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Neurological disorders affecting body language

Neurological disorders affecting body language

Are there neurological disorders which do not affect the emotions per se but affect how they are expressed by the body?

Say, normally positive emotions are associated with the tips of the lips facing upwards; do some people express positive emotions in different ways?

Alternatively, when an average person discovers something funny for some period of time they breathe abnormally (so-called laughter); could some people's reaction entail e.g. blinking instead of that?


This is usually referred to as emotional expression or affect display, which can be verbal as well as non-verbal, whereas body language is exclusively non-verbal, and not exclusive to emotion.

This function can certainly go wrong:

There are a few disorders that show deficiency in emotional expression and response. These include alexithymia, autism, hypomimia and involuntary expression disorder.

And also:

Disorders involving… reduced affect displays most commonly include schizophrenia, post traumatic stress disorder, depression, autism and persons with traumatic brain injuries.

However, afflicted individuals do not typically substitute one expression for another - they usually either do not express some emotions (eg, Spock, who would have been diagnosed with alexithymia), or they express some emotions inappropriately (eg, the Joker, who presumably suffers from PBA). It's unlikely that someone would express happiness by tapping their foot, or laughter by blinking their eyes.


Body Language and the Brain: How We Read the Unspoken Signs?

Our interactions with other people involve both verbal and non-verbal communication, with information being processed in parallel. Non-verbal communication includes body language and can be very useful in making conclusions about unspoken intentions. Although we rely on verbal communication to receive information, it seems highly important to understand body language as well. Body language informs us about feelings and intentions of other people. From the evolutionary perspective, observing and reacting to emotional conditions of others may have been critical for our survival.

Indeed, the scientific literature suggests that we are more impressed by the information received non-verbally. Maybe this is because more than 50% of communication is based on our body language. On the other hand, less than 10% comes from what we actually say, while almost 40% comes from the tone of our voice.

At first look, it might seem easy to understand someone’s body language, through the perception of their body posture, gestures, and movements. But, the process is more complex than it looks. It involves specific regions and complex neuronal networks in our brain decoding body expressions and giving them adequate meaning. While the recognition of facial expressions is well studied, processing of body posture and gestures has received less attention until recently.

How does brain read body language?

The scientific literature suggests that brain has several specialized structures that process socially relevant information. As neuroimaging studies have revealed, the processing of body expressions activates a complex network of neurons. This not only includes visual areas but also includes subcortical and cortical emotion-related regions, as well as regions involved in planning and execution of actions.

The visual representation of the human body and its emotions activates two main visual areas in the brain. These are the extrastriate body area and the face-selective fusiform body area. Using MRI scans, researchers measured the degree of activation in these brain areas in response to “normal” and “emotional” body language by showing short video clips to volunteers. These clips represented people who were performing emotionally neutral gestures and movements or expressing 5 basic emotions: happiness, sadness, anger, disgust, or fear.

The results showed that brain areas were influenced by the emotional weight of body movements. More precisely, activation of the extrastriate body area (EBA) and the face fusiform body areas (FBA) were significantly greater in response to emotional body language than to neutral body language. Also, both of the areas reacted most strongly to happiness, anger, and disgust. While fear significantly influenced the EBA, the modulation was not significant in the case of FBA. Sadness failed to significantly activate both regions. The lack of modulation by sadness may be due to the excitement associated with sadness. Levels of excitement have a crucial role in activation of the amygdala, a part of the brain playing an important role in the processing of emotions. In addition, there is a positive correlation between amygdala activation and modulation of EBA and FBA areas.

Despite the complex non-facial gestures that people use to communicate most of the studies are based on facial expression only. To address this issue, one recent study created a set of body language patterns by taking photos of actors personifying emotional states. The photos portrayed typical emotional states (for instance “I am in love”, “I hate you” and others), i.e., they captured gestures and actions reflecting emotional body language. The results of this study have indicated that the body (including the face) mimics and gestures undergo prioritized fast procession.

In order to better measure neural processes involved in the comprehension of emotional body language, a short verbal description of the emotional state preceded the pictures. The verbal descriptions were both congruent (matching the state presented on pictures) and incongruent. The analyses showed that body language is rapidly compared with verbal information. Importantly, the results indicated that incongruent body language was revealed just 300 ms following the stimulus. Thus, the process of body language comprehension in the brain is obviously able to provide information about the sincerity of others. This is important for regulation of our social interactions.

Can we react unintentionally to body language?

There are inconsistent data on how the brain processes emotional stimuli as an important part of our body language. While some findings suggest that emotional stimuli are processed automatically, i.e., without attention, other researchers believe that attention is necessary for processing emotional expressions. Namely, behavioral studies have found that the processing of facial expression occurs not only automatically but without conscious awareness as well. It has been shown that brain regions, such as the amygdala, may be activated when emotional stimuli (such as fear) are masked and the subject seems to be unaware of them. Still, most of the studies suggesting that the processing of body postures is automatic have focused on the interpretation of fearful body language.

Are there any factors affecting the brain coding of body language?

The activation of specific brain regions by witnessing body language may vary in accordance with individual differences. Factors such as personality, genotype, and gender may affect the neuronal response to body language. For instance, in response to emotionally aversive (unpleasant) stimuli, specific brain regions are more activated in women as compared to men. On the other side, activation is greater in men when it comes to viewing emotional faces, scenes, and words. Still, empathy levels may influence these gender differences. As one study demonstrated, participants with higher self-reported empathy were characterized by higher activation in brain areas associated with the interpretation of emotions.

Despite our limited knowledge of body language processing by the brain, several conclusions can be made:

  • Specific brain areas are activated in order to process body language and facial expressions. Among these, two visual areas and the amygdalas are the most important ones.
  • We may react more explicitly to body language expressing happiness than sadness, due to higher activation of specific brain regions.
  • There may be some gender difference in reacting to body language, due to the different activation of brain areas. Still, personality is an important cofactor.
  • Sometimes, like in the case of fearful body language, we might react unintentionally.

The lack of detailed research leaves lots of question about the processing of body language, as well as about how we use this channel of communication, intentionally or not. As the neuroscience on the subject advances, we will most certainly learn much more about this fascinating topic.


Neurological Conditions

A neurological condition is any disorder which affects the central nervous system. The nervous system acts as a command center for the body, and when communication is interrupted, a variety of disorders and symptoms are possible. This can be caused by a physical injury to the brain, nerves or the spinal cord as well as infections, diseases or genetics.

Below is a list of the most common neurological conditions seen in children waiting for forever families. We provide the following information for reference purposes only and cannot attest to the accuracy of the information. We highly recommend speaking with an experienced physician for further details on each condition.

Common Neurological Conditions

Children with apraxia have difficulties with speech. Their brain has difficulty coordinating movement of the speech muscles. In a very young child, they may have a delay in speech development and trouble eating. In older children, they may have difficulty imitating sounds, be difficult to understand, have difficulty producing longer words or have more difficulty with speech when they are anxious.

Causes:
Apraxia can be developmental or acquired. Developmental apraxia occurs in children and is present at birth. The causes for developmental apraxia are unknown however researchers have found that children with this condition often have a family history of communication disorders or learning disabilities. Acquired apraxia can occur at any time in life and may be due to a brain injury, brain tumor or stroke.

Possible complications:
A child may acquire apraxia due to a brain injury such as a stroke, infections or traumatic brain injury. It may also occur due to a genetic disorder, syndrome or metabolic condition such as velocardiofacial syndrome and galactosemia.

Treatment:
Speech language therapy is necessary to help children with apraxia of speech. They will most likely need frequent and intensive one-on-one therapy. They may also benefit from learning additional forms of communication such as sign language.

Prognosis:
In many cases, with treatment, children with apraxia can live normal, healthy lives. However, the long-term prognosis depends on the cause and severity of apraxia as well as the effectiveness of speech therapy.


An arachnoid cyst is a fluid-filled sac that can develop between the surface of the brain and the cranial base or on the arachnoid membrane. Most cases begin during infancy, but sometimes the onset of symptoms may be delayed until adolescence. Some of the symptoms of a large cyst may be headaches, seizures, hydrocephalus, increased cranial pressure, developmental delay, behavioral changes, weakness or paralysis on one side of the body, lack of muscle control, head bobbing, and visual impairment.

Causes:
Most arachnoid cysts are present at birth and while the specific cause is unknown, researchers believe they occur during development of the central nervous system. Arachnoid cysts can develop in adults as a result of brain surgery or injury.

Possible complications:
Arachnoid cysts can sometimes be associated with genetic disorders such as Cockayne syndrome and Menkes syndrome.

