24 Psychiatric Neurological Comorbidities Update PDF

No v em be r 202 4 CNS Module: Neurological and Psychiatric Comorbidities & Treatment Prof Charlotte Kamal Department of Psychiatry, MUB Dr Mohamed Alsaffar, Dr. Fergus Murphy Clinical Lecturers Department of Psychiatry, Dublin CNS MODULE LEARNING OUTCOMES 1. Describe the deve...

No v em be r 202 4 CNS Module: Neurological and Psychiatric Comorbidities & Treatment Prof Charlotte Kamal Department of Psychiatry, MUB Dr Mohamed Alsaffar, Dr. Fergus Murphy Clinical Lecturers Department of Psychiatry, Dublin CNS MODULE LEARNING OUTCOMES 1. Describe the development, structure and function of the healthy c entral nervous system 2. Use effective strategies (e.g. communication, collaboration, interventions) as part of a multidisciplinary and interprofessional team to manage patients and populations with common or important central nervous system conditions 3. Display high-quality communication with patients utilising a range of communication frameworks and approaches 4. Identify the key elements of performing a Central Nervous System history 5. Demonstrate the basic principles in conducting a structured histor y and physical examination of the central nervous system 6. Demonstrate the application of professionalism, leadership and res ilience (i.e. the constructs of Personal and Professional Identity) to manage self a nd engage with patients, colleagues and communities in the context of dealing with CNS conditions. 7. Describe the normal molecular, cellular and biochemical functions in the healthy CNS system  CNS MODULE LEARNING OUTCOMES 8. Explain the pathological and immunological processes underlying CNS diseases 9. Outline the characteristics of the major groups of microorganisms that play important roles in the development of CNS diseases 10. Describe the epidemiology, aetiology, pathogenesis, pathological appearances, clinical manifestations, complications and prognosis of common or i mportant diseases 11. Discuss the scientific basis, selection and interpretation of appropriate diagnostic investigations for CNS diseases 12. Use an evidence- based approach to choose the appropriate medicines to manage common or important CNS diseases and describe the mechanism of action of those medicines and their adverse effects 13. Describe the primary and secondary prevention of common or important CNS ACTIVITY LEARNING OUTCOMES 1. Recognise the clinical presentation of common psychiatric disorders 2. Outline the nature of anxiety, mood and psychotic disorders 3. Identify the mental states associated with common psychiatric disorders 4. Describe the two diagnostic classification systems used to diagnose psychiatric illness 5. Recognise combined disease burden in patients with neurological and psychiatric disease 6. Identify multidisciplinary approaches to management of neuropsychiatric illness ALO 1 RECOGNISE THE CLINICAL PRESENTATION OF COMMON PSYCHIATRIC DISORDERS & ALO 2 OUTLINE THE NATURE OF ANXIETY, MOOD AND PSYCHOTIC DISORDERS o Depression / mood disorders o Anxiety / anxiety disorders o Schizophrenia / psychotic disorders o Substance abuse  CLINICAL PRESENTATION OF COMMON PSYCHIATRIC DISORDERS – MOOD DISORDERS Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian & New Zealand Journal of Psychiatry. 2021;55(1):7-117. CLINICAL PRESENTATION AND NATURE OF MOOD DISORDERS Low mood Depression Degree – mild, moderate, severe Duration – at least 2 weeks Impacts functioning Image by: Azahara Quesada Tellez https://my.clevelandclinic.org/health/diseases/9290-depression CLINICAL PRESENTATION AND NATURE OF MOOD DISORDERS Elevated mood Mania >/= 1 week Impacts functioning Image by: Azahara Quesada Tellez CLINICAL PRESENTATION AND NATURE OF MOOD DISORDERS – MOOD SPECTRUM Images by: Azahara Quesada Tellez Dysthymia Image by: Azahara Quesada Tellez CLINICAL PRESENTATION AND NATURE OF ANXIETY DISORDERS Anxiety Disorders "anxious" "worried" v. Anxiety Disorder (Generalized Anxiety Disorder Panic Disorder Agoraphobia Specific Phobia Social Anxiety Disorder Separation Anxiety Disorder) (Obsessive- Compulsive Disorder Post Traumatic Stress Disorder) https://invermeresummityouthcentre.org/anxiety/ CLINICAL PRESENTATION AND NATURE OF ANXIETY DISORDERS Physical – Muscle tension/ motor restlessness. - Sympathetic autonomic overactivity : frequent GI symptoms (nausea and/or abdominal distress) sweating, trembling, shaking, and/or dry mouth, palpitations or increased heart rate, sensations of shortness of breath, feelings of choking, chest pain, feelings of dizziness or light-headedness, chills or hot flushes, tingling or lack of sensation in extremities (i.e., paraesthesia) Cognitive / emotional - Subjective experience of nervousness, restlessness, or being ‘on edge’, difficulty concentrating, irritability, depersonalization or derealization, fear of losing control or going mad, fear of imminent death https://www.cognitive-behaviour-therapy.co.za/disorders_anxiety.htm Behavioural – avoidance of perceived threat, avoidant coping mechanisms, use of alcohol and tranquillisers to relax, avoid places where the panic is more prevalent COMMON MENTAL DISORDERS - ANXIETY SYMPTOMS 1. Feelings of anxiety or worry – persistent or intermittent, generalised or specific 2. Associated with biological symptoms – disrupted sleep, easily fatigued, restless, irritable, agitated (wound up – increased appearance of energy) 3. Associated with physical (somatic) feelings like headaches, muscle aches, stomach aches, unexplained pains, rapid heart beat, breathing rapidly, sweating, trembling, feeling week, pins and needles in extremities 4. Cognitive symptoms - altered cognition (difficulty concentrating, paying attention, memory, feeling of impending danger or doom) CLINICAL PRESENTATION AND NATURE OF ANXIETY DISORDERS Generalized anxiety disorder https://my.clevelandclinic.org/health/diseases/23940-generalized-anxiety-disorder- gad CLINICAL PRESENTATION OF PSYCHOTIC DISORDERS Psychosis Loss of contact with reality Symptom which occurs in many disorders - Primary psychotic disorders e.g. schizophrenia - Secondary to other conditions e.g. Mood disorders with psychosis Substance induced psychosis Organic psychosis Image by: Azahara Quesada Tellez CLINICAL PRESENTATION OF PSYCHOTIC DISORDERS Schizophrenia Primary psychotic disorder Difficulty thinking or concentrating that represents a change in the person’s previous behaviour Feeling suspicious, paranoid, or uneasy around others Sudden decline in job or school performance Spending more time alone than usual Image by: Azahara Quesada Tellez Unusual and intense new ideas or feelings, or conversely, no feelings at all Lack of self-care or personal hygiene Having a hard time separating reality from fantasy Difficulty communicating or confused speech CLINICAL PRESENTATION AND NATURE OF PSYCHOTIC DISORDERS Positive Symptoms – something added - Persistent delusions (e.g., grandiose delusions, delusions of reference, persecutory delusions) Getty Images - Persistent hallucinations (most commonly auditory, although they may be in any sensory modality) - Disorganized thinking (formal thought disorder) (e.g., tangentiality and loose associations, irrelevant speech, neologisms ‘word salad’ - Experiences of influence, passivity or control (i.e., the experience that one’s feelings, impulses, actions or thoughts are not generated by oneself, are being placed in one’s mind or withdrawn from one’s mind by others, or that one’s thoughts are being broadcast to others CLINICAL PRESENTATION AND NATURE OF PSYCHOTIC DISORDERS Negative symptoms – something missing - Affective flattening (reduced emotional range evident on expression) - Alogia or paucity of speech - Avolition (lack of drive or motivation) - Asociality - Anhedonia (lack of interest or enjoyment) Getty Images CLINICAL PRESENTATION AND NATURE OF SUBSTANCE ABUSE Alcohol Drugs – tablets, powder, injection, 'headshop', herbal, smoke Getty Creative Images Misuse – abuse – dependence Substance abuse/dependence in isolation Substance abuse/dependence comorbid with mental illness Mental illness secondary to substance abuse https://familycaregiversonline.net/wp- content/uploads/Substance-Abuse_Older-Adults_FI.png CLINICAL PRESENTATION AND NATURE OF SUBSTANCE ABUSE Presentation depends on substance used & whether intoxicated or withdrawal Getty Creative