ISSN: 2167-1044 Case Report Research Article Open Access Journal of Depression and Anxiety Hudak, J Depress Anxiety 2015, 4:4 DOI: 10.4195/2167-1044.1000195 Open Access The Treatment of Obsessive Compulsive Disorder in a Patient with Down Syndrome Robert Hudak* University of Pittsburgh School of Medicine, USA Abstract Many mental health professionals do not properly recognize the co-occurrence of psychiatric disorders and intellectual disorders. Most mental health professionals do not receive training in the diagnosis and treatment of dual diagnosed individuals. Little is known about the clinical presentation and treatment of OCD in individuals who have Down Syndrome. We describe a case of OCD in an individual with Down Syndrome in which the diagnosis of OCD was overlooked for four years after first contact with mental health professionals. The treatment of the patient is reviewed, including medication management as well as the challenges in using evidence based psychotherapy. Keywords: Obsessive compulsive disorder; down syndrome; OCD; tic disorder Introduction Despite the fact that individuals with intellectual disabilities are at an increased risk for psychiatric problems, a fact that has been well documented in scientific literature for decades, many mental health professionals do not properly recognize the co-occurrence of psychiatric disorders and intellectual disorders [1]. Most mental health professionals do not receive training in the diagnosis and treatment of dual diagnosed individuals, and most clinical treatment studies list intellectual disabilities as exclusion criteria. Obsessive Compulsive Disorder (OCD) likewise tends to be under recognized and missed during mental health examinations [2] and even when it is diagnosed properly, mental health clinicians often do not initiate appropriate, evidence based treatment [3]. Therefore, it is not surprising that little is known about the clinical presentation and treatment of OCD in individuals who have Down Syndrome. We describe a case of OCD in an individual with Down Syndrome in which the diagnosis of OCD was overlooked for four years after first contact with mental health professionals. The treatment of the patient is reviewed, including medication management as well as the challenges in using evidence based psychotherapy. Case Presentation Mr. B. is a 21 year old white male with a past medical history significant for a diagnosis of Trisomy 21 which was diagnosed at birth. He presented to our clinic accompanied by his parents with complaints of behavioral concerns effecting him at home as well as at his supported work program. He had become irritable at both work and home, would refuse to go to work, and was using vulgarity while at his place of employment. He would repeat certain vulgarities over and over, and the words did not always seem to be precipitated by a specific person or event, and were often not targeted at any individual. He described this as an intentional ritual done to relieve distress and it did not appear tic-like. He was also noted to have unusual behaviors- specifically he would continuously ask his mother if she was “OK”. She could not simply answer “yes”, but she had to use a very specific phrase when responding to him: any other phrasing would prompt him to become anxious and ask the question again. This would occur multiple times in an hour. He was unable to go to bed unless the kitchen and living room was arranged in a specific way resulting in a diminished sleep schedule. He would experience crying spells when his living space was rearranged. He would turn the lights off and on in certain rooms in his J Depress Anxiety ISSN: 2167-1044 JDA an open access journal house repeatedly; however, this would not occur in places unfamiliar to him. Mother states that he could spend up to an hour at a time with these routines and that he would appear anxious during these periods. Upon exam, patient appeared embarrassed when asked about these symptoms and would minimize them, saying that they were no big deal and did not wish to talk about them. In addition to the decreased sleep secondary to his late bed time, the patient had a 25 pound weight loss despite having a good appetite. Numerous motor tics in his head and extremities were observed. He denied having a depressed mood, denied suicidal ideation, and no neurovegetative signs were elicited. His past medical history was significant for hypothyroidism and a congenital hearing deficit. A CT scan of his brain was within normal limits. His developmental history is significant for having walked at 18 months and speaking his first words at 21 months. He was tested in elementary school and found to have an IQ of 63. While he was in the 7th grade, teachers had told the family that he would not start his lessons unless his desk was arranged in a certain way. He had been treated by psychiatrists at his local mental health center since age 17, and had been diagnosed with ‘anxiety’.

