Neuropsychiatric manifestations in neurological disorders


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Neuropsychiatric manifestations in neurological disorders

  1. 1. NEUROPSYCHIATRICMANIFESTATIONS INNEUROLOGICAL DISORDERSDr. A.V. SrinivasanMD.,DM.,Ph.D .,D.Sc (HON).F.I.A.N.,F.A.AN.Emeritus professor of Tamilnadu Dr. M.G.RMedical University. Adjunct Professor –IIT, ChennaiFormer Head, Institute of Neurology- Madrasmedical college.IMA SOUTH 10-09-11
  2. 2. INTRODUCTION: “The world is noT only gueerer Than we imagine “ “iT is gueerer Than we can imagine” J.B.s haldaneWe learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts R.B. Schmeck
  3. 3. 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
  4. 4.  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
  5. 5. CEREBRAL WHITE MATTERDISORDER AND BEHAVIOURDisorder Pathology Clinical features Clinical pathological correlationMultiple sclerosis Inflammatory Cognitive loss demyelination Demention Mood Strong disordersToluene Toxic Cognitive lossleukoencohalopat demyelination Apathy Dementia StronghyBinswanger’s Ischemic Apathydisease Demyelination Abulia Strong DementiaTraumatic brain White matter Attentioninjury shearing Dement ion Strong Depression Speak obligingly even if you cannot oblige
  6. 6. Disorder Pathology Clinical features Clinical pathological correlationMetachromatic Dysmyelination Mental Retardationleukodystrophy Psychosis Demention StrongCobalamin White matter Cognitive lossdeficiency degeneration Demention Strong PsychosisAIDS White matter Cognitive lossdemention pallor Apathy Dementia ModeratecomplexNormal white matter Cognitive losspressure compression Apathy Dementia Moderatehydrocephalus Every thing should be made as simple as possible; but not simpler
  7. 7. NEUROBEHAVIORAL FUNCTIONS Attention Memory Language Visio spatial ability Complex Emotional Competence Neuronal damage, including that of neuronal cell membrane
  8. 8. BEHAVIOUR OCCURRING IN ALZHEIMER’S DISEASE AND THE REPORTED INFLUENCE OF INCREASED OR DECREASED CHOLINERGIC ACTIVITY EACH BEHAVIOUR.  Behaviour Reduced cholinergic function Enhanced cholinergic functionPsychosis Delusion is common in AD Delusions in ad are decreased Thought disorder in AD by physostigmine Is increased with anticholinergic medications delusions correlat with cholinergic deficiency in low body demention Delusion in delirium are Delusions occur in anti Decreased by physostigmine cholinergic delirium Anti cholinergic agents Physostigmine may reduced exacerbate Schizophrenia Psychosis in schizophrenia Nicotinic therapy normalizes Nicotinic receptors are reduced in Electro physiologic Schizophrenia abnormalities in schizophreniaDevelop the heart; art comes automatically
  9. 9. Behaviour Reduced cholinergic Enhanced cholinergic function functionDepression Major depression is rare in AD Cholinergic agents produce depression in some a patients Anticholinergic drugs reduce Cholinergic depression in some depressed hypersensitivity produce individuals a depression syndrome in animals Anticholinergic agents produce Anticholinergic agents euphoria there is long REM have anti manic effects latency in AD REM latency is shortened in depression REM latency is prolonged by REM latency is shortened anticholinegric agents by Cholinergic agents Abnormal DST in AD Abnormal DS with Cholinergic agents Anticholinergics increase serum cortisol Love is selfishness and selfishness is lovelessness
  10. 10. Behaviour Reduced cholinergic function Enhanced cholinergic functionAgitation Increased in AD increased in AD Reduced by physostigme in treated with anticholinergic AD agentsPersonality Apathy is common in ad reduced Apathy in AD is reduced by affinitive behaviour induced by Tacrine Anticholinergic agents Knowledge without action is useless; Action without knowledge is foolish
  11. 11. 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
  12. 12. NEUROLOGICAL CONDITIONSPRESENTING WITH PSYCHIATRICAND 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
  13. 13. Primary CNS Dep Anx Psy Man AggDisordersDementia/retardation + + + +Alzheimer disease + + + +Huntington’s chores + + + +Other dementias + + + + +Mental retardation + + + + +Epilepsy (especially + + + + +temporal lose)ExtraphyamidaldisorderCalcinations of basal +ganglia Being ignorant is not so much a shame as being unwilling to learn
