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NG<br />BOON KEAT<br />MOHD<br />HANAFI<br />PSYCHOLOGICAL<br />MEDICINE<br />CONFERENCE<br />
MR. S<br />55-year-old | Security Guard <br />Married | 3 children<br />Progressively worsened disturbed behaviourfor 4 da...
HISTORY OF PRESENT ILLNESS<br />Brought by the son to the accident and emergency due to bizarre behaviours:<br />Appeared ...
WITHIN 3 DAYS<br />Decrease need for sleep <br />Increase activities<br />Wandering around the house non-stop<br />Pacing ...
FURTHER CURRENT HISTORY<br />No psychotic symptoms<br />No depressive symptoms<br />Clear history of past depressive episo...
WHAT<br />DO YOU<br />THINK?????<br />
PAST PSYCHIATRIC HISTORY<br />Since 2002  Multiple admission due to inappropriate behavior with depression.<br />Treated ...
PAST PSYCHIATRIC HISTORY<br />8/02<br />Sm: Abnormal behaviour & Epilepsy<br />SurgDx: AVM<br />1/06, 7/06, 12/06<br />Mul...
PAST MEDICAL HISTORY<br />Known case of epilepsy since young.<br />Patient was seeking psychiatric service in UMMC in 2002...
Diagnosed to have arteriovenous malformation.<br />Healthy without other medical conditions.<br />No previous history of E...
Follow-up in neuro-surgical and neuro-medicalclinic.<br />Relatively “stable”<br />
FAMILY HISTORY<br />d. | unknown cause<br />70 | housewife |  no medical illness<br />No psychiatric, suicide history in t...
PERSONAL HISTORY:                        EARLY CHILDHOOD<br />13/4/1955 | AlorStar<br />uncomplicated FTSVD | village midw...
PERSONAL HISTORY:                      SCHOOL PERFORMANCE<br />SRK Kancut| SMK Syed Omar<br />Moderate achievement in prim...
PERSONAL HISTORY:                          WORK RECORDS<br />Move to Kuala Lumpur | 18-year-old<br />Work | security guard...
PERSONAL HISTORY:                        SEXUAL ATTITUDE AND PRACTICE<br />Nosexual experience | before marriage<br />1st ...
PERSONAL HISTORY: MARRIAGE<br />Arrangedby parents<br />His wife: 53 year old | Freelance teacher| Had been supportive to ...
HIS CHILDREN<br />55 | retired security<br />53 | housewife |  freelance teacher<br />36 | factory worker<br />d.18 | MVA<...
PERSONAL HISTORY:                         SOCIO-CULTURAL BACKGROUND<br />RM5000 family income per month??<br />Socialize w...
PERSONAL HISTORY:                    SUBSTANCE USE<br />Smoking| 74 pack years<br />No alcohol consumption |<br />No subst...
PERSONAL HISTORY:                             PRE-MORBID PERSONALITY<br />Proper social | relationships<br />Stable mood |...
MENTAL STATE:                                   GENERAL APPEARANCE<br />Alert | conscious | cooperative<br />Easily make r...
MENTAL STATE:                                 SPEECH & THOUGHT<br />↑ amount | ↑ tone | ↑ rate<br />Pressured speech<br />...
MENTAL STATE:                                      MOOD & PERCEPTION<br />Sadin mood<br />Inappropriate affect | incongrue...
MENTAL STATE:                         COGNITIVE FUNCTION<br />Time, Place, Person | Orientated<br />Remote, Recent Memory ...
MENTAL STATE:                             COGNITIVE FUNCTION 2<br />Attention | Easily distracted<br />Concentration | Can...
PHYSICAL EXAMINATION<br />Alert | conscious | not in respiratory distress. <br />37.5˚C | 92 beats pm | 20 bpm| 120/80. <b...
IN SUMMARY<br />History| irritable, aggressive and shouting for 4 days, with maniac symptoms | no depressive symptoms with...
WHAT<br />IS THE MOST<br />LIKELY<br />PROVISIONAL DIAGNOSIS?<br />
PROVISIONAL DIAGNOSIS<br />BIPOLAR I DISORDER<br />manic episode <br />The patient has had at least one previous major dep...
DIFFERENTIAL DIAGNOSIS<br />
WARD: Investigation done<br />Full Blood Count | Liver Function Test | Glucose Level | Renal Profile<br />Normal<br />CT B...
PROVISIONAL DIAGNOSIS<br />ORGANIC MOOD DISORDER<br />
FINAL DIAGNOSIS: AXIS<br />
MANAGEMENT IN THE WARD<br />| Psychiatric View | <br />Psychotic medication not aim to cure the organic condition<br />ECT...
MANAGEMENT IN THE WARD<br />| Neurosurgical View | <br />CT Brain done  Cerebral oedema and complex AVM<br />No surgical ...
