Medical Management Considerations
Psychosis is a general term and symptoms of psychosis may occur in a variety of medical as well as psychiatric illnesses. Psychotic symptoms are the result of an impairment in the process of thinking in which a person has difficulty perceiving thoughts and things as they really are. The most important psychiatric disorder in which psychotic symptoms predominate is schizophrenia. This chronic condition often begins in late adolescence and early adulthood and is often accompanied by a significant decline in overall functioning. Great progress has been made in controlling the symptoms of schizophrenia but no cure is known. The onset of schizophrenia may be acute, but more typically develops insidiously over many months. The exact cause of schizophrenia is unknown but it is clearly a neurobiological disorder with a strong genetic basis. Positive symptoms of psychosis may include hallucinations (hearing, seeing, or feeling things that are not there), delusions (false or often bizarre beliefs), and disorders in the flow of thought (vague, loose, and difficult to follow thinking). Negative symptoms of psychosis, including depression, social withdrawal, lack of initiative, and absence of normal personality features, may also be important characteristics of other psychiatric disorders. The differential diagnosis of schizophrenia includes mood disorders and may be difficult, particularly during the first episode of psychosis. In all cases where a diagnosis of schizophrenia is being considered, referral to a psychiatrist for assessment and recommendations is indicated.
Schizophrenia occurs in approximately 1% of the world’s population and may be even more common in individuals with developmental disabilities. It is difficult to determine the exact prevalence in persons with mental retardation because much of the diagnostic criteria for schizophrenia requires verbal reports from the individual. In persons with moderate or more severe mental retardation a diagnosis of Psychosis, Not Otherwise Specified may be more appropriate. The peak ages of onset are in the early 20s for males and late 20s early 30s for females. Fortunately, onset in young children is rare.
DSM-IV criteria for schizophrenia require a 1-month period characterized by two or more of the following symptoms:
Only one of the five may be required if the delusions are bizarre or if voices carry on a running commentary or include two or more voices talking to each other. These symptoms must be accompanied by social/occupational dysfunction, and be associated with a period of disturbance of at least six months. Mood disorders with psychotic features must be ruled out as well as psychosis caused by medications or drugs of abuse or a medical condition. Episodes of psychosis of a shorter duration (less than six months) may meet criteria for a Brief Psychotic Disorder or a Schizophreniform Disorder.
Symptoms of psychosis in persons with developmental disabilities are similar in all age groups and similar to those seen in the general population. Diagnostic difficulties increase with the degree of mental retardation and it may be particularly difficult to assess disordered thinking in individuals with limited verbal abilities. [Return to the index for a full document on Mental Retardation.] Particular care must be made to distinguish true hallucinations from imaginary companions and delusions from child-like wishes or misperceptions based on poor cognitive understanding of the environment. In the former, a useful rule of thumb is whether the person is frightened, bothered, or confused by the “imaginary friends.” If so, one must be more concerned that they may represent true symptoms. Similarly, night terrors and other sleep related phenomena must not be confused with true psychosis. A diagnosis of psychosis in individuals with mental retardation should never be made quickly. Medical and neurological illnesses must be carefully ruled out (see below). Typically, multiple informants over an extended period of time are required to firmly establish the diagnosis. This is particularly true if one is attempting to distinguish schizophrenia from a mood disorder with psychotic features, e.g., bipolar disorder. Another important consideration is that people with developmental disabilities including autism are particularly vulnerable to stress and may transiently develop psychotic features that quickly resolve as the stress is removed. Similarly, individuals with developmentally disabilities are more likely to be the victims of trauma and abuse. They may develop symptoms of Post Traumatic Stress Disorder with dissociative features that may be confused with psychosis. [Return to the index for a full document on Post Traumatic Stress Disorder and Abuse.]
MEDICAL MANAGEMENT CONSIDERATIONS
In any individual presenting with an acute psychosis, after the initial history is obtained, the next step is a comprehensive medical and physical assessment. A neurological and physical examination should be performed. A variety of conditions need to be considered. These include:
Laboratory evaluation will depend on history and exam but generally would include:
If neurological findings suggesting a structural lesion are present, an MRI and EEG should be performed. Some experts recommend these studies for all first episodes of psychosis even if the neurological examination is unremarkable and particularly when psychosis appears in adolescents, a slightly younger age group than the peak age of 20.
