Postgraduate Seminar (Webex Online) Date: 18/02/2021

1. NEUROPSYCHIATRIC
MANIFESTATIONS OF
HUNTINGTON’S DISEASE
Presenter: Dr Norili Farhana bt Ahmad Saberi
Supervisor: Prof Dr Zahiruddin bin Othman

2. Introduction
◦ Huntington’s disease (HD) is a progressive neurodegenerative
disorder usually beginning in midlife with the characteristic
triad of motor, cognitive and psychiatric symptoms.
◦ Dr George Huntington first described motor dysfunction as
well as the neuropsychiatric aspects of self-awareness and
sexual inhibition in 1872.
◦ In 1993, the disease was substantiated by DNA evidence – a
pathological expansion of CAG trinucleotide repeats--- gene
coding for huntingtin protein on chr 4.
◦ HD is transmitted as an autosomal dominant trait with high
penetrance.
◦ The prevalence of HD varies significantly between
geographical regions, with lower incidence in Asian
populations.
◦ Worldwide prevalence: 8/100000

3. Diagnosis
◦ Average age of onset: 30-50 year old (can be predicted by the
number of CAG repeat.
◦ HD can be diagnosed on the basis of family history and motor
symptoms, with progression and severity of the illness generally
measured by motor deterioration and detailed
neuropsychological assessment of cognition.
◦ Juvenile Huntington's disease (onset before age 20) may present
more commonly with bradykinesia, dystonia, and rigidity than
with the choreic movements characteristic of the adult- onset
disorder.
◦ It is listed in the Diagnostic and Statistical Manual of Mental
Disorders 5 as Major or Mild Neurocognitive Disorder Due to
Huntington’s Disease, in the ICD-10 as HD (code G10), and new
diagnostic criteria have been proposed.
Huntington's disease is an autosomal dominant
disorder, which means that a person needs only
one copy of the defective gene to develop the
disorder.

4. A cut-off score of 40 or more
CAG repeats is used to
determine a positive test
(those who will eventually
become symptomatic with
HD, should they live long
enough).
There is an inverse
relationship between the
length of the repeat and the
age of onset, with those
having longer CAG repeats
having earlier onset.
However, CAG repeat length
does not reliably indicate
the course or symptoms of
illness.

5. Neuropathology and biomarker investigations
◦ Gradual atrophy of the striatum (caudate and putamen)
due to neuronal loss is the neuropathological and
neuroradiological hallmark of HD.
◦ Specific loss of medium spiny neurons (MSN) in the dorsal
striatum, expressing either Dopaminergic type 1 or 2
receptors, is seen as the basis for the clinical phenotype
with disease progression (see Figure 1).
◦ Other neuronal loss eventuate to generalised cerebral
atrophy.
◦ Pathogenesis: Triplet repeat ‘CAG’ expansions within the
huntingtin gene results in toxic gain of function---
accumulation of defective protein in neurons leading to
GABA- ergic and cholinergic indirect striatal neuron
atrophy--- inhibitory pathway degenerate--- hyperkinetic
movements

7. ◦ Brain imaging is a recommended part of diagnostic
assessment.
◦ Magnetic Resonance Imaging (MRI) studies reveal
characteristic atrophy of the putamen, caudate and
globus pallidus in HD patients.
◦ Frontostriatal or corticostriatal MRI atrophy (particularly
caudate and putamen) have been implicated as a
useful marker for disease progression.
◦ Clinically, measuring intercaudate distance against the
inner aspect of the skull, or the frontal span of the
lateral ventricle, are useful methods for identifying
caudate atrophy (see Figure 2).
◦ Significant cerebral cortical grey and white matter loss
in patients with HD is also common, particularly in
frontal zones.

