Psychosocial Adjustment

Management issues for the mental health specialist consulting on these cases are acute and chronic. Presentation is based on both the location of the tumor and the age of the patient. Psychiatric morbidity is high among survivors of malignant pediatric brain tumors. These patients are exposed to surgery, radiation, and chemotherapeutic agents that cause acute and chronic effects on the brain and CNS. Patients may develop endocrinopathies, growth abnormalities, intellectual decline, neurocognitive and psychosocial dysfunction, and a variety of behavioral and emotional disorders including depression, anxiety, dementia, and personality disorders (Zebrack et al. 2004). Patients with CNS malignancies are more likely to experience a psychiatric hospitalization than survivors of other forms of cancer. Cranial radiation is particularly problematic; the severity of late neu-ropsychiatric effects in the survivors of pediatric malignant brain tumors is related to the radiation dose and the age at treatment (Danoff et al. 1982). The effects of radiotherapy peaks some 3-5 years after treatment, with evidence of focal necrosis and progressive necrotizing leukoencephalopathy with necrosis, demyelination, and reactive gliosis. Patients may also present with increased ventricular size, widened sulci, areas of hypodensity or hyperintensity, and focal calcifications years after treatment (Valk and Dillon 1991). Psychotic symptoms develop following infarction, tumors, or traumatic brain injury and can appear years after the original insult.

Frontal Lobe Tumors

The frontal lobes of the brain function to maintain judgment, motivation, and essential aspects of personality including appropriate social skills. In adolescents and adults, lesions of the frontal lobe have resulted in the development of apathy, disinhibition, and emotional lability. It also appears that a certain degree of laterality exists, with left-hemisphere lesions associated with depression and right-hemisphere lesions associated with impulsivity and mood lability. Lesions of the frontal lobe can also affect attention, insight, mood, planning, and interpersonal communication depending on the location (Mah et al. 2004). The nonmotor frontal lobe is subdivided into the prefrontal anterior cingulate and the dor-solateral, orbitofrontal, and ventromedial cortices. The dorsolateral prefrontal cortex generates goal-directed behavior; thus, lesions in this area lead to labile affect, depression, and poor executive functioning. Judgment and socialization are based in the orbitofrontal cortex, and patients with tumors in this area tend to be disinhibited, with a "pseudopsy-chopathy" that may include mood fluctuations, self-mutilation, antisocial behaviors, and personality traits characteristic of borderline personality (Berlin et al. 2004). Ventromedial prefrontal cortex is responsible for empathy, foresight, and reversal learning. Deficits that result from lesions in this area include the persistence of high-risk negative behaviors that in the past were rewarded but currently have severe and adverse consequences. The anterior cingu-late affects motivated attention and concentration along with the ability to recognize affect and mood conflicts. Tumors in this area interfere with these functions and lead to deficits in concentration, awareness, and mood congruence.

Craniopharyngioma

Craniopharyngiomas are benign, slow-growing tumors that develop from remnants of the craniopha-ryngeal duct. They are relatively rare and grow in close proximity to the hypothalamus and pituitary. As a result, the tumor disrupts both the endocrine and autonomic nervous systems. Injury to the hypothalamus can produce changes in eating, sleeping, reproduction, and body temperature. Affected connections from the hypothalamus to the limbic system can lead to increased emotionality. Psychiatric disorder is also a consequence of resulting changes in endocrine functioning, as are the alterations in sleeping, eating, and autonomic functioning that frequently accompany hypothalamic injury. Following surgery for craniopharyngioma, nearly 60% of patients experience obesity due to hypothalamic in-sensitivity to endogenous leptin release (Roth et al. 1998). The extent of hypothalamic damage, assessed on magnetic resonance imaging, correlates with the postoperative body mass index. These patients are also described as labile, aggressive, and disinhibited in patterns similar to those identified in frontal lobe syndromes.

Posterior Fossa Tumors

The posterior fossa syndrome is identified in over 30% of children after the resection of a cerebellar tumor. Young children with posterior fossa tumors will present with lethargy, failure to thrive, and slowing of developmental milestones before specific neurological signs appear. They may also present with psychiatric symptoms characterized by bizarre behavior, emotional lability, extreme irritability, and decreased initiation of voluntary behavior. This presentation is identified as a posterior fossa syndrome and is noted in nearly 30% of patients following resection of cerebellar neoplasms. The symptoms accompany lesions in the vermis, floor of the fourth ventricle, or both (Levisohn et al. 2000; Sadeh and Cohen 2001). A study of 19 young patients with posterior fossa lesions noted increased emotional lability, persistent apathy and dysphoria, and inattention following surgery (Turkel et al. 2004).

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