organic mood disorder and avm

MEDICINEPSYCHOLOGICAL

CONFERENCE

MOHD

HANAFI

NG

BOON KEAT

MR. S

55-year-old | Security Guard

Married | 3 children

Progressively worsened disturbed behaviour for 4 days

HISTORY OF PRESENT ILLNESS• Brought by the son to the accident and

emergency due to bizarre behaviours:– Appeared to be irritable and aggressive– Shouting with vulgar words– No physical damages to self or other

people

• Known case of psychiatric illness, under UMMC follow-up

WITHIN 3 DAYS• Decrease need for sleep • Increase activities

– Wandering around the house non-stop– Pacing faster than normal

• Talkative– Described as talking non-sense

• Impaired functions– Cannot do daily activities properly– Getting complains from working colleagues

• Mood is happy without reason

FURTHER CURRENT HISTORY

• No psychotic symptoms• No depressive symptoms• Clear history of past depressive

episodes

THINK?????

DO YOU

WHAT

PAST PSYCHIATRIC HISTORY

• Since 2002 Multiple admission due to inappropriate behavior with depression.

• Treated with:– Lorazepam | anxiolytic– Chlopromazine | antipsychotic– Perphenazine | antipsychotic– Carbamazepine | anxiolytic

• Poor compliance to medication

Current Admissi

on

2002 2005 2006 2007 2008 2009 2010

8/02Sm: Abnormal behaviour &

EpilepsySurg Dx: AVM

12/05Sm: ↓ need of

sleep, aggressive [shouting]

1/06, 7/06, 12/06Multiple admission

on Epilepsy

19/8 – 21/9Stressor: stolen motor,

Fired from jobSm: shouting to family,

aggitated

10/09Motor Vehicle accident: cross the highway | polytrauma [contusion,

haemothorax, SDH, AVM

PAST PSYCHIATRIC HISTORY

10/09After operation:

ruptured diagphragm

with right upper limb fracture

PAST MEDICAL HISTORY• Known case of epilepsy since young.• Patient was seeking psychiatric

service in UMMC in 2002 and was referred to surgical team the same year.

• Diagnosed to have arteriovenous malformation.

• Healthy without other medical conditions.• No previous history of ECT:

– AVM– Epilepsy

• Follow-up in neuro-surgical and neuro-medical clinic.

• Relatively “stable”

FAMILY HISTORY

• No psychiatric, suicide history in the family

• No history of epilepsy, neurological disease in the family.

• Family relationships are good.

d. | unknown cause

70 | housewife | no medical illness

PERSONAL HISTORY: EARLY CHILDHOOD

13/4/1955 | Alor Star

uncomplicated FTSVD | village midwife.

No health problems | No developmental delay

PERSONAL HISTORY: SCHOOL PERFORMANCE

SRK Kancut | SMK Syed Omar– Moderate achievement in primary

school– Drop-out of school after SRP due to

poor performance– No disciplinary problem– Socialize with friends

PERSONAL HISTORY: WORK RECORDS

Move to Kuala Lumpur | 18-year-old

Work | security guard since then.

Never change his job.

Income | around RM1000

PERSONAL HISTORY: SEXUAL ATTITUDE AND PRACTICE

No sexual experience | before marriage

1st intercourse | age of 30

No history of child abuse

PERSONAL HISTORY: MARRIAGE

Arranged by parents

His wife: 53 year old | Freelance teacher | Had been supportive to the husband despite his condition

PERSONAL HISTORY: SOCIO-CULTURAL BACKGROUND

RM5000 family income per month??

Socialize with friends?

No criminal records

$

PERSONAL HISTORY: SUBSTANCE USE

Smoking | 74 pack years

No alcohol consumption |

No substance abuse

MENTAL STATE: COGNITIVE FUNCTION

Time, Place, Person | Orientated

Remote, Recent Memory | Good [date of birth & breakfast]

5mins memory test | Remember only 1

Information/knowledge | Appropriate

Proverbs | Can answer [Udang di sebalik batu & sikit-sikit lama-lama jadi bukit]

Similarities | Give 2 [apple & orange: tastes, eaten]

MENTAL STATE: COGNITIVE FUNCTION 2

Attention | Easily distracted

Concentration | Cant do it [serial 7 test, digit span, world backward]

Judgement | Cant assess[patient started irritable and agitated]

Insight | Poor [he and others do not realised his abnormality | not accept and do not need

treatment]

Predisposing Factors

Biological

Multiple epilepsyAVM & MVA

Psychological

Personality??

Social

Work stressLower socio-economic

support

Precipitating Factors

Biological

Poor compliancePoor insight

Psychological

Weak belief in religion

Social

Financial problems

Family problems

Perpetuating Factors

Biological

DisabilityAVM complication

Psychological

Poor insightPoor coping skill

Social

Financial problemsPoor social support

Unemployed

Prognostics Factors

Protective

No psychotic featuresSupportive family members

Poor

Poor insightProgression of the disease

LIKELYIS THE MOSTWHAT

PROVISIONAL DIAGNOSIS?

PROVISIONAL DIAGNOSIS

• manic episode • The patient has had at

least one previous major depressive episode, manic

episode, or mixed episode

BIPOLAR I DISORDER

DIFFERENTIAL DIAGNOSISDifferential Diagnosis

Factor Suggesting Factor Opposing

Schizoaffective In mania, symptoms usually change quickly in content and seldom outlast the over-activity.

