INTELLECTUAL DEVELOPMENTAL DISORDERS AND
MENTAL HEALTH:
CLASSIFICATION AND DIAGNOSTIC ISSUES
Marco Bertelli, MD, Psychiatr...
WPA-SPID POSITION STATEMENT
 ID is a health condition
 ID is a meta-syndrome characterised by an
impairment in cognitive...
IDD DEFINITION
 A group of developmental conditions characterized by a significant
impairment of cognitive functions, whi...
ID: DISABILITY OR DISORDER ?

?
ID: DISABILITY OR DISORDER ?

+
Is IQ reduction an useful criterion for ID?

1.Ardila A., (1999). A Neuropsychological Approach to Intelligence. Neuropsyc...
IQ AND COGNITIVE PROFILE IN GS
Syndrome

ID level

Down

Mild, moderate or severe

X Fragile

15% mild
49% moderate
26% se...
IQ AND COGNITIVE PROFILE IN GS - 2
Syndrome

ID level

Warkany 2
(trisomy 8)

moderate or severe

Phenylketonuria

moderat...
WAIS IV SUBTESTS AND SUBSCORES

Copyright © 2008 Pearson Education, Inc. or its affiliate(s). All rights reserved.
SCFs AND NOT IQ
FOR BIOLOGICAL SUBSTRATES

Findings of recent studies of genetics, neuroimaging and
neurophysiology identi...
17,5 %
12,5 %

6%
2,5%

RM

FIL

NORMALE

ALTO

GENIO

Hassiotis A, Strydom A, Hall I, Ali A, Lawrence-Smith G, Meltzer H,...
BORDERLINE INTELLIGENCE
N = 8450 adults

 around 1/8 of the population has borderline intelligence
(12,3% of the sample)
...
Is the age limit of 18 an useful criterion for ID?

Although the specific age limit of 18 is clearly arbitrary,
WPA-SPID m...
INCREASE OF AUTISM AND ASDs
PREVALENCE RATE

■

Autism1

1. Newschaffer et al., 2007.
2. Lazoff et al., 2010; Baron-Cohen ...
PREVALENCE RATE (%)
ASD AND ID
 PDD in ID = 30-40%1
 ID in autism = 25-80%2
 in ID around 50% of ASDs has been previous...
PREVALENCE RATE (%)
ASD AND SCHIZOPHRENIA

 21% of people with schizophrenia receive a
lifetime diagnosis of PDD-NOS1
 a...
PREVALENCE RATE (%)
OF PSYCHIATRIC DISORDERS IN ID WITH AND WITHOUT AUTISM

Prevalence

Tool

with A

without A

Bradley &...
GENETIC OVERLAPPING BETWEEN AUTISM AND IDD
Gene:

Protein:

• FMR1 Xq27.32

• neuroligina3

• GRIK2 6q16.32

• neurexina3
...
GENETIC OVERLAPPING
BETWEEN AUTISM AND SCHIZOPHRENIA
 Chromosome 1q21.1 deletion 1
Chromosome 15q13.3 deletion 1
Chromoso...
THE PROTEINS OF COGNITION
Pum 2 and elF4E and Scn1a
Neuroligina

SHANK-3
CNTNAP2
'cadherin' (Calcium
dependent adhesion
mo...
THE ROLE OF FMRP IN MAJOR MENTAL DISORDERS

 Fragile X Mental Retardation Protein is highly enriched in neurons and
binds...
GENETICS OF NEURODEVELOPMENTAL DISORDERS

RELN

reelin

neuronal migration and synaptic function

Npas4G

Npas4

social an...
METACATEGORY

WPA-SPID proposed to include in a cluster of disorders
sharing salient cognitive symptoms and similarities o...
ICD-11-beta morbidity linearisation
and “impairment of behaviour”
• 05 Mental and behavioural disorders
NEURODEVELOPMENTAL...
DSM-5 ID/IDD Position
• disturbo con insorgenza nell‟età evolutiva che include deficit
intellettivi e adattivi negli ambit...
DSM-5 ID/IDD Position - 2
• il disturbo è stato collocato in un raggruppamento meta-sindromico, o
meta-strutturale, denomi...
DSM-5 ID/IDD Diagnostic Criteria
A. Deficit delle funzioni intellettive, come il ragionamento, la soluzione
di problemi, l...
PROPOSAL OF LINEAR STRUCTURE FOR ICD-11
F: MENTAL AND BEHAVIOURAL DISORDERS (meta-structure)
F1: NEURO-DEVELOPMENTAL DISOR...
LIFE EVENTS AND PSYCHIATRIC
DISORDERS IN PwID
 Association between recent life events and traumatic
experiences across th...
A NEW CULTURAL MODEL FOR
NEURODEVELOPMENTAL DISORDERS / CONDITIONS
PSYCHO-CHARACTERISATION
SPECIF COGNITIVE FUNCTIONS
INDI...
MARCO BERTELLI
MD, Psychiatrist, Psychotherapist

