Organic mental disorders, in contrast to functional (i.e., psychological) disorders, have historically been defined as mental disorders that can be attributed to biological pathology. Disorders that were classified as organic mental disorders in previous editions of the DSM have been divided into three separate sections in the DSM-IV: (1) Delirium, Dementia, and Amnestic and Other Cognitive Disorders; (2) Mental Disorders Due to a General Medical Condition; and (3) Substance-Related Disorders. Organic mental disorders may be classified as either acute or chronic based on duration, abruptness on onset, and defining symptoms. Proper assessment and diagnosis of organic disorders is essential, as leaving them untreated may lead to further deterioration or premature death. The majority of organic disorders are maintained by the underlying biological cause, and therefore require medical treatment to ameliorate the condition. However, a biopsychosocial approach to treatment is required to address all symptoms, particularly as organic disorders often have affective and relational consequences as well. Psychotherapy and cognitive rehabilitation strategies have been shown to be effective with a variety of acute and chronic organic disorders. Although therapeutic interventions with chronic degenerative conditions, such as Alzheimer’s dementia, cannot produce permanent change, they can optimize the person’s functioning and increase quality of life. In other cases, such as moderately severe amnesia, memory functions that have been compromised may be recovered through neuro-rehabilitation. Each individual (i.e., case) is unique and depends not only on the physical factors involved but also on personal, relational, and contextual features. Thus, clinicians that practice with this heterogeneous population need considerable knowledge and clinical experience which should include competence in geropsychology and neuropsychology as well as rehabilitative and psychotherapeutic procedures.
36.1 14.1 Overview
Organic mental disorders have traditionally been defined as mental disorders that result from underlying physical processes, distinct from “functional” disorders, which are considered to be psychological in origin (Lipowski, 1984; Spitzer et al., 1992). This dichotomy originated with acceptance of Cartesian dualism in the seventeenth century (Spitzer et al.). From this emerged two separate classes of psychiatry: one emphasizing the anatomy and physiology of the brain, and the other the unconscious mind and other mental phenomena (Spitzer et al.). The DSM-I included a section titled “organic brain disorders” [sic], which consisted of acute (reversible) and chronic (irreversible) classifications (American Psychiatric Association [APA-psychiatry], 1952). The DSM-II renamed the disorders “organic brain syndromes” [sic], which were subdivided into psychotic and nonpsychotic, and further narrowed down as acute (reversible) or chronic (irreversible; APA-psychiatry, 1968). Both sources defined the essential feature of these disorders as “basic organic brain syndrome” [sic] – a unitary clinical picture characterized by global cognitive impairment (Lipowski, 1980, 1984; Seltzer & Sherwin, 1978). These approaches were very restricted, and led to invalid prognoses and inadequate treatments, especially with regard to the chronic/irreversible versus acute/reversible distinction (Lipowski; Seltzer & Sherwin). The DSM-III expanded the definition of an organic disorder from “basic organic brain syndrome” [sic] to “psychological or behavioral abnormality associated with transient or permanent dysfunction of the brain” (APA-psychiatry, 1980, p. 101). With this revision, the distinctions between psychotic/nonpsychotic and reversible/irreversible were abolished. It was recognized that symptoms consisted of more than cognitive impairment, and that they may even manifest in a similar manner to nonorganic syndromes (Lipowski). Since that time, there has been debate over the appropriateness of the term “organic disorders,” and with the release of the DSM-IV in 1994, it was abolished altogether. It has been argued that the use of this term implies that “functional disorders” do not have an organic basis; in other words, that symptomatically nonorganic problems should not be investigated for organic etiology (Hays, 1985; Kopelman & Fleminger, 2002; McEvoy, 1981; Spitzer et al.). Because organic disorders may manifest as functional syndromes, this prevents proper diagnosis and deprives the client of necessary treatment (Hays; McEvoy; Spitzer et al.; Taylor, 2007). Classifying a patient as having either an organic or functional issue may bias professionals’ conceptualization of the syndrome, leading to erroneous diagnosis and treatment (Drossman, 2006; Spitzer et al.). The term “organic disorders” is also problematic in that it implies that biological processes do not contribute to nonorganic disorders, though we now know that this is not true (Kopelman & Fleminger; Spitzer et al.). What were once called “organic disorders” are now divided into Delirium, Dementia, and Amnestic and Other Cognitive Disorders; Mental Disorders Due to a General Medical Condition; and Substance-Related Disorders in the DSM-IV (APA-psychiatry, 2000). Despite this, the term “organic disorder” will be used throughout this chapter for ease of reference to these categories.
Organic mental disorders may be classified as either acute or chronic based on duration, abruptness of onset, and defining symptoms. Acute reactions have an abrupt onset, and the majority of them can be reversed when the organic pathology is treated. The most important diagnostic feature in acute conditions is impairment of consciousness, namely deficits in memory, thinking, and attention. Chronic disorders, on the other hand, are marked by general cognitive impairment that may initially manifest as changes in behavior. They have a more gradual onset than acute reactions, and they are typically the result of widespread affections of the brain, although some may be localized. It is sometimes difficult to distinguish between acute and chronic disorders, and there is the possibility for an acute condition to develop into a chronic condition over time (Lishman, 1998; also see the forthcoming revision of this text by David, Fleminger, Kopelman, Lovestone, & Mellers, 2009).
The primary change in acute organic reactions is impairment of consciousness, which may range from slight clouding of awareness to severe coma. This may include difficulty in judging time, focusing attention, or thinking clearly. Disruptions in sleep are also present in most cases. These impairments often fluctuate, typically worsening at night, a characteristic that distinguishes an acute reaction from a chronic one. As impairment of consciousness increases, motor behavior tends to deteriorate, and emotionality progresses to a flat affect. In a minority of cases, the opposite occurs – hyperactivity, boisterousness, and repetitive, purposeless behavior accompanied by affective disturbances such as depression, paranoia, fear, and anxiety. Logic and reasoning also become impaired, and subjective reality supersedes external reality in the person’s consciousness. Delusions may become a part of this reality, the most common being persecutory ideation. Disordered perception is common in acute reactions, often resulting in depersonalization and difficulty in accurately perceiving auditory and visual stimuli. The most common perceptual disturbances are visual hallucinations. Registration, retention, and recall of information may also be impaired. Upon recovery from the condition, there is often an amnesic gap with vivid memory of sensory impressions, particularly hallucinations. In its early stages, an acute organic reaction may present with features seen in phobia, depression, hypochondriasis, conversion disorders, and schizophrenia (Lishman, 1998).
The majority of chronic organic disorders emerge gradually without an obvious precipitating incident, although some cases follow acute episodes such as anoxia or trauma. The earliest signs of chronic organic disorder are typically seen in deterioration of memory or more general intellectual impairment, particularly in terms of abnormal behaviors, loss of initiative, and episodes of confusion. If these changes are not obvious right away, one may notice changes in personality such as inappropriate social behaviors or exaggeration of preexisting personality traits. As the condition progresses, reduced concentration, decreased ability to pursue decisive action, and mental fatigue become evident. Thinking is slowed, and logic and abstract reasoning are impaired. Judgment is impaired, and the person typically does not have insight into his or her condition. Disorientation to time typically occurs early on, while disorientation to place and person occurs later in the illness. Memory deficits are usually global, involving impairment of registration, retention, and recall. Memory for names and past events may become disorganized as well, and confabulation often occurs. As with acute organic reactions, persecutory delusions and paranoia may become part of the person’s reality. Poverty of speech is typically manifested in perseveration, reduced vocabulary, and poor sentence construction. In the later stages of the illness, the person may become mute or express only selected words. Hygiene and continence tend to deteriorate. Early in the course of the illness, agitation, anxiety, depression, anger, confusion, and suspicion are often seen. As the condition worsens emotions become shallow and flat, at times characterized by periodic outbursts of laughing, anger, or crying (Lishman, 1998).
Disorders that were previously classified as organic mental disorders have been divided into three separate sections in the DSM-IV: (1) Delirium, Dementia, and Amnestic and Other Cognitive Disorders; (2) Mental Disorders Due to a General Medical Condition; and (3) Substance-Related Disorders. The first group of disorders is characterized by a significant change in cognitive functioning that is due to a general medical condition, a substance, or a combination of these. The second section describes mental disorders that are the physiological result of a general medical condition. Finally, substance-related disorders are caused by taking medication, ingesting drugs or alcohol, or exposure to toxins. This section of the DSM includes two categories: Substance-Induced Disorders and Substance Use Disorders. This chapter does not cover Substance Use Disorders because they do not fall under the category of organic mental disorders (APA-psychiatry, 2000).
36.2 14.2 Recognition of Symptoms and Their Assessment
One of the most challenging aspects of working with clients with psychological or physical disorders is correctly diagnosing the condition. Many organic disorders are manifested in behavioral, mental, and emotional symptoms that are commonly associated with psychological disorders (Taylor, 2007). Although most clients who present for assessment and/or treatment have psychosocial issues, clinicians must be careful to assess for, and rule out, organicity (Taylor), as failure to recognize an organic disorder may lead to severe deterioration or even death (Dilsaver, 1992). The current section provides an overview of organic disorders and their symptoms as defined by the DSM-IV-TR (APA-psychiatry, 2000), and then focuses on the assessment and diagnosis of these conditions.
