Psychiatric disorders, functional neurological disorders and epilepsy Flashcards
What percentage of the EU population suffer from a mental disorder?
38%
What is the hypothesis of schizophrenia?
Disorder of the pre-frontal cortex, hypothesis is there is an excess of dopamine
What are the two pathways in the brain that dopamine is involved in?
Mesocortical pathway (ventral tegmental to cerebral cortex). Helps in cognition and executive function
Mesolimbic pathway (ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia). Helps in regulation of emotional behaviour
What are the symptoms of schizophrenia?
Delusions, hallucinations, disorganised thought, speech and behaviour, logia (lack of conversation) and abolition (lack of motivation)
What is the lifetime prevalence of depression?
Men 12%
Women 20%
What is the hypothesis of depressive disorders?
Disorder of limbic function (disruption in balance of reward and emotion)
Hypothesis= monoamine deficiency
How is depression treated?
Diet
Exercise
Drugs (SSRI, SNRI, TCA)
Psychotherapy
What is the hypothesis on anxiety disorders?
Disorder of limbic function, central role of amygdala- signalling is increased and has an overwhelming effect on PFC
What is treatment for anxiety?
Psychotherapy and drugs (SSRI, SNRI, TCA)
What are the 3 main clusters of personality disorders?
(a) odd/eccentric= paranoid, schizoid (avoid social activities)
(b) dramatic/emotional/erratic= antisocial, borderline, narcissistic and histrionic
(c) anxious/fearful= avoidant, obsessive compulsive and dependant
What is a functional neurological disorder?
- FND describes a disorder of the voluntary motor or sensory system with genuine systems including paralysis, tremor, dystonia, sensory disturbance (including visual loss), speech symptoms
- The hallmark is that such symptoms can be positively identified as internally inconsistent with recognised pathophysiological disease
- Functional neurologic disorder is related to how the brain functions, rather than damage to the brain’s structure
What is a functional disorder?
Where symptoms cannot be positively identified as internally consistent with recognised pathophysiological disease
What percentage of medical symptoms are ‘unexplained’?
30%
What is the Gordian knot and what are the different factors in it?
Helps identify where symptoms are coming from:
How do you diagnose a functional neurological disorder?
Make a list of all physical symptoms and consider all other pathological disease triggers including pain, injury
Make a diagnosis on the basis of positive physical symptoms and a familiar history NOT because the scan is normal
What are dissociative disorders?
Mental disorders that involve experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity.
Why can pain cause functional neurological disease?
Pain has an enormous attentional salience so there is consequences for cognitive capacity and sensory processing accuracy
Why can disability/disease cause functional neurological disease?
Models in PFC are plastic- if a leg is immobilised for a period the brain learns to expect that it will not move when standard voluntary pathways are activated. The model can persist after the immobilisation is removed.
What factors can trigger functional neurological disorders?
- Pain
- Disability
- Disease
- Mood disorders
How are functional neurological disorders treated?
Addressing the precipitating and sustaining factors:
- Pain
- Underlying disease and disability
- Mood disorders
- Reconditioning
Explain the condition, explain what rather than why as cause is often complicated/ we do not know
What is a seizure?
An abnormal excessive firing of brain cells
What is epilepsy?
The tendency to recurrent, abnormal spontaneous firing of neurones (having seizures)
What are some provoking factors for epilepsy?
Hypoglycaemia
Electrolyte imbalance
Acute head injury
Drug abuse
Alcohol withdrawal
What are some of the social factors that affect people with epilepsy?
Employment opportunities
Driving
Embarrassment/reduced confidence
Social prejudice
What are some morbidities that can arise for people with epilepsy?
Injuries
Side effects of anti-epileptic drugs
Aspiration (loss of swallow reflex)
Cognitive decline
Depression and psychosis (bi-directional)
What are the 3 main categories of epilepsy?
What different categories are focal onset seizures classified into?
Classified into whether awareness is there (aware or impaired) and whether it is motor or non-motor
What two categories are generalised and unknown onset seizures split into?
Motor and non-motor
How can the different types of epilepsy be classified?
Useful to classify in a 2x 2 grid;
Is it focal or generalised as well as idiopathic or symptomatic
(idiopathic= lack of eitiology, usually genetic)
What types of epilepsy are generalised idiopathic?
