Year 2 BB2: Brain and Behaviour 2

Lecture: Introduction to BB2

1. Review the main functions of non-neuronal cells in the PNS and CNS in health and disease
2. Review the main neurotransmitters used by the nervous system
3. Review the main pathways by which the sensory modalities of touch, pain and proprioception are transmitted from the periphery to the brain, where they decussate, the basic tests used to assess their integrity and the clinical signs associated with damage
4. Know the main components of the motor system with particular emphasis on the monosynaptic reflex and the corticospinal (pyramidal) tract, their clinical significance, how to test reflexes and how to recognise damage to the motor system
5. Review the organisation and functions of the cranial nerves, the basic tests used to assess their integrity and the clinical signs associated with their damage
6. Review the functional organisation of the cerebral hemispheres, including higher mental functions and tests associated with them
7. Know the distribution of the principal arteries of the brain and spinal cord and the main functional areas of the brain and spinal cord that they cover

Lecture: The Pharmacology of Movement Disorders

1. Non-pharmacological management of basal ganglia disease and future directions
2. Circuitry of the basal ganglia, main neurotransmitters and alterations associated with basal ganglia disease (Parkinson’s disease and Huntington’s disease)
3. Review of pharmacological treatment of Parkinson’s disease
4. Review of Huntington’s disease

Lecture: Motor Systems II

1. Describe the pathophysiologic mechanisms of spasticity, clonus, hyperreflexia and decorticate and decerebrate postures.
2. Describe the functional characteristics of the major motor tracts (pyramidal, reticulospinal and vestibulospinal) and their origins
3. Describe the acute and chronic deficits arising from lesioning of individual motor tracts and the acute and chronic deficits arising from lesioning the motor cortex; be able to compare with lesions of the lower motorneurone.
4. Which regions of the cortex are involved in motor control?
5. Describe the pathophysiology, clinical symptoms and basic treatments of movement disorders

Lecture: Basal Ganglia

1. Can describe the pathophysiology, clinical symptoms and basic treatments of movement disorders
2. Describe the morphology and blood supply of the caudate and lentiform nuclei and the associated internal capsule
3. Describe the principal afferent and efferent connections of the caudate nucleus and putamen (striatum).
4. Describe the connections of the globus pallidus & subthalamic nucleus.
5. Explain the circuitry of the substantia nigra and its association with Parkinson's disease.
6. Describe the role of the basal ganglia in motor control and discuss how their damage can lead to Parkinson’s disease, Huntington’s chorea, ballismus and athetosis.

Lecture: Cerebellum

1. Describe the main gross anatomical features of the cerebellum, including its input and output pathways and its lobular arrangement.
2. Describe the microanatomical arrangement of the cerebellum including the cortical morphology and connections of the deep nuclei.
3. Describe the functional subdivisions of the cerebellum and the effect of injury in different regions.
4. Describe the functional significance of the cerebellar connections to the vestibular system

Lecture: Clinical Skills Lecture - Neurological Examination of the Limbs

1. Appreciate the anatomical / physiological basis of the peripheral neurological examination
2. How to gain consent to examine a person / patient’s peripheral neurological system
3. Know how to position a patient / person correctly prior to examining their peripheral neurological nervous system, gait and cerebellar system.
4. Be able to identify the common clinical signs that show a patient has neurological deficit and / or the patient is unwell.
5. Appreciate how to systematically observe a patient from the end of the bed using the 'feet to face' principle, identifying some common abnormalities of peripheral neurological disease.
6. Be able to demonstrate the appropriate techniques required to perform a systematic examination of a patient’s peripheral neurological system including gait and cerebellar disorders.
7. Appreciate how to perform the associated clinical examination and investigations required to complete a neurological assessment.
8. Appreciate how to complete the neurological assessment of a patient.

Lecture: Anatomy & Physiology of Pain

1. Review terms associated with pain systems
2. Explain transduction, transmission, perception and modulation in the nociceptive system
3. Describe the heterogeneity of nociceptors and its functional significance
4. Define in detail pain pathways and their functional roles
5. Explain the concepts of peripheral and central sensitization and their importance to medicine

Lecture: Pharmacology of Pain

1. Description of the main types of analgesic drugs- opiods and non-opiods.
2. Definition of the concept of "analgesic ladder"
3. Description of local and general anaesthetics
4. Management of trigeminal neuralgia

Lecture: Epilepsy

1. Cellular mechanisms linked to seizures and epileptogenesis
2. Anti-epileptic drugs: classification and discussion of mechanism of action
3. Classification of seizures

