Malcolm Weller

Movement Disorders and Neuroleptic Medication

Skilled voluntary movements involving fine adjustments are initiated by the large pyramidal-shaped Betz cells in the motor cortex. The decussating pathway receives contributions from the cerebellum and the complex extrapyramidal system. The term “extrapyramidal system” originally referred to an anatomical concept although more recently it has been considered a functional unit. Within this system attention has been focused on the basal ganglia, and, specifically, the dopaminergic nigrostriatal system, as being important in motor planning (Marsden, 1980). Figure 1 illustrates, diagrammatically, the postulated interaction among dopaminergic, cholinergic, and GABAergic neurons in the nigrostriatal system (Kebabian and Calne, 1979; Marsden and Jenner, 1980). For a more elaborate representation of the neurotransmitter systems in this area, see Hornykiewicz (1981).

The limitations of psychiatric diagnoses.

Psychiatric disorders are not always easy to incorporate within the medical model, neuropathological changes are seldom demonstrable and, when they are, they are irrelevant to functional illnesses. The meaning of the term illness in this group is not the same as in medicine generally and the validity of each illness category depends on the internal consistency and homegeneity of the category, the lack of overlap with other categories and the inter-rate reliability, but these desiderata are not adequately met for neurotic and personality problems or alchoholism. The major division between schizophrenia and manic depressive psychosis is not as sharply delineated as might be imagined and trans-Atlantic diagnostic practices have swung from one type of divergence to another. Nevertheless an increasing number of physical findings in these disorders suggest that they are frequently underpinned by organic factors. By definition this is certainly the case for organic psychoses, including epileptic psychosis and dementia. On the other hand, alchoholism, drug addiction, psychopathy and neuroses may be better incorporated within a psychological model, although here too weaker, but still apparent, physical and genetic factors remain intriguing features for medical consideration. Nevertheless life expectancy, fertility and socioeconomic circumstances are adversely affected by most psychiatric disorders, making them genuine illnesses by such criteria.

Predispositions to outcome.

psychology at Cambridge University before he became a medical student, and trained in medicine at Newcastle, winning a prize at both Universities. He was liaison psychiatrist at Charing Cross Hospital to the Department of Neurology and became Head of the Brain Injury Unit at St Anne’s Hospital. He has been very helpful in arranging this and the second head injury meeting on November 26. A very warm welcome to you, Malcolm. Please address our Society on Predispositions to Outcome. Professor Weller: Thank you. I will focus on mild head injury. It can be difficult to disentangle patients’ symptoms following head injury, their understandable psychiatric reactions, expectations and the effects of actual brain damage. Curiously, these difficulties are greatest when the head injury suffered is mild; the difficulties are compounded by circularity in definitions and overlapping diagnostic criteria. The complexity of the issues is greater because of conscious and unconscious factors when there is litigation. In the UK head injury is believed to cost £1 million plus per annum and approximately 90% of these injuries are classified as “mild” using the Glasgow Coma Scale score 13–15; loss of consciousness <20 min; and post-traumatic amnesia <24h (Kay and Teasdale, 2001). (See appendix.) We learned from the last speaker that in a Glasgow survey 83% of people who have a head injury have a mild head injury. Across the board, the figures that I have indicate that it is even higher at 90%. The people who have the severest head injuries may suffer very serious impairments which are difficult to remedy and they may die young. The people with mild head injuries, for some paradoxical reason, are also extremely difficult to help. They form a very large proportion of the medico-legal conundrums where lawyers and experts struggle to disentangle the effect of the head injury per se from other factors. The period of post traumatic amnesia in the definition of mild head injury according to the above criteria is long. The length is due to the fact that people go to sleep; they suffer a head injury, go to hospital and they go to sleep, so we do not always know when they recovered from the period of post traumatic amnesia. This is significant because there is a very big difference between losing consciousness for a few minutes and losing consciousness for very many hours. Risk factors for head injury include (DSM-IV and Annegers et al 1980):