psychiatry 5th year, 3rd lecture (dr. rebwar ghareeb hama)

Organic Mental DisordersOrganic Mental Disorders

Dr. Rebwar Ghareeb HamaDr. Rebwar Ghareeb HamaPsychiatristPsychiatrist

University of SulaimaniUniversity of SulaimaniCollege of MedicineCollege of Medicine

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DementiaDementiaDementiaDementia is a syndrome usually of chronic is a syndrome usually of chronic

and progressive nature characterized by and progressive nature characterized by decline of memory, personality and intellectdecline of memory, personality and intellect

Diagnostic criteria of dementiaDiagnostic criteria of dementia::• decline of learning new informationdecline of learning new information• decline of other cognitive functions (thinking, decline of other cognitive functions (thinking,

judgement, planning, organizing, processing of judgement, planning, organizing, processing of information)information)

• no disorder of consciousnessno disorder of consciousness• affective disorders (impaired emotional control - affective disorders (impaired emotional control -

lability, irritability, apathy, decline of social lability, irritability, apathy, decline of social functioning)functioning)

• the symptoms evident for at least 6 monthsthe symptoms evident for at least 6 months22

DementiaDementia

The degrees of dementia:The degrees of dementia:• mildmild• moderatemoderate• seriousserious

Dementia is usually (80%) an Dementia is usually (80%) an irreversible processirreversible process

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Dementia in Alzheimer’s DiseaseDementia in Alzheimer’s Disease

DAT = dementia of Alzheimer's typeDAT = dementia of Alzheimer's type:: The most frequent type of dementiaThe most frequent type of dementia Primary degenerative cerebral disease of Primary degenerative cerebral disease of

unknown etiologyunknown etiology Characterized with marked reduction of Characterized with marked reduction of

neurons, appearance of neurofibrillary neurons, appearance of neurofibrillary tangles and senile plaques (beta-amyloid)tangles and senile plaques (beta-amyloid)

Especially cholinergic system is affectedEspecially cholinergic system is affected

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DAT with Early OnsetDAT with Early Onset

Dementia before the age of 65Dementia before the age of 65 Relatively rapid deteriorationRelatively rapid deterioration Aphasia, agraphia, alexia, apraxiaAphasia, agraphia, alexia, apraxia

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DAT with Late OnsetDAT with Late Onset

Dementia after the age 65Dementia after the age 65 Family history of DAT or Down’s Family history of DAT or Down’s

syndromesyndrome Slow progression, no insightSlow progression, no insight Severe impairment of memory, Severe impairment of memory,

confabulationsconfabulations

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Causes of DementiaCauses of Dementia

1.1. Pharmacogenic dementia Pharmacogenic dementia (anticholinergics, benzodiazepines, (anticholinergics, benzodiazepines, cytostatics, ...)cytostatics, ...)

2.2. Alcohol dementiaAlcohol dementia (Korsakov, Wernicke) (Korsakov, Wernicke)

3.3. Intoxicant dementia of other Intoxicant dementia of other etiologyetiology (CO, Pb, Hg, solvents) (CO, Pb, Hg, solvents)

4.4. Dementia at vitamin deficit Dementia at vitamin deficit (niacin-(niacin-pellagra, vit. B12)pellagra, vit. B12)

5.5. Dementia of endocrine originDementia of endocrine origin (hypothyroid, Cushing)(hypothyroid, Cushing)

6.6. Dementia due to dialysisDementia due to dialysis77

Causes of DementiaCauses of Dementia

7.7. Metabolic dementiaMetabolic dementia (hypernatremia, (hypernatremia, hypocalemia)hypocalemia)

D. at uraemiaD. at uraemia (uremic encephalopathy) (uremic encephalopathy)

D. at WilsonD. at Wilson

D. at liver encephalopathyD. at liver encephalopathy

8.8. D. due to hypoxiaD. due to hypoxia

9.9. D. due to traumaD. due to trauma

10.10. D. at epilepsyD. at epilepsy

11.11. D. due to infectionD. due to infection (human immunodeficiency (human immunodeficiency virus disease, prion infection - Creutzfeldt-Jakob virus disease, prion infection - Creutzfeldt-Jakob d., kuru)d., kuru)

