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Psychiatry 5th year, 3rd lecture (Dr. Rebwar Ghareeb Hama)
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Psychiatry 5th year, 3rd lecture (Dr. Rebwar Ghareeb Hama)

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The lecture has been given on Mar. 29th, 2011 by Dr. Rebwar Ghareeb Hama.

The lecture has been given on Mar. 29th, 2011 by Dr. Rebwar Ghareeb Hama.

Published in: Health & Medicine

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  • 1. Organic Mental Disorders Dr. Rebwar Ghareeb Hama Psychiatrist University of Sulaimani College of Medicine
  • 2. Dementia
    • Dementia is a syndrome usually of chronic and progressive nature characterized by decline of memory, personality and intellect
    • Diagnostic criteria of dementia :
      • decline of learning new information
      • decline of other cognitive functions (thinking, judgement, planning, organizing, processing of information)
      • no disorder of consciousness
      • affective disorders (impaired emotional control - lability, irritability, apathy, decline of social functioning)
      • the symptoms evident for at least 6 months
  • 3. Dementia
    • The degrees of dementia:
      • mild
      • moderate
      • serious
    • Dementia is usually (80%) an irreversible process
  • 4. Dementia in Alzheimer’s Disease
    • DAT = dementia of Alzheimer's type :
    • The most frequent type of dementia
    • Primary degenerative cerebral disease of unknown etiology
    • Characterized with marked reduction of neurons, appearance of neurofibrillary tangles and senile plaques (beta-amyloid)
    • Especially cholinergic system is affected
  • 5. DAT with Early Onset
    • Dementia before the age of 65
    • Relatively rapid deterioration
    • Aphasia, agraphia, alexia, apraxia
  • 6. DAT with Late Onset
    • Dementia after the age 65
    • Family history of DAT or Down’s syndrome
    • Slow progression, no insight
    • Severe impairment of memory, confabulations
  • 7. Causes of Dementia
    • Pharmacogenic dementia (anticholinergics, benzodiazepines, cytostatics, ...)
    • Alcohol dementia (Korsakov, Wernicke)
    • Intoxicant dementia of other etiology (CO, Pb, Hg, solvents)
    • Dementia at vitamin deficit (niacin-pellagra, vit. B12)
    • Dementia of endocrine origin (hypothyroid, Cushing)
    • Dementia due to dialysis
  • 8. Causes of Dementia
    • Metabolic dementia (hypernatremia, hypocalemia)
    • D. at uraemia (uremic encephalopathy)
    • D. at Wilson
    • D. at liver encephalopathy
    • D. due to hypoxia
    • D. due to trauma
    • D. at epilepsy
    • D. due to infection (human immunodeficiency virus disease, prion infection - Creutzfeldt-Jakob d., kuru)
    • D. at brain tumors
  • 9. Vascular Dementia
    • Diagnostic guidelines :
    • Presence of a dementia
    • Uneven impairment of cognitive function + focal neurological signs
    • Insight and judgement relatively well preserved
    • An abrupt onset or a stepwise deterioration
  • 10. Vascular Dementia
    • Associated features :
    • Hypertension
    • Emotional lability, weeping or explosive laughter
    • Transient episodes of clouded consciousness
    • Personality relatively well preserved, accentuation of previous traits (egocentrism, paranoid attitudes, irritability)
  • 11. Dementia in Other Diseases Classified Elsewhere
    • Dementia in Pick’s disease
    • A progressive dementia
    • A predominance of frontal lobe features (euphoria, emotional blunting, coarsening of social behaviour, disinhihition, apathy)
    • Behavioural manifestations
    • Dementia in Creutzfeldt-Jakob disease
    • Fairly rapid progressing over months to 1-2 years
    • Multiple neurological signs (pyramidal + extrapyramidal, ataxia)
  • 12. Dementia in Other Diseases Classified Elsewhere
    • Dementia in Huntington’s disease
    • Family history of H’s d.
