Pseudobulbar Palsy

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Patients with pseudobulbar palsy demonstrate pathological laughing, crying, and grimacing, often following little or no stimulation. Spastic weakness of the lower cranial nerve muscles (cranial nerves V, VII, and IX through XII) may be noticed on examination with accompanying dysarthria. This syndrome may be seen in patients with upper motor neuron dysfunction including those with amyotrophic lateral sclerosis, multiple sclerosis, or bilateral cerebral infarction. Patients with progressive supranuclear palsy (PSP), Parkinson's disease, and other parkinsonian syndromes may have pseudobulbar palsy in addition to more classic signs and symptoms. Mutism associated with pseudobulbar symptoms has also been reported after the resection of posterior fossa tumors in children. y Most therapies are ineffective; however, trials of agents that modulate biogenic amines such as levodopa, amantadine, amitriptyline, and fluoxetine may ameliorate the paroxysms of abnormal affective behavior.

TABLE 3-2 -- SELECTED ETIOLOGIES ASSOCIATED WITH DISORDERS OF MOOD, EMOTION, AND THOUGHT

Etiological Category

Selected Specific Etiologies

Chapter

HEREDITODEGENERATIVE DISORDERS

Storage diseases: lipidoses, glycogen disorders, and leukoencephalopathies

Cerebral lipidoses--psychotic features Metachromatic leukodystrophy--psychotic features

30

Amino/organic acidopathies, mitochondrial enzyme defects and other metabolic errors

Homocystinuria--psychotic features

Acute intermittent porphyria--psychotic features depression

31

Degenerative dementias

Diffuse Lewy bodv disease--psychotic features, dyscontrol syndromes Alzheimer's disease--psychotic features, depression, dyscontrol syndromes

33

Movement disorders

Parkinson's disease-depression, anxiety, apathy Progressive supranuclear palsy--depression, anxiety, apathy Wilson's disease--psychotic or manic features, depression, anxiety

Huntington's disease--psychotic or manic features, anxiety, dyscontrol syndromes, depression Tourette's syndrome--anxiety, obsessive-compulsive syndrome

34

Degenerative motor, sensory and autonomic disorders

Fabry's disease--psychotic features

36

ACQUIRED METABOLIC AND NUTRITIONAL DISORDERS

Endogenous metabolic disorders

Adrenal, parathyroid, thyroid dysfunction (hypo and hyper)--depression, manic features, anxiety, dyscontrol syndromes

Cardiovascular disease, pulmonary insufficiency, anemia, hypoglycemia, pheochromocytoma--anxiety

38

Exogenous acquired metabolic disorders of the nervous system: toxins and illicit drugs

Carbon monoxide poisoning--psychotic features Heavy metals--psychotic features, anxiety

Amphetamine, hallucinogens, belladonna alkaloids, barbiturate withdrawal. cocaine, phencyclidine--psychotic features, dyscontrol syndromes

39

Nutritional deficiencies and syndromes associated with alcoholism

Vitamin B12 deficiency--psychotic features, depression, anxiety Wernieke-Korsakoff syndrome--psychotic features Pellagra--psychotic features, anxiety Alcohol--psychotic and manic features Alcohol withdrawal--anxiety

40

INFECTIOUS DISORDERS

Viral infections

Encephalitis--psychotic or manic features, anxiety, dyscontrol syndromes, altered sexuality Epstein-Barr virus-depression Postencephalitic--obsessive-compulsive syndrome

41

Nonviral infections

Neurosyphilis--psychotic or manic features, anxiety Tuberculosis--depression

42

Transmissible spongiform encephalopathy

Creutzfeldt-Jakob disease--psychotic features

43

HIV and AIDS

Depression Manic features

44

NEUROVASCULAR DISORDERS

Stroke involving temporal/frontal lobe--psychotic or manic features, anxiety, apathy Stroke involving right parietal lobe--depression, apathy

45

NEOPLASTIC DISORDERS

Primary neurological tumors

Cerebral glioma--psychotic and manic features, depression, anxiety, dyscontrol syndromes Parasagittal/orbital ridge meningioma--apathy and dyscontrol syndromes Hypothalamic/temporal lobe tumors--altered sexuality syndromes

46

Metastatic neoplasms and paraneoplastic syndromes

Cerebral metastasis--psychotic features, depression, mania, anxiety, dyscontrol syndromes, apathy

47

DEMYELINATING DISORDERS

Demyelinating disorders of the central nervous system

Multiple sclerosis--manic features, depression, anxiety

48

TRAUMATIC DISORDERS

Head trauma--depression, psychotic or manic features, apathy syndromes, anxiety, obsessive-compulsive syndrome, apathy

50

AUTOIMMUNE AND INFLAMMATORY DISORDERS

Systemic lupus erythematosus--psychotic features, anxiety Rheumatoid arthritis, temporal arteritis, polyarteritis nodosa--anxiety

51

EPILEPSY

Temporal lobe epilepsy--psychotic or manic features, anxiety (aura), dyscontrol syndromes, altered sexualitv syndromes

52

HEADACHE AND FACIAL PAIN SLEEP DISORDERS

Migraine--manic features, anxiety

53

Sleep apnea, narcolepsy--depression

54

DRUG-INDUCED AND IATROGENIC NEUROLOGICAL DISORDERS

Ibuprofen, ampicillin, streptomycin, tetracycline, beta-blockers, vincristine, azathioprine. amantadine, cimetidine, prednisone, dopaminergics--depression

Amphetamines, baclofen, isoniazid, dopaminergics, opiates, cimetidine, captopril--manic features

Caffeine (and withdrawal), penicillin, sulfonamides, sympathomimetics, amphetamines--anxiety Barbiturates, amphetamines--dyscontrol syndromes Dopaminergics, amantadine--altered sexuality syndromes

55

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