Childhood organic neurological disease presenting as psychiatric disorder

Pseudo-ataxia due to Osteoid Osteoma

Background

Ataxia is diagnosed by typical features on examination suggestive of a cerebellar etiology and can invoke extensive diagnostic testing. Osteoid osteomas (OOs) are benign bone tumors of the lower limbs that occasionally present with focal neurological signs.

Case Report

A 3-year-old male presented with apparent progressive gait ataxia and non-specific leg pain. Initial imaging was unremarkable. However, 12 months later, a lesion was identified in the distal right femur, which was found to be an OO. The gait disorder and pain resolved after surgery.

Discussion

This case highlights the challenges of diagnosing a gait disorder in young children.

Liaison child and adolescent psychiatry

Liaison child and adolescent psychiatry has been described as the “partnership of child psychiatrists, paediatricians and other specialities concerned with children to provide integrated medical and psychological care for children” (Black et al, 1990). Although liaison work conjures up visions of the psychiatrist on the paediatric ward, it may also involve collaboration with community paediatric and primary care services. Indeed, the number of different professionals that may be involved with even quite mildly ill children is large (see Box 1). Much of the work is indirect (e.g. consultation with other professionals), but this and direct therapeutic work with children and families may continue long after discharge from the paediatric wards and clinics.

Advantages of Structure-Based Drug Design Approaches in Neurological Disorders

OBJECTIVE

The purpose of the review is to portray the theoretical concept on neurological disorders from research data.

BACKGROUND

The freak changes in chemical response of nerve impulse causes neurological disorders. The research evidence of the effort done in the older history suggests that the biological drug targets and their effective feature with responsive drugs could be valuable in promoting the future development of health statistics structure for improved treatment for curing the nervous disorders.

METHODS

In this review, we summarized the most iterative theoretical concept of structure based drug design approaches in various neurological disorders to unfathomable understanding of reported information for future drug design and development.

RESULTS

On the premise of reported information we analyzed the model of theoretical drug designing process for understanding the mechanism and pathology of the neurological diseases which covers the development of potentially effective inhibitors against the biological drug targets. Finally, it also suggests the management and implementation of the current treatment in improving the human health system behaviors.

CONCLUSION

With the survey of reported information we concluded the development strategies of diagnosis and treatment against neurological diseases which leads to supportive progress in the drug discovery.

Neurology in the German training system for psychiatrists - a personal view

In mid-19th-century Germany the conviction that 'mental disease is brain disease' was accompanied by a call for social reform in psychiatry. During neurology training, future psychiatrists often encounter patients with mental disorders rarely seen in psychiatric departments and learn how to avoid misdiagnosing brain diseases as mental disorders.

Psychiatric symptoms causing delay in diagnosing childhood cancer: two case reports and literature review

INTRODUCTION

A somatic disorder may initially be overlooked when a child presents with psychiatric symptoms. We report two children with anorexia nervosa as initial diagnosis and in whom there was a delay in the final diagnosis of the underlying malignancy. A literature survey was performed including patients under 18 years of age with psychiatric symptoms in whom later on an oncological diagnosis became evident as an explanation.

RESULTS

We have found 30 additional cases, with a median delay of 12 months until the diagnosis of the tumour. Overall, 16 boys and 16 girls had a solid tumour: 26 central nervous system tumours, 3 tumours of the gastrointestinal tract and 3 others. In 25 out of 32 patients anorexia nervosa was assumed, although it always appeared to be atypical. Patients younger than 7 years had a significantly longer delay until final diagnosis, while no other patient characteristics correlated with such delay.

DISCUSSION

In addition to careful physical (including full neurological) examination, we advise additional neuroimaging especially in each case of atypical presentation of anorexia nervosa, in order to avoid a delay in diagnosis of a possible malignancy. Furthermore, it is desirable to perform a re-examination when a psychiatric disorder does not respond to therapy, in order not to overlook an underlying oncological disease.

