Dr Keith Ganasen Department of Psychiatry UCT

Transcription

1 Dr Keith Ganasen Department of Psychiatry UCT

2 A. Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test B. Concurrent deficits or impairments in present adaptive functioning (i.e., the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety.

3 C. The onset is before age 18 years. Code based on degree of severity reflecting level of intellectual impairment: 317 Mild Mental Retardation: IQ level to approximately Moderate Mental Retardation:IQ level to Severe Mental Retardation: IQ level to Profound Mental Retardation: IQ level below 20 or Mental Retardation, Severity Unspecified: when there is strong presumption of Mental Retardation but the person's intelligence is untestable by standard tests

4 (From the DSM-IV) refers to how effectively individuals cope with common life demands and how well they meet the standards of personal independence expected of someone in their particular age group, sociocultural background, and commununity setting. Adaptive functioning may be influenced by various factors, including education, motivation, personality characteristics, social and vocational opportunities, and the mental disorders and general medical conditions that may coexist with ID.

5 Wechsler Adult Intelligence Scale (WAIS) - IQ Vineland Adaptive Behaviour Scale Adaptive Functioning Administered an interpreted by psychologist

6 Approximately 3% of world population may have IQ test of 70 Of the 3 %: 85% = Mild ID 10% = Moderate ID 4% = Severe ID 1-2% = Profound ID About 40% of the aetiologies of ID are unknown (reducing)

7 (Epidemiological data varies) High prevalence of psychiatric co-morbidity (30-50%) especially in moderate to severe ID Some psychiatric disorders are more prevalent than in general population eg. schizophrenia, bipolar disorder, ADHD, autism, dementia Higher prevalence of multiple disability including neurological disorders, cancers, GIT problems and other sensory problems

8 (or Problem Behaviours in some texts) Term used in field of ID to define a range of disruptive and dangerous behaviours or socially unacceptable behavior that causes distress, harm or disadvantage to the person themselves, or to other people, and usually requires some intervention eg. aggression, destruction of property, self-injury (SIB), pica, stereotypies Prevalence 8-17% (depending on study) Is primary reason for referrals and institutionalization

9 Challenging behaviours (CB) is the most important factor associated with the use of psychotropics CB appear to target behaviours of choice vs core symptoms of psychopathology Up to 45% of people with ID (PWID) receive psychotropics Up 30% of these receive psychotropics in the absence of a diagnosed psychiatric disorder Most common are the antipsychotics (66%)

10 CB persists over time and it is necessary to start treatment early But there are a number of causes/contributors to CB Eg. Organic factors, environmental stressors, communication difficulties, (and psychiatric illnesses) Due to communication difficulties, some behaviours are learned in childhood, and persist

11 Recognises the problem of the high rate of prescription of pscyhotropics for CB It is a source of concern due to the scarce evidence for their effectiveness, adverse effects, impact on quality of life Many receive multiple psychotropics in high dose How should we approach the management of CB in PWID and the role of Psychopharmacology?

12 Did a systematic review of the evidence and consensus based on good practice This guide neither supports nor refutes the use of psychotropics for CB (without a diagnosed axis 1 psychiatric disorder) But it provides carers with good practice advice despite the lack of good quality evidence on the subject

13 Identify and address the cause of the challenging behaviour Many possible causes Organic problems are common Environmental stressors and interpersonal relationship difficulties Boredom, lack of stimulation Communication difficulty about the person s distress Use a MDT approach to address the behaviour with non-pharmacological methods first if possible

14 Obvious physical or psychiatric disorders should be managed appropriately as per guidelines When no physical or psychiatric disorder diagnosed, and non-pharmacological interventions are failing Risk vs benefit Severity of CB Risk loss of placement Patient/carer choice?

15 A slow and considered approach to the use of psychotropics can be tried, and possible adverse effects monitored carefully List the target symptoms along with the frequency and severity at the beginning (can use appropriate scales where available) Start low and titrate slow Minimum required dose Can be used in combination with psychology Could consider withdrawal of medication at a later stage

16 Typical and Atypical antipsychotics Mood stabilisers Antiepileptics Anxiolytics Antidepressants Stimulants Others

17 A typical case may be of a young female with Moderate to severe Intellectual Disability, Epilepsy, Autism, and various challenging behaviours that cause distress Difficult to be sure if there is also an anxiety disorder, psychosis, or mood disorder Considered trial of medication targeting the challenging behaviour may be warranted Eg. risperidone, quetiapine, SSRI, antiepileptics Remember, may also have a high BMI, Hpt, DM, hypothyroidism Consider if behaviour related to menstrual cycle

18 20 yo Male, moderate to severe ID, 4yr hx of excessive overactivity, unable to take him anywhere. However, no clear Sx of Bipolar, possible psychosis, possible ADHD?? Safely considered trials of appropriate medication Responded remarkably to Quetiapine plus Clonidine

19 Adult with Autism, in an environment that is not autism friendly, person engages in self injurious behaviour (biting, head banging) Use of an SSRI to alleviate anxiety in combination with various Occupational Therapy exercises to alleviated distress (drawing, puzzles etc)

20 Person with a genetic disorder eg Cornelia De Lange symdrome Behavioural phenotype resembles that of Bipolar Disorder, or Intermittent Explosive Disorder, and is associated with destruction of property Use of an antipsychotic is warranted, possibly an SSRI too, and/or a mood stabiliser Remember endocrine effects

21 Try to identify the cause of the challenging behaviour Try non-pharmacological methods first if possible However, psychotropics are often necessary for a while at least Choose medication based on target symptoms eg. SSRI for anxiety, antipsychotic for aggression stereotypies, clonidine/methylphenidate for hyperactivity Start low, go slow, combine with other therapies where possible, monitor frequency and intensity of Sx, and consider stopping at some point if possible

22 Most often, the problem is not that people with ID do not understand us, but rather that we do not understand them

23 Questions/Discussion