Medical Psychiatry

Total Page:16

File Type:pdf, Size:1020Kb

Medical Psychiatry Introduction Medical Psychiatry: Cognitive Disorders and Delirium: A syndrome, not a disease Many underlying causes Somatoform Disorders Reversible global impairment of cognitive processes Impairment of: consciousness, Cynthia L. Gauss, MD cognitive function, awareness VCU School of Medicine Inova Campus 1 2 Disturbed Functioning Time Course Cognitive: perceiving, thinking, Rapid onset – hours to days remembering Brief fluctuating course Arousal and attention: involves Rapid resolution, once underlying reticular activating system causes identified and treated Psychiatric symptoms: mood, perception, and behavior Patients with delirium: longer Neurologic symptoms: asterixus, hospital stays, more likely to die nystagmus 3 4 Many Different Names Epidemiology Delirium is a common disorder Acute brain syndrome General population: 0.4% age 18 and Acute confusional state older, 1.1% age 55 and older Metabolic encephalopathy 10-30% hospitalized medically ill Toxic psychosis 30% surgical and cardiac ICU pts. Toxic encephalopathy 40-50% patients s/p hip surgery Sundowning 90% postcardiotomy patients ICU psychosis 30-40% hospitalized patients with AIDS 5 6 1 Risk Factors Other Risk Factors Age: 30-40% hospitalized elderly Pre-existing brain damage Pain History of delirium Malnutrition Alcohol, drug dependence Dehydration Poor mobility Diabetes Cancer Sleep deprivation Sensory impairment Male gender Young children 7 8 Etiology CNS Causes Central nervous system illness Epilepsy Systemic disease, metabolic Brain trauma disturbance Meningitis Intoxication or withdrawal from Tumor substances or medications Vascular disease 9 10 Systemic Illness Drugs, Poisons Anticholinergic Endocrine Vitamin Phencyclidine dysfunction deficiencies Anticonvulsants Phenytoin Antihypertensive Liver (hepatic Infection Ranitidine encephalopathy) (fever,sepsis) Antiparkinsonian Salicylates Antipsychotics Kidney (uremic Electrolyte Opiates Cardiac glycosides encephalopathy) imbalance Sedatives Cimetidine Lung disease Trauma (head, Steroids Clonidine Cardiovascular body) Disulfiram Heavy metals disease Postoperative Carbon monoxide states Insulin 11 12 2 DSM-IV-TR Criteria Of Pathophysiology Delirium Cholinergic dysfunction: possible Disturbance of consciousness (i.e., common denominator reduced clarity of awareness of the Excess dopamine: believed to lead to environment with reduced ability to agitation, psychosis focus, sustain or shift attention) Involvement of reticular activating formation leads to problems with attention 13 14 DSM-IV-TR Criteria Of 5 Types Delirium Delirium due to a general medical A change in cognition (such as memory condition deficit, disorientation, language Substance intoxication delirium disturbance or the development of a perceptual disturbance that is not better Substance withdrawal delirium accounted for by a preexisting established Delirium due to multiple etiologies or evolving dementia. The disturbance develops over a short Delirium not otherwise specified period of time (usually hours to days) and (unknown cause or due to causes tends to fluctuate during the course of the not listed, such as sensory day. deprivation) 15 16 Diagnosis Other Diagnostic Features Most significant features: Disturbed psychomotor behavior – Decreased and fluctuating levels of Disturbance of sleep/wake cycles consciousness Mood alterations – Disturbance of attention Perceptual disturbance – Disorientation – Memory disturbance Disturbed thought processes Neurological abnormalities 17 18 3 Diagnostic Procedures Diagnosis Mental status exam, including mini- The main goal is to determine and mental status exam treat the underlying medical cause of the delirium. Longitudinal, systematic clinical assessments Physical exam Laboratory data 19 20 Laboratory Data Differential Diagnosis Blood chemistries: Chest X-ray electrolytes, renal Drug screen Dementia and liver fx, EEG: slow waves glucose Brief psychotic disorder Blood, urine and Schizophreniform disorder CBC with diff CSF cultures Thyroid function