8. ◦ Other investigations that are used to characterise HD but are not common in the
general clinical setting include functional imaging (e.g. single-photon emission
computed tomography (SPECT), positron emission tomography (PET) and functional
MRI (fMRI).
◦ Recent findings in cerebrospinal fluid (CSF) studies suggest the potential utility of
neurofilament light (a marker of neuronal degeneration) for determining and
monitoring HD.
◦ Other diagnostic work-up includes serum and CSF analysis to exclude other causes of
symptoms (see Table 2 for common differential diagnoses).

10. Clinical features of HD
◦ There is variability in the clinical phenotype with
respect to timing of onset, symptoms and progression
of cognitive, motor and neuropsychiatric symptoms,
and of frequent weight loss and sleep disturbances.

11. Motor
Symptoms
◦ There may be abnormal movements or subtle
clumsy and awkward movements evident early
in the onset of HD, which may not be reported
as symptoms.
◦ This premotor stage is often called the
prodromal, preclinical, pre-symptomatic or
asymptomatic phase, or ‘preHD’.
◦ Once the classic involuntary motor symptoms
and signs are evident, usually beginning with
chorea, the terms symptomatic or manifest HD
are used.
◦ These motor symptoms progressively worsen
during the course of the disease, and cause
significant difficulties for activities of daily life
and function, resulting in increasing disability
(see Table 3).

13. Cognitive
symptoms of
HD
◦ The cognitive symptoms in HD primarily reflect a form of
subcortical dementia characterized by memory
deficits, psychomotor slowing and impairment in
executive, perceptual and spatial skills.
◦ Memory problems arise from an inefficient memory
strategy for acquiring and retrieving memories rather
than a primary disorder of retention, and thus may
reflect executive dysfunction.
◦ As HD advances, the ability to communicate
diminishes.
◦ Common speech difficulties include dysarthria, with
poor articulation and slurring of words, slow production
of words, poor speech initiation and difficulty
organising thoughts.

14. Psychiatric manifestations: the
behavioural and psychological
symptoms of HD (BPSHD)
◦ Since the first description of HD, behavioural, emotional and psychiatric symptoms
have been a core feature of the illness.
◦ Pre-symptomatic HD gene carriers exhibit a greater prevalence of psychiatric
symptoms, particularly affective disturbances, which can precede the classical motor
symptoms by up to a decade.
◦ The BPSHD have been considered the presenting symptoms of HD in up to half of all
people with HD.
◦ In symptomatic HD patients, it is estimated that up to 73–98% of HD patients will have a
major psychiatric disorder or psychiatric symptoms.
◦ Not all symptoms are experienced by all, and symptoms can wax and wane.

15. Neuropsychiatric manifestations
Apathy Depression Grieving Suicide
Irritability Aggression Anxiety Psychosis
Mania
Impulsivity/
disinhibition/
dysexecutive
behaviour
OCD/S
Unawareness/
anosognosia/
Loss of insight
Disturbance in
Sleep-wake
cycle

20. Advanced stage and death
◦ HD is a progressive neurodegenerative disorder that leads to increasing amounts
of disability and dependency, ultimately leading to death.
◦ Motor symptoms of advanced HD typically include prominent bradykinesia,
dystonia and rigidity, and increased muscle tone may result in joint contractures.
◦ Choreiform movements lessen but may persist in the orobuccal region and the
extremities.
◦ Double incontinence can occur, and cachexia (wasting) can become manifest
in advanced HD.
◦ Swallowing is severely impaired--- to prevent aspiration and the significant weight
loss associated with the later stages of disease, nasogastric or percutaneous
endoscopic gastronomy (PEG) is often implemented.
◦ In the late stages, the person with HD presents with severe dementia, and is
usually confined to a wheelchair or bed and reliant on high-level nursing care.
◦ Pressure sores are common due to increased immobility.
◦ The median survival is 24 years from diagnosis, with aspiration pneumonia the
most common cause of death. Other causes include heart disease, nutritional
deficiencies, skin ulcers, cardiovascular-related events and suicide.