Treatment:
Smaller cysts that are causing no symptoms are normally just observed for changes. Larger cysts that are putting pressure on the brain and causing symptoms may require surgery.

Prognosis:
Children with small cysts that cause no symptoms typically lead healthy lives. If larger cysts are treated early, the prognosis is usually very good and symptoms are resolved. If left untreated, severe, permanent brain damage can occur.


Cerebral Palsy
(CP) is a general term that describes any disorder affecting body movement and muscle control. There are many types of CP and a variety of symptoms such as stiff contracted muscles, lack of muscle tone, lack of coordination, poor balance, and uncontrolled movements. It can affect one or two limbs, half the body, or the entire body. It can also affect a child&rsquos ability to use their facial muscles causing difficulty eating or speaking. Children with CP can have a wide spectrum of abilities. Some children are only mildly affected, while others will have severe complications and limitations.

Causes:
CP is usually present at birth and can be caused by genetic mutations and maternal infections during pregnancy such as measles, syphilis or exposure to toxins as well as a traumatic birth resulting in a lack of oxygen. It can also be caused by a stroke, infection in the brain, or traumatic brain injury.

Possible complications:
Some children with CP are unable to walk or speak. They may also have an underlying neurological condition. Muscle weakness, muscle spasticity and coordination problems can cause abnormal bone development, arthritis, breathing disorders and malnutrition.

Treatment:
Children with cerebral palsy can benefit from several areas of treatment.

  • Physical Therapy: PT can help your child strengthen and stretch weak muscle groups. This will also help with flexibility, balance, motor development and mobility.
  • Occupational Therapy: OT can help your child use adaptive equipment such as a walker, wheelchair or cane to gain as much independence as possible.
  • Speech Therapy: Speech-language therapy can help your child strengthen the muscles necessary to speak. A therapist may also help your child use alternative communication methods, such as an electronic communication device, if speech is too difficult.
  • Surgery: Surgery can be used to help stretch tendons and muscles, lessoning contractures and reducing pain.

Prognosis:
The long-term prognosis for a child cerebral palsy depends on the cause and severity of need. Many children with CP are able to live full and independent lives.


The brain is made up of millions of nerve cells gathered together. By passing electrical signals to each other, these nerve cells can control the body&rsquos function, senses and thoughts. Sometimes the process of exchanging signals is suddenly interrupted and a seizure occurs. About 1% of people in the United States may have at least one seizure. A diagnosis of epilepsy typically means a person has had two or more seizures not caused by an outside medical condition such as low blood sugar, fevers, or heart problems. There are different types of seizures, based on the part of the brain that is involved. Some seizures present with sudden uncontrollable limb movements and unconsciousness, some present with staring and strange behavior, and some are only noticed by the child that is experiencing the seizure. Seizures usually begin in childhood, although they can happen at any age.

Causes:
In about half of cases, the exact cause of epilepsy is unknown. In the other half of cases, the cause can be linked to genetics, head trauma, tumors or stroke, infectious diseases or even birth trauma.

Possible complications:
Left untreated, persistent seizures can lead to brain damage. Seizures can also put a person at risk in certain situations such as when driving a car. People diagnosed with epilepsy are also at risk for sudden, unexplained death.

  • Medication: Most people with epilepsy can become seizure-free by taking anti-seizure medication.
  • Surgery: If doctors are able to determine that the seizures all originate in the same area of the brain, they may be able to surgically remove that part of the brain to reduce eliminate seizures. Surgery can have significant side-effects.
  • Diet: Some children with epilepsy have been able to reduce their seizures by following a ketogenic diet, high in fats and low in carbohydrates.

Prognosis:
The long-term prognosis for epilepsy depends on the severity of seizures and treatment. If frequent, severe seizures have occurred without treatment, permanent brain damage is possible. However, over half of children diagnosed with epilepsy can eventually discontinue medication and lead a seizure-free life.


Hydrocephalus
occurs when the fluid in the brain cannot drain away into the bloodstream because the normal pathways are blocked. The fluid is still being made by the brain, so the buildup of fluid will cause pressure to rise inside the brain. A child with hydrocephalus may have abnormally large head measurements. They may experience difficulty feeding, irritability, delayed cognitive development, headaches, vomiting, blurred vision, difficulty walking and delayed growth.

Causes:
Our bodies continually produce cerebral spinal fluid, which circulates through the ventricles of the brain and the spinal column and is also absorbed by the body. Hydocephalus develops when there is an excess of fluid on the brain. This is usually caused by an obstruction, where fluid is blocked from leaving one part of the brain (non-communicating hydrocephalus). It can also rarely be caused by an overproduction of fluid or an inability for the body to absorb some of the fluid (communicating hydrocephalus). Hydrocephalus may occur in infancy or in older children and can be caused by a brain bleed (which may be as a result of a premature birth), meningitis, cysts or brain tumors, or other rare causes.

Possible complications:
Left untreated, hydrocephalus can cause permanent brain damage. Children with hydrocephalus can also experience learning delays, hormonal imbalances, seizures, and hearing and vision issues. Hydrocephalus is also common in children with Spina Bifida.

Treatment:
The most common treatment for hydrocephalus is surgery to put in a shunt, which is a tube that helps drain fluid from the brain. One end of the tube is usually placed in a ventricle of the brain and the other end is put in a part of the body where the cerebral spinal fluid can be more easily absorbed, such as the abdomen or the heart. Another option is a Ventriculostomy, which is a surgical procedure where a doctor creates a hole in one of the ventricles to help drain the fluid. This surgery is not an option for every child, and there is also a risk that the hole will close on its own.

Prognosis:
The long-term prognosis for children with hydrocephalus depends on the severity and treatment. Children who also have spina bifida may have more long-term complications. Untreated, hydrocephalus can be fatal. However, with early intervention, many kids with hydrocephalus go on to lead healthy lives.


During early development, the spinal column begins as a flat plane. In the first month of pregnancy it begins to curl and eventually seals into a tube shape. When a child has spina bifida, this means the tube did not completely seal. There are three types of spina bifida:

  • Occulta: This is the mildest form and involves an opening into the vertebrae without a protrusion of the spinal cord or meninges. Many people do not know they have this. There may be a large mold or patch of hair or a deep dimple on the skin along the spine.
  • Meningocele: The spinal cord will have developed normally, but when the child is born there is a sac protruding from a hole in the vertebrae and out of the back. It is important to have surgery early as the sac may break and infection and nerve damage may occur. Often this form of spina bifida does not present any problems once the back is closed.
  • Myelomeningocele(Meningomyelocele): This is the most common and the most serious form of spina bifida. The protruding sac on the back will contain tissue, spinal fluid, nerves and part of the spinal cord. The spinal cord may be damaged or not properly formed. There is always some degree of paralysis and loss of sensation below the damaged vertebrae. Children may need a walker or wheel chair depending on the level of paralysis.

Causes:
The exact causes of spina bifida are unknown. However, genetics may play a role as well as high fevers and certain medications. A lack of folic acid during pregnancy may also lead to neural tube defects.

Possible complications:
Children with myelomeningocele often have hydrocephalus and/or clubbed feet. Some children with spina bifida have problems such as curvatures in the back, hip dislocation, ankle and foot deformities and contracted muscles. Depending on the severity of the spina bifida, children are also at greater risk for paralysis and infection.

Treatment:
Children with meningocele and myelomeningocele need surgery to put the meninges (nerves) back into the spinal column and close the opening in the spine.

Prognosis:
The long-term prognosis for children with spina bifida depends on the severity and treatment. Surgery should be done as early as possible to have the best possible results. However, children in certain countries may not be able to have early intervention. The longer a child goes without surgery, the greater the risk for serious, long-term complications such as infection and paralysis.


Disorders of body temperature

The human body generates heat capable of raising body temperature by approximately 1°C per hour. Normally, this heat is dissipated by means of a thermoregulatory system. Disorders resulting from abnormally high or low body temperature result in neurologic dysfunction and pose a threat to life. In response to thermal stress, maintenance of normal body temperature is primarily maintained by convection and evaporation. Hyperthermia results from abnormal temperature regulation, leading to extremely elevated body temperature while fever results from a normal thermoregulatory mechanism operating at a higher set point. The former leads to specific clinical syndromes with inability of the thermoregulatory mechanism to maintain a constant body temperature. Heat related illness encompasses heat rash, heat cramps, heat exhaustion and heat stroke, in order of severity. In addition, drugs can induce hyperthermia and produce one of several specific clinical syndromes. Hypothermia is the reduction of body temperature to levels below 35°C from environmental exposure, metabolic disorders, or therapeutic intervention. Management of disorders of body temperature should be carried out decisively and expeditiously, in order to avoid secondary neurologic injury.

