Volume 3, 2018, 18-24 REVIEW ARTICLE Psychiatric aspects of tumours of the central nervous system NUNO MADEIRA* PEDRO OLIVEIRA Psychiatry Department, Centro Hospitalar e Universitário de Coimbra; Faculty of Medicine, University of Coimbra TIAGO Santos Department of Psychiatry and Mental Health, Baixo Vouga Hospital Centre EMíLIA ALBUqUERqUE Psychiatry Unit, Francisco Gentil Portuguese Institute of Oncology, Coimbra Abstract: The incidence of brain tumours has increased in recent years. They represent the second most common cause of death attributable to neurological conditions. Although expansive brain lesions often lead to observation by Neurology or Neurosurgery, it is not uncommon for psychiatric symptoms to be the reason for initial contact with medical care. Brain tumours may present as symptomatology similar to the so-called primary, or functional, psychiatric disorders. However, in contrast to psychiatric disease in other types of cancer, where adjustment disorders predominate, organic syndromes are the most frequent diagnosis in patients with CNS tumours. Anatomic location represents one of several factors that contribute to the nature and severity of psychiatric conditions. Tumours of the frontal lobe are more frequently associated with changes in executive function, amotivational syndrome and personality changes. Temporal tumours can trigger psychotic symptoms such as hallucinations and delusions. The treatment of the symptomatology will essentially involve removal of the lesion whenever possible. Nevertheless, symptomatic treatment of psychiatric manifestations should always take place. Psychopharmacology, psychotherapy and psychoeducation of caregivers are the best modes of treatment. Keywords: Central Nervous System Neoplasms; Psycho-oncology; Psychiatric Symptoms Introduction rior fossa, the most common supratentorial lesions being Psycho-oncology spans the two principal psychiatric and those of the frontal (22%) and temporal lobes (22%); 12% psychological dimensions of cancer: on the one hand, the are located in the parietal lobes, 10% in the sella turcica, experiences of patients and their family members over the and 4% in the occipital cortex 2 . course of the disease, and also the stress felt by care-giv- Cerebral metastases generally manifest as hemiparesis ing professionals; on the other, the psychological, behav- and cognitive dysfunction; unilateral hypoesthesia, atax- ioural and social factors that influence risk, detection and ia and aphasia are less common symptoms 3 . The usual survival of oncological disease 1 . symptomatology of primary brain tumours – solid tu- The incidence of brain tumours has increased in recent years. mours or lymphomas – is cognitive dysfunction, head- They represent the second most common cause of death at- aches, vomiting, seizures and focal deficits 4 . Disease tributable to neurological causes, the first being stroke 2 . progression and the toxic effects of treatment (e.g. radio- Brain tumours can be classified according to their nature therapy) tend to cause cognitive deterioration to worsen (primary or metastatic), histology or location. Gliomas and, at advanced stages, demential syndromes or changes (40-55%) and meningiomas (10-20%) represent the ma- in consciousness. jority of expansive intracerebral lesions. Metastatic le- While expansive brain lesions often lead to observation by sions (15-25%) originate most commonly from lung and Neurology or Neurosurgery, it is not uncommon for initial breast tumours. 30% of tumours are located in the poste- contact with medical care to be prompted by psychiatric symptoms. A study of 530 patients with brain tumours re- * Correspondence to: [email protected] ported that in 18% of cases clinical presentation was psy- Psychiatric aspects of tumours of the central nervous system 19 chiatric 5 . A recent analysis of patients with meningiomas medial syndrome, which manifests above all as apathy, indicated that 21% of the study sample had initially pre- is usually related to tumour lesions of midline structures sented with psychiatric symptoms in the absence of neu- (thalamus, third ventricle, hypothalamus and pituitary), rological signs 6 . and also occurs following bilateral occlusion of the ante- rior cerebral arteries and bilateral thalamic infarcts. Lastly, Clinical Aspects orbitofrontal syndrome, in which changes in behaviour Brain tumours may present in the form of symptoms and pragmatics are to the fore, is associated with tumours similar to primary, or functional, psychiatric disorders. (e.g. inferior frontal meningiomas), as well as post-trau- However, in contrast with what happens with regard to matic lesions, vascular lesions of the anterior cerebral ar- psychiatric illness in other types of cancer, where