The motor disorders of mental handicap. An overlap with the motor disorders of severe psychiatric illness

Psychiatric illness and learning disability: a dual diagnosis

The prevalence of moderate to profound learning disability is roughly 3 per 1000 and of mild learning disability about 3 per hundred (Abramowicz & Richardson, 1975). There are estimated to be more than 120 million people with learning disability worldwide.

Motor Abnormalities: From Neurodevelopmental to Neurodegenerative Through "Functional" (Neuro)Psychiatric Disorders

Background

Motor abnormalities (MAs) of severe mental disorders have been traditionally neglected both in clinical practice and research, although they are an increasing focus of attention because of their clinical and neurobiological relevance. For historical reasons, most of the literature on MAs has been focused to a great extent on schizophrenia, and as a consequence their prevalence and featural properties in other psychiatric or neuropsychiatric disorders are poorly known. In this article, we evaluated the extent to which catatonic, extrapyramidal and neurological soft signs, and their associated clinical features, are present transdiagnostically.

Methods

We examined motor-related features in neurodevelopmental (schizophrenia, obsessive compulsive disorder, autism spectrum disorders), "functional" (nonschizophrenic nonaffective psychoses, mood disorders) and neurodegenerative (Alzheimer's disease) disorders. Examination of the literature revealed that there have been very few comparisons of motor-related features across diagnoses and we had to rely mainly in disorder-specific studies to compare it transdiagnostically.

Results

One or more motor domains had a substantial prevalence in all the diagnoses examined. In "functional" disorders, MAs, and particularly catatonic signs, appear to be markers of episode severity; in chronic disorders, although with different degree of strength or evidence, all motor domains are indicators of both disorder severity and poor outcome; lastly, in Alzheimer's disease they are also indicators of disorder progression.

Conclusions

MAs appear to represent a true transdiagnostic domain putatively sharing neurobiological mechanisms of neurodevelopmental, functional or neurodegenerative origin.

Movement side effects of antipsychotic drugs in adults with and without intellectual disability: UK population-based cohort study

OBJECTIVES

To measure the incidence of movement side effects of antipsychotic drugs in adults with intellectual disability and compare rates with adults without intellectual disability.

DESIGN

Cohort study using data from The Health Improvement Network.

SETTING

UK primary care.

PARTICIPANTS

Adults with intellectual disability prescribed antipsychotic drugs matched to a control group of adults without intellectual disability prescribed antipsychotic drugs.

OUTCOME MEASURES

New records of movement side effect including acute dystonias, akathisia, parkinsonism, tardive dyskinaesia and neuroleptic malignant syndrome.

RESULTS

9013 adults with intellectual disability and a control cohort of 34 242 adults without intellectual disability together contributed 148 709 person-years data. The overall incidence of recorded movement side effects was 275 per 10 000 person-years (95% CI 256 to 296) in the intellectual disability group and 248 per 10 000 person-years (95% CI 237 to 260) in the control group. The incidence of any recorded movement side effect was significantly greater in people with intellectual disability compared with those without (incidence rate ratio 1.30, 95% CI 1.18 to 1.42, p<0.001, after adjustment for potential confounders), with parkinsonism and akathisia showing the greatest difference between the groups. Neuroleptic malignant syndrome, although occurring infrequently, was three times more common in people with intellectual disability-prescribed antipsychotic drugs (incidence rate ratio 3.03, 95% CI 1.26 to 7.30, p=0.013). Differences in rates of movement side effects between the groups were not due to differences in the proportions prescribed first and second-generation antipsychotic drugs.

CONCLUSIONS

This study provides evidence to substantiate the long-held assumption that people with intellectual disability are more susceptible to movement side effects of antipsychotic drugs. Assessment for movement side effects should be integral to antipsychotic drug monitoring in people with intellectual disability. Regular medication review is essential to ensure optimal prescribing in this group.

