Psychiatry for Neurologists

423 Pages·2006·2.89 MB·English

by  Christopher G. Goetz MD (auth.), Dilip V. Jests MD, Joseph H. Friedman MD (eds.)

Psychiatry for Neurologists
C C N
U R R E N T L I N I C A L E U R O L O G Y
Daniel Tarsy, , S E
MD ERIES DITOR
Psychiatry for Neurologists,edited by Dilip V. Jeste and Joseph H. Friedman, 2006
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Psychiatry
for Neurologists
Edited by
Dilip V. Jeste,
MD
Departments of Psychiatry and Neurosciences, University of California,
San Diego and VA San Diego Healthcare System, San Diego, CA
Joseph H. Friedman,
MD
Parkinson’s Disease and Movement Disorders Center, NeuroHealth,
Warwick, RI and Brown University Medical School, Providence, RI
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Library of Congress Cataloging-in-Publication Data
Psychiatry for neurologists / edited by Dilip V. Jeste, Joseph H. Friedman.
p. cm. -- (Current clinical neurology)
Includes bibliographical references and index.
ISBN 1-58829-483-8 (alk. paper)
1. Neuropsychiatry. 2. Psychiatry. 3. Neurologists. I. Jeste, Dilip V.
II. Friedman, Joseph H. III. Series.
RC341.P892 2005
616.8--dc22
2005001928
Dedication
ForSusie,
with love, admiration, and gratitude
for the many sacrifices,
great and small.
—JHF
To Sonali, Shafali, and Neelum,
for filling my life with fun and love.
—DVJ
v
Series Editor’s Introduction
Psychiatry for Neurologists is an ambitious volume that was recruited for the Current Clinical
Neurology series because of a perceived need to provide neurologists with a useful and convenient
resource covering the areas of clinical psychiatry that impact the management of neurological disor-
ders. Although it may be a cliché to reiterate that the disciplines of neurology and psychiatry concern
the same organ, the fact is that long ago they unfortunately went their separate ways. The reasons for
this and a description of the paths they followed are elegantly reviewed by Dr. Goetz in his chapter
concerning the history of neurology and psychiatry in America. Curiously, although in this country
neurology became more allied with internal medicine, it has continued to share its specialty board
with psychiatry. Somehow, this alliance managed to survive the mid-20th century era when psycho-
analytic theory and practice, founded by the neurologist Sigmund Freud, held sway.
Beginning in the 1950s, the arrival of effective antipsychotic drugs, antidepressants, lithium, and
anxiolytic agents provided an alternative medical approach to the treatment of psychiatric disorders.
The effects of these agents, many of which were originally discovered serendipitously, precipitated
enormous interest into the biochemical underpinnings of psychiatric disorders. Thus, by the 1970s,
the dopamine hypothesis of schizophrenia and norepinephrine and serotonin hypotheses of depres-
sion were born. The remarkable effects of hallucinogenic drugs gave further impetus to the field,
driving a concept suggesting a possible “chemistry of the mind” that might unlock the secrets of all
psychiatric disease. Although that somewhat overreaching promise has not been realized, even for
the psychotic disorders, a new generation of biological psychiatrists is actively engaged in the study
of the molecular and genetic basis of psychiatric disorders.
It is no accident that the editors, Drs. Jeste and Friedman, have spent much of their careers study-
ing the neurological effects of antipsychotic drugs. The striking ability of antipsychotic drugs to
mimic parkinsonism, tremor, dyskinesia, and dystonia was appreciated early on as a potential win-
dow into understanding the pathophysiology of organic movement disorders and paralleled the
impact these drugs had on the understanding of psychotic disorders. Thus, in no small part, owing to
the psychiatric and neurological effects of antipsychotic drugs, psychiatry and neurology began to
share an area of common ground. The concept of a motor and limbic striatum and proposals concern-
ing parallel cortical-subcortical motor and limbic circuits helped shape the understanding of both
extrapyramidal and psychiatric disorders. With the advent of effective treatments for psychotic disor-
ders and Parkinson’s disease, together with their inevitable side effects (antipsychotics cause
movement disorders and antiparkinson drugs cause psychosis), it became clear that psychiatrists and
neurologists need each other. Now other areas of mutual interest and concern are being increasingly
appreciated. This volume provides the comprehensive and useful overview needed to allow neurolo-
gists to feel comfortable managing the psychiatric aspects of the neurological disorders they treat.
After all, it is the same organ!
Daniel Tarsy, MD
Parkinson’s Disease & Movement Disorders Center
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
vii
Preface
Although one of the editors is trained in both psychiatry and neurology (DJ), the other, not origi-
nally interested in behavioral problems at all, has come, through long clinical practice, to be increas-
ingly convinced of the broad overlap between the two disciplines. This means that the lack of an
appreciation and understanding of the behavioral problems that are so common in neurological
patients puts both the neurologist and the patient at a disadvantage in both diagnosis and treatment.
And although there are texts on “neuropsychiatry” and “neurology for psychiatrists,” we envisioned
a resource that will acquaint clinical neurologists with “bread-and-butter” psychiatric issues that
these physicians face with their neurological patients. Some patients will have behavioral problems
as a result of their primary neurological problems, such as Huntington’s disease or Tourette’s
syndrome, whereas others have primary psychiatric disorders and later develop neurological
problems, such as persons with schizophrenia who develop seizures, strokes, Parkinson’s disease,
and the like. However, it becomes increasingly apparent with experience that it is the exceptional
neurological patient who does not have some behavioral component as part of the illness.
InPsychiatry for Neurologists, we have focused on practical issues and mostly shied away from
