ORGANIC

MENTAL
DISORDERS
& SLEEP
DISORDERS

Nelson A.T. Mallillin, M.D., F.P.N.A.

Neurology and Psychiatry
Neurophysiology and Polysomnography
 Delirium, Dementia, Amnestic and other
Cognitive Disorders

- clinically significant deficits in cognition or

memory representing a significant change
from a previous level of functioning.
- Origin - most often a Medical condition
Cognitive Impairment – cardinal symptom
COGNITION – learning and memory.
language, problem solving, attention and
concentration, orientation, judgment, social
abilities, general intelligence etc.
- widespread (frontal, temporal and parietal
lobes)
 DELIRIUM

- disturbance in consciousness and a

change of cognition that develops over a
short time.
- sudden onset
- brief and fluctuating course
- rapid improvement once causative factor is
eliminated
- is a syndrome, not a disease
- most of the causes arise outside the central
nervous system
 ETIOLOGY

Major Causes:

1. CNS Diseases
2. Systemic Disease
3. Intoxication or Withdrawal from
pharmacological or toxic agents
 Physical and Laboratory
Examination
Delirium
- a medical emergency whose cause should
be established quickly
- usually diagnosed at the bedside
- Mini Mental State Examination (MMSE)
- PE usually reveals clues to the cause of
the delirium
- EEG – generalized slowing (differentiated
from Psychosis or Depression)
 CLINICAL FEATURES

Key feature of Delirium - Impairment of

Consciousness
- reduced clarity of awareness of the environment

1. Abnormal Arousal

a. Hyperactivity associated with increased alertness

- Ex. Delirium of substance withdrawal
- usually with autonomic signs (flushing,tachycardia etc.)

b. Hypoactivity associated with decreased alertness

- may be mistaken as depression, catatonia or dementia
2. Impaired Orientation
Time – first and most common
Self – not usually lost
3. Language abnormalities
- rambling, irrelevant speech, impaired
ability to comprehend speech
4. Perception abnormalities
- visual/auditory hallucinations and illusions
- often distracted by irrelevant stimuli
5. Mood disturbances
- anger, rage, unwarranted fear
- rapidly alternate in the course of a day
6. Sleep wake cycle disturbances
- usually short and fragmented
- Sundowning – exacerbation of delirious
symptoms at bedtime
7. Neurologic Symptoms
- dysphasia, tremors, asterixis, incoordination,
urinary incontinence
 DIFFERENTIAL DIAGNOSIS
1. Dementia
DELIRIUM DEMENTIA

Acute Chronic
Rapid onset Insidious (Usually)
Days-Weeks duration Months-Years
Fluctuating Course Chronically Progressive
Fluctuating Consciousness Normal
Impaired orientation Intact initially
 DELIRIUM DEMENTIA

Emotionally Anxious, Labile but not usually

Irritable anxious
Thinking often disordered Decreased amount
Recent memory impaired recent and remote
memory impaired
Hallucinations common Hallucinations less
common
Psychomotor function Normal
retarded, agitated or mixed
 DELIRIUM DEMENTIA
Sleep Disrupted Less Disruption
Attention and Awareness Less impaired
Prominently impaired
Reversible Majority irreversible
2. Schizophrenia and Mania
- not as rapidly fluctuating, do not impair
level of consciousness or impair cognition
specifically
 COURSE AND PROGNOSIS

Delirium – poor prognostic sign

22-33% = Three month mortality rate
50% = One year mortality rate
- course usually rapid
- symptoms usually recede 3 to 7 days
after causative factor removed
 TREATMENT

Primary Goal
– Identify and Treat Underlying Cause
- correction of metabolic abnormalities,
hydration etc.
Pharmacotherapy
- for psychosis and insomnia
- low doses of high potency antipsychotics
(Haloperidol)
- Benzodiazepines or hydroxyzine for
insomnia
 DEMENTIA

- Multiple cognitive deficits that include

impairment in memory WITHOUT
impairment of consciousness
Causes of Dementia
 DSM IV Highlights
A. Development of multiple cognitive deficits manifested by
both
1. Memory Impairment – emphasized
2. Other Cognitive Disturbance
a. Aphasia (language disturbance)
b. Apraxia (impaired ability to carry out motor commands)
c. Agnosia (failure to recognize or identify objects)
d. Disturbance of executive functioning (planning, organizing
etc.)
B. Significant impairment
C. Gradual onset and continuous
 Dementia
Early Signs and Symptoms

Forgetful and absent-minded (do not

improve with cues)
Fatigue
Difficulty recalling familiar words
Difficulty learning new things
Deterioration in judgement and social
behavior
 Dementia
Intermediate Signs and Symptoms