Keywords: Fever Hyperthermia Hypothermia Thermoregulation.


Recognising and explaining functional neurological disorder

Functional disorders are conditions whose origin arises primarily from a disorder of nervous system functioning rather than clearly identifiable pathophysiological disease—such as irritable bowel syndrome, fibromyalgia, and functional neurological disorder (FND)—they are the second commonest reason for new neurology consultations. 1 FND is common in emergency settings, 2 stroke, 3 and rehabilitation services. 4 It causes considerable physical disability and distress, and often places an economic burden both on patients and health services. 5 Many clinicians have had little formal clinical education on the assessment and management of these disorders, and patients are often not offered potentially effective treatments.

In practice, FND should be diagnosed by someone with specific expertise in the diagnosis of neurological conditions. Our recommendation is to refer all patients with a suspected diagnosis of FND to secondary care. However, the diagnosis may be raised as a possibility with the patient in primary care, and knowledge of how the diagnosis is confirmed greatly aids subsequent management.

In this article we offer evidence based advice to generalists on how to recognise FND, based on clinical diagnostic and prognostic studies. Although the focus of this paper is on recognising FND, we have included a short box on management to make readers aware that there are good treatments available for FND and that some patients can get better.

Sources and selection criteria

We conducted a PubMed search of evidence for diagnosis of functional neurological disorder (FND) until June 2020, especially systematic reviews. 14 …


What is Labile Affect?

Labile Affect is the act of inappropriate laughter due to a nervous system disorder. Some patients laugh or cry uncontrollably and aren't able to stop without therapy or medication.

We often look to a person’s facial expressions or body language to gauge how they are feeling inside. These signs are also known as affect. When we smile, cross our arms, or clench our jaw, it is often a reflection of our mood or internal feelings.

Psychologists and medical professionals are currently studying affect, and how it may change at different rates. Dramatic shifts in mood often come with dramatic shifts in outward expression. These dramatic expressions may or may not reflect a person’s true feelings. When this happens, psychologists may label it as Labile Affect, or Emotional Lability. Other names for this event include Inappropriate Affect or Pseudobulbar Affect, but I’ll explain that fancy name in a bit.

Labile Affect may refer specifically to the rapid change in someone’s mood or how they display that mood. Other forms of Inappropriate Affect include “Shallow Affect” (having no emotion or expression, even in dramatic situations) or “Blunted Affect” (showing very little emotion while recalling or experiencing a dramatic situation.)

One of the most famous examples of Labile Affect is the Joker in the 2019 movie. Examples of Labile Affect behavior include:

  • Laughing uncontrollably at a somber occasion
  • Crying uncontrollably for no reason at all (including seasonal allergies!)
  • Showing absolutely no signs of emotion after hearing dramatic news

These episodes are typically brief, lasting only a few minutes.


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Essentials of Assessment

History

Evaluations are generally based on 3 sources of information: (1) observation and interview of the patient (2) information from others (eg, family, significant others, other clinicians) that corroborates, refutes, or elaborates on the patient’s report and (3) medical records. 14

The primary assessment tool is direct face-to-face interview of the patient. Evaluations based solely on review of records and interviews of persons close to the patient are inherently limited by a lack of the patient’s perspective. Furthermore, the clinical interview provides a sample of the patient’s interpersonal behavior and emotional processes and can either support or qualify diagnostic inferences from the history.

Key information that should be derived from the interview should include the following:

  1. Are symptoms minimized or exaggerated by the patient or others?
  2. Does the patient appear to provide accurate information?
  3. Do particular questions evoke hesitation or signs of discomfort?
  4. Is the patient able to communicate about emotional issues?
  5. How does the patient respond to the clinician’s comments and behaviors? 14

Medical history (significant medical problems or prior hospitalizations, history of head trauma), current medications (including psychotropic use), psychiatric history (illnesses, treatment received, outcomes), risk of harm to self or others, legal history, history of alcohol and other substance use, psychosocial history, and review of systems (including other psychiatric symptoms) should also be included. 14

Physical examination

The physical examination should be thorough because, even if there are no neurologic findings, a systemic illness may be present that is producing psychiatric symptoms.

Vital signs and a detailed musculoskeletal and neurologic examination, including a mental status exam, are of particular importance. Components of a mental status examination include appearance, behavior, speech, attitude, mood, affect, thought process and content, perception, cognition, insight, and judgment. 3

On occasions, patients may exhibit physical signs that provide insight that a comprehensive psychological evaluation may be warranted. For instance, Waddell signs were developed in 1980 to identify patients with low back pain who were likely to experience poor surgical outcomes. 23 Having 3 or more of the following constitutes a positive result:

  1. Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness
  2. Simulation tests: these are based on movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation
  3. Distraction tests: positive tests are rechecked when the patient’s attention is distracted, such as a straight leg raise test
  4. Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomy
  5. Overreaction: subjective signs regarding the patient’s demeanor and reaction to testing

Clinicians should interpret these signs with caution, and results should not be used for medico-legal purposes. 23

Close involvement in the patient’s general medical evaluation and ongoing care can also improve the patient’s care by promoting cooperation, facilitating follow-up, and permitting prompt reexamination of symptomatic areas when symptoms change. 14

Functional assessment

Structured assessment of physical and instrumental function may be useful in assessing strengths and disease severity. Functional assessments include assessment of physical activities of daily living (eg, bathing, dressing) and instrumental activities of daily living (e.g., driving, taking medication as prescribed, shopping, keeping house, caring for a child or other dependent). 14 The Pain Disability Questionnaire was developed as a measure of functional status of patients with pain and is based on the biopsychosocial approach to pain. 4,20

Laboratory studies

There are no specific guidelines about which tests should be routinely done. Several studies have demonstrated the limited utility and higher cost of ambulatory screening. Patients on psychotropic medications should be monitored for side effects specific to that therapy. When substance use is suspected, determining blood alcohol levels or screening for substances of abuse may be especially important. 14,15 Examples of tools available for screening for substance abuse/use include the Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain (SOAPP), and the CAGE. 21

Imaging

Specialized modalities (eg, computerized scanning, magnetic resonance imaging) can be used to screen for possible causes of delirium (eg, fever, metabolic abnormalities) or neurologic conditions with behavioral manifestations that could be mistaken for a psychiatric disorder (eg, patient with a brain tumor in the frontal lobes might present with a mood disorder). 3

Several neuroimaging studies suggest that specific neural networks modulate aspects of emotional behavior and are implicated in the pathophysiology of mood disorders: medial prefrontal cortex and closely related areas in the medial and caudolateral orbital cortex, amygdala, hippocampus, and ventromedial parts of the basal ganglia. 16

Supplemental assessment tools

The current methodology and content of psychiatric diagnosis, growing specificity of treatment planning in regard to both medication and psychosocial interventions, and nature of the health care delivery system all influence the context that determines the use of clinical rating scales and neuropsychologic tests to inform assessment and treatment planning. 17

Examples of functional domains to be measured and corresponding clinical rating scales include the following:

  1. Quality of life (eg, Quality of Life Enjoyment and Satisfaction Questionnaire)
  2. Mental health status and functioning (eg, Clinical Global Impression Scale, Global Assessment of Functioning Scale, Social and Occupational Functioning Assessment Scale)
  3. Cognitive disorders (Delirium Rating Scale Revised-98, Mini-Mental State Examination),
  4. Alcohol use disorder (CAGE Questionnaire),
  5. Mood disorders (Beck Depression Inventory Second Edition, Hamilton Depression Rating Scale, Patient Health Questionnaire, Geriatric Depression Scale), and
  6. Anxiety disorder (Hamilton Anxiety Rating Scale). 14

Neuropsychologic testing has a broad range of application, but the decision to order neuropsychologic testing for an individual patient remains a matter of clinical judgment. Neuropsychologic testing may be requested when cognitive deficits are suspected or there is a need to grade for severity or progression of deficits over time and for distinguishing between cognitive disorders (eg, dementia) and malingering or factitious disorders. 14

Early predictions of outcomes

Age (younger age at pain onset), sex (women > men), number of pain areas, frequency and severity of pain, psychosocial problems (problems with social and leisure activities), unemployment, and compensation are mediating factors in the course and prognosis of individuals with chronic pain and mental disorders. 3,9,8,10

Waddell signs do not discriminate organic from non-organic sources of pain, and do not correlate with psychological distress. However, positive results have been associated with poorer treatment outcomes, and higher pain levels. 24

Environmental

According to the International Classification of Functioning, Disability and Health, environmental factors that can influence the functioning of individuals with mood disorder and chronic widespread pain include the following: medication use, immediate family/friends, health professionals, individual attitudes of family/friends/health professionals, and availability of social security services/systems (ie, aimed at providing income support). 18,19

Social role and social support system

An assessment of family, peer networks, cultural identity, and other support systems plays an important part in the psychiatric evaluation because of the potential role of these systems in ameliorating or augmenting the patient’s signs and symptoms of illness. This is particularly true when evaluating individuals with complex biopsychosocial challenges or serious psychiatric or general medical conditions. 14

Professional Issues

Throughout the assessment, useful clinical information is obtained by being sensitive to issues of development, culture, and the clinician’s own possible biases or prejudices about patient’s subculture, race, ethnicity, primary language, health literacy, disabilities, sex, sexual orientation, familial/genetic patterns, religious and spiritual beliefs, and social class influencing the patient’s symptoms and behavior. 14


The World Health Report 2001: Mental Disorders affect one in four people

One in four people in the world will be affected by mental or neurological disorders at some point in their lives. Around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide.