Images - Can mimic depression - Can mimic mania - Can mimic psychosis - Can mimic anxiety - Can induce mental illness and brain impairment https://familycaregiversonline.net/wp- content/uploads/Substance-Abuse_Older-Adults_FI.png MENTAL STATE EXAMINATION 1. Snapshot of a patient’s thoughts, emotions an behaviour at the time of observation 2. Helps identify the presence and severity of any mental condition 3. Helps identify the presence of risk to self or others (LATER, year 4) 4. Structured format when written down but done during the interview while the patient is talking ALO 3 IDENTIFY MENTAL STATES ASSOCIATED WITH COMMON PSYCHIATRIC DISORDERS Appearance: Young man in early 20s dressed in clean trousers and neatly ironed shirt. He appears well-kempt and his personal hygiene is good although he is pale and sweaty Behaviour: He sits in the chair but appears agitated, bouncing his knee as he speaks and wringing his hands Affect: His affect is reactive (reduced emotional reactivity) and appears to be congruent with his mood Mood: He appears objectively anxious and that he feels "worried and anxious" Speech: Normal tone, with good range of tone, normal pitch and volume but his speech is a little fast Thought form: he is speaking a lot, answering the questions asked but with a large amount of detail. There is plenty of content and it makes coherent sense Thought content: Worried about the future, about having enough time for the consult, about whether it will cost money and whether he has enough. Worried that you will not be able to help. Worried about physical symptoms of palpitations and sweating and pins and needles. No evidence of suspicion or paranoia Perception: He denies any hallucinations or perceptual abnormalities and does not appear to be responding to any external stimuli Cognition / Insight / Judgement/ Risk: for spiralling ALO 3 IDENTIFY MENTAL STATES ASSOCIATED WITH COMMON PSYCHIATRIC DISORDERS What does this mental state suggest? Can you suggest whether it is mild, moderate or severe?  ALO 3 IDENTIFY MENTAL STATES ASSOCIATED WITH COMMON PSYCHIATRIC DISORDERS Appearance: Young man in early 20s dressed in a dark coloured tracksuit, he looks dishevelled and his personal hygiene is poor Behaviour: He sits in the chair but appears agitated, occasionally getting up and looking around him. His eyes dart up to the corner where there is a smoke alarm with a red light on it. Minimal eye contact with you even when talking or addressed directly. Affect: His affect is blunted (reduced emotional reactivity) and appears to be incongruent with his mood. He is guarded Mood: He appears objectively agitated and irritable but subjectively reports his mood is "fine" Speech: soft speech, mumbling, reduced in volume and tone - monotonous Thought form: he is speaking a lot (mumbling) but he does not directly answer the questions and while there is plenty of content it is unclear and hard to make sense of – indicates formal thought disorder Thought content: Suspicious of the red light in the ceiling, asks are there cameras monitoring the room? Appears preoccupied with being followed and observed - paranoid Perception: He denies any hallucinations or perceptual abnormalities but he appears to be responding to auditory stimuli as he stops mid- sentence and appears to be listening to something you cannot hear Cognition / Insight / Judgement/ Risk: for spiralling  ALO 3 IDENTIFY MENTAL STATES ASSOCIATED WITH COMMON PSYCHIATRIC DISORDERS What does this mental state suggest? Can you suggest whether it is mild, moderate or severe? ALO 3 IDENTIFY MENTAL STATES ASSOCIATED WITH COMMON PSYCHIATRIC DISORDERS Appearance: Middle aged person dressed in a dark coloured tracksuit, clothes crumpled and dowdy, looks unkempt Behaviour: Sitting quietly in the chair with shoulders slumped; Eyes downcast, minimal eye contact even when talking or addressed directly Limited movement, hands are on their lap Mood: appears objectively low, their responses reveal they feel low "I'm feeling so sad and down" Affect: Their affect is congruent with their mood with reduced emotional reactivity and some tears Speech: soft speech, hard to hear, minimal brief responses