12.12. D. at brain tumorsD. at brain tumors88

Vascular DementiaVascular Dementia

Diagnostic guidelinesDiagnostic guidelines::

a)a) Presence of a dementiaPresence of a dementia

b)b) Uneven impairment of cognitive function Uneven impairment of cognitive function + focal neurological signs+ focal neurological signs

c)c) Insight and judgement relatively well Insight and judgement relatively well preservedpreserved

d)d) An abrupt onset or a stepwise An abrupt onset or a stepwise deteriorationdeterioration

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Vascular DementiaVascular Dementia

Associated featuresAssociated features::a)a) HypertensionHypertensionb)b) Emotional lability, weeping or explosive Emotional lability, weeping or explosive

laughterlaughterc)c) Transient episodes of clouded Transient episodes of clouded

consciousnessconsciousnessd)d) Personality relatively well preserved, Personality relatively well preserved,

accentuation of previous traits accentuation of previous traits (egocentrism, paranoid attitudes, (egocentrism, paranoid attitudes, irritability)irritability)

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Dementia in Other Diseases Dementia in Other Diseases Classified ElsewhereClassified Elsewhere

Dementia in Pick’s diseaseDementia in Pick’s diseasea)a) A progressive dementiaA progressive dementiab)b) A predominance of frontal lobe features A predominance of frontal lobe features

(euphoria, emotional blunting, coarsening (euphoria, emotional blunting, coarsening of social behaviour, disinhihition, apathy)of social behaviour, disinhihition, apathy)

c)c) Behavioural manifestationsBehavioural manifestations

Dementia in Creutzfeldt-Jakob diseaseDementia in Creutzfeldt-Jakob diseasea)a) Fairly rapid progressing over months to 1-Fairly rapid progressing over months to 1-

2 years2 yearsb)b) Multiple neurological signs (pyramidal + Multiple neurological signs (pyramidal +

extrapyramidal, ataxia)extrapyramidal, ataxia)1111

Dementia in Other Diseases Dementia in Other Diseases Classified ElsewhereClassified Elsewhere

Dementia in Huntington’s diseaseDementia in Huntington’s disease

a)a) Family history of H’s d.Family history of H’s d.

b)b) Onset at a relatively young ageOnset at a relatively young age

c)c) Involuntary choreiform movementsInvoluntary choreiform movements

d)d) Slow progression of dementiaSlow progression of dementia

Dementia in Parkinson’s diseaseDementia in Parkinson’s disease

In severe cases, no particular In severe cases, no particular distinguishing featuresdistinguishing features

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Dementia in Other Diseases Dementia in Other Diseases Classified ElsewhereClassified Elsewhere

Dementia in human immunodeficiency virus Dementia in human immunodeficiency virus (HIV) disease(HIV) disease

a)a) HIV infectionHIV infectionb)b) Complaints of forgetfulness, slowness, Complaints of forgetfulness, slowness,

poor concentration, difficulties with poor concentration, difficulties with problem-solving and readingproblem-solving and reading

c)c) Apathy, social withdrawal, affective Apathy, social withdrawal, affective disorderdisorder

d)d) Neurological signs (tremor, ataxia, Neurological signs (tremor, ataxia, hyperreflexia,...)hyperreflexia,...)

General paralysis of the insane (GPI – General paralysis of the insane (GPI – paralysis progressiva)paralysis progressiva)

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Treatment of DementiaTreatment of Dementia

A)A) Pharmacotherapy of cognitive symptomsPharmacotherapy of cognitive symptoms1.1. Cholinesterase inhibitors - (physostigmin, Cholinesterase inhibitors - (physostigmin,

rivastigmin, donepezil, metrifonat, galantamin, rivastigmin, donepezil, metrifonat, galantamin, tacrin)tacrin)

2.2. Selegilin, lecitin, propentophylinSelegilin, lecitin, propentophylin3.3. Nootropic agents + agents with a scavanger effect Nootropic agents + agents with a scavanger effect

