MENTAL RETARDATION

MENTAL RETARDATION

Mental retardation is the state of arrested or incomplete development of intellectual functions characterized by impairment in cognitive, language, motor and social skills, manifested at birth or early childhood.

In a normal child the Chronological Age (CA) equals the Mental Age (MA).

Intelligent Quotient (IQ) = Mental Age (MA) divided by Chronological age (CA), the whole multiplied by 100.

IQ provides a rough measure of a child’s level of intellectual functioning and is used to screen those suspected to have mental retardation. But IQ does not reveal the capacity for adaptive behaviour of the child which is also a measure of intelligence. Milestones are delayed in Mental retardation.

Developmental Milestones

Age	Motor Activity	Social Activity	Mental Activity
1-2 months	Sleeps most of the time but while awake waves both his arms and legs Grasps things when put in hand. Holds head for a few seconds.	---	Cries differently
2-3 months	Eyes follow bright light. Fixes eyes on mother	Smiles at mother	---
4-5 months	Holds head steadily. Tries to roll over. Plays with fingers. Eyes follow moving objects. Sleeps for 20 hours a day.	Makes cooing sounds. Recognizes mother	Recognizes mother.
6 months	Sits without support. Plays with toes. Reaches and grasps things. Sleeps for 18 hours a day	Recognizes friends. Smiles and laughs	Shows pleasure by smiling and displeasure by crying.
9 months	Sits up alone. Crawls towards objects. Tries to pull himself      up. Sleeps 16-17 hours a day.	---	Says one or two syllables
12 months	Stands alone. Walk with support. Feeds himself with fingers. Sleeps for 16 hours a day	Understands the meaning of yes  and no.	Says 2-3 words. Gazes at simple pictures and mirror.
18 months	Throws a ball. Walks easily. Plays with toys. Drinks from glass or cup.	Prefers to play Alone	Says a few words
2 yrs	Runs. Climbs on stools. Balances on one foot. Sleeps for 14 hours a day.	Helps to wash and dress himself	Talks well. Says short sentences, names, familiar things. Copies a circle.
3 yrs	Runs quickly, jumps, rides a bicycle, attains bladder control, Buttons and unbuttons clothes.	Plays simple  games with other   children	Points to all familiar things
4-5 yrs	Hope on one foot. Sleeps 12 hours a day. Dresses and undresses without support	Plays with other children	Counts objects and up to 10 or more, Makes simple drawings with crayons, knows names of colours, knows right or left and morning and evening

CLASSIFICATION

1. Mild mental retardation                   IQ 50-69
2. Moderate Mental retardation          IQ 35-49
3. Severe Mental Retardation              IQ 20-34
4. Profound Mental Retardation         IQ less than 20

Mild Mental Retardation (IQ 50-69)

In preschool years they are usually indistinguishable from children with normal intelligence and problems of learning are only defected once they enter school. Sensory and motor impairment is minimal and non conspicuous. They can develop social and communication skills adequate for a self supportive life in adulthood. They are able to achieve academic skills of about 6^th grade by late teens. As adults they have a mental age of 9-12 yrs. They can lead to a successful and independent life ordinarily, but may need help under stressful social and economic situations. Marriage and child rearing may pose problems. They used to be referred to as the educable group of the mentally retarded. Unskilled or semi skilled manual work is accomplished with no difficulty.

Moderate Mental Retardation (IQ 35-49)

As adults they reach a mental age of 6-8 years and 2^nd grade level of academic skills. Most can talk and engage in simple instructions. Social and interpersonal skills are poor. They need training in self help and social and occupational skill from which they can profit. Simple routine work could be undertaken by them in familiar surroundings. They need supervision and guidance and leading an independent life is not possible. They may undertake skilled and semiskilled work under sheltered conditions. They usually referred as the ‘trainable group’.

Severe Mental Retardation (IQ 20-34)

As adults their mental age corresponds to 3-6 years. There is a marked motor impairment and in the preschool years their development milestones are delayed. Associated handicaps are often seen and need to be attended too. Speech is minimal and communication skills are very poor. With training they are able to develop self protective skills and simple skills can be performed under supervision.

Profound Mental Retardation (IQ below 20)

They attain the mental age of less than 3 years as adults. Their communication skills are limited to very simple commands and requests. They need a highly structured protective environment and require continuous supervision and nursing care.

Causes of Mental Retardation

                                                                                   Psycho-social Causes

            

                                                                                                * Poverty and Malnutrition

                                                                                                                    * Familial retardation

Biological Causes 

Prenatal Factors       Prenatal Factors        Postnatal Factors                           

* Genetic and                                * Birth injury                             * Infections

   chromosomal                                                                                                        

   aberration                                     * Kernicterus                              * Cerebral Palsy                   

* Prematurely                                                                       

* Congenital anomalies                                                                               * Trauma

                                                                                                                              

* Meternal infections,                                                                                        * Intoxications

   intoxications and

   teratogens during

   pregnancy                                                                                            

                           

 * Complications of

    Pregnancy

EPILEPSY

EPILEPSY

It can be defined as a condition characterized by recurrent unprovoked seizures. A seizure is a sudden involuntary alteration in perception or behaviour caused by an abnormal synchronized discharge of cortical neurons in the central nervous system. An attack of seizure can be defined as epilepsy only when it has a recurrent tendency to occur. At least two unprovoked seizures are required for the diagnosis of epilepsy.

