NEUROPSYCHIATRIC MANIFESTATIONS IN NEUROLOGICAL DISORDERS

Dr. A.V. SrinivasanMD.,DM.,Ph.D .,D.Sc (HON).F.I.A.N.,F.A.AN.Emeritus professor of Tamilnadu Dr. M.G.R Medical University. Adjunct Professor –IIT, ChennaiFormer Head, Institute of Neurology- Madras medical college.IMA SOUTH 10-09-11

INTRODUCTION:

“The world is not only gueerer than we imagine “

“It is gueerer than we can imagine”

J.B.S Haldane We learn by thinking and the quality of the learning outcome

is determined by the quality of our thoughtsR.B. Schmeck

NEUROANATOMICAL PERSPECTIVES

Cerebral white matters are reciprocally connected to parietal, Temporal and occipital lobes in addition to extensive subcortical connection.

Ratio of white to grey matter is significantly higher in the right than the left hemisphere particular is in frontal lobes.

Groups of white matter pathways are recognised which completely myelinate in II or III decade. They are projection, Commissural and Association fibres.

“ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy

Salient physiological aspect is the presence of myelin which results in marked increase in axonal conduction velocity.

The potential recovery is grater in white matter disorders than is grey matter disorders.

Finally white matter figures prominently in a general theory of brain-behaviour relationships due to its multiple networks of interconnected neurons that subservice various behavioural functions.“By Nature All Men/ Women are alike but

by Education widely different” - Chinese

CEREBRAL WHITE MATTER DISORDER AND BEHAVIOUR

Disorder Pathology Clinical features Clinical pathological correlation

Multiple sclerosis

Inflammatory demyelination

Cognitive loss Demention Mood disorders

Strong

Toluene leukoencohalopathy

Toxic demyelination

Cognitive lossApathy Dementia Strong

Binswanger’s disease

IschemicDemyelination

ApathyAbuliaDementia

Strong

Traumatic brain injury

White matter shearing

AttentionDement ionDepression

Strong

Speak obligingly even if you cannot oblige

Disorder Pathology Clinical features Clinical pathological correlation

Metachromatic leukodystrophy

Dysmyelination

Mental Retardation Psychosis Demention

Strong

Cobalamin deficiency

White matter degeneration

Cognitive loss DementionPsychosis

Strong

AIDSdemention complex

White matter pallor

Cognitive lossApathy Dementia Moderate

Normal pressure hydrocephalus

white matter compression

Cognitive lossApathy Dementia Moderate

Every thing should be made as simple as possible; but not simpler

NEUROBEHAVIORAL FUNCTIONS

Attention

Memory

Language

Visio spatial ability

Complex

Emotional CompetenceNeuronal damage, including that of

neuronal cell membrane

BEHAVIOUR OCCURRING IN ALZHEIMER’S DISEASE AND THE REPORTED INFLUENCE OF INCREASED OR DECREASED CHOLINERGIC ACTIVITY EACH BEHAVIOUR. Behaviou

rReduced cholinergic function

Enhanced cholinergic function

Psychosis Delusion is common in AD Thought disorder in ADIs increased with anticholinergic medications delusions correlat with cholinergic deficiency in low body dementionDelusions occur in anti cholinergic delirium Anti cholinergic agents exacerbate Schizophrenia

Nicotinic receptors are reduced in Schizophrenia

Delusions in ad are decreased by physostigmine

Delusion in delirium are Decreased by physostigmine

Physostigmine may reduced Psychosis in schizophrenia Nicotinic therapy normalizesElectro physiologic abnormalities in schizophrenia

Develop the heart; art comes automatically

Behaviour Reduced cholinergic function

Enhanced cholinergic function

Depression Major depression is rare in AD

Anticholinergic drugs reduce depression in some depressed individuals

Anticholinergic agents produce euphoria there is long REM latency in AD

REM latency is prolonged by anticholinegric agents Abnormal DST in AD

Abnormal DS with Anticholinergics

Cholinergic agents produce depression in some a patientsCholinergic hypersensitivity produce a depression syndrome in animalsAnticholinergic agents have anti manic effects REM latency is shortened in depression REM latency is shortened by Cholinergic agents

Cholinergic agents increase serum cortisol

Love is selfishness and selfishness is lovelessness

Behaviour

Reduced cholinergic function

Enhanced cholinergic function

Agitation Increased in AD increased in AD treated with anticholinergic agents

Reduced by physostigme in AD

Personality

Apathy is common in ad reduced affinitive behaviour induced by Anticholinergic agents

Apathy in AD is reduced by Tacrine

Knowledge without action is useless;

Action without knowledge is foolish

NEURO PSYCHIATRIC SYMPTOMS Apathy Agitation Anxiety Irritability Dysphoria Aberrant motor behaviour Disinhibition Delusion Hallucination Euphoria Night time behaviour disturbance Appetite and eating abnormality

Science is below the mind; Spirituality is beyond the mind

NEUROLOGICAL CONDITIONS PRESENTING WITH PSYCHIATRIC AND BEHAVIOUR PROBLEMS.

