Izben C. Williams, MD, MPH Instructor. Lecture # 13 SOME OTHER PSYCHIATRIC DISORDERS.

BEHAVIORAL SCIENCE

Izben C. Williams, MD, MPHInstructor

Lecture # 13

SOME OTHER PSYCHIATRIC DISORDERS

Other Psychiatric Disorders

Some other psychiatric disorders

COGNITIVE DISORDERSPERSONALITY DISORDERSDISSOCIATIVE DISORDERSOBESITY AND EATING

COGNITIVE DISORDERS

DEF: CognitionCognition is the set of all mental abilities and processes related to knowledge: It includes attention, memory & working

memory, judgment & evaluation, reasoning & "computation", problem solving & decision making, comprehension & production of language, etc.

Cognitive Disorders: 1Delirium, Dementia, and Amnestic disorder

They are caused by general medical conditions, substances, or a combination of these factors

Cognitive disturbances involve symptoms such as Memory impairment Speech and language difficulties Altered level of consciousness, confusion Impairment of ability to plan and engage in complex

Cognitive Disorders: 2a. These difficulties are due to abnormalities in

neural chemistry, structure, or physiology originating in the brain or secondary to systemic illnesses

b. Patients with cognitive disorders may show psychiatric symptoms secondary to the cognitive problems (eg. Depression, anxiety, paranoia, hallucinations and delusions)

See characteristics and etiology of cognitive disorders in text….. (Fadem: Table 14-1, p131)

Cognitive Disorders: 3DELIRIUM - Diagnostic features:

Clouding of consciousnessImpaired cognitionShort or fluctuating courseNot better explained by dementiaCaused by general medical condition or

dementia

Cognitive Disorders: 4DELIRIUM – Associated features and

Diagnose:Disturbance in sleep-wake cycleDisturbance in psychomotor behaviorEmotional disturbancesAbnormal electroencephalogram Evidence of general medical condition or

substance use

Cognitive Disorders: 5

DELIRIUM – Epidemiology:Children and the elderly are most susceptibleStudies indicate that up to 25% of elderly

hospitalized patients have delirium

Cognitive Disorders: 6DELIRIUM – Treatment:

Correct the underlying causeEnvironmental management – quiet well-

lighted room and frequent orientation can decrease agitation

Protective restraints or antipsychotic medication can control or decrease agitation and risk of injury

Cognitive Disorders: 7DEMENTIA – Diagnostic features:

Memory impairment – develops insidiously; as dementia progresses, learning deficits become more prominent, and recent memories are lost. Eventually, older memories are compromised. Increased rick of physical dangers

Aphasia – loss of language function (word finding, sentence construction, understanding instructions) communication becomes increasingly more difficult sometimes resulting in mutism.

Cognitive Disorders: 8DEMENTIA – Diagnostic features:

Apraxia – inability to execute complex motor behaviors

Agnosia – failure to recognize or identify previously known objects and is not due to impaired sensory function

Disturbance in executive function – impaired ability to think abstractly and plan. Initiate, sequence, monitor, monitor and stop complex behavior. Difficulty conceptualizing or solving problems (eg. a grocery list)

Cognitive Disorders: 9DEMENTIA – Associated features and

Diagnosis:Emotional changes – labile and disinhibitedPersonality disturbances – moody, irritable,

mood ± Psychotic symptoms – usually delusionsNeuroimaging – generalized or focal cerebral

atrophy, enlarged ventricles and cortical sulci, Evidence of general medical condition or

substance use

Cognitive Disorders: 10DEMENTIA – Epidemiology:

The prevalence of dementia varies by age……. 5% of population older than age 65 20% of population older than age 85 More than 75% of dementia is caused by

Alzheimer’s Disease or cerebrovascular disease

Familial pattern: some types of neurodegenerative dementias are heritable

Cognitive Disorders: 11DEMENTIA – Course

Depending on the underlying cause, the onset of dementia may be sudden or gradual and function may stabilize or deteriorate

In children , dementia may result in developmental delays rather than deterioration of function

