Olgu Sunumları / Case Reports Atypical Psychiatric Symptoms Associated with Left Temporal Lesion: Two Cases Yavuz Selvi1, Adem Aydin3, Lutfullah Besiroglu2 ÖZET: ABS TRACT: 1Assistant Professor of Psychiatry, 2Associate Sol temporal bölge lezyonu ile ilişkili atipik psiki- Atypical psychiatric symptoms associated with Professor of Psychiatry, Department of yatrik semptomlara sahip iki olgu sunumu left temporal lesion: two cases Psychiatry, Yuzuncu Yıl University, School of Medicine, Van-Turkey, 3Psychiatrist, Department of Psychiatry, Genel tıbbi durumla ilişkili pek çok etmen psikiyatrik Brain lesion is a major risk factor for the development of Training and Research Hospital Van-Turkey bozukluklara sebep olabilir ve beyin lezyonları da özellikle psychiatric symptoms. There is an association between lesion Ya zış ma Ad re si / Add ress rep rint re qu ests to: tipik olmayan belirti ve bulgular oluşturması sebebiyle type, location, and psychiatric symptoms. Common psychiatric Uzm. Dr. Adem Aydin, Van Eğitim Araştırma önemli bir risk faktörüdür. Psikiyatrik belirtilerle beyin içi comorbidities of brain lesions include affective, cognitive, Hastanesi Psikiyatri Kliniği, Van-Turkey lezyonun tipi ve lokalizasyonu arasında ilişki vardır. Bu vaka and behavioral disorders; therefore, organic causes should be sunumunda sol temporal bölgede lezyonu bulunan iki olgu carefully investigated by clinicians and treatment regimens Telefon / Phone: +90-506-359-1849 dolayısıyla, belirgin nörolojik belirtiler ortaya çıkmadan planned by considering organic causes. In this report, two Elekt ro nik pos ta ad re si / E-ma il add ress: görülen karışık psikiyatrik belirtiler ve bu tür olgularda patients with left temporal lesions, who developed atypical [email protected] tedavi yaklaşımları tartışılacaktır. Her iki olgu da hem tanı psychiatric symptoms, are described and the distinctive Ka bul ta ri hi / Da te of ac cep tan ce: hem de tedavi açısından klinisyenin beyin lezyonuna ikin- features of their diagnoses are summarized. 11 Haziran 2010 / June 11, 2010 cil olarak oluşan psikiyatrik bozuklukların ayırıcı tanısının yapılmasında dikkatli olması gerektiğini hatırlatmaktadır. Key words: Mood, brain lesion, temporal lobe, injury, Bağıntı beyanı: Y.S., A.A., L.B.: Yazarlar bu makale ile antiepileptic ilgili olarak herhangi bir çıkar çatışması Anahtar sözcükler: Duygudurum, beyin lezyonu, temporal bildirmemişlerdir. lob, hasarlanma, antiepileptik Bulletin of Clinical Psychopharmacology 2010;20:329-333 Declaration of interest: Y.S., A.A., L.B.: The authors reported no Kli nik Psi ko far ma ko lo ji Bül te ni 2010;20:329-333 conflict of interest related to this article. INTRODUCTION periods. During this critical period, symptoms may worsen and the consequences may be compounded (4). Many organic causes can produce psychiatric symptoms and/or disorder(s). Clinicians must distinguish CASE 1 secondary psychiatric disorders from primary ones to develop a correct treatment plan. Most secondary The patient is a 45 year old right handed woman. She psychiatric disorders occur following brain injury (i.e. is a widow with 5 children. She was brought to the our tumors, cerebrovascular lesions, head traumas, infectious clinic by her brother because of psychotic symptoms, diseases, etc.) (1). The study of discrete organic cerebral including suspiciousness, speaking to herself, lesions resulting in clearly definable psychiatric disorders aggressiveness and swearing, and mood symptoms, may provide an understanding of the underlying including excessive joyfulness, talking, and spending. pathophysiological bases of these disorders (2). Brain Her illness started 2 years ago. There was no life event lesions are a major risk factor for development of stressor before her illness began. She left her house and psychiatric symptoms. There is an association between she was not taking care of her children. She was crying lesion type, location, and psychiatric symptoms. The and laughing in the same time. Her symptoms continued existence of organic lesions localized in the brain must be for two years without recovery. On psychiatric investigated if the patient has atypical and complex examination, the patient’s mood was irritable. Her psychiatric symptoms. Common psychiatric co-morbidities emotional tone and speech did not agree. She had rapid of brain lesions include affective, cognitive, and behavioral and pressured speech. She did not have adequate ability to disorders (3). Until a diagnosis is established, patients concentrate or pay attention. She reported auditory may be deprived of appropriate treatment for prolonged hallucinations and her associations were becoming loose. Klinik Psikofarmakoloji Bülteni, Cilt: 20, Sayı: 4, 2010 / Bulletin of Clinical Psychopharmacology, Vol: 