Brief report: childhood disintegrative disorder: a brief examination of eight case studies

Childhood disintegrative disorder (CDD) is a rare condition characterized by distinct regression of developmental and behavioral functioning following a period of apparently normal development for at least 2 years. The purpose of this article is to present the developmental, behavioral, psychosocial, and medical histories of eight children who have been diagnosed with CDD in an attempt to advance the understanding of this rare disorder. Results indicate the average age of onset was 3.21 years. Three cases reported an insidious onset while two cases exhibited acute onset. Developmental and behavioral milestones were met at age appropriate times in each case and significant deterioration of formerly acquired skills and abnormalities in functioning were clinically present in all eight cases.

Are Autistic and Catatonic Regression Related? A Few Working Hypotheses Involving Gaba, Purkinje Cell Survival, Neurogenesis, and ECT

Autistic regression seems to occur in about a quarter of children with autism. Its cause is unknown. Late-onset autistic regression, that is, after 2 years of age, shares some features with catatonic regression. A working hypothesis is developed that some children with autistic regression suffer from early-onset catatonic regression. This hypothesis cannot be answered from current data and is difficult to address in clinical studies in the absence of definite markers of autistic and catatonic regression. Treatment implications are theoretical and involve the potential use of anticatatonic treatments for autistic regression. Focus is on electroconvulsive therapy (ECT)--an established but controversial treatment that is viewed by many, but not all, as the most effective treatment for severe, life-threatening catatonic regression. Clinical trials of ECT in early- or late-onset autistic regression in children have not been done yet. The effects of electroconvulsive seizures--the experimental analogue of ECT--should also be tested in gamma-aminobutyric acid-ergic animal models of autistic regression, autism, catatonia, and other neurodevelopmental disorders. Purkinje cell survival and neurogenesis are putative outcome measures in these models.

Severe generalized dystonia due to primary putaminal degeneration: case report and review of the literature

Putaminal lesions of a variety of etiologies may cause secondary dystonia. We report on a case of primary putaminal degeneration as a cause of severe childhood-onset generalized dystonia and review the literature of the pathology of dystonia. A 44-year-old patient with severe generalized childhood-onset dystonia and macrocephaly underwent neurological evaluation and neuropathological examination. Neurological examination was normal apart from dystonia and signs referable to prior cryothalamotomy. Workup for metabolic and genetic causes of dystonia was negative. Neuroimaging showed severe bilateral putaminal degeneration, which subsequently correlated with the neuropathological findings of gliosis, spongiform degeneration, and cavitation. The substantia nigra pars compacta contained a normal number of neurons but decreased tyrosine hydroxylase immunoreactivity. There were no histopathological markers of other metabolic or degenerative diseases.

A management model for pediatric somatization

Medically unexplained physical symptoms are common in pediatric settings, though little systematic research is available to guide the development of treatment efforts for pediatric somatization and somatoform disorders. This paper presents a management model for pediatric somatization based on principles distilled from the available pediatric and adult literature. Careful assessment, frank presentation of the diagnosis, and a cognitive-behavioral and rehabilitative approach are emphasized, along with aggressive psychiatric treatment of comorbid psychopathology. Well-designed empirical studies of intervention are needed that should examine efficacy as well as the relationship between symptomatic improvement, functional improvement, and comorbid anxiety and depressive symptoms.

Case study: negative reinforcement and behavioral management of conversion disorder

Behavioral interventions have been advocated for conversion disorder, but controlled trials are lacking. The authors report the case of a 12-year-old boy with conversion disorder after 3 months of persistent right arm pain and immobility whose symptoms rapidly resolved after an outpatient behavioral intervention using negative reinforcement. The importance of careful assessment, frank discussion of the diagnosis, patient and family psychoeducation, and a rehabilitative mindset are emphasized. Negative reinforcement may be a powerful tool in the management of pediatric conversion disorder, with the potential to reduce parental anxiety and prevent unnecessary physical assessments and interventions.

Childhood disintegrative disorder

Childhood disintegrative disorder (CDD) is a clinical syndrome characterized by disintegration of mental functions and regression of acquired language and intellectual functions after a period of normal development typically of 3 to 4 years. Although recognized for many years, research on this condition is less advanced than that in autism. Epidemiological data are limited but the condition is much less common than autism. The relationship of this condition to autism remains the topic of debate. Neuropathological and other medical conditions are sometimes associated with the disorder but contrary to earlier belief this is not typical. Collaborative research would facilitate our understanding of this condition.