Generally the seizures are classified into Partial and Generalized.

Partial Seizures

Partial seizures begin focally in a restricted focus of cerebral cortex in contrast to generalized seizure types.

1. Simple Partial Seizure: Consciousness and ability to interact with external environment are not impaired. It can be: (a) with motor signs, (b) with somato-sensory or special sensory symptoms, (c) with autonomic symptoms or signs, or (d) with psychic symptoms.
2. Complex Partial Seizure: Consciousness is impaired. Patient is unable to respond normally to external stimuli because of altered awareness. It can be: (a) Simple partial onset followed by impairment of consciousness, or (b) with impairment of consciousness at onset.
3. Secondary Generalized Partial Seizures: Consciousness is impaired and tonic–clonic (convulsions) movements occur. It can be: (a) Simple partial seizures evolving to generalized seizures, (b) Complex partial seizures evolving to generalized seizures, or (c) Simple partial seizures evolving to complex partial seizures and complex partial seizures then evolving to generalized seizures.

Generalized Seizures

In generalized seizures, there is a diffuse disturbance of cortical function and seizures begin more or less simultaneously in both the cerebral hemispheres. Usually consciousness is impaired and motor manifestations are usually bilateral and synchronous. There are six types of generalized seizures.

1.       Tonic-clonic Seizures: Similar in behaviour to secondarily generalized seizures, but they begin without an aura or complex partial seizures and the tonic or clonic movements are symmetric.

2.      Absence Seizures: Two type: –Typical and Atypical. Typical absence seizures are characterized by lapses of consciousness (absence) that rarely last longer than 10 seconds. A typical absence seizure almost always produce motor signs especially changes in tone. They last for more than one 10 sec. and are usually followed by postictal confusion.

3.       Myoclonic Seizures: Myoclonus is a sudden involuntary, brief, shock like muscle contraction that can result from epileptic and non-epileptic mechanisms. Myoclonic seizures of cortical origin are unilateral or bilateral synchronous jerks than can be single or repeated arrhythmically succession. It can occur both in primary and secondarily generalized epilepsies and are a defining feature of juvenile myoclonic epilepsy. These seizures have no postictal state.

4.       Clonic Seizures: These are essentially tonic clonic seizures without the tonic component. These seizures are followed by postictal confusion.

5.       Tonic Seizures: These are characterized by tonic spasms of truncal and facial muscles with associated flexion or extension of extremities and impairment of consciousness. They usually last 5 to 20 sec.

6.      Atonic Seizures: Atonic seizures consist of a sudden loss of tone in postural muscles. Usually they are lasting for less than 5 sec. Although they are associated with the change of consciousness, there are no noticeable postictal changes. When they are mild and restricted to some muscles only, they may cause a brief head drop but when severe, they lead to sudden collapse and fall.

 Diagnosis

1.      History: The history is obtained from the patient and the witnesses is the most important information in establishing the diagnosis of seizure disorder (describe in detail the events before, during and after the seizure).To determine the cause of a seizure, it should know that whether there is a family history of epilepsy, personal history of head trauma, birth complications, febrile convulsions, middle ear or sinus infections, alcohol or drug abuse or symptoms of cancer.

2.      Physical Examinations: Signs of head trauma, infection of the ear or sinuses (which may spread to the brain), any neurocutaneous markers (tuberous sclerosis) or evidence of systemic malignancy.

3.      Laboratory Tests: Blood sugar, serum calcium estimation, serum electrolytes and liver function tests in adults, electroencephalography (EEG) in the waking and sleeping states, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI).

Psychiatric Consequences of Epilepsy

Short-term Effects

1.      Preictal disturbances: Irritability, depression, fearfulness and apathy.

2.   Periictal disturbances: Aura, weird indescribable feelings, epigastric sensations, fear, feelings of unreality, illusions and hallucinations in all sensory modalities, deja’ vu and jamais vu phenomenon, forced thinking and alterations of consciousness.

3.      Postictal disturbances: Postictal confusion and disorientation and transient psychotic symptoms like hallucinations (auditory) and delusions (persecutory) occur in many cases. Sometimes the postictal psychosis continues for several weeks and in some patients it becomes fixed and fails to resolve. In others it is transitory or short lasting for one and two days only.

Long-term effects

1.      Cognitive disturbances: Impaired attention, concentration and memory.

2.      Personality changes: Aggression, alteration of sexuality, elation, depression, lability of mood, deepening of emotions, hypergraphia, obsession, paranoid symptoms, philosophical and religious interest and viscous speech.

3.      Psychotic disturbances: Schizophrenia, serious depressive symptoms and bipolar mood disorder.

4.      Neurotic disorders: Anxiety disorder, mood disturbances and dissociative disorders.

DEMENTIA

DEMENTIA

It is progressive generalized impairment of intellectual functions and memory without impairment of consciousness. 

