Down's syndrome with mania

Pharmacotherapy of Down syndrome

Introduction: Comorbid psychiatric disorders are common in Down syndrome (DS). Evidence for pharmacotherapy of psychiatric co-morbidity in DS is limited. Areas covered: This article reviews the literature on the pharmacotherapy of psychiatric conditions co-occurring with DS, including major depressive disorder (MDD), bipolar disorder, anxiety disorders, obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), psychosis, and catatonia. A section on the phenomenon of regression is included. Expert opinion: For MDD, we typically begin with selective serotonin reuptake inhibitors (SSRIs). For bipolar disorder, we often use carbamazepine. For psychotic symptoms, we begin with risperidone or aripiprazole. We use buspirone to treat anxiety. For obsessional slowness/OCD, we begin with an SSRI. For stereotypical repetitive behavior, we tend to use buspirone. For ADHD, we begin with guanfacine. For irritability of comorbid ASD, we use risperidone or aripiprazole. For dementia in DS, we refer to a neurologist for medical work-up and medication management. We treat catatonia-like 'regression' with lorazepam. If ineffective, we use memantine or clozapine. Electroconvulsive therapy is considered if pharmacotherapy is ineffective. We treat 'regression' with symptoms of MDD ± psychosis, with an antidepressant and an antipsychotic if needed. Randomized controlled trials of medications for comorbid psychiatric disorders in DS are warranted.

Comorbid Down's syndrome, Tourette syndrome and intellectual disability: registry prevalence and developmental course

The co-occurrence of Tourette syndrome (TS) and Down's syndrome (DS) has been previously reported in the literature. In the present study, a retrospective record review was conducted using the North Dakota TS registry in order to ascertain the number of cases of TS and DS, and to develop case descriptions. We identified five cases from North Dakota. Two of these patients were simply comorbid for TS and DS. One was additionally comorbid for bipolar disorder, another for childhood disintegrative disorder and a third had a D/G group translocation. The association between DS and TS occured in 2% of TS patients. Contrary to the situation in patients with pervasive developmental disorders, the presence of TS in DS may be a negative prognostic indicator.

Major depression in a small group of adults with Down syndrome

The clinical histories and treatment of the nine individuals with Down syndrome (DS) and major depression (MD) previously noted in a report on the psychopathology of a population of 164 adults with DS with and without health disorders from a Down Syndrome Clinic are presented (Myers & Pueschel, 1991). The clinical characteristics including DSM-III-R (1987) criteria of these 9 patients plus 13 individuals with DS and MD described in case reports in the literature are summarized. Depression is rarely verbalized and commonly appears as crying, depressed appearance, or mood lability. Vegetative symptoms of disinterest with severe withdrawal and mutism, psychomotor retardation, decreased appetite, weight loss, and insomnia are prominent. Verbal expression of preoccupations of suicide, death, self-depreciation, and guilt were infrequent and may either be not present or not reported due to mutism or moderate level of mental retardation (MR). Hallucinations were prominent. Family history of depression was infrequent. Psychological stressors were noted mostly in the study sample and not in the 13 from the literature. The pattern of vegetative symptomatology with few verbal complaints and prominent hallucinations may be related to moderate mental retardation in these groups with DS rather than specifically to DS.

Is there an inverse relationship between Down's syndrome and bipolar affective disorder? Literature review and genetic implications

Several authors have suggested the existence of an inverse relationship between bipolar affective disorder and Down's syndrome (DS). The present authors have examined this hypothesis by a critical review of the literature. The present findings are consistent with a reduced rate of bipolar disorder in subjects with DS when compared with non-DS mentally retarded adults and with the general population. Thus, possession of an extra copy of chromosome 21 may confer protection against bipolar disorder. This could be the result of non-specific mechanisms or the action of a disease-modifying gene. However, the most interesting possibility is that either dominant or recessive alleles act at a major susceptibility locus for bipolar disorder on chromosome 21. Testable predictions result from the major susceptibility locus models. In order to investigate these hypotheses further, the present authors suggest the following: (1) further studies of the prevalence of bipolar disorder in DS; and (2) the reporting of all cases of bipolar disorder in trisomy 21 with details of the meiotic origin of the non-disjunction and details about affective disorder in relatives of the proband.