to questions, monotone Thought form: speech is clear and coherent indicating no thought disorder Thought content: no interest in anything, is life worth living? Feeling guilty over things they think they have done, not convinced they have done something evil or bad, just a feeling Perception: Denies any hallucinations or perceptual abnormalities and does not appear to be responding to any external stimuli Cognition / Insight / Judgement/ Risk: for spiralling ALO 3 IDENTIFY MENTAL STATES ASSOCIATED WITH COMMON PSYCHIATRIC DISORDERS What does this mental state suggest? Can you suggest whether it is mild, moderate or severe?  ALO 4 DESCRIBE THE TWO DIAGNOSTIC CLASSIFICATION SYSTEMS USED TO DIAGNOSE PSYCHIATRIC ILLNESS ICD –11: International Statistical Classification of Diseases and Related Health Problems (known informally as the International Classification of Disease) (11th edition) DSM-V: Diagnostic and statistical manual of mental disorders (5th edition)  ALO 4 DESCRIBE THE TWO DIAGNOSTIC CLASSIFICATION SYSTEMS USED TO DIAGNOSE PSYCHIATRIC ILLNESS ICD –11 Published by World Health organisation (WHO) Globally used medical classification system used in epidemiology, health management and for clinical purposes Covers all diseases Diagnostic classification for clinical utility Also coded for insurance purposes Multi-disciplinary and multi-lingual  ALO 4 DESCRIBE THE TWO DIAGNOSTIC CLASSIFICATION SYSTEMS USED TO DIAGNOSE PSYCHIATRIC ILLNESS DSM-V Published by American Psychiatric Association North American (and internationally for research) Covers mental disorders only Use: research, clinical (diagnosis after evaluation), medication regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policymakers Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients with mental disorders ALO 5 RECOGNISE COMBINED DISEASE BURDEN IN PATIENTS WITH NEUROLOGICAL AND PSYCHIATRIC DISEASE Neuropsychiatry – Interface between neurology and psychiatry. Behavioural and psychological manifestations associated with neurological conditions: - Stroke - Epilepsy - Head Injury - Parkinson's Disease - Multiple Sclerosis - Huntington's Disease - Wilson's Disease - etc ALO 5 RECOGNISE COMBINED DISEASE BURDEN IN PATIENTS WITH NEUROLOGICAL AND PSYCHIATRIC DISEASE All psychiatric disorders can co-exist with neurological presentations Depression - most common psychiatric co-morbid condition. Other mental disorders – psychosis, anxiety, mania – increased prevalence. Dynamic presentations due to progression of the neurological disease/changes in prescribed medication Aessment – biopsychosocial approach, multidisciplinary, be aware of co-morbidity Unfortunately, increased risk of suicide in people with neuropsychiatric presentations ALO 5 RECOGNISE COMBINED DISEASE BURDEN IN PATIENTS WITH NEUROLOGICAL AND PSYCHIATRIC DISEASE Detailed neuropsychological testing can identify specific problem areas including in comprehension, insight, judgment, IQ deficits etc. Examples of Cognitive Screening and Assessment Tools: - MMSE - MOCA - ACE: Addenbrooke's Cognitive Examination - Frontal assessment battery – FAB (bed-side test examining lexical fluency, abstract thinking, impulse control, and Luria test) - Etc.  PSYCHIATRIC CONSEQUENCES OF STROKE/ATROPHY - Alzheimer’s Dementia - Gradual onset of short-term memory difficulties. More common in females. Global and hippocampal atrophy on scan. - Vascular dementia - Sudden onset, step wise deterioration and presence of risk factors for CVS disease. Usually gross and local ischaemic changes on scan. - Fronto-temporal dementia - Emotional and personality changes usually occur early, followed by cognitive deficits that fluctuate in severity. Fronto-temporal atrophy. Earlier onset – 45- 65yoa – compared to AD and VD - Subcortical strokes - Affects basal ganglia/thalamus/brain stem. Gross psychomotor slowing, depressed mood, movement disorders, mild amnesia and personality changes can all occur. PSYCHIATRIC CONSEQUENCES OF STROKE - Post-stroke depression: - Most common psychiatric consequence: 40-50% of people who develop depression present in the 1st month post stroke. - Most occur within three months. - Increased risk where the