Consciousness

Question 1

Consciousness define

Answer 1

Is a state of awareness of the self and the environment

Question 2

What are the 3 dimensions of unconsciousness

Answer 2

Coma - clouding, drowsiness, sopor
Deep sleep- stages of sleep
Unconscious mind- preconscious

Question 3

Normal consciousness to coma

What is clouding

Answer 3

Drowsiness/agitation with memory disturbance and disorientation
Impaired attention, concentration, recognition, comprehension, understanding and judgement

Question 4

Normal consciousness -> coma

What is drowsiness

Answer 4

Tendency to drift into sleep without sensory stimulation

Slow actions, slurred speech, reduced reflexes and muscle tone

Question 5

Normal consciousness-> coma

What is a coma

Answer 5

Reduced eye opening, verbal response and motor response

Question 6

Some characteristics of normal perception

Answer 6

We can distinguish perceiving with our sense organs from imagining the same objects
When we perceive something we realise it’s possible relevance to our emotions and actions
Normal sensation has a quality of objectivity
The observer feels certain that the object exists even if no one else is experiencing it at the same time
Experience of object perception is involuntary
Quality of independence

Question 7

Abnormal perception

Answer 7

Sensory distortions
- intensity and quality of perception and associated feelings 
False perceptions 
- illusion 
- hallucinations
-pseudohallucinations

Question 8

Illusions.

Answer 8

Complete illusions - you fill in the missing gaps
Affect illusions - these are dependent upon an individuals mood state
Pareidolic illusions - these illusions arise due to excessive fantasy thinking

Question 9

Hallucinations

Answer 9

A perception-like experience

• in the absence of an external stimulus
• which has the full force and impact of real perception
• which is unwilled, occurs spontaneously, and cannot be readily controlled by the subject

Question 10

Sleep

Answer 10

Sleep is a complex physiological process - not simply the absence of waking it is a special activity of the brain controlled by elaborate and precise mechanisms

Question 11

Sleep behavioural definition

Answer 11

Recurrent regular reversible state characterised by quiescence and dismissed responsiveness to external cues

• lack of mobility.
• closed eyes.
• reduced response to external stimulation
• characteristic sleeping posture
• reversible unconscious state

Question 12

Sleep measurements

Answer 12

EEG 
Eye movements
Muscle tone 
Polysomnography 
- eeg, eye movements and muscle tone

Question 13

Sleep- neurophysiological definitions brain activity measured by EEG

Answer 13

Wakefulness eyes open beta rhythm 
Eyes closed alpha rhythm 
Sleep 5 phases - non R.E.M. 
1 alpha waves alpha theta transition 
2 sleep spindle, k complex 
3 delta waves 
4 delta waves 
R.E.M. 
Theta waves PGO waves R.E.M. Atonia
Sympathetic tone increased 
4-6 cycles a night ~90 min
R.E.M. Duration increased with every cycle

Question 14

Physiological determinants of sleep

Answer 14

Sleep drive in the homeostatic forebrain

Circadian drive - supra chiasmatic nucleus

Question 15

Circadian rhythms

Answer 15

Clock genes - Bmal 1 only non redundant clock gene: deletion causes immediate loss of circadian rhythm in constant darkness no resting by light
Autonomous tissue specific oscillators in mammals
SCN,liver, heart demonstrates oscillations and clock gene expression allows for fine tuning
Autoregulation: maintain oscillatory mechanism using transcriptional feedback loops to up or down regulate clock settings
Coordination: SCN is master clock synchronising circadian rhythm via neural and endocrine regulators, average free running intrinsic period = 24.18 hrs in humans

Question 16

Causes of excessive sleepiness

Answer 16

Increased sleep drive 
Sleep disruption 
- sleep wake dysregulation 
- circadian misalignment 
- sleep disruption

Question 17

Sleep wake disregulation

Answer 17

Narcolepsy
Idiopathic hypersomnia
Recurrent hypersomnia
Post traumatic hypersomnia

