Case Report
FRONTAL LOBE LESIONS MASQUERADING AS PSYCHIATRIC DISTURBANCES*
RICHARD
Several papers have appeared in the literature calling attention to the relationship between brain tumours and psychological symptoms (l, 3-7, 10, 11, 14-16). The purpose of this paper is to focus specifically on lesions of the frontal lobes, how they may masquerade under the guise of a functional psychiatric disorder, and what clues may be useful in uncovering their real nature. Psychiatric symptoms are frequently the earliest and sometimes the only manifestations of a cerebral space-occupying lesion (1, 3-7, 15, 16). Often, the more obvious motor and sensory deficits may be lateappearing, and the behavioural changes may be the first sign that something is wrong. These changes can result from the disability and loss of function which the patient is experiencing (2, 9, 11). On the other hand, these behavioural symptoms can result from tissue destruction and alteration of cerebral function. The prevalence of brain tumours in the general population is estimated to be 40 per 100,000 (8). It is also estimated that approximately 2 percent of patients admitted to psychiatric facilities have brain tumours (6). The family physician or emergency room casualty officer may first come into contact with the patient who has a cerebral lesion. Because of the behavioural symptoms which the patient exhibits and the absence of focal neurological signs, the 'Manuscript received March 1977; revised May 1977. 'Clinical Instructor in Psychiatry, Faculty of Medicine, University of Ottawa and the Royal Ottawa Hospital, Ottawa, Onto Can. Psychiatr. Assoc. J. Vol. 22 (1977)
J.
CARLSON,
M.D. 1
patient may then be referred to a psychiatrist. Three cases from the author's firsthand experience, seen over a two-year period, are presented here. Case 1 A 31-year old single male student in computer sciences was brought to the emergency room by his friends because of a 2-day history of change in behaviour. He had become less talkative, very withdrawn and sometimes somnolent, especially with a small drink of alcohol. There were sounds which he heard, such as someone mumbling to him. According to his friends, he gave short, inappropriate answers to questions. He was referred for psychiatric examination. A further history was obtained that for the past 2-3 weeks he had been seeing various physicians complaining of headache and depression. He was able to continue his studies and drive a taxi part-time until one week before admission, when he felt very depressed. He had always been a quiet, shy person described as a "loner". There was no precipitating event, previous psychiatric history, or family history of mental illness. On examination the patient was withdrawn, preoccupied, slightly agitated and appeared to be hallucinating. His affect was flattened, but not depressed. He spoke in brief sentences, with thought blocking, incoherence and loosened associations. There were no apparent delusions. He had difficulty following simple instructions, memory was difficult to test, but orientation was intact. Vital signs were normal, and general physical and neurological examinations revealed no abnormalities. He complained of a generalized headache. The patient was admitted to the psychiatric unit with the tentative diagnosis of acute schizophreniform psychosis, but immediate investigations were ordered. Within 24 hours, the patient developed a slight temperature elevation
315
316
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
and mild nuchal rigidity. A lumbar puncture revealed xanthochromia and increase in WBC's. An EEG showed a left fronto-parietal disturbance, and a brain scan showed a lesion in that area. Angiography demonstrated a left infrafrontal subdural hematoma from an aneurysmal malformation. The patient was taken to surgery, and post-operatively made an excellent recovery with return to pre-morbid functioning and no signs of psychosis. Case 2 A 60-year old woman was admitted to hospital from a convalescent home with a two-week history of withdrawal, feeling severely depressed and suicidal, not communicating with others, and acting very suspicious. She had grand mal epilepsy since the age of 18 and a bilateral hearing impairment for 5 years, and complained of headaches and fatigue for one year. She was maintained on diphenylhydantoin and phenobarbital for many years, having a seizure about once a month, but lately the seizures were as frequent as every other day, mostly nocturnal. Her past history included a 13-year stay in a psychiatric facility with a diagnosis of epilepsy with psychosis. On this admission, the patient was very depressed and tearful, had delusions of worthlessness and that death was near, but memory and orientation were good. Physical examination was unremarkable except for hearing impairment and a right lateral rectus muscle palsy which she had had since birth. She initially received amitriptyline, with resulting confusion and somnolence. She also had several grand mal seizures. Neurological consultation did not reveal any focal signs. An EEG revealed symmetrical paroxysmal spikes in both fronto-temporal regions. The brain scan showed a circular area of activity in the midline frontal area, suggesting a meningioma. She was transferred to a neurosurgical service. At surgery a frontal parasagittal meningioma was found and removed. Her postoperative course was fairly smooth and she returned to a good level of functioning with no depression or seizures.
