Transcript Precipitating factors

Disorders of
consciousness.
Basic
psychopathological
syndromes.
Olena Smashna
Delirium
is from Latin and literally means the
individual is not at the top of his/her
form and travelling at a lower level than
normal [de – (off, away from) + lira (a
ridge between ploughed furrows)].
Delirium
 is
an outcome of a general medical
condition and drug intoxication or
withdrawal. It may accompany
dysfunction of various bodily organs
such as the kidneys and liver, but it
may also accompany primary
pathological processes in the brain.
Predisposing factors
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Advanced age
• Dementia
• Functional impairment in
activities of daily living
• Medical comorbidity
• History of alcohol abuse
• Male gender
• Sensory impairment
(blindness, deafness)
Precipitating factors
Acute myocardial events
• Acute pulmonary events
• Bed rest
• Fluid and electrolyte disturbance
(including dehydration)
• Drug withdrawal (sedatives, alcohol)
• Infection (especially respiratory,
urinary)
• Medications
• Uncontrolled pain
• Urinary retention
• Indwelling catheters
• Severe anaemia
• Use of restraints
• Intracranial events
The diagnostic criteria have
changed over time.
5 sets of diagnostic criteria:
 1)
due to a general medical
condition,
 2) due to substance intoxication,
 3) due to substance withdrawal,
 4) due to multiple aetiologies,
 5) not otherwise specified.
 C.
The disturbance develops over
a short period of time (usually
hours to days) and tends to
fluctuate during the course of the
day.
 D.
There is evidence from the
history, physical examination, or
laboratory findings that suggest
the disturbance is caused by the
direct physiological
consequences of a general
medical condition.
Three clinical subtypes of delirium:
 1.
Hyperactive (hyperaroused,
hyperalert, or agitated)
 2. Hypoactive (hypoaroused,
hypoalert, or lethargic)
 3. Mixed (alternating features of
hyperactive and hypoactive types)
Hyperactive symptoms
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Restlessness
Fast or loud speech
Irritability
Combativeness
Impatience
Swearing
Singing
Laughing
Uncooperativeness
Euphoria
Anger
Wandering
Easy startling
Fast motor responses
Distractibility
Tangentiality
Nightmares
Persistent thoughts
Hyperactive delirium
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is rarely taken to be agitated depression,
however, it may be more difficult to
exclude a severe anxiety disorder.
Hallucinations and delusions associated
with delirium may suggest a “functional”
psychosis, but the picture is clarified by
looking for clouding of consciousness
(concentration), cognitive difficulties
(memory and orientation difficulties) and
a fluctuating course.
Hypoactive symptoms
Decreased
alertness
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Lethargy
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Slowed
movements
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Staring
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Apathy
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Hypoactive delirium
 may
look like severe depression,
with lack of movement and interest
in the surroundings. Such depression
is usually preceded by a history of
mood disorder, and the thought
content is usually helpful.
Prevention
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In efforts to prevent delirium, the following points
are recommended:
– • Routine cognitive testing on admission and
during hospitalization
– • Cease or minimize use of potentially problematic
medications
– • Ensure the continued use of glasses and hearing
aids as appropriate
– • Ensure adequate intake of fluids and nutrition by
providing assistance as necessary
– • Early identification and treatment of dehydration
– • Early mobilization
– • Avoid restraints (chemical and physical)
– • Involving family members or one-to-one nursing
to calm and reorientate.
– • Adequate pain relief, while avoiding
anticholinergic complic
The Confusion Assessment
Method (CAM)
 The
CAM is a brief structured
assessment. It can achieve better
than 95% sensitivity and specificity
and is quick and easy to administer.
The presence or absence of the four
following elements is determined by
the clinician. The diagnosis of
delirium is made when both 1 and 2
and either or both 3 and 4 are
present:
Testing attention
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A commonly used method of testing
attention is to ask the patient to perform
the serial 7’s test. This test requires more
calculation skill than attention.
