Management of psychotic and mood disorders in intellectual disability: A case series.

People with intellectual disability (ID) have a greater frequency of psychiatric illnesses, ranging from 10% to 80%, as compared to the general population. It has been proven that mood stabilizers are beneficial in the management of behavior issues in people with ID. Here, we report a series of five cases with mild and moderate ID with behavioral disturbances including mood and psychotic symptoms managed successfully with sodium valproate as the part of the treatment. Copyright:

Compared with the general population, people with intellectual disability (ID) have a higher prevalence of psychiatry disorders, ranging from 10% to 80%.[1] People with ID are more likely to develop behavioral issues, which might include aggressiveness toward people or property, self-injurious behavior (SIB), extreme stereotyped behavior, hyperactivity, and severe tantrums, to name a few. Behavioral issues can occur in the absence of a diagnosable illness, but they can also be symptomatic symptoms of a mental or physical condition. When a person's behavior issue is serious enough to put themselves or others in danger or threaten their ability to function in society, medication may be administered to help them manage their behavior.[2] We present a series of five cases of ID associated with behavioral problems who were successfully managed with psychiatric treatment [Table 1].

Table 1

Characteristics of the patients with intellectual disability and comorbid disorders

	Age (years)	Sex	Occupation	Grade of intellectual disability	Psychiatric manifestation	Co-morbidities
1	16	Male	Student	Moderate ID	Bipolar disorder current episode mania with psychotic symptoms	-
2	28	Female	Homemaker	Moderate ID	Mixed anxiety and depression	Hypothyroidism
3	25	Male	Welder	Moderate ID	Paranoid schizophrenia	-
4	28	Male	Attendant	Mild ID	Paranoid Schizophrenia	Type 2 diabetes mellitus
5	29	Male	Laborer	Mild ID	Paranoid Schizophrenia	-

ID: Intellectual disability

CASE REPORTS

Case 1

A 16-year-old male, educated till 9th class, brought to the OPD with mother and class teacher, presented with irritability, aggressive behavior, over-talkativeness, big talks, over-religiosity, having superpowers of God, and hearing his voices for 6 months. His mother also reported muttering to self, gesturing to self, and smiling to self. This started 6 months back with the death of his father. The patient could not cope up with the loss and developed low mood, crying spells, and became irritable and aggressive after a month. He used to abuse his sisters, throw things such as mobile, remote, and use to tear off his clothes. At that time, he also started visiting holy places more with his uncle and worship God and Goddesses and hearing voices of God telling him he is “Son of Parmeshwar” and his superpowers. His teacher also reported decline in his scholastic performance. On mental status examination (MSE), delusions of grandiose identity with 2nd person auditory hallucinations were present. He was diagnosed with bipolar disorder, the current episode mania with psychotic symptoms with moderate ID, with an intelligent quotient (IQ) score of 49. He responded satisfactorily to the treatment with tablet olanzapine 20 mg and tablet sodium valproate 500 mg along with supportive psychotherapy.

Case 2

A 28-year-old female, educated till 7th class, married and divorced 4 years back, brought to OPD by her sister, presented with apprehension, low mood, crying spells, worrying thoughts for 3 months. It started when her father expired 3 months back due to cardiac arrest. She could not bear the stress of her father loss and started developing low mood, crying spells. She also developed apprehension with palpitation at times of overthinking. According to her husband, they were not aware of her condition of problem in concentration and understanding before marriage, so they broke the marriage within a month. On examination, she has a swelling in the anterior portion of her neck. IQ was 46. TSH value was raised, 81 IUi/ml. Ultrasonography neck showed subacute thyroiditis. She was diagnosed with mixed anxiety and depression with moderate ID with hypothyroidism. She was treated with tablet sodium valproate 300 mg B.D., escitalopram 10 mg H.S, and tablet thyroxine 50 mcg.

