Introduction to neuropsychiatry Flashcards
What are some Neuropsychiatry problems ?
Psychiatric symptoms in the context of neurological disorder
Examples;
- Dementia
- Parkinsons
- Multiple Sclerosis
- Huntingtons
- Motor Neurone Disease
- Functional Neurological Disorder
What are the Behavioural and Psychological Symptoms of dementia (BPSD)?
Psychotic symptoms;
- Hallucinations
- Delusions
- Misidentifications
Behavioural symptoms;
- Aberrant motor behaviour
- Irritability / Aggression
- Agitation
- Sleep disturbance
- Stereotypes
- Hyperorality
- Eating disturbance
- Hypersexuality
Affective symptoms (Emotional stuff);
- Depression
- Anxiety
- Apathy
- Elation
- Disinhibition
What are some features you are likely to see in your patients with BPSD or neuropsychiatric symptoms?
BPSD or neuropsychiatric symptoms;
- Most (90%) patients have symptoms, often multiple
- Present throughout the course of the disease
- More common with disease progression
- May remit but highly recurrent
- Likely to be the most problematic aspect for carers
- A major source of caregiver distress
- Both are strongly associated with nursing home placement
What are some causes of patients with BPSD or neuropsychiatric symptoms?
Causes of BPSD or neuropsychiatric;
- Complex interaction between anatomical, biochemical and functional changes
- Features vary according to severity and type of dementia as different brain regions affected
- Predisposing factors - genes and premorbid personality (If someone was a little anxiety or obsessive might come out in dementia )
What changes might you see if dementia occurs in different lobes?
Frontal lobe;
- Judgement
- Reasoning
- Behaviour
- Voluntary movements
- Expressive language (Broca’s)
This area stops us from getting in trouble !
Temporal lobe;
- Emotions
- Learning and memory
- Audition
- Olfaction
- Language comprehension (Wernicke’s area)
Parietal lobe;
- Spatial orientation
- Perception
- Initial cortical processing of tactile and proprioceptive information
- Language comprehension (Wernicke’s area)
Occipital lobe;
- Vision
Where in the brain is Alzheimers most likely to affect and what are the key symptoms of it ?
Key signs + Symptoms;
- Impaired activities of daily living and altered patterns of behaviour
- Associated symptoms of depression, insomnia, incontinence, delusions, illusions
More temporal and parietal initially, see lots of cortical loss, shrinkage, space in temporal-parietal area.
Where in the brain is Dementias with Lewy bodies most likely to affect and what are the key symptoms of it ?
Key signs + Symptoms;
- Recurrent visual hallucinations that are typically well formed and detailed
- Systematised delusions (Defective cholinergic activity correlates with delusions etc)
Systematised delusions - have a whole story around delusion, think people look at them funny thinking they’re queen of Spain cause they believe they are, etc
- Will affected occipital, basal ganglia and moving forward, frontal lobes relatively spared until later on.
- Will see recurrent visual hallucinations, particularly formed in detail should be thinking Lewy body
- Have to say probable as not 100% until post mortem
What is the difference between Parkinson’s disease and Dementia with Lewy bodies?
Dementia with Lewy bodies and Parkinsons disease dementia are separate identities which share many clinical, neurochemcal and morphological features
Distinction is based on time of onset of motor and cognitive symptoms
Dementia with Lewy bodies;
- More pronounced cortical atrophy
- Elevated cortical and limbic Lewy body pathologies
- Higher amyloid beta and Tau loads in cortex and striatum
- No differences in cortical and striata cholinergic and dopaminergic deficits
:Compared to Parkinsons disease,
Very similar, motor symptoms first then dementia = Parkinson’s
Cognitive then motor symptoms = Lewy body
Where in the brain is Fronto-temporal dementias most likely to affect and what are the key symptoms of it ?
Key signs + Symptoms;
- Behavioural disorder
- Affective symptoms
(More of a personality change)
Frontal involvement and a little temporal
Usually ask close relative to come to confirm if change in personality etc.
Posh to swearing, giggling, crying - lack of social tact, disinhibited
Do things normally wouldn’t do, shop lift, get blind drunk.
Can get pseudodementia where you are depressed but appears as dementia so try antidepressants
Where in the brain is Vascular dementias most likely to affect and what are the key symptoms of it ?