Summarises the primary CNS disorders associated with the 5 major psychiatric symptoms.

Depression Anxiety Psychosis Mania Aggression

Hate screeches, fear squeals; conceits trumpets

but love since lullabies

Primary CNS Disorders

Dep Anx Psy Man Agg

Dementia/retardation

+ + + +

Alzheimer disease + + + +

Huntington’s chores + + + +

Other dementias + + + + +

Mental retardation + + + + +

Epilepsy (especially temporal lose)

+ + + + +

Extraphyamidal disorder

Calcinations of basal ganglia

+

Being ignorant is not so much a shame as being unwilling to learn

Dep Anx Psy Man Agg

Parkinson’s disease + + + +

Progressive supranulear palsy

+

Wilson’s disease + + +

Frontal lobe syndrome infection

Aids + + +

Neurosyphilis + + +

Encephalitis meningitis + + +

Migraine +

Multiple sclerosis + + + + +

Dep Anx Psy Man Agg

Pseudo bulbar palsy +

Strokes + + + + +

Traumatic brain injury + + + +

Tumours

CNS Tumours + +

Temporal lobe tumours

+ + + +

Give us the GRACE to accept with serenity the things that cannot be changed the COURAGE to

change the things that should be changed and the WISDOM to know the difference

Medication Dep Anx Psy Man Agg

Anticholinergic + +

Antidepressants +

Antihistamines +

Antihypertensive + + +

Baclofen +

Barbiturates + + +

Cimetidine +

Corticosteroids + + + + +

Decongestants + +

Dep Anx Psy Man Agg

Estrogen + +

Insulin +

Interferon + +

Isoniazed +

Levodopa and other dopamine agonists

+ + + +

Neuroepletics + +

Nonsterodial anti-inflam + + +

Opioids +

Character gets you out of bed commitment moves you to action faith, hope and Discipline follow through to completion

MEDICAL Dep Anx Psy Man Agg

Sympathomimetics/brinchodilantors

+ +

Thyroid preparation +

Drugs of abuse

Alcohol intoxication + + + + +

Alcohol withdrawal + + + +

Amphetamine intoxication + +

Amphetamine withdrawal + + +

Benzodiazepine intoxication +

Benzodiazepine withdrawal + + +

MEDICAL Dep Anx Psy Man Agg

Caffeine withdrawal + + +

Cociane intoxication + + +

Marijuana intoxication + +

Opiate intoxication + +

Phencyclidine intoxication + + + +

A bad teacher complains;

A good teacher explains;

The best teacher inspires;

THE EVALUATION OF PSYCHIATRIC SYTEMS: Medical history For hyper metabolic syndromes For aggression Psychiatric history For depression For hyper metabolic syndromes Medication Physical examination Mental status For suicide attempt Laboratory investigation For anxiety For hyper metabolic syndromes

It is the providence of the knowledge to speak and it is the privilege of the wisdom to listen - Hodly’s

CLINICALLY INDICATED:

Chest x ray Electrocardiogram EEG Head CT/MRI Lumber puncture RPR HIV FOR depression: Cortisol levels For anxiety: Plasma catecholamine

Opinion is ultimately determined by the feelings

and not by the intellect

PSYCHOSIS:

Head trauma

SOL

Vascular insults

CNS infection

Huntington

Alzheimers

Picks

The Truth is fear and immorality are two of the greatest inhibitors of Performance to progress

CLINICAL CLUES:

If sudden, it is likely to be acute encephalopathy

If the symptoms are chronic, hallucinations and delusions are added and tend to be associated with dementia or static Encephalopathy

Psychosis with delusional belief are common in subcortical disorders associated with extrapyramidal symptoms,A true commitment is a heart felt promise to youarself

from which you will not back down -

D. Mcnally

TREATMENT

4 POINT leather restriants

Haloperidol or droperidol

Lorazepam if agitation is more

D 1 Receptor blocking neuroleptics may be used.

