J7ournal ofNeurology, Neurosurgery, and Psychiatry 1993;56: 1149-1156 1149 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.11.1149 on 1 November 1993. Downloaded from NEUROLOGICAL EMERGENCY Acute behaviour disturbances GG Lloyd Psychiatric disorders are commonly encoun- Affective disorders tered in neurological practice and most neu- The fundamental disturbance is a change of rologists accept the need to assess and mood (or affect), either depression or elation. manage behavioural problems. The more However, mood disturbance is not necessarily complicated cases require expert psychiatric the most prominent symptom and it may be intervention and, for optimum care, it is masked by a wide range of other abnormali- essential that there is close collaboration ties which at first sight suggest the presence of between neurologist and psychiatrist. organic disease. Affective disorders have a Many neurological conditions, particularly tendency to recur. When the recurrences those with cerebral involvement, increase the always take the same form, the condition is risk of developing a psychiatric disorder. referred to as unipolar affective disorder; Furthermore psychiatric disorders can be when the mood change varies between associated with symptoms such as headache, depression or elation it is described as bipolar dizziness and weakness which suggest neuro- affective disorder. logical disease but for which no organic explanation can be found. This phenomenon, DEPRESSIVE DISORDER known as somatisation, is being increasingly Depression not associated with organic dis- recognised and accounts for a substantial pro- ease usually presents to the neurologist with portion of patients who are referred to neuro- symptoms such as headache, dizziness, dis- logical departments. turbance of higher mental function and facial Schiffer' evaluated a consecutive series of or bodily pain.4 Psychological symptoms, 241 patients attending an American neurol- emotional conflicts, and life stresses may not ogy service and found that 101 (41.9%) had be volunteered and are only elicited by tact- symptoms sufficient to warrant a psychiatric ful, direct questioning on the part of the diagnosis according to DSM-III criteria. Of examining doctor. Fitzpatrick and Hopkins5 57 inpatients, 10 were considered to have a assessed a series of patients referred to a neu- primary psychiatric disorder and five of these rologist with headaches not due to structural http://jnnp.bmj.com/ had no neurological illness. Among 184 out- disease and found that 37% had an affective patients, 32 had a primary psychiatric disor- disorder of at least mild severity. The preoc- der and 30 of these had no neurological cupation with pain may dominate the clinical illness. Kirk and Saunders2 had previously picture to such an extent that the patient does described a retrospective survey from a neu- not appear depressed and does not readily rological clinic in northeast England and admit to feeling depressed. This has been reported that, during a four year period, 358 described in relation to facial pain6; the cogni- (13-2%) of 2716 patients had a psychiatric tive features of depression such as self on September 28, 2021 by guest. Protected copyright. disorder with no evidence of neurological ill- reproach, suicidal thinking and psychomotor ness. retardation were uncommon but, in addition If the psychiatric disorder underlying the to pain, the patients complained of insomnia, neurological symptoms is not recognised, fatigue, irritability, and agitation. patients can be subjected to unnecessary and Depression also complicates existing neu- expensive investigations3. They may receive rological disease. In some cases-for exam- symptomatic treatment which fails to alleviate ple, spinal cord injuries,78 depression appears their condition and they will become dissatis- to result largely from the personal and social fied with the result of their treatment and try implications of the neurological disability. to consult other specialists in the hope of In diseases in which there is cerebral in- finding a more effective remedy. volvement, the aetiology of depression is Some of the psychological symptoms and more complex. The mood disturbance may behavioural disturbances which the neurolo- be triggered by the emotional impact of the Department of gist encounters are of sudden onset and disease but may also result from structural Psychiatry, Royal require urgent attention. This review pathology, possibly through interference Free Hospital, describes the clinical features and manage- with neurotransmitter pathways within the London, UK G GLloyd ment of those disorders which are most likely brain. Depressive disorders with cerebral in- Correspondence to: to give rise to acute behavioural problems in volvement are classified as the organic mood Dr Uloyd neurological practice. disorders by the International Classification 1150 Lloyd J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.11.1149 on 1 November 1993. Downloaded from of Disease (ICD-10).9 One of the most signif- should evaluate the patient as soon as icant features of these disorders is that the possible. A number of management options, mood disturbance, either depression or including outpatient or day hospital treat- mania, may be the first manifestation of ment, are available according to the perceived underlying neurological pathology. 10 risk and availability of social support. When Suspicion of unrecognised physical illness the risk is high and the patient has little in the should be particularly high if there is no clear way of support, admission to a psychiatric psychosocial precipitant, if the mood disorder ward should be advised; this may have to first presents in middle or late life and if there involve invoking the Mental Health Act if the is no family or personal disposition to psychi- patient cannot be persuaded to accept volun- atric illness." tary admission. Depression has been described as a presenting feature of cerebral tumours,12 Stupor multiple sclerosis,"3 14 Parkinson's disease'5 16 Stupor is another serious complication of and Huntington's chorea17 18 but most atten- depression. It is a term that leads to disagree- tion has been given to its association with ment between neurologists and psychiatrists, cerebrovascular disease. Eastwood et al 19 re- who use it in different ways. It is sometimes ported that 10% of patients in a stroke reha- used to describe an intermediate stage on the bilitation inpatient unit had a major spectrum of impaired consciousness that depressive disorder, while 40% had symp- eventually leads to coma. Lishman29 argues toms of minor depression. Robinson et al 20 that this is an incorrect use of the concept studied patients admitted to hospital after an which he believes is more appropriately acute stroke and found that 27% demon- defined as a syndrome in which the patient is strated symptoms of major depression, while conscious but makes no spontaneous move- 20% had symptoms of minor depression. The ment and shows little response to external association between mood disturbance and stimuli; in the most advanced form of stupor severity of physical impairment is not a strong the patient is completely mute and immobile. one and it has been proposed that the site of Consciousness is inferred by the fact that the vascular lesion is important in determin- there may be purposeful eye movements, fol- ing post-stroke depression. Left-sided lesions lowing the actions of other people in the in the frontal lobe or basal ganglia have been vicinity, and also by the patient's recall of particularly implicated.2' Other reports have events once recovery has occurred. In psychi- not confirmed this hypothesis and have found atric practice, depression and schizophrenia a lower prevalence of depressive illness, espe- are the commonest causes of stupor.30"3 The cially when the survey has included patients diagnosis depends on eliciting a history of the not admitted to hospital.22 relevant symptoms during the weeks before Some patients with cerebrovascular disease the onset of stupor. In the case of depression experience mood disturbances that are too there is a history of progressive psychomotor brief to justify the diagnosis of a depressive retardation in addition to the psychological illness.2' This phenomenon, known as patho- symptoms of low mood, guilt and self logical emotionalism, is manifest by rapid reproach. A full neurological evaluation, in- changes of mood, sudden episodes of crying, cluding CT of the brain, is essential before a can be made with and inappropriate and uncontrollable laugh- diagnosis confidence. http://jnnp.bmj.com/ ter. This type of mood change has been Cerebral disorders that can give rise to the observed more commonly in patients with clinical picture of stupor include dementia, lesions in the left frontal and temporal areas. encephalitis, and cerebral tumour or cyst in the upper midbrain or posterior diencephalon Assessment ofsuicide risk causing increased intracranial pressure. The risk of suicide is one of the reasons why depression can become an acute medical Management ofdepressive disorder problem and it must be considered when Depression usually responds to a combined on September 28, 2021 by guest. Protected copyright. assessing any patient who is thought to be approach of antidepressant medication and depressed. The risk is increased in several cognitive therapy. Tricyclic antidepressants neurological disorders,2425 particularly multi- (amitriptyline,