    • Onset at a relatively young age
    • Involuntary choreiform movements
    • Slow progression of dementia
    • Dementia in Parkinson’s disease
    • In severe cases, no particular distinguishing features
  • 13. Dementia in Other Diseases Classified Elsewhere
    • Dementia in human immunodeficiency virus (HIV) disease
    • HIV infection
    • Complaints of forgetfulness, slowness, poor concentration, difficulties with problem-solving and reading
    • Apathy, social withdrawal, affective disorder
    • Neurological signs (tremor, ataxia, hyperreflexia,...)
    • General paralysis of the insane (GPI – paralysis progressiva)
  • 14. Treatment of Dementia
    • A) Pharmacotherapy of cognitive symptoms
    • Cholinesterase inhibitors - (physostigmin, rivastigmin, donepezil, metrifonat, galantamin, tacrin)
    • Selegilin, lecitin, propentophylin
    • Nootropic agents + agents with a scavanger effect (piracetam, Gingko biloba, vitamine E)
    • Agonists of muscarinic (M 1 , M 3 ) and nicotinic acetylcholine receptors (nicotine)
    • Nootropic agents (cerebral metabolic enhancers) + Ca channel antagonists (nimodipin, cinnarizin)
    • Nootropic agents + antiinflammatory agents (acetylosalicylic acid, ibuprofen, indometacine)
    • Nerve growth factors (cerebrolysin)
    • Somatostatin deficit (octostatin)
  • 15. Treatment of Dementia
    • B) Pharmacotherapy of non-cognitive symptoms
    • Depression, anxiety - SSRI (citalopram, fluvoxamin, paroxetin, …), SNRI (venlafaxin)
    • Psychotic + confusional states - neuroleptics with minimal adrenolytic + anticholinergic effects (tiaprid, sulpirid, risperidon, haloperidol, clozapin)
    • Insomnia - non-benzodiazepine hypnotics (zolpidem, zopiclon)
    • Epileptic seizures - carbamazepin, valproic acid, Na valproate
    • C) Psychotherapy
    • Reeducation of cognitive, emotional + behavioural disorders
    • Family therapy
    • Alzheimer’s society
  • 16.
  • 17. Delirium
    • Diagnostic guidelines:
    • Impairment of consciousness and attention
    • Global disturbance of cognition (perceptual distortions, illusions, hallucinations, impairment of abstract thinking and comprehension, disorientation for time + place)
    • Psychomotor disturbances (hypo- or hyperactivity,...)
    • Disturbances of sleep (reversal of the sleep-wake cycle)
    • Emotional disturbances (anxiety, fear, irritability, apathy, perplexity)
  • 18. SYNONYMS FOR DELIRIUM
    • Acute confusional state
    • Toxic-metabolic encephalopathy
    • Organic brain syndrome
    • ICU psychosis
  • 19. CAUSES of Delirium
    • METABOLIC;
    • Hypernatremia
    • Hypercalcemia
    • Hypo-, hyper-glycemia
    • Uremia (uremic encephalopathy)
    • Liver failure (hepatic encephalopathy)
  • 20. INFECTIOUS;
    • Urinary tract infection
    • Pneumonia
    • Sepsis
    • Delirium may be the first sign of infection, predating fever, leukocytosis, CXR findings
  • 21. MEDICATIONS;
    • Anticholinergics (Cogentin, Artane)
    • Psychotropic medications (Thorazine, Mellaril, TCAs, Paxil, Benzodiazepines)
    • Lithium toxicity
    • Steroids
    • Narcotics
  • 22. CNS CAUSES OF DELIRIUM;
    • Alcohol withdrawal (delirium tremens) -- very agitated delirium
    • Barbiturate/benzo withdrawal (rare)
    • Post-ictal
    • Increased intracranial pressure
    • Head trauma
    • Encephalitis/meningitis
    • Vasculitis
  • 23. MANAGEMENT OF DELIRIUM
    • Find the cause(s)
    • Usually multifactorial
    • Look for medication toxicity
    • Re-orient patient
    • Quiet, unstimulating environment
    • Antipsychotic medications for agitation
    • Benzodiazepines often makes delirium worse
    • Observation/restraints only when needed
  • 24. Other Mental Disorders Due to Brain Damage and Dysfunction and to Physical Disease
    • Diagnostic guidelines:
    • Evidence of cerebral disease, damage or dysfunction, or of systemic disease
    • A temporal relationship (weeks or a few months) between the development of the underlying disease and the onset of the mental syndrome
    • Recovery from the mental disorder following removal or improvement of the underlying presumed cause
    • Absence of evidence to suggest an alternative cause of the mental symptoms
  • 25.
