CLINICAL HANDBOOK OF SCHIZOPHRENIA

442 VI. SPECIAL POPULATIONS AND PROBLEMStant, as is an account of success or failure in meeting developmental milestones at appropriateages. Behavioral problems that emerged during childhood development need close attention.Social and educational histories help to complete the developmental picture. Theevaluator should inquire specifically about any history of previous psychiatric symptoms.Physical examination, with an emphasis on the neurological exam and a carefulmental status exam, complement and enhance the understanding gained from the comprehensivehistory. The initial evaluation of most individuals should include a generallaboratory screen, such as complete blood count (CBC), urinalysis, and a metabolicpanel. Genetic tests may be indicated depending on the history and on recognized signsand symptoms. We strongly emphasize attention to general medical health, especially forpersons with severe disability who are not able to orally communicate symptoms or distresseffectively. Medical illness can cause CNS dysfunction that results in delirium withpsychotic symptoms. Signs and symptoms of medical illness can also mimic psychosis.One patient, who was incapable of speech, was referred to our care and was thought tohave a psychosis that resulted in physical agitation, nonstop yelling, and obvious emotionaldistress. The etiology of this syndrome proved to be a severe deglutition disorderthat resulted in most of his oral intake going into his lungs. The entire syndrome wascured by an appropriate surgical procedure.A psychologically informed analysis of behavioral function, combined with neuropsychologicalassessment, almost always yields important data. For individuals withacute psychotic illness, this specialized neuropsychological testing can be deferred untilafter initial treatment and stabilization.Electroencephalography (EEG) can give useful information about cerebral functionbut does not usually open an avenue to treatment of schizophrenia unless epilepticdysrhythmia is present. Brain imaging is indicated for many individuals, especially thosehaving their initial assessment. We generally favor magnetic resonance imaging (MRI)over computed tomography (CT) because of the larger amount of anatomical informationobtained.TREATMENT OF SCHIZOPHRENIA IN PERSONS WITH IDThere are few evidence-based reports in the form of controlled, randomized drug trialsconcerning pharmacotherapy for schizophrenia in the context of ID. In 1999, Dugganand Brylewski conducted an extensive computer literature search for evidence of efficacyfor any antipsychotic drug in treatment of people with a dual diagnosis of schizophreniaand ID. They found “no trial evidence to guide the use of antipsychotic medication forthose with both intellectual disability and schizophrenia” (p. 94).Our MEDLINE search found one other study, which compared risperidone and placeboin a study involving 118 children with ID and severe behavioral disturbance. Therisperidone group showed significantly greater improvement than did the placebo group(Aman, DeSmedt, Derivan, Lyons, & Findling, 2002). This report pertained only to children,not to adults.How do we treat schizophrenia in persons with ID? We use a combination ofpharmacotherapy and psychosocial therapy, which represents the two main lines ofthinking about the causes and treatment of psychiatric illness over the past 200 years.Neither approach can or should be neglected in 2008. Both aspects of treatment will continueto be needed for the foreseeable future. We do not yet have a cure for schizophrenia.Pharmacotherapy for schizophrenia in persons with ID does not fundamentally differfrom treatment of schizophrenia in nondisabled persons. Except in emergencies, we