Organic Disorders

Question 1

What is the definition of organic disorder?

Answer 1

Organic disorder = mental disorder due to common, demonstrable aetiology in cerebral disease, brain injury, or other insult leading to cerebral dysfunction

Question 2

Are organic disorders acquired or congenital?

Answer 2

They are acquired, so different from intellectual disability

Question 3

Classification of organic disorders?

Answer 3

• Primary
  
  • Direct effect on the brain
• Secondary
  
  • Systemic diseases that affect the brain in addition to other organ systems

Question 4

Epidemiology - organic disorder

(age, onset)

Answer 4

• Onset
  
  • Any age
  • Adult or later life

Question 5

Classification of organic disorder?

Answer 5

• Acute/subacute
  
  • Delirium
  • Organic mood disorder
  • Organic psychotic disorder
• Chronic
  
  • Dementia
  • Amnesic syndrome
  • Organic personality change

Question 6

What are examples of organic disorders?

Answer 6

• Acute/subacute
  
  • Delirium
  • Organic mood disorder
  • Organic psychotic disorder
• Chronic
  
  • Dementia
  • Amnesic syndrome
  • Organic personality change

Question 7

What are some common features of organic disorders?

Answer 7

• Cognitive
  
  • Memory
  • Intellect
  • Learning
• Sensorium
  
  • Consciousness
  • Attention
• Mood
  
  • Depression
  • Elation
  • Anxiety
• Psychotic
  
  • Hallucinations
  • Delusions
• Personality and behavioural disturbance

Question 8

What can the following be broken down into:

• cognitive
• sensorium
• mood
• psychotic

Answer 8

• Cognitive
  
  • Memory
  • Intellect
  • Learning
• Sensorium
  
  • Consciousness
  • Attention
• Mood
  
  • Depression
  • Elation
  • Anxiety
• Psychotic
  
  • Hallucinations
  • Delusions

Question 9

What is the general management for organic disorders?

Answer 9

• Correct diagnosis for correct management
• Medication usually not that useful except for acute situations
• MDT approach
• Management of environment

Question 10

What is the prognosis for general disorders?

Answer 10

• Some irreversible and progressive
• Some transient/respond to treatment

Question 11

Aetiology - delirium tremens

Answer 11

• Alcoholic withdrawal

Question 12

Presentation - delirium tremens

Answer 12

• Fluctuating confusion
• Disorientation in time and place
• Memory impairment
• Psychotic phenomena
  
  • Such as hallucinations, delusional thinking

Question 13

Management - delirium tremens

Answer 13

• Benzodiazepines

Question 14

What is Wernicke-Korsakoff syndrome also called?

Answer 14

Wernicke’s encephalopathy

Question 15

Aetiology - Wernicke-Korsakoff syndrome

Answer 15

• Thiamine deficiency

Question 16

Presentation - Wernicke-Korsakoff syndrome

Answer 16

• Acute confusional state
• Ataxia
• Opthalmoplegia
• Nystagmus

Question 17

Treatment - Wenicke-Korsakoff syndrome

Answer 17

• High potency parenteral B1 replacement
  
  • 3-7 days
  • All patients with Wernicke’s encephalopathy or at high risk should get parenteral thiamine, others undergoing detoxification or under invest4igation should get oral thiamine
• Avoid carbohydrate load until thiamine replacement completed
• Concurrent treatment for alcohol withdrawal

Question 18

Prognosis - Wernicke-Korsakoff syndrome

Answer 18

• Untreated acute phase lasts about 2 weeks
• 84% develop Korsakoff psychosis with 15% mortality
• With treatment
  
  • Confusional state and opthalmoplegia can resolve within days
  • Nystagmus, neuropathy and ataxia may be prolonged or permanent

Question 19

What is alcohol amnesic syndrome also called?

Answer 19

Korsokoff’s psychosis

Question 20

Clinical features - alcohol amnesic syndrome

Answer 20

• Characterised by marked impairment of anterograde memory (ability to learn new information), disturbance of time sense
• No clouding of consciousness, absence of defect in immediate recall or global impairment
• Variable degrees of cognitive impairment
• Personality changes
• Apathy
• Loss of initiative
• Confabulation in early stage

Question 21

What is alcohol amnesic syndrome characterised by?

