tutorial psychia 56
TRANSCRIPT
-
7/30/2019 Tutorial Psychia 56
1/126
Psychiatry tutorial
Surat Tanprawate, MD, FRCP(T)
Division of Neurology, Chiang Mai University
11.05.2013
-
7/30/2019 Tutorial Psychia 56
2/126
Neurology and neuropsychiatry
Neurological disorders that present with cognitive, and
behavioral disfunction: frontal lobe syndrome, temporal lobe
epilepsy, etc.
The disorder that combine neurology and psychiatry
manifestation: Alzhermers disease, Huntingtons disease, etc.
Psychiatric consequence of neurological disease: post-stroke
depression
Functional symptoms in neurology
-
7/30/2019 Tutorial Psychia 56
3/126
Outline
Clinical symptoms a/o syndromes
mood/affect lability, personality alterations, psychosis
(hallucination/illusion), obsessive-compulsive disorder, dissociative
disorder, alter sexual behavior/paraphilic disorder
disorder of consciousness, delirium and dementia, amnestic disorders,
aphasia, alexia, agraphia, apraxia, disorder of visual processing, frontal
lobe syndrome
Common diseases
dementia, movement disorder, epilepsy, stroke, headache
-
7/30/2019 Tutorial Psychia 56
4/126
Clinical
symptoms/syndro
mes
Mood and affect lability
-
7/30/2019 Tutorial Psychia 56
5/126
Lability of mood and affect
Lability of mood
rapid shift of one mood state to another
orbitofrontal cortex dysfunction, basal ganglia disorder(HD)
Lability of affect
sudden changes in emotional expression
eg. pseudobalbar palsy, epileptic seizure
-
7/30/2019 Tutorial Psychia 56
6/126
Pseudobu lbar palsy
Bulbar palsy refers to bilateral
impairment of function of the cranial V,VII, IX, X and XI, which occurs due tolower motor neuron lesion either atnuclear or fascicular level in the medullaroblongata or from bilateral lesions of thelower cranial nerves outside the brainstem
Balbar: LatinBulb: A globular or fusiformanatomical structure or
enlargement.Bulbus: swollen root
The Brainstem
-
7/30/2019 Tutorial Psychia 56
7/126
Pseudobu lbar palsy
Pseudobulbar palsy resultsfrom an upper motor neuronlesion to the corticobulbarpathway in the pyramidal tract.
Symptoms:
-difficulty chewing, swallowing-slurred speech (often initialpresentation)-inappropriate emotionaloutbursts.
Pathological laughing and crying
-
7/30/2019 Tutorial Psychia 56
8/126
QuickTime an d a
H.264 decompressorare needed to see this picture.
Pathological Laughter
-
7/30/2019 Tutorial Psychia 56
9/126
Pathological crying
QuickTime and adecompressor
are needed t o see this picture.
-
7/30/2019 Tutorial Psychia 56
10/126
Distinguishing types of crying:
Pathological crying linked to infarct in basis of pontis and
corticobulbar pathways and occurs in response to mood
incongruent cues.
Emotionalism is crying that is congruent with mood
(sadness) but patient is unable to control crying as they
would have before stroke.
Catastrophic reaction is crying or withdrawal reaction
triggered by a task made difficult or impossible by a
neurologic deficit (e.g. moving a hemiplegic arm)
associated with post-stroke depression
-
7/30/2019 Tutorial Psychia 56
11/126
Epileptic seizure
A gelastic seizure
sudden burst of energy, usually in the form of laughing orcrying
Cause: hypothalamic hamartomas, temporal and frontal lobe
lesion
Frontal lobe and temporal lobe epilepsy
-
7/30/2019 Tutorial Psychia 56
12/126
Personality alteration in neurological disorder
Apathy
FTD, AD, medial frontal lesion, basal ganglia, vascular dementia
Disinhibition
Orbitofrontal lesion, caudate disorder(HD)
Irritability
Orbitofrontal lesion, caudate disorder(HD)
Explosive
Posttraumatic encephalopathy, HD
Plascidity
Kluver-Busy syndrome with bilateral temporal lobe dysfunction
-
7/30/2019 Tutorial Psychia 56
13/126
Clinical
symptoms/syndro
mes
Hallucination and illusion
-
7/30/2019 Tutorial Psychia 56
14/126
Hallucination and illusion
Hallucination=sensory experiences occurring without
stimulation of the relevant sensory organ
Illusion=misperceptions of external events
Hallucinations may involve all sensory modality
Hallucinations: simple (unformed) vs formed
-
7/30/2019 Tutorial Psychia 56
15/126
Visual pathway
Eye
Opticnerves
Geniculocalcarine projections
Occipitalcortex
Temporallobe
-
7/30/2019 Tutorial Psychia 56
16/126
Complex visual hallucination
3 basic underlying mechanism
irritative processes in the association cortex generating
discharges falsely interpreted as due to sensory input
release phenomena due to defective visual input causing faulty
cortical stimulation
faulty visual processing in which inputs are normal but lesionsresult in an inappropriate pattern of cortical excitation
Manford M, and Andermann F. Brain 1998;121, 1819-1840
-
7/30/2019 Tutorial Psychia 56
17/126
Common causes of complex visual
hallucination
Migraine aura
Epilepsy
Charles- Bonnet syndrome
Peduncular hallucinosis
Treated idiopathic Parkinsons
diseaseLewy body
dementiaNarcolepsy-cataplexy
syndromeSchizophreniaDelirium
-
7/30/2019 Tutorial Psychia 56
18/126
a uc na on o e cere racortex
Destructive lesion: release hallucination
Neuronal hyperexcitability: migraine and
epileptic seizure
-
7/30/2019 Tutorial Psychia 56
19/126
A 37 Y.O. man with
abnormal visual
symptoms for 2 weeks QuickTime and adecompressor
are needed to s ee this picture.
