Organic mental Organic mental disordersdisorders
Zoltán HidasiZoltán Hidasi
What is organic?What is organic?►NeurologyNeurology►PsychiatryPsychiatry►Organic psychosyndromesOrganic psychosyndromes
►Organic (mental )Organic (mental ) disordersdisorders►Functional disordersFunctional disorders
NeuropsychiatryNeuropsychiatry►Biological psychiatryBiological psychiatry►Cognitive neuroscience Cognitive neuroscience ►NeuropsychologyNeuropsychology►(Neurology – Psychiatry)(Neurology – Psychiatry)
►NeuropsychiatryNeuropsychiatry
DSM IV TRDSM IV TR►Delirium, dementia, amnestic Delirium, dementia, amnestic
disorders and otherdisorders and other cognitive cognitive disorders. disorders.
►DSM V: Major/mild neurocognitive DSM V: Major/mild neurocognitive disorderdisorder
►Mental disorders due to a medical Mental disorders due to a medical conditioncondition
ICD 10ICD 10►Organic and symptomatic mental disordersOrganic and symptomatic mental disorders
DementiaDementia Organic amnestic syndromeOrganic amnestic syndrome DeliriumDelirium Other mental disorders caused by brain lesion Other mental disorders caused by brain lesion
and dysfunction or somatic disorderand dysfunction or somatic disorder►Organic hallucinosis, organic catatonia, organic Organic hallucinosis, organic catatonia, organic
delusional disorder, organic mood disorder, organic delusional disorder, organic mood disorder, organic anxiety disorder, etc.anxiety disorder, etc.
►Mental and behavioural disorders caused by Mental and behavioural disorders caused by psychoactive substancespsychoactive substances
Etiology, causes, pathologyEtiology, causes, pathology► Central nervous systemCentral nervous system
NeurodegenerationNeurodegeneration Cerebrovascular originCerebrovascular origin Inflammation, tumorInflammation, tumor DemyelinationDemyelination EpilepsyEpilepsy TraumaTrauma OtherOther
► Outside the central nervous systemOutside the central nervous system EndocrineEndocrine Metabolic, cardio-vascular diseasesMetabolic, cardio-vascular diseases Nutritional disturbanceNutritional disturbance InfectionInfection
► Drug intoxication, drug withdrawalDrug intoxication, drug withdrawal Alcohol, illegal drugs, medicationAlcohol, illegal drugs, medication
From neurological point of From neurological point of view…view…
►Cerebrovascular diseasesCerebrovascular diseases►Neurodegenerativ diseases Neurodegenerativ diseases ►Parkinson’s disease, other movement dis. Parkinson’s disease, other movement dis. ►EpilepsyEpilepsy►Head trauma –brain injuriesHead trauma –brain injuries►TumorsTumors►NeuroinfectionsNeuroinfections►Neuroimmunology (multiple sclerosis)Neuroimmunology (multiple sclerosis)
Classification of Classification of syndromatologysyndromatology
►Acute – chronicAcute – chronic►Diffuse (global) – focal (local) - multifocal Diffuse (global) – focal (local) - multifocal
brain disfunctionbrain disfunction► Lobe syndromesLobe syndromes
FRONTAL FRONTAL apathy,apathy, disinhibition disinhibition, lack of iniciative and , lack of iniciative and
spontaneity, spontaneity, motivation, perseveration, impulsivitymotivation, perseveration, impulsivity TEMPORAL TEMPORAL
affective,affective, agression,agression, fear,fear, explosion,explosion, psychosis,psychosis, disorientationdisorientation