Chromosomal aberrations and bipolar affective disorder

Chromosomal abnormalities associated with bipolar disorder may help in the localisation of susceptibility genes for bipolar illness by pinpointing 'candidate' regions of the genome for further study using molecular genetic methods. We review descriptions of chromosomal abnormalities in association with bipolar and related affective disorders and evaluate their relevance for localising susceptibility genes for bipolar disorder, using standardised criteria. We found 28 reports. We identified four genomic regions of potential interest: 11q21-25; 15q11-13; chromosome 21;Xq28. It is important that clinicians are able to recognise patients who may have chromosome abnormalities which could help in the localisation of susceptibility genes for psychiatric disorders. We suggest referral for specialist investigation and karyotyping, to a psychiatric genetics research group, of any patient with functional psychosis and one or more of the following: (a) a strong family history of functional psychosis; (b) mental retardation; (c) another disease known to be caused by a single gene; or (d) congenital abnormalities.

Late onset mania in Down's syndrome

Manic episodes have seldom been reported in individuals with Down's syndrome. The case of an individual with Down's syndrome who developed a manic episode in later life is described. This manic episode was subsequently followed by a first depressive episode.

Bipolar disorder associated with Klinefelter's syndrome and other chromosomal abnormalities

A patient with bipolar disorder and previously undiagnosed Klinefelter's syndrome presented with acute mania refractory to pharmacotherapy and was successfully treated with electroconvulsive therapy. This case constitutes the 31st case report documenting the coexistence of bipolar disorder with chromosomal anomalies and the 14th such patient with Klinefelter's syndrome. The relevance of this case to understanding the genetics of bipolar disorder is explored through a review of previously published reports of bipolar patients with chromosomal abnormalities. The relatively high incidence of Klinefelter's syndrome among this group of patients is discussed in the context of evidence for linkage of bipolar illness to the X chromosome.

Mania and Down's syndrome

Until recently, it was considered that Down's syndrome precluded a diagnosis of mania, or gave rise to an atypical presentation. There have been seven case reports of mania in people with Down's syndrome and all these cases are reviewed. The clinical features of mania are noted to be similar to those previously described in individuals with learning disabilities due to other causes. However, all reported cases are male and none has a family history of affective disorder. In two of the seven men reported, the illness followed a rapid cycling pattern. Hypothyroidism and monoamine biochemistry in people with Down's syndrome are discussed in the context of these atypical features.

Differential rates of psychiatric disorders in adults with Down's syndrome compared with other mentally handicapped adults

The total number of adults with Down's syndrome living in Leicestershire, ascertained by widespread enquiry, was found to be 378. Of these, 371 were matched with adults with mental handicap due to other pathologies, on the basis of age, sex, and type of residence. Those with Down's syndrome were found to have a different spectrum of mental disorders from those without the syndrome. In particular, Down's syndrome patients were more likely to have been diagnosed as having depression and dementia; the controls were more likely to have been diagnosed as suffering from conduct disorder, personality disorder, or schizophrenia/paranoid state. The same proportion of each group had been given a diagnosis of autism.

Chromosomal aberrations and schizophrenia. Autosomes

Chromosomal aberrations associated with schizophrenic disorders may suggest regions in which to focus a search for genes predisposing to schizophrenia by a linkage strategy. As for other genetic illnesses, chromosomal abnormalities may also provide useful tools for subsequent physical mapping, fine localisation, and isolation of important susceptibility genes. Identification of several chromosomal aberrations may be especially important, given the unknown pathophysiology, the paucity of known brain genes, and the probable genetic heterogeneity of schizophrenia and manic-depression. However, because psychiatric disorders are common and inherited in a complex manner, researchers must use caution when drawing inferences about associations with chromosomal aberrations. Reported abnormalities involving autosomes (chromosomes 1-22) associated with psychotic disorders are reviewed. Their relevance to linkage studies localising genes for schizophrenia was estimated by standardised criteria for specificity, diagnosis, family history, and overall weight of evidence. Four 'possibly relevant' chromosomal regions were identified: 5q, 11q, 18q, and 19p. This paper outlines strategies for future studies to detect new chromosomal aberrations associated with major psychotic disorders that may be relevant to isolating the genes for schizophrenia.

Familial manic-depressive illness with deleted short arm of chromosome 21: coincidental or causal?

A 35-year-old Arab lady and her mother, both with bipolar manic-depressive illness and 46,XX,21p-(pcen----pter), are reported. The clinical significance of this association is considered.

Schizophrenia and mental handicap: an historical review, with implications for further research

The relationship between schizophrenia and 'mental handicap' has been obscured by historical changes and varying diagnostic criteria. It has been generally accepted that there is an increased incidence of psychotic illness among people with intellectual retardation, but detailed community surveys are limited. Catatonia, severity of illness and research potential are all to be found in this 'dual diagnosis' group. The value of an historical analysis is underlined.