Moderate MR adult patient with impulse control disorder

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Gavanshir

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How do you handle a moderately MR patient with impulse control disorder who is fixated on food and often physically attacks staff when there is no food or sugary drinks left?

I obviously like to avoid use of restraints in this patient but that hasn't always been possible. It has also been difficult to snow him when he does get agitated. Any wisdom is appreciated!

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Please provide a more detailed presentation. What is the actual diagnosis - is it only Impulse Control Disorder? Any medical issues? I would assume patient is overweight at a minimum. What meds are already prescribed, what has already been tried, and for how long? Any behavioral approaches in place?

It occurs to me I should charge for consultation work. ;)

Generally, psychiatrists often use antipsychotics, mood stabilizers, and sometimes TCAs in these types of cases. Comorbidities matter a lot.
 
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Hehe let's call this one an SDN freebie.

I'm not personally involved in the care of this patient, only interested in the management of his acute agitation as I often get called for him during calls. I don't believe he has any other diagnosis at this time other than moderate MR and impulse control disorder. Yes he is moderately overweight and all of his "fits" relate to him demanding more food or soda so I have stayed away from Zyprexa. He is usually verbally redirectable but only temporarily. I have been called about him between 3-6am pretty much consistently every night since last week.

Are there any techniques other than Haldol/Ativan + 4 pt restraints that may be effective?

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Has he been tested for diabetes? If he's already in the hospital, a mixed meal test tolerance test would be easy to conduct.
 
How do you handle a moderately MR patient with impulse control disorder who is fixated on food and often physically attacks staff when there is no food or sugary drinks left?

I obviously like to avoid use of restraints in this patient but that hasn't always been possible. It has also been difficult to snow him when he does get agitated. Any wisdom is appreciated!

Sent from my SM-G935F using SDN mobile
have you Googled 'Prader-Willi' syndrome?
 
How do you handle a moderately MR patient with impulse control disorder who is fixated on food and often physically attacks staff when there is no food or sugary drinks left?

I obviously like to avoid use of restraints in this patient but that hasn't always been possible. It has also been difficult to snow him when he does get agitated. Any wisdom is appreciated!

Sent from my SM-G935F using SDN mobile
if you google 'management of Prader-Willi syndrome' one of the first links is to a reputable text from Springer Press which is actually a free legit download from the publisher...in case that's a part of what's going on.
 
Get someone with ABA (Applied Behavior Analysis) experience in board. Seen it work wonders with MR/Autism/mod to severe TBI.
I was thinking along the same lines- sometimes a person just needs to know what to expect and then he can stop panicking. If this is a very frequent thing that he wakes up "needing" food at 3 am, it would be so easy to put it on a daily schedule for him and show him:"look, when you wake up very hungry, there is a snack on your schedule." So much better than letting a battle occur and maybe escalate every time.
 
I was thinking along the same lines- sometimes a person just needs to know what to expect and then he can stop panicking. If this is a very frequent thing that he wakes up "needing" food at 3 am, it would be so easy to put it on a daily schedule for him and show him:"look, when you wake up very hungry, there is a snack on your schedule." So much better than letting a battle occur and maybe escalate every time.

If I recall correctly, there have been articles published in the Journal of Applied Behavior Analysis (free) with single case designs outlining components of successful behavior modification plans-- generally using a differential reinforcement paradigm along with functional communication training and even a token/chart reward system to help manage behavioral disturbance in prader-willi syndrome--which generally relates to the problem of the person exhibiting aggression or self-injury which is intermittently reinforced by access to food...for which they have an insatiable drive. Tough cases and staff training to consistently follow the plan is essential. Got any competent psychology staff trained in applied behavior analysis, plan implementation, and staff training?
 
SSRIs do wonders, I've found, in MR and/or autistic patients in decreasing impulsivity. You can also try risperidone or Abilify but I try and avoid meds that need labs and cause further weight gain since it's usually very difficult for these patients to get labs.
 
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SSRIs do wonders, I've found, in MR and/or autistic patients in decreasing impulsivity. You can also try risperidone or Abilify but I try and avoid meds that need labs and cause further weight gain since it's usually very difficult for these patients to get labs.

Yes and in many cases I've observed and treated as an OCD type presentation. I'd also focus on sleep hygiene and possibly sleep meds if he is consistently waking up over night. My guess is there is also a fairly significant behavioral component and that tantruming or aggression has historically resulted in filling the pie hole.
 
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Seems like a tricky situation, especially for night staff because it's going to be hard to keep consistency.

One night the staff is going to find extra snacks to give him what he wants then the weekend night crew may be demanding IM Thorazine from the night intern in the exact same situation
 
Tough situation. Definitely a firm believer in behaviour modification strategies, but the practicalities of implementing this with staff can be challenging at the best of times and more so if the problem is occurring at odd hours.

For patients without primary psychotic disorders, I’ve found that initiating regular low doses of either a mood stabiliser (eg. valproate 100mg BD) or an antipsychotic (eg. risperidone 0.25-0.5mg BD) to be quite effective both in terms of limiting aggressive behaviours and avoiding situations where you’re needing to use 4 point restraint.