Movement Disorders in Adults With Intellectual Disability and Behavioral Problems Associated With Use of Antipsychotics

BACKGROUND

Antipsychotic drugs are prescribed to approximately 30% to 40% of adults with intellectual disability (ID) and behavioral problems despite lack of evidence of effectiveness and potential adverse effects, including movement disorders.

AIMS

The aim of this study was to examine the prevalence of movement disorders (dyskinesia, akathisia, dystonia, and parkinsonism) in in-patient adults with mild to borderline ID and behavioral problems associated with use of antipsychotics.

METHODS

Prevalence of movement disorders was measured with a standardized protocol. The strength of the association between antipsychotic drug use and movement disorders was assessed using logistic regression analysis.

RESULTS

Almost half (44.0%) of 134 in-patient adults with ID and behavioral problems had any movement disorder. Parkinsonism, dyskinesia, akathisia, and dystonia were present in, respectively, 36.6%, 11.2%, 9.0%, and 0.7% of patients with ID. It appeared that current use of any antipsychotic drug (odds ratio, 3.0; 95% confidence interval, 1.0-8.4) and a dose in target range (odds ratio, 5.5; 95% confidence interval, 1.5-20.4) were significantly associated with the risk of having movement disorders.

CONCLUSIONS

The prevalence of movement disorders in people with ID and behavioral problems is high, especially in ID patients using antipsychotics. More attention is needed for these movement disorders and their potential impact.

Diagnostic Assessment of Movement Disorders and Psychomotor Deficiency in Residual Schizophrenia

Movement disorders and motor deficiency is highly represented among patients in Schizophrenia – residual type (DSM IV):  37% of patients examined in our research had psycho‑motor disturbances. Dominant disturbances are the following: disturbed tonus among 65% of patients, abnormal postural reactions among 90%, abnormal voluntary movements among 75%, disturbed speech among 85%, disturbed static and dynamic postures among 90%. Involuntary movements are present among 20% of patients.Classic neurological diagnostics offers general assessment of the motor status. Standardized clinical motor scales only register the presence and intensity of the motor disturbance. Rehabilitation treatment requires individual and up to date functional diagnostics of the motor deficiency.We would like to stress that psychiatric patients in psychotic, (prepsychotic) and postpsychotic states, besides being mentally ill, also suffer from serious movement disorders  (psychomotor disturbances and deficits) which put them into the category of  disabled persons, who besides requiring psychiatric (neuropsychiatric) treatment, also require systematic psychomotor and speech  rehabilitation.

Physical mobility limitations in adults with intellectual disabilities: a systematic review

BACKGROUND

Mobility limitations increase with age in the general population. Despite a growing population of older adults with intellectual disabilities (ID), mobility is rarely studied in the ID literature. The specific aim of this study was to identify and summarise primary literature investigating mobility limitations in adults with ID.

METHODS

This study was a systematic review of the epidemiological literature (incidence and prevalence) of mobility limitations among adults with ID. Four electronic databases were searched from January 1980 to May 2007 for publications according to predefined inclusion/exclusion criteria. Additional sources were consulted. Two reviewers extracted data from each of the included articles.

RESULTS

Thirty-two publications representing 31 studies were ultimately included. In general, studies did not focus on mobility but were conducted for other purposes. All studies were conducted in industrialised countries. Only one study used a longitudinal design; the remainders were cross-sectional. Few investigators reported on the representativeness of the sample or the validity of the measurement tool. Study samples differed substantially and investigators used numerous definitions of mobility limiting comparability between studies.

CONCLUSIONS

There is a need for increased research on mobility limitations among adults with ID, particularly longitudinal research. Researchers investigating mobility limitations should use validated measurement tools and offer detailed descriptions of the study sample and how it compares with an identifiable population.