PARIETALPARIETALgnostic and gnostic and cognitive dysfunctions (alexia, cognitive dysfunctions (alexia, acalculia, agraphia), apraxias acalculia, agraphia), apraxias
Delirium - SyndromatologyDelirium - Syndromatology►Acute course Acute course – (sudden onset, short episode)– (sudden onset, short episode)► Impairment of consciousnessImpairment of consciousness►Global impairment of cognitive functions Global impairment of cognitive functions
(memory, attention, orientation, thinking, etc.)(memory, attention, orientation, thinking, etc.)►Perceptual disturbance Perceptual disturbance (multimodal (multimodal
illusions and hallucinations)illusions and hallucinations)►Behavioural changesBehavioural changes (agitation) (agitation)►Fluctuating courseFluctuating course
Delirium - EtiologyDelirium - Etiology►Any cause, resulting in global dysfunctionAny cause, resulting in global dysfunction►General medical condition (e.g. infection, General medical condition (e.g. infection,
metabolic reasons, hypoxia)metabolic reasons, hypoxia)►Substance inducedSubstance induced►Multiple causeMultiple cause
►Therapy: Causal, symptomatological Therapy: Causal, symptomatological (BZD, NL)(BZD, NL)
EtiologyEtiology►Etiological factors?Etiological factors?►Risk (predisposing) factorsRisk (predisposing) factors
►Trigger (precipitating) factorsTrigger (precipitating) factors
►Hyperactive, hypoactive, mixed formHyperactive, hypoactive, mixed form
Risk factors 1. Risk factors 1. ► Age: 65+ sex: maleAge: 65+ sex: male►Dementia (+++), other cognitive disorderDementia (+++), other cognitive disorder►DepressionDepression► Vision-, hearing impairmentVision-, hearing impairment►Dehydration, malnutritionDehydration, malnutrition►Medication (multiple drugs, psychoactive Medication (multiple drugs, psychoactive
drugs), alcoholdrugs), alcohol► Immobility, pain, constipationImmobility, pain, constipation► Sleep deprivationSleep deprivationSaxena et al, 2009.Saxena et al, 2009.
Risk factors 2.Risk factors 2.►Somatic illnessesSomatic illnesses
Severe illnessSevere illness Many illnessesMany illnesses Chronic liver or kidney failureChronic liver or kidney failure Stroke, other neurological disorderStroke, other neurological disorder Metabolic disorderMetabolic disorder Trauma, bone fractureTrauma, bone fracture Terminal stateTerminal state HIV infectionHIV infection
Saxena et al, 2009.Saxena et al, 2009.
Precipitating 1.Precipitating 1.►Comorbid disordersComorbid disorders
InfectionInfection HypoxiaHypoxia Severe acute disorder (pl. AMI)Severe acute disorder (pl. AMI) Liver, kidney disorderLiver, kidney disorder Urinary retention, constipationUrinary retention, constipation AnaemiaAnaemia FeverFever ShockShock
Saxena et al, 2009.Saxena et al, 2009.
Precipitating factors 2.Precipitating factors 2.► Iatrogenic complicationIatrogenic complication►Metabolic imbalanceMetabolic imbalance► Neurological disease (head trauma)Neurological disease (head trauma)► SurgerySurgery►Medication Medication
overdose, politherapyoverdose, politherapy sedatives, hypnotics, anticholinergic drugs, antiepilepticssedatives, hypnotics, anticholinergic drugs, antiepileptics
► Eniviromental factors Eniviromental factors (ICU, phycical restraint, bladder (ICU, phycical restraint, bladder catheters, multiple/invasive manipulations, emotional catheters, multiple/invasive manipulations, emotional stress)stress)
► PainPainSaxena et al, 2009.Saxena et al, 2009.