Answer 21

• Characterised by marked impairment of anterograde memory (ability to learn new information), disturbance of time sense

Question 22

Prognosis - alcohol amnesic syndrome

Answer 22

• Can improve with prolonged abstinence

Question 23

Aetiology - hepatic encephalopathy

Answer 23

• Normal seen in advanced alcohol liver disease
• Related to build up of toxic products like ammonia

Question 24

Clinical features - hepatic encephalopathy

Answer 24

• General psychomotor retardation
• Drowsiness
• Fluctuating levels of confusion

Question 25

Prognosis - hepatic encephalopthy

Question 26

Pathology - alcohol related brain damage

Answer 26

* Part of a spectrum of alcohol related disorders, not specific diagnosis

Question 27

Alcohol related brain damage - aetiology

Answer 27

* Can result from neurotoxic effects of alcohol * Head injury * Vitamin deficiencies * Cerebrovascular disease * Hypoxia * Hypoglycaemia * Seizures

Question 28

Alcohol related brain damage - epidemiology

Answer 28

* 35% of alcohol dependent people exhibit post-mortem evidence of this * Prevalence rising

Question 29

Alcohol related brain damage - clinical features

Answer 29

* Cognitive impairment * Impairment in short-term memory, long-term recall, new skill acquisition, set-shifting abilities * Visuospatial ability declines greater than language ability decline

Question 30

Alcohol related brain damage - investigations

Answer 30

* Imaging * Cortical atrophy (mainly white matter loss) and ventricular enlargement

Question 31

Alcohol related brain damage - prognosis

Answer 31

* Ability may recover spontaneously with abstinence/greatly reduced drinking

Question 32

Dementia - pathology

Answer 32

* A syndrome characterised by global cognitive impairment which is chronic in nature * Underlying pathology is variable and usually, but not always, progressive

Question 33

Dementia - types

Answer 33

* Alzheimer’s * Vascular * Mixed * Lewy body * Frontotemporal * Due to other brain disorders * Huntington’s disease * Head injury * Parkinson’s disease

Question 34

Compare the differences between dementia and pseudodementia for: - onset - long/short term symptoms - mood - answering of questions - hiding/showing amnesia - cognitive abilities

Answer 34

Question 35

Steroid induced psychosis - epidemiology

Answer 35

* 1/3 of patients treated with steroids display mild-moderate psychotic symptoms

Question 36

Steroid induced psychosis - management

Answer 36

* Taper steroids if possible * Consider antipsychotic/mood stabiliser

Question 37

Anti-NMDA receptor encephalitis - pathology

Answer 37

* Autoimmune disease that targets NMDA receptors * Ionotropic glutamate receptor involved in synaptic plasticity and memory function

Question 38

Anti-NMDA receptor encephalitis - aetiology

Answer 38

* ½ associated with malignancy

Question 39

Anti-NMDA receptor encephalitis - clinical features

Answer 39

* Often presents with psychiatric symptoms

Question 40

Anti-NMDA receptor encephalitis - investigations

Answer 40

* MRI * Bilateral hippocampal hyper intensity * EEG * “Delta brush” * Biochemistry * Positive NMDAr antibodies in blood and CSF

Question 41

What is seen in the following for anti-NMDA receptor encephalitis: - MRI - EEG - biochemistry

Answer 41

* MRI * Bilateral hippocampal hyper intensity * EEG * “Delta brush” * Biochemistry * Positive NMDAr antibodies in blood and CSF

Question 42

Anti-NMDA receptor encephalitis - management

Answer 42

* Immunotherapy and tumour resection if indicated * IVIg, plasmapheresis, rituximab

Question 43

Anti-NMDA receptor encephalitis - prognosis

Answer 43

* With treatment is generally good

Question 44

What is delirium characterised by?

Answer 44

An aetiologically non-specific syndrome characterised by: * Concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and sleep-wake cycle

Question 45

Delirium - aetiology

Answer 45

* Medication * Drug abuse * Withdrawal syndromes * Metabolic * Vitamin deficiencies * Endocrinopathies * Infections * Neurological causes * Toxins and industrial exposures * (Basically anything)

Question 46

Delirium - presentation

Answer 46

* Impairment of consciousness and attention * Global disturbance of cognition * Psychomotor disturbances * Disturbance of sleep-wake cycle * Emotional disturbance * Rapid onset * Diurnally fluctuating * Physical signs * Due to underlying disease * Autonomic activation – tachycardia, hypertension, diaphoresis, dilated pupils, fever * Dysgraphia

Question 47

Describe the differences between delirium and dementia in terms of: - onset - course - duration - alertness - orientation - registration - episodic memory - thinking - perception - speech - sleep/wake cycle - other acute pathology - EEG - CT, MRI

Answer 47

Question 48

What are the differences between delirium and psychosis for: - conscious level - thinking - delusions - cognitive functions - hallucinations

Answer 48

Question 49

Delirium - management

Answer 49

* Environmental and supportive measures * Education of relatives * Make environment safe * Optimise stimulation * Orientation * Medication * Avoid sedation unless required for safety * Guidelines do not support use of medications in delirium * Unless for acute management for safety – antipsychotics, benzodiazepines, promethazine

Question 50

Delirium - prognosis

Answer 50

* Fluctuating course * Gradually resolves after cause treated * Slower symptom resolution in elderly * Mortality * 20% die during admission * Up to 50% within 1 year