Lecture: Pain Mechanisms & Management

1. Theories of pain
2. Types of pain
3. Where it comes from and how it explains morbidity and mortality
4. Assessment
5. Management: psychopharmacology and adjunctive therapies

Lecture: Head Injury

1. Appreciate the importance of TBI
2. Apply existing knowledge of anatomy, physiology and pathology to TBI
3. Describe the principles of management of TBI

Lecture: The Vestibular System

1. List the functional roles of the vestibular system
2. Describe how the vestibular system detects angular and linear acceleration
3. Describe the vestibulo-ocular reflex and explain how nystagmus can occur
4. Describe the central pathways of the vestibular system
5. List the clinical signs of vestibular system dysfunction
6. Describe tests for balance disorders

Lecture: Blood supply to the Brain II

1. Review the main venous drainage of the brain
2. Describe the anatomical basis of a subarachnoid, epidural and subdural hemorrhage/hematomas
3. Describe the anatomical basis of strokes and transient ischemic attacks and potential collateral circulation
4. Review the main arterial supply of the brain

Lecture: Headache and Migraine

1. The characteristics of the three main primary headaches.
2. The areas of the brain involved in migraine.
3. Understand the difference between primary and secondary headaches
4. Understand the role of genetic and environmental factors in headache (thresholds and triggering / precipitating factors)

Lecture: Drug Dependance

1. Discuss addiction mechanisms
2. Review treatments for drug dependence
3. Discuss concepts of drug dependence, drug tolerance, drug abuse
4. Give examples of types of drugs which are abused

Lecture: Antidepressant drugs

1. Classification of mood disorders
2. Pathophysiology of depression
3. Types of antidepressant drugs, mechanisms of action and adverse effects
4. Non-pharmacological treatment of mood disorders

Lecture: Addiction

1. Discuss the interplay of physiological and psychological factors in addiction
2. Show awareness of the main treatment approaches and their efficacy
3. Appreciate problems with defining addiction
4. Review psychological mechanisms involved in compulsive drug use

Lecture: Deep Brain Stimulation

1. Discuss the potential mechanisms of DBS
2. Understand the pros and cons of DBS
3. Understand what is deep brain stimulation (DBS)
4. Understand the various diseases which may benefit from DBS
5. Ability to associate DBS at various brain regions with various clinical conditions

Lecture: Clinical Skills Exam of Cranial Nerve

1. Appreciate the anatomical basis of the central neurological examination
2. Know how to gain consent to examine a person / patient’s cranial nerves
3. Know how to position a patient / person correctly prior to examining their cranial nerves.
4. Know how to identify the common clinical signs that show a patient has neurological deficit and / or the patient is unwell.
5. Know how to systematically observe a patient from the end of the bed using the 'feet to face' principle, identifying some common abnormalities of central neurological disease.
6. Be able to demonstrate the appropriate techniques required to perform a systematic examination of cranial nerves II, III, IV, V, VI, VII and XII.
7. Know how to perform the associated clinical examination and investigations required to complete a neurological assessment.

Lecture: The Limbic System

1. Describe the morphology of the main limbic structures - the hippocampus, the amygdaloid and the septal nuclei.
2. Explain the principal connections between the foregoing limbic structures and the hypothalamus, anterior and dorso-medial thalamic nuclei, prefrontal cortex and midbrain reticular formation.
3. Describe the effects of lesions in the amygdala and fornix.
4. Describe the Kluver Bucy syndrome, temporal lobe epilepsy and Wernicke-Korsakoff syndrome.
5. Discuss the theories of prefrontal cortex and temporal lobe function based on clinical evidence.

Lecture: Dementia

1. Classify dementia
2. Describe the pathogenesis of Alzheimer's disease
3. Describe alterations in cholinergic neurotransmission and the use of acetylcholinesterase inhibitors
4. Be able to describe the use of memantine and its rationale
5. Describe new therapeutic approaches in Alzheimer's disease

Lecture: Memory & Amnesia

1. Describe the types of amnesia
2. Be able to define declarative memory and procedural memory
3. Discuss spatial memory
4. To name the brain areas associated with acquisition and storage of declarative memory and procedural memory
5. Introduce mechanisms underlying learning and memory (LTP)

Lecture: Persistant Vegative State

1. Define ethical issues such as the end of life decision.
2. Discuss treatments for vegetative state.
3. Describe the anatomical correlates of disorders of consciousness.
4. Define what consciousness is and its components.
5. Describe how consciousness is measured using the Glasgow coma scale
6. Give a classification of unconscious states.
7. Define the terminology used for vegetative states.
8. Define the role of functional imaging in the vegetative state.
9. Explain the prognosis and outcome of the vegetative state.