Vol. 22, NO.6
patient had become progressively more somno_ lent. His headaches of many years' duration had become more pronounced in the last two months. Loss of the family dog and failure to be promoted in his job resulted in him withdrawing. The patient's appetite was good but it took him a very long time to eat. There also were periods of several seconds of memory loss or confusion in the last month. His premorbid personality was one of perfectionism, obsessiveness and stubbornness. On admission the patient was thin, appeared deeply depressed and had severe psychomotor retardation. He answered questions with very short replies and had delusions that the end of the world was approaching. Anger became apparent at times when talking about work, saying "they'll be sorry" repeatedly. He did not cooperate for testing of memory and orientation. Physical examination revealed generalized hyperreflexia, but no other neurological signs. It was felt that he might be suffering from an endogenous depression, but an organic etiology was immediately investigated. An EEG and brain scan done shortly afterwards were consistent with a space-occupying frontal lesion. At surgery a right frontal astrocytoma grade IV was removed. Post-operatively the patient's presenting symptoms had disappeared and he seemed more like his usual self, according to the wife.
Discussion Lesions of the central nervous system have been known to present in the disguise of functional psychiatric disturbances, and especially in the early stages their true identity may not be apparent (4, 5, 15). Those involving the frontal lobes are particularly adept at mimicking behavioural disorders (I, 7). The three cases presented here, all involving frontal lobe lesions, are indicative of the problem one faces when a patient presents with what appears to be a major psychiatric illness. Each of these individuals, seen in an emergency room setting, was referred for psychiatric evaluation. The onset of illness was variable, from two days to two months. Case] Two of the patients had no prior psychiatric This patient, a 55-year old married male government clerk, previously reported, (5), was history and in the other (case 2) the sent to the emergency department by his family emergent symptoms were qualitatively and doctor for psychiatric examination and admis- quantitatively different from those prevision because of severe depression of two ously reported. The changes in affect months' duration. Over the last three years the (flatness, depression, inappropriateness),
October, 1977
FRONTAL LOBE LESIONS
317
behavioural changes, disturbances in atten- ence of a lesion. Disturbances in thought, tion, delusions and hallucinations seen in affect and perception cannot always be these patients have been reported by others assessed as purely functional. as occurring in patients with cerebral lesions (3, 13). However, these do not give References any indication as to the organic etiology and 1. Avery, T.L.: Seven cases of frontal tumour may, in fact, lead one to think of a with psychiatric presentation. Br J psychiatric illness, such as depression or Psychiatry 119: 19, 1971. schizophrenia. The absence of neurological 2. Beres, D., Brennan, c.: Mental reactions in signs initially, or if present but non-specific patients with neurological disease. Psy(case 3) may further confuse the issue. choanal Q 19: 170, 1950. 3. Blumer, D.: Neurological states masqueradThere are some signs, however, which ing as psychoses. Maryland State Med J 19: point in the direction of organic pathology. 55,1970. Of note in all of these patients was the 4. Blustein, J.E., Seeman, M.V.: Brain presence of headache, not a very common tumours presenting as functional psychiatric complaint in schizophrenia or even in disturbances. Can Psychiatr Assoc J 17SS: severe depression with psychomotor retar59,1972. dation, but a significant symptom in 60 5. Blustein, J.E.: Further observations on percent of all patients with brain tumour brain tumours presenting as functional (12). Somnolence, especially with the psychiatric disturbances. Psychiatric Jourintake of alcohol or neuroleptic medication, nal Univ Ottawa 1: 21, 1976. 