2 - MENTAL HEALTH & DYSEXECUTIVE SYNDROMES

Question 1

EXAMPLES OF + & - STRESS

Answer 1

Table

Question 2

Stress & HPA axis

Answer 2

Image

How stress affect learning, behavior… (aCC → dlPFC, mPFC…)

Question 3

Long term adaptations to stress

Answer 3

Image

Decrease BDNF => decrease neuroplasticity
Increase EPI => Increase NE => At some point, decrease attention
Free radical => + time => oxidative stress => increase neurotoxicity
After 10 days => anatomical changes in AM
CA1 = primary part of cornu ammonis => part of hippocampus => snail form

Question 4

TBI:
- acronym
- other name
- recap
- symptoms
- duration
- incidence

Answer 4

Traumatic brain injury

other name of concussion

Recap concussion
- Internal forces vs external one
- 2 to 3 weeks headache, normal => after not normal => post-concussion syndrome

Symptoms
- Worsening headaches
- Light & sound hypersensitivity
- Sleep disturbance
- Attention & working memory issues
- Anxiety
- Depression

Duration
- Symptoms usually last for 7 to 10 days
- Some patients may still present symptoms after 90 days
- Persisting for longer than 2-3 weeks: PCS
- Impact on ADLs
- Impact on interpersonal relationships
- Impact on professional pathway

Incidence & distribution
- Incidence similar for both sexes
- Women usually experience exacerbated symptoms
- Likely related with level of progesterone, with women that presented higher level at event of injury showing lower scores in executive functions one month after injury
- History of TBI related to increased lifetime occurrence of MDD up to 26%

Question 5

Most common issues:
- affective disorders
- stress-related

Answer 5

Affective disorders
- MDD (Major Depressive Disorder)
- Bipolar (manic / depressive)
- Euthemyc bipolar

Stress-related
- GAD (General Anxiety Disorder)
- SAD (Seasonal Affective Disorder)
- PTSD (Post-Traumatic Stress Disorder)
- SpPh (Specific Phobia)

Question 6

Affective disorders:
- biological symptoms
- psychological symptoms

Answer 6

Biological symptoms
- Sleep disorders
- Constipation
- Eating disorders

Psychological symptoms
- Unstable mood
- Anxiety & irritability
- Motivation & isolation
- Hypochondria
- Attentional disorders
- Memory impairment
- Delusional guilt
- Suicidal thoughts
- Idiopathic pain
- Fatigue

Question 7

Depression in TBI

Answer 7

Patients with TBI & depression are:
- Older
- More likely to be socioeconomically disadvantaged
- Have lower marital rates & higher unemployment rates
- Similar Glasgow Coma Scale scores & injury severity
- Lower Abbreviated Injury Scale scores but comparable cognitive & social measures

Question 8

Executive functions:
- depend on
- background concepts
- syndromes affect functioning most perceived by:

Answer 8

EXECUTIVE FUNCTIONS
Executive functions depending on cognitive abilities

Background concepts
Refers to group of cognitive operations supported by overlapping neural networks, essential for managing
information & managing oneself
- Attention
- Working memory
- Self-control
- Response inhibition

IMAGE

Syndromes affecting executive functions in TBI patients very common. They affect functioning in way that is most perceived by:
- Lack of motivation
- Diminished attention
- Diminished inhibitory control
- Impaired ability to access memory
- Impaired ability to consolidate memory
- Impairment in anticipation
- Difficulty in goal selection
- Difficulties in planning
- Delayed sequencing motor behavior
- Impairment in visuospatial processing
- Deficit in verbal / non-verbal expression

Question 9

Dysexecutive syndromes

Answer 9

dlPFC syndrome
OFC syndrome
mPFC syndrome
SMA syndrome

Question 10

dlPFC syndrome description

Answer 10

dlPFC syndrome
- Non-dominant dlPFC mostly affected as part of DEN
- Often observed in frontal contusion & cases of severe concussion
- Patient profile
o Abulia: pathological difficulty to make decisions or act on procedures
o Apathy: lack of interest or enthusiasm in activities previously enjoyed
o Psychomotor slowing: slower voluntary movements & automatic reactions
o Preservation: inability to construct different strategies to substitute one not effective

Question 11

OFC syndrome description

Answer 11

OFC syndrome
- Orbital cortex severely damaged, including mPFC, affecting mostly social behavior & decision making
- Patients often described as “going through personality changes” after concussion or CTE
- Patient profile:
o Childlike euphoria
o Facetious humor
o Shallow affect
o Social disinhibition
o Impulsivity
o Distractibility
o Difficulty maintaining set

