Chapter 23
Neuropsychiatry
188
, Chapter 23: Neuropsychiatry
Introduction
Neuropsychiatry involves the interface between psychiatry and neurology.
Neuropsychiatry is a specialist medical discipline involving the behavioural or psychological difficulties
associated with known or suspected neurological conditions such as stroke, epilepsy, head injury, psychogenic
non-epileptic seizures, Huntington’s disease, Parkinson’s disease, multiple sclerosis and Wilson’s disease.
The basic skills required in consultation liaison psychiatry are similar to those in other psychiatric settings. In
addition, however, the psychiatrist has to develop several new skills:
o Learning how to conduct complex psychiatric assessments in the medical or surgical wards.
o Learning how to understand and respond to the needs of the referrer, either physician or surgeon, even
when no psychiatric disorder is present.
o Particular interview skills are required to initiate and complete a psychiatric assessment and record the
appropriate clinical signs in the mental state examination.
o Assessment of depression in the physically ill.
o Detection of psychological disorders that present with somatic symptoms.
o Assessment of illness behaviour.
o The psychiatrist should be able to assimilate all the relevant facts into a formulation of the case, including
the physical and psychological aspects.
Liaison psychiatry involves:
o Close collaboration with medical colleagues in terms of initial communication and ongoing contact.
o Reading between the lines of a referral and a pro-active approach to problem solving.
o Understanding psychiatric illness and how it influences medical presentations.
o Understanding medical illness and how it influences psychiatric presentations.
o Active consideration of follow-up and integration with community psychiatry and primary care as
appropriate
o Risk assessment skills.
Basic principles
All psychiatric disorders can co-exist with neurological presentations.
Depression is the most common psychiatric co-morbid condition.
Other common psychiatric disorders that occur at an increased rate are psychosis, anxiety disorders and substance
misuse.
These psychiatric disorders can vary over time in relation to the progression of the neurological disorder and
changes in prescribed medications.
There is an increased risk of suicide in people with neuropsychiatric presentations.
Rating scale
To assess frontal lobe function - the Frontal Assessment Battery (FAB).
Neuropsychological testing may be undertaken to identify specific problem areas such as comprehension,
insight and judgement (Addenbrooke’s Cognitive Examination).
Biological management of neuropsychiatric presentations
Depression
o Most common psychiatric presentation associated with neurological illness.
o SSRIs are generally considered to be the first-line treatment choice.
o TCAs can be efficacious but may be difficult for patients to tolerate.
o Newer antidepressants (e.g. bupropion, mirtazapine) also may be efficacious.
o ECT is effective for patients with treatment resistant depression.
Psychosis
o Typical antipsychotics are efficacious but can have significant adverse effects in neurological patients.
Atypical antipsychotics should be considered the first-line treatment choice.
o Clozapine has the strongest database but is generally considered second-line or third-line because of
side effects.
Anxiety, mania, and agitated states
o Anxiety and agitation are common in neurological patients.
o Mania is much less common.
o First-line treatment choice depends on symptom presentation and aetiology.
For agitated or manic patients, consider anticonvulsants and/or atypical antipsychotics.
For anxious patients, consider SSRIs.
o Benzodiazepines can be effective but can have significant adverse effects in neurological patients.
189
Neuropsychiatry
188
, Chapter 23: Neuropsychiatry
Introduction
Neuropsychiatry involves the interface between psychiatry and neurology.
Neuropsychiatry is a specialist medical discipline involving the behavioural or psychological difficulties
associated with known or suspected neurological conditions such as stroke, epilepsy, head injury, psychogenic
non-epileptic seizures, Huntington’s disease, Parkinson’s disease, multiple sclerosis and Wilson’s disease.
The basic skills required in consultation liaison psychiatry are similar to those in other psychiatric settings. In
addition, however, the psychiatrist has to develop several new skills:
o Learning how to conduct complex psychiatric assessments in the medical or surgical wards.
o Learning how to understand and respond to the needs of the referrer, either physician or surgeon, even
when no psychiatric disorder is present.
o Particular interview skills are required to initiate and complete a psychiatric assessment and record the
appropriate clinical signs in the mental state examination.
o Assessment of depression in the physically ill.
o Detection of psychological disorders that present with somatic symptoms.
o Assessment of illness behaviour.
o The psychiatrist should be able to assimilate all the relevant facts into a formulation of the case, including
the physical and psychological aspects.
Liaison psychiatry involves:
o Close collaboration with medical colleagues in terms of initial communication and ongoing contact.
o Reading between the lines of a referral and a pro-active approach to problem solving.
o Understanding psychiatric illness and how it influences medical presentations.
o Understanding medical illness and how it influences psychiatric presentations.
o Active consideration of follow-up and integration with community psychiatry and primary care as
appropriate
o Risk assessment skills.
Basic principles
All psychiatric disorders can co-exist with neurological presentations.
Depression is the most common psychiatric co-morbid condition.
Other common psychiatric disorders that occur at an increased rate are psychosis, anxiety disorders and substance
misuse.
These psychiatric disorders can vary over time in relation to the progression of the neurological disorder and
changes in prescribed medications.
There is an increased risk of suicide in people with neuropsychiatric presentations.
Rating scale
To assess frontal lobe function - the Frontal Assessment Battery (FAB).
Neuropsychological testing may be undertaken to identify specific problem areas such as comprehension,
insight and judgement (Addenbrooke’s Cognitive Examination).
Biological management of neuropsychiatric presentations
Depression
o Most common psychiatric presentation associated with neurological illness.
o SSRIs are generally considered to be the first-line treatment choice.
o TCAs can be efficacious but may be difficult for patients to tolerate.
o Newer antidepressants (e.g. bupropion, mirtazapine) also may be efficacious.
o ECT is effective for patients with treatment resistant depression.
Psychosis
o Typical antipsychotics are efficacious but can have significant adverse effects in neurological patients.
Atypical antipsychotics should be considered the first-line treatment choice.
o Clozapine has the strongest database but is generally considered second-line or third-line because of
side effects.
Anxiety, mania, and agitated states
o Anxiety and agitation are common in neurological patients.
o Mania is much less common.
o First-line treatment choice depends on symptom presentation and aetiology.
For agitated or manic patients, consider anticonvulsants and/or atypical antipsychotics.
For anxious patients, consider SSRIs.
o Benzodiazepines can be effective but can have significant adverse effects in neurological patients.
189
