision when they're stressed out. We want to maximize people's prefrontal cortices so that they can think through, assess risk properly, and think through their options, and choose good options and prosocial options. And so oftentimes, I think, unfortunately, benzos are great for inhibiting the amygdala and calming down anxiety, but it globally inhibits our brains, right? GABA is widely distributed in our CNS, so we're also inhibiting our motor cortex and making people more clumsy. We're also inhibiting their prefrontal cortex, which we need activated to help people not be disinhibited, to help people engage in cognitive processing, right? So we want to be careful with these meds, and we want to be careful, especially anything with anticholinergic properties that can compound intellectual problems. But there is certainly a place for medicine as a piece of a biopsychosocial comprehensive treatment plan, and generally want to treat symptomatically and try to avoid drug-drug interactions, be mindful of comorbidities, be mindful of anticholinergic properties, be mindful of over-sedation. And so I will leave it there. Sorry I didn't get to the case. In summary, there are mixed findings about criminogenic and violence risk factors in IDD. We know that they are over-represented in the criminal justice-involved population, but there might be lots of reasons for that. Some might be directly related to IDD, but many are probably related to mediating variables like trauma and poverty. And because of impaired cognition, because of behavioral dysregulation, this often may increase antisocial behaviors. And though antisocial personality disorder and IDD share common traits and common courses and common risk factors, they are rare together, but those antisocial behaviors are common, and we can hopefully manage them with improving the environment around them, educating caregivers, providing safe supervision, reinforcing reinforcement among the caregivers, and using psychotherapy. Especially there's lots of great adaptive models out there, so I will leave it there. Thank you.

Personality Disorders

Intellectual Disability

Diagnosis Challenges

Mental Illness Prevalence

Developmental Context

Cultural Context

Systemized Support

Borderline Personality Disorder

Multidisciplinary Approach

Antisocial Personality Disorder

Criminal Justice System

Trauma-Informed Care

Therapeutic Models