1. MENTAL DISORDERS DUE to a GENERAL MEDICAL CONDITION Augusto B. Cruz Jr., MD, DPBP Department of Psychiatry College of Medicine

2. In the PAST… ORGANIC PATHOLOGY vs. Caused by specific physiological abnormalities Examples: brain tumors or thyroid diseases causing psychosis, anxiety, or depression FUNCTIONAL PATHOLOGY Not caused by specific physiological abnormalities Examples: schizophrenia, depressive & anxiety disorders Adapted from Lazare & Anderson, 1979

3. At PRESENT… DSM-IV eliminated distinction between functional & organic disorders Many physiological abnormalities have been identified for most mental disorders MENTAL DISORDER due to a GENERAL MEDICAL CONDITION

4. Why are medical conditions considered as causing mental disorders? 1. Psychiatric symptoms abate significantly with medical treatment 2. Medical symptoms clearly related to onset of psychiatric symptoms 3. Medical disorder explains patient’s symptom pattern Lazare & Anderson, 1979

5. AIDES to DIAGNOSIS  History  Mental status examination  Physical & neurological examinations  Laboratory studies  Observation of natural history of symptoms  Response to treatment  Specialty consultation Lazare & Anderson, 1979

6. GENERAL PRINCIPLES in DIAGNOSIS 1. Make an initial presumption of medical cause when dealing with psychosis. 2. Strongly suspect a medical disorder when visual hallucinations, distortions, & illusions are predominant. 3. Suspect a medical disorder when onset of psychiatric symptoms is acute. Adapted from Lazare & Anderson, 1979

7. GENERAL PRINCIPLES in DIAGNOSIS 4. Consider acute decompensation of cardiovascular, pulmonary, hepatic, renal or endocrine systems in a patient with psychotic reactions. 5. Do not disregard a medical condition just because of specific content of symptoms. Adapted from Lazare & Anderson, 1979

8. GENERAL PRINCIPLES in DIAGNOSIS 6. Strongly suspect a medical condition in older patients. 7. Do not disregard medical condition just because of an “obvious” psychological precipitating event. 8. Do not rely on psychiatric symptoms alone to distinguish diagnosis. Adapted from Lazare & Anderson, 1979

9. GENERAL PRINCIPLES in DIAGNOSIS 9. Beware of the labels “hysteria” or “hypochondriasis” (longitudinal follow- up of such patients reveal a medical condition). 10. Do not disregard medical condition just because medical physician is referring patient for psychiatric consultation. Adapted from Lazare & Anderson, 1979

10. DIFFERENTIALS IN DIAGNOSING ABNORMAL BEHAVIOR IN THE MEDICALLY ILL Mental disorder due to a General Medical Condition Psychological Factors Affecting Medical Condition.

11. MENTAL DISORDERS due to a GENERAL MEDICAL CONDITION AMNESTIC DISORDER DELIRIUM DEMENTIA PSYCHOTIC DISORDER MOOD DISORDERANXIETY DISORDER SEXUAL DYSFUNCTION SLEEP DISORDER CATATONIC DISORDER PERSONALITY CHANGE

12. BIOLOGICAL CORRELATES OF DEPRESSION ENDOCRINE DO: diabetes mellitus, hypothyroidism MEDICATIONS AND DRUGS: amphetamine withdrawal, methyldopa, clonidine, diuretics, propranolol, barbiturates, benzodiazepines, cimetidine, corticosteroids, metoclopramide, NSAIDS, oral contraceptives, opiates INFECTIONS: HIV, post-influenza, pneumonia, hepatitis, TB TUMORS: lung, pancreas, CNS NEUROLOGIC: dementia, complex partial epilepsy, parkinson’s, postconcussion, stroke, sleep apnea

13. MEDICAL CAUSES OF ANXIETY AND PANIC CARDIOVASCULAR: angina pectoris, cerebral insufficiency, CHF, dysrrhythmias, hypovolemia, MI, paroxysmal atrial tachycardia, mitral valve prolapse, syncope METABOLIC CONDITIONS: anemia, hypoglycemia, hyponatremia, hyperkalemia, hyperthermia, heavy metal toxicity, vitamin deficiency DRUGS: alcohol, aminophylline, aniticholinergics, anti-TB, beta- blockers(withdrawal), caffeine, cannabis, digitalis toxicity, dopamine, ephedrine, lidocaine, phenylephrine, phenylpropanolamine, salicylates, steroids, theophylline

14. MEDICAL CAUSES OF ANXIETY AND PANIC RESPIRATORY CONDITIONS: asthma, COPD, lung cancer, pneumonia, pneumothorax, respirator dependence GASTROINTESTINAL: Crohn’s ds, peptic ulcer ds. NEUROLOGIC: cerebrovascular disease, encephalitides, myasthenia gravis, multiple sclerosis, postconcussion syndrome, seizure disaorders, subarachnoid hemorrhage, transient ischemic attacks, vascular headaches, Meniere’s ds.

