Psychiatric Presentation of Neurological Disease

Question 1

How to differentiate between organic and non-organic disorders

Answer 1

1- History

• psychiatric: onset in early life , late teens, drugs being used , family history of mental illness
• Physical : onset is later in life, drugs being used

2- Symptoms

• Psychiatric: symptoms can hit suddenly but usually prodrome, conscious ( no confusion )
• Physical : non-auditory hallucinations , confusion, neurological deficits , fluctuating levels of consciousness , disorientations

3- Onset

• psychiatric : young
• physical : older age

4- Investigations: physical ops , cognitive assessment , urine drug screen , bloods routine , CT/MRI , EEG

5-

Question 2

47 yr man admitted with GI pain

• on examination he has nystagmus and ataxia
• no close family but notes show heavy alcohol use
• speaks positively about being in hospital
• Met consultant several times but gets them each time as if it’s the first
• Says he had champagne and kippers for breakfast in hospital

What is going on ?

Answer 2

Wernicke-Korsakoff Syndrome

Presenting with Confabulation , nystagmus and ataxia

Question 3

What is Wernicke-Korsakoff Syndrome and how does it present

Answer 3

A thiamine B1 deficiency
- Cause : chronic alcohol use

Presents First with Wernicke's Encephalopathy ( may not be the case for all patients ) 
1- Ophthalmoplegia 
2- ataxia 
3- confusion 
- treatable 

If not treated then develop Korsakoff

Korsakoff Syndrome
1- prominent impairment of memory formation
2- Confabulation
3- Relative presentation of other mental functions
- more difficult to create

Question 4

What is the treatment of Wernicke’s syndrome

Answer 4

Thiamine B12

Question 5

How is Wernicke’s Korsakoff syndrome managed

Answer 5

Wernicke’s Usually gone undiagnosed

1- High dose of IV thiamine - pabrinex ( for reversible Wernicke’s )
2- Abstinence from alcohol ( especially at Korsakoff stage )

Question 6

76 yr man present with 3 day poor attention confusion , paranoia , aggression

• abrupt onset
• accusing staff of stealing
• icing rats running around bed
• no history of mental illness
• no history of drug or alcohol use
• no changes to medications

What is going on ? Why ?

Answer 6

Sudden onset gives suspicion that it is physical

Delirium : acute confusional state

Delirium has abrupt onset of pronounced attentional abnormalities with disorders perception and memory ( visual hallucinations )

Question 7

What is delirium

Answer 7

acute confusional state with abrupt onset

Question 8

Causes of delirium

Answer 8

Infections , withdrawals , trauma , CNS disease, hypoxia , deficiencies, underlying dementia , environmental , toxins , drugs

Common in old age

Question 9

76 yr man admitted with Lower respiratory tract infection

• confused and tearful
• unable to tel why in hospital
• 6 months of increasing forgetfulness , losing things , relating himself , getting lost
• no history of mental illness
• no history of drug or alcohol use
• no changes to medications

What is going on ?

Answer 9

Dementia suspected due to gradual onset

Question 10

What are the reversible causes of Dementia

Answer 10

1- B12 & folate deficiency 
2- Hypothyroidism 
3- Wilson's disease - serum copper 
4- HIV 
5- systemic illness : LFTs, U&E 
6- Syphilis serology : VDRL

Question 11

How to distinguish between Delirium and Dementia

Answer 11

Delirium : 
1- Progression: fluctuating with lucid intervals , worse at night
2- Consciousness : altered 
3- Attention: impaired , distracted 
4- Memory : impaired 
5- Thinking: disorganized, delusional 
6- sleep-awake cycle: disrupted 
7- Perception: hallucinations , illusions - usually visual 

Dementia 
1- progression: more consistent over the day 
2- Consciousness : clear 
3- Attention : normal 
4- Memory: impaired 
5- Thinking: lack of thought 
6- sleep-awake cycle: normal 
7- perception: hallucinations in later stages of illness

Question 12

22 yr man describes unusual experiences

• whole world feel more real , as if everything is crystal clear
• then feels as if he’s there not there , like a dream
• Feels as if have lived through this same moment many times before
• hears what people say but doesn’t make sense
• doesn’t talk during episodes because says foolish things

What is going on ?

