ORGANIC MENTAL DISORDERS-PSYCHOPATHOLOGY -MRS MILU MARIA ANTO

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ORGANIC MENTAL DISORDERS
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INTRODUCTION

• Organic mental disorders refer to one of a number
  of mental disturbances of the brain due to
  temporary or permanent causes such as aging,
  metabolic irregularities, cardiovascular
  disturbances, drug or alcohol abuse, degenerative
  diseases or infection.

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• Symptoms for organic mental disorder then are
  dependent on the reason for the illness.
• is a general term used to describe physical
  conditions that can cause mental changes.

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• OBD can mimic any psychiatric disorder
• Should be the first consideration in evaluating a
  patient with any psychological or behavioural
  clinical syndrome

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Normal Brain Anatomy
Cerebral Cortex
Reticular Activating System
Brain Stem
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Cerebral Cortex

• Cognition
• Voluntary Movement
• Sensation

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Brain Stem

• Midbrain
• Cranial Nerve III
• pupillary function
• eye movement

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Brain Stem

• Pons
• Cranial Nerves IV, V, VI
• conjugate eye movement
• corneal reflex

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Medulla Cranial Nerves IX, X Pharyngeal
(Gag) Reflex Tracheal (Cough) Reflex
Respiration
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Reticular Activating System

• Receives multiple sensory inputs
• s
• Mediates wakefulness

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History

• Hippocrates introduced the term phrenitisand
  its association with physical and febrile
  diseases.
• Celsus elaborated the concept of delirium and
  dementia
• Aretaeus categorized OMD into acute and chronic
  types

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• Galen explained primary and secondary brain
  dysfunctions
• Von Bonhoeffer introduced the concept of clouding
  of consciousness
• Bleuler offered a coherrent definition of chronic
  organic brain syndrome

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Index of Organicity

1. First episode
2. Sudden onset
3. Older age of onset
4. History of drug or alcohol use
5. Current medical or neurological illness
6. Neurological symptoms and signs such as seizures,
   impairement of consciousness,head injuary

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• 7. confusion, disorientation, memory impairment
  or soft neurological signs
• 8.Visual other non auditory hallucinations

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SUBCATEGORIES

• DELIRIUM
• DEMENTIA
• ORGANIC AMNESTIC SYNDROME
• OTHER ORGANIC MENTALDISORDERS

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• characterized by an acute change in cognition and
  a disturbance of consciousness,
• usually resulting from an underlying medical
  condition or from medication
• or drug withdrawal.

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• Delirium affects 10 to 30 percent of hospitalized
  patients with medical illness
• more than 50 percent of persons in certain
  high-risk populations are affected.

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Diagnostic Criteria for Delirium

• A. Disturbance of consciousness (i.e., reduced
  clarity of awareness about the environment) with
  reduced ability to focus, sustain, or shift
  attention.
• B. A change in cognition (e.g., memory deficit,
  disorientation, language disturbance) or
  development of a perceptual disturbance that is
  not better accounted for by a preexisting,
  established, or evolving dementia.

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• C. The disturbance develops over a short period
  of time (usually hours to days) and tends to
  fluctuate during the course of a day.
• D. Evidence from the history, physical
  examination, or laboratory findings indicate that
  the disturbance is caused by direct physiologic
  consequences of a general medical
  condition.(DSM-IV-TR2000).

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CLINICAL FEATURES

• Acute change in mental status
• Presence of medical illness
• Visual hallucinations
• Fluctuating levels of consciousness
• Acute onset of psychiatric symptoms without prior
  history of psychiatric illness

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• Acute onset of new or different psychiatric
  symptoms with history of prior psychiatric
  illness
• Patient described as confused or disoriented
• Diffuse slow waves or epileptiform discharges on
  electroencephalogram

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EPIDEMIOLOGY

• 14-24 prevalence at time of hospital admission
• 6-56 incidence (new cases) during admission
• 63 of patients had no signs of delirium at 3
  month follow-up
• 68 of patients had no signs of delirium at 6
  month follow-up

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Predisposing factors

• Pre exsisting brain damage or dementia
• extremes of age
• Pervious history of delirium
• Alcohol or drug dependence
• Generalised or focal brain lesions
• Chronic medical illness

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• 7. Surgical procedure and post operative period
• 8. Severe psychological symptoms such as fear
• 9. Treatment with psychotropic drugs
• 10. Present or past history of head injury
• 11. Individual susceptibility to delirium

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Screening Tools

• The Folstein Mini-Mental State Examination
  (MMSE)- screens for deficits in
  orientation,attention, memory, language, and
  visuoconstruction abilities.
• Confusion Assessment Method.
• The Delirium Rating Scale (DRS) and
• The Memorial Delirium Assessment Scale (MDAS)
• measure the severityof delirium.

