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Generalized Anxiety Disorder pathophysiology
Quiz by Danielle Clegg
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Generalized anxiety disorder [t comes from the GREEK name "Epilepsia" which means "taking hold of or seizing". - It is a disorder characterized by: recurrent seizures. SEIZURES R ectment transient attacks of: R epresent: R esult from: ASSOCIATED WITH: somatic, psychic, or, autonomic clinical featmes. clinical features of abnormally hyperexcitable cortical neurons. paroxvsmal and excessive electrical neuronal discharges. EEG changes & may be disturbance of consciousness. same causes of convulsions 1. Idiopathic epile~ • It is the commonest cause. no cause can be detected ( 65 % ) • It may be associated with positive family history in some cases. • It starts in the l st & 2nd decades in the form of: -- Grand ma! epilepsy. Petit mal epilepsy. Myoclonic epilepsy. Atonic seizures. 2. Secondary epilepsy A. Local causes in the brain: l. Congenital: 2. Traumatic: cerebral palsy. a cause can be detected cerebral contusion or laceration. 3. Inflammatory: 4. Neoplastic: 5. Degenerative: 6. Vascular: encephalitis, brain tumours. mening1t1s, presenile dementia. brain abscess. stroke (especially hemon-hagic), hypertensive encephalopathy. B. General causes with secondary effects on the brain: I. Toxic: 2. Iatrogenic: 3. Metabolic: 4. Endocrinal: 5. Organ failure: 6. Heart disease: 7. Nutritional: - Alcohol, cocaine, lead. - Lidocaine, INH. - j glucose & ! glucose. - Hypoparathyroidism. - Hepatic failme. - Adam's Stoke's attacks. - Pellagra. - Botulism, tetanus. - Ambilhar, Amphetamine, Aminophylline. - j Ca & ! Ca. - Hype1thyroid crisis. - Renal failure. - Fallot's tetralogy. - j Na & ! Na. - Vitamin B6 deficiency. 8. Physical: 9. HYSTERICAL. - High fevers. - Heat stroke. 136 137 CLINICAL PICTURE 1. GENERALISED SEIZURES " Excessive electrical discharges from cortical neurons in BOTH hemispheres simultaneously " I. II. 1. Grand Mal Epile~: 1. Pre-ictal stage "attacks of tonic-clonic convulsions " (aura) It is a warning sign of a coming attack. It may be: • Somatic: • Psychic: • Autonomic: 2. Ictal stage Myoclonus, Hallucinations. Tachycardia, (seizure) Sudden loss of consciousness: Parasthesias. Sweating. for seconds to minutes. -- Tonic phase (few seconds) o The UL & LL: o o o o The HEAD: The JAWS: CYANOSIS: are extended. is retracted to one side & the eye balls rolled up. are firmly clenched, with biting of the TONGUE. due to impaired respiration. There may be incontinence of urine. Clonic phase (few minutes) o The UL & LL: o The HEAD: 3. Post-ictal stage - It may be: • Somatic: • Psychic: • Autonomic: Drug of choice: contract & relax repeatedly & rapidly. jerks forcibly. (sequelae) Todd's paralysis(< 24 hours, due to neuronal exhaustion). Confusion. Vomiting. Carbamazepine (Tegretol) or Phenytoin (Epanutin) Petit Mal Epilepsy: "attacks of loss of consciousness " " Absence " It starts in childhood & improves at puberty & usually disappears at the age of 20. 2. It is NOT PRECEEDED by aura & NOT FOLLOWED by sequelae. 3. It is usually PRECIPITATED by: hyperventilation 4. It is characterized by: or photic stimulation. sudden loss of consciousness of short duration (few seconds). 5. It may be associated with: • High frequency ( 50 attacks / day). • Falling to the ground without warning. • Jerky movements of the head & UL Drug of choice: (myoclonic petit mal). Valproate (Depakine) or Succinimide (Zarontin) 137 138 Ill. M oclonic Seizures: "attacks of involuntary clonic movements " - It is characterized by: sudden, jerky, shock-like INVOLUNTARY muscle contraction. • The jerks are bilateral contractions, mainly of the shoulders and arms. • However, some patients repmtjerking in the lower limbs, trunk, or head. - It may be of 2 types: - Occurs singly • Simple: • As a pait of: I Drug of choice: IV. Atonic seizures: (no loss of consciousness). - Grand mal epilepsy (aura). - Petit mal epilepsy. Valproate (Depakine) or Clonazepam (Rivotril) I - Transient attacks of brief loss of postural tone, often resulting in falls and injuries. 