Question 12

mPFC syndrome description

Answer 12

mPFC syndrome (working memory)
- More common in cases of vascular damage (EDH / SHD / ICB) from multiple etiologies, with
executive component of movement processing being damaged
- Patient profile:
o Paucity of spontaneous movement often seen in gesticulation
o Sparse verbal output, with preserved repetition
o Loss of movement control (spasticity) & sensitivity in lower extremities
o Incontinence

Question 13

SMA syndrome

Answer 13

SMA syndrome
- Most common after tumor resection & lobotomy, but sometimes seen after vascular injuries
- Symptoms usually transient, lasting days to weeks
- Patient profile:
o Hemiparesis
o Speech impairment (depending on laterality)
o Hesitancy in movement & speech
o Planning & navigation deficit

Question 14

DSM 5 - DISRUPTIVE MOOD DYSREGULATION DISORDER

Answer 14

DISRUPTIVE MOOD DYSREGULATION DISORDER
A. Severe recurrent temper outbursts (verbal/behavioral), grossly out of proportion
(intensity/duration)
B. Temper outbursts are inconsistent with developmental level.
C. Tenmper outbursts (on avarege) 3 or more times/week.
D. Mood between temper outbursts: irritable or angry.
E. A to D have been present for 12 months or more
F. A to D are present in at least 2 of 3 settings.
G. Diagnosis should not be made before the age of 6.
H. Age of onset of symptoms should be before 10 years old.
I. J. & K. differential diagnostic and exclusion of other conditions or pharmacological reasons

Question 15

DSM 5 - MAJOR DEPRESSIVE DISORDER

Answer 15

MAJOR DEPRESSIVE DISORDER
A. 5 or more of the following, most of the day, nearly every day:
• Depressive mood
• Markedly diminished interest/pleasure, in almost all activities
• Significant weight loss when not dieting or weight gain. Change in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive/inappropriate guilt
• Diminished ability to concentrate, or indecisiveness
• Recurrent thoughts of: death, suicidal ideation, planning, attempt
B. Symptoms cause significant distress or impairment in social, occupational, or other life aspect
C. Episode is not attributed to other physiological or substance-related event
D. and E. depressive episodes not attributed to other mental health condition

Question 16

DSM 5 - GENERALIZED ANXIETY DISORDER

Answer 16

A. Excessive anxiety & worry over more days than not, for at least 6 months, about several events &
activities
B. Difficult to control worry.
C. Anxiety and worry are associated with 3 or more* of the following: - Restlessness
- Being easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
D. Anxiety, worry, or physical symptoms cause clinically significant distress or impairment in ADL
E. and F. Not attributed to substance use, or other medical conditions

Question 17

DSM 5 - POST TRAUMATIC STRESS DISORDER

Answer 17

POST-TRAUMATIC STRESS DISORDER
A. Exposure to actual or threatened death, serious injury, or sexual violence in one of following ways:
• Directly experiencing trauma
• Witnessing in person event occurring to others
• Learning that event occurred to close family member or close friend.
• Experiencing repeated or extreme exposure to adverse details of traumatic events (not
electronic media)
B. Presence of at least one intrusion symptom:
• Recurrent, involuntary, & intrusive distressing memories
• Recurrent distressing dreams
• Dissociative reactions
• Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize traumatic events
• Marked psychological reactions to internal or external cues that symbolize traumatic events
C. Persistent avoidance of stimuli associated with traumatic event, as evidenced by at least one of
following:
• Avoidance or efforts to avoid distressing memories, thought, or feelings about trauma
• Avoidance or efforts to avoid external reminders
D. Negative alterations in cognition/mood, evidenced by two or more of the following:
• Dissociative amnesia (not accounted for head injury or drugs)
• Persistent and exaggerated negative beliefs or expectations about oneself or others
• Persistent, distorted cognitions about cause or consequences of traumatic event (blame)
• Persistent negative emotional state
• Diminished interest or participation in significant activities
• Detachment or estrangement from others
• Inability to experience positive emotions
E. Alterations in arousal & reactivity associated with traumatic event, evidenced by at least two of
following:
• Irritable behavior and angry outbursts (with little or no provocation)
• Reckless or self-destructive behavior
• Hypervigilance
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance
F. Duration of disturbance is more than one month.
G. Disturbance causes clinically significant distress or impairment in social, occupational, or other
functioning area.
H. Exclude effects of substances & other mental health condition