Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-060The Psychiatric Manifestations ofCNS MalignanciesM. Glantz and E. MasseyDuke University Medical Center, Durham, NC, USADIAGNOSISA variety of signs and symptoms may lead to the diagnosis ofcentral nervous system (CNS) cancer. One-quarter to one-third ofpatients will be diagnosed following a recognized seizure 4,13,14,30 .Others will come to neurologic or neurosurgical attention becauseof focal weakness or headache 21,43,44 . Tumor-related alterations inbehavior will be demonstrated by 50–90% of patients at sometime during their illness 13,14,31–33 , and in as many as two-thirds ofall patients, a psychiatric manifestation is the initial or onlycomplaint 31–39 . In a majority of these patients, the diagnosis ofcancer is only made once ‘‘hard’’ neurologic deficitsappear 14,24,26,36,39 or at autopsy 21,22 . Meanwhile, treatment for thepsychiatric disturbance is often initiated. This pattern is mostfrequent in the elderly 22 in cases where the tumor occurs in arelatively ‘‘silent’’ area of the brain (the frontal lobe, occipitallobe, ventricle, corpus callosum or septum pellucidum) 37,40–46 andwhen the tumor is relatively slow-growing (astrocytoma, oligodendroglioma,meningioma) 11,14,31,32,34,37,43,45,47,48 .THE PSYCHIATRIC MANIFESTATIONS OF BRAINTUMORSpharmacotherapy—tricyclic antidepressants, selective seratoninre-uptake inhibitors or methylphenidate for depression 58 ; lithium,haloperidol or carbamazepine for mania 31,32,59,60 ; neuroleptics forschizophrenic symptoms 31,32,41 . Paradoxically, successful treatmentof the psychiatric symptoms may delay the correct diagnosisif treatment is initiated without an appropriate search forunderlying disease.Tumor-related SymptomsNeurologic and psychiatric disturbances related directly to thepresence of cancer in the CNS can be catalogued according tothe type of symptom, or the site of the lesion (Tables 60.2 and60.3).Behavioral symptoms are most frequently reported (75–90% of cases) with frontal or temporal lobe tumors 33,47,61 .Inabout one-third of patients these are the initial manifestationsTable 60.2lesionsLocation of the lesionCommon neurologic deficits associated with focal brainCorresponding sign or symptomMany factors, including the tumor itself, increased intracranialpressure 63 , a variety of treatments, the patient’s response to hisillness and the premorbid personality, contribute to the psychiatricsymptoms of patients with neoplasms (Table 60.1). These maybe difficult to separate. Moreover, the signs and symptoms (bothneurologic and behavioral) of a CNS cancer may be intermittentor may fluctuate 24,41,50,51 . Behavioral disturbances may resolvewith surgery or radiation therapy, even if long-standing 39,45,48,51,52 .Frequently, they improve following ECT 55–57 or conventionalTable 60.1Causes of neurobehavioral disturbance in patients with cancerDirect involvement of the nervous system with cancer focal lesionsIncreased intracranial pressureSeizuresMetabolic derangementsNutritional deficienciesEndocrinologic dysfunctionOpportunistic infectionsComplications of therapyPsychological response to the illnessNeurologic paraneoplastic syndromesFrontal lobeTemporal lobeParietal lobeOccipital lobeBasal ganglia, diencephalon,limbic structuresCerebellumSpinal cordLeptomeningealContralateral hemiparesis or hemisensorydeficit; motor aphasia; Brun’s ataxia;incontinence; frontal release signs (snout,grasp, etc)Contralateral hemiparesis or hemisensorydeficit; visual field abnormalities;aphasiasContralateral neglect; visuospatial andcognitive disturbances; apraxia;contralateral visual field deficitContralateral visual field deficitContralateral hemiparesis or sensorydisturbance; aphasias; visual fielddeficits; apraxiaLimb (cerebellar hemisphere) or gait(midline) ataxia; dysarthria; eyemovement disturbancesPain, weakness and sensory disturbancebelow the level of the lesion; sphincterdysfunctionCranial neuropathy; diminished (oftenasymmetric) deep tendon reflexes;weakness; radicular pain; sphincterdysfunctionPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd