EPPP: Disorders

traumatic brain injury (TBI)

• core deficits: attention, memory, executive functioning, impairments in emotional & behavioral functioning &/or physical functioning

• rule -out: progressive decline = dementia

closed-head TBI

• skull intact

• damage to axons when brain rapidly shifts & rotates inside skull

• brain injured by acceleration/deceleration (e.g., car accident)

• coup injury: damage at the site of impact

• contrecoup injury: damage on the opposite side of impact (from when brain rebounds inside skull

• associated with: widespread cognitive deficits; deficits are generalized

• damage ranges from concussion to coma; may include physical, cognitive, and/or emotional impairments

  • can be immediate or develop over hours

• initial CT/MRI scan may miss it

diffuse axonal injury (DAI)

• Widespread brain injury from shearing forces, typically in closed head injury

• organic factor linked to post-concussional syndrome (PCS)

• Occurs when: Rapid acceleration/deceleration; Car accidents; Shaking injuries

open-head TBI

• skull is penetrated/breached

• focal brain damage

• localized deficits depend on area damaged

  • if damage to frontal lobe: personality change

• usually does NOT include loss of consciousness

• caused from: gunshot wound; object penetration

Glasgow Coma Scale (GCS)

• used to determine severity of TBI

• assesses CNS & PNS response

post-traumatic amnesia (PTA)

• temporary memory loss (anterograde amnesia) & confusion after TBI

• individual is awake but disoriented.

  • often lasting minutes to a few days, typically indicates a mild TBI

• duration of this is predictor of persistence of cognitive, motor, personality, & other symptoms caused by injury

retrograde amnesia

• recent memories more affected than remote memories

• after TBI this may occur

shrinking retrograde amnesia

most remote memories return first

rule for acute Traumatic Brain Injury (TBI) classification:

• 30-24-7 rule

  • Mild TBI: loss of consciousness is <30 minutes

  • Moderate TBI: loss of consciousness is <24 hours

  • Severe TBI: loss of consciousness is >7 days

mild TBI

• Core pattern: Brief loss of consciousness or none; Temporary confusion; Symptoms usually resolve

• Common deficits: Headache; Attention problems; Memory complaints; Irritability

• short PTA & good recovery

• EPPP cues: “Concussion,” “briefly dazed,” “returned to baseline”

moderate TBI

• Core pattern: Longer loss of consciousness & PTA; Clear cognitive deficits

• Common deficits: Memory impairment; Attention problems; Executive dysfunction; Emotional lability

• potential for meaningful recovery

• EPPP cues: “Prolonged confusion,” “hospitalization,” “rehabilitation”

severe TBI

Core pattern: Prolonged unconsciousness; Persistent impairment

Common deficits: Major cognitive deficits; Personality changes; Reduced independence

EPPP cues: “Coma,” “long-term care,” “major functional impairment”

6 core factors that influence TBI recovery

severity of injury, age, gender, SES, pre-injury physical functioning, pre-injury mental functioning

recovery time for TBI

• greatest amount occurs during first 3 months

• additional recovery thru first year

post concussion syndrome (PCS)

• Symptoms include: headaches, dizziness, fatigue, concentration/memory issues, blurred vision, sleep problems, mood changes (anxiety, irritability), neurological signs (seizures, visual field cuts, hemiparesis [one-sided weakness])

  • may linger for weeks, months, or longer after a head injury, often beyond the typical recovery period.

• symptoms occur in ½ of patients w/ mild TBI

• major or mild neurocognitive disorder due to TBI

• can occur right after brain injury or right after recovery of consciousness (& continues past acute post-injury period)

cerebrovascular accident

• commonly known as a stroke, happens when blood flow to a part of the brain is suddenly blocked (ischemic stroke) or a blood vessel ruptures (hemorrhagic stroke)

• it deprives brain cells of oxygen and causing them to die, leading to potential disability or death.