the theoretical. For example, we have favored the approach of describing depression and its
treatment in Parkinson’s disease rather than addressing the role of the basal ganglia in mood. We
think the available neuropsychiatry texts address these theoretical issues quite well, but that these
texts have mainly targeted psychiatric audiences who are looking for a grounding in neurophysiology
and anatomy, seeking “hard” explanations for disorders that until recently have been considered
“functional.”
Neurology residency training only recently has mandated a rotation on the psychiatry service.
This has resulted in a generation of neurologists who often have little direct experience with primary
psychiatric disorders and have no intellectual foundation on which to interpret their findings. In the
hospital, the liaison psychiatrists, themselves sometimes adrift in the world of neurological disorders,
often prove unable to provide significant assistance in the interpretation or management of behav-
ioral problems, leaving the neurologist without a true safety net. Psychiatry for Neurologists is
intended to help the clinical neurologist interpret the behavioral problems in their patients them-
selves, not necessarily to manage the problems independently, but rather to understand the patient in
a larger context. This will hopefully allow the neurologist to better interpret the psychiatric problems
leading to improved interactions with psychiatric consultants, when they are needed.
When one editor (JHF) started working in Parkinson’s disease 20 plus years ago, it was clear to
him that it was a movement disorder, that the discussions over depression being intrinsic or reactive
were akin to wondering about the number of angels that could dance on the head of a pin. With
greater experience and increased sensitivity, he has come to realize that Parkinson’s disease is really
a “neurobehavioral disorder” defined clinically by its movement disorder. The most devastating
aspects of Parkinson’s disease are, in fact, the behavioral aspects, not the movement dysfunction.
There is sometimes a tendency to regard psychiatry as a “different” type of medical practice because
the patients don’t get “sick” in the same way. The stigma against mental illness needs to be combated
with education. There is an interesting “The Far Side” cartoon by Gary Larson. A patient is lying on
a couch and a somewhat deranged appearing Sigmund Freud imitation is scribbling in his pad, “Just
plain nuts.” It is time to move beyond this image. As we learn more and more about emotional
problems, we find “organic” explanations in genetic and physiological derangements. One gene
ix
x Preface
problem creates tics, a “neurological” disorder, while a closely related mutation causes obsessive-
compulsive disorder, a “psychiatric” disorder. Why these fall into separate categories owes more to
accidents in history (see chapters by Goetz and Boller) than anything else. Alzheimer’s disease and
dementia with Lewy bodies are good examples of illnesses that fall clearly into both camps, with many
successful collaborations. We believe that neurology and psychiatry are increasingly coming together
after a long period of moving apart. We hope to help reduce this gap at least a little with this text.
Joseph H. Friedman, MD
Dilip V. Jeste, MD
Contents
Dedication...........................................................................................................................................v
Series Editor’s Introduction...........................................................................................................vii
Preface.................................................................................................................................................ix
Contributors.....................................................................................................................................xiii
Part I. Introduction
1 Historical Interfaces Between American Neurology and Psychiatry ...........................3
Christopher G. Goetz
2 The Evolution of Psychiatry and Neurology: Two Disciplines Divided
by a Common Goal?.............................................................................................................11
François Boller and Gianfranco Dalla Barba
Part II. Evaluation
3 Psychiatric Evaluation of the Neurological Patient........................................................17
Stephen Salloway, Colin Harrington, and Sandra Jacobson
Part III. Major Psychiatric Disorders
4 An Overview of Depression................................................................................................33
Irene Hegeman Richard and Jeffrey M. Lyness
5 Anxiety Disorders.................................................................................................................43
Julie Loebach Wetherell, Ariel J. Lang, and Murray B. Stein
6 Schizophrenia ........................................................................................................................59
David P. Folsom, Adam S. Fleisher, and Colin A. Depp
7 Hysteria in Neurological Practice: The Somatoform
and Dissociative Disorders..................................................................................................67
Fred Ovsiew
8 Catatonia: Clinical Features, Differential Diagnosis, and Treatment.................................81
Patricia I. Rosebush and Michael F. Mazurek
9 Addictions..............................................................................................................................93
David W. Oslin
10 Personality Disorders.........................................................................................................105
Marc E. Agronin
Part IV. Psychiatry of Major Neurological Disorders
11 Psychiatric Complications in Dementia..........................................................................123
Daniel Weintraub and Anton P. Porsteinsson
12 Psychiatric Complications of Stroke ................................................................................137
Sergio E. Starkstein and Robert G. Robinson
13 Neuromuscular Disorders.................................................................................................153
Jeffrey Allen Cohen and Renee Marie Vebell
xi