Caused by Brain Tumors Psychiatric Tables: Two Case Reports

PhD Dr Nihan Oğuz1, Cem İlmen2, Ferhan Yener3

INTRODUCTION

Brain tumors commonly cause epileptic seizures, headaches, and focal neurological findings. Aside from these symptoms, they can lead to various psychiatric symptoms less often, such as cognitive changes, slow speech, difficulty maintaining mental functions, loss of interest in daily activities, personality changes, and inability to hear high-frequency sounds (1). These symptoms can be thought of as anxiety, depression, or asthenia.

Psychological symptoms from tumors; They can occur when the thalamocortical structures, cerebral white matter, long fiber systems, the frontal, temporal cortex, and corpus callosum are affected (2).

Patients may not be able to see these symptoms clearly. They can only express that they are tired, weak and dizzy; they can answer it after a long pause or with a few words. Sometimes patients are in a state of complete confusion or dementia. If left untreated, the tendency to sleep increases gradually and the patients can develop stupor or coma with increased intracranial pressure. This article presents two cases of psychiatric symptoms caused by a meningioma and a brain tumor, the origin of which we have not been able to understand, and the resulting psychiatric disorders are discussed.

CASE-1

Patient 48 years old, born in Kastamonu, married, mother of four children, lives in a village in Kastamonu, illiterate. She came to our hospital with relatives and complained of headache, dizziness, abdominal pain, frequent urination, and insomnia. The patient's complaints started 6 years ago after their house burned down, according to relatives. It was learned that he often argued with his neighbors, suffered from aggression and forgetfulness, could not do housework, talked and cursed to himself, undressed, got angry easily, could not sit still, was depressed and even often ran away from home. It was found that the patient who had not previously shown these behaviors, had pronounced personality changes in the past 3 years, spoke meaninglessly, and urinated. No significant trait was found in personality development or in the history of the disease. No notable traits related to psychiatric or other illnesses were found in his family. The patient did not use any psychoactive substances, including smoking.

In the systemic examination of the patient, who was conscious and could hardly communicate by speaking, the blood pressure was 110/70 mm / Hg, pulse 80 / min and rhythmic, body temperature 36.2 oC. No pathological findings were found. Routine laboratory results, EKG and EEG were within normal limits. The neurological examination revealed no pathological findings other than disorientation. His psychiatric examination found that his self-care was limited and that he was active, hardly answering questions and being tired. His involuntary attention and concentration were reduced. It was observed that the recognition and inscription memory was impaired and his near and far memory was partially sufficient. It was observed that thoughts could be focused on the goal, but his associations were slow and tending to decay and he spoke irrationally. There were delusions of persecution and delusions of hearing.The patient shouted prayers and spoke to himself in the ward; The meeting could not be concluded due to a lack of cooperation. Cognitive functions could not be fully investigated. On cranial magnetic resonance imaging, which was performed to detect an expansive lesion compatible with meningioma on computed tomography, extra axial mass lesions formed in the olfactory groove in the anterior cranial fossa and in the right para-axial lesion and formed a close relationship with each other and accompanying parenchymal White matter edema was noted. The results were rated as "Extra-Axial Meningioma Masses".
It was found that the brief mental examination (KAM) carried out later gave the patient 10 out of 30 points. Treatment started with haloperidol 20 mg / day, biperiden 4 mg / day, chlorpromazine 100 mg / day, carbamazepine 400 mg / day. Due to the frequent agitation of the patient in the ward, antipsychotic injections were also added and the patient had to lie in bed for many days. As a result of the consultation with the neurosurgery, the patient was intravenously administered 8 mg / day of dexamethasone ampoule as an anti-edema treatment. It was observed that the symptoms of the patient transferred to the neurosurgical service and operated on decreased after the operation, his psychotic symptoms did not go away, and he was able to communicate more easily. With this result, the patient was diagnosed with "psychotic disorder due to a general medical condition" on the first axis and "parafalxian meningioma" on the third axis according to the DSM-IV diagnostic criteria.

CASE-2

Male patient, 46 years old, married, born in Elazig, father of 2 children, retired, residing in Istanbul; He and his relatives applied to our hospital because of restlessness and inner unrest. The patient's relatives learned that his symptoms began 10 to 15 days ago, accompanied by insomnia, constant hand washing, looking for something and then tidying up again. No significant trait was found in personality development or in the history of the disease. There were no significant characteristics of any psychiatric or other illness in his family. The patient did not use any psychoactive substances, including smoking.

Systemic examination of the patient, who was conscious and had difficulty communicating, did not reveal any pathological findings. His neurological examination revealed no pathological findings other than disorientation.On his psychiatric examination, it was found that his self-sufficiency was normal, he hardly answered the questions because of his irritability and anger, he rated his mood as "good" and he reacted with fear. His involuntary attention and concentration were reduced. The cognitive and descriptive memory was impaired, and his near and far memory was partially sufficient. It has been observed that thoughts can be focused on the goal, but its associations are slow and tend to be distracting. No psychotic findings were found in terms of content.
Speech and speech reactions have been observed to respond with short and single words after a long reaction time.
The study of cognitive functions could not be completed due to the inability to work together. The patient was referred to a hospital, where he could be operated on immediately with the previous diagnosis "Anxiety disorder due to encephalitis or extensive lesion (with obsessive-compulsive symptoms)". Later, as a result of the examinations, it was learned from the patient's relatives that the patient had an extensive lesion, had an operation, and that his symptoms of anxiety decreased after the operation. With this result, the patient was diagnosed with “anxiety disorder due to a general medical condition (with obsessive compulsive symptoms) according to the diagnostic criteria of DSM-IV in the first axis.

