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 Parkinson’s disease, other movement

dis. 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 illusions (multimodal illusions

and hallucinations)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 deprivation

Saxena 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, sedatives, hypnotics, anticholinergic drugs,

antiepilepticsantiepileptics► 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, (intelligence, learning, language, orientation, perception, attention, language, orientation, perception, attention, judgement, problem solving, social judgement, problem solving, social functioning)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)