B12 and folate Mood disorders RPR CAT scan of brain Anxiety disorders Urinalysis Lumbar puncture Malingering HIV EKG 21 22 Course And Prognosis Treatment Sudden onset Resolves over hours to weeks After treating underlying causes, The primary aim of treatment: treat usually resolves in 3-7 days the underlying medical cause of the delirium Most recover Treat the symptoms of delirium Others progress to stupor, coma or seizures Provide a safe and supportive environment 20-75% die during hospitalization 25% die within 6 months 35% die within a year 23 24 4 Pharmacologic Treatment Behavioral Management Ensure safety: fall prevention, Minimize polypharmacy in general remove dangerous items, 1 to 1 Check medication levels sitter, avoid restraints Treat psychosis with Haldol (po and Consistent staff, family, friends IM) or atypical antipsychotics: Calm environment: avoid sensory Risperdol (po,IM,m-tabs) Zyprexa deprivation and over-stimulation (po, zydis, IM), Geodon (po, IM) or Regular orientation, explanations, Seroquel reassurances Avoid benzodiazepines alone, except Provide calendars, familiar objects, for alcohol, sedative withdrawal 25 nightlight, glasses, hearing aid 26 Dementia Epidemiology Global decrease of cognition in 8 to 10% over 65 develop dementia multiple domains 40% over age 80 develop dementia Stable level of consciousness Dementia of Alzheimer’s type Due to abnormalities in brain structure increases in prevalence with age Risk increases with age Annual cost: 80 to 100 billion $/year Leads to institutionalization 50% of nursing home patients have Often permanent Alzheimer’s 15% of dementias are reversible if 2 million people in nursing homes treated with dementia 27 28 Epidemiology Etiology Dementia most commonly occurs Alzheimer’s dz Nutritional (B12, after age 60 Vascular dementia folate, thiamine Rare cases occurs in 40s or 50s Drugs, toxins deficiency, pellagra) (early-onset dementia) (including alcohol) Anoxia Alzheimer’s is leading cause Tumors Normal-pressure hydrocephalus Vascular dementia 2nd leading cause Infections (Creutzfeld-Jacob, Head trauma The two together make up 75% AIDS, neurosyphilis, Inflammatory dz meningitis) (Lupus, MS) 29 30 5 Etiology Diagnosis: DSM-IV-TR Neurodegenerative Metabolic Dementia of the Alzheimer’s Type Disorders: disorders: Vascular dementia (Multi-infarct – Parkinson’s disease – Leukodystrophies dementia) – Huntington’s dz – Dialysis dementias Dementia due to a general medical – progressive – Renal insufficiency supranuclear palsy – Hepatic insufficiency condition – Pick’s disease – Hypo- and hyper- Substance-induced persisting – Wilson’s disease thyroidism dementia – Cushing’s syndrome Dementia due to multiple etiologies Dementia not otherwise specified 31 32 DSM-IV-TR Criterion DSM-IV-TR Criterion The development of multiple – One (or more) of the following cognitive cognitive deficits manifested by disturbances: • aphasia (language disturbance) both: • apraxia (impaired ability to carry out motor – Memory impairment (impaired ability to activities despite intact motor function learn new information or to recall • agnosia (failure to recognize or identify objects previously learned information) despite intact sensory function) • disturbance in executive functioning (ie, planning, organizing, sequencing, abstracting) 33 34 DSM-IV-TR Criterion Diagnosis Clinical examination: mental status and physical exam The cognitive defects in Criteria A1 Comprehensive history from pt, family and A2 each cause significant Memory, problems with behavior and impairment in social or occupational functioning, mood and personality functioning and represent a changes significant decline from a previous Mini-mental status exam (Folstein’s) level of functioning. Need a baseline score The deficits do not occur exclusively Widely used, can compare between during the course of a delirium. different clinicians, and as illness progresses 35 36 6 Laboratory Work-Up Psychiatric Symptoms Personality changes CBC Chest X-ray Hallucinations and delusions Chemistries: EKG Mood changes: anxiety and Electrolytes, renal CT or MRI of