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• Slide Presentation for the lecture of: Shirley PortugueseBeer Yaakov Mental Health Center, Israel

• Topic of lecture: Psychiatric Manifestations of Medical Problems in Adults with Intellectual Disability

• The lecture was given at Beit Issie Shapiro’s 6th International Conference on Disabilities - Israel

• Year: 2015

Psychiatric manifestationsof Medical Problems in Adults with Intellectual DisabilityShirley Portuguese MD MHABINA Clinic, Beer Yaakov Psychiatric center

Content

BINA Clinic Psychiatric Comorbidities in ID Physical Comorbidities in ID Psychiatric Manifestations of medical problems – case

studies How to Prepare for the Psychiatrist ?

BINA Clinic

Beer Yaakov outpatient clinic Multidisciplinary model by a joining psychiatrist References including: Welfare municipal Units,

service suppliers, child and adolescent psychiatric clinics, special Education facilities, etc.

ID Psychiatric Comorbidities

Up to 2/3 of ID adults have comorbid psychiatric disorder

Prevalent - Mood disorders, Autism, ADHD, Schizophrenia and Conduct disorder

The more severe the disability the higher the rate of psychiatric disorders.

Common Medical Manifestations in ID

Physical maintenanceHygiene, vision, hearing, dental problems

Genetically relatedDown syndrome - heart, ear, eye, thyroid, blood, GI etcTuberous sclerosis - brain, kidney, etcFragile X - ear, sinus, eye, seizures, ADHD etc

Common Medical Manifestations in ID Stress related - Peptic ulcer, Myocardial infarction

etc Sedentary Lifestyle - metabolic syndrome, sleep

apnea etc Iatrogenic – including medication side effects : - Antipsychotic (eg Risperidone) akathisia, dystonia etc- Benzodiazepine (eg Clonex) drowsiness, coordination etc

AbstractUp to two thirds of adults with intellectual disability have a comorbid psychiatric disorder, including mood disorders, autism, ADHD, schizophrenia and conduct disorder. The more severe the disability the higher the rate of psychiatric disorders. The presentation of medical problems can mimic psychiatric signs and symptoms thus hinder proper diagnosis and treatment. Medical causes can include medication side effects (such as antipsychotic medications causing dystonia or akathisia), metabolic deficits (such as diabetes and vitamin deficiencies), sleep disorders (such as sleep apnea syndrome) and many more. Medical problems might be masked by language and communication thus not addressed by the general practitioner. A psychiatrist specializing in adults inflicted by intellectual disability should be aware of possible physical diseases that might mimic psychiatric disorders allow for a better medical care.

Patient A

50 y female with ID (moderate) from hostel Primary Complaint- Anxiety 3 months not improved

by SSRI History- Picky eater, vegetarian, severe

menstruation Interview – Anxious, irritable, fatigue, refuses to

work Physical examination – warm clothes, pale, pulse

90/min

Patient A Diagnosis - Anemia Treatment- Food supplements (iron, B12), stop

bleeding

Patient B

42 y female ID (severe) from hostel Primary Complaint- Eating problems 1 mo, food cut

for her Interview - Slowness, back aches, Odd gait Physical- muscles spasms of lower back and jaw

Patient B Diagnosis –Dystonia

Risperidone started 1 mo due to behavioral disturbances

Antipsychotic side effects include Dystonia Treatment- stop Risperidone if possibleTry Anticholinergic medications

Patient C

35y Male with Down’s syndrome Complains- Cognitive decline inc. memory and

concentration Family crisis 3 years ago -> depressive symptoms and

behavioral disorders. Received SSRI -> Zyprexa. Gained 20 kg in 2 years. Interview- sleepiness, low concentration Mother says he snores

Patient C diagnosis - Sleep Apnea syndrome

Obstruction of larynx causing decline in oxygen delivery to the brain

Results- sleepiness, decline of concentration & attention, depression, anxiety etc

Childhood – Large Adenoids, Adulthood – Obesity Treatment – CPAP (mask during sleep)

Patient D

27y Female with ID Complains- Irritability, Anger outbursts,

preoccupation with toilet, wet herself for 2 weeks Received Benzo -> worsening of wetting. Interview- has an new boyfriend in hostel,

abdominal pain especially during urination

Patient D diagnosis

Urine sample- Urinary Tract infection Symptoms – persistent urge to urinate, burning

sensation while urinating, frequent urination, pelvic/ rectal pain

Treatment- Oral antibiotics

Medical issues to address Before attending a Psychiatrist Vision & Hearing Pain and discomfort (inc. teeth, ears, abdomen) Blood pressure, pulse Blood Tests – blood count, liver and kidney function,

TSH, B12, Folic acid, Glucose Complete medical history including medications and

family history, preferably GP visit

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