DISSCUSION<br />NEURO-<br />PSYCHOLOGICAL<br />CORRELATIONS<br />
FROM THE NEUROLOGICAL ASPECT<br />AVM<br />Mania and frontal lobe<br />
MANIA AND FRONTAL LOBE<br />Secondary mania can be resulted from frontal lobe lesion<br />Multiple case studies reported t...
PATHOPHYSIOLOGY<br />No clear mechanism<br />Postulation: <br />1. Brain asymmetry causing dis-inhibition syndrome.<br />2...
AVM: SHORT OVERVIEW<br />Patient has a right extensive fronto-temporo-occipital AVM<br />Not curable in this case<br />Cau...
AVM: DEFINITION<br />Lesions of the cerebral vasculature<br />Blood flows from arterial to venous system<br />Without capi...
AVM: CLINICAL PRESENTATION<br />Clinical presentations:<br />Haemorrhage(41-79%)<br />Seizure(11-33%)<br />Heache<br />Pro...
AVM: GRADING<br />
AVM: TREATMENT<br />Surgerynot a chance<br />Vascular surgery not a chance<br />Radiosurgery only chance for the patien...
DSM-IV criteria for mood disorder resulting from medical or neurologic condition, manic type (secondary mania)<br />Elatio...
ORGANIC MOOD DISORDER: CLASSIFICATION<br />ICD-10   specifies that the affective disorder must be judged not to represent ...
MOOD DISORDER(DSM-IV & ICD 10)<br />
ORGANIC MOOD DISORDER: EPIDEMIOLOGY<br />Depression in the medically ill appears to be equally prevalent by sex, or possib...
ORGANIC MOOD DISORDER: AETIOLOGY<br />cortical degenerations<br />extrapyramidal disorders<br />cerebrovascular diseases<b...
ORGANIC MOOD DISORDER: MANAGEMENT<br />Poststroke Depression  Nortriptylineand trazodone. <br />(Lipsey et al., 1984; Red...
Organic Mood Disorder and AVM
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Organic Mood Disorder and AVM

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This is real case in UMMC, Malaysia... We've learn a lot by only 1 patient.... It is good if we can elicit the higher function of this patient.

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Organic Mood Disorder and AVM

  1. 1. NG<br />BOON KEAT<br />MOHD<br />HANAFI<br />PSYCHOLOGICAL<br />MEDICINE<br />CONFERENCE<br />
  2. 2. MR. S<br />55-year-old | Security Guard <br />Married | 3 children<br />Progressively worsened disturbed behaviourfor 4 days<br />
  3. 3. HISTORY OF PRESENT ILLNESS<br />Brought by the son to the accident and emergency due to bizarre behaviours:<br />Appeared to be irritable and aggressive<br />Shouting with vulgar words<br />No physical damages to self or other people<br />Known case of psychiatric illness, under UMMC follow-up<br />
  4. 4. WITHIN 3 DAYS<br />Decrease need for sleep <br />Increase activities<br />Wandering around the house non-stop<br />Pacing faster than normal<br />Talkative<br />Described as talking non-sense<br />Impaired functions<br />Cannot do daily activities properly<br />Getting complains from working colleagues<br />Mood is happy without reason<br />
  5. 5. FURTHER CURRENT HISTORY<br />No psychotic symptoms<br />No depressive symptoms<br />Clear history of past depressive episodes<br />
  6. 6. WHAT<br />DO YOU<br />THINK?????<br />
  7. 7. PAST PSYCHIATRIC HISTORY<br />Since 2002  Multiple admission due to inappropriate behavior with depression.<br />Treated with:<br />Lorazepam| anxiolytic<br />Chlopromazine | antipsychotic<br />Perphenazine | antipsychotic<br />Carbamazepine | anxiolytic<br />Poor compliance to medication<br />
  8. 8. PAST PSYCHIATRIC HISTORY<br />8/02<br />Sm: Abnormal behaviour & Epilepsy<br />SurgDx: AVM<br />1/06, 7/06, 12/06<br />Multiple admission on Epilepsy<br />10/09<br />Motor Vehicle accident: cross the highway |polytrauma[contusion, haemothorax, SDH, AVM <br />Current Admission<br /> 2005 2006 2007 2008 2009 2010<br />12/05<br />Sm: ↓ need of sleep, aggressive [shouting]<br />19/8 – 21/9<br />Stressor: stolen motor,<br />Fired from job<br />Sm: shouting to family, aggitated<br />10/09<br />After operation: ruptured diagphragm with right upper limb fracture<br />
  9. 9. PAST MEDICAL HISTORY<br />Known case of epilepsy since young.<br />Patient was seeking psychiatric service in UMMC in 2002 and was referred to surgical team the same year.<br />
