Neuropsychiatry

Head injury

Head trauma can result in an array of mental symptoms. Head trauma most commonly

occurs in people 15 to 25 years of age and has a male ‐to‐female predominance of

approximately 3 to 1.

It is thought that all patients with serious head trauma, more than half of patients with

ongoing neuropsychiatric sequelae resulting from the head trauma.

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Neuropsychiatry:
A. Head injury
Head trauma can result in an array of mental symptoms. Head trauma most commonly
occurs in people 15 to 25 years of age and has a male to female predominance of
approximately 3 to 1.
It is thought that all patients with serious head trauma, more than half of patients with
moderate head trauma, and about 10 percent of patients with mild head trauma have
ongoing neuropsychiatric sequelae resulting from the head trauma.
Head trauma can be divided grossly into penetrating head trauma (e.g., trauma produced by
a bullet) and blunt trauma, in which there is no physical penetration of the skull.
Blunt trauma is far more common than penetrating head trauma. Motor vehicle accidents
account for more than half of all the incidents of blunt central nervous system (CNS) trauma
Clinical indicators of head injury severity
· The duration of retrograde amnesia--the period leading up to the injury for which
memories have been lost
· The depth of unconsciousness as assessed by the worst score on the Glasgow Coma
Scale--a score of 3 indicates absent responses; 15 is normal consciousness
· The duration of coma--this may be difficult to ascertain because of routine sedation
and ventilation following severe head injuries
· Neurological evidence of cerebral injury--abnormality on neuroimaging or EEG
· The duration of post traumatic amnesia--the interval between injury and the return
of normal day to day memories
PTA <1 hour ­ Mild injury
PTA 1 24 hrs ­ moderate injury
PTA 1 7 days ­ severe injury
PTA >7 days ­ very severe injury.
Early fits, within the first week, are relatively benign, sensitive to prophylactic
anticonvulsants, and are only weak predictors of later epilepsy. Only about 5 per cent of
closed head injuries go on to develop late seizures, compared with 30 per cent after an open
head injury .
Post traumatic epilepsy increases psychiatric morbidity, particularly mood disorders,
behavioural problems, and psychotic illness, and may increase the risk of late dementia
The postconcussive syndrome remains controversial, because it focuses on the wide range of
psychiatric symptoms, some serious, that can follow what seems to be minor head trauma
Research criteria include:
A. A history of head trauma that has caused significant cerebral concussion.
The manifestations of concussion include loss of consciousness, posttraumatic
amnesia, and, less commonly, posttraumatic onset of seizures.
B. Evidence from neuropsychological testing or quantified cognitive assessment of
difficulty in attention (concentrating, shifting focus of attention, performing
simultaneous cognitive tasks) or memory (learning or recalling information).
C. Three (or more) of the following occur shortly after the trauma and last at least 3
months:
1. becoming fatigued easily2. disordered sleep
3. headache
4. vertigo or dizziness

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No specific treatment is suggested. As patients with head trauma may be particularly
susceptible to the side effects of psychotropic drugs, treatment should be initiated in lower
dosages than usual, and they should be titrated upward more slowly than usual.
SSRIs can be used to treat depression, and either anticonvulsants or antipsychotics can be
used to treat aggression and impulsivity. Not much evidence exists for using propanalol in
head injury related aggression.…read more

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Serum prolactin
levels rise sharply to a peak at 20 minutes and returns to normal within 1 hour after a
generalised tonic clonic seizure, which can be used to identify pseudoseizures.
Psychiatric phenomenon in temporal lobe epilepsy (TLE):
Auras: Forced thinking is a cognitive phenomenon associated with TLE, where the
individual has a compulsion to think on a certain restricted topic. Also noted is intrusion of
stereotyped words or thoughts called evocation of thoughts.…read more

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Carbamazepin
e
Block sodium
channels
Dizziness, drowsiness,
ataxia,
agranulocytosis (rare),
cardiac conduction
defects,
hyponatremia, rash
etc.
Induces Cyt P450.
Induces own
metabolism, reduces
levels of OCP,
warfarin, valproate,
antidepressants etc.
Lamotrigine Block sodium
channels
Rash etc. Inhibit Cyt P450.
CBZ reduces levels.
Phenytoin Block sodium
channels
Gabapentin GABA
potentiation
Sedation, dizziness
ataxia
Does not induce /
inhibit Cyt P450.
Topiramate Both block
sodium channels
& GABA
potentiation.
Psychomotor slowing,
drowsiness
CBZ & Valproate
lower its
concentration
C.…read more

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REM sleep is characterised by an activated EEG, loss of tone in antigravity muscles,
dreaming, and periodic bursts of rapid eye movements. Nightmares tend to occur in this
stage.
The REM latency is shortened in some patients with depressive disorders, eating disorders,
narcolepsy, Borderline personality disorder, alcohol use disorder and schizophrenia. The
amount of REM sleep is increased as well in these disorders.
Narcolepsy: Characterised by attacks of daytime somnolence. More common in males.…read more

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Anticipation). Early onset of Huntington's disease is associated with an affected father
rather than an affected mother Longer repeats in genes inherited through the paternal line
provide a likely explanation of the high incidence of paternal inheritance in juvenile onset
cases.
Prevalence is 5 cases per 100,000 of the population. Loss of GABA receptors in striatum
(Putamen & Caudate nucleus) is observed early in the disease as is decreased glucose
metabolism in these areas.…read more

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Fore tribe PNG). The younger
age groups are mostly affected. EEG, CSF, and MRI are generally less helpful than in
sporadic cases
vCJD (Human BSE)
vCJD: caused by bovine spongiform encephalopathy (BSE) like prions derived from infected
beef products. Early features: depression, anxiety, social withdrawal, peripheral sensory
symptoms then later features Cerebellar ataxia, chorea, or athetosis often precedes dementia,
advanced disease as sporadic CJD. More than 60% present initially with psychiatric
symptoms (anxiety, depression, irritability, delusions, hallucinations and withdrawal).…read more

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Late ­onset mania often occurs with
CD4 below 200cells/mm3 and cognitive impairment (? At onset AIDS related dementia)
Frequency of AIDS related psychosis and mania 0.5% to 15%. Depression occurs in 30 50%.
AIDS ­related dementia usually begins after 10yrs and with CD4 counts below
200cells/mm3. Features include: apathy, memory loss ± delusions; hallucinations, cerebellar
signs, myoclonus. Post mortem findings in HIV dementia are variable and can include white
matter pallor and gliosis, cortical neuronal loss, multinucleated giant cells.…read more

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The aetiology is not known but MS is considered to be an autoimmune disease. The
symptoms of MS include: Visual disturbances; muscle weakness; trouble with coordination
and balance; sensations such as numbness, prickling, or pins and needles & thinking and
memory problems. The diagnosis of MS is based on a classic presentation (i.e., optic neuritis,
Paper III: Neuropsychiatry Diet II: 2008
11
transverse myelitis, internuclear ophthalmoplegia, paresthesias) and on the identification of
other neurologic abnormalities, which may be indicated by the patient history and exam.…read more

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Cardiac surgery
Predictors associated with postoperative freedom from cardiac symptoms: fewer
preoperative cardiac hospitalisations; low levels of angina, dyspnoea, fatigue, and sleep
problems; low levels of anxiety, depression, hostility, and life change events; and high levels
of psychosocial well being, hopefulness, overall satisfaction, and social support.…read more

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