• core symptoms:

  • weakness or loss of sensation (opposite side of body where stroke occurred

  • visual field loss

• FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911) require immediate emergency care, as rapid treatment is crucial to minimize brain damage

2 types cerebrovascular accident

• ischemic (thrombosis & embolism)

• hemorrhagic (hemorrhage)

ischemic stroke (& 2 causes of it)

• blood clot blocks an artery in the brain, cutting off blood supply and causing brain cells to die; usually from plaque buildup

  • very common (about 87%)

• thrombosis (blood clot blocks artery; gradual blockage)

• embolism (clot forms somewhere else (often from heart) & travels to block a brain artery; sudden onset)

hemorrhagic stroke

• occurs when a blood vessel in or around the brain ruptures and bleeds, damaging brain tissue by increasing pressure and toxicity, leading to cell death; very sudden onset

cerebrovascular accident/stroke 7 risk factors

hypertension; atherosclerosis (thickening of arterial walls); atrial fibrillation (irregular heartbeat); myocardial infarction (heart attack); diabetes mellitus; smoking; increasing age (risk increases after 60 yrs old)

effects of Left (Dominant) Hemisphere Stroke

• aphasia (language impairment)

  • impairment in speaking, understanding, reading, and writing, but not intelligence

• ideomotor apraxia (motor planning disorder)

  • understands a command or task but struggles to perform the correct learned movements, like a gesture or using a tool)

• Right-sided weakness/paralysis

• EPPP cues: “Trouble speaking or understanding speech.,” “Word-finding problems,” Frustrated, aware of deficits.”

• one word clue: Language

effects of Right (Non-Dominant) Hemisphere Stroke

• contralateral (left) neglect (profound deficit in attention & awareness of left side of space, body, & environment)

• Left-sided weakness/paralysis

• dressing apraxia (cant dress oneself)

• EPPP cues: “Ignores left side of body/space,” “Poor awareness of deficits (anosognosia),” “Flat or inappropriate affect.”

• one word clue: neglect

7 neuropsychiatric symptoms after stroke

• depression, anxiety, mania, apathy (lack of interest/motivation), pathological crying or laughter, psychosis, &/or dementia

• depression most common (occurs in 40% of these patients)

  • onset is immediate for some & for others it starts several months later

sudden motor focal deficits associated w/ stroke

• Unilateral weakness or paralysis

• Face, arm, and/or leg on one side

sudden speech/language focal deficits associated w/ stroke

• Aphasia (expressive or receptive)

• Slurred speech (dysarthria)

sudden sensory focal deficits associated w/ stroke

• Numbness or loss of sensation on one side

  • Face, arm, or leg

sudden vision focal deficits associated w/ stroke

• Loss of vision in one visual field

• Double vision

sudden visuospatial/awareness focal deficits associated w/ stroke

• Unilateral neglect (usually left neglect)

• Poor awareness of deficits (anosognosia)

sudden coordination/balance focal deficits associated w/ stroke

• Sudden ataxia (lack of muscle coordination, awkward movements affecting walking, speech, swallowing, and fine motor skills)

• Dizziness with focal signs

Delirium

• symptoms: Sudden change in mental status; Fluctuating alertness; Inattention; Disorganized thinking; Reduced awareness of environment; disturbance in memory, orientation, &/or language; acute confusion

• onset: acute (from hours to days)

• course: fluctuates

• duration: usually reversible

• many features (onset, course, duration, & attention) are opposite of dementia features

• Key EPPP cues: Sudden onset (develops over short period of time); evidence of medical cause; Reversible; “sudden confusion in hospital”

• Rule-out: Dementia (gradual); Psychiatric disorder

intellectual disability

• Impaired intellectual functioning (reasonong, problem-solving)AND impaired adaptive functioning (self-care, social skills)

• global deficits

• EPPP cues: onset before 18; academic + daily living difficulties

• rule-out for learning disorder

speciffic learning disorder

• academic skill deficit in reading (dyslexia), math (dyscalculia), or written expression (dysgraphia)

• Persisting for ≥6 months, despite intervention

• EPPP cues: average/above average intelligence; isolated academic difficulty; deficit in ONE academic domain; onset during school years; persistent academic underachievement

Multiple Sclerosis

• autoimmune demyelinating disease of the CNS

→ immune system attacks myelin → disrupted nerve conduction.

• neurological/physical, cognitive, & psychological/emotions symptoms

• Symptoms include muscle weakness, coordination problems, and cognitive impairment. It can lead to varied neurological symptoms depending on the areas affected.