21. Management of Neuropsychiatric
Symptoms in HD
◦ Given the complexity of HD with its changing needs
and range of problems, its management requires a
multidisciplinary approach, involving a range of
clinicians including a physician (neurologist,
psychiatrist) and allied health worker (social worker,
occupational and speech therapists, physiotherapist,
nurse).

23. Non-pharmacological management
◦ Non-pharmacological strategies are complementary to pharmacological strategies.
◦ A thorough assessment of medical and environmental triggers for the neuropsychiatric
symptoms will allow development of specific individualised strategies for behavioural
management.
◦ The Antecedent, Behaviour and Consequence approach (A, B and C) is one way of
characterising events and resultant behaviour.
◦ Person-centred care or an individualised approach may reduce these behaviours.
◦ This involves a collaborative approach where the strategies are focused on meeting
the person’s needs and is consistent with their unique personal and social history.
◦

24. Caring for carers
◦ Looking after someone with HD can be a demanding
and stressful role.
◦ The age of onset of HD is highly variable and hence
carers could be a child or spouse of any age.
◦ Unexpected changes in role and the relationship and
other losses add to the burden of care.
◦ Family members caring for a person with HD may face
significant issues about their own prognosis and
uncertainty about their future, as well as the effect that
knowledge of the disorder may have on extended
family.

26. Pharmacological management
◦ Pharmacological management is restricted to symptomatic relief of the motor,
behavioural and psychiatric aspects of HD, and while there are few evidence- based
trials, general guidance can be offered.
◦ Regular medical assessments and consideration of other medical comorbidities and of
previous medication strategies are fundamental.
◦ Discussion with the patient and carers about the aims and risk-benefit analysis for medi-
cation and how to monitor for side effects is essential.

27. Pharmacological management

28. Cognition
◦ The cognitive impairment seen in HD is a form of subcortical dementia characterised
by slowing of thought processing, executive dysfunction and memory impairment.
◦ The memory deficit is initially due to inattention and difficulties with retrieval.
◦ Donepezil has been trialled for cognitive decline but with limited benefits.
◦ A study of rivastigmine in 11 patients with HD suggested improvement in motor scores
and a trend towards improvement in cognition and functional scores, but more study is
required.
◦ Currently, there are no known effective disease-modifying treatments for cognitive
decline in HD.

29. Brain stimulation interventions
◦ Deep-brain stimulation of the internal globus pallidus may improve chorea but may
worsen other symptoms such as dysarthria and bradykinesia. However, these studies
have been limited by small sample sizes and bias in selection of patients.
◦ Transcranial magnetic stimulation is non-invasive and its therapeutic benefit remains
unclear.
Disease-modifying therapies
◦ no conclusive evidence

30. Suicidal Attempt in Huntington Disease: A Case Report
Saifuddin TM, Amilin N, Zafri A
◦ Mr. Y, 56 years old Chinese gentleman who was diagnosed as Huntington disease by Neuromedical
department at the age of 52, was brought in by his roommate to casualty due to suicidal attempt by
ingesting herbicide after quarreled with his friend tree days prior to the admission.
◦ His roommate had realized it after he had persistent vomiting. Upon further questioning, he admitted
hearing voices which he described as second person and commanding in nature for 1 year duration.
◦ He also admitted feeling of depressed but not fulfilled the criteria for Major Depressive Disorder.
◦ When asked regarding reason he wanted to commit suicide, he keep on saying that he felt mad
toward his friend. His judgment was also poor.
◦ There was difficulty in taking history from him in view of his speech difficulty. History from roommate
revealed that he was socially withdrawn since one year ago.
◦ Most of the time he just stay in the house watching television.
◦ He was noted to have hallucinating behavior as was described by his roommate. Patient also noted to
express that people wanted to do bad things to him. His roommate also noticed abnormal behavior
such as burning newspaper (almost every day), throwing coins on the floor without no reason and
squeezing plastic bottle to make disturbing noises repeatedly.
◦ He also noted become more forgetful and become less amount of understandable speech.

