schizophrenia has never been met (though patient may have tactile or olfactory hallucinations if they are related to the delusional theme)
C. functioning not markedly impaired; behaviour not obviously odd or bizarre D. if mood episodes occur concurrently with delusions, total duration has been brief relative to duration of the delusional periods
E. the disturbance is not due to the direct physiological effects of a substance or GMC
subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified
treatment:
psychotherapy, antipsychotics, antidepressants
prognosis: chronic, unremitting course but high level of functioning
Folstein Mini Mental State Exam (MMSE) to assess Dementia:
Orientation (time and place) – 5 points
Memory (immediate and delayed recall) – 5 points Attention and Concentration
Language (comprehension, reading, writing, repetition, naming)
Spacial ability (intersecting pentagons)
Gross screen for cognitive dysfunction: Total score is out of 30; <24 abnormal 20-24 mild, 10-19 moderate,
<10 severe
See attached Form
DSM-IV-TR Diagnostic Criteria for Dementia (Alzheimer’s Type) A. the development of multiple cognitive deficits manifested by both
1. memory impairment (impaired ability to learn new information or to recall previously learned information)
2. >1 of the following cognitive
disturbances:
o aphasia (language disturbance) o apraxia (impaired
ability to carry out motor activities despite intact motor function) o agnosia (failure to
recognize or identify objects despite intact sensory function) o disturbance in
executive functioning (i.e.
planning, organizing, sequencing, abstracting) B. the cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning
C. the course is
characterized by gradual onset and continuing cognitive decline
D. the cognitive deficits in Criteria A1 and A2 are not due to any of the following:
1. other central nervous system conditions that cause progressive deficits in memory and cognition
2. systemic conditions that are known to cause dementia
3. substance-induced conditions
E. the deficits do not occur exclusively during the course of a delirium F. the disturbance is not better accounted for by another Axis I disorder
Investigations (rule out reversible causes)
standard: as in Delirium
as indicated: VDRL, HIV, SPECT, CT head in dementia
indications for CT head, as in Delirium section plus: age <60, rapid onset (unexplained decline in cognition or function over 1-2 months), dementia of relatively short duration (<2 years), recent significant head trauma, unexplained neurological symptoms (new onset of severe
headache/seizures) Management
treat medical problems and prevent others
provide orientation cues (e.g. clock, calendar)
provide education and support for patient and family (day programs, respite care, support groups, home care)
consider long-term care plan (nursing home) and power of attorney/living will
inform Ministry of Transportation about patient’s inability to drive safely
consider pharmacological therapy
o cholinesterase inhibitors (e.g.
donepezil
(Aricept)) for mild to severe disease o glutamatergic
NMDA receptor antagonist (e.g memantine) for moderate to severe disease o low-dose
neuroleptics (haloperidol, risperidone) and antidepressants if behavioural or emotional symptoms prominent - start low and go slow o reassess
pharmacological therapy every 3 months
Substance Abuse History Validated screening questionnaire (Alcohol):
C ever felt the need to Cut down on drinking?
A ever felt Annoyed at criticism of your drinking?
G ever feel Guilty about your drinking?
E ever need a drink first thing in morning (Eye opener)?
for men, a score of >2 is a positive screen and for women, a score of >1 is a positive screen
if positive CAGE, then assess further to distinguish between problem drinking and alcohol dependence General Assessment
When was the last drink?
Do you have to drink more to get the same effect?
Do you get shaky or nauseous when you stop drinking?
Have you had a withdrawal seizure?
How much time and effort do you put into obtaining alcohol?
Has your drinking affected your ability to work, go to school, or have relationships?
Have you suffered any legal consequences?
Has your drinking caused any medical problems?