    • Types: organic hallucinosis, org. catatonic disorder, org. delusional (schizophrenia-like) disorder, org. affective disorders (manic, depressive, anxiety, emotionally labile), mild cognitive disorder (may precede, accompany, or follow a wide variety of infections and physical disorders)
  • 26. Personality and Behavioural Disorders Due to Brain Disease, Damage and Dysfunction
    • Organic personality disorder
    • Diagnostic guidelines :
    • Consistently reduced ability to persevere with goal-directed activities
    • Altered emotional behaviour (emotional lability, euphoria, irritability, outbursts of anger and aggression,...)
    • Expression of needs and impulses without consideration of consequences or social convention
    • Cognitive disturbances
    • Marked alteration of language production
    • Altered sexual behaviour (hyposexuality, change of sexual preference)
  • 27. Personality and Behavioural Disorders Due to Brain Disease, Damage and Dysfunction
    • Postencephalitic syndrome
    • R esidual behavioural change following recovery from encephalitis often reversible
    • (apathy, irritability, some lowering of cognitive functioning, altered sleep pattern, a variety of neurological dysfunctions, …)
    • Postconcussional syndrome
    • O ccurs following head trauma
    • C omplaints of headache, dizziness, fatigue, irritability, difficulty in concentrating and performing mental tasks, impairment of memory, insomnia, reduced tolerance to stress, emotional excitement or alcohol, …(sometimes associated with compensation motives)
  • 28. CARDIAC DISEASE
    • 20% of patients with CAD or post-MI are depressed
    • Risk factors; female, prior depression, disabled
    • 6-month mortality was 17% for depressed, 3% non-depressed
  • 29. CANCER
    • About 50% of cancer patients feel depressed
    • Uncontrolled pain
    • Delirium
    • Brain metastases
    • Disability and independence
    • Disfigurement
    • Life cycle issues -- dying young, unfinished business
    • Chemotherapy
  • 30. STROKE
    • 30-50% depressed, about half with major depression
    • More common with left anterior lesions
    • Not merely secondary to neurological disability
    • Antidepressant treatment is effective
    • High-risk period is 1st 2 years post-stroke
    • Depression associated with higher morbidity and mortality
    • Treatment probably improves rehabilitation
  • 31. Epilepsy
    • Pre- ictal; (Tension, Irritability, Anxiety & Depression)
    • Ictal; Confusional state, Anxiety, Psychoses, Automatism)
    • Post- ictal; (Psychoses, Cognitive dysfunction, violence)
    • Inter- ictal; (Cognitive impairment, Personality change, psychoses, Depression & emotional disorder, Suicide)
  • 32. OTHER DISEASES ASSOCIATED WITH DEPRESSION
    • Parkinson’s
    • Huntington’s
    • Multiple sclerosis
    • Epilepsy
    • AIDS
    • Hypothyroidism
    • Hyperthyroidism
    • Hyperparathyroidism
    • Cushing’s
    • Chronic fatigue syndrome
  • 33. MEDICATIONS CAUSING DEPRESSION
    • Reserpine
    • Methyldopa
    • Inderal (rare)
    • High-dose (older) oral contraceptives
    • Corticosteroids
    • Benzodiazepines
    • Alcohol
    • Opioids
    • Opiate analgesics
    • Cocaine withdrawal