  10. 10. Diagnosed to have arteriovenous malformation.<br />Healthy without other medical conditions.<br />No previous history of ECT:<br />AVM<br />Epilepsy<br />
  11. 11. Follow-up in neuro-surgical and neuro-medicalclinic.<br />Relatively “stable”<br />
  12. 12. FAMILY HISTORY<br />d. | unknown cause<br />70 | housewife | no medical illness<br />No psychiatric, suicide history in the family<br />No history of epilepsy, neurological disease in the family.<br />Family relationships are good.<br />
  13. 13. PERSONAL HISTORY: EARLY CHILDHOOD<br />13/4/1955 | AlorStar<br />uncomplicated FTSVD | village midwife.<br />No health problems| Nodevelopmental delay<br />
  14. 14. PERSONAL HISTORY: SCHOOL PERFORMANCE<br />SRK Kancut| SMK Syed Omar<br />Moderate achievement in primary school<br />Drop-out of school after SRP due to poor performance<br />No disciplinary problem<br />Socialize with friends<br />
  15. 15. PERSONAL HISTORY: WORK RECORDS<br />Move to Kuala Lumpur | 18-year-old<br />Work | security guard since then.<br />Never change his job.<br />Income | around RM1000<br />
  16. 16. PERSONAL HISTORY: SEXUAL ATTITUDE AND PRACTICE<br />Nosexual experience | before marriage<br />1st intercourse |age of 30<br />No history of child abuse<br />
  17. 17. PERSONAL HISTORY: MARRIAGE<br />Arrangedby parents<br />His wife: 53 year old | Freelance teacher| Had been supportive to the husband despite his condition<br />
  18. 18. HIS CHILDREN<br />55 | retired security<br />53 | housewife | freelance teacher<br />36 | factory worker<br />d.18 | MVA<br />38 | despatch<br />37 | despatch<br />
  19. 19. PERSONAL HISTORY: SOCIO-CULTURAL BACKGROUND<br />RM5000 family income per month??<br />Socialize with friends?<br />No criminal records<br />$<br />
  20. 20. PERSONAL HISTORY: SUBSTANCE USE<br />Smoking| 74 pack years<br />No alcohol consumption |<br />No substance abuse<br />
  21. 21. PERSONAL HISTORY: PRE-MORBID PERSONALITY<br />Proper social | relationships<br />Stable mood |but depress occasionally<br />Personality trait??<br />Weak faith | religion<br />Favouritepast time | sports<br />Coping skill | sports<br />
  22. 22. MENTAL STATE: GENERAL APPEARANCE<br />Alert | conscious | cooperative<br />Easily make rapport | poor eye contact<br />Hospital attire | unhygienic<br />Anxious | frowning of the forehead<br />
  23. 23. MENTAL STATE: SPEECH & THOUGHT<br />↑ amount | ↑ tone | ↑ rate<br />Pressured speech<br />Malay-spoken | coherence but irrelevance<br />thought blocking | flight of ideas<br />NO<br />Loose/clang association | circumstantialities | neologism | obsession/phobua | delusions<br />Suicidal thought<br />
  24. 24. MENTAL STATE: MOOD & PERCEPTION<br />Sadin mood<br />Inappropriate affect | incongruent<br />NO<br />Hallucinations| Pseudohallucinations |Illusions| Derealization/Depersonalization| Flashback<br />
  25. 25. MENTAL STATE: COGNITIVE FUNCTION<br />Time, Place, Person | Orientated<br />Remote, Recent Memory | Good<br />[date of birth & breakfast]<br />5mins memory test | Remember only 1<br />Information/knowledge | Appropriate<br />Proverbs | Can answer <br />[Udang di sebalikbatu & sikit-sikit lama-lama jadibukit]<br />Similarities | Give 2<br />[apple & orange: tastes, eaten]<br />
  26. 26. MENTAL STATE: COGNITIVE FUNCTION 2<br />Attention | Easily distracted<br />Concentration | Cant do it<br />[serial 7 test, digit span, world backward]<br />Judgement | Cant assess<br />[patient started irritable and agitated]<br />Insight | Poor <br />[he and others do not realised his abnormality | not accept and do not need treatment]<br />
  27. 27. PHYSICAL EXAMINATION<br />Alert | conscious | not in respiratory distress. <br />37.5˚C | 92 beats pm | 20 bpm| 120/80. <br />Couldn’t assess<br />1st day | patient irritable and agitated<br />2nd day | patient physically restrained and chemically sedated<br />
  28. 28. IN SUMMARY<br />History| irritable, aggressive and shouting for 4 days, with maniac symptoms | no depressive symptoms within the current period<br />Previous History | psychiatric illness since 2002 | not complicant with medication | Complicated with AVM and MVA<br />Mental State | easilydistracted | mostly cannot assess| poorinsight<br />
  29. 29.
  30. 30.
