Organic Mental Disorders

UG Class
Dept. of Psychiatry
1

• In ICD 10, included under F00-F09.
• It includes-
• Dementia- Alzheimer’s, vascular, others, unspecified.
• Organic amnestic disorder
• Delirium
• Mental disorders due to brain damage/ dysfunction or physical
illness.
• Personality & behavioral disorders due to brain damage/
dysfunction/ disease.
• All are characterized primarily by impairment of cognition.
2

• Traditionally, those disorders which had an identifiable
pathological condition such as brain tumour,
cerebrovascular disease, or drug intoxication were called
as organic.
• Those brain disorders with no generally accepted organic
basis (e.g., depression) were called functional disorders.
• This distinction between organic vs functional disorders is
out-dated now.
• Every psychiatric disorder has an organic (i.e., biological
or chemical) component.
3

• A 78 year-old man admitted to the surgery ward for elective hernia repair.
The hernia has been enlarging and becoming more painful in the past year,
interfering with his appetite.
• Past hist:- k/c/o Hypertension, BPH, OA of knees that causes difficulty with
his ADLs on treatment for the same.
• Moderate hearing difficulty. History of declining cognitive abilities. In the past
few years, and particularly in the past several months, his cognition has
declined and he has depended increasingly on his wife for support.
• Personal hist:- No history of smoking and no alcohol use.
• O/E:- BP 140/80; Pulse 72 regular; Resp. 16, easy; Temp. 97.0 F.
• Systemic ex:- CVS, RS, PA- NAD.
• Lab: normal.
• Patient was posted for hernia repair and operated for the same.
• He undergoes hernia repair with no intra-operative problems and with
minimal blood loss.
4

• Patient is kept in post op ward for observation.
• In the post op rounds:- Temp 100.8, BP/P/R stable, complains of pain and
gets pain killer with relief. Low grade bowel sounds are noted to be present.
• In the evening, nurses note that the patient is agitated.
• He is trying to pull out his IV cannula , trying to get out of bed without
assistance, is calling out frequently. Noticed to have anger outbursts and
claims the staff is trying to harm him. Found to make gestures in the air as if
is communicating with someone.
• Wife reports that this kind of behavior was not observed previously, neither
any psychiatric consultation was sorted in the past.
• O/E- lethargic. It takes several attempts to gain his attention to answer
questions. Once focused on a question he rambles in a disorganized way,
his speech is incoherent. He is disoriented to time, place & person. Auditory
& Visual hallucinations, delusions of persecution are present. There are no
focal neurological deficits and his exam is otherwise unchanged.
5

• Also called as-
• Acute brain syndrome
• Acute confusional state
• Acute infective psychosis
• Acute organic reaction
• Acute psycho-organic syndrome
• ICU psychosis
6

• It is defined as acute onset of fluctuating cognitive impairment
and a disturbance of consciousness.
• It is a syndrome, not a disease.
• Has many causes, all of which result in a similar pattern of
signs and symptoms relating to the patient's level of
consciousness and cognitive impairment.
• Hallmark symptom is impairment of consciousness, usually
occurring in association with global impairments of cognitive
functions. Abnormalities of mood, perception and behaviour
are common psychiatric symptoms.
• Has a sudden onset (hours or days), a brief and fluctuating
course, and rapid improvement when the causative factor is
identified and eliminated.
7

• It is one of the poor prognostic sign.
• The 3-month mortality rate of patients who have an
episode of delirium is estimated to be 23 to 33 percent.
• The 1-year mortality rate for patients who have an
episode of delirium may be as high as 50 percent.
• Elderly patients who experience delirium while
hospitalized have a 20 to 75 mortality rates.
• Major causes:- CNS disease (like epilepsy), systemic
disease (like infections, cardiac failure), and intoxication
or withdrawal from pharmacological or toxic agents (like
alcohol).
8

1. Central nervous system disorder:- Seizures, Migraine, Head trauma, brain tumor,
subarachnoid hemorrhage, subdural, epidural hematoma, abscess, ICH, cerebellar
hemorrhage, nonhemorrhagic stroke, transient ischemia
2. Metabolic disorder:- Electrolyte abnormalities, DM, hypoglycemia, hyperglycemia, or
insulin resistance
3. Systemic illness Infection:- Sepsis, malaria, viral, plague, Lyme disease, syphilis, or
abscess, Trauma, Change in fluid status , Nutritional deficiency, Burns, Uncontrolled
pain,Heat stroke, High altitude (usually >5,000 m)
4. Medications :- Antibiotics, antivirals, and antifungals, Steroids, Anesthesia, Cardiac
medications, Antihypertensives, Antineoplastic agents, Anticholinergic agents, NMS,
Serotonin syndrome , OTC preparations Herbals, teas, and nutritional supplements.
5. CVS:- Cardiac failure, arrhythmia, myocardial infarction, cardiac assist device, cardiac
surgery
6. RS:- COPD, hypoxia, SIADH, acid base disturbance
7. Endocrine:- Adrenal crisis or adrenal failure, thyroid abnormality, parathyroid
abnormality
8. Hematological:- Anemia, leukemia, blood dyscrasia, stem cell transplant
9. Renal:- Renal failure, uremia, SIADH
10.Hepatic:- Hepatitis, cirrhosis, hepatic failure
11.Neoplasm:- Neoplasm (primary brain, metastases, paraneoplastic syndrome)
9

1. Clouding of consciousness.
2. Disturbance of cognition: a. impairment of immediate &
recent memory, with relatively intact remote memory; b.
disorientation to TPP.
3. Psychomotor disturbances: a. shifts from hypo-activity to
hyper-activity; b. increased reaction time; c. increased or
decreased flow of speech; d. enhanced startle reaction.
4. Disturbance sleep-wake cycle: a. insomnia or reversal of
the sleep-wake cycle; b. nocturnal worsening of symptoms
(sun downing); c. disturbing dreams and nightmares which
may continue as hallucinations or illusions after awakening.
5. Rapid onset and fluctuations of the symptoms over the
course of the day.
6. Objective evidence from history, physical and neurological
examination or laboratory tests of an underlying cause.
10

• Major neurotransmitter hypothesized in delirium is
acetylcholine.
• Major neuroanatomical area is the reticular formation.
• Usually diagnosed at the bedside and is characterized by
the sudden onset of symptoms.
• Bedside mental status examination can be used to
document the cognitive impairment and to provide a
baseline from which to measure the patient's clinical
course.
• Physical examination often reveals clues to the cause.
• The presence of a known physical illness or a history of
head trauma or alcohol or other substance dependence
increases the likelihood of the diagnosis. 11

• The symptoms usually persist as long as the causally
relevant factors are present, although delirium generally
lasts less than a week.
• After identification and removal of the causative factors,
the symptoms usually recede over a 3- to 7-day period.
• The older the patient and the longer the patient has been
delirious, the longer the delirium takes to resolve.
• Management- Identification of the underlying cause &
correction of the cause. Supportive treatment for the
same.
12

• Important goal of treatment is to provide physical, sensory, and
environmental support.
• Physical support:- to prevent pts getting into accidents.
• Patients should be neither sensory deprived nor overly
stimulated by the environment.
• Familiar pictures and decorations.
• Presence of a clock or a calendar.
• Regular orientations to person, place, and time help make
patients with delirium comfortable.
• Delirium can sometimes occur in older patients wearing eye
patches after cataract surgery (black-patch delirium). Such
patients can be helped by placing pinholes in the patches to
let in some stimuli or by occasionally removing one patch at a
time during recovery.
13

• The two major symptoms that require pharmacological
treatment- Psychosis and Insomnia.
• Psychosis is best treated with antipsychotics like-
haloperidol (Serenace), SGAs like risperidone,
quetiapine, olanzapine & aripiprazole.
• Insomnia is best treated with benzodiazepines with short
or intermediate half-lives like-lorazepam. In case of
alcohol withdrawal longer acting drugs are used.
• In intractable delirium, ECT can also be considered.
14

• A 66-year old male high school science department head, an
experienced and enthusiastic camper and hiker, became extremely
fearful while on a trek in the mountains.
• Gradually, over the next few months, he loses interest in his usual
hobbies. Formerly a voracious reader, he stops reading.
• Develops difficulty doing computations and makes gross errors in
home financial management.
• On several occasions, he becomes lost while driving in areas that
were formerly familiar to him.
• He begins to write notes to himself so that he would not forget to do
errands. Very abruptly he decided to retire from work.
• Intellectual deterioration gradually progresses. He spends most of
the day piling miscellaneous objects in one place and then
transporting them to another spot in the house.
• He becomes stubborn and querulous. Eventually, he requires
assistance in shaving and dressing.
15

• When examined 6 years after the first symptoms had developed, the
patient is alert and cooperative.
• He is disoriented with respect to place and time. He could not recall
the names of four or five objects after a 5-minute interval of
distraction. He could not remember the names of his college and
graduate school or the subject in which he had majored. He could
describe his job by title only.
• His speech is fluent and well articulated, but he has considerable
difficulty finding words and uses many long, essentially meaningless
phrases.
• He does simple calculations poorly. He could not copy a cube or
draw a house. His interpretation of proverbs is concrete.
• He has no insight into the nature of his disturbance.
• Neurological examination reveals nothing abnormal, and routine
laboratory tests are also negative. A CT showed marked cortical
atrophy.
16

• Defined as progressive impairment of cognitive functions
occurring in clear consciousness (i.e., in the absence of
delirium).
• It consists of a variety of symptoms that suggest chronic
and widespread dysfunction.
• Global impairment of intellect is the essential feature,
manifested as difficulty with memory, attention, thinking,
and comprehension.
• Other mental functions can often be affected, including
mood, personality, judgment, and social behaviour.
17