brain and liver function depression SPECT or PET of “Pseudodementia” B12, folate brain Dementia can co-exist with Urinalysis Neuropsychologic RPR (syphilis) al testing depression HIV Dementia is a risk factor for depression 37 38 Alzheimer’s Dementia Alzheimer’s Dementia Continuing and gradual decline Onset: ages 40-90 Definitive diagnosis: brain autopsy Early onset < age 65 Senile plaques (amyloid) Late onset > age 65 Neurofibrillary tangles Apolipoprotein E (APOE) 4 allele: Early onset linked to chromosome increased risk mutations 1, 14, 21 Systemic and other brain diseases Confirmatory testing: SPECT or PET need to be ruled out scan, APOE-4, presenilin 39 40 Vascular Dementia Lewy Body Disease Associated with arteriosclerosis Clinical features similar to Cannot make diagnosis without Alzheimer’s clinical evidence (focal neurological Early onset visual hallucinations and signs) or evidence from brain parkinsonism imaging Lewy bodies: eosinophilic inclusions Often abrupt deterioration in neurons throughout the cortex Fluctuating, step-wise progression Patients very sensitive to typical Associated with HTN, diabetes, antipsychotics stroke 41 42 7 Fronto-Temporal Dementia Pharmocologic Treatment (Pick’s
Recommended publications
  • Body Dysmorphic Disorder the Drive for Perfection
    1.0 ANCC CONTACT HOUR Body dysmorphic disorder The drive for perfection BY AMANDA PERKINS, DNP, RN Abstract: Body dysmorphic disorder EVERYTHING AROUND US focuses on (BDD) is an obsessive-compulsive and beauty, from commercials to magazines, related disorder that pushes people social media to movies. Already beauti- toward perfection, affecting 5 to 7.5 ful models are airbrushed to make them million people in the US. Individuals look “perfect” in a way that is unattain- with BDD spend a great deal of time able. People can easily apply filters to focusing on perceived flaws and ways in their selfies, removing even the slightest which to hide these flaws. The time imperfections. In this way, our society spent on these negative thoughts can 1 interfere with quality of life and the reinforces the need to be beautiful. ability to carry out daily tasks. This article Body dysmorphic disorder (BDD) is a discusses BDD, including symptoms, body image disorder that pushes people diagnosis, treatment, complications, and toward perfection, affecting approxi- the nurse’s role. mately 1 out of 50 people, or 5 to 7.5 million people in the US, according to Keywords: behavioral health, body the Anxiety and Depression Association SHUTTERSTOCK / EU dysmorphic disorder, dysmorphia, of America (ADAA).2,3 Individuals who . mental health, obsessive-compulsive have BDD spend a great deal of time disorder, social media focusing on perceived flaws and ways in PHOTOGRAPHEE 28 l Nursing2019 l Volume 49, Number 3 www.Nursing2019.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. www.Nursing2019.com March l Nursing2019 l 29 Copyright © 2019 Wolters Kluwer Health, Inc.
    [Show full text]
  • Conversion Disorder in a Depressed Patient: the Analysis of Paralysis
    Jefferson Journal of Psychiatry Volume 16 Issue 1 Article 3 January 2001 Conversion Disorder in a Depressed Patient: The Analysis of Paralysis Michael A. Chen Ph.D. University of Michigan Medical School, Ann Arbor, MI David S. Im M.D. Department of Psychiatry, University of Michigan Medical Center, Ann Arbor, MI Follow this and additional works at: https://jdc.jefferson.edu/jeffjpsychiatry Part of the Psychiatry Commons Let us know how access to this document benefits ouy Recommended Citation Chen, Michael A. Ph.D. and Im, David S. M.D. (2001) "Conversion Disorder in a Depressed Patient: The Analysis of Paralysis," Jefferson Journal of Psychiatry: Vol. 16 : Iss. 1 , Article 3. DOI: https://doi.org/10.29046/JJP.016.1.002 Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol16/iss1/3 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Jefferson Journal of Psychiatry by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. Conversion Disorder in a Depressed Patient: The Analysis of Paralysis 2 Michael A. Chen, Ph.D. I and David S.
    [Show full text]
  • Guidelines for Treating Dissociative Identity Disorder in Adults, Third
    This article was downloaded by: [208.78.151.82] On: 21 October 2011, At: 09:20 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Trauma & Dissociation Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjtd20 Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision International Society for the Study of Trauma and Dissociation Available online: 03 Mar 2011 To cite this article: International Society for the Study of Trauma and Dissociation (2011): Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, Journal of Trauma & Dissociation, 12:2, 115-187 To link to this article: http://dx.doi.org/10.1080/15299732.2011.537247 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
    [Show full text]
  • Functional Neurologic Disorders and Related Disorders Victor W Mark MD ( Dr
    Functional neurologic disorders and related disorders Victor W Mark MD ( Dr. Mark of the University of Alabama at Birmingham has no relevant financial relationships to disclose. ) Originally released April 18, 2001; last updated December 13, 2018; expires December 13, 2021 Introduction This article includes discussion of psychogenic neurologic disorders, functional neurologic disorder, functional movement disorder, conversion disorder, and hysteria. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations. Overview Several behavioral disorders are related by (1) their resemblance to other, more familiar neurologic disorders; (2) lack of well-established biomarkers (eg, structural lesions on brain imaging studies, seizure waveforms on EEGs); and (3) aggravation of symptoms with the patient s attention to the disorder. However, the features and causes for these disorders are very different among themselves. This topic reviews functional neurologic disorder, Munchausen syndrome, Munchausen syndrome by proxy, and Ganser syndrome. Key points • Functional neurologic disorders are commonly encountered in general neurologic practices and, hence, knowing their manifestations and treatment is crucial for clinical care. • The disturbance is involuntary, yet at the same time it can be controlled by the patient intermittently. • Despite being self-controllable, the disturbance is generally disabling unless expert professional care is provided. • There is no consistent association between functional neurologic disorder and either posttraumatic emotional stress or sexual abuse. • Functional neurologic disturbances disorder responds best to empathetic concern by the clinician; demonstration that the disorder lacks a structural or permanent etiology; explanation that it can be improved with distraction; and guided attempts to reduce triggers of onset. Cognitive behavioral therapy, combined with physical therapy when warranted, is emerging as a successful intervention.
    [Show full text]
  • Stem Cells and Neurological Disease the Transplant Site
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.74.5.553 on 1 May 2003. Downloaded from EDITORIAL 553 Stem cells shown to survive and ameliorate behav- ................................................................................... ioural deficits in an animal mode of Par- kinson’s disease,3 although in this study 20% of rats still developed teratomas at Stem cells and neurological disease the transplant site. In contrast, Kim et al, using a different approach that relies on R A Barker, M Jain,RJEArmstrong, M A Caldwell transfection with Nurr1 (a transcription ................................................................................... factor involved in the differentiation of dopaminergic cells), have demonstrated The therapeutic implications and application of stem cells for functional efficacy without tumour formation.4 the nervous system Human embryonic stem cells have now been isolated5 and grown in culture with enrichment for neuronal lineages, here has recently been a great deal of (c) ability to migrate and disseminate possible through exposure to a combina- interest in stem cells and the nerv- following implantation within the adult tion of growth factors and mitogens.6 Tous system, in terms of their poten- CNS; These cells, when placed in the develop- tial for deciphering developmental issues (d) possible tropism for areas of path- ing rat brain, can migrate widely and as well as their therapeutic potential. In ology; differentiate in a site specific fashion this editorial we will critically appraise without the formation of teratomas.7 the different types of stem cells, their (e) ease of manipulation using viral and non-viral gene transfer methods; However, the safety of these cells needs therapeutic implications, and the appli- further investigation before they can be (f) ability to better integrate into normal cations to which they have been put, considered for clinical use.
    [Show full text]
  • Secondary Enuresis & Body Dysmorphic Disorder in A
    Psychiatria Danubina, 2010; Vol. 22, Suppl. 1, pp 53–55 Conference paper © Medicinska naklada - Zagreb, Croatia SECONDARY ENURESIS & BODY DYSMORPHIC DISORDER IN A CAUCASIAN MALE WITH CATATONIC SCHIZOPHRENIA: A case report Nuruz Zaman, Milind Karale & Mark Agius South Essex Partnership University Foundation NHS Trust, UK SUMMARY We describe a patient with Schizophrenia and secondary enuresis. The enuresis settled with resolution of his psychotic symptoms but later remerged after starting Clozapine. We explore the mechanisms of incontinence in Schizophrenia and those due to Clozapine. This case highlights the need to inquire about incontinence in patients with schizophrenia prior to prescribing clozapine. Key words: schizophrenia – enuresis – clozapine – incontinence - body dysmorphic disorder * * * * * Introduction Clozapine. This case highlights the need to inquire about incontinence in patients with schizophrenia prior Urinary incontinence in patients with schizophrenia to prescribing clozapine. can present with daytime urinary leakage, urge incontinence and bed wetting. The association between Case Report bedwetting and schizophrenia has been noted since the pre neuroleptic era when Kraeplin reported a group of Mr AP is a 21 year old man who was referred to an schizophrenic patients with resistant incontinence. child and adolescent outpatient clinic at the age of 17 Various mechanisms have been postulated for this with a six month history of not coping with training and association. The ventricular enlargement (hydrocepha- educational tasks. He had low mood, poor self esteem, lus), selective neuronal loss with gliosis, and dopamine occasional aggressive outbursts and certain compulsion dysregulation in schizophrenia may indicate a like repeatedly checking doors, windows and mirrors. neurological basis to the incontinence. These anatomical He walked with his hand over his nose and perceived lesions might interrupt the pathways of bladder control people to be laughing at his nose.
