Intro to Neuropsychiatry Flashcards
Define neuropsychiatry.
Psychiatric symptoms in the context of neurological disorder
Identify diseases with a neuropsychiatric component.
- Dementia
- Parkinsons
- Multiple Sclerosis
- Huntingtons
- Motor Neurone Disease
- Functional Neurological Disorder
Describe the spectrum of behavioral and psychological symptoms of dementia BPSD.
In dementia, majority of patients have some features of behavioral and/or psych symptoms, which come in three types:
1) Affective symptoms
- Depression
- Anxiety
- Apathy
- Elation
- Disinhibition
2) Psychotic symptoms
- Hallucinations
- Delusions
- Misidentifications (misidentify people they have known for years)
3) Behavioral symptoms
- Aberrant motor behaviour
- Irritability/aggression
- Agitation
- Slepe distrubances
- Stereotypies
- Hyperorality
- Eating disturbance
- Hypersexuality
What proportion of dementia patients have neuropsychiatric symptoms ? at which step of the disease do they present ?
90%
Present throughout course of disease, but more common with disease progression. May remit but highly recurrent.
How do neuropsychiatric symptoms in dementia affect carers ?
- Likely to be the most problematic aspect for carers
- A major source of caregiver distress
- Strongly associated with nursing home placement (because caregivers may not be able to cope anymore after certain time)
What is the aetiology of neuropsychiatric symptoms ?
Complex interaction between anatomical, biochemical and functional changes
What do the types of neuropsychiatric symptoms present depend on, in dementia ?
Features vary according to severity and type of dementia as different brain regions affected
What are predisposing factors to neuropsychiatric symptoms in dementia ?
- Genes
- Premorbid personality (i.e. someone who has always been irritable, may worsen in dementia)
What functions is the frontal lobe responsible for ?
Judgement Reasoning Behaviour Voluntary movements Expressive language (Broca's)
What function is the parietal lobe responsible for ?
Spatial orientation
Perception
Initial cortical processing of tactile and proprioceptive information
Language comprehension (Wernicke’s)
What function is the temporal lobe responsible for ?
Emotions Learning and memory Audition Olfaction Language comprehension (Wernicke's)
What function is the occipital lobe responsible for ?
Vision
Describe the neuropsychiatric symptoms associated with AD. Link this to the parts of the brain involved.
Impaired activities of daily living and altered pattern of behavior
AD is initially a temporal and parietal disorder, but then spreads throughout the brain. Thus, initially, may get symptoms which are related to these lobes, especially memory, learning, emotion, language comprehension (and word finding) (TEMPORAL), as well as language comprehension, and visuospatial abilities (PARIETAL).
As more areas of the brain get involved, get defects related to those. When the frontal lobe gets involved, inability to do ADLs.
Describe neuropsychiatric symptoms associated with Dementia with Lewy bodies.
Cortical atrophy is generalised, with defective cholinergic activity correlating with hallucinations (visual, that are typically well formed and detailed) and delusions (systematised, i.e. whole delusion system around something)
Distinguish between dementia related to PD and Lewy Body Dementia.
- Dementia with Lewy bodies and Parkinson’s disease dementia are separate entities which share many clinical, neurochemical and morphological features
- Distinction based on time of onset of motor and cognitive symptoms (if patient present with motor symptoms first, then dementia then diagnosis of PD, and vice versa)
- More pronounced cortical atrophy, elevated cortical and limbic Lewy body pathologies, higher Aβ and tau loads in cortex and striatum in DLB compared to PDD, and earlier cognitive defects in DLB.
- No differences in cortical and striatal cholinergic and dopaminergic deficits
Describe the neuropsychiatric symptoms associated with fronto-temporal dementia. Link this to the parts of the brain involved.
Frontal and temporal lobes affected
1) Behavioral symptoms
- Early loss of personal awareness (neglect of personal hygiene, and grooming)
- Early loss of social awareness (lack of social tact, misdemeanours such as shoplifting)
- Early signs of disinhibition (unrestrained sexuality, violent behaviour, inappropriate jocularity, restless pacing)
- Mental rigidity and inflexibility
- Hyperorality (oral/dietary changes, food fads, excess smoking and alcohol consumption, oral exploration of objects)
- Stereotyped and preservative behaviour (wandering, mannerisms such as slapping, singing, dancing…)
- Utilisation behaviour (unrestrained exploration of objects in environment)
- Distractibility, impulsivity, impersistence
- Early loss of insight into fact that altered condition is due to pathological change of own mental state
2) Affective symptoms
- Depression, anxiety, excessive sentimentality, suicidal and fixed ideation, delusion
- Hyponchondriasis
- Emotional unconcern (indifference and remoteness, lack of empathy and sympathy, apathy)
- Amimia (inertia, aspontaneity)
(ALSO speech disorder because Broca’s and Wernick’s areas may be affected)
Define pseudo-dementia.
Can look like dementia when actually older person is depressed
Describe the neuropsychiatric symptoms associated with vascular dementia. Link this to the parts of the brain involved.
Pseudobulbar palsy:
Personality and mood changes, abulia, depression, emotional incontinence, or other subcortical deficits, including psychomotor retardation and abnormal executive function (also disconnect between affect and mood, e.g. may be telling you sad news and laughing)
Identify the main types of dementias.
Lewy Body dementia AD Fronto-temporal dementia Vascular dementia Alcohol dementia
How can you distinguish vascular dementia from the other types ?
If it does not fit with anything else, and have high BP or another CV risk factor, probably this.
Can affect anywhere in the brain.
Describe neuropsychiatric symptoms in MS, including their timeline.
- Dysphoria, agitation, anxiety, irritability
- MDD ~50%- very high rates, likely to reflect cortical damage, not just reaction to disability
- Suicide (higher rates)
- Mania- e.g oribitofrontal prefrontal cortex-impulsivity, mood lability,
- Pseudobulbar affect-10% MS patients-disconnect between mood and affect- ‘tears without sadness’
- Psychosis (hallucinations + delusions) 2-3 x more common in MS patients compared to general population e.g medial temporal damage
TIMELINE
Common
Can be first presentation of MS
Which neurodegenerative disorders are associated with higher rates of suicide than the average population ?
Those where patients retain insight
Describe neuropsychiatric symptoms in Huntington’s.
- Progressive dementia and movement disorder
- Early depression and behavioural disturbances common- especially irritability, apathy, anxiety, dysphoria and agitation- independent of cognitive and motor aspects
- Psychotic symptoms rare
- Insight retained until late stages
- High suicide rate ~ 10%
Describe pathophysiology of Huntington’s.
• Abnormal huntingtin protein leads to degeneration of neurons- particularly caudate, putamen and cerebral cortex (so increase in size of lateral ventricles)
