Psychiatric Concerns of People Having Intellectual Disabilities

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Psychiatric Concerns of People Having
Intellectual Disabilities

• Coni Kalinowski, MD
• August 2007

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Unique considerations in the medical evaluation
of people having intellectual disabilities

• May have metabolic basis for their disability
  that will have other medical ramifications
• May not communicate verbally
• May have few life choices
• May have difficulty with self-observation or
  report
• May have concomitant physical disabilities
• Are more likely to have a history of trauma
• May not be able to understand the purpose of
  medical examination
• Medical concerns are more likely to present with
  behavioral or psychiatric manifestations

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When there is a change in behavior

• Is it due to a medical problem?
• Is it due to situational factors?
• Is it due to environmental factors?
• Is it learned behavior?
• Is it due to a psychiatric condition?

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Presentation of medical illness

• Specific complaint
• Non-specific change in self-care or behavior
• Aggression or self-injury

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Challenges in obtaining the medical history

• Verbal report of symptoms may be inconsistent or
  compliant
• The individual may not be able to report
  chronology
• Staff reports may not fully represent the
  persons concerns
• Easy to over-estimate the accuracy of the
  individuals report

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Suggestions for practice

• Lower the threshold for more intensive medical
  investigation
• Re-consider possible medical causes for behaviors
  or symptoms that have not responded to usual
  behavioral and psychiatric treatment
• Obtain collateral information if possible

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Common medical conditions that may cause
behavioral manifestations

• Sleep apnea
•               Down Syndrome
•               Hypotonia
•               Micrognathia
•               Obesity

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Common medical conditions that may cause
behavioral manifestations

• Seizures
• Auras
• Ictal
• Post-ictal
• Interictal

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Common medical conditions that may cause
behavioral manifestations

• Dental problems
• Infections
• Thyroid disease
•                Down Syndrome

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Common medical conditions that may cause
behavioral manifestations

• Medication side effects
•            Phenobarbital, Mebaral, Mysoline
•            Psychotropics
• Chronic pain
• Loss of vision or hearing

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The dual diagnosis concept

• Treatment vs. chemical restraint
• Diagnostic criteria are being modified in order
  to be appropriate to individuals having
  intellectual disabilities
• In general, psychiatric disorders are about twice
  as prevalent in people having intellectual
  disability

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Mood disorders

• Depression and Mania
• Believed to have higher prevalence in population
  having intellectual disabilities

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Depressive episode

• Persistent depressed mood or anhedonia
• Increased or decreased appetite with weight
  change
• Insomnia or hypersomnia
• Psychomotor retardation or agitation
• Loss of interest in activities
• Fatigue and loss of energy
• Feelings of worthlessness, inappropriate guilt
• Decreased concentration, indecisiveness
• Thoughts of death or suicide

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Operationalizing depressive symptoms for people
having intellectual disabilities

• Depressed mood crying, whining, whimpering,
  hangs head, avoids eye contact
• Loss of interest/anhedonia does not initiate
  usual activities, refuses usual activities, does
  not initiate interpersonal contact, deterioration
  in self care and grooming, isolative in room
• Change in appetite change in weight, loss of
  interest in favorite foods, slow to eat, refuses
  meals
• Change in sleep TFA, EMA, trouble getting up in
  AM, up in the middle of the night, excessive
  napping, stays in bed though not asleep, insomnia
• Psychomotor agitation/retardation rocking,
  pacing, wringing hands, slowed movements, slow to
  dress/bathe, indecision, trouble getting started
  on activities

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Operationalizing depressive symptoms for people
having intellectual disabilities

• Fatigue and loss of energy napping, loss of
  stamina, refusal of walks or usual exercise,
  difficulty completing task or activity, slowed
  movement, lying down
• Worthlessness and guilt SIB, inattention to
  hazards, decreased self care and grooming,
  decreased interest in appearance, accepting
  blame, self-deprecating comments
• Diminished cognitive ability forgetfulness,
  inattention, difficulty with follow-through on
  task, decreased skills, wandering from group or
  activity, indecision, refuses choices
• Behavioral disturbance SIB or aggression

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Mania

• Persistently expansive, elevated, or irritable
  mood
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Pressured speech, hyperverbal
• Racing thoughts, flight of ideas
• Distractibility
• Hyperkinesis, increased activity
• High risk, flamboyant pleasurable behaviors

