Dr Saurav Deka is an MBBS ,MD clinical                pharmacologist having good clinical experience                in neu...
Neurological Disorder  With Behavioral   Manifestation
Contents•   Introduction•   Clinical manifestations•   Pathogenesis and pathophysiology•   Prognosis•   Management
Introduction• All human behavior is generated by the brain• Unlike some neurologic signs like hemiparesis,aphasia  most be...
Introduction• Yet those behavioral signs and symptoms may  go unnoticed• Most of time these these manifestion of  neurolog...
IntroductionBehavioral disturbances due to primary neurologic conditions  can be distinguished from idiopathic psychiatric...
NEUROLOGIC DISEASE &CLINICAL MANIFESTATIONS
Neurologic Disease• Alzheimer disease• Parkinson disease• Stroke• Epilepsy• Brain Tumour• Trauma brain• Huntington disease...
Clinical Manifestations•   Disturbances in emotional expression•   Disturbances in motor function•   Perceptual disturbanc...
Disturbances In Emotional Expression• Disturbances in emotional expression are 2 to 3 times more  common in patients with ...
Melancholia Melancholia is a pathologic emotional state strongly  associated with mortality from suicide and with  positi...
Features of Melancholia and Syndromes            Mistaken for Clinical DepressionMelancholia                           Apa...
Hypomania Mistaken for Bipolar DisorderHypomania    • Infectious, exaggerated happiness or modest, easy irritability when ...
Emotional Expression in Neurologic DisordersDisease              Apathy                   Melancholia                     ...
Clinical Manifestations•   Disturbances in emotional expression•   Disturbances in motor function•   Perceptual disturbanc...
Disturbances in motor function• Changes in motor functioning can be simple  Simple : eg like hemiparesis Complex : eg park...
Catatonia• Catatonia can be missed, first, from the mistaken idea that  patients with catatonia must be frozen in an odd p...
Clinical Manifestations•   Disturbances in emotional expression•   Disturbances in motor function•   Perceptual disturbanc...
Perceptual disturbancesPerceptual disturbances occur in all sensory modalitiesHyperesthesia and hypoesthesia              ...
Clinical Manifestations•   Disturbances in emotional expression•   Disturbances in motor function•   Perceptual disturbanc...
Delusions and abnormal thoughtPhenomena                        Description                                    Differential...
Phenomena                  Description                                       Differential Diagnosis Doppelganger          ...
Clinical Manifestations•   Disturbances in emotional expression•   Disturbances in motor function•   Perceptual disturbanc...
Cognitive dysfunctionMost behavioral disorders have associated cognitive   impairments.An increasingly common clinical cha...
Depressive PseudodementiaVs From Alzheimer                            DiseaseClinical Feature     Depressive Pseudodementi...
Clinical Manifestations•   Disturbances in emotional expression•   Disturbances in motor function•   Perceptual disturbanc...
Personality Changes Seen in Neurologic DiseaseDescriptor       Behavioral Traits                                          ...
PATHOGENESIS      ANDPATHOPHYSIOLOGY
Functional brain Systems and Their                  Signature PsychopathologyFunctional brain system        Psychopatholog...
PrognosisBehavioral disturbances are substantial factors determining quality of life for   persons with neurologic disease...
Management Treating the underlying condition When behavioral disturbances persist,   treatments are similar to those for...
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Behaviourial manifestation in neurologic disease

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Behaviourial manifestation in neurologic disease

  1. 1. Dr Saurav Deka is an MBBS ,MD clinical pharmacologist having good clinical experience in neurologic disease while he was working in clinical field . He has been working as medical advisor in some reputed pharmaceutical company of India from 2008.The topic discussed is a complex one which is edited by Dr Deka . He has complied lot of information scattered in literature about this topic. You can contact him for any other topic : hisaurav2007@gmail.comTopic : Neurological Disorder With Behavioral Manifestation
  2. 2. Neurological Disorder With Behavioral Manifestation
  3. 3. Contents• Introduction• Clinical manifestations• Pathogenesis and pathophysiology• Prognosis• Management
  4. 4. Introduction• All human behavior is generated by the brain• Unlike some neurologic signs like hemiparesis,aphasia most behavioral signs do not localize to specific brain sites• Behavioral disturbances occur to majority of patients with neurologic disease
  5. 5. Introduction• Yet those behavioral signs and symptoms may go unnoticed• Most of time these these manifestion of neurologic disease is ascribed to pre existing phychiatric diorder• Misunderstood as “Phychogenic” in origin
  6. 6. IntroductionBehavioral disturbances due to primary neurologic conditions can be distinguished from idiopathic psychiatric disease by applying principles of brain-behavior relationships.
