A variety of anxiety disorders can occur in people with mental retardation, including Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, phobias and Obsessive Compulsive Disorder (OCD). The identification of anxiety disorder in people with developmental disabilities can be elusive if the approach is purely probing for anxiety symptoms with the patient. In people with communication difficulties and difficulty with verbally expressing emotional states the diagnosis must be postulated from observations made by primary caretakers. For example caretakers may describe social avoidance, withdrawal, escalation of behaviors in new settings, increase in reparative actions or stereotypes, persistence on sameness in environment, and signs of autonomic arousal. Some genetic syndromes include a behavioral phenotype consistent with an anxiety disorders (e.g., Prader Willi syndrome and OCD ; Fragile X and anxiety/social withdrawal). The prevalence of anxiety disorders has been estimated at 10 – 25% in persons with mental retardation and is thought to be equally prevalent in males and females.
Condensed Diagnostic and Statistical Manual of Mental Disorders Ed. IV (DSM-IV) Criteria
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
Compulsions as defined by (1) and (2):
Given the range of anxiety disorders that can occur in people with mental retardation, a careful assessment for these disorders must be attempted. Factors which can impact the expression of an anxiety disorder include comorbid mood disorder, association with a genetic syndrome and its behavioral phenotype, medication induced and psychosocial stress factors (e.g., loss of caregiver, changes in living situation). The work-up should also rule out any other causes, such as hyperthyroidism, that can masquerade as mental illness. The evaluation for anxiety disorders should include interview with family/caregivers/educational or vocational staff, direct observation of behavior and impact on ability to function, functional behavioral assessment, medication and side effects evaluation, medical history/physical exam, and an assessment of communication skills. The physician or other primary care provider must determine developmental age, as it is well known that behavior is developmental. What is “normal” for a two-year old could be problematic for a ten-year-old child. If this is not taken into consideration, one can make an inaccurate diagnosis.
The treatment needs to involve psychosocial treatment preferably by a multidisciplinary team. The team will need to assess functional analysis of behavior, support services of caregivers, environmental modifications, cognitive-behavioral therapy, client and/or caregiver education, and consider psychopharmacological interventions. In some situations heightened levels of anxiety associated with anxiety disorders can present with severe self-injurious behaviors or aggression. Therefore, assessing safety of the person or others must be the first consideration. If safety cannot be adequately secured in their current setting, acute treatment modalities need to be considered such as hospitalization or 1:1 staffing.
Medications can be an important component of the treatment of anxiety disorders, some examples are listed below:
Aman, M.G., Collier-Crespin, A., Lindsay, R.L. (2000). Pharmacotherapy of Disorders in Mental Retardation. European Child and Adolescent Psychiatry 9, Supplement 1:I, 98-107.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association
Jellinek, M., Patel, B.P., Froehle, M.C. (2002). (Eds.) Bright Futures in Practice: Mental Health (vols. I & II). Arlington, VA: National Center for Education in Maternal and Child Health.
Kaplan, H.I., Sadock, B.J. (1995). (Eds.) Comprehensive Textbook of Psychiatry/VI, Volume 2, 6th edition. Baltimore: Williams & Wilkins.
Linna, S.L., Moilanen, I., Ebeling, H., Piha, J., Kumpulainen, K., Tamminen, T., Almqvist, F. (1999). Psychiatric Symptoms in Children with ntellectual Disability. European Child & Adolescent Psychiatry, 8, Supplement 4, IV/77-IV82.
Masi. G., Brovedani, P., Mucci, M., Favilla, L. (2002). Assessment of Anxiety and Depression in Adolescents with Mental Retardation. Child Psychiatry and Human Development, 32(3), 227-237.
Masi, G., Favilla, L., Mucci, M. (2000). Generalized Anxiety Disorder in Adolescents and Young Adults with Mild Mental Retardation. Psychiatry, 63(1), 54-64.
Rush AJ, Frances A (2000) (Eds), Treatment of psychiatric and behavioral problems in mental retardation. American Journal of Mental Retardation 105:3, 1-71
Szymanski, L., King, B.H. (1999). Practice Parameters for the Assessment & Treatment of Children, Adolescents, & Adults with Mental Retardation and Comorbid Mental Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), supplement, 5S-31S.
American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue N.W.
Washington, D.C. 20016-3007
The Arc (formally Association for Retarded Citizens)
500 East Border Street, Suite 300
Arlington, Texas 76010
California Department of Developmental Services
P.O. Box 944202
Sacramento, CA 94244-2020
California Regional Centers 915-654-1958,
California Alliance for the Mentally Ill
1111 Howe Avenue, Suite 475
Sacramento, CA 95825-8541
National Mental Health Association Information Center
2001 North Beauregard Street, 12th floor
Alexandria, VA 22311
Association of University Centers on Disabilities
8630 Fenton Street, Suite 410
Silver Spring, MD 20910-3803
The National Association for the Dually Diagnosed
132 Fair Street
Kingston, NY 12401
Project MED (Medical Education for Consumers)
The Tarjan Center for Developmental Disabilities at UCLA
California Mental Health and Developmental Disabilities Center
American Psychiatric Association
1400 K Street N.W.
Washington, DC 20005
Theodore A. Kastner, M.D., M.S.
Leonard Magnani, M.D., Ph.D.
Felice Weber Parisi, M.D., M.P.H.
Terrance D. Wardinsky, M.D.
Funded by a grant from the California Department of Developmental Services
For more information, contact:
Center for Health Improvement
1330 21st Street, Suite 100
Sacramento, CA 95814
This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.