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Recognition of sleep disorders is important because: They are common, affecting approximately 10-15% of the US population.Many medical, neurological, and psychiatric disorders present with sleep problems.Sleep disorders can have a significant affect on a patient's physical, social, and occupational life. [ABSTRACT FROM AUTHOR]

Movement disorders (MDs) typically result from abnormalities of the extrapyramidal system. The core structures of the extrapyramidal system include the caudate nucleus, globus pallidus, substantia nigra, red nucleus, thalamic nucleus, subthalamic nucleus and their connections to the cerebral cortex, brain stem, and cerebellum, with the final output being pyramidal tract. The main transmitter substances are dopamine, acetylcholine, GABA and glutamate. MDs can be hyperkinetic, hypokinetic, or dyskinetic. This chapter highlights the approach to common MDs. [ABSTRACT FROM AUTHOR]

Peripheral neuropathy (PN) is a term applied to any condition affecting peripheral nerve function. The disorder can affect the peripheral nerve soma (motor or sensory neurons), which are referred to as neuronopathies, or peripheral nerve fibers, which are neuropathies. Most peripheral nerves are mixed, having sensory motor and autonomic nerves. The pure form of sensory or motor neuropathy occurs when the soma (dorsal root ganglion or anterior horn cells) are selectively involved. [ABSTRACT FROM AUTHOR]

History: Obtaining a careful and thorough history of the headache is the most important part of the evaluation. You should establish the following as you are taking the history: Age at onset of headache.Onset of headache: whether it is acute, subacute, or chronic.Severity and frequency of the headache.Characteristics of the pain as described by the patient.Location and duration of the headache.Any associated symptoms or signs.What the aggravating or relieving factors are.Have there been any recent changes of headache type?Any relation to menstrual period or season?How often are medications used or how was the response to previous treatment? [ABSTRACT FROM AUTHOR]

Differentiate dizziness from true vertigo (sensation of movement) and other terms that are used by the patient, because the description by the patients can be nonspecific, many times, for example,"lightheadedness," "faint" or "giddiness" is vertigo and vice versa.Sudden onset of vertigo is due to asymmetry of vestibular system dysfunction.Approximately half of patients presenting with dizziness have true vertigo.Establish the onset of problem, and whether it is acute, subacute, or chronic.Vertigo is usually paroxysmal. Constant vertigo suggests psychogenic and not vestibular dysfunction. Chronic conditions such as acoustic neuroma rarely present with vertigo.Aggravating factors can be head or body position.Benign positional vertigo accounts for about half of all cases of vertigo.Associated symptoms: nausea, vomiting, fullness of ears, hearing loss, tinnitus, all of which suggest otological etiologies; headaches, diplopia, blurred vision, ataxia, paresthesia, all suggestive of central nervous system (CNS) etiologies.History of recent ear or upper respiratory infection or head trauma.History of drug regimen or drug overdose.History of depression or other psychiatric problems.Vertigo that is provoked by exertion, loud noise, sneezing, or coughing (Tullio's phenomenon) is suggestive of perilymphatic fistula. [ABSTRACT FROM AUTHOR]

In this chapter, only generalized convulsive status epilepticus (SE), is discussed. [ABSTRACT FROM AUTHOR]

Coma: a state of unconsciousness and unresponsiveness to external stimuli. Coma is caused by dysfunction of either or both the reticular activating system and cerebral cortex. [ABSTRACT FROM AUTHOR]

Back and neck pain are common complaints and are the main reasons for work-related injury and disability claims, with a major economic affect in industrial countries. Many conditions cause back and neck pain (spinal, nonspinal, psychological). Back pain is treated with many specialties: family practice, orthopedic, chiropractic, neurological surgery and neurologists. [ABSTRACT FROM AUTHOR]

The motor unit is the anatomic core of the peripheral nervous system. It consists of motor neurons or anterior horn cells, and muscle fibers that are innervated their peripheral axons. Other parts of motor units are the nerve root, plexus, and neuromuscular junction. Knowing components of the motor unit helps you localize the site of pathology in the peripheral nervous system. [ABSTRACT FROM AUTHOR]

Acquired central nervous system (CNS) demyelinating disorders that are commonly seen in adults include: Multiple sclerosis (MS).Acute disseminated encephalomyelitis (ADEM).Acute/subacute transverse myelitis.Isolated optic neuritis (ON).Clinically isolated syndrome (CIS).Cerebral pontine myelinolysis. [ABSTRACT FROM AUTHOR]

