Psychiatrist notes

• Neurocognitive disorders


  Cognitive deficit and decline from previous cognitive functioning

  
• DSM-5 classification of neurocognitive disorders

  • Delirium
  • Major Neurocognitive Disorder
  • Mild Neurocognitive Disorder
• Defining features of neurocognitive disorders

  • Cognitive deficit
  • Decline from previous cognitive functioning

  
• Cognition


  Higher mental processes, including complex attention, executive functioning, learning and memory, language, social cognition, perceptual motor skills, and mathematical skills/calculation

  
• Delirium


  Acute disturbance in attention and awareness that develops over a short period and fluctuates during the day, accompanied by additional cognitive deficits
• Characteristics of delirium


  • Acute onset
  • Change in attention and awareness
  • Accompanied by other cognitive deficits like disorientation, memory deficits, language impairment, and perceptual disturbances
  • Sleep-wake disturbances
  • Psychomotor changes
  • Hypersensitivity to light/sounds
  • Sleep-rhythm disturbance
  • Fluctuation of picture
• DSM-5 criteria for delirium

  A. Disturbance in attention and awareness

  B. Develops over a short period (hours to days) and fluctuates during the day

  C. Additional disturbance in cognition
• Causes of delirium


  • Drugs (BZ, anti-Ach, antiHT, alcohol intoxication/withdrawal)
  • Infections (any infection in vulnerable, CNS infections)
  • Metabolic (hyper-/hypoglycaemia, dehydration)
  • Trauma (TBI, multiple injuries)
  • Oxygen deficit (CVS/respiratory causes)
  • Postictal
  • Endocrine (Thyroid-, parathyroid-, adrenal dysfunction)
  • Nutritional deficiencies (Thiamine, B12, Folic acid)
• Risk factors for delirium

  • Older age
  • Psychiatric history: Dementia & depression
  • Physical illness: Severity & comorbidity
  • Diminished ADL skills/immobility
  • Urinary catheters
  • Lab results: ↓ albumin, ↓ haematocrit, ↓/↑ glucose
  • Sensory impairment (visual & auditory)
  • Increased length of hospital stay
  • Excess alcohol use
  • Polypharmacy

  
• Management of delirium


  1. Make an accurate diagnosis

  2. Get collateral

  3. Medical, substance history & examination

  4. Treat the underlying condition

  5. Stop offending drugs

  6. Avoid sedation unless absolutely required

  7. Medication only as a last resort

  8. Take steps to prevent/manage delirium

  9. Provide physical support and ensure safety

  10. Maintain nutrition and hydration

  11. Provide appropriate sensory & social stimulation

  12. Prohibit the use of cot sides

  13. Nurse the person low to the floor
• Major Neurocognitive Disorder (Dementia)


  Deterioration in cognition with clear consciousness, often mistaken for normal ageing, with cognitive, behavioural, mood, and functional symptoms

  
• DSM-5 criteria for Major Neurocognitive Disorder


  A. Significant cognitive decline in 1/> domain based on concern of individual/informant/clinician and impairment in cognitive performance

  B. Interferes with independence in everyday activities

  Not exclusively during a delirium and not better explained by another mental disorder

  
• Causes of Major Neurocognitive Disorder

  • Degenerative disease of CNS (Alzheimer's, Frontotemporal dementia, Lewy body disease, Huntington's disease, Parkinson's disease, MS)
  • Systemic disease (Vascular dementia, Thyroid disease, Post-hypoglycaemia, Encephalopathy, Hypoxia)
  • Deficiency states
  • Substances, medication & toxins
  • Intracranial pathology (TBI/tumours)
  • Infectious (Prion disease, HIV, TB, Neurosyphilis)
  • Other diseases/Multiple etiologies

  
• Management of Major Neurocognitive Disorder

  1. Make an etiological diagnosis

  2. Disease specific management

  3. Management of behavioral problems

  4. Prevention of complications

  5. Support of the family

  6. Involve multidisciplinary team (social worker, OT, PT, lawyer, nursing personnel)

  7. Non-pharmacological interventions (cognitive stimulation, identify behavioural problems & precipitants, nursing care plan, cognitive & behavioural therapy, interpersonal therapy)

  8. Pharmacological interventions (Acetylcholinesterase inhibitors)

  9. Provide familiar personnel, clues to environment, calm and quiet environment, avoid physical restraints, regular physical activity, structured activities, social contact, medical interventions
• Delirium


  Abrupt/acute onset, fluctuating and then typically resolves, impaired awareness, disturbed attention, poor working memory and immediate recall, increased/decreased psychomotor activity, incoherent/slow speech
• Dementia


  Gradual/insidious onset, progressive deterioration, clear and alert until advanced stages, often intact attention until advanced stages, initially poor short-term memory and later long-term memory impairment, often normal psychomotor activity until advanced stages, word finding difficulties/aphasia

  
• Relevance to Occupational Therapy

  Cognitive deficits influence different aspects of daily functioning like hygiene, learning, leisure, work, communication, mobility, managing shopping/finances, decreased awareness of risks and safety
• Role of Occupational Therapy

  1. Evaluation includes interview with individual and family/caretaker

  2. Identify areas of intervention & determine priorities

  3. Principles of intervention: suit abilities of the person, consider motivation, awareness of limitations, personality & environment, setting (hospital, home/care-facility)

