This document provides an overview of several topics relating to psychiatric aspects of organic brain illnesses: - Common organic causes of psychiatric presentations include epilepsy, Parkinson's disease, central nervous system infections, and various forms of dementia. - Key points about specific conditions are discussed, such as post-ictal psychosis occurring in 7-10% of people with epilepsy. Parkinson's disease can cause dementia in 50-80% of patients as well as depression. - Alzheimer's disease is the most common cause of dementia. Major neurocognitive disorder is characterized by significant cognitive decline interfering with daily life, while mild neurocognitive disorder involves lesser impairment.

1. 16 OCT 2020 PSY CLINIC, HTAR KLANGMentor: Dr Teng / Presenter: Adib ‘Afifi
SOME PSYCHIATRIC ASPECT
OF ORGANIC BRAIN ILLNESSES
Houseman teaching:

2. Understand the relation of psychiatry and some common cause of organic brain diseases.
Identify common organic causes of psychiatric presentations
Differentiate dementia and delirium
Principle management of dementia
Identify neuro cognitive domains, differences between major and minor neurocognitive
disorders
AIM OF TEACHING

3. Common organic causes
Epilepsy- psychiatric aspects
Parkinson’s disease and related syndrome
CNS infections
Dementia
Alzheimer’s disease
Vascular Dementia (vascular neurocognitive disorder)
Major and Mild Neurocognitive disorders
CONTENT

4. All psychiatric illness are, by they nature, organic, ie they involve abnormalities of normal brain
structures to function.
The term ‘organic ilness’ in modern psychiatric classification, however, refers to those conditions
with demonstrable aetiology in central nervous system (CNS) pathology.
Organic illnesses are included in the lists of differential diagnoses for most psychiatric syndromes.
For this reason, most patients presenting with psychiatric symptomatology merit a thorough
physical examination (including neurological examination, and, in some cases, special
investigations before a diagnosis of primary psychiatric illness is made.
While psychiatrist do not have to be expert neurologists, a sound knowledge of those conditions
that bridge neurology and psychiatry is essential.
INTRODUCTION

5. Neurological (encephalitis eg HSV, epilepsy, dementia, brain tumour/abscess, stroke)
Endocrine (hyper/hypoparathyroidism, Addison disease)
Metabolic (uremia, sodium imbalance)
Autoimmune (SLE, autoimmune encephalitis)
Medications (steroids, isoniazide, anticholinergics)
Drugs of abuse (amphetamines, cocaine, cannabis, opioids)
Toxins
ORGANIC CAUSES OF PSYCHOSIS

9. Epileptic seizure is a transient occurrence of signs and symptoms due to abnormal
excessive or synchronous neuronal activity in the brain.
It carries significant disease burden and increased risk of psych illness, most common
being depression and anxiety which affect up to 30% people with epilepsy.
Post ictal psychosis: affect 7-10% of people with epilepsy. Risk factors: >10yr history of
seizure, bilateral ictal foci, structural brain abnormalities and previous hx of psych
disorder.
Episodes often triggered by cluster of, or marked increase, in generalised seizure
followed by 24-72H period of normal mental state, after which psychotic sx develop
including delusion (paranoid, persecutory, religious), visual and auditory hallucinations.
EPILEPSY: PSYCHIATRIC ASPECTS

10. Results in progressive impairment of voluntary initiation of movement, associated
with dementia with variable severity, as well as psychiatry morbidity.
It is caused by gradual loss of dopaminergic neurons in the substantia nigra. This
results in ↓ DA and ↑ACh in basal ganglia.
Occurs in 20/100,000 people. Typically onset in the 50s and peaks 70s.
Characterised by 4 core symptoms : slow, ‘pill-rolling’ tremor; rigidity, bradykinesia;
and postural abnormalities
PARKINSON’S DISEASE

11. Resting, ‘pill rolling’ tremors; Early signs, of
Parkinson; increases during excitement/fatigue
and diminished during sleep
Lead pipe of cog wheel rigidity

13. 50-80% patients develop dementia. Clinical features usually a subcortical dementia
with slowing, impaired cognitive function, personality change and memory
impairment. Hallucinations and paranoia are common.
40-70% may develop depression. Treatment: SSRIs, ECT (improve the depressive
illness but can precipitate delirium)
Psychosis/delirium occurs in some cases and is commonly due to medications used in
Parkinson’s disease.
Dopamine dysregulation syndrome: pt develop addictive behaviour towards DA
agonist meds. Cause ‘punding’, ICD’s and psychosis.
PARKINSON’S AND RELATED CONDITION