Delirium. Delirium is the most clinically severe acute organic disorder (Goodwin & Guze, 1996). A diagnosis of delirium requires a disturbance in consciousness and a change in cognition that is not accounted for by dementia. Deliria are usually of rapid onset and are directly caused by medication, substance intoxication or withdrawal, toxin exposure, a general medical condition, or a combination of these. The client experiencing delirium will find it difficult to focus or shift attention, and may perseverate on ideas. Common cognitive deficits include impaired memory, disorientation to time or place, perceptual disturbances, and speech or language impairments. The disturbance of consciousness, rapid onset, and fluctuation in symptom severity throughout the day distinguish delirium from dementia (APA-psychiatry, 2000; Broshek & Marcopulos, 1999).
Dementia. Most cases of dementia are the result of brain disease or loss of brain tissue (Goodwin & Guze, 1996). Dementia is diagnosed based on the presence of multiple cognitive deficits, including memory impairment and at least one of agnosia (inability to identify or recognize objects), aphasia (degeneration of language), apraxia (difficulty executing motor activities), or disturbed executive functioning (decline in abstract reasoning and difficulty with planning and completing complex behavior) (APA-psychiatry, 2000). Clients with dementia may initially present with somatic complaints or depressive symptoms (Goodwin & Guze). These symptoms are of gradual onset and are the result of a general medical condition or the continuing effects of substance use, or both. Memory impairment is first observed in the client’s difficulty learning new material. He or she then forgets recent memories, eventually forgetting earlier ones. These symptoms significantly impair the person’s social or occupational functioning (APA-psychiatry; Perez Riley, 1999). The DSM-IV further differentiates between ten subtypes of dementia based on etiology, such as Alzheimer’s dementia, vascular dementia, and dementia due to head trauma (APA-psychiatry), with 60–80% of the cases being Alzheimer’s (Pelton, 2003). Each type of dementia has unique features with implications regarding prognosis and treatment (O’Donnell, Molloy, & Rabheru, 2001; Perez Riley, 1999).
Amnestic Disorders. Amnestic disorders are characterized by memory impairment that is caused by substance use or a general medical condition. As with dementia, this deficit severely inhibits the client’s social or occupational functioning, and shows a marked decline from his or her previous level of functioning. Learning and recall of new information is always impaired, whereas ability to recall previously learned information depends on the extent of the brain damage. In the early stages of development, symptoms associated with delirium, such as disorientation and confusion, may be evident, but these typically diminish over time. Amnestic disorders are distinguished from deliria through the ability to shift and focus attention, and from dementias through the absence of additional cognitive deficits (APA-psychiatry, 2000).
Mental Disorders Due to a General Medical Condition. Mental disorders due to a general medical condition are the direct physiological result of such a condition, as determined through laboratory tests, history, or physical examination. Although it may be difficult to link a disorder directly to a medical condition, evaluation of a number of factors can help this: a temporal association between psychiatric symptoms and onset, remission, or exacerbation of a medical condition, presence of features not typical of the primary disorder, and remission of medical and psychiatric symptoms with treatment of the medical condition. The DSM-IV distinguishes between ten disorders that may be due to a general medical condition, including personality change, psychosis, sexual dysfunction, catatonia, and, delirium, dementia, and amnestic disorders (APA-psychiatry, 2000).
Substance-Induced Disorders. Substance-induced disorders are the result of toxin exposure, ingestion of a drug of abuse, or side effects of medication. The DSM-IV identifies 12 categories of substances that may cause a substance-induced disorder, such as alcohol, amphetamines, caffeine, cannabis, nicotine, opioids, sedatives, and polysubstances. Substance intoxication and withdrawal are common to each substance but nicotine does not cause intoxication. Symptoms are substance-specific, and in order to be diagnosed, there must be clinically significant impairments in functioning. These syndromes are temporary, and symptoms remit at some point after discontinuation of substance use. Substance-specific descriptions are provided in the DSM. Other substance-induced disorders are categorized in the DSM-IV according to the nature of their symptoms, for example, sexual dysfunction, mood disorder, dementia, and psychotic disorder (APA-psychiatry, 2000).
Accurate assessment and diagnosis are vital with clients with organic disorders, as some of these conditions may lead to further decline or death if left untreated (Broshek & Marcopulos, 1999; Dilsaver, 1992; Lishman, 1998). Unfortunately, this is often complicated, as symptoms of organic conditions often closely resemble those of psychological disorders. Some of the more common symptoms include paranoid delusions associated with schizophrenia, depression, mania, anxiety, obsessions and compulsions, and violent behavior (Goodwin & Guze, 1996; Lishman; Taylor, 2007). Further complicating this, there may be losses and stressors in the person’s life that the clinician may mistake for playing an etiological role in a psychosocial dysfunction. Psychological and organic disorders may also coexist. Therefore, when a client with a psychiatric history presents with new symptoms, they must be assessed independently as they may not be of psychological origin (Taylor). These disorders may also interact and affect symptom presentation (Sullivan, 1990).
Beyond overt presenting symptoms, there are several subtle characteristics that differentiate organic from psychological disorders (Dilsaver, 1992; Goodwin & Guze, 1996; Lishman, 1998; Taylor, 2007). A disorder is more likely to be organic than psychosocial, if onset of the first episode is after the age of 40, there is no family or individual history of psychiatric illness, the client has a systemic disease, the client is taking centrally acting drugs, the client exhibits disorientation or recent memory impairment, the client is experiencing epileptic fits, the client is not able to discriminate sensory input, there is a temporal association between the episode and withdrawal of a drug, the client is using a substance of abuse, the client has an autonomic dysfunction, the client is experiencing nonauditory hallucinations, the client’s reasoning abilities have diminished, or if the client was functioning well prior to symptom onset (Dilsaver; Goodwin & Guze; Lishman; Taylor). Taylor has also indicated seven situations in which organicity should be assumed until proven otherwise: the client has suffered a head injury, has noticed a change in his or her headache pattern, is experiencing visual disturbances such as double vision, has speech deficits such as dysarthria or aphasia, has difficulty with balance and changes in gait, has sustained deviations in vital signs such as heart rate, or is experiencing changes in consciousness such as drowsiness and lapses. Differential diagnosis among the organic disorders themselves may also be complicated and ambiguous, but is essential for treatment planning (Zarit & Zarit, 2007). The reader is encouraged to consult the DSM-IV-TR (APA-psychiatry, 2000) and Lishman for specific details on differentiating among organic disorders and between organic and psychological disorders.
Given the challenges presented in accurate diagnosis of organic disorders, very thorough clinical assessment procedures need to be carried out. Throughout assessment, the clinician must attend to the client’s appearance, general behavior, mood, and thought content (Howieson & Lezak, 2008; Lishman, 1998; Taylor, 2007). History taking from both the client and others in the client’s life is essential, and is often the key to determining whether a disorder is organic or psychological in origin (Campbell, 2000; Dilsaver, 1992; Goodwin & Guze, 1996; Howieson & Lezak; Lichtenberg & Duffy, 2000; Lishman; Taylor). In addition to narrowing down the diagnosis, obtaining a detailed history also guides further assessment procedures, gives a context in which to interpret test results, provides an opportunity to assess the client’s perceptions and nonverbal behaviors, and helps determine the appropriate treatment direction (Dilsaver; Goodwin & Guze; Lishman; O’Donnell et al., 2001; Strauss, Sherman, & Spreen, 2006; Taylor). It is important to look at the client’s past medical history, particularly for diseases associated with psychosis, as well as family medical and psychiatric history, as many organic disorders have a genetic basis (Campbell; Dilsaver; Goodwin & Guze; Lishman; Strauss et al., 2006). Recent and past use of alcohol, drugs, and medications needs to be discussed, particularly in terms of any temporal relation between use and the onset of the disorder (Campbell; Dilsaver; Lishman; Strauss et al., 2006). For detailed instructions regarding interviewing and history taking refer to Strauss et al.
A complete neuropsychiatric evaluation is time-consuming and expensive. Therefore, when time or resources are limited, brief screening tests may be used. These tests may facilitate differential diagnosis, allowing more prompt and effective treatment (Serper & Allen, 2002). Some simple tests that, if positive, indicate organicity are likely to include the Write-a-Sentence Test (assesses global brain dysfunction), the Draw-a-Clock Test (assesses visual-spatial ability and ability to write sequential numbers and tell time), and the Copy-a-Three-Dimensional-Figure Test (assesses spatial appreciation; Taylor, 2007; Zarit & Zarit, 2007). Brief cognitive screening tools that may be used include the Standardized Mini Mental Status Examination (SMMSE; Molloy, 1999) and the Modified Mini Mental Status Examination (3MS; Teng & Chui, 1987), the Neurobehavioral Cognitive Status Examination (COGNISTAT; Kiernan, Mueller, Langston, & Van Dyke, 1987), the Cognitive Capacity Screening Examination (CCSE; Jacobs, Bernhard, Delgado, & Strain, 1977), the High Sensitivity Cognitive Screen (HSCS; Fogel, 1991) which may detect mild impairments, and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998), which is suitable for more severely impaired clients (Serper & Allen; Strauss et al., 2006; Zarit & Zarit). Despite the utility of these instruments, the clinician must pursue further evaluation, if there is ambiguity regarding diagnosis.