6. Hobbs, G.E.: Brain tumours simulating was also noted. In addition, such findings psychiatric disease. Can Med Assoc J 88: as absence of previous psychiatric illness, 186,1963. the acute or sub-acute behavioural changes, 7. Hunter, R., Blackwood, W., Bull, 1.: Three and minor or non-specific neurological cases of frontal meningiomas presenting signs may offer further clues to the psychiatrically. Br Med J 3: 9, 1968. examiner. Some of these have been reported 8. Kurtzke, J.F., Kurland, L.T., Goldberg, by other authors (1, 4, 5). I.D.: The numerical impact of the major Disturbances in thinking, perception and neurologic and sense organ disorders. Trans affect, usually attributable to functional Am Neurol Assoc 96: 265, 1971. disorders, may have an organic basis and 9. Lipowski, Z.J., Kiriakos, R.Z.: Borderfurther remind us of the neurological lands between neurology and psychiatry: observations in a neurological hospital. component of behaviour. Particular attenPsychiatryinMed3: 131, 1972. tion has been drawn to those lesions of the frontal lobes where, perhaps more than 10. Patton, R.B., Sheppard, J.A.: Intracranial tumors found at autopsy in mental patients. other areas of the brain, the symptoms Am JPsychiatry 113: 319,1956. resulting may appear purely psychiatric. 11. Remington, F.B., Rupert, S.L.: Why paEmphasis has been placed on the importients with brain tumors come to a psychiatance of headache and somnolence, in the tric hospital. Am J Psychiatry 119: 256, absence of specific neurological signs, in an 1962. effort to elucidate the organic nature of the 12. Rushton, J.G., Rooke, E.D.: Brain tumor illness. headache. Headache 2: 147, 1962. Summary This paper presents three cases of frontal lobe lesions from the author's experience (subdural hematoma, meningioma and astrocytoma) which initially appeared as schizophrenia or depression. Attention is drawn, in the absence of specific neurological signs, to the importance of headache and somnolence in offering clues to the pres-
13. Mayer-Gross, Slater, Roth: Clinical Psychiatry. E. Slater, M. Roth, eds., London: Balliere, Tindall and Cassell, 3rd ed.,1970. 14. Strauss, H.: Intracranial neoplasms masked as depressions and diagnosed with the aid of electroencephalography. J Nerv Ment Dis 122: 185, 1955. 15. Thompson, G.N.: Cerebral lesions simulating schizophrenia: three case reports. J Soc Bioi Psychiatry 11: 59, 1970.
318
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
16. Waggoner, R.W., Bagchi, B.K.: Initial masking of organic brain changes by psychic symptoms. Clinical and electroencephalographic studies. Am J Psychiatry 110: 904, 1954.
Resume Cet article presente trois cas de lesions du lobe frontal (hematome sous-dural, meningiome et astrocytome) rencontres au cours
Vol. 22, No.6
de la pratique clinique de I'auteur, lesquels se manifesterent initialement par un tableau de schizophrenic ou de depression. On souligne I' importance de la cephalee et de la somnolence, en l' absence de signes neurologiques specifiques, comme indices de la presence de telles lesions. Les troubles de la pensee, de I'affectivite et de la perception ne doivent pas toujours etre interpretes comme purement fonctionnels.
FRONTAL LOBE LESIONS MASQUERADING AS PSYCHIATRIC DISTURBANCES*
RICHARD
Several papers have appeared in the literature calling attention to the relationship between brain tumours and psychological symptoms (l, 3-7, 10, 11, 14-16). The purpose of this paper is to focus specifically on lesions of the frontal lobes, how they may masquerade under the guise of a functional psychiatric disorder, and what clues may be useful in uncovering their real nature. Psychiatric symptoms are frequently the earliest and sometimes the only manifestations of a cerebral space-occupying lesion (1, 3-7, 15, 16). Often, the more obvious motor and sensory deficits may be lateappearing, and the behavioural changes may be the first sign that something is wrong. These changes can result from the disability and loss of function which the patient is experiencing (2, 9, 11). On the other hand, these behavioural symptoms can result from tissue destruction and alteration of cerebral function. The prevalence of brain tumours in the general population is estimated to be 40 per 100,000 (8). It is also estimated that approximately 2 percent of patients admitted to psychiatric facilities have brain tumours (6). The family physician or emergency room casualty officer may first come into contact with the patient who has a cerebral lesion. Because of the behavioural symptoms which the patient exhibits and the absence of focal neurological signs, the 'Manuscript received March 1977; revised May 1977. 'Clinical Instructor in Psychiatry, Faculty of Medicine, University of Ottawa and the Royal Ottawa Hospital, Ottawa, Onto Can. Psychiatr. Assoc. J. Vol. 22 (1977)
J.