• Types of Dementia
• Alzheimer’s Disease (AD)
• Vascular Dementia
• Fronto Temporal Dementia (FTD)
• Pick’s Disease
• Dementia with Lewy Bodies (DLB)
• Creutzfeldt-Jakob Disease (CJD)
• Huntington’s disease (HD)
• Parkinson’s disease (PD)
• Wernicke-Korsakoff Syndrome
• And more..
• More then half of all dementias are Alzheimer’s Disease,
followed by Vascular Dementia.
• AD and other forms of dementia are irreversible, however
there are some that can be reversed with the appropriate
treatment.
18

• AD is the 4th most common cause of death after heart
disease, cancer and stroke.
• Gradual onset and continuous cognitive decline.
• Late-onset AD occurs at 65 years of age and up
(majority).
• Early-onset AD can occur between age 40 and 65 years.
• There is no cure for AD, however there are several
treatments to help slow down progress of AD
• Interventions
• Anti-depressants / Antipsychotics
• Nutrition, meaningful activities, and a familiar environment.
19

• Usually the first symptom to emerge in AD and many
other dementias is forgetfulness.
• Increasing impairment of learning and short term
memory.
• Impoverished speech.
• Shrinking vocabulary and decreased word fluency.
• Patient is aware of these difficulties and may avoid new
situations to minimize embarrassment or failure.
• May become depressed as they realize what’s happening
(presence of insight).
• Difficulty with perception (agnosia) or executive
movements (apraxia). 20

• Difficulties with executive functions.
• Abstract thinking gradually becomes difficult.
• Difficulty comprehending novel situations and subtle
changes of language and nonverbal expression.
• Frequent incorrect word substitutions (paraphasia).
• Delusions and hallucinations.
• Personality changes.
• Rapid changes in emotion / agitation.
• Impaired long-term memory.
21

• Profound anterograde and retrograde amnesia.
• Poor judgement and impulse control
• Disinhibited behaviours are common.
• Loss of insight (Anosagnosia)
• Alleviates depression.
• Extreme apathy and exhaustion.
• Loss of spontaneous speech / Mute.
• “Vegetative state”
• Complete dependence on caregivers.
22

1. Evidence of each of the following:
a.Decline in memory
b.Decline in other cognitive abilities - deterioration in judgement and thinking
(planning and organizing) and in the general processing of information.
2. Preserved awareness of the environment
a.During a period of time long enough to enable the unequivocal demonstration of 1.
3. A decline in emotional control or motivation, or a change in social
behaviour, manifest as at least one of the following:
a.Emotional lability;
b.Irritability;
c.Apathy;
d.Coarsening of social behaviour.
4. For a confident clinical diagnosis, 1 should have been present for at
least six months; if the period since the manifest onset is shorter, the
diagnosis can only be tentative.
23

• Alzheimer's- early onset- rapid onset & progression.
Aphasia, alexia, acalculia, apraxia.
• Alzheimer’s- late onset- very slow, gradual onset &
progression. Predominance of memory impairment over
intellectual impairment.
• Vascular dementia- Unequal distribution of deficits in
higher cognitive functions with some areas affected and
others relatively spared. Thus memory may be quite
markedly affected while thinking, reasoning and
information processing may show only mild decline.
24

• Pick’s disease- predominance of frontal lobe features &
behavioural manifestations.
• CJD- progresses rapidly over months to 1 or 2 years and
is accompanied or followed by multiple neurological
symptoms.
• Huntington’s disease- Involuntary choreiform movements
(typically of the face, hands, and shoulders, or in the gait)
are early manifestations. They usually precede the
dementia.
25

• Some patients with depression have symptoms of
cognitive impairment which is difficult to distinguish from
symptoms of dementia.
• This clinical picture is sometimes referred to as pseudo-
dementia or depression-related cognitive dysfunction.
• Clinical features distinguishing from true dementia- pt
complain of cognitive loss, emphasize disability, highlight
failures, make little effort even to perform simple tasks,
pervasive affective change.
26

• First step- Verification of the diagnosis.
• Accurate diagnosis is imperative, for the progression may
be halted or even reversed if appropriate therapy is
provided.
• Preventive measures are important, particularly in
vascular dementia. They might include changes in diet,
exercise, and control of diabetes and hypertension.
• Pharmacological agents might include antihypertensive,
anticoagulant, or antiplatelet agents.
• Blood pressure control should aim for the higher end of
the normal range.
• Surgical removal of carotid plaques may prevent
subsequent vascular events in carefully selected 27

• General treatment approach- to provide supportive medical
care, emotional support for the patients and their families,
and pharmacological treatment for specific symptoms,
including disruptive behaviour.
• Patients often benefit from a supportive and educational
psychotherapy in which the nature and course of their
illness are clearly explained.
• Also benefit from assistance in grieving and accepting the
extent of their disability and from attention to self-esteem
issues.
• Areas of intact functioning should be maximized by helping
patients identify activities in which successful functioning is
possible.
• BZDs for insomnia and anxiety, antidepressants for 28

Organic Mental Disorders

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Organic Mental Disorders