2. PARTIAL SEIZURES "Excessive electrical discharges from cmtical neurons in a ce1tain area in ONE hemisphere" A. Simple seizures: " No disturbance in consciousness " - The CP depends on the site of the hyperexcitable neurones in the cerebral cortex, whether in: "Motor area or Senso,y areas". 1. Motor fits: • Focal fits: • Motor jacksonian fits: 2. General Sensory fits: • Focal fits: • Sensory jacksonian fits: 3. Special Senso1y fits: • Visual hallucinations: • Auditory hallucinations: • Olfactory hallucinations: B. Complex seizures: - SITE: movement of part of a limb or the whole limb. movement of one side of the body (see before). parasthesia of part of a limb or the whole limb. parasthesia of one side of the body (see before). irritation of the visual sensory area. irritation of the auditory sensory area. initation of the uncus. " disturbance in consciousness " The hyperexcitable neurons are in the Temporal lobe "Temporal lobe epilepsy". - DURATION: The seizure lasts few seconds to few minutes. - The seizure starts with A ura, followed by A bsence, Automatism, Amnesia: 1. 2. 3. 4. A ura: A bsence: Automatism: A mnesia: Olfactory hallucinations, Deja-vu phenomenon, Sensation of fear. Absent patient with staring eyes (with no response to conversation). Involuntary Purposeless acts: motor ( eg, lip smacking, chewing) or verbal. No recalling of the seizure. 138 139 3. PARTIAL SEIZURES ~ GENERALISED SEIZURES " Partial seizures may spread to involve the whole brain .- secondarily generalised seizures " . HY-sterical epilepsY • Usually: • The cause: • Incidence: young neurotic Sj2 . psychological & there is no organic lesion. usually occurs in the presence of people. • It is associated with: • EEG: • It is not associated with: normal. • Missed ttt. • Menses. • Alkalosis. anxiety, palpitaion & hyperventilation. tongue biting or incontinence of urine. • Alcohol use & Drug abuse ( e.g. cocaine ). • S timulation by photons & Hyperventilation. • S leep deprivation & Stress & sudden withdrawal of antiepileptic drngs. INVESTIGATIONS 1. EEG: • It is the most specific test for epilepsy because it records the electrical activity of the brain. • It shows specific pattern: 2. LOCAL INVESTIGATIONS: "Epilepsy waves". "CT & MRI of the brain" • To identify or exclude a LOCAL CAUSE of seizures in the brain. 3. GENERAL INVESTIGATIONS: "Laboratory investigations" • To search for a GENERAL CAUSE of seizures, e.g. blood glucose. 139 140 TREATMENT A. General Measures: 1. 2. Moderation of the patient's physical activity. A void the precipitating factors ( Alcohol, hyperventilation, photic stimulation ...... ). 3. A ketogenic diet is encouraged because it will induce acidosis: - Acidosis is beneficial as it raises the threshold of stimulation of the brain cells. B. Specific Treatment: 2. 1. Treatment of the cause in secondary epilepsy. Anti-epileptic drugs: a) Always sta1t with one drug, then add another drug if there is no response. b) Always stop the drugs ONLY if: • The patient stays free of symptoms for at least 2 years. • The patient has a normal EEG. 3. Side effects of Anti-epileptic drugs: I . Skin rash. 2. 3. Bone marrow depression. Ataxia. Drug 1. Barbiturates (Pbenonobarbitone) 2. Hydantoin (Epanutin) 3. Carbamazepine 4. Clonazepam 5. Valproate 6. Succinamide ANTI-EPILEPTIC DRUGS NEW ANTI-EPILEPTIC DRUGS - These drugs are new dtugs that may be used in resistant seizures. 