  4. Experts at addressing the effects of cognitive impairments on daily life

  5. Use person-centered perspective, set collaborative goals and intervention priorities

  6. Usually begin with basic ADLs, can include more difficult tasks

  7. Treatment framework: Individual sessions, group treatment, guidance for caregivers

  8. Develop strategies, often together with caregivers, to improve the person's competency & sense of well-being

  9. Adapting the environment, setting up compensatory strategies, and reorganizing and simplifying tasks

  10. With appropriate interventions, individuals can remain independent in self-care and other activities well into the disease process
• Modifiable risk factors for dementia prevention

  • Low educational level in childhood
  • Hearing loss
  • Hypertension
  • Obesity
  • Smoking
  • Depression
  • Physical inactivity
  • Social isolation
  • Diabetes
  • Excessive alcohol consumption
  • Head injury
  • Air pollution

  
• Occupational therapists serve a vital role for adults with cognitive impairment, can facilitate new brain pathways and improve functional skills, enabling individuals to participate more fully in self-care, work, leisure and community activities enhances quality of life while reducing the burden on caregivers
• Psychotic disorders


  Schizophrenia spectrum and other psychotic disorders
• Causes of mental illness

  • Genetic factors
  • Biochemical factors (Neuropathology, Neural circuits, Neuroendocrinology)
  • Psychosocial (Stressors, Migration, Substances)
  • Epigenetics
• Dopaminergic pathways


  Mesolimbic - positive symptoms

  Mesocortical - negative & cognitive

  Tuberoinfundibular - hyperprolactinemia

  Nigrostriatal - movement symptoms
• Types of psychotic disorders

  • Schizophrenia
  • Schizoaffective Disorder
  • Schizophreniform Disorder
  • Delusional Disorder
  • Brief Psychotic Disorder
  • Psychosis due to another medical condition
  • Substance induced Psychotic Disorder
  • Unspecified
• Schizophrenia Spectrum Disorder


  • DSM-5 refers to it the schizophrenia spectrum

  Signs and symptoms variable; severe and long lasting

  Onset before 25 years

  Affects persons of all classes - 1% of the population

  Diagnosis leads to poor social care and stigma
• Schizophrenia diagnosis criteria


  A. At least 2 ≥ of the following symptoms: Delusions, Hallucinations, Disorganised speech, Grossly disorganised/catatonic behaviour, Negative symptoms

  B. Decrease in functioning; work; interpersonal relations

  C. Continuous symptoms for at least 6/12

  D. Not meet criteria for SAD or Mood disorder with psychotic features

  E. Not due to a GMC/physiological effect of substances

  F. Over and above ASD or Communication disorder of childhood onset

  
• Negative symptoms of schizophrenia

  • Social withdrawal (asocial)

  "Flat affect" dull or monotonous speech, and lack of facial expression

  Difficulty expressing emotions (alogia)

  Anhedonia

  Lack of motivation

  Ambivalence

  
• Cognitive symptoms of schizophrenia


  • Inability to process information and make decisions

  Difficulty focusing or paying attention

  Problems with memory

  Difficulty learning new tasks

  Poor motivation
• Types of delusions


  • Erotomaniac delusions

  Grandiose delusions

  Mixed delusions

  Persecutory delusions

  Somatic delusions

  Bizarre delusions
• Factors associated with suicide and homicide in schizophrenia

  • Long duration of untreated psychosis

  Comorbid major depressive episode with hopelessness; despondency; previous history of suicide

  Comorbid substance use disorders; personality disorders

  In the first 10 years of illness; 1st six months post-discharge

  High premorbid functioning (young high achiever with high expectations of self)
• Schizophreniform Disorder


  Same symptoms as schizophrenia, lasts more than 1 month, less than 6, SAD and Bipolar or depressive disorder ruled out, not due to substances or GMC, 60-80% progress to schizophrenia, remainder have no recurrent psychotic symptoms
• Schizoaffective Disorder


  Meet schizophrenia and mood disorder criteria, absolute psychotic symptoms for 2/52 without mood symptoms, those with mood symptoms do better than those with schizophrenia symptoms, increased risk of schizophrenia in relatives

  
• Delusional Disorder


  One month history of non-bizarre delusions, never met criteria for schizophrenia, functioning not markedly impaired, common in advanced ages 40 plus, difficult to treat, screen for homicide risk
• Brief Psychotic Disorders


  Retrospective diagnosis, lasts more than one day, but less than a month, common in personality disorders, people with poor coping skills, evidence of a psychosocial stressor, sudden onset, symptoms include labile mood, confusion, screaming/muteness, strange behaviour, always exclude GMC or substances, hospitalisation, pharmacotherapy, and individualised psychotherapy
• Psychotic disorder not otherwise specified

  Does not meet any criteria for any psychotic disorder, information is lacking or insufficient to make a diagnosis, postpartum psychosis common 2-3 weeks after birth, usually within 8 weeks, mood symptoms, psychosis and thoughts of harming baby, postpartum psychosis is a psychiatric emergency
• Causes of psychotic disorder due to a general medical condition

  • HIV psychosis

  Post-epileptic seizures

  Post-head injury

  Neoplasms

  Multiple sclerosis

  Sarcoidosis

  Systemic lupus erythematous
• Substances that can cause substance induced psychotic disorder

  • Cannabis

  Alcohol

  Hallucinogens

  Opioids

  Medications: Steroids, certain AED-Kepra
• Symptoms of catatonia specifier


  • Motoric immobility or excitement

  Profound negativism

  Echolalia

  Echopraxia

  Waxy flexibility

  Stereotypy

  Mannerisms

  Grimacing

  Stupor

  Mutism

  Posturing
• Catatonia can have various causes
• Information is lacking or insufficient to make a diagnosis