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Behaviour/personality change

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Organic Causes

  • Dementia: Progressive memory loss, disorientation, language difficulties, particularly in Alzheimer’s.
  • Delirium: Acute onset, fluctuating consciousness, often secondary to infection, medication, or metabolic disturbance.
  • Brain Tumour: New-onset headache, focal neurological deficits, seizures.
  • Traumatic Brain Injury: History of head trauma, cognitive impairment, emotional lability.
  • Cerebrovascular Accident (Stroke): Sudden onset, focal neurological signs, aphasia, especially in frontal lobe strokes.

Psychiatric Causes

  • Depression: Persistent low mood, anhedonia, sleep disturbances, appetite changes.
  • Bipolar Disorder: Episodes of mania (elevated mood, hyperactivity) and depression, often with inter-episode normalcy.
  • Schizophrenia: Hallucinations, delusions, thought disorder, social withdrawal.
  • Personality Disorders: Long-term patterns of dysfunctional thinking and behavior, interpersonal issues, e.g., Borderline Personality Disorder.
  • Anxiety Disorders: Excessive worry, avoidance behavior, physical symptoms like palpitations.
  • Post-Traumatic Stress Disorder (PTSD): Flashbacks, hypervigilance, emotional numbness, following traumatic events.

Metabolic/Endocrine Causes

  • Hypothyroidism: Lethargy, weight gain, depression, cold intolerance.
  • Hyperthyroidism: Anxiety, irritability, weight loss, heat intolerance.
  • Hyponatremia: Confusion, lethargy, seizures, often due to SIADH, diuretics.
  • Hypoglycemia: Sweating, tremors, confusion, potentially progressing to coma if untreated.
  • Cushing’s Syndrome: Weight gain, facial fullness, mood swings, easy bruising.
  • Addison’s Disease: Fatigue, hyperpigmentation, weight loss, hypotension.

Substance-Related Causes

  • Alcohol Abuse: Chronic use may lead to cognitive impairment, depression, personality changes.
  • Drug Abuse: Particularly with stimulants (e.g., cocaine) or hallucinogens, may cause paranoia, aggression, psychosis.
  • Medication Side Effects: E.g., steroids, antidepressants, antipsychotics, can lead to mood changes, confusion.
  • Withdrawal Syndromes: From alcohol, benzodiazepines, can result in anxiety, agitation, seizures, delirium.

Infective Causes

  • Meningitis/Encephalitis: Headache, fever, neck stiffness, altered mental state, often acute onset.
  • HIV/AIDS: Can lead to cognitive impairment, mood changes, especially with associated infections like cryptococcal meningitis.
  • Syphilis (Neurosyphilis): Insidious onset of cognitive decline, personality change, often with neurological signs.
  • Prion Diseases (e.g., Creutzfeldt-Jakob Disease): Rapidly progressive dementia, myoclonus, ataxia.

Key Points in History 🥼

Presenting Complaint

  • Onset: Sudden suggests delirium or stroke; insidious onset points to dementia or chronic psychiatric disorders.
  • Duration: Acute may indicate infection, withdrawal; chronic is more suggestive of degenerative or psychiatric causes.
  • Triggers: Recent head injury, new medications, or substance use.
  • Associated Symptoms: Hallucinations (psychiatric), fever (infective), weight changes (endocrine), headache (CNS causes).

Background

  • Past Medical History: Previous psychiatric disorders, dementia, diabetes (hypoglycemia), stroke, head trauma.
  • Drug History: Use of medications known to affect mental status, such as steroids, antipsychotics, antidepressants.
  • Family History: Dementia, psychiatric disorders, substance abuse.
  • Social History: Alcohol and drug use, occupational exposures, recent life stressors, trauma.

Possible Investigations 🌡️

Laboratory Tests

  • Full Blood Count (FBC): To identify infection, anemia.
  • Urea and Electrolytes (U&Es): Check for electrolyte imbalances such as hyponatremia.
  • Liver Function Tests (LFTs): Assess for hepatic encephalopathy.
  • Thyroid Function Tests (TFTs): To rule out hypo- or hyperthyroidism.
  • Blood Glucose: Check for hypoglycemia.
  • Vitamin B12 and Folate: Deficiency can cause cognitive impairment.
  • Toxicology Screen: If substance abuse is suspected.
  • Autoimmune Screen: If considering autoimmune encephalitis.
  • Serology (e.g., HIV, syphilis): For suspected infective causes.

Imaging

  • CT/MRI Brain: For suspected structural causes such as tumour, stroke, or head trauma.
  • Chest X-Ray: To check for infection or malignancy that could have CNS involvement.
  • EEG: Useful in suspected encephalitis, seizure activity.

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Neurosciences