Psychiatric Disorders

Psychiatric disorders are estimated to afflict up to 50 percent of the developmentally disabled population. Although mood disorders, particularly depression, are most frequent, they are relatively unlikely to precipitate ED evaluations. Instead, emergency visits are usually precipitated by aggression or extreme agitation. In such cases, benzodiazepines or low-dose, low-potency antipsychotics, such as chlorpromazine, may be acutely helpful in controlling the patient's behavior sufficiently to proceed with an evaluation. However, it is essential to try to identify the underlying etiology of these behaviors and changes in their frequency or intensity. Undiagnosed, painful medical problems, including severe constipation, often lead to exacerbation. 16 Sleep apnea can also be manifest as increased irritability. In addition, anxiety may be manifest primarily as agitation. Often environmental factors can be identified that are increasing the patient's anxiety. Such factors may include changes in caretakers or recent onset of sensory deficits that have not yet been corrected. Sometimes the anxiety is the result of posttraumatic stress disorder. At other times, it may occur in the context of "panic attacks," which are manifested atypically due to language limitations. Akathisia, a dose-related side-effect syndrome caused by both typical and atypical antipsychotics, is manifest as agitation and hyperactivity. It should be considered anytime there is a history of worsening agitation with increased antipsychotic medications. Similarly, large doses of some of the newer anticonvulsants (e.g., gabapentin and lamotrigine) have been associated with agitation. Rarely, the agitation may occur in response to psychotic symptoms such as hallucinations or paranoid delusions.

If the patient appears to be psychotic, it is important to distinguish between true responses to internal stimuli, motor and verbal tics, and self-stimulating behaviors characteristic of autism. Catatonic behavior may reflect delirium, depression, or status epilepticus with absence or partial-complex seizures. Psychosis is probably the most common misdiagnosis in this population. Mood disorders typically present with changes in the patient's sleep, appetite, and activity level. Treatment with antidepressants is indicated and effective. Appropriate treatment for any underlying medical or psychiatric disorder should be undertaken. Remember that developmentally disabled individuals often require smaller doses of psychotropic medications and may be more sensitive to adverse effects.

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