Case 3

A 25-year-old male, educated till 10th class, working as a welder, presented with irritability, muttering, and gesturing to self, suspiciousness toward neighbor that they will harm him for 10 years. He used to have irrelevant talks and use to talk to self only, making some gestures. His sleep and appetite are also decreased. On MSE, delusion of persecution, with 2nd and 3rd person auditory hallucinations were present. IQ was 46. He was diagnosed with paranoid schizophrenia with moderate ID with Type 2 diabetes. He was treated on these medications: tablet trifluoperazine 10 mg BD, tablet trihexyphenidyl 2 mg B.D, tablet sodium valproate 500 mg BD, and tablet metformin 500 mg b.d and eventually on injection haloperidol 50 mg L.A given monthly. He showed significant improvement and was continued on these medications.

Case 4

A 28-year-old male, educated till 10th class, working as an attendant in D. Y. Patil Medical College, Pune, presented with irritable behavior, muttering to self, and hearing unreal voices of songs for 12 years. He was apparently alright 12 years back when he started developing irritable behavior, used to talk to himself, and used to make gestures. He complains that he hears whatever songs he used to listen to even when no one is around and no songs are playing. His sleep and appetite are also disturbed. On MSE, delusion of reference, with 2nd person auditory hallucinations were present. IQ was 54. He was diagnosed with mild ID with Paranoid Schizophrenia. He was started on tablet olanzapine 10 mg and tablet sodium valproate 1000 mg with good response.

Case 5

A 29-year-old male educated till 8th standard, working as a daily wage laborer was brought to the psychiatric OPD by his mother with the complaints of irritability, aggressive and abusive behavior, demanding behavior, and reduced sleep for about 4 months with a past history of hearing of unreal voices without stimulus and on irregular in medications. On MSE, the patient had a delusion of reference and worrying thoughts. IQ score was 61. With a diagnosis of mild ID with Paranoid Schizophrenia, he has treated with tablet olanzapine 10 mg and tablet sodium valproate of 1000 mg along with regular counseling.

DISCUSSION

People with ID are vulnerable to psychiatric manifestations because of their limited cognitive abilities. Most of the patients need assistance to obtain benefit from health services. When people with ID have additional psychiatric disorders, they become even more dependent on others and may require urgent mental health services. Treating coexisting psychiatric disorders may affect rehabilitation intervention in people suffering with ID. Thus, it is especially important to accurately diagnose any coexisting psychiatric or physical disorders so that the appropriate services can be provided.[3] Comorbidities such as hypothyroidism, diabetes, and cardiovascular manifestations are commonly present in children with ID. Males and females with ID had 1.6–3.4-fold greater age-adjusted chances of having a recorded diagnosis of obesity or diabetes mellitus than the general population. Individuals with IDs require diabetes and blood pressure screening, as well as measures to prevent obesity from developing in childhood. Adapted community-based health promotion programs are needed to guarantee more equitable health for these populations.[4] Individuals with mild intellectual impairment or borderline intellectual functioning are most commonly referred to specialist treatment programs for problems with rage and aggression.[5] In many situations, such difficulties have a high level of comorbidity with mental health issues (e.g., substance addiction, trauma, and personality disorders) and social circumstances (e.g., financial and interpersonal problems).[6] As we see in all the above cases with the chief complaints of behavioral disturbance and mild and moderate ID, these cases also need psychotropic drugs which was a common factor.[2]

The prevalence of violent or SIB among persons with ID ranges between 9% and 15%. Impulse control problems with recurring, episodic, and/or explosive symptoms are frequently misdiagnosed as seizures, which can also be treated with valproate.[7] These five patients responded very well to sodium valproate. A systematic review was conducted to determine the evidence base for the effectiveness of mood stabilizers in the management of behavior problems in adults with ID. The findings support the use of lithium and some antiepileptic mood stabilizer medications for the management of behavior problems in adults with ID.[2] Antipsychotics, notably risperidone, appear to help children with intellectual disabilities reduce troublesome behaviors. Lithium has the potential to reduce aggressiveness. Antiepileptic medications, anxiolytics, and naltrexone have minimal evidence to support their use in the treatment of problem behaviors.[8] Similarly, the problem behaviors were very well controlled on adding sodium valproate in their treatment with a regular follow-up seen in these patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.