(piracetam, Gingko biloba, vitamine E)(piracetam, Gingko biloba, vitamine E)

4.4. Agonists of muscarinic (MAgonists of muscarinic (M11, M, M33) and nicotinic ) and nicotinic acetylcholine receptors (nicotine)acetylcholine receptors (nicotine)

5.5. Nootropic agents (cerebral metabolic enhancers) + Nootropic agents (cerebral metabolic enhancers) + Ca channel antagonists (nimodipin, cinnarizin)Ca channel antagonists (nimodipin, cinnarizin)

6.6. Nootropic agents + antiinflammatory agents Nootropic agents + antiinflammatory agents (acetylosalicylic acid, ibuprofen, indometacine)(acetylosalicylic acid, ibuprofen, indometacine)

7.7. Nerve growth factors (cerebrolysin)Nerve growth factors (cerebrolysin)8.8. Somatostatin deficit (octostatin)Somatostatin deficit (octostatin)

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Treatment of DementiaTreatment of Dementia

B)B) Pharmacotherapy of non-cognitive symptomsPharmacotherapy of non-cognitive symptoms1.1. Depression, anxiety - SSRI (citalopram, fluvoxamin, Depression, anxiety - SSRI (citalopram, fluvoxamin,

paroxetin, …), SNRI (venlafaxin)paroxetin, …), SNRI (venlafaxin)2.2. Psychotic + confusional states - neuroleptics with minimal Psychotic + confusional states - neuroleptics with minimal

adrenolytic + anticholinergic effects (tiaprid, sulpirid, adrenolytic + anticholinergic effects (tiaprid, sulpirid, risperidon, haloperidol, clozapin)risperidon, haloperidol, clozapin)

3.3. Insomnia - non-benzodiazepine hypnotics (zolpidem, Insomnia - non-benzodiazepine hypnotics (zolpidem, zopiclon)zopiclon)

4.4. Epileptic seizures - carbamazepin, valproic acid, Na Epileptic seizures - carbamazepin, valproic acid, Na valproatevalproate

C)C) PsychotherapyPsychotherapy1.1. Reeducation of cognitive, emotional + behavioural Reeducation of cognitive, emotional + behavioural

disordersdisorders2.2. Family therapyFamily therapy3.3. Alzheimer’s societyAlzheimer’s society 1515

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DeliriumDelirium

Diagnostic guidelines:Diagnostic guidelines:a)a) Impairment of consciousness and attentionImpairment of consciousness and attentionb)b) Global disturbance of cognition (perceptual Global disturbance of cognition (perceptual

distortions, illusions, hallucinations, distortions, illusions, hallucinations, impairment of abstract thinking and impairment of abstract thinking and comprehension, disorientation for time + comprehension, disorientation for time + place)place)

c)c) Psychomotor disturbances (hypo- or Psychomotor disturbances (hypo- or hyperactivity,...)hyperactivity,...)

d)d) Disturbances of sleep (reversal of the sleep-Disturbances of sleep (reversal of the sleep-wake cycle)wake cycle)

e)e) Emotional disturbances (anxiety, fear, Emotional disturbances (anxiety, fear, irritability, apathy, perplexity)irritability, apathy, perplexity)

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SYNONYMS FOR DELIRIUMSYNONYMS FOR DELIRIUM

Acute confusional stateAcute confusional state Toxic-metabolic encephalopathyToxic-metabolic encephalopathy Organic brain syndromeOrganic brain syndrome ICU psychosisICU psychosis

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CAUSES of DeliriumCAUSES of Delirium

METABOLIC;METABOLIC; HypernatremiaHypernatremia HypercalcemiaHypercalcemia Hypo-, hyper-glycemiaHypo-, hyper-glycemia Uremia (uremic encephalopathy)Uremia (uremic encephalopathy) Liver failure (hepatic Liver failure (hepatic

encephalopathy)encephalopathy)

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INFECTIOUS;INFECTIOUS;

Urinary tract infectionUrinary tract infection PneumoniaPneumonia SepsisSepsis Delirium may be the first sign of Delirium may be the first sign of

infection, predating fever, infection, predating fever, leukocytosis, CXR findingsleukocytosis, CXR findings