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MANAGEMENT

• IDENTIFYING UNDERLYING MEDICAL CONDITIONS
• correct the underlying medical condition causing
  the disorder
• Careful review of the medical history, physical
  examination findings, laboratory evaluations, and
  any drugs the patient is using, illicit drugs,
  and alcohol.

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• 2. SYMPTOMATIC TREATMENT
• include the use of antipsychotic drugs to
  control agitation and hallucinations,and to clear
  the sensorium
• Haloperidol (Haldol) has been studied most often
  in the symptomatic management of delirium,but
  risperidone (Risperdal) and olanzapine (Zyprexa),
  which are newer, atypical antipsychotics, have
  been the subjects of a few case reports.

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• 3. ENVIRONMENTAL INTERVENTIONS
• A. Provide support and orientation
• Communicate clearly and concisely give
  repeated verbal reminders of the day,time,
  location, and identity of key persons, such as
  members of the treatment team and relatives.
• Provide clear signposts to patients location,
  including a clock, calendar, and
• chart with the days schedule.

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• Place familiar objects from patients home in the
  room.
• Ensure consistency in staff (e.g., a key nurse).
• Use television or radio for relaxation and to
  help the patient maintain contact with the
  outside world.
• Involve family members and caregivers to
  encourage feelings of security and orientation.

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B. Provide an unambiguous environment

• Simplify care area by removing unnecessary
  objects allow adequate space between beds.
• Consider using private room to aid rest and avoid
  extremes of sensory experience.
• Avoid using medical jargon in patients presence
  because it may encourage paranoia.

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• Ensure that lighting is adequate provide a 40-
  to 60-watt night light to reduce misperceptions.
• Control sources of excess noise (e.g., staff,
  equipment, visitors) aim for fewer Sthan 45 dB
  during the day and fewer than 20 dB during the
  night.
• Maintain room temperature between 21.1C
  (69.98F) and 23.8C (74.8F)

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C. Maintaining competency

• Identify and correct sensory impairments ensure
  patients have their glasses,hearing aids, and
  dentures. Consider whether interpreter is needed.
• Encourage self-care and participation in
  treatment (e.g., ask patient for feedback on
  pain).
• Arrange treatments to allow maximum periods of
  uninterrupted sleep.

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• Maintain activity levels ambulatory patients
  should walk three times dailynonambulatory
  patients should undergo full range of movement
  exercise for 15 minutes three times daily.
• (BMJ 2001)

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DEMENTIA

• Dementia is the decline of cognitive
• functions of sufficient severity to interfere
  with two or more of a persons daily living
  activities.
• It is not a disease in itself, but rather a group
  of symptoms which may accompany certain diseases
  or physical conditions.

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Top Ten Signs of Dementia

• 1. Progressive short-term memory loss
• 2. Confusion of time and place
• 3. Difficulty with familiar tasks
• 4. Misplaced objects
• 5. Problems with abstract thinking

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• 6. Poor judgment, poor problem solving ability
• 7. Lack of initiative and motivation
• 8. Personality changes, more irritable or
  frustrated
• 9. Mood changes, increased anxiety
• 10. Language difficulties, difficulty finding
  words and names

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Differential diagnosis

• Normal aging process- dementia is diagnosed only
  when there is demonstrable intellectual and
  memory impairment.
• normal aging process is bengin senescent
  forgetfulness.

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• 2. Delirium
• these two may overlap
• 3. Depressive psuedodementia
• depression may mimic dementia
• 4. Late onset schizhophrenia( paraphrenia)

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Difference between dementia and delirium

• Features delirium
  dementia
• Onset acute
  insidious
• Course recover in 1wk or in a mth
  protracted
• Clinical features
• Consciousness clouded
  normal
• Orientation grossly disturbed
  normal,disturbed in
• 
  
  later stages
• Memory immediate retention,recall,
  immediate retention and
  
• recent memory
  impaired recall normal,recent
  emory
• 
  disturbed
• Comprehension impaired
  only in late stages
• Sleep-wake cycle grossly disturbed
  normal

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• Attention concentration grossly disturbed
  normal
• Diurnal variation
  present,sundowning absent
• Perception visual
  illusions and hallucinations may
• 
  hallucinations occur
• other features
  asterixis,multifocal catastrophic reaction,
• 
  myoclonus perseveration

