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JR is 28 years old. He lives with his mother and younger brother, has a part time janitorial job at the local YMCA. He loves “girls”, watching YouTube videos, and following March Madness. After graduating high school, he gained volunteer experience and vocational training. He stays home two days per week so that he can have enough time to attend his appointments and volunteer with Meals on Wheels.
JR is formally diagnosed with Autism Spectrum Disorder, Generalized Anxiety Disorder, and Mild Intellectual Disability. He meets some of the diagnostic criteria for Borderline Personality Disorder, but has never been diagnosed. He had a seizure once, when he was 9 years old. It was not well documented, and he cannot recall it. His father and step-father are deceased, and his mother’s recollection of the seizure is fuzzy.
His mother complains that JR can become angry and explosive at times, and get into fights with his younger brother, but that he is generally helpful around the house and picks up after himself. She is proud that he has maintained his janitorial job for almost two years.
Mental health and anger
He also has a history of Bipolar II Disorder and Intermittent Explosive Disorder. It is unclear as to how he obtained these diagnoses, but they are documented in his charts. JR takes medications to treat anxiety and “agitation”, and asthma. He sees a speech-language pathologist to address his communication disorder. When encouraged to identify and discuss mental health symptoms, he admits to feeling angry sometimes, pacing, and says “I get mad easy”. JR is fearful of developing intimacy and resents his mother sometimes for being too overprotective. He likes to flirt with women, although it is challenging for him and he often gets rejected. He’d like to obtain a driver’s license so that he can drive himself around, but he can’t afford the expenses and both he and his mother are concerned for his safety.
JR represents one of many people supported by the Arc of Monroe and other agencies that provide services and supports to persons with intellectual and developmental disabilities. JR is a complex and unique person. He has strengths and weaknesses. He is labeled as I/DD and Autistic, but that is not all that defines him. He is diagnosed with anxiety, but that does not encompass all of who he is either. His thoughts, feelings, and behaviors are unique to him, and it can be difficult to differentiate between the symptoms that are attributed to his disability and the symptoms that are attributed to his mental health diagnoses. His home, work, and volunteer environments play a significant role in his symptom presentation as well, as do his social experiences with peers, family, support staff, and coworkers. JR is, for all intents and purposes, considered dually diagnosed. Or, more appropriately, someone with co-occurring disorders. While the term “dual diagnosis” is typically used to refer to those diagnosed with both mental health disorders and substance abuse or dependence disorders, it can also be used to refer to those diagnosed with I/DD and mental health diagnoses.
With the arrival of the DSM-5 in 2013, the American Psychiatric Association eradicated the longstanding multiaxial system for mental disorders. The removal of the multiaxial system had implications for clinician’s diagnostic practices. For those with I/DD and co-occurring mental health diagnoses, the process of differentiating between conditions that share similar signs and symptoms presents a unique challenge. There may be medical issues and environmental factors that influence a patient’s symptom presentation as well. Because people with I/DD may experience communication barriers, and exist in a world that is dissimilar to the general population in terms of living environments, workplace environments, and relationships/interactions with others, assessments (and consequently treatment interventions) can also be more difficult. It is fairly common for patients with co-occurring conditions to “mask” their disability, or “mask” their mental health diagnoses, as they may not want to be seen as any “worse” or “bad”. They are also more likely to have involvement in their treatment from family members and staff providers than the general public, which can be helpful at times but also compound the problem.
Clinicians need to consider all sources of information gathered during the assessment phase, including that from the patient themselves, the collaterals, and the patient’s charts. While many patients have difficulty identifying and expressing their symptoms accurately and objectively, those with co-occurring conditions may be exceptionally challenged in this area. Therefore, responding to treatment interventions may be more of a lengthy and arduous process.
In the example of JR, he and his mother are in agreement that he has “anger” problems. However, his workplace supervisor does not see this problem manifest itself while he’s at work. His supervisor reports that JR maintains his composure when faced with challenging situations and does not seem to struggle with anger outbursts. JR feels confident at work. He is dependable, and performs tasks quickly.
His mother does not believe he is “ready” to date, and his supervisor has had to remind him a handful of times to avoid flirting with female customers while on the clock. His speech-language pathologist is working with him on articulating himself more clearly, so that he can be easily understood by others and form more meaningful connections. While JR has some awareness of how his multiple diagnoses impact him, he can be resistive to implementing change. As someone with Autism Spectrum Disorder, he struggles to express his emotions and tends to lack awareness of other’s emotions. He does not always recognize how his thoughts, feelings, and behavior have an effect on others. He can handle a heavy task load in a variety of settings and makes significant contributions to his home, work, and volunteer environments. He takes great pride in himself but simultaneously experiences guilt, shame, frustration, and insecurity.
It is important to recognize the unique traits and characteristics that comprise each and every one of us, and to focus and build upon our strengths. Like so many others, JR is “dually diagnosed”, presenting with co-occurring conditions. Emotional wellness, adherence to expectations for appropriate behavior, and achievement of inner peace IS possible for JR, but it requires compassion, understanding, and patience toward his unique complexities.
Delaine Fico is a Social Worker (LMSW) for the Arc of Monroe. In her free time she enjoys writing, drumming, spending time with loved ones and playing with her Great Dane, Bella.