14. Viral encephalitis: etiology; mumps, varicella zoster, rubella.
Resulting in behavioural problems, learning difficulties, ADHD like symptoms in children.
TB meningitis: in high prevalence areas most common in children, and vice versa.
Psychiatric symptoms: apathy, withdrawal, insidious personality changes, delirium,
hallucinations, chronic behavioural problems.
Neurosyphilis: chronic outcome of spirocheatal infection of the brain parenchyma.
It manifests roughly 15-20years after infection.
Classic symptoms: grandiosity, euphoria, and mania with mood congruent delusion.
Disinhibition, personality change and memory impairment are also common.
CENTRAL NERVOUS INFECTIONS

15. Syndrome characterised by progressive, irreversible global cognitive deficits.
DEMENTIA

18. assessment— diagnostic, functional and social
Cognitive enhancement— acetylcholinesterase inhibitors (donezepil, galantamine,rivastigmine),
glutamate receptor antagonist (memantine)
Treat psychosis/agitation— consider antipsychotic
Treat depression/insomnia— SSRIs
Treat medical illness— avoid drugs which may worsen cognitive impairment eg opiates BDZ,
anticholinergics
Psychological support to both patient and caregivers
Functional management— maximise mobility, encourage independence with self care, toilet and feeding
Social management— accommodation, activities, financial matters, legal matters
PRINCIPLES OF MANAGEMENT

19. Also termed ‘dementia of Alzheimer type’ (DAT), it is the most common cause of
dementia in older people (70%).
It is a degenerative disease of the brain, with prominent cognitive and behavioural
impairment that is sufficiently severe to interfere significantly with social and
occupational function.
Risk factors: increasing age, down syndrome, DM, smoking, HPT in middle age
Protective factors: higher level of premorbid education, higher level of physical
activity in middle age, NSAIDs
ALZHEIMER’S DISEASE

20. PATHOPHYSIOLOGY

22. There are as yet no truly disease modifying drugs available for DAT.
Available drugs provide mild symptomatic benefits in some patients.
1. Acetylcholinesterase inhibitors- donepezil, rivastigmine, galantamine
Other drugs- memantine
PHARMACOLOGICAL TREATMENT

24. VaD: 2nd most common cause of dementia (20% of all causes)
Often coexist with DAT and results from thromboembolic or hypertensive infarction of
small and medium sized vessels.
Features suggestive: sudden onset, stepwise deterioration, and risk factor of
cardiovascular diseases.
Onset: 60-70 y/o, male > female
Risk factors: personal/family history of CV diseases, smoking, DM, HPT, hyperlipidemia.
VASCULAR DEMENTIA

25. 3 common syndromes commonly recognised:
Cognitive deficits following a single stroke. Not all strokes results in cognitive impairment,
but when they do, usually depend upon site of infarct. Difficulties with language, praxis or
executive function are most common. May remain fixed, recover partially or completely.
Cognitive deficits from multiple strokes (multi infarct dementia).
Progressive small vessel disease (Binswanger disease). Clinically characterised by
gradual intellectual decline, generalised slowing, and motor problems (eg gait
disturbance and dysarthria). Depression and pseudo bulbar palsy are common.
CONT.

26. MAJOR AND MILD
NEUROCOGNITIVE DISORDERS
BASED ON DSM-5

28. A: evidence of significant cognitive decline from previous level of performance in 1 or
more cognitive domains based on:
Concern of individual, a knowledgeable informant, or clinician that there has been
a significant decline in cognitive function
A substantial impairment in cognitive performance, preferably documented by
standardised neuropsychological testing, or, in its absence, another quantified
clinical assessment.
MAJOR NEUROCOGNITIVE DISORDER

29. B: the cognitive deficits interfere with independence in everyday activities ( ie in
minimum, requiring assistance with complex instrumental activities of daily living
such as paying bills or managing medications).
C: the cognitive deficits does not occur exclusively in the context of the delirium.
D: the cognitive deficits are not better explained by another mental disorders (eg
MDD, schizophrenia)
CONT.

30. Specify whether due to:
Alzheimer’s disease
Frontotemporal lobar degeneration
Lewy body disease
Vascular disease
Traumatic brain injury
Substance/medication use
HIV infection
Prion disease
Etc.
CONT.
Specify:
Without behavioural disturbance
With behavioural disturbance (eg.
Psychotic symptoms, mood disturbance,
agitation, apathy.
Specify severity:
Mild: difficulties with instrumental
activities (managing money, housework)
Moderate: difficulties with basic daily
activity (eg feeding, dressing)
Severe: fully dependent.

31. THANK YOU