Obsessional slowness in Down's syndrome

Treating Obsessive Compulsive Disorder in Adolescents and Adults with Down Syndrome: Results from a Scoping Rapid Review

PURPOSE

Adolescents and adults with Down syndrome are noted to display symptoms and behaviors consistent with a diagnosis of Obsessive Compulsive Disorder. While evidenced-based interventions, including psychopharmacology and therapeutic interventions including exposure and response prevention, exist and effectively treat obsessive-compulsive symptoms in neurotypical populations, less is known about effective treatments for similar presentations in persons with Down syndrome.

METHODS

A scoping rapid review was conducted in April 2023 to determine what treatments are being used to target obsessive-compulsive symptoms and related behaviors in adolescents and adults with Down syndrome, the quality of those treatments, and their alignment with current evidenced-based interventions.

RESULTS

A total of eleven articles, all single case or case series, published between 1992 and 2017 were identified describing the treatment of 32 adolescents and adults with Down syndrome and obsessive-compulsive traits and behaviors including: hoarding, cleaning, gross motor compulsions, and food, hygiene, dressing, and checking rituals. Interventions used most often aligned with evidenced-based guidelines for treating obsessive compulsive disorder and included psychopharmacology, psychotherapy, and complementary and alternative medicine.

CONCLUSIONS

While the outcomes of most interventions yielded partial or significant reduction in symptoms, poor research quality and limited generalizability noted across all studies make it difficult to inform guidelines for caring for this high-needs population. In the future, we believe it is necessary to perform more rigorous research focused on treating obsessive compulsive symptoms in individuals with Down syndrome with sufficient follow-up to fully assess treatment effectiveness.

Obsessional slowness in obsessive-compulsive disorder: identifying characteristics and comorbidities in a clinical sample

BACKGROUND

Obsessional slowness (OS) is characterised by debilitating motor slowness during initiation and completion of daily tasks such as washing, dressing, eating or walking. Yet, the clinical features of OS are still poorly understood.

METHODS

This study aimed to delineate demographics, comorbid disorders and obsessive-compulsive symptoms (OCS) associated with OS. Cross sectional data from 667 OCD outpatients aged 9-82 years (M = 37.86, SD = 12.78) who underwent comprehensive standardised assessments administered by trained clinicians were analysed. Participants with (n = 189) and without (n = 478) OS were compared and contrasted.

RESULTS

Logistic regression revealed that being single, having tics and displaying higher severity of aggression, contamination, symmetry and hoarding symptoms significantly predicted participants having OS.

CONCLUSIONS

This is the largest-scale descriptive study of OS, which also provides preliminary evidence that OS may be a more severe form of OCD. Further empirical validation of these findings is required, and future research should focus on developing OS assessment.Key PointsThis was the first large-scale descriptive study of obsessional slowness (OS), that provided preliminary evidence for an OS phenotype within obsessive-compulsive disorderOS is associated with increased severity of aggression, contamination, symmetry and hoarding obsessive-compulsive symptomsIndividuals with OS are more likely to have comorbid tics, suggesting that there may be underlying motor factors contributing to this conditionFuture research would benefit from collecting both qualitative and quantitative data when assessing OS.

Pharmacotherapy of Down syndrome

Introduction: Comorbid psychiatric disorders are common in Down syndrome (DS). Evidence for pharmacotherapy of psychiatric co-morbidity in DS is limited. Areas covered: This article reviews the literature on the pharmacotherapy of psychiatric conditions co-occurring with DS, including major depressive disorder (MDD), bipolar disorder, anxiety disorders, obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), psychosis, and catatonia. A section on the phenomenon of regression is included. Expert opinion: For MDD, we typically begin with selective serotonin reuptake inhibitors (SSRIs). For bipolar disorder, we often use carbamazepine. For psychotic symptoms, we begin with risperidone or aripiprazole. We use buspirone to treat anxiety. For obsessional slowness/OCD, we begin with an SSRI. For stereotypical repetitive behavior, we tend to use buspirone. For ADHD, we begin with guanfacine. For irritability of comorbid ASD, we use risperidone or aripiprazole. For dementia in DS, we refer to a neurologist for medical work-up and medication management. We treat catatonia-like 'regression' with lorazepam. If ineffective, we use memantine or clozapine. Electroconvulsive therapy is considered if pharmacotherapy is ineffective. We treat 'regression' with symptoms of MDD ± psychosis, with an antidepressant and an antipsychotic if needed. Randomized controlled trials of medications for comorbid psychiatric disorders in DS are warranted.

