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Behavioural Deterioration in ID — MRCPsych Paper B MCQ

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ModerateIntellectual DisabilityBehavioural Deterioration in IDMRCPsych Paper B

A 32-year-old man with moderate intellectual disability and epilepsy has developed 2 weeks of shouting, disturbed sleep and occasional self-injury. There has been no increase in witnessed seizures, acute injury or immediate danger to others. A carbamazepine trough concentration is below the laboratory reference range, but adherence and the reason for the low concentration have not yet been established. What is the most appropriate initial approach?

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Correct answer: C — Carry out a phased biopsychosocial and functional assessment, including physical health, pain, medication and environmental factors

Explanation lettering: E = shown as A · D = shown as B · B = shown as C · A = shown as D · C = shown as E

B is correct. New behaviour that challenges in a person with intellectual disability requires a phased biopsychosocial and functional assessment. This should examine physical illness and pain, mental state, medication effects and adherence, seizure history, communication needs, recent life events and environmental triggers. The low carbamazepine concentration is relevant but does not by itself establish that undertreated epilepsy is causing the behaviour or justify immediate dose escalation. Carbamazepine may subsequently be optimised if assessment identifies epilepsy or medication adherence as a contributing factor. Antipsychotics are not first-line without a relevant psychiatric indication, failed psychosocial approaches or very severe risk. Neurology referral may be appropriate but should not delay the broader assessment. Inpatient restrictive management is disproportionate without immediate serious risk.

Reference: National Institute for Health and Care Excellence. Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges. NICE guideline NG11, recommendations 1.5.1, 1.5.5, 1.5.11 and 1.8.1. 2015, updated 2020. https://www.nice.org.uk/guidance/ng11/chapter/recommendations