1. Lamotrigine: 200 - 400 mg/ day. 2. Felbamate: 3. Gabapentin: 400- 800 mg/ day. 600 - 1200 mg/ day. \ " General rules for use ": Dose 100-600 mg I day 100-600 mg / day 200-600 mg I day 2-6 mg I day 500-1500 mg I day 500-1000 mg / day Best indicated - Broad spectrum. - Not for petit mal. - Grand mal. - Motor Jacksonian fits. - Grand mal. - Motor Jacksonian fits. - Complex seizures. - Not for petit ma!. - Myoclonic. - Grand mat. - Broad spectrum. - Petit mat. 140 141 STATUS EPILEPTICUS DEFINITION - A medical emergency: 1. Repeated attacks of generalized convulsions, with lack of recove,y of consciousness, 2. Persistent attack of seizure lasting for at least 30 minutes. OR, - If the convulsions are not stopped rapidly, coma deepens & death may occur due to: heart failure or respiratory failure or brain damage or hyperpyrexia. - The most common causes are: sudden withdrawal of anti-epileptic drugs & stroke. TREATMENT A. General Measures: l. Take care of: " ABC " • Place the patient on the ground, to guard against falling from bed. • Mouth gag & 02 inhalation ( endo-tracheal intubation may be needed). • Record the vital signs regularly. 2. Take a sample of: - Venous blood: for the level of: - A.tierial blood: for the level of: 3. a nti-epileptic drugs, a lcohol. pH, p0 2, pC02, HC0 3. Give cerebral dehydrating measures: e.g. Frusemide, cone. Mannitol, Dexamethazone. B. Specific Treatment: - Phenytoin with diazepam (or clonazepam) immediately: 1. Phenytoin: 2. Diazepam: Clonazepam: seizures recur: 15 mg I Kg slow infusion. 5 mg slowly IV, to be repeated after 5 minutes if seizures recur: maximum dose: 20 mg. OR: 2 mg slowly IV, to be repeated after 5 minutes if maximum dose: 6 mg. - If seizures persist after 20 min. of Phenytoin & diazepam: 3. PHENOBARBITONE: - In resistant cases: 200 mg infusion. 4. GENERAL ANAESTHESIA: may be used.Oral Manifestations of Viral Infections Viral infections can lead to a variety of oral manifestations, which may vary depending on the type of virus involved. Below are the key viral infections and their associated oral symptoms. --- 1. Herpes Simplex Virus (HSV) Infections Type: HSV-1 and HSV-2 Common Oral Manifestations: Primary Herpetic Gingivostomatitis: In children, presents as painful swelling and redness of the gums, with vesicular lesions on the lips, tongue, and hard palate. Recurrent Herpes Simplex: Cold sores (herpes labialis) often appear on the lips or around the mouth, and are painful and fluid-filled. Herpetic Whitlow: Infection of the fingers, often seen in healthcare workers. Clinical Features: Vesicular lesions that break to form ulcers Painful and burning sensations in affected areas Swollen lymph nodes Fever (during primary infection) Diagnosis: Direct immunofluorescence, PCR, or viral culture. --- 2. Varicella-Zoster Virus (VZV) Infections Type: Varicella (chickenpox) and Herpes Zoster (shingles) Common Oral Manifestations: Varicella: Enanthem (oral lesions) such as vesicular lesions on the hard palate, tongue, and lips, in conjunction with the characteristic skin rash. Herpes Zoster (Shingles): Unilateral painful oral lesions, often involving the hard and soft palate, and can extend to the tongue or buccal mucosa along the distribution of the trigeminal nerve. Clinical Features: Vesicular lesions that ulcerate Pain and discomfort in affected areas Fever, malaise, and headache (for chickenpox) Diagnosis: PCR, direct fluorescence antibody test, and clinical signs. --- 3. Human Papillomavirus (HPV) Infections Type: Multiple strains, including HPV types 16 and 18 Common Oral Manifestations: Oral Warts: Benign, non-painful growths typically found on the lips, palate, tongue, and floor of the mouth. Condyloma Acuminatum: Wart-like lesions in the mouth, often associated with genital HPV. Oropharyngeal Cancer: Certain high-risk HPV strains (e.g., HPV-16) are linked to cancers of the oropharynx, including tonsils and base of tongue. Clinical Features: Raised, fleshy, or cauliflower-like growths Rarely associated with pain or discomfort Diagnosis: Biopsy and PCR testing for HPV. --- 4. Coxsackievirus Infections Type: Hand, Foot, and Mouth Disease (HFMD) Common Oral Manifestations: Oral Ulcers: Painful, shallow ulcers typically seen on the soft palate, tonsils, tongue, and buccal mucosa. Vesicular Lesions: Small vesicles that ulcerate to form painful sores. Clinical Features: Red spots or vesicles that turn into ulcers Fever, sore throat, and malaise Rash and lesions on hands and feet Diagnosis: Clinical presentation and PCR. --- 5. Measles (Rubeola) Type: Paramyxovirus Common Oral Manifestations: Koplik Spots: Small, white or bluish-white spots seen on the buccal mucosa opposite the molars before the rash appears. Generalized Oral Ulceration: Following the appearance of Koplik spots, mucosal lesions may develop. Clinical Features: High fever, cough, and rash (starts on the face and spreads) Conjunctivitis Koplik spots as early indicators Diagnosis: Clinical signs and serology for measles antibodies. --- 6. HIV/AIDS Type: Human Immunodeficiency Virus Common Oral Manifestations: Oral Candidiasis: Fungal overgrowth in the mouth due to immunosuppression. Kaposi's Sarcoma: A form of cancer that appears as purple or brown lesions in the mouth, especially in the palate or gingiva. Oral Hairy Leukoplakia: White, hairy lesions on the lateral borders of the tongue, often associated with Epstein-Barr virus. Herpes Simplex and Zoster: Recurrent infections in the oral cavity. Clinical Features: Candidiasis: White plaques that can be scraped off Kaposi’s Sarcoma: Purple, macular lesions Hairy Leukoplakia: White, corrugated patches on the tongue Recurrent infections and oral ulcers Diagnosis: HIV testing, biopsy for Kaposi's sarcoma, and culture for candidiasis. --- 7. Influenza Virus Type: Influenza A and B Common Oral Manifestations: Pharyngitis: Sore throat and erythema of the oropharyngeal mucosa. Dry Mouth: Often secondary to fever and dehydration. Mucosal Erosions: Rare, but may occur in severe cases. Clinical Features: Fever, cough, sore throat, muscle aches, and headache Red or swollen tonsils and oral mucosa Diagnosis: Rapid influenza tests and PCR. --- 8. Epstein-Barr Virus (EBV) Type: Epstein-Barr virus Common Oral Manifestations: Oral Hairy Leukoplakia: White, asymptomatic, corrugated patches on the lateral borders of the tongue. Pharyngitis: Sore throat with swelling of tonsils. Oral Ulcers: Occasionally seen in association with infectious mononucleosis. Clinical Features: Fever, sore throat, and swollen lymph nodes (mononucleosis) Fatigue and malaise Diagnosis: EBV serology and PCR. --- 9. Rabies Virus Type: Rabies virus Common Oral Manifestations: Hydrophobia: Difficulty swallowing and fear of water. Increased Salivation: Resulting from dysfunction in the throat and jaw muscles. Clinical Features: Progressive neurological symptoms Paroxysms of pain or spasms in the throat and mouth Diagnosis: Clinical signs, rabies testing (saliva, CSF, or tissue biopsy). --- 10. Human Immunodeficiency Virus (HIV) Common Oral Manifestations: Oral Candidiasis: White, creamy lesions in the mouth, especially in immunocompromised individuals. Kaposi’s Sarcoma: Purple or red lesions on the palate and gingiva. Herpes Simplex: Recurrent oral lesions. Oral Hairy Leukoplakia: A condition linked with Epstein-Barr virus, presenting as white patches on the lateral borders of the tongue. --- Conclusion Oral manifestations of viral infections are varied and can provide valuable clues for diagnosing systemic viral diseases. Clinicians must consider the specific features and patterns of lesions in combination with other clinical signs for an accurate diagnosis. Some infections may also have long-term oral health implications, requiring management and prevention strategies.Generalised algebraic statementsGENERALIZE via QUIZALIZE Please read the sentences carefully. Fill in the missing word/s on the blank space provided.Generalize Place Value UnderstandingGeneralize similar shapes7.5.A Generalize critical attributes of similarity between similar shapes