IzBen C. Williams, MD, MPH Lecturer. Lecture # 13 SOME OTHER PSYCHIATRIC DISORDERS.

BEHAVIORAL SCIENCE

IzBen C. Williams, MD, MPHLecturer

Lecture # 13

SOME OTHER PSYCHIATRIC DISORDERS

Other Psychiatric Disorders

Some other psychiatric disorders

COGNITIVE DISORDERSDISSOCIATIVE DISORDERSOBESITY AND EATING DISORDERS

COGNITIVE(Neurocognitive)

DISORDERS


DEF: CognitionCognition (Latin: cognitio = the act or process of knowing): is the set of all mental abilities and processes related to knowledge and understanding, through experience, and the senses.

Elements of CognitionAll Conscious Mental Activities

Attention Reasoning and computation

Memory and working memory

Problem solving and decision making

Judgment and evaluation Comprehension and production of language

Learning Insight …..etc


The major Cognitive Disorders are: (1)Delirium, Dementia, and Amnestic disorder

They are caused by a general medical condition. Patients with these disorders are encountered by clinicians in every specialty

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

tasks


Cognitive Disorders: (2)a. 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 manifest psychiatric syndromes secondary to the cognitive problems (eg. Depression, anxiety, paranoia, hallucinations and delusions)

See Characteristics and Etiologies of Cognitive Disorders, in text….. (Fadem: Table 14-1)


Cognitive Disorders: (3)DELIRIUM - Diagnostic features include:

Clouding of consciousness and confusion 2° to CNS impairment

Usually occurs with acute medical illnessShort or fluctuating courseNot better explained by dementiaCommon in surgical and coronary care

units and in elderly debilitated patients


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: (6)DELIRIUM – Treatment:

Correct the underlying causeEnvironmental management – quiet well-

lighted room and frequent orientation can decrease agitation

Protective physical restraints or antipsychotic medication (chemical restraints) can control or decrease agitation and risk of self injury


Cognitive Disorders: (7)DEMENTIA – Diagnostic features i:

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: (8)DEMENTIA – Diagnostic features ii:

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: (9)DEMENTIA – 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: (10)DEMENTIA – 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: (11)DEMENTIA – 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: (12)DEMENTIA – 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: (13)DEMENTIA – Treatment:

Stabilizing or correcting underlying general medical condition

Medication: antipsychotic for psychotic symptoms

Familiar surroundings, reassurance, and support

Other Psychiatric DisordersCognitive Disorders: (14)AMNESTIC DISORDER – 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: (15)AMNESTIC DISORDER – 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: (16)AMNESTIC DISORDER – 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: (17)AMNESTIC DISORDER – Etiologies

Bilateral damage (transient or chronic) to the diencephalon and medio-temporal structures (eg. mamillary 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: (18)AMNESTIC DISORDER – 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


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 Dissociative amnesia

Patients with this disorder have amnesia for important personal information

Dissociative fugue is now considered a subset of this state. In this condition a patient suddenly travels away and cannot recall his/her past. The patient may be confused about self identity or assume a new identity.


DISSOCIATIVE DISORDERS Dissociative identity disorder (mpd)

Patient has two or more distinct identities or personality states that control his actions. The host personality, who may present to the physician, is aware of “lost time”, but may not know what occurs during that time and may be embarrassed to discuss it. Most patients with this disorder experienced severe childhood trauma (eg sexual or physical abuse)


DISSOCIATIVE DISORDERS Depersonalization-derealization

disorder (includes trance state)A patient with this disorder has feelings of

detachment from body or mind; however reality testing remains in tact. The symptoms of depersonalization cause the patient significant distress or functional impairment


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.

To be considered overweight you should: be more than 20% over ideal weight (based

on weight height charts), or have a body mass index (BMI) of 30 or

higher (this 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 (JHSPH)

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 (ie. one third) of the 36 had obesity rates of 30 percent or higher.

Obesity OBESITY EPIDEMIOLOGY:Profiling an epidemic (HSPH)

Today, one out of three adults in the US is obese (36 percent)

Obesity is more common in lower socioeconomic groups

The health implications of this NCD trend, are profound

Obesity Trend

USA: Prevalence of obesity in adults by State, 2013

Obesity OBESITY EPIDEMIOLOGY:

Profiling an Epidemic:

No state had a prevalence of obesity less than 20% (compare with 1990).

7 states and the District of Columbia had a prevalence of obesity between 20% and <25%.

23 states had a prevalence of obesity between 25% and <30%.

18 states had a prevalence of obesity between 30% and <35%.

Obesity OBESITY EPIDEMIOLOGY:Profiling an Epidemic:

2 states (Mississippi and West Virginia) had a prevalence of obesity of 35% or greater.

The South had the highest prevalence of obesity (30.2%), followed by the Midwest (30.1%), the Northeast (26.5%), and the West (24.9%).

The prevalence of obesity was 27.0% in Guam and 27.9% in Puerto Rico.+

USA: Prevalence of obesity in adults by State, 2013

Obesity OBESITY EPIDEMIOLOGY:Profiling an epidemic (HSPH)

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

Intense fear of being overweight or becoming obese

Distorted body image Amenorrhea (for 3 consecutive cycles)

Eating Disorders

1. Bulimia Nervosa (2 types purge/non-purge)

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

Recurrent, inappropriate weight-control behavior with episodes of eating binges,

Often accompanied by restrictive diets, self-induced vomiting, and use of laxatives, emetics, or diuretics to maintain or lose weight

Eating Disorders

TREATMENT of eating disorders includes:

Medical assessmentDrug therapyBehavioral interventionsPsychotherapy

Eating Disorders

TREATMENT of eating disorders : 1. Anorexia nervosa (usually in patient treatment )

Primary immediate treatment involves medical management of fluids, electrolytes and nutritional status, combined with….

Structured behavior modification programs Long-term treatment emphasizes the medical status

of the patient including regular dietary counseling by a dietitian and individual or group psychotherapy

Eating Disorders

TREATMENT of eating disorders:2. Bulimia

Treatment also involves medical management,

Cognitive therapy, and Behavior modification Drug therapy with SSRIs, tricyclic

antidepressants, or MAOIs is effective in some patients

Vignettes – Dissociative Disorders

Students are encouraged to surf the web for subject related vignettes. Here are a few for Dissociative Disorders:

https://www.youtube.com/watch?v=7TlYGivBGYE

https://www.youtube.com/watch?v=n1is6S4sCK4

https://www.youtube.com/watch?v=j_rEBKxW3qE









IzBen C. Williams, MD, MPH Lecturer. Lecture # 13 SOME OTHER PSYCHIATRIC DISORDERS.

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