2. Psychiatric manifestations of Medical Problems in Adults with Intellectual Disability Shirley Portuguese MD MHA BINA Clinic, Beer Yaakov Psychiatric center

3. Content  BINA Clinic  Psychiatric Comorbidities in ID  Physical Comorbidities in ID  Psychiatric Manifestations of medical problems – case studies  How to Prepare for the Psychiatrist ?

4. 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.

5. 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.

6. Common Medical Manifestations in ID Physical maintenance Hygiene, vision, hearing, dental problems Genetically related Down syndrome - heart, ear, eye, thyroid, blood, GI etc Tuberous sclerosis - brain, kidney, etc Fragile X - ear, sinus, eye, seizures, ADHD etc

7. 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

8. Abstract Up 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.

9. 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

10. Patient A Diagnosis - Anemia  Treatment- Food supplements (iron, B12), stop bleeding

11. 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

12. Patient B Diagnosis –Dystonia  Risperidone started 1 mo due to behavioral disturbances  Antipsychotic side effects include Dystonia  Treatment- stop Risperidone if possible Try Anticholinergic medications

13. 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

14. 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)

15. 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

16. 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

17. Medical issues to address B efore 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

18. QUESTIONS?