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
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