TFcQture

coion
The Diagnosis of
Organic Brain Syndrome
DAVID M. BERGER, MD
SUMMARY
Because it stems from a variety of causes and interacting factors, pockets. Memory may be impaired but
organic brain syndrome is a difficult condition to diagnose. not abstract thinking, or vice versa. In
Several factors make it distinguishable from functional disorders, mental retardation, the entire spec-
schizophrenia or hysteria. The syndrome cannot be considered in trum of intellectual functioning is
isolation from the patient's personality, however, since this will depressed and more uniformly so. In
affect his coping with the disorder. hysteria the impairment is inconsistent
- abstract thinking may seem im-
Dr. Berger is coordinator of service and education in the paired at one moment but not the
next. Also, hysterics' responses some-
Department of Psychiatry at Mt. Sinai Hospital, Toronto and times appear ridiculous. Asked how
associate professor of psychiatry at the University of Toronto. many legs a three legged stool has, the
Address for reprints: Room 929, Mt. Sinai Hospital, patient may answer 'four'.
600 University Ave., Toronto, Ont. M5G 1X5. The patient with organic impair-
ment also has difficulty focusing on
what is relevant and screening out
ORGANIC BRAIN syndrome refers cultural background. The clinical pic- what is less relevant. He finds it
to a disorder of thinking, feeling ture represents a complex combination difficult to shift easily from one sub-
or acting due to damage or destruction of the direct consequences of the ject to another and then back again.
of neurons. The damage or destruc- damage to the brain itself and the This difficulty, as well as the impair-
tion, rather than the nature of the individual's efforts to cope with the ment in attention and concentration,
noxious process, is responsible for the resulting defect. leads to a 'looseness' of thinking often
characteristic clinical picture. When mistaken for one of the signs of
damage is diffuse or widespread, the General Deficits schizophrenia. However, there is a
basic disturbance in psychic function One or several of the following five difference; the loose associations of
is the same, regardless of whether the clusters of general impairment are schizophrenia are more bizarre and
underlying condition is heart failure, present in most cases of organic brain more ridden with sexual and aggressive
bromism, head injury or senile degen- syndrome: content. Asked how a train and a
eration. When damage is to a particular 1. Intellectual impairment. The pa- bicycle are similar, the organically
system or region of the brain, the tient has difficulty conceptualizing in impaired patient may ramble on about
localization rather than the nature of abstract terms. His thinking tends engines, windows and benches. The
the organic factor yields the charac- towards the concrete. Asked how a schizophrenic is more likely to asso-
teristic syndrome. train and a bicycle are similar, he will ciate to an episode in which a sexual
Diagnosis involves two steps: estab- state that both have wheels. Pressed assault occurred on a train.
lish that the syndrome is organic for another similarity, he will not be 2. Memory. Recent memory loss is
rather than a functional disorder such able to answer more abstractly, for also pathognomonic of organic brain
as hysteria or schizophrenia, and iden- example, that both are modes of trans- syndrome. Subtracting serial sevens
tify the etiologic factors which are portation. If he is next confronted from 100 requires the patient to 'hold
directly or indirectly responsible for with a more difficult question, e.g., on' to the answer from each previous
the neuronal damage. 'how are a tree and a fly similar?' he calculation as he performs the next
This paper focuses on the first step: may react with a 'catastrophic reac- subtask. Because the organically im-
recognizing the clinical picture as or- tion' - an overwhelming anxiety paired patient has difficulty shifting
ganic rather than functional. An or- attack which appears to be less volun- easily from one subject to another, a
ganic brain syndrome is not an etiol- tary and more reflexive than the usual relatively easy task for the unimpaired
ogy-specific entity but rather the end anxiety attack - and/or by ignoring individual, asking the patient to name
product of a variety of causes and the question and repeating the answer a city between each calculation will
interacting factors. Overemphasizing for the previous question: 'both are put further stress on his intellectual
the etiological role of a single organic modes of transportation'. functioning and may bring out an
factor obscures the clinical variations Organic responses differ from those otherwise hidden memory defect.
determined by involvement of differ- of mentally retarded patients and 3. Affect. This is often described as
ent systems or regions of the brain and hysterics. In organic impairment, intel- labile and superficial. Lability is easily
by the individual's psychological and lectual deficits occur in isolated observable. The patient's mood swings,
112 CAN. FAM. PHYSICIAN 23:344 MARCH 1977
from jocularity to sadness for ex- change, and diminished appreciation ing level of consciousness. When it
ample, are extreme and occur rather of moral responsibility are symptoms occurs, one can assume that the
too easily. The term 'superficial' de- associated with frontal lobe pathology. neuronal damage is diffuse and gener-
fines an affect that is facetious, lacking Visual hallucinations suggest temporal alized. It is due to failure of general
depth or sincerity. Deciding whether lobe lesions if they are 'formed', occip- metabolic support of the brain or to
or not a patient's affect is 'superficial' ital lobe if they are 'unformed'. The the action of endogenous or exoge-
seems to me rather subjective and not various agnosias and aphasias point to nous toxic substances which depress
too useful clinically. It does not help parietotemporal dysfunction. In the cerebral metabolism.