Alteration or changing mental status is a common cause of hospital admission, and neurologists are often asked to evaluate these patients in consultation. [ABSTRACT FROM AUTHOR]

Suspect central nervous system (CNS) infection when the patient presents with fever, headaches, nausea and vomiting, photophobia, alterations of mental state, or focal neurological deficit.The triad of meningitis—fever, headaches, and meningismus—are not always present in all patients, but fever and headaches are the most common occurrence.Jolt-accentuated headache, increased intensity of headache by side-to-side head movement, is another useful sign.Encephalitis can occur when a febrile patient presents with behavior, personality changes, mental dysfunction, and seizure, with or without focal neurological deficit. Meningitis and encephalitis often occur together (meningoencephalitis).All patients with suspected CNS infection should have blood cultures, brain imaging (computed tomography scan/magnetic resonance imaging [MRI]), and cerebrospinal fluid (CSF) examination.Because of a high rate of morbidity and mortality in bacterial meningitis and herpes simplex encephalitis, empiric broad-spectrum combined antibiotic and acyclovir therapy should begin promptly and not be delayed when performing imaging or spinal tap.Consult an infectious disease specialist when you are dealing with CNS infection. [ABSTRACT FROM AUTHOR]

Seizures are transient abnormal neuronal discharges of the cerebral cortex that often result in stereotyped behavior.Seizure is often a manifestation or symptom of many medical conditions. Epilepsy is the occurrence of two or more unprovoked seizures. Epilepsy is a chronic disorder. In other words, a seizure is a sign, and epilepsy is a disorder.It has been estimated that approximately 10% of individuals reaching age 70 will have a seizure, but only 1-2% will be subject to recurrence and become epileptic. After a generalized tonic-clonic seizure, with normal exam, magnetic resonance imaging (MRI), and electroencephalogram (EEG), 15-30% have recurrence.Seizure should be differentiated from syncope, migraine, transient ischemic attack, multiple sclerosis, hypoglycemic attack, sleep disorder (narcolepsy/ cataplexy/night terror, rapid eye movement behavior disorder), anxiety attacks, and pseudoseizure (psychogenic nonepileptic seizure).Routine workup for onset of unprovoked seizure in adults includes blood count, chemistry profile, EEG, and neuroimaging (computed tomography scan, MRI). Further workup depends on individual case (lumbar puncture).Late onset of seizures is usually because of vascular, degenerative, and neoplastic processes. However, more than half of the patients remain idiopathic, which is possibly genetically determined. Family history of seizure, previous history of head trauma, and prior history of seizure including febrile convulsion in childhood are important to establish. [ABSTRACT FROM AUTHOR]

Stabilize the vital signs and monitor the heart and blood pressure (BP).Start intravenous line and administer intravenous fluid (25% normal saline at a rate of 50-75 mL/hour).Draw blood and send to the lab for complete blood count, prothrombin time, partial thromboplastin time, platelet, chemistry profile, cardiac enzymes, and arterial blood gases.Obtain a 12-lead electrocardiogram.Obtain brief, but pertinent, medical and neurological history, and establish the onset and duration of stroke.Do a 5-minute neurological examination focusing on mental status, pupillary function, stiff neck, and focal neurological deficits.Consult the neurologist and stroke team at your hospital.Obtain head computed tomography (CT) scan without contrast to exclude hemorrhagic stroke or mass lesion. [ABSTRACT FROM AUTHOR]

Remember the following general rules when you are ordering a diagnostic test or procedure on your patient: 1.Diagnostic procedures are a supplement or an extension of your history and physical examination, and are ordered to support your clinical impression or exclude other possibilities.2.Diagnostic procedures should be considered on an individual basis and not routinely; not all patients with dementia need to have an electroencephalogram (EEG) or spinal tap. Each patient should be analyzed individually.3.The clinician should be familiar with the test, knowing how it is done (explaining it to the patient), and the risks, limitations, contraindications and indications, sensitivity, and specificity.4.Consider the potential risk(s) (invasiveness) and cost of the test. Explain these facts to the patient when necessary. For practical purposes, consider ordering the test that gives you the most information and is noninvasive. Consider ordering an invasive test when it has a high sensitivity, specificity, and is beneficial to the patient by influencing the treatment and/or outcome.5.At times, it is necessary and justified to repeat a test. Some disease processes require time to establish their full clinical expression; repeating a test will increase its diagnostic yield, for example, repeating an EEG in the evaluation of a seizure disorder.6.When ordering a test, provide adequate and pertinent information regarding the history and physical findings to the consultant. Be as specific as possible regarding what you are looking for. [ABSTRACT FROM AUTHOR]

