Discussion As noted above, psychiatric disorders are often overlooked in patients with intellectual disabilities including Down Syndrome. In addition, while OCD is one of the most common psychiatric illnesses, affecting approximately 2.5% of the population [4], it is often overlooked or misdiagnosed in a clinical setting. It would therefore be expected that OCD would be frequently overlooked in patients with Down Syndrome. One difficulty is that people with intellectual disabilities are often noted to have significant traits of perfectionism: their need for routine and dislike of change will cause them to be very regimented. The compulsions that someone with OCD suffers from may be mistaken for this perfectionism. This was the case with Mr. B.- his rituals of lining things up in school and work was assumed by his psychiatrists as stemming from his need for consistency. Upon closer examination of the history of his behavior as explained by his family members indicated that he was anxious while performing these rituals, and he was able to verbalize that he did not wish to be performing these tasks which is consistent with compulsive rituals. A proper diagnosis was vital to address these issues. The initial medications used for the patient’s crying spells and anxiety were unsuccessful due to the fact that the fluoxetine was not titrated to a high enough dose generally accepted to be effective in the treatment of OCD and buproprion is not an SSRI and is therefore generally ineffective in OCD treatment. There is very little published work on the comorbidity of OCD in Down Syndrome. Charlot et al. [5] reported on a case series of 11 patients with Down Syndrome who had obsessional slowness without other OCD symptoms noted. Raitasuo et al. [6] reported on a patient with comorbid Down Syndrome, OCD, and Anorexia Nervosa. However, no controlled studies of treatment of OCD in Down Syndrome have been performed. As it has been suggested that people with Down Syndrome may experience alterations in serotonin levels [1] and any subsequent effect that this would have on their response to SSRI treatment is J Depress Anxiety ISSN: 2167-1044 JDA an open access journal Page 2 of 2 not known. Mr. B. responded to high dose SSRI therapy in line with recommended guidelines for OCD treatment [7] and in the absence of additional evidence it is recommended to use standard anti-obsessional medication treatment- SSRI’s as first line treatment and clomipramine being reserved as second line therapy due to concerns of side effects. Constipation is an especially problematic side effect of clomipramine in patients with Down Syndrome which may markedly limit its use in this population. In addition to SSRI pharmacotherapy, ERP is the gold standard for OCD psychotherapy and treatment with an efficacy equivalent or superior to medications [8]. ERP was initiated with Mr. B. as it was deemed this this technique would have a reasonable chance of success due to his ability to verbalize the intrusive nature of his symptoms, his desire to stop them, and his ability to give informed consent to a trial. While little has been written about doing ERP in this population, Mr. B was able to do some work in the office. Therapy was not able to be continued because of access problems due to his great distance from our center, but it is felt that the initial trial was a successful proof of concept and it is recommended to attempt ERP in patients with a similar IQ or higher who also meet those criteria. It should be noted that ERP can be difficult to obtain for anyone diagnosed with OCD due to the paucity of clinicians properly trained in these techniques, and finding a trained therapist who also has experience with intellectual disabilities is even more difficult. OCD and Down Syndrome can occur together and can often be misdiagnosed. Standard anti-obsessional pharmacotherapy should be offered, and patients should be screened for their appropriateness for ERP. More work in this area is needed, and further research elucidating proper protocols in treating OCD in patients with Down Syndrome and other Intellectual Disabilities should be performed.

