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Title: ORGANIC MENTAL DISORDERS-PSYCHOPATHOLOGY -MRS MILU MARIA ANTO


1
ORGANIC MENTAL DISORDERS
2
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.

3
  • 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.

4
  • OBD can mimic any psychiatric disorder
  • Should be the first consideration in evaluating a
    patient with any psychological or behavioural
    clinical syndrome

5
Normal Brain Anatomy
Cerebral Cortex
Reticular Activating System
Brain Stem
6
Cerebral Cortex
  • Cognition
  • Voluntary Movement
  • Sensation

7
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8
Brain Stem
  • Midbrain
  • Cranial Nerve III
  • pupillary function
  • eye movement

9
Brain Stem
  • Pons
  • Cranial Nerves IV, V, VI
  • conjugate eye movement
  • corneal reflex

10
Medulla Cranial Nerves IX, X Pharyngeal
(Gag) Reflex Tracheal (Cough) Reflex
Respiration
11
Reticular Activating System
  • Receives multiple sensory inputs
  • s
  • Mediates wakefulness

12
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

13
  • 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

14
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

15
  • 7. confusion, disorientation, memory impairment
    or soft neurological signs
  • 8.Visual other non auditory hallucinations

16
SUBCATEGORIES
  • DELIRIUM
  • DEMENTIA
  • ORGANIC AMNESTIC SYNDROME
  • OTHER ORGANIC MENTALDISORDERS

17
  • 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.

18
  • 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.

19
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.

20
  • 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).

21
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

22
  • 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

23
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

24
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

25
  • 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

26
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.

27
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.

28
  • 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.

29
  • 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.

30
  • 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.

31
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.

32
  • 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)

33
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.

34
  • 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)

35
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.

36
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

37
  • 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

38
Differential diagnosis
  • Normal aging process- dementia is diagnosed only
    when there is demonstrable intellectual and
    memory impairment.
  • normal aging process is bengin senescent
    forgetfulness.

39
  • 2. Delirium
  • these two may overlap
  • 3. Depressive psuedodementia
  • depression may mimic dementia
  • 4. Late onset schizhophrenia( paraphrenia)

40
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

41
  • 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

42
  • 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

43
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

44
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

45
  • 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

46
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

47
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.

48
  • the most common form of dementia
  • was first described by German psychiatrist and
    neuropathologist Alois Alzheimer in 1906 and was
    named after him

49
Symptoms
  • Gradual memory loss
  • Decline in ability to perform routine tasks
  • Disorientation to time and place Impairment of
    judgment
  • Personality changes

50
  • Difficulty learning new information
  • Loss of language and communication skills

51
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

52
  • 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.

53
  • 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.

54
  • 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.

55
  • 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.

56
  • 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.

57
  • 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

58
  • Denies there is a problem and becomes defensive.
  • Requires help with some of the more complicated
    aspects of independent living

59
  • 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.

60
  • 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.

61
  • 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.

62
  • 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.

63
  • 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.

64
  • 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.

65
  • 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.

66
  • 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

67
  • 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.

68
  • 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.

69
  • Reflexes become abnormal
  • Seizures are possible.
  • Muscles grow rigid.
  • Generally bedridden.
  • Spends more time asleep.
  • Require round-the-clock care

70
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

71
  • 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

72
  • Eight cognitive domains are most commonly
    impaired in AD
  • memory, language, perceptual skills, attention,
    constructive abilities, orientation,
    problemsolving and functional abilities

73
Management
  • Pharmaceutical
  • Acetylecholinesterase inhibitiors
  • memantine (brand names Akatinol, Axura,
    Ebixa/Abixa, Memox and Namenda)
  • antipsychotic drugs are modestly useful in
    reducing aggression and psychosis

74
  • Psychosocial intervention
  • sensory integration therapy
  • emotion-oriented psychosocial intervention
  • Behavioural intervention attempt to identify and
    reduce the antecedents and consequences of
    problem behaviours.

75
  • Emotion-oriented interventions include
    reminiscence , supportive psychotherapy, and
    simulated presence therapy-(playing a recording
    with voices of the closest relatives ) etc.
  • Cognitive retraining methods

76
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

77
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

78
  • 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.

79
  • Abrupt onset
  • Acute exacerbations
  • Fluctuating course
  • Presence of hypertension or cardiovascular
    disease
  • History of previous stroke

80
  • Emotional lability is common
  • EEG and MRI scan help in diagnosis
  • Treat the underlying cause

81
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

82
  • 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.

83
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.

84
  • 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.

85
  • L-DOPA does not improve the dementiacholinesteras
    e inhibitors may.
  • Clozapine is useful for psychotic symptoms

86
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)

87
  • 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.

88
symptoms
  • Uninhibited and socially inappropriate behavior
  • Inappropriate sexual behavior
  • Loss of concern about personal appearance and
    hygiene

89
  • 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.

90
  • 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.

91
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

92
  • 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

93
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

94
  • 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.

95
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.

96
  • 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.
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