Increasing the number of inter-arch contacts improves mastication in adults with Down syndrome: a prospective controlled trial

Feeding difficulties due to their condition have been widely described for babies, children and adults with Down syndrome (DS). A previous study demonstrated that, compared with wearing a placebo appliance, wearing an occlusal appliance increased inter-arch dental contacts, improved the oral health status of adults with DS and normalised their mandibular rest position. This longitudinal prospective controlled trial aimed to evaluate whether increasing inter-arch contacts in adults with DS would lead to improved masticatory efficiency. Fourteen subjects with DS (mean age±SD: 28.5±9.3years) and twelve controls without DS (24.6±1.0years) were video recorded while chewing samples of carrot and peanuts with and without an oral appliance that was designed to equalise the number of posterior functional units (PFUs) in both groups. Three parameters were collected during mastication for 15cycles and until swallowing: food refusals, food bolus granulometry (D50) and kinematic parameters of the chewing process (number of cycles, chewing duration and cycle frequency within the chewing sequence). In the DS group, increasing the number of PFUs led to a decrease in bolus particle size, to fewer masticatory cycles needed to produce a bolus ready for swallowing and to a decrease in the occurrence of food refusal, while mean chewing frequency did not vary. In the control group, bolus granulometry and chewing time increased with appliance wear while mean chewing frequency decreased. These changes clearly indicate a functional improvement in subjects with DS. This study also demonstrated a causal relationship between the number of functional pairs of posterior teeth and improved mastication. Any evaluation of feeding behaviour in persons with DS should consider inter-arch dental contacts as an explicative variable for feeding problems and their nutritional and respiratory consequences.

Revisiting the Syndrome of "Obsessional Slowness"

Background

Obsessional slowness (OS) denotes a rare condition of disablingly slow motor performance. It was originally described in patients with obsessive-compulsive disorder as a "primary" condition; however, subsequent reports have included heterogeneous clinical populations. We wished to reassess patients with this diagnosis at our own institution and also revisit the literature to provide an overview of this condition.

Methods

Clinical documentation and videos of 3 patients diagnosed with OS in the National Hospital for Neurology and Neurosurgery (London, UK) were reviewed. One of the patients was clinically reappraised. A systematic review of published articles with sufficient clinical patient information was also conducted.

Results

Our 3 cases were male with symptom onset in adolescence or early adulthood. Motor slowness with poverty of movement and a history of obsessive-compulsive symptoms were characteristic. Poor speech production, bizarre postures, mannerisms, echophenomena, and oculogyric tics were also noted. Dopaminergic imaging was normal in 2 cases. One case had autistic features. Systematic literature review identified 77 further cases. Male preponderance with symptom onset mainly during the second decade and presence of obsessive-compulsive symptoms were noted. Additional motor and neuropsychiatric features were often present.

Conclusion

The existence of OS as a "primary" condition is doubtful. This diagnosis has been given to characterize different clinical presentations ranging from obsessive-compulsive disorder with motor slowness resulting from covert obsessive-compulsive symptoms to catatonia. Clinicians should be aware of this syndrome to separate it from juvenile parkinsonism and other causes of motor slowness given that diagnostic approaches and treatment strategies differ.

Psychiatric disorders in adolescents and young adults with Down syndrome and other intellectual disabilities

BACKGROUND

Relative to other aspects of Down syndrome, remarkably little is known about the psychiatric problems experienced by youth and young adults with this syndrome and if these problems differ from others with intellectual disabilities. Yet adolescence and young adulthood are particularly vulnerable time periods, as they involve multiple life transitions in educational, medical, and other service systems.

METHODS

This study compared the psychiatric diagnoses of 49 adolescent and young adult patients with Down syndrome to 70 patients with other intellectual disabilities (IDs). The groups were similar in age, gender, and level of intellectual impairment. The 119 participants, aged 13 to 29 years (M = 21) were evaluated in one of two specialized psychiatric clinics.

RESULTS

In contrast to previous literature, those with Down syndrome versus other IDs had significantly higher rates of psychosis NOS or depression with psychotic features (43% versus 13%). Unlike the ID group, psychosis was predominantly seen in females with Down syndrome. Marked motoric slowing in performing routine daily activities or in expressive language was manifested in 17% of patients with Down syndrome. No group differences were found in anxiety or depressive disorders, and the ID group had significantly higher rates of bipolar and impulse control disorders.

