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Organic Psychiatry

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Richard Duffy

on 5 February 2015

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Transcript of Organic Psychiatry


Antibiotics
Anesthesia
Pain killers
Steroids
Sedatives
L-Dopa
Lithium
Gross
structural brain
Core features
Organic psychiatry
Dr Richard Duffy MRCPsych
Special lecturer in psychiatry

Thiamine (vitamin B1) deficiency
damage to the medial thalamus
Mammillary bodies of the hypothalamus - due to small haemorrhages
generalized cerebral atrophy
Causes
Thiamine deficiency
Alcoholism
Eating disorders
Malnutrition
Chemotherapy- induced vomiting
Abdominal pain or discomfort, dilated pupils , flushed face, nausea, rapid heart rate/pulse, sweating
Normal function:
Central representation of auditory and vestibular info
Memory (hippocampal gyrus)
Dominant: verbal
Non-dominant: music, visual (faces, art)
Central representation of smell & taste (uncus)
Upper homonymous visual pathways
Prosody (non-dominant)- rhythm+intonation of speech
Disturbed contralateral proprioception
Anosognosia (unaware of disability)
Hemisomatosognosia(neglect of one side of the body)
Prosopagnosia (faces)
Dressing dyspraxia
Motor/sensory dysphasia
Motor apraxia
Gerstmann’s syndrome:
Finger agnosia
Dyscalculia
R-L disorientation
Agraphia
Either lobe:
Visuospatial agnosia
Contralateral cortical memory loss
Astereognosis (by touch)
Agraphaestesia
Slightly increased reflexes
Mild facial weakness
Normal function:
Cognition
Information Processing
Pain and Touch Sensation
Spatial Orientation
Speech
Visual Perception

Verbal fluency (FAS or animal)
Cognitive estimates
Luria’s motor test
Go-no-go
Similarities and dissimilarities
Proverb interpretation
Primative reflexes
Clinical signs:
Impaired concentration & attention
Impaired ability to carry out planned activity
Contralateral spastic paresis (motor cortex)
Broca’s aphasia
Grasp reflex
Orbitofrontal:
Forced utilisation of presented objects
Unilateral anosmia
Optic atrophy
Loss of drive
Apathy
Loss of concern Re: personal appearance
Disinhibition
Antisocial behaviour
Overtalkativeness
Prankish joking (Witzelsucht)
Hypersexuality
Lack of insight
Involved in “executive function” i.e. planning, organizing, problem solving, selective attention, personality, behaviour and emotions.

Anterior portion is the prefrontal cortex
Executive function
determination of personality.

Posterior part consists of the premotor and motor areas.
Motor areas produce movement
Premotor areas modify movements.

The frontal lobe is divided from the parietal lobe by the central sulcus
Avoid! Use minimum...
Haloperidol – 0.5-1mg BD with 4-hourly PRNs
Quetiapine 12.5-25mg BD elderly – may be increased every 1-2 days up to 100mg daily
Aviod BZD – disinhibition (lorazepam 0.5-1mg- 2-4 hourly)
DTs indication for BDZ (Chlordiazepoxide) Haloperidol will lower seizure threshold
Sleep
Deprivation
Head trauma - concussion, traumatic bleeding, penetrating injury, etc
Gross structural damage from brain disease - stroke, spontaneous bleeding, tumour, etc
Hydrocephalus
Attention abnormal
Behaviour disturbance
Cognitive function impaired
Disturbance of perception
Disordered sleep-wake cycle
Emotional changes
Fluctuating course

Hallucinations or perceptual distortions may occur in delirium, but they are not essential for the diagnosis.
Strange beliefs may be held but not considered fixed delusions as short lived, may be left with a delusional memory
Emotional lability

Temporary reduction in the ability to form short-term or long-term memory.
Simple short-term memory tasks may be preserved, but the more complex may be affected
Reduction in formation of new long-term as initial formation of memories generally requires a higher degree of attention.
Cognitive function may be impaired in a patient who is fully aware
The state of delirium most familiar to the average person is that which occurs from extremes in pain, lack of sleep, or emotional shock.