Aripiprazole use in individuals with intellectual disability and psychotic or behavioural disorders: a case series

People with intellectual disabilities may be at greater risk of developing movement disorders as a consequence of their underlying neurological damage, especially when they are treated with typical antipsychotic agents. Aripiprazole is a novel antipsychotic quinolone derivative that has been approved for the treatment of schizophrenia in adults. However, there are few reports on the use of aripiprazole in people with intellectual disabilities. Herein, we report on the use of aripiprazole in five individuals with intellectual disabilities and psychotic illness (four cases) or challenging behaviour (one case). Four of the five patients had an additional diagnosis of schizophrenia and one had autism spectrum disorder and challenging behaviour. Issues related to the usefulness of aripiprazole in the management of schizophrenia and challenging behaviour in people with intellectual disabilities are also discussed. Aripiprazole was well tolerated and effective in each of the cases and appears to be a safe and efficacious alternative in the management of patients with both intellectual disabilities and schizophrenia. It can also be a useful treatment option in the management of challenging behaviour, especially when it is used as a part of a biopsychosocial approach.

The Importance of Catatonia and Stereotypies in Autistic Spectrum Disorders

Motor disturbances are often observed in individuals with autistic spectrum disorders (ASDs) and recognized as diagnostic features of these disorders. The movement disorders characteristically associated with autism include stereotypies and self-injurious behavior. Yet, individuals with ASD may also be at the risk for catatonia. Although not as frequent as stereotypies, up to 17% of older adolescents and adults with autistic disorder may have severe catatonic-like symptoms. Catatonia may be a comorbid risk factor of autism that warrants further empirical and clinical evaluations. Clinicians may need to be attentive to more subtle signs of catatonic-like symptoms in individuals diagnosed with ASDs, especially as they enter adolescence and young adulthood. Stress has been implicated as a possible precursor for symptoms; however, its role has not been empirically proven as a potential risk factor. Clinicians might also need to assess for signs of significant declines in motor movements, as this appears to be a useful diagnostic indicator of catatonic-like symptoms. The literature on stereotypies and autism is more extensive than for catatonia and ASDs, probably because of the higher rate of stereotypies with autism. Explanations for the occurrence of stereotypies range from genetic to behavioral contingencies, with evidence for a multifactor explanation. Assessment measures often include items that assess for stereotypies to aid with diagnosing these symptoms in individuals with autism. Treatment for stereotypies is largely behavioral at the present time and requires consistent reinforcement of treatment gains to manage the symptoms successfully. An important area of future research in autism is the relation among different types of motor abnormalities, including stereotypies and catatonia.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia'): I. Demographic and clinical correlates in the chronic phase

This study set out to determine the frequency of catatonic syndrome in chronic schizophrenia and its association with sociodemographic, clinical, and treatment variables. A cross-sectional assessment of a randomly selected cohort of patients (n=225; mean age=42+/-7 years; mean length of illness=20.4+/-7.5 years) with DSM-IV schizophrenia was employed using standard rating instruments for catatonia, drug-induced extrapyramidal symptoms (EPS), and psychotic, depressive, and obsessive-compulsive symptoms. Using a rather narrow definition of catatonia [the presence of four or more signs/symptoms with at least one having a score '2' or above on the Bush-Francis Catatonia Rating Scale (BFCRS)], 72 subjects (32%) met the criteria for the catatonia group (mean number of catatonic signs/symptoms=5.9+/-2.0; mean sum score of 8.7+/-3.4 on the BFCRS). The frequency distribution of catatonic signs/symptoms in the catatonic group and in the whole sample was very similar, with mannerisms, grimacing, stereotypes, posturing, and mutism being the most frequent. In the logistic regression analysis, catatonic subjects had a significantly earlier age of onset, more negative symptoms, and were more likely to receive benzodiazepines than their noncatatonic counterparts. In multiple regression analysis, the severity of catatonia as indicated by the sum score of BFCRS was predicted only by earlier age of onset and negative symptoms. Using relatively narrow criteria, this study confirmed that, if methodically assessed, catatonic signs and symptoms are prevalent in patients with chronic schizophrenia. Catatonia can be differentiated from EPS. Catatonic features indicate a generally poor prognosis in the chronic phase of schizophrenia.

Antipsychotic medication versus placebo for people with both schizophrenia and learning disability

BACKGROUND

Antipsychotic medication is the standard treatment for people with learning disability and schizophrenia.

