Secondary Schizophrenia (106 page)

that meningiomas produced neuropsychiatric symp-is in contrast to functional psychotic disorders where
Organic Syndromes of Schizophrenia – Section 3

auditory hallucinations are the commonest. Visual
4. Sensory changes, especially if visual
hallucinations may be brief, unformed, and stereotypi-5. Other focal neurological signs and symptoms,
cal or they may be complex and well formed. Auditory
such as localized weakness or sensory loss, ataxia,
hallucinations may occur with temporal-lobe tumors
or incoordination

and are usually simpler in nature, consisting of ring-ing, whistling, hissing, or buzzing noises
[17]
. Other
Many of these signs, however, occur in the later stages
types of hallucinations are rare, although there have
of a brain tumor and may not be evident, especially
been isolated reports of olfactory and tactile halluci-with “silent” indolent-growing tumors.

nations
[48, 49].

Older patients and those with late-onset psychosis
Formal thought disorder has not commonly been
require a higher index of suspicion as brain tumors
described in case series of psychosis secondary to brain
occur more frequently in this group
[6].

tumor
[24,
50]
, but there are isolated reports of cases
with loosening of associations
[34].

Neuroimaging

Catatonia is rarely caused by an underlying brain
Computer tomography (CT) and MRI scans have
tumor, although rare cases have been reported
[24,
51,

largely replaced plain skull X-ray, electroencephalog-

52, 53].

raphy (EEG), pneumoencephalography, echoen-Other psychiatric symptoms may occur along with
cephalography, and radioisotope brain scans as the
psychotic symptoms in the context of a brain tumor.

standard diagnostic tests to detect the presence of
These include depression
[17,
50, 54, 55],
mania
[50,

a brain tumor. Both CT and MRI provide greater
56, 57, 58, 59]
, and personality changes
[50, 54,
60, 61]

resolution of anatomic brain structures and are able
and may predate the diagnosis of the tumor.

to distinguish normality from pathology.

The capacity of CT scans to detect neoplasms is
Diagnostic evaluation

increased by the use of intravenous contrast, enhanc-Although a brain tumor remains a relatively rare cause
ing the presence of such lesions. Other radiological
of psychosis, some patients warrant a higher index of
features that may indicate the presence of a brain
suspicion for this diagnosis. Psychiatrists require some
tumor include calcification, cerebral edema, obstruc-awareness of the clinical features that may heighten
tive hydrocephalus, and midline shift. CT scanning
the possibility of a brain tumor in order to guide
may fail to detect very small tumors, masses located
their practice in determining an appropriate diagnos-in the posterior fossa, tumors that are isodense with
tic workup for a suspected intracranial mass lesion.

respect to brain tissue, and tumors diffusely involving
the meninges.

MRI is superior to CT scanning due to its higher
History and examination

resolution, greater sensitivity for detecting very small
The yield of diagnostic evaluation is increased by care-lesions, and lesser exposure to radiation for the patient;
ful history taking and a thorough physical examina-however, it is vastly more expensive and is contraindi-tion, bearing in mind that the neurological examina-cated in patients with ferrometallic objects (e.g. pace-tion may be entirely normal. Price and colleagues
[45]

makers). Enhancement of tumor masses is possible
suggest that the following clinical features in a known
with gadolinium.

psychiatric patient or a patient with an index presenta-Hollister and Boutros
[62]
reviewed the clinical use
tion of psychiatric symptoms should heighten the clin-of CT and MRI scans in psychiatric patients, conclud-ician’s index of suspicion of a brain tumor:
ing that the onset of psychotic symptoms or personality change after the age of 50 years or the presence
1. Seizures, especially if new onset in an adult or if
of focal neurological signs are sound indications for
they are focal or partial seizures

ordering one of these scans in a psychiatric patient.

2. Headaches, especially if new onset, generalized,
and dull (i.e. nonspecific), of increasing severity
and/or frequency, positional or nocturnal, or
Other

present immediately on awakening

Given that noninvasive radiography has high sensi-3. Nausea and vomiting
tivity and specificity in detecting brain tumors, other
266

Chapter 20 – Brain tumors

more invasive tests have a minimal role in the inves-schizophrenia in whom a slow-growing cerebral tumor
tigation of a suspected brain tumor. A lumbar punc-is identified.

ture may be done for other reasons and may be asso-Current neuroanatomical models of schizophrenia
ciated with a brain tumor if elevated cerebrospinal
propose that the etiology of psychosis relates to a “dis-fluid (CSF) protein and increased intracranial pres-connectivity syndrome” with aberrant integration of
sure (ICP) are found, although these findings are non-complex, interdependent neural mechanisms under-specific. Furthermore, in the presence of raised ICP,
lying perception and cognition, in particular affecting
there is a risk of cerebral herniation following lumbar
limbic and other subcortical structures
[67].
In a recent
puncture and, hence, this is not recommended practice
review of diseases of white matter and schizophrenia-when a brain tumor is suspected.

like psychosis, Walterfang and colleagues
[68]
empha-The EEG in patients with brain tumors may show
size that diffuse, rather than discrete lesions, partic-nonspecific abnormalities such as spikes and slow
ularly in the fronto-temporal zones, have been most
waves; however, in the majority, the EEG is reported as
strongly associated with schizophrenia-like psychosis.

unremarkable. This investigation has poor sensitivity
The involvement of limbic and limbic-related areas
and specificity in detecting brain tumors but may have
is thought to be highly significant and may pro-an important role in the evaluation of seizures associ-duce defective integration of perceptual information
ated with an intracranial tumor.

and its relevance
[21].
Hence, it is not surprising
Neuropsychological testing may show localizing
that the preponderance of brain tumors contributing
cognitive deficits but has a low diagnostic yield for
to psychosis is situated in the frontal and temporal
identifying brain tumors. Such testing has a greater
lobes.

role in determining a baseline of tumor-associated
Focal lesions do not precisely define the neuro-cognitive dysfunction compared with serial test results
transmitters involved in psychosis but areas contain-in the post-treatment setting.

ing dopaminergic or cholinergic circuits are frequently
involved
[31,
69].
The dopaminergic/cholinergic balance may also be important in the genesis of psychosis
Interrelationships

[69].