20, N.: 4, 2010 - www.psikofarmakoloji.org 329 Atypical psychiatric symptoms associated with left temporal lesion: two cases She had mood-incongruent delusions of a persecutory of the EEG and MRI findings. Carbamazepine 800 mg. type with euphoria. Her immediate and recent memory and clonazepam 1.5 mg. per day were prescribed for the were impaired. Neurological examination showed no patient. Over the next 15 days psychomotor agitation and abnormal findings such as nystagmus, speech disturbance, mood lability gradually decreased. ataxia, motor and sensory disturbances, or involuntary movements. The rest of her general physical examination CASE 2 was within normal limits. In her past medical history, she had sustained an unclear head injury which had been The patient is a 32-year old right handed woman; she accompanied by loss of consciousness two years ago. is married and has 4 children. She had complaints of Before the trauma, she had no significant medical or markedly diminished pleasure, loss of energy, feelings of psychiatric problems When the patient was evaluated by worthlessness, and thoughts of death. The complaints had an electroencephalography, focal wave complexes which gradually increased and she had attempted suicide by were localized in the left temporal area and slight neuronal jumping. On psychiatric examination, she was pessimistic hyperexitability were noted. The brain MRI demonstrated during the psychiatric interview. She expressed suicidal an area of malacia (3X2,5 cm) in the anterior part of the ideation. Her mood was irritable and depressed. She had left temporal lobe (Figure 1). auditory hallucinations and nihilistic delusions. The Figure 1: Magnetic resonance imaging in case 1. T1 weighted axial images. Clinical Progression: During admission to the neurological examination showed no abnormal findings; psychiatry clinic, the patient was disoriented, with however, her electroencephalogram showed focal spike- inappropriate affect and psychomotor agitation. Rapid and wave discharges which localized in the left temporal area. abrupt changes in emotional tone were observed. A mixed Her general physical examination was within normal and atypical symptomatology was noted. All psychiatric limits, but the brain MRI demonstrated an area of malacia symptoms and findings continued, although her (5x2 cm size) which was localized in the left temporal disorientation improved within a day. It was thought that lobe (Figure 2). She had a history of head trauma. She had this clinical presentation was not due to delirium. It was fainted and lost consciousness one year ago. She had been proposed that these symptoms were likely related to an treated for cerebral hemorrhage. Post-traumatic mania had underlying neuropathological condition after consideration developed after the trauma and this episode ended four 330 Klinik Psikofarmakoloji Bülteni, Cilt: 20, Sayı: 4, 2010 / Bulletin of Clinical Psychopharmacology, Vol: 20, N.: 4, 2010 - www.psikofarmakoloji.org Y. Selvi, A. Aydin, L. Besiroglu Figure 2: Magnetic resonance imaging in case 2. T1 weighted axial images. months later without treatment. Before the trauma, she bipolar disorder (8-10). Koponen and colleagues (2002) had no significant medical or psychiatric problems. There have also showed rates as high as 48.3% for any was no family history of neurological and psychological psychiatric disorder starting after the brain injury, with abnormalities. major depression being the most common diagnosis Clinical Progression: Electro-convulsive therapy (26.7%) (11). Neither mania nor depression are rare (ECT) was given for her suicidal thoughts and depressed complications of brain lesions, but case reports of mood. Agitation occurred after each ECT application and depressive and manic episodes related to brain injury are her agitation did not respond to haloperidol injections. rare. In case 2; the patient had a manic episode after brain Although her depressed mood and suicidal thoughts trauma and post-traumatic mania had been diagnosed. improved, her agitation increased and emotional lability After 1 year from the first episode, the depressive episode began . Both depressed and manic reactions were observed occurred with psychotic features. The patient’s clinical during the day after ECT applications. condition did not improve with ECT and antipsychotic Carbamazepine 600 mg., amytriptiline 50 mg., and treatment, but symptoms gradually decreased with clonazepam 1.5 mg. per day were started because of antiepileptic treatment. Major depression is a frequent continued symptoms and the ECT-induced manic reaction. complication of brain injury and may present with many Mood lability, anxiety, and agitation improved with this different features. Executive dysfunction,