Treatments are available, but nearly two-thirds of people with a known mental disorder never seek help from a health professional. Stigma, discrimination and neglect prevent care and treatment from reaching people with mental disorders, says the World Health Organization (WHO). Where there is neglect, there is little or no understanding. Where there is no understanding, there is neglect.

In a new report entitled "New Understanding, New Hope" the United Nations&rsquo health agency seeks to break this vicious cycle and urges governments to seek solutions for mental health that are already available and affordable. Governments should move away from large mental institutions and towards community health care, and integrate mental health care into primary health care and the general health care system, says WHO.

"Mental illness is not a personal failure. In fact, if there is failure, it is to be found in the way we have responded to people with mental and brain disorders," said Dr Gro Harlem Brundtland, Director-General of WHO, on releasing the World Health Report. "I hope this report will dispel long-held doubts and dogma and mark the beginning of a new public health era in the field of mental health," she added.

A lack of urgency, misinformation, and competing demands are blinding policy-makers from taking stock of a situation where mental disorders fi gure among the leading causes of disease and disability in the world, says WHO. Depressive disorders are already the fourth leading cause of the global disease burden. They are expected to rank second by 2020, behind ischaemic heart disease but ahead of all other diseases.

The report invites governments to make strategic decisions and choices in order to bring about positive change in the acceptance and treatment of mental disorders. The report says some mental disorders can be prevented most mental and behavioural disorders can be successfully treated and that much of this prevention, cure and treatment is affordable.

Despite the chronic and long-term nature of some mental disorders, with the proper treatment, people suffering from mental disorders can live productive lives and be a vital part of their communities. Over 80% of people with schizophrenia can be free of relapses at the end of one year of treatment with antipsychotic drugs combined with family intervention. Up to 60% of people with depression can recover with a proper combination of antidepressant drugs and psychotherapy. Up to 70% of people with epilepsy can be seizure free when treated with simple, inexpensive anticonvulsants.

The responsibility for action lies with governments, says WHO. Currently, more than 40% of countries have no mental health policy and over 30% have no mental health programme.

Around 25% of countries have no mental health legislation. The magnitude of mental health burden is not matched by the size and effectiveness of the response it demands. Currently, more than 33% of countries allocate less than 1% of their total health budgets to mental health, with another 33% spending just 1% of their budgets on mental health. A limited range of medicines is suffi cient to treat the majority of mental disorders. About 25% of countries, however, do not have the three most commonly prescribed drugs used to treat schizophrenia, depression and epilepsy at the primary health care level. There is only one psychiatrist per 100 000 people in over half the countries in the world, and 40% of countries have less than one hospital bed reserved for mental disorders per 10 000 people.

The poor often bear the greater burden of mental disorders, both in terms of the risk in having a mental disorder and the lack of access to treatment. Constant exposure to severely stressful events, dangerous living conditions, exploitation, and poor health in general all contribute to the greater vulnerability of the poor. The lack of access to affordable treatment makes the course of the illness more severe and debilitating, leading to a vicious circle of poverty and mental health disorders that is rarely broken.

The report says new knowledge can have a tremendous impact on how individuals, societies and the public health community deal with mental disorders. We now know that large mental institutions no longer represent the best option for patients and families. Such institutions lead to a loss of social skills, excessive restriction, human rights violations, dependency, and reduced opportunities for rehabilitation. Countries should move towards setting up community care alternatives in a planned manner, ensuring that such alternatives are in place even as institutions are being phased out.

"Science, ethics and experience point to clear paths to follow. In the face of this knowledge, a failure to act will reflect a lack of commitment to address mental health problems," said Dr Benedetto Saraceno, Director of WHO&rsquos Mental Health and Substance Dependence department.

The policy directions have never been so clear, says WHO. Governments who are just starting to address mental health will need to set priorities. Choices must be made among a large number of services and a wide range of prevention and promotion strategies.

WHO&rsquos message is that every country, no matter what its resource constraints, can do something to improve the mental health of its people. What it requires is the courage and the commitment to take the necessary steps.

The report is part of a year-long campaign on mental health. For the first time, multiple events at WHO including its premier report, technical discussions at the World Health Assembly and World Health Day, have all focused on one topic &ndash mental health.


Why do I feel so flat, and what can I do about it?

Not everyone responds to emotional stimuli in the same way, but, in some, there may be no response at all.

This lack of reaction is called flat affect and can be a symptom of a psychiatric disorder or a side effect of another medical condition.

Those with flat affect do not lack emotion, but rather their emotions are thought to be unexpressed. This visual or verbal absent can be caused by conditions that include schizophrenia, autism , depression, and traumatic brain injury.

Emotions to stimuli that are not expressed by people with flat affect include facial, voice and body language changes.

Share on Pinterest Flat affect is characterized by a lack of response to emotional stimuli. This may include having a neutral facial expression.

Symptoms of flat affect can include:

  • monotone voice
  • lack of eye contact, changes in facial expressions, or interest
  • lack of verbal and nonverbal responses

Typically, a particular experience or situation will produce an emotional response in someone, such as elation, fear, sadness, or anger.

Therapist Deb Smith explains “in those who are experiencing a flat affect, these normal responses are not exhibited. For example, a person without flat affect who is experiencing a happy event will typically exhibit behaviors indicating happiness, such as smiling and laughter, whereas someone with a flat affect will show no response.”

For example, a person who is exhibiting a symptom of flat affect may not be able to empathize with a person who is sad, angry, or happy.

For some people and for some medical conditions, flat affect may be more pronounced than others.

Schizophrenia

Schizophrenia is a severe form of mental illness where someone has auditory and visual hallucinations, false beliefs, disorganized thought and behavior patterns, and a flat affect.

The flat affect experienced by those with schizophrenia is due to an impairment in the way they function on an emotional level. It is deemed a negative side effect of the disease, as it is not in line with normally expected emotions and behaviors.

Depression

Depression is a common mental health condition where a person experiences feelings of sadness, which can lead to a loss of interest in activities, decreased productivity, and other emotional and physical symptoms and conditions.

In some people, this state of mind and body can lead to a person displaying flat affect.

Autism

Autism is a condition with varying symptoms and severity, but which describes a spectrum of disorders that include abnormal or challenging social skills, repetitive behaviors, and abnormalities in speech and nonverbal communication.

Some of those affected by autism will be unable to speak and intellectually disabled to varying degrees. Consequently, those with autism are often described as having flat affect.

Parkinson’s disease (PD)

Parkinson’s disease is a neurological disease most commonly affecting the older population that presents with symptoms, including resting tremor, rigidity, limited movements, and instability. Some people with PD also experience depression, anxiety, psychosis , dementia, and flat affect.

Traumatic brain injury (TBI)

Those who suffer a traumatic brain injury caused by a blunt trauma, fall, blast injury or other violent situation may experience post-trauma flat affect.

In addition to blunt trauma, brain injuries caused by strokes, especially right hemisphere strokes, can cause a person to experience flat affect.

While flat affect and blunted affect may sometimes appear interchangeable, they are different.

Those with flat affect have no response to emotional stimuli. Blunted affect, however, describes a dulled or constricted response, where a person’s emotional response is not as intense as normally expected.

Blunted affect is commonly seen in those with post-traumatic stress disorder or PTSD.

When an event causes a person to experience or witness physical harm or violence, they can go on to develop PTSD. This may cause them to have long-term anxiety and fear, which can be debilitating.

PTSD has many symptoms and often leads to nightmares and flashbacks to the original event. People with PTSD can also experience social detachment and a blunted or numbed affect in response to emotional stimuli.

Again, trauma therapist Deb Smith explains that “many clients coming in for treatment of PTSD will initially present with a blunted affect. However, the combination of treatments used to treat PTSD often alleviate that symptom. This in turn returns the client to their pre-trauma affect.”