  14. 14. Dep Anx Psy Man AggParkinson’s disease + + + +Progressive supranulear palsy +Wilson’s disease + + +Frontal lobe syndromeinfection Aids + + + Neurosyphilis + + +Encephalitis meningitis + + +Migraine +Multiple sclerosis + + + + +
  15. 15. Dep Anx Psy Man Agg Pseudo bulbar palsy + Strokes + + + + + Traumatic brain injury + + + + Tumours CNS Tumours + + Temporal lobe + + + + tumoursGive 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
  16. 16. Medication Dep Anx Psy Man AggAnticholinergic + +Antidepressants +Antihistamines +Antihypertensive + + +Baclofen +Barbiturates + + +Cimetidine +Corticosteroids + + + + +Decongestants + +
  17. 17. Dep Anx Psy Man AggEstrogen + +Insulin +Interferon + +Isoniazed +Levodopa and other + + + +dopamine agonistsNeuroepletics + +Nonsterodial anti-inflam + + +Opioids +Character gets you out of bed commitment moves you to action faith, hope and Discipline follow through to completion
  18. 18. MEDICAL Dep Anx Psy Man AggSympathomimetics/brinchodila + +ntorsThyroid preparation +Drugs of abuseAlcohol intoxication + + + + +Alcohol withdrawal + + + +Amphetamine intoxication + +Amphetamine withdrawal + + +Benzodiazepine intoxication +Benzodiazepine withdrawal + + +
  19. 19. MEDICAL Dep Anx Psy Man AggCaffeine withdrawal + + +Cociane intoxication + + +Marijuana intoxication + +Opiate intoxication + +Phencyclidine intoxication + + + + A bad teacher complains; A good teacher explains; The best teacher inspires;
  20. 20. 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 syndromesIt is the providence of the knowledge to speak and it is the privilege of the wisdom to listen - Hodly’s
  21. 21. 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
  22. 22. PSYCHOSIS: Head trauma SOL Vascular insults CNS infection Huntington Alzheimers PicksT T he ruth is fear and immorality are two of the greatest inhibitors of Performance to progress
  23. 23. 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 com itm is a heart felt prom to y m ent ise ouarself fromwhich y will not ou back down - D. Mcnally
  24. 24. 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
  25. 25. MANIAMania is a mood disturbance accompanied by Decreased sleep Racing thoughts Increased talkativeness Distractibility Increased activityThe 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
  26. 26. TREATMENT Mild symptoms -Lithium carbonate -Valproate -Benzodiazepine Severe symptoms - Neuroleptic - ECT God is a comedian performing before an audience that is afraid to laugh
  27. 27. 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
  28. 28. 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
  29. 29. AMNESTIC SYNDROMES Impairment of short term and long term memory occurring in a normal of consciousness. The pattern of memory loss follows RIBOT’S LAWCLINICAL CLUES CharacteristicsSyndrome/ Etiology Oculomotor signs, ataxiaWernince- Korsakoff syndrome delirium Severely impaired - Acute (Wernicke’s anterograde memoryencephalopathy) Associated with - Chronic (Korsakoff confabulationamenesia) If you think you can or you can’t You are always right
  30. 30. Syndrome/ Etiology CharacteristicsTrasient global amnesia Anteto grade amnesia during episode Duration of a few hours History of trauma Brief period of retrograde amnesia Variable period antero gade amnesiaHead trauma History of trauma Brief period of retrograde amnesia Variable period antero grade amnesiaAlcohol 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”
  31. 31. Syndrome/ Etiology CharacteristicsEpilepsy May be associated with motor abnormalitiesBenzodizepine or other Consciousness oftenMedication usage disturbed impairment short term memoryDissociative amesia Loss of memory for time following a traumatic event itself Loss of primary autobiographical material Normal short memory May not be concerned about symptoms  Being ignorant is not so much a shame as being unwilling to learn
  32. 32. Syndrome/ Etiology CharacteristicsDissociative fugue Sudden unexpected travel away from home inability to recent pasts Loss of personal identityAmenesi a associated Often PCA distribution infarcts (bilateral)with stroke Hypoxic episode Often 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 sessions Deficits resolve within 6 months The art of medicine is caring for the heart of the patient
  33. 33. 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 management Success in life is a matter not so much of talent and opportunity as of concentration and perseverance - C.W. Wendte
  34. 34. 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