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Operationalizing manic symptoms in people having
intellectual disabilities

• Elevated mood grandiose beliefs, extreme levity
  or laughter, giving away money or possessions,
  extravagant plans, extreme sociability often to
  the point of intrusiveness, insisting on having
  own way, extreme determination
• Irritability sensitivity to noise or
  stimulation, emotional lability, very upset by
  small events, cursing, increased combativeness or
  anger, increased altercations with peers,
  argumentative
• Inflated self-esteem believes others' belongings
  are his/hers, talks about owning impressive
  things, over-estimates abilities, exaggerates
  accomplishments, wants larger portion or larger
  things
• Decreased need for sleep insomnia not
  accompanied by daytime fatigue, frequent
  awakenings, increased night-time activity (e.g.,
  rummaging in belongings, waking others to
  socialize)

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Operationalizing manic symptoms in people having
intellectual disabilities

• Hyperverbal continuous talking, interrupts
  others repeatedly, excessively lengthy
  explanations or stories, increased vocalizations,
  increased babbling to self
• Racing thoughts rapid speech, jumps from one
  topic to another or one activity to another, does
  not complete sentences.
• Distractibility easily disturbed by noises or
  surrounding activity, cannot complete tasks, very
  active but productivity decreased, trouble
  staying on task, trouble with multi-step tasks
• Hyperkinesis in constant motion, purposeless
  activity, cannot sit down, pacing or circling,
  rearranging furniture or belongings
• High risk or flamboyant activity increased
  sexuality, wears bright colors or dramatic
  clothes, more impulsive behaviors (taking others'
  food or belongings, bolting from group)

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Psychotic Disorders

• Brief psychoses may be more common in people
  having intellectual disabilities
• Psychotic symptoms are not uncommonly associated
  with episodes of mood disorders
• Schizophrenia was likely over-diagnosed in the
  past in individuals having idiosyncratic
  behaviors associated with autistic disorder,
  obsessive-compulsive disorder, or mood disorders

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Psychotic symptoms

• Hallucinations
• Delusions
• Disorganized thoughts and behavior
• Referential ideation
• Negative symptoms flat affect, alogia, avolition

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Identification of psychosis in individuals having
intellectual disabilities

• Afraid others are trying to hurt him/her
• Neglects hygiene
• Decline in dressing/grooming
• Seems confused
• Poor appetite or fearful of eating
• Change in sleep habits
• Reports messages from TV or radio
• Talks about odd or bizarre topics

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Identification of psychosis in individuals having
intellectual disabilities

• Listens to things others dont hear
• Looks at things that arent there
• Appears fearful for no reason
• Makes false accusations of others
• Talks or babbles to self
• Laughs without cause
• Seems lost in own thoughts
• Cant concentrate on tasks
• Incoherent speech

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Obsessive-Compulsive Disorder

• Obsessions
• Attempts to suppress or ignore
• Recognized as a product of ones own mind
• Compulsions
• Recognized to be excessive or unreasonable
• Interferes with functioning

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Obsessive-Compulsive Disorder in Intellectual
Disability

• Insight affects the clinical manifestations
• Ordering compulsions
• Completeness compulsions
• Cleanliness compulsions
• Checking and touching compulsions
• Grooming compulsions

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Behavioral Phenotypes

• Down Syndrome
• Williams Syndrome
• 22Q11 (Cardio-velo-facial syndrome)

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Practice guidelines for psychotropic medications

• Start low and go slow
• Differentiate treatment from chemical restraint
• Chemical restraint should only be used in
  combination with other treatment modalities
  (behavioral, psychotherapy) to ensure safety
  until the individual has learned better coping
  skills
• Avoid long-term treatment with benzodiazepines
• Avoid anticholinergics
• Avoid prn medications
• Match the intensity of the medication to the
  severity, frequency, and latency of the behavior
  reserve antipsychotics for severe, recurrent
  injurious behaviors

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Practice guidelines for psychotropic medications

• Use standardized measures to monitor for
  medication side effects whenever possible
• Reduce antipsychotic medications periodically to
  look for tardive side effects
• Eliminate conventional antipsychotics in favor of
  atypicals unless contraindicated due to severe
  metabolic effects
• Avoid intra-class polypharmacy
• Make sure there is clinical justification for
  inter-class polypharmacy
• Eliminate ineffective medications, especially
  when other medications are added.