When diagnosis remains unclear after the interview and screening, the client should be referred for physical and neurological examinations (Dilsaver, 1992; Lishman, 1998; Taylor, 2007). Examinations often identify etiology and guide treatment (Boutros, Thatcher, & Galderisi, 2008; Howieson & Lezak, 2008; Lishman). A medical examination may confirm organicity; however, clinicians are cautioned not to disregard evidence of organicity if the patient has been medically cleared, as signs of organic etiology may be missed, especially early on (Taylor). Physical signs that are important to watch for are listed in Lishman. Ancillary investigations are often required as well, including procedures such as electroencephalography (EEG), radiography, computerized axial tomography, and magnetic resonance imaging (Boutros et al., 2008; Lishman). If the diagnosis is still unclear, the client should undergo a neuropsychological assessment (NPA; Campbell, 2000). NPA is the best way to assess cognitive impairments resulting from damage to brain tissue (Manning, 2001). It involves a report of impaired and preserved cognitive functions, and may distinguish between organic and psychological symptoms. Furthermore, it may detect subtle neurological deficits in the early stages of the illness, when other tests, such as medical exams, fail to find any evidence of dysfunction (Manning). A complete assessment should examine orientation, attention and concentration, memory, intelligence, general knowledge, conscious awareness, affect, language functions, verbal fluency, and visuospatial and constructional abilities (Campbell; Howieson & Lezak; Lishman; Manning; Taylor).
Neuropsychological testing is unique in that it involves comparing the client’s current functioning with the estimated level of premorbid functioning, as well as comparing his or her current functioning in different areas (Howieson & Lezak, 2008; Zarit & Zarit, 2007). Some of the cognitive tests that are commonly used include the Dementia Rating Scale-2 (DRS-2; Jurica, Leitten, & Mattis, 2001), the Delirium Rating Scale (DRS; Trzepacz, Baker, & Greenhouse, 1988), the Wechsler Adult Intelligence Scale-III and the Wechsler Memory Scale-III (Psychological Corporation, 2002), the Bender–Gestalt Test (Bender, 1938), the Kaplan Baycrest Neurocognitive Assessment (KBNA; Leach, Kaplan, Rewilak, Richards, & Proulx, 2000), the National Adult Reading Test-2 (NART-2; Nelson & Willison, 1991), the Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983), and the Kendrick Cognitive Test for the Elderly (Kendrick, 1985). The Neuropsychological Assessment Battery (NAB; Stern & White, 2003) consists of modules assessing major functional domains important to NPA, and is appropriate for use with adults up to the age of 97 (Strauss et al., 2006). If a client is severely impaired, other screening tests such as the Severe Impairment Battery (SIB; Panisset, Roudier, Saxton, & Boller, 1994) may be used to prevent a floor effect. There are several assessment instruments that focus specifically on different elements of cognition, executive function, personality and affect, conceptual functions, attention, memory, language, perception, and sensory and motor function (Howieson & Lezak; Lichtenberg, 1999a; Strauss et al.; Sultzer, 2000; Zarit & Zarit). For further information on these, the reader is encouraged to consult Strauss et al. and Lishman (1998).
It is important to keep in mind that people may perform poorly on these cognitive tests for a number of reasons aside from impairment, including education, cultural differences, language or hearing difficulties, or age (Campbell, 2000; Molloy, Darzins, & Strang, 1999; Perez Riley, 1999). Therefore, tests should be carefully selected based on characteristics of the particular client. For example, there are several brief assessment batteries that have been designed for use with an elderly population so as to avoid lengthy NPA batteries (Lichtenberg & Duffy, 2000). Similar or related abilities should be assessed with multiple measures to increase validity of test interpretation (Howieson & Lezak, 2008; Zarit & Zarit, 2007). Due to the difficulty of differential diagnosis, the extensive nature of NPA, and the immediate importance of identifying the disorder, assessment and diagnosis of organic disorders should ideally be carried out by a multidisciplinary team of experienced professionals (Broshek & Marcopulos, 1999).
36.2.1 14.2.1 Maintenance Factors in Organic Disorders
The factors that contribute to maintenance of an organic disorder depend largely on its primary etiopathology (APA-psychiatry, 2000). Chronic conditions are usually progressive, and are maintained by the damage that has been done, as well as the further damage that typically occurs as a result. However, gradual improvement or a halt in degeneration may be obtained through treating the primary pathology or presenting symptoms (Lishman, 1998). Acute conditions are maintained by electrical, biochemical, or mechanical disturbances in brain function, and are typically resolved when the underlying pathology is treated (Lishman).
Delirium results from a dysfunction in neurotransmission, neuronal metabolism, or input from subcortical structures (Blass, Nolan, Black, & Kurita, 1991). There are a number of potential causes, such as primary central nervous system disorders, systemic disturbances, and drug or toxin exposure. Generally, delirium is maintained by its underlying cause. For example, delirium due to medication, such as anticholinergic drugs, benzodiazepines, or opiates, typically continues so long as the drug remains in the system (Trzepacz & Meagher, 2008). However, there are specific factors that may prolong an episode of delirium (Lishman, 1998; Trzepacz & Meagher). Medications, particularly pain medications and anticholinergic drugs, tend to aggravate the condition (Trzepacz & Meagher). Delirium lasts longer when there have been structural and degenerative changes in the brain, making older individuals, especially those with dementia, particularly susceptible (APA-psychiatry, 2000; Trzepacz & Meagher). Stressful environments and situations may also prolong or exacerbate symptoms (Tune, 2000; Zarit & Zarit, 2007). As well, multiple etiologies often occur serially or concurrently, which generally increases the length of the episode. Recovery is faster when the underlying etiological factor is corrected or self-limited (Trzepacz & Meagher).
In most cases, dementia is a chronic degenerative condition maintained by the progressive loss of neurons in the brain (Lishman, 1998; Trzepacz & Meagher, 2008). However, depending on the etiology, dementia may also be static or may even remit (APA-psychiatry, 2000; Lishman, 1998). The most common form, Alzheimer’s dementia, is a progressive neurodegenerative condition caused by the accumulation of specific proteins in the brain (APA-psychiatry; Trzepacz & Meagher). In addition to the primary effects, this also sets off other neurological events that contribute to additional damage, eventually leading to death (Zarit & Zarit, 2007). In vascular dementia, the damage resulting from hemorrhages or ischemia is permanent, but further degeneration may be prevented by treatment of the vascular disease and hypertension (APA-psychiatry; Reichman, 2000; Trzepacz & Meagher). The majority of dementias due to general medical conditions, such as HIV, Huntington’s, and Parkinson’s disease, are progressive. However, some may be static or show improvement, such as dementia due to head injury if there is only one incident of injury (APA-psychiatry; Lishman; Trzepacz & Meagher). Dementia may be exacerbated by factors such as high levels of psychological stress, ingestion of certain medications, or the existence of comorbid health or psychological issues, such as depression (Trzepacz & Meagher; Zarit & Zarit). In cases where the dementia is a result of a treatable problem, such as nutritional deficiency, hypothyroidism, or toxin exposure, the dementia typically worsens so long as the etiological source is present; alleviation of the original cause may stop progression of the dementia, and possibly partially reverse it (Zarit & Zarit).
Amnesia may result from a variety of factors, such as head injury, medical conditions, substance use or abuse, electroconvulsive therapy, and strokes (APA-psychiatry, 2000; Trzepacz & Meagher, 2008). The duration of amnesia depends on the underlying primary pathology (APA-psychiatry). The neural mechanisms underlying memory are unclear, and theories up to this point are incomplete and speculative (Eslinger, Zappala, Chakara, & Barrett, 2007; Lishman, 1998), although it has been established that in cases of brain injury, longer amnestic episodes are associated with more hemispheric lesions (Trzepacz & Kennedy, 2005). As well, damage to middle-temporal lobe structures appears to cause persisting impairments in declarative memory (APA-psychiatry; D’Esposito, 2000). On average, amnestic disorders due to brain injury last longer than those due to other causes, perhaps due to the extent of the damage (Trzepacz & Kennedy). With concussions, anterograde amnesia may last a few seconds to several hours, although it rarely exceeds a day. Retrograde amnesia typically “shrinks” over time (Collins, Iverson, Gaetz, & Lovell, 2007). Amnesia following mild traumatic brain injury typically lasts less than 30 min (Iverson, Lange, Gaetz, & Zasler, 2007). With more severe brain trauma, amnesia may last a few minutes to months after the injury. In these cases, memory usually improves gradually over time (Eslinger et al., 2007). Older clients experience longer episodes of amnesia than younger ones, implicating the role of age in the maintenance of these disorders (Trzepacz & Kennedy). As with the other organic disorders, if the primary cause is addressed, amnesia may be ameliorated.
Specific maintenance factors associated with disorders due to a general medical condition depend on the individual case, as there are a variety of medical conditions that may be involved, as well as several different symptom presentations. In general, these disorders are maintained by the persistence of the underlying medical condition. If the medical issue is addressed, the disorder may subside, although some conditions lead to permanent neurological damages that maintain the disorder (APA-psychiatry, 2000).
Substance-induced disorders are maintained by the immediate or residual effects of the substance on the central nervous system, and thus typically disappear at some point after exposure to the substance is discontinued (APA-psychiatry, 2000; Lishman, 1998). However, some substances cause permanent changes to the function and/or structure of the nervous system (Doctor, 2008). Effects of the substance on the person are highly dependent on the individual, the type of substance, particularly in regard to mechanisms of action and half-life, and the length of exposure to it (APA-psychiatry; Doctor). For example, if one is exposed to certain nerve agents, symptoms are maintained for prolonged periods because acetylcholinesterase has been completely inactivated, and it takes a significant amount of time to regenerate the enzyme. With a condition caused by carbon monoxide poisoning, symptoms are maintained by high levels of carboxyhemoglobin, which is eventually reduced by supplemental oxygen (Doctor). With drugs of abuse, during the time of use, they influence the brain by interacting with specific neurotransmitter receptors or affecting the quantity of neurotransmitter present at the synapse (Nestler & Self, 2008). Therefore, so long as these chemicals remain in the brain symptoms will be observed. When drugs and alcohol are used repeatedly over time, protein synthesis and patterns of gene expression may be altered for extended periods, producing long-term symptoms (Nestler & Self). The three chronic substance-induced disorders are Substance-Induced Persisting Dementia, Substance-Induced Persisting Amnestic Disorder, and Hallucinogen-Persisting Perception Disorder (APA-psychiatry). Aside from those disorders, symptoms should resolve within 4 weeks after the cessation of withdrawal or intoxication symptoms (APA-psychiatry).
36.2.2 14.2.2 Evidence-Based Treatment Approaches
Historically, organic disorders have been treated as biological diseases distinct from functional disorders, which have been considered psychological in origin (Spitzer et al., 1992). However, through modern research and practice, it has become clear that there are complex interactions between psychological and biological phenomena in both organic and functional illnesses (Spitzer et al.). In organic disorders, psychological and neurological factors typically interact to contribute to symptom presentation, and thus a biopsychosocial approach to the client is required for effective treatment (Drossman, 2006; Forrest, 2008). A detailed neuropsychological assessment provides key information about potential treatments and approaches (Howieson & Lezak, 2008). Treatments range from molecular pharmacotherapy to psychotherapeutic interventions (Horst & Burke, 2008). Because organic disorders have traditionally been viewed as medical issues, research on psychotherapeutic intervention is relatively limited, but has been shown to be very effective in many cases (Forrest).
Psychotherapy with Older Adults. Although organic conditions may be diagnosed at any age, the elderly are particularly susceptible to the development of these disorders (Lipowski, 1980, 1984; Seltzer & Sherwin, 1978; Taylor, 2007). Thus, it is important for the clinician to be aware of the unique aspects of psychotherapy with this population. According to Zarit and Zarit (2007), “geriatric-focused psychotherapy” [sic] involves paying particular attention to assessment, the treatment setting, preparing the client for therapy, goals of therapy, the therapeutic relationship, the role of family, and any medications and medical conditions. It is particularly important to discuss the client’s past experiences in therapy, and his or her expectations of the current therapy, as older clients may have misconceptions about the process of therapy (Gallagher-Thompson & Thompson, 1996; Lewinsohn & Tilson, 1987; Zarit & Zarit). In establishing goals, the therapist should focus on supporting the client’s autonomy as much as possible, and identifying the treatable aspects of his or her condition. Although the prognosis may be bleak, as with Alzheimer’s dementia, there is much that the therapist can do to enhance strengths and increase the client’s quality of life (Zarit & Zarit). Effective approaches are typically brief, structured, positively focused, and goal-oriented (Lewinsohn & Tilson; Teri & Logsdon, 1992). When counseling the elderly, it is more likely that family members will become involved in the process, and in the case of degenerative disorders they may also enter therapy to deal with the stress of caring for their loved one (Zarit & Zarit). The therapist may have to slow the pace of therapy, accommodate sensory deficits by presenting information in several modalities, and use written reminders to facilitate memory of details within and between sessions (Gallagher-Thompson & Thompson; Zarit & Zarit). Theoretical orientations typically used with the elderly include behavioral, cognitive-behavioral, psychodynamic, and family systems, in addition to some supportive counseling, psychoeducation, and relaxation (Gallagher-Thompson & Thompson, 1995; Teri & McCurry, 2000; Zarit & Zarit). Although pharmacotherapy may be important in addressing symptoms of organic disorder, potential damaging effects are unpredictable and dangerous, and thus clinicians should carefully monitor their clients’ progress (Grossberg & Manepalli, 1995; Zubenko & Sunderland, 2000). Older clients are sensitive to the toxic effects of psychotropic medications in particular, and these medications tend to interact with neurological drugs that may be used to target biological issues (Dubovsky & Buzan, 2000; Grossberg & Manepalli). Where possible, then, supportive and behavioral interventions should be used instead of neuroleptics (Grossberg & Manepalli).
Cognitive Impairment. Cognitive deficits are common in many organic mental disorders (APA-psychiatry, 2000). The areas to be targeted in treatment are determined through a thorough neuropsychological assessment, and the etiology and prognosis will determine the individual treatment program and goals (Franzen & Lovell, 2008; Gordon & Hibbard, 2005; Pierson & Griffith, 2006). In many cases of cognitive impairment, an individualized cognitive rehabilitation program will be implemented. This typically involves a multidisciplinary team and various techniques intended to increase functioning in specific daily activities (Belleville, 2008; Cicerone, 2007; Gordon & Hibbard; Pierson & Griffith; Ylvisaker, Hanks, & Johnson-Greene, 2002; Zarit & Zarit, 2007). Common interventions include cognitive remediation, stimulation, and training. Cognitive remediation is typically carried out by a psychologist and focuses on strategies to assist clients to complete daily tasks that are difficult due to the impairment (Cicerone; Gordon & Hibbard). Cognitive stimulation may be done in groups, and involves activities intended to increase general social and cognitive functioning (Belleville; Wenisch et al., 2006; Zarit & Zarit). Cognitive training is implemented individually or in small groups and involves specific, targeted exercises to increase cognitive functioning in activities of daily living (Belleville; Cicerone; Gordon & Hibbard; Zarit & Zarit). Interventions have been developed to address impairments in executive functioning, language, attention, visual perception, and memory (Bangirana, Idro, John, & Boivin, 2006; Cicerone; Franzen & Lovell; Gordon & Hibbard; Pierson & Griffith). Computer-assisted programs may be used to augment these techniques, and handheld computers may be used as compensatory aids to daily living (Bangirana et al., 2006; Franzen & Lovell; Gentry, 2008; Tesar, Bandion, & Baumhackl, 2005). When impairment is caused directly by brain injury, such as a stroke or physical trauma, the efficacy of cognitive interventions is not affected by the severity of the damage, although more damage slows the rate of learning (Gordon & Hibbard). The greater the intensity and duration of therapy, the greater the increase in cognitive functioning (Bode, Heinemann, Semik, & Mallinson, 2004; Gordon & Hibbard; Saxena, Ng, Yong, Fong, & Ko, 2006). To maintain benefits gained as a result of these cognitive interventions, clients should attend brief booster sessions as needed, and consult their therapists if they experience any significant changes in their daily lives (Gordon & Hibbard). Long-term psychotherapy should also be provided alongside cognitive interventions to provide education, promote awareness, and help with adjustment issues (Cicerone; Gordon & Hibbard; Ponsford, 2005). In addition, psychotherapy may be provided to address behavior problems associated with cognitive impairment (Benedict et al., 2000; Franzen & Lovell). Adequate nutrition and physical exercise have also been shown to be important in the enhancement of cognitive functioning, and thus should be addressed as part of the client’s treatment regimen (Bangirana et al.; Pierson & Griffith). For more information on evidence-based cognitive rehabilitation strategies, see Cicerone.
Delirium. Delirium is a dangerous condition, as it is associated with high mortality rates. Research has been done on the prevention of delirium, particularly in the elderly who have higher prevalence rates of the disorder (Inouye et al., 1999; Trzepacz & Meagher, 2008). Inouye et al. implemented a prevention program targeting six risk factors for delirium in hospitalized elders: hearing impairment, sleep deprivation, visual impairment, cognitive impairment, dehydration, and immobility. The program decreased the incidence of delirium, as well as the duration of the episodes that did occur (Inouye et al.). Preoperative patient preparation and education have also been shown to be helpful in reducing rates of delirium (Trzepacz & Meagher). Postoperative passive music therapy may reduce the incidence of delirium in elderly patients (Trzepacz & Meagher). Primary prevention is the most effective strategy in reducing the frequency and complications associated with delirium (Inouye, 2006; Inouye et al.).
Timely identification and treatment of delirium are vital. The immediate priority is for medical professionals to determine the underlying cause of the delirium and treat it (Rabins, 1991; Trzepacz & Kennedy, 2005; Trzepacz & Meagher, 2008; Zarit & Zarit, 2007). In addition, environmental manipulation, treatment of behavioral symptoms, and psychosocial support for the client and family should be implemented (Inouye, 2006; Trzepacz & Kennedy; Trzepacz & Meagher; Tune, 2000). If the physician is able to identify and alleviate the underlying etiology, delirium will subside, although recovery may be slow (APA-psychiatry, 2006; Inouye; Rabins; Zarit & Zarit). However, if the underlying source cannot be determined, the patient should be kept in a calm, dim lit room on close observation for 12–24 h, and may be given an antipsychotic to assist with relaxation (APA-psychiatry; Inouye; Zarit & Zarit). During the episode, the patient should be kept on close observation by medical staff, particularly in regard to fluids, vital signs, and oxygen level (APA-psychiatry; Inouye). Patients, their families, and other staff members should also be educated about the current delirium and its expected course (APA-psychiatry; Rabins; Trzepacz & Meagher). Manipulating the environment to be calming and reassuring may prevent worsening of the condition. This may be achieved through changing lights to cue day and night, using orienting items such as calendars, correcting auditory and visual impairments, regulating stimulation, and having familiar objects and people present (APA-psychiatry; Inouye; Rabins; Trzepacz & Kennedy; Trzepacz & Meagher; Tune; Zarit & Zarit). Patients should be reassured that their condition will pass, and should be reoriented frequently (APA-psychiatry; Rabins; Trzepacz & Meagher; Tune). Psychological interventions that can decrease cognitive disturbance include explaining of recent events, clarifying misperceptions, repeating information, and validating real events (Broshek & Marcopulos, 1999; Tune). To deal with affective reactions, the clinician may reduce feelings of isolation, acknowledge affect, encourage realistic hope, emphasize familiarity, and help the patient gain a sense of control (Broshek & Marcopulos). In some cases, electroconvulsive therapy may also be used to treat a delirium (APA-psychiatry; Coffey & Kellner, 2000; Dubovsky & Buzan, 2000). Physical restraints and pharmacotherapy should be avoided, as they may exacerbate the delirium, and may have particularly adverse effects in the elderly (Inouye; Rabins; Zarit & Zarit). However, if the person is a danger to themselves or others, antipsychotics may be used to ease the symptoms, except in the case of delirium due to alcohol withdrawal, where benzodiazepines would be prescribed (Dubovsky & Buzan; Rabins; Trzepacz & Meagher). It is important to note that management of a delirious patient is specific to the etiology, and thus treatments must be tailored to the individual case (APA-psychiatry). Once delirium has subsided, support should be provided to help the client adjust to what has happened and educate him or her on how to minimize risk of a future episode (APA-psychiatry; Inouye; Trzepacz & Meagher). Depression or posttraumatic stress disorder following the delirium may also need to be addressed (Trzepacz & Meagher).