differentiate organic from functional last instance, it is helpful to know
disorders. Both the 'belle indifference' whether the patient is left or right Acute vs. Chronic Brain
of hysteria and the 'inappropriate handed. Signs such as these are only Syndrome
affect' of schizophrenia may appear suggestive that the major lesion affects Both acute and chronic brain
superficial. a particular anatomical site. Neverthe- syndrome manifest some or all of the
4. Judgment and ability to plan less they are worth bearing in mind focal and general deficits listed above.
ahead. Although there is no doubt that during the clinical enquiry. In addition, an acute brain syndrome
judgment is impaired, it is a complex may have an acute onset, and is often
function with many gradations and Delirium associated with delirium. However, the
presents to some extent the same Delirium refers to a reduction in ultimate distinction is that an acute
difficulties mentioned in relation to level of consciousness or to a fluctuat- brain syndrome is reversible, while a
the term 'superficial'. Assessing the
degree of impairment of judgment, in
less overt cases, relies rather too
heavily on the physician's subjective
impression, and is of little assistance in * Th~~~ERAPEUTIC
distinguishing organic from functional
disorders.
5. Orientation attention concentra-
tion. In addition to difficulties with Alpb FOR
attention and concentration, the pa-
tient may be disoriented as to time,
place and person. Orientation is largely . CAiRE S
a spatiovisual function and may be
missed if one relies solely on the
patient's verbal communications. The
patient may be able to name and
describe various people including him-
self, yet his ability to draw a person
may be grossly impaired. The drawings
of a schizophrenic are more bizarre
and chaotic than the drawings of an
organically impaired individual. In the
latter, limbs may be omitted and fine
details labored over endlessly with
poor results.
Focal Deficits
A second cluster of signs and
symptoms includes those findings JLLIE wR5UUu
which suggest that a particular neuro-
anatomical site is affected. For ex- PHARMACCUTICALS
ample, angry outbursts, personality BELLEVILLE, ONTARIO K8N 5E9

CAN. FAM. PHYSICIAN 23:345 MARCH 1977 11 3

 Static
Bactrim* exertion
chronic one is not. It was formerly
believed that acute onset and delirium
suggest a favorable prognosis. Since

Roche in
hypertensives:
this is not so, the terms 'acute' and
'chronic' cannot be applied until after
the fact and are hardly worth consider-
consider ing. In his search for a cause of the
impairment, the physician should
Declinax® simply note the nature of the onset
(debrisoquine sulfate) and whether or not the patient exhi-
bits delirium.
concurrently
Rx summary with a Individual Coping Styles
The deficits listed above do not
IndicaUons
beta-blocker occur in a vacuum. They occur in an
The following types of infections when caused by susceptible individual who has already developed a
pathogens:
* Upper and lower respiratory tract infections (particularly lifestyle and modes of adapting to
chronic bronchitis and including acute and chronic otitis media)
* Genitourinary tract infections: acute, recurrent, and chronic stress. Adaptive styles are highly indi-
cystitis, pyelonephritis, urethritis (including uncomplicated
gonococcal urethntis), prostatitis, vaginitis, cervicitis, salpingitis vidualized. An individual who tends to
* Gastrointestinal tract infections
It is not indicated in infections due to Pseudomonas, Mycoplasma,
be organized and orderly, may for
or viruses.
Contraindications
example handle a recent memory de-
Evidence of marked liver damage; blood dyscrasias; known fect with increasingly obsessional be-
hypersensitivity to trimethoprim or sulfonamides; or marked
renal impairment where repeated serum assays cannot be car- havior. An individual who blocks out
ried out.
Infants dunng the first few weeks of life (especially premature or denies problems - an alcoholic, for
infants). example - may handle recent memory
For the time being, during pregnancy.
Adverse reactions
Most frequent: nausea; vomiting, gastnc intolerance; and rash. loss with denial, and by filling in the
Less frequent: diarrhea; constipation, flatulence; anorexia;
pyrosis; gastntis; gastroenteritis; urticaria; headache; and liver
memory gaps with confabulation.
changes (abnormal elevations in alkaline phosphatase and
serum transaminase). Occasionally reported: glossitis; oliguria;
Attempted restitutive behavior is part
hematuria; tremor; vertigo; alopecia; and elevated BUN, NPN, of the clinical picture of an organic
and serum creatnine.