CONCLUSIONS

These preliminary observations warrant further studies on genetic, neurological, and psychosocial factors that place some young people with Down syndrome or other IDs at high risk for severe psychiatric illness.

Early onset obsessive compulsive disorder with obsessive slowness: a case report and demonstration of management

Obsessive slowness is a rare entity and is conceptualized either as primary psychiatric illness or as part of obsessive compulsive disorder (OCD). Often its outcome is frustrating even with treatment. We report a case of early onset severe OCD with obsessive slowness which showed good response to combined pharmacotherapy and behavioral therapy.

Cognitive deficits and associated neurological complications in individuals with Down's syndrome

Improvements in medical interventions for people with Down's syndrome have led to a substantial increase in their longevity. Diagnosis and treatment of neurological complications are important in maintaining optimal cognitive functioning. The cognitive phenotype in Down's syndrome is characterised by impairments in morphosyntax, verbal short-term memory, and explicit long-term memory. However, visuospatial short-term memory, associative learning, and implicit long-term memory functions are preserved. Seizures are associated with cognitive decline and seem to cause additional decline in cognitive functioning, particularly in people with Down's syndrome and comorbid disorders such as autism. Vision and hearing disorders as well as hypothyroidism can negatively impact cognitive functioning in people with Down's syndrome. Dementia that resembles Alzheimer's disease is common in adults with Down's syndrome. Early-onset dementia in adults with Down's syndrome does not seem to be associated with atherosclerotic complications.

The nature and treatment of compulsions, obsessions, and rituals in people with developmental disabilities

Developmental disabilities such as intellectual disability and autism are often accompanied by special sets of behaviors which are major challenges for the person and those in their community. Among the most worrisome of these are compulsions, rituals and obsessions. Often these behaviors are left untreated; however, when intervention does occur it is often with pharmacotherapy. There are psychological treatments for these issues as well but a concerted focus to develop these procedures, unlike efforts in differential diagnosis, has not occurred. Additionally, no reviews of how best to treat these problematic behaviors have been published to date. The present paper reviews what is available with respect to these treatment approaches with an eye to what appears to be effective, what has been treated and what is yet to be explored from a research point of view.

Psychiatric and behavioral disorders in persons with Down syndrome

Similar to the state of the broader intellectual disabilities field, many gaps exist in the research and treatment of mental health concerns in people with Down syndrome. This review summarizes key findings on the type and prevalence of behavior and emotional problems in children, adolescents, and adults with Down syndrome. Such findings include relatively low rates of severe problems in children, and well-documented risks of depression and Alzheimer's disease in older adults. The review also considers emerging data on autism, and the paucity of studies on adolescents. Three next steps for research are highlighted, including a need to: (1) connect research on psychiatric status and diagnoses across developmental periods, including adolescence, and to examine such associated processes as sociability, anxiety and attention; (2) unravel complicated biopsycho-social risk and protective factors that serve to increase or diminish psychopathology; and (3) identify evidence-based treatments that both reduce distressful symptoms and enhance well-being in individuals with Down syndrome.

Anxiety and panic responses to a predator in male and female Ts65Dn mice, a model for Down syndrome

Hyperactivity is a feature frequently reported in behavioral studies on the Ts65Dn (TS) mouse, the most widely accepted model of Down syndrome, when tested in anxiety-provoking situations such as the plus-maze and the open-field tests. Although this behavior could be considered as an expression of reduced anxiety, it has been considered as a consequence of a lack of behavioral inhibition and/or reduced attention. This study addressed anxiety and panic behavior of male and female TS mice by evaluating serum biochemical parameters and behavioral responses to a predator in the Mouse Defense Test Battery. Flight, risk assessment, defensive threat/attack and escape attempts were measured during and after rat confrontation. When confronted to a rat, male TS mice showed similar biochemical and behavioral responses as control mice. However, female control and TS mice presented lower serum adrenocorticotropic hormone (ACTH) levels under basal conditions and higher corticosterone levels after predator exposure than male mice. Thus, there was a larger increase in ACTH and corticosterone levels after predator exposure with respect to the undisturbed condition in females than in males. In addition, TS females showed some alterations in defensive behaviors after predator exposure. The results emphasize the need to consider gender as a confounding factor in the behavioral assessment of TS mice.