Psychiatric Manifestations of Medical and Neurological Conditions Anthony P. Weiss, M.D., M.Sc. Massachusetts General Hospital

Questions for Discussion 1)What are the psychiatric manifestations of medical & neurological conditions? 2)What conditions can cause these psychiatric manifestations? 3)What is the role of the C/L psychiatrist in managing these patients?

Questions for Discussion 1)What are the psychiatric manifestations of medical & neurological conditions? 2)What conditions can cause these psychiatric manifestations? 3)What is the role of the C/L psychiatrist in managing these patients?

Karte des menschlichen Gehirns Korbinian Brodmann ( )

ABC’s of C/L Psychiatry Affective –Depressed or elevated mood, anxiety, irritability Behavioral –Amotivation, insomnia, anorexia –Agitation, hypersexuality, wandering Cognitive –Changes in memory, language, executive skills –Changes in thought content:delusions or hallucinations

Questions for Discussion 1)What are the psychiatric manifestations of medical & neurological conditions? 2)What conditions can cause these psychiatric manifestations? 3)What is the role of the C/L psychiatrist in managing these patients?

Vascular a)Infarction b)Intracerebral hemorrhage c)Vasculitides

Vascular: Infarction Affective –Depression –Affective incontinence Behavioral Cognitive –Aphasia, anosognosia –Multi-infarct dementia

Post-stroke Depression Risk Factors Infarct location (left frontal pole) Infarct size Subcortical atrophy Prior history of depression Family history of depression Lack of social support

Vascular: Infarction Affective –Depression –Affective incontinence Behavioral Cognitive –Aphasia, anosognosia –Multi-infarct dementia

Infectious a)Viral b)Bacterial c)Fungal d)Protozan e)Prion

Infectious: Neurosyphilis 1° = chancre 2° = rash 3° = late sequelae Tabes Dorsalis Sharp pain in legs Ataxia Charcot joints General Paresis Pupillary changes Tremor Slurred speech years

Infectious: Neurosyphilis Affective –Depression, euphoria, anxiety –Personality changes Behavioral –Disinhibition Cognitive –Memory impairment, loss of insight –Delusions and hallucinations

Neoplastic a)Primary CNS b)Metastases within CNS parenchyma c)Paraneoplastic syndromes

Neoplastic: Limbic Encephalitis Affective –Depression and anxiety (esp. early in course) Behavioral Cognitive –Memory impairment –Hallucinations

Metabolic a)Nutritional b)Electrolyte c)Endocrinopathies d)Organ failure

Metabolic Standard Assessment Vitamin B 12 “Chem 7” –Na + level –BUN/Cr –Glucose Arterial blood gas Liver function tests and ammonia level TSH

Traumatic a)Subdural hematoma b)Concussive syndromes

Paroxysmal a)Complex partial epilepsy b)Transient global amnesia c)Post-ictal confusion d)Complex migraine e)Acute intermittent porphyria f)Catatonia g)Neuroleptic malignant syndrome

Seizures GeneralizedPartial Grand MalAbsenceComplexSimple

Psychiatric Sequelae of Epilepsy Pre-ictal (aura) Ictal Post-ictal Depression Psychosis Personality

Emotionality Mania Depression Guilt Humorlessness Altered sexual interest Aggression Anger and hostility Hypergraphia Religiosity Philosophical interest Sense of personal destiny Hypermoralism Dependency Paranoia Obsessionalism Circumstantiality Viscosity TLE Personality From Bear and Fedio, 1977

Pharmacologic/Toxicologic a)Alcohol b)Illicit drugs c)Medications d)CO Poisoning e)Heavy metal poisoning

“Pseudodelirium” a)Acute mania b)Disorganized schizophrenia c)Severe depression d)Conversion disorder e)Fugue states f)Malingering

Degenerative a)Parkinson’s disease b)Huntington’s chorea c)Wilson’s disease

Parkinson’s Disease Affective –Depression –Anxiety Behavioral –Insomnia Cognitive –Bradyphrenia –Dementia (Lewy Body) –Delusions and hallucinations

Questions for Discussion 1)What are the psychiatric manifestations of medical & neurological conditions? 2)What conditions can cause these psychiatric manifestations? 3)What is the role of the C/L psychiatrist in managing these patients?

Role of the C/L Psychiatrist Accurately describe the symptoms Consider the potential perturbations Assist in narrowing the differential Assist in treating the symptoms and/or the underlying perturbation

Summary 1)What are the psychiatric manifestations of medical & neurological conditions? 2)What conditions can cause these psychiatric manifestations? 3)What is the role of the C/L psychiatrist in managing these patients?