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• Dementia Psuedodementia
• 1.Rarely complains of
  1. always complains abt memory
• cognitive impairment
  impairment
• 2. Emphasizes achievement 2.
  emphasizes disability
• 3. Appears unconcerned 3.
  often communicates distress
• 4. Labile affect
  4. severe depression on examination
• 5. Makes errors on cognitive exam 5. dont
  know answers
• 6. Recent memory impairment 6. recent
  memory imp rare
• 7. Confabulation may be present 7.
  confabulation very rare
• 8. Poor performance on similar tests 8. marked
  variability
• 9. History of depression 9.
  past history of manic or depressive
• less common
  episode

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Causes of Dementia

• Dementia subtypes
• Early onset before the age of 60
• Less than 5 of all cases of AD
• Strong genetic link
• Tends to progress more rapidly
• Late onset after age 60
• Represents the majority of cases

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CAUSES OF DEMENTIA

• The causes of dementia include various diseases
  and infections, strokes, head injuries, drugs,
  and nutritional deficiencies
• In classifying dementias, medical professionals
  may either separate cortical or subcortical
  dementias or divide reversible and irreversible
  dementias

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• FUNCTION CORTICAL DEMENTIA SUBCORTICAL
  DEMENTIA
• Site of lesion cortex ( frontal and
  temporoparieto-subcortical grey matter
• occipital
  association areas
• and
  hippocampus
• 2.Example Alzheimers disease,
  Huntingtons chorea
• picks disease,
  Parkinson's disease,
  Wilsons
  
• 
  
  disease
• 3.Severity severe
  mild to moderate
• 4. Motor system usually normal
  dysarthria,flexed/extended
• 
  
  posture
• 5. Other features simple delusion, depression
  complex delusions,depression
• uncommon,severe
  aphasia, common,mania rare
• 
  amnesia,apraxia,acalculia,
• 6. Memory deficit recall helped by very little
  cues recall partially helped by cues
• 
  and
  recognition tasks

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Classification of dementia

1. ALZHEIMERS DISEASE
2. VASCULAR DEMENTIA
3. PARKINSONS DISEASE
4. LEWY BODY DEMENTIA
5. HUNTINGTONS DISEASE
6. CREUTZFELDT-JAKOB DISEASE
7. PICK DISEASES

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ALZHEIMERS DISEASE

• Alzheimers disease is the most common type of
  dementia, accounting for 50-70 of cases and
  affecting as many as 5.2 million Americans.
  Alzheimers disease is a progressive,
  degenerative disease that attacks the brain and
  results in impaired memory, thinking and behavior.

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• the most common form of dementia
• was first described by German psychiatrist and
  neuropathologist Alois Alzheimer in 1906 and was
  named after him

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Symptoms

• Gradual memory loss
• Decline in ability to perform routine tasks
• Disorientation to time and place Impairment of
  judgment
• Personality changes

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• Difficulty learning new information
• Loss of language and communication skills

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The 7 stages of diagnostic framework

• Stage 1 - No impairment
• Memory and cognitive abilities seem to be normal.
  
• medical interview a health care professional
  identifies no evidence of memory or cognitive
  problems

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• Stage 2 - Minimal Impairment (Very Mild Cognitive
  Decline)
• Could be normal age-related changes, or the
  earliest signs of Alzheimer's.
• occasional memory lapses, such as forgetting
  familiar words or the names, and perhaps where
  they left their keys, glasses or some other
  everyday object.

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• Stage 3 - Early Confusional (Mild Cognitive
  Decline). Duration - 2 to 7 years.
• The patient has slight difficulties which have
  some impact on certain everyday functions. In
  many cases the patient will try to conceal the
  problems.
• Problems include difficulties with word recall,
  organization, planning, mislaying things, failing
  to remember recently learned data which may cause
  problems at work and at home - family members and
  close associates become aware.

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• Problem reading a passage and retaining
  information from it.
• The ability to learn new things may be affected.
• Problems with organization.
• Moodiness, anxiety, and in some cases depression.
  

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• Stage 4 - Moderate Cognitive Decline. (Mild or
  Early Stage Alzheimer's Disease). Duration -
  about 2 years
• Still identifies familiar people and is aware of
  self.
• Reduced memory of personal history.

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• Problems with numbers which impact on family
  finance - managing bills, checkbooks, etc.
  Previously doable numerical exercises, such as
  counting backwards from 88 in lots of 6s become
  too difficult.
• Knowledge of recent occasions or current events
  is decreased.

