Psychosis as primary presentation of Brain Tumor: A Case Report

Abstract

<h3>Introduction</h3> Psychosis can be of primay and secondary etiology. Secondary psychosis could be due to TBI, toxic/drug induced, metabolic, congenital, cerebrovascular and malignancy. Brain tumors most commonly present with neurological manifestations. In rare cases, primary presentation of brain tumor is psychiatric symptom which could be depression, apathy, mania, psychosis, eating disorder, personality changes. In a range of psychiatric symptoms, mood symptoms are the commonest (36%) and psychotic symptoms were found in 22% of the patients. Brain tumors present wtih neurological symptoms due to mass effect. In rare occasions, brain tumors present with primary psychiatric presentation without any neurological deficit or symptoms. <h3>Methods</h3> Elmhurst Hospital CPEP (Comprehensive Psychiatric Emergency Program) is uniquely placed licensed, hospital-based psychiatric emergency program which establishes a primary entry point to the mental health system for individuals who may have psychiatric comorbidity, to receive emergency observation, evaluation, care and treatment. We have reported a case of a new onset psychosis secondary to brain tumor. Previous studies and reviews were reviewed using PubMed, Medline and google scholar. Search terms used were "secondary psychosis", "psychosis", "brain tumor". We reviewed available literature related to psychiatric manifestations of brain tumor. <h3>Results</h3> According to American Brain Tumor Association (ABTA), nearly 80,000 cases of primary brain tumors were diagnosed in 2018. Glioblastoma represents 14.9% of all primary brain tumors and 56.1% of all gliomas. Brain tumors are an uncommon, but important, cause of secondary psychosis. There is also evidence that intracranial tumors are increased in patients with psychiatric illness. The psychiatric manifestations of brain tumor could be of different multitude. The symptomatology may range from vague apathy and personality change to prominent depression, mania, psychotic symptoms, eating disorder, which are refractory to treatment, until the primary etiology is discovered and treated. There have been studies to determine correlation between the location of tumor and symptomatology. Some studies showed, dorsolateral tumors lead to difficulties with organization and planning. Orbitofrontal tumors cause disinhibition, and medical frontal tumors cause apathy and abulia. Frontal tumors may exhibit personality changes in the patient. Diencephalic and pituitary lesions lead to vegetative symptoms. Diencephalic lesions have been shown to manifest hypersomnic and hyperphagic varients of depressive disorders. Tumors located in the temporal lobes or limbic structures are most likely to produce psychosis, with one study demonstrating that 20% of tumors in the temporal lobe resulted in psychotic symptoms. There has been no association between histological type of tumor and the frequency of psychosis. However, low grade, slow growing tumor have been found most likely to associated with psychotic symptoms in the absence of neurological symptoms. This case highlights the need of thorough history, physical examination, high clinical suspicion and neurological imagines in case of first episode of psychosis, which are the keys to the diagnosis. <h3>Conclusions</h3> The patient's psychotic symptoms (disorganized behavior, disorganized speech) were abated following the treatment of primary etiology. This finding is consistent with previous reports in the literature and suggests, once primary etiology of psychotic disorder is properly treated, the psychotic manifestations usually subside (excpetion of a few cases where the psychotic symptoms persisted), which might not require concomitant short-term treatment for psychosis, depending on the severity of the symptomatology. This case report also implies the importance of neuroimagine in patints with first episode of psychosis, despite absence of any neurological finding, to rule out any underlying organic cause. 1. Keshavan Matcheri S, Kaneko Yoshio: Secondary psychoses: an update. World Psychiatry 2013; 12:4–15. 2. Madhusoodanan Subramoniam, Ting Mark Bryan, Farah Tara, Ugur Umran: Psychiatric aspects of brain tumor: A review. World J Psychiatry 2015; 5(3):273–285, September 22. 3. Khong Su-Yen MBChB, MRCOG, Leach John MA, MRCS, Greenwood Catherine MD, MRCOG: Meningioma Mimicking Pueperal Psychosis. Obstet Gynecol 2007; 109:515–516. 4. Filley CM, Kleinschmidt-DeMasters BK: Neurobehavioral presentations of brain neoplasms. West j Med 1995; 163:19–25. <h3>Funding</h3> No finacial disclosure or conflicts of interest.