Answer 12

Temporal Lobe Epilepsy ( TLE )

Question 13

When are TLE common

Answer 13

Early onset , age 10-20 years

Question 14

Symptoms of TLE

Answer 14

1- aura 
2- deja-vu 
3- upset stomach 
4- sense of fear or panic 
5- strange smell

Question 15

What are the types of TLEs

Answer 15

1- Mesial temporal lobe epilepsy

• medial or internal structures of temporal love
• seizures being in hippocampus or surrounding areas
• 80% of TLE seizures

2- neocortical/lateral temporal lobe epilepsy
- involves outer part of temporal lobe

Question 16

What accounts for 80% of TLE seizures

Answer 16

Mesial Temporal lobe epilepsy

Question 17

Treatment for TLE

Answer 17

1- Medications : not common to get rid of seizures entirely
2- Neurostimulations ( VNS )
3- surgery - temporal lobectomy

Question 18

42 yr man brought in by wife with 1 week of strange behaviour

• seeking out homeless people claiming they are old friend souls needed to be saved
• sees angels over those worthy of his prayers
• said his wife had a demon in he that her death will cleanse her
• background of poorly controlled epilepsy , last seizure 10 days ago

What is going on ?

Answer 18

Post-Ictal Psychosis

Question 19

When is Post-Ictal Psychosis common

Answer 19

With TLE and long history of drug resistant seizures

Question 20

How does Post-ictal psychosis present

Answer 20

• Lucid intervals of hours or days
• 23% of violence towards others
• 7% with suicial behaviour
• religious / save people beliefs
• can be any psychotic symptoms

After seizure ( within 10 days window )

Question 21

Diagnosis Criteria of Post-ictal Psychosis

Answer 21

1- episode of psychosis developing within 1 week of seizure or cluster of seizures
2- psychosis lasting at least 15 hours and less than 2 months
3- Mental state characterized by delirium type picture , delusions or hallucinations in clear consciousness
4- no evidence of treatment with antipsychotics or psychosis in last 3 months
5- no evidence of anti epileptic drug toxicity
6- EEG demonstrating non convulsive status
7- no evidence of recent head trauma , substances intoxication or withdrawal

Question 22

How to manage Post-ictal Psychosis

Answer 22

1- Benzodiazepine + antipsychotic

2- 50% will have recurrent post-octal psychosis so long term antipsychotic should be considered

Question 23

23 yr woman admitted with 1 week of persecutory delusions , auditory hallucinations and pressured speech

• no psych history
• noted by family to behaving oddly in preceding weeks
• marked insomnia
• 1 week after admission develops abnormal movements , noted that could be a seizure
• catatonic symptoms emerging ( abnormal movements, posturing , resistance, copying people’s speech)
• Bloods, CT, MRI normal
• CSF encephalitis antibodies appear

What is going on ?

Answer 23

Anti-NMDA receptor encephalitis

Question 24

What is Anti-NMDA encephalitis

Answer 24

Encephalitis caused by CSF antibodies and often presented with psychosis/psychiatric symptoms and only 50% present with neurological signs

Question 25

How to diagnose Anti-NMDA encephalitis

Answer 25

EEG & CSF autoantibodies test.

Blood autoimmune encephalitis antibodies ( NMDAR) will show

Question 26

82 yr man presents with prominent visual hallucinations

• intermittent feeling that someone else is in room
• ongoing for 6 weeks
• no FMH of mental illness
• no substance misuse
• no acute physical illness
• background of 12 year history of Parkinson’s disease

What is going on ?

Answer 26

Parkinson Disease Psychosis

Question 27

How common of PD patients will develop psychosis during their illness

Answer 27

50% of patients will develop psychosis

Question 28

How does Parkinson Disease Psychosis present

Answer 28

1- Hallucinations : visual and auditory
2- sense of presence /visual illusions
3- delusions
4- may or may not retain insight

• established PD diagnosis

Question 29

Risk factors of Parkinson Disease Psychosis

Answer 29

1- Older age 
2- greater severity of illness 
3- longer duration of illness 
4- idiopathic PD 
5- REM behavioural disorder 
6- underlying dementia.delirium /depression 
7- impaired vision 
8- use of dopaminergic agents

Question 30

Treatment for Parkinson Disease Psychosis

Answer 30

1- reduce or stop anti-PD medications ( excess dopamine could cause psychosis )
2- antipsychotics
- may worsen movement symptoms
- increased morbidity and mortality in elderly patients with dementia
- Clozapine is best option but involves complex monitoring
3- Acetylcholinesterase inhibitors

Question 31

What is the best antipsychotic used for Parkinson Disease Psychosis & why but what is the disadvantage

Answer 31

Clozapine since it has a decreased affect on movement symptoms

requires complex monitoring ( weekly bloods and EEG )

Question 32

Which Neurological disease have mental illness as co-morbidities ( list which mental illnesses for each neurological disease )

Answer 32

1- Stroke - depression ( most common ) , anxiety , emotional incontinece
2- Epilepsy - mood/affective disorders ( most common ) , anxiety , psychosis , suicide
3- MS - Depression ( most common ) , bipolar disorder , anxiety , juice , psychosis