Accordingly, they recommend the
following:
– • Days of the week backwards
– • Months of the year backwards
– • Digit span (forwards and backwards)
– • Spell “world” backwards
Delirium tremens.
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Delirium tremens, also known as alcohol
withdrawal delirium and more commonly as
"DTs," develops in the setting of the alcohol
withdrawal syndrome, and is seen in about
5% of hospitalized alcoholics. It is
characterized by gross accentuation of the
tremor and autonomic signs and by the
development of confusion, disorientation, and
hallucinations.
the patient is generally agitated, markedly
tremulous, and very easily startled; mydriasis
and generalized hyperreflexia are
prominent,as are such autonomic signs as
diaphoresis, tachycardia, elevated blood
pressure, and increased respirations.
Delirium tremens.
 Visual
hallucinations are very common; they
tend to be extremely vivid and complex.
Often the patient sees insects or animals:
dogs circle the bed; rats eat at the toes;
bugs crawl on the arms and face. They may
cringe in fear or try to swat them away. At
times the patient may see simply a benign
procession of animals, which he may watch
from the bed as if it were an amusing
procession. Curiously one also often sees a
predilection for hallucinating strings or
threads; the patient may pick them out of
the air or warn the physician to avoid
running into one stretched across the
hospital room.
 Often
the visual hallucinations
may be provoked by suggestion.
In the classic "string test" the
examiner holds her hands about
a foot and a half apart, the
thumbs and index fingers
apposed, several feet in front of
the patient and asks if the
patient sees anything. After the
patient reports seeing nothing,
the examiner asks "Don't you
see the string?," whereupon the
patient does indeed see a string
stretched between the
examiner's hands.
Delirium tremens.
 Tactile
hallucinations may accompany the
visual ones: the skin is ripped by teeth;
spiders bite; bugs are felt crawling all
over. The patient may complain of
electric shocks or of pins being stuck into
the toes.
 Auditory
hallucinations are common.
Patients may hear bells, whistles, or
alarms. If voices are heard, they tend to
be critical, persecutory, or warning of
dire events. Patients hear accusations of
neglecting their children; the children are
starving because the patients spent their
paychecks on drink. The death sentence
is pronounced; the physician is revealed
as the executioner.
Delirium tremens.
 Delusions
are common and tend to be
persecutory. Murderers are outside the
door; the nurse is bringing poison to the
patient; other patients talk about and
conspire against the patient.
 Disorientation always occurs, often to
both time and place. At times this
disorientation
is
intensified
by
hallucinations. The patient refuses the
bedtime medicine offered by the nurse
and announces that it must be morning
as the birds are chirping; if questioned as
to orientation to place, the patient,
seeing the clouds out the window, may
report being in an airplane or perhaps an
air ambulance.
Delirium tremens.
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Memory tends to be severely disturbed. The patient is
unable to recall the name of the physician or of the
hospital. Recall of events before admission is also often
quite spotty.
The behavior of these patients is commensurate with
their symptoms. Some may sit tremulously on the bed,
picking at the bed sheets or brushing away insects.
They may grasp at strings in the air and mumble
agitatedly about events occurring outside the window.
Others may strike out at their "persecutors"; they may
attempt to escape through the door or jump out the
window.
In contrast one may occasionally encounter a "quiet"
delirium tremens. Here the tremor and autonomic signs
and symptoms are minimal, and the patient, all the
while experiencing sometimes fantastic visual
hallucinations, may lie relatively quietly in bed.
Oneiroid (lat. - is dream) - or dream-like
fantastic delusional derangement of
consciousness, is characterized by a
kaleidoscopic quality of psychopathological
experiences, wherein reality, illusions and
hallucinations are merged into one. It is typically
accompanied by motor and, in particular,
catatonic disturbances.
Main psychopathological
syndroms.
