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Dr. I Gusti Ayu Endah Ardjana, Sp.KJ(K)

Department of Psychiatry
Faculty of Medicine Udayana University – Sanglah Hospital
Organic mental disorder
Scope of discussion
 Organic mental disorder is a mental disorder caused by:
 Systemic disease causing brain dysfunction
 Brain disorders
 Should be noted in axis III of multiaxial diagnostic
 Onset: all age, but tend to happen in:
 Young adult
 Elderly
 Possible characteristics:
 Reversible
 Irreversible and progressive
Psychopathologic manifestation

Highly varied with two main features:

 Syndromes with apparent cognitive dysfunction:
 Impairmentin memory, learning ability, or sensory
disturbance e.g. impaired consciousness and attention
 Syndromes with predominant psychiatric features
 Impairment in perception, thought content, feeling,
emotion, personality, and behavior
 Minimal (if any) deficit in cognition and sensory
Based on ICD-10/PPDGJ III:
 Delirium
 Dementia (and its subtypes)
 Organic amnesic syndrome
 Other mental disorders due to brain damage and
dysfunction and to physical disease
 Personality and behavioral disorders due to brain
disease, damage and dysfunction
 Unspecified organic or symptomatic mental
Definition of Delirium

 Generalized dysfunction of brain

 Temporary and reversible

 Usually has acute onset (occasionally sub-

acute onset)
Patients at high risk of developing delirium:

 Pediatric patients
 Elderly (>60 years old), especially elderly with dementia
and/or other comorbid conditions
 Patients with CNS disturbance, e.g. CVA, Parkinson’s
disease, dementia, brain tumor
 Post-surgery patients
 Patients with burns
 Withdrawal state in patients with dependency to
psychoactive substances
 Patients with history of previous delirium
Delirium - etiology
Various medical conditions may induce delirium, i.e:
1. Systemic disturbance
 Systemic infection with fever and sepsis

 Acute metabolic disturbance, acidosis, alkalosis, kidney failure, liver

failure, electrolyte imbalance, etc.
 Endocrine disturbance, e.g. hypo/hyperfunction of pituitary,
pancreas, adrenal, thyroid, parathyroid
 Deficiency of vitamin (B1, B12), folic acid, nicotinic acid, niacin

 Cardiovascular disturbance: arrhythmia, heart failure, myocard

infarct, shock, hypotension, hypertension
 Post surgery state

 Hypoxia, lung failure, anemia

 Toxins: CO, heavy metals, pesticides

 Drug-induced: anticonvulsant, anticholinergic, steroid, NSAID,

antihypertensives, antipsychotic, hypnotic sedatives, etc.
Delirium - etiology
2. Brain disturbance
 Infection (meningitis, encephalitis, HIV, etc.), tumor

(primary and metastatic), brain trauma, brain

vascular disorders, seizure/convulsion
3. Withdrawal state in patients with dependency to
psychoactive substances
4. No specific etiology

Hypothesis: delirium is caused by

 Decreased acetylcholine activity within the
brain, especially in reticular formation, an
area responsible for:
 Regulation of attention
 Alertness and arousal

 Increased release of dopamine or

decreased/increased serotonergic activity
Characteristic of clinical features of delirium

Characteristic of clinical features of delirium

 Prodromal symptoms, e.g.:

 Restlessness, anxiety, irritability

 Sleep disturbance

 Distractibility

 Two characteristic features  temporary course:

 Acute onset
 Fluctuation of symptoms during the day
Common clinical symptoms
1. Disturbance in consciousness (cloudy consciousness)
and decreased alertness
2. Neuropsychiatric disturbance, e.g.:
 Attention disturbance (focusing, maintaining, and
distracting attention)
 Short term memory disturbance, amnesia
 Disorientation (people, place, and time)
 Visuo-constructional disturbance (impairment in Clock
Drawing Test or in imitating simple geometric pattern)
 Disturbance of glorious functions
 Disturbance of thought process
 Disturbance of speech and language
Common clinical symptoms (cont.)
3. Perceptual disturbance such as hallucination and illusion
 Visual hallucination occurs more often than auditory

