The video below is the section for Vascular Neurocognitive Disorder from Part 2 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 2, click here. To watch Part 1, click here. To register for our webinar series to watch future lectures and discuss your questions with a content expert, click here.
Transcript of DSM-5 EPPP Lecture Video: Vascular Neurocognitive Disorder
NARRATIVE DEFINITION: Major or mild vascular Neurocognitive Disorders (NCD), previously referred to as Cerebrovascular Accidents (CVAs) or strokes, occur when there is a disruption of blood flow to the brain, resulting in an inadequate supply of oxygen and consequent neural cell death. There are two primary types of strokes: hemorrhagic and ischemic.
In hemorrhagic strokes, there is bleeding within the brain, often from malformed blood vessels or blood vessels weakened by hypertension. Accumulated blood from leaking vessels puts pressure upon and causes damage to surrounding brain tissue.
In ischemic strokes, blood flow is obstructed by the presence of thrombi (blood clots that form within a blood vessel) or emboli (dislodged pieces of matter such as blood clots, fat, or bacterial debris) within a blood vessel. Acute ischemic strokes are more prevalent, accounting for approximately 85% of all major or mild vascular neurocognitive disorders.
The onset of a stroke is generally sudden, with symptoms appearing in less than an hour. Common stroke symptoms include unilateral weakness or paralysis in the arms and legs; facial muscle weakness or “drooping”; numbness, tingling, or impaired sensations; changes in vision; aphasia; loss of memory; drooling or difficulty swallowing; loss of balance or coordination; vertigo; personality changes; uncontrollable eye movements; drowsiness, lethargy, or loss of consciousness; and emotional lability.
In approximately one-third of all vascular NCDs, the stroke occurs while the individual is asleep. In these cases, the individual awakes to the experience of stroke symptoms. Symptom intensity may wax and wane, or the symptoms may become increasingly severe over the course of several hours.
When symptoms disappear entirely in less than 24 hours, this is referred to as a transient ischemic attack (TIA). A history of TIAs is a significant risk factor for eventually experiencing a full-blown stroke.
Another major risk factor for major or mild vascular NCD is increasing age; the likelihood of having a stroke doubles each decade after 45 years of age. By age 75, the probability of having a stroke is 1 to 2%. Additional risk factors include being male, using oral contraceptives, smoking, hypertension (high-blood pressure), heart disease, and hypercholesterolemia (excessive cholesterol in the blood).
Major or mild vascular NCD is the second most common cause of NCD after Alzheimer’s disease. Prevalence rates in the U.S. range from 0.2% for ages 65-70 up to 16% for those over age 80. The mortality rate is approximately one of every 18 deaths in the United states. Only 10% of stroke victims make a full recovery, while the mortality rate is approximately 30%. Long-term effects of strokes include hemispatial neglect, dementia, seizures, speech difficulties, perceptual disturbances, depression, mood swings, impaired memory and attention, anosognosia (i.e., ignorance of one’s own disabilities), impaired judgment, incontinence, and physical symptoms such as partial paralysis, weakness, or limited range of motion. In general, physical disabilities are resolved more quickly than are cognitive deficits.
The DSM-5 uses the diagnosis Major or Minor Neurocognitive Disorders with specifiers to note the cause. The difference between major or minor would come from whether or not the cognitive decline from the previous level of performance was significant (major) or modest (minor) and whether the cognitive deficits interfere with their independence in every day activities (major) or they do not interfere with everyday activities (minor). The diagnosis of major or mild vascular neurocognitive disorders may also specify Without behavioral disturbances or With behavioral disturbances and include a severity specifier or Mild, Moderate, or Severe in reference to ability to manage daily activities.
- Involves disrupted blood flow to brain, which causes oxygen deprivation in the brain and neural cell death
- Involves a range of physical, cognitive, and behavioral effects, including unilateral weakness or paralysis in the arms and legs; facial muscle weakness or “drooping”; numbness, tingling, or impaired sensations; changes in vision; aphasia; loss of memory; drooling or difficulty swallowing; loss of balance or coordination; vertigo; personality changes; uncontrollable eye movements; drowsiness, lethargy, or loss of consciousness; and emotional lability
- Two primary types of stroke
a. Hemorrhagic: bleeding into brain from weakened blood vessels (often linked to hypertension)
b. Ischemic: obstructed blood flow related to clots or dislodged tissues; 85% of CVA’s
- Short-lived CVA called transient ischemic attack (TIA), symptoms remit within 24 hours
Risk Factors for Major or Minor Neurocognitive Disorder due to Vascular Disease
- Being male
- Using oral contraceptives
- Heart disease
- Hypercholesterolemia (i.e. excessive cholesterol in the blood)
- History of TIA’s
- Advancing age; every decade after age 45 the likelihood of having a stroke doubles
- After age 75, the probability of having a stroke is 1-2%
- Mortality rate in the U.S. is approximately 1 in every 18 deaths
- Only 10% make full recovery
Unilateral paralysis of the extremities, drooping eyelids, personality changes, and dementia are most characteristic of:
A. major or mild neurocognitive disorders due to traumatic brain injuries.
B. major or mild vascular neurocognitive disorders.
C. major or mild neurocognitive disorders due to Parkinson’s Disease.
D. major or mild neurocognitive disorders due to cerebral palsy.
RATIONALE: B is correct, as these symptoms are more characteristic of major or mild vascular neurocognitive disorders than of major or mild neurocognitive disorders due to TBI or Parkinson’s Disease. Cerebral palsy is not listed under major or mild neurocognitive disorders, but also does not match the characteristic as well. Answer A is incorrect, although some of the symptoms may be present in both the disorders. major or mild neurocognitive disorders due to TBI may involve impaired cognitive abilities, including executive function deficits, slow speed of processing, poor attention/concentration, and fatigue. In addition, changes in physical abilities and personality often occur. Answer C is incorrect as NCD due to Parkinson’s Disease is linked to dysregulation in the production of the neurotransmitter dopamine, involved in the coordination of smooth and complex movement; dopamine deficits result in impaired motor activity. Answer D is also incorrect. Symptoms of cerebral palsy (CP) include the inability to perform voluntary movements (ataxia), muscle stiffness, increased muscle tone (spasticity), and awkward gait. In severe case, CP may also be associated with increased drooling, learning disabilities, seizures, urinary and bowel problems, and hearing deficits.