Now if you're only on call for the patient overnight, this sort of change should normally fall on the regular treating team to implement. However, if a patient is getting both haloperidol and lorazepam in the early hours they may be sedated to the point where they do present as a management issue for much of the morning resulting in the the issue consistently being left to afterhours staff to deal with.
 
Thanks for the suggestions. Patient is in the 40s age range. I don't think it's Prader-Willie's because the fixation is really for soda, every once in a while it might be crackers but 9/10 it's soda, and one particular brand of soda. Thorazine, Haldol/Ativan and Zyprexa have been his mainstays. Unfortunately the inpatient psych unit is just not equipped with the right staff to handle this kind of patient. Without giving specifics, he is stuck here now because of a family issue that needs to be resolved. SSRIs, mood stabilizers and antiepileptics are interesting suggestions, I wonder if there is any evidence to support their use in this case?

In regards to appetite suppressing medications, such as what?
 
Thanks for the suggestions. Patient is in the 40s age range. I don't think it's Prader-Willie's because the fixation is really for soda, every once in a while it might be crackers but 9/10 it's soda, and one particular brand of soda. Thorazine, Haldol/Ativan and Zyprexa have been his mainstays. Unfortunately the inpatient psych unit is just not equipped with the right staff to handle this kind of patient. Without giving specifics, he is stuck here now because of a family issue that needs to be resolved. SSRIs, mood stabilizers and antiepileptics are interesting suggestions, I wonder if there is any evidence to support their use in this case?

In regards to appetite suppressing medications, such as what?
Not the person who wrote that, but in my experience Prozac out of the SSRIs has an appetite reducing effect. Paxil is the exact opposite in my experience.

L-tryptophan reduces appetite and has some research showing benefit in assisting with both sleep and depression (it's a precursor to serotonin). Have some milk and peanut butter before bed.

I asked before and maybe it's so obvious that it was ruled out to begin with, but could it be diabetes presenting with reactive hypoglycemia? If he's eating constantly during the day, he could be compensating for the insulin insensitivity, but overnight not eating the excess insulin production doesn't slow down fast enough and can cause a drop. Even relative reactive hypoglycemia can cause huge hunger pangs.

Out of curiosity, is the patient diagnosed with impulse control disorder specifically because of this outburst for soda in the middle of the night in the setting of the hospital, or was it diagnosed previous to that? The reason I ask is that I think there are millions of "healthy" people who wake up for midnight snacks and would be pretty ornery if someone got in their way.

And if he's taking Zyprexa . . . well I gained 60 lbs in a couple of months on Zyprexa. I remember the first night I took it. I didn't know what was happening to me. I was drinking straight out of a 2 liter bottle of Coke (which I never normally would drink) as I was falling asleep. If I forced myself to go to bed without giving in to it I would wake up with jerks a half hour later and have to get sugar. It would have been tortuous to deny myself sugar on that drug. I went off of it very quickly because of that problem.
 
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I would think through the phenomenology, but here are some heuristics I like:

1) More on the obsessive/compulsive end- use an SRI and/or a high potency D2 blocking antipsychotic
2) Autism- as we all know Risperdal and Abilify have the best evidence but you have to be careful because it looks like antipsychotic mediated weight gain involves some increase in motivational salience/ventral striatal activatio
3) Mood stabilizer (my order would be Lithium, Lamictal, Depakote), particularly if BPAD family history
4) Don't forget food addiction (which should be in the DSM). Since he is moderate ID he might be able to complete a YFAS (though might be tough to get him to do it!) but you can try off label use of Naltrexone.
 
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I don't know if it would be appropriate in this situation, but maybe topiramate for reducing agitation and appetite? Especially if you are going to put him on an antiepileptic anyway.
 
I don't know if it would be appropriate in this situation, but maybe topiramate for reducing agitation and appetite? Especially if you are going to put him on an antiepileptic anyway.
is the idea to take a moderately intellectual disabled person and make them profoundly intellectual disabled with the help of topamax?
 
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We had a somewhat similar patient on one of our inpatient units - he was a big guy, very strong, and would get insanely worked up such that he would begin assaulting staff (this happened multiple times), threatening staff and other patients, etc. etc.. He held diagnoses of moderate ID and "schizophrenia" (nothing in our 3 weeks together on the unit supported that diagnosis). He was essentially being treated for his aggression as his family felt unsafe with him at home and he kept getting kicked out of group homes because of his behavior.

We tried multiple regimens - both scheduled and PRN - and what ultimately ended up working was some specifically timed doses of chlorpromazine (50 mg PO BID at specific times) as he tended to get agitated at the same time each day. For emergency medications, we would use 25 mg IM. This seemed to work pretty well for him. Obviously at those doses you're getting very little if any dopamine blockade, but the sedation was sufficient to control his behavior without making him a zombie.

Anyway, something to think about. I think there are a million different ways to approach this kind of patient, and what's "best" is ultimately what will work and what the patient will take.
 
is the idea to take a moderately intellectual disabled person and make them profoundly intellectual disabled with the help of topamax?

That's pretty harsh, considering the topic of the discussion is "how to prevent this guy from getting put in restraints and forcibly medicated every day".
 
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