Understanding Mental Disorders Due To Medical Conditions Or Substance Abuse

What Every Therapist Should Know

Ghazi Asaad

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780876307519
• eBook ISBN: 9781135063566
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This text is a unique handbook that will heighten the awareness of all mental health professionals and students toward organic factors in mental illness.

1

HISTORY, DEFINITIONS, AND PHENOMENOLOGY

HISTORY

Since the beginning of Medicine, there has been the belief that certain mental disorders are caused by physical factors. Early medical writings described delirium, which was referred to as phrenitis at that time, with great clarity and consistency. In the 4th century B.C., Hippocrates wrote of phrenitis or delirium and defined the condition as a mental disorder associated with physical diseases, especially those of febrile nature.

In the first century, Celsus coined the two famous terms “Delirium” and “Dementia.” He designated the term delirium to describe acute mental disorders associated with fevers and elaborated that certain cases of delirium could be followed by dementia continua or true insanity.

Most writers during the 1st and 2nd centuries made a clear distinction between delirium and dementia based on the chronicity of the condition. It was known then that delirium can arise not only from fever but also from drunkenness and poisoning from certain drugs. Galen taught that acute mental illness can arise either from primary cerebral disease or from secondary brain disease in reaction to distant diseased organs, as in the case of pneumonia. Soranus described several cases of delirium and noted that patients with delirium could be hyperactive or hypoactive, and may suffer from severe insomnia. In the centuries that followed, several new terms were introduced to describe various forms of “organic” mental disorders. However, the terms delirium and dementia have survived nearly 2000 years, despite inconsistent usage from time to time (Lipowski, 1980a).

Following the fall of Roman civilization, little was added to the concept of “organic” mental disorders. In the 13th century, Thomas Aquinas believed that insanity was primarily a somatic disturbance. He was considered by some psychiatric historians to be the precursor of the so-called organicistic school of psychiatry that became prevalent during the second half of the 19th century in Germany (Mora, 1980). In the 14th, 15th and 16th centuries, knowledge about causes, clinical manifestations, and treatments of delirium and dementia was advanced by several other investigators.

The distinction between delirium and dementia continued to evolve during the 17th century, shedding more light on causes and clinical manifestations. Thomas Willis devoted a book to mental disorders, which he viewed as diseases of the brain. He described both acute and chronic “organic” mental disorders in great detail. Morton, a contemporary of Willis, added that delirium represented a waking dream. That notion was further developed in the 18th century by Quincy, who elaborated that delirium represented dreams of waking persons with excited incoherent ideas and irregular fluctuations. These views in relation to pathophysiology of delirium remain valid to the present date (Lipowski, 1980a).

The 19th century witnessed significant advances in medical knowledge. The concept of “organic” mental disorders was further refined and integrated to highlight the correlation between physical illness and mental disorders. Pinel and Esquirol made significant contributions towards the progress of the understanding of “organic” mental disorders. Others, with equally important contributions to the field, included Rush, Prichard, and Griesinger (Zilboorg, 1941).

The contributions of Bonhoeffer towards acute “organic” mental disorders had far-reaching effects on the progress of organic psychiatry in the beginning of the 20th century. This was followed by equally important work conducted by Bleuler, who focused his attention on chronic “organic” mental disorders and made invaluable contributions to the field (Lipowski, 1980a).

The second half of the 20th century has witnessed remarkable progress in the field of mental disorders due to medical conditions. This was largely due to technological advances in the areas of brain imaging, including computerized axial tomography (CAT) scan, magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT) scans. In addition, brain research focusing on molecular neurobiology and neurotransmitters has exploded over the past decade and contributed immensely to our current understanding of brain functions and mental illness (Yudofsky & Hales, 1992).

DEFINITIONS

“ORGANIC” MENTAL DISORDERS refer to a group of psychiatric disorders caused by permanent damage to or temporary dysfunction of the brain (Lipowski, 1980b). The underlying cerebral disease may be primary in nature, involving anatomical, neurophysiological, or biochemical changes arising within the brain tissue itself, or it may be secondary to a systemic disease involving other organs.

Examples of mental disorders that are caused by primary brain diseases include delirium in association with head injury, hallucinations occurring in temporal lobe epilepsy, and dementia resulting from Parkinson’s disease. Examples of secondary mental disorders include delirium in association with hepatic failure, anxiety in the course of thyroid disease, and dementia associated with anemia and vitamin B12 deficiency. Other examples of secondary mental disorders include intoxications with alcohol, drugs, and various pharmacological agents.

The term “organic” has served the purpose of distinguishing mental disorders that are caused by physical factors from those that were presumed to be “functional” in nature. However, current evidence strongly suggests that all mental disorders are probably caused by “organic” factors. For this reason, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) has eliminated the term “organic” completely and classified all “organic” mental disorders under delirium, dementia, amnestic disorders, mental disorders due to a general medical condition, and substance-related disorders. Furthermore, DSM-IV (1994) uses the term “primary” mental disorders to refer to all other mental disorders including those known as “functional” mental disorders.