The natural history of somatic morbidity in disintegrative psychosis and infantile autism: a validation study

In order to study the validity of disintegrative psychosis (DP) as defined in ICD-9, we compared the natural history of somatic morbidity of 13 patients given this diagnosis in childhood with a control group of 39 patients with infantile autism (IA) matched for gender, age, IQ and social class. Average follow-up time was 22 and 23 (11-33) years, respectively. Significantly more DP patients (85 versus 41%) had been admitted to a non-psychiatric hospital during the follow-up period. They also had significantly more admissions (3.6 versus 1.0) and stayed longer in hospital (78 versus 4 days) than patients with IA. Three of the DP individuals had an associated medical disorder and made extensive use of somatic services during the follow-up period. Altogether the DP group had utilised the medical health care system more than patients with IA suggesting that they had more medical symptoms than the IA group. On the whole our findings suggest that individuals with DP and IA should be conceptualised as essentially distinct and should be studied separately as regards aetiology, pathophysiology, course and treatment.

Validity of childhood disintegrative psychosis. General findings of a long-term follow-up study

BACKGROUND

Empirical evidence for the validity of the diagnostic label disintegrative psychosis is sparse. The issue of whether it is a separate form of infantile autism is unresolved.

METHOD

To investigate the validity of disintegrative psychosis as defined in ICD-9, the natural history of 13 cases were compared with 39 matched cases of infantile autism on various outcome variables. Average follow-up time was 22 (11-33) years.

RESULTS

Statistically significant differences were found between the two groups in terms of number of admissions to non-psychiatric departments, occurrence of comorbid epilepsy, social style, and score on the Global Assessment of Functioning scale. In most other areas assessed there was a tendency, although statistically insignificant, towards a better outcome in the infantile autism comparison group.

CONCLUSIONS

Our findings provide some support for maintaining a diagnostic category of disintegrative psychosis as distinct from infantile autism.

Psychosis as a presentation of physical disease in adolescence: a case of Niemann-Pick disease, type C

This study reports the case of a 16-year-old male who presented with a history of prominent psychotic symptoms and paranoid delusions which overshadowed subtle signs and symptoms of cognitive and motor dysfunction. Intensive neurobehavioral and biochemical investigations eventually led to the diagnosis of Niemann-Pick disease, type C (NPC), an autosomal recessively inherited storage disease that is associated with the accumulation of cholesterol in lysosomes and difficulties in the processing of exogenously derived cholesterol. Clues to the presence of a neurological disorder included: a history of insidiously declining academic and athletic performance which antedated the onset of psychosis; abnormalities on mental status examination, including psychomotor slowing, memory difficulties, and impairment of higher attentional functions; physical findings of subtle downgaze impairment, mild symmetrical hyperreflexia, and lower-extremity hypertonia with flexor plantar responses, marked impairment of upper-extremity rapid alternating movements, action tremor, and bilateral posturing with stress gait maneuvers. This case demonstrates the importance of careful and persistent neurodiagnostic evaluation in adolescents with psychotic presentations, particularly when cognitive and motor deterioration is suspected, and even when head CT and MRI scans are judged to be normal.

Psychogenic disorders of vision in childhood ("visual conversion reactions"): perspectives from adolescence: a research note

Fifteen adolescents who had exhibited psychogenic disorders of vision in childhood were compared with a control group of adolescents who had experienced childhood visual dysfunction of organic origin. The principal modes of assessment were clinical interviews, the Parental Bonding Instrument (PBI), and self-report measures concerning specific personality traits. Adolescents who had previously presented with psychogenic disorder were more likely to (1) report having experienced school difficulties and the loss of a significant figure at the time of presentation, (2) rate their mothers as over-involved on the PBI and (3) report adjustment difficulties and obsessional personality traits in adolescence.

Heller syndrome in a pre-school boy. Proposed medical evaluation and hypothesized pathogenesis

The case of a 6-year-old boy who developed childhood disintegrative disorder (Heller syndrome) at the age of 4 years is presented, and specifics of the neurologic evaluation are detailed. A table is provided suggesting the complete neurologic work-up with the potential findings for children presenting with signs and symptoms of deterioration. A hypothesis for the aetiology of Heller syndrome proposes that predisposing genetic factors when combined with an environmental stress result in the deposition of amyloid and the disruption of synaptic transmission during the deterioration period. Speculation that the deterioration may be self-limited by activation of an immune response is based upon earlier findings that interleukin 1 has been shown to be involved in the breakdown of amyloid precursor protein in humans.