A comprehensive mental health consultation and/or referral must be obtained.
Individuals with or without developmental disabilities with an acute psychosis or exacerbation of a chronic disorder may present with symptoms of agitation, confusion and/or aggression. Hospitalization may be required for safe management. Suicidal and homicidal thinking must be carefully assessed. Command hallucinations to harm oneself or others represent a major emergency and hospitalization is mandatory.
Treatment with anti-psychotic medications is central to the management of schizophrenia. There is some evidence that delay in treatment, once the diagnosis has been established, may worsen outcome. Medication treatment of an initial episode of schizophrenia should be under the care of an experienced psychiatrist. Long-term care may involve coordinated care with a primary care physician and a psychiatric consultant.
Anti-psychotic drugs used to treat schizophrenia and related psychoses are described (somewhat inaccurately) as “typical” or “atypical”. The “typical” anti-psychotics are traditional drugs primarily interacting with the dopamine system. The newer “atypical” anti-psychotics have a broader range of action, affecting other receptor systems including serotonin.
Examples of traditional anti-psychotic medications include:
Examples of newer “atypical” anti-psychotics include:
Choice of an anti-psychotic medication depends primarily on somewhat different side-effect profiles. Although it is still imperative to check for tardive diskinesia, in general, the “atypicals” are now first choices and are somewhat better tolerated by most patients. Clozapine is a special case in that it has demonstrated effectiveness in treatment resistant schizophrenia but also has a significant side-effect profile including agranulocytosis, requiring special monitoring. Clozapine is therefore utilized only when other medications have proven ineffective.
The prescribing physician must be well informed about the side effects of the anti-psychotics and important drug interactions and is referred to a number of sources (e.g., Shiloh, et al.). Particular considerations when treating individuals with developmental disabilities include the following:
All of these considerations require careful client and caregiver consent and education.
Schizophrenia is a chronic and lifelong illness and when it occurs in an individual with a lifelong disability the challenges are indeed daunting. Other critical aspects of treatment include:
ORAL HEALTH CONSIDERATIONS
A thorough knowledge of the dental implications of schizophrenia and other psychoses will aid a primary care provider and dental practitioner in preventing dental problems and providing the most appropriate treatment. In particular, care should be taken to prevent adverse drug interactions between the medications addressing the psychosis and the medications used during dental treatment. Treatment options and limitations, as well as daily measures to take to prevent dental problems and maintain oral health, should be clearly explained to persons with developmental disabilities and their families/caregivers. Dental caries is an infectious and transmissible disease. Every person should be referred to an oral health professional for evaluation and have an oral health care plan by age 1 to prevent early childhood caries and later periodontal disease.
Managing the preventive, restorative, and surgical aspects of dental treatment involve an early (by age 1) and regular oral health evaluation and caries risk assessment, as well as the establishment of a customized oral health care plan.
The patient may or may not be able to provide consent for the dental treatment. Practitioners should approach patients with paranoid schizophrenia in a nonthreatening manner, avoid sudden movements, and prepare patients on what to expect during the treatment.
[Return to the index for a full document on Dental Care]
American Academy of Child and Adolescent Psychiatry (1999), Your Adolescent: Emotional, Behavioral, and Cognitive Development from Early Adolescence through the Teen Years; Pruitt DB, ed. New York: Harper Collins
American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington DC: American Psychiatric Association
American Psychiatric Association (1997) Practice Guidelines for the Treatment of Patients with Schizophrenia, American Journal of Psychiatry 154(S4): 1-63
Borus N, ed (1999) Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental Retardation. Cambridge: Cambridge University Press
Campbell M, Rapoport JL, Simpson GM (1999), Antipsychotics in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38(5): 537-545
Cherry KE, Peen, D, Matson, JL, Bamburg, JW (2000), Characteristics of schizophrenia among persons with severe or profound mental retardation. Brief Reports 51(7): 922-924
Clark DJ (2001), Treatment of schizophrenia. In: Treating Mental Illness and Behavior Disorders in Children and Adults with Mental Retardation; Dosen A, Day K, Eds, Washington DC: American Psychiatric Press, pp 183-200
Dosen A, Day Kenneth, eds (2001) Treating Mental Illness and Behavior Disorders in Children and Adults with Mental Retardation. Washington: American Psychiatric Press
Duggan L, Brylewski J (1999), Effectiveness of antipsychotic medication in people with intellectual disability and schizophrenia: a systematic review. Journal of Intellectual Disability 43 (Part 2): 94-104
Dykens EM (2000), Psychopathology in children with intellectual disabilities. Journal of Child Psychology and Psychiatry 41: 407-417
Madrid AL, State MW (2000), Pharmacologic management of psychiatric and behavioral symptoms in mental retardation. Child and Adolescent Psychiatric Clinics of North America 9: 225-243
McClellan J, Werry J (2001), Practice parameters for the assessment and treatment of children and adolescents with Schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry 40(S7): 4S-23S.