DELIRIUM refers to an acute mental disorder characterized by disturbances in cognition and in the ability to maintain attention to external stimuli. The patient is often disoriented, agitated, and incoherent, and may experience various forms of hallucinations and illusions. Occasionally, the level of consciousness is reduced; sometimes, the patient is unable to remain awake during the examination. The disorder is typically of a transient duration, the length of which depends on the underlying etiology. Delirium can be caused by a wide variety of medical conditions. Examples include uremia and intoxication with anticholinergic medications.

DEMENTIA refers to a chronic mental disorder characterized by impairment of memory and intellect, and by personality changes. Typically, the level of consciousness is not affected. The onset is insidious and the course is often progressive. Like delirium, dementia can be caused by a wide variety of medical conditions. Examples include Alzheimer’s disease and AIDS dementia.

AMNESTIC DISORDER is a term used in DSM-IV (1994) to refer to impairment in short and long term memory that is caused by specific factors. Examples include amnestic disorders associated with alcoholism and thiamine deficiency.

CONFUSION is a term often used by clinicians to describe a variety of conditions. It generally refers to symptoms and signs that indicate that the patient is unable to think with his or her customary clarity and coherence (Lishman, 1987). It is often used to describe disorientation in cases of delirium, dementia, or psychosis. This term has limited usefulness due to its lack of specificity. For that reason, the use of the term should be avoided unless further clinical description is provided.

HALLUCINOSIS refers to hallucinatory symptoms of various forms that occur in clear states of consciousness in the absence of other psychotic symptoms such as delusions or thought disorder. The condition is caused by specific physical factors and can be persistent or recurrent. Examples include prolonged use of alcohol and temporal lobe epilepsy (Asaad, 1990).

MOOD DISORDER DUE TO MEDICAL CONDITIONS refers to either a depressive or elated state that can arise as a result of physical disorders. Examples include thyroid disease and side effects to corticosteroids.

ANXIETY DISORDER DUE TO MEDICAL CONDITIONS denotes prominent and recurrent panic attacks or anxiety symptoms that are caused by certain illnesses. Examples include hypoglycemia and pulmonary embolism.

PERSONALITY CHANGE DUE TO MEDICAL CONDITIONS refers to persistent disturbance in behavior characterized by recurrent outbursts of rage, impaired social judgment, and affective instability. Frontal lobe tumors and temporal lobe epilepsy are leading examples of this condition.

PHENOMENOLOGY

Mental disorders due to medical conditions or substance abuse usually manifest with cognitive, emotional, and behavioral symptoms, depending on the nature of the underlying disease, the areas involved, and the severity of the illness. The clinical presentation of each disorder may vary considerably, and is usually heavily influenced by the patient’s premorbid personality organization, intellectual and educational level, and psychodynamic background (Lishman, 1987).

The types of physical factors that can cause temporary dysfunction or permanent damage to the brain involve a great number of pathological processes. Head injury, brain tumors, strokes, autoimmune diseases, degenerative brain diseases, metabolic disorders, and infections are examples of such processes.

LEVEL OF CONSCIOUSNESS changes often occur in reaction to an acute disorder such as head trauma or intoxication. The degree of impairment of consciousness can vary depending on the type and degree of injury, the areas of the brain affected, and the age and physical condition of the patient. Older individuals, especially those who are physically debilitated, are at a greater risk for developing alterations in their level of consciousness. Furthermore, in the same individual, the level of consciousness can fluctuate from time to time within the same day. For instance, delirious patients tend to suffer from further impairment in their consciousness towards nighttime. Impairment in consciousness can vary from mild inattentiveness to the environment to severe impairment of consciousness to the degree of coma. In between the two extremes, variable degrees of impairment can be encountered. Often, the sleep-wakefulness cycle is disrupted, and most patients report insomnia and vivid dreams (Lipowski, 1980b).

BEHA VIORAL CHANGES develop in the course of mental disorders due to medical conditions or substance abuse. In acute conditions, such as delirium, the patient is often agitated and highly irritable, although in some instances the patient may become subdued and unresponsive. Increased psychomotor activity in cases of acute disorders is often characterized by being purposeless and automatic. Startle reactions are common. Combative and assaultive behavior can develop. In chronic disorders, such as dementia, on the other hand, behavioral changes often are subtle and insidious. Typically, the patientbegins to show signs of disinhibition such as making inappropriate remarks or exhibiting inappropriate sexual behavior. Usually, the patient shows little affect concerning his or her inappropriate behavior. Occasionally, the patient may become angry or agitated.