Release hallucination from
temporo-occipital lobe
infarct
-
7/30/2019 Tutorial Psychia 56
20/126
Michael B. R. et al. Brain1996: 119, 355-361
n=163
99% 31%
6%
18%
Typical aura:
-Visual
-Sensory
-Speech
Migraine Aura
-
7/30/2019 Tutorial Psychia 56
21/126
Typical aura
Typical aura consisting ofvisual and/or
sensory and/or speech symptoms.Gradual
development, duration no longer than onehour, a mix of positive and negative features
and complete reversibility characterize the
aura which is associated with a headache that
does not fulfill criteria for Migraine withoutaura.
-
7/30/2019 Tutorial Psychia 56
22/126
Typical visual aura is simple
Visual aura
-
7/30/2019 Tutorial Psychia 56
23/126
-
7/30/2019 Tutorial Psychia 56
24/126
Blindness, visual hallucination and
Charles Bonnet syndrome(CBS)
Charles Bonnet, Swissphilosopher whodescribed CBS in 1760
The disease is named after the Swissphilosopher, who described the conditionin 1769.
He first documented it in his 89-year-oldgrandfather who was nearly blind fromcataract in both eyes but perceived men,women, birds, carriages, buildings,tapestries, physically-impossiblecircumstances and scaffolding patterns.
-
7/30/2019 Tutorial Psychia 56
25/126
Charles Bonnet syndrome(CBS)
prevalence: 1%-10%
mentally healthy people with often significant visual loss from eye
or optic pathway
visual hallucination: vivid, complex, recurrent
sufferers understand that the hallucinations are not real
Rx: It usually disappears within a year
SSRI may be helpful
-
7/30/2019 Tutorial Psychia 56
26/126
Peduncular hallucinosis
Hallucination of the midbrain
Described a 72-year-old womans visualhallucination of colorfully dressed people andchildren which occurred at dusk. Thehallucinations occurred during normalconscious state and the patients neurologicalsigns were associated with thosecharacteristic of an infarct to the midbrain and
pons. Von Bogaert, Lhermittes colleague,named these type of hallucinationspeduncular in reference to the cerebralpeduncle as well as to the midbrain and itssurroundings.
LhermitteFrench neurologist
-
7/30/2019 Tutorial Psychia 56
27/126
Visual halluc ination w ith
Park insonism
Parkinsonism is the syndrome including
bradykinesia, plus one of following
resting tremor, cogwheel rigidity, and postural
instability
Parkinsonism can be broadly divided as typical
parkinsonism(Parkinsons disease) and atypicalparkinsonism
-
7/30/2019 Tutorial Psychia 56
28/126
Visual halluc inat ion w ith
Park insonism
Parkinsons disease with visual hallucination
Usually occur in PD who taking levodopa
Atypical parkinsonism
Dementia with Lewy Bodies(DLB)
Parkinsonism, dementia, vivid visual hallucination,
and fluctuation of consciousness
C i f DLB ith AD d PD
-
7/30/2019 Tutorial Psychia 56
29/126
Comparison of DLB with AD and PD
DOUG NEEF.Am Fam Physician 2006;73:1223-9,
-
7/30/2019 Tutorial Psychia 56
30/126
Visual hal lucinat ion in DLB
Psychotic symptoms: 80 % of the patients
Visual hallucination: purely visual, vivid, colorful, 3-dimensional
hallucinations of humans or animals
DLB patient can experience severe reactions to antipsychotic
medications
Treatment
avoid antipsychotic, treat with cholinesterase inhibitors
-
7/30/2019 Tutorial Psychia 56
31/126
Visual halluc inat ion in
schizophrenia
Schizophrenia Organic cause
Animals and figures may beprominent
Usually in colour
with auditory hallucination
occur throughout working hours
less paranoid and thoughtdisorder more insight associated with abnormal
physical signs/symptoms
more often nocturnal, and areassociated with drowsiness
-
7/30/2019 Tutorial Psychia 56
32/126
Complex visual hallucination in focal
epilepsy
usually brief, sterotyped and fragmentary
associated with other seizure manifestation
Strong evidence: EEG recording
-
7/30/2019 Tutorial Psychia 56
33/126
Disorder of consciousness
Clinical
symptoms/syndrom
es
-
7/30/2019 Tutorial Psychia 56
34/126
Arousal and awareness, the two components of consciousness in
coma, vegetative state, minimally conscious state, and locked-in
syndrome.