OBJECTIVES

To determine the effects of any antipsychotic medication compared with placebo for treating people with a dual diagnosis of learning disability and schizophrenia.

SEARCH STRATEGY

For this update we searched the Cochrane Schizophrenia Group's Register of trials (July 2004), relevant reference lists and sought unpublished data from pharmaceutical companies.

SELECTION CRITERIA

We included all randomised clinical trials of longer than one month's duration, involving people with both schizophrenia and learning disability (a measured IQ of 70 or less) that evaluated antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

We reliably selected and assessed studies for methodological quality. Two reviewers, working independently, extracted data. We would have analysed dichotomous data on an intention-to-treat basis and presented continuous data with 65% completion rate. For dichotomous outcomes, our intention was to estimate a fixed effect relative risk (RR) with the 95% confidence interval (CI) together with the number needed to treat/harm (NNT/H).

MAIN RESULTS

We found only one relevant randomised trial using our search method and this had to be excluded. This study included four people with a dual diagnosis of schizophrenia and learning disability, but results were only available for two of the participants. It was unclear as to which groups the other two people were allocated. In order to display the data, we would have had to have made too many assumptions about these two people and any results would be uninformative and potentially misleading.

REVIEWERS' CONCLUSIONS

Using the methods described we found no randomised controlled trial evidence to guide the use of antipsychotic medication for people with both learning disability and schizophrenia. Until the urgent need for randomised controlled trials is met, clinical practice will continue to be guided by extrapolation of evidence from randomised controlled trials involving people with schizophrenia, but without learning disability, and non-randomised trials of those with learning disability and schizophrenia.

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour without additional mental illness.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Library, EMBASE, MEDLINE, PsycINFO and BIOSIS were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4, 8 and 12 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only nine randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWERS' CONCLUSIONS

There are limited data on this important issue and more research is urgently needed.

Antipsychotic medication for those with both schizophrenia and learning disability

BACKGROUND

Antipsychotic medication is the standard treatment for people with learning disability and schizophrenia.

OBJECTIVES

To determine the efficacy of any antipsychotic medication for treating people with a dual diagnosis of learning disability and schizophrenia.

SEARCH STRATEGY

Electronic searching of Biological Abstracts, the Cochrane Schizophrenia Group's Register of trials, the Cochrane Library, EMBASE, PsycLIT and MEDLINE. Unpublished data were sought from pharmaceutical companies. Both authors independently selected the relevant studies from the reports identified in this way.

SELECTION CRITERIA

1. All randomised controlled trials of antipsychotic medication, regardless of dosage, versus a placebo control, of longer than one month's duration. 2. Anyone over 18 years of age with both learning disability and schizophrenia. Learning disability was defined as a measured IQ of 70 or less. Any mode of diagnosis of schizophrenia was acceptable.

DATA COLLECTION AND ANALYSIS

The two reviewers independently attempted to select and then extract data but it was not possible to do this with the single study that met the inclusion criteria.

MAIN RESULTS

Only one relevant randomised trial was found by the searches. This study included four people with a dual diagnosis of schizophrenia and learning disability, but results were available for only two. The groups to which the other two people were allocated were unclear. In order to display the data, too many assumptions would have to have been made about these other two people and any results would be uninformative and potentially misleading.

REVIEWER'S CONCLUSIONS

Using the methods described the reviewers found no randomised controlled trial evidence to guide the use of antipsychotic medication for those with both learning disability and schizophrenia. Until the urgent need for randomised controlled trials is met clinical practice will continue to be guided by extrapolation of evidence from randomised controlled trials involving people with schizophrenia but without learning disability and non-randomised trials of those with learning disability and schizophrenia.

Antipsychotic medication for challenging behaviour in people with learning disability

BACKGROUND

The term 'challenging behaviour', in the absence of psychiatric disorder, encompasses a wide range of behaviours that may be harmful to people or property, may be difficult to manage and may limit access to community facilities. Antipsychotic medications have been used to modify such behaviours in people with learning disability, but there is little evidence to suggest that the benefits outweigh the risks.

