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MENTAL
DISORDERS
& SLEEP
DISORDERS
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
1. Abnormal Arousal
Acute Chronic
Rapid onset Insidious (Usually)
Days-Weeks duration Months-Years
Fluctuating Course Chronically Progressive
Fluctuating Consciousness Normal
Impaired orientation Intact initially
DELIRIUM DEMENTIA
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
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
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
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
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
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
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
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
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