Other Psychiatric DisordersCognitive Disorders: 12DEMENTIA – Etiologies

Neurodegenerative diseases: include Alzheimer, Parkinson, Pick, Huntington diseases and ALS-dementia complex

Infectious causes; include HIV, Creutzfeldt-Jakob disease, viral, bacterial or parasitic brain infections,

Cerebrovascular disease, epilepsy, traumatic brain injury and other intracranial processes

Substance-induced persisting dementias: the commonest is alcohol

Other Psychiatric DisordersCognitive Disorders: 13DEMENTIA – Treatment:

Stabilizing or correcting underlying general medical condition

Medication: antipsychotic for psychotic symptoms

Familiar surroundings, reassurance, and support

Other Psychiatric DisordersCognitive Disorders: 14AMNESTIC DISORDERS – Diagnostic

Features:The essential feature of amnestic disorders is

impairment of memory, which does not occur solely during the course of delirium or dementia Memory impairment – difficulty learning

new information; immediate memory relatively in tact but mid term memory at risk;

Other aspects of cognition are relatively in tact

Other Psychiatric DisordersCognitive Disorders: 15AMNESTIC DISORDERS – Associated

features Confusion and disorientation as a result of

recent memory impairmentConfabulation – they imagine events to

compensate for faulty recall (and may adamantly defend their ideas)

Emotional changes – subtle emotional changes; sometimes appear inappropriately unconcerned and amotivated

Other Psychiatric DisordersCognitive Disorders: 16AMNESTIC DISORDERS – Epidemiology &

CourseMore common in populations with higher

prevalence of alcohol abuse and head traumaYoung adult men and individuals with antisocial

personality disorder are at greater riskCourse:

Onset may be rapid (eg. when resulting from trauma or biochemical injury)

More insidious onset in neurodegenerative conditions

Other Psychiatric DisordersCognitive Disorders: 17AMNESTIC DISORDERS – Etiologies

Bilateral damage (transient or chronic) to the diencephalon and medio-temporal structures (eg. mamilary bodies, fornix, hippocampus) may produce memory dysfunction in the absence of other cognitive symptoms

Such damage can be caused by Acute and chronic alcohol use and thiamine

deficiency, Head trauma, CVS disease, hypoxia, seizures,

infections, chronic use of some psychotropic medication

Other Psychiatric DisordersCognitive Disorders: 17AMNESTIC DISORDERS – Treatment

As with delirium and dementia, stabilization or correction of the underlying medical condition is definitive Tx for amnestic disorders

Avoid further brain insults of any kindFamiliar surroundings, reassurance and

support as patient gradually becomes reoriented

PERSONALITY DISORDERS

Personality DisordersWhat is this Personality that may

become disordered?PERSONALITY:

DEF: The set of ingrained characteristics (traits) that define the behavior, thoughts and emotions of an individual

These characteristics allow us to maintain an equilibrium between our internal drives and the world around us, and they dictate our lifestyle (modus operandi)

Personality DisordersA Personality disorder is a chronic or

lifelong pattern of behavior that is characterized by a group of traits that are:Severely dysfunctional in terms of

interpersonal relationshipsUsually more troublesome to others than to

the affected individualRelatively stable over time

Personality DisordersClusters of Personality disorders: 1. Cluster A: The odd and eccentric group

(paranoid, schizotypal, schizoid)2. Cluster B: The dramatic, emotional, and erratic

group in which self-preoccupation predominates (narcissistic, histrionic, borderline, antisocial)

3. Cluster C: Anxious and fearful group(obsessive- compulsive, dependent, avoidant)

This grouping into three clusters is based on similarities in symptoms or traits

Personality DisordersEach cluster has its own hallmark

characteristics and genetic or familial associations

Diagnosis depends also on a personality disorder being present by early adulthood

See diagnostic characteristics for individual disorders (Fadem: Table 14.3)

A diagnosis of antisocial personality disorder is not made before age 18, conduct disorder is ascribed instead.