-
7/30/2019 Tutorial Psychia 56
35/126
Behavioral state confused with coma
-
7/30/2019 Tutorial Psychia 56
36/126
Behavioral state Definition Lesion Comment
Locked-in
syndrome
Alert and aware, quadriplegic
with lower CN palsy
Bilateral anterior pontine Similar state:severe
polyneuropathyMG, NM blocking agent
Persistent
vegetative state
Absent cognitive function but
retain vegetative component
Extensive cortical grey
and subcortical white
matter with relative
preservation of brain stem
Synonyms include apallic
syndrome, coma vigil,
cerebral cortical death
Abulia Severe apathy, patient neitherspeak nor moves
spontaneously
Bilateral frontal medial Severe case resemble
akinetic mutism, but
patient is alert and aware
Catatonia Mute, and mark decreasemotor activity
Usually psychiatric May be mimicked by
frontal lobe dysfunction
and drug
Pseudocoma Feigned coma
Behavioral state confused with coma
-
7/30/2019 Tutorial Psychia 56
37/126
Locked in
syndrome
-
7/30/2019 Tutorial Psychia 56
38/126
Apathy Abul iaAkinet ic
mut ism
Diso rders of Dim inished Mot ivat ion
DDx
Those in which diminished activity is actually due to another impairment
Stupor or coma, delirium, aprosodia, catatonia, akinesia
Those in which diminished activity is associated with diminished
motivation but both are due to some other disorder
depression, demoralization, dementia
-
7/30/2019 Tutorial Psychia 56
39/126
Motivat ional ci rcu i t ry.
Robert S. Marin,. J Head Trauma Rehabil.2005:4(20)377-388
Conditions associated with apathy, abulia, and akinetic mutism
-
7/30/2019 Tutorial Psychia 56
40/126
Conditions associated with apathy, abulia, and akinetic mutism
Robert S. Marin,. J Head Trauma Rehabil.2005: 4(20)377-
388
-
7/30/2019 Tutorial Psychia 56
41/126
Frontal Lobe Syndrome
Clinical
symptoms/syndrom
es
-
7/30/2019 Tutorial Psychia 56
42/126
-
7/30/2019 Tutorial Psychia 56
43/126
Phineas P. Gage
QuickTime and a
YUV420 codec decompressorare needed to see t his picture.
Phineas P. Gage (18231860)was an American railroad constructionforeman now remembered for survivingan accident in which a large iron rodwas driven completely through hishead, destroying much of his brain's leftfrontal.
-
7/30/2019 Tutorial Psychia 56
44/126
Prefron tal co rtex
Prefrontal cortex mediates complex human behavior, and three major
behavioral syndromes associated with prefrontal dysfunction have been
identified
Dorsolateral prefrontal area
Orbitofrontal area
Anterior cingulate area
-
7/30/2019 Tutorial Psychia 56
45/126
Generalorganizat ionof
the fronta l-subcort ica l ci rcu i ts
Cummings JL.Arch Neurol. 1993;50:873-880
-
7/30/2019 Tutorial Psychia 56
46/126
3 dist inc t cor t ical subco r t ical ci rcu i t
Organization of the three frontal-subcortical circuits in which lesions produce alterations ofcognition and emotion. VA indicates ventral anterior; MD, medial dorsal.
