Practical Psychiatry in Medicine Part 11. Organic Brain Syndrome Organic brain syndrome (OBS) components of cognition may be af­ patient. These personality changes refers to those conditions charac­ fected in varying degrees in OBS. may be extremely distressing and terized by changes in mental func­ Each component of cognition is bewildering to the patient’s family. tioning, particularly cognition, functionally related to every other Finally, part of the clinical pic­ which result from diffuse or local component. For example, memory ture presented by the patient with destruction of brain tissue or from underlies all of the highest integra­ OBS is a function of the patient’s an alteration of metabolism that af­ tive functions of the brain. To rea­ psychologic reaction to his own fects all or part of the brain. These son; to establish orientation in cerebral deficit, especially when syndromes are etiologically asso­ time, place, or person; to decide on confronted with an environmental ciated with a wide variety of disor­ a goal and keep it in mind; to exer­ challenge that highlights an intel­ ders: trauma, intoxication, cise judgment (which requires as­ lectual deficit. metabolic disorders, neoplasms, sessment of the present in the light Classification of OBS vascular insufficiency, infections, of past experience); to speak coher­ degenerative neurologic diseases, ently; all require the constant use A time-honored system of and occult hydrocephalus. In view of memory. classification considers the organic of the extremely broad range of Disorders of memory are ex­ brain syndromes as falling into two etiologic factors, diagnosis and tremely common in OBS and can groups: acute brain syndrome and management rest upon the physi­ generally be classified into two chronic brain syndrome. The es­ cian’s knowledge of general types: anterograde amnesia and re­ sential difference between these medicine and neurology. In this trograde amnesia. The former re­ two groups is that the former is re­ chapter, we will describe the mental fers to impairment in the ability to versible and the latter is irreversi­ and behavioral characteristics of acquire new memories, ie, learn­ ble. The simplicity of this the various types of OBS and some ing. Retrograde amnesia refers to classification scheme and its em­ broadly applicable principles of difficulty in recalling information phasis on the critical issue of re­ management. that has already been learned, ie, versibility (and hence treatability) memories from the past. In retro­ are its major virtues. However, not General Considerations grade amnesia it is common for more all brain syndromes that have an In most organic brain syn­ recently acquired information to be acute mode of onset are reversible, dromes, the cognitive functions of lost before older information is for­ nor are all brain syndromes that the mind are the most severely af­ gotten, ie, “ recent memory” is develop slowly over a long period fected. Cognition refers to all those usually affected more than is “re­ of time irreversible. Further, this mental processes involved in the mote memory.” Most patients with simple dichotomous scheme does acquisition and utilization of OBS with memory impairment not do justice to the various sub- knowledge: conscious awareness, have a combination of anterograde types of organic brain syndromes. interpretation of sensory stimuli or and retrograde amnesia. Lipowski6 has proposed a tenta­ perception, attention, concentra­ Affect and various aspects of tive classification of OBS which tion, memory, reasoning, and behavior are also commonly af­ makes allowance for the diversity judgment. Any one or all of the fected in OBS. In fact, it is not rare of syndromes encountered by the for an early manifestation of or­ clinician. While early assessment ganic brain disease to consist of a of potential reversibility and slowly progressive change in per­ treatability is of the greatest impor­ the following chapter has been selected tance, it is nonetheless true, as hy the Publisher from its forthcoming sonality associated with emotional hook, Practical Psychiatry in Medicine, by blunting or indifference, apathy, Lipowski has commented, that re­ John B. Imboden, MD and John Chapman versibility can only be established Oroaitis, MD, in the hope that it will have and inappropriate social behavior 'mmediate usefulness to our readers. which is “out of character” for the with certainty retrospectively, that THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 5, 1978 1125 ORGANIC BRAIN SYNDROME there are degrees of reversibility, associated with visual and auditory and insidiously when it is etiolog- and therefore the use of that one hallucinations, often of a frighten­ ically associated with such condi­ characteristic