1. NEUROPSYCHIATRIC
MANIFESTATIONS IN
NEUROLOGICAL DISORDERS
Dr. A.V. Srinivasan
MD.,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, Chennai
Former Head, Institute of Neurology- Madras
medical college.
IMA SOUTH 10-09-11

3. 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 thoughts
R.B. Schmeck

4. 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

5.  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

6. CEREBRAL WHITE MATTER
DISORDER AND BEHAVIOUR
Disorder Pathology Clinical features Clinical
pathological
correlation
Multiple sclerosis Inflammatory Cognitive loss
demyelination Demention Mood Strong
disorders
Toluene Toxic Cognitive loss
leukoencohalopat demyelination Apathy Dementia Strong
hy
Binswanger’s Ischemic Apathy
disease Demyelination Abulia Strong
Dementia
Traumatic brain White matter Attention
injury shearing Dement ion Strong
Depression
Speak obligingly even if you cannot oblige

7. Disorder Pathology Clinical features Clinical
pathological
correlation
Metachromatic Dysmyelination Mental Retardation
leukodystrophy Psychosis Demention Strong
Cobalamin White matter Cognitive loss
deficiency degeneration Demention Strong
Psychosis
AIDS White matter Cognitive loss
demention pallor Apathy Dementia Moderate
complex
Normal white matter Cognitive loss
pressure compression Apathy Dementia Moderate
hydrocephalus
Every thing should be made as simple as possible; but
not simpler

8. NEUROBEHAVIORAL FUNCTIONS
 Attention
 Memory
 Language
 Visio spatial ability
 Complex
 Emotional Competence Neuronal damage, including that of
neuronal cell membrane

9. BEHAVIOUR OCCURRING IN ALZHEIMER’S
DISEASE AND THE REPORTED INFLUENCE
OF INCREASED OR DECREASED
CHOLINERGIC ACTIVITY EACH
BEHAVIOUR.
Behaviour Reduced cholinergic function Enhanced cholinergic
function
Psychosis 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
schizophrenia
Develop the heart; art comes automatically

10. Behaviour Reduced cholinergic Enhanced cholinergic
function function
Depression 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

11. Behaviour Reduced cholinergic function Enhanced cholinergic
function
Agitation Increased in AD increased in AD Reduced by physostigme in
treated with anticholinergic AD
agents
Personality 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

12. 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

13. 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

14. Primary CNS Dep Anx Psy Man Agg
Disorders
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

15. 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 + + + + +

16. 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

17. Medication Dep Anx Psy Man Agg
Anticholinergic + +
Antidepressants +
Antihistamines +
Antihypertensive + + +
Baclofen +
Barbiturates + + +
Cimetidine +
Corticosteroids + + + + +
Decongestants + +

18. 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

19. MEDICAL Dep Anx Psy Man Agg
Sympathomimetics/brinchodila + +
ntors
Thyroid preparation +
Drugs of abuse
Alcohol intoxication + + + + +
Alcohol withdrawal + + + +
Amphetamine intoxication + +
Amphetamine withdrawal + + +
Benzodiazepine intoxication +
Benzodiazepine withdrawal + + +

20. 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;

21. 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

22. 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

23. PSYCHOSIS:
 Head trauma
 SOL
 Vascular insults
 CNS infection
 Huntington
 Alzheimers
 Picks
T T
he ruth is fear and immorality are two of the greatest inhibitors of
Performance to progress

24. 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

25. 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

26. 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

27. TREATMENT
 Mild symptoms -Lithium carbonate
-Valproate
-Benzodiazepine
 Severe symptoms - Neuroleptic
- ECT
God is a comedian
performing before an
audience
that is afraid to laugh

28. 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

29. 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

30. 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 CLUES Characteristics
Syndrome/ Etiology
Oculomotor signs, ataxia
Wernince- Korsakoff syndrome delirium
Severely impaired
- Acute (Wernicke’s anterograde memory
encephalopathy) Associated with
- Chronic (Korsakoff confabulation
amenesia)
If you think you can or you can’t You are always right

31. 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”

32. Syndrome/ Etiology Characteristics
Epilepsy May be associated with
motor abnormalities
Benzodizepine or other Consciousness often
Medication usage disturbed impairment short
term memory
Dissociative 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

33. Syndrome/ Etiology Characteristics
Dissociative fugue Sudden unexpected travel away from
home inability to recent pasts
Loss of personal identity
Amenesi 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

34. 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

35. 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

37. DEDICATED TO MY FAMILY FOR
MAKING EVERYTHING
WORTHWHILE

38. READ NOT TO CONTRADICT OR
CONFUTE
NOR TO BELIEVE AND TAKE FOR
GRANTED
BUT TO WEIGH AND CONSIDER
THANK YOU
My sincere thanks to P.SAMPATH (CRC)
And UCB PHARMA LIMITTED