CREA (AMG Research and Evolution Centre) Scientific Director
Via del San...
Intellectual Developmental Disorders and Mental Health: classification and diagnostic issues
Intellectual Developmental Disorders and Mental Health: classification and diagnostic issues
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Intellectual Developmental Disorders and Mental Health: classification and diagnostic issues

  1. 1. INTELLECTUAL DEVELOPMENTAL DISORDERS AND MENTAL HEALTH: CLASSIFICATION AND DIAGNOSTIC ISSUES Marco Bertelli, MD, Psychiatrist, MISP Presidente EAMH-ID - European Association on Mental Health in Intellectual Disability Presidente WPA-SPID - World Psychiatric Association - Section Intellectual Disability Segretario SIDiN – Società Italiana per i Disturbi del Neurosviluppo Presidente Eletto AISQuV - Società Italiana per lo studio della Qualità di Vita Direttore Scientifico CREA - Research and Clinical Centre of Fondazione San Sebastiano, Florence (Italy) www.crea-sansebastiano.org office: mbertelli@crea-sansebastiano.org private: bertelli.fi@tiscali.it
  2. 2. WPA-SPID POSITION STATEMENT  ID is a health condition  ID is a meta-syndrome characterised by an impairment in cognitive functioning prior to the acquisition of skills through learning  the intensity of the deficit is such to interfere in a significant way with individual normal functioning as expressed in limitations in activities and restriction in participation (disabilities) Salvador-Carulla L.. and Bertelli M. Intellectual Disability: A Hidden Mental Health Priority Area. Psychopathology, 2007
  3. 3. IDD DEFINITION  A group of developmental conditions characterized by a significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behavior and skills.  IDD is a life span condition requiring consideration of developmental stages and life transitions.  Most individuals with IDD continue to acquire skills and competencies, especially with optimal care, training, education and opportunities for learning.  However IDD is a vulnerable group associated with a higher rate of mental and physical disorders and related unmet care needs as well as an increased risk of abuse and neglect. Salvador-Carulla L.. Reed G., Bertelli M. et al, World Psychiatry, in press
  4. 4. ID: DISABILITY OR DISORDER ? ?
  5. 5. ID: DISABILITY OR DISORDER ? +
  6. 6. Is IQ reduction an useful criterion for ID? 1.Ardila A., (1999). A Neuropsychological Approach to Intelligence. Neuropsychology Review, Vol. 9, No. 3,1999; 45. 2.Salvador-Carulla L., Bertelli M. (2007). Intellectual Disability: A Hidden Mental Health Priority Area. Psychopathology. 41:10-16. 3. Tiekstra M, Hessels MG, Minnaert AE. Learning capacity in adolescents with mild intellectual disabilities. Psychol Rep. 2009 Dec;105(3 Pt 1):804-14; 35. 4.Torresan, P. (2006). Le intelligenze multiple. Revista Conceptos, UMSA.
  7. 7. IQ AND COGNITIVE PROFILE IN GS Syndrome ID level Down Mild, moderate or severe X Fragile 15% mild 49% moderate 26% severe 10% profound Williams 7q delection Mild or moderate Smith-Magenis (17p delection) Specific Cognitive Dysfunction Mild or moderate Bertelli et al. (2011). PSICOGEN (PSIchyatric disorders and Cognition in GENetic syndromes).In submission.
  8. 8. IQ AND COGNITIVE PROFILE IN GS - 2 Syndrome ID level Warkany 2 (trisomy 8) moderate or severe Phenylketonuria moderate or severe Klinefelter (47 XXY) absent or borderline Galctosemia Specific Cognitive Dysfunction absent or borderline Bertelli et al. (2011). PSICOGEN (PSIchyatric disorders and Cognition in GENetic syndromes).In submission.
  9. 9. WAIS IV SUBTESTS AND SUBSCORES Copyright © 2008 Pearson Education, Inc. or its affiliate(s). All rights reserved.