Loss of logic, memory, motor ability

Impatience
Restlessness
Physical/verbal aggression
Speech/verbal and math skills decline
Social skills decline
Paranoia
 Dementia
Advanced Signs and Symptoms

Bladder/bowel control declines

Difficulty following simple commands
Hallucinations
Emotional deterioration
Loss of insight
Severe motor deterioration
 Other Causes of Dementia

1. Picks Disease – Picks Bodies

(intraneuronal deposits), frontotemporal
region
2. Lewy Body Disease
3. Huntington’s Disease – subcortical type –
more motor, less language
4. Parkinsons Disease – 20-30% with
dementia
5. HIV related dementia – 14% annual rate
6. Head trauma (Ex. Chronic Subdural
Hematoma)
7. Creutzfeldt-Jakob Disease – prion
infection
8. Brain Tumors (especially frontal and
temporal)
9. Normal pressure hydrocephalus
(dementia, ataxia and incontinence)
 CLINICAL FEATURES
1. Memory Impairment – early and prominent
feature
- involvement of recent events first progressing
to remote memory
2. Orientation- affected late
3. Language – vague, stereotyped, imprecise
4. Personality Changes – introverted, irritable,
hostile
5. Hallucinations- 20-30%
6. Delusions – 30-40%
7. Depression and Anxiety – 40-50%
 DIFFERENTIAL DIAGNOSIS

1. Delirium
2. Transient Ischemic attacks
3. Depression – pseudodementia
4. Schizophrenia
5. Factitious Disorder
6. Normal Aging (MCI)
 COURSE AND PROGNOSIS
- classic course is an onset at 50 or 60 years
old with gradual deterioration in 5 to 10
years
- Alzheimers dementia – mean survival of 8
years
- 15% are Reversible (hypothyroidism,
subdural hematomas etc.)
- more rapid if with early onset or if with a
family history
 TREATMENT
- generally supportive
- treatment of associated medical conditions, proper
nutrition, emotional support to patients and their families
Pharmacological
- avoid barbiturates, long acting benzodiazepines and
anticholinergics
- low dose antipsychotics (Ex. Quetiapine) for agitation
- short acting benzodiazepines for sleep
- for Alzheimer Dementia
- Cholinesterase Inhibitors – Donepezil (Aricept),
Galantamine (Reminyl), Rivastigmine (Exelon)
- Glutamate receptor antagonist – Memantine (Abixa)
 AMNESTIC DISORDERS

- Memory impairment in the absence of other

significant cognitive impairments
- Anterograde amnesia – inability to learn
new information
- Retrograde Amnesia – inability to recall
previously remembered knowledge
- most commonly found in alcohol use
disorders and in head injury
- short term and recent memory affected,
immediate and remote memory intact
- diagnosed according to etiology
1. Amnestic disorder due to a general
medical condition
2. Substance induced persisting amnestic
disorder
3. Amnestic disorder NOS
1. Thiamine Deficiency secondary to alcohol
dependence – most common etiology
Korsakoffs Syndrome – amnestic disorder due to
thiamine deficiency
- seen in alcoholics, poor nutrition, gastric
carcinoma, prolonged IV hyperalimentation,
hemodialysis, hyperemesis gravidarum
- may progress to Wernickes Encephalopathy –
confusion, ataxia, ophthalmoplegia
2. Head Trauma (Concussion and
Contusions, Epidural and Subdural)
3. Hypoxia
4. Cerebral Infarction
5. Herpes Simplex Encephalitis
 DIFFERENTIAL DIAGNOSIS

1. Dementia and Delirium – amnesia is a

component
2. Factitious Disorders
3. Dissociative Disorders

TREATMENT
- Identification of cause and reversal if
possible
 MENTAL DISORDERS DUE TO A
GENERAL MEDICAL CONDITION
- psychiatric symptoms that are part of a
syndrome caused by a non-psychiatric
medical condition
A. Degenerative Disorders
- depression, dementia and psychosis with
disorders affecting the basal ganglia
- Parkinsons Disease, Huntington’s Disease,
Wilsons Disease, Fahr’s Disease
 B. EPILEPSY

- 30-50% with psychiatric problems

- Change in personality – most common
behavioral change
- Psychosis, violence, depression less
common
- Seizures – spontaneous, excessive,
paroxysmal discharges from neurons
 Specific Types