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• Sequential tasks become more difficult, including
  driving, cooking, planning dinner for guests,
  many domestic chores, shopping alone, and reading
  and then selecting what is in a menu at the
  restaurant.
• Withdraws from conversations, social situations,
  and mentally challenging situations

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• Denies there is a problem and becomes defensive.
• Requires help with some of the more complicated
  aspects of independent living

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• Stage 5 - Moderately Severe Cognitive Decline
  (Moderate or Mid-stage Alzheimer's Disease).
  Duration - about 18 months
• Cognitive deterioration is more serious.
• Cannot survive independently in the community and
  requires some assistance with day-to-day
  activities.
• Cannot remember details about personal history,
  such as name of where they went to school,
  telephone numbers, personal address, etc.

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• Confused about what day it is, month, year.
• Confused about where they are or where things
  are.
• Problems with numbers mathematical abilities get
  worse.
• Easy prey for scammers.
• Require supervision and sometimes help when
  dressing, including selecting right clothing for
  the season or occasion.

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• Require help carrying out some daily living
  tasks.
• Can still eat and go to the toilet unaided.
• Unable to recall current information
  consistently.
• Usually remember substantial amounts about
  themselves, such as their name, name of spouse
  and children.

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• Stage 6 - Severe Cognitive Decline (Moderately
  Severe Mid-stage Alzheimer's Disease). Duration -
  about 2½ years.
• Memory continues to deteriorate. There is a
  considerable change in personality. Require
  all-round help with daily activities.

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• Virtually totally unaware of present and most
  recent experiences.
• Cannot recall personal history very well.
• Can still usually recall their own name.
• Know family members are familiar but cannot
  recall their names.
• Can communicate pleasure and pain nonverbally.

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• Ability to dress progressively deteriorates. Need
  help dressing and undressing.
• Ability to bathe and wash self progressively
  deteriorates.
• Fecal and/or urinary incontinence more likely.
• Need help when going to the toilet - flushing,
  wiping, disposing of tissues.

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• Disruption of sleep patterns.
• Wander off and become lost.
• Suspicious, paranoid, aggressive. May believe
  caregiver is an impostor, devious, scheming,
  cunning, dishonest.
• Repeat words, phrases or repetitively utters
  sounds.
• Repetitive/compulsive behavior, such as tearing
  up tissues or wringing hands.

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• Disturbed, agitated, especially later on in the
  day.
• Hallucinations, also more common later on in the
  day. May hear, smell or see things that are not
  there.
• Eventually need care and supervision, but can
  respond to non-verbal stimuli

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• Stage 7 - Very Severe Cognitive Decline (Severe
  or Late-stage Alzheimer's Disease). Duration - 1
  to 2½ years
• Severely limited cognitive ability.
• Patients lose their ability to recognize speech,
  but may utter short words or moans to
  communicate.

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• Usually the ability to walk unaided is lost
  first, then the ability to sit unaided, plus the
  ability to smile, and eventually the ability to
  hold the head up.
• Body systems start to fail and health
  deteriorates.
• Swallowing becomes increasingly more difficult.
  Chocking when eating/drinking becomes more
  common.

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• Reflexes become abnormal
• Seizures are possible.
• Muscles grow rigid.
• Generally bedridden.
• Spends more time asleep.
• Require round-the-clock care

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Criteria

• The National Institute of Neurological and
  Communicative Disorders and Stroke (NINCDS) and
  the Alzheimer's Disease and Related Disorders
  Association (ADRDA, now known as the Alzheimer's
  Association) established the most commonly used
  NINCDS-ADRDA Alzheimer's Criteria for diagnosis
  in 1984

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• extensively updated in 2007
• presence of cognitive impairement, and a
  suspected dementia syndrome, be confirmed by
  neuropsychological testing
• A histopathologic confirmation including a
  microscopic examination of brain tissue is
  required for a definitive diagnosis

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• Eight cognitive domains are most commonly
  impaired in AD
• memory, language, perceptual skills, attention,
  constructive abilities, orientation,
  problemsolving and functional abilities

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Management

• Pharmaceutical
• Acetylecholinesterase inhibitiors
• memantine (brand names Akatinol, Axura,
  Ebixa/Abixa, Memox and Namenda)
• antipsychotic drugs are modestly useful in
  reducing aggression and psychosis

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• Psychosocial intervention
• sensory integration therapy
• emotion-oriented psychosocial intervention
• Behavioural intervention attempt to identify and
  reduce the antecedents and consequences of
  problem behaviours.

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• Emotion-oriented interventions include
  reminiscence , supportive psychotherapy, and
  simulated presence therapy-(playing a recording
  with voices of the closest relatives ) etc.
• Cognitive retraining methods

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Caregiving

• A small recent study in the US concluded that
  patients whose caregivers had a realistic
  understanding of the prognosis and clinical
  complications of late dementia were less likely
  to receive aggressive treatment near the end of
  life
• Caregiver burden awreness programmes, better
  psychological management

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Vascular Dementia

• The second most common type of dementia is
  vascular dementia.
• This occurs when a stroke interrupts blood flow
  to the brain and impairs cognitive function.
• Also known as multi-infract dementia
• 10-15 0f dementias belong to this

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• The onset of vascular dementia can be sudden as
  many strokes can occur before symptoms appear.
• Many times, vascular dementia may seem similar to
  Alzheimers disease.

