How do people torment themselves spiritually?

Mental suffering often goes undetected

Mental illnesses in the narrower sense often manifested themselves in their patients with a variety of behavioral problems, says Voss, listing a few important ones: hyperactivity, screaming, stereotypes (compulsive repetitive movements or expressions), emotional or social withdrawal, apathy, sleeping and eating disorders, pica (Appetite for inedible things such as hair or insects), aggression against oneself or others.


"The intellectual disability and the accompanying psychological problems are often rooted in a common cause, namely brain damage," reports psychiatrist Professor Dr. Michael Seidel, senior physician in the field of disabled assistance at the Bodelschwinghschen Anstalten in Bethel, last June at a capital symposium of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) on the subject. However, the problems could often also be traced back to physical illness, medication, changes in the environment and traumatic experiences. “The living conditions can severely destabilize people with intellectual disabilities,” confirms Voss: “Imagine that you cannot get along at all with your job or bed neighbors in the home. But you cannot classify the problem, you cannot make it understandable to third parties and you cannot easily evade it as a guardian. That puts a strain on the psyche. ”For Voss, her personal experiences and studies clearly show:“ Even when people are intellectually restricted, they feel just as mentally distressed as everyone else. So they also need an equally good system of help. "


Abnormal behavior as a call for help


But this assessment does not seem to have spread sufficiently. "Doctors, relatives, carers and therapists often view abnormal behavior as an expression of intellectual disability and not as a cry for help," says Seidel. In addition, psychiatrists did not learn how to deal with the mentally handicapped during their medical studies or specialist training, adds Voss. "In addition, there are problems on the part of the patient, such as a reduced understanding of speech or expression, or a reduced ability to observe themselves." All in all, many of those affected only received psychiatric treatment very late, possibly never, or without a thorough diagnosis they would have side effects Psychotropic drugs quasi immobilized - thus possibly bypassing the underlying disease.


Doctors seem to have long since overlooked not only psychological problems, but also physical ones. Voss and colleagues diagnosed at least one physical illness in almost two thirds of all 1565 patients admitted to the KEH between 2004 and 2008. "Many mentally handicapped people cannot classify pain and other symptoms rationally or verbally articulate them and instead express them atypically in the form of behavioral problems," Voss explains this observation.


Marcel Menzel (name changed), for example, a man in his mid-thirties with Down's syndrome, lost his happiness in 2008 and instead began to scratch the backs of his hands and remove every shirt, T-shirt and sweater that the carers in his living group had put on him. to tear right on the body. After six months, his helpless family doctor referred him to the KEH, where the doctors did not diagnose a psychological problem, but a solid organic one: a badly inflamed gastric mucous membrane densely populated with the Helicobacter pylori bacterium. Menzel received antibacterial and acid-lowering therapy that worked within a few days. Along with the complaints, his behavioral problems also decreased.


Detailed analysis


On the basis of such experiences, Voss and colleagues first carry out an extensive physical examination for each newly admitted patient. Only in the second step do they search for a mental illness in the narrower sense. If possible, they not only ask the patient himself, but also his relatives and caregivers, who know him and his characteristics best, and take a close look at all behavioral problems as the most important symptoms. When and why did they appear for the first time? How often do they take place, how difficult are they, how do they express themselves exactly? Doctors gain information about this by observing patients for several days, often not only on the ward, but also at home, in the home or at work. Special forms are used to document and characterize the behavioral problems. The data flow into the psychiatric examination. This is based on special modifications of catalogs with diagnostic criteria, such as the "International Classification of Diseases" of the World Health Organization in its tenth version (ICD-10), for use with the mentally handicapped.


If no mental illness in the narrower sense can be determined, Voss and colleagues research in the third and last step for possible sources of unrest in the patient's environment. For example, has the familiar home interior changed, did your favorite carer leave, did a new resident come? Perhaps a remedy can be found, put the bed back into its old position, relocate the neighbor. "We should always try to identify and eliminate stress factors rather than remodeling a stressed mentally handicapped person," comments Seidel. Some facts cannot be changed, but they can be managed better through certain rituals under psychological supervision, says Voss. A loss-plagued patient, for example, can visit his former supervisor again at the new workplace and bring him a self-painted farewell picture. It often also proves to be helpful to temporarily reduce the requirements and tasks of the person concerned.


