CASE REPORT

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A MENTALLY RETARDED PATIENT WITH SCHIZOPHRENIA

PSYCHIATRIC DISORDER AND MENTAL RETARDATION

Psychiatric disorder is more common in people with learning disabilities than in general population. Organic, social, and educational factors are contributory. Nearly all adults with severe MR have structural brain disease, and epilepsy is more common in this population. SNS had two past episodes of seizures. Rutter and colleague in their study, showed a clear association between neurological abnormality, epilepsy, learning disability and psychiatric disorder. In addition to these organic factors education failure, rejection and lack of social acceptance, reduced or lack of job opportunities, diminished self esteem, sexual difficulties and problems of dysmorphic appearance have increased the susceptibility to this disorder.⁶

People with learning disabilities experience the gamut of anxiety neurotic and depressive reactions, states of panic, unhappiness, loss and bereavement. An estimated 15% of adults with severe learning disabilities have a severe associated behavioural disorder. These behavioural disorders may include self-injury, restlessness, aggressiveness, noisiness and destructiveness; impulsivity and imperviousness to pain.⁷ Experts estimated that the emotional, behavioural and psychiatric disorders are three to four times more common in people with MR and developmental disabilities than the public.⁸ People with dual diagnosis of schizophrenia and MR are often overlooked and neglected. This is due to the symptoms of mental illness are different in individuals with cognitive impairments. Individual with cognitive impairment may not articulate delusion in the same way as others without. In case of SNS, it was very difficult to elicit the history of delusion and hallucinations because of her concurrent MR.

MANAGEMENT OF SCHIZOPHRENIA

Management of schizophrenia involves hospitalization, biopsychosocial and physical measures.9 The primary aim of treatment is a rapid remission of the acute psychotic episode using the most effective and best-tolerated drugs.¹ Nearly 80% of patients with first episode of schizophrenia will eventually recover; up to 70 % of patients will have a second episode within five to seven years.¹

Antipsychotic drugs

New antipsychotic drugs such as risperidone, olanzapine, clozapine and quietiapine are effective in treating positive and negative symptoms of schizophrenia.¹⁰ It has side effects such as increased blood sugar and serum lipids, which require close monitoring.¹¹ However the comparative lack of side effects of these atypical antipsychotic drugs as compared to conventional antipsychotics, improved the drug compliance during maintenance and thus reduce the risk of relapse.¹⁰

Supportive psychotherapy

The best-studied form of psychotherapy, which can enhance drug treatment, is supportive psychotherapy.⁹ The essential of this treatment is to form a trusting relationship with the patients and to make them feel comfortable with the therapist. It also focuses on present issues; helping to develop social skills, and teaching coping and problem solving techniques.⁸ Psychotherapy was given especially to SNS’s parents, so that they could better cope with her illness.

Supportive psychotherapy encompasses various activities intended to prevent relapse or deterioration and to overcome symptoms. In supportive therapy, positive efforts are made to minimize anxiety and to enhance self-esteem. It emphasized on working together with the patient to achieve results.¹²

Vocational rehabilitation
Vocational training plays an important role in the rehabilitation and management of these patients. Vocational service providers focus their efforts on social skills training; supportive therapies to address work readiness and demoralization issues.¹³ Working with peers can facilitate a sense of individual empowerment and offer role-modelling opportunities through exposure to others who have faced similar obstacles.¹³ In case of SNS perhaps; she would benefit from vocational rehabilitation training and learn some social skills.