A. Absences Seizure (Petit Mal)

- sudden onset of blank stares in children
B. Complex Partial Seizures (Temporal lobe)
- most common form of epilepsy in adults (3 in
1,000)
- most likely to produce psychiatric symptoms
- may present as a schizophrenia like psychosis
- characterized by automatisms, autonomic
effects, visceral sensations
1. Preictal
a. Affective states – fear, panic,
depression, elation
b. Automatisms – lip smacking, finger
rubbing, chewing
c. Autonomic Sensations
d. Cognitive changes
2. Ictal
- brief, disorganized and uninhibited behavior
characteristic
- amnesia for the event
3. Interictal
a. Personality disturbances
- religiosity, heightened experience of
emotions, changes in sexual behavior
b. Psychotic symptoms
- seen in 10-30%
c. Violence – episodic
DIAGNOSIS
– Clinical and by EEG

TREATMENT
- Anticonvulsants
Carbamazepine (Tegretol), Oxcarbazepine
(Trileptal), Valproic Acid (Depakote)
 C. Brain Tumors
- 50% experience mental changes
- 80% of the time, tumor is in frontal or limbic
region
- deficits noted in cognition, language,
memory, perception, awareness
- Suicidal ideation in 10 %
- Slow tumors produce personality changes
- Rapid tumors produce cognitive changes
 D. Head Trauma

- Neuropsychiatric symptoms seen in

a. 100% of severe head trauma
b. > 50% of moderate head trauma
c. 10% of mild head trauma
- Duration of disorientation is an approximate
guide to prognosis
 Major Symptoms

Acute – Amnesia, agitation, withdraw

behavior, psychosis, delirium
Chronic – Amnesia, psychosis, mood
disorder, personality change
 E. Demyelinating Disorders
Multiple Sclerosis
- 30-50% with cognitive impairment most
of
which are serious
- memory most commonly affected
- behavioral – euphoria (25%), depression
(25-50%) and personality changes (20-
40%)
- intellectual deterioration in 60%
- hysteria common
 F. Infectious Diseases
a. Herpes Simplex Encephalitis – most common
type of focal encephalitis
- affects frontal and temporal lobes – complex
partial epilepsy
b. Rabies Encephalitis
c. Neurosyphilis (late stage) – 10 to 15 years later
d. Chronic meningitis – seen in association with
AIDS
e. Subacute Sclerosing Panencephalitis
f. Prion Diseases (CJD, Kuru)
 G. Immune Disorders

Systemic Lupus Erythematosus – 50%

eventually develop mental symptoms
- depression, emotional lability,
nervousness
- Treatment with steroids – mania and
psychosis
 H. Endocrine Disorders

a. Hyperthyroidism
- confusion, anxiety, agitated depressive state
b. Hypothyroidism
- paranoia, depression, hypomania,
hallucinations, slowed thinking (myxedema
madness)
c. Parathyroid Disorders
d. Adrenal Gland
Cushings Syndrome – agitated depression,
suicide, psychotic reactions
e. Pituitary Disorders
 I. Metabolic Disorders

a. Hepatic encephalopathy
b. Uremic Encephalopathy
c. Hypoglycemic Encephalopathy
d. Diabetic Ketoacidosis
 J. Nutritional Disorders

a. Niacin deficiency (Pellagra) – apathy,

depression, delirium, dementia
b. Thiamine deficiency (Korsakoffs and
Wernickes Encephalopathy)
c. Cobalamin Deficiency
 K. Toxins

a. Mercury – Mad Hatters syndrome

- patients are irritable, quarrelsome, lose
temper easily, have cognitive impairment
b. Lead
c. Manganese
d. Thallium
 SLEEP DISORDERS

- Sleep disturbance- early

symptom of impending
mental illness
- Mental disorders
associated with
characteristic changes in
sleep physiology
 NORMAL SLEEP

Electroencephalography
Beta – >14 Hz – awake with eyes open
Alpha – 8-13 Hz – awake with eyes closed
Theta – 4-7 Hz – drowsy, Stage 1 sleep
Delta – 1-3 Hz – sleep
 2 States of Sleep

A. Non REM Sleep (NREM)

– total of 75-80% of sleep time
- most physiological activities are
reduced
- decreased pulse rate, respiration, blood
pressure
- satisfies metabolic needs – increases
after exercise and starvation
 Stages of Non REM Sleep

Stage 1 – lightest and shortest stage of sleep

- low voltage regular activity at 3-7 Hz
- 5% of sleep

Stage 2 – longest phase of sleep (45%)

- characterized by vertex sharp waves,
sleep spindles, K complexes
Stage 3,4 – Deepest part of sleep
- one and one-half hours after sleep onset
- delta sleep or slow wave sleep
- Stage 3 (12 percent), Stage 4 (13 percent)
- if aroused, disoriented and thinking
disorganized
- specific problems with arousal leads to
enuresis, somnambulism, night terrors
(Parasomnias)
 B. Rapid Eye Movement (REM
Sleep)
- high level of brain and physiological activity
similar to wakefulness (Paradoxical Sleep)
- increased pulse, respiration, blood
pressure (sometimes higher than
wakefulness)
- Dreaming – most distinctive feature –
abstract and surreal (lucid and purposeful
in NREM sleep)
- Poikilothermia – failure to respond to
changes in ambient temperature by
shivering or sweating
- Nocturnal Penile Tumescence
- REM Latency of 90 minutes (fairly
consistent)
- EEG of low voltage, random fast activity
with saw tooth waves
- EMG – marked reduction in muscle tone
96/81 95/79
AWAKE
STAGE II
STAGE III-IV
REM STAGE
AGE DISTRIBUTION
Newborn – 50 % REM, 50% NREM
Adult – NREM 75%, REM 25%
Elderly – decreased slow wave sleep and
REM sleep
 The Cycling of
Human Sleep Stages:
Early Adulthood
Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

1 2 3 4 5 6 Hour
 The Cycling of
Human Sleep Stages:
Old Age
Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

1 2 3 4 5 6 Hour
 SLEEP REGULATION

Serotonin
– needed to initiate and maintain sleep
- destruction of dorsal raphe nuclei –
decreased sleep
- ingestion of L-Tryptophan – reduced sleep
latency and nocturnal awakenings
Acetylcholine
- needed to produce REM sleep
1. Major depression (supersensitivity to
acetylcholine)
- shortened REM latency, increased
percentage of REM sleep, REM in first half
of night
- antidepressants reduce REM sleep and
prolong slow wave sleep
2. Alzheimer Disease (loss of cholinergic
neurons)
- reduced REM and slow wave sleep

Norepinephrine
- controls sleep pattern
- excess firing produce wakefulness and
reduction in REM
 SLEEP REQUIREMENTS

Short Sleepers
- less than 6 hours per day
- less REM periods
- efficient, ambitious, socially adept, content with
life
Long Sleepers
- more than 9 hours per night
- more REM
- mildly depressed, anxious, socially withdrawn
 SLEEP DISORDERS
- more than half do NOT seek medical
advice
- Insomnia – most common and most widely
recognized sleep disorder
- Increased prevalence in
1. Female
2. Presence of medical and mental disorders
3. Older age
4. Substance Abuse
 PRIMARY SLEEP DISORDERS
- caused by abnormal sleep-wake
mechanism or conditioning
A. Dysomnias
- includes primary insomnia, primary
hypersomnia, narcolepsy, breathing
related sleep disorders, circadian rhythm
sleep disorders
B. Parasomnia
- includes nightmares, sleep terror, sleep
walking
 DYSOMNIAS
A. Primary Insomnia
- DSM IV essentials
- must be present for at least 1 month and
causes significant distress
- characterized by both difficulty falling
asleep and repeated awakenings
- patients preoccupied with getting enough
sleep
 TREATMENT

Psychotherapy – NOT useful

1. Deconditioning Technique – beds to be
used for sleeping and nothing else
2. Use of benzodiazepines and hypnotics
- generally NOT prescribed for more than
two weeks
3. Light therapy
4. Non specific measures (Sleep hygiene)
- Ex. arise at the same time daily, limit
caffeinated products etc.
 B. Primary Hypersomnia

- predominant symptom of excessive

sleepiness for at least one month and
causes significant distress (DSM IV)
Treatment
- Stimulants (Amphetamines), Non Sedating
Antidepressants (SSRI’s)
 C. Narcolepsy

- excessive daytime sleepiness and

abnormal REM sleep occurring daily for at
least 3 months (DSM IV)
- 0.02 to 0.16% prevalence in adults and
with familial incidence
Sleep Attacks – most common symptoms
- patients cannot avoid falling asleep
 REM Sleep Abnormalities

1. Hypnagogic or hypnopompic
hallucinations
2. Cataplexy
- seen in 75%
- sudden loss of muscle tone – jaw drop,
weakness of knees, head drop
- patients remain awake if cataplexy brief
- often precipitated by laughter or anger
- EEG – REM pattern
3. Sleep Paralysis
- seen in 25-50%
- often on waking up
- patients awake and conscious but unable to move
a muscle
- lasts less than a minute