stroke affects left-sided frontal lobe and basal ganglia. - Post-stroke anxiety: Approximately 25% of people post stroke meet criteria for GAD - Post stroke psychosis: Psychosis may result from stroke, particularly right hemisphere infarcts - Personality changes: - Irritability, accentuation of previous personality, marked change in personality (eg frontal lobe – disinhibition) - Lability and marked emotional changes: difficulty controlling emotional behaviour PSYCHIATRIC CONSEQUENCES OF EPILEPSY - Epilepsy and psychiatric disorders: - Bidirectional relationship - Potential significant impact on quality of life - Prevalence: 20-30% of people with epilepsy have a psychiatric comorbidity - Particularly strong relationship in Temporal Lobe Epilepsy - Up to 50% of people with TLE develop psychiatric disorders - Most common are depression, anxiety and psychosis (psychosis has 6-12 times risk of general population) - Psychosis most dramatic psychiatric consequence of TLE - Risk factors for epilepsy: - Genetic pre-disposition - Neurodevelopmental issues e.g. ASD - Head injury - Medication related (e.g. antispychotics lowers seizure threshold)  MANAGEMENT OF EPILEPSY Role of the neurologist in the psychiatric management of patients with epilepsy – primarily seizure control. Once psychiatric symptoms identified, the following questions arise: – Are the symptoms related to the occurrence of seizures (pre-ictal, ictal, post-ictal)? – Are the symptoms related to anti-epileptic drugs (AEDs), anti-seizure medications (ASMs) – Is there another cause?  PSYCHIATRIC CONSEQUENCES OF EPILEPSY - Pre-ictal - Vague symptoms in hours and days before seizure - May include….. - Depersonalisation, derealisation - Cognitive symptoms (déja vú, jamais vú) - Affective symptoms (irritability, lability, anxiety, euphoria) - Perceptual experiences (auditory, visual, olfactory hallucinations) - Relieved by seizure - Ictal - Anxiety - Depression (guilt, hopeless, suicidal ideation) - Psychosis (visual, gustatory, olfactory, auditory hallucinations)  PSYCHIATRIC CONSEQUENCES OF EPILEPSY - Post-ictal: - Psychosis: usually follows a cluster or increased frequency of seizures, and a lucid period of 12-72 hours. Delusions, hallucinations, thought disorder, mania – duration transient to weeks - Depression/anxiety/mania - Confusion, disorientation, inattention, variable levels of consciousness and sometimes paranoia - Inter-ictal: - Depression – commonest psychiatric disorder in epilepsy (approximately 40% of people) - Anxiety - Psychosis (resembles schizophrenia but no negative symptoms and onset many years after onset of seizure diagnosis)  PSYCHOGENIC NONEPILEPTIC SEIZURES (PNES) OR JUST ‘NON-EPILEPTIC SEIZURES’ - Paroxysmal episodes that resemble epileptic seizures but are psychological in origin (i.e., emotional, stress-related) - Seizure-like manifestations (limb jerking, truncal movements) without abnormal electrical activity in the brain - They are involuntary dissociative experiences i.e. manifestation of distress. - Seen in 20-30% of patients referred to tertiary care for intractable seizures - Classed as ‘’Dissociative Neurological Symptoms Disorder’’ in ICD- 11 but - More commonly referred to as ‘’Functional Neurological Symptoms Disorder’’ or ‘’Conversion Disorder’’ in DSM-V - A physical/neurological cause must be excluded.  PSYCHIATRIC MANIFESTATIONS OF PARKINSON'S DISEASE - Depression: the most common psychiatric symptom in Parkinson's disease (PD) - Anxiety symptoms often co-occur with motor and non-motor symptoms - Psychosis: Rare in untreated individuals but anti-parkinsonian medication (dopamine agonists) can precipitate psychosis. - Dementia in PD – Usually occurs after years of Parkinson’s disease progression, and assoc. with impaired executive function, memory impairment, and psychotic symptoms. - Treatment Complications: - Dopamine dysregulation syndrome (complication of dopamine replacement therapy) causing impulse control disorder. - Dopamine agonists/levodopa can cause psychosis. - Deep brain stimulation implants for PD have precipitated psychosis, while also treating motor symptoms effectively.  