Diagnosing Dain Bread

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The use of the term "Organic Brain Syndrome" has fallen out of favor, is not in the DSM IV, and has always been poorly defined. However, I've seen so many of these polysubstance dependence IV drug users that have been out in the sun that come in disheveled, malodorous, skin that looks like beef jerky, with rambling speech + poverty of content, poor working memory, flat affect, poor insight/judgment, and non-specific psychiatric symptoms. They have been substance free and urine tests negative, yet these symptoms seem to persist and are chronic in nature. They do not meet criteria for dementia but you know something bad happened to their brain from all the drug use. Other than reporting the objective findings on my assessment is there anything else on Axis I that I can add to elucidate these prominent findings? I was thinking Cognitive d/o NOS but then DSM IV says to use "Substance related d/o NOS" if cognitive dysfunction is due to a specific or unknown substance?

Recently published neuroimaging article from the UK on cocaine and accelerated aging:
http://www.neuroscience.cam.ac.uk/Up...d%20ageing.pdf

People often comment that using drugs "fries your brain." I haven't seen too much specific data on this phenomenon. Oh yeah, we get scans showing that the brains of cocaine users after the cocaine use could be different on the order of years.

I do know someone did a grand rounds on this in my area showing data that cocaine can cause something on the order of mini-strokes on the smallest capillaries in the brains and that may account for some of the changes in brain scans.

I suspect many of these patients are schizophrenics with a predominance of negative symptoms who fly under the radar because of a lack of overt psychotic symptoms. As we know, there is a high comorbidity of substance abuse/dependence in these folks. If they ever engaged with treatment beyond the weekly slumber party in the ED, or someone in said ED had the time to take a full developmental and psychosocial history, I suspect the diagnosis would be clearer.

Regarding the term "organic brain syndrome," my understanding is that this describes behavioral manifestations of TBI, seizures and other diffuse "organic" brain insults. I suppose chronic drug use could cause this, too.

Originally Posted by strangeglove

I suspect many of these patients are schizophrenics with a predominance of negative symptoms who fly under the radar because of a lack of overt psychotic symptoms. As we know, there is a high comorbidity of substance abuse/dependence in these folks. If they ever engaged with treatment beyond the weekly slumber party in the ED, or someone in said ED had the time to take a full developmental and psychosocial history, I suspect the diagnosis would be clearer.

This is a valid hypthosesis looking at the negative symptoms of Schizophrenia. These symptoms are mainly apparent during the latter course of this chronic disease and will continue to be present even in the absence of positive symptoms. However, the DSM IV is setup such that you cannot make the diagnosis of Schizophrenia by negative symptoms alone. I agree with you in that elucidating a hx of positive symptoms can be difficult for the reasons you described above, especially in an ER setting. In addition, these patients can be very poor historians. They are often estranged by their families and thus obtaining collateral for a psychosocial hx is impossible. Without knowing the correct diagnosis, it makes it difficult to know which treatment approach to take. For example, do we start a 2nd generation antipsychotic to treat the negative symptoms Schizophrenia vs. no medications as we are primarily dealing with a cognitive disorder secondary to chronic polysubstance dependence? I suppose with these cases we can always simply just take a shotgun scatter blast approach ie, add an SSRI + an atypical which covers your depression and augmentation strategy as well as Schizophrenia.

I know this isnt very specific, but i tend to think a lot of it is polyfactorial and cumulative. The effects of the drugs themselves in a subtle dementia sense, things like the abovementioned microstrokes, repeat trauma in being inebriated and falling and hitting their heads, poor living conditions and nutrition (lack of thiamine etc), who knows whet effects of past seizures, underlying baseline cognitive disorders that may have led to poor societal integration and substance use in the first place, etc.

Originally Posted by F0nzie

This is a valid hypthosesis looking at the negative symptoms of Schizophrenia. These symptoms are mainly apparent during the latter course of this chronic disease and will continue to be present even in the absence of positive symptoms. However, the DSM IV is setup such that you cannot make the diagnosis of Schizophrenia by negative symptoms alone. I agree with you in that elucidating a hx of positive symptoms can be difficult for the reasons you described above, especially in an ER setting. In addition, these patients can be very poor historians. They are often estranged by their families and thus obtaining collateral for a psychosocial hx is impossible. Without knowing the correct diagnosis, it makes it difficult to know which treatment approach to take. For example, do we start a 2nd generation antipsychotic to treat the negative symptoms Schizophrenia vs. no medications as we are primarily dealing with a cognitive disorder secondary to chronic polysubstance dependence? I suppose with these cases we can always simply just take a shotgun scatter blast approach ie, add an SSRI + an atypical which covers your depression and augmentation strategy as well as Schizophrenia.