Hematological changes, occurring particularly in the elderly, brain syndrome, as are 'functional'
are mostly transient and reversible (pnmarily, neutropenia and symptoms such as depression, which
thrombocytopenia; less frequently, leukopenia, aplastic or hemo-
lybc anemia, agranulocytosis, and bone marrow depression).
Precautions
represents the individual's reaction to
As with other sulfonamide preparations, benefit should be Doclinaxg (debrisoquine sulfate) loss of cognitive function and the
cntically appraised against risk in patients with liver damage, Rx Summary
renal damage, urinary obstruction, blood dyscrasias, allergies,
or bronchial asthma. Indication: Control of moderate to severe
failure to cope with the resulting
The possibility of supennfection with a non-sensitive organism essential hypertension. defect.
should be bome in mind.
Dosage and administration Contraindications: Known hypersensitivity to The clinical picture of an organic
the drug, proved or suspected pheochromo-
Children less than 2 years:
2.5 ml of suspension twice a day. cytoma, severe renal insufficiency, severe brain syndrome follows interaction of
Children 2 to 5 years:
2.5-5 ml of suspension twice a day.
impairment of cerebral or coronary circulation.
It is incompatible with MAO inhibitors and
various factors, including cognitive
Children 6 to 12 years:
5-10 ml of suspension twice a day. should not be used concurrently with these deficits, attempted restitutive be-
Adults and children over 12 years of age:
Standard dosage: 1 'Bactrim' DS 'Roche' tablet or 2 adult tablets,
agents. havior, and the psychological reaction
Adverse reactions: Most frequent is of the individual to the impairment.
twice daily. orthostatic hypotension with attendant dizzi-
Minimum dosage and dosage for long-term treatment:
Y2 'Bactrim' DS 'Roche' tablet or 1 adult tablet, twice daily. ness, vertigo, nausea, sweating and syncope. The latter encompasses the patient's
Maximum dosage (overwhelming infections): Anorexia, heartburn and abdominal discomfort. efforts to avoid painful affects which
1 12 Bactrim' DS 'Roche' tablets or 3 adult tablets, twice daily. Mild CNS stimulation.
Supply
DS tablets, containing 160 mg tnmethoprim and 800 mg Precautions: Caution in patients with renal emerge when he cannot cope with
sulfamethoxazole. Bottles of 100 and 500. insufficiency, arteriosclerotic heart disease, cognitive demands. A brain syndrome
Adult tablets, containing 80 mg trimethopnm and 400 mg myocardial infarction, cerebral vascular
sulfamethoxazole. Bottles of 100 and 500.
'Bactrim' 'Rophe' is also available as suspension (aniseed-
disease. Patients currently receiving levodopa, becomes an identifiable clinical entity,
anorectic agents, mild stimulants or tricyclic
flavoured) 40 mg trimethoprim and 200 mg sulfamethoxazole antidepressants. not when a deficit occurs, but when
per tsp (5 Ml).
Bottles of 100 and 400 ml. Liver, renal and hematopoietic function tests the deficit can no longer be coped
Product monograph available on request.
should be performed regularly during long-
term therapy.
with in what are usually considered
* Trade Mark of Hoffmann-La Roche Limited Dosage: Average dosage for moderate socially acceptable adaptive styles.
OReg. Trade Mark hypertension: initial dosage, 5-10 mg per day; The clinical picture is determined
maintenance dosage, 10-30 mg per day.
Average dosage for severe hypertension: by:
initial dosage, 10 mg per day; maintenance
dosage, 30-60 mg per day. If required, dosage
II
can be increased to a maximum of 140 mg 1. The speed with which the illness
per day.
Supply: Tablets, 10 mg, 20 mg; 100, 500.
develops. The more acute the onset,
the less likely will the individual be
0Reg. Trade Mark able to muster adaptive defences to
cope with the defect. There will be
. greater confusion and disorganization.
2. The degree of organic impair-
ment.

M 3. The importance to the individual

Hoffmann-La Roche Limited Hoffmann-La Roche Limited
of the particular function which is
Vaudreuil, Quebec ws Vaudreuil, Quebec
11 4 CAN. FAM. PHYSICIAN 23:346 MARCH 1977
impaired: An impairment of abstract here. Systemic disorders such as Cush-
thinking would be more crucial, for
example, to a physicist than an
accountant.
ing's syndrome, myxedema and
anemia, for example, may present with
SIow->fok
(ferrous sulfate-folic acid)
a 'functional' picture rather than a
classical picture of organic impair- hematinic with folic acid
4. The individual's past psycho- ment. Indications
logical development and his character- Prophylaxis of iron and folic acid
istic adaptive patterns, including his Etiologic Considerations deficiencies and treatment of
cultural background. Variations in the presentation of megaloblastic anemia, during pregnancy,
puerperium and lactation.