ISSN: 2167-1044 Sagsrapport Forskningsartikel Åben adgang Tidsskrift for depression og angst Hudak, J Depressionsangst 2015, 4: 4 DOI: 10.4195 / 2167-1044.1000195 Open Access Behandling af tvangslidelse hos en patient med dun Syndrom Robert Hudak * University of Pittsburgh School of Medicine, USA Abstrakt Mange fagfolk inden for mental sundhed genkender ikke korrekt forekomsten af ​​psykiatriske lidelser og intellektuelle lidelser. De fleste fagfolk inden for mental sundhed får ikke træning i diagnose og behandling af dobbeltdiagnosticerede individer. Man ved ikke meget om den kliniske præsentation og behandling af OCD hos personer, der har Downs syndrom. Vi beskriver et tilfælde af OCD hos en person med Downs syndrom, hvor diagnosen OCD blev overset i fire år efter første kontakt med psykiatriske fagfolk. Behandlingen af ​​patienten gennemgås, herunder styring af medicin samt udfordringerne ved at bruge evidensbaseret psykoterapi. Nøgleord: Obsessiv kompulsiv lidelse; Downs syndrom; OCD; tic lidelse Introduktion På trods af at personer med intellektuelle handicap har en øget risiko for psykiatriske problemer, en kendsgerning, der har været veldokumenteret i videnskabelig litteratur i årtier, anerkender mange fagfolk inden for mental sundhed ikke korrekt forekomsten af ​​psykiatriske lidelser og intellektuelle lidelser [1 ].De fleste fagfolk inden for mental sundhed får ikke træning i diagnose og behandling af dobbeltdiagnosticerede individer, og de fleste kliniske behandlingsundersøgelser viser intellektuelle handicap som udelukkelseskriterier. Obsessive Compulsive Disorder (OCD) er ligeledes tilbøjelige til at blive anerkendt og savnet under mental sundhedsundersøgelser [2], og selv når det diagnosticeres korrekt, indleder psykiatriske klinikere ofte ikke passende, evidensbaseret behandling [3]. Derfor er det ikke overraskende, at der er lidt kendt om den kliniske præsentation og behandling af OCD hos personer, der har Downs syndrom. Vi beskriver et tilfælde af OCD hos en person med Downs syndrom, hvor diagnosen OCD blev overset i fire år efter første kontakt med psykiatriske fagfolk. Behandlingen af ​​patienten gennemgås, herunder styring af medicin samt udfordringerne ved at bruge evidensbaseret psykoterapi. Sagspræsentation Mr. B. er en 21 år gammel hvid mand med en tidligere medicinsk historie, der er signifikant for en diagnose af Trisomy 21, som blev diagnosticeret ved fødslen. Han præsenterede for vores klinik ledsaget af sine forældre med klager over adfærdsmæssige bekymringer, der påvirker ham derhjemme, samt på hans understøttede arbejdsprogram. Han var blevet irritabel både på arbejde og i hjemmet, ville nægte at gå på arbejde og brugte vulgaritet, mens han var på sit job.Han gentog visse vulgariteter igen og igen, og ordene syntes ikke altid at blive udfældet af en bestemt person eller begivenhed og var ofte ikke målrettet mod nogen person. Han beskrev dette som et forsætligt ritual udført for at lindre nød, og det virkede ikke tic-lignende. Han blev også bemærket for at have usædvanlig opførsel - specifikt ville han løbende spørge sin mor, om hun var ”OK”. Hun kunne ikke bare svare ”ja”, men hun måtte bruge en meget specifik sætning, når hun svarede på ham: enhver anden formulering ville få ham til at blive ængstelig og stille spørgsmålet igen. Dette ville forekomme flere gange i løbet af en time. Han var ude af stand til at gå i seng, medmindre køkkenet og stuen var arrangeret på en bestemt måde, hvilket resulterede i en nedsat søvnplan. Han ville opleve grådende trylleformularer, når hans bolig blev omarrangeret. Han ville tænde og tænde lysene i visse rum i hans J Depression Angst ISSN: 2167-1044 JDA en journal med åben adgang hus gentagne gange; dette ville dog ikke forekomme steder, som han ikke kendte. Mor siger, at han kunne bruge op til en time ad gangen med disse rutiner, og at han ville virke ængstelig i disse perioder. Efter undersøgelsen syntes patienten flov, da han blev spurgt om disse symptomer og ville minimere dem og sagde, at de ikke var noget stort og ikke ønskede at tale om dem.Ud over den nedsatte søvn sekundært til hans sene sengetid havde patienten et vægttab på 25 pund på trods af at han havde en god appetit. Talrige motoriske tics i hans hoved og ekstremiteter blev observeret. Han benægtede at have et deprimeret humør, nægtede selvmordstanker og ingen neurovegetative tegn blev fremkaldt. Hans tidligere medicinske historie var vigtig for hypothyroidisme og et medfødt høreunderskud. En CT-scanning af hans hjerne var inden for normale grænser. Hans udviklingshistorie er vigtig for at have gået 18 måneder og tale sine første ord 21 måneder. Han blev testet i folkeskolen og viste sig at have en IQ på 63. Mens han var i 7. klasse, havde lærere fortalt familien, at han ikke ville begynde sine lektioner, medmindre hans skrivebord var arrangeret på en bestemt måde. Han var blevet behandlet af psykiatere på hans lokale mentale sundhedscenter siden 17 år og var blevet diagnosticeret med 'angst'.