ORGANIC PSYCHIATRY ORGANIC PSYCHIATRY Organic disorders psychiatric or

ORGANIC PSYCHIATRY

ORGANIC PSYCHIATRY • Organic disorders – psychiatric or physical? - Anorexia nervosa – gynaecology, endocrine – Alcohol dependence – gastroenterologist – Parkinson’s Disease - neurologist

ORGANIC PSYCHIATRY • Most psychiatric disorders have cerebral substrate • Biopsychosocial model • DSM IV - “ the term organic mental disorder is no longer used in DSM-IV because it incorrectly implies that non-organic mental disorders do not have a biological basis”

ORGANIC PSYCHIATRY • Cognitive disorders : – Delirium – Dementias – Amnestic Disorders • Mental Disorders resulting from a general medical condition: – endocrine disorders – Immune dis. – Metabolic dis. – Nutritional dis. – toxins

ORGANIC PSYCHIATRY • Neuropsychiatric disorders – Epilepsy – Head trauma – CNS tumours – CNS infection – Demyelinating dis. – Degenerative dis. • psychosomatic – Somatoform disorders – Psychological Factors Affecting Medical Condition

DSM-IV Diagnostic Criteria for Psychological Factors Affecting Medical Condition A. A general medical condition (coded on Axis III) is present. B. Psychological factors adversely affect the general medical condition in one of the following ways: (1) the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition.

(2) the factors interfere with the treatment of the general medical condition. (3) the factors constitute additional health risks for the individual. (4) stress-related physiological responses precipitate or exacerbate symptoms of a general medical condition.

• Mental disorder affecting medical condition (e. g. , an Axis I disorder such as major depressive disorder delaying recovery from a myocardial infarction) • Psychological symptoms affecting medical condition (e. g. , depressive symptoms delaying recovery from surgery; anxiety exacerbating asthma)

Personality traits or coping style affecting medical condition (e. g. , pathological denial of the need for surgery in a patient with cancer, hostile, pressured behavior contributing to cardiovascular disease) • Maladaptive health behaviors affecting medical condition (e. g. , lack of exercise, unsafe sex, overeating) • • Stress-related physiological response affecting general medical condition (e. g. , stress-related exacerbations of ulcer, hypertension, arrhythmia, or tension headache) • Other unspecified psychological factors affecting medical condition (e. g. , interpersonal, cultural, or religious factors)

Consultation – Liaison Psychiatry

ORGANIC PSYCHIATRY • Mini Mental State Examination – Folstein Screening, not diagnostic Maximum score of 30 24 or less is suggestive of impairment

Delirium • • 10% hospitalized pts 20% post burn 30% I. C. U Elderly , young

Delirium 1. A change in cognition or development of a perceptual disturbance is present and not explained by a preexisting, established or evolving dementia. 2. The disturbance developed over a short period of time (usually hours to days) and tends to fluctuate.

Delirium 3. The level of consciousness (awareness of the environment) is disturbed or fluctuates. 4. There is evidence that a drug, acute illness or metabolic disturbance is present that could explain the change in cognition.

• acute confusional state • acute mental status change • altered mental status • organic brain syndrome • reversible dementia • toxic or metabolic encephalopathy

Dementia 1. Cognitive impairment is present, memory loss , impairment of language, praxis, recognition or abstract thinking. 2. The cognitive impairment is chronic and progressive and has resulted in functional decline. 3. Delirium has been ruled out.

Alzheimer’s disease 1. Dementia is present (see above), plus: 2. History, physical and mental status examinations are consistent with Alzheimer’s disease. 3. Screening blood tests (CBC, BUN, calcium, liver function, thyroid function, vitamin B 12 and others as indicated) and review of medications do not reveal any major untreated cause of cognitive impairment. 4. Brain imaging study (CT or MRI) is normal or shows atrophy (many authorities do not recommend neuroimaging studies except in uncertain cases).

• Mild cognitive impairment is now considered a strong early predictor of Alzheimer’s disease. • Promptly and correctly diagnosing Alzheimer’s disease allows for initiation of therapy to slow the progression of the disease. • Cognitive screening and assessment instruments should be considered for the detection of dementia.

Vascular dementia 1. Dementia is present (see above), plus: 2. Two or more of the following are present: focal neurologic signs on physical examination; an onset that was abrupt, stepwise or stroke-related; or brain imaging study (CT or MRI) shows multiple strokes.

Amnesic syndrome • • • characterized by: prominent impairment of recent and remote memory preservation of immediate recall Absence of generalized cognitive impairment retrograde amnesia – pathological inability to recall events that occurred prior to the onset of the illness • anterograde amnesia – pathological inability to lay down new memories after the onset of the illness. • The most common cause is deficiency of the thiamine

COMPLEX PARTIAL SEIZURES

NEUROPSYCHIATRIC ASPECTS OF HEAD INJURY • Site of the injury determines functional impairment, limitation, or loss – Frontal lobe (most common) • • • Planning and initiating activity Impulsivity Exercising judgment Understanding social situations Regulating emotions – Motor cortex • Purposeful movement (apraxia) • Coordination (ataxia) • Speaking (aphasia) – Limbic system • Emotional responses • Anxiety • Depression – Temporal lobe and hippocampus • Memory losses • Temporal gradient - better memory farther back in time; loss of more recent memory(may include learning new information) – Parietal lobe • Language difficulties (e. g. agnosia)

• A 75 -year-old man is intubated and receiving mechanical ventilation. Medications are nitroglycerin paste, ranitidine, and digoxin. He has no history of psychiatric illness or recent use of alcohol or sedative drugs. • Two days postoperatively, he becomes agitated and attempts to remove the endotracheal tube and other catheters. He is awake and fearful. He is unable to respond to “yes/no” questions consistently or to follow simple commands.