Lecture: Symptoms of the Mind

1. Describe the structure of the Mental State Examination
2. Outline the role of diagnostic criteria in making a psychiatric diagnosis
3. Know the core signs and symptoms of mental state abnormalities in key mental disorders (psychosis, affective disorder, and neuroses)

Lecture: Schizophrenia

1. Structural changes in schizophrenia
2. Schizophrenia: general concepts, symptoms and genetics
3. Treatment of schizophrenia
4. New perspectives
5. General management criteria

Lecture: Anxiety

1. Anxiolytic drugs: mechanisms of action and side-effects
2. Neurobiology of sleep
3. Hypnotic drugs: benzodiazepines and non-benzodiazepines
4. Description and classification of anxiety disorders

Lecture: Learning and Conditioning

1. Distinguish different types of conditioning and learning.
2. Provide examples of psychological treatments based on theories of learning.

Lecture: Stroke

1. Describe the pathophysiology of stroke in relation to risk factors.
2. Recognise the common neurovascular syndromes and mechanisms of stroke.
3. Understand the role of thrombolysis in the treatment of acute ischaemic stroke.
4. Understand the principles of management of patients who have suffered a stroke.

Lecture: Sleep and Arousal

1. Describe the EEG and its significance
2. Describe the stages of sleep and the significance of REM sleep
3. Describe the mechanisms triggering and maintaining sleep
4. Describe some common pathologies of sleep and the consequences of insomnia

Lecture: Multiple Sclerosis

1. Describe typical MRI and CSF and how they help the diagnosis
2. Be able to identify someone who may have MS and describe the clinical types of MS
3. Identify the compartments and cells involved in pathology
4. Discuss the therapeutic areas and objectives

Lecture: PBLs 1-3 Debrief

Lecture: PBLs 4-6 Debrief

Enrichment Lecture 2: The Genetics of Brain Tumours

Workshop: Pharmacology of Drug Dependence

1. Describe physical and psychological drug dependence.
2. Explain mechanisms underlying pharmacodynamic and pharmacokinetic tolerance.
3. Give examples of major drugs that cause dependence and induce tolerance.

Clinical Skills: Cranial Nerves

Workshop: The Pharmacology of Synaptic Transmission

Computer-Assisted-Learning (CAL) sessions provide information which will complement that given in lectures, tutorials and clinical demonstrations. The sessions will also give an opportunity for self-assessment. 

Professor Adina Michael-Titus will take the sessions.

1. Describe the neuronal structures involved in synaptic transmission.
2. Describe the main steps involved in neurotransmission.
3. Describe the effects of neurotransmitters at postsynaptic level.
4. List and classify major types of neurotransmitters.
5. Review the basic mechanisms underlying neuronal excitability.

Workshop: Dopaminergic Systems: Pharmacology and Pathology

1. Describe the dopaminergic pathways in the central nervous system.
2. List and characterise the main types of dopaminergic receptors.
3. Describe the mechanism of action of drugs that act on dopaminergic systems.
4. Review the main circuits involved in the control of movement.

Enrichment Lecture 1: Cannabis - Uses and Abuses

Presented by Professor David Baker

Workshop: Central 5-Hydroxytryptamine (5-HT) Transmission

1. Describe the 5-HT pathways in the central nervous system.
2. List and characterise the main types of 5-HT receptors.
3. Describe the mechanism of action of drugs that act on 5-HT systems.

Clinical Skills: PNS II

Anatomy: Session 1

Anatomy: The CNS

1. Can describe the pathophysiology, clinical symptoms and basic treatments of movement disorders

Anatomy: The Limbic System

Anatomy: Head Injury

Practical: Pain

Practical: EEG

B&B2 PBL 1: MR BODY

Mr Louie Body is a 66-year-old man who initially presented with resting tremor in his right hand three years ago. He also noticed that many of his daily actions were becoming slow and, for instance, when he tried to do up buttons or use a knife to eat, that these tasks were increasingly difficult. His wife complained at the time that he was increasingly moody.

Muscle strength and reflexes were normal. His doctor prescribed Madopar®. Mr Body found that his symptoms dramatically resolved after starting Madopar® and his day to day activities nearly returned to normal. However, in recent months he has had a return of the symptoms which have become worse. He slowly shuffles into the surgery and says in a monotonous voice that there are times during the day when he cannot move at all in spite of increasing drug doses.