the clinical picture sometimes suggest Contraindications
5. The nature of support he receives specific causes (e.g. Korsakoffs Hemochromatosis, hemosiderosis and
from family, friends and physicians. syndrome). In most instances, how- hemolytic anemia.
ever, the etiology cannot be discerned Wamings
6. The current life situation. Is it from the clinical picture. The physi- Keep out of reach of children.
stressful or conflict ridden? cian is obliged to consider the entire Advere Reactions
The following adverse reactions have
gamut of pathology, not only local been reported:
If the impairment is not severe, if it intracranial factors, but also systemic Nausea, diarrhea, constipation, vomiting,
is of insidious onset, if the impaired causes such as thyroid disorder and dizziness, abdominal pain, skin rash and
headache.
function is relatively unimportant to steroid toxicity. Precautions
the individual, and if his premorbid The use of folic acid in the treatment of
personality was relatively adaptive, the Management pernicious (Addisonian) anemia, in which
more successfully will he be able to The treatment of an organic brain Vitamin B12 is deficient, may return the
peripheral blood picture to normal while
cope with a greater degree of impair- syndrome includes symptomatic man- neurological manifestations remain
ment, and the longer will he be able to agement and treatment of the under- progressive.
postpone the onset of apparent signs lying causative factors. Symptomatic Oral iron preparations may aggravate
and symptoms. In such instances, the management includes the maintenance existing peptic ulcer, regional enteritis
and ulcerative colitis.
final clinical picture is likelier to in- of vital functions in acute and severe Iron, when given with tetracyclines, binds
clude less severe functional symptoms cases; in chronic insidious conditions, in equimolecular ration thus lowering the
(e.g., mild anxiety or depression, it includes helping both the patient absorption of tetracyclines.
obsessional behavior). Where the situa- and his environment (i.e., relatives, Dosage
Prophylaxis: One tablet daily throughout
tion is not so favorable, the final friends, employers) to adjust to the pregnancy, puerperium and
clinical picture is likely to include impairment. Environmental manipula- lactation. To be swallowed whole at
more regressive psychopathology (e.g. tion can take many forms, from simple any time of the day regardless of
meal times.
a 'schizophrenic' reaction or a depres- occupational adjustment to admission Treatment of megaloblastic anemia:
sion of psychotic proportions). to a nursing home. Mourning the loss During pregnancy, puerperium and
This model would explain why of function is a useful and natural lactation; and in multiple pregnancy:
some elderly depressed patients with process for the patient with organic two tablets, in a single dose, should
be taken daily.
definite signs of organicity clear up impairment. Brief psychotherapy to Supplied
completely when the depression is facilitate this process is an underused SLOW-Fe folic tablets have an off-white
lifted. Their ability to cope with their but useful modality. In fact the entire colour and are supplied in push-through
impairment ('impairment' being at spectrum of psychiatric treatment foil packs of 30; available in units of 30
best a relative term) has improved. should be employed to manage the and 120 tablets.
When an elderly patient presents with 'functional' symptoms. Refrences
1. Nutrition Canada National Survey A report
organic impairment as well as 'func- Sedatives and tranquillizers can be by Nutrition Canada to the Department of
National Health and Welfare, Ottawa,
tional' psychological symptoms, it helpful but should be used only Information Canada, 1973. Reproduced by
should not be assumed that the latter sparingly. In my experience, organ- permission of Information Canada.
are solely a reaction to the impair- ically impaired patients tend to be 2. R. R. Streiff, MD, Folate Deficiency and Oral
Contraceptives, Jama, Oct. 5, 1970,
ment. The functional symptoms may over medicated. Medication often Vol. 214, No. 1.
be the result of a psychological causes REM deprivation, which in-
trauma, loss of a loved one for ex- creases confusion and restlessness. This
ample. By hindering the individual's often leads to an increase in medica-
ability to cope, the stress may in- tion and sets up a vicious cycle. In
directly make apparent organic impair- such cases, the patient's apparent de-
ment that might otherwise have been terioration can be reversed by with-
dealt with. drawing all medication.
When the physician is uncertain
about the presence of organic brain
syndrome, psychological tests are use-
ful. These are highly detailed, highly References
structured and standardized clinical 1. FREEDMAN, A. M., KAPLAN, H. I.,
examinations, the results of which SADOCK, B. J.: Comprehensive Textbook
have been subjected to quantification of Psychiatry II. Baltimore, Williams and
Wilkins pp. 1060-11S7, 1975.
and analysis. It must be added that the 2. ROSEN, R., GREGORY, I.: Abnormal
clinical picture of organic impairment Psychology. Philadelphia, W. B. Saunders DORVAL, OUEBEC
is not always as clear cut as presented Company pp. 422-4S6, 1966. H9S 1 Bi C-6026
See flae 65
CAN. FAM. PHYSICIAN 23:347 MARCH 1977 115