Impact of medications and poisons
Mental disorders are often the result of the toxic effects of medications and industrial substances on the central nervous system.
- Antituberculosis drugs: act similarly to MAO inhibitors. They pose a risk of manic psychoses and are strictly incompatible with tricyclic antidepressants.
- Anticholinergics (atropine, trihexyphenidyl): at the peak of poisoning, they cause delirium with mydriasis and tachycardia, and in severe cases, coma. Treating such psychoses with neuroleptics that have anticholinergic effects is contraindicated.
- Antihypertensive and antiparkinsonian drugs: the former can provoke delirium upon a sharp drop in blood pressure or depression with long-term use, while the latter cause schizophreniform hallucinosis due to dopamine receptor hyperactivation.
Common household and industrial poisons include organic solvents (causing euphoria progressing to encephalopathy), organophosphorus compounds (provoking bradycardia, coma, and seizures), and carbon monoxide. Following resuscitation from carbon monoxide poisoning, patients frequently exhibit Korsakoff's amnestic syndrome, aphasia, and organic personality changes.
Chronic heavy metal intoxications
Diagnostics of such poisonings are challenging due to the non-specificity of early symptoms. Each substance has distinct features of nervous system damage:
- Mercury: in the early stages, it manifests as asthenia, tremor, and hyperhidrosis. A specific mercurial erethism is characteristic—marked timidity, shyness, sleep disturbances, and emotional instability. Later, insight is lost and memory is impaired.
- Lead: causes severe headaches, irritability, severe depression with anxiety, as well as delusions of reference and psychosensory disorders.
- Arsenic and manganese: arsenic poisoning is accompanied by hepatomegaly and dyspepsia, while prolonged contact with manganese inevitably leads to severe encephalopathy.
Principles of managing intoxication psychoses
Treatment begins with the immediate cessation of contact with the toxin. A critical step is the administration of specific antidotes. For instance, atropine is used for organophosphate poisoning, neostigmine methylsulfate for atropine overdose, sodium chloride neutralizes lithium salts, and ethanol neutralizes methanol.
Further tactics include:
- Detoxification: gastric lavage, hemodialysis, plasmapheresis, or forced diuresis (depending on the molecular weight of the substance).
- Functional restoration: once encephalopathy has formed, detoxification no longer provides psychiatric improvement. A prolonged course of nootropics, vitamins, and metabolic therapy is required.
- Psychopharmacotherapy: neuroleptics are used to relieve hallucinations and agitation, and antidepressants are used to correct mood (taking into account compatibility with the toxin).
Somatogenic mental disorders
These arise against the background of ischemia, hypoxia, or purulent processes. They follow an exogenous pattern and directly depend on the stage of the underlying disease:
- Indolent stage (or convalescence): asthenia and hypochondria predominate; euphoria or dysphoria is possible.
- Sharp exacerbation: acute psychoses manifest—delirium (often against a background of high fever), ammentia, hallucinosis.
- Outcome: formation of a persistent psycho-organic syndrome with dementia or seizures.
Special attention is paid to cardiac patients. Myocardial infarction can lead to dangerous euphoria with anosognosia (denial of illness). Following cardiac surgery, psychoses typically manifest on days 2–3. Renal failure is characterized by marked adynamia and stuporous states.
Endocrine pathologies and psychoendocrine syndrome
There is no specificity to mental disorders in endocrine gland diseases: different pathologies can produce a similar clinical picture. In the early stages, they mimic schizophrenia or bipolar disorder, while in the later stages, they progress to severe encephalopathy.
The fundamental manifestation is considered to be psychoendocrine syndrome (according to M. Bleuler). Typical features include:
- Mixed affective states with irritability, anger, and exhaustion.
- Alteration of drives: their pathological enhancement or weakening, but strictly without perversion.
- In Cushing's disease: passivity, decreased libido, bizarre cenestopathies, while emotional dullness is absent.
- In hyperthyroidism: fussiness, sharp mood swings from laughter to tears, and a lack of adequate insight into one's condition.
Briefly: answers to topical questions
What mental disorders develop in the acute period of myocardial infarction?
Acute psychoses, panic, and specific reactions with underestimation of the severity of the condition develop in the acute period of myocardial infarction.
- Acute psychoses — most commonly manifest as ammentia or delirium.
- Euphoria — a specific reaction accompanied by anosognosia (underestimation of the severity of one's condition).
- Panic — the highest degree of anxiety arising from a real threat of death against the background of pain syndrome.
What psychopathological syndromes develop in severe renal failure (uremia)?
Uremic encephalopathy, affective disorders, psychoses, and consciousness-blunting syndromes develop in severe renal failure (uremia).
- Uremic encephalopathy — manifests as apathy in the early stages, asthenic syndrome, and convulsive twitching.
- Affective and motor disorders — adynamic depressions and catatonia-like stupor arise against the background of marked adynamia and passivity.
- Acute psychoses — low-symptom delirious and ammentive states with mild agitation.
- Uremic coma — a terminal, extremely severe unconscious state.
Patients on maintenance hemodialysis may also experience psychoses or specific dementia.
What acute mental disorders occur in the initial period of traumatic brain injury?
Syndromes of altered consciousness, acute psychoses, affective and mnemonic disorders occur in the acute period of traumatic brain injury.
- Loss of consciousness — up to the development of coma.
- Acute psychoses — occur rarely, proceeding with clouding of consciousness (delirium, oneiroid state, twilight state).
- Amnestic disorders — episodes of global amnesia (up to 24 hours) or gross memory disorders of the Korsakoff amnestic syndrome type.
- Affective disturbances — brief hypomanic states following brief loss of consciousness.
Antidotes are easy to remember by antagonist pairs: organophosphates are treated with Atropine, and Atropine overdose with Prozerin (neostigmine). Lithium is washed out with ordinary Salt (NaCl), and Methyl alcohol is blocked by Ethyl alcohol.
Class and exam questions
Can encephalopathy be cured with detoxification IV drips alone?
No. In chronic intoxications, elimination of the poison does not eliminate the already formed organic defect. A prolonged course of therapy with nootropics and vitamins is mandatory.
How to distinguish psychosis from a psychological reaction to a severe illness?
Psychogenic reactions are associated with experiences (fear of death, disability, cosmetic defects), whereas somatogenic disorders correlate with the physical condition (fever, hypoxia) and are often accompanied by clouding of consciousness.
Why do manic psychoses occur in tuberculosis?
Most often, the cause of such states is not the infection itself, but the toxic effect of antituberculosis chemotherapy on the central nervous system.
What else to study on this topic
- Mechanisms of formation of Korsakoff's amnestic syndrome
- Differential diagnosis of psychoendocrine syndrome and schizophrenia
- Specifics of antipsychotic use in somatic comorbid patients
- Clinical presentation and management of atropine delirium
- The role of nootropics in the treatment of organic brain lesions
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Other topics in "Chapter 19. Organic, Exogenous, and Somatogenic Mental Disorders"
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