The Merging Tracks of Anosognosia and Neglect

Anosognosia and hemineglect are among the most startling neurological phenomena identified during the 20th century. Though both are associated with right hemisphere cerebral dysfunction, notably stroke, each disorder had its own distinct literature. Anosognosia, as coined by Babinski in 1914, describes patients who seem to have no idea of their paralysis, despite general cognitive preservation. Certain patients seem more than unaware, with apparent resistance to awareness. More extreme, and qualitatively distinct, is denial of hemiplegia. Various interpretations of pathogenesis are still deliberated. As accounts of its captivating manifestations grew, anosognosia was established as a prominent symbol of neurological and psychic disturbance accompanying (right-hemisphere) stroke. Although reports of specific neglect-related symptomatology appeared earlier, not until nearly 2 decades after anosognosia’s inaugural definition was neglect formally defined by Brain, paving a path spanning some years, to depict a class of disorder with heterogeneous variants. Disordered awareness of body and extrapersonal space with right parietal lesions, and other symptom variations, were gathered under the canopy of neglect. Viewed as a disorder of corporeal awareness, explanatory interpretations involve mechanisms of extinction and perceptual processing, disturbance of spatial attention, and others. Odd alterations involving apparent concern, attitudes, or belief characterize many right hemisphere conditions. Anosognosia and neglect are re-examined, from the perspective of unawareness, the nature of belief, and its baffling distortions. Conceptual parallels between these 2 distinct disorders emerge, as the major role of the right hemisphere in mental representation of self is highlighted by its most fascinating syndromes of altered awareness.

THUR 054 The heart holds answers the brain cannot to see

Neuronal ceroid lipofuscinosis (NCL) is a range of inherited lysosomal storage disorders. This case highlights the cardiac pathology associated with NCL and reports improved seizure control following correction of cardiac arrhythmias.A 26-year-old woman presented with episodes of altered awareness with head and eye deviation on a background of a progressive neurodegenerative disorder. She initially presented at 7 years of age with progressive retinal dystrophy. As a teenager she developed seizures with prominent myoclonus, psychosis, cognitive impairment and immobility. Her epilepsy was refractory to treatment and seizures had increased in frequency prior to admission.ECG demonstrated sinus bradycardia of 30bpm and episodes of 20 s sinus arrest. This was managed by the insertion of a pacemaker, resulting in a dramatic reduction in the frequency of her seizures. Investigation into the underlying disorder was revisited identifying vacuolated lymphocytes and homozygous CLN3 gene deletions. These findings are consistent with a diagnosis of juvenile NCL (Batten disease).This case demonstrates the importance of cardiac monitoring in investigating a change in seizure pattern. We hypothesise that the patient presented with reflex hypoxic seizures secondary to asystolic episodes. It also highlights the value of securing a diagnosis to enable appropriate cardiac screening in NCL patients.

Need For Long-Term Care in Children is Increasingly Caused by Disorders of Psychological Development. Changes in the Care Causing Diagnoses According to German Social Code (SGB XI) Between 2009–2014

Aim of the study There is an ongoing discussion on the increasing number of children with mental and developmental disorders, with some even needing long-term care according to the German Social Code XI. This study was performed to identify the main diagnoses justifying such care in children and to analyse their prevalence over time. Methods The diagnoses justifying long-term care were evaluated using care assessments of Bavarian children and adolescents between 2009 to 2014 by the medical service of statutory health insurance. Results Over the years investigated, the percentage of assessments due to a mental and behavioural disorder rose significantly from 36.2 to 42.2%. Since 2012, the most common diagnose changed from Down's syndrome to pervasive developmental disorders with marked increase of also mixed specific developmental disorders. In new applications for nursing insurance services the proportion of pervasive developmental disorders rose gradually from 151 in 2010 to 254 in 2014. During the whole period of time, the overall care dependency in children seemed to be stable. Conclusions These observations might rather be influenced by altered awareness of health and illness, increasing readiness to seek help with psychological or developmental impairments as well as changed diagnostic criteria than by a steady increase in affected individuals.

Fear, Pain, Denial, and Spiritual Experiences in Dying Processes

Purpose: Approaching death seems to be associated with physiological/spiritual changes. Trajectories including the physical–psychological–social–spiritual dimension have indicated a terminal drop. Existential suffering or deathbed visions describe complex phenomena. However, interrelationships between different constituent factors (e.g., fear and pain, spiritual experiences and altered consciousness) are largely unknown. We lack deeper understanding of patients’ inner processes to which care should respond. In this study, we hypothesized that fear/pain/denial would happen simultaneously and be associated with a transformation of perception from ego-based (pre-transition) to ego-distant perception/consciousness (post-transition) and that spiritual (transcendental) experiences would primarily occur in periods of calmness and post-transition. Parameters for observing transformation of perception (pre-transition, transition itself, and post-transition) were patients’ altered awareness of time/space/body and patients’ altered social connectedness. Method: Two interdisciplinary teams observed 80 dying patients with cancer in palliative units at 2 Swiss cantonal hospitals. We applied participant observation based on semistructured observation protocols, supplemented by the list of analgesic and psychotropic medication. Descriptive statistical analysis and Interpretative Phenomenological Analysis (IPA) were combined. International interdisciplinary experts supported the analysis. Results: Most patients showed at least fear and pain once. Many seemed to have spiritual experiences and to undergo a transformation of perception only partly depending on medication. Line graphs representatively illustrate associations between fear/pain/denial/spiritual experiences and a transformation of perception. No trajectory displayed uninterrupted distress. Many patients seemed to die in peace. Previous near-death or spiritual/mystical experiences may facilitate the dying process. Conclusion: Approaching death seems not only characterized by periods of distress but even more by states beyond fear/pain/denial.

Always Worth a Second Look

The serotonin syndrome is a toxic syndrome resulting from excessive stimulation of central 5-HT1A and 5-HT2A receptors. This is most commonly an iatrogenic syndrome, which in its most severe form can be fatal. It is more common for milder forms to present, and there is increasing recognition of serotoninergic drugs that can give rise to serotonin syndrome when used in combination. It is essential for physicians to be familiar with the clinical features of serotonin toxicity and similar syndromes discussed in this chapter that are marked by altered awareness, autonomic instability, changes in muscle tone, and pyrexia. Withdrawal of the drug(s) believed to be responsible and supportive care are the primary therapeutic steps.