Transcript Organic Mental Disorders

ORGANIC MENTAL DISORDER
器質性精神病
楊誠弘醫師
臺北榮民總醫院精神部
103年12月16 日
授課目標
一、學習何為器質性精神病
二、器質性精神病之表現為何
三、器質性精神病之分類及原因
個案報告
一位住院病人的家屬向查房的內科醫師
表示：「醫生，我爸爸為什麼晚上不睡
覺，認不得人，看到牆壁上有幻影，還
不吃飯，說有人在菜中下毒」，經會診
精神科，原來是因病患身體嚴重感染，
腦部功能暫時異常引起譫妄，產生像精
神病的症狀，經感染控制後，精神症狀
就消失了，以上案例是內外科住院病人
因身體因素引起之急性器質性精神病。
此種急性器質性精神病會引起意識模
糊、睡眠障礙、錯亂、語無倫次、靜呆
、幻覺、譫妄、坐立不安、無感情、激
動、誇大、焦慮、迷惘狀態、人及物的
失識及記憶力障礙等症狀，其原因為腦
部疾病，如急性腦部創傷、腦部感染、
腦瘤及血管性疾病等，
另一種原因為全身性疾病，包括藥物
、毒物、內分泌障礙、肝臟腦病變、腎
臟尿毒性腦病變、肺臟一氧化炭中毒及
缺氧性腦病變、心血管心臟衰竭、維他
命缺乏、全身性感染、電解質不平衡、
手術後狀態、創傷等，處理方式主要為
檢驗及治療引起精神症狀之身體因素。
另外有一種慢性器質精神病，例如慢
性腦傷、癲癇、巴金氏症及老年失智症
等，會引起如人格退化症狀，如缺乏機
智、禮貌、體貼及敏銳的感覺，另外也
出現新的特質改變，如變的囉唆、迂迴
、強求、未壓抑等，或變的冷漠、遲鈍
、延緩及笨拙等，及變的喜怒無常、易
怒、埋怨及爆發性等，
除了人格退化及改變外，慢性器質精
神病亦會引起智力功能的障礙，包括記
憶力、注意力、理解力、判斷力障礙，
一般說來，人格退化及智力功能障礙是
慢性及不可逆，並且是進行性的，除此
之外，有時如急性器質性精神病一樣，
亦會合併有妄想、幻覺、憂鬱、躁症、
焦慮及行為障礙等精神症狀，此時可針
對精神症狀給予精神藥物之治療。
總之器質性精神病有下面之特色：
（1）是因身體疾病引起的。
（2）身體的疾病和精神病症狀之間有明顯
時間關係。
（3）並且兩者之病程經過，一定有平行的
關係。
如此可說器質性精神病是「外因性」
或「器質性」，也可說是以身體障礙為
基礎之精神病。
Clinical manifestation
Commonly used terms
• Confusion: unable to think with
customary clarity and coherent
• Clouding of consciousness: the mildest
sate of impairment of consciousness
• Twilight states: dream-like states
• Coma: extreme of impairment of
consciousness
• Stupor: organic and non-organic
Commonly used terms
•
•
•
•
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Organic personality change
Chronic amnesic syndrome
Organic hallucinosis
Delirium
Dementia
Clinical picture in acute organic
reactions (acute brain syndrome,
acute confusional state, delirium)
Impairment of consciousness: from
dulling of awareness to profound coma,
disorder of attention
Psychomotor behavior: diminish or
hyperactivity
Thinking and reasoning: idea of
reference and delusion
Memory: disorientation
Perception: hallucinations,
misidentifications
Emotion: depression, anxiety and
irritability
Other features: psychological reaction,
personality change, paranoid reaction,
schizophrenia
ICD-10 criteria of delirium
（a）Impairment of consciousness and
attention, with reduced ability to
direct, focus, sustain, and shift
attention.
（b）Global disturbance of cognitive :
perceptual distortions, illusions
and hallucinations, mostly in the
visual modality; impairment of
abstract thinking and
comprehensions; impairment of
immediate recall and recent
memory; disorientation for time
and sometimes place and person as
well.
（c）Psychomotor disturbance which
may consist of hypoactivity or
hyperactivity of unpredictable
shifts between the two.
（d）Disturbance of the sleep-wake
cycle: insomnia, daytime
drowsiness, sleep reversal;
nocturnal worsening of symptoms;
or disturbing dreams and
nightmares which may continues
as hallucinations on awakening.
（e）Emotional disturbances:
depression, anxiety, fear,
irritability, euphoria, apathy or
perplexity.
Clinical picture in chronic organic
reactions (chronic brain syndrome,
chronic confusional state, dementia)
Mode of presentation: cognitive function
impairment insidiously
General behavior: catastrophic reation,
futile and aimless
Thinking: impoverish of content,
intellectual flexibility is lost,
judgement is impaired early
Speech: poverty of speech, dysphasia
Memory: confabulations
Emotion: blunting and shallowness, poor
impulse control
Other features: neurotic manifestations,
schizophrenia, hallucinations
ICD-10 criteria of dementia
1 A decline in memory affecting both
verbal and non-verbal material,
sufficient at least to interfere with
everyday activities.
2 A decline in other cognitive abilities,
characterised by deterioration in
judgement and thinking and
in the general processing of
information. Deterioration from a
previously higher level of
performance should be established.
For a confident diagnosis both 1 and 2
must have been present for at least 6
months.
3 Preserved awareness of the
environment during a period
sufficiently long to allow the
unequivocal demonstration of the
symptoms in 1 and 2; when there are
superimposed episodes of delirium,
the diagnosis of dementia should be
deferred.
4 Decline in emotional control or
motivation, or change in social
behavior manifest as at least one of
emotional lability, irritability, apathy
or coarsening of social behavior.
Clinical picture in focal cerebral
disorder
Frontal lobes: personality change
Parietal lobes: motor dysphasia, etc
Temporal lobes: sensory dysphasia,
alexia, agraphia, amnesia, etc
Occipital lobes: vision
Diencephalon and brainstem:
hypersomnia, amnesia, etc
Basal ganglia: involuntary movement
Differential diagnosis: Causes of acute
and chronic organic reactions:
Differentiation from non-organic conditions:
EEG, psychometirc testing, radiographic
procedures and functional brain imaging
techniques
Differentiation between acute and chronic
organic reactions: hisotry of the mode of
onset of disorder
Differentiation between diffuse and focal
lesions: EEG, ERP, MRI, Functional MRI,
MEG, MRS, Lumbar puncture