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Transcript of 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
Chemotherapy- induced vomiting
Abdominal pain or discomfort, dilated pupils , flushed face, nausea, rapid heart rate/pulse, sweating
Central representation of auditory and vestibular info
Memory (hippocampal gyrus)
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)
Contralateral cortical memory loss
Astereognosis (by touch)
Slightly increased reflexes
Mild facial weakness
Pain and Touch Sensation
Verbal fluency (FAS or animal)
Luria’s motor test
Similarities and dissimilarities
Impaired concentration & attention
Impaired ability to carry out planned activity
Contralateral spastic paresis (motor cortex)
Forced utilisation of presented objects
Loss of drive
Loss of concern Re: personal appearance
Prankish joking (Witzelsucht)
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
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
Head trauma - concussion, traumatic bleeding, penetrating injury, etc
Gross structural damage from brain disease - stroke, spontaneous bleeding, tumour, etc
Cognitive function impaired
Disturbance of perception
Disordered sleep-wake cycle
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
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
Hallucinations or illusions (any modality)
Sensation of deja vu, recalled emotions or memories
Sudden, intense emotion
poverty of speech
lack of insight
Delirium - acute onset of fluctuating global cognitive impairment associated with behavioural abnormalities
High Risk Groups
Blind or deaf
post op espically cardiac
EtOH or BDZ dependent
Common cause of inappropriate referrals to psychiatry
loss of awareness of the surroundings, environment and context in which the person exists.
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).
of awareness and affect
Distorted emotional states
Treat underlying cause!!!!
Moderately lit, quiet
Consistency of staff
Reassurance & orientation
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
Up to 80% of mechanically ventilated ICU patients
Can occur with MI
withdrawal & Intoxication
alcohol withdrawal (delirium tremens)
Other licit and illicit drug withdrawal can sometimes cause delirium.
UTI, LRTI, wounds, IV lines
Intra-cranial – encephalitis, meningitis
ESR & CRP
WCC and diff
Ix for EtOH abuse?
Tx thiamine deficiency?
Medical/ neurological disease
Hypoxia (respiratory or cardiac failure)
Electrolyte imbalance (dehydration)
Neurological contidion - Epilepsy post-ictal, status
Neoplasm – paraneoplastic syndrome, metastases, primary brain
Systemic illness – infections, dehydration, burns, uncontrolled pains, other systemic conditions – cardiac, pulmonary, endocrine, hematological, renal, hepatic, SLE
Rx: IV Thiamine
Carl Wernicke (1848 -1905)
Korsakoff's Amnestic syndrome
Tx: Thiamine for 2yrs
Sergei Sergeievich Korsakoff (1854-1900)
Frontal Lobe tests
Parietal Lobe Lesion
Dominant Parietal Lobe
Temporal Lobe Function
Temporal Lobe Eplipsy
Automatisms (Abnormal lip, head or limb movements, repetitive momements)
Psychosis - delusions and hallucinations of smell taste and sound
"Yells and falls to the floor" type seizure
Complex partial seizure
Language disorder (aphasia)
Pains (strange sensations, numbness, crawling tingling)
Panic (or rage or hypersexuality)
You find yourself not believing the stories
Autonomic Nervous System symptoms
HAPPY CLAPPY DJ
Most dementias (epsically vascular and Huntingtons)
Ca Channel blockers
Space occupying lesion
CNS infection (Lyme's Dx, vCJD)
Mitral valve Dx
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
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