Psychiatric Presentation of Neurological Disease Flashcards
How to differentiate between organic and non-organic disorders
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-
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 ?
Wernicke-Korsakoff Syndrome
Presenting with Confabulation , nystagmus and ataxia
What is Wernicke-Korsakoff Syndrome and how does it present
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
What is the treatment of Wernicke’s syndrome
Thiamine B12
How is Wernicke’s Korsakoff syndrome managed
Wernicke’s Usually gone undiagnosed
1- High dose of IV thiamine - pabrinex ( for reversible Wernicke’s )
2- Abstinence from alcohol ( especially at Korsakoff stage )
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 ?
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 )
What is delirium
acute confusional state with abrupt onset
Causes of delirium
Infections , withdrawals , trauma , CNS disease, hypoxia , deficiencies, underlying dementia , environmental , toxins , drugs
Common in old age
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 ?
Dementia suspected due to gradual onset
What are the reversible causes of Dementia
1- B12 & folate deficiency 2- Hypothyroidism 3- Wilson's disease - serum copper 4- HIV 5- systemic illness : LFTs, U&E 6- Syphilis serology : VDRL
How to distinguish between Delirium and Dementia
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
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 ?
Temporal Lobe Epilepsy ( TLE )
When are TLE common
Early onset , age 10-20 years
Symptoms of TLE
1- aura 2- deja-vu 3- upset stomach 4- sense of fear or panic 5- strange smell
What are the types of TLEs
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
What accounts for 80% of TLE seizures
Mesial Temporal lobe epilepsy
Treatment for TLE
1- Medications : not common to get rid of seizures entirely
2- Neurostimulations ( VNS )
3- surgery - temporal lobectomy
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 ?
Post-Ictal Psychosis
When is Post-Ictal Psychosis common
With TLE and long history of drug resistant seizures
How does Post-ictal psychosis present
- 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 )
Diagnosis Criteria of Post-ictal Psychosis
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
How to manage Post-ictal Psychosis
1- Benzodiazepine + antipsychotic
2- 50% will have recurrent post-octal psychosis so long term antipsychotic should be considered
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 ?
Anti-NMDA receptor encephalitis
What is Anti-NMDA encephalitis
Encephalitis caused by CSF antibodies and often presented with psychosis/psychiatric symptoms and only 50% present with neurological signs
How to diagnose Anti-NMDA encephalitis
EEG & CSF autoantibodies test.
Blood autoimmune encephalitis antibodies ( NMDAR) will show
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 ?
Parkinson Disease Psychosis
How common of PD patients will develop psychosis during their illness
50% of patients will develop psychosis
How does Parkinson Disease Psychosis present
1- Hallucinations : visual and auditory
2- sense of presence /visual illusions
3- delusions
4- may or may not retain insight
- established PD diagnosis
Risk factors of Parkinson Disease Psychosis
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
Treatment for Parkinson Disease Psychosis
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
What is the best antipsychotic used for Parkinson Disease Psychosis & why but what is the disadvantage
Clozapine since it has a decreased affect on movement symptoms
requires complex monitoring ( weekly bloods and EEG )
Which Neurological disease have mental illness as co-morbidities ( list which mental illnesses for each neurological disease )
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