    [Show full text]
  • Primer Progressive Aphasia with Psychiatric Symptoms
    Case Report iMedPub Journals ACTA PSYCHOPATHOLOGICA 2017 http://www.imedpub.com ISSN 2469-6676 Vol. 3 No. 4: 36 DOI: 10.4172/2469-6676.100108 Primer Progressive Aphasia with Psychiatric Metehan Yildirim1, Gülfizar Sözeri-Varma1*, Symptoms Çağatay Öncel2, Ibrahim Şendur1 and Osman Özdel1 Abstract 1 Department of Psychiatry, Pamukkale Primary Progressive Aphasia (PPA) is a rare neurodegenerative disease that is University, Denizli, Turkey rarely observed with the relative preservation of mental functions such as memory, 2 Department of Neurology, Pamukkale visuospatial functions, personal characteristics but that causes degeneration of University, Denizli, Turkey speech function. Even though cognitive and behavioral functions are preserved during the starting stages, psychiatric symptoms may develop with the advancement of the disease. The objective of this study was to present a primary *Corresponding author: progressive aphasia case followed due to conversion disorder and depression for Gülfizar Sözeri-Varma about 30 years and to discuss the confounding effects of the existing psychiatric symptoms at the diagnosis stage. [email protected] Keywords: Aphasia; Primer Progressive Aphasia (PPA); Depression; Conversion disorder Associate Professor, Faculty of Medicine, Department of Psychiatry, Pamukkale Received: May 17, 2017; Accepted: June 14, 2017; Published: June 20, 2017 Univercity, Turkey. Tel: +902582699000/4508 Introduction Primary Progressive Aphasia (PPA) is a neurodegenerative Citation: Yildirim M, Varma GS, Öncel C, disease that
    [Show full text]
  • Case Report Huntington's Disease in a Patient Misdiagnosed As
    Hindawi Case Reports in Psychiatry Volume 2018, Article ID 3915657, 4 pages https://doi.org/10.1155/2018/3915657 Case Report Huntington’s Disease in a Patient Misdiagnosed as Conversion Disorder João Machado Nogueira ,1 Ana Margarida Franco ,1 Susana Mendes,1 Anabela Valadas,2 Cristina Semedo,2 and Gustavo Jesus3 1 Department of Psychiatry and Mental Health, Setubal´ Hospital Center, Rua Camilo Castelo Branco, 2910-446 Setubal,´ Portugal 2Department of Neurology, Setubal´ Hospital Center, Rua Camilo Castelo Branco, 2910-446 Setubal,´ Portugal 3University Psychiatric Clinic, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal Correspondence should be addressed to Joao˜ Machado Nogueira; [email protected] and Ana Margarida Franco; [email protected] Joao˜ Machado Nogueira and Ana Margarida Franco contributed equally to this work. Received 6 October 2017; Revised 4 January 2018; Accepted 22 January 2018; Published 18 February 2018 Academic Editor: Toshiya Inada Copyright © 2018 Joao˜ Machado Nogueira et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Huntington’s disease (HD) is an inherited, progressive, and neurodegenerative neuropsychiatric disorder caused by the expansion of cytosine-adenine-guanine (CAG) trinucleotide in Interested Transcript (IT) 15 gene on chromosome 4. Tis pathology typically presents in individuals aged between 30 and 50 years and the age of onset is inversely correlated with the length of the CAG repeat expansion. It is characterized by chorea, cognitive defcits, and psychiatric symptoms. Usually the psychiatric disorders precede motor and cognitive impairment, Major Depressive Disorder and anxiety disorders being the most common presentations.
