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Rene M. Samaniego, M.D., FPPA Makati Medical Center Consultation-Liaison Psychiatry Cognitive-Behavioral Therapy Psychiatric DOs (?) GMC (?) Substances (?) (prescription, nonprescription, illegal) ‘Nonorganic’ or ‘Functional’ or ‘Primary’ Psychiatric DOs (?) ‘Organic’ GMC (?) Substances (?) (prescription, nonprescription, illegal) Evidence from history, P.E., or laboratory findings that disturbance is the direct physiological consequence of a GMC 30-year old female Psychiatric: depressed affect; lethargy; difficulty in concentration; psychomotor retardation Medical: cold intolerance, dry skin, constipation, weight gain, brittle hair TFT: TSH; FT4 Evidence from history, P.E., or laboratory findings that disturbance is the direct physiological consequence of a GMC Require two things: 1) presence of a GMC; 2) the psychiatric disorder is etiologically related to the GMC through a physiological mechanism The GMC may be part of the psychiatric disturbance, but not the sole etiology of it Temporal association between the onset, exacerbation, or remission of the GMC & mental DO E.g., symptoms of anxiety in parathyroid adenoma that resolve after surgical excision & restoration of a normal serum calcium level Treatment of GMC that alleviates the psychiatric symptomatology may provide stronger evidence of an etiological relationship Some psychiatric disorders may emerge several years after the onset of the medical problem E.g., psychosis secondary to epilepsy Signs and symptoms of a psychiatric DO can be among the first to appear before the detection of the underlying GMC E.g., depression preceding choreiform movements in Huntington’s disease; depression before detection of pancreatic CA A psychiatric DO due to a GMC can be amenable to symptomatic treatment even while the GMC remains active E.g., depression in epilepsy Presence of atypical features of the primary mental DO Atypical onset or course e.g., acute schizophrenic-like symptoms in a 75-y.o. individual Unusual associated features or symptoms e.g., visual or tactile hallucinations in major depression Features disproportionately more severe than would be expected given the overall presentation e.g., a 50-pound weight loss in a mildly depressed individual The co-occurrence of a psychiatric DO and a GMC may also be just coincidental E.g., Depressive episode precipitated by stroke acting as a psychosocial stressor, rather than resulting from the direct physiological effects of the stroke E.g., Patient with a history of depressive episodes suddenly developed signs and symptoms of hypothyroidism The disturbance should not be better accounted for by another mental disorder The disturbance does not occur exclusively during the course of a delirium First, exclude syndromes in which psychotic symptoms may be present in association with cognitive impairment (e.g., delirium, dementia, and amnestic disorder) Psychosis is usually NOT associated with changes in the level of sensorium Etiology: Cerebral or systemic disease that affects brain function Infections Intracranial Masses Tumors Subdural masses Brain abscess Trauma Head injury Neurodegenerative DOs Parkinson’s Disease Huntington’s Disease Pick’s Disease Amyotropic Lateral Sclerosis Wilson’s Disease Creutzfield-Jakob Disease AIDS Viral encephalitis Neurosyphilis Meningitis Nutritional DOs Wernicke-Korsakoff syndrome (thiamine deficiency) Vitamin B12 deficiency Folate deficiency Pellagra Substances Metabolic DOs Hypothyroidism & Hyperthyroidism Renal insufficiency, severe Cushing’s syndrome Hepatic insufficiency Parathyroid disease Chronic Inflammatory DOs Systemic Lupus Erythematosus Multiple Sclerosis Whipple’s Disease Alcohol Amphetamines Cocaine Phencyclidine Hallucinogens Sedative, hypnotic, & anxiolytics Cannabis Course & Prognosis: depend largely on the etiology E.g., psychotic symptoms secondary to head trauma improve dramatically during recovery E.g., infectious process causing irreversible CNS tissue