Dementia. With development of medications that may slow the degenerative process of dementia, there is increasing emphasis on early diagnosis and intervention (Ritchie & Portet, 2006; Zarit & Zarit, 2007). Identification of Mild Cognitive Impairment (MCI), early-stage cognitive decline that may develop into dementia, also allows practitioners to work with the client and family members on coping skills and future planning that facilitates prevention of predictable problems that typically accompany dementia (O’Donnell et al., 2001; Vance & Burrage, 2006; Wenisch et al., 2006; Zarit & Zarit). When possible, clinicians should work with both clients and caregivers, individually and together in sessions, to educate them about the illness and address issues such as coping with memory loss, relationship changes, and feelings of grief (Miller & Reynolds, 2006; Zarit, Femia, Watson, Rice-Oeschger, & Kakos, 2004; Zarit & Zarit). A strong relationship with the caregiver(s) is vital, as with the progression of the dementia, it will be increasingly important to maintain therapy with them. If the client does not have social support, the therapist must obtain appropriate support that is in the best interests of the client (Zarit & Zarit). The primary goal of therapy with the client with MCI is to enhance communication skills and decrease dysfunctional behavior, improving social interactions and self-image (O’Donnell et al.). Cognitive-behavior therapy has been shown to be efficacious in increasing quality of life and decreasing comorbid mood disorders such as depression and anxiety in clients in the early stages of dementia (Laidlaw, Thompson, Dick-Siskin, & Gallagher-Thompson, 2003; Scholey & Woods, 2003; Thompson, Wagner, Zeiss, & Gallagher, 1990). Programs such as cognitive stimulation, remediation, and training may be used to optimize cognitive functioning and delay decline (Belleville, 2008; Savorani et al., 2004; Wenisch et al.; Zarit & Zarit). Promotion of healthy habits, such as proper nutrition and abstinence from substance use, may reduce cognitive degeneration (Vance & Burrage). Memory strategies can also be used to preserve daily functioning (Troyer, Murphy, Anderson, Moscovitch, & Craik, 2007). Group therapy for clients that have been diagnosed with early-stage dementia has been shown to be beneficial for coping and decreasing feelings of isolation (Zarit et al., 2004; Zarit & Zarit). Reminiscence on intact memories encourages self-esteem, and an overall focus on the here and now promotes development of coping strategies (Zarit & Zarit). Group therapies with both clients and caregivers have also been shown to increase quality of life and decrease family conflict (Logsdon, McCurry, & Teri, 2006; Zarit et al.). Research into pharmacological primary prevention based on known risk factors and biomarkers, particularly for Alzheimer’s dementia, is on the rise, and will hopefully decrease the prevalence of this disease in the years to come (Cummings, Doody, & Clark, 2007).
Traditionally, psychotherapy with clients who have dementia has been regarded as ineffective, particularly as it cannot arrest the course of the illness (Lichtenberg & Duffy, 2000; Zarit & Leitsch, 2001). However, advances in psychotherapy research with these clients have revealed benefits of several forms of therapy, including memory training, aromatherapy, validation therapy, pet therapy, milieu therapy, cognitive-behavior therapy, visual imagery and art therapy, reminiscence therapy, touch and massage therapy, cognitive rehabilitation, reality orienta-tion, speed feedback therapy, music therapy, and environmental manipulation (Abraham, Neundorfer, & Currie, 1992; Desai & Grossberg, 2005; Forrest, 2008; Laidlaw et al., 2003; Lichtenberg & Duffy; O’Donnell et al., 2001; Ootani, Nara, Kaneko, & Okamura, 2005; Savorani et al., 2004; Teri & McCurry, 2000; Wilkins & Carr, 2000; Zarit & Zarit, 2007). As with MCI, cognitive rehabilitation programs may be used to enhance cognitive function (Belleville, 2008; Zarit & Zarit). With later-stage dementia, cognitive techniques become less relevant, but affective orientations may still be beneficial. Although verbal exchanges may be lacking in logical content, they can be emotionally meaningful to the client (Forrest; Lichtenberg & Duffy; Werezak & Morgan, 2003). Interactions with the individual should be supportive and involve aspects like humor and empathy (Werezak & Morgan). Identifying activities that are pleasant to the client is important in maintaining quality of life, and in severe clients may be assessed using the Pleasant Events Schedule-AD (PES-AD; Teri & Logsdon, 1991). In most cases, behaviorist techniques, particularly classical conditioning, reduce behavioral problems, and support coping skills and activities of daily living (Lichtenberg, 1999b; Lichtenberg & Duffy; Logsdon, Teri, & McCurry, 2006; O’Donnell et al.; Teri, 1996; Teri, Huda, Gibbons, Young, van Leynseele, 2005; Zarit & Zarit). The focus of treatment is contributing to temporary gains in mood, daily functioning, and behavior (Zarit & Leitsch). The physical and psychosocial environment has been shown to be very important for functioning and quality of life in people with severe dementia. Physical layout of living space should include memory aids and promote orientation and way-finding; private space should be cognitively stimulating and personalized (Forrest; O’Donnell et al.; Werezak & Morgan, 2003). Setting up a positive environment like this reduces the need for physical and chemical restraints (O’Donnell et al.; Werezak & Morgan). See Thomas (1996) for a description of The Eden Alternative, a conceptual framework for creating institutional settings that are comfortable and home-like (Tavormia, 1999). Group therapy is also effective with dementia patients, and is conducive to expressive therapies like music and art (Abraham et al., 1992; Lichtenberg & Duffy). Pharmacologically, cholinesterase inhibitors are the preferred form of treatment of cognitive impairment, although not all dementias are associated with degeneration of cholinergic markers (Apostolova & Cummings, 2008; Desai & Grossberg; Dubovsky & Buzan, 2000; Holtzheimer, Snowden, & Roy-Byrne, 2008; Lerner & Riley, 2008; Olazaran et al., 2004; Ritchie & Portet, 2006; Rongve & Aarsland, 2006; Wilkins & Carr; Zarit & Zarit). Psychotropic medications for reducing agitation and behavioral difficulties have had mixed results in terms of efficacy, and nearly always contribute to further cognitive and motor decline, and should be avoided where possible (Apostolova & Cummings; Dubovsky & Buzan; Holtzheimer et al., 2008; Zarit & Zarit). If medication is necessary, atypical antipsychotics may be considered to treat these symptoms, as they tend to have fewer side effects (Apostolova & Cummings; Holtzheimer et al.; Zarit & Zarit). Regardless of the approach to treatment, it is important that the practitioner recognizes that at best, outcomes may consist of only modest gains or delay of further decline (Zarit & Leitsch).
Family therapy and caregiver education are very important when working with clients with dementia, as caregivers play a large role in treatment, and this disorder often upsets the balance of relationships (Apostolova & Cummings, 2008; Forrest, 2008; Lichtenberg & Duffy, 2000; Miller & Reynolds, 2006; Teri & McCurry, 2000; Zarit & Leitsch, 2001). Caregivers generally experience physical, social, financial, and emotional losses; 90% report being emotionally affected, and 66% report depression (Desai & Grossberg, 2005). Therapy helps caregivers more effectively interact with the dementia client by increasing their well-being and promoting skill development in behavior management and coping. There also are interventions focused directly on helping the caregiver to support the dementia client, leading to more positive outcomes in patients, including delayed institutionalization (Apostolova & Cummings; Coon, Thompson, Steffen, Sorocco, & Gallagher-Thompson, 2003; Laidlaw et al., 2003; Logsdon et al., 2006; Teri, 1996; McCurry, Gibbons, Logsdon, Vitiello, & Teri, 2003; Mittelman, Roth, Haley, & Zarit, 2004; Teri et al., 2003; Teri, Logsdon, Uomoto, & McCurry, 1997; Teri & McCurry; Teri, McCurry, Logsdon, & Gibbons, 2005; Whitlatch, Zarit, Goodwin, & von Eye, 1995; Zarit & Leitsch).
