Brain tumors can present with psychiatric symptoms and manifest differently based on their location in the brain. The document discusses various brain tumors like meningioma, pituitary tumors, and glioblastoma that commonly present with symptoms like depression, anxiety, personality changes, and psychosis. It also outlines risk factors for developing psychiatric manifestations and their management approaches. Specifically, it provides case examples of patients who presented with primary psychiatric symptoms but were later diagnosed with underlying brain tumors based on imaging and biopsy results.

1. NEUROPSYCHIATRIC
ASPECTS OF
BRAIN TUMORS
CHAIR PERSON : DR. GOPALAKRISHNAN
PRESENTER : DR. SRAVANTHI.P
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2. OVERVIEW
 INTRODUCTION
 CLASSIFICATION OF BRAIN TUMORS
 PSYCHIATRIC MANIFESTATIONS IN BRAIN TUMOR PATIENTS
• RISK FACTORS FOR DEVELOPING PSYCHIATRIC MANIFESTATIONS
• PSYCHIATRIC MANIFESTATION BASED ON LOCATION
• SPECIFIC BRAIN TUMORS
• MANAGEMENT OF PSYCHIATRIC SYMPTOMS IN BRAIN TUMOR PATIENTS
 BRAIN TUMORS IN PSYCHIATRIC PATIENTS
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3. INTRODUCTION
 Brain tumors are relatively common with an annual incidence of 9/100000 for primary
brain tumors and 8.3 /100000 for metastatic brain tumors 1.
 In India , incidence of primary brain tumor is 3.4 per 100,000 populations for males and 1.2
per 100,000 populations for females
 Most brain tumors present with specific neurologic signs due to mass effect. However, in
rare cases they may present primarily with psychiatric symptoms.
 A study by Keschner et al 2 reported that 78% of 530 patients with brain tumors had
psychiatric symptoms of which only 18% presented with these symptoms as the first
clinical manifestation of a brain tumor.
 Due to the neuronal connections of the brain, a lesion in one region may manifest a
multitude of symptoms depending on the function of the underlying neuronal foci 1.
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4. CLASSIFICATION OF BRAIN TUMORS
15-25%
40-55%
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5. Age(years) Most common Second most common
0-4 Embryonal tumor Pilocytic Astrocytoma
5-14 Pilocytic Astrocytoma Malignant Glioma NOS
15-34 Pituitary tumor Pilocytic Astrocytoma
/ meningioma
35- 85+ Meningioma Glioblastoma /
Pituitary tumors
Overall Meningioma Pituitary tumors
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6. RISK OF DEVELOPING
PSYCHIATRIC SYMPTOMS3-5
 Fronto – temporo - limbic and Frontal or deep midline tumors
 Large (>5 cm) or multifocal tumors
 Aggressively growing malignant tumors
 Increased ICP
 Obstructive hydrocephalus
 Significant tumor-related physical functional impairment
 Prior brain injury
 History of psychiatric illness
 Family history of psychiatric illness
 Lower premorbid intellectual capabilities
 Poorer adaptive coping skills or psychosocial support
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7. PSYCHIATRIC
MANIFESTATIONS
BASED ON
LOCATION OF THE
BRAIN TUMOR
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8. FUNCTIONS OF BRAIN
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9. FRONTAL LOBE TUMORS (22%)
Disinhibition / Impulsivity
Euphoria
Depression
Dementia
PARIETAL LOBE TUMORS (12%)
Lack of awareness of Symptoms
Poor Self-care & grooming of contralateral side
OCCIPITAL LOBE TUMORS (4%)
Visual Hallucinations (55%)
Behavioral Symptoms(17%)
Affective Symptoms
TEMPORAL LOBE TUMORS (22%)
Depressed mood with Apathy
Euphoria / Mania
Irritability
Personality Changes
Anxiety
BRAIN TUMORS
& PSYCHIATRIC
SYMPTOMS
6-8
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10. TUMOR LOCATION PSYCHIATRIC SYMPTOMS
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Corpus Callosum Personality changes and Psychosis
Basal Ganglia Impaired Attention , Memory Loss, Depression , Personality
changes, Movement disorders
Thalamus Memory loss , confusion , Emotional Liability , Hemi-
anesthesia
Hypothalamus Hypersomnia and eating disorders
Pituitary Gland(10%) Emotional liability , Depression , Psychotic symptoms
Brain stem and cerebellum
(30%)
Affective changes , Paranoid Delusions ,Personality changes
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11. SPECIFIC BRAIN
TUMORS
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12. CASE VIGNETTE 9
A 52-year-old male patient came to psychiatry OPD
• 1-month history of depressive symptoms
• Past medical and psychiatric history was unremarkable.