HALLUCINATIONS AND ILLUSIONS are common in cases of acute disorders. Typically, visual hallucinations are more common than others, and simple unformed types of hallucinations are more frequent than complex ones. However, tactile, auditory, olfactory, and gustatory hallucinations occur frequently. In addition, highly formed complex hallucinations are not uncommon. Hallucinations of similar nature can also occur in cases of chronic disorders (Asaad, 1990).

DISORIENTATION for time, place, and person can occur in both acute and chronic disorders. Disorientation is usually profound in cases of acute disorders, although in advanced cases of chronic disorders equally profound disorientation may be observed. In both situations, disorientation for time develops early and is later followed by disorientation for place, and then for person.

MEMORY IMPAIRMENT is a cardinal symptom in dementias and other amnestic disorders. The onset is usually gradual and involves recent memory. Long-term memory is usually preserved until the final stages of the disease. Typically, the patient is unaware of his or her memory difficulties, and tends to confabulate. Memory impairment also occurs in the course of acute disorders. However, this impairment is transient and is largely due to difficulties in paying attention to the environment, perceiving the stimulations, and comprehending the information.

THINKING DISTURBANCES can be encountered in the course of acute disorders. The patient may not be able to think coherently or logically. Reality testing may become impaired and the patient may express bizarre ideas and fantasies. Ideas of reference and paranoid delusions can occur. In chronic disorders, the thinking process is generally slow and impoverished. Abstract thinking is usually lost, along with the ability to reason and plan. Intellectual capacity is diminished over time; in most patients, insight and judgment are compromised.

SPEECH can be affected in mental disorders due to medical conditions or substance abuse. In acute conditions, the patient’s speech is often incoherent, loud, and repetitive. In chronic conditions, disturbance in speech is progressive and tends to mirror the underlying thinking process.

MOOD CHANGES AND ANXIETY occur in mental disorders due to medical conditions or substance abuse. Depressive or manic symptoms can develop in acute as well as chronic disorders. Associated features including sleep and appetite disturbances as well as suicidal ideation, and attempts at suicide can occur. Severe anxiety and panic attacks in the course of mental disorders due to medical conditions or substance abuse may resemble to a large extent primary anxiety and panic disorders, respectively.

CLINICAL MANIFESTATIONS OF BRAIN LESIONS

As indicated earlier, the signs and symptoms encountered in the course of any mental disorder resulting from medical conditions or substance abuse depend, at least in part, on the areas of the brain that are involved in the injury or the dysfunction. This observation is of special importance since it may alert the physician to the nature and extent of the underlying illness, and prompt the initiation of appropriate diagnostic tests and specific treatment. It is important to emphasize here that, in addition to psychiatric symptoms, various physical and, especially, neurological signs and symptoms are likely to be present.

FRONTAL LOBE lesions typically produce symptoms of behavior changes consisting of social disinhibition and poor judgment. Inappropriate sexual behavior and general indifference to serious situations often occur. The patient seldom shows signs of anxiety or any other meaningful emotional responses; instead, he or she may show elevated mood with empty affect. Emotional lability with rapid shifts between tearfulness and euphoria may be observed. Cognitive functions, including concentration, calculation, abstract thinking, and planning ability may become compromised.

In addition, several neurological signs and symptoms may develop, including motor weakness or paralysis, gait disturbances, exaggerated reflexes, and the emergence of the grasp reflex as well as a positive Babinski response. Disturbances in language functions may occur if the lesion involves the dominant hemisphere. Visual abnormalities can occur due to orbital lesions. Urinary as well as fecal incontinence may occur relatively early in the course o...

Table of contents

• Front Cover
• Half Title
• BRUNNER/MAZELBASIC PRINCIPLES INTO PRACTICE SERIES
• Title Page
• Copyright
• Dedication
• CONTENTS
• Introduction
• 1. History, Definitions, and Phenomenology
• 2. Delirium
• 3. Dementia and Amnestic Disorder
• 4. Psychotic Disorders Due to Medical Conditions
• 5. Mood Disorder and Anxiety Disorder Due to Medical Conditions
• 6. Personality Change Due to Medical Conditions
• 7. Alzheimer’s Disease and Other Degenerative Dementias
• 8. Mental Disorders Arising from Cerebrovascular Diseases
• 9. Psychiatric Disorders Arising from Brain Tumors
• 10. Psychiatric Manifestations of Traumatic Brain Injuries
• 11. Psychiatric Aspects of Seizure Disorders
• 12. Psychiatric Manifestations of Central Nervous System Infections
• 13. Psychiatric Manifestations of Endocrine Disorders
• 14. Psychiatric Manifestations of Metabolic and Vitamin Deficiency Disorders
• 15. Psychiatric Manifestations of Exposure to Toxic Substances and Pharmacological Agents
• 16. Alcohol-induced Mental Disorders
• 17. Drug-induced Mental Disorders
• References
• Index