Personality DisordersIndividuals in each cluster have a tendency

to employ particular defense mechanisms :Cluster A: Affected individuals use the defense

mechanisms of projection and fantasy and may have a psychotic tendency

Cluster B: Affected individuals tend to use dissociation, denial, splitting and acting out

Cluster C: Affected individuals tend to use isolation, passive aggression, and hypochondriasis

Personality DisordersTREATMENT:

Individual and, where tolerable, group psychotherapy may be useful for those who seek help

Pharmacotherapy can be useful on treating symptoms of co-morbid conditions such as depression and anxiety

However personality disorders are, by and large, resistive to treatment

DISSOCIATIVE DISORDERS

Dissociative Disorders

DISSOCIATIVE DISORDERS: are a group of psychiatric syndromes characterized by sudden, temporary disruption in some aspect of consciousness, identity, or motor behavior

DISSOCIATIVE DISORDERS Several types are recognized

1) Dissociative amnesia (includes fugue)2) Dissociative identity disorder (mpd)3) Depersonalization-derealization

disorder (includes trance)See characteristics @ MAYO Clinic siteDissociative fugue (psychogenic fugue)Possession/trance disorder

DISSOCIATIVE DISORDERS Although these syndromes are statistically

rare, when they do occur they present very dramatic clinical pictures of severe disturbance in normal personality functioning

Under normal circumstances the functions of memory, personal identity and motor behavior are critical for the integrated operation of the complex set of mental and behavioral activities we call personality

DISSOCIATIVE DISORDERS Etiology: dissociative disorders are

commonly related to disturbing emotional experiences in the patient’s recent or remote past

OBESITY AND

EATING DISORDERS

Obesity OBESITY DEFINITION:

Obesity is a complex disorder involving an excessive amount of body fat.

Being more than 20% over ideal weight (based on weight height charts), or having a body mass index (BMI) of 30 or higher is considered obese

BMI is: weight in kg/height in m²

Obesity

BMI Weight status

Below 18.5 Underweight

18.5-24.9 Normal

25.0-29.9 Overweight

30.0-34.9 Obese (Class I)

35.0-39.9 Obese (Class II)

40.0 and higher Extreme obesity (Class III)

Obesity OBESITY EPIDEMIOLOGY:Profiling an epidemic (HSPH)

In 1990, obese adults made up less than 15 percent of the population in most U.S. states.

By 2010, 36 states had obesity rates of 25 percent or higher,

12 of the 36 had obesity rates of 30 percent or higher.

Today, one out of three adults in the US is obese (36 percent) and roughly two out of three are overweight or obese (69 percent)

The health implications of this NCD trend, are profound

Even more alarming, the prevalence of overweight and obesity in children and adolescents is on the rise, and youth are becoming overweight and obese at earlier ages.

Genetic factors play an important role in obesity. Adult weight is closer to that of biologic rather than adoptive parents

Obesity One out of six children and adolescents

ages 2 to 19 is obese and one out of three is overweight or obese.

Early obesity not only increases the likelihood of adult obesity, it also increases the risk of heart disease in adulthood, as well as the prevalence of weight-related risk factors for cardiovascular disease such as high blood pressure, high cholesterol, and high blood sugar

Life is real simple

As easy as 1..2…3

Obesity

TREATMENT Physiological/(understanding the

physiologic control of eating behavior) Behavioral Environmental/social Dietary manipulation Pharmacological Surgical

Transition

Eating Disorders

DEFINITION: Any of a range of psychological disorders characterized by abnormal or disturbed eating habits. Includes 1. Anorexia Nervosa2. Bulimia Nervosa

Eating Disorders1. Anorexia Nervosa

Anorexia nervosa is an eating disorder that is characterized by obsessional weight loss without an identifiable organic cause

Disregards acceptable weight for age & height

Fear of gaining weight or becoming obese Disturbed body image Amenorrhea (for 3 consecutive cycles

Eating Disorders

1. Bulimia Nervosa (2 types purge/nonpurge)

Is characterized by ravenous over eating followed by guilt, depression, and anger at oneself for doing so. Other features….

Recurrent episodes of binging Recurrent inappropriate weight-controlling

behavior Self-evaluation unduly influenced by shape and

weight

Eating Disorders

TREATMENT:

Izben C. Williams, MD, MPH Instructor. Lecture # 13 SOME OTHER PSYCHIATRIC DISORDERS.

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