    [Show full text]
  • 16 Functional (Psychogenic) Movement Disorders
    16 Functional (Psychogenic) Movement Disorders Professor MJ Edwards St George’s University Hospital, University of London, London UK Introduction Functional (psychogenic) disorders are common throughout neurological practice, and functional movement disorders (FMD) are a particularly common presentation. While they are often thought of as difficult to diagnose with confidence, but there are a number of clinical findings and targeted investigations that can aid diagnosis. Evidence regarding the best approach to treatment is still developing, but decent explanation of the diagnosis in a manner the patient can understand is clearly a rate limiting step in any move towards successful treatment. This is the job of the neurologist, and hence developing an understanding of this disorder is clearly important for all neurologists. Definitions One of the first issues to consider is the lack of consensus on what to call functional movement disorders. We have a number of words at our disposal, from “hysteria” (with all its unfortunate connotations regarding the source of these problems being the uterus), to functional, supratentorial, non-organic, and the latest contender: medically unexplained symptoms. We know already what patients think about these words, thanks to Stone et al (2002), and their study of “the number needed to offend”. Patients attending a neurology clinic were asked “if your doctor said you had X, would you think he was suggesting that you were (or had) Y. Words which patients felt meant that the doctor was suggesting that they were “putting it on”, “mad”, or that “symptoms were all in the mind” were judged offensive. Of the commonly used euphemisms for psychogenic illness, “functional” came out best of all, with “hysteria” and “medically unexplained symptoms” causing almost the same amount of “offence”.
    [Show full text]
  • Anxiety Disorders
    Anxiety disorders Quality standard Published: 6 February 2014 www.nice.org.uk/guidance/qs53 © NICE 2019. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of- rights). Anxiety disorders (QS53) Contents Introduction ......................................................................................................................................................................... 4 Why this quality standard is needed ........................................................................................................................................ 4 How this quality standard supports delivery of outcome frameworks...................................................................... 6 Coordinated services...................................................................................................................................................................... 11 List of quality statements................................................................................................................................................ 12 Quality statement 1: Assessment of suspected anxiety disorders ................................................................ 13 Quality statement............................................................................................................................................................................ 13 Rationale ............................................................................................................................................................................................
    [Show full text]
  • Psychogenic Movement Disorders Amitabh Gupta and Anthony E
    Psychogenic movement disorders Amitabh Gupta and Anthony E. Lang Movement Disorders Unit, Toronto Western Hospital, Purpose of review University of Toronto, Ontario, Canada This review summarizes the progress made in the area of psychogenic movement Correspondence to Dr Anthony E. Lang, MD, FRCPC, disorders (PMDs) over the past 2 years, and a simplified classification of diagnostic Director, Movement Disorders Unit, Toronto Western Hospital, 399 Bathurst Street, McLaughlin 7-418, certainty is proposed that incorporates electrophysiological assessment. Toronto M5T 2S8, Ontario, Canada Recent findings Tel: +1 416 603 6422; fax: +1 416 603 5004; e-mail: [email protected] Functional magnetic resonance imaging studies have demonstrated altered blood flow in conversion disorders that may reflect changes in synaptic activity. Current Opinion in Neurology 2009, 22:430–436 Electrophysiological testing shows limitations in distinguishing between psychogenic and organic propriospinal myoclonus and dystonia. Recent evidence cautions against the uncritical acceptance of all cases of posttraumatic myoclonus and ‘jumpy stump’ as being organic in nature. ‘Essential palatal tremor’ is recognized as a rather heterogeneous group of tremors that includes psychogenic tremor. Two recent studies evaluating the long-term prognosis of psychogenic tremor differ in the degree of unfavorable outcome. Different groups of PMDs might have distinctive gait characteristics with prognostic, diagnostic, or therapeutic value. Two recent reviews provide comprehensive information on the understudied area of PMDs in children. Summary The diagnosis of PMDs should not be regarded as a diagnosis of exclusion. Careful clinical assessment is critical, and imaging or electrophysiological studies may provide important insights and confirmation of the diagnosis though some cases remain challenging and current assessments fail to provide needed clarification.
    [Show full text]
  • The ICD-10 Classification of Mental and Behavioural Disorders Diagnostic Criteria for Research
    The ICD-10 Classification of Mental and Behavioural Disorders Diagnostic criteria for research World Health Organization Geneva The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this organization, which was created in 1948, the health professions of some 180 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. By means of direct technical cooperation with its Member States, and by stimulating such cooperation among them, WHO promotes the development of comprehensive health services, the prevention and control of diseases, the improvement of environmental conditions, the development of human resources for health, the coordination and development of biomedical and health services research, and the planning and implementation of health programmes. These broad fields of endeavour encompass a wide variety of activities, such as developing systems of primary health care that reach the whole population of Member countries; promoting the health of mothers and children; combating malnutrition; controlling malaria and other communicable diseases including tuberculosis and leprosy; coordinating the global strategy for the prevention and control of AIDS; having achieved the eradication of smallpox, promoting mass immunization against a number of other
    [Show full text]