damage, psychotic symptoms may not improve despite treatment of the infection Treatment: Basic principles involve rapid identification and treatment of the underlying cause Standard treatments for symptomatic relief (e.g., anti-psychotics) Characterized by: 1)depressed mood - prominent, persistent, distressing, & functionally impairing 2)elevated, expansive, or irritable mood The mood manifestation can either be depressed, manic, or mixed Fully or partly fulfill criteria Epidemiology: unknown Depression in medically ill slightly higher in men Illnesses in which depressive episodes are common: strokes, Parkinson’s disease, Huntington’s disease, HIV infection, & MS Manic symptoms less prevalent in neurological disease than depression Trauma Drug Intoxication Alcohol or sedative-hypnotics Antipsychotics/Antidepressants Metoclopramide, H2 blockers Antihypertensives Sex steroids Drug Withdrawal Nicotine, caffeine, alcohol or sedative-hypnotics, cocaine, amphetamines Tumors 1* cerebral Systemic neoplasm Cerebral contussion Subdural hematoma Infection Cerebral (e.g., HIV, meningitis, encephalitis, syphilis) Systemic (e.g., sepsis, UTI, PN) Cardiac & Vascular Cerebrovascular (e.g., infarcts, hemorrhage, vasculitis) Cardiovascular (e.g., low-output states, CHF) Demyelinating Diseases Physiological or Metabolic Hypoxemia Electrolyte disturbances Renal or hepatic failure Hypo- or hyperglycemia Post-ictal states Endocrine Thyroid or glucocorticoid disturbances Nutritional Vitamin B12 deficiency Folate deficiency Multiple sclerosis Neurodegenerative Diseases Parkinson’s disease Huntington’s disease Depressive symptoms: depressed mood; decrease interest in activities; poor sleep & appetite; lethargy; psychomotor agitation/retardation; feelings of worthlessness, excessive guilt; poor concentration & indecisiveness; recurrent thoughts of death or suicidal ideations Manic symptoms: mood persistently elevated, expansive, irritable; inflated self-esteem; decreased need for sleep; more talkative than usual; flight of ideas or racing thoughts; distractibility; increase in goal-directed activities Course & Prognosis: Secondary depressive disorders have poorer prognosis than primary depression; usually runs a chronic course, characterized by remissions & recurrences, and sometimes by continuous illness Prognosis will depend on the etiology E.g., depression secondary to hypothyroidism has a better outcome than depression in metastatic pancreatic carcinoma Treatment: resolving the underlying medical cause Standard treatments: antidepressants (SSRIs, tricyclics, MAOIs, & psychostimulants) Psychotherapy: an adjunctive approach The concept of psychiatric disturbance secondary to a medical illness difficult for many patients to grasp Key feature: presence of anxiety symptoms (generalized anxiety, panic attacks, obsessivecompulsive symptoms, or phobias) Endocrinopathies Substance Intoxication Caffeine Amphetamines, cocaine, & other sympathomimetic agents Alcohol Cannabis Metabolic Derangements Substance Withdrawal Caffeine Nicotine Alcohol Sedative-hypnotics Pheochromocytoma Hyperthyroidism & hyperparathyroidism Hypercortisolemic states (adrenal dysfunction) Hypoxemia Hypercalcemia Hypoglycemia Caffeine Caffeine Caffeine 1 cup of coffee = 100–150mg caffeine Caffeine Intoxication – consumption of caffeine in excess of 250mg at one time Caffeine Intoxication Tachycardia or cardiac arrythmia Diuresis GI disturbances Restlessness, nervousness or excitement Rambling flow of thought & speech Insomnia; etc Caffeine Beverage Caffeine Regular brewed coffee 170-200 mg Decaffeinated brewed coffee 10 mg Instant coffee 90-140 mg Brewed tea 60-100 mg Canned iced tea 25-35 mg Cola drinks 40-60 mg Dark chocolate 20 mg Milk chocolate 6 mg ***Daily limit of 200 mg recommended by the AMA Caffeine Caffeine withdrawal – results from a prolonged daily intake of caffeine followed by an abrupt cessation, or reduction in the amount of use Usually lasts 4 to 5 days Nicotine Nicotine A ‘psychostimulant’ Associated