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MEDICATIONS;MEDICATIONS;

Anticholinergics (Cogentin, Artane)Anticholinergics (Cogentin, Artane) Psychotropic medications Psychotropic medications

(Thorazine, Mellaril, TCAs, Paxil, (Thorazine, Mellaril, TCAs, Paxil, Benzodiazepines)Benzodiazepines)

Lithium toxicityLithium toxicity SteroidsSteroids NarcoticsNarcotics

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CNS CAUSES OF DELIRIUM;CNS CAUSES OF DELIRIUM; Alcohol withdrawal (delirium tremens) -- Alcohol withdrawal (delirium tremens) --

very agitated deliriumvery agitated delirium Barbiturate/benzo withdrawal (rare)Barbiturate/benzo withdrawal (rare) Post-ictalPost-ictal Increased intracranial pressureIncreased intracranial pressure Head traumaHead trauma Encephalitis/meningitisEncephalitis/meningitis VasculitisVasculitis

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MANAGEMENT OF DELIRIUMMANAGEMENT OF DELIRIUM

Find the cause(s)Find the cause(s) Usually multifactorialUsually multifactorial Look for medication toxicityLook for medication toxicity Re-orient patientRe-orient patient Quiet, unstimulating environmentQuiet, unstimulating environment Antipsychotic medications for agitationAntipsychotic medications for agitation Benzodiazepines often makes delirium Benzodiazepines often makes delirium

worseworse Observation/restraints only when neededObservation/restraints only when needed

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Other Mental Disorders Due to Brain Damage Other Mental Disorders Due to Brain Damage and Dysfunction and to Physical Disease and Dysfunction and to Physical Disease

Diagnostic guidelines:Diagnostic guidelines:a)a) Evidence of cerebral disease, damage or Evidence of cerebral disease, damage or

dysfunction, or of systemic diseasedysfunction, or of systemic diseaseb)b) A temporal relationship (weeks or a few A temporal relationship (weeks or a few

months) between the development of the months) between the development of the underlying disease and the onset of the underlying disease and the onset of the mental syndromemental syndrome

c)c) Recovery from the mental disorder following Recovery from the mental disorder following removal or improvement of the underlying removal or improvement of the underlying presumed causepresumed cause

d)d) Absence of evidence to suggest an Absence of evidence to suggest an alternative cause of the mental symptomsalternative cause of the mental symptoms

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Types: organic hallucinosis, org. Types: organic hallucinosis, org. catatonic disorder, org. delusional catatonic disorder, org. delusional (schizophrenia-like) disorder, org. (schizophrenia-like) disorder, org. affective disorders (manic, affective disorders (manic, depressive, anxiety, emotionally depressive, anxiety, emotionally labile), mild cognitive disorder (may labile), mild cognitive disorder (may precede, accompany, or follow a precede, accompany, or follow a wide variety of infections and wide variety of infections and physical disorders)physical disorders)

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Personality and Behavioural Disorders Due to Personality and Behavioural Disorders Due to Brain Disease, Damage and DysfunctionBrain Disease, Damage and Dysfunction

Organic personality disorderOrganic personality disorderDiagnostic guidelinesDiagnostic guidelines::a)a) Consistently reduced ability to persevere with Consistently reduced ability to persevere with

goal-directed activitiesgoal-directed activitiesb)b) Altered emotional behaviour (emotional lability, Altered emotional behaviour (emotional lability,

euphoria, irritability, outbursts of anger and euphoria, irritability, outbursts of anger and aggression,...)aggression,...)

c)c) Expression of needs and impulses without Expression of needs and impulses without consideration of consequences or social consideration of consequences or social conventionconvention

d)d) Cognitive disturbancesCognitive disturbancese)e) Marked alteration of language productionMarked alteration of language productionf)f) Altered sexual behaviour (hyposexuality, change Altered sexual behaviour (hyposexuality, change

of sexual preference)of sexual preference) 2626

Personality and Behavioural Disorders Due to Personality and Behavioural Disorders Due to Brain Disease, Damage and DysfunctionBrain Disease, Damage and Dysfunction

