|Year : 2014 | Volume
| Issue : 2 | Page : 112-114
"Negative symptoms"secondary to intracranial tumor
Natasha Kate, Shubhangi Parkar, Sampada Raikar, Bijal Sangoi
Department of Psychiatry, KEM Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||3-Mar-2015|
Dr. Natasha Kate
Department of Psychiatry, KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: Lead author is the assistant
editor of the journal of submission.
Intracranial tumors are increasingly common in the elderly population. They may present with varied symptoms, some of which may be psychiatric in nature. In patients with known psychiatric disorders, these symptoms may be misattributed resulting in a delay in diagnosis and management. We present a case of an elderly female with paranoid schizophrenia and new onset symptoms secondary to intracranial tumor, which were initially misdiagnosed.
Keywords: Elderly, intracranial tumor, secondary negative symptoms
|How to cite this article:|
Kate N, Parkar S, Raikar S, Sangoi B. "Negative symptoms"secondary to intracranial tumor. J Geriatr Ment Health 2014;1:112-4
|How to cite this URL:|
Kate N, Parkar S, Raikar S, Sangoi B. "Negative symptoms"secondary to intracranial tumor. J Geriatr Ment Health [serial online] 2014 [cited 2019 Nov 19];1:112-4. Available from: http://www.jgmh.org/text.asp?2014/1/2/112/152434
| Introduction|| |
Over the last 20 years, the overall incidence of brain tumors has increased significantly with an average annual percentage change of approximately 1%.  The average annual percentage increases in primary brain tumor incidence for ages 75-79, 80-84, and 85 and older were 7%, 20.4%, and 23.4%, respectively.  Early symptoms are often behavioral or psychological, and these may be easily missed leading to delay in diagnosis and management. We present a case that demonstrates the need for the clinician to be ever vigilant, especially in the elderly patient.
| Case Report|| |
A 57-year-old female, homemaker, with a 25-year history of paranoid schizophrenia presented to us with recent-onset symptoms of withdrawn behavior, lethargy and a decrease in her spontaneous speech, affective response, initiative, and activity that began since the last 6 months and were gradually progressive. Since the last 25 years, the patient had been having episodes characterized by delusions of persecution and reference, auditory and visual hallucinations, aggression, socially inappropriate behavior and impaired self-care. She was diagnosed with paranoid schizophrenia 20 years and was treated with antipsychotic medication. Over the years, whenever she would be treated with antipsychotics, she would improve completely, with the return to premorbid functioning with no residual symptoms. Noncompliance, however, would often lead to recurrence of symptoms. She had been maintaining well and was on tablet risperidone 4 mg/day and tablet trihexyphenidyl 4 mg/day 6 months prior to index presentation. About 6 months back developed new set of symptoms. What initially began as a reluctance to do small household tasks, increased over a period of 1-2 months to the patient ceasing to do all household work. She would keep lying down in bed the entire day; rarely interact spontaneously, although she would give relevant replies whenever she was addressed. She would not have any facial expression, nor take any interest in the going-ons of her family members unlike previously. Self-care and sleep were maintained though her appetite had decreased. She would report a dull, aching headache which was worse in the mornings, but there was no associated nausea or vomiting. There was no reported slowness of activities, and no impairment in tasks that she did perform, nor was there any forgetfulness. Her treating psychiatrist considered a diagnosis of residual schizophrenia in view of these prominent "negative" symptoms, following which she was shifted to tablet quetiapine 25 mg/day, and tablet risperidone and tablet trihexyphenidyl was tapered off. Tablet quetiapine was then increased over a period of 2 months to 300 mg/day with no improvement of symptoms. During this time, patient began to have episodes of dizziness, which were initially believed to be due to postural hypotension, though, no postural drop in blood pressure was recorded. Patient and family member did not notice any positional associations with the episodes of dizziness. As symptoms did not improve, consultation was sought at our center.