Dementia - SyndromatologyDementia - Syndromatology►Chronic course Chronic course (10% above 65 y, 16-25% above 85 (10% above 65 y, 16-25% above 85
y)y)►Multiple cognitive deficits incl. memory Multiple cognitive deficits incl. memory
impairment impairment (intelligence, learning, language, (intelligence, learning, language, orientation, perception, attention, judgement, orientation, perception, attention, judgement, problem solving, social functioning)problem solving, social functioning)
►No impairment of consciousnessNo impairment of consciousness►Behavioural and psychological Behavioural and psychological
symptoms of dementia (BPSD)symptoms of dementia (BPSD)►Progressive - staticProgressive - static►Reversible (15%) - irreversibleReversible (15%) - irreversible
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Cognitive/non-cognitiveCognitive/non-cognitive►Non-cognitive symptomsNon-cognitive symptoms►Behavioural symptomsBehavioural symptoms►Psychological and behavioural Psychological and behavioural
symptoms zichológiai in dementia symptoms zichológiai in dementia (BPSD)(BPSD) delusion, hallucination, depression, delusion, hallucination, depression,
anxiety, agitation/agression, anxiety, agitation/agression, euphoria/mania, disinhibition, irritability, euphoria/mania, disinhibition, irritability, apathy, motor behaviour apathy, motor behaviour
Dementia - ClassificationDementia - Classification►SeveritySeverity
Mild cognitive impairment (MCI)Mild cognitive impairment (MCI) Mild dementiaMild dementia Moderate dementiaModerate dementia Severe dementiaSevere dementia
►Localization Localization Cortical Cortical SubcorticalSubcortical
►EtiologyEtiology
Dementia -EtiologyDementia -Etiology► Alzheimers disease (60-70%)Alzheimers disease (60-70%)► Vascular dementia (10-20%)Vascular dementia (10-20%)► Neurodegenerative disorders Neurodegenerative disorders
(FTD, Lewy body dis, Parkinson, Huntington, etc.)(FTD, Lewy body dis, Parkinson, Huntington, etc.)►Drugs and toxinsDrugs and toxins► Intracranial massesIntracranial masses► AnoxiaAnoxia► TraumaTrauma► Infections Infections (JCD, HIV, etc)(JCD, HIV, etc)► NutritionNutrition►MetabolicMetabolic► PseudodementiaPseudodementia
Dementia - DiagnosisDementia - Diagnosis►Signs and symptomsSigns and symptoms►Laboratory dataLaboratory data►EEG, CT, MRIEEG, CT, MRI►Psychological testing (MMS)Psychological testing (MMS)
Dementia - TherapyDementia - Therapy►Causal if possibleCausal if possible►NootropicsNootropics►Neuroprotection Neuroprotection ►AChEI (rivastigmine, donepezil, AChEI (rivastigmine, donepezil,
galantamin)galantamin)►Glutamate antagonists (Memantine)Glutamate antagonists (Memantine)►BPSD BPSD (anxiolitics, antidepressant, antipsychotics, (anxiolitics, antidepressant, antipsychotics,
etc.)etc.)
Mental disorders due to a Mental disorders due to a General Medical Condition (DSM General Medical Condition (DSM
IV)IV)►Psychotic disorder due to a general Psychotic disorder due to a general
medical conditionmedical condition►Mood disorderMood disorder►Anxiety disorderAnxiety disorder►Sexual disfunctionSexual disfunction►Sleep disorderSleep disorder►Catatonic disorderCatatonic disorder►Personality changePersonality change
Therapy in neuropsychiatryTherapy in neuropsychiatry►PharmacotherapyPharmacotherapy►Psychotherapy, psycho-social Psychotherapy, psycho-social
treatmenttreatment Improving cognitive abilitiesImproving cognitive abilities RehabilitationRehabilitation Treating affective and anxiety symptomsTreating affective and anxiety symptoms Treating other psychological symptomsTreating other psychological symptoms
Pharmacotherapy in Pharmacotherapy in neuropsychiatry 1.neuropsychiatry 1.
►Targets of pharmacotherapyTargets of pharmacotherapy Etiological background Etiological background ProgressionProgression Psychiatric symptoms Psychiatric symptoms
►Target symptom: Target symptom: Cognitive Cognitive Agitation/aggressionAgitation/aggression Mood Mood PsychoticPsychotic Other behaviouralOther behavioural
Neurologic symptomsNeurologic symptoms
Pharmacotherapy in Pharmacotherapy in neuropsychiatry 2.neuropsychiatry 2.
►Aspects of pharmacotherapyAspects of pharmacotherapy Mental statusMental status Neurological statusNeurological status Social statusSocial status Etiological backgroundEtiological background
►Typical v. atypical symptomsTypical v. atypical symptoms
Pharmacotherapy in Pharmacotherapy in neuropsychiatry 3.neuropsychiatry 3.
►Special aspectsSpecial aspects AgeAge PolimorbidityPolimorbidity Pharmacokinetics (interactions) Pharmacokinetics (interactions) Optimal dosing ( +/-)Optimal dosing ( +/-) Side effects (cognitive, other)Side effects (cognitive, other)