Psychiatric Management in Neurological Disease

All psychiatrists are familiar with drug-induced parkinsonism, and most psychiatrists in a long professional life see patients with Parkinson’s disease, strokes, multiple sclerosis, and AIDS. Many psychiatrists see dystonias such as Meige’s syndrome, spasmodic dysphonia, and neck dystonia (torticollis). Psychiatrists study Wilson’s disease for board examinations, and most psychiatrists probably have seen patients with Fahr’s syndrome and not known it. When a psychiatrist is treating a patient with a neurological syndrome, a review of neuroanatomy and neurophysiology is in order. Often, the clinician is left with best guesses with regard to psychiatric disease as to which came first, the chicken or the egg? Now comes a book that puts together the interaction of psychiatric and neurological diseases.

There are psychiatric symptoms attributable to the characteristic neuroanatomical lesions or neurophysiological alterations of neurological disorders. There are psychiatric symptoms attributable to psychological responses or the drugs used to treat to neurological illnesses. Finally, there are co-occurring psychiatric disorders that seem coincident. Many neurological diseases are rarely fatal for several years and have high psychiatric comorbidity. It behooves all psychiatrists to be familiar with the information in this book, especially psychiatrists who work with a geriatric population or do consultation-liaison work.

The first chapter, by the editor, covers general psychiatric principles in neurological disorders. He sets the stage for the book by stating, “Neurological disorders disrupt basal ganglia-cortical circuits at various levels.” These are the “essential pathways that integrate and mediate mood, cognition, movement, behavior, and other functions critical to psychiatry.” This chapter covers signs localizing to brain structures and behavioral findings helpful in localization. Lauterbach points out that depression is very common in patients with neurological disorders and describes the dilemma of distinguishing it from apathy. There are two useful tables listing potential interactions between diseases and psychotropic medications and potential drug-drug interactions. I found this chapter exceptionally well written and informative.

The remainder of the book reviews specific neurological disorders: Parkinson’s disease, Huntington’s disease, Wilson’s disease, Fahr’s syndrome, dystonia, stoke, multiple sclerosis, and AIDS. There is a final chapter on family management issues. Each of the disease/syndrome chapters is organized in the same format: a brief description of the disorder, prevalence, clinical recognition and neurological presentation, pathological features (including genetics), neuroimaging, laboratory investigation and predictive testing, psychiatric manifestations, neurological management and psychiatric management, and finally a brief summary. These sections of the chapters are well referenced.

I found myself highlighting “pearls” throughout the book. A few examples follow. “Psychosis is rare in untreated PD [Parkinson’s disease] and usually indicates an adverse treatment response” (p. 51). “Dopaminergic agents typically produce silent, nonthreatening visual hallucinations of fully formed human or animal figures in a clear sensorium” (p. 51). “HD [Huntington’s disease] demonstrates autosomal dominant transmission; homozygotes have no more severe disease than heterozygotes” (p. 75). “Clinical suspicion is critical to diagnosing WD [Wilson’s disease]. The disease must be actively considered in the neuropsychiatric differential diagnosis in order to avoid missing the diagnosis” (p. 101). (Take-home message: remember it after taking boards.) With regard to Fahr’s syndrome: “Every first-onset case with dementia, psychosis, or mood disorder deserves MRI scan” (p. 160) (to rule out calcification of the basal ganglia). With regard to dystonias: “All commercially available SSRIs [selective serotonin reuptake inhibitors] have been associated with acute dystonic reactions” (p. 207). With regard to strokes: “Pseudobulbar affect…pathological emotions occurred in 12 (18%) of 66 patients examined 2–3 months poststroke” (p. 222). With regard to multiple sclerosis: “Impairment of one or more cognitive abilities is present in 54%–65% of patients in clinic-based studies and in 43%–46% in community based studies” (p. 252). “Delirium is very common in HIV-infected patients. It is estimated that nearly 30% of hospitalized medical and surgical patients may have an undetected delirious process, and delirium has been found to be the most frequent neuropsychiatric disorder in patients with AIDS” (p. 276).

This is a very useful book for all psychiatrists, especially those who work in consultation-liaison psychiatry, medical psychiatry, and geriatric psychiatry. Neurologists may also find it useful. In the preface, the editor states that books exist on the psychiatry of Alzheimer’s disease and epilepsy, but I hope that these diseases might also be added to future editions of this book. I also would hope that future editions might also include traumatic brain injury and psychiatry.