MS can mimic & is often misdiagnosed as:

• Major Depressive Disorder; Anxiety disorders; Somatic Symptom Disorder

• Functional Neurological Symptom Disorder (severe emotional or mental stress manifests as real physical (neurological) symptoms)

Neurological / Physical features of MS

• Weakness; Numbness or tingling; Visual disturbances (optic neuritis, double vision); Gait/balance problems; Fatigue (VERY common)

Cognitive features of MS

• Slowed processing speed; Attention problems; Memory difficulties; Executive dysfunction

Psychological / Emotional features of MS

• Depression (very common); Emotional lability; Anxiety; Pseudobulbar affect (inappropriate laughing/crying)

MS course of illness

• Relapsing–Remitting (MOST COMMON)

  • Episodes of symptoms

  • Partial or full recovery between attacks

• Other types (know names only):

  • Primary progressive

  • Secondary progressive

Functional Neurological Symptom Disorder (Conversion Disorder)

• Neurological symptoms that are: Inconsistent with known neurological disease; Not intentionally produced; Symptoms are real; Associated with functional impairment

Symptoms of Functional Neurological Symptom Disorder (Conversion Disorder)

• Paralysis or weakness; Seizures (psychogenic non-epileptic seizures); Blindness or sensory loss; Aphonia (loss of voice); Gait abnormalities

key diagnostic rule for Functional Neurological Symptom Disorder (Conversion Disorder)

There is evidence of incompatibility between symptoms and neurological disease

Differentiation between Functional Neurological Symptom Disorder (Conversion Disorder) & Neurological Disorders

• findings are inconsistent; MRI is normal; symptoms improve w/ distraction; unconscious control (can't control them, even though they seem voluntary)

Differentiation between Functional Neurological Symptom Disorder (Conversion Disorder) & Somatic Symptom Disorder (SSD)

• Main issue: neurological symptoms/deficits that are not explained by medical conditions.

• focuses on function (vs thoughts/behaviors)

• neuro exam shows inconsistent findings (vs normal)

Differentiation between Functional Neurological Symptom Disorder (Conversion Disorder) & Malingering

• not intentional production of symptoms for external incentives, involuntary symptoms without obvious rewards.

major neurocognitive disorder (dementia)

• Core deficits: Progressive cognitive decline; Memory + other cognitive domains (e.g., attention, language, executive functioning, perceptual-motor, &/or social cognition)

• Key EPPP cues: Gradual onset/worsening, progressive; Interferes with independence

• Rule-out: Delirium (acute); Depression (“pseudodementia”)

dementia with lewy bodies

• core triad

  • Fluctuating cognition / attention - affected early

  • Recurrent visual hallucinations (well-formed) - occur early

  • Parkinsonism (rigidity, bradykinesia)

    • dementia comes before motor symptoms

• gradual onset; progressive

• cognitive fluctuations early

• memory impairment is NOT always 1st deficit

• late stages: severe physical & cognitive decline

  • bedriddden: cant walk, talk, swallow, incontinence

Parkinson’s disease

• Neurodegenerative movement disorder caused by dopamine loss in the substantia nigra → basal ganglia dysfunction

• REM sleep behavior disorder

• gradual onset usually older adulthood

• progressive (symptoms worsen)

• dopamine loss/deficiency

• movement (motor symptoms 1st)

• dementia appears later in the disease

• EPPP tie-in: Subcortical disorder

affective/cognitive symptoms of Parkinson’s

• Flat affect; Depression

• Cognitive slowing; executive dysfuntion

• Possible Parkinson’s dementia (late)

motor symptoms of Parkinson’s

• TRAP

  • Tremor (resting, “pill-rolling”)

  • Rigidity (cogwheel)

  • Akinesia / Bradykinesia (slowness)

  • Postural instability

Parkinson’s disease dementia

• motor symptoms appear first

• dementia develops later

Huntington’s Disease

• genetic neurodegenerative disorder

• Autosomal dominant

• Progressive and fatal

• Core symptom triad:

  • Motor: hyperkinetic/chorea (involuntary movements)

  • Cognitive: executive dysfunction → dementia

  • Personality/behavior changes (irritability, impulsivity)

• EPPP vignette cues: “Middle-aged adult with involuntary movements, personality change, and family history”

• 50% chance of parent giving gene to their child

• onset often mid-adulthood

emotional & cognitive symptoms of Huntington’s Disease

• these symptoms occur 1st (often before major motor symptoms)

• depression, apathy (lack of interest), anxiety, antisocial tendencies, poor judgement, personality change, executive dysfunction, irritability/impulsivity, &/or forgetfulness

• gradual process to deficits in planning, problem-solving → dementia

Fetal Alcohol Spectrum Disorder

• Core deficits: Executive dysfunction; Learning problems; Impulse control deficits

Alzheimer’s Disease

• Progressive neurodegenerative disorder characterized by gradual memory loss, especially new learning, followed by global cognitive decline.

