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
1990s 2000s 2010s 1992 2002 2003 2012 2012 2013 2014 2015
THE GREAT DIVIDE PSYCHIATRY NEUROLOGY
WHAT IS NEUROPSYCHIATRY? Mindless neurology Brainless psychiatry Neuro-psychiatry
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
Neuropsychiatric disorders BASAL GANGLIA: Parkinson disease Tourette syndrome
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.
Parkinson disease motor signs: Resting Tremor (Pill-Rolling) Rigidity (Cogwheel) Bradykinesia Flexed Posture with shuffling gait
Psychosis in PD Psychosis is the strongest predictor of family breakdown and nursing home placement in Parkinson Disease Goetz C et al. Neurology 1996
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
IMPULSE CONTROL DISORDERS IN PARKINSON DISEASE
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;23:2864-2877
Deep Brain Stimulation (DBS)
Memoria minuitur nisi eam exerceas (If you don t use it, you lose it) Cicero De Senectute VII, 21
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
Neuropsychiatric disorders BASAL GANGLIA: Parkinson disease Tourette syndrome
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
THE BIRTH OF MODERN NEUROPSYCHIATRY A. Brouillet, Une Leçon Clinique à la Salpêtrière (1887)
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
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
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
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.
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
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
Birmingham Neuropsychiatry Research Group Symmetry (evening up) «Just right» (ordering) Arythmomania (counting) Forced touching (dangerous objects) Checking Contamination (washing)
Psychological Physical Obsessional Cognitive Cavanna et al. Neurology 2008;71:1410-6
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group N Engl J Med. 2010 Dec 9;363(24):2332-8.
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group
Birmingham Neuropsychiatry Research Group Only 6/29 patients with TS discontinued aripiprazole because of the severity of specific adverse effects.
Birmingham Neuropsychiatry Research Group DBS (Deep Brain Stimulation)
Birmingham Neuropsychiatry Research Group
BMJ 1992;305:1563-1567