Treating flat affect can be challenging, as it depends on the underlying cause. People who think that they or a loved one may be experiencing symptoms of flat or blunted affect should speak to a doctor for evaluation.

Learning more about what could be causing this symptom is vital if a person is to be treated in the most appropriate way.

Therapists, psychologists, and other specialist doctors will be better able to assess and treat a person with flat affect after they have evaluated the individual’s health history and done a physical examination.

Additionally, a careful review of any medications may be helpful in determining the cause of flat affect.


Disorders of body temperature

The human body generates heat capable of raising body temperature by approximately 1°C per hour. Normally, this heat is dissipated by means of a thermoregulatory system. Disorders resulting from abnormally high or low body temperature result in neurologic dysfunction and pose a threat to life. In response to thermal stress, maintenance of normal body temperature is primarily maintained by convection and evaporation. Hyperthermia results from abnormal temperature regulation, leading to extremely elevated body temperature while fever results from a normal thermoregulatory mechanism operating at a higher set point. The former leads to specific clinical syndromes with inability of the thermoregulatory mechanism to maintain a constant body temperature. Heat related illness encompasses heat rash, heat cramps, heat exhaustion and heat stroke, in order of severity. In addition, drugs can induce hyperthermia and produce one of several specific clinical syndromes. Hypothermia is the reduction of body temperature to levels below 35°C from environmental exposure, metabolic disorders, or therapeutic intervention. Management of disorders of body temperature should be carried out decisively and expeditiously, in order to avoid secondary neurologic injury.

Keywords: Fever Hyperthermia Hypothermia Thermoregulation.


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Why do I feel so flat, and what can I do about it?

Not everyone responds to emotional stimuli in the same way, but, in some, there may be no response at all.

This lack of reaction is called flat affect and can be a symptom of a psychiatric disorder or a side effect of another medical condition.

Those with flat affect do not lack emotion, but rather their emotions are thought to be unexpressed. This visual or verbal absent can be caused by conditions that include schizophrenia, autism , depression, and traumatic brain injury.

Emotions to stimuli that are not expressed by people with flat affect include facial, voice and body language changes.

Share on Pinterest Flat affect is characterized by a lack of response to emotional stimuli. This may include having a neutral facial expression.

Symptoms of flat affect can include:

  • monotone voice
  • lack of eye contact, changes in facial expressions, or interest
  • lack of verbal and nonverbal responses

Typically, a particular experience or situation will produce an emotional response in someone, such as elation, fear, sadness, or anger.

Therapist Deb Smith explains “in those who are experiencing a flat affect, these normal responses are not exhibited. For example, a person without flat affect who is experiencing a happy event will typically exhibit behaviors indicating happiness, such as smiling and laughter, whereas someone with a flat affect will show no response.”

For example, a person who is exhibiting a symptom of flat affect may not be able to empathize with a person who is sad, angry, or happy.

For some people and for some medical conditions, flat affect may be more pronounced than others.

Schizophrenia

Schizophrenia is a severe form of mental illness where someone has auditory and visual hallucinations, false beliefs, disorganized thought and behavior patterns, and a flat affect.

The flat affect experienced by those with schizophrenia is due to an impairment in the way they function on an emotional level. It is deemed a negative side effect of the disease, as it is not in line with normally expected emotions and behaviors.

Depression

Depression is a common mental health condition where a person experiences feelings of sadness, which can lead to a loss of interest in activities, decreased productivity, and other emotional and physical symptoms and conditions.

In some people, this state of mind and body can lead to a person displaying flat affect.

Autism

Autism is a condition with varying symptoms and severity, but which describes a spectrum of disorders that include abnormal or challenging social skills, repetitive behaviors, and abnormalities in speech and nonverbal communication.

Some of those affected by autism will be unable to speak and intellectually disabled to varying degrees. Consequently, those with autism are often described as having flat affect.

Parkinson’s disease (PD)

Parkinson’s disease is a neurological disease most commonly affecting the older population that presents with symptoms, including resting tremor, rigidity, limited movements, and instability. Some people with PD also experience depression, anxiety, psychosis , dementia, and flat affect.

Traumatic brain injury (TBI)

Those who suffer a traumatic brain injury caused by a blunt trauma, fall, blast injury or other violent situation may experience post-trauma flat affect.

In addition to blunt trauma, brain injuries caused by strokes, especially right hemisphere strokes, can cause a person to experience flat affect.

While flat affect and blunted affect may sometimes appear interchangeable, they are different.

Those with flat affect have no response to emotional stimuli. Blunted affect, however, describes a dulled or constricted response, where a person’s emotional response is not as intense as normally expected.

Blunted affect is commonly seen in those with post-traumatic stress disorder or PTSD.

When an event causes a person to experience or witness physical harm or violence, they can go on to develop PTSD. This may cause them to have long-term anxiety and fear, which can be debilitating.

PTSD has many symptoms and often leads to nightmares and flashbacks to the original event. People with PTSD can also experience social detachment and a blunted or numbed affect in response to emotional stimuli.

Again, trauma therapist Deb Smith explains that “many clients coming in for treatment of PTSD will initially present with a blunted affect. However, the combination of treatments used to treat PTSD often alleviate that symptom. This in turn returns the client to their pre-trauma affect.”

Treating flat affect can be challenging, as it depends on the underlying cause. People who think that they or a loved one may be experiencing symptoms of flat or blunted affect should speak to a doctor for evaluation.

Learning more about what could be causing this symptom is vital if a person is to be treated in the most appropriate way.

Therapists, psychologists, and other specialist doctors will be better able to assess and treat a person with flat affect after they have evaluated the individual’s health history and done a physical examination.

Additionally, a careful review of any medications may be helpful in determining the cause of flat affect.


The World Health Report 2001: Mental Disorders affect one in four people

One in four people in the world will be affected by mental or neurological disorders at some point in their lives. Around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide.

Treatments are available, but nearly two-thirds of people with a known mental disorder never seek help from a health professional. Stigma, discrimination and neglect prevent care and treatment from reaching people with mental disorders, says the World Health Organization (WHO). Where there is neglect, there is little or no understanding. Where there is no understanding, there is neglect.

In a new report entitled "New Understanding, New Hope" the United Nations&rsquo health agency seeks to break this vicious cycle and urges governments to seek solutions for mental health that are already available and affordable. Governments should move away from large mental institutions and towards community health care, and integrate mental health care into primary health care and the general health care system, says WHO.

"Mental illness is not a personal failure. In fact, if there is failure, it is to be found in the way we have responded to people with mental and brain disorders," said Dr Gro Harlem Brundtland, Director-General of WHO, on releasing the World Health Report. "I hope this report will dispel long-held doubts and dogma and mark the beginning of a new public health era in the field of mental health," she added.

A lack of urgency, misinformation, and competing demands are blinding policy-makers from taking stock of a situation where mental disorders fi gure among the leading causes of disease and disability in the world, says WHO. Depressive disorders are already the fourth leading cause of the global disease burden. They are expected to rank second by 2020, behind ischaemic heart disease but ahead of all other diseases.

The report invites governments to make strategic decisions and choices in order to bring about positive change in the acceptance and treatment of mental disorders. The report says some mental disorders can be prevented most mental and behavioural disorders can be successfully treated and that much of this prevention, cure and treatment is affordable.

Despite the chronic and long-term nature of some mental disorders, with the proper treatment, people suffering from mental disorders can live productive lives and be a vital part of their communities. Over 80% of people with schizophrenia can be free of relapses at the end of one year of treatment with antipsychotic drugs combined with family intervention. Up to 60% of people with depression can recover with a proper combination of antidepressant drugs and psychotherapy. Up to 70% of people with epilepsy can be seizure free when treated with simple, inexpensive anticonvulsants.

The responsibility for action lies with governments, says WHO. Currently, more than 40% of countries have no mental health policy and over 30% have no mental health programme.

Around 25% of countries have no mental health legislation. The magnitude of mental health burden is not matched by the size and effectiveness of the response it demands. Currently, more than 33% of countries allocate less than 1% of their total health budgets to mental health, with another 33% spending just 1% of their budgets on mental health. A limited range of medicines is suffi cient to treat the majority of mental disorders. About 25% of countries, however, do not have the three most commonly prescribed drugs used to treat schizophrenia, depression and epilepsy at the primary health care level. There is only one psychiatrist per 100 000 people in over half the countries in the world, and 40% of countries have less than one hospital bed reserved for mental disorders per 10 000 people.