Subacute sclerosing panencephalitis presenting with psychosis and possible sexual abuse

A previously healthy 8-year-old girl began to experience nightmares, soon followed by sleeplessness and perceptual abnormalities including visual hallucinations. She also complained that she had been attacked and possibly assaulted sexually. Physical investigations were considered to have provided no relevant abnormality and psychiatric enquiries were begun directed towards possible sexual abuse. However, the child's mental and physical state continued to deteriorate and evidence of a progressive organic process was then obtained from past school reports, review of the initial EEG findings and further EEG investigations. The latter in particular indicated a diagnosis of SSPE which was confirmed immunologically. Treatment was ineffective and the child died 7 months after the onset of the illness. The details of the psychological changes at the onset of SSPE are ill-defined. This case illustrates that they can include psychotic phenomena but also that the basic nature of the disorder may be misconstrued as psychological depending on the circumstances.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.

Paediatrics and child psychiatry: past, present and future

The historical development of the relationship between paediatrics and child psychiatry is outlined and the closer working relationships between the two disciplines over the past 30 years are noted. Various ways in which child psychiatrists can contribute to paediatric practice are described, as well as the degree to which paediatricians can contribute to an understanding of child psychiatric disorders. It is suggested that new developments in paediatric practice and an increase in interest in genetic and brain mechanisms in child psychiatric disorders, will increase the need for collaboration between the two specialties.

An emerging schizophrenic syndrome

This case history describes a 16-year-old adolescent male who developed schizophrenia with prominent negative symptoms. For the previous 6 years his diagnosis had been oppositional defiant disorder or conduct disorder. The clinical presentation, differential diagnosis, and management are discussed. The case exemplifies issues addressed in DSM IV.

A selective review of child psychiatric syndromes with a somatic presentation

This review focuses on 'aches and pains' and conversion syndromes as a basis for the description of psychological factors and mechanisms of relevance for the somatisation of distress in childhood and which may contribute to medical help-seeking for children. The characteristic pattern of associated psychological factors includes child personality features; academic concerns; family health problems; and styles of family interaction. Further research is required to explore in more depth the nature of these factors, the mechanisms that mediate the development of severe handicapping problems, and effective interventions.

Childhood disintegrative disorder: issues for DSM-IV

Childhood disintegrative disorder, also known as Heller syndrome or as disintegrative psychosis, is a relatively uncommon condition which has variably been included in official diagnostic systems. Available evidence regarding the validity of this diagnostic concept, particularly with regard to autism, supports inclusion of the category in DSM-IV. Proposed criteria and narrative description for the disorder are presented.

An integrated medical and psychiatric approach to conversion symptoms in a four-year-old

Conversion disorder is a challenging diagnosis in children and adolescents. Medical and psychiatric diagnoses need to be evaluated both separately and in relation to each other. This case highlights both the diagnostic criteria for a conversion disorder in a young child and the need for an integrated medical and psychiatric approach by physicians.

Differential diagnosis and treatment of conversion disorder and Guillain-Barre syndrome

Three cases are presented which illustrate the possible difficulties in differentiating between the diagnoses of Guillain-Barre Syndrome and conversion disorder. Accepted criteria are specified for each condition, as well as some associated features often characteristic of similar cases. Supportive interdisciplinary treatment for Guillain-Barre Syndrome is reviewed, and an interdisciplinary multi-modal approach to treatment of conversion disorder is described.

Conversion disorder (DSM-III 300.11): symptomatology and course in childhood and adolescence

The incidence, age and sex distribution, symptomatology, psychosocial stress factors and course of conversion symptoms in a child and adolescent psychiatric patient sample were studied. Under the age of 10 conversion symptoms are comparatively rare and consequently require careful diagnosis, particularly regarding visual and hearing defects. Predominant conversion symptoms are seizures, gait problems and paralysis.

