Change in Behaviour History
Author – Dr Karthikeyan Sivaganesh Editor – Dr James Mackintosh
Last updated 25/07/24
Table of Contents
Introduction
Change in a person’s behaviour or personality can be categorised as Organic (i.e. underlying biological disease) or Non-Organic such as personality disorders, bipolar disorder, depression stress, etc. Organic causes can be further divided into primary e.g. neurological or secondary e.g. from medications.
The affected individual may not be aware, and therefore getting a collateral history is vital as it can help identify the specific behavioural issue e.g. impulsive, sexual, anti-social, etc.
Common Causes of Behaviour/Personality Change
| Primary | Secondary |
|---|---|
Brain tumours - primary or metastases | Stress e.g. from work, finance, bereavement |
Neurodegeneration e.g. Parkinson’s disease, Alzheimer’s, frontotemporal dementia | Psychiatric e.g. post-traumatic stress disorder (PTSD), personality disorders, depression, bipolar disorder (BPD) |
Head injury/stroke affecting frontal lobes | Haematological e.g. porphyrias |
Hydrocephalus, Arteriovenous Malformation (can cause obstructive hydrocephalus) | Drug-induced
|
Infections affecting the brain e.g. encephalitis, meningitis, toxoplasmosis, neurocysticercosis | Endocrine e.g. Cushing’s syndrome, Hypothyroidism, Graves’ disease |
HIV-associated CNS lymphoma | Gastrointestinal e.g. liver failure (raised ammonia crosses blood-brain barrier altering behaviour), Wilson’s disease, haemochromatosis |
Presenting Complaint
Onset
- Hours → Recreational drug use (e.g. cocaine), Delirium
- Days → Drug induced e.g. anti-seizure medication like levetiracetam, BPD
- Weeks/Months → Brain injury, Brain tumours, Alcohol misuse, Hydrocephalus, Depression, PTSD, Schizophrenia
- Years → Neurodegeneration e.g. Parkinson’s disease, Frontotemporal Dementia
- Post-Trauma e.g. abuse, road traffic accident → acute stress reaction (if symptoms occur <1 month after exposure to trauma) or PTSD (if symptoms occur >1 month after exposure to trauma)
Character
- Sexual/gambling/inappropriate behaviour, progressive → Frontotemporal dementia, bipolar disorder
- Depression, aggressive behaviour, confusion, progressive → Alzheimer’s dementia
- Progressive change in behaviour → Brain Tumour
- Anti-social/inappropriate behaviour, non-progressive → Alcohol misuse, Drug abuse
- Age-inappropriate behaviour, not drug-induced or explained by social or cultural factors → consider personality disorders, trauma and safeguarding issues in children/teenagers
- Flashbacks, nightmares, avoidance (of people or situation), hypervigilant, emotional numbing → PTSD
- Low mood, Anergia (lack of energy to perform daily function) and Anhedonia (loss of interest in activities previously enjoyed by patient) → Depression
- Odd, Eccentric behaviour e.g. paranoia, preferring solitary activities, behaving emotionless, strange beliefs → cluster A personality disorders e.g. paranoid, schizoid or schizotypal
- Dramatic, highly emotional, attention seeking, grandiosity, impulsive → Cluster B personality disorders e.g. borderline, histrionic, narcissistic and antisocial
- Anxious, fearful and worried behaviour → Cluster C personality disorders e.g. Obsessive compulsive personality disorder, avoidant personality disorder and dependent personality disorder
- Abnormally elevated mood, pressured speech, flight of ideas, grandiose delusions → manic episode of bipolar disorder
- Delusions, hallucinations, disorganised speech → psychosis
- If associated with mood disturbance → depression, bipolar disorder, schizoaffective disorder
MLA Tip 💡
To consider personality disorder as a differential, the person must be >18 years old, the behaviour must cause interpersonal dysfunction (difficulty communicating and mingling with society) and behaviour cannot be explained by organic causes or cultural factors
Associated Symptoms
- Fever, seizures, confusion, photophobia → viral/bacterial encephalitis
- If seizures are absent → consider meningitis
- Worsening headache → hydrocephalus, brain tumour
- Rapid eye movement sleep behaviour disorder e.g. acting out dreams, visual hallucination e.g. lilliputian → Lewy Body Dementia
- Memory loss, visual agnosia → Alzheimer’s dementia
- Weight loss, loss of appetite, change in bowel habits → malignancy
- Sleep problems, difficulty concentrating, persistent negative emotional state → depression, PTSD