The poor often bear the greater burden of mental disorders, both in terms of the risk in having a mental disorder and the lack of access to treatment. Constant exposure to severely stressful events, dangerous living conditions, exploitation, and poor health in general all contribute to the greater vulnerability of the poor. The lack of access to affordable treatment makes the course of the illness more severe and debilitating, leading to a vicious circle of poverty and mental health disorders that is rarely broken.

The report says new knowledge can have a tremendous impact on how individuals, societies and the public health community deal with mental disorders. We now know that large mental institutions no longer represent the best option for patients and families. Such institutions lead to a loss of social skills, excessive restriction, human rights violations, dependency, and reduced opportunities for rehabilitation. Countries should move towards setting up community care alternatives in a planned manner, ensuring that such alternatives are in place even as institutions are being phased out.

"Science, ethics and experience point to clear paths to follow. In the face of this knowledge, a failure to act will reflect a lack of commitment to address mental health problems," said Dr Benedetto Saraceno, Director of WHO&rsquos Mental Health and Substance Dependence department.

The policy directions have never been so clear, says WHO. Governments who are just starting to address mental health will need to set priorities. Choices must be made among a large number of services and a wide range of prevention and promotion strategies.

WHO&rsquos message is that every country, no matter what its resource constraints, can do something to improve the mental health of its people. What it requires is the courage and the commitment to take the necessary steps.

The report is part of a year-long campaign on mental health. For the first time, multiple events at WHO including its premier report, technical discussions at the World Health Assembly and World Health Day, have all focused on one topic &ndash mental health.


What is Labile Affect?

Labile Affect is the act of inappropriate laughter due to a nervous system disorder. Some patients laugh or cry uncontrollably and aren't able to stop without therapy or medication.

We often look to a person’s facial expressions or body language to gauge how they are feeling inside. These signs are also known as affect. When we smile, cross our arms, or clench our jaw, it is often a reflection of our mood or internal feelings.

Psychologists and medical professionals are currently studying affect, and how it may change at different rates. Dramatic shifts in mood often come with dramatic shifts in outward expression. These dramatic expressions may or may not reflect a person’s true feelings. When this happens, psychologists may label it as Labile Affect, or Emotional Lability. Other names for this event include Inappropriate Affect or Pseudobulbar Affect, but I’ll explain that fancy name in a bit.

Labile Affect may refer specifically to the rapid change in someone’s mood or how they display that mood. Other forms of Inappropriate Affect include “Shallow Affect” (having no emotion or expression, even in dramatic situations) or “Blunted Affect” (showing very little emotion while recalling or experiencing a dramatic situation.)

One of the most famous examples of Labile Affect is the Joker in the 2019 movie. Examples of Labile Affect behavior include:

  • Laughing uncontrollably at a somber occasion
  • Crying uncontrollably for no reason at all (including seasonal allergies!)
  • Showing absolutely no signs of emotion after hearing dramatic news

These episodes are typically brief, lasting only a few minutes.


Essentials of Assessment

History

Evaluations are generally based on 3 sources of information: (1) observation and interview of the patient (2) information from others (eg, family, significant others, other clinicians) that corroborates, refutes, or elaborates on the patient’s report and (3) medical records. 14

The primary assessment tool is direct face-to-face interview of the patient. Evaluations based solely on review of records and interviews of persons close to the patient are inherently limited by a lack of the patient’s perspective. Furthermore, the clinical interview provides a sample of the patient’s interpersonal behavior and emotional processes and can either support or qualify diagnostic inferences from the history.

Key information that should be derived from the interview should include the following:

  1. Are symptoms minimized or exaggerated by the patient or others?
  2. Does the patient appear to provide accurate information?
  3. Do particular questions evoke hesitation or signs of discomfort?
  4. Is the patient able to communicate about emotional issues?
  5. How does the patient respond to the clinician’s comments and behaviors? 14

Medical history (significant medical problems or prior hospitalizations, history of head trauma), current medications (including psychotropic use), psychiatric history (illnesses, treatment received, outcomes), risk of harm to self or others, legal history, history of alcohol and other substance use, psychosocial history, and review of systems (including other psychiatric symptoms) should also be included. 14

Physical examination

The physical examination should be thorough because, even if there are no neurologic findings, a systemic illness may be present that is producing psychiatric symptoms.

Vital signs and a detailed musculoskeletal and neurologic examination, including a mental status exam, are of particular importance. Components of a mental status examination include appearance, behavior, speech, attitude, mood, affect, thought process and content, perception, cognition, insight, and judgment. 3

On occasions, patients may exhibit physical signs that provide insight that a comprehensive psychological evaluation may be warranted. For instance, Waddell signs were developed in 1980 to identify patients with low back pain who were likely to experience poor surgical outcomes. 23 Having 3 or more of the following constitutes a positive result:

  1. Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness
  2. Simulation tests: these are based on movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation
  3. Distraction tests: positive tests are rechecked when the patient’s attention is distracted, such as a straight leg raise test
  4. Regional disturbances: regional weakness or sensory changes which deviate from accepted neuroanatomy
  5. Overreaction: subjective signs regarding the patient’s demeanor and reaction to testing

Clinicians should interpret these signs with caution, and results should not be used for medico-legal purposes. 23

Close involvement in the patient’s general medical evaluation and ongoing care can also improve the patient’s care by promoting cooperation, facilitating follow-up, and permitting prompt reexamination of symptomatic areas when symptoms change. 14

Functional assessment

Structured assessment of physical and instrumental function may be useful in assessing strengths and disease severity. Functional assessments include assessment of physical activities of daily living (eg, bathing, dressing) and instrumental activities of daily living (e.g., driving, taking medication as prescribed, shopping, keeping house, caring for a child or other dependent). 14 The Pain Disability Questionnaire was developed as a measure of functional status of patients with pain and is based on the biopsychosocial approach to pain. 4,20

Laboratory studies

There are no specific guidelines about which tests should be routinely done. Several studies have demonstrated the limited utility and higher cost of ambulatory screening. Patients on psychotropic medications should be monitored for side effects specific to that therapy. When substance use is suspected, determining blood alcohol levels or screening for substances of abuse may be especially important. 14,15 Examples of tools available for screening for substance abuse/use include the Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain (SOAPP), and the CAGE. 21

Imaging

Specialized modalities (eg, computerized scanning, magnetic resonance imaging) can be used to screen for possible causes of delirium (eg, fever, metabolic abnormalities) or neurologic conditions with behavioral manifestations that could be mistaken for a psychiatric disorder (eg, patient with a brain tumor in the frontal lobes might present with a mood disorder). 3

Several neuroimaging studies suggest that specific neural networks modulate aspects of emotional behavior and are implicated in the pathophysiology of mood disorders: medial prefrontal cortex and closely related areas in the medial and caudolateral orbital cortex, amygdala, hippocampus, and ventromedial parts of the basal ganglia. 16

Supplemental assessment tools

The current methodology and content of psychiatric diagnosis, growing specificity of treatment planning in regard to both medication and psychosocial interventions, and nature of the health care delivery system all influence the context that determines the use of clinical rating scales and neuropsychologic tests to inform assessment and treatment planning. 17

Examples of functional domains to be measured and corresponding clinical rating scales include the following:

  1. Quality of life (eg, Quality of Life Enjoyment and Satisfaction Questionnaire)
  2. Mental health status and functioning (eg, Clinical Global Impression Scale, Global Assessment of Functioning Scale, Social and Occupational Functioning Assessment Scale)
  3. Cognitive disorders (Delirium Rating Scale Revised-98, Mini-Mental State Examination),
  4. Alcohol use disorder (CAGE Questionnaire),
  5. Mood disorders (Beck Depression Inventory Second Edition, Hamilton Depression Rating Scale, Patient Health Questionnaire, Geriatric Depression Scale), and
  6. Anxiety disorder (Hamilton Anxiety Rating Scale). 14

Neuropsychologic testing has a broad range of application, but the decision to order neuropsychologic testing for an individual patient remains a matter of clinical judgment. Neuropsychologic testing may be requested when cognitive deficits are suspected or there is a need to grade for severity or progression of deficits over time and for distinguishing between cognitive disorders (eg, dementia) and malingering or factitious disorders. 14

Early predictions of outcomes

Age (younger age at pain onset), sex (women > men), number of pain areas, frequency and severity of pain, psychosocial problems (problems with social and leisure activities), unemployment, and compensation are mediating factors in the course and prognosis of individuals with chronic pain and mental disorders. 3,9,8,10

Waddell signs do not discriminate organic from non-organic sources of pain, and do not correlate with psychological distress. However, positive results have been associated with poorer treatment outcomes, and higher pain levels. 24

