Organic Psychiatric Disorders-I

Delirium & Dementia

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Dr. Dhana Ratna Shakya
MD-psych; MBBS; Asst. Professor
Department of Psychiatry

(2008, July- August)

 Objectives of this lecture-
 Familiarize concept of ‘organic psychiatric
disorders’
 List of common conditions
 Dementia- definition, clinical features, causes,
treatment
 Delirium- definition, clinical features, causes,
management
 Amnesic disorder- definition, clinical features,
causes, management
ORGANIC PSYCHIATRIC DISORDERS
 Identifiable cerebral (coarse brain disease) or
systemic pathology (general medical condition)
responsible for psychological symptoms
 Display signs of organic disease as well.
 Causes- Coarse brain diseases and General
medical conditions- epilepsies, brain tumors,
head trauma, degenerative, demyelinating,
infectious, auto-immune, metabolic disorders,
endocrinal diseases, nutritional deficiencies
 Useful tool- Mini-mental status examination
‘MMSE’ (Folstein and Folstein, 1970)
Mini-mental status examination (MMSE)
 Screening test of cognitive state for practitioners, monitor
 30 points: <25- possible impairment, <20- definite
 5- Time orientation (time, day, date, month, season)
 5- Place orientation (place- hospital, area- tol, location- storey,
village/city, district)
 3- Registration (mango, chair, coin)
 3- Recall after 5 minutes
 5- Concentration (100-7, 40-3, days- forward & back)
 2- Naming (pen, watch)
 1- Repetition of a sentence (Neither this, nor that.)
 3- 3 step comprehension of 3 commands in a series.
 1- Read and follow the command (Close your eyes)
 1- Write a sentence
 1- Copy a drawing.
ICD-10 Organic Mental & Behavioral disorders
 F00- F03: Dementias-
 F04 & F(10- 19).6: Amnesic syndromes
 F05 & F(10- 19).4: Delirium
 F06: Other Organic Psychiatric disorders– Psychotic
(hallucinosis, catatonic, delusion), Mood, Anxiety,
Dissociative
 F07: Personality & Behavioral disorders

 Seizures/ Epilepsy
 Primary diseases, damage and dysfunction of brain &
physical diseases secondarily affecting brain
 2 main clusters of syndrome- cognitive or perception,
thought, mood and emotion, personality
 DEMENTIAS
 Multiple cognitive deficits (memory ± judgment ±
cognition ± personality changes) with consciousness
remaining intact
 Core features-
 Forgetfulness- impair registration, storage and
retrieval of new information, patient is unaware of
 Change in personality and behavior
 Apathetic, disinterested but alert
 Dysfunction- interference with ADL, role function
 Other symptoms- impaired thought process, delusion,
hallucination, depression
 Chronic and progressive course
 Duration- at least 6 months
 DEMENTIAS
 Common Causes-
1. Alzheimer’s disease 3. Infections- HIV/ AIDS, CJD
2. Vascular dementias 4. Diseases- Pick’s, Huntington’s, PD
5. Substance/ toxins- atropine, gasoline. Fumes, alcohol
 Differential diagnosis- Pseudo-dementias, depression

 Management Guidelines-
 Inform- memory loss is common in old age and
behavioral problems result from that
 Rehabilitation- supportive measures, orienting cues

 Safety measures

 Medications-
 MEDICATIONS
 Specific drugs (Nootropics)-
 ACE inhibitors- Rivastigmine, Galantamine, Donepezil
 NMDA Receptor antagonist- Memantine
 Others- Piracetam, Pyritinol; vasodilator: flunarizine;
ergot: dihydroergotoxine
 Treatment of specific cause (e.g. vascular)
 Anti-psychotics- to control agitations
 Supplementary/ anti-oxidants
 Avoid sedative/ hypnotics, unnecessary
medications
 DELIRIUM
 Disturbance of consciousness and cognitive functions
 Clinical features-
 Confusion/ clouded consciousness/ awareness or
thinking, often accompanied by-
 Loss of orientation
 Agitation/ restlessness
 Emotional upset
 Poor memory
 Impaired attention
 Illusions/ Hallucinations
 Alterations of sleep awake cycle
 Features suggestive of conditions leading to delirium
 DELIRIUM
May or not superimpose on dementia
Etiology-
 Different GMCs or coarse brain diseases
 Elderly, recent trauma/surgery, sensory impairment

 Substance- Wernicke’s encephalopathy,

 Syncope/ arrhythmias, hypoxia, hypertensive crisis

 Hypoglycaemia,

 CNS infections, raised ICP, trauma/ injuries

 Poisoning
 Management guidelines
Immediate intervention required
 Management of etiological conditions
 Inform patient /family- condition being temporary
 Environmental measure- Frequent reminders of
orientation- with cues; familiar people, things and
safe, calm place
 General- hydration, nutrition
 Medications- Avoid unnecessary medication
 Anti-psychotic- low dose Haloperidol/
risperidone
 Avoid benzodiazepine, EXCEPT in alcohol or
benzodiazepine withdrawal delirium
 AMNESTIC DISORDER