CARLSON,
M.D. 1
patient may then be referred to a psychiatrist. Three cases from the author's firsthand experience, seen over a two-year period, are presented here. Case 1 A 31-year old single male student in computer sciences was brought to the emergency room by his friends because of a 2-day history of change in behaviour. He had become less talkative, very withdrawn and sometimes somnolent, especially with a small drink of alcohol. There were sounds which he heard, such as someone mumbling to him. According to his friends, he gave short, inappropriate answers to questions. He was referred for psychiatric examination. A further history was obtained that for the past 2-3 weeks he had been seeing various physicians complaining of headache and depression. He was able to continue his studies and drive a taxi part-time until one week before admission, when he felt very depressed. He had always been a quiet, shy person described as a "loner". There was no precipitating event, previous psychiatric history, or family history of mental illness. On examination the patient was withdrawn, preoccupied, slightly agitated and appeared to be hallucinating. His affect was flattened, but not depressed. He spoke in brief sentences, with thought blocking, incoherence and loosened associations. There were no apparent delusions. He had difficulty following simple instructions, memory was difficult to test, but orientation was intact. Vital signs were normal, and general physical and neurological examinations revealed no abnormalities. He complained of a generalized headache. The patient was admitted to the psychiatric unit with the tentative diagnosis of acute schizophreniform psychosis, but immediate investigations were ordered. Within 24 hours, the patient developed a slight temperature elevation
315
316
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
and mild nuchal rigidity. A lumbar puncture revealed xanthochromia and increase in WBC's. An EEG showed a left fronto-parietal disturbance, and a brain scan showed a lesion in that area. Angiography demonstrated a left infrafrontal subdural hematoma from an aneurysmal malformation. The patient was taken to surgery, and post-operatively made an excellent recovery with return to pre-morbid functioning and no signs of psychosis. Case 2 A 60-year old woman was admitted to hospital from a convalescent home with a two-week history of withdrawal, feeling severely depressed and suicidal, not communicating with others, and acting very suspicious. She had grand mal epilepsy since the age of 18 and a bilateral hearing impairment for 5 years, and complained of headaches and fatigue for one year. She was maintained on diphenylhydantoin and phenobarbital for many years, having a seizure about once a month, but lately the seizures were as frequent as every other day, mostly nocturnal. Her past history included a 13-year stay in a psychiatric facility with a diagnosis of epilepsy with psychosis. On this admission, the patient was very depressed and tearful, had delusions of worthlessness and that death was near, but memory and orientation were good. Physical examination was unremarkable except for hearing impairment and a right lateral rectus muscle palsy which she had had since birth. She initially received amitriptyline, with resulting confusion and somnolence. She also had several grand mal seizures. Neurological consultation did not reveal any focal signs. An EEG revealed symmetrical paroxysmal spikes in both fronto-temporal regions. The brain scan showed a circular area of activity in the midline frontal area, suggesting a meningioma. She was transferred to a neurosurgical service. At surgery a frontal parasagittal meningioma was found and removed. Her postoperative course was fairly smooth and she returned to a good level of functioning with no depression or seizures.
Vol. 22, NO.6
patient had become progressively more somno_ lent. His headaches of many years' duration had become more pronounced in the last two months. Loss of the family dog and failure to be promoted in his job resulted in him withdrawing. The patient's appetite was good but it took him a very long time to eat. There also were periods of several seconds of memory loss or confusion in the last month. His premorbid personality was one of perfectionism, obsessiveness and stubbornness. On admission the patient was thin, appeared deeply depressed and had severe psychomotor retardation. He answered questions with very short replies and had delusions that the end of the world was approaching. Anger became apparent at times when talking about work, saying "they'll be sorry" repeatedly. He did not cooperate for testing of memory and orientation. Physical examination revealed generalized hyperreflexia, but no other neurological signs. It was felt that he might be suffering from an endogenous depression, but an organic etiology was immediately investigated. An EEG and brain scan done shortly afterwards were consistent with a space-occupying frontal lesion. At surgery a right frontal astrocytoma grade IV was removed. Post-operatively the patient's presenting symptoms had disappeared and he seemed more like his usual self, according to the wife.