DISCUSSION AND CONCLUSION

Altered psychological status can be the first symptom in 15 to 20% of patients with brain tumors. Among the mental symptoms of intracranial tumors; Personality changes, emotional problems, intellectual losses.

Mental symptoms were 94% in temporal lobe tumors, 90% in frontal lobe tumors and 47% in infratentorial tumors. Another study found personality changes in 18% of cases (1). Frontal lobe tumors can be associated with personality changes and dementia. Dementia; It can be characterized by apathy, dullness, drowsiness. In rare cases, psychosis can also occur. Corpus callosum tumors; They can be seen in the form of depression, dementia, personality changes, or psychosis. Hypothalamic tumors; They can manifest with endocrine changes (diabetes insipidus, amenorrhea, anorexia, hyperphagia), episodic anger and aggression, personality change, dementia, delirium. Third ventricular colloid cysts can also cause dementia with compression of the adjacent diencephalic tissue (3). While frontal lobe meningiomas cause a picture that resembles severe depression, diencephalic tumors can lead to mood disorders with hypomanic cycles. Tumors that cause psychosis are often localized in the temporal lobe and in the diencephalon. It has been shown that tumors causing catatonia are localized in the third ventricle, periventricle, and corpus callosum. It has been suggested that Capgras syndrome and Fregoli syndrome are caused by dysfunction of the right hemisphere (4).

Personality changes can occur as the tumor grows in frontal lobes. Disinhibition, irritability, impaired judgment, abulia, and extreme behaviors that cannot be prevented can be seen in damage to the right orbitofrontal and basal temporal cortex. Dorsolateral prefrontal cortex damage; It can manifest with apathy, indifference, and psychomotor disability. Akinetic mutism and apathy can be associated with anterior cingulate gyrus lesions. Euphoria in the right frontal injury, akinesia, abulia, and depressive affect can occur in the left frontal injury (1). In fact, the first case was found to have no history of psychiatric problems and complaints of headache, dizziness and abdominal pain started 6 years ago. It was found that behavior disorders such as frequent urination symptoms, aggression, forgetfulness, inability to do housework, self-talk and swearing, undressing and running away from home increased in 3 years. In their psychiatric and neurological examination, lack of orientation, attention and memory, unsystematic paranoia and auditory hallucinations attract attention. Although the patient's decrease in awareness of the environment makes us think due to the loss of cognitive functions and general health, the appearance of symptoms 6 years ago, the increase in the last 3 years, and the absence of delirium. Fluctuations in consciousness during the day are meant to distract us from a diagnosis of delirium. The inevitable excessive behavior of the patient, disinhibition, irritability and disturbed thinking suggest damage to the right frontal (orbitofrontal cortex). The regression of the patient's symptoms after the operation "when it becomes olfactory and a meningioma with parafalcine location on the right" shows the direct relationship.

It has been suggested that in the absence of neurological symptoms, the first sign of meningioma in their fifties could be psychiatric symptoms. It has been reported that psychiatric symptoms can appear as particularly mood disorders (7). The aggressive behavior, the abusive language, the undressing, the need to leave, unsystematic paranoia and auditory hallucinations in our case suggest manic episodes with psychotic characteristics due to the general state of health. However, the patient moved away from this diagnosis because there was no clearly elevated or irritable mood, especially behavioral disorders and unsystematic psychotic symptoms.

In temporo limbic tumors, a psychotic picture similar to schizophrenia can occur. The reason for this is that the papezeous ring (hippocampus, fornix, mammillary body, mamillothalamic pathway, anterior thalamic nucleus, cingulate gyrus, parahippocampus gyrus) of the limbic structures is affected. Involvement of the right temporal lobe can lead to a manic picture, irritability, panic disorder, and personality changes (2). In the second case, the lack of a history of psychiatric findings, the absence of any traits in his medical history, sudden restlessness, irritability, hand washing and sorting that began 10 to 15 days ago at the age of 46 suggested a right temporal lobe dysfunction. During the psychiatric and neurological examination of the patient, attention is drawn to loss of irritability, confusion, orientation, attention, and memory functions. Similar to the first case, the loss of cognitive functions in the second case indicated a diagnosis of delirium due to general health. However, the fact that there are no fluctuations in consciousness during the day has deterred us from diagnosing delirium.

It has been suggested that the first symptom of primary brain tumors originating from the right hemisphere may be anxiety (8). Although we don't have objective imaging findings, the patient's symptoms suggest involvement of the right hemisphere, particularly the temporal lobe. Similarly, a 69-year-old female patient with a right temporal lobe meningioma who experienced anxiety attacks, later developed depersonalization and perceptual disorders, and had no history of psychiatric illness was found to have symptoms after surgery and symptoms ( 5).

In the first case, frequent urination is observed with non-indicative symptoms such as headache and insomnia. Pollakiuria suggests central diabetes insipidus, a possible endocrinological change. This suggests that the tumor is affecting the posterior axis of the pituitary. Pituitary tumors; They can cause depression, apathy, paranoia, and endocrinological changes (such as Cushing, diabetes insipidus) (6).

Left hemisphere lesions cause depression and catastrophic change. Right hemisphere lesions can cause happiness and emotional responses. According to the emotional balance hypothesis, the right hemisphere is responsible for negative emotions, and the left hemisphere is responsible for positive emotions. Vascular lesions in the left anterior hemisphere can lead to major depression. Again, while akinesia and depression occur in the left-sided lesions; Euphoria and inability to understand the severity of the disease can occur with right-sided lesions (1,9). While affective psychoses are generally caused by dysfunction of the right hemisphere, schizophrenia-like psychosis can be caused by dysfunction of the left hemisphere (6).

In conclusion, when treating late onset cases with no history of psychiatry, general health should not be ignored.

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