as the basis for ing nature, and fragmented, chang­ tions as slowly progressive hepatic classification is of dubious validity. ing paranoid delusions. The patient or renal failure; hypothyroidism; Lipowski groups organic brain may talk excitedly and in a ram­ chronic intoxication with barbitu­ syndromes as follows: bling, incoherent manner. rates, bromides, or lead; a slowly 1. OBS with global cognitive im­ Delirious patients, whether ex­ growing intracranial neoplasm; pairment cited, quiet, or in between these normal pressure hydrocephalus: 2. OBS with selective psychologic two extremes, may pose consider­ and so forth. The syndrome may deficit or abnormality able danger to themselves be­ follow an acute organic affection of 3. Symptomatic functional syn­ cause of their disorientation and the CNS such as that produced by dromes poor judgment. The panicky, ex­ trauma, infection, intracranial The last group includes psy­ cited, confused patient is a particu­ hemorrhage, cerebrovascular oc­ chotic states in which there is a lar danger to himself and some­ clusion, and intracranial neo­ toxic factor and which may resem­ times to others. The patient may plasma. ble functional emotional disorders, disconnect intravenous tubing, The syndrome is characterized an example being the schizophrenia­ walk off the ward, or jump out the by diffuse impairment of cognitive like syndrome sometimes seen with window. function: patients do poorly in amphetamine intoxication. Delirious states characteristi­ tasks of memory, especially of re­ cally wax and wane during the 24- cent events, learning new facts, OBS with Global Cognitive Impair­ hour period, tending to get worse at orientation, abstract reasoning, ment night. This fluctuation in the pa­ concentration, and comprehension, The three syndromes in this cat­ tient’s condition may be fairly Unlike delirium, the course is egory have in common an impair­ marked, so that if he is seen during usually protracted. ment of many cognitive functions. one of his better periods (which Of great importance is the po­ may occur in midday) the diagnosis tential, sometimes complete, re­ may be missed. If there is a history versibility of subacute amnestic- Delirium (usually from the evening nursing confusional states. Therefore the In delirium, a rapidly developing staff) that the patient has been irri­ timely diagnosis of this syndrome is confusional state, the basic fea­ table, unreasonable, or otherwise of considerable importance, since tures of impaired cognition are typ­ has exhibited periods of trou­ effective treatment of the underly­ ically present, namely, defective blesome behavior, it is wise to ing disorder can reverse some orall memory (retrograde and antero­ suspect delirium and to examine of the mental deficit and can grade), disorientation, faulty judg­ the patient at various times in the prevent the progression to irrever­ ment, and difficulty in concentra­ 24-hour cycle, especially in the sible dementia. tion, comprehension, and reason­ evening. ing. The causes of delirium are man­ Dementia Some delirious patients, though ifold and include drug intoxication, Dementia refers to organic brain quite confused, may remain rela­ drug or alcohol withdrawal, head syndromes associated with cere­ tively quiet, inactive, and depend­ trauma, infections, vascular dis­ bral cortical damage and charac­ ing upon the nature and progres­ ease, and metabolic disorders. terized by widely varying degrees sion of the underlying disease of impairment of cognitive func­ process, may slip into deeper levels Subacute Amnestic-Con- tion. The condition usually, but not of impaired consciousness, stupor, fusional State always, has a slow and insidious or coma. The EEG of this type of Subacute amnestic-confusional onset. Depending upon the nature patient is apt to show high state, sometimes referred to as of the underlying disorder, the state amplitude, slow background activ­ “ reversible dementia,” is in­ of dementia may be static or pro­ ity.4 termediate between delirium and gressive. Most patients withdemeO' Other delirious patients exhibit dementia. The mode of onset is re­ tia, even those in whom the condi­ marked excitement and hyperac­ lated to the underlying cause; the tion is progressive, show a consid­ tivity. These features are apt to be condition is apt to develop slowly erable fluctuation in intellectual 1126 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 5,1978 ORGANIC BRAIN SYNDROME functioning, having moments of pathologically identical with senile friends and relatives may react to relative lucidity and periods in dementia and is arbitrarily distin­ these “personality changes” with which cognitive functions are par­ guished from it by its onset before irritation but as the patient’s con­ ticularly