Discussion Lesions of the central nervous system have been known to present in the disguise of functional psychiatric disturbances, and especially in the early stages their true identity may not be apparent (4, 5, 15). Those involving the frontal lobes are particularly adept at mimicking behavioural disorders (I, 7). The three cases presented here, all involving frontal lobe lesions, are indicative of the problem one faces when a patient presents with what appears to be a major psychiatric illness. Each of these individuals, seen in an emergency room setting, was referred for psychiatric evaluation. The onset of illness was variable, from two days to two months. Case] Two of the patients had no prior psychiatric This patient, a 55-year old married male government clerk, previously reported, (5), was history and in the other (case 2) the sent to the emergency department by his family emergent symptoms were qualitatively and doctor for psychiatric examination and admis- quantitatively different from those prevision because of severe depression of two ously reported. The changes in affect months' duration. Over the last three years the (flatness, depression, inappropriateness),
October, 1977
FRONTAL LOBE LESIONS
317
behavioural changes, disturbances in atten- ence of a lesion. Disturbances in thought, tion, delusions and hallucinations seen in affect and perception cannot always be these patients have been reported by others assessed as purely functional. as occurring in patients with cerebral lesions (3, 13). However, these do not give References any indication as to the organic etiology and 1. Avery, T.L.: Seven cases of frontal tumour may, in fact, lead one to think of a with psychiatric presentation. Br J psychiatric illness, such as depression or Psychiatry 119: 19, 1971. schizophrenia. The absence of neurological 2. Beres, D., Brennan, c.: Mental reactions in signs initially, or if present but non-specific patients with neurological disease. Psy(case 3) may further confuse the issue. choanal Q 19: 170, 1950. 3. Blumer, D.: Neurological states masqueradThere are some signs, however, which ing as psychoses. Maryland State Med J 19: point in the direction of organic pathology. 55,1970. Of note in all of these patients was the 4. Blustein, J.E., Seeman, M.V.: Brain presence of headache, not a very common tumours presenting as functional psychiatric complaint in schizophrenia or even in disturbances. Can Psychiatr Assoc J 17SS: severe depression with psychomotor retar59,1972. dation, but a significant symptom in 60 5. Blustein, J.E.: Further observations on percent of all patients with brain tumour brain tumours presenting as functional (12). Somnolence, especially with the psychiatric disturbances. Psychiatric Jourintake of alcohol or neuroleptic medication, nal Univ Ottawa 1: 21, 1976. 6. Hobbs, G.E.: Brain tumours simulating was also noted. In addition, such findings psychiatric disease. Can Med Assoc J 88: as absence of previous psychiatric illness, 186,1963. the acute or sub-acute behavioural changes, 7. Hunter, R., Blackwood, W., Bull, 1.: Three and minor or non-specific neurological cases of frontal meningiomas presenting signs may offer further clues to the psychiatrically. Br Med J 3: 9, 1968. examiner. Some of these have been reported 8. Kurtzke, J.F., Kurland, L.T., Goldberg, by other authors (1, 4, 5). I.D.: The numerical impact of the major Disturbances in thinking, perception and neurologic and sense organ disorders. Trans affect, usually attributable to functional Am Neurol Assoc 96: 265, 1971. disorders, may have an organic basis and 9. Lipowski, Z.J., Kiriakos, R.Z.: Borderfurther remind us of the neurological lands between neurology and psychiatry: observations in a neurological hospital. component of behaviour. Particular attenPsychiatryinMed3: 131, 1972. tion has been drawn to those lesions of the frontal lobes where, perhaps more than 10. Patton, R.B., Sheppard, J.A.: Intracranial tumors found at autopsy in mental patients. other areas of the brain, the symptoms Am JPsychiatry 113: 319,1956. resulting may appear purely psychiatric. 11. Remington, F.B., Rupert, S.L.: Why paEmphasis has been placed on the importients with brain tumors come to a psychiatance of headache and somnolence, in the tric hospital. Am J Psychiatry 119: 256, absence of specific neurological signs, in an 1962. effort to elucidate the organic nature of the 12. Rushton, J.G., Rooke, E.D.: Brain tumor illness. headache. Headache 2: 147, 1962. Summary This paper presents three cases of frontal lobe lesions from the author's experience (subdural hematoma, meningioma and astrocytoma) which initially appeared as schizophrenia or depression. Attention is drawn, in the absence of specific neurological signs, to the importance of headache and somnolence in offering clues to the pres-
13. Mayer-Gross, Slater, Roth: Clinical Psychiatry. E. Slater, M. Roth, eds., London: Balliere, Tindall and Cassell, 3rd ed.,1970. 14. Strauss, H.: Intracranial neoplasms masked as depressions and diagnosed with the aid of electroencephalography. J Nerv Ment Dis 122: 185, 1955. 15. Thompson, G.N.: Cerebral lesions simulating schizophrenia: three case reports. J Soc Bioi Psychiatry 11: 59, 1970.
318
CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
16. Waggoner, R.W., Bagchi, B.K.: Initial masking of organic brain changes by psychic symptoms. Clinical and electroencephalographic studies. Am J Psychiatry 110: 904, 1954.
Resume Cet article presente trois cas de lesions du lobe frontal (hematome sous-dural, meningiome et astrocytome) rencontres au cours
Vol. 22, No.6
de la pratique clinique de I'auteur, lesquels se manifesterent initialement par un tableau de schizophrenic ou de depression. On souligne I' importance de la cephalee et de la somnolence, en l' absence de signes neurologiques specifiques, comme indices de la presence de telles lesions. Les troubles de la pensee, de I'affectivite et de la perception ne doivent pas toujours etre interpretes comme purement fonctionnels.