Moderate Drinking Men: 2 or less/day Women: 1 or less/day Elderly: 1 or less/day Drinking Problem Drinking above the
recommended guidelines, associated with:
Drinking to or reduce depression or anxiety
Loss of interest in food
Lying/hiding drinking habits
Drinking alone
Injuring self or others while intoxicated
Were drunk more than three or four times last year
Increasing tolerance
Withdrawal symptoms:
feeling irritable,
resentful, unreasonable when not drinking
Experiencing medical, social, or financial problems caused by drinking
Adverse Medical Conditions -alcohol
GI: gastritis, dyspepsia, pancreatitis, liver disease, bleeds, diarrhea,
oral/esophageal cancer Cardiac: hypertension, alcoholic cardiomyopathy Neurologic: Wernicke-Korsakoff syndrome, peripheral neuropathy Hematologic: anemia, coagulopathies
Other: trauma, insomnia, family violence,
anxiety/depression, social/family dysfunction, sexual dysfunction, fetal damage
Investigations
GGT and MCV for baseline and follow-up monitoring
AST, ALT (usually, AST:ALT approaches 2:1 in an alcoholic)
CBC (anemia,
thrombocytopenia), PT (decreased clotting factors production by liver)
Management
intervention should be consistent with patient’s motivation for change (motivational
interviewing)
regular follow-up is crucial
10% of patients in alcohol withdrawal will have seizures or delirium tremens
Alcoholics
Anonymous/12-step program
outpatient/day programs for those with chronic, resistant problems
family treatment (Al-Anon, Alateen, screen for spouse/child abuse)
in-patient program if:
dangerous or highly unstable home environment
severe
medical/psychiatric problem
addiction to drug that may require
in-patient detoxification
refractory to other treatment programs
Non Pharmacological
behaviour modification:
hypnosis, relaxation training, aversion therapy,
assertiveness training, operant conditioning
supportive services:
half-way houses, detoxification centres, Alcoholics Anonymous
psychotherapy, motivational interviewing
medications important as
adjunctive treatment:
SSRIs, ondansetron, topiramate
pharmacologic
diazepam for withdrawal
disulfiram (Antabuse) o blocks
conversion of acetaldehyde to acetic acid
(which leads to flushing, headache, nausea/vomiti ng,
hypotension if alcohol is ingested)
naltrexone
o competitive opioid antagonist that reduces cravings and pleasurable effects of drinking o note:
prescription opioids become ineffective;
may trigger withdrawal in
opioid-dependent patients Signs of Alcohol withdrawl (Delerium Tremens)
Autonomic hyperactivitiy (diaphoresis, tachycardia, increased respiration) Hand tremor
Insomnia
Psychomotor agitation Anxiety
Nausea or vomiting Grand mal seizures Visual/tactile/auditory hallucinations
Persecutory delusions Management of Alcohol Withdrawal
Monitor using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scoring system.
Areas of assessment include
nausea and vomiting
paroxysmal sweats
tactile disturbances
visual disturbances
tremor
anxiety
auditory disturbances
headache, fullness in head
agitation
o orientation and clouding of sensorium
all categories are scored from 0-7 (except:
orientation/sensorium 0-4), maximum score of 67
mild <10
moderate 10-20
severe
>20
basic treatment protocol using CIWA-A scale
o diazepam 20 mg PO q1-2h prn until CIWA-A <10 points; tapering dose not required o observe 1-2 h
after last dose and re-assess on CIWA-A scale o thiamine 100 mg
IM then 100 mg PO OD for 3 days o supportive care
(hydration and nutrition)
if history of withdrawal seizures
o diazepam 20 mg q1h for minimum of three doses regardless of subsequent CIWA scores
if history of seizure disorder or multiple withdrawal seizures despite diazepam, use anti-seizure medication (e.g. Dilantin)
if oral diazepam not tolerated
o diazepam 2-5 mg IV/min –
maximum 10-20 mg q1h; or lorazepam SL
if >65 yr or severe liver disease, severe asthma,
or respiratory failure are present, use short acting benzodiazepine
o lorazepam PO/SL/IM 1-4 mg q1-2h
if hallucinosis present o haloperidol 2-5
mg IM/PO q1-4h – max 5 doses/day or atypical antipsychotics (olanzapine, risperidone) o diazepam 20 mg
x 3 doses as seizure prophylaxis (haloperidol lowers seizure threshold)
admit to hospital if:
o still in withdrawal after >80 mg of diazepam
o delirium tremens, recurrent
arrhythmias, or multiple seizures o medically ill or
unsafe to discharge home Wernicke-Korsakoff Syndrome
alcohol-induced amnestic disorders due to thiamine deficiency
necrotic lesions –
mammillary bodies, thalamus, brain stem
Wernicke’s encephalopathy (acute and
reversible): triad of nystagmus (CN VI palsy), ataxia and confusion
Korsakoff’s syndrome (chronic and only 20%
reversible with treatment):
anterograde amnesia
and confabulations;
cannot occur during an acute delirium or dementia and must persist beyond usual duration of
intoxication/withdraw al
management
o Wernicke’s : thiamine 100 mg PO OD x 1-2 weeks o Korsakoff’s
: thiamine 100 mg PO bid/tid x 3-12 mon Prognosis
relapse is common and should not be viewed as failure
monitor regularly for signs of relapse
25-30% of abusers exhibit spontaneous improvement over 1 year
