QUESTION:

I am a clinician working with a number of individuals with mild to severe mental retardation (in residential placement) and BPD. I can find almost no literature addressing this dual diagnosis. My focus in treatment is staff education, very structured behavior programs, and close collaboration w/ prescribing psychiatrists. I am currently trying to adapt techniques from DBT to suit the cognitive needs of my population. Can you make any suggestions or point me to information sources?

DR. HELLER'S ANSWER:

This is a tough, tough situation. I'm not aware of any literature, but I've taken care of a few and it is extraordinarily difficult. In general you do the best you can do to make the diagnoses - and getting the family history helps enormously since most problems are genetic.

DBT is highly unlikely to work with mentally retarded individuals. The thought or cognitive processes need to be counted on to overcome broken emotional ones. When both areas are in bad shape, there is really only medication to keep things under control. This is a situation where I try to treat all the diagnoses and use higher SSRI and anti convulsive doses than usual, since the threat of violence is ever present. Violence against the caretakers or self-mutilation does not one any good, and the risks of these medications is very, very small and usually manageable.

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