|Year : 2015 | Volume
| Issue : 1 | Page : 94-96
Normal pressure hydrocephalus presenting as delusional disorder
Shruti Srivastava, Manjeet Singh Bhatia, Priyanka Gautam
Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
|Date of Web Publication||16-Jul-2015|
Assistant Professor, Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Normal pressure hydrocephalus (NPH) is caused by aqueductal stenosis resulting in syndrome 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 female patient presenting with delusions, gait disturbances, urinary incontinence in her 50s.
Keywords: Delusions, normal pressure hydrocephalus, organic delusional disorder
|How to cite this article:|
Srivastava S, Bhatia MS, Gautam P. Normal pressure hydrocephalus presenting as delusional disorder. Ind Psychiatry J 2015;24:94-6
Normal pressure hydrocephalus (NPH) is a syndrome of gait disturbance, cognitive impairment and urinary incontinence caused by aqueductal stenosis leading to chronic abnormal accumulation of cerebrospinal fluid (CSF) in the cerebral ventricles leading to a dilatation of the ventricular system and to subsequent damage of the adjacent parenchyma. It may be primary or secondary to other diseases such as meningitis or traumatic brain injury.  The cognitive and mental symptoms are a prominent part of the clinical picture. Delusions can usually be a prominent early feature, combined with slowing of mental and physical activity, which may lead to a diagnosis of delusional disorder, schizophrenia, depression or dementia. 
These delusional disorders are known as organic delusional disorders (ODDs) and are syndromes produced by neurological disease or toxic metabolic disorders and are associated, mainly with limbic system and basal ganglia dysfunction. , Epidemiology of ODD is not very well studied and according to Lo et al.  prevalence of ODDs is 0.4% of total admissions and 2.9% of organic mental disorders.
Neuropsychiatric symptoms in the form of cognitive impairment, anxiety, depression and psychosis have been described in association with NPH. Among them, disturbances in executive and memory function predominate.  Psychosis with NPH is rarely seen, and where described, it was seen that these symptoms were generally mild and most common presentation was apathy. , Though NPH has been reported in cases of schizophrenia and delusional disorders, , still the exact association between the two is yet to be elucidated.
Management of ODD requires extensive workup including neuroimaging to rule out various metabolic, endocrine and neurodegenerative disorders (Alzheimer's, Fahr's) as psychoses can be an incidental finding in such disorders.  From last two decades, antipsychotics remain the main-stay of the therapy but with the research in psychosocial interventions, highly structured, integrated programs such as cognitive behavioral therapies are being used.  Among pharmacological options, atypical antipsychotics are used to treat delusional disorders in elderly population because of less extrapyramidal side effects. 
| Case report|| |
Mrs. S 55-year-old woman was first observed by her family approximately 1½ years back when she started complaining of headache and developed the belief that people were after the life of her only daughter and her children. She proceeded to say that her things were being stolen and her own relatives were involved in it. She would substantiate her accusations by saying that she could hear them talking to her and would start abusing her relatives visiting her without provocation. Her husband's denial only would make her angry. In the next few months, she began to see every relative and neighbor as a threat to her daughter and herself. She would remain alert and fearful and would not sleep in the night. She became suspicious, socially withdrawn, and quiet and stopped doing household work.
Along with those complaints, Mrs. S started having complaints of giddiness while walking, vomiting, urinary incontinence and increased frequency and intensity of the headache.
Her daughter described her as well-adjusted premorbidly. There was no known past or family history of mental illness, substance abuse or suicide.
On examination, her blood pressure was found to be 118/84 mmHg with a pulse rate of 80/min. Her Glasgow Coma Scale score at the time of admission was 15 (eye movement-4, verbal response-5, and motor response-6). The neurological examination revealed ataxia and her fundus examination was normal. On mental status examination, delusion of persecution, impaired attention and concentration was found.
Few months after the onset of neurological symptoms, Mrs. S sought medical help for the 1 st time. She was extensively worked up to rule out various etiologies known to contribute to organic psychosis. Patient had normal blood counts, hemoglobin, blood sugar, lipid profile, serum electrolytes, kidney and liver function tests. Her thyroid function test, serum calcium, and phosphorus were normal. Mini Mental State Examination Score was found to be 28 indicating good cognitive functioning.
Brain magnetic resonance imaging (MRI) showed prominent sulcal spaces, and dilated ventricular system suggestive of diffuse cerebral atrophy and mild cerebellar atrophy [Figure 1].
|Figure 1: Brain magnetic resonance imaging showing prominent sulcal spaces, and ventricular system dilated with diffuse cerebral atrophy|
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She received olanzapine 5 mg initially, she developed tremors for which trihexyphenidyl 2 mg was added. Her delusions improved, but complaints of giddiness and vomiting persisted. Neurosurgical opinion was sought and patient was managed conservatively. She was started on betahistine 8 mg 3 times a day, antiemetic drug was added. Her symptoms improved gradually, and all her complaints subsided.
| Discussion|| |
According to International Classification of Diseases-10, the diagnosis fulfills the criteria for F06.2, ODDs (schizophrenia like). Objective evidence of cerebral disorder by history is present in the form of classical triad of NPH, and it was confirmed by MRI brain findings. Symptoms of mental disorder predominantly delusions, presented with the neurological complaints and evidence for another mental disorder or family history was absent. There is no history suggestive of any altered sensorium. 
Her brain MRI revealed hydrocephalus with pan-ventricular enlargement without any evidence of a mass lesion. It suggests a process affecting the subarachnoid spaces or CSF absorptive surfaces which may be seen in conditions causing acute inflammation or delayed scarring (i.e., trauma, infection or hemorrhage) as well as with leptomeningeal metastases from a systemic cancer. 
Normal pressure hydrocephalus presenting with psychiatric disorder poses both diagnostic and therapeutic challenge. 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 an elderly is not usual presentation of psychotic symptoms in this age group. Depression is also common in the elderly population but it must be distinguished from the negative symptoms of psychosis as apathy, which is seen to be a common presentation of psychosis due to or comorbid with NPH in the elderly population. ,
The first-line treatment for delusions and hallucinations, even in the elderly population, consist of antipsychotics. Typical antipsychotics such as haloperidol and chlorpromazine are effective in treating these symptoms, but they have significant side effects including extrapyramidal symptoms Atypical antipsychotics in low dosages are seen to be devoid of such side effects and are effective as treatment of psychotic symptoms in elderly population, though they have their own side effects such as risperidone can cause urinary incontinence, which are not generally seen at low doses.  Risperidone in the dosages from 1 to 4 mg has been used in NPH with psychosis, without any significant problem and seems to be a good option for the treatment. ,
One should be clinically vigilant in such late onset psychotic patients, presenting with behavioral complaints, without significant past psychiatric history. It is the thorough assessment, by which these patients can be recognized at an early stage and treatment can be instituted to reverse troublesome symptoms and thereby reduce the morbidity associated with late onset psychosis.
| Acknowledgments|| |
Authors are thankful to Dr. Sanjiv Sinha, Professor and Head, Department of Neurosurgery, G. B Pant Hospital, New Delhi.
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