60-70% of individuals with jobs and families have an improved quality of life 1 year
post-treatment Cocaine Intoxication
elation, euphoria, pressured speech, restlessness,
sympathetic stimulation (i.e. tachycardia,
mydriasis, sweating)
prolonged use may result in paranoia and
psychosis Overdose
medical emergency:
hypertension,
tachycardia, tonic-clonic seizures, dyspnea, and ventricular arrhythmias
treatment with IV diazepam to control
seizures and propanolol or labetalol to manage hypertension and arrhythmias Withdrawal
initial crash (1-48 hrs):
increased sleep, increased appetite
withdrawal (1-10 wks):
dysphoric mood plus fatigue, irritability, vivid, unpleasant dreams, insomnia or
hypersomnia,
psychomotor agitation or retardation
complications: relapse, suicide (significant increase in suicide during withdrawal period)
management: supportive management
Treatment of Chronic Abuse
optimal treatment not established
psychotherapy, group therapy, and behaviour modification useful in maintaining abstinence
studies of dopamine agonists to block cravings show inconsistent results Complications
cardiovascular:
arrhythmias, MI, CVA, ruptured AA
neurologic: seizures
psychiatric: psychosis, paranoia, delirium, suicidal ideation Ganja
marijuana is the most often used illicit drug
psychoactive substance
delta-9-tetrahydrocannabinol (9 -THC)
smoking is the most common mode of self-administration
intoxication characterized by tachycardia, conjunctival vascular engorgement, dry mouth, increased appetite, increased sense of well-being, euphoria/laughter, muscle relaxation, impaired performance on
psychomotor tasks including driving
high doses can cause depersonalization, paranoia, and anxiety
may trigger psychosis and schizophrenia in predisposed individuals
chronic use associated with tolerance and an apathetic, amotivational state
cessation does not produce significant withdrawal phenomenon
treatment of dependence includes behavioural and psychological interventions to maintain an abstinent state
Medical Uses of Ganja Anorexia-cachexia (AIDS, cancer)
Spasticity, muscle spasms (multiple sclerosis, spinal cord injury)
Levodopa-induced dyskinesia (Parkinson's Disease)
Controlling tics and obsessive-compulsive behaviour (Tourette's syndrome)
Reducing intra-ocular pressure (glaucoma) Mood Disorders
Mood disorders are defined by the presence of mood episodes
mood episodes represent a combination of
symptoms comprising a predominant mood state that is abnormal in
quality or duration;
examples include: major depressive, manic, mixed, hypomanic
types of mood disorders include:
o depressive (major depressive disorder, dysthymia) o bipolar (bipolar I/II
disorder, cyclothymia) o secondary to
GMC, substances, medications Secondary Causes of Mood Disorders
infectious:
encephalitis/meningitis, hepatitis, pneumonia, TB, syphilis
endocrine:
hypothyroidism, hyperthyroidism, hypopituitarism, SIADH
metabolic: porphyria, Wilson’s disease, diabetes
vitamin disorders:
Wernicke’s, beriberi, pellagra, pernicious anemia
collagen vascular diseases: SLE, polyarteritis nodosa
neoplastic: pancreatic cancer, carcinoid, pheochromocytoma
cardiovascular:
cardiomyopathy, CHF, MI, CVA
neurologic:
Huntington’s disease, multiple sclerosis,
tuberous sclerosis, degenerative (vascular, Alzheimer’s)
drugs: antihypertensives, antiparkinsonian,
hormones, steroids, antituberculous,
interferon, antineoplastic medications
Medical Workup of Mood Disorder
routine screening:
o physical examination o complete blood
count
o thyroid function test
o electrolytes o urinalysis, urine
drug screen
addtional screening:
o neurological consultation o chest x-ray o electrocardiogram
o CT scan
Risk Factors for Depression
sex: female > male
age: onset in 25-50 year age group
family history:
depression, alcohol abuse, sociopathy
childhood experiences:
loss of parent before age 11, negative home environment (abuse, neglect)
personality: insecure, dependent, obsessional
recent stressors (illness, financial, legal)
postpartum <6 months
lack of intimate,
confiding relationships or social isolation
DSM-IV-TR Criteria for Major Depressive Episode
A. >5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the
symptoms is either 1) depressed mood, or 2) loss of interest or
pleasure (anhedonia) Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations
depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or
inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly every day
recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. the symptoms do not meet criteria for a Mixed Episode
C. the symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning
D. the symptoms are not due to the direct
physiological effects of a substance or a GMC
E. the symptoms are not better accounted for by bereavement, i.e. after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or
psychomotor retardation Criteria for Depression (>5):
MSIGECAPS
M - Depressed Mood S - Increased/decreased Sleep
I - Decreased Interest G - Guilt
E - Decreased Energy C - Decreased Concentration
A - Increased/decreased Appetite
P - Psychomotor agitation/retardation S - Suicidal ideation