Psychosis is a phenomenon with a variety of differing
Pituitary tumors often produce hormones; how-etiologies found in many conditions. Secondary pre-ever, the similarity of psychiatric presentation of secre-sentations of psychosis may account for approximately
tory and nonsecretory adenomas suggests that the
3% of new cases of schizophrenia
[63].
Although sec-intracerebral extension of the tumor may be more
ondary schizophrenias may sometimes be discernible
important than endocrine dysfunction in the induc-from primary psychotic disorders
[26,
64],
many have
tion of psychosis
[60, 70].

clinically identical presentations
[65]
. Even though the
terminology has changed, Ferraro
[66]
posed the con-

Treatment of psychosis in setting of

ceptual dilemma that continues to plague psychiatrists: “What should our attitude be in the presence
brain tumor

of organic cerebral changes found in cases clinically
Literature guiding the treatment of psychosis in asso-diagnosed as functional psychosis? Must we adhere
ciation with brain tumors is relatively sparse. In some
to the concept that a diagnosis of schizophrenia is
cases, active medical and surgical treatment of the
incompatible with the presence of cerebral pathology?

brain tumor will ameliorate the psychotic symptoms
Must we, every time that organic changes are found
[6,
32, 33, 36, 39, 41, 55,
71, 72, 73]
although it was
in the brain of a supposedly schizophrenia patient,
not always clear if the patients were continued on psy-change our diagnosis to one of organic psychosis
chotropic medication.

simulating dementia praecox? Must we talk in such
In other cases, psychotic symptoms persisted or
cases of schizophrenia-like condition? Must we, on
even worsened despite treatment of the underlying
the other hand, maintain the diagnosis of schizophre-brain tumor
[3, 29,
40, 43].
Given the potential of
nia and qualify it as being precipitated by such and
these symptoms to cause subjective distress, func-such organic disease?” This dilemma is perhaps most
tional impairment, and disability, it is important for
poignantly expressed in the patient with a diagnosis of
these psychotic symptoms to be treated in their own
267

Organic Syndromes of Schizophrenia – Section 3

right. The treatment of these psychiatric symptoms
Summary and conclusions

may enhance the patient’s quality of life regardless of
Brain tumors occur with greater frequency in indi-the curability of the tumor
[57].

viduals with mental illness than the general popu-The psychopharmacological management of psy-lation and are an uncommon but important cause
chosis in patients with an intracerebral tumor fol-of secondary schizophrenia. The symptomatic pre-lows the same general therapeutic principles that
sentation of psychosis associated with brain tumors
apply to tumor-free patients. Antipsychotic medi-appears to vary from those indistinguishable from pri-cations remain the cornerstone of treatment. Low-mary schizophrenia to more typical “organic” presen-potency typical antipsychotics may produce signifi-tations involving nonauditory hallucinations, neuro-cant anticholinergic side effects and potentiate the risk
logical signs, and prominent cognitive impairment.

of delirium, while high-potency agents may result in
The nature of brain tumors presenting with psychotic
unwanted extrapyramidal side effects. Although there
symptoms may vary markedly, but it would appear
is a paucity of controlled research on the efficacy
that tumors in frontal and temporal regions, together
of the newer atypical antipsychotics in the treatment
with the pituitary, are most frequently associated with
of brain tumor patients, it is noteworthy that they
psychosis. Presentations have been reported in asso-have been reported to be effective in the treatment
ciation with increasing age and the presence of
of psychosis associated with other neurological dis-other neurological symptoms, but not exclusively so.

orders
[45].
Given their improved adverse effect pro-The associated tumor type has varied greatly within
file, they may be considered in preference to typi-reports. Rapidly growing, high-grade tumors appear
cal antipsychotic agents. It is important to be cog-more likely to present with other neurological features
nizant of the need to “start low and go slow,” especially
as well as psychosis. Probably more common is the
given the therapeutically effective dose of antipsy-association with low-grade, slow-growing tumors such
chotic is often lower than in the treatment of prias meningiomas. The nature of the etiological associa-mary schizophrenia and also that brain tumor patients
tion in this setting is complex and, in the case of slow-generally would appear to have a greater susceptibil-growing tumors, possibly unclear.

ity to side effects of psychotropic medication. This is
especially true of patients who are in the immediate
postoperative period or are receiving chemotherapy or
Implications for clinical practice

radiotherapy.

The clinical implications of this association can be
Although the focus of a separate chapter, it is worth
divided into those related to assessment and those
noting that seizures secondary to a brain tumor may
related to management. The role of structural neu-also be a contributing factor, or on occasion, the main
roimaging as a screening measure in patients present-factor leading to psychotic symptoms. The latter is
ing with psychosis remains controversial in some quar-most likely to be true in patients with partial seizures
ters. Specifically in relation to brain tumors, further
secondary to a temporal lobe tumor. Effective seizure
investigation appears to be warranted in any patient
treatment with anticonvulsant medication may thus be
presenting with the onset of psychosis later than the
an effective treatment for psychotic symptoms in such
usual age range, in the presence of atypical features
a case. Given the high frequency of seizures in patients
or other neurological symptoms, including persistent
with high-grade tumors, it is also worthy to bear in
headache. However, relying on such indicators alone
mind the possible role of some anticonvulsants in the
may result in the failure to diagnose some of the more
induction of psychotic symptoms.