No hallucination No delusion

Anxiety Reduced need of sleep Restless Irritable

Symptoms less than 6 month There is abnormal behaviour

Hyperthyroidism restlessness irritability

manic episodes no cold or heat intolerance, excessive

sweating, palpitation and tremor. Dementia middle-aged or older

expansive behavior absence of gross mood disorder,

extreme social disinhibition (e.g. urinating in public) strongly suggests frontal lobe pathology.

past history of affective disorder.

Substance Abuse state of excitement. Cannot elicit usage of drugs [amphetamine]

WARD: Investigation done

Full Blood Count | Liver Function Test | Glucose Level | Renal Profile

Normal

CT Brain was ordered…..

PROVISIONAL DIAGNOSIS

ORGANIC MOOD DISORDER

FINAL DIAGNOSIS: AXIS

Axis Multi-axial Classification

Diagnosis

Axis I Clinical Disorder 293.83: Mood disorder due to a general medical condition

Axis II Personality Disorder/Mental R.

nil

Axis III General Medical Condition

Arterio-venous Malformation [Diseases of the vascular]

Axis IV Psychosocial & Environment

Economic problems

Axis V Global Assessment of Functioning

50 [Some Serious Symptoms or Serious Impairment in Functioning]

MANAGEMENT IN THE WARD

| Psychiatric View | • Psychotic medication not aim to

cure the organic condition• ECT cancelled

• Given Rozidal, Carbamazepine, Lorazepam, Chlorphomazine

MANAGEMENT IN THE WARD

| Neurosurgical View | • CT Brain done Cerebral oedema and complex AVM

• No surgical management available (grade 5 AVM)

NEURO-

PSYCHOLO

GICAL

CORRELATIO

NSDISSCUSIO

N

FROM THE NEUROLOGICAL ASPECT

• AVM• Mania and

frontal lobe

MANIA AND FRONTAL LOBE• Secondary mania can be resulted from frontal

lobe lesion• Multiple case studies reported that most mania

symptoms occurs in RIGHT frontal lobe lesion.• Can occur immediately or later in life after injury.

PATHOPHYSIOLOGY• No clear mechanism

– Postulation: • 1. Brain asymmetry causing dis-inhibition

syndrome.• 2. Limbic system damage.

» Psychosomatics 48:433-435, September-October 2007 doi: 10.1176/appi.psy.48.5.433

AVM: SHORT OVERVIEW• Patient has a right extensive fronto-

temporo-occipital AVM• Not curable in this case• Causing the mood symptoms and

epilepsy

AVM: DEFINITION–Lesions of the cerebral vasculature–Blood flows from arterial to venous

system–Without capillary system–Shunt

AVM: CLINICAL PRESENTATION• Clinical presentations:

– Haemorrhage(41-79%)– Seizure(11-33%)– Heache

• Prognosis– Average rate of haemorrhage – 2.8-4.6%

AVM: GRADING

AVM: TREATMENT

– Surgery not a chance– Vascular surgery not a

chance– Radiosurgery only chance

for the patient(do in stages)

DSM-IV criteria for mood disorder resulting from medical or neurologic condition, manic type (secondary

mania)• Elation or irritability • Four of the following:

– inflated self-esteem or grandiosity– decreased need for sleep– pressured speech– flight of ideas– Distractibility– increased goal-directed activity or psychomotor

agitation– excessive involvement in pleasurable activities

ORGANIC MOOD DISORDER: CLASSIFICATION

• ICD-10 specifies that the affective disorder must be judged not to represent an emotional response to the patient’s knowledge of having a

concurrent brain disorder.

ICD-10

• F00-F09 Organic, including symptomatic, mental disorders

• F06 Other mental disorders due to brain damage and dysfunction and to physical illness.

• F06.3 Organic mood [affective] disorders

• .30 Organic manic disorder.31 Organic bipolar disorder.32 Organic depressive disorder.33 Organic mixed affective disorder

DSM IV

• 293.83: Mood disorder due to a general medical condition

MOOD DISORDER(DSM-IV & ICD 10)

SIMILARITIES•Both contain categories for single & recurrent episodes of mood disorder•Both recognize mild but persistent mood disturbance in which there is either a repeated high and low mood OR a sustained of depressive mood.

DIFFERENCES•In DSM-IV, if mood disorder is due to medical condition @ Substance induce, it is included as subcategories of mood disorder.•In ICD 10, these condition are classified as mood disorder under Organic Mental Disorder

ORGANIC MOOD DISORDER: EPIDEMIOLOGY

• Depression in the medically ill appears to be equally prevalent by sex, or possibly slightly

higher in men (Caine and Lyness, 2000).

• Patients with secondary mania are more likely to have negative family and personal

histories of mood disorder (Evans et al., 1995)

ORGANIC MOOD DISORDER: AETIOLOGY

–cortical degenerations–extrapyramidal disorders–cerebrovascular diseases–cerebral neoplasms & trauma–CNS infections –endocrine disorders–inflammatory (Cummings and Mega, 2003).

Lesion-deficit and functional imaging frontal and temporal cortices and striatum

(Mayberg et al., 2002).

disruption of known neurochemical pathways involving frontal-striatal-

thalamic and baso-temporal limbic circuits (Alexander et al.,

1990).

ORGANIC MOOD DISORDER: MANAGEMENT

• Poststroke Depression Nortriptyline and trazodone. (Lipsey et al., 1984; Reding et al., 1986).

• Traumatic Brain Injury Depression Desipramine and sertraline

(Wroblewski et al., 1996; Fann et al., 2000).

• Manic Lithium (Evans et al., 1995).

• Secondary Mania Clonidine, valproate, carbamazepine and antipsychotics

(Bakchine et al., 1989; Starkstein et al., 1991)

organic mood disorder and avm

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