Parkinson disease psychiatry — structured clinical viva · Psych Vivas

Prompt

You are the CL psychiatry registrar. Neurology asks you to review a 70-year-old man with Parkinson disease who has formed visual hallucinations, passive suicidal ideation, and a new history (from his wife) of pathological gambling after starting ropinirole. Discuss classification of PD psychosis, differentials, stepwise DRT and antipsychotic management including clozapine and pimavanserin, ICD versus DDS, depression treatment evidence, agents to avoid, and shared-care disposition.

Interpretation

Reveal interpretation

Leading diagnoses: PD psychosis (visual hallucinations after PD onset; check Ravina duration/recurrence criteria and exclude delirium) plus agonist-related ICD (gambling after ropinirole) plus depression with passive SI.[1][2]

Differentials to voice: delirium/infection; DLB vs PDD if cognition dominant early; primary mood/psychotic disorder; DDS if compulsive DRT overuse rather than pure behavioural ICD.[1][6]

Acute/stepwise plan: safety and suicide assessment; collateral always for ICD; reduce/stop ropinirole with neurology; strip anticholinergics/amantadine if present; avoid haloperidol/risperidone/olanzapine traps; if needed low-dose clozapine with FBC or pimavanserin 34 mg where available.[3][4][7]

Depression: treat — CBT and/or SAD-PD agents (paroxetine/venlafaxine XR) with MAO-B interaction caution.[5]

Close: joint PD–psychiatry follow-up, financial safeguards, caregiver education, mortality-aware antipsychotic stewardship.[2][7]

Key points

References

[1]Ravina B, Marder K, Fernandez HH, et al. Diagnostic criteria for psychosis in Parkinson's disease: report of an NINDS, NIMH work group Mov Disord, 2007.PMID 17266092
[2]Weintraub D, Koester J, Potenza MN, et al. Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients Arch Neurol, 2010.PMID 20457959
[3]Parkinson Study Group Low-dose clozapine for the treatment of drug-induced psychosis in Parkinson's disease N Engl J Med, 1999.PMID 10072410
[4]Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson's disease psychosis: a randomised, placebo-controlled phase 3 trial Lancet, 2014.PMID 24183563
[5]Richard IH, McDermott MP, Kurlan R, et al. A randomized, double-blind, placebo-controlled trial of antidepressants in Parkinson disease Neurology, 2012.PMID 22496199
[6]O'Sullivan SS, Evans AH, Lees AJ Dopamine dysregulation syndrome: an overview of its epidemiology, mechanisms and management CNS Drugs, 2009.PMID 19173374
[7]Seppi K, Ray Chaudhuri K, Coelho M, et al. Update on treatments for nonmotor symptoms of Parkinson's disease-an evidence-based medicine review Mov Disord, 2019.PMID 30653247

Interpretation

Reveal interpretation

Differentials to voice: delirium/infection; DLB vs PDD if cognition dominant early; primary mood/psychotic disorder; DDS if compulsive DRT overuse rather than pure behavioural ICD.[1][6]

Depression: treat — CBT and/or SAD-PD agents (paroxetine/venlafaxine XR) with MAO-B interaction caution.[5]

Close: joint PD–psychiatry follow-up, financial safeguards, caregiver education, mortality-aware antipsychotic stewardship.[2][7]

Key points

References

[1]Ravina B, Marder K, Fernandez HH, et al. Diagnostic criteria for psychosis in Parkinson's disease: report of an NINDS, NIMH work group Mov Disord, 2007.PMID 17266092
[2]Weintraub D, Koester J, Potenza MN, et al. Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients Arch Neurol, 2010.PMID 20457959
[3]Parkinson Study Group Low-dose clozapine for the treatment of drug-induced psychosis in Parkinson's disease N Engl J Med, 1999.PMID 10072410
[4]Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson's disease psychosis: a randomised, placebo-controlled phase 3 trial Lancet, 2014.PMID 24183563
[5]Richard IH, McDermott MP, Kurlan R, et al. A randomized, double-blind, placebo-controlled trial of antidepressants in Parkinson disease Neurology, 2012.PMID 22496199
[6]O'Sullivan SS, Evans AH, Lees AJ Dopamine dysregulation syndrome: an overview of its epidemiology, mechanisms and management CNS Drugs, 2009.PMID 19173374
[7]Seppi K, Ray Chaudhuri K, Coelho M, et al. Update on treatments for nonmotor symptoms of Parkinson's disease-an evidence-based medicine review Mov Disord, 2019.PMID 30653247