At this time, on mental status examination, patient did not voice any depressive symptoms, delusions or hallucinations. On inquiry, she would only report that she did not have any desire to work or interact and would feel like lying down all the time. She did not elaborate further despite repeated inquiry. Her spontaneous speech was minimal though it was relevant and coherent, her reaction time was increased, her affect was flat, and her attention span was impaired. There were no signs of catatonia, disorientation, or inappropriate behavior. Her Mini Mental Status Examination score was 25. On detailed physical examination, her pulse was 70/min, her blood pressure was 130/90 mmHg, with no postural fall in blood pressure. There was no other evidence of any extra pyramidal symptoms (tremors, rigidity or hypersalivation). Her central nervous system examination did not reveal apraxias, agnosias, anomias or memory impairment. There was no abnormality in her cranial nerves, motor, sensory or cerebellar functions, except for impairment in tandem walking. However, her fundus examination revealed bilateral papilledema. Following this, a magnetic resonance imaging of the brain was done which revealed left side acoustic schwannoma extending into internal acoustic canal, causing decompensated hydrocephalus and increased intracranial pressure. A neurosurgery liaison was sought, and the patient was started on intravenous mannitol 100 mL t.i.d. and injection Dexamethasone 4 mg t.i.d to decrease the raised intracranial pressure. With the above treatment for 3 days, there was sudden and significant improvement in symptoms. The patient became much more interactive, interested in her surroundings, began initiating and performing all her tasks with enthusiasm as per premorbid self. Tablet quetiapine was decreased to 200 mg, with no impact on symptomatology. The nature of the tumor and the prognosis was discussed with the patient and the family and following written informed consent, patient was taken up for left retrosigmoid craniotomy with excision of left acoustic schwannoma, following which she has been maintaining well with regards to her psychiatric symptoms for the last 3 months.
| Discussion|| |
Intracranial tumors may manifest specific or general symptoms depending upon their location and/or secondary to increased intracranial pressure. Headache is the most common symptom reported by patients with intracranial tumors.  Papilledema develops in about 25% of patients with a brain tumor but may be absent even when intracranial pressure is increased.  Changes in the patient's mental state or psychiatric symptoms are the next most common presentation. , Often seen psychiatric symptoms include irritability, lethargy, confusion, psychomotor retardation, and sometimes even frank psychosis and delirium.  When such symptoms occur in patients with known psychiatric disorders, misattribution of symptoms (of the tumor) to the primary psychiatric illness or medications is common. This may occur despite symptoms of the tumor being different from the underlying psychiatric disorder. Diagnosis of primary brain tumors in the elderly is more difficult because symptoms may mimic the physical and cognitive changes seen in the normal aging process.
Our patient had few early warning symptoms which were missed during her initial clinical assessments. Headache that was worse in the mornings, sudden change in her symptom profile and episodes of dizziness, would all make a clinician wary when present in a "normal" individual. But given her past psychiatric history, our patient's initial symptoms were misattributed. Her dizziness was secondary to the tumor of the vestibular nerve while headache was a sign of raised intracranial pressure. As our patient had a left acoustic schwannoma, it was possible that her psychiatric symptoms were secondary to the location of the tumor. Previous reports have identified psychotic disorders and mood disorders in conjunction with cerebro-pontine tumors. , However, the decompensated hydrocephalus and raised intracranial pressure could also be responsible for the new onset symptoms, which were possibly initially diagnosed as "negative symptoms of schizophrenia." The fact that these symptoms improved significantly after dexamethasone and mannitol (which decreases intracranial pressure) further points toward the role of the raised intracranial pressure in her present symptomatology.
This case highlights the need for the psychiatrist to be on the alert, whenever a patient has a sudden change in symptoms, especially if the patient is elderly. In addition, this care underlines the importance of detailed physical examination, especially fundus examination in all our patients, lest we miss an underlying comorbid physical disorder.
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