• General and systemic examination within normal limits.
• He was prescribed tablet escitalopram 10 mg/day and asked for follow-up in psychiatry OPD.
• Even after 1-month, patient's depression did not improve and he complained of headache. His wife
also complained that he forgets things easily but patient showed relative lack of insight to these
complaints.
• Patient was advised contrast-enhanced computed tomography (CECT) head and it showed an
extraxial dural based well defined circumscribed lobulated mass involving bilateral frontal
regions, which showed intense homogenous enhancement suggestive of FRONTAL
MENINGIOMA .
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13. MENINGIOMA 10,11
o Account for 36% of all primary brain tumors .
o Most meningiomas are benign and slow growing .
o Only less than 10 % malignant .
o More common in females .
o Though seen in all ages , Most common in adults of 40-60 years age .
o Symptoms of a meningioma vary by the location and size of the tumor .
o Initially present with Headache / seizures due to increased pressure of the tumor.
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14. • Genetic defect : Inactivating mutation of Merlin gene on chromosome 22q (Most common)
Deletion of Chromosome 22 q
Deletions of 1p, 6q, 9p, 10q, 14q, 18q
Mutations in VEGF (angiogenic)
• Site of origin : Fronto-temporal convexities (most common)
Tentorium cerebelli
Sphenoidal wings
Olfactory groove
• Majority are supratentorial tumors
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15. o Diagnosis
• CT Brain : Iso intense or slightly hyper intense; calcification at the outer surface
or heterogeneously throughout the mass
• CECT / MRI brain : Smoothly contoured mass , with one edge abutting the inner
surface of the skull , along the dura with prominent vascularity .
o Treatment
 Observation
 Surgical excision
 Radiation ( smaller tumors )
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16. CASE VIGNETTE12
Mr A , 29-year-old unmarried male
• Presented with three months history of depressive symptoms
increased biological functions .
• His HAM-D score was 14 ; MMSE score was 23 with predominant
deficit in concentration, and difficulty in registering and recall .
• Diagnosis of moderate depressive episode (ICD-10) was made
• Patient was started on antidepressant Bupropion up to a dose of 300 mg/day.
• He was followed up on OP basis; after a course of four weeks, he showed no improvement in symptoms.
• Considering the atypical features, cognitive deficits, and poor response to antidepressant, MRI brain was
done which showed PITUITARY MACRO ADENOMA compressing on the hypothalamus
• His prolactin level was 1020 ng/ml , detailed visual field examination showed bitemporal hemianopsia.
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17. PITUITARY TUMORS
o Account for 8% of all primary brain tumors .
o Most of them are benign.
o More common in females .
o Mostly seen in adolescents and adults .
o Tumors can be Secreting or non secreting tumors based on hormone secretion
o Diagnosis is by Gadolinium enhanced MRI
o Treatment is based on symptoms – based on the hormone that is oversecreted
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18. Pituitary Tumors 13 Symptoms Treatment
Prolactin secreting Hypogonadism 1. Long acting Dopamine agonists
2. Trans sphenoidal surgery (70-90%)
Growth Hormone
secreting
Acromegaly 1. Trans –sphenoidal Surgery (90%)
2. Dopamine agonists / Somatostatin analogue
3. Radiotherapy
ACTH secreting Cushing’s syndrome 1. Trans – sphenoidal surgery
2. Radiotherapy (stereotactic)
3. Ketoconazole/Etomidate/Mifepristone
4. Bilateral adrenalectomy ( Refractory)
Glycoprotein hormone
secreting and NON-
Secreting Tumors
• Pressure symptoms
• Syndrome of thyroid
harmone resistance
1. Trans-sphenoidal resection
2. Radiotherapy
3. Bromocriptine / Octreotide
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19. CASE VIGNETTE 14
• 76-year-old man, was admitted to psychiatric ward with manic symptoms for past 2 months .
• Systemic examination and all investigations were found normal.
• Mr A had a 12-year history of treatment-resistant depression. During the last depressive episode, a neurologist
considered the possibility of Parkinson’s & dementia and treated & remitted 1 year prior to the current episode.
• In addition, Mr A had a history of hypertension, benign prostatic hypertrophy, glaucoma, gastric ulcer, and
degenerative lumbar disc disease.
• Patient improved symptomatically and was discharged after 1 month with a diagnosis of BPAD (DSM-IV
TR criteria).
• At his first follow-up consultation 1 month later, Mr A showed marked sedation and significant cognitive
deficits where all the drugs where reduced in dosage .