  10. 10. SCFs AND NOT IQ FOR BIOLOGICAL SUBSTRATES Findings of recent studies of genetics, neuroimaging and neurophysiology identified more correlations with cognitive functions (such as perceptual organization deficit, poor working memory, lexical, visual-spatial and phonological processing) than with IQ scores1,2,3,4,5,6 1. Steinlin M. (2008). Cerebellar disorders in childhood: cognitive problems. Cerebellum. 7:607-10; 2.Tavano A., Borgatti R. (2010). Evidence for a link among cognition, language and emotion in cerebellar malformations. Cortex. 46:907-18; 3.Ardila A., Pineda D., Rosselli M. (2000). Correlation between intelligence test scores and executive function measures. Archives of Clinical Neuropsychology. 15:31-6; 4.Friedman N.P., Miyake A., Corley R.P., Young S.E., Defries J.C., Hewitt J.K. (2006). Not all executive functions are related to intelligence. Psychological Science. 17:172-9; 5.Johnson W., Jung R.E., Colom R., Haier R.J. (2008). Cognitive abilities independent of IQ correlate with regional brain structure. Intelligence. 36:18-28; 6.Mackintosh NJ. (1999). IQ and Human Intelligence. Reviewed by Robert Plomin. The American Journal of Human Genetics. 65:1476-1477.
  11. 11. 17,5 % 12,5 % 6% 2,5% RM FIL NORMALE ALTO GENIO Hassiotis A, Strydom A, Hall I, Ali A, Lawrence-Smith G, Meltzer H, Head J, Bebbington P. Psychiatric morbidity and social functioning among adults with borderline intelligence living in private households. J Intellect Disabil Res. 2008 Feb;52(Pt 2):95-106.
  12. 12. BORDERLINE INTELLIGENCE N = 8450 adults  around 1/8 of the population has borderline intelligence (12,3% of the sample)  this people present higher rate of: - neurotic disorders - substance abuse - personality disorders - social disability - psycho-pharmacological therapies, but not speech therapies - health service use, including emergency services Hassiotis A. et al. J Intellect Disabil Res. 2008 Feb;52(Pt 2):95-106
  13. 13. Is the age limit of 18 an useful criterion for ID? Although the specific age limit of 18 is clearly arbitrary, WPA-SPID members expressed general agreement on the importance to keep a distinction between a persistent process that begins at birth and a change occurring after a normal development.
  14. 14. INCREASE OF AUTISM AND ASDs PREVALENCE RATE ■ Autism1 1. Newschaffer et al., 2007. 2. Lazoff et al., 2010; Baron-Cohen et al., 2009 ■ ASD2
  15. 15. PREVALENCE RATE (%) ASD AND ID  PDD in ID = 30-40%1  ID in autism = 25-80%2  in ID around 50% of ASDs has been previously diagnosed with schizophrenia3  risk of underestimating ASD in ID in favour of schizophrenia4 1. Kraijer 1997 (N=718); Morgan et al. 2002 (N=571); La Malfa et al., 2004 (N=166 adults); Cooper et al., 2007 2. Hoekstra et al., 2009 BJP; Centers for Disease Control and prevention USA, 2006; Edelson, 2006; Matson e Shoemaker, 2009; Baird et al., 2006; Noterdaeme e Wriedt, 2010; Bryson and Smith, 1998 3. Bryson et al. Prevalence of autism among adolescents with intellectual disabilities. Canadian J of Psychiatry, 2008; 53(7): 449-59 4. Palucka et al., 2009; Savage et al., 2007
  16. 16. PREVALENCE RATE (%) ASD AND SCHIZOPHRENIA  21% of people with schizophrenia receive a lifetime diagnosis of PDD-NOS1  around 50 % of people with autismo also meets criteria for schizophrenia disorganised-type2  at least 1.5% of psychiatric outpatients don‟t receive the right diagnosis of ASD; 26% of these is diagnosed with schizophrenia3 1. Sporn et al., 2004; Towbin et al., 2005 2. Konstantareas and Hewitt, 2001 3. Nylander and Gilberg, 2001
