AFFECTIVE DISORDERS IN INTELLECTUAL DISABILITIES DIAGNOSTIC PITTFALLS AND PHARMACOLOGICAL TREATMENT STRATEGIES Mental Health in Intellectual Disabilities (formerly MHMR), Antwerp, May 31th 2007 Prof.Dr. Willem M.A. Verhoeven Vincent van Gogh Institute for Psychiatry, NL- Venray
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AFFECTIVE DISORDERS IN INTELLECTUAL DISABILITIES DIAGNOSTIC PITTFALLS AND PHARMACOLOGICAL TREATMENT STRATEGIES Mental Health in Intellectual Disabilities.
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AFFECTIVE DISORDERS IN INTELLECTUAL DISABILITIES
DIAGNOSTIC PITTFALLS AND PHARMACOLOGICAL TREATMENT STRATEGIES
Mental Health in Intellectual Disabilities (formerly MHMR), Antwerp, May 31th 2007
Prof.Dr. Willem M.A. Verhoeven
Vincent van Gogh Institute for Psychiatry, NL-Venray
Prevalence of affective spectrum disorders(Bipolar)Affective Anxiety OCD
Lund, 1985 1.7 2.0 -
Acta Psychiatr Scand
Corbett, 1979 4.0 25.4 -In: Psychiatric Illness
and Mental Handicap
Cooper & Bailey, 2001 6.0 7.2 2.5Ir J Psychol Med
Holden & Gitlesen, 2004 11 25 9
J Intellect Disabil Res
Cooper et al., 2007 6.6 3.8 0.7Br J Psychiatry
DIMENSIONAL DIAGNOSTIC PROCEDURES AND FUNCTIONAL PHARMACOTHERAPY OF AFFECTIVE
DISORDERS IN INTELLECTUAL DISABILITIES
• diagnostic procedures
• manifestations of depression
• unstable mood disorder
• behavioural phenotypes and depression
• pharmacotherapeutic strategies
DIAGNOSTIC INSTRUMENTS
• ICD-10 Guide for Mental Retardation
• DSM-IV
• ICD-10
• Diagnostic Criteria for psychiatric disorders for use with adults with Learning Disabilities/Mental Retardation (DC-LD)
• Clinical Diagnosis
DIAGNOSTIC PROCEDURES REFERENCE COMPLAINT
VIDEO REGISTRATION + CONSENSUS MEETING
SPECIFICATION OF SYMPTOMATOLOGY
QUESTIONS:genetic etiology
neurological examinationepilepsy
somatic examinationcourse
hereditary factorsplasma concentrations psychotropics and anticonvulsants
delirious stateenvironmental variables
results previous interventionsattenuation of treatment effects
tar dive behavioural effects of psychotropics and anticonvulsants
NEUROPSYCHIATRIC EXAMINATION
DIFFERENTIAL DIAGNOSISDIAGNOSTIC HYPOTHESIS
TREATMENT ADVISE
BEHAVIOURS, SIGNS AND SYMPTOMS OF DEPRESSION Level of intellectual disability (number of subjects)
Diagnosis Severe/profound (n=15) Mild/moderate (n=7) Depressed affect 15 6Sleep disturbance (insomnia = 13; hypersomnia = 1) 14 5Appetite disturbance (decrease = 12; increase = 1) 13 3Loss of interest 12 0Social isolation 11 0Self-injurious behaviour 10 5Psychomotor agitation 10 6Aggression 9 2Irritability 7 2Lack of emotional response 6 4Screaming 6 0Stereotypical behaviour 6 0Psychomotor retardation 5 3Weight loss 6 0Anxiety 5 6Constipation 5 0Loss of energy 5 2Unreasonable self-reproach x 3Delusion (mood congruent) x 2Diurnal variation of mood x 2
From: Tsiouris, JIDR, 2001
SYMPTOMS OF DEPRESSION IN INTELLECTUAL DISABILITIES
MORE THAN 50% LESS THAN 50%irritability somatic complaintsdepressed affect lack of emotional responsetearfulness diurnal variationloss of interest psychomotor retardationsleep disturbance loss of appetitepsychomotor agitation weight lossself-injurious behaviour suicidal ideationloss of energy obsessive-compulsive behaviourconstipation euphoriaanxiety labile moodaggression screamingsocial isolation stereotyped behaviourantisocial behaviour vomitingdecreased concentration incontinenceanhedonia guilt feelingsincreased speech change in sexual activitiesdecreased appetite hallucinationswithdrawn behaviour delusions Adapted from Charlot et al. 1993; Meins, 1995; Marston et al., 1997
SYMPTOMS (PRESENCE ≥50%) OF AFFECTIVE SPECTRUM DISORDERS* IN INTELLECTUAL DISABILITIES (n=285)
depression affective spectrum
(n=58) (n=136)psychomotor agitation + +stereotypies - +aggression - +self-injuries - +anxieties + +irritability + +depressed mood + -mood swings + +dysphoria - +loss of energy + -loss of interest + -withdrawn behaviour + -difficult to handle + + *depression, anxiety disorder, bipolar disorder and unstable mood disorderVerhoeven et al., The European Journal of Psychiatry, 18:49-53, 2004
UNSTABLE MOOD DISORDER
Sollier (1901)
"on voit des changements brusques d’humeur que rien ne paraît motiver,
des actes bizarres et des mouvements capricieux"
Duncan (1936)
considerable degree of emotional instability that could not be considered as typical for bipolar affective disorder
Verhoeven & Tuinier (1997):
high prevalence of atypical bipolar and mood disorders with features like inactivity, lability and irritability unstable mood disorder, characterized by an episodic pattern of disturbed mood, anxiety and behaviour
UNSTABLE MOOD DISORDER
IN INTELLECTUAL DISABILITIES
affective instability episodic motor inhibition or disinhibition
subjects:- 18 male, 10 female- mean age: 37.3 year- mild to severe intellectual disabilitiesetiology:- unknown: 18- perinatal complications: 6- encephalitis postvaccinalis: 1- specific syndromes: 6diagnosis:- rapid or episodic fluctuations in behaviour- prominent mood deviations mostly with motor signs like self-injuries