1. Angela Hassiotis UCL and Camden & Islington Foundation Trust
Symposium 190: Mental health and borderline intellectual functioning: how should services respond? Findings from the UK Adult Psychiatric Morbidity Surveys
Angela Hassiotis
UCL and Camden & Islington Foundation Trust

3. Will cover
Background
Methods
Results
Conclusions

4. What is Borderline intellectual functioning (BIF)?
IQ based definition (70-85)
Included in DSM-IV but has since been omitted from recent revisions
Not included in ICD 10
Not coded in International Classification of Functioning
Likely to include 13% of population

5. Impact of BIF
Persons with BIF may not be recognised as a special group for services but included in studies
Overshadowed by other mental disorders, particularly psychosis or intellectual disability (ID)
Neurodevelopmental deficits and increased psychiatric morbidity

6. Development and education
“slow learners”
impaired information processing (Vaney et al 2015)
motor and executive function abnormalities (Baglio et al, 2014)
Motor abnormalities, e.g. manual dexterity, balance (Vuijk et al, 2010)
Impulse control problems (van der Meere et al, 2012)
IQ range 77-81

7. Health comorbidities in children with BIF
Psychological distress/low self-esteem (Karande et al, 2008)
Inattention and impulsivity
Lower engagement between parents and children with BIF
Parents of BIF children see them as behaviourally disturbed (Valliant and Davis, 2000; Fenning et al, 2007)
The Longitudinal Study of Australia Children showed over a fifth of all children with obesity also had BIF and a threefold rise in any mental condition (Emerson and Robertson, 2010)
High rates of exposure to socioeconomic disadvantage
(Emerson et al, 2010)

8. interventions
Parent training programmes for challenging behaviour (7 out of 11 studies)
Social competence training
CBT
1 RCT of risperidone vs placebo (n=13)

9. Adults with BIF

10. APMS Programme of national surveys started in 1993
Carried out by the Office of National Statistics and commissioned by the DH or devolved governments in the UK
Most recently the National Centre for Social Research has taken over ( )
Examine a wide range of populations and disorders
Adults living in private households; Residents of institutions providing care and support to people with mental health problems; Homeless adults; Adults with a psychotic disorder; Prisoners and young offenders; Young people in local authority care; Children and adolescents; Carers.

12. General design Standardised questionnaires Two-phase approach
Domains examined reflect policy priorities and are added at each new survey
Ethical review
Inclusion of the National Adult Reading Test (prediction of verbal IQ)

13. What we know of adults with BIF (APMS 2000 & 2007)
20% have a common mental disorder
9.5% have severe alcohol dependence
Appear to receive more psychiatric/other medications
Majority of GP consultations are for physical problems
More admissions for mental ill-health
(Hassiotis et al 2008)
Twice as likely report non-fatal self harm (Hassiotis et al, 2011)
Less happy (Hassiotis et al, 2012)
2.7% have Autism Spectrum Disorder (vs 0.4% in vIQ>100) (Brugha et al, 2009)
Lower IQ is associated with problem gambling (Rai et al, 2014)

15. IQ and psychosis
reduced IQ may serve both as an outcome, or a causal factor in relation to psychotic disorders

16. BIF and Psychosis: analysis of associations using the Adult Psychiatric Morbidity Surveys
Using the combined 2000 and 2007 surveys we investigated whether individuals with BIF
have a higher prevalence of psychotic disorders
are more likely to report specific types of psychotic symptoms (paranoia, mania, thought insertion, strange experiences and hallucinations)
And
To investigate whether anxiety and depression mediate or moderate the relationship between BIF and psychotic disorder.

17. Instruments Phase 1 of surveys Psychosis Screening Questionnaire (PSQ)
Clinical Interview Schedule-Revised (CIS-R)
Diagnostic Interview Schedule
Existing survey methodology

19. Relationship between BIF, psychosis, sociodemographic and clinical variables
Odds Ratio (OR) P
95% Conf. Interval (CI)
Lower Upper
Unadjusted
1.89
0.03
1.08, 3.31
Adjusted for each moderator
Age
2.23
0.01
1.25, 3.99
Sex
1.90
1.08, 3.33
Social Class (L)
1.48
0.20
0.81, 2.69
Ethnicity
1.71
0.07
0.96, 3.05
Cannabis Use
1.95
0.02
1.12, 3.41
Stimulant Use
1.91
1.09, 3.37
Psychedelic Use
1.11, 3.44
Adjusted for All Confounders
1.59
0.15
0.84, 2.99

20. Relationship between BIF and individual PSQ itemsn %
Odds Ratio (OR) P
95% Conf. Interval (CI)
Hypomania
985
52.5
0.94
0.28
0.83, 1.05
Thought Insertion
156
8.3
1.00
0.99
0.81, 1.24
Persecution
408
21.8
1.17
0.03
1.01, 1.34
Strange experiences
188
10.0
1.31
0.01
1.08, 1.60
Hallucinations
131
7.0
1.93
0.00
1.53, 2.44

21. Mediators of the relationship between BIF and psychosis
Odds Ratio (OR) P
95% Conf. Interval (CI)
Unadjusted
1.89
0.03
1.08, 3.31
Adjusted for Depression
1.15
0.73
0.52, 2.57
Adjusted for Anxiety
1.81
0.04
1.02, 3.20
Adjusted for both Depression and Anxiety
1.19
0.68
0.53, 2.65

22. Summary of findings
Further confirmation of significant morbidity associated with BIF
Findings on ethnicity defer from those of a similar investigation
Potentially treatable common disorders such as depression appear to explain the relationship
Social adversity appears to be an important factor in onset of psychosis and is further underlined by lower social class
Common mental disorders and building resilience may need to be the focus of interventions in this group
It is questionable whether this patient group is managed effectively within current mental health services

23. Future?
Literature consistently suggests increased mental illhealth in adults with BIF
Is the lack of inclusion in classification systems likely to increase psychological distress by underascertainment?
Are patients with BIF managed effectively within existing mental health care models?
How to achieve balance between preserving autonomy and protecting against exploitation?