  17. 17. PREVALENCE RATE (%) OF PSYCHIATRIC DISORDERS IN ID WITH AND WITHOUT AUTISM Prevalence Tool with A without A Bradley & Bolton, 2006 SAPPA Bradley et al., 2004 DASH 50 >50 16,7 25 50 67 58 8 8 8 25 8 Depression Mania Eating Disorders Schizophrenia Bradley E.A. and Bolton P. Episodic psychiatric disorders in teenagers with learning disabilities with and without autism. British Journal of Psychiatry, 2006, 189: 361-366 Bradley E.A., Summers J.A., Wood H.L., Bryson S.E. Comparing rates of psychiatric and behavior disorders in adolescents and young adults with severe intellectual disability with and without autism. J of Autism and Developmental Disorders, 2004; 34(2): 151-161
  18. 18. GENETIC OVERLAPPING BETWEEN AUTISM AND IDD Gene: Protein: • FMR1 Xq27.32 • neuroligina3 • GRIK2 6q16.32 • neurexina3 • HOXA1 7p15.32 • SHANK-33 • PTCHD11 • CNTNAP24 • NLGN4 and IL1RAPL12 • PUM25 implications in mRNA • RPL102 • CGG trinucleotide6 deletion • 1q21.12  LTD on mGluR7 • 15q13.32 • 16p11.22 1Noor A, Scherer SW. Disruption at the PTCHD1 locus on Xp22.11 in autism spectrum disorder and intellectual disability. Sci Transl Med. 2010 September 15; 2(49) 2Pinto D, Scherer SW. Functional Impact of Global Rare Copy Number Variation in Autism Spectrum Disorder Nature. 2010 July 15; 466(7304): 368–372. doi:10.1038/nature09146 3Bakkaloglu B, et al. Molecular cytogenetic analysis and resequencing of contactin associated protein-like 2 in autism spectrum disorders. Am J Hum Genet. 2008 Jan;82(1):165-73. 4Alarcón M, et al. Linkage, association, and gene-expression analyses identify CNTNAP2 as an autism-susceptibility gene. Am J Hum Genet. 2008 Jan;82(1):150-9 5Vessey J.P., Schoderboeck L., Gingl E., Luzi E, et al. Mammalian Pumilio 2 regulates dendrite morphogenesis and synaptic function. PNAS ( Proceedings of the National Academy of Sciences). Published online before print January 28, 2010 6Gabis LV, Baruch YK, Jokel A, Raz R. Psychiatric and autistic comorbidity in fragile x syndrome across ages. J Child Neurol. 2011 Aug;26(8):940 7Lüscher C, Huber KM. Group 1 mGluR-dependent synaptic long-term depression: mechanisms and implications for circuitry and disease. Neuron. 2010 Feb 25;65(4):445-59
  19. 19. GENETIC OVERLAPPING BETWEEN AUTISM AND SCHIZOPHRENIA  Chromosome 1q21.1 deletion 1 Chromosome 15q13.3 deletion 1 Chromosome 3q29 and 22q11.21 deletion Chromosome 16p11.2 duplication 1 exonic NRXN1 deletion 1 exonic VIPR2 and C16orf72 duplication 1  Chromosome 16p11.22  NRXN1 2p16.3 gene disrupted in ASD, MR, schizophrenia4  16p13.11 deletion  Deficits in RNA transcription without changes in DNA sequence5-6 1. Levinson DF, Gejman PV. Copy Number Variants in Schizophrenia: Confirmation of Five Previous Findings and New Evidence for 3q29 Microdeletions and VIPR2 Duplications. Am J Psychiatry. 2011 Mar;168(3):302-16 2. McCarthy SE, Sebat J. Microduplications of 16p11.2 are associated with schizophrenia. 2009 Nov;41(11):1223-7 3. Akbarian S, Huang HS. Epigenetic regulation in human brain-focus on histone lysine methylation. Biol Psychiatry, 2009 Feb 1;65(3):198-203; Singh SM, O'Reilly R. (Epi)genomics and neurodevelopment in schizophrenia: monozygotic twins discordant for schizophrenia augment the search for disease-related (epi)genomic alterations. Genome, 2009 Jan;52(1):8-19 4. Pinto D, Scherer SW. Functional Impact of Global Rare Copy Number Variation in Autism Spectrum Disorder Nature. 2010 July 15; 466(7304): 368–372. doi:10.1038/nature09146 5. Akbarian S, Huang HS. Epigenetic regulation in human brain-focus on histone lysine methylation. Biol Psychiatry, 2009 Feb 1;65(3):198-203 6. Singh SM, O'Reilly R. (Epi)genomics and neurodevelopment in schizophrenia: monozygotic twins discordant for schizophrenia augment the search for disease-related (epi)genomic alterations. Genome, 2009 Jan;52(1):8-19