1.Subcortical (e.g., internal capsule) versus cortical lesion: Motor weakness (paresis) usually affects the face, arm, and leg equally.Primary sensory deficits (paresthesia, numbness) are more prominent because of involvement of the posterior limb of the internal capsule. Cortical lesions affect higher cortical sensory, manifesting as agnosia, agraphesthesia, and impairment of double simultaneous stimulation.Visual field defects are more common because visual tracts travel through the posterior limb of the internal capsule. Occipital lobe lesions produce visual field defect, but usually are not associated with motor or sensory deficit.Speech dysarthria is more common. A dominant cortical lesion produces aphasia and apraxia.2.Gerstmann's syndrome. This syndrome is commonly caused by a stroke affecting the left angular and supramarginal gyrus and clinically characterized by finger agnosia, left-right disorientation, agraphia, and dyscalculia.3.Watershed or border zone infarcts. Watershed areas are end-artery zones between superficial branches of a major cortical blood supply such as between the anterior cerebral artery-middle cerebral artery and middle cerebral artery-posterior cerebral artery. Bilateral watershed infarcts occur in severe hypotension or hypoxia, and unilateral watershed infarcts occur when the affected artery is stenotic, and collateral circulation cannot compensate in a hypotensive episode. [ABSTRACT FROM AUTHOR]

A primary objective of medical students and residents rotating in the neurology service is to learn and to be able to perform a good neurological examination. They often think that the neurological examination is difficult and hard to remember. However, more importantly, I believe that many medical students and junior residents do not know what to look for, how to find neurological signs, and how to interpret their findings. [ABSTRACT FROM AUTHOR]

Narcolepsy is a sleep disorder with prominent sleep attacks as a form of excessive daytime somnolence. The other associated features of narcolepsy occur with varying frequency. These include cataplexy, hypnagogic and hypnopompic hallucinations, and sleep paralysis. [ABSTRACT FROM AUTHOR]

Neurological function figures prominently in essentially all of the 11 symptoms related to cancerrelated fatigue in the proposed diagnostic criteria. Some studies have suggested that quality-of-life measures may be as important as predictors of survival in cancer as is response to chemotherapy. [ABSTRACT FROM AUTHOR]

The diagnosis of cerebral palsy is a clinical one, consisting of the clinical history of the mother and infant and the pediatric and neurological examination of the infant. The diagnosis is dependent on two key findings: evidence of nonprogressive damage to the developing brain and the presence of a resulting impairment of the motor (neuromuscular) control system of the body, the latter usually accompanied by a physiological impairment and functional disability. [ABSTRACT FROM AUTHOR]

First described in the 1960s, corticobasal degeneration is also known as cortical-basal ganglionic degeneration. It typically comes on as an asymmetric parkinsonian syndrome, most often in the sixth decade or later. Long considered a rare disorder, the description of additional cases and case series in recent years has widened the clinical spectrum. [ABSTRACT FROM AUTHOR]

Although not a neurological disease per se, AIDS is included here because of its wide-ranging relevance to neurological practice and the multiple infections that can be associated with nervous system manifestations (Table 1 - Table 3). [ABSTRACT FROM AUTHOR]

The Jones criteria (Table 1) continue to form the core of diagnosing acute rheumatic fever. It is included here because of its association with neurological disorders, such as Sydenham's chorea, and its etiological link with pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections syndrome Chapter 10 [ABSTRACT FROM AUTHOR]

Headaches caused by disorders of the neck has been a controversial subject; some feel that it is, at best, a rare syndrome. The original diagnostic criteria were proposed by Sjaastad in 1990, and are shown in Table 1. [ABSTRACT FROM AUTHOR]

A disorder of purine synthesis, adenylosuccinate lyase deficiency is a rare condition, with only about 40 published cases. It presents in early life with mental retardation and seizures. Although no specific diagnostic criteria have been proposed for the clinical syndrome, Table 1 summarizes clinical findings in 20 patients and may be useful as a guide in suspecting the diagnosis. [ABSTRACT FROM AUTHOR]

Aicardi-Goutieres syndrome was first described in 1984 in a series of eight patients. The clinical picture is of infants with familial progressive encephalopathy, basal ganglia calcification, and chronic cerebrospinal fluid pleocytosis (Table 1). It is a very rare syndrome, suspected to be familial with autosomal-recessive inheritance, and occurrence in siblings has been reported. A majority of reported cases have elevated serum levels of α-interferon, which is of unclear pathogenic significance. [ABSTRACT FROM AUTHOR]

There is no universal consensus regarding the diagnosis of brain death using standardized criteria (see the excellent review of this by Wijdicks, 2002). The most widely known are the original Harvard criteria from 1968. The lack of widely accepted criteria operationally means that physicians are subject to local guidelines in specific cases. Other sets of guidelines for determining brain death include the Ad Hoc Committee on Death of the Minnesota Medical Association (1976), the Conference of the Medical Royal Colleges (1976), the United States Collaborative Study of Cerebral Death (1977), and the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1981). Differences among their criteria include (1) the regions of brain that must lose all function, (2) the extent and characteristics of areflexia, (3) the duration of the clinical observation, and (4) the role and category of confirmatory tests. [ABSTRACT FROM AUTHOR]

Perhaps no neurological condition better illustrates the evolution of diagnostic criteria over time or has better known criteria than multiple sclerosis (MS). [ABSTRACT FROM AUTHOR]

The existence of alcohol-related dementia is complicated by the various syndromes described in individuals who abuse alcohol, as well as other possible comorbidities contributing to cognitive dys function in these individuals (vitamin B12 deficiency, subdural hematomas and head injuries, cere-brovascular disease, etc.). Knowledge about whether alcohol abuse may be a risk factor for other dementias is also sparse. [ABSTRACT FROM AUTHOR]

Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is associated with mutations in the NOTCH 3 protein, which maps to chromosome 19q12. NOTCH signaling is important in development, but in adults, NOTCH 3 expression is limited to vascular smooth muscle cells, where its function is unknown. Pathologically, there are granular deposits in small cerebral arteries producing ischemic stroke because of vessel wall thickening, fibrosis, and occlusion. These deposits are found in small arteries throughout the body, and diagnosis may be confirmed by the presence of the osmiophilic granules in the basement membrane of vascular smooth muscle cells on skin biopsies. [ABSTRACT FROM AUTHOR]

Diagnosis is a fundamental activity of the physician and most other health care professionals. Therapeutic efforts to treat, prognosticate, palliate, or counsel logically emanate from knowledge of the nature of the patient's disease, or at least, the symptoms and objective physical signs produced by that condition. In general, the medical model uses the term disease in referring to conditions with adverse outcomes (1). The manifestations of disease constitute the illness reported by the patient and observed by the physician in the course of taking a history and conducting a physical examination (2). A diagnosis is the label given the patient's illness or disease by the clinician. [ABSTRACT FROM AUTHOR]

Human development begins with genetic endowment and neurophysiological potential, and unfolds via the interaction between the individual and his or her nurturing environment. Psychosocial adversity, abuse, neglect, trauma and illness can adversely affect the developmental trajectory. The risk and protective influences of environment are interwoven with biological vulnerabilities and resilience to determine the complex aspects of psychiatric health or illness. [ABSTRACT FROM AUTHOR]

Psychiatric complications are very common in all dementias, which are best conceptualized as neuropsychiatric diseases. The most common complications involve disturbances in emotions (depression, anxiety, apathy, affective lability, irritability, and euphoria), psychosis (delusions and hallucinations), and behavior (restlessness and aggression). These complications are quite heterogeneous and can be difficult to categorize because of fluctuations in symptoms over time and the frequent occurrence of subsyndromal symptoms. Psychiatric co-morbidity is very common in dementia, and most of these symptoms or syndromes are associated with excess functional disability. In addition, psychiatric disturbances in the context of dementia are associated with poorer outcomes, decreased quality of life, increased institutionalization, and caregiver distress. Our understanding of the etiology and pathophysiology of behavioral and psychological signs and symptoms in dementia is limited. Screening instruments are available to assist in clinical evaluation and there are a variety of treatment options, both psychopharmacological and psychosocial. This chapter covers the neurobehavioral complications of common dementias not covered elsewhere in this book, specifically Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). [ABSTRACT FROM AUTHOR]

Clinical issues related to informed consent and competency are present in all areas of medicine and are, quite possibly, the most relevant in the disciplines of psychiatry and neurology. The very nature of the specialty (involving disease of mind or brain) often calls into question the ability of the patient to understand the medical procedures or treatment that are being proposed. [ABSTRACT FROM AUTHOR]

The complexities of neurological practice have increased considerably in the 21st century. There is now greater awareness of links between neurological and psychiatric disorders as the branch of neuropsychiatry has moved ahead. It is well known, for example, that patients with dementia, Parkinson's disease, multiple sclerosis, and other disorders may have various behavioral problems well before the diagnosis is confirmed. This results in an increased need for having an understanding of psychological issues that neurological patients have. Depression commonly is associated with chronic pain and medical illnesses. This chapter focuses on these issues, as well as threatened violence and aggressive behavior in patients with traumatic brain injury (TBI). [ABSTRACT FROM AUTHOR]

Psychotherapy has developed, in the past 100 or more years, from a theoretically derived intervention with little empirical support to a broad range of interventions for which there is an equally broad range of evidence. This chapter provides an overview of psychotherapy for psychiatric disorders. The goals of this chapter are to review the history of psychotherapy development, identify the primary efficacious approaches of psychotherapy, and describe the interventions currently used with specific disorders. This chapter focuses on evidence-based psychotherapies (with demonstrated treatment benefit in stringently controlled research trials) because it is our perspective that training and education in treatment should emphasize those interventions supported by scientific data. We hope to provide readers with an adequate understanding of the current literature to make effective treatment recommendations. [ABSTRACT FROM AUTHOR]

Neurosurgery for psychiatric indications is perhaps the strongest statement to date that psychiatric disorders, like neurological disorders, are grounded in brain dysfunction. The premise underlying the effectiveness of these procedures is that altering brain structure will change mental functioning. As we learn more about how biological states serve as a substrate for complex mental phenomena, the practice of psychiatry approaches that of other medical specialties, such as neurology. Psychiatric disorders are increasingly conceptualized as an alteration of brain processing and treatments are designed to intervene on a neurobiological level. Although the pull to connect mind and brain has been evident throughout the history of medicine, it has only been recently that we have begun to understand how and why brain-based interventions affect mental functioning in a clinically meaningful way. [ABSTRACT FROM AUTHOR]

Electroconvulsive therapy (ECT) is the oldest somatic treatment still used in modern psychiatric practice, but is also laden with controversy. Although there are effective antidepressant medications, ECT continues to be widely used and may effectively treat depression in patients who have not responded to psychotherapy or medications. However, some patient advocacy groups lobby for bans on this treatment, claiming it is "inhumane" and citing possible cognitive and memory side effects. Regardless of the debate, it is an important treatment option for severely ill patients. [ABSTRACT FROM AUTHOR]

The modern era of psychotropic medications has supplied providers and patients with substantial ammunition in the treatment of psychiatric disorders. Despite the variety of psychotropic medications available for the treatment of common psychiatric conditions, room for improvement exists. Antipsychotics, antidepressants, and anxiolytics with enhanced efficacy, refined pharmacological profiles, and reduced side effects would be welcomed. In addition to improvements in the pharmacological treatment of the most common psychiatric disorders, pharmacological treatment of other psychiatric illnesses should be enhanced. Psychotropic medications are commonly used for many disorders besides schizophrenia, depression, bipolar disorder, and anxiety disorder. The prescription of antipsychotics for aggression associated with dementia and anxiolytics for sleep disturbances are examples. Medications not classically considered to be psychotropics are also used for psychiatric conditions (e.g., anticonvulsant medications for mood stabilization). This diverse use of medications with psychotropic properties, both indicated and off-label, is accompanied by evidence that varies widely in terms of its quality and quantity of support. All of these factors can create confusing therapeutic situations for psychiatrists and nonpsychiatrists when prescribing psychotropic medications. [ABSTRACT FROM AUTHOR]

Consciousness requires both arousal and attentiveness; one is conscious of something. Arousal is mediated by the reticular activating system of the brainstem and diencephalon. Attentiveness depends on the cerebral cortex, especially polymodal association areas. [ABSTRACT FROM AUTHOR]

Fatigue is a common symptom in neurological, psychiatric, and general medical disorders and often causes difficulties for both patients and health care providers. As a result of fatigue, individuals with medical illnesses experience limitations in their daily living and coping, and clinicians become frustrated by management uncertainties. This chapter reviews current efforts to understand, measure, and treat fatigue. [ABSTRACT FROM AUTHOR]