Impairment in problem solving
This involves many sub-skills and basic mental abilities, any of which may be impaired
Loss of the capacity for clear and coherent thought.
disorganised or incoherent speech
inability to concentrate
lack of any goal-directed thinking.
10 - 30% medical & surgical patients
30% surgical ICU burns patients
30 - 40% hospitalised AIDs & elderly px
40 – 50% recovering px for hip # surgery
Up to 80% ICU & terminally ill px
Epigastric sensations
Hallucinations or illusions (any modality)
Sensation of deja vu, recalled emotions or memories
Sudden, intense emotion
Symptoms:
anterograde amnesia
retrograde amnesia
confabulation
poverty of speech
lack of insight
apathy
Delirium
Treatment
Aetiology
Epidemiology
Delirium - acute onset of fluctuating global cognitive impairment associated with behavioural abnormalities
Wernicke-Korsakoff Syndrome
High Risk Groups
Elderly
Preexisting dementia
Blind or deaf
Very Young
post op espically cardiac
EtOH or BDZ dependent
Common cause of inappropriate referrals to psychiatry
Mnemonic
Confusion &
loss of awareness of the surroundings, environment and context in which the person exists.
Disorientation
may occur in time (not knowing what time of day, day of week, month, season or year it is), place (not knowing where one is) or person (not knowing who one is).
Poor attention
Abnormalities
of awareness and affect
Distorted emotional states
Memory
formation
disturbance
Treat underlying cause!!!!
Moderately lit, quiet
Consistency of staff
Reassurance & orientation
Side room
Sedation
Environmental
Up to 80% of mechanically ventilated ICU patients
ICU delirium predicts a 3 to 11-fold increased risk of death at 6 months even after controlling for relevant covariates such as severity of illness.
Assoc with complications of mechanical ventilation including nosocomial pneumonia, self-extubation, and re-intubation
Critical Illness
Up to 80% of mechanically ventilated ICU patients
Can occur with MI
Substance
withdrawal & Intoxication
alcohol withdrawal (delirium tremens)
benzodiazepine withdrawal
Other licit and illicit drug withdrawal can sometimes cause delirium.
disorders
Infection
UTI, LRTI, wounds, IV lines
Intra-cranial – encephalitis, meningitis
ESR & CRP
WCC and diff
Swabs
MSU
Blood cultures
Ix
Ix for EtOH abuse?
Nutritional
Deficiencies
Thiamine
Nicotinic Acid
B12
Tx thiamine deficiency?
Medication
Metabolic
Medical/ neurological disease
Hypoxia (respiratory or cardiac failure)
Hypo/hyper glycaemia
Electrolyte imbalance (dehydration)
Uraemia
Liver failure
Renal failure
Porphyria
Cushing’s
Neurological contidion - Epilepsy post-ictal, status
Raised ICP
Neoplasm – paraneoplastic syndrome, metastases, primary brain
Systemic illness – infections, dehydration, burns, uncontrolled pains, other systemic conditions – cardiac, pulmonary, endocrine, hematological, renal, hepatic, SLE
Classic triad:
Ophthalmoplegia
Ataxia
Confusion
Also:
Nystagmus
Ptosis
Anorexia
Vomiting
Wernicke's encephalopathy
Rx: IV Thiamine
Carl Wernicke (1848 -1905)
Korsakoff's Amnestic syndrome
Tx: Thiamine for 2yrs
Sergei Sergeievich Korsakoff (1854-1900)
Frontal Lobe tests
Personality change
Frontal Lobe
Frontal Signs
Parietal Lobe
Parietal Lobe Lesion
Dominant Parietal Lobe
Lesion
Non-Dominant Parietal
Lobe Lesion
Occipital lesion
Blindness
Visual agnosia
Temporal Lobe Function
Temporal Lobe Eplipsy
Hemianopia
Automatisms (Abnormal lip, head or limb movements, repetitive momements)
Psychosis - delusions and hallucinations of smell taste and sound
Precognition
"Yells and falls to the floor" type seizure
Complex partial seizure
Language disorder (aphasia)
Amnesia
Pains (strange sensations, numbness, crawling tingling)
Panic (or rage or hypersexuality)
You find yourself not believing the stories
Deja vu
Jamais vu
Aura
Autonomic Nervous System symptoms
HAPPY CLAPPY DJ
Neurology
Endocrine
Other
Meds
Depression
Elation
Anxiety
Psychosis
Most dementias (epsically vascular and Huntingtons)
Parkinsons
MS
Neurosyphilis
Head injury
Hypo/hyperthyroidism
Cushing's
Addison's
Hypopituitarism
Hyperparathyroidism
Menopause
Anaemia
Infections
HypoNa
SLE
Acute porphyria
Wilson's
Steroids
Beta-blockers
Ca Channel blockers
Anticonvulsants
L-Dopa
OCP
MS
Neurosyphilis
Eplipsy
Brain tumour
Cushings
Hyper/hypothyroidism
Corticosteroids
Antidepressants
Hyperthyroidism
Hypoglycaemia
Pheochromocytoma
Hypoparathyroidism
SSRIs
Antihypertensives
Brinchodilators
Antocholinergics
Huntington's
MS
Space occupying lesion
CNS infection (Lyme's Dx, vCJD)
SLE
Acute Porphyria
Wilson's
Hypernayremia
Hypocalcaemia
Steroids
Beta-blockers
L-Dopa
Sympathomimetics
Hyperthyroidisn
Cushing's
SLE
Arrhythmias
IHD
Mitral valve Dx
Asthma
COPD
TLE
Delerium Vs. Dementia
Onset Acute in delerium with rapid disorintation
Duration days to months in delerium
Consciouness/Alertness/Attention intact in dementia
Instant recall inpaired early in delerium
Delusions and Hallucinations are earlier and more common in delerium
Thinking reduced in dementia but confused and possibly increased in delerium
Celebral lobes
Test
What features distinguish dementia from delirium list four?
84y.o. brought into hospital with confusion and memory problems what is the differential ?
This has come on in the last few days now what is the differential and what are the most likely causes?
What are the main features of Wernickes encephalitis?

How do you treat it?
Name 5 tests of the frontal lobe that can be done at the bedside
Name four features of temporal lobe eplipsy
What are the four features of Gerstmanns syndrome
Full transcript