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Organic,

including

symptomatic,

mental disorders

FOO - F09AGUS HARDJANA SAIMAN dr,Sp.KJ

padjadjaran university

maranatha christian university

immanuel christian teaching hospital


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Overview

This block (F00-F09) in ICD X and the PPDGJ III classification are :

F00. Dementia in Alzheimer's disease

F0l . Vascular dementia

F02. Dementia in other diseases classified elsewhere

F03. Unspecified dementia

F04. Organic amnesic syndrome, not induced by alcohol and otherpsychoactive substancesF05. Delirium, not induced by alcohol and other psychoactive

substances

F06. Other mental disorders due to brain damage and dysfunction

and to physical diseaseF07.Personality and behavioural disorders due to brain disease,damage and dysfunction

F09 Unspecified organic or symptomatic mental disorder


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Historically: the field of neurology - organic disorders

psychiatry - functional disordersTraditionally: - organic brain disorders -

- "nonorganic"

-"symptomatic".

That distiction is also antiquated, since basic neuroscience can

identify structural correlates of functional abnormalities at the levelof genes and other molecules.

The division between structural and functional rests solely on which

biological level is arbitrarily chosen as the cutoff po int .

An accurate approach is to accept the ideas that each biological

d isorder,including mental illness, has a structural pathology at somelevel or assortment of levels and that structural abnormal ity is

reflected as a disorder of func t ion or regulat ion.


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DELIRIUM the hallmark symptom of delirium is an impairment of

consciousness, usually seen in association with global impairmentsof cognitive functions.

DEMENTIA is a syndrome due to disease of the brain, usually of a

chronic or progressive nature, in which there is disturbance of

multiple higher cortical functions, including memory, thinking,

orientation, comprehension, calculation, learning capacity, language,

and judgement.


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I.DELIRIUM

- an imp airment of consc iousness, a sudden onset (hours or

days) a br ief and f luctu at ing cou rse, and a rapid im prov ement

- Delir ium is a synd rome, no t a disease. to have many

causes,central and systemic,acute confus ional state, acute

bra in synd romes, metabol ic encephalopathy, toxic p sychosis,

and acute brain fai lure.- (l ) the cl in ical need to ident i fy and treat the under lying cause

and

- (2) the need to avert the developm ent of delir ium related

compl icat ions.

Such compl icat ions inc lude accidenta l in jury b ecause of thepat ients cloud ed consc iousness or impaired coord inat ion or

the unnecessary use of restraints.


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EPIDEMIOLOGY

Del i rium is a common disorder .

- Ab out 10 to 15 percent of pat ients o n general surgical wards

and

15 to 25 percent of p at ients on general medical wards

About 30 percent of p at ient in surgic al intensive care units andcardiac intensive care un its and

40 to 50 percent of pat ients wh o are recover ing from surg ery for

hip fractu res have an episo de of del ir ium .

-The causes of po stop erat ive del i r ium in clude stress of su rgery,

pos toperat ive pain, insom nia, pain medicat ion, electroly teimbalances, infect ion, fever, and b lood loss .


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EPIDEMIOLOGY

- Ad vanced age is a major r isk factor for th e developm ent of

delir ium.

About 30 to 40 percent of hospita l ized pat ients more than 65

years o ld have an episode of del i r ium.- Other predisp os ing factors for the development of deli r ium

are young age (that is, child ren), preexist ing b rain damage , a

histo ry of del i r ium , alcoh ol d ependence, diabetes, cancer,

sensory imp airment and malnutr i t ion.

-The presence of del ir ium is a bad pro gno st ic sig n.


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ETIOLOGY

The major causes of del i r ium :

central nervous system diseasesys temic disease (for example, cardiac fai lure), and either

intoxicat ion or w ithdrawal from ph armacological or toxic agents .

When evaluat ing a del i r ious pat ient, the cl in ic ian shou ld assum e that any

drug the patient has taken may be causatively relevant to the del ir ium .

Pathophys io logical mechanisms have been sugested

for del ir iumneurotransmit ter hyp othesized to b e involved in del ir ium is acetylcho l ine,

and neuroanatom ical area is the reticular formation.

In part icular, the deli r ium associated with alcohol w ithdrawal has been

associated w ith hypeact iv i ty of the locus ceruleus and i ts noradrenergic

neurons.

Other neurotransm itters that have been imp licated are serotonin and

glutamate.


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DIAGNOSIS

It may occu r at any age but is m ost common after the age of 60 years.

The del i r ious state is transient and o f f luctuat ing intensi ty; m ost c asesrecover wit hin 4 weeks o r less.

However, del ir ium last ing, with f luctuat ions, for up to 6 months is n ot

uncommon

A d eli r ious s tate may be su per imposed on, or pro gress into,dementia.