Or, you could attempt to engage them in a treatment that includes supportive psychotherapy, cognitive remediation and social services/case management. It would be nice if such treatments were more available.

Originally Posted by strangeglove

Or, you could attempt to engage them in a treatment that includes supportive psychotherapy, cognitive remediation and social services/case management. It would be nice if such treatments were more available.

Yea totally. I'm working in an underserved area with a lot of recent budget cuts and it's not easy getting these folks the care they need. Sometimes some of the state agencies will throw on an arbitrary axis 1 non-substance related disorder to get them the help they need.

Originally Posted by F0nzie

Yea totally. I'm working in an underserved area with a lot of recent budget cuts and it's not easy getting these folks the care they need. Sometimes some of the state agencies will throw on an arbitrary axis 1 non-substance related disorder to get them the help they need.

Such a difficult position, this needing of labels to get help but then the often negative effects of such labels themselves...

Sometimes some of the state agencies will throw on an arbitrary axis 1 non-substance related disorder to get them the help they need.

And often-times that "help" will allow an antisocial person to get disability when the person is perfectly capable of working and a get-out-of-jail-free card for every time they assault someone.

A local community service agency encourages their doctors to put an Axis I of a psychotic or bipolar disorder even when the doctor doesn't even believe in it so the person could get "help." Of course if you ask them their policy, of course they won't admit they're falsely diagnosing people.

On the flip-side, when I was in the state forensic hospital, I'd be taking these people off of meds, finding out they really weren't mentally ill to begin with (unless you consider antisocial PD a mental illness), and now, IMHO, the person was now in an even worse position to get their life straight because they felt entitled to disability because they were on it for years, and my actions were taking it away, since attacking people and using drugs got them on disability in the first place, their mindset is to get back at it.

Originally Posted by whopper

A local community service agency encourages their doctors to put an Axis I of a psychotic or bipolar disorder even when the doctor doesn't even believe in it so the person could get "help." Of course if you ask them their policy, of course they won't admit they're falsely diagnosing people.

On the flip-side, when I was in the state forensic hospital, I'd be taking these people off of meds, finding out they really weren't mentally ill to begin with (unless you consider antisocial PD a mental illness), and now, IMHO, the person was now in an even worse position to get their life straight because they felt entitled to disability because they were on it for years, and my actions were taking it away, since attacking people and using drugs got them on disability in the first place, their mindset is to get back at it.

I don't know if there is an analogous situation to this in the US but there is also a political context to this in the UK at least.

During the Thatcher years unemployment figures were a huge political problem. The Conservative government massaged the numbers down by getting people to claim sickness/disability benefits/welfare. This made the unemployment numbers look good but it put a lot of people on the scap heap for life along with a meal ticket. This legacy remains a problem to this day. The number of unemployed people hidden from the numbers because they get benefits for having depression / a bad back.

I guess the US has worse "job seekers" (note the orwellian terminology) benefits but those people you get off disability....won't they start showing up as unemployed? Mr. Obama wont like that.

Not quite sure how you would go about diagnosing this except maybe via EEG, but I have seen things like this go under mild-mod anoxic brain injury when it's known that patient uses opiates and the change has happened abruptly. The specific scenario I'm thinking of is a woman that showed up to the ED over the winter holiday, had been a past heroin user, disappeared with an old party buddy and family brought her to the ED a few days later as she was acting completely bizzare (walking around nude at home, pooped in her grandson's bed level of stuff) and she had fresh track marks. Cleared medically for CNS infection/metabolic issue/head injury etc. I only admitted her on an overnight but got to talk to the attending on her team later in the month and found out they'd dx'ed anoxic brain injury. Now I'm not sure if the history made them feel confident enough to pursue this or what that did to rule-in or if it's just that the dx was made by medicine trained docs that don't know the plethora of substance-use related dx in the DSM

And regarding how the US "hides" it's unemployed- we simply stop counting the unemployed after they have been seeking employment a certain amount of time. I think it's a year or two, your unemployment runs out and you aren't considered unemployed even though you don't have a job which is mainly a way to massage some data to pretty it up

Originally Posted by Mattchiavelli

And regarding how the US "hides" it's unemployed- we simply stop counting the unemployed after they have been seeking employment a certain amount of time. I think it's a year or two, your unemployment runs out and you aren't considered unemployed even though you don't have a job which is mainly a way to massage some data to pretty it up

I think this is the method we must be using in the UK to count homeless people.