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Psychiatric Manifestations of Medical and Neurological Conditions

Psychiatric Manifestations of Medical and Neurological Conditions. Anthony P. Weiss, M.D., M.Sc. Massachusetts General Hospital. Questions for Discussion. What are the psychiatric manifestations of medical & neurological conditions? What conditions can cause these psychiatric manifestations?

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Psychiatric Manifestations of Medical and Neurological Conditions

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  1. Psychiatric Manifestations of Medical and Neurological Conditions Anthony P. Weiss, M.D., M.Sc. Massachusetts General Hospital

  2. Questions for Discussion • What are the psychiatric manifestations of medical & neurological conditions? • What conditions can cause these psychiatric manifestations? • What is the role of the C/L psychiatrist in managing these patients?

  3. Questions for Discussion • What are the psychiatric manifestations of medical & neurological conditions? • What conditions can cause these psychiatric manifestations? • What is the role of the C/L psychiatrist in managing these patients?

  4. Karte des menschlichen GehirnsKorbinian Brodmann (1868-1918)

  5. ABC’s of C/L Psychiatry • Affective • Depressed or elevated mood, anxiety, irritability • Behavioral • Amotivation, insomnia, anorexia • Agitation, hypersexuality, wandering • Cognitive • Changes in memory, language, executive skills • Changes in thought content:delusions or hallucinations

  6. Questions for Discussion • What are the psychiatric manifestations of medical & neurological conditions? • What conditions can cause these psychiatric manifestations? • What is the role of the C/L psychiatrist in managing these patients?

  7. Vascular • Infarction • Intracerebral hemorrhage • Vasculitides

  8. Vascular: Infarction • Affective • Depression • Affective incontinence • Behavioral • Cognitive • Aphasia, anosognosia • Multi-infarct dementia

  9. Post-stroke DepressionRisk Factors • Infarct location (left frontal pole) • Infarct size • Subcortical atrophy • Prior history of depression • Family history of depression • Lack of social support

  10. Vascular: Infarction • Affective • Depression • Affective incontinence • Behavioral • Cognitive • Aphasia, anosognosia • Multi-infarct dementia

  11. Infectious • Viral • Bacterial • Fungal • Protozan • Prion

  12. Infectious: Neurosyphilis 1° = chancre 2° = rash 3° = late sequelae 10-20 years • Tabes Dorsalis • Sharp pain in legs • Ataxia • Charcot joints • General Paresis • Pupillary changes • Tremor • Slurred speech

  13. Infectious: Neurosyphilis • Affective • Depression, euphoria, anxiety • Personality changes • Behavioral • Disinhibition • Cognitive • Memory impairment, loss of insight • Delusions and hallucinations

  14. Neoplastic • Primary CNS • Metastases within CNS parenchyma • Paraneoplastic syndromes

  15. Neoplastic: Limbic Encephalitis • Affective • Depression and anxiety (esp. early in course) • Behavioral • Cognitive • Memory impairment • Hallucinations

  16. Metabolic • Nutritional • Electrolyte • Endocrinopathies • Organ failure

  17. MetabolicStandard Assessment • Vitamin B12 • “Chem 7” • Na+ level • BUN/Cr • Glucose • Arterial blood gas • Liver function tests and ammonia level • TSH

  18. Traumatic • Subdural hematoma • Concussive syndromes

  19. Paroxysmal • Complex partial epilepsy • Transient global amnesia • Post-ictal confusion • Complex migraine • Acute intermittent porphyria • Catatonia • Neuroleptic malignant syndrome

  20. Seizures Generalized Partial Absence Grand Mal Complex Simple

  21. Psychiatric Sequelae of Epilepsy • Pre-ictal (aura) • Ictal • Post-ictal • Depression • Psychosis • Personality

  22. TLE PersonalityFrom Bear and Fedio, 1977 Emotionality     Mania     Depression     Guilt     Humorlessness     Altered sexual interest     Aggression     Anger and hostility     Hypergraphia Religiosity     Philosophical interest     Sense of personal destiny     Hypermoralism     Dependency     Paranoia     Obsessionalism     Circumstantiality     Viscosity

  23. Pharmacologic/Toxicologic • Alcohol • Illicit drugs • Medications • CO Poisoning • Heavy metal poisoning

  24. “Pseudodelirium” • Acute mania • Disorganized schizophrenia • Severe depression • Conversion disorder • Fugue states • Malingering

  25. Degenerative • Parkinson’s disease • Huntington’s chorea • Wilson’s disease

  26. Parkinson’s Disease • Affective • Depression • Anxiety • Behavioral • Insomnia • Cognitive • Bradyphrenia • Dementia (Lewy Body) • Delusions and hallucinations

  27. Questions for Discussion • What are the psychiatric manifestations of medical & neurological conditions? • What conditions can cause these psychiatric manifestations? • What is the role of the C/L psychiatrist in managing these patients?

  28. Role of the C/L Psychiatrist • Accurately describe the symptoms • Consider the potential perturbations • Assist in narrowing the differential • Assist in treating the symptoms and/or the underlying perturbation

  29. Summary • What are the psychiatric manifestations of medical & neurological conditions? • What conditions can cause these psychiatric manifestations? • What is the role of the C/L psychiatrist in managing these patients?

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