Environmental

According to the International Classification of Functioning, Disability and Health, environmental factors that can influence the functioning of individuals with mood disorder and chronic widespread pain include the following: medication use, immediate family/friends, health professionals, individual attitudes of family/friends/health professionals, and availability of social security services/systems (ie, aimed at providing income support). 18,19

Social role and social support system

An assessment of family, peer networks, cultural identity, and other support systems plays an important part in the psychiatric evaluation because of the potential role of these systems in ameliorating or augmenting the patient’s signs and symptoms of illness. This is particularly true when evaluating individuals with complex biopsychosocial challenges or serious psychiatric or general medical conditions. 14

Professional Issues

Throughout the assessment, useful clinical information is obtained by being sensitive to issues of development, culture, and the clinician’s own possible biases or prejudices about patient’s subculture, race, ethnicity, primary language, health literacy, disabilities, sex, sexual orientation, familial/genetic patterns, religious and spiritual beliefs, and social class influencing the patient’s symptoms and behavior. 14


Recognising and explaining functional neurological disorder

Functional disorders are conditions whose origin arises primarily from a disorder of nervous system functioning rather than clearly identifiable pathophysiological disease—such as irritable bowel syndrome, fibromyalgia, and functional neurological disorder (FND)—they are the second commonest reason for new neurology consultations. 1 FND is common in emergency settings, 2 stroke, 3 and rehabilitation services. 4 It causes considerable physical disability and distress, and often places an economic burden both on patients and health services. 5 Many clinicians have had little formal clinical education on the assessment and management of these disorders, and patients are often not offered potentially effective treatments.

In practice, FND should be diagnosed by someone with specific expertise in the diagnosis of neurological conditions. Our recommendation is to refer all patients with a suspected diagnosis of FND to secondary care. However, the diagnosis may be raised as a possibility with the patient in primary care, and knowledge of how the diagnosis is confirmed greatly aids subsequent management.

In this article we offer evidence based advice to generalists on how to recognise FND, based on clinical diagnostic and prognostic studies. Although the focus of this paper is on recognising FND, we have included a short box on management to make readers aware that there are good treatments available for FND and that some patients can get better.

Sources and selection criteria

We conducted a PubMed search of evidence for diagnosis of functional neurological disorder (FND) until June 2020, especially systematic reviews. 14 …


Body Language and the Brain: How We Read the Unspoken Signs?

Our interactions with other people involve both verbal and non-verbal communication, with information being processed in parallel. Non-verbal communication includes body language and can be very useful in making conclusions about unspoken intentions. Although we rely on verbal communication to receive information, it seems highly important to understand body language as well. Body language informs us about feelings and intentions of other people. From the evolutionary perspective, observing and reacting to emotional conditions of others may have been critical for our survival.

Indeed, the scientific literature suggests that we are more impressed by the information received non-verbally. Maybe this is because more than 50% of communication is based on our body language. On the other hand, less than 10% comes from what we actually say, while almost 40% comes from the tone of our voice.

At first look, it might seem easy to understand someone’s body language, through the perception of their body posture, gestures, and movements. But, the process is more complex than it looks. It involves specific regions and complex neuronal networks in our brain decoding body expressions and giving them adequate meaning. While the recognition of facial expressions is well studied, processing of body posture and gestures has received less attention until recently.

How does brain read body language?

The scientific literature suggests that brain has several specialized structures that process socially relevant information. As neuroimaging studies have revealed, the processing of body expressions activates a complex network of neurons. This not only includes visual areas but also includes subcortical and cortical emotion-related regions, as well as regions involved in planning and execution of actions.

The visual representation of the human body and its emotions activates two main visual areas in the brain. These are the extrastriate body area and the face-selective fusiform body area. Using MRI scans, researchers measured the degree of activation in these brain areas in response to “normal” and “emotional” body language by showing short video clips to volunteers. These clips represented people who were performing emotionally neutral gestures and movements or expressing 5 basic emotions: happiness, sadness, anger, disgust, or fear.

The results showed that brain areas were influenced by the emotional weight of body movements. More precisely, activation of the extrastriate body area (EBA) and the face fusiform body areas (FBA) were significantly greater in response to emotional body language than to neutral body language. Also, both of the areas reacted most strongly to happiness, anger, and disgust. While fear significantly influenced the EBA, the modulation was not significant in the case of FBA. Sadness failed to significantly activate both regions. The lack of modulation by sadness may be due to the excitement associated with sadness. Levels of excitement have a crucial role in activation of the amygdala, a part of the brain playing an important role in the processing of emotions. In addition, there is a positive correlation between amygdala activation and modulation of EBA and FBA areas.

Despite the complex non-facial gestures that people use to communicate most of the studies are based on facial expression only. To address this issue, one recent study created a set of body language patterns by taking photos of actors personifying emotional states. The photos portrayed typical emotional states (for instance “I am in love”, “I hate you” and others), i.e., they captured gestures and actions reflecting emotional body language. The results of this study have indicated that the body (including the face) mimics and gestures undergo prioritized fast procession.

In order to better measure neural processes involved in the comprehension of emotional body language, a short verbal description of the emotional state preceded the pictures. The verbal descriptions were both congruent (matching the state presented on pictures) and incongruent. The analyses showed that body language is rapidly compared with verbal information. Importantly, the results indicated that incongruent body language was revealed just 300 ms following the stimulus. Thus, the process of body language comprehension in the brain is obviously able to provide information about the sincerity of others. This is important for regulation of our social interactions.

Can we react unintentionally to body language?

There are inconsistent data on how the brain processes emotional stimuli as an important part of our body language. While some findings suggest that emotional stimuli are processed automatically, i.e., without attention, other researchers believe that attention is necessary for processing emotional expressions. Namely, behavioral studies have found that the processing of facial expression occurs not only automatically but without conscious awareness as well. It has been shown that brain regions, such as the amygdala, may be activated when emotional stimuli (such as fear) are masked and the subject seems to be unaware of them. Still, most of the studies suggesting that the processing of body postures is automatic have focused on the interpretation of fearful body language.

Are there any factors affecting the brain coding of body language?

The activation of specific brain regions by witnessing body language may vary in accordance with individual differences. Factors such as personality, genotype, and gender may affect the neuronal response to body language. For instance, in response to emotionally aversive (unpleasant) stimuli, specific brain regions are more activated in women as compared to men. On the other side, activation is greater in men when it comes to viewing emotional faces, scenes, and words. Still, empathy levels may influence these gender differences. As one study demonstrated, participants with higher self-reported empathy were characterized by higher activation in brain areas associated with the interpretation of emotions.

Despite our limited knowledge of body language processing by the brain, several conclusions can be made:

  • Specific brain areas are activated in order to process body language and facial expressions. Among these, two visual areas and the amygdalas are the most important ones.
  • We may react more explicitly to body language expressing happiness than sadness, due to higher activation of specific brain regions.
  • There may be some gender difference in reacting to body language, due to the different activation of brain areas. Still, personality is an important cofactor.
  • Sometimes, like in the case of fearful body language, we might react unintentionally.

The lack of detailed research leaves lots of question about the processing of body language, as well as about how we use this channel of communication, intentionally or not. As the neuroscience on the subject advances, we will most certainly learn much more about this fascinating topic.


Neurological Conditions

A neurological condition is any disorder which affects the central nervous system. The nervous system acts as a command center for the body, and when communication is interrupted, a variety of disorders and symptoms are possible. This can be caused by a physical injury to the brain, nerves or the spinal cord as well as infections, diseases or genetics.

Below is a list of the most common neurological conditions seen in children waiting for forever families. We provide the following information for reference purposes only and cannot attest to the accuracy of the information. We highly recommend speaking with an experienced physician for further details on each condition.

Common Neurological Conditions

Children with apraxia have difficulties with speech. Their brain has difficulty coordinating movement of the speech muscles. In a very young child, they may have a delay in speech development and trouble eating. In older children, they may have difficulty imitating sounds, be difficult to understand, have difficulty producing longer words or have more difficulty with speech when they are anxious.

Causes:
Apraxia can be developmental or acquired. Developmental apraxia occurs in children and is present at birth. The causes for developmental apraxia are unknown however researchers have found that children with this condition often have a family history of communication disorders or learning disabilities. Acquired apraxia can occur at any time in life and may be due to a brain injury, brain tumor or stroke.

Possible complications:
A child may acquire apraxia due to a brain injury such as a stroke, infections or traumatic brain injury. It may also occur due to a genetic disorder, syndrome or metabolic condition such as velocardiofacial syndrome and galactosemia.

Treatment:
Speech language therapy is necessary to help children with apraxia of speech. They will most likely need frequent and intensive one-on-one therapy. They may also benefit from learning additional forms of communication such as sign language.