with chronic obstructive pulmonary disease, cancers, coronary heart disease, peripheral vascular disease Nicotine Withdrawal Nicotine craving Frustration, irritability, & anger Anxiety Difficulty concentrating Restlessness Bradycardia Increased appetite Alcohol Alcohol Intoxication A ‘depressant’ Can hasten onset of sleep, BUT can disrupt normal sleep cycle Sedative effect & ready availability used to relieve anxiety, insomnia, & depression Alcohol Intoxication Maladaptive behavioral changes Mild intoxication: relaxed, talkative, euphoric, disinhibited Alcohol Intoxication Slurred speech Incoordination Unsteady gait Memory impairment Stupor ‘Blackouts’ Alcohol Withdrawal Begins within several hours after cessation of, or reduction in, prolonged heavy alcohol consumption Alcohol Withdrawal Autonomic hyperactivity Hand tremor Insomnia Nausea & vomiting Transient illusions or hallucinations Anxiety Seizures Endocrinopathies Substance Intoxication Caffeine Amphetamines, cocaine, & other sympathomimetic agents Alcohol Cannabis Metabolic Derangements Substance Withdrawal Caffeine Nicotine Alcohol Sedative-hypnotics Pheochromocytoma Hyperthyroidism & hyperparathyroidism Hypercortisolemic states (adrenal dysfunction) Hypoxemia Hypercalcemia Hypoglycemia Neurologic DOs Vascular (cerebrovascular disease, subarachnoid hemorrhage, migraine) Trauma (cerebral trauma & postconcussive syndromes) Degenerative types (Huntington’s disease) Systemic Conditions Hypoxia (cardiovascular diseases, cardiac arrhythmia, pulmonary insufficiency, anemia) Course & Prognosis: Depend on the specific cause E.g., anxiety due to hyperthyroidism remits well with treatment E.g., anxiety due to cardiomypathy with a low-output state may run a more chronic course Treatment: Treat the underlying cause Symptomatic treatment with benzodiazepines & antidepressant medications (like SSRIs) to treat specific symptoms (panic attacks or obsessivecompulsive symptoms) Insomnia: deficiency of sleep Hypersomnia: excess of sleep Parasomnia: abnormal behavior or activity during sleep Circadian Rhythm Sleep Disorder: disturbance in the timing of sleep Condition Sleep Symptoms Parkinsonism Frequent awakenings, disturbance of circadian rhythm Dementia Sundowning, frequent awakenings Epilepsy Diff. initiating sleep, frequent awakenings, parasomnias Cerebrovascular Disease Diff. initiating sleep, frequent awakenings Huntington’s Disease Frequent awakening Kleine-Levin Syndrome Hypersomnia Uremia Restless legs, nocturnal myoclonus Treatment: Identification and treatment of the cause Symptomatic treatments: 1) sedative-hypnotics for insomnia 2) stimulants for hypersomnia 3) benzodiazepines for restless leg syndrome or nocturnal myoclonus 4) antidepressants (tricyclics) for regulation of REM sleep for circadian rhythm sleep disorders 1. Female or male hypoactive sexual desire DO 1. Male erectile DO 2. Dyspareunia Local Disease Processes that Affect 1* or 2* Sexual Organs Medications Cardiac drugs (anti-hypertensives e.g., β-blockers, clonidine, diuretics) H2 blockers Anti-cholinergics Anti-convulsants Anti-psychotics/Anti-depressants Sedative-hypnotics Substances of Abuse Alcohol Opioids Stimulants Cannabis Sedative-hypnotics Congenital anomalies or malformations Trauma Tumors Infection Post-surgical or post-irradiation neurological & vascular pathology Neurological CNS (e.g., strokes, multiple sclerosis) PNS (e.g., peripheral neuropathy) Vascular Atherosclerosis Vasculitis Endocrine Diabetes Mellitus Alterations in thyroid function, adrenal cortex, gonadotropins, gonadal hormones Course & Prognosis: Depends on the cause E.g., Drug-induced syndromes generally remit with discontinuation (or dosage reduction) of the offending agent; endocrine-based dysfunctions also improve with restoration of normal physiology E.g., sexual dysfunctions due to neurological disease, protracted or progressive Treatment: Varies widely Address underlying pathology Symptom-based treatments: for male ED, you may give pharmacological