If Medical workup does not indicate an etiology,

psychiatric hospitalization

  Serious, sincere, systematic studies,

surely secure supreme success

MANIA

Mania is a mood disturbance accompanied by

Decreased sleep Racing thoughts Increased talkativeness Distractibility Increased activity

The neurological conditions associated with it are

Temporal lobe seizure Ms Right hemispheric strokes Central nervous spine tumors

The sign wasn’t placed there

By the Big Printer in the sky

TREATMENT

Mild symptoms -Lithium carbonate -Valproate -Benzodiazepine

Severe symptoms - Neuroleptic - ECT

God is a comedian performing before an

audience

that is afraid to laugh

HYPERMETABOLIC SYNDROMES

muscle rigidity Hyperthermia Autonomic Dysfunction  They are NMS Serotonin Syndrome Malignant hyperthermia Lethal Catatonias

There are sixty trillion cells in the human body

MANGEMENT

Medical causes to be excluded Supportive cate- Temp. Control, Hydration Treatment of complication

-Hypertension

- Cardiac Arrhythmias

- Divc

- Rhabdomyolysis with renal failure

-Pulmonary Embolism

Baby hears 30,000 cycles / sec, teenage boy hears 20,000 and

old hears 4,000 cycles / sec

AMNESTIC SYNDROMES Impairment of short term and long term

memory occurring in a normal of consciousness.

The pattern of memory loss follows RIBOT’S LAW

CLINICAL CLUESSyndrome/ Etiology

Characteristics

Wernince- Korsakoff syndrome - Acute (Wernicke’s encephalopathy) - Chronic (Korsakoff amenesia)

Oculomotor signs, ataxia deliriumSeverely impaired anterograde memoryAssociated with confabulation

If you think you can or you can’t You are always right

Syndrome/ Etiology Characteristics

Trasient global amnesia Anteto grade amnesia during episode Duration of a few hours History of trauma Brief period of retrograde amnesia Variable period antero gade amnesia

Head trauma History of trauma Brief period of retrograde amnesia Variable period antero grade amnesia

Alcohol related blackout Aassociated with prolonged alcohol abuse and severe intoxication

“Motivation is the Spark that lights

the Fire of Knowledge and

fuels the engine of Accomplishment”

Syndrome/ Etiology Characteristics

Epilepsy May be associated with motor abnormalities

Benzodizepine or other Medication usage

Consciousness often disturbed impairment short term memory

Dissociative amesia Loss of memory for time following a traumatic event itselfLoss of primary autobiographical material Normal short memoryMay not be concerned about symptoms 

Being ignorant is not so much a shame as being unwilling to learn

Syndrome/ Etiology Characteristics

Dissociative fugue Sudden unexpected travel away from home inability to recent pastsLoss of personal identity

Amenesi a associated with stroke

Often PCA distribution infarcts (bilateral)Hypoxic episodeOften accompanied by focal deficits such as hemianpsia, cortical blindness visual agonsia.

Dementia Memory impairment in the setting of other cognitive deficits that impair daily living.

Electroconvulsive therapy

Only after repeated sessionsDeficits resolve within 6 months

The art of medicine is caring for the heart of the patient

TREATMENT

Memory impaired - complete and behavior rehabitation

Wernicke’s Encephalopathy - Thiamine

TGA- No independent risk factor for stroke

- 94% TGA - 5-7% Can develop epilepsy Dissociate amnesia – psychiatrist

managementSuccess in life is a matter not so much of talent and opportunity

as of concentration and perseverance

- C.W. Wendte

CONCLUSIONS  Psychiatric consultation may clarify the

presence of a primary psychiatric condition

“The great majority of us are required to live a life of constant systematic duplicity. Your health is bound to be affected if day after day you say the opposite of what you feel; if you grovel before what you dislike and rejoice at what bring you nothing but misfortune. The nervous system is not just a fiction it is part of our physical body and our soul exists in space and inside us; like the teeth in our mouth. It can’t forever be treated with impunity,”We possess by nature the factors out of which personality can be made, and to organize

them into effective personal life is every man’s primary responsibility

- Harry Emerson Fosdick

DEDICATED TO MY FAMILY FOR MAKING EVERYTHING

WORTHWHILE

READ NOT TO CONTRADICT OR CONFUTENOR TO BELIEVE AND TAKE FOR GRANTEDBUT TO WEIGH AND CONSIDER

THANK YOU

My sincere thanks to P.SAMPATH (CRC)

And UCB PHARMA LIMITTED