OBJECTIVES

To determine the effectiveness of antipsychotic medication for people with learning disability and challenging behaviour.

SEARCH STRATEGY

Biological abstracts, the Cochrane Library, the Cochrane Schizophrenia Group's Register, EMBASE, MEDLINE, PsycLIT were searched. Further references were sought from published trials and pharmaceutical companies. Trials were reliably identified and data extracted.

SELECTION CRITERIA

All randomised controlled trials of antipsychotic medication versus placebo.

DATA COLLECTION AND ANALYSIS

Reviewers independently evaluated and analysed data on an intention to treat basis. Data were evaluated at 4 and 8 weeks as longer follow-up data were not available. Reviewers assumed that those subjects lost to follow-up had a bad outcome.

MAIN RESULTS

Only three randomised controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with learning disability and challenging behaviour.

REVIEWER'S CONCLUSIONS

There is limited data on this important issue and more research is urgently needed.

Antipsychotic medication for challenging behaviour in people with intellectual disability: a systematic review of randomized controlled trials

A study was performed to determine the effectiveness of antipsychotic medication for people with intellectual disability (ID) and challenging behaviour. Randomized controlled trials comparing antipsychotic medication to placebo in people with ID and challenging behaviour were identified by electronic searching and hand-searching. Reviewers independently evaluated and analysed data on an intention-to-treat basis. Only three randomized controlled trials could be included in the analyses. These trials provided no evidence as to whether antipsychotic medication does or does not help adults with ID and challenging behaviour. There is limited data on this important issue and good quality research is urgently needed.

Effectiveness of antipsychotic medication in people with intellectual disability and schizophrenia: a systematic review

The aim of the present study was to determine the efficacy of any antipsychotic medication for treating people with a dual diagnosis of intellectual disability and schizophrenia. The authors performed an electronic search of Biological Abstracts, the Cochrane Schizophrenia Group's Register of trials, the Cochrane Library, EMBASE, PsycLIT and MEDLINE. Unpublished data were sought from pharmaceutical companies. Both authors independently selected the relevant studies from the reports identified in this way. Only one relevant randomized trial was found by the searches (Foote 1958). This study included four people with a dual diagnosis of schizophrenia and intellectual disability, but results were only available for two subjects. The groups to which the other two people were allocated were unclear. Using the methods described, the reviewers found no trial evidence to guide the use of antipsychotic medication for those with both intellectual disability and schizophrenia. Until the urgent need for randomized controlled trials is met, clinical practice will continue to be guided by evidence from trials involving people with schizophrenia but without intellectual disability.

Convergence of limbic input to the cingulate motor cortex in the rhesus monkey

Limbic system influences on motor behavior seem widespread, and could range from the initiation of action to the motivational pace of motor output. Motor abnormalities are also a common feature of psychiatric illness. Several subcortical limbic-motor entry points have been defined in recent years, but cortical entry points are understood poorly, despite the fact that a part of the limbic lobe, the cingulate motor cortex (area 24c or M3, and area 23c or M4), contributes axons to the corticospinal pathway. Using retrograde and anterograde tracers in rhesus monkeys, we investigated the ipsilateral limbic input to area 24c and adjacent area 23c. Limbic cortical input to areas 24c and 23c arise from cingulate areas 24a, 24b, 23a, 23b, and 32, retrosplenial areas 30 and 29, and temporal areas 35, TF and TH. Areas 24c and 23c were also interconnected strongly. The dysgranular part of the orbitofrontal cortex and insula projects primarily to area 24c while the granular part of the orbitofrontal cortex and insula projects primarily to area 23c. Afferents from cingulate area 25, the retrocalcarine cortex, temporal pole, entorhinal cortex, parasubiculum, and the medial part of area TH target primarily or only area 24c. Our findings indicate that a variety of telencephalic limbic afferents converge on cortex lining the lower bank and fundus of the anterior part of the cingulate sulcus. Because it is known that this cortex gives rise to axons ending in the spinal cord, facial nucleus, pontine gray, red nucleus, putamen, and primary and supplementary motor cortices, we suggest that the cingulate motor cortex forms a strategic cortical entry point for limbic influence on the voluntary motor system.

