5/6 - Intellectual Disability

Question 1

How may mania present in ID?

Answer 1

NON-SPECIFIC BEHAVIOURS

• agitation
• physical + verbal aggression
• property destruction

MOOD

• irritability (angry, hostile)
• inappropriate laughing, singing, whistling etc.

BEHAVIOURAL

• hyperactivity
• increased communication (loud/rapid/incoherent speech + tangentiality)
• disinhibited behaviour (obscene gestures, expose self)
• “baseline exaggeration”: increased intensity/frequency of usual activities/traits
• “psychosocial masking” activities MAY not be viewed as goal-directed per say + grandiosity may be mundane (eg. dress up/behave like staff)

BIOLOGICAL

• lack of sleep
• weight loss
• increased appetite

*** may require fewer features/alteration of existing criteria

*** assume mania until proven otherwise (if throwing furniture)&raquo_space;> extreme aggression is always mania until proven otherwise

Question 2

How may depression present in ID?

Answer 2

NON-SPECIFIC BEHAVIOURS

• agitation
• physical + verbal aggression (not as much as in mania)
• self-injurious behaviours

MOOD

• irritability (angry, hostile) > most common than depressed mood
• tearfulness, sad, less smiling/laughing
• lack of enjoyment/interest
• anxious

BEHAVIOURAL

• social withdrawal
• refuse to participate in usual activities
• impaired functioning (reduced self-care)
• increase in specific problem-behaviours (self-injury, screaming etc.)
• diminished communication
• less confidence (more reassurance seeking or anxiety)
• loss of energy (fatigue)
• psychomotor agitation/retardation

BIOLOGICAL

• changes in sleep pattern
• changes in weight + appetite
• onset/increase in somatic sx
• reduced ability to concentrate/make decisions

LESS COMMON

• worthlessness/guilt
• thoughts of death/suicide
• anhedonia/loss of energy

Question 3

More generally, explain the differences in presentation of depression between general population and those with ID

Answer 3

• point-prev 4%, BUT likely under-recognised due to atypical presentations + communication impairments
• ID has pathoplastic effects on the presentation of MDD > some sx don’t present (eg. guilt) and others occur frequently even when uncommon in general population (eg. aggression, problem behaviours)
• behaviours often non-specific (could be illness, pain, life circumstances etc.) and may overshadow MDD
• MDD one of the most common mental health problems in adults with ID
• DSM/ICD not developmentally useful (eg. lack of verbal communication > cannot report recurrent suicidal ideation)
• use standard diagnostic criteria as a template, but require alteration
• a hierarchical approach to diagnosis is taken: 1. integral part of ID/cause of ID? 2. secondary to developmental dx, psych illness or PD

CHANGES TO THE TWO KEY SX:

• depressed mood may present as irritable mood (including aggression + reduced tolerance levels)
• loss of interest/pleasure may present as social withdrawal, reduced self-care, reduced speech/communication

Question 4

Why is psychosis difficult to identify in adults with ID?

Answer 4

DELUSIONS

• misunderstood fact may be mistaken for delusion
• fantasy may be mistaken for delusion

HALLUCINATIONS

• talking to self common (not psychotic)
• role-play conversations common (not psychotic)
• need to establish presence of actual auditory hallucinations to be certain of psychosis)

CATATONIA

• could be due to medical conditions (eg. encephalitis)
• maybe more common in people with ID(?)