Amnestic Disorders. In cases of amnesia that are due to reversible underlying etiologies, such as poisoning, malnutrition, and infections, amnesia typically subsides if the cause is properly treated by a physician (Taylor, 2007). In longer-term or permanent cases of amnesia due to head trauma and/or structural damage to the brain, symptoms may be reduced through rehabilitative techniques (APA-psychiatry, 2000; Franzen & Lovell, 2008). Internal strategies improve memory ability, whereas external strategies compensate for memory deficits through the use of aids (Dobkin, 2000; Franzen & Lovell; Troyer et al., 2007). Typically when one form of memory is impaired, another remains intact, and thus internal mnemonic strategies may be used to maximize utility of remaining skills (Cicerone, 2007; Franzen & Lovell). Visual imagery is commonly employed to assist in registration and retention of verbal information (Cicerone; Dobkin; Franzen & Lovell). Some techniques that may be used include peg mnemonics, the method of loci, and face–name association (Franzen & Lovell; Glasgow, Zeiss, Barrera, & Lewinsohn, 1977; Lewinsohn, Danaher, & Kikel, 1977). The efficacy of these strategies, however, is largely dependent on the nature of the brain damage as well as individual characteristics. Verbal mnemonic strategies may also be used with some clients, and involve exercises such as rhyming strategies, spaced retrieval, and semantic elaboration (Cicerone; Franzen & Lovell; Troyer et al.). For clients who have difficulty registering written information, the PQRST approach may be used: Preview information, Question the information, Read actively, State the information over again, and Test retention by answering the questions that were written (Franzen & Lovell; Glasgow et al., 1977). Internal techniques are most effective in the long term, if there is contextual interference and intermittent, rather than constant, feedback throughout therapy (Dobkin). Cognitive rehabilitation involves both internal and external memory strategies designed to address attentional impairments, followed by impairments in encoding and recall of information (Dobkin). External memory aids may be used to compliment internal exercises, or may be used in place of them with clients with severe amnesia. Strategies should be practical and aimed at daily activities, as the goal of such techniques is to support daily functioning (Cicerone; Troyer et al.). Memory storage may be achieved through keeping a memory book that lists one’s schedule of daily activities. Electronic storage devices such as personal digital assistants (PDAs) may also be used (Cicerone; Dobkin; Franzen & Lovell). External cues, such as timers and calendars, are very useful for informing the client when behaviors must be performed at a particular time (Cicerone; Dobkin; Franzen & Lovell; Troyer et al.). External strategies are most effective when the client is educated about them, followed up by initiation and maintenance of the new behaviors and recognized for the positive changes in his or her daily life (Troyer et al.). Studies have examined the efficacy of pharmacotherapy for memory impairment, and depending on the nature of the damage, some cholinergic and catecholaminergic medications have demonstrated reduction of attentional and memory deficits (Dobkin; McAllister, 2005). For any given memory intervention to be effective, there must be a thorough assessment to pinpoint the memory systems that need to be targeted, and interventions must be tailored to these and other individual characteristics (Glasgow et al.; Lewinsohn et al., 1977).
Mental Disorders Due to a General Medical Condition. Generally, treatment of mental disorders that result from an underlying medical condition is addressed by medical professionals. Once the cause has been alleviated, the disorder typically subsides. However, some disorders due to a general medical condition may have long-term or permanent effects, for example cognitive or memory dysfunction, the symptoms of which are usually addressed by mental health professionals (APA-psychiatry, 2000; Franzen & Lovell, 2008). Treatments of other disorders due to general medical conditions, for example sexual dysfunction, personality change, anxiety disorder, and mood disorder, are beyond the scope of this chapter. For more information on psychotherapy with clients with organic disorders, see Forrest (2008).
Substance-Induced Disorders. Treatment of substance-induced disorders is largely dependent on the particular case due to individual and environmental factors, the nature of the disorder, and the substance associated with the disorder (APA-psychiatry, 2006), although intoxication and withdrawal typically subside after removal of the substance from the system (Doctor, 2008). Depending on severity, clients experiencing symptoms of intoxication or withdrawal may require hospitalization to ensure appropriate treatment of medical symptoms (APA-psychiatry). Intoxicated clients should remain in a controlled environment with periodic reorientation, reassurance, reality testing, and decreased exposure to stimuli (APA-psychiatry). In the majority of cases, intoxication is self-limiting and will resolve naturally (APA-psychiatry). However, some substances are dangerous or may have been consumed in high doses, and may require removal from the body through methods such as gastric lavage and the administration of charcoal (Doctor). If necessary, drug effects may also be reversed by giving the client antagonists, or the client may be sedated if he or she is extremely agitated (APA-psychiatry). Specialized medical treatments are often required in cases of toxin exposure (Doctor). Withdrawal symptoms may be treated pharmacologically with an agonist associated with the particular substance, as well as other medications that ease symptoms, such as benzodiazepines for alcohol withdrawal (APA-psychiatry). Withdrawal from particular substances, such as opioids, may require complex drug treatments and long-term agonist or antagonist treatments if there is a history of abuse (APA-psychiatry). Clients experiencing withdrawal should also be given reassurance and general support. As well, the patient and his or her family should be educated about substance use (APA-psychiatry).
Substance-related issues may sometimes lead to health complications, general impairment, and an array of secondary mental disorders (APA-psychiatry, 2000; Maxwell, 2005). For example, unless a client is treated with thiamine to reverse the effects of chronic alcohol use, he or she may develop Korsakoff’s syndrome, a persisting amnestic disorder (APA-psychiatry, 2006). In addition, general medical conditions can develop as a result of substance use, and may in turn lead to the development of a mental disorder due to medical complications (APA- psychiatry; Maxwell). Behavioral disturbances may also result from substance use (APA-psychiatry; Maxwell). Therapeutically, substance-induced delirium, dementia, and amnestic disorders are generally addressed in the same manner as when these disorders result from different etiologies (APA-psychiatry). The treatment of other substance-induced disorders, such as sleep, psychotic, anxiety, and mood disorders, is beyond the scope of this chapter.
36.2.3 14.2.3 Mechanisms of Change Underlying the Intervention
Due to the biological nature of organic mental disorders, medical treatment is often the primary intervention. Specifically in acute cases of delirium, amnesia, substance-induced disorders, and disorders due to a general medical condition, symptom alleviation typically occurs through medical treatment of the underlying cause (APA-psychiatry, 2000, 2006; Doctor, 2008; Inouye, 2006; Rabins, 1991; Taylor, 2007; Zarit & Zarit, 2007). However, even in these cases, cognitive, behavioral, and affective interventions may be applied to address specific issues or decrease symptom presentation (Forrest, 2008). Chronic conditions, on the other hand, typically require psychological interventions for functional recovery or symptom amelioration.
Cognitive Impairment. Cognitive rehabilitation programs are tailored to the individual client, and may include interventions that involve environmental modification, compensatory mechanisms, or recovery of cognitive ability itself (Gordon & Hibbard, 2005). Environmental modifications improve daily functioning by tailoring the client’s environment to his or her specific needs (Gordon & Hibbard). Compensatory approaches involve learning new skills or behaviors, and may involve the use of aids such as handheld computers (Franzen & Lovell, 2008; Gentry, 2008; Gordon & Hibbard). For example, skills training focuses on increasing cognitive functioning in daily life; thus, training is specific to tasks that the client will be performing, and rehabilitation occurs through acquisition of domain-specific knowledge (Cicerone, 2007). Direct interventions are intended to recover cognitive functions that have been lost (Gordon & Hibbard). Recovery depends on there being a range of neurological processes that can be used to complete a given task under a variety of conditions (Cicerone). When a client is motivated and actively participates in his or her cognitive rehabilitation program, reorganization of neurologic and cognitive processes may take place, as intra-systemic processes may take over the role of the damaged tissue and/or intact higher cortical centers may influence lower levels of function (Cicerone; Franzen & Lovell). Specific cognitive areas may be targeted, known as process-specific remediation. Here, it is assumed that improvements in the specific function will generalize to similar cognitive areas (Cicerone). Comprehensive programs that involve psychotherapy, cognitive remediation, functional skills training, and individual and group treatments are the most effective (Cicerone; Gordon & Hibbard). Groups are particularly helpful in enhancing social skills and interpersonal functioning, and psychoeducation is crucial in helping clients to adapt to cognitive impairment (Belleville, 2008; Gordon & Hibbard; Zarit & Zarit, 2007). Comprehensive programs are effective because they improve overall functional application of intact cognitive abilities (Cicerone).
Delirium. The environmental modifications recommended in the treatment of delirium decrease symptom expression by reducing factors known to aggravate the condition (Trzepacz & Meagher, 2008; Tune, 2000). Reassurance and therapeutic conversations with the client work in a similar manner, as they reduce agitation and cognitive and emotional disturbance (Broshek & Marcopulos, 1999; Tune). Because clients experiencing an episode of delirium are cognitively impaired and confused, failure to provide orientation, reassurance, and a calm, structured environment may lead to further confusion or fear that may interfere with medical treatment and pose a risk to the patient and staff (Trzepacz & Kennedy, 2005).
Dementia. For the most part, therapeutic work with dementia patients is not intended to produce permanent change, but rather temporary gains in daily functioning, affect, and behavior (Zarit & Leitsch, 2001). Cognitive rehabilitation techniques for persons with dementia are used to optimize residual functioning (Lichtenberg & Duffy, 2000). Verbal communication remains important with severely impaired individuals because it is emotionally meaningful to them due to the nonverbal and subvocal aspects of these exchanges, and memory of affective experiences remains when cognitive recall does not (Forrest, 2008; Lichtenberg & Duffy; Werezak & Morgan, 2003). Dementia patients continue to experience emotions, and these emotions in turn affect their behavior (Werezak & Morgan). Treatments, such as pet therapy, music therapy, and touch therapy, have a calming effect on dementia patients, reducing agitation and therefore dysfunctional behaviors (O’Donnell et al., 2001). Even with the most severely impaired individuals, comfort and sensual pleasure can increase quality of life and should be provided as part of care (O’Donnell et al.). Adapting the physical environment for clients with dementia is important in reducing disorientation, confusion, and agitation (O’Donnell et al.; Werezak & Morgan). This is achieved through reducing over-stimulation and setting up an environment that promotes orientation, a sense of control, and social interactions (O’Donnell et al.; Werezak & Morgan). Behavioral interventions with dementia patients typically follow an ABC model – Antecedent, Behavior, Consequence (Zarit & Zarit, 2007). Once the triggers of the behavior have been identified, these can be avoided in order to prevent the behavior from occurring (Ford & Urban, 1998; Logsdon et al., 2006; Zarit & Zarit). Problem behaviors may also be maintained through the positive consequences that follow them. Therefore, identifying and removing this reinforcement should decrease the behavior (Ford & Urban; Zarit & Zarit).