agents like sildenafil (Viagra) or surgical implantation of a penile prosthesis When reversal of underlying cause is not possible, supportive and behaviorally oriented psychotherapy (include both patient & partner); psychoeducation & development of sexual interactions not limited by dysfunction Motoric immobility (assuming fixed postures & waxy flexibility) Excessive motor activity (purposeless & not influenced by external stimuli) Extreme negativism or mutism Peculiarities of voluntary movement Echolalia or echopraxia Common causes: neoplasms, encephalitis, head trauma, diabetes, metabolic disorders Course & prognosis: Depend on the etiology Treatment: Resolve underlying cause; antipsychotic medications may improve postural abnormalities even though no effect on underlying disorder Note: Always rule out schizophrenia in patients with catatonic symptoms Personality change – the person’s fundamental means of interacting & behaving have been altered If you have an adult individual who suddenly develops significant personality change, always suspect a brain injury Specific personality trait changes for specific brain diseases: passive & self-centered behaviors in Alzheimer’s dementia; or apathy in frontal lobe lesions Head Trauma Multiple Sclerosis (subcortical white matter degeneration) Hydrocephalus Toxins Frontal Lobe Tumors Meningiomas Gliomas Progressive Dementia Syndromes AIDS Dementia complex Huntington’s disease Progressive supranuclear palsy Irradiation with a predilection to the white matter Course & Prognosis: Depends on the etiology E.g., correction of a hydrocephalus; surgery, chemotherapy, or radiation therapy of mass lesions can improve the personality change dramatically E.g., head trauma, improvement in the personality change is slow and gradual (months or years), may have residual personality disturbances E.g., degenerative processes, disruptive in early phase of disease, then become more apathetic, unresponsive as disease progresses Treatment: Correct underlying pathology, symptomatic treatment For control of affective symptoms (impulsivity, aggression, explosiveness): mood stabilizers such as lithium carbonate, valproic acid, & carbamazepine; also ß-adrenergic antagonists like propranolol For apathy & inertia, psychostimulants For those whose cognitive & verbal skills are preserved, psychotherapy In DSM-IV-TR classification, clustered together & apart from the secondary psychiatric disorders Defined by impairment in cognition (specifically memory, language, and attention) cognitive impairment is their cardinal symptom Considered as a syndrome, not a disease entity Underrecognized & underdiagnosed A.k.a. acute confusional state, acute brain syndrome, metabolic encephalopathy, toxic psychosis, acute brain failure Hallmark of delirium: impairment of consciousness in association with global impairments of cognitive functions Psychiatric symptoms Abnormalities in mood irritability, dysphoria, anxiety, or euphoria Abnormalities in perception illusions or hallucinations Decreased level of consciousness diminished ability to focus & sustain attention Disorientation, especially to time & place Psychiatric symptoms Disorganization in their thought process (mildly tangential to frankly incoherent Psychomotor hyperactivity or hypoactivity Disruption of the sleep-wake cycle (fragmentation of sleep at night with or without daytime drowsiness) Neurologically: tremor, asterixis, nystagmus, incoordination, & unrinary incontinence Intracranial Causes Epilepsy & post-ictal states Brain trauma (especially concussion) Infections (meningitis, encephalitis) Neoplasms Vascular disorders Extracranial Causes Drugs (ingestion or withdrawal) Anticholinergic agents Anticonvulsants Antihypertensive agents Antiparkinsonian agents Antipsychotics Cardiac glycosides Opiates Sedatives Steroids Cimetidine, clonidine, disulfiram, insulin, phenytoin, ranitidine Poisons Carbon monoxide Heavy metals & other indstrial poisons Endocrine Dysfunction (hyperor