Neuropsychiatric disorders

Neuropsychiatric disorders- Dr Pallav Jain

1. Neuropsychiatric disorders : Neurological perspective PRESENTER- DR.PALLAV JAIN DM RESIDENT(NEUROLOGY) GMC,KOTA

2. Introduction M any patients who present with or are brought psychiatric symptoms Delusions, hallucinations, behavioral and personality changes W hether these symptoms are due to organic diseases affecting the brain or primary psychiatric illnesses

3. Introduction Brain disorders may cause psychiatric symptoms Neuropsychiatric symptoms- Psychiatric symptoms caused by organic brain disorders. N europsychiatric disorders- N eurological disorders that cause psychiatric symptoms

4. Neuropsychiatric disorder commonly occurs in elderly patients O ccasionally mimics endogenous psychoses. O rganic factors should be carefully evaluated in in patients with psychiatric symptoms among the elderly.

5. Neuropsychiatric Disorders Neurodegenerative diseases Cerebrovascular disorders Subdural hematoma Encephalitis Traumatic brain injury Brain tumor Metabolic encephalopathy Intoxication

6. Clinical Manifestations of Neuropsychiatric Disorders Multiple Neuropsychiatric Symptoms Occur Simultaneously N eurological , neuropsychological, and psychiatric symptoms concurrently in the course of illness

7. Multiple neuropsychiatric symptoms Clinical manifestations of neuropsychiatric disorders usually consist of the multiple components of psychiatric symptoms . C ognitive impairment, disturbance of consciousness, anxiety, mood disorders, hallucination, delusion, behavioral change , and apathy, commonly occur concurrently in the course of cerebral disorders The psychiatric symptoms are usually accompanied by other psychiatric symptoms. N europsychiatric symptoms rarely occur independently in the course of illness .

8. Neuropsychiatric Symptoms Probable –Cognitive impairment-Core symptoms –Disturbance of consciousness Possible –Neurotic complaints, anxiety –Mood changes –Psychotic States: Hallucination & delusion –Behavioral and personality changes

9. Earliest Symptoms Mild neuropsychiatric symptoms(anxiety , depression, apathy ) occasionally precede dementia in cerebral disorders Neuropsychiatric symptoms in the MCI stage- predictors of conversion to dementia Not Pathognomonic No type of neuropsychiatric symptom is pathognomonic to a specific cerebral disorder. Almost all neuropsychiatric symptoms may occur in any of the cerebral disorders.

10. Mimic Endogenous Psychoses Cerebral disorders may mimic endogenous psychoses. Paranoid-hallucinatory state and mood disorders could be caused by cerebral diseases. Visual hallucination, especially , commonly occurs in cerebral disorders. Delusions of persecution and infidelity are occasionally seen in patients with organic brain disorders. E ndogenous psychosis should be diagnosed carefully by excluding the possibility of cerebral disorders.

11. Neuropsychiatric Symptoms Hallucination Delusion Anxiety N eurotic complaints Apathy mood disorder behavioral change personality alteration

12. Clues to organic etiology A typical age of onset, specially after age 45 A bsence of a family history of psychiatric illness A bsence of any past psychiatric disturbances or premorbid behaviors characteristic of functional psychiatric disorders P resence of family history of neurologic disorders such as Huntington’s disease P resence of focal neurological signs

13. Presence of mental status deficits suggestive of focal or degenerative brain disorders Presence of unusual psychiatric syndromes or atypical mixed states (such as prominent mood changes with mood-incongruent delusions) History of a medical disorder or neurologic condition Presence of unusual temporal features such as abrupt onset, quick resolution or rapid fluctuation Treatment resistance or unusual treatment response

14. Neuropsychiatric Symptoms and Corresponding Neuroanatomy Depression Prefrontal cortex (particularly left anterior regions,anterior cingulate gyrus, subgenu of the corpuscallosum , orbitofrontal cortex), basal ganglia, left caudate Mania Inferomedial and ventromedial frontal cortex, right inferomedial frontal cortex, anterior cingulate, caudate nucleus, thalamus, and temporothalamic projections Apathy Anterior cingulate gyrus, nucleus accumbens , globus pallidus , thalamus OCD Orbital or medial frontal cortex, caudate nucleus, globus pallidus Disinhibition Orbitofrontal cortex, hypothalamus, septum

15. Paraphilia Mediotemporal cortex, hypothalamus, septum, rostral brainstem Hallucination Unimodal association cortex, orbitofrontal cortex, paralimbic cortex, limbic cortex, striatum, thalamus, midbrain Delusions Orbitofrontal cortex, amygdala, striatum, thalamus

16. Delusions Delusions are false beliefs despite evidence to the contrary Diseases associated Delirium. Dementing diseases- Alzeimer’s disease,Vascular dementia,HD Temporal lobe epilepsy Multiple sclerosis Post-traumatic encephalopathy. Wilson’s disease, other degenerative EPS disease. toxic and metabolic disorders