- Psychosis with absent mood disorders e.g. depression → schizophrenia
Red Flags
- Fever, confusion, acute change in cognition → infectious encephalitis
- Night sweats, fever, weight loss → Tuberculous Encephalopathy or CNS lymphoma
- Signs of raised intracranial pressure e.g. headache worse on coughing → brain tumour, brain bleed, hydrocephalus
- Progressive worsening headache → brain tumour, brain bleed, hydrocephalus
- FLAWS symptoms → Malignancy
MLA Tip 💡
FLAWS is an acronym that can be used to screen for systemic disease, particularly cancer. It stands for Fever, Lethargy, Appetite change, Weight loss, Sweating at night
Background
Past Medical History
- Head trauma or stroke → brain injury
- Malignancy e.g. prostate cancer, breast cancer → brain metastases
- Depression, cognitive impairment in elderly person (>65 years) → dementia
- Arteriovenous (AV) malformation → obstructive hydrocephalus
- Spina bifida/neural tube defects → congenital hydrocephalus
- Epilepsy → antiseizure medications
- HIV → immunodeficiency causes CNS lymphoma
Family History
- Frontotemporal dementia has a strong familial component
- Neurofibromatosis can increase the risk of brain tumours
- Primary brain tumours in first-degree family members
- Hereditary hemorrhagic telangiectasia increases the risk of AV malformations
- Schizophrenia has a strong familial component
Social History
- Recreational drug use e.g cocaine, amphetamines or alcohol abuse
- Multiple sexual partners → HIV-associated CNS lymphoma
- History of abuse, traumatic event → depression, PTSD
Common OSCE Histories
| Condition | Typical History |
|---|---|
Brain Tumour | Worsening headache with signs and symptoms of raised intracranial pressure e.g. dilated pupil, impaired abduction, headache worse on coughing or lying down, etc and acute neurological deficits e.g. weakness, sensory changes |
Frontotemporal dementia (FTD) | Young-onset (<65 years) dementia, strong family history of FTD, disinhibition behaviour often sexual, impulsive or aggressive. |
Encephalitis/Meningoencephalitis | Acute symptoms onset, fever, signs of meningism e.g. neck stiffness, photophobia with seizures, confusion and altered mental status. |
Post-stroke behaviour change | History of stroke affecting frontotemporal lobes. Increased irritability and aggression are common phenomena. |
Post-Traumatic Stress Disorder (PTSD) | History of nightmares, suddenly waking up in night with fear, avoiding certain situations or people, hypervigilant, exaggerated startle response after a traumatic event e.g. car accident, victim of abuse, etc. |
Depression | Person with low mood, tiredness, lack of energy, anhedonia, weight changes (i.e. gaining or losing weight) often following a significant event such as bereavement, receiving bad news, etc. |
Bipolar disorder | Often presents with a manic episode (e.g. pressured speech, grandiose delusions, inflated self-esteem) and appearing rested despite having very little sleep |
Schizophrenia | Psychosis triad (delusions, hallucinations, disorganised speech) that is not mood congruent i.e. secondary to a mood disorder such as depression with symptoms lasting more than 6 months. |
Examining Change in Personality or Behaviour
When examining a person with behavioural change, a cranial and peripheral nerve exam is the most important to perform to identify any focal neurological deficits.
Look for signs of space occupying the lesion:
- Surgical oculomotor nerve palsy (dilated, unreactive pupil)
- Abducens nerve palsy
- Hemiparesis (note weakness is more common if frontal lobes are affected)
- Upper motor neuron signs
Doing a mental status examination and cognitive assessments (especially in elderly patients) are equally important as they can guide towards a psychiatric condition or dementia respectively. Remember common things are common!
If you are unsure, be honest and tell the examiner of your key findings and how you will confirm the possible aetiology e.g. MRI head, urine toxicology
- https://www.rcemlearning.co.uk/reference/acute-behavioural-disturbance/#1639499533066-71ae3a3b-43c2 [Accessed 15/7/24]
- https://www.msdmanuals.com/en-gb/home/mental-health-disorders/overview-of-mental-health-care/personality-and-behavior-changes#Evaluation_v1665589 [Accessed 15/7/24]
- https://patient.info/doctor/personality-disorders-and-psychopathy [Accessed 15/7/24]