hypofunction) Pituitary, pancreas, adrenal, parathyroid, thyroid Non-endocrine Diseases Liver (hepatic encephalopathy) Kidney (uremic encephalopathy) Lung (carbon dioxide narcosis, hypoxia) Cardiovascular system (cardiac failure, arrhythmias, hypotension) Deficiency States Thiamine, nicotinic acid, B12, or folic acid deficiencies Systemic infections (with fever and sepsis) Electrolyte imbalance of any cause Post-operative states Trauma (head or general body) Course, Prognosis & Treatment Usually has a sudden onset (hours or days) Prodromal symptoms (restlessness & fearfulness) Has a brief & fluctuating course, improves rapidly (within 3 to 7 days) when causative factor is identified & treated General rule: the older the patient and the longer the patient has been delirious, the longer the delirium takes to resolve Cardinal symptom is cognitive impairment Unlike delirium, no impairment in consciousness; no alteration and fluctuation in consciousness Main manifestation is diminution in cognition: general intelligence, learning & memory, language, problem solving, orientation, perception, attention & concentration, judgment, & social abilities Personality changes may also be noted Dementia of the Alzheimer’s type – most common cause (50-60% of the cases); occurs in patients over 65 y.o.; manifested by progressive intellectual deterioration, delusions, or depression Vascular dementia – next most common cause is (10-20% of the cases), caused by thrombosis or hemmorhage Dementia secondary to other medical conditions Neurodegenerative disorders: Parkinson’s or Huntington’s disease Infectious: AIDS, CJD, viral encephalitis Nutritional disorders: Wernicke-Korsakoff syndrome caused by thiamine deficiency Metabolic disorders: hypothyroidism & hyperthyroidism, Cushing’s syndrome Chronic inflammatory disease: SLE, & MS Dementia can also be substance-induced, either caused by a medication or toxins Dementia due to multiple etiologies Dementia, not otherwise specified, in which the etiology is unknown Course & Prognosis: Varies steady progression (Alzheimer’s dementia) incrementally worsening course (vascular dementia) stable dementia (dementia secondary to a head trauma) Treatment: identify the cause, determine whether reversible or irreversible For the reversible dementias (hydrocephalus, hypothyroidism, or brain tumors) the dementia may be halted or reversed For more progressive types (Alzheimer’s dementia), employ symptomatic treatment cholinesterase inhibitors like donepezil (Aricept), rivastigmine (Exelon); galantamine (Reminyl); tacrine (Cognex), and memantine (Abixa) For psychiatric symptoms associated with dementia Benzodiazepines for insomnia and anxiety Antidepressants for depression Antipsychotics for hallucinations and delusions Be aware of idiosyncratic effects in the geriatric population (paradoxical excitement, confusion, & increased sedation) There are a variety of substances (medications, illegal substances, or toxins) that may cause different psychiatric DOs Considerations: 1) determine that the symptoms developed within a month of the substance intoxication or withdrawal; 2) the substance is etiologically related to the psychiatric DO 1) 2) 3) 4) If the symptoms precede the onset of the substance or medication use If the symptoms persist for a substantial period of time (about 1 month) after the cessation of an acute withdrawal or severe intoxication If the symptoms are substantially in excess of what would be expected, given the type, duration, or amount of the substance used If there are other evidence suggesting that there is an existence of a non-substance-induced DO (history of recurrent non-substance-related psychiatric episodes) The psychiatric disorder may be caused by the combined effects of a GMC and substance use dual diagnosis (e.g., Mood DO due to GMC and Substance-Induced Mood DO) When the presentation contains a mix of symptoms (e.g., mood and anxiety) – assign a single diagnosis based on which symptoms predominate in the clinical presentation Thank you!