Early cognitive symptoms of Alzheimer’s

• anterograde memory impairment (can’t form new memories)

• anomia (word-finding difficulty)

later cognitive symptoms of Alzheimer’s

• language decline

• executive dysfunction

• loss of daily functioning

• hallucinations (false sensory experiences)

• visuospatial deficits

  • visual agnosia (can’t recognize familar objects or faces)

  • impaired depth perception

  • spatial disorientation & difficulty navigating familiar environments → wandering

course & onset of Alzheimer’s

• Insidious (gradual/subtle) onset

  • decline develops over months or years

Neuropathology of Alzheimer’s

• Amyloid plaques; Neurofibrillary tangles (tau)

affective/behavioral features of Alzheimer’s

• apathy; depression, irritability (later)

  • not usually seen in early stages

Alzheimer’s vs Delirium — onset

gradual vs sudden & fluctuating

Alzheimer’s vs Delirium — course

progressive vs fluctuating

Alzheimer’s vs Delirium — early cognitive symptoms

memory vs attention

Alzheimer’s vs Delirium — impact on consciousness

intact early vs altered

Alzheimer’s vs Parkinson’s - 1st symptoms

memory vs movement

Vascular Dementia

• decline caused by blocked blood flow → cells damaged → issues w/ memory; planning; judgement; concentration

• often appears after a stroke(s) or gradually from small vessel damage

• cognitive abilities drop in stages with periods of stability between worsening episodes

Alzheimer’s vs Vascular Dementia - cognitive decline

gradual vs stepwise

Mild Neurocognitive Disorder/Mild Cognitive Impairment (MCI)

• stage between normal aging & dementia

• cognitive decline ( forgetting names, losing things, etc)

• daily functioning mostly intact

• can progress to dementia

• some causes of it (vitamin deficiency, sleep issues, medical side effects) are treatable

Delirium:

onset; course; primary deficit; motor symptoms; daily functioning

• onset: sudden (hours-days)

• course: fluctuating

• primary deficit: attention/awareness

• motor symptoms: possible agitation or slowing

• daily functioning: impaired; reversible

Mild Neurocognitive Disorder (MCI)

onset; course; primary deficit; motor symptoms; daily functioning

• onset: gradual

• course: stable or progressive

• primary deficit: mild cognitive decline

• motor symptoms: none

• daily functioning: most intact

Alzheimer’s

onset; course; primary deficit; motor symptoms; daily functioning

• onset: gradual

• course: progressive

• primary deficit: memory (new learning)

• motor symptoms: late

• daily functioning: impaired; irreversible

Vascular Dementia

onset; course; primary deficit; motor symptoms; daily functioning

• onset: sudden or gradual

• course: stepwise decline

• primary deficit: executive/ attention

• motor symptoms: focal deficits possible

• daily functioning: impaired

Dementia w/ Lewy Bodies

onset; course; primary deficit; motor symptoms; daily functioning

• onset: gradual

• course: fluctuating

• primary deficit: attention + visuospatial

• motor symptoms: Parkinsonism early

• daily functioning: impaired

Parkinson’s Disease w/ Dementia

onset; course; primary deficit; motor symptoms; daily functioning

• onset: gradual

• course: progressive

• primary deficit: executive/attention

• motor symptoms: Parkinsonism first

• daily functioning: impaired

ADHD

• Core DSM features: Persistent pattern of inattention and/or hyperactivity-impulsivity; Onset before age 12; Present in two or more settings; Interferes with functioning

Epilepsy

recurrent, unprovoked seizures (abnormal, excessive neuronal firing)

focal (partial) seizures

• Originate in one hemisphere

• Consciousness may be preserved or impaired

• Symptoms depend on brain area involved

• sometimes become generalized seizure

• simple partial:no loss of consciousness

  • temporal lobe seizures most common

• complex partial seizure : some alteration in consciousness

• EPPP cue: aura, localized motor/sensory symptoms

generalized seizures

• Involve both hemispheres

• Loss of consciousness

• No aura

• * 2 types: tonic-clonic (grand mal) & absence (petit mal)

tonic-clonic (grand mal seizure)

• tonic: stiffening

• clonic: rhythmic jerking

• postictal confusion

absence (petit mal seizure)

• brief staring spells

• no postictal confusion

• common in children

Postictal State

• confusion; fatigue; headache; amnesia

• helps distinguish seizures from syncope (fainting) or panic

Aura

• Warning sign

• Actually a focal seizure

• Sensory, emotional, or motor symptoms

differentiation between seizure & syncope

• postictal confusion vs rapid recovery

• tongue biting vs rare

• incontinence vs possible incontinence

• jerky movements vs possible but brief

temporal lobe seizures

• deja vu

• emotional changes

• automatic behaviors (lip smacking)

• hallucinations

frontal lobe seizure

• motor symptoms (jerky arm/leg movements)

• speech arrest (inability to talk)

• sleep disturbance

• hallucinations/illusions

parietal lobe seizure

• physical sensations on opposite side of body (numbness, tingling, burning)

occipital lobe seizure

• rapid blinking

• unusual visual phenomena

8 endocrine disorders

Hypothyroidism; Hyperthyroidism; Cushing’s Syndrome; Addison’s Disease; Diabetes Mellitus (esp. poor glucose control); Parathyroid Disorders; Pheochromocytoma; Sex Hormone Disorders

Hypothyroidism

A condition where the thyroid gland does not produce enough thyroid hormones, leading to symptoms such as fatigue, weight gain, and sensitivity to cold.

Hypothyroidism

psychological symptoms; physical cues; mimics; differentiator; EPPP cue

• Depression, fatigue, psychomotor slowing, poor concentration, memory problems

• Weight gain, cold intolerance, dry skin, constipation, bradycardia

• Mimics: Major Depressive Disorder

• Differentiator: Physical slowing + abnormal TSH (hormone to regulate metabolism)

• Always rule it out before diagnosing depression

Hyperthyroidism

A condition where the thyroid gland produces excessive thyroid hormones, resulting in symptoms like weight loss, rapid heartbeat, anxiety, and increased warmth or sweating.

Hyperthyroidism

psychological symptoms; physical cues; mimics; differentiator; EPPP cue

• Anxiety, irritability, emotional lability, insomnia, restlessness

• Weight loss, heat intolerance, tremor, tachycardia, sweating

• Mimics: Anxiety disorders, panic disorder, mania

• Differentiator: Tremor + weight loss + tachycardia

• anxiety w/ weight loss

Cushing’s Syndrome

A disorder caused by prolonged exposure to high levels of cortisol, leading to symptoms such as weight gain, fatigue, high blood pressure, and changes in mood or cognition.

Cushing’s Syndrome

psychological symptoms; physical cues; mimics; differentiator; EPPP cue

• Depression, anxiety, irritability, cognitive impairment, possible psychosis

• Moon face, buffalo hump, central obesity, purple striae

• Mimics: MDD, bipolar disorder

• Differentiator: Characteristic body changes

• Cortisol excess → mood + cognitive dysfunction

Addison’s Disease

A disorder resulting from insufficient production of cortisol, leading to symptoms such as fatigue, weight loss, low blood pressure, and mood changes.

Addison’s Disease

psychological symptoms; physical cues; mimics; differentiator; EPPP cue

• Depression, apathy, fatigue

• Weight loss, hypotension, hyperpigmentation, GI distress

• Mimics: Depression

• Differentiator: Low blood pressure + hyperpigmentation

• Chronic fatigue + depression + hypotension

Diabetes Mellitus

A metabolic disorder characterized by high blood sugar levels due to insufficient insulin production or resistance to insulin, leading to symptoms such as increased thirst, frequent urination, fatigue, and blurred vision.

Diabetes Mellitus

psychological symptoms; physical cues; mimics; differentiator; EPPP cue

• Irritability, confusion, mood swings, cognitive changes

• Polyuria (excessive urine), polydipsia (excessive thirst/fluid intake), fatigue

• Mimics: Delirium, mood disorders

• Differentiator: Blood glucose abnormalities

• Acute mental status change → rule out hypo/hyperglycemia

Hypoinsulinism

• leads to diabetes mellitus

• if left untreated, increase in appetite w/ weight loss; increased susceptibility to infection, apathy, confusion, mental dullness

• patients w/ type 2 diabetes who get sudden increase in glucose levels → onset of negative mood, impaired concentration, working memory, & processing speed

Hyperinsulinism

• A condition characterized by excessive levels of insulin in the blood, which can lead to hypoglycemia and its associated symptoms such as dizziness, sweating, confusion, and irritability.

• complication of diabetes, liver disease, pancreatic tumor, or consequence of using certain drugs

Parathyroid Disorders

Leads to irregular calcium regulation. They can cause symptoms like muscle cramps, fatigue, and bone pain.These disorders can result in increased or decreased levels of calcium in the blood, leading to various physical and psychological symptoms, including fatigue, weakness, and cognitive changes.