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• Abrupt onset
• Acute exacerbations
• Fluctuating course
• Presence of hypertension or cardiovascular
  disease
• History of previous stroke

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• Emotional lability is common
• EEG and MRI scan help in diagnosis
• Treat the underlying cause

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Dementia with Lewy bodies

• another degenerative brain disorder, and a common
  form of dementia.
• In Lewy body dementia (LBD), microscopic protein
  deposits (Lewy bodies) are found in the dying
  nerve cells.
• Cognitive impairment Fluctuation of alertness
  Visual hallucinations Severe motor defects
  Reduced facial expression Shuffling gate
  Tremors Rigidity Unsteady gate and balance,
  leading to frequent falls

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• Cholinesterase inhibitors are valuable (and more
  effective than in Alzheimers disease).
• Antipsychotics should be avoided because of the
  risk of sensitivity reactions and increased
  mortality.

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Parkinsons disease dementia

• Dementia with Lewy bodies merges into Parkinsons
  disease dementia. The convention is that the
  latter category is used for dementia occurring
  more than 12 months after onset of parkinsonism.
• By this definition, dementia occurs in about 40
  of cases of Parkinsons disease, especially later
  onset cases.

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• A progressive disorder of the central nervous
  system which affects more than one million
  Americans. People with Parkinsons disease lack
  dopamine, which is important to the central
  nervous system and the ability to control muscle
  activity.

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• L-DOPA does not improve the dementiacholinesteras
  e inhibitors may.
• Clozapine is useful for psychotic symptoms

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FRONTO-TEMPORAL DEMENTIA

• Frontotemporal Lobar Degeneration is also called
  FTD or Picks disease, and is a term that
  describes three disease subtypes
• Frontotemporal dementia (FTD)
• Primary progressive aphasia (PPA)
• Semantic depression (SD)

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• FTD represents about 10-20 of all dementia
  cases, and it is one of the most common dementias
  affecting a younger population.
• The average age of diagnosis is about 60, with
  symptoms beginning in a persons 40s or 50s.
  The course of the disease ranges from 3 to 17
  years.

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symptoms

• Uninhibited and socially inappropriate behavior
• Inappropriate sexual behavior
• Loss of concern about personal appearance and
  hygiene

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• Compulsive eating and oral fixation
• Apathy, loss of initiative, lack of concern for
  others
• Speech and language difficulties
• Memory loss
• There is no specific treatment. Patients are very
  sensitive to many psychotropic drugs, which
  should be used with caution to treat depressive
  or psychotic symptoms.

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• Arnold Pick, who first described the disease in
  1892,
• Pick's disease is a rare disorder that causes the
  frontal and temporal lobes of the brain, which
  control speech and personality, to slowly
  atrophy.

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HUNTINGTONS DISEASE

• An inherited, degenerative brain disease
  affecting the mind and body. The disease usually
  begins mid-life.
• Symptoms Intellectual decline Irregular and
  involuntary movements Personality changes
  Memory disturbance Slurred speech Impaired
  judgment Psychiatric problems

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• A genetic marker linked to Huntingtons disease
  has been identified, and researchers are working
  to learn more about the gene itself.
• No treatment is available to stop the progression
  of the disease though some of the symptoms can be
  controlled by medication.s

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CREUTZFELDT-JAKOB DISEASE (CJD)

• A rare, fatal brain disorder most likely caused
  by a virus that progresses very swiftly.
• Symptoms Failing memory Behavioral changes
  Lack of coordination Pronounced mental
  deterioration ,Involuntary movements Blindness
  Weakness in the arms and/or legs Eventual coma

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• Death in CJD patients is usually caused by
  infections while bedridden and unconscious.
• A definitive DIAGNOSIS of CJD can be obtained
  only through an examination of brain tissue,
  usually done at autopsy.

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Organic Amnesic syndrome

• Amnesic (or amnestic) syndrome completes the
  triad of conditions (with dementia and delirium)
  which affect memory and which always have an
  organic cause.

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• Its features are
• Selective loss of recent memory.
• Confabulation the unconscious fabrication of
  recent events to cover gaps in memory.
• Time disorientation.
• Attention and immediate recall intact.
• Long-term memory and other intellectual faculties
  intact.