  20. 20. THE PROTEINS OF COGNITION Pum 2 and elF4E and Scn1a Neuroligina SHANK-3 CNTNAP2 'cadherin' (Calcium dependent adhesion molecules) 10 and 9 Neurexine 1 (NRXN1) N= 3540 under genomic comparative hybridization NRXN1 mutation resulted to be associated with ASDs, IDD, and SLD Ching MS, Shen Y, Tan WH, et al. Deletions of NRXN1 (neurexin-1) predispose to a wide spectrum of developmental disorders. Am J Med Genet B Neuropsychiatr Genet. 2010 Apr 7.
  21. 21. THE ROLE OF FMRP IN MAJOR MENTAL DISORDERS  Fragile X Mental Retardation Protein is highly enriched in neurons and binds to approximately 4% of mRNAs in mammalian brain  FMRP loss is a hallmark of fragile X syndrome (FXS), the most common inherited form of mental retardation  reductions of FMRP in psychiatric disorders • autism • schizophrenia • bipolar disorder • major depressive disorder Fatemi SH, Folsom TD. The role of fragile X mental retardation protein in major mental disorders. Neuropharmacology. 2011 Jun;60(7-8):1221-6. Epub 2010 Nov 22.
  22. 22. GENETICS OF NEURODEVELOPMENTAL DISORDERS RELN reelin neuronal migration and synaptic function Npas4G Npas4 social and cognitive functions 1q21.1 CHD1, PBKAB2 chromatine and AMP kinase regulation 16p11.2 SEZ6L2 expressive language and socialisation 16p13.1 NDE1, NTAN1 synaptic plasticity, memory GRIN2 NMDA rec working memory and perceptual binding TCF4 TCF4 memory and attention (N150) NRXN1 neurexine synaptic functions CNTNAP2 contactin-L2 cell adhesion and receptors SHANK 3 ProSAP2 synapse and dendritic spine formation Ullman et al.,Human mutation, 2007; Folsom et al. Neuropharmacology, 2012; Coutallier et al. PLos One, 2012; Crespi et al. J Neurodev Disord, 2012; Endele et al. Nat Genet, 2010 ; Hennekam et al. Dev Med Child Neurol, 2012
  23. 23. METACATEGORY WPA-SPID proposed to include in a cluster of disorders sharing salient cognitive symptoms and similarities on risk factors, clinical factors, genetic phenotype, early onset, course, and co-morbidity. F7 Salvador-Carulla L.. Reed G., Bertelli M. et al, World Psychiatry, in press F1
  24. 24. ICD-11-beta morbidity linearisation and “impairment of behaviour” • 05 Mental and behavioural disorders NEURODEVELOPMENTAL DISORDERS Disorders of Intellectual Development (DID) 5A00. Mild DID: IQ 50-69; in adults mental age (MA) 9 - <12 y 5A01. Moderate DID: IQ 35-49; in adults, MA 6 - <9 y 5A02. Severe DID: IQ 20 – 34; in adults, MA 3 - <6 y 5A13. Profound DID: IQ <20; in adults, MA <3 y 5A0Y. Other disorders of intellectual development 5A0Z. Disorders of intellectual development, unspecified ICD-10 impairment of behaviour F7x. 1 “RETIRED”
  25. 25. DSM-5 ID/IDD Position • disturbo con insorgenza nell‟età evolutiva che include deficit intellettivi e adattivi negli ambiti della concettualizzazione, della socializzazione e delle capacità pratiche • i livelli di gravità vengono definiti sulla base del funzionamento adattivo e non sui punteggi di quoziente intellettivo (QI), poiché è stato giudicato che sia il funzionamento adattivo, nelle aree della concettualizzazione, della socializzazione e delle abilità pratiche, a determinare il livello di supporto necessario a mantenere una condizione di vita accettabile. In più, quando basse (inferiori a 60), le misure di QI perdono di validità • si continuano a distinguere 4 livelli di gravità (lieve, moderato, grave e gravissimo), ma con criteri diversi dal DSM-IV e IV-TR. APA. Diagnostic and Statistic Manual for Mental Disorders - %th edition, 2013
  26. 26. DSM-5 ID/IDD Position - 2 • il disturbo è stato collocato in un raggruppamento meta-sindromico, o meta-strutturale, denominato „disturbi del neurosviluppo • il gruppo include condizioni con insorgenza in età evolutiva, tipicamente precoci, spesso precedenti l‟ingresso a scuola e caratterizzate da deficit di sviluppo che producono compromissioni del funzionamento personale, sociale, scolastico o occupazionale • il range di deficit spazia da limitazioni molto specifiche dell‟apprendimento e del controllo delle funzioni esecutive ad una compromissione globale delle abilità sociali o dell‟intelligenza • i disturbi del neurosviluppo si presentano spesso insieme, per esempio individui con autismo hanno spesso anche disabilità intellettiva (disturbo dello sviluppo intellettivo) e molti bambini con disturbo da deficit d‟attenzione e iperattività hanno spesso anche un disturbo specifico dell‟apprendimento. APA. Diagnostic and Statistic Manual for Mental Disorders - %th edition, 2013
  27. 27. DSM-5 ID/IDD Diagnostic Criteria A. Deficit delle funzioni intellettive, come il ragionamento, la soluzione di problemi, la pianificazione, il pensiero astratto, il giudizio, l‟apprendimento scolastico o l‟apprendimento dall‟esperienza, confermato sia da valutazione clinica che da prove d‟intelligenza individualizzate e standardizzate. B. Deficit del funzionamento adattivo che si manifesti col mancato raggiungimento degli standard di sviluppo e socio-culturali per l‟indipendenza personale e la responsabilità sociale. Senza supporto continuativo i deficit adattivi limitano il funzionamento in una o più attività della vita quotidiana, quali la comunicazione, la partecipazione sociale e la vita indipendente, in più ambiti diversi, come la casa, la scuola, il lavoro e la comunità. C. Insorgenza dei deficit intellettivi e adattivi nell‟età evolutiva. APA. Diagnostic and Statistic Manual for Mental Disorders - %th edition, 2013
  28. 28. PROPOSAL OF LINEAR STRUCTURE FOR ICD-11 F: MENTAL AND BEHAVIOURAL DISORDERS (meta-structure) F1: NEURO-DEVELOPMENTAL DISORDERS (meta-category) F1.Y PROBLEM BEHAVIOURS/BEHAVIOUR DISORDER (category) F1.Y.1 Mild and infrequent F1.Y.2 Mild and frequent F1.Y.3 Severe and infrequent F1.Y.4 Severe and frequent F1.Y.5 External boundary prevents expression of behaviour objects) Self-injury F1.Y.8 Unspecified F1.Y.1-8.1 Physical aggression to others F1.Y.1-8.2 Verbal aggression (e.g. screaming) F1.Y.1-8.3 Destructive to property (e.g. throwing/pulling F1.Y.1-8.4 F1.Y.1-8.5 Oppositional F1.Y.1-8.6 Overly-demanding F1.Y.1-8.7 Sexually inappropriate (e.g. repeated stripping) F1.Y.1-8.8 Other Can multiple sub-sub categories be specified or not? – alternative descriptors if not WHO WG on ID for ICD-11. Proceedings of the fourth meeting, Buenos Aires 2011.
  29. 29. LIFE EVENTS AND PSYCHIATRIC DISORDERS IN PwID  Association between recent life events and traumatic experiences across the life span and psychiatric disorders in PwID more than in general population  Transition phases and PDs  Though they have been less studied by the literature regarding predictors of mental illness, traumatic experiences seem to play a more important role in psychopathology than life events1 Martorell A., et al., 2009
  30. 30. A NEW CULTURAL MODEL FOR NEURODEVELOPMENTAL DISORDERS / CONDITIONS PSYCHO-CHARACTERISATION SPECIF COGNITIVE FUNCTIONS INDIVIDUAL SKILLS INDIVIDUAL ATTRIBUTION OF IMPORTANCE OFFER OF A WIDE RANGE OF OPPORTUNITIES IMPROVEMENT OF THE INDIVIDUAL IMPORTANCE/SATISFACTION INDIVIDUAL QoL Bertelli et al. Advances in Mental Health and Intellectual Disabilities, in press
  31. 31. MARCO BERTELLI MD, Psychiatrist, Psychotherapist CREA (AMG Research and Evolution Centre) Scientific Director Via del Sansovino, 176 - 50142 Firenze (Italy) www.wpanet.org/spid www.crea-amg.org bertelli.fi@tiscali.it mbertelli@crea-amg.org

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