17. Types of delusions Simple persecutory delusions- elementary , loosely structured beliefs that are usually transient Complex delusions- more rigid and stable structure and they are associated with substantial, though distorted, observation Grandiose delusions- were seen only in one patient with Huntington’s disease. Delusions associated with specific neurological conditions

18. C omplexity of delusions R elated to the severity of intellectual impairment. M oderately to severely cognitively impaired- display simple delusions secondary to their poor judgment and reasoning capacity . L ess cognitively impaired-greater ability to think and reason and thus have complex, elaborate delusions . Most of the secondary delusions are manifested by paranoid delusions and ideas of reference and/or persecution

19. CNS disease vs primary psychiatric diseases N eurological illness tend to be persecutory beliefs Cognitive abnormalities-common with organic delusions Neurological illness-Associated with visual hallucinations, primary psychiatric illness –associated complex auditory hallucinations D ementing illness- mainly simple delusions . More common in diseases affecting both cerebral hemispheres Onset of delusions to be delayed for considerable period of time after the occurrence of brain insult .

20. Hallucinations Hallucinations are sensory perceptions occurring without the appropriate stimulation of the corresponding sensory organ . Hallucinations in other sensory modalities are less common than visual hallucinations in neurological illnesses

21. Visual Hallucinations P erception of an external visual stimulus where none exists. V isual illusion-distortion or modification of real external visual stimuli Simple hallucinations("elementary“, " non-formed)- Lights , colors, lines, shapes , or geometric designs. Complex hallucinations(formed)-images of people, animals, objects, or a lifelike scene Simple visual hallucinations occur, they are almost always organic.

22. Diffrential diagnosis Retinal Pathology N ever complex, Insight is intact,monocular Scotoma develops after the onset of simple hallucinations. do not tend to grow or spread Charles Bonnet syndrome A bsence of auditory or somatosensory hallucinations A bnormal thought content Insight is usually retained

23. Migrainous Simple,typically linear or geometric ( eg , zig-zag lines) in appearance C lassic-fortification spectra. Generally binocular, can occur in any area of the visual field Growth or spread of the aura occurring over a few minutes Epileptic often colorful and circular or spherical in appearance, can be simple or complex visual illusions ,binocular spread occurs more rapidly, over a few seconds Simple-occipital , occipitotemporal , and occipitoparietal regions of the cortex Complex-the occipitotemporal region and the temporal lobe

24. Neurodegenerative disease(DLB,PD) complex , binocular, and occur throughout the entire visual field. Insight may or may not be retained Alcohol and benzodiazepine withdrawal Usually produce complex hallucinations with vivid imagery Associated with agitation, tremulousness,autonomic hyperactivity. Hallucinations in other modalities can occur, often lack insight

25. Peduncular hallucinosis Affecting the midbrain, in particular, the paramedian reticular formation The hallucinations are complex and binocular, involving both visual fields. The content of the complex imagery varies and is usually described as vivid and colorful . A ssociated tactile and auditory content Insight is variably retained Other signs of brainstem and diencephalon dysfunction are often present

26. Psychiatric illness Most are complex. Auditory hallucinations typically accompany the visual hallucinations C ontent usually disturbing and antagonistic. Many patients will lack insight Other psychiatric symptoms are usually present .

27. Auditory hallucinations O ften indicate primary psychiatric problem. O ften difficult for the patient to localize in space (often sensed as occurring inside the head). V oice often comments on the patient’s behavior and /or echos the patient’s thoughts. O ccur in conjunction with persecutory delusions in the delusional disorders .

28. Olfactory hallucinations R eported in temporal lobe epilepsy D istinguished from those occurring in psychiatric disorders by absence of associated delusions and recognition of the symptom as a part of the illness .

29. Depression N eurological diseases by themselves can produce depressive symptoms without any mood changes. D epression is reactive to the neurological disability. M istakenly diagnosed as depressive owing to neurological symptoms Depressed patient may be mistakenly diagnosed as demented.

30. Pseudo-dementia Used for describing cognitive deficits in psychiatric disorders , especially depression . D epressive states adversely affect cognitive functions, especially in old-age or geriatric depression “The dementia component”-combination of various cognitive deficits found in these psychiatric disorders “The pseudo component ”- lack of the neurodegenerative dementia

31. What to look for Generally, the patient presents by himself Equal loss for recent and remote events Characterized by patchy or specific memory loss Their attention and concentration is not there Gave frequent “don’t know” answers. Performance on similarly difficult neuro-psychological tasks are much variable

32. Neurological diseases associated with depression Neurodegenerative disease Extrapyramidal disorders Stroke and vascular dementia. CNS Infections Multiple sclerosis. Epilepsy . Endocrine disorders Systemic illnesses Medications

33. Pseudobulbar Affect

34. Stroke I nterruption of bilateral frontotemporal lobe function-increased risk of depressive and psychotic symptoms Wernicke aphasia-Paranoia and psychosis Reduplicative paramnesia P atients claim that they are simultaneously in two or more locations . C ombined lesions of frontal and right temporal lobes Capgras syndrome F alse belief that someone familiar has been replaced by an identical-appearing imposter R ight temporal-limbic-frontal disconnection

35. Epilepsy Behavioral and cognitive dysfunction is frequently observed in patients with epilepsy . Behavioral symptoms may be more prominent in later-onset seizures . Anticonvulsants have been reported to be associated with a host of effects on sleep such as insomnia, alterations of sleep architecture, and in some cases, worsening of sleep disordered breathing (barbiturates and benzodiazepines). These may all adversely affect cognition.

36. Postictal depression Prevalence not been established . Depressive symptoms have been known to last up to 2 weeks Interictal depression M ost common type of depression in epileptic patients P revalence ranges from 20% to 70% S ymptoms are often chronic and less prominent Treatment Antidepressant medication(SSRIs) and optimized seizure control. ECT-severe or treatment-refractory depression.

37. Psychaitric disturbances in epileptic patients Ictal Anxiety, intense feelings of horror,depressed mood,hallucinations,illusion,obsession.aggression,laughter Post ictal Agitation,depression,hallucination,aggression,confusion,mania , Inter-ictal Panic,generalized anxiety disorder,phobia,major depressive disorder,obsssesive compulsive disorder,agression

38. Postictal psychosis Psychosis may commonly manifest as a postictal phenomenon. Diagnostic criteria - An episode of psychosis emerging within 1 week after the return of normal mental function following a seizure; An episode length between 24 hours and 3 months; and No evidence of EEG-supported NCSE, anticonvulsant toxicity, previous history of interictal psychosis, recent head injury, or alcohol or drug intoxication.

39. Postictal psychosis Commonly associated with temporal lobe epilepsy. Psychotic symptoms-auditory , visual, or olfactory hallucinations. Abnormalities of thought content or form may include ideas of reference, paranoia, delusions, grandiosity, religious delusions, thought blocking, tangentiality , or loose associations . P rompt response to low-dose antipsychotics or benzodiazepines.

40. Neurodegenerative disease Psychotic symptoms are more common in PD Greater cognitive impairment Longer duration of illness Greater daytime somnolence Older age and in those who are institutionalized. Historical accounts of PD rarely described psychotic symptoms P sychosis occurred secondary to dopamine agonist use .

41. Psychosis in Parkinson disease Psychosis in dementia with Lewy bodies Psychosis is generally medication induced Psychosis occurs in the absence of antiparkinsonian medications Hallucinations are usually fleeting and nocturnal Hallucinations are generally persistent/recurrent Dementia may or may not accompany psychosis. Presence of dementia is required for a diagnosis Motor impairment virtually always precedes psychosis Motor impairment may occur after psychosis Neuroleptics worsen motor function Neuroleptic sensitivity increased morbidity and mortality Disordered dopaminergic transmissions Disordered cholinergic transmission Visual hallucinations are more common than delusions Visual hallucinations and delusions occur at similar frequencies

42. Treatment of psychotics symptoms Discontinuation of anticholinergics, selegiline , and amantadine before reducing L-dopa is recommended. Following these discontinuations, reduction and simplification of dopamine agonists may be beneficial. Atypical antipsychotics are added only when a reduction of other medications has not resulted in improvement

43. Neuropsychiatric Effects of Deep Brain Stimulation Deep brain stimulation (DBS) is a well-recognized treatment for motor complications of levodopa therapy. anxiety was improved outcomes for impulse-control were mixed weight gain secondary to increased eating behaviors was consistent, depressive episodes were more frequent although less severe apathy worsened no conclusion could be reached from suicidal ideation assessment.

44. Psychosis in Alzheimer disease Schizophrenia in the elderly Incidence 30%–50% <1% Bizarre or complex delusions Rare Common Misidentification of caregivers Common Rare Hallucinations Visual Auditory Schneiderian first-rank symptoms Rare Common Eventual remission of psychosis Common Rare Active suicidal ideation Rare Common

45. PRINCIPLES OF NEUROPSYCHIATRIC EVALUATION N ormal neurological examination-Not exclude neurological conditions R outine laboratory testing, brain imaging,EEG and CSF do not necessarily exclude diseases of neurological origin. New neurological complaints or behavioral changes that are atypical for a coexisting primary psychiatric disorder should not be dismissed as being of psychiatric origin in a person with a pre-existing psychiatric history.