Diagno st ic g uidel ines

For a def in i te diagno sis, symp toms, mi ld or severe, shou ld be present

in each one of the fol lowing areas:

(a) impairment of cons cious ness and attent ion

(b) global disturb ance of cogn i t ion(c) psyc hom otor disturb ances hypo or hyperact iv i ty

(d) distu rbance of the sleep - wake cyd e

(e) emotio nal dist urb ances, e.g. depressio n, anxiety or fear,

irr i tabi l i ty, euphoria, apathy, or wondering perplexity.


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DIAGNOSIS

Includes:

acute brain syndrom eacute con fusion al s tate (nonalcoho l ic)

acute infect ive psychos is

acute organic react ion

acute psycho-organic synd rome


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Different ial d iagnosis :

Dement ia (FOO - F03),

acute and trans ient psy chotic disord ers (F23. -),

acute states in schizop hrenia (F20. -)

mood [affect ive] diso rders (F30 - F39)

Del i rium, induced b y alcohol and other psy choact ive

sub stances, should be cod ed in the appropr ia te sect ion

(Flx.4).

F05.0 Del i r ium, not su per imposed on dementia, so desc r ibed

This code shou ld be used for deli r ium that is no t

super imposed Upon pre-exist ing dementia.


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Different ial d iagnosis :

F05.1 Del ir ium , superimposed on dementia

This co de should be used for cond i t ions meet ing

the above cr i ter ia bu t develop ing in the cou rse of adementia (FOO - F03).

F05.8 Other delir ium

Includes: del ir ium of m ixed or ig in

subacute confus ional state or del i r ium

F05.9 Delir ium , unspecif ied


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COURSE AND PROGNOSIS

Altho ugh the onset of del ir ium is usual ly sudden, prod romalsymptom s (for examp le, rest lessness and fearfu lness) may occur in

the days preceding th e onset of f lor id sym ptom s.

After the identi f ication and th e removal of the causative facto rs, the

symptom s of del ir ium usual ly recede over a three-to-seven-day

period,

The older a patient is and the longer the patient h as been del ir ious,

the long er it takes for the del ir ium to resolve. that is remembered

only vaguely.

The occurrence of del i r ium is asso ciated w ith a high m ortal ity rate inthe next year, prim ari ly because of the serious n ature of the

associated medical con di t ions that lead to del i r ium .


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TREATMENTThe pr imary goal is to treat the under ly ing condi t ion

that is causing the del ir ium .

The other important goal of treatment is the provis ionof ph ysical . senso ry, and environmental support .

Usually,deler ious patients are helped by having a

fr iend or a relat ive in the room or b y the presence of a

regu lar sitt er.


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TREATMENT

Pharmacological Treatment

Treatment are psy chos is and in somnia.

The drug of ch oice for psy cho sis is haloper ido l (Haldol) a

butyrop henone ant ipsy cho t ic drug;

Phenothiazines should be avoided del i r ious pat ients , because

thos e drugs are assoc iated sign i f icant ant icho l inergic effect

Insomnia is best treated with either benzodiazepines w ith short

half- l ives or w ith hydro xy zine (Vistar i l), 100 mg.

Benzodiazepines w ith long half l ives and barbi turates shou ld beavoided un less they are being used aspart of the treatment for

the under lying diso rder ( for example, alcoho l w ithdrawal).


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II.DEMENTIA

Dementia is a syndrom e due to disease of the brain, usual ly of a

ch ronic o r progress ive nature,

Disturbance of mu l t ip le higher cor t ica l funct ions, includ ing

memory , think ing, or ientat ion, com prehension , calculat ion,

learning capacity, language, and judgement.

This syn drom e occ urs in A lzheimer 's disease, in

cerebro vascu lar disease, and in oth er condit io ns p r imar i ly or

secondar i ly affect ing the brain.

Dementia produ ces an appreciable decl ine in in tellectu al

func t ionin g, and usual ly some inter ference w ith personal

act iv i t ies of d aily l iv ing , suc h as w ashing, dressing , eat ing,

personal hygiene, excretory and toi let act iv i t ies. i tsel f w i l l

depend largely on the soc ial and c ultural sett ing in which th e

patient l ives.


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EPIDEMIOLOGY

Dementia is essential ly a disease of the aged.

Of Am ericans over the age of 65, about 5 p ercent h ave severedementia, and 15 percen t have mild d ementia.

50 to 60 percent have dementia of th e Alzheimer 's ty pe

Alzheimer 's typ e occupy mo re than 50 percent of n urs ing h ome

beds.

The second m ost common typ e of dement ia is vascular dement ia-

account for 15 to 30 percent of all dementia cases.