Postencephalitic syndromePostencephalitic syndromeRResidual behavioural change following recovery esidual behavioural change following recovery from encephalitis often reversiblefrom encephalitis often reversible(apathy, irritability, some lowering of cognitive (apathy, irritability, some lowering of cognitive functioning, altered sleep pattern, a variety of functioning, altered sleep pattern, a variety of neurological dysfunctions, …)neurological dysfunctions, …)

Postconcussional syndromePostconcussional syndrome OOccurs following head traumaccurs following head trauma CComplaints of headache, dizziness, fatigue, omplaints of headache, dizziness, fatigue,

irritability, difficulty in concentrating and irritability, difficulty in concentrating and performing mental tasks, impairment of memory, performing mental tasks, impairment of memory, insomnia, reduced tolerance to stress, emotional insomnia, reduced tolerance to stress, emotional excitement or alcohol, …(sometimes associated excitement or alcohol, …(sometimes associated with compensation motives)with compensation motives) 2727

CARDIAC DISEASECARDIAC DISEASE

20% of patients with CAD or post-MI 20% of patients with CAD or post-MI are depressedare depressed

Risk factors; female, prior depression, Risk factors; female, prior depression, disableddisabled

6-month mortality was 17% for 6-month mortality was 17% for

depressed, 3% non-depresseddepressed, 3% non-depressed2828

CANCERCANCER

About 50% of About 50% of cancer patients cancer patients feel depressedfeel depressed

Uncontrolled painUncontrolled pain DeliriumDelirium Brain metastasesBrain metastases Disability and Disability and

independence independence

DisfigurementDisfigurement Life cycle issues -- Life cycle issues --

dying young, dying young, unfinished unfinished businessbusiness

ChemotherapyChemotherapy

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STROKESTROKE

30-50% depressed, 30-50% depressed, about half with about half with major depressionmajor depression

More common with More common with left anterior lesionsleft anterior lesions

Not merely Not merely secondary to secondary to neurological neurological disabilitydisability

Antidepressant Antidepressant treatment is effectivetreatment is effective

High-risk period is 1st High-risk period is 1st 2 years post-stroke2 years post-stroke

Depression associated Depression associated with higher morbidity with higher morbidity and mortalityand mortality

Treatment probably Treatment probably improves improves rehabilitationrehabilitation

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EpilepsyEpilepsy

Pre- ictal; Pre- ictal; (Tension, Irritability, Anxiety & (Tension, Irritability, Anxiety & Depression)Depression)

Ictal;Ictal; Confusional state, Anxiety, Confusional state, Anxiety, Psychoses, Automatism) Psychoses, Automatism)

Post- ictal;Post- ictal; (Psychoses, Cognitive (Psychoses, Cognitive dysfunction, violence)dysfunction, violence)

Inter- ictal;Inter- ictal; (Cognitive impairment, (Cognitive impairment, Personality change, psychoses, Personality change, psychoses, Depression & emotional disorder, Suicide)Depression & emotional disorder, Suicide)

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OTHER DISEASES ASSOCIATED OTHER DISEASES ASSOCIATED WITH DEPRESSIONWITH DEPRESSION

Parkinson’sParkinson’s Huntington’sHuntington’s Multiple sclerosisMultiple sclerosis EpilepsyEpilepsy AIDSAIDS

HypothyroidismHypothyroidism HyperthyroidismHyperthyroidism HyperparathyroidismHyperparathyroidism Cushing’sCushing’s Chronic fatigue Chronic fatigue

syndromesyndrome

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MEDICATIONS CAUSING MEDICATIONS CAUSING DEPRESSIONDEPRESSION

ReserpineReserpine MethyldopaMethyldopa Inderal (rare)Inderal (rare) High-dose (older) High-dose (older)

oral contraceptivesoral contraceptives CorticosteroidsCorticosteroids

BenzodiazepinesBenzodiazepines AlcoholAlcohol OpioidsOpioids Opiate analgesicsOpiate analgesics Cocaine withdrawalCocaine withdrawal

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