Psychoorganic
 Amnestic
 Convulsive
 Disorder of conciousness
 Catatonic
 Gebefrenic
 Gallucinatory-delusional
 Hypochondric
 Affectiv
 Neurotic
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Neurotic syndroms
 Anxious
 PHOBIC
 Obsessiv-compulsiv
 Astenic
Anxious syndrom
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Anxiety is an unpleasant
emotional state with qualities
of apprehension, dread,
distress and uneasiness and is
often accompanied by
physical sensations such as
palpitations, nausea, chest
pain and shortness of breath.
Normal anxiety
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is applied to states of arousal/anxiety which
occur in everyday life, in response to stimuli. It
has an adaptive role and is a signal to take
action. In normal anxiety the assessment of the
danger is appropriate and the action taken is
effective. The healthy person who has lost her/his
pay-packet will be anxious about paying
outstanding bills.
Fear is generally regarded to be an extreme form
of normal anxiety. If an intruder comes into the
house most the healthy persons will be fearful.
Pathological anxiety
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is diagnosed when there is
inaccurate or excessive assessment
of danger. The individual may be
unable to make any response, or
make an excessive protective
response. The person with
pathological anxiety may be so
disabled that he/she is unable to
conduct his/her usual duties such as
prepare a meal, or overestimate a
danger such that he/she makes
maladaptive adjustments (the
person anxious about lifts will have
to take the stairs).
Criteria
– A. Excessive anxiety and worry (apprehensive
expectation), occurring more days than not for at
least 6 months, about a number of events or activities
(such as work or school activities).
– B. The person finds it difficult to control the worry.
– C. The anxiety and worry are associated with three
(or more) of the following
 1. restlessness or feeling keyed up or on edge
 2. being easily fatigued
 3. difficulty concentrating or mind going blank
 4. irritability
 5. muscle tension
 6. sleep disturbance (difficulty falling or staying
asleep, or restless unsatisfying sleep).
– D. The anxiety, worry or physical symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
The features of panic attack
include:
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1. palpitations
2. sweating
3. trembling or shaking
4. shortness of breath or sensation
of smothering
5. feeling of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, lightheaded, or faint
9. derealization (feelings of
unreality) or depersonalization
(being detached from oneself)
10. fear of losing control or going
crazy
11. paresthesia (numbness or
tingling sensations)
12. chills or hot flushes
The features of agoraphobia
include:
– A. Anxiety about being in places or
situations from which escape might be
difficult (or embarrassing) or in which help
may not be available. Agoraphobic fears
typically involve characteristic clusters of
situations that include being outside the
home alone; being in a crowd or standing in
a line; being on a bridge; and travelling in a
bus, train, or automobile.
– B. The situations are avoided (e.g., travel is
restricted) or else are endured with marked
distress or with anxiety about having a Panic
Attack or require the presence of a
companion.
PHOBIC SYNDROM
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The specific phobias feature marked and persistent fears which
are excessive to any risks. Commonly feared objects include
animals, insects, aspects of the natural environment, heights,
injections/blood, and dental procedures.
The diagnostic criteria for specific phobia are as follows:
– A. Marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipated presence
of a specific object or situation (e.g., flying, heights,
animals, injections, blood)
– B. Exposure to the phobic stimulus almost always provokes
an immediate anxiety response, which may take the form of
a situationally bound or situationally predisposed Panic
Attack.
– C. The person recognizes that the fear is excessive or
unreasonable.
– D. The phobic situation is avoided or else endured with
intense anxiety or distress
– E. The avoidance, anxious anticipation, or distress in the
feared situation interferes significantly with the person’s
normal routine, occupational (or academic) functioning, or
social activities or relationships, or there is marked distress
about having the phobia.
Sub-classification
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– 1.
– 2.
– 3.
– 4.