Prognosis:
In many cases, with treatment, children with apraxia can live normal, healthy lives. However, the long-term prognosis depends on the cause and severity of apraxia as well as the effectiveness of speech therapy.


An arachnoid cyst is a fluid-filled sac that can develop between the surface of the brain and the cranial base or on the arachnoid membrane. Most cases begin during infancy, but sometimes the onset of symptoms may be delayed until adolescence. Some of the symptoms of a large cyst may be headaches, seizures, hydrocephalus, increased cranial pressure, developmental delay, behavioral changes, weakness or paralysis on one side of the body, lack of muscle control, head bobbing, and visual impairment.

Causes:
Most arachnoid cysts are present at birth and while the specific cause is unknown, researchers believe they occur during development of the central nervous system. Arachnoid cysts can develop in adults as a result of brain surgery or injury.

Possible complications:
Arachnoid cysts can sometimes be associated with genetic disorders such as Cockayne syndrome and Menkes syndrome.

Treatment:
Smaller cysts that are causing no symptoms are normally just observed for changes. Larger cysts that are putting pressure on the brain and causing symptoms may require surgery.

Prognosis:
Children with small cysts that cause no symptoms typically lead healthy lives. If larger cysts are treated early, the prognosis is usually very good and symptoms are resolved. If left untreated, severe, permanent brain damage can occur.


Cerebral Palsy
(CP) is a general term that describes any disorder affecting body movement and muscle control. There are many types of CP and a variety of symptoms such as stiff contracted muscles, lack of muscle tone, lack of coordination, poor balance, and uncontrolled movements. It can affect one or two limbs, half the body, or the entire body. It can also affect a child&rsquos ability to use their facial muscles causing difficulty eating or speaking. Children with CP can have a wide spectrum of abilities. Some children are only mildly affected, while others will have severe complications and limitations.

Causes:
CP is usually present at birth and can be caused by genetic mutations and maternal infections during pregnancy such as measles, syphilis or exposure to toxins as well as a traumatic birth resulting in a lack of oxygen. It can also be caused by a stroke, infection in the brain, or traumatic brain injury.

Possible complications:
Some children with CP are unable to walk or speak. They may also have an underlying neurological condition. Muscle weakness, muscle spasticity and coordination problems can cause abnormal bone development, arthritis, breathing disorders and malnutrition.

Treatment:
Children with cerebral palsy can benefit from several areas of treatment.

  • Physical Therapy: PT can help your child strengthen and stretch weak muscle groups. This will also help with flexibility, balance, motor development and mobility.
  • Occupational Therapy: OT can help your child use adaptive equipment such as a walker, wheelchair or cane to gain as much independence as possible.
  • Speech Therapy: Speech-language therapy can help your child strengthen the muscles necessary to speak. A therapist may also help your child use alternative communication methods, such as an electronic communication device, if speech is too difficult.
  • Surgery: Surgery can be used to help stretch tendons and muscles, lessoning contractures and reducing pain.

Prognosis:
The long-term prognosis for a child cerebral palsy depends on the cause and severity of need. Many children with CP are able to live full and independent lives.


The brain is made up of millions of nerve cells gathered together. By passing electrical signals to each other, these nerve cells can control the body&rsquos function, senses and thoughts. Sometimes the process of exchanging signals is suddenly interrupted and a seizure occurs. About 1% of people in the United States may have at least one seizure. A diagnosis of epilepsy typically means a person has had two or more seizures not caused by an outside medical condition such as low blood sugar, fevers, or heart problems. There are different types of seizures, based on the part of the brain that is involved. Some seizures present with sudden uncontrollable limb movements and unconsciousness, some present with staring and strange behavior, and some are only noticed by the child that is experiencing the seizure. Seizures usually begin in childhood, although they can happen at any age.

Causes:
In about half of cases, the exact cause of epilepsy is unknown. In the other half of cases, the cause can be linked to genetics, head trauma, tumors or stroke, infectious diseases or even birth trauma.

Possible complications:
Left untreated, persistent seizures can lead to brain damage. Seizures can also put a person at risk in certain situations such as when driving a car. People diagnosed with epilepsy are also at risk for sudden, unexplained death.

  • Medication: Most people with epilepsy can become seizure-free by taking anti-seizure medication.
  • Surgery: If doctors are able to determine that the seizures all originate in the same area of the brain, they may be able to surgically remove that part of the brain to reduce eliminate seizures. Surgery can have significant side-effects.
  • Diet: Some children with epilepsy have been able to reduce their seizures by following a ketogenic diet, high in fats and low in carbohydrates.

Prognosis:
The long-term prognosis for epilepsy depends on the severity of seizures and treatment. If frequent, severe seizures have occurred without treatment, permanent brain damage is possible. However, over half of children diagnosed with epilepsy can eventually discontinue medication and lead a seizure-free life.


Hydrocephalus
occurs when the fluid in the brain cannot drain away into the bloodstream because the normal pathways are blocked. The fluid is still being made by the brain, so the buildup of fluid will cause pressure to rise inside the brain. A child with hydrocephalus may have abnormally large head measurements. They may experience difficulty feeding, irritability, delayed cognitive development, headaches, vomiting, blurred vision, difficulty walking and delayed growth.

Causes:
Our bodies continually produce cerebral spinal fluid, which circulates through the ventricles of the brain and the spinal column and is also absorbed by the body. Hydocephalus develops when there is an excess of fluid on the brain. This is usually caused by an obstruction, where fluid is blocked from leaving one part of the brain (non-communicating hydrocephalus). It can also rarely be caused by an overproduction of fluid or an inability for the body to absorb some of the fluid (communicating hydrocephalus). Hydrocephalus may occur in infancy or in older children and can be caused by a brain bleed (which may be as a result of a premature birth), meningitis, cysts or brain tumors, or other rare causes.

Possible complications:
Left untreated, hydrocephalus can cause permanent brain damage. Children with hydrocephalus can also experience learning delays, hormonal imbalances, seizures, and hearing and vision issues. Hydrocephalus is also common in children with Spina Bifida.

Treatment:
The most common treatment for hydrocephalus is surgery to put in a shunt, which is a tube that helps drain fluid from the brain. One end of the tube is usually placed in a ventricle of the brain and the other end is put in a part of the body where the cerebral spinal fluid can be more easily absorbed, such as the abdomen or the heart. Another option is a Ventriculostomy, which is a surgical procedure where a doctor creates a hole in one of the ventricles to help drain the fluid. This surgery is not an option for every child, and there is also a risk that the hole will close on its own.

Prognosis:
The long-term prognosis for children with hydrocephalus depends on the severity and treatment. Children who also have spina bifida may have more long-term complications. Untreated, hydrocephalus can be fatal. However, with early intervention, many kids with hydrocephalus go on to lead healthy lives.


During early development, the spinal column begins as a flat plane. In the first month of pregnancy it begins to curl and eventually seals into a tube shape. When a child has spina bifida, this means the tube did not completely seal. There are three types of spina bifida:

  • Occulta: This is the mildest form and involves an opening into the vertebrae without a protrusion of the spinal cord or meninges. Many people do not know they have this. There may be a large mold or patch of hair or a deep dimple on the skin along the spine.
  • Meningocele: The spinal cord will have developed normally, but when the child is born there is a sac protruding from a hole in the vertebrae and out of the back. It is important to have surgery early as the sac may break and infection and nerve damage may occur. Often this form of spina bifida does not present any problems once the back is closed.
  • Myelomeningocele(Meningomyelocele): This is the most common and the most serious form of spina bifida. The protruding sac on the back will contain tissue, spinal fluid, nerves and part of the spinal cord. The spinal cord may be damaged or not properly formed. There is always some degree of paralysis and loss of sensation below the damaged vertebrae. Children may need a walker or wheel chair depending on the level of paralysis.

Causes:
The exact causes of spina bifida are unknown. However, genetics may play a role as well as high fevers and certain medications. A lack of folic acid during pregnancy may also lead to neural tube defects.

Possible complications:
Children with myelomeningocele often have hydrocephalus and/or clubbed feet. Some children with spina bifida have problems such as curvatures in the back, hip dislocation, ankle and foot deformities and contracted muscles. Depending on the severity of the spina bifida, children are also at greater risk for paralysis and infection.

Treatment:
Children with meningocele and myelomeningocele need surgery to put the meninges (nerves) back into the spinal column and close the opening in the spine.

Prognosis:
The long-term prognosis for children with spina bifida depends on the severity and treatment. Surgery should be done as early as possible to have the best possible results. However, children in certain countries may not be able to have early intervention. The longer a child goes without surgery, the greater the risk for serious, long-term complications such as infection and paralysis.