• Four months after being discharged, Mr. A developed left-side hemiparesis and was referred to emergency
department, where a CT scan revealed a large right frontal lobe tumor, confirmed by the MRI scan and later
diagnosed “postoperatively” as GLIOBLASTOMA
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20. GLIOBLASTOMA MULTIFORME
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o Account for 20 % of all intracranial tumors
o Peak Age group – Middle age
o Seen more in Men
o Genetic Involvment –
• Amplification of EFGR gene
• Mutations of p53
• Isocitrate Dehydrogense (IDH1 & IDH2)
• Under-expression of tumor suppressor gene PTEN
o On Imaging , heterogenous mass with a centre that is hypointense and non-enhancing .
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22. o Treatment:
• Debulking
• Corticosteroids
• Radiation (6000cGy)
• Chemotherapy ( Nitrosurea agents )
• Immunotherapy (Tyrosine kinase Inhibitors)
o Prognosis :
• Generally poor
• Only 20% survive for more than 1 year after diagnosis
o Cerebral Edema and raised ICT – usual causes of death
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23. • 52-year-old was admitted initially in the Emergency Department with c/o nausea, vomiting and headache
• She had no psychiatry history other than depressive symptoms 9 months ago , treated.
• Medical history included the excision of an ulcerated malignant melanoma in the right thigh 4 years before,
in remission, and hysterectomy for uterine fibroid.
• Her neurological exam was unremarkable.
• After three days at one night, she was having psychomotor agitation and disinhibited behaviour. When
interviewed next morning, she was still restless and fidgeting the bedsheets, with spatiotemporal
disorientation, speaking quickly with a somehow incoherent speech.
• On CT scan , expansive lesion within the right posterior frontal lobe, heterogeneous and hyperdense,
conditioning mass effect on adjacent structures was found.
• Later, a chest/abdomen/pelvis CT scan and a whole-body Positron Emission Tomography (PET) scan identified
multi-organic metastatic disease affecting the lungs, pancreas and peritoneum. The patient was also medicated
with oral dexamethasone and transferred to the Neurosurgery Department.
• She underwent surgical removal of part of the brain lesion, with a biopsy consistent with MELANOMA
BRAIN METASTASES.
CASE VIGNETTE
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24. METASTATIC BRAIN TUMORS
• Accounts for 20-25% of total brain tumors
• About 85% of metastatic lesions are located in the cerebrum
15% are located in the cerebellum
• The incidence increases after 4th decade and is highest in people over 65 years of age
• Relatively Rare in children (6%)
• Generally metastatic tumors are either single expansive tumor or multiple small tumors.
• Common symptoms being
 Headache
 Seizures
 Cognitive disturbances with personality changes
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25. (50 %)
(20%)
(5%)
(<5%)
COMMON PRIMARIES OF
BRAIN METASTASIS
(<5%)
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26. Diagnosis:
Initially by imaging
Confirmed by Tissue Biopsy .
Treatment:
• Early Treatment – Steroids / anti-epileptics
1. Surgery
2. Radiation
3. Chemotherapy
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27. MANAGEMENT OF
PSYCHIATRIC
SYMPTOMS WITH
BRAIN TUMORS
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28. GENERAL PRINCIPLES
• Management of underlying tumor.
• Psychoeducation to the family members about the prognosis of the brain
tumors
• Brain tumor patients also benefit from psychotherapy sessions, which help in
existential and spiritual matters 18
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29. DEPRESSION
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 No proven role of anti-depressants
 Among SSRIs, Sertraline is preferred as first line drug
 For refractory cases, Nortriptylline (TCA) is advised
 Rarely , in severe cases , Unilateral Brief pulse ECT is shown effective
 Psychosocial interventions and supportive therapy.
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30. ANXIETY
 Supportive psychotherapy
 SSRI
 Buspirone
 Long-acting benzodiazepines
 PANIC DISORDER – Anti-epileptic drugs
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31. PERSONALITY CHANGES
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 Lithium, carbamazepine, and valproic acid can be given for the labile affect and
impulsivity .
 Aggression can be controlled using lithium, anticonvulsive medication, or a combination.
 Apathy and inertia could be improved using psychostimulants.
 Psychotherapy such as cognitive rehabilitation therapy and problem-solving therapy.
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32. STEROID INDUCED PSYCHOSIS
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 Non-pharmacological methods to reduce patient agitation, anxiety, and disorientation can be
applied like
 Nursing by familiar faces,
 Proper lighting
 Regular reassurance and re-orientation
 Gentle distraction when necessary.
 Antipsychotic medication ( Haloperidol ; Risperidone ; Aripiprazole ; Olanzapine) is also
indicated.
 For manic symptoms , sodium valproate, or lithium preferred.
 For the depressive symptoms , TCAs are best avoided and ECT is shown effective.