ad- tery, multiple sclerosis and fronto-temporal dementia 8 . justment disorders predominate, organic syndromes are the most common diagnosis in patients with tumours of Table 1. Frontal syndromes the CNS. DORSOLATERAL syndrome Although some symptoms or syndromes may be associ- Predominant involvement of executive functions. ated with dysfunction of certain parts of the brain (e.g. Poor planning depression and personality changes in frontal tumours and Reduced mental flexibility psychosis in temporal lesions), anatomic location repre- Abstraction deficit sents one of several factors that contribute to the nature Persistence and severity of the psychiatric picture. Fast-growing tu- Apathy Distractibility mours are more frequently associated with agitation and Personal neglect psychosis, and more obvious cognitive dysfunction. Less Behaviours directed at stimuli aggressive lesions are associated with apathy, depression and incomplete personality changes. Multiple tumour sites VENTROMEDIAL syndrome tend to cause more significant behavioural changes. In- Deficit of initiative and motivation. creased intracranial pressure, a non-specific consequence Apathy Abulia of tumours of the CNS, is associated with apathy, depres- Incontinence sion, irritability, agitation and changes of consciousness. Gait changes Silent onset and few symptoms are a feature of the evo- lution of tumours of certain regions of the brain; lesions ORBITOFRONTAL syndrome of the anterior part of the frontal lobes, the corpus callo- Predominance of personality changes. sum, the non-dominant parietal and temporal cortex and Deterioration of social pragmatics the posterior fossa are examples of this 2 . Disinhibition Impulsiveness Moria (foolish euphoria) Frontal Lesions Emotional lability The frontal lobe constitutes the most recently evolved re- Distractibility gion of the brain in phylogenetic terms and the largest in Olfactory changes the central nervous system, representing 1/3 of its total volume. From the anatomo-functional point of view, the This anatomo-functional division is rarely clear in clin- frontal lobe is divided into at least five specialised regions: ical practice: pure presentations of these syndromes are (1) motor cortex, (2) pre-motor cortex, (3) frontal opercu- uncommon. In addition, personality changes, particular- lum, (4) para-olfactory or subcallosal zone and (5) pre- ly associated with frontal lesions (more than 70% of cas- frontal cortex. The pre-frontal cortex is the region of the es), may occur in disorders of diencephalic and temporal frontal lobe most commonly related to metacognitive abil- structures. ities, executive functions and social behaviour in general. Psychotic symptoms may be present in 10% of frontal tu- It can be divided into three distinct zones, which corre- mours. Delusions are usually fragmented and hallucina- spond to the dorsolateral, orbitofrontal and frontomedial tions are rarely auditory and complex, in contrast to what cortex. In general terms, we can organise the nature of the is most characteristic of schizophrenic psychosis 2 . deficits resulting from lesions in accordance with the pro- posed division of the pre-frontal cortex by establishing the Temporal lesions existence of three syndromes – see Table 1. 7 In addition to frequent symptoms of the ictal sphere, tu- Dorsolateral, or disorganised, syndrome, characterised mours of the temporal region have in the past been associ- by impairment of executive functions, is due in the major- ated with psychotic symptoms of a schizophreniform type. ity of cases to tumour lesions, ischaemic lesions, trauma However, more recent reports have described atypical or neurodegenerative disease of the frontal lobe 8 . Ventro- symptoms, not always associated with schizophrenia: vis- 20 Nuno Madeira | Pedro Oliveira | Tiago Santos | Emília Albuquerque ual, olfactory or tactile hallucinations, and mood swings Onset of symptoms is acute or subacute, and the latter are with suicidal behaviours, with conserved affect and social transient and reversible. These chronological characteris- interaction. tics help differentiate it from demential syndrome. In their Behavioural symptoms are common in temporal lesions: early stages, cases of hypoactive delirium may be inter- personality changes have been described in more than preted as depression. In rare situations, delirium may be the 50% of patients. As described in lesions of the frontal initial manifestation of neoplastic lesions in the CNS 15 . lobe, psychiatric symptoms like apathy, irritability and The approach to delirium includes from the start identify- emotional lability occur. Anxiety is also present in more ing and correcting, wherever possible, underlying causes than 30% of cases 2 . (see Table 2). Parietal