  7. 7. NEUROLOGIC DISEASE &CLINICAL MANIFESTATIONS
  8. 8. Neurologic Disease• Alzheimer disease• Parkinson disease• Stroke• Epilepsy• Brain Tumour• Trauma brain• Huntington disease• Multiple sclerosis• Wilson Disease
  9. 9. Clinical Manifestations• Disturbances in emotional expression• Disturbances in motor function• Perceptual disturbances• Delusions and abnormal thought content• Cognitive dysfunction• Personality and personality change
  10. 10. Disturbances In Emotional Expression• Disturbances in emotional expression are 2 to 3 times more common in patients with neurologic, especially among the elderly .(Coffey and Coffey 2011)• Distinguishing these states from idiopathic psychiatric illness is difficult when clinicians use descriptors like “depression” and “anxiety• Emotional expressions of pathologic states such as melancholia, apathy, and mania are subjectively and objectively distinct.
  11. 11. Melancholia Melancholia is a pathologic emotional state strongly associated with mortality from suicide and with positive responses to specific treatments (Taylor and Fink 2006), Making it the most important emotional disturbance for clinicians to distinguish from demoralization, depression associated with personality deviation, and apathy from frontal circuitry disease. Unlike these other conditions, melancholia is often accompanied by psychosis and catatonia. Patients may also appear reversible “pseudodementia. Mania is rarely seen in neurologic practice, but chronic hypomania is important to distinguish from frontal disinhibition syndromes.
  12. 12. Features of Melancholia and Syndromes Mistaken for Clinical DepressionMelancholia Apathy Demoralization Pathologic mood of unremitting  Diminished goal-directed overt  Nonpathologic, sad, or dysphoric gloom or apprehension behavior (eg, lack of productivity, mood in response to illness effort, initiative) Psychomotor retardation or  Emotional responsivity to agitation  Diminished goal-directed positive events cognition (eg, lack of interests in Vegetative signs reflecting an hobbies or new experiences, lack  Feelings of understandable exaggerated stress response (eg, of concern for ones health) helplessness and hopelessness anorexia and weight loss, slowed bowel motility,  Diminished emotional  Feelings of subjective insomnia, loss of libido, altered concomitants of goal-directed incompetence (eg, “I cant do it”) circadian rhythms) behavior (eg, unchanging affect, absence of excitement or  Pessimistic thinking with Cognitive impairment in emotional intensity) demanding or indifferent concentration and working behavior memory  Not attributable to intellectual impairment, emotional distress, or diminished arousal
  13. 13. Hypomania Mistaken for Bipolar DisorderHypomania • Infectious, exaggerated happiness or modest, easy irritability when frustrated • Emotional lability, transient with depressive features • Hyperactivity and pressured speech; increased productivity unless mania emerges • Decreased sleep need • Increased appetitive behaviors (eg, food, sex, drugs) • Psychosis uncommon; some psychosensory features may occurDisinhibition • Behavioral impulsivity and coarsening of personality; loss of social graces • Distractibility and modest hyperactivity, but with reduced productivity • Witzelsucht, but no sustained expansive mood state • No psychosis • No change in sleep needDelirium (hyperactive type) • Acute onset, fluctuating course • Altered level of arousal and alertness (EEG abnormal) • Impulsivity, distractibility, fearfulness, irritability • Multisensory hallucinations and delusions • General medical condition (eg, infection) or intoxication (eg, medication overdose) • Signs of general medical illness (eg, fever)Pathologic laughing and crying (PLC) • Paroxysmal and brief • Emotional expression disconnected from emotional experience (emotions are excessive or socially inappropriate) • Denial of feeling the emotion expressed
  14. 14. Emotional Expression in Neurologic DisordersDisease Apathy Melancholia Demoralisation laughing & cryingAlzheimer disease •45-90% •15-50% , Less common •30-40% •Early onset •Early onset, •Mixed laugh & cry •Congnitive complainParkinson disease •30-50% •30-50% Prevalence is as high as •Precede onset of •Precede onset of motor 36% in multiple systems motor symptoms symptoms atrophy.Stroke Anergia 3-6 month after stroke Catastrophic 10-25% Bradykinesisa ImmediateEpilepsy Most commonBrain Tumour Tumor histology doesnot predict symptoms .frontal lobe tumor associated with frontal lobe syndrome temporal tumors produce emotional disturbance ,right sided lesion more associated with disinhibition and elevated mood .Trauma brain 40-50% rare Not known 5-11% Early onsetHuntington disease Associate with rare Stress of fatal degeneration of disease caudate nucleusMultiple sclerosis 50% Non Melancholic depression 10-20% Lesion in left frontal region ,cortical atrophyWilson disease Disinhibition (50% to 70%): Irritability, aggression, and “incongruous behavior”. The 10-fold increase in prevalence of bipolar disorder among persons with Wilson disease likely reflects the prevalence of disinhibition rather than primary manic-depression.