Amnestic Disorders. Internal memory strategies aimed at the recovery of lost function work through the same neurological reorganization mechanisms as remediation of other cognitive deficits (Cicerone, 2007). Through a rehabilitation program, remaining memory functions can replace those that have been lost (Cicerone; Franzen & Lovell, 2008). For example, visual imagery strategies may be used with patients that have impairments in verbal memory (Frazen & Lovell). With clients with severe amnesia, internal strategies are typically ineffective (Cicerone). Therefore, in these cases, and to compliment internal strategies in milder cases, external and compensatory strategies are common. These work through providing an immediate external reminder or cue – they do not require the client to use his or her memory to remember when or how to complete particular tasks (Cicerone; Dobkin, 2000; Franzen & Lovell; Troyer et al., 2007).
Mental Disorders Due to a General Medical Condition and Substance-Induced Disorders. Organic disorders falling under these two categories are addressed by treating the underlying etiology. Once the condition that is causing the neurological issue is eliminated, symptoms typically disappear (APA-psychiatry, 2000, 2006; Doctor, 2008). The mechanisms underlying treatments that may be used for remaining long-term effects, such as cognitive or memory impairment, are discussed elsewhere in the current section.
36.3 14.3 Basic Competencies of the Clinician
At a minimum, psychologists should be familiar with the signs and symptoms of organic disorder so that they can appropriately refer clients to certified clinical neuropsychologists. Psychologists wishing to work with patients with a range of organic disorders require knowledge in both neuropsychology and geropsychology due to the high incidence of these disorders in the elderly (Haley & Mangum, 1999; Lipowski, 1980, 1984; Seltzer & Sherwin, 1978; Taylor, 2007). If a clinician chooses to work with particular subtypes, depending on their nature, he or she may choose to focus on one field and supplement particular areas with knowledge from the other. For example, clinical neuropsychologists may choose to focus on geriatric neuropsychology, integrating competencies from geropsychology into their established knowledge of neuropsychology (Hannay et al., 1998). However, if a clinician wishes to work in pediatric neuropsychology, specialized knowledge of geropsychology is not necessary.
Competency in both neuropsychology and geropsychology will be covered in the following sections. It is assumed that practitioners already possess competency in general clinical practice in psychology.
Neuropsychology. Clinical neuropsychology is recognized as a practice specialty, and thus even basic competence requires specialized knowledge and training (Hess & Hart, 1990). Because clinical neuropsychology stems from the integration of clinical psychology and neuroscience, competent practice in this domain requires knowledge and skills in both areas (Hess & Hart). For a psychologist to work ethically with patients with organic disorders, he or she must have knowledge of brain function and organization, psychopathology and systemic pathology, clinical interviewing and history taking, a variety of assessment instruments and techniques of administration, specific interventions pertaining to this population, pharmacology, consultation, patient education, ethics, and effective strategies for working with families and institutions such as hospitals and schools (American Psychological Association [APA-psychology], 2008b; Bush, 2007; Hess & Hart). Psychologists who wish to practice with this population should have formal training in these areas. For example, the clinical interview alone requires a history of varied experience in neuropsychological assessment and in-depth knowledge of neuropsychology (Strauss et al., 2006).
Geropsychology. Although licensed psychologists possess skills that can be applied to their work with older adults, ethical standards dictate that psychologists working with this population should have some prior training and, ideally, supervised experience (APA-psychology, 2004; Haley & Mangum, 1999; Qualls, 1998; Zarit & Zarit, 2007). Basic knowledge may be obtained through self-study, graduate training, or continuing education (Qualls). At a minimum, such training should include information on psychopathology and the psychological, biological, and social changes that accompany aging, such as cognitive and sensory deficits, developmental issues, and physical illness (APA-psychology; Lewinsohn, Teri, & Hautzinger, 1984; Qualls; Zarit & Zarit). Clinicians should be familiar with the tests and procedures used to assess for, and diagnose, organic disorders in older adults, and should be aware of how to optimize conditions for testing with this population in order to obtain valid results (APA-psychology; Haley & Mangum; Lewinsohn et al., 1984; Zarit & Zarit). Psychologists should know how to tailor therapy to client characteristics through techniques such as pacing and accommodating sensory deficits (Lewinsohn et al.; Zarit & Zarit). They should also be familiar with specific interventions that have been shown to be appropriate with older adults with organic mental disorders (APA-psychology; Lewinsohn et al.). The clinician should have a basic understanding of pharmacology as it applies to organic disorders, and the potential effects of different medications on symptom presentation (APA-psychology). When working with this population, it is particularly important for clinicians to monitor their potential age-related biases (APA-psychology; Zarit & Zarit). Negative stereotypes may lead to over-pathologizing and unreasonably low expectations for therapeutic success, decreasing the quality of treatment and prevention (APA-psychology). On the other hand, some practitioners may tend toward a positive bias, minimizing negative attributions and thus preventing effective treatment (APA-psychology; Zarit & Zarit). Multicultural competency is crucial in working with this population as well, as factors such as sexual orientation, ethnicity, gender, and socioeconomic status may influence symptom presentation and how assessment and treatment should be addressed (APA-psychology). A key factor in basic competence is being able to distinguish between clients who can be treated by the generalist versus those that should be referred to an expert in geropsychology (APA-psychology; Qualls).
36.4 14.4 Expert Competencies of the Clinician
Neuropsychology. Clinical neuropsychology is a practice specialty that is regulated by the American Board of Clinical Neuropsychology (ABCN) under the American Board of Professional Psychology (ABPP; ABPP, n.d.). A diploma from the ABCN is the primary credential recognizing a practitioner’s competence in clinical neuropsychology (ABCN, 2007; ABPP, n.d.). Clinical neuropsychologists have expertise in using assessments and interventions with clients based on their knowledge of human behavior as it relates to normal and abnormal functioning of the central nervous system (American Academy of Clinical Neuropsychology [AACN], 2007; Hannay et al., 1998). Specialists in neuropsychology have in-depth knowledge in the core domains of this field of practice, including consumer protection, assessment, supervision, intervention, research, professional development, and consultation (Hannay et al.; Hess & Hart, 1990). Clinical neuropsychologists possess specialized knowledge of neuroimaging, neuropsychology of behavior, neuroanatomy, neurochemistry and psychopharmacology, neuropathology, effects of systemic conditions on the central nervous system, and the etiology, symptom expression, prognosis, and treatment of neurological and related disorders (AACN; APA-psychology, 2008b; Hannay et al.; Hess & Hart). Their clinical knowledge includes neuropsychological research design and analysis, neuropsychological assessment and intervention, practical implications of neuropsychological disorders, and professional and ethical issues in neuropsychology (APA-psychology; Bush, 2007; Hannay et al.; Hess & Hart). Ethical issues of particular importance include autonomy, informed consent, issues in third party assessments, confidentiality, and test security (AACN; Bush). Clinical neuropsychologists have practical skills in a variety of areas. Within the domain of assessment, practitioners are proficient at gathering information and history taking, selecting assessment instruments, administering and scoring assessment tools, obtaining and integrating multiple sources of information, interpreting assessment results, providing diagnoses (differentiating between organic and psychogenic disorders, as well as between different etiologies of neurogenic disorders), writing up reports, planning treatments, and giving feedback to clients and/or their families (AACN; APA-psychology; Hannay et al.; Hess & Hart). In formulating a diagnosis, they are also aware of any factors that could potentially exacerbate or ameliorate the patient’s presenting issue (AACN). In terms of treatment, neuropsychologists are able to specify intervention targets and needs, implement an intervention plan, and assess treatment outcome (APA-psychology; Hannay et al.). Some primary neuropsychological interventions include cognitive remediation, psychoeducation, psychotherapy, cognitive retraining, and environmental manipulation (APA-psychology). In both assessment and intervention with neuropsychological issues, practitioners must remain aware of cultural, disability, linguistic, and other socioeconomic and demographic variables, individualizing their work with the client accordingly (AACN; APA-psychology; Bush; Hannay et al.). Particularly with assessment, these factors may affect the meaning of test results or the tests may not be valid for the population, in which case supplementary information must be obtained (AACN). Competency is also required in the areas of consultation, research, teaching, and supervision (Hannay et al.). Once competence has been established clinical neuropsychologists should frequently engage in continuing education activities in order to maintain it (AACN; Bush; Hannay et al.). A key source that will assist in maintaining currency in this area in the immediate future is the revision of Lishman’s (1998) classic text, scheduled to be published in 2009 (David et al., 2009).