Dementia is classified as:

1. Alzheimer’s type
2. Vascular dementia: Vascular dementias are sub classified as: a. Those with an acute onset, b. Multi infract dementia, c. subcortical vascular dementia.

3. Dementias in other diseases like Pick’s disease, Creutzfeldt–Jakob (CJ) disease, Huntington’s disease, Parkinson’s disease and HIV disease.

Specific Impairment

1.      Organic Hallucinosis [Causes: Substance abuse (alcohol, cannabis, LSD-Lysergic Acid Disethylamide), Temporal lobe tumors, etc.]

2.      Organic Catatonic Disorder [Causes: Encephalitis, Carbon monoxide poisoning, Neoplasms, etc.]

3.      Organic Delusional Disorder [Causes: Substances abuse (cannabis, amphetamines, and alcohol), Temporal lobe lesions etc.]

4.      Organic Mood Disorder [Causes: Infection, Endocrine disorders, Brain lesions and drugs like steroids and antihypertensives]

5.      Amenstic Syndrome: Amenstic disorders are characterized by severe memory impairment for recent events. Long term memory is sometimes affected. Immediate recall of events is normal, as are the other cognitive functions. The patient is alert and the conversation can be carried out normally. Learning of new materials is grossly affected. Secondary to the memory impairment there may be disorientation of time. Gaps in the memory are filled with confabulation. [Causes: Alcohol abuse and thiamine deficiency. Gastric carcinoma and dietary deficiencies resulting into thiamine deficiency produces amnestic syndromes. Damage to diencephalic and medial temporal structures (mamillary bodies, fornix, hippocampus) as a result of surgery or trauma, anoxia, infarction, infections, carbon monoxide poisoning or neoplasms of the third ventricle result in Amenstic syndromes]

6.      Personality Changes [Causes: Frontal lobe lesions, Encephalitis, Concussions, etc.]

Impairment due to Focal Brain Damage

1. Frontal Lobe Syndrome: Personality Changes: – Socially disinhibited (e.g.: urinate in public), Inattentive and easily distractible, slow and non-spontaneous, careless in dress, eats voraciously and general efficiency deteriorates. Generalized convulsions may occur. Memory and Intellect may not be impaired. Neurological deficits accompany depending on the area affected.
2. Temporal Lobe: Some temporal lobe lesions are asymptomatic but they are usually accompanied by personality changes. There is greater intellectual impairment, irritability and aggressive, epilepsy, schizophrenia, learning impairment and neurological deficits.
3. Parietal Lobe: Personality changes are uncommon but sensory defects are marked. Right-left disorientation, agnosias and dysphasias are also seen. Right-left disorientation, finger agnosia, agraphia and acalculia are together called Gerstmann’s syndrome.
4. Occipital Lobe: Visual disturbances (Lemianopias, loss of colour vision and loss of vision) and complex visual hallucinations are seen. Personality changes are uncommon.
5. Mid brain and Thalamus: Lesions of the third ventricle, mid brain, thalamus brings about personality changes, characterized by diminution of initiative, regression to a childish state and fatuous jocularity. There is deterioration of personal habits.

DELIRIUM

DELIRIUM

Delirium is and acute reversible organic condition of multiple aetiology (Trauma, Infection, Metabolic Causes, Endrocrine, Vascular Causes, Neoplasms, Drugs, Epilepsy, Vitamin Deficiency (B₁, B₁₂), Sensory Deprivation, Alcohol Withdrawal State). It has an acute onset and rapid progress. The most conspicuous feature is the clouding of consciousness which ranges from a mild dulling to deep coma.

ORGANIC M D*

ORGANIC MENTAL DISORDERS

These disorders constitute a wide variety of clinical conditions with markedly different manifestations. Cerebral dysfunction may be primary as infections, injuries or other disease conditions that affect the brain directly, or secondary as systemic disease or condition outside the brain which affect the brain functions secondarily.

A three dimensional approach is needed to distinguish different organic disorders:

1. Whether the resultant symptoms are acute or chronic.

2. Whether the insult to the brain is widespread or focal and

3. Whether the psychological impairment is generalized or specific (generalized – all the mental functions are effected such as primary mental functions, memory and cognition; specific - only one or two functions are affected such as perception, mood, volition, thinking or memory, leaving the other functions and sensorium intact).

The organic mental disorders are divided into:

1. Dementia (Alzheimer’s, vascular and others)

2. Delirium (excluding those due to substance use)

4. Other mental disorders due to the brain dysfunction

5. Personality and behaviour disorders due to brain     dysfunction

Delirium and dementia are widespread generalized psychological impairments. Delirium is an acute impairment. Dementias are chronic. Organic Amnesic syndrome is a specific impairment affecting memory functions. Other mental disorders are also specific impairments affecting perception (organic hallucinations), volition (organic cabatonic disorder), thought (organic delusional disorder), and mood (organic mood disorder) Organic personality and behavioral disorders are generalized conditions due to widespread or focal brain dysfunction.