  15. 15. Clinical Manifestations• Disturbances in emotional expression• Disturbances in motor function• Perceptual disturbances• Delusions and abnormal thought content• Cognitive dysfunction• Personality and personality change
  16. 16. Disturbances in motor function• Changes in motor functioning can be simple Simple : eg like hemiparesis Complex : eg parkinsonism• Changes can be subtle and nonspecificeg : restlessness suggesting anxiety or• Changes can be dramatic and diagnostic eg postures or stereotypy suggesting catatonia.
  17. 17. Catatonia• Catatonia can be missed, first, from the mistaken idea that patients with catatonia must be frozen in an odd posture.• Many conditions elicit Catatonia Postictal states Nonconvulsive status Complex partial seizures Basal ganglia disease Stroke (ischemic and hemorrhagic) Encephalitis Postencephalitic states Temporal lobe infarction Thalamic lesions Demyelinating disease Tuberous sclerosis Narcolepsy
  18. 18. Clinical Manifestations• Disturbances in emotional expression• Disturbances in motor function• Perceptual disturbances• Delusions and abnormal thought content• Cognitive dysfunction• Personality and personality change
  19. 19. Perceptual disturbancesPerceptual disturbances occur in all sensory modalitiesHyperesthesia and hypoesthesia Distortions of stimulus intensity (eg, a dim light appears as glaring)Synesthesia Stimulation of one sensory modality eliciting a perception in a different sensory modality (eg, “seeing a sound”)Dysmegalopsia Distortions of the size and shape of objectsColor spectrum distortions Changes in color perceptionIllusions False perceptions or misinterpretations of environmental stimuliHypnagogic and hypnopompic hallucinations Visual or auditory perceptions, not vivid but distinct from dreams, occurring while falling asleep or on wakingExtracampine hallucinations False perception outside the limits of the normal sensory field (eg, hearing plotters in another country)Peduncular hallucinations Visual perceptions of cartoon-like people or animals that are non- threateningAutoscopic hallucinations Perceptions of ones own image, often sensed as vague or slightly to one sideLilliputian (or Brobdingnagian) hallucinations Visual perceptions of small (or gigantic) objects or creaturesTactile hallucinations Perceptions experienced as emanating from inside the body or from the skinOlfactory (or gustatory) hallucinations Sudden, intense perceptions of smells (or tastes) that are often unpleasantPhoneme (voices) hallucinations Hallucinated voices, varying from vague or muffled whispers to sustained or clear voices, perceived as originating from a source external to oneselfMusical hallucinations Perceptions of vivid, often familiar tunes or lyrics
  20. 20. Clinical Manifestations• Disturbances in emotional expression• Disturbances in motor function• Perceptual disturbances• Delusions and abnormal thought content• Cognitive dysfunction• Personality and personality change
  21. 21. Delusions and abnormal thoughtPhenomena Description Differential DiagnosisDelusions of persecution • Isolated and simple “The nurse is trying to kill me” Neurodegenerative conditions • Isolated and elaborate Eg, a man believed his wife and the Encephalopathy, temporal lobe dysfunction government had teamed up in a complicated plot to “render him impotent” • Non-isolated The patient demonstrates other Mood disorders, schizophrenia psychopathologyDelusions of misidentification • Capgras syndrome A relative or familiar person is believed to More often right-hemisphere lesions from a be replaced by a similar-looking impostor stroke or seizure focus, traumatic brain injury, neurodegenerative conditions • Fregoli syndrome Unfamiliar persons are thought to be well known to the patient and often said to be celebrities
  22. 22. Phenomena Description Differential Diagnosis Doppelganger The belief that one has a double who carries out independent actionsReduplicative paramnesia A familiar person, place, or object is believed to be duplicatedDelusions of passivity Experience of being controlled by an outside Schizophrenia, manic-depression, right- force or having another persons thoughts hemisphere lesionsDelusions of poverty Beliefs of becoming bankrupt or losing ones Melancholia home and belongingsNihilistic delusions Beliefs of being dead or that ones body or Manic-depression (90%), brain tumor,(Cotard syndrome) body parts are deteriorating migraineDelusions of grandiosity Inflated self-importance and beliefs of Manic-depression, conditions involving superior accomplishments, bodily frontal lobe circuitry dysfunction perfections, and attention from othersErotomania Delusional belief that ones love for another Neurologic disease (25%; degenerative person (sometimes a celebrity) is conditions, HIV.,seizure disorder, reciprocated hemorrhage, traumatic brain injury), schizophrenia (35%), mood disorders (22%)Delusional memories False memories derived from illusions in Mood disorders, schizophrenia(paramnesia) association with intense emotion (eg, the depressed person “remembers” past sins)