Geropsychology. Clinical geropsychology is recognized as a practiced proficiency by the American Psychological Association, and signifies a higher level of competence than basic (APA-psychology, 2008a; Qualls, 1998). Although practitioners who are proficient in geropsychology are not considered experts, they have a high level of competence in working with this population, and constitute the majority of psychologists providing services to older adults (Qualls). According to the American Psychological Association, practitioners with this proficiency provide consultation, assessment, and intervention services to older adults in regard to a number of issues, such as capacity for decision making, behavioral problems, problems in daily living, and psychopathology. To be recognized as having this proficiency, one must have specialized knowledge in research and theory on aging, biological aspects of aging, social and psychological aspects of aging, and cognitive psychology, particularly in regard to normal and abnormal changes in cognition (APA-psychology, 2004, 2008a). Geropsychologists have a thorough understanding of assessment instruments that are psychometrically suitable for older adults, and are familiar with the theories and research behind them (APA-psychology; Haley & Mangum, 1999). They are comfortable with, and skilled at, gathering information from informants for assessment and treatment purposes (APA-psychology). These clinicians know how to accommodate sensory impairments, and any other potentially interfering factors, in order to obtain valid assessment results (APA-psychology; Zarit & Zarit). They have thorough knowledge of evidence-based treatment approaches with this population, as well as interventions that may be used with caregivers and families (APA-psychology). Some distinctive interventions with this population include psychoeducation for caregivers, reminiscence therapy, expressive therapies, and grief therapy (APA-psychology). Geropsychologists know how to work within an interdisciplinary team, and are familiar with the role of each discipline, particularly within residential and inpatient settings (APA-psychology). They are familiar with psychotropic drugs and other types of medication, and their potential to interact with each other and with organic disorders (APA-psychology). Practitioners with this proficiency typically have some knowledge about behavioral medicine, such as how factors like nutrition and exercise can affect mental health in older adults (APA-psychology; Lichtenberg & Rosenthal, 1994). Geropsychologists should have worked through any biases or attitudes they previously held toward the elderly, and therefore have a realistic perception of the abilities and vulnerabilities of older adults (APA-psychology). They are knowledgeable in cross-cultural factors pertinent to the therapeutic process, and familiarize themselves with cohort experiences and how they may affect treatment (APA-psychology). Psychologists at this level of competence are aware of the common ethical issues pertaining to working with older adults, such as informed consent, confidentiality, and conflict of interest between the client and his or her legal guardian in making treatment decisions (APA-psychology; Whitehouse, 2000; Zarit & Zarit). They are also able to deal with such issues effectively (APA-psychology). Knowledge about ethics and legal issues related to death is important as well (APA-psychology). Finally, geropsychologists must remain current in their knowledge of new developments in the field through continuing education (Haley & Mangum).
With difficult cases, practitioners with proficiency in clinical geropsychology may need to consult a specialist with expertise in the area (Qualls, 1998). Because clinical geropsychology is not formally recognized as a specialty, expertise is determined through an informal process (Qualls). Expert status is reserved for those professionals who “devote their careers to advanced practice, research, and training in geropsychology” (Qualls, p. 24). These practitioners advance the field through setting standards for practice, providing consultation, training clinicians at the proficiency and specialty levels, and contributing to the development of new knowledge in the field (1998). Typically a clinician must be considered an expert to work as a mental health consultant in an institutional setting (Zarit & Zarit, 2007). Not only are specialized knowledge and skills required, but the therapist must also know how to function within a greater system that includes working with a variety of disciplines (Zarit & Zarit). For more information on working as a consultant in a geriatric inpatient or residential setting, see Zarit and Zarit.
36.5 14.5 Transition from Basic Competence to Expert
Neuropsychology. Because expert competency in clinical neuropsychology is formally acknowledged when a practitioner has obtained specialist certification from the ABPP, the process of developing expert competence in the field is aligned with fulfilling the requirements of this diploma. General requirements and recommendations for obtaining certification are described below. Please note that specific eligibility criteria may differ based on certain individual factors, such as when the person received his or her doctorate (ABCN, 2007; ABPP, n.d.).
Specialization is built upon existing clinical competency in a health service delivery predoctoral program (APA-psychology, 2008b; Hannay et al., 1998; “Reports of the INS,” 1987). Therefore, training is obtained either through specialty programs at the predoctoral and internship levels or through postdoctoral training in a specialized clinical neuropsychology program (AACN, 2007; ABPP, n.d.; APA-psychology; Hannay et al.; “Reports of the INS”). Continuing education is not adequate for establishing competence in clinical neuropsychology (AACN; Hannay et al.). To be eligible for certification, practitioners must possess a doctorate in psychology and have obtained the equivalent of 3 years of experience in clinical neuropsychology and 2 years of supervision in the area, either through a graduate internship or through a postdoctoral residency equivalent to 2 years of full-time education and training (AACN; ABCN, 2007; Hannay et al.; “Reports of the INS”). For graduate students wishing to specialize, internships should be completed through a CPA or APA accredited program (ABPP, n.d.; Hannay et al.), and may be initiated following 2 years in a Ph.D. program in clinical neuropsychology or clinical, counseling, or school psychology (“Reports of the INS”). Practicing clinicians wanting to specialize must have a Ph.D. in one of these areas, or have achieved equivalency through postdoctoral respecialization (“Reports of the INS”). The internship or residency should involve direct neuropsychological services for at least 50% of the time, with interns spending at least 20% of their time in general training in clinical psychology, and postdoctoral practitioners devoting at least 25% of the time to clinical research (“Reports of the INS”). Internships and residencies should be associated with a hospital setting that has neurological/neurosurgical services, as a psychiatric setting alone will not offer the same degree of experience in neurology (“Reports of the INS”). Practicum training must include training in neurological diagnosis, consultation to neurological/neurosurgical services, consultation to psychiatric or medical services, consultation to clients and referral sources, neuropsychological interventions, and neuropsychological assessment, interpretation, and report writing (“Reports of the INS”). Experiential training should occur in each of these areas, with sufficient exposure to work with neurological patients as well as patients with psychiatric conditions and medical patients with neurobehavioral disorders (“Reports of the INS”). Upon completion of the residency or internship, the practitioner is expected to have participated in scholarly activity and is expected to demonstrate advanced knowledge of brain–behavior relationships and advanced skill in assessment, treatment, and consultation with professionals and neuropsychological patients (Hannay et al.; “Reports of the INS”). He or she must also be eligible for licensure for independent practice, as a license is required to apply for certification through the ABPP (ABCN; ABPP, n.d.; Hannay et al.). ABCN then determines if the candidate is eligible for certification, and if the application is accepted, the practitioner completes a written exam, work samples, and an oral exam (ABCN; ABPP, n.d.). For more detailed information regarding eligibility and the application process, see ABCN. Information regarding education and practicum training in clinical neuropsychology may be obtained through the American Psychological Association Division 40 Web site (www.div40.org/training/index.html). For further information on competence in clinical neuropsychology, see Hannay et al.
Geropsychology. There are three primary strategies for obtaining proficiency in geropsychology: continuing education/respecialization programs, readings, and supervised practice (APA-psychology, 2004, 2008a; Qualls, 1998). There are several workshops and conferences that provide continuing education in geropsychology (Qualls). Psychologists in Long-Term Care (PLTC) also provide training to promote development of consultation, therapy, and assessment skills in working with older adults (APA-psychology). On top of pursuing education, psychologists wanting to gain proficiency in geropsychology should consult the published literature within the discipline. Practice handbooks, conference summaries, and books are available for practitioners seeking knowledge on research and practice in the field (Qualls). For a list of some valuable resources in this area, see Psychological Services in Long-Term Care Resource Guide (Duffy, 2006). Qualls has also identified some useful journals, including the Journal of Clinical Geropsychology, Journal of Mental Health and Aging, Clinical Gerontologist, Aging and Mental Health, The Gerontologist, International Journal of Aging and Human Development, and Psychology and Aging. In addition to continuing education and self-study, the practitioner seeking proficiency in geropsychology must obtain supervised clinical experience (Qualls). He or she must have at least 100 h of supervised client contact at the pre- or postdoctoral level of training, including experience in interviewing, assessment, and treatment in a variety of settings (Qualls). Through this experience, the practitioner should become familiar with treatment institutions used by the elderly, and with working with other disciplines frequently involved in the treatment of older adults (Lichtenberg, 1999b; Qualls). For students wishing to pursue a career in this field, training in clinical geropsychology is provided in some graduate programs (APA-psychology; Lewinsohn et al., 1984). Further information on continuing education and training opportunities may be obtained through Division 20 (Adult Development and Aging; apadiv20.phhp.ufl.edu) and Division 12, Section II (Clinical Geropsychology; www.geropsych.org) of the American Psychological Association (APA-psychology; Qualls). For additional details on competency in geropsychology, see Santos and VandenBos (1982).
36.6 14.6 Summary
A variety of diverse mental illnesses are subsumed under the category of “organic disorder.” Although the DSM-IV abandoned this terminology so that all mental disorders would be acknowledged as involving brain function, it remains that the primary feature of this class of disorders is their medical origin. Proper assessment and diagnosis is essential, as leaving organic disorders untreated may lead to further deterioration or death. Most organic disorders are maintained by the underlying biological cause, and thus treatment of that cause is an important factor in ameliorating the condition. However, a biopsychosocial approach to treatment is required to address all symptoms, particularly as organic disorders often have affective and relational consequences as well. Psychotherapy and cognitive rehabilitation strategies have been shown to be effective with a variety of acute and chronic organic disorders. Although therapeutic interventions with chronic degenerative conditions, such as Alzheimer’s dementia, cannot produce permanent change, they can optimize the person’s functioning and increase quality of life. In other cases, such as moderate amnesia, memory functions that have been lost may be recovered through neurological reorganization. Each individual case is unique depending on the factors involved in the damage and other personal, relational, and environmental traits. Thus, clinicians that practice with this heterogeneous population must be very knowledgeable and experienced. Unless they choose to specialize in a particular area of neuropsychology, practitioners should have competence in both geropsychology and neuropsychology. Maintenance of competence in this area is vital, as research in this field continues to grow. We are bound to see continuing developments in this area as our knowledge of organic and other psychiatric illness increases.