46. The possibility of iatrogenically induced symptoms must be taken into account. Treatments of primary psychiatric and neurological behavioral disturbances share common principles Response to therapy does not constitute evidence for a primary psychiatric condition.

47. Diagnostic evaluation P atient’s medical history, neurological examination Routine laboratory evaluation-CBC, electrolytes,renal & liver function Nutritional and Toxicology screen - cobalamin (B12), homocysteine, methylmalonic acid , folate, ceruloplasmin , Infections- HIV,rapid plasma regain Additional tests-ANA, paraneoplastic panel,urine porphobilinogen

48. CSF analysis Genetic testing MRI-structural abnormalities, evidence of metabolic storage diseases EEG - history of intermittent, discrete, or abrupt episodes of psychiatric dysfunction, stereotypy of hallucinations, automatisms

49. Management of neuro-psychiatric symptoms Patients with underlying neurological conditions tend to be more susceptible to the adverse reactions of psychotropic medications, particularly to extrapyramidal and cognitive side effects. These adverse reactions tend to be minimized with initiation of medications at low doses and use of gentle titration Common precipitant Medication side effects Hypnotics/sedatives-generally be avoided in patients Pain may also precipitate neuropsychiatric symptoms

50. Anti psychotics in dementia Not approved by FDA for the treatment of behavioral disorders in patients with dementia Should not be used routinely. Cautious use advocated for severe psychosis or aggression if non- pharmacologica measures fail. Clinicians should use one drug at a time, start with a low dose, and titrate slowly. Olnazapine , Risperidone,Quitepine are preferred.

51. Keep in mind-treatment may help some problems but cause or exacerbate others Treatment should be maintained only if benefits are apparent Discontinuation should be attempted at regular intervals Patients who have DLB may be especially sensitive to antipsychotic medication

52. SSRIs-(particular citalopram)-useful in agitation and paranoia Drugs to avoid — Benzodiazepines Therapies with possible benefit( in sleep disturbance) Melatonin Light therapy Dextromethorphan-quinidine-FDA approved for symptomatic treatment of pseudobulbar affect

53. Depression M ild to moderate major depression-psychotherapy or medication . Medications- SSRIs,SNRIs and bupropion . P sychotherapeutic optionsproven to be effective Cognitive behavioral therapy (CBT ) I nterpersonal therapy (IPT), and Problem-solving therapy (PST)

54. Refractory depression ECT VNS transcranial magnetic stimulation deep brain stimulation, or stereotactic ablative surgery There is currently little evidence to guide the optimal treatment approach for patients with neurological disease and comorbid psychiatric symptoms

55. Conclusion

56. Refrences

57. Tinnitus is almost always organic. A uras of temporal lobe epilepsy. Alcohol Withdrawal states especially from can cause auditory hallucination that feature voices They may also occur with deafness, brainstem lesions and epilepsy.

58. Haptic/pain hallucination U nusual bodily experiences and pain. P hantom limb pain. Hallucinatory duplication of the limb or other body segment or a sensation of distorted body shape may occur with migraine, as an epileptic aura, with toxic encephalopathy or following the use of hallucinogenic drugs. Formication hallucination the feeling that bugs are crawling on the skin . C ommon in alcohol,drug withdrawal states,toxic and metabolic conditions. If the sensation is unilateral - thalamic or parietal lesion . Tactile hallucinations D elirium,opiate withdrawal

59. Diseases associated with mania 1 . Huntington’s disease. 2. Wilson’s disease. 3.Idiopathic basal ganglia calcification. 4.Stroke . 5.Trauma . 6.Multiple sclerosis, 7.General paresis. 8.Viral encephalitis and postencephalitic syndromes. 9.Frontal degenerative disorders. 10.Following thalamotomy . 11.Drugs.a.Steroids.b.Benzodiazepines.c.Dopaminergic agents.d.Thyroid preparations.e.Sympathomimetics.f.Stimulants.g . Antidepressant agents may precipitate manic episodes in depressed patients.

60. Obsessive-Compulsive Disorder Obsessions are recurrent, intrusive, senseless ideas, thoughts and images that are ego-dystonic and involuntary. Compulsions are repetitive activities carried out in response to an obsession and executed in a stereotyped and ritualized fashion.

61. Neurological disorders associated with obsessive-compulsive disorder Acute dystonia with oculogyric crises Anoxia with bilateral globus pallidus lesions Anoxic injury to caudate and putamen Bilateral caudate nucleus infarctions Carbon monoxide intoxication with bilateral globus pallidus injury Carbon monoxide poisoning with bilateral caudate nucleus lesions Huntington’s disease Manganese intoxication Neuroacanthocytosis Parkinsonism with compulsions during “on” period in patients experiencing on-off swings Postencephalitic parkinsonism Progressive supranuclear palsy Sydenham’s chorea Tourette’s disorder