Paranoid psychosis presentation in normal pressure hydrocephalus

Tapal Renu Mounika; Harshitha Veeramachaneni; Ananda Reddy Endreddy; VV Seshamma

doi:10.4103/tjp.tjp_26_22

CASE REPORT

Year : 2022 | Volume : 8 | Issue : 2 | Page : 110-112

Paranoid psychosis presentation in normal pressure hydrocephalus

Tapal Renu Mounika, Harshitha Veeramachaneni, Ananda Reddy Endreddy, VV Seshamma
Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

Date of Submission	15-Jul-2022
Date of Decision	27-Oct-2022
Date of Acceptance	07-Nov-2022
Date of Web Publication	16-Dec-2022

Correspondence Address:
Dr. Harshitha Veeramachaneni
Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjp.tjp_26_22

Abstract

Normal pressure hydrocephalus (NPH) is caused by aqueductal stenosis, where excessive cerebrospinal fluid (CSF) accumulates in the ventricles of the brain. It is characterized by the triad of gait disturbance, cognitive impairment, and urinary incontinence. Late-onset psychosis should be evaluated thoroughly to rule out any organic cause. We present the case of a male patient presenting with delusions, hallucinations, gait disturbances, and urinary incontinence in his late 60s.

Keywords: Neuropsychiatric manifestations, normal pressure hydrocephalus, paranoid psychosis

How to cite this article:
Mounika TR, Veeramachaneni H, Endreddy AR, Seshamma V V. Paranoid psychosis presentation in normal pressure hydrocephalus. Telangana J Psychiatry 2022;8:110-2

How to cite this URL:
Mounika TR, Veeramachaneni H, Endreddy AR, Seshamma V V. Paranoid psychosis presentation in normal pressure hydrocephalus. Telangana J Psychiatry [serial online] 2022 [cited 2023 Jun 5];8:110-2. Available from: https://tjpipstsb.org/text.asp?2022/8/2/110/363972

Introduction

Normal pressure hydrocephalus (NPH) or Hakim-Adam's Syndrome is a potentially reversible dementia characterized by a clinical triad of gait disturbance, incontinence, and dementia. Studies show a variety of psychiatric manifestations associated with NPH, which include personality changes, anxiety, depression, psychosis, mania, aggression, and obsessive-compulsive disorder.^[1] These manifestations are related to alterations in the activities of central serotonergic, dopaminergic, and noradrenergic neurotransmitter systems.^[2] Psychosis with NPH is rarely seen, and where described, it was seen that these symptoms were generally mild.^[3] This is a case report of NPH presenting with paranoid psychosis.

Case Report

A 60-year-old male who studied till secondary schooling hailing from rural habitat belonging to middle socioeconomic status and running a grocery store, was brought by his daughter and wife with chief complaints of suspiciousness on wife, hearing of voices, talking to self, anger, and irritability toward wife, verbally and physically abusing wife and sleep disturbances for 3 months. The presenting complaints started as insidious onset, gradually progressive in nature. His wife reported that his current symptoms had been preceded by memory disturbances, slowness of walking, and urinary incontinence of 8 months duration.

He has no history of medical comorbidities or head injury, or substance use. There is no past or family history of neuropsychiatric illness.

On physical examination, his blood pressure was found to be 132/84 mmHg with a pulse rate of 85/min. The neurological examination revealed ataxia, and his gait was broad-based magnetic-type. On mental status examination, he appeared poorly kempt with fleeting eye contact, increased psychomotor activity, relevant and coherent speech, thought content of delusions of infidelity, dull mood, blunted affect, perception abnormality of 2^nd and 3^rd person auditory hallucinations, and lack of insight. Mini mental state examination (MMSE) scoring was 17/30 (Severe cognitive impairment). Routine blood and urine tests, thyroid profile, and fundus examination revealed no abnormalities. As the neurological examination revealed ataxia and gait disturbances, neurology consultation was done where magnetic resonance imaging was advised, which revealed moderate dilatation of ventricles with acute callosal angle suggesting NPH [Figure 1]. According to ICD-10, the patient was diagnosed as F06.2 - Other mental disorders due to brain damage and dysfunction due to physical disease - Organic delusional disorder (Secondary to NPH).

Figure 1: Magnetic resonance imaging showing moderate dilatation of the ventricular system

Click here to view

The patient was started on tablet risperidone 4 mg and neurosurgeon consultation was taken and patient underwent ventriculoperitoneal shunting.