People with schizophrenia often encounter stigmatization and discrimination. The family physician, apart from focus on treatment, should put emphasis on holistic and social approach, as treatment failure is the result of breakdown in social circumstances. Psychological intervention particularly cognitive behavioural therapy (CBT) and family interventions are recommended, as an indispensable part of the treatment for people with schizophrenia and their families. ¹⁴

Family intervention for schizophrenia
Families play a big role in helping to reduce relapses. Families need to be educated about the illness and taught to identify and avoid problem situations. Families are in a pivotal position to discern sign and symptoms of an impending relapse and thus prevent them from setting full-blown disease. Studies have shown that a high expressed emotion includes critical comments and hostility among family members, can increase the risk of relapses.⁹ It is also important to work with the family to improve their knowledge of the condition and to nurture emotional relationships and communication between patient and their carers.¹

Families also need help with their own personal emotional response to their relative’s illness and may benefit from techniques in stress management, and coping strategies.⁹ Family intervention strategy was used in SNS case because it was difficult for the family to accept the illness especially in circumstance where parents were aware that the child is subnormal. SNS parents were educated about the illness, and taught to avoid problem situations and hostile attitude. There is a role of support groups for family members, and it would help them to share experiences and emotions. These groups may also later be empowered to campaign the rights of the mentally ill patients and help to destigmatise mental illness.⁹

Cognitive behavior therapy

Cognitive behavioural therapy (CBT) is now the fastest growing treatment modality for psychosis. CBT improve the cognitive impairments associated with schizophrenia such as distractibility, poor attention and memory impairment. Studies have shown that it has a significant effect on positive symptoms such as hallucinations and delusions.⁹ However it might be difficult to apply in patients with mental retardation as in SNS it was not used as treatment modality.

Behavioural therapy

Behavioural therapy addresses the patient’s abilities and deficits. Many patients lose their basic social skills due to illness process, and make them unable to function socially. The social skills of patients can be taught through role-play, videotape reviewing of others or performing assignment.⁹ Again it might be difficult to apply in patients with concurrent mental retardation.

Group therapy

Group therapy can reduce social deprivation and isolation, improve relationships and help the patient to seek solutions for their problems.⁹ However the role of group therapy in mentally retarded patient with schizophrenia like SNS is difficult to ascertain because of their subnormal IQ level they cannot participate effectively in these interventions.

Psycho-education

Poor medication adherence is one of the major determinants of outcome in schizophrenia. Compliance can be improved by using educational intervention such as psycho-education that has the potential of increasing patient’s understanding of, and insight into their illness and its treatment and thereby improving prognosis. It can reduce health care costs and burden that schizophrenia places on the individual, their families and the community.^14-15

Cochrane systematic review has shown that psycho-educational intervention significantly decreases relapse or readmission rates in patients with schizophrenia compared with standard care.¹⁵

Role of psychologist

Psychologists apply measures to assess the effectiveness of medications and interventions to increase the medications compliance by using behaviour management technique. They can help to reduce the stress faced by patients with schizophrenia by teaching them stress management skills, environmental management skills and social skills, which are necessary to build up their social networks.

Psychologists can educate the patients and their family recognition of impending illness and strategies to reduce its likelihood. They assess the needs of the patients to determine the most appropriate resources to help them in their daily living. For instance behavioural and skills training approaches can improve patients functioning and help them to develop support systems in their environment.¹⁶ SNS was referred to psychologist for assessment, IQ test, and subsequent management.

The close liaison between psychiatrists, psychologists, primary care professionals, educational and vocational services can help to diagnose the disorder early and allow early treatment and rehablitation.1 Health education programmes can create greater awareness among the general public about psychosis and the need for prompt self-referral or referral by caregivers. Close ties need to be developed between key agencies in contact with adolescence and young adults for example teachers and health workers to facilitate the pathway to care for those experiencing recent onset of psychosis.¹⁰

CONCLUSION

Family physicians have a pivotal role in early identification, diagnosis and management of schizophrenia, and in close monitoring of patients who are at high risk. They can educate patients and their caregivers about the illness and suggest practical coping strategies that may result in reduced risk of relapses. Health education programmes can create better awareness among the public about psychosis and the need for timely self-referral or referral by caregivers. The role of health care workers and teachers is vital in early identification of children with mental retardation especially those who have learning disability. This will guide proper evaluations and referrals so that early intervention can be done for the child.

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