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

2. 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?

3. 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?

6. Karte des menschlichen Gehirns Korbinian Brodmann (1868-1918)

7. 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

8. 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?

10. Vascular a)Infarction b)Intracerebral hemorrhage c)Vasculitides

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

12. 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

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

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

15. 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 10-20 years

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

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

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

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

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

21. Traumatic a)Subdural hematoma b)Concussive syndromes

22. 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

23. Seizures GeneralizedPartial Grand MalAbsenceComplexSimple

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

25. 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

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

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

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

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

30. 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?

31. 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

32. 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?