  23. 23. Clinical Manifestations• Disturbances in emotional expression• Disturbances in motor function• Perceptual disturbances• Delusions and abnormal thought content• Cognitive dysfunction• Personality and personality change
  24. 24. Cognitive dysfunctionMost behavioral disorders have associated cognitive impairments.An increasingly common clinical challenge is faced when a person over 65 years of age presents with a significant decline in behavioral functioning. Between ages 65 and 75 years, melancholia is several- fold more likely. So it is a this diagnostic dilemma
  25. 25. Depressive PseudodementiaVs From Alzheimer DiseaseClinical Feature Depressive Pseudodementia Alzheimer dementiaMood Melancholic Apathetic, avolitional  Cognition Bradyphrenia, executive dysfunction,  Visuospatial deficits, executive  recall deficits, false negative errors,  dysfunction, recall deficits, false negative  some benefit from serial presentation,  errors, no benefit from serial presentation,  less behavioral consistency more behavioral consistency  Insight Exaggerates problems Minimizes problems  Course Episodic; more discrete onset Progressive; insidious onset with mild  cognitive impairment  Personal history Mood disorder Late-life non-melancholic depression  Family history Mood disorder Dementia  Functional imaging Frontal or diffuse hypometabolism Biparietal and temporal hypometabolism  Structural imaging Normal or with mild atrophy without  Temporal atrophy and ventricular  progression enlargement
  26. 26. Clinical Manifestations• Disturbances in emotional expression• Disturbances in motor function• Perceptual disturbances• Delusions and abnormal thought content• Cognitive dysfunction• Personality and personality change
  27. 27. Personality Changes Seen in Neurologic DiseaseDescriptor Behavioral Traits Differential Diagnosis“Epileptic” Adhesive and viscous, stubborn and perseverative, humorless  Epilepsy (up to 60%), chronic manic- sobriety, pedantic and circumstantial speech, hypergraphic,  depression pseudo-profundity, hyposexual  “Paranoid” Moody and irritable, suspicious and defensive, quarrelsome  Chronic limbic system disease, alcoholism and litigious, “neighborhood crank”  “Emotional” Deep emotions, intense expressions, easily tearful,  Epilepsy (less common) Witzelsucht, hyperreligious  “Frontal lobe” Lateral orbital prefrontal: irritability and emotional lability,  Stroke (particularly large or multiple  episodic dyscontrol and unplanned violence, suspiciousness,  lesions in anterior areas), tumor (left  restlessness and impulsivity, self-destructive and lacking  frontal areas associated with apathy, right  insight, childishly self-centered and insensitive, overly  frontal areas with disinhibition), traumatic  talkative brain injury (40% lateral orbital prefrontal,    10% to 30% dorsolateral prefrontal, 30%  Dorsolateral prefrontal: lack of spontaneity and initiative, loss  to 50% mixed), neurodegenerative  of drive or ambition, loss of interests, sluggish, socially  conditions isolative, dysphoric  “Rigid” Inflexible, stoic, frugal, slow-tempered, orderly, muted  Parkinson disease emotional expression, vulnerability to depression
  28. 28. PATHOGENESIS ANDPATHOPHYSIOLOGY
  29. 29. Functional brain Systems and Their Signature PsychopathologyFunctional brain system Psychopathologic featuresFrontal lobe circuits Catatonia, basal ganglia signs, apathy and disinhibition (“frontal lobe syndromes”)  Cerebellar-pons Apathy, mutism, disinhibition  Dominant cerebral cortex   • Frontal Apathy, disinhibition   • Temporal Psychosensory phenomena   • Parietal Gerstmann syndrome (dysgraphia, dyscalculia, finger agnosia, and left-right  disorientation)  Non-dominant cerebral cortex   • Frontal Motor aprosodia   • Temporal parietal Misidentification delusions; passivity delusions; receptive aprosodia; psychosensory  phenomena  Stress response system Melancholia, anxiety disorders  Hedonistic reward system Substance abuse  Arousal system Stupor, delirium, sleep disorders
  30. 30. PrognosisBehavioral disturbances are substantial factors determining quality of life for  persons with neurologic disease. Compared to the general population, suicide risk is increased among patients  with I. Huntington disease (12-fold), II. epilepsy (11-fold), III. traumatic brain injury (8-fold), IV.multiple sclerosis (7-fold), V. stroke (2-fold), VI.migraine with aura (3-fold) Ref : Arciniegas DB, Anderson CA. Suicide in neurologic illness. Curr Treat Options Neurol 2002;4:457-68
  31. 31. Management Treating the underlying condition When behavioral disturbances persist,  treatments are similar to those for patients  with primary psychiatric disorders  Refer to Coffey CE, McAllister TW, Silver JM. Guide to Neuropsychiatric Therapeutics. Philadelphia, PA: Lippincott Williams & Wilkins, 2007
  32. 32. THANK YOU

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