MOTION AND E-MOTION. Andrea Cavanna MD PhD FRCP

Transcription

1 MOTION AND E-MOTION Andrea Cavanna MD PhD FRCP Consultant in Behavioural Neurology, BSMHFT, Birmingham, UK Hon Professor in Neuropsychiatry, Aston University, Birmingham, UK Hon Reader in Neuropsychiatry, University of Birmingham, UK

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3 1990s 2000s 2010s

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5 THE GREAT DIVIDE PSYCHIATRY NEUROLOGY

6 WHAT IS NEUROPSYCHIATRY? Mindless neurology Brainless psychiatry Neuro-psychiatry

7 Movement disorders and psychiatry CNS pathology leads to both motor and behavioural symptoms > PARKINSON DISEASE, TOURETTE SYNDROME Drugs for movement disorders can cause psychiatric disorders > ICDs & PSYCHOSIS IN PARKINSON DISEASE Drugs for psychiatric disorders can cause movement disorders > IATROGENIC MOVEMENT DISORDERS Psychogenic movement disorders

8 Neuropsychiatric disorders BASAL GANGLIA: Parkinson disease Tourette syndrome

9 James Parkinson (1817)... by the absence of any injury to the senses and to the intellect, we are taught that the morbid state does not extend to the encephalon.

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12 Parkinson disease motor signs: Resting Tremor (Pill-Rolling) Rigidity (Cogwheel) Bradykinesia Flexed Posture with shuffling gait

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17 Psychosis in PD Psychosis is the strongest predictor of family breakdown and nursing home placement in Parkinson Disease Goetz C et al. Neurology 1996

18 Psychosis in PD Visual hallucinations (not affect-laden, not threatening) and paranoid delusions are the most common symptoms The cause is usually multifactorial: dopaminergic treatment coupled with denervation hypersensitivity of mesolimbic/mesocortical DA receptors Risk factors: stage and severity of PD; coexistence of dementia, sleep disturbances, depression Coffey et al. 2007

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21 IMPULSE CONTROL DISORDERS IN PARKINSON DISEASE

22 Michael Trimble Neuropsychiatry Research Group In vivo functional connectivity pattern of the Nucleus Accumbens (NAcc): Resting State Functional Connectivity (rsfc) Meta-Analytic Connectivity Modeling (MACM) J Cogn Neurosci 2011;23:

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38 Deep Brain Stimulation (DBS)

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48 Memoria minuitur nisi eam exerceas (If you don t use it, you lose it) Cicero De Senectute VII, 21

49 Movement disorders and psychiatry CNS pathology leads to both motor and behavioural symptoms > PARKINSON DISEASE, TOURETTE SYNDROME Drugs for movement disorders can cause psychiatric disorders > ICDs & PSYCHOSIS IN PARKINSON DISEASE Drugs for psychiatric disorders can cause movement disorders > IATROGENIC MOVEMENT DISORDERS Psychogenic movement disorders

50 Neuropsychiatric disorders BASAL GANGLIA: Parkinson disease Tourette syndrome

51 Tourette syndrome This is truly of tremendous importance. Any understanding of such a syndrome must vastly broaden our understanding of human nature in general [...] I know of no other syndrome of comparable interest. Letter from A. Lurija to O. Sacks, 1975

52 THE BIRTH OF MODERN NEUROPSYCHIATRY A. Brouillet, Une Leçon Clinique à la Salpêtrière (1887)

53 Birmingham Neuropsychiatry Research Group

54 Birmingham Neuropsychiatry Research Group

55 Birmingham Neuropsychiatry Research Group

56 TICS involuntary, sudden, rapid, recurrent, nonrhythmic, movements or vocalizations TOURETTE SYNDROME 2+ motor tics (blinking, grimacing ) & 1+ vocal tics (sniffing, grunting ) Childhood-onset M:F 4:1

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58 Basal ganglia volumes were measured on high resolution magnetic resonance images acquired for 154 subjects with TS and 130 healthy control subjects ALL (N=154) CHILDREN (N=94) ADULTS (N=60) TS TS * * * TS TS TS * TS TS TS * TS

59 1. Right before I do a tic, I feel like my insides are itchy. 2. Right before I do a tic, I feel pressure inside my brain or body. 3. Right before I do a tic, I feel wound up or tense inside. 4. Right before I do a tic, I feel like something is not just right. 5. Right before I do a tic, I feel like something isn t complete. 6. Right before I do a tic, I feel like there is energy in my body that needs to get out. 7. I have these feelings almost all the time before I do a tic. 8. These feelings happen for every tic I have. 9. After I do the tic, the itchiness, energy, pressure, tense feelings, or feelings that something isn t just right or complete go away, at least for a little while. 10. I am able to stop my tics, even if only for a short period of time.

60 Birmingham Neuropsychiatry Research Group

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64 Birmingham Neuropsychiatry Research Group

65 Birmingham Neuropsychiatry Research Group Specialist GTS clinics 654 files: NHNN (n=516) + St Georges H (n=138) 15 excluded: consent not explicit (n=3) + other tic disorders (n=12) 639 patients (70.1% male; mean age 26.1) NHIS (Robertson and Eapen 1996), DCI (Robertson et al 1999), YGTSS (Leckman et al 1989) 10.6% GTS only (66.6% +ADHD; 36.4% +OCD, 36.1% +affective disorders) PCFA Cavanna et al. J Neurol Neurosurg Psychiatry 2011

66 Birmingham Neuropsychiatry Research Group Symmetry (evening up) «Just right» (ordering) Arythmomania (counting) Forced touching (dangerous objects) Checking Contamination (washing)

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70 Psychological Physical Obsessional Cognitive Cavanna et al. Neurology 2008;71:1410-6

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74 Birmingham Neuropsychiatry Research Group N Engl J Med Dec 9;363(24):

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79 Birmingham Neuropsychiatry Research Group Only 6/29 patients with TS discontinued aripiprazole because of the severity of specific adverse effects.

80 Birmingham Neuropsychiatry Research Group DBS (Deep Brain Stimulation)

81 Birmingham Neuropsychiatry Research Group

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