Other dementia 1 to 5 percen t of all

By the year 2030 an est imated 20 percent of the- popu lat ion wi l l b e

more than 65 years o ld. Thus, the current annual cos t of $15 bi l l ion

for car ing fo r dementia pat ients


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ETIOLOGY

Dementia has many causes;

Dementia of the Alzheimer's Type

Alo is Alzheimer in 1907,

Senile plaques,

Am yloid precursor protein.

Neurotransmitt er abno rmali t ies.

Other po tential causes.

Vascu lar Dementia

Binswanger'sdisease.

Pick's Disease

Creutzfeldt-Jakob Disease

Hunt ingto n's DiseaseParkin son 's Disease

HIV-Related Dementia

Head Traum a-Related Dementia

Dementia can be a sequela of h ead tr auma,


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A lzheimer's disease

Is a primary degenerative cerebral disease

It is usual ly insid iou s in on set and develops s lowly ,per iod canbe as sho rt as 2 or 3 years,

The onset can be in mid dle adul t l i fe (Alzheimer 's disease ofpresenile onset), high er in later l i fe (Alzheimer's disease of

seni le o nset).

There are characteristic changes in the brain:a marked reduct ion in the pop ulat ion of neurons

appearance of neurof ibr i l lary tangles

neur i t ic (argentophi l ) plaques, which c onsis t largely of amy loid

and granulovacu olar bodies.

Neurochemical :a marked reduct ion in the enzyme chol ineacety l -t ransferase, and in other n eurotransmit ters and

neuromodulators.

Dementia in Alzheimer's disease is at present irreversible.


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Figure 10-4. Microscopic brain section showing pyramidal cell layer of hippocampuswith numerous triangular intraneuronal neurofibrillary tangles [ ] and several senileplaques [ ] (Bielschowsky stain; original magnification x190). Figure provided by Dr.H. V. Vinters, Section of Neuropathology, UCLA Medical Center, Los Angeles, CA,from Vinters et al. 1988. Used with permission.


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F01. Vascu lar dementia

Vascular (form erly arter iosc lerot ic) dementia wh ich in cludes

mult i infarct dementia, histo ry of TIA w ith br ief imp airment of

con scio usness, f leet ing pareses, or v isual loss.

Diagno st ic guidel ines

The presence of a dementia

Impairment of cogn i t ive funct ion and focal neuro logical signs.

Insig ht and judgement m ay be relat ively wel l preserved.


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F01. Vascu lar dementia

An abrupt on set or a stepw ise deter iorat ion, conf i rmation

can be provided only by c omputer ized axial tomography or

neurop athological exam inat ion.

As soc iated features are: hypertens ion, carot id b rui t ,

emotio nal labi l ity w ith transient depressive mood , weepingor explos ive laugh ter, and transient episo des of clo uded

cons ciousn ess or del ir ium, of ten provoked by fur ther

infarct ion.

Person ali ty is bel ieved to be relat ively wel l preserved, butpersonali ty changes may be evident


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Figure 10-7. T2-weighted magnetic resonance imaging of a patient withvascular dementia shows extensive white-matter hyperintensities. Figureprovided by Dr. Bruce L. Miller, UCLA Harbor Medical Center, LosAngeles, CA. Used with permission.


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Different ial diagnos is.

Consider: delir ium (F05. -); oth er dement ia, part icular ly in

Alzheimer's d isease (FOO. -); mood [affectiv e] diso rders (F30 -F39); m ild o r moderate mental retardatio n (F70 - F71); su bdural

haemor rhage (traumatic (S06.5), no nt raum atic (162.0)).

F0l .0 Vascu lar dementia of acute onset

Usually develops rapid ly af ter a suc cession o f strok es fromcerebrov ascular throm bos is, embo l ism , or haemorrhage.

F0l .1 Mufti- infarct dementia

This is more gradual in onset than the acute form

F0l .2 Subc ort ic al vascular dementia

h istory of hyper tension and in CT foci of ischaemic destruct ion

in the deep white matter of th e cerebral hemispheres

F0l .3 Mixed cort ical and sub cort ic al vascu lar dementia

F0l .8 . Other vasc ular dementia


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F02.8 Dement ia in other specif ied diseases classif ied elsewhere

Inclu des dementia in:

Carbonmonox ide pois on ing (T58)

cereb ral lipid os is (E75. -)epilepsy (G40. -)

general paralys is o f the insane (A52. 1)

hepato lenticu lar degeneration (Wilso n's disease) (E83 .0)

hy perc alcaem ia (E83 .5)

hypo thy roid ism , acqu ired (E00. -, E02)

into xic ations (T36 - T65)

mult ip le sc lerosis (G35)

neuro syph il is (A52. 1)

niacin deficienc y pellagra] 52)

po lyarter i t is nodosa (M30.0)

sy stemic lupu s erythematosus (M32. -)trypano som iasis (Afr ican B56. -, American B57. -)

vitam in B 12 deficiency ,E53.8)

F03.Unspecif ied dement ia


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CLINICAL FEATURES

Memory ImpairmentOrientat ion

Language Impairment

Personal ity Changes

Psychosis.Other Impairments

Psychiatr ic.