PSYCHIATRIC MANIFESTATIONS OF HEAD INJURIES - Head Injuries: May be open, closed, acceleration/deceleration, focal/diffuse - Impairment depends on the site/severity of the injury: - Amnesia (anterograde/retrograde) - Cognitive: Personality and behavioural changes - Mood/Anxiety disorders: Up to 50% of people have depression after a traumatic brain injury (TBI), mania can occur but less common - Psychosis: TBI a risk factor for schizophrenia; post traumatic psychosis usually better prognosis than primary psychotic disorder and less/no negative symptoms; damage to brain usually frontal/temporal v. schizophrenia  PSYCHIATRIC MANIFESTATIONS OF HEAD INJURIES Substance abuse disorders - Bi-directional relationship - Alcohol or drugs are directly involved in > 33% of incidents that cause brain injury - Increased risk of developing a substance misuse/abuse disorder after TBI BRAIN AREAS AND FUNCTION  OTHER NEUROPSYCHIATRIC CONDITIONS Huntington's disease (HD) - Genetic, AD, trinucleotide repeat disorder - Motor abnormalities, cognitive disturbance and psychiatric symptoms - Psychiatric: Depression – most common psychiatric symptoms of HD, two peaks: initial stages of the disease and peak during stage 2 when independence diminishes – both periods associated with increased risk suicide Multiple Sclerosis (MS) - White matter, demyelinating disease - Psychiatric symptoms include cognitive deterioration (attention, concentration, memory, impaired decision making), lability of mood, depression (most common psychiatric symptoms (50% of people) Increased suicidal ideation and completed suicide - Primary mood disorder v drug induced low mood: steroids, interferon, baclofen, dantrolene and tizanidine can all cause depression.  ALO 6 IDENTIFY MULTIDISCIPLINARY APPROACHES TO MANAGEMENT OF NEUROPSYCHIATRIC ILLNESS Delirium is a common presentation in hospital settings – Often referred to psychiatry for assessment but it is organic in origin Treat the cause of delirium Aggression, disinhibition and impulsivity are common in neurological patients and require careful assessment to distinguish from anxiety, agitation and mania. Careful history and physical examination, evaluation of investigations can help clearly distinguish what is comorbid or additional (e.g. what is new-onset anxiety, depression or psychosis versus adverse effect of medication change)  ALO 6 IDENTIFY MULTIDISCIPLINARY APPROACHES TO MANAGEMENT OF NEUROPSYCHIATRIC ILLNESS Collaboration between liaison psychiatry and medical colleagues. Positive, team-working, problem-solving approach required. Consideration of medical and psychiatric information required. Understanding medical illness and how it influences psychiatric presentations, and vice versa. Active consideration of the roles of each member of the MDT - Psychology, OT, social work, nursing, medical specialties  CONCLUSION Blurred boundaries between neurological and psychiatric illness Complex presentations – be aware of comorbidity, bidirectional relationships, and iatrogrenic illness. Early diagnosis key to improving prognosis in many conditions e.g. delirium MDT working essential within and between medical and neuropsychiatry teams e.g. case conferences, meetings. ACTIVITY LEARNING OUTCOMES 1. Recognise the clinical presentation of common psychiatric disorders 2. Outline the nature of anxiety, mood and psychotic disorders 3. Identify the mental states associated with common psychiatric disorders 4. Describe the two diagnostic classification systems used to diagnose psychiatric illness 5. Recognise combined disease burden in patients with neurological and psychiatric disease 6. Identify multidisciplinary approaches to management of neuropsychiatric illness RESOURCES https://psychscenehub.com/psychinsights/ten-point- guide-to-mental-state-examination-mse-in-psychiatry/ Longer article going into the MSE in detail https://youtu.be/ZGR4Lnn8VCw how to perform a mental state examination PsychScenehub https://emedicine.medscape.com/article/1186336- overview?form=fpf (medscape article on epilepsy and psychiatric conditions – extremely detailed so for intererest and the headlines only) THANK YOU! QUESTIONS? This Photo by Unknown Author is licensed under CC BY-SA