Childhood absence epilepsy
Juvenile myoclonic epilepsy
Commonly develop in childhood- genetic
What are some examples of focal symptomatic epilepsy?
Temporal lobe epilepsy
Frontal lobe epilepsy
Occipital lobe epilepsy
What are the risk factors for epilepsy?
Family history, significant head injuries, encephalitis/meningitis and febrile convulsions
What is important is getting in the history of a patient presenting with epilepsy?
Pre event history= warning ‘aura’
During event= eyewitness and patient’s point of view
Post event
What are the tests for epilepsy?
There is no test, we test the cause of the seizures (MRI/CT) and then classify the syndrome (EEG- recording of brain waves)
What is the treatment for a single seizure?
Typically no treatment- it is common to have another seizure though so treatment may be an option
How well do anti-convulsant drugs work?
70% respond with 1 AED
80% with 2 AEDs
85% with 3 AEDs
Leaves 15% unable to be treated with AEDs
What option is there for patients who do not respond to anti-convulsant drugs?
Epilepsy surgery- however is a 1% risk of stroke or death
How do you distinguish between seizures and syncope?
Identifiable triggers are associated with syncope and seizures tend to have a longer duration than syncope and are followed by postictal confusion and significant fatigue
What is a seizure?
A seizure is a short episode of symptoms caused by abnormal electrical activity in the brain
What is a tonic clonic seizure?
Tonic-clonic seizures involve both stiffening and twitching or jerking of a person’s muscles.
What are some symptoms of a focal seizure?
Aura, automatism, lip-smacking, plucking at clothes, hair, abnormal taste and smell, nausea, unreality or deja vu fear.
What are the different classifications of epilepsy?
Focal
Generalised
Unclassified
What are some of the common factors that trigger epilepsy?
Inadequate sleep
Alcohol abuse
Medications such as antidepressants
Menstrual cycle
What are the DVLA rules for epilespy?
You must tell DVLA if you’ve had any epileptic seizures or blackouts.
You must stop driving straight away.
You can reapply if you haven’t had a seizure for at least a year for epilepsy
If it was a one off seizure, can drive again after a seizure-free 6 months
What category is a tonic-clonic seizure?
Generalised seizure
What is absence seizure?
In absence seizure- with this type of seizure you have a brief loss of consciousness or awareness. Usually occurs in children
What is a myoclonic seizure?
A myoclonic seizure is caused by a sudden contraction of the muscles, which causes a jerk. These can affect the whole body but often occur in just one or both arms.
What is a tonic seizure?
A tonic seizure causes a brief loss of consciousness and you may become stiff and fall to the ground.
What is a atonic seizure?
An atonic seizure causes you to become limp and to collapse, often with only a brief loss of consciousness.
What are simple and complex focal seizures?
Simple- simple actions such as an odd taste, pins and needles or muscular jerks
Complex- commonly arise from temporal lobe. May fiddle with an object, wander aimlessly, have odd emotions
What is a secondary generalised seizure?
Sometimes a focal seizure develops into a generalised seizure. Known as secondary generalised seizure
What is syncope?
Syncope is defined as transient loss of consciousness (TLoC) due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery
What are the causes of syncope?
Vasovagal syncope
Emotional
Carotid sinus hypersensitivity- occurs when rotating the head
Post exercise
Medications
Vomiting, diarrhoea
Haemorrhage
Cardiac arrythmias
What is recovery from syncope like?
Almost immediate restoration of appropriate behaviour and orientation but there may be marked fatigue.
What are differential diagnosis of syncope?
Falls/trauma
Epilepsy
Alcohol/drug missuse
Nacroplexy
What is narcoplexy and cataplexy?
Narcolepsy is a rare long-term brain condition that causes a person to suddenly fall asleep at inappropriate times
Most people who have narcolepsy also experience cataplexy, which is sudden temporary muscle weakness or loss of muscular control.
What investigations should be done in a patient who presents with syncope?
- ECG: there may be evidence of ischaemia or arrhythmias.
- Fasting blood glucose, if hypoglycaemia is a possibility
- FBC if anaemia or bleeding is suspected (acute anaemia will cause syncope)
- Orthostatic blood pressure measurement.