Neurological .

Catastroph ic react ion .

Sundowner synd rome.


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DIFFERENTIAL DIAGNOSIS

dep ress ive di so rder (F30 - F39),del ir ium (F05); m ild o r moderate mental retardation (F70 -

F71);

iatrogenic mental diso rders due to medication (F06. -).

Dementia of the Alzheimer 's Type versus Vascular

Dementia

Vascu lar Dementia versus Trans ient Ischemic Attack

Del i r ium

Depression

Fact i t ious Disorder

SchizophreniaNormal Ag ing


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The class ic cou rse of dementia is an ons et in

the patient 50s o r 60s, with g radual

deterioration o ver 5 to 10 yearsleading

eventually to death.

The age of onset and rapidi ty o f deter iorat ionvary among dif ferent types of dementia

Psycho socia l Factors

TREATMENT


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TREATMENT

Some cases of d ementia are regarded as treatable

The general treatment approach

prov ide supp ort ive medical care,

emotional su ppo rt for the pat ients and their fami l ies,

the maintenance of the patient 's phy sical health, .

symptom atic treatment

Part icular attent ion m ust be pro vided to caretakers

and fami ly members

When the d iagnosis o f vascular dementia is made,

r isk factors

Pharmaco logic al Treatments

Current ly avai lable treatments psyc hoact ive drugs

Tetrahyd roam inoacridine (Tacrine)

Psychodynam ic Factors


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III. AMNESTIC DISORDERS

single symptom of a memory disorder that causes sigcant impairment insocial or occupational functioning.

EPIDEMIOLOGY

Amnesia is most commonly found in alcohol use disorders and head injury.

ETIOLOGY

Thiamine deficiency. Hypo-glycemia, hypoxia (including carbon monoxide

poisoning), and herpes simplex encephalitis ,tumors, cerebrovasculardiseases, surgical procedures, or multiple sclerosis plaques General insults

to the brain-for example, seizures, electroconvulsive therapy (ECT), and

head trauma-.

Many drugs benzodiazepines triazolam (Halcion),

CLINICAL FEATURES AND SUBTYPES


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CLINICAL FEATURES AND SUBTYPES

(anterograde amnesia - retrograde amnesia).

Short term memory and recent memory are usually impaired.

Memory for overlearned information the such as childhoodexperiences,

Cerebrovascular Diseases.

Multiple Sclerosis

Korsakoff's Syndrome

Alcoholic Blackouts

Electroconvulsive Therapy

Head Injury

Transient Global Amnesia


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DIFFERENTIAL DIAGNOSIS.

Dementia and Delirium

Normal Aging

Dissociative Disorders

Factitious Disorders


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The specific cause of the amnestic disorder

determines the course and the prognosis for a

patient.

Transient amnestic disorder with full recovery is

common in temporal lobe epilepsy,ECT, the intake ofsuch drugs as benzodiazepines and barbiturate , and

resuscitation from cardiac arrest.

Permanent amnestic syndromes may follow a head

trauma,carbon monoxide poisoning. a cerebralinfarction, subarrachnoid hemorrhage, and herpes

simplex encephalitis.


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F06.Other mental disorders due to brain damage and

dysfunction and to physical disease

The decision to classify a clinical syndrome here is supported bythefollowing:

(a)evidence of cerebral disease, damage or dysfunction, or of systemic

physical disease,

(b)a temporal relationship (weeks or a few months) between the

development of the underlying disease and the onset of themental

syndrome;

(c)recovery from the mental disorder following removal or improvement of

the underlying presumed cause;

(d)absence of evidence to suggest an alternative cause of the mental

syndrome (such as a strong family history or precipitating stress).


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EPILEPSY

GENERAL SEIZURE.ABSENCES (PETIT MAL).

Partial seizures.

SymptomsPreictal symptoms.

Ictal symptoms.

Interictal Symptoms

PERSONALITY DISTURBANCES.

PSYCHOTIC SYMPTOMS.

VIOLENCE.

MOOD DISORDER SYMPTOMS.


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IMMUNE DISORDERS

AIDS.

Systemic Lupus Erythematosus

ENDOCRINE DISORDERS

Thyriod Disorders

Parathyroid Disorders

Adrenal Disorders

(Addison's disease). (Cushing's syndrome)

Pituitary Disorders

Sheehan's syndrome.


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terim k sih

t s

perh ti n


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