31. ◦ Mental state examination revealed thin build Chinese gentleman with chorea movement, with good
eye contact.
◦ His mood was not depressed and his affect was restricted.
◦ He had disorganized speech.
◦ He admitted having auditory hallucination.
◦ Mini Mental State Examination showed deficit in his attention and memory.
◦ All blood investigation was normal.
◦ He was referred to medical team in casualty to look for possible progression of the disease and was
discharged by medical team.
◦ Then he was admitted to psychiatric ward for observation in view of poor social support and he was
medically stable.
◦ He was started with Tablet Olanzapine 2.5 mg per day. After started with Olanzapine, he was stable
without any psychotic symptoms.
◦ From observation, he was cooperative with no abnormal behavior and no depressive symptoms
noted. He also denied suicidal thought. His movement disorder was also improving.
◦ He was discharged to nursing home with tablet Olanzapine 2.5 mg ON after day six of admission.

32. Part 2: Neuro EXAM
◦ History: Patient’s particular
◦ Chief complaint: eg: clumsiness or gradual cognitive decline/ involuntary motor movement
or mood changes
◦ HOPI: onset of the sx, progression, motor sx, cognitive and neuropsychiatric symptoms,
substance use, suicide, functionality
◦ Past med hx: swallowing problems, weight loss (can also put in HOPI), medications
◦ Past surgical hx:
◦ Family hx: present
◦ Premorbid personality
◦ Physical examination:
◦ General examination--- abnormal involuntary movement (chorea),Muscle twitching, poor
posture, impaired gait and balance, dysarthria
◦ Neurological examination: Upper limb and lower limb– dystonia, rigidity, incoordination
(dysdiadochokinesia, past pointing).
◦ Can mentioned want to Complete examination by with eye examination and MMSE

33. ◦ Dx: UMN, Hyperkinetic movement
Disorder possible/likely HD
◦ Ddx: Parkinson Disease, Wilson disease
(any other causes of chorea)
◦ Ix: Genetic testing, MRI brain
◦ Mx: Tetrabenazine, Antipsychotics

34. Conclusion
◦ It is important for clinicians to be aware of the high rate of psychiatric symptoms in HD,
as they manifest before motor symptoms are evident (which is when HD is typically
diagnosed), cause significant functional impairment and affect quality of life.
◦ Management of the neuropsychiatric manifestations of HD requires judicious
application of pharmacological and non-pharmacological interventions.
◦ As HD progresses, treatments often need to be modified as symptoms and signs evolve,
and as the benefit-to-risk ratio shifts accordingly.

35. Reference
◦ Goh A.M.Y., Wibawa P., Loi S. M., Walterfang M., Velakoulis D., Looi J.C.L (2018), Huntington’s
disease: Neuropsychiatric manifestations of Huntington’s disease, Australasian Psychiatry
2018, Vol 26(4) 366–375, The Royal Australian and New Zealand College of Psychiatrists
◦ Sunjay P., Pamela S., (2018) Neurology A Visual Approach, CRC Press, Taylor & Francis group
◦ Loi S. M., Walterfang M., Velakoulis D., Looi J.C.L (2018), Huntington’s disease: Managing
neuropsychiatric symptoms in Huntington’s disease, Australasian Psychiatry 1–5, The Royal
Australian and New Zealand College of Psychiatrists DOI: 10.1177/1039856218766120
journals.sagepub.com/home/apy
◦ Saifuddin TM, Amilin N, Zafri A., (2016), Suicidal Attempt in Huntington Disease: A Case
Report, MPJ Online Early.
◦ Anthony S. D., Simon F., Michael D. K., Simon L., John D.C.M., (2009) Organic Psychiatry, A
Textbook of Neuropsychiatry, Fourth Edition

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