– 5.
animal type
natural environment type
situational type
blood/injection type (see next entry)
other type
Obsessions
 are
persistent, intrusive ideas,
thoughts, impulses, or images that
are experienced as inappropriate and
that cause marked anxiety or
distress. The individual is able to
recognise that the obsessions are the
product of his or her own mind and
not imposed from outside (that is,
they are not related the psychotic
experience of thought insertion).
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most common obsessions are
repeated thoughts about
contamination (e.g., becoming
contaminated by shaking hands)
repeated doubts ( e.g., wondering
wether one has left a door unlocked),
a need to have things in a particular
order (e.g., intense distress when
objects are disordered), aggressive
or horrific impulses (e.g., to hurt
one’s child or shout an obscenity in
church), and sexual imagery .
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Compulsions are repetitive behaviours
(e.g., hand washing, ordering, checking)
or mental acts (e.g., praying, counting,
repeating words silently), the goal of
which is to prevent or reduce anxiety or
distress which accompanies an obsession.
The individual feels driven to perform the
compulsion. The individual with obsessions
about contamination may wash hands
until the skin is damaged. Individuals may
perform stereotyped acts according to
idiosyncratically elaborated rules without
being able to indicate why they are doing
them. Compulsive behaviour may not be
connected in a realistic way with what it
are designed to neutralize.
The positive symptoms
(phenomena which are in addition
to normal experience),
are the most remarkable features of the
 acute/psychotic phase, and include
hallucinations, delusions and disorders of
the form
 of thought such as derailment,
incoherence and neologisms. These may
also be
 present during the chronic phase, but with
the passage of time they usually decrease
 or at least have less impact on the
patient’s life.
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The negative symptoms (loss
of personality features and
abilities) are the most
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troublesome symptoms of the chronic phase of schizophren
ia and include diminished
emotional expression (flattening or blunting of affect),
reduced ability to experience
pleasure (anhedonia), reduced interpersonal skills, social
isolation, reduced
motivation and drive (avolition/apathy) and thought
disorder of t he poverty of thought
type (alogia). While the negative symptoms are the
predominant feature of the chronic
phase, they may also be present at the first psychotic
episode, and may even precede
the first psychotic episode during a prodromal period.
Delusional syndrom
 Delusions
are false beliefs that
continue to be believed in spite
of evidence to the contrary
(these are beliefs which are not
held by the general public, or a
any sub-group of the
community).
Delusions may occur
in schizophrenia,
 bipolar disorder
(manic or
depressed phases),
 major depressive
disorder,
 substance abuse
 organic mental
disorders
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Paranoyal syndrom
 Systematized
delusions are united
by a single theme. They are often
highly detailed and may remain
unchanged for years
Paranoid syndrom
Persecutory (or paranoid)
delusional syndrom
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are usually beliefs that
the individual is being
harassed, watched or
bugged. They often
involve spies, bikies,
God, Satan or
neighbours
Ex.: Patient belief that
the secret service has
a plan to kill him. He
began to think that
food is poisoning by
pursuers.
Delusions of reference
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are the belief that the everyday
actions of others are premeditated
and make special reference to the
patient. Commonly patients
complain about being talked about
on television or the radio. Patients
may believe that music played or
words spoken on television have
been specifically chosen to identify
or annoy them. People crossing
the street or coughing may be
interpreted as purposeful actions,
performed to indicate something
to or about the patient.
Delusions of control involve the belief that
others are controlling the patient ’s thoughts,
feelings or actions.
Thought broadcasting, the belief that
one’s thoughts can be heard by others (
e.g., “My brain is connected to the world
mind. I can control all heads of state
thought my thoughts.”).
 Thought insertion, the belief that
thoughts have been removed from one’s
mind by an outside agency (e.g., “They
make me think bad thoughts and are rotting
my brain”.).