Sleep Onset REM Period – main polysomnographic

abnormality
- REM appears within 10-15 minutes
- related to HLA DR2
 TREATMENT

1. Regimen of forced naps

2. Stimulants (Amphetamines,
Methylphenidate)
3. Antidepressants
4. Modafinil – adrenergic agonist
 D. Breathing Related Sleep
Disorder
- Apneas, hypopneas, oxygen
desaturations
1. Obstructive Sleep Apnea Syndrome
- cessation of airflow in nose or mouth
lasting more than 10 seconds
- common in snorers, obese and older
individuals
- respiratory effort present
- pathological if more than 5 episodes an hour or
30 episodes a night
- can produce cardiovascular changes,
arrhythmias, transient alterations in blood
pressure
- leads to excessive daytime sleepiness secondary
to multiple microawakenings
- Treatment – Continuous Positive Airway Pressure
(CPAP)
- weight loss, nasal surgery, tracheostomy,
uvulopalatoplasty
2. Central Alveolar Hypoventilation
- inadequate tidal volume or respiratory rate
during sleep
- no apneas
- Death may occur during sleep (Ondine’s
curse)
Treatment: Mechanical ventilation
 E. Circadian Rhythm Sleep
Disorders
- misalignment between desired and actual
sleep periods
1. Delayed sleep phase type
- late sleep onset and late awakening
times
2. Jet lag type
- seen with travel to more than one time
zone
3. Shift work type
4. Unspecified type (advanced sleep phase,
etc.)
- Quality of sleep is normal but timing is off
- Self limited – resolves as body readjusts to
new sleep wake schedule
Treatment
Bright Light Therapy – most effective
treatment to entrain the sleep cycle
Melatonin – induces sleep
 PARASOMNIAS

1. Nightmare Disorder
- long frightening dream were one awakens
frightened
- almost always occur during REM sleep
- can occur at any time of the night but usually in
latter half after a long REM period
- good recall and often detailed
- less anxiety, vocalization, motility, and autonomic
discharge than in sleep terrors
- No specific treatment. Benzodiazepines and
tricyclic antidepressants may help.
 PARASOMNIAS

2. Sleep Terror Disorder

- sudden awakening with intense anxiety, autonomic
overstimulation, excessive movement, crying out
- especially common in children
- seen in 1-6% of children, more common in boys, tend to
run in families
- occur during deep Non-REM sleep (Stage 3,4) – usually
during first two hours of sleep
- patient with no recall the next morning
- no specific treatment – low dose Diazepam
- awakening child before regular night terror for several
days may eliminate terrors for extended periods
 PARASOMNIAS

3. Sleepwalking Disorder (Somnambulism)

- complex activity of leaving bed and walking about without
full consciousness
- most common in children, generally disappears
spontaneously with age
- episodes are brief
- with amnesia for the event
- occurs during deep Non-REM sleep (Stage 3-4)
- Initiated during first third of the night
- may be initiated by placing a child who is in stage 4 of
sleep in a standing position
- Benzodiazepines may be used – suppresses stage 4 of
sleep
 Sleep Disorder Related to Another
Mental Disorder
A. Insomnia that is related to a mental disorder (e.g major
depression, panic disorder, schizophrenia) and that lasts
for at least 1 month
- 35% of patient who complain of insomnia has an
underlying psychiatric problem
- half of these patients have major depression
B. Hypersomnia related to a mental disorder usually found
in
a. Early stage of mild depressive disorder
b. Grief
c. Personality disorders
d. Dissociative disorders
e. Somatoform Disorders
 Sleep Disorder Due to a General
Medical Condition

- may include insomnia, hypersomnia, parasomnia

or a combination of these
A. Sleep related epileptic seizures
B. Sleep related cluster headaches and chronic
paroxysmal hemicrania
C. Sleep related Asthma
D. Sleep related Cardiovascular Symptoms
E. Sleep related Gastroesophageal reflux
F. Sleep related Hemolysis (Paroxysmal Nocturnal
Hemoglobinuria)
 Substance Induced Sleep Disorder

- Insomnia, Hypersomnia, Parasomnia, or combination

caused by use of a medication or intoxication or
withdrawal from a drug of abuse
1. Somnolence – related to tolerance or withdrawal from a
CNS stimulant (cocaine, caffeine etc.) or to sustained use
of CNS depressants
- may be associated with severe depression which may
reach suicidal proportions
2. Insomnia – associated with tolerance or withdrawal from
sedative hypnotic drugs and CNS stimulants, and with
long term alcohol consumption
3. Sleep problems side effect of many drugs
(antimetabolites, thyroid preparation, anticonvulsants
etc.)