15. PARKINSON’S DISEASE Degeneration of substantia nigra Unknown cause Depression, anxiety, psychosis

16. HUNTINGTON’S DISEASE “Huntington’s chorea” Degeneration of caudate nucleus Autosomal dominant

17. EPILEPSY Recurrent episodes of seizures Transient paroxysmal pathophysiological disturbances of cerebral function Caused by spontaneous and excessive discharges of neurons

18. Mental Symptoms in the interictal period (Temporal lobe Epilepsy) Psychosis Hallucinations, paranoid delusions Remains warm and appropriate affect Personality changes Increased religiosity Changes in sexual behaviour (hyper/hypo) Fetishism. Transvestism Lack of interest in sexual matters, reduced arousal Mood symptoms (temporal & non-dominant) Violent behaviour (temporal and frontal lobe)

19. BRAIN TUMORS ~50% experience mental symptoms ~80% have tumors in frontal or limbic regions Symptoms Impaired intellectual functions Impaired language functions Loss of recent memory

20. BRAIN TUMORS Symptoms Perceptual defects Altered consciousness Akinetic mutism/vigilant coma Patient is immobile and mute but alert Tumors in upper part of brain stem

21. SYSTEMIC LUPUS ERYTHEMATOSUS Autoimmune disease Sterile inflammation of multiple organ systems More common in females May be precipitated by pregnancy (first 6 weeks postpartum)

22. NEUROPSYCHIATRIC SLE Delirium Mood syndromes Psychosis Generalized seizures Signs of diffuse CNS involvement (global cognitive dysfunction, eg, dementia) Singer & Denburg, 1990; Moore & Jefferson, 1996

23. DEMENTIA

24. DEMENTIA of ALZHEIMER’S TYPE Most common: 50-60% Increases with age Average duration from onset of symptoms to death: 8-10 years Plateaus may occur but progression resumes after 1 to several years

25. VASCULAR DEMENTIA Second most common: 15-30% Risk factors Male sex Hypertension Cardiovascular risk factors

26. OTHER CAUSES of DEMENTIA Each representing less than 1-5% Head trauma Drugs and toxins (eg, alcohol) Intracranial masses Normal-pressure hydrocephalus Parkinson’s disease

27. SENILE PLAQUES and NEUROFIBRILLARY TANGLES

28. NEUROPATHOLOGY of ALZHEIMER’S DEMENTIA Neuronal loss (esp. cortex and hippocampus) Synaptic loss

29. ETIOLOGY of VASCULAR DEMENTIA Arteriosclerotic plaques or thromboemboli  Occlusion of small and medium-sized cerebral vessels  Infarction and multiple parenchymal lesions throughout the brain

30. MULTIPLE COGNITIVE DEFICITS in DEMENTIA Memory impairment One or more cognitive disturbances Aphasia Apraxia Agnosia Disturbance in executive functioning: planning, organizing, sequencing, abstracting

31. CLINICAL FEATURES of DEMENTIA Significant impairment in social or occupational functioning Significant decline from a previous level of functioning Disorientation Language: vague, imprecise, stereotyped, circumstantial

32. PESONALITY CHANGES in DEMENTIA Marked in frontal and temporal involvement: may be irritable and explosive Preexistent traits accentuated Become introverted Less concerned about their behavior Lack of judgment Poor impulse control

33. PSYCHIATRIC SYMPTOMS in DEMENTIA 40-50% have depression and anxiety 10-20% have depressive syndrome 20-30% have hallucinations 30-40% have delusions (paranoid, persecutory, unsystematized) Laughter or crying without reason

34. DELIRIUM

35. EPIDEMIOLOGY of DELIRIUM General surgical wards ~ 10-15% General medical wards ~ 15-25% ICU (Surgical and Cardiac) ~ 30% Surgery from hip fractures ~ 40-50% Postcardiotomy ~ >90% Severe burns ~ 20% AIDS ~ 30%

36. RISK FACTORS for DELIRIUM Advanced age 30-40% of hospitalized patients older than 65 Young age (children) Preexisting brain damage (eg, dementia, CVD, tumor) History of delirium

37. RISK FACTORS for DELIRIUM Alcohol dependence Diabetes Cancer Sensory impairment (eg, blindness) Malnutrition

38. ETIOLOGY of DELIRIUM NEUROANATOMICAL AREAS Reticular formation (regulates attention and arousal) Dorsal tegmental pathway (projects from mesencephalon to tectum and thalamus) Hyperactivity of locus ceruleus

39. CLINICAL FEATURES of DELIRIUM Key features Impaired consciousness (reduced clarity of awareness of environment) Reduced ability to focus, sustain or shift attention