 Thoughts withdrawal, the belief that’s
thoughts has been removed from ones mind
by an outside agency (e.g., “The devil takes
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Ideas of physical action –
they are sure that some
people make some harm
to their inner organs;
 Ideas of psychic actions –
with the help of telepathy,
biofields, noosphere act on
their mind, behavior;
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Criteria for Hypomanic Episode
A. A distinct period of persistently
elevated, expansive, or irritable mood,
lasting throughout
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at least 4 days, that is clearly different
from the usual nondepressed mood.
 B. During the period of mood disturbance,
three (or more) of the following symptoms
have
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persisted (four if the mood is only
irritable) and have been present to a
significant degree:
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(1.)
inflated self-esteem or grandiosity
(2.)
decreased need for sleep (e.g., feels rested
after only 3 hours of sleep)
(3.)
more talkative than usual or pressure to keep
talking
(4.)
flight of ideas or subjective experience that
thoughts are racing
(5.)
distractibility (i.e., attention too easily drawn to
unimportant or irrelevant
external stimuli)
(6.)
increase in goal-directed activity (either socially,
at work or school, or sexually)
(7.)
excessive involvement in pleasurable activities
that have a high potential for
painful consequences (e.g., engaging in unrestrained
buying sprees, sexual
indiscretions, or foolish business investments)
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C. The episode is associated with an unequivocal change
in functioning that is
uncharacteristic of the person when not symptomatic.
D. The disturbance in mood and the change in functioning
are observable by others.
E. The episode is not severe enough to cause marked
impairment in occupational
functioning or in usual social activities or relationships
with others, or to necessitate
hospitalization to prevent harm to self or others, or
there are no psychotic features.
F. Symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition
(e.g., hyperthyroidism).
Depression may cause a person
to:
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Feel sad or anxious for a significant time.
Feel hopeless or pessimistic.
Have slowed thoughts and speech because of low energy.
Have difficulty concentrating, remembering, and making
decisions.
Have changes in eating and sleeping habits leading to too
much or too little eating or sleeping.
Have decreased interest in usual activities, including sex.
Have suicidal thoughts.
Not enjoy things he or she normally would.
Depression
Feelings
depressed mood remorseful
by feeling sad, low, blue,
hopeless, helpless, useless,
guilty, ashamed, remorseful
• loss of interest in work
• loss of feelings for family or
friends
• anxiety, fears, worries
 worthlessness, undeserving even of
help
 pessimism
 loss of interest in sex
 inability to experience pleasure, have
fun
•
Thoughts
 slowed
thinking, difficulty in
concentrating, in making decisions,
mixed-up thoughts
 preoccupation with failures, loss of
self-esteem, obsession with certain
thoughts that one cannot seem to turn
off
 loss of touch with reality, hearing
voices (hallucinations) or having
strange ideas (delusions)
 thoughts of suicide, of homicide
(Approximately 15% of untreated or
inadequately treated patients with an
affective illness commit suicide, often
just as the depression is lifting and
more energy and activity is
experienced.)
Warning signs of suicide include:
Use of illegal drugs or drinking alcohol
heavily.
 Talking, writing, or drawing about death,
including writing suicide notes and
speaking of items that can cause physical
harm, such as pills, guns, or knives.
 Spending long periods of time alone.
 Giving away possessions.
 Acting aggressive or suddenly appearing
calm.
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Types of psychomotor
excitement.
.
 Depressive
Manic
 Catatonic
 Psychogenic
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Types of stupor
 Hallucinative
 Depressive
 Catatonic
 Psychogenic
Catatonic syndrom
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“wax flexibility ” or “catalepsy” – which posture
we put them – they will take it, doesn’t react on
speech, doesn’t to contradict on putting him in
that posture, can stay for a long time. Can be
accompanied with negativism – that he make
opposite things.
Symptom of “air pillow”-patient lays in bed and
his head is in the air, over a pillow, because of
muscle tonus.
Automatic obedience – a catatonic patient may
perform, without hesitation, all simple commands
in a robot-like fashion.
Disorders of will sphere: