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Fifth stage
Psychiatry
Lec-10
.د
الهام
27/11/2016
Amnestic disorders
Amenstic disorders are syndromes characterized by memory impairment
( anterograde And / or retrograde amnesia ) which are cause by general medical condition or
substance abuse, and where delirium and dementia have been excluded as causative of the
amnesia . it may be transient or chronic e.g of AD
Wernickes encephalopathy :
An acute syndrome with
• Ataxia
• Ophthalmoplagia
• Nystagmus
• Lack of memory
caused by thiamine depletion . usually related to alcohol abuse
korsakoff psychosis
Amnesia and confabulation associated with atrophy of the mamillary bodies
• Usually following wernickes encephalopathy
• Rarer causes include head injury basal temporal lobe encephalitis and vascular causes
Head Injury
• Mainly to anterior temporal poles, antero grade or
• post - traumatic amnesia ( PTA ) , with retrograde amnesia almost absent , prognosis is
related to length of PTA . better prognosis associated with PTA less than 1 wk .
temporal lobe surgery
hypoxic brain damage
e.g following asphyxia from Co poisoning , near drowning
MS 40% of patient have some amnesia
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Alcohol Blockout
Significant alcohol intoxication may lead to amnesia for the period of intoxication , this only
occurs in chronic alcohol misuse
Transient global amnesia (TGA)
This is a syndrome of amnesia affecting the temporal lobes and / or diencephalon it is more
common over 50 years and may occur in hypertension or migraine
Other Causes Of Amnesia
• drugs ( benzodiozepines , anticholinergics )
• space occupying lesions
• hypoglycemia
Psychiatric Sequelae Of CVA
These include
• cognitive disorders
• vascular dementia
• subcortical dementia
• amnestic disorder
Personality Changes
Irritability , catastrophic reactions in response to stress & loss of intellectual flexibility
Post-stroke Depression
In up to 60 % of cases , it's onset is usually between 3-24 months
following the stroke
Psychoses
Manic , hypomanic and paraniod psychosis may result from CVA
korsakoff psychosis
A rare chronic complication of subarachnoid haemorrhage
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Psychiatric aspects of head injury
most significant head injuries are closed and involve a period of loss of consciousness (which
may extend from brief concussion to prolonged coma ). On recovery of consciousness is
classified in terms of
acute psychological effects of head injury
• Post - traumatic amnesia ( PTA )
Include the period of injury and the period following injury ( until normal memory resumes )
PTA may end abruptly
• Retrograde amnesia ( RA )
Include the period between the last clearly recalled memory prior to the injury and the injury
itself, lasting seconds or minutes , and shrinks with time .
Factors associated with increased psychiatric morbidity following head injury
• Increased duration of loss of consciousness
• Increased duration PTA
• Increased age , arterio sclerosis , and alcoholism
• Increased area of damage
• Increased neurological sequelae C focal deficits , epilepsy , etc
• Dominant or bilateral hemisphere involvement
• The presence of compensation
Chronic psychiatric syndrome following head injury
• Cognitive impairment, especially after closed head injury , PTA lasting > 24 hours
• Personality and behavioral changes mainly head injury to orbito-frontal or anterior
temporal lobes , frontal lobe syndrome characterized by disinhibition impulsivity irritability
and aggressive routbursts
• Psychosis , a schizophrenia - like psychosis temporal injury , while affective psychoses
(esp. mania in 9 % patients ) are associated with right temporal or orbito - frontal injury .
• Neurotic - disorders
Depressive illness is most common but anxiety states (including PTSD ) are common sequelae
• Post - traumatic syndrome
also called " post - concusional syndrome ". main symptoms are headache , dizziness ,
insomnia , irritability , emotional lability , increased sensitivity to noise , light etc , fatigue ,
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poor concentration anxiety and depression post - traumatic epilepsy - occurs in 5 % closed
and 30 % open head injury
• Punch - drunk syndrome
Boxer may develop diffuse injury to the cortex , based ganglia , and cerebellum , giving rise
to extra - pyramidal symptoms or subcortical dementia , pathology shows cerebral atrophy
and neuro-fibrilary tangles.
Psychiatric aspect of epilepsy
Many different types of psychiatric disorders are associated with epilepsy , including
cognitive , affective , emotional, & behavioural disturbances, these can occur before (pre-
ictal), during (ictal), after (post-ictal) or between seizures.
The relationship between epilepsy & psychiatric disorders may reflect several factors:
• A shared aetiology or pathophysiology , for e.g temporal lobe epilepsy (TLE) appears to
predispose to epilepsy & to psychosis.
• The stigma & psychosocial impairment associated with epilepsy.
• The side effect of anti epileptic drugs .
• Pre-ictal psychiatric disturbances :tension, irritability , anxiety , & depression are some
times apparent as prodromata for several hr.s or even days before seizure , generally
increasing in intensity as the seizure approaches
• Ictal psychiatric disturbances are common & diverse :
- transient confusional state
- affective disturbances
- anxiety
- psychoses may occur ( sudden onset & termination of the disturbances)
- olfactory or gustatory hallucinations
- amnesia for the period of the disturbances
- ictal violence is extremely rare
• Post - Ictal Disturbances:
- Psychotic symptoms are seen in about 10%of cases and are associated with bilateral seizure
foci, long duration of epilepsy and structural brain lesions
- Diverse motor, sensory , cognitive and autonomic dysfunction can also Occur
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- Post - Ictal Violence is rare but more common than during seizure , there is usually amnesia
for the event.
• Inter - Ictal Psychiatric Disturbances:
- Cognitive Impairments a few epileptic patients show a progressive decline in cognitive
function and of particular concern in pediatric practice
- Personality
- a minority of patients have serious personality difficulties and this reflect the adverse
complications of epilepsy on education , employment and social life .
- Inter - Ictal Psychosis
• Religious and paranoid delusions appear to be common
- Suicide
- Suicide is four times , and D.S.H six times more frequent among people with epilepsy than
among the general population .
- Depression and emotional disorders . Depression is common in people with epilepsy
Risk Factors of depression in epilepsy
• Family history of mood disorder
• Focus in temporal of frontal lobe
• Left sided focus
• Perceived Stigma
• Fear of seizure
• Decreased social support
• Unemployment
• Poly pharmacy and high Serum levels of anti epileptic drugs