Question 18

Sleep disruptions

Answer 18

Obstructive sleep apnea hypopnoea syndrome 
Depression 
Parasomnias 
R.E.M. Sleep behaviour disorder
PD
MS
Myotonic dystrophy 
Restless leg syndrome 
Periodic limb movement disorder 
Central sleep apnea syndrome 
Central alveolar hypoventilation syndrome

Question 19

Parasomnia - slow-wave sleep disorders

Answer 19

Sleep walking and night terrors : stage 4 non rem sleep arousal disorders
Sleep walking : motor activity - walking independent complex behaviour can occur
Night terrors - scremjnnng, autonomic hyperaeousal sweating, confusion, rapid heart rate
Common in children
Usually unaware of their activity
Aetiology unknown
Risk of injury - forensic aspects
Injury prevention is the primary objective of management

Question 20

Parasomnias - R.E.M. Sleep behaviour disorders

Answer 20

Presence of muscle tone during R.E.M. Sleep associated with active complex behaviours in absence of epileptiform activity
Act out dramatic and or violent uncharacteristic dreams during R.E.M. Sleep
Usually amnesia for voluntary muscle activity but can remember dream
Onset ~90 mins after sleep
Shouting/grunting/assaulting sleep partner

Question 21

Restless leg syndrome

Answer 21

Clinal features
Dysaethesias unpleasant sensations in the legs creeping, crawling, tingling, pulling, pain
Relief With voluntary movement associated motor hyperactivity
Irresistible urge to move the legs
Suppression of activity leads to discomfort

Question 22

Narcolepsy

Answer 22

Fall asleep uncontrollably throughout the day for periods between 1-30mins
Even while engaged in activity
Abnormal sleep pattern: decreased R.E.M. Latency
Classic symptoms include cataplexy, sleep paralysis, and hyponogogic hallucinations

Question 23

Cataplexy

Answer 23

Loss of muscle tone a symptoms of narcolepsy

Question 24

Treatment for narcolepsy

Answer 24

Stimulants
Depression common so this is treated with antidepressants
Sodium oxybate - cataplexy-date rape drug

Question 25

Apnoea

Answer 25

Brief interruptions of breathing during sleep
Apnoeic events - breathing pauses up to 30/hr
Central neural control of breathing not initiated
Obstructive inflow/outflow obstruct airway
Frequent arousal for deep sleep as po2 Dec

Question 26

OSA

Answer 26

Weight loss not sleeping on back
Modafinil last dose midday
Continuous positive airway pressure (CPAP) via mask into nasal passages to keep airway open at 3-18cm water pressure
Surgery to remove obstructions

Question 27

Insomnia

Answer 27

Perception/complaint of inadequate or poor quality sleep 
- difficultly falling asleep 
Waking up frequently 
Waking up too early 
Unrefreshing sleep 
Causes tiredness lack of energy irritability 
Transient <2 weeks 
Intermittent 2-4 weeks 
Chronic >month

Question 28

Insomnia risk factors

Answer 28

Increased age female
Psychiatric disorders - depression, anxiety disorders
Medical disorders - hypothyroidism, pain
Substances caffeine, alcohol, nicotine.
Other shift work exercise, sleep apnoea
Iatrogenic

Question 29

Insomnia- non pharmacological treatments

Answer 29

Avoid exacerbants - caffeine, alcohol, nicotine, exercising within 5-6 hours of sleep , noise or temp extreme, daytime naps
Pleasurable, comfortable, dark, environment
Regular schedule
Reconditioning using bed for sleep only
If can’t sleep for 30+ mins get up do a relaxing activity until sleepy
Cognitive restructuring stop thinking that with on,h a few hours sleep can do nothing when you can function
Relaxation therapy - bath breathing exercises
Sleep restriction - Dec sleep time by an hour to increase sleep drive

Question 30

Insomnia pharmacological interventions

Answer 30

Sedative lowest dose
Nice
BZD and Z drugs both act as BZD agonists but VZD cheaper
Short acting BZD have significant effects

Question 31

Sleep deprivation

Answer 31

European working time directive 2004

Junior dr max shift 13hrs followed by a break of at least 11