Temporal lobe seizures have been historically intriguing to psychiatrists. Patients often report an aura without ensuing motor convulsions. Epigastric sensations, derealization, hallucinations, intense fear and anxiety, déjà vu, and jamais vu are some of the features of a temporal lobe seizure. Intermittent onset of symptoms and normal findings on brain imaging studies in most cases, as well as normal surface electroencephalographic recordings may lead to an incorrect diagnosis of a functional psychiatric disorder. The reader is also referred to the Gastaut-Geschwind syndrome, which describes the temporal lobe epilepsy personality.3 A cohort of patients with temporal lobe epilepsy who showed personality characteristics (eg, aggression, hypergraphia, hyperreligiosity, increased ethical and moral concerns, change in sexuality, eccentricity, viscosity, humorlessness, and circumstantiality) are described.
Often a person may have underlying nonconvulsive status epilepticus that may present with neuropsychiatric symptoms such as cognitive changes, bizarre behavior, psychosis, affective disturbances, catatonic state, and autonomic disturbances.
Occasionally, a brain tumor may pre-sent with psychiatric symptoms without overt neurological signs or symptoms.1 Frontal lobe tumors are often disguised in their presentation with few or no neurological symptoms at first. They may present with personality changes or a picture that resembles a dementing illness or with apathy, somnolence, irritability, or akinetic mutism. Sexually inappropriate behavior, childishness, and lack of insight may also be present. Corpus callosum tumors, especially within the inferior and posterior parts of the corpus callosum, may present with psychiatric symptoms including thought disorder, rapid cognitive decline, and somnolence. Temporal lobe tumors probably cause the highest frequency of psychiatric symptoms. Diencephalic tumors affecting the thalamus, hypothalamus, and third ventricle may present with marked amnesia, confabulation, somnolence mimicking dementia, delirium, or depression.
Multiple sclerosis is a multifaceted disease with varied manifestations. Neurological diagnosis of multiple sclerosis is often difficult in the early stages and often missed by neurologists and psychiatrists. Patients may initially present with nonspecific cognitive deficits, such as memory or attention problems, and constitutional symptoms, such as fatigue. An in- correct diagnosis of conversion disorder, hysteria, or fibromyalgia may be made, or the symptoms may be attributed to preexisting psychiatric conditions, such as anxiety or depression.
As with many other neurological conditions, a close working re- lationship with a neurologist is essential for providing appropriate diagnosis and management. Depression may be present in multiple sclerosis patients for some time before the disease declares itself, and anxiety is also common. Bipolar disorder and psychosis, on the other hand, are rare in patients with multiple sclerosis.
A 37-year-old Ivy League college graduate was seeing a psychiatrist for treatment of depression and anxiety. After several years of treatment, he complained of the recent onset of confusion, memory problems, and some urinary hesitancy. These were initially attributed by the psychiatrist to either the patient's stressors or adverse effects of medications. No neuropsychiatric workup was ordered.
Eventually, the patient sought his own referral and was evaluated by a neurologist who diagnosed progressive multiple sclerosis. An MRI scan of the brain, at this point, revealed significant white matter disease. The patient later sued the psychiatrist for malpractice for failure to diagnose the condition or to make an appropriate referral.
The classic triad of Parkinson disease consists of akinesia/bradykinesia, rig-idity, and tremors. Motor signs may not be evident initially, and some patients may present with depression. Certain features are common between depression and Parkinson disease, eg, psychomotor slowing, attention/concentration deficits, flat or blunted affect, and memory problems. Anxiety disorder, social phobia, and panic disorder are present in up to 25% of patients with Parkinson disease.1 The psychiatrist should consider Parkinson disease in elderly patients presenting with depression and/or anxiety for the first time. A thorough medical history and neurological examination may help confirm the diagnosis in the earlier stages. Clinicians should also be aware of psychiatric adverse effects of antiparkinsonian medications, such as hallucinations and delusions.
Neurosyphilis, the great imitator, is making a comeback because of the prevalence of HIV/AIDS.4 Neuro-syphilis is a form of tertiary syphilis. The frontal lobes are often affect- ed, which can lead to personality changes, irritability, decline in personal hygiene, and disinhibition. Dementia and depression are now more common with neurosyphilis.1 A neurological examination may reveal pupillary abnormalities, tremors, and dysarthria. Lishman describes atypical presentations resulting from partial suppression of the infection in the earlier stages by antibiotics given for other purposes.1 These patients may present with seizures, declining vision, confusion, and other neurological symptoms.