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33. BRAIN TUMORS
IN PSYCHIATRIC
PATIENTS
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34. WARNING SIGNS
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35. CT MRI
PREFERRED
FOR
Diagnosis of Brain tumors Follow up of brain tumors
SENSITIVE Acute hemorrhage
Calcification
Bony involvement
To Visualize Skull base
Brain stem ;
Posterior fossa tumors
Remarks Can detect >90% of brain tumors
Might miss -
• Small tumors
• Tumors adjacent to bone
• Brain stem tumors
• Low grade astrocytomas
Can detect small tumors
Provide more anatomic detail
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36. DIAGNOSTIC MODALITIES FOR BRAIN TUMORS
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37. REFERENCES
1. Madhusoodanan S, Ting MB, Farah T, Ugur U. Psychiatric aspects of brain tumors: A review. World J Psychiatry 2015; 5(3): 273-285
2. Keschner M, Bender MB, Strauss I. Mental symptoms associated with brain tumour: a study of 530 verified cases. JAMA 1938
3. Price TRP, Goetz KL, Lovell MR. Neuropsychiatric aspects of brain tumors. In: Yudovsky SC, Hales RE, eds. The American Psychiatric Press Textbook of
Neuropsychiatry. Washington, DC: American Psychiatric Press, 1992: 473-497.
4. Lampl Y, Barak Y, Achiron A, Sarova Pinchas I. Intracranial meningiomas. Correlation of peritumoural oedema and psychiatric disturbances. Psychiatr Res
1995; 58: 177-180.
5. Starkstein SE, Robinson RG, Price TR. Comparison of cortical and subcortical lesions in the production of post stroke mood disorders. Brain 1987; 110:
1045-1059.
6. M. ALLEN; A CLINICAL STUDY OF TUMOURS INVOLVING THE OCCIPITAL LOBE, Brain, Volume 53, Issue 2, 1 July 1930, Pages 194–243
7. Price, T.R.P., Goetz, K.L. & Lovell, M.R. (2005) Neuropsychiatric aspects of brain tumours. In: Yudofsky, S.C. & Hales, R.E. (eds) Textbook of
Neuropsychiatry and Clinical Neurosciences, 4th edn, pp. 753–782
8. Madhusoodanan S, Opler MG, Moise D, et al. Brain tumor location and psychiatric symptoms: is there any association? A meta-analysis of published case
studies. Expert Review of Neuroptherapeutics. 2010; 10 : 1529-1536.
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Psychiatry, 57(1), 91–93.
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11. LIN, Q., LING, F., & XU, G. (2016). Invasive benign meningioma: Clinical characteristics, surgical strategies and outcomes from a single neurosurgical
institute. Experimental and Therapeutic Medicine, 11(6), 2537–2540.
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38. REFERENCES
12. Muraleedharan M, Behere RV. Pituitary adenoma with hypothalamic involvement: a case of ‘atypical’ atypical depression. Open J Psychiatry Allied Sci. 2017
Nov 6.
13. Pamela U. Freda, Sharon L. Wardlaw; Diagnosis and Treatment of Pituitary Tumors, The Journal of Clinical Endocrinology & Metabolism, Volume 84, Issue
11, 1 November 1999, Pages 3859–3866
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Companion for CNS Disorders, 16(6),
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16. Morais, Sofia, Cabral, Ana, Santos, Graça, & Madeira, Nuno. (2017). Melanoma brain metastases presenting as delirium: a case report. Archives of Clinical
Psychiatry , 44(2), 53-5
17. Zakrzewski J, Geraghty LN, Rose AE, Christos PJ, Mazumdar M, Polsky D, et al. Clinical variables and primary tumor characteristics predictive of the
development of melanoma brain metastases and post-brain metastases survival. Cancer. 2011;117(8):1711-20
18. Kangas, M. (2015). Psychotherapy Interventions for Managing Anxiety and Depressive Symptoms in Adult Brain Tumor Patients: A Scoping Review. Frontiers
in Oncology, 5, 116.
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analysis. Oncotarget, 8(55), 94932–94943. http://doi.org/10.18632/oncotarget.19843
20. Pelletier G, Verhoef MJ, Khatri N, Hagen N. Quality of life in brain tumor patients: The relative contributions of depression, fatigue, emotional distress, and
existential issues. J Neurooncol. 2002;57:41–9
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22. Sadock, Benjamin J. Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 10th Edition. Wolters Kluwer Health, 20170511
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40. TO BE ADDED
1. ASTROCYTOMA
2. PARANEOPLASTIC SYNDROMES
3. PSYCHIATRIC MANIFESTATIONS OF ANTI-TUMOR AGENTS
4. PSEUDOTUMOR CEREBRI
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