He now suffers from frequent falls and has micrographia, and also shows cogwheel rigidity. His wife and daughter are finding it increasingly difficult to care for him, and they say he is very depressed and has lost interest in life. He also has moments of confusion, and his memory seems affected. They want to know if there are any alternative drugs or other types of treatment that might improve his present condition. They have heard about a new drug, rotigotine, and they have also found on the internet some information about beneficial effects of vitamin E. The doctor tells them that he is considering adding selegiline to his medication.

1. Can describe the pathophysiology, clinical symptoms and basic treatments of movement disorders

B&B2 PBL 2: PAIN

Jerry is a 51 year-old keen sportsman who comes to see his GP because of pain and stiffness in both his lower back and buttocks following a game of squash. He has been taking over-the-counter analgesics (paracetamol and ibuprofen) for the past week. Although he feels the medication has had some effect, he is concerned that the condition has gone on so long. The GP discusses with Jerry reasons why both his back and buttocks could be painful and stiff and recommends he continue taking the over-the-counter analgesics. He also prescribes him a course of physiotherapy. Jerry’s condition improves steadily over the month.

Several months later, Jerry’s back pain suddenly returns. He attends the GP stating that it seems much worse than the previous time, with the pain now also radiating down the back of his left leg as far as his toes. He says it feels like someone is giving him electric shocks! The over the counter medicines are ineffective at relieving his pain. The GP prescribes diclofenac and tramadol and asks him to return in 3 weeks. When Jerry returns he reports that the back pain has largely resolved, but the leg pain has not.

The GP orders some imaging tests at the hospital and writes a referral to a specialist to discuss the treatment options. The imaging tests show degenerative problems in the spine and the specialist suggests an operation to solve the problem. Jim agrees to the operation. However, the operation fails to cure the pain radiating down his leg which now, in addition to being lancinating, has a burning quality. The pains are so bad that sometimes he is kept awake for 24-36 hours at a time.

The specialist refers Jerry to a pain clinic at the local hospital. Over the following six months, the pain clinicians try acupuncture but this proves ineffective, as are strong opioid drugs and drugs like amitriptyline. Then Jerry is prescribed pregabalin. After two weeks, Jerry reports a significant decrease in his pain and is able to sleep better at night. For the first time in over a year Jerry feels that his condition is improving.

1. Can describe the pathophysiology, clinical symptoms and basic treatments of headache

B&B2 PBL 3: SHOULD I HAVE A BABY?

A 35 year-old married woman presents to her GP for advice about getting pregnant. At age 33 she had two tonic-clonic seizures in the space of a few months, likely to have been caused by a meningioma in the right parietal lobe. Since then, she has been prescribed carbamazepine to control her seizures and has been seizure free. She recently reduced the frequency and dosage of the drug but then had a convulsive seizure, so she resumed taking the medication. She again tapered off the medication and again had an unprovoked seizure. She wants to know whether or not the drug would affect her baby, whether it is safe to take carbamazepine during pregnancy, and wonders whether there are other drugs or methods that can manage her condition. She also wants to know whether her new baby will be prone to epilepsy.

B&B2 PBL 4: JIM

After the unexpected death of his mother 12 months ago, Jim, a 44 year-old truck driver has recently lost his job due to the economic downturn. He now experiences problems with his sleep, waking early in the morning and feeling dreadful. His wife also notices that he has lost a lot of weight and does not seem to enjoy his food anymore. He feels worthless especially because he is unable “to provide for the family” and describes himself as “a pretty useless piece of kit”. He is consumed with guilt and is tearful on most days, which makes him feel exhausted. He no longer enjoys socialising with his family and friends, often choosing to remain indoors. There have been times when he wishes he could fall asleep and never wake up, but is reluctant to end his life because of the impact of this on his wife and two children.

Jim and his wife go together to his GP to ask for “sleeping tablets”, so that he can get his energy back. The GP explores Jim’s problems and performs a mental state examination as part of his overall assessment. He diagnoses him with mild to moderate depression, although considers that some of his symptoms might be related to a grief reaction following the death of his mother. Usually cognitive behavioural therapy (CBT) is offered for cases of mild-moderate depression as a first line treatment option, but as Jim presents with passive suicidal ideation and considering the long waiting list for CBT, the GP decides to prescribe him citalopram.                  