After a few days, the doctors made a psychological diagnosis to Alexander Kraft: his aggressive behavior conceals a depression. Accordingly, he is now adjusted to a suitable antidepressant. "Psychotropic drugs can be used in people with intellectual disabilities according to the same medical guidelines as usual," says Voss. "And if the selection is made in line with the diagnosis, the drugs also achieve similarly good effects." However, the treatment should, if possible, be combined with psychotherapy.


"Contrary to the outdated opinion of some specialist societies, psychotherapies are also suitable for use with people with reduced intelligence," emphasizes Voss. However, like the procedures for psychological diagnostics, the treatments should be modified to suit the specifics of their target group. The therapists usually hold relatively short sessions, speak slowly, choose simple words and, if possible, illustrate what has been said with the help of drawings, scales or pictograms. Group therapies seem to work better than individual sessions.


Psychotherapy is possible


Kraft visits the "upward group" for depressed patients three times a week. In the half-hour sessions, the participants learn to assess their current feelings, including by classifying them in scales, and to understand their depressive mood as a symptom of illness. They look for possible triggers, such as drastic life events, and for personal mood-enhancing strategies. And they practice role-playing in making contact with other people, expressing opinions, enforcing wishes and resolving conflicts. Many depressed patients tend to withdraw from society and have poor self-esteem.


There are also suitable therapeutic approaches for other psychological diagnoses in people with intellectual disabilities. In this way, schizophrenia patients train to interpret the signs of a possible flare-up in good time. Trauma patients cope more easily with memories by putting them in a lockable fantasy box forever. And anxious patients practice relaxation techniques and face the confrontation with the fear-inducing person, such as a spider, first only in a picture, later in reality.


"Regardless of their precise diagnosis, many people affected benefit from social skills training," says Voss. "Above all, it serves to strengthen self-confidence and to better deal with negative feelings, stress and stressful situations." Alexander Kraft also attends the short training session three times a day. "Above all, I learn not to attack objects or people when I'm exploding," he explains. "Instead, for example, I squeeze a hedgehog ball as hard as I can until the tension drops again." Kraft's therapy plan also includes non-specific measures for relaxation and mental support. Once a week, he and the others from the garden therapy group equip themselves with shovels, rakes and buckets to tend the flower and herb beds on the premises. Kraft goes to art therapy twice a week. Brushes and watercolors, crayons and wax crayons are always available in the room. The pictures from the last session hang in neat rows on the wall: colorful lines and blobs, a man with a big bulbous belly, a sheep against a green background - a gallery with weekly changing exhibitions that help the participating artists to enjoy themselves and self-affirmation. Kraft just proudly shows the picture frame that he pasted with small blue stones during occupational therapy. He wants to bring it to his mother. He will probably be allowed to go home in three weeks, but will then come for outpatient treatment once a week for several months. "In this way we can look after and stabilize him over the long term without tearing him out of his familiar surroundings for too long," explains Voss.


According to her, the combination of psychotropic drugs and therapy can achieve similarly good healing rates in the mentally handicapped as elsewhere: around 60 percent in the schizophrenia and anxiety patients, even 80 percent in the depressed. In addition to personal contact with her patients, she finds such successes particularly beautiful. "My work affects me when we have patients sent way too late," she says. Then she tells of a 45-year-old with a slight intellectual disability who has been hallucinating for some time and is walking far over. During the first physical examination at the KEH, the doctors discovered a tumor that had already occupied a large part of the right breast and had already damaged the skin. "There was an operation straight away," says Voss. “Even so, the prognosis at such a late point in time is very bad. It shouldn't have come to that. «Even patients with mental illnesses often have to suffer unnecessarily long. »People with an intellectual disability can be happy just like us and participate in a varied, livable world. But for that they need the attention and support of their fellow human beings. "/