40. CLINICAL FEATURES of DELIRIUM Abnormal arousal Hyperactivity with increased alertness Substance withdrawal delirium Hypoactivity with decreased alertness Mixture of hyperactivity and hypoactivity

41. CLINICAL FEATURES of DELIRIUM Impaired orientation Mild cases: loss of orientation to time Severe cases: loss of orientation to place and person (of others not of self)

42. CLINICAL FEATURES of DELIRIUM Language abnormalities Rambling, irrelevant or incoherent speech Inability to comprehend speech Impaired ability to register, retain and recall memories; remote memories may be preserved

43. CLINICAL FEATURES of DELIRIUM Impaired problem-solving abilities Unsystematized, often paranoid, delusions Distracted by irrelevant stimuli Agitated by new information Hallucinations and illusions Visual or auditory most common Simple geometric figures or colored patterns to fully formed people and scenes

44. CLINICAL FEATURES of DELIRIUM Mood abnormalities: anger, rage, unwarranted fear, apathy, depression, euphoria Sleep Fragmented Sleep-wake cycle reversed Nightmares (continue as hallucinations in wakefulness) Sundowning

45. CLINICAL FEATURES of DELIRIUM Symptoms develop over a short period of time (hours to days) Symptoms fluctuate over the course of a day

46. DIFFERENTIAL DIAGNOSIS of DELIRIUM FEATUREDELIRIUMDEMENTIA Impaired memory+++ Impaired thinking+++ Impaired judgment+++ Clouding of consciousness+++- Major attention deficits++++* Fluctuation over the course of a day ++++ Disorientation+++++* From: Liston EH, Psychiatr Ann, 1984.

47. COURSE and PROGNOSIS of DELIRIUM Onset usually sudden Persists as long as cause(s) is/are present Generally lasts less than one week After removal of cause(s) Symptoms recede over 3- to 7-day period Some symptoms take 2 weeks to resolve

48. DELIRIUM POOR PROGNOSIS 3-month mortality 23-33 % 1-year Mortality Up to 50%

49. AMNESTIC DISORDERS

50. AMNESTIC DISODERS Due to a General Medical Condition Substance-Induced Persisting Amnestic Disorder Transient (1 month or less) Chronic (More than 1 month)

51. MAJOR CAUSES of AMNESTIC DISODERS Thiamine deficiency (Korsakoff’s syndrome) Hypoglycemia Seizures Head trauma Cerebral tumors Herpes simplex encephalitis Alcohol use disorders Benzodiazepines

52. DIAGNOSIS of AMNESTIC DISODERS Characterized by memory impairment (anterograde & retrograde amnesia) Absence of other significant cognitive impairments Significant decline from previous level of functioning Significant impairment in functioning Short-term and recent memory usually impaired Immediate memory remains intact

53. CLINICAL FEATURES of AMNESTIC DISODERS Onset of symptoms Sudden: trauma, CVDs, neurotoxins Gradual : nutritional deficiency, cerebral tumors Sublte or gross changes in personality Apathetic Lack initiative Unprovoked episodes of agitation Overly friendly or agreeable

54. CLINICAL FEATURES of AMNESTIC DISODERS Bewildered or confused Attempts to cover confusion with confabulation Insight into condition is not good

55. COURSE and PROGNOSIS of AMNESTIC DISORDERS Full recovery Temporal lobe epilepsy ECT Benzodiazepines Permanent amnesia Head trauma Carbon monoxide poisoning Cerebral infarction Subarachnoid hemorrhage Herpes simplex encephalitis

56. TREATMENT of AMNESTIC DISORDERS Treat underlying cause Psychotherapy Explain to patient what is happening Illness Emotional experience Allow patient to grieve over lost faculties

57. DIFFERENTIALS IN DIAGNOSING ABNORMAL BEHAVIOR IN THE MEDICALLY ILL Mental disorder due to a General Medical Condition Psychological Factors Affecting Medical Condition.

58. PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION (DSM IV 316) Mental disorder affecting…. Psychological symptoms affecting… Personality traits or coping style affecting… Maladaptive health behaviors affecting… Stress related physiological response affecting… Other or unspecified psychologicaL factors affecting…

59. Mental disorder affecting… An Axis I disorder such as a major depressive disorder delaying recovery from a myocardial infarction

60. Psychological symptoms affecting… Depressive symptoms delaying recovery from surgery Anxiety affecting asthma

61. Personality traits or coping style affecting… Pathological denial of a need for surgery in a patient with cancer Hostile, pressured behavior contributing to cardiovascular disease

62. Maladaptive health behaviors affecting… Overeating Lack of exercise Unsafe sex

63. Stress related physiological response affecting… Stress related exacerbations of peptic ulcers, hypertension, arrhythmia, or tension headache

64. Other or unspecified factors affecting… Interpersonal Cultural Religious

65. MARAMING SALAMAT! THANK YOU FOR LISTENING!