As the GP is concerned about Jim’s safety, he is offered follow-up appointments on a fortnightly basis. After two months, Jim reports that his energy level and appetite have improved, along with a reduction in the intensity and frequency of his suicidal thoughts. However his sleep still remains a problem and he continues to have strong feelings of guilt. The GP changes his medication to Mirtazapine and a week later he begins the CBT. During the therapy, it is discovered that Jim’s guilt is largely focused on his regret for not visiting his mother for five weeks leading up to her death, following a disagreement. He uses the CBT approach to develop an alternative way of evaluating his emotions and feelings regarding the relationship with his mother’s and her death.

B&B2 PBL 5: TOM

Tom is a 49 year-old homeless man brought to A&E after a fall. He smells of alcohol and appears to be mildly intoxicated. An ambulance was called by his friend after Tom had a fight and fell over outside the local pub. He has some bruising below his right eye. He has had several A&E attendances over the past few months. He is unsteady walking and has a broad- based or ‘ataxic’ gait. His account of events is confused and he is sleepy in the A&E department.

On examination, he is noted to have a nystagmus and is unable to move his left eye to gaze to the left (abduction). When the A&E doctor asks him to point to his nose and then to the doctor’s finger, he has a marked intention tremor and ‘past pointing’. Blood tests are ordered and as a result he is treated urgently with a vitamin, which is given to him intravenously. He is admitted to the ward.

The admitting doctor tries to take an alcohol history from him but he is vague and unable to give a coherent reply. His friend accompanying him tells the doctor he drinks about 9 cans of strong lager per day from about 11am onwards. He has a drink first thing just to keep his hands from shaking. He has been a heavy drinker for most of his adult life. The doctor prescribes medication to prevent withdrawal symptoms during his admission.

After 3 weeks Tom is stable and medically fit for discharge but the ward nurses are worried about how he will cope at home. He has not learnt the layout of the ward during his stay and often goes into other patients’ rooms looking for the bathroom. He has not learnt any of the nurses’ or doctors’ names during his stay. When he is asked about his home details, address and social history etc., he gives a coherent and plausible reply but it has become obvious over time that he keeps changing his story, giving a completely different description of his home situation each time he is asked. One day he said he was working as a postman, and lives on his own in a flat. The next day he said he was a porter and lived in hospital accommodation. His brain scan shows marked reduction in mammillary body volume.

B&B2 PBL 6: VOICES

Linda is a 32 year-old secretary. Her difficulties started 8 years ago when she became stressed and tired due to working during the day and then taking care of her father in the evenings. She had been seeing her GP for support but became increasingly distressed, withdrawn and suspicious. She disclosed to her GP that she had started "hearing voices". She had tried to ignore them, but they had become more intrusive and she believed that people were talking about her behind her back. The voices were whispering unpleasant comments about her while she was at work, or at other times they were loud and were instructing her to hurt others or herself.  She became very anxious and mistrustful of her colleagues and friends. She stopped seeing her friends and started having several drinks at the end of the day, to "make the voices go away". She felt as if there was a conspiracy against her, she believed she was being watched and followed and she found it increasingly difficult to leave the house to get to work. She believed that someone was controlling her from afar, making shooting pains appear in her body. She believed that someone was going into her files at work and removing 'certain things', but was unwilling to say more. Linda was referred to a specialist and was seen in the outpatient department. She was prescribed several medications over the years including haloperidol, risperidone and olanzapine. The medication helped the voices to become less persistent, and she continued in her office job. However she put on weight and the drugs made her feel strange, so at times she did not take them, and stopped taking them altogether about a year ago.

Linda lives alone and is currently unemployed, having lost her last job 2 months ago due to poor attendance.  She has come to the specialist outpatient clinic; her appearance is untidy and she looks anxious and uncomfortable in the waiting room. In the appointment she tells you she cannot concentrate on anything and cannot cope with everyday tasks, such as opening the mail and sorting out bills. She is rather quiet and she seems distracted. She is worried about things at home but denies feeling low all the time; she enjoys spending time with her little nephews. Her brother Tim has accompanied her and he asks you what is wrong with his sister, as she is so different from the outgoing person she used to be. Their mother had mental health problems and was in and out of hospital when they were growing up, so he is worried that it might be the same problem. Their mother killed herself by hanging when they were in their teens so Tim is understandably worried about what might happen to Linda and wants to know if it is part of the illness that people try to kill themselves. He asks you what may have caused her condition and asks whether his own children could become affected. Linda wants to know if she will ever recover and asks you if there are other medications she could try that do not give her side effects. Tim is worried that even if you give her a new tablet she will stop taking them again.