Neuropsychiatric Disorders

Neuropsychiatric disorders
Chapter:
Neuropsychiatric disorders
Author(s):
Mervi L.S. Pitkanen
, Tom Stevens
, and Michael D. Kopelman
DOI:
10.1093/med/9780199204854.003.2604
Neuropsychiatry is concerned with disorders of affect, cognition, and behaviour that arise from overt
disorder in cerebral function, or from indirect effects of extracerebral disease.
The clinician needs to have a practical approach to the assessment, investigation, and management
of patients manifesting cognitive and behavioural change, and to be aware of the specific cerebral and
extracerebral disorders that commonly involve or are accompanied by cognitive or behavioural
change.
In the assessment and classification of mental and behavioural disorders it is crucial to: (1) distinguish
between acute and chronic disordersparticularly between delirium and dementia; (2) distinguish
between cognitive and psychiatric disordermisdiagnosis of depression presenting as a
pseudodementia, or of delirium as psychosis, are errors that can have dire consequences for the
patient; (3) determine whether cognitive impairment is specific or generalizedspecific impairments
are more likely to be due to a focal brain lesion; and (4) determine whether any underlying condition is
reversible or irreversible.
Acute cognitive and behavioural disturbance
Deliriumcan be caused by a very wide range of conditions and needs to be distinguished from acute
psychosis, which can be difficult. Features that support the diagnosis of delirium are: (1) deficits of
attention that may range from distractibility and inability to follow complicated conversations, through
an almost complete inability to register information or to concentrate (manifest poor performance on
serial subtraction test), progressing in the extreme case to diminished consciousness and coma; (2)
attentional difficulties that tend to have a sudden onset and to fluctuate over time; (3) muddled
thinking and speech showing considerable perseveration; (4) illusions and hallucinations that tend to
include a strong visual component, although auditory hallucinations and misperceptions are common;
and (5) delusions are usually simple, persecutory in nature, fluctuating, and transient.
Psychiatric disordersa past history of psychiatric contact or treatment should be sought in all those
with behavioural disturbance. In patients with an underlying psychiatric disorder there is usually a
background of insidious behavioural disturbance or personality change. Delusions in psychotic
disorders tend to be complex, bizarre, and consistently held, visual hallucinations are rare, and
marked attentional and memory deficits are not typical (see Chapter 26.5.7).
Alcohol and substance misuseabout one-quarter of all male medical admissions have a current or
previous alcohol problem, and such patients are vulnerable to a large number of complications that
may precipitate delirium.
Clinical approachit is necessary to consider a wide range of factors and medical conditions that can
both predispose to and precipitate delirium. A history of alcohol and/or illicit substance misuse is of
particular importance. Although not always easy, a thorough physical examination with particular
attention to the neurological system is essential. A routine screenincluding full blood count,
electrolyte, and -glutamyl transferase (GGT) measurements, liver and thyroid function tests, glucose
estimation, and C-reactive protein (CRP)/erythrocyte sedimentation rate (ESR)is required, as this
might indicate delirium where the diagnosis is in doubt. Infection is implicated in around one-third of
hospital inpatients who are delirious, and a midstream urine sample (MSU) and chest radiograph are
usually warranted. Relevant history and findings on physical examination determine the need for more
specific investigation, e.g. brain CT, lumbar puncture, malarial blood film.
Managementdelirium is a medical emergency. Management consists of treating the underlying

causes and containment of any behavioural disturbance with general measures in the first instance,
including nursing in a bright, simple room with minimal changes in staff and good lighting at night.
Where sedation is required, then a regular oral antipsychotic such as haloperidol can be administered
(see Chapter 26.3).
Chronic and subacute cognitive and behavioural disturbance
The diagnostic challenges in this group of patients are exemplified by the complex differentiation
between dementia and depression or depressive pseudodementia.
Dementiathis is a progressive neurodegenerative syndrome involving a pervasive impairment of

higher cortical functions resulting from widespread brain pathology. Reversible causes must be
excluded. A typical diagnostic screen will include a full blood count, electrolyte and metabolic screen,
thyroid screen, vitamin B12 and folate levels, syphilis serology, urinalysis, chest radiography,
electrocardiography, and CT/MRI brain imaging. In some cases, lumbar puncture,
electroencephalography, and (rarely) brain biopsy will be required. Functional brain imaging is likely to
assume greater importance in the future.
Focal cognitive disordersa variety of neuropsychiatric syndromes may arise from regional cerebral
impairments of diverse cause and may present in the absence of generalized cognitive impairment:
frontal lobe, temporal lobe, parietal lobe, and diencephalic syndromes are recognized.
Organic comorbidity in psychiatric disorders
Missing an underlying organic diagnosis remains a continuing concern for clinicians responsible for
the assessment and treatment of new cases of an apparent psychiatric disorder. (1) Organic psychotic
disorderdebate remains over the degree of investigation appropriate at the onset of psychosis.
Patients with cognitive impairment, abnormal neurological signs, atypical illnesses not responding to
treatment, or other indications from the history, certainly warrant further investigations. Where
appropriate, this should include neuroimaging, electroencephalography, syphilis serology, and other
investigations indicated by the clinical picture. (2) Organic mood disordera variety of medical
conditions are associated with prominent affective disorder. (3) Organic personality disorder
insidious changes in personality may reflect frontal lobe pathology.
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Neuropsychiatric disorders

Acute cognitive and behavioural disturbance

Managementdelirium is a medical emergency. Management consists of treating the underlying

Chronic and subacute cognitive and behavioural disturbance

Dementiathis is a progressive neurodegenerative syndrome involving a pervasive impairment of

Organic comorbidity in psychiatric disorders

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