Movement disorder in Down's syndrome: a possible marker of the severity of mental handicap

This study examined the nature and prevalence of abnormal movements in adults with Down's syndrome and also the clinical correlates of orofacial dyskinesia and the relationship between dyskinesia and the level of functional and intellectual disability. Movement disorder, language age, and disability were assessed in an epidemiologically based sample of 145 individuals with Down's syndrome. Abnormal involuntary movements were common, with > 90% exhibiting dyskinesia, predominantly orofacial. Stereotypes were present in one-third of the sample. There was an association between the severity of dyskinesia and both current language age and functioning in terms of self-care and practical and academic skills, which suggested that dyskinesia may be a marker of the severity of mental handicap. The presence of dyskinesia was unrelated to neuroleptic exposure. Dyskinesia and stereotypies are very common in individuals with Down's syndrome and may represent an inherent manifestation of the disorder. The relationship between mental age and dyskinesia in Down's syndrome warrants further research.

Psychiatry and learning disability

My involvement with the psychiatry of learning disability began in 1968 when Professor Batchelor, then Professor of Psychiatry at the University of Dundee, suggested that mental illness in people with learning disability was a clinically interesting and under-researched topic which merited further investigation. At that time, mental illness was not usually considered even a part of the medical specialty of learning disability – or at least, not in Scotland. People in mental handicap hospitals who developed signs of mental illness were normally passed on to colleagues in general psychiatry who were considered to have the investigative and treatment expertise. If admission to in-patient care was considered necessary, it was usually to the local general psychiatry service.

A controlled community study of movement disorder in people with learning difficulties on anti-psychotic medication

The results of a community-based study measuring the occurrence of movement disorders in a population of people with learning difficulties treated with antipsychotic medication are presented. This group was compared with an age- and sex-matched group with a similar degree of handicap, who were not treated with antipsychotic medication. When medication was given within British National Formulary Guidelines, no significant increase in movement disorders in the treated group was found. The relevance of this to psychiatric practice is discussed.

Assaultiveness among institutionalised adults with mental retardation

In an institution, 57 people with mental retardation who had shown assaultive behaviour during the last year were compared with a control group of 57 people in the same institution, matched by sex, level of retardation and age. The study group were younger and had more people with a moderate level of mental retardation than the total population of the institution. Compared with the controls, the assaultive group had more resources available, had more psychopathology, consumed more psychotropic drugs, and had a higher frequency of other problem behaviour. We found no group differences in personal skills, including communication. Generally, the observed covariates of assaultive behaviour resembled that seen in other populations with assaultive behaviour.

Risk factors for tardive dystonia: a case-control comparison with tardive dyskinesia

The objective of this study was to determine the putative risk factors for the development of tardive dystonia (TDt) in contrast with tardive dyskinesia (TD). Fifteen TDt patients seen in the Movement Disorders Clinic were compared with 2 groups of 15 TD controls each. The first control group was drawn from the Clinic and matched with the TDt cases for severity, using degree of dysfunction as the matching variable. The second control group comprised mild TD cases drawn from a separate study of drug-induced movement disorders in chronic schizophrenia and were matched for age and sex with the TDt cases. A number of demographic, treatment-related, diagnosis-related and historical variables suggested in the literature were examined. Most risk factors for TDt that have been suggested by previous studies were not supported. The first control group was significantly older than the TDt cases. The TDt patients had a more frequent past history of acute drug-induced dystonia and of postural tremor prior to the onset of the mental illness, although only the former reached statistical significance. The results suggested that TDt and TD do not differ in most putative risk factors, although the small sample size increases the likelihood of a type II error. It is inconclusive on the role of young age and male sex as risk factors. TDt cases may, however, be individuals vulnerable to the development of dystonia, with neuroleptics probably bringing out such a vulnerability. This finding needs to be examined in larger studies.