 Acquired impaired ability to learn and recall new

information or recall previously learned knowledge
 Other clinical features-
 No disturbance of consciousness, attention,
global function (delirium), abstract thinking or
personality (dementia)
 Recent and or remote memory impaired »
confabulation
 E.g. Korsakoff’s psychosis/ syndrome
 AMNESTIC DISORDER
 Causes-
 Systemic medical diseases- thiamine deficiencies
 Hypoglycemia
 Primary brain conditions- seizures, head trauma,
tumor, CVA, infections, hypoxia, TGA, ECT
 Substance/ neuro-toxins

 Management guidelines-
 Treatment of cause- high dose thiamine in
thiamine deficiency
 Supportive care
 Psychotherapy
THANK YOU !
 Organic Psychiatric Disorders-II
Seizure disorders
 Seizure/ Epilepsy- definition, introduction
 Clinical features,
 Classification,
 Causes,
 Psychiatric Illness in Seizures
 Management Principles
SEIZURE DISORDERS/ EPILEPSIES
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 Seizure- Ictus: sudden, involuntary behavioral
events associated with paroxysmal hyper-
synchronous electrical discharges in the brain
 Convulsions- paroxysms of involuntary
muscular contractions and relaxations
 Primary or Secondary seizure
 Epilepsy- recurrent tendency to experience
seizure (2 or more episodes with no
discernible cause)
 International Classification of Epileptic seizures

I. Partial (Focal or local): emanating from a focus in one

of the hemispheres
a. Simple partial seizures- no alteration in consciousness
or psychic symptom- motor, somato-sensory,
autonomic or mixed
b. Complex partial seizures- altered consciousness or
psychic symptom
c. Partial seizures with secondary generalizations
II. Generalized (convulsive/ non-convulsive)- involve
both hemispheres- Absence/ Myoclonic/ Clonic/
Tonic/ Tonic-clonic/ Atonic- akinetic
III. Unclassified.
 SEIZURE DISORDERS/ EPILEPSIES
 Epidemiology- (0.5- 1%) of population
 Among 10 most important causes for disability
 Etiology of seizures-
 Idiopathic/ Unknown- epilepsy
 Infection- meningitis, encephalitis, tuberculosis, HIV/ AIDS.
 Neoplasm- primary, secondary- metastatic
 Vascular- ischemic/hemorrhagic stroke, hypertensive
encephalopathy
 Trauma
 Metabolic/ Drug/ toxins
 Hereditary
 Febrile convulsions
 Nutritional deficiencies- vitamin B6
 Immunologic- systemic lupus erythematosus SLE
 Seizure and Mental illness
 Post-ictal characteristics- post-ictal confusion,
twilight state, post-ictal psychosis, delirium
 Inter-ictal disorders- inter-ictal psychosis,
exacerbations of personality characteristics
 Behavioral disturbances variably related to ictus-
 Mood disorders: left hemisphere- depression,
Suicide- (4-5) times more common
 Hypo-sexuality/ Aggression/ violence
 Cognitive deficits
 Personality changes- hyper-religiosity,
viscosity
 Distinction between Seizure and
Pseudo-seizures
S. No. Features True seizure Pseudo-seizure
1. Emotional precipitant ± ++
2. During night/while alone Common Uncommon
3. Stereotype of aura & ictus Usual None
4. Cyanotic skin changes Common None
5. Self injury, tongue bite Common Rare
6. Incontinence Common Rare
7. Post-ictal confusion Present None
8. Effect of suggestion Seldom Often
9. EEG changes + ±
10. Corneal reflex - +
11. Onset Sudden Gradual
12. Termination Gradual Abrupt
13. Pelvic thrusts, hyper-arching - Suggestive
 MANAGEMENT GUIDELINES
Diagnosis-
 Detailed history- from patient, witness, parent,
family members
 EEG- confirmation/ making differential
diagnoses. Normal EEG does not exclude
seizures.
 Routine screening tests

 CT/ MRI to rule out specific causes

 Gold standard of diagnostic method- ‘video-

EEG’ documentation
 Treatment of Seizures
 Mandatory strategy
 Choice of anti-epileptic drugs (AEDs)
depends on type of seizures, adverse effects
and drug interactions
 Adequate dosing- serum level estimations
 At least 2 years after control of seizure
 Mono-therapy as far possible
 AED e.g. sodium valproate, carbamazepine,
Phenytoin, Phenobarbotone, newer AEDs
 Psycho-education regarding
Epilepsy-
 A medical disease: disease of brain- needs drug
 Treatment is possible and available- effective and safe
 Disease not transmissible, only 10-20% have family
history
 Patient can live normal life like others with treatment
 Avoid triggers/ precipitants-
 Sleep deprivation, bright lights, systemic
infections, hungers, heights, other risky situations
 Psycho-active substances
 Non-compliance to treatment
 FIRST AID during seizures
 Help patient into lying down position. Do not move the
patient into another position/ place during the attacks
 Loosen the tight clothes
 Do not allow crowd/ panics.
 Make patient lie down on the side and do not use pillow.
 Move sharp and other objects away which may harm
 Do not force anything into patient’s mouth
 Do not hold the patient tightly to control jerks
 Do not give any drink or food during seizure
 Note the duration of attack
 After attack, pacify and reassure the patient.
 Who needs referral?
 Status epileptics
 Doubtful diagnosis
 Not controlled with mono-therapy
 Adverse effects
 Pregnant patient
THANK YOU !