  31. 31. WHAT<br />IS THE MOST<br />LIKELY<br />PROVISIONAL DIAGNOSIS?<br />
  32. 32. PROVISIONAL DIAGNOSIS<br />BIPOLAR I DISORDER<br />manic episode <br />The patient has had at least one previous major depressive episode, manic episode, or mixed episode <br />
  33. 33. DIFFERENTIAL DIAGNOSIS<br />
  34. 34. WARD: Investigation done<br />Full Blood Count | Liver Function Test | Glucose Level | Renal Profile<br />Normal<br />CT Brain was ordered…..<br />
  35. 35.
  36. 36.
  37. 37. PROVISIONAL DIAGNOSIS<br />ORGANIC MOOD DISORDER<br />
  38. 38. FINAL DIAGNOSIS: AXIS<br />
  39. 39. MANAGEMENT IN THE WARD<br />| Psychiatric View | <br />Psychotic medication not aim to cure the organic condition<br />ECT cancelled<br />Given Rozidal, Carbamazepine, Lorazepam, Chlorphomazine<br />
  40. 40. MANAGEMENT IN THE WARD<br />| Neurosurgical View | <br />CT Brain done  Cerebral oedema and complex AVM<br />No surgical management available (grade 5 AVM)<br />
  41. 41. DISSCUSION<br />NEURO-<br />PSYCHOLOGICAL<br />CORRELATIONS<br />
  42. 42. FROM THE NEUROLOGICAL ASPECT<br />AVM<br />Mania and frontal lobe<br />
  43. 43. MANIA AND FRONTAL LOBE<br />Secondary mania can be resulted from frontal lobe lesion<br />Multiple case studies reported that most mania symptoms occurs in RIGHT frontal lobe lesion.<br />Can occur immediately or later in life after injury.<br />
  44. 44. PATHOPHYSIOLOGY<br />No clear mechanism<br />Postulation: <br />1. Brain asymmetry causing dis-inhibition syndrome.<br />2. Limbic system damage. <br />Psychosomatics 48:433-435, September-October 2007 doi: 10.1176/appi.psy.48.5.433 <br />
  45. 45. AVM: SHORT OVERVIEW<br />Patient has a right extensive fronto-temporo-occipital AVM<br />Not curable in this case<br />Causing the mood symptoms and epilepsy<br />
  46. 46. AVM: DEFINITION<br />Lesions of the cerebral vasculature<br />Blood flows from arterial to venous system<br />Without capillary system<br />Shunt<br />
  47. 47. AVM: CLINICAL PRESENTATION<br />Clinical presentations:<br />Haemorrhage(41-79%)<br />Seizure(11-33%)<br />Heache<br />Prognosis<br />Average rate of haemorrhage – 2.8-4.6%<br />
  48. 48. AVM: GRADING<br />
  49. 49. AVM: TREATMENT<br />Surgerynot a chance<br />Vascular surgery not a chance<br />Radiosurgery only chance for the patient(do in stages)<br />
  50. 50. DSM-IV criteria for mood disorder resulting from medical or neurologic condition, manic type (secondary mania)<br />Elation or irritability <br />Four of the following: <br />inflated self-esteem or grandiosity<br />decreased need for sleep<br />pressured speech<br />flight of ideas<br />Distractibility<br />increased goal-directed activity or psychomotor agitation<br />excessive involvement in pleasurable activities  <br />
  51. 51. ORGANIC MOOD DISORDER: CLASSIFICATION<br />ICD-10 specifies that the affective disorder must be judged not to represent an emotional response to the patient’s knowledge of having a concurrent brain disorder.<br />
  52. 52. MOOD DISORDER(DSM-IV & ICD 10)<br />
  53. 53. ORGANIC MOOD DISORDER: EPIDEMIOLOGY<br />Depression in the medically ill appears to be equally prevalent by sex, or possibly slightly higher in men <br />(Caine and Lyness, 2000).<br />Patients with secondary mania are more likely to have negative family and personal histories of mood disorder <br />(Evans et al., 1995)<br />
  54. 54. ORGANIC MOOD DISORDER: AETIOLOGY<br />cortical degenerations<br />extrapyramidal disorders<br />cerebrovascular diseases<br />cerebral neoplasms & trauma<br />CNS infections <br />endocrine disorders<br />inflammatory <br />(Cummings and Mega, 2003). <br />
  55. 55. ORGANIC MOOD DISORDER: MANAGEMENT<br />Poststroke Depression  Nortriptylineand trazodone. <br />(Lipsey et al., 1984; Reding et al., 1986). <br />Traumatic Brain Injury Depression Desipramineand sertraline <br />(Wroblewski et al., 1996; Fann et al., 2000).<br />Manic Lithium <br />(Evans et al., 1995). <br />SecondaryMania Clonidine, valproate, carbamazepine and antipsychotics<br />(Bakchine et al., 1989; Starkstein et al., 1991)<br />

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