4. Psychomotor disturbance
 Hyperactivity

 Hypoactivity  depression/non cooperativeness

 Depends on the etiology, occasionally there’re neurologic symptoms

such as tremor, myoclonus, change of reflexes and muscle tone
5. Disturbance of mood/emotion, such as:
 Anxiety, fear, depression, irritability, anger, euphoria, apathy
occurs often
 In some patients, fluctuated labile affect might occur during the
course of the day
Common clinical symptoms (cont.)
Common clinical symptoms (continued)
 Disturbance in sleep pattern, usually patients appeared
 Sleepy
 Sleep for short time
 Fragmented sleep
 Symptoms of delirium may exacerbate near around sunset time
(“sundowning” symptoms)
 As a consequence of fluctuations of symptoms, a “lucid
interval” may appear  fully blown symptoms which
progressively reduced and replaced by tranquility/nearly no
symptoms especially apparent amnesia
 Careful neuropsychiatric assessment would be able to detect
cognitive deterioration in lucid interval
Specific Substance Intoxication Delirium:
* Alkohol
• Amphetamin
• Cannabis
• Cocaine
• Hallucinogen
• Inhalant
• Opioid
• Phencyclidine, sedative, hypnotic/anxiolytic,
• other (or Unknown) e.g , cimetidine, digitalis,
Specific Substance Withdrawal Delirium:
• Alkohol
• Sedative
• Hypnotic
• Anxiolytic
• Other substance.
Examination and diagnosis
Diagnosis is established based on finding of symptoms as
1. Decreased consciousness/alertness & decreased ability to
focus, maintain, and shift attention
2. Cognitive changes such as recent and short term memory
 Disorientation
of time – place – people, disturbance of
language, perceptual disturbance not related with dementio
3. The disturbances above occurs for hours until day and
tend to fluctuate during the day
4. There’s evidence  etiology ~ other general medical
condition/condition of intoxication/substance withdrawal
(from anamnesis, physical examination/laboratory)
Delirium – differential diagnoses
Delirium Depression Alzheimer’s dementia
Onset Abrupt Relatively discrete Insidious
Initial Difficulty with attention and Dysphoric mood or lack Memory deficits: verbal
symptoms disturbed consciousness of pleasure or spatial
Timeline Fluctuating over days to Persistent; usually Gradually progressive
weeks lasting months over years
Family Not contributory May be positive for May be positive for
history depression Alzheimer’s dementia
Memory Poor registration Patchy or inconsistent Short term memory
loss of memory worse than long term
Subjective Absent Present Variable, usually absent
Language Difficulty attending to Increased speech Difficulty with naming
deficits conversation or written task latency objects
Affect Often labile Depressed or irritable Vary; may be neutral
Possible psychiatric complications
 Usually no psychiatric complications due to
irreversibility  the organic disease improve but
the perceptual disturbance sometimes lead to harm
for the patient and other people
 Require careful observation because the organic
disease may cause functional psychosis /
Course of disease and prognosis
 Symptoms will continue while the etiologic factors
haven’t been properly addressed
 When the etiology has been addressed, delirium
should improve within 3-7 days / 2 weeks at most
 The older the patient  the longer delirium lasts 
the longer delirium disappears
 Partial amnesia may follow after recovery
 Delirium is often followed by depression / post
traumatic stress disorder
Management, principles
1. Require collaboration with other departments ~
2. Immediately address the organic cause  to save
patient’s life (improve the physiology of the body)
3. Conducted examination ~ assumed etiology &
immediately address the suspected cause
4. Monitor and evaluate and manage psychiatric symptoms
 Medical treatment
 Physical restraint: used when less restrictive measures have
failed or when the patient exhibits severe agitation or
violent behavior
 Manipulation of environment
Pharmacologic interventions, principles
 If possible, avoid using medications until the underlying cause has
been determined
 Use lower dose for elderly patients and persons with parkinsonism,
traumatic brain injury (TBI), and mental retardation
 First line medications are typical or atypical antipsychotics
 Begin with a single antipsychotics and titrate the dose to symptom
 Bedtime or twice daily (bid) dosing on and as needed (prn) basis is often
 Avoid benzodiazepines and anticholinergics
 they may increase confusion or paradoxically increase disinhibition
 Watch for respiratory depression and oversedation
 Benzodiazepines are associated with prolongation and worsening of
delirium symptoms
 Consider non benzodiazepine anxiolytics
 Medical treatment  symptomatic with:
 Haloperidol 0.5 – 1 mg p.o / i.v per 4 hours
 Risperidone 0.5 – 1 mg p.o per 4 hours
 Lorazepam 0.5 – 1 mg p.o per 4 hours
Duration and dose of administration depends on clinical
 Manipulation of environment
 Calm and comfortable room with good lighting
 Provide familiar ambience
 Patient should be accompanied with familiar caregiver
 Preventive measures of harm to self and other people
Thank you..