Cummings JL.Arch Neurol. 1993;50:873-880
-
7/30/2019 Tutorial Psychia 56
47/126
Orbitofrontal cortex
Anterior cingulate gyrus
Symptoms of f rontal lobe dys funct ion
aphathy
disinhibition
anosmia
-
7/30/2019 Tutorial Psychia 56
48/126
Symptoms of f rontal lobe dys funct ion
Executive function planning, initiating,sequencing(maintaining, alternating, stopping),
and monitoring behaviorExecutive dysfunction poor strategiesincluding impaired planning when copying
constructions and when organizing material to be
remembered
impaired set shifting in response to changingtask contingencies
abnormalities of motor programming compromised attention
-
7/30/2019 Tutorial Psychia 56
49/126
Aphasia
Clinical
symptoms/syndrom
es
-
7/30/2019 Tutorial Psychia 56
50/126
Aphasia
Aphasia refers to an impairment in linguistic
communication produced by brain dysfunction
It must be distinguished from other disorders ofverbal output such as dysarthria, mutism, and the
abnormal language production of patients with
thought disorder
-
7/30/2019 Tutorial Psychia 56
51/126
Language test
Speech fluency
Comprehension
Repetition
Naming
Writing
-
7/30/2019 Tutorial Psychia 56
52/126
A: Wernicke's areaB: concept center
M: Broca's area
a--> A
-auditory input to Wernicke's area
M --> m
-motor output from Broca's area
A --> M
-tract connecting Wernicke's and Broca's areas
A --> B
-pathway essential for understanding spoken
input
B --> M
-pathway essential for meaningful verbal
output.
Lichtheim's diagram of the language system
Conduction aphasia
Transcortical
sensory aphasia
transcortical motor
aphasia
Pure
word
deafness
Articulatory
disorder
(aphemia)
Sensory
aphasia
Motor
aphasia
-
7/30/2019 Tutorial Psychia 56
53/126
-
7/30/2019 Tutorial Psychia 56
54/126
Aphasia chart
-
7/30/2019 Tutorial Psychia 56
55/126
Broca had the opportunity to examine the brain of a
language-impaired patient, M. Leborgne, when it
came to autopsy.
The patient had been capable of very little speech
although his comprehension appeared well preserved
Pierre Paul Bro ca (1824 1880)
French physician
Brocas aphasia
-
7/30/2019 Tutorial Psychia 56
56/126
He saw a patient whose comprehension was severely
impaired; when the patient came to autopsy, the lesion was
discovered in the posterior, superior left temporal lobe
Wernicke hypothesized that this area was the locus of
storage of "auditory word images," which were necessary for
the production as well as the comprehension of speech.
Carl Wernick e(1848-1905)German physician, psychiatrist,
neuropathologist
Wernickes aphasia
-
7/30/2019 Tutorial Psychia 56
57/126
Common neurological diseases
Alzheimers disease and dementia syndromes
Parkinsons disease and other Parkinsonism
Headache disorders
-
7/30/2019 Tutorial Psychia 56
58/126
Common diseases
Parkinsons disease and other
Parkinsonism
-
7/30/2019 Tutorial Psychia 56
59/126
James Parkinson,London
(1755 1824)
An Essay on the ShakingPalsy(1817)
Shaking Palsy(Paralysis agitans)
He identified 6 cases, 3 of whom he personallyexamined; 3 he observed on the streets ofLondon
J Neuropsychiatry Clin Neurosci2002;14:22336
P l i it
-
7/30/2019 Tutorial Psychia 56
60/126
Rigidity
Stooped posture
Hips and knees
slightly flex
Tremor
Short shuffling
steps
Reduce arm swing
Paralysis agitan
(shaking palsy)
-
7/30/2019 Tutorial Psychia 56
61/126
Parkinsonism
clinical syndrome of bradykinesia, restingtremor, cogwheel rigidity, and postural instability
Parkinsons disease
clinical syndrome of asymmetrical parkinsonism,usually with rest tremor, in association with the
specific pathological findings of depigmentation
of the SN as a result of loss of melanin-ladendopaminergic neurons containing eosinophilic
cytoplasmic inclusions(Lewy bodies)
-
7/30/2019 Tutorial Psychia 56
62/126
Something look alike
Gait disorder
Tremor: severe essential tremor,cerebellar tremor
Depression
Psychomotor retardation Frontal lobe syndrome
Group of Park inson ism P ki di
-
7/30/2019 Tutorial Psychia 56
63/126
Group of Park inson ism Parkinsons disease Secondary park inson ism hydrocephalus, vascular
parkinsonism, encephalitis, druginduced parkinsonism
Park inson plus synd rome Progressive supranuclear
palsy(PSP), corticobasaldegeneration(CBD), multiple systematrophy(MSA), Dementia of LewyBodies(DLB)
Hered itar arkinson ism
TYPICAL ORCLASSIC
ATYPICAL
-
7/30/2019 Tutorial Psychia 56
64/126
Parkinsons
disease
-
7/30/2019 Tutorial Psychia 56
65/126
Gibb et al, 1988, Table from Litvan et al, 2003
-
7/30/2019 Tutorial Psychia 56
66/126
PD- d iagnost ic c r i ter ia
Gibb et al, 1988, Table from Litvan et al, 2003
Diagnosticaccuracy to 82%
-
7/30/2019 Tutorial Psychia 56
67/126
Non-motor symptoms
Loss of sense of smell, constipation
REM behavior disorder (a sleepdisorder) Mood disorders
Orthostatic hypotension (low bloodpressure when standing up)
Parkinson plus syndrome: Key
-
7/30/2019 Tutorial Psychia 56
68/126
Parkinson-plus syndrome: Key
features
Multiple system atrophy Parkinsonism, Cerebellar sign, Autonomic dysfunction
Progressive supranuclear palsy Parkinsonism, vertical gaze palsy
Corticobasal degeneration Parkinsonism, limb apraxia
Dementia with lewy bodies Parkinsonism, visual hallucination, fluctuation of
consciousness, dementia
-
7/30/2019 Tutorial Psychia 56
69/126
Drug induced parkinsonism
-
7/30/2019 Tutorial Psychia 56
70/126
Drug induced parkinsonism
Cause: dopamine receptor blocking drug Common: typical neuroleptic antipsychotic drug,
antidopaminergic antiemetic, reserpine (decreasepresynaptic)
Uncommon: SSRIs, lithium, phenytoin, methyldopa,valproic acid, flunarizine
Sign: symmetrical
postural tremor present
May up to 6 months after stop medication
-
7/30/2019 Tutorial Psychia 56
71/126
-
7/30/2019 Tutorial Psychia 56
72/126
Common diseases
Tremor
-
7/30/2019 Tutorial Psychia 56
73/126
Tremor
a rhythmic oscillation of a body partproduced by alternating or synchronous
contraction of opposing muscles
other movement clinical symptoms can be act liketremor: dystonic tremor, myoclonic tremor
-
7/30/2019 Tutorial Psychia 56
74/126
-
7/30/2019 Tutorial Psychia 56
75/126
Step app roach- MDS consensus
1. Inspection the tremor
2. Specific examination for assessment ofsigns related to tremor
3. Syndrome classification of tremor
Terminology for tremor and the
-
7/30/2019 Tutorial Psychia 56
76/126
Terminology for tremor and thehierarchical relation of the terms as
indicated by the numbers
-
7/30/2019 Tutorial Psychia 56
77/126
Inspection
Frequency
Low (7 Hz)
Location
Head: chin, face, tongue,palate
Upper extremity: shoulder,elbow, wrist, fingers
Trunk Lower extremity: hip, knee,
ankle joint, toes
Specific examination for
-
7/30/2019 Tutorial Psychia 56
78/126
Specific examination forassessment of:
Akinesia/bradykinesia Muscle tone (including Froments sign for the upper
and lower extremity and coactivation sign forpsychogenic tremor)
Postural abnormalities Dystonia Cerebellar signs
Pyramidal signs
Neuropathic signs Systemic signs (thyrotoxicosis and so forth) Gait and stance (orthostatic tremor)
Syndrome classification of tremor
-
7/30/2019 Tutorial Psychia 56
79/126
Syndrome Activity Specific S/S
Additional
features Cause
Physiologic tremor Rest NoAnxiety
aggravated
Physiologic
response
Enhance
physiologic tremor Postural, KineticHyperthyroid,
tachycardia
Response to beta-
blocker
Hyperthyroid,
drugs
Essential tremor Postural, Kinetic NoResponse to
alcoholNo
Parkinsoniantremor
RestBradykinesia,
postural instability,
rigidity
Response to L-dopa
Neuro-degeneration
Cerebellar tremorPostural, kinetic,
intentionAtaxia
May plus with
other neurological
deficit
Various cause
affected cerebellar
pathway
Syndrome classification of tremor
-
7/30/2019 Tutorial Psychia 56
80/126
Essential tremor
Core criteria for identifying ET Bilateral action tremor of the hands and
forearms
Absence of other neurological signs, with theexception of the cogwheel phenomenon
May have isolated head tremor with noabnormal posture
-
7/30/2019 Tutorial Psychia 56
81/126
Essential tremor
Secondary criteria for identifying ET
Long duration (>3 years) Family history: reported in > 50% of the
patients
Beneficial response to ethanol
-
7/30/2019 Tutorial Psychia 56
82/126
Achimedes spiral
-
7/30/2019 Tutorial Psychia 56
83/126
Treatment ET
First line
Propranolol start at 10 mg x 3 => 240-320 mg/d Primidone
Second line
Gabapentin, topiramate, clozapine, long actingbenzodiazepine (clonazepam)
-
7/30/2019 Tutorial Psychia 56
84/126
Common diseases
Alzheimers disease and other dementia
syndromes
Definition Amnestic syndrome
P f d l f h i di
-
7/30/2019 Tutorial Psychia 56
85/126
Definition Profound loss of the episodic memory Dementia
Acquired and persistent compromisein multiple cognitive domains that aresevere enough to interfere with every
day functioning Delirium or acute confusional state (ACS)
Prominent deficits or fluctuations inattention processing
Mild cognitive impairment (MCI)
the transitional state between theni iv h n n rm l in
-
7/30/2019 Tutorial Psychia 56
86/126
NEJM 2004
-
7/30/2019 Tutorial Psychia 56
87/126
Is it pseudo-dementia?
Term applied to apparent cognitive impairment associatedwith psychiatric disorders, most often depression (50-100%).
Four criteria proposed by Caine (1981) for diagnosis
1) intellectual impairment in a patient with a primarypsychiatric disorder
2) features of impairment are similar to those seen in CNSdisorders
3) the cognitive deficits are reversible 4) there is no known neurological condition to account for
the presentation
Caine (1981)
Sign suggest pseudo-dementia
-
7/30/2019 Tutorial Psychia 56
88/126
Sign suggest pseudo dementia
depressed affect/mood
neurovegetative signs slow, aspontaneous, monotonous speech
long response latency frequent "I dont know" responses quick to give up, but persists with encouragement
disorientation impaired attention/distraction incomplete responses
Sign suggest pseudo-dementia
-
7/30/2019 Tutorial Psychia 56
89/126
Sign suggest pseudo dementia
forgetfulness - particular deficits in learning newinformation, although memory may be patchy
poor abstraction
typically make errors of omission, vs. errors of commission
awareness of cognitive difficulties may have concern over deficits - "Do I have Alzheimers?
See, I cant remember anything!"
if psychosis, delusions typically nihilistic, self-deprecatory,paranoid
no signs of aphasia, apraxia, or agnosia
greater similarity to subcortical dementias, such asParkinsons
-
7/30/2019 Tutorial Psychia 56
90/126
-
7/30/2019 Tutorial Psychia 56
91/126
Cl ifi ti f d ti
-
7/30/2019 Tutorial Psychia 56
92/126
Classification of dementia
Based on caused Cerebral disorder (with or without extrapyramidal
feature) VS systemic disorder
Reversible-Arrestable VS irreversible disorder
Based on site
Cortical VS subcortical Anterior (frontal premoter cortex) VS posterior(parietal and temporal lobe)
Progressive
-
7/30/2019 Tutorial Psychia 56
93/126
gneurodegenerative disease
Alzheimers
disease
Non-Alzheimers
disease
Parkinsons plus
dementia syndrome- PD, PSP, MSA, CBD,DLB, FTD-PD
Other- Picks disease
- Huntingtons chorea- Hereditary ataxia
- Wilsons disease
hemorrhage
-
7/30/2019 Tutorial Psychia 56
94/126
Treatable-Arrestable dementia Infection
CJD and varient,HIV infection,PML,Neurosyphilis,
TB, fungus,protozoal,
Whippels
diaease
Vitamin deficiency Vitamin B12
deficiency
Endocrine and other organ failureHypothyroidismAdrenal insufficiency and Cushing
syndromeHypo- hyperparathyroidismOrgan failure
Renal failure, Liver failureToxic/ metabolicAlcoholic dementia , Drug medication and
narcotic, Heavy metal intoxication, Dialysis dementia, Organic toxin,
Porphyria
Treatable-Arrestable
-
7/30/2019 Tutorial Psychia 56
95/126
Treatable Arrestable
dementia
Tumor Brain tumor (primary or metastatic),
Paraneoplastic limbic encephalitis
Head trauma and diffuse brain damage Dementia pugilistica, Chronic subdural
hematoma, Post anoxia, Postencephalitis
Normal pressure hydrocephalus
L b l i
-
7/30/2019 Tutorial Psychia 56
96/126
Lab evaluation
AAN guideline (Knopman et al. 2001)
Routine screening
Vitamin B12
Hypothyroidism
Clinical suspicious Blood screening for syphilis
Others Genetic testing: Apo E genotype
CSF test: beta amyloid, tau, AD7C-NTP
L b l ti
-
7/30/2019 Tutorial Psychia 56
97/126
Lab evaluation
AAN guideline (Knopman et al. 2001)
Non-contrast CT brain or MRI scan inmost case Minimizing the risk of failing to detect a
potentially treatable disorder
Identifying comorbidity such as stroke orischemic change
NINCDS-ADRDA Criteria
-
7/30/2019 Tutorial Psychia 56
98/126
NINCDS ADRDA Criteria
for diagnosis AD
DEMENTIA established by clinical examination;confirmed by cognitive screening test(MMSE)
Deficit of TWO or MORE area of cognitive function Progressive worsening of memory and other cognitive
function
No disturbance of consciousness
Onset between ages 40 and 90, most often after age 65 Absence of systemic disorders or others brain diseases
that could account for the deficits and progression
Neurology, Vol. 34, pp 939-944
-
7/30/2019 Tutorial Psychia 56
99/126
-
7/30/2019 Tutorial Psychia 56
100/126
-
7/30/2019 Tutorial Psychia 56
101/126
Parkinsonian Dementia Syndrome
-
7/30/2019 Tutorial Psychia 56
102/126
y Degenerative disorder
Familial HD, neuroacanthocytosis, MJD, progressive subcorticalgliosis, familial FTD
Sporadic PD with dementia, Parkinson plus syndrome(PSP, CBD,
MSA subtype), Dementia with Lewy bodies(DLB)
Secondary parkinsonism Drug, vascular, NPH, Whipples disease
Inherited metabolic disorder Wilsons disease
Hallevorden-Spatz disease
Idiopathic basal ganglia calcification
PDD vs DLB1 year rule
Parkinsons disease dementia(PDD)
-
7/30/2019 Tutorial Psychia 56
103/126
( )
THE LANCET Neurology 2003
Parkinson Dementia Syndrome
-
7/30/2019 Tutorial Psychia 56
104/126
Parkinson Dementia Syndrome
D.S. Geldmacher Clin Geriatr Med20 (2004) 2743
Frontotemporal lobe
-
7/30/2019 Tutorial Psychia 56
105/126
p
dementia Group of neurodegenerative dementia ofvaried etiology, in which the frontal a/o
temporal lobes are relatively selectively
affected, even into later stages of thedisease, and are associated with varying
amount of subcortical pathology and
degeneration
Mistaken for a psychiatric disorder
associated with inappropriate social behavior early
affects those middle aged rather than the elder
-
7/30/2019 Tutorial Psychia 56
106/126
Clinical feature of FTD
-
7/30/2019 Tutorial Psychia 56
107/126
Common diseases
Seizure and Epilepsy
Seizure and Epilepsy
-
7/30/2019 Tutorial Psychia 56
108/126
Seizure and Epilepsy
Seizure: the clinical manifestation of an
abnormal and hypersynchronousdischarge of a population of corticalneurons
Epilepsy: a tendency toward recurrent seizures
unprovoked by systemic or neurologicinsults
Classification of
-
7/30/2019 Tutorial Psychia 56
109/126
Epilepsy/Seizure
International League Against Epilepsy (ILAE)classification systems.
Seizures (1981)
Based on clinical features and EEG findings.
Replaces old terms such as Grand Mal, Petit Mal,psychomotor.
Epilepsies and Epileptic Syndromes (1989) Epileptic disorders with similar signs, symptoms, prognosis
and response to treatment.
Important for choosing treatment options and counselingpatients regarding etiology, genetics and likely prognosis etc.
ILAE Cl ifi ti f S i
-
7/30/2019 Tutorial Psychia 56
110/126
ILAE Classification of Seizures
Partial (Focal) Seizures: Arise in a limited number of cortical neurones within
one hemisphere
Generalized Seizures: Appear to arise simultaneously in both hemispheres
Unclassifiable Seizures:
ILAE Classification of the Epilepsies and
Epileptic Syndromes:
-
7/30/2019 Tutorial Psychia 56
111/126
Epileptic Syndromes:
Focal Generalised Undetermined Special Syndromes
Idiopathic Symptomatic/Cryptogenic Idiopathic Symptomatic/Cryptogenice.g.
- Benign Rolandic
- Benign Occipital
e.g.
- TLE
- FLE
- PLE- OLE
e.g.
- Childhood Absence
- Juvenile Absence
- Juvenile Myoclonic- GTCS on awakening
e.g.
- West Syndrome.
- Lennox-Gastaut.
-
7/30/2019 Tutorial Psychia 56
112/126
Seizure vs Syncope
-
7/30/2019 Tutorial Psychia 56
113/126
Seizure vs Syncope
Bhidayasiri R. et al. Neurological differential diagnosis 2005
Epileptic vs Pseudoseizure
-
7/30/2019 Tutorial Psychia 56
114/126
p p
Bhidayasiri R. et al. Neurological differential diagnosis 2005
-
7/30/2019 Tutorial Psychia 56
115/126
Common diseases
Headache disorder
International Classification
f H d h Di d 2004
-
7/30/2019 Tutorial Psychia 56
116/126
of Headache Disorder-2004
International Classification
of
Headache Disorder 2004
http://ihs-classification.org
Part 1. The primary headaches
- Migraine, TTH, CH and otherTACs, and other primary
headache disorder
Part II. The secondaryheadaches
-Headache attributed to ....
Part III. Cranial neuralgias,central and primary facial painand other headaches
Patient presents withcomplaint of a headache Red flag signs
http://ihs-classification.org/http://ihs-classification.org/http://ihs-classification.org/http://ihs-classification.org/ -
7/30/2019 Tutorial Psychia 56
117/126
Critical first step:
Hx taking, physical exam
Red flag signs or
alarming signs
Meets criteria for primary
headache disorder?
Migraine
headache
Tension-type
headache
Cluster
headache
and other
TACs
Chronic daily
headache (CDH)
Investigation
Secondary
headache
disorder
Other (rare)
headache
disorder
(+)(-)
(+)
Abnormal neurologicalexamination
Focal neurologic s/sother than typical visual
or sensory aura
-
7/30/2019 Tutorial Psychia 56
118/126
Normal neurological
examination
Papilledema
Temporal
profile
Concurrent
event
Provoking
activityAge
Age> 50
Sudden onset
-SAH, ICH, masslesion (posteriorfossa)
Worsening
headache
-Mass lesion, SDH,
MOH
Pregnancy, postpartum
-Cerebral vein
thrombosis, carotid
dissection, pituitary
apoplexy
Headache with
cancer, HIV,
systemic illness
(fever, arteritis,
collagen vascular
disease)
Neck stiffness
Triggered by cough,
exertion or Valsava
-SAH, mass lesion
Worse in the
morning-IICP
Worse on
awakening
-Low CSF pressure
Criteria for diagnosis
-
7/30/2019 Tutorial Psychia 56
119/126
Migraine without aura Infrequent ETTH
ICHD-II Cephalalgia.2004Migraine with typical aura needs 2 attacks
In children, the attack may last 1-72 hours
g
The Classic Migraine =
Mi i ith
-
7/30/2019 Tutorial Psychia 56
120/126
Migraine with aura
Migraine management
-
7/30/2019 Tutorial Psychia 56
121/126
Migraine management
Patient communication and education
Life style change and avoid trigger factors
Acute headache management
Prophylactic headache management
Pharmacotherapy for acute migraine attack
-
7/30/2019 Tutorial Psychia 56
122/126
Non-specific
Acetaminophen,
NSAIDs
butalbital
caffeine,
opioids
neuroleptic
Pharmacotherapy for acute migraine attack
SpecificDihydroergotamineErgotamineTriptan
Concept for prophylactic treatment
-
7/30/2019 Tutorial Psychia 56
123/126
Rightdrug
Right
person
Right
dose
Preventive medication thatwas proven the efficacy
Consider patient profiles, and
co-morbidities
Titrate into the appropriated
dose
Rightduration
On the preventive therapylong enough
-
7/30/2019 Tutorial Psychia 56
124/126
Recommended
medication for
migraine
prevention EFNSguideline 2009
Evers, S et al.
European Journal of Neurology 2009, 16: 968981
Drugs Relative indicationsRelative
t i di tiAdverse effect
Indications, contraindications, and adverse effects of conventional migraine preventive drugs
-
7/30/2019 Tutorial Psychia 56
125/126
Drugs Relative indicationscontraindication
Adverse effect
Amytriptiline (TCA)
Propranolol (B-
blocker)
Flunarizine (CCB)
Valproic acid (AED)
Topiramate (AED)
Other pain disorders,
depression, anxiety,
insomnia
Hypertension, angina
Hypertension, vertigo
Epilepsy, mania,
anxiety
Epilepsy, mania,
anxiety
Mania, urinary
retention, heart blocks,
glaucoma
Asthma, depression,
CHF, Raynauds
disease
Obesity, depression,
PD
Liver disease, bleeding
disorder
Renal calculosis, liver
disease
Drowsiness, dry
mouth, increase
appetite, weight gain
Fatique, lethargy,
nausea, depression,
dizziness
Drowsiness, weight
gain, depression, PD
Nausea dyspepsia,
sedation, increase
appetite, weight gain
Paresthesia, weight
loss, alter taste,
language disturbance
F. Galletti et al. Progress in Neurobiology 89 (2009) 176192
-
7/30/2019 Tutorial Psychia 56
126/126
All the Best for You
FB page: openneurons