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| CASE REPORT |
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| Ahead of print publication |
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A young woman with intellectual disability, epilepsy, and psychosis of unclear prognosis
Ayush Lall, B Lakshmi Dorai, C Pradeep, A Esaimozhi
Department of Psychiatry, Vinayaka Mission Kirpunanda Variyar Medical College and Hospital, Salem, Tamil Nadu, India
| Date of Submission | 24-Apr-2022 |
| Date of Decision | 09-May-2022 |
| Date of Acceptance | 10-May-2022 |
| Date of Web Publication | 05-Dec-2022 |
Correspondence Address:
Ayush Lall,
Department of Psychiatry, Vinayaka Mission Kirpunanda Medical College and Hospital, Chinnaseeragapadi, Salem - 636 308, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aip.aip_72_22
Intellectual disability is a known condition, but psychosis and its extension in functional areas of life, with episodes of seizures in between, make the case complex and leave clinicians with a limited choice of treatment and unpredictable outcomes. We present the case of a 20-year-old female with intellectual disability, episodes of seizures, and pattern of psychosis, with its course describing the perplexity of the treatment in the area of its outcome predictability, which also highlights the lack of a structured approach for clinicians' guidance in managing it as a multidisciplinary field.
Keywords: Case report, epilepsy, intellectual disability, psychosis
How to cite this URL:
Lall A, Dorai B L, Pradeep C, Esaimozhi A. A young woman with intellectual disability, epilepsy, and psychosis of unclear prognosis. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Apr 2]. Available from: https://www.anip.co.in/preprintarticle.asp?id=362705 |
| Introduction | |  |
There are few studies conducted that included people with intellectual disability and episodes of seizures, and psychopathology eliciting psychosis even when the prevalence of epilepsy in the general population and those with intellectual disability remains high.[1],[2] There are some meta-analyses done before and recently that give two opposite results for the association of psychosis with epilepsy in people with intellectual disability. A recent meta-analysis published in 2021 by Akrout Brizard et al. suggested a significantly lower rate of psychosis among the epilepsy group compared with the nonepilepsy group, and also, psychosis is significantly more prevalent in adults with intellectual disabilities compared with the general population.[3] Psychotic symptoms may appear in different ways when epilepsy is present, making it difficult to diagnose and further classify into specific types.[3] It has always been a challenging task to diagnose psychosis in people with intellectual disability in the presence of recent episodes of seizures and to state treatment outcomes.[3] Cases with documented psychosis, with its type and extension in the individual's lifestyle, help in understanding the pattern of illness and pharmacological treatment outcomes to be expected during the management of psychosis, especially when expecting the complete remission of symptom. All together this makes it necessary to report cases, which comprises work eliciting psychosis and seizures in people with intellectual disability, highlighting the reason for future studies and the requirement of well-structured guidelines.
| Case Report | | |
A 20-year-old unmarried female presented with a history of talking to self and paranoid delusion for 2 years. The patient was observed to have conversations when alone, related to her family's safety. The patient had this event daily, once, or twice a day, lasting for at least 1 h, in the past 2 years. The patient denied auditory hallucinations.
The patient expressed her fear that someone intends to physically harm her and her family members. Expressing her fear verbally, the patient said she feared some people would find and beat her, mostly referring patient's neighbors or policemen. The patient also showed her suspicion in action, as the patient often checked windows and doors whenever suspected someone spying on her, and closed all windows and doors to prevent any events that could be harmful to her. The patient refuses to consume food prepared and served by anyone except her mother as the patient trusted her. The patient was found screaming for help while she had a bath.
Symptoms signifying neurological and cerebellar dysfunction, such as giddiness or gait disturbances, were absent. No history of substance abuse was found.
The patient's past medical history includes a diagnosis of generalized tonic–clonic epilepsy, for which the patient is receiving maintenance therapy with valproate (200 mg orally thrice daily) for 2 years. The patient had the first episode of seizure at the age of 3 and then the second episode 2 years back. According to the patient's caretaker, in the past 2 years, the patient had nearly 20 episodes of seizures, with the same pattern each time. The last episode was 4 months ago. The patient's psychotic symptoms started 2 weeks after the second episode of seizure, which was 2 years back. At that time, noncontrast computed tomography brain scan revealed no significant findings, and basic blood investigations stayed within normal limits. Her family history was unremarkable.
