1. Organic Mental Disorders

2. Overview of Psychiatric Disorders
Those due to known organic cause
Those in which organic factor has not yet been found
Those that are primarily due to psychosocial factor

3. Contd…
Organic mental disorders are behavioral or psychological disorders associated with transient or permanent brain dysfunction due to cerebral disease either by primary brain pathology or secondary due to systemic disease
Organic mental disorder should be first considered in evaluating patient with any psychological or behavioral clinical syndrome

4. High Index of Organic Mental Disorder
1st episode
Sudden onset
Older age of onset
H/O drug or alcohol use disorder
Concurrent medical or neurological illness
Neurological symptoms- seizure, impaired consciousness, head injury,confusion,disorientation, memory impairement
Prominent hallucinations

5. Subcatogery of OMD Delirium Dementia Organic amnestic syndrome
Other OMD

6. Delirium
Delirium is a transient, potentially reversible dysfunction in cerebral metabolism, that has an acute or subacute onset and is typically manifested by alterations of levels of consciousness and change in cognition.
It is the most common psychiatric syndrome found in a general medical hospital.
Elderly patients presenting to the emergency room is as high as 80%

7. Delirium by Other Names
Intensive care unit psychosis
Acute confusional state
Acute brain failure
Encephalitis
Encephalopathy
Toxic metabolic state
Central nervous system toxicity
Paraneoplastic limbic encephalitis
Sundowning
Cerebral insufficiency
Organic brain syndrome

8. Causative factors for delirium
Central nervous system disorder
Metabolic disorder
Systemic illness
Medications
Seizure Migraine Head trauma, brain tumor, subarachnoid hemorrhage, subdural, epidural hematoma, abscess, intracerebral hemorrhage, cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia
Electrolyte abnormalities Diabetes, hypoglycemia, hyperglycemia, or insulin resistance
Infection Trauma Change in fluid status Nutritional deficiency Burns Uncontrolled pain Heat stroke High altitude (usually >5,000 m)
Pain medications, anti-HTN,anticonvulsants Antibiotics, antivirals, and antifungals Steroids,sedatives,alcohol Anesthesia

9. Cardiac Pulmonary Endocrine Hematological Renal Hepatic Neoplasm
Contd…
Cardiac failure, arrhythmia, myocardial infarction, cardiac surgery
Chronic obstructive pulmonary disease, hypoxia, acid base disturbance
thyroid abnormality, parathyroid abnormality, Adrenal crisis
Anemia, leukemia, blood dyscrasia,
Renal failure, uremia
Hepatitis, cirrhosis, hepatic failure
Neoplasm (primary brain, metastases, paraneoplastic syndrome)
Intoxication and withdrawal
Heavy metals and aluminum
Cardiac
Pulmonary
Endocrine
Hematological
Renal
Hepatic
Neoplasm
Drugs of abuse
Toxins

10. Predisposing Factors Pre-existing brain damage or dementia
Extremes of age
H/O delirium
Alcohol or drug dependence
Generalized or focal cerebral lesion
Chronic medical illness
Pre-and post-op
Severe psychological symptoms
Rx with psychotropic drugs
H/O head injury
Vision impairment
Use of bladder catheter
Malnutrition
Epidural use

11. The diagnostic features of delirium in the current DSM (DSM-IV)
Disturbance of consciousness
Change in cognition
The disturbance that develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
Evidence from the history,.

12. According to the ICD-10for a definitive diagnosis of delirium symptoms mild or severe,should be present in each one of the following areas:-
1)Impairement of consciousness and attention.
2)Global disturbances of cognition.
3)Psychomotor disturbances.
4)Disturbances of sleep-wake cycle
5)Emotional disturbances,
Eg.depression,anxiety,fear,irritability.

13. Delirium due to a general medical condition
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
Substance intoxication delirium
There is evidence from the history, physical examination, or laboratory findings of either 1 or 2:
1 the symptoms developed during substance intoxication
2 medication use is etiologically related to the disturbance.
Substance withdrawal delirium
There is evidence from the history, physical examination, or laboratory findings that the symptoms developed during, or shortly after, a withdrawal syndrome.
Delirium due to multiple etiologies
There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology
Delirium not otherwise specified

14. Diagnostic features Discriminating features
1 Waxing and waning awareness.
2 Acute onset of cognitive dysfunction.
Consistent features
1 Disorientation, usually to time.
2 Memory impairment, particularly recent memory.
3 Hallucinations, typically visual, and misperceptions.
4 Language dysfunction, such as an impaired ability to name objects.
5 Definable cause.
Variable features
1 Hyperactivity and/or hypoactivity.
2 Mood disturbance.
3 Alteration in sleep-wake cycle.
4 Delusions.
5 Impaired judgment.
6 Dreamlike experience for patient.

15. 7)diurnal variation is marked,usually worsening of symptoms in evening and night(called sundowning).
8)speech and thought disturbances like slurring of speech,incoherence,dysarthria.
9)motor symptoms include asterixis(flapping tremor).

16. Laboratory Workup of the Patient with Delirium
Standard studies    Blood chemistries (including electrolytes, renal and hepatic indexes, and glucose)    CBC    TFT    Serologic tests for syphilis    HIV antibody test    Urinalysis    Electrocardiogram    Electroencephalogram    Chest radiograph    Blood and urine drug screens
Additional tests when indicated    Blood, urine, and cerebrospinal fluid (CSF) cultures    B12, folic acid concentrations    CT & MRI    LP and CSF examination

17. Differential Diagnosis

18. Treatment
The treatment of delirium involves treating the primary causative condition, providing supportive care, and preventing injurious behaviors.e.g. o2 for hypoxia, 100mg of B1 for thiamine deficiency
Emergency psychiatric Rx e.g. benzodiazepines (10mg of diazepam or 2mg of lorazepam IV) or antipsychotics (5mg of haloperidol or 50mg of chlorpromazine IM)
Supportive medical and nursing care
If severe pain or dynpnoea, prescribe opioids for both their analgesic and sedative effects

19. Prognosis
Among delirious hospitalized medical patients mortality is as high as 20–40%.

20. Prevention Good general medical and nursing care
Recognition and effective treatment
Screening for alcohol dependence is important
Elderly patients unwell physically or having a major procedure, who have pre-existing cognitive problems.
Hypnotics are associated with an increased risk of delirium; routine use should be avoided