Key signs + Symptoms;
- Personality and mood changes, abulia, depression, emotional incotinence or other subcortical defects including psychomotor retardation and abnormal executive function
- Pseudobulbar Palsy - more of a disconnect of emotions (e.g tells have dementia and starts laughing - pseudobulbar palsy )
2nd commonest, can co-exist with other dementias
E.g Alzheimer’s
Risk factors same as vascular disease, smoking, diet etc
Lots of little infarcts, emboli, effecting different parts of brain, various red dots representing lack of perfusion
Lots of different symptoms depends on infarcts so not much of diagnostic clue just see a different course of progression, is stepwise where as Alzheimer’s is much more gradual (more sudden onset)
What are the key symptoms and features of Multiple Sclerosis ?
Multiple Sclerosis;
- Nervous system symptoms common and can be first presentation of MS
- Dysphoria, agitation, anxiety, irritability
- Major Depressive Disorder, approx 50%, very high rates likely to reflect cortical damage not just reaction to disability
- Suicide
- Mania - e.g orbitofrontal prefrontal cortex-impulsivity, mood lability, personality changes seen in mania (a lot ability to stop self in frontal lobe, seen in ADHD)
- Pseudobulbar affect - 10% MS patients disconnect between mood and affect - ‘tears without sadness’, or giggling to bad news
- Psychosis 2-3x more common in MS patients compares to general population (e.g medial temporal damage)
Can happen anywhere in brain, classic presentations but can get demyelination lots of places
Typically start to drop stuff then visual problem, blindness in 1 eye - MRI diagnose
What are the features of Huntington’s disease?
Huntingtons;
- Abnormal Huntington protein leads to degeneration of neurons - particularly caudate, putamen and cerebral cortex (neostriatum)
- Progressive dementia and movement disorder
- Early depression and behavioural disturbances common - especially irritability, apathy, anxiety, dysphoria and agitation - independent of cognitive and motor aspects
- Psychotic symptoms rare
- Insight retained until late stages
- High suicide rate - 10%
(Psychiatry has a relatively high mortality rate that many don’t think about)
What are the features of Motor Neurone Disease (ALS)?
Motor Neurone Disease (ALS);
- Traditional view ‘mind spared’ as Steven Hawking had it but this is incorrect !
- Neuropsych symptoms may precede motor symptoms
- Cognitive and behavioural deficits in up to 50% - executive function, social and language deficits - dementia (FTD type)
- Familial MND (Motor neurone disease) and FTD (fronto-temporal dementia) have genetic overlap - trinucelotide expansion in C9orf72
Different types of MND like ALS but US uses ALS as umbrella, for us ALS is a type of MND
What are the features of a Functional Neurological Disorder ?
Patients have a problem with the functioning of the nervous system and how the brain and body sends and/or receives signals, rather than a structural disease process such as MS or stroke.
Symptoms are real and often fluctuate…
Symptoms;
- Functional movement disorder
- Conversion disorder
- Psychogenic seizures / movement disorder
- Dissociative seizures / motor disorder
- Non-epileptic seizures
- Occur in about 1/4 of neurology clinic patients
May also have chronic pains, fatigue, sleep problems, memory symptoms, bowel and bladder symptoms, anxiety and depression
Structural brain imaging usually normal, functional MRI: HYPERCONNECTIVITY between caudate, amygdala, prefrontal and sensorimotor areas
(Hyperconnectivity in some patients and may explain why - newer finding, can also see in autism)
Historically viewed as entirely psychological - ‘repressed stress’ and gets converted to physical symptoms
Current view proposes that FND has many causes from past trauma, stress, migraine, physical injury, infection - which trigger abnormal pattern of brain functioning
Conversion disorders, psychogenic seizures, right sided paralysis with nothing organic going on in brain? Think patients putting it on cause brain is normal on scan, same with patient having seizure, doesn’t look fully like seizure and tests are negative, including EEG whilst having seizure but have this, not fake!
(E.g think of video of girl who woke up and couldn’t walk anymore, but could run)
What treatments can we give for Functional Neurological Disorders ?
- Motor symptoms can be helped by physio / speech training movement patterns that have gone wrong
- CBT for dissociative seizures
(E.g think of video of girl who woke up and couldn’t walk anymore, but could run)