The patient had the support of family members for day-to-day activities and self-care. After the assessment, she was found to have a mild intellectual disability. The patient was able to complete her schooling till the sixth standard, after which the patient was unable to pass her exams.
During the onset of psychotic symptoms, the patient was started with antipsychotics risperidone 1 mg morning and 2 mg at night, trihexyphenidyl 2 mg morning, and diazepam 10 mg at night. The patient was taken for consultation with other physicians, as according to patient's caretaker, the patient was unable to fully achieve premorbid living. After multiple such consultations from different physicians, who kept on modifying the treatment, the patient is now on oral medications, including antipsychotics risperidone 3 mg at night in combination with trihexyphenidyl 2 mg, mirtazapine 15 mg at night, and nitrazepam 10 mg at night. Antiepileptics initially were changed from phenytoin to sodium valproate, and 4 months ago, it was again changed to phenytoin 100 mg in the morning and 200 mg at night which resulted in better control of epilepsy. With changes in medicines, any change in psychotic features remains significantly inappreciable.
| Discussion | | |
Neuropsychiatric manifestations in people with intellectual disability are mostly underreported and misdiagnosed, and sometimes, they remain untreated.[4] Challenges for the diagnosis and treatment of psychiatric comorbidity in intellectual disability can be because of limited choice of structured clinical interviews or well-structured treatment guidelines addressing the outcome of treatment for psychosis.[4] This case highlights the pattern of psychosis and its extension in the patient's life adding up the functional impairment that was already present due to intellectual disability which finally led to multiple consultations from different specialists and then changes in the choice of treatment. This case also highlights the lack of knowledge in this field, leading to unclear prediction of treatment response. For people with intellectual disability, there is a higher chance of developing drug-resistant epilepsy leading to a higher chance of sudden unexpected death in epilepsy.[5] Therefore, careful monitoring and course prediction also with proper counseling of same to the patient's relative are important. In this case, the use of phenytoin before and restarting again was more dependent on clinical judgment of appropriate treatment for epilepsy, and by the use of sodium valproate, a balance of preventing seizure and psychosis was tried to achieve. As in previous researches, phenytoin is considered a possible risk factor for the development of psychosis in low intelligence level, it is important to carefully prioritize the desired outcomes and drugs to achieve the same.[6] Appropriateness of the diagnosis and management of episodes of seizures becomes essential to reduce the considerable social impact, potential stigmatization, secondary handicap, and low self-esteem compounded by social exclusion as seen in people with intellectual disability.[7] Therefore, in future with increase in number of studies including individuals having together intellectual disability, epilepsy and psychosis may help in forming well-structured guidelines and predictability of treatment outcomes to guide clinicians in this field.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Clancy MJ, Clarke MC, Connor DJ, Cannon M, Cotter DR. The prevalence of psychosis in epilepsy; a systematic review and meta-analysis. BMC Psychiatry 2014;14:75. |
| 3. | Akrout Brizard B, Limbu B, Baeza-Velasco C, Dep S. Association between epilepsy and psychiatric disorders in adults with intellectual disabilities: Systematic review and meta-analysis. BJPsych Open 2021;7:e95. |
| 4. | Kishore MT, Udipi GA, Seshadri SP. Clinical practice guidelines for assessment and management of intellectual disability. Indian J Psychiatry 2019;61:194-210. [ PUBMED] [Full text] |
| 5. | Shankar R, Donner EJ, McLean B, Nashef L, Tomson T. Sudden unexpected death in epilepsy (SUDEP): What every neurologist should know. Epileptic Disord 2017;19:1-9. |
| 6. | Noguchi T, Fukatsu N, Kato H, Oshimma T, Kanemoto K. Impact of antiepileptic drugs on genesis of psychosis. Epilepsy Behav 2012;23:462-5. |
| 7. | Good Psychiatric Practice, Management of Epilepsy in Adults with Intellectual Disability, College Report CR203 Constitute College Policy, The Royal College of Psychiatrists; 2017. |
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