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TRANSCRIPT
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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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COURSE AND PROGNOSIS
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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COURSE AND PROGNOSIS
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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