Rett syndrome: review and discussion of current diagnostic criteria

Rett syndrome is a mental retardation syndrome that occurs only in females and consists of normal pre-, peri-, and neonatal growth and development. It is followed by rapid neurobehavioral deterioration in late infancy or early childhood, a developmental arrest, plateauing, and then either a course of retarded development or continued deterioration. The period of rapid neuro-behavioral deterioration manifests as a partial autistic syndrome, with loss of production and comprehension of language, hyperactivity, hyperventilation, hand-wringing, and ataxic gait. Current diagnostic criteria are discussed and suggestions for further research are presented.

Diagnosis and treatment of hysterical conversion reactions

Twenty children with hysterical conversion reactions were reviewed. The ways in which they became ill, the attitudes of their families to their illnesses and their underlying personal problems were noted. Treatment comprised avoiding unnecessary investigations and removing symptoms by using graded exercises given by physiotherapists. Exploration of the underlying psychological problems took place at a pace with which the family could cope because many families were reluctant at first to accept that the illness was psychological. Seventeen of the 20 children recovered completely within three months of starting treatment. The results show that early diagnosis and close liaison between paediatricians, physiotherapists, and child psychiatrists are necessary if prolonged handicap is to be avoided.

Clinical features of conversion disorder

This study reviewed the case notes of 52 children diagnosed as suffering from hysterical conversion during admission to a paediatric teaching hospital over a 10 year period. The disorder was rare below 8 years of age and girls outnumbered boys three to one. Altogether 75% of the children presented during spring and summer; at the time of end of year exams and the beginning of the new school year. The presentation was usually polysymptomatic with gait disturbance being the main complaint in 36 children. Sensory abnormality, predominantly pain, was present in 40 children; this indicates a strong association between psychogenic pain and conversion disorder in children. At discharge 32 were completely recovered or had appreciably improved. There was a core group that presented particular difficulties with diagnosis and showed little positive response to treatment.

Neuropsychiatry and child psychiatry: the case of the brainstem evoked potential as an illustration

In child psychiatry one may frequently and reasonably suspect the existence of a neurophysiological abnormality of some kind even though this abnormality is not detectable with readily available technology: in children presenting developmental or acquired aphasia, in some specific learning disabilities, in severe developmental disorders or perhaps in a subgroup of those labeled Attention Deficit Disorder. 1. The importance for us as child psychiatrists to keep in mind the possible role of neurophysiological factors is put into perspective. 2. What Evoked Potentials are is briefly described as well as the basic principles of the technique used in recording them. 3. A review of the literature reveals how the Brainstem Auditory Evoked Responses (BAER) have helped in understanding unknown facets of known diseases (Diabetes, Hyperthyroidism, Bell Palsy, etc. . . . ) from this, it is argued that this is reasonable to expect the same usefulness for diagnosis in child psychiatry. 4. An opinion is offered as to how and when a child psychiatrist should make use of this investigation.

Disintegrative psychosis of childhood: teenage follow-up

Nine patients with disintegrative psychosis of childhood were reviewed after follow-up periods of 11 to 16 years. Eight of the nine had a uniform picture of early normal development for two years or more, followed by subacute regression over a period of a few months, to become functionally severely retarded with autistic behavioural features and overactivity. Neurological investigations were consistently negative. The clinical course has remained largely static for these patients, but two have developed epilepsy. They are likely to remain severely handicapped, but not to deteriorate. It is possible that this remarkably homogeneous clinical picture is the result of unidentified encephalopathic processes occurring during early childhood.

Patterns of intellectual change in the dementing school child

Four children with intellectual deterioration are discussed. The importance of a developmental and educational history and sequential psychological testing is emphasized. Progressive visual impairment, clumsiness and increasingly poorly-controlled fits should alert teachers and doctors to the possibility of associated intellectual deterioration. As well as global loss, tests of memory and mental arithmetic, manipulative and perceptual skills were the most sensitive index of dementia. We propose a further subcategory of the present codes of classification of childhood psychiatric disorders.

The insidious presentation of the juvenile form of metachromatic leucodystrophy

Certain progressive cerebral diseases can present with emotional and behavioural disorders. The juvenile form of metachromatic leucodystrophy is one of these. The histories of two children with this condition are given to demonstrate the insidious form of onset.