Reiss S, Aman MG, eds (1998), Psychotropic Medications and Developmental Disabilities: The International Consensus Handbook. Columbus: Ohio State University Press
Rush J, Frances A, eds (2000) Expert Consensus Guideline Series: Treatment of psychiatric and behavioral problems in mental retardation. American Journal of Mental Retardation: 105(3):159-226.
Southern Association of Institutional Dentists (2001), “Module 9: Clinical Concerns in Dental Care for Persons with Mental Illness.” Modules. Accessed April 22, 2003 at http://saiddent.org/modules/17_module9.pdf
Szymanski L, King BH (1999), Practice parameters for the assessment and treatment of children, adolescents, and adults with mental retardation and comorbid mental disorders. Journal of the American Academy of Child and Adolescent Psychiatry 38(S12): 5S-31S.
Szymanski L, King BH, Goldberg B, et al., (1998), Diagnosis of mental disorders in people with mental retardation. In: Psychotropic Medications and Developmental Disabilities: The International Consensus Handbook; Reiss S, Aman MG, eds. Columbus: Ohio State University Press, pp. 3-17.
University of Florida, College of Dentistry, Department of Pediatric Dentistry (2001), “Schizophrenia.” Oral Health Care for Persons with Disabilities. Accessed April 22, 2003 at http://www.dental.ufl.edu/Faculty/Pburtner/disabilities/mnschizo.htm
Van Bellinghen M, De Troch C (2001), Risperidone in the treatment of behavioral disturbances in children and adolescent with borderline intellectual functioning: a double-blind, placebo-controlled pilot trial. Journal of Child and Adolescent Psychopharmacology 11(1): 5-13
Volkmar FR, Dykens E (2002), Mental Retardation. In: Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Ed.; Lewis M, ed., Philadelphia: Lippincott Williams & Wilkins, pp. 603-611
RESOURCES FOR FAMILIES
American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Avenue, N.W.
Washington, D.C. 20016-3007
American Dental Association
Tips for People Who Have Special Needs
American Psychiatric Association
1400 K Street N.W.
Washington, DC 20005
The Arc (formally Association for Retarded Citizens)
500 East Border Street, Suite 300
Arlington, Texas 76010
Association of University Centers on Disabilities
8630 Fenton Street, Suite 410
Silver Spring, MD 20910-3803
California Alliance for the Mentally Ill
1111 Howe Avenue, Suite 475
Sacramento, CA 95825-8541
California Mental Health and Developmental Disabilities Center
California Regional Centers
The National Association for the Dually Diagnosed
132 Fair Street
Kingston, NY 12401
National Mental Health Association Information Center
2001 North Beauregard Street, 12th floor
Alexandria, VA 22311
National Oral Health Information Clearinghouse
Oral Conditions in Children with Special Needs
A Guide for Health Care Providers
Project MED (Medical Education for Consumers)
Southern Association of Institutional Dentists
Special Olympics Special Smiles
A Guide to Good Oral Health for Persons with Special Needs http://www.specialsmiles.org/booklet.htm
The Tarjan Center for Developmental Disabilities at UCLA
University of Florida
College of Dentistry
Department of Pediatric Dentistry
Oral Health Care for Persons with Disabilities
University of the Pacific
School of Dentistry
Center for Oral Health for People with Special Needs
or http://www.dental.uop.edu , Community Programs
Theodore A. Kastner, M.D., M.S.
Paul Glassman, D.D.S., M.A., M.B.A.
Donald M. Hilty, M.D.
Leonard Magnani, M.D., Ph.D.
Christine Miller, R.D.H., M.H.S., M.A.
Mary B. Tierney, M.D.
Terrance D. Wardinsky, M.D.
Primary authors: Andrew Russell, M.D. and Bhavik Shah, 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.