Diskussion Som nævnt ovenfor overses psykiatriske lidelser ofte hos patienter med intellektuelle handicap inklusive Downs syndrom. Derudover, mens OCD er en af ​​de mest almindelige psykiatriske sygdomme, der rammer ca. 2,5% af befolkningen [4], overses den ofte eller fejldiagnosticeres i kliniske omgivelser. Det forventes derfor, at OCD ofte overses hos patienter med Downs syndrom. Et problem er, at mennesker med intellektuelle handicap ofte bemærkes at have væsentlige træk ved perfektionisme: deres behov for rutine og modvilje mod forandring vil få dem til at blive meget regimenteret. De tvang, som en person med OCD lider af, kan forveksles med denne perfektionisme. Dette var tilfældet med Mr. B. - hans ritualer om at oprette ting i skole og arbejde blev antaget af hans psykiatere som stammer fra hans behov for konsistens. Ved nærmere undersøgelse af historien om hans opførsel som forklaret af hans familiemedlemmer indikerede, at han var ængstelig, mens han udførte disse ritualer, og han var i stand til at formulere, at han ikke ønskede at udføre disse opgaver, hvilket er i overensstemmelse med tvangsritualer. En korrekt diagnose var afgørende for at løse disse problemer.De indledende medikamenter, der blev brugt til patientens grædestave og angst, mislykkedes på grund af det faktum, at fluoxetin ikke blev titreret til en høj nok dosis, der generelt blev accepteret til at være effektiv til behandling af OCD, og ​​buproprion er ikke en SSRI og er derfor generelt ineffektiv i OCD-behandling. Der er meget lidt offentliggjort arbejde om comorbiditet af OCD i Down Syndrome. Charlot et al. [5] rapporterede om en sagserie på 11 patienter med Downs syndrom, der havde besat langsomhed uden andre OCD-symptomer. Raitasuo et al. [6] rapporterede om en patient med comorbid Down Syndrome, OCD og Anorexia Nervosa. Der er imidlertid ikke udført kontrollerede studier af behandling af OCD i Downs syndrom. Som det er blevet foreslået, at mennesker med Downs syndrom kan opleve ændringer i serotoninniveauet [1], og enhver efterfølgende virkning, som dette ville have på deres respons på SSRI-behandling, er J Depression Angst ISSN: 2167-1044 JDA en journal med åben adgang Side 2 af 2 ikke kendt. Mr. B. reagerede på SSRI-behandling med høj dosis i overensstemmelse med de anbefalede retningslinjer for OCD-behandling [7], og i mangel af yderligere beviser anbefales det at bruge standard anti-obsessionel medicinbehandling - SSRI'er som førstelinjebehandling og clomipramin forbeholdes som anden linjebehandling på grund af bekymringer om bivirkninger.Forstoppelse er en særlig problematisk bivirkning af clomipramin hos patienter med Downs syndrom, som markant kan begrænse dets anvendelse i denne population. Ud over SSRI-farmakoterapi er ERP guldstandarden for OCD-psykoterapi og behandling med en effektivitetsækvivalent eller bedre end medicin [8]. ERP blev indledt med Mr. B. da det blev anset for, at denne teknik ville have en rimelig chance for succes på grund af hans evne til at tale den påtrængende karakter af hans symptomer, hans ønske om at stoppe dem og hans evne til at give informeret samtykke til en forsøg. Mens der ikke er skrevet meget om at udføre ERP i denne befolkning, var Mr. B i stand til at udføre noget arbejde på kontoret. Terapi var ikke i stand til at fortsætte på grund af adgangsproblemer på grund af hans store afstand fra vores center, men man mener, at det indledende forsøg var et vellykket bevis på konceptet, og det anbefales at forsøge ERP hos patienter med en lignende IQ eller højere, der også opfylder disse kriterier. Det skal bemærkes, at ERP kan være vanskeligt at få for alle, der er diagnosticeret med OCD på grund af manglen på klinikere, der er korrekt uddannet i disse teknikker, og det er endnu vanskeligere at finde en uddannet terapeut, der også har erfaring med intellektuelle handicap. OCD og Downs syndrom kan forekomme sammen og kan ofte fejldiagnosticeres. Standard anti-besat farmakoterapi bør tilbydes, og patienter skal screenes for deres egnethed til ERP.Der er behov for mere arbejde på dette område, og der bør udføres yderligere forskning, der belyser ordentlige protokoller til behandling af OCD hos patienter med Downs syndrom og andre intellektuelle handicap.