Postoperatively, his gait improved and urinary incontinence subsided. Tablet Risperidone was stopped. One month after the surgery, the patient was followed up regularly and was maintained well with no active psychotic symptoms. MMSE score improved from 17 to 25.

Discussion

NPH usually manifests with Hakim's triad, followed by psychiatric manifestations as the illness progresses. A similar pattern was observed in our case. A study conducted by Oliveira et al. showed that psychiatric symptoms could occur in the early course of NPH.^[1] Unusual appearances of NPH symptoms may hinder early diagnosis and, consequently, proper treatment. Sometimes, even response to typical treatment in psychiatric syndromes may be impaired, like a patient in their study having schizophrenia with intolerance to even low doses of antipsychotics, who was subsequently revealed to be having communicating normal pressure hydrocephalus.^[1] The cause of these neuropsychiatric symptoms in NPH may result from alternations in neurotransmitter activity or structural brain damage. One possible mechanism for normal pressure hydrocephalus presenting with psychosis is reductions in postsynaptic D2 dopamine receptors (putamen and nucleus accumbens) with concomitant preservation of normal presynaptic activity (striatum).^[2] This would imply an increase in dopamine synthesis and turnover in intact presynaptic dopaminergic neurons to compensate for the reduced postsynaptic receptor activity.^[2] Furthermore, ventricular enlargement due to aqueduct stenosis can cause the schizophreniform type of psychosis.^[4]

Yusim et al. reported a case of NPH presenting with Othello syndrome. In our case, the patient had the delusion of infidelity along with auditory hallucinations.^[5]

Cognitive symptoms present in these patients can be both because of age-related changes and also, because of the illness but the presence of delusions and hallucinations in the elderly is not a usual presentation of psychotic symptoms in this age group.^[6] It is a well-accepted fact that patients with a Neurodegenerative disorder often receive psychiatric diagnoses. This can happen in NPH as well. However, the percentage of NPH contributing to the secondary cause of psychosis in the elderly is not known.^[7]

Improvement of psychosis with CSF shunting procedures supports causal relation between NPH and Psychosis. Data showing improvement of psychosis in NPH, consequent to CSF shunt procedure, is sparse.^[7]A study conducted by Kito Y et al. showed that there is a correlation between neuropsychiatric symptoms and urinary incontinence and cognitive decline which may be due to frontal dysfunction. The study also showed improvements in the neuropsychiatric symptoms and triad symptoms in patients who underwent shunt operations which may be due to improved oxygen metabolism or cerebral perfusion in the frontal cortex and thalamus, which are known to occur in NPH patients following shunt operations.^[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Oliveira MF, Oliveira JR, Rotta JM, Pinto FC. Psychiatric symptoms are present in most of the patients with idiopathic normal pressure hydrocephalus. Arq Neuropsiquiatr 2014;72:435-8.
2.	Markianos M, Lafazanos S, Koutsis G, Sfagos C, Seretis A. CSF neurotransmitter metabolites and neuropsychiatric symptomatology in patients with normal pressure hydrocephalus. Clin Neurol Neurosurg 2009;111:231-4.
3.	Lying-Tunell U. Psychotic symptoms in normal-pressure hydrocephalus. Acta Psychiatr Scand 1979;59:415-9.
4.	Lin CH, Tsai PC, Huang YH, Cheng YC. Normal pressure hydrocephalus presenting as psychotic symptoms: A case report. Taiwan J Psychiatry 2020;34:92. [Full text]
5.	Yusim A, Anbarasan D, Bernstein C, Boksay I, Dulchin M, Lindenmayer JP, et al. Normal pressure hydrocephalus presenting as Othello syndrome: Case presentation and review of the literature. Am J Psychiatry 2008;165:1119-25.
6.	Srivastava S, Bhatia MS, Gautam P. Normal pressure hydrocephalus presenting as delusional disorder. Ind Psychiatry J 2015;24:94-6. [PUBMED] [Full text]
7.	Mathew R, Archana NU, Sheetal S. Idiopathic normal pressure hydrocephalus presenting as psychosis. Neurol India 2021;69:1356-8. [PUBMED] [Full text]
8.	Kito Y, Kazui H, Kubo Y, Yoshida T, Takaya M, Wada T, et al. Neuropsychiatric symptoms in patients with idiopathic normal pressure hydrocephalus. Behav Neurol 2009;21:165-74.