- The document describes the case of a 28-year-old woman who experienced rapid deterioration with 9 hospitalizations for psychosis over the course of a year. She had been diagnosed with a prolactin-secreting pituitary tumor. - Treatment of her conditions was complex due to the counteractive nature of medications used to treat psychosis (dopamine antagonists) versus those used to treat her prolactinoma (dopamine agonists). - After her most recent hospitalization, her cabergoline treatment for the prolactinoma was discontinued due to concerns about potential psychotic side effects. Clozapine was also initiated for her psychosis. Her condition improved after getting off cabergoline and starting clozap

1. Pituitary adenoma
and psychosis
Dr/ Zeinab El Nagar
Lecturer Of Psychiatry
Ain Shams University

2. • People with Brain Tumors and Pituitary Tumors may sometimes experience
emotional problems and changes in thinking abilities.
• such tumors sometimes affect thinking (or cognitive) processes such as
memory, language and concentration.
• The pituitary gland, although strictly speaking is not part of the brain, is closely
connected to the hypothalamus in the brain, which has an important role in
coordinating different brain functions
• The Pituitary Gland is attached to, and receives, chemical messages in the
bloodstream from the Hypothalamus.
• The pituitary gland is divided into two sections known as lobes, the anterior lobe
and the posterior lobe, and each lobe releases different hormones.

3. • The Anterior Pituitary Gland secretes:
1. Growth Hormone which promotes growth Prolactin
2. Adrenocorticotropic which stimulates the adrenal glands
3. Thyroid-Stimulating Hormone which stimulates the thyroid gland and in turn
the metabolic rate
4. Follicle-Stimulating Hormone and Luteinizing Hormone, which influence the
production of hormones from the ovaries and testes
• The Posterior Pituitary Gland secretes
1. Vasopressin, which causes the kidneys to retain water, and also regulates
blood vessels
2. Oxytocin, which facilitates childbirth and the production of milk for breast-
feeding.

4. • Pituitary tumors arise from the pituitary gland within the base of the skull.
• These tumors are almost always benign.
• Symptoms arise when these tumors secrete hormones or become large enough
to compress adjacent structures.
• As these tumors enlarge, the normal pituitary function is destroyed.
• This destruction produces various hormonal deficiencies.
• Pressure on nearby structures can produce double vision and facial numbness.
• The nerves of vision, the optic nerves, are directly above the pituitary gland and
upward growth of pituitary tumors frequently causes progressive visual loss.

5. • Types ofTumors
• Generally, these tumors can be subdivided in to
1. non-hormone producing tumors of the pituitary gland
2. hormone producing tumors
3. other intra-sellar tumors
4. para-sellar tumors.
Prolactinomas are the most common pituitary tumor

6. • Neurological Symptoms
1. headaches
2. double vision
3. loss of peripheral vision leading to blindness
4. facial pain or numbness

7. Other symptoms
• Hypopituitarism
• lack of energy
• weight loss, nausea, vomiting, constipation
• amenorrhea and infertility
• dry skin, increased pigmentation of the skin
• cold intolerance
• mental status changes: sleepiness, psychosis, collapse, depression
• Individuals with a brain tumour or pituitary tumour sometimes experience depression
or anxiety.
• People often report physical symptoms and changes to their behaviour.

8. mental status changes with pituitary tumors
• Apathy, a lack of feeling or expression of your emotions.
• Euphoria, a feeling of great happiness or well being which is usually exaggerated
and not appropriate to the individual's current life situation.
• experience sudden mood changes and feel like on an emotional rollercoaster, one
minute feeling high and the next minute feeling down.
• experience a decrease in self-esteem, Lack of confidence. For example, changes in
body shape or weight may occur with some Pituitary and Brain Tumours, and this
can lead to problems with self-image

9. mental status changes with pituitary tumors
• thinking problems such as poor memory or distractibility.
• many factors are associated with such problems including the size of the tumour
and where it is located in the brain.
• Attention and Concentration Becoming distracted easily and having trouble
sustaining focus on a task over a longer period of time are common symptoms.
For example, loosing the thread of conversations
• not being able to concentrate when more than one thing
• Sometimes individuals have difficulty learning new information
• People may have difficulty remembering conversations, events or names
although their memory for events many years ago is well preserved.
• People may also have difficultly remembering to do something

10. pituitary tumor and psychosis
• There is not an extensive literature on patients with both psychosis and a pituitary
tumor.
• Acute psychosis has been reported in a woman with a known prolactinoma.
• also cases were reported of patients with psychoses and concomitant prolactin-
secreting pituitary tumors.
• A review of the literature on bromocriptine and psychosis concluded that
confusion, hallucinations, and delusions have often been reported with the use of
bromocriptine, .
• In addition, cabergoline-induced psychotic exacerbation in schizophrenic patients.

11. pituitary tumor and psychosis
• Some authors have reported prolactinoma growth with risperidone treatment and
suggest using other antipsychotic medications, which do not affect prolactin
secretion .
• It has been reported that psychotic patients treated with aripiprazole showed a
lower liability toward hyperprolactinemia .
• Others have recommended the use of clozapine
• A successful treatment of schizophrenia with no elevation of serum prolactin levels
using a combination of olanzapine and quetiapine was reported in a patient who
could not tolerate clozapine (Sigman and Drury., 2011)

12. Diagnosis
• The clinical diagnosis depends upon the combination of symptoms and signs
resulting from the size of the tumor and/or the type of hormone produced.
• Pituitary adenomas may be imaged with CT or MR scans.
• Evaluation of pituitary function is possible by measuring hormone levels in the
blood and urine.
• Occasionally, the measurement of ACTH levels in the venous blood draining the
pituitary.
• Formal evaluation of the visual fields are useful in outlining peripheral visual loss
before and after surgery .

13. Treatment
Medical therapy is useful in treating some hormone secreting adenomas:
• Prolactinomas: Dopamine agonists which effect the D2 receptors for dopamine
effectively treat prolactin tumors. About 80% to 90% of patients will normalize
their serum prolactin levels. Parlodel (bromocriptine) has been used for many
years. A new drug, Dostinex (carbergoline), may be more effective with fewer
side effects. It can be given by mouth twice a week.
• Cushing's disease
• Acromegaly

14. Surgery:
• transphenoidal approach and transcranial operations for pituitary tumors.
• Today, pituitary surgeons utilize the transsphenoidal approach for most
pituitary tumors. It is safe, effective, and requires a short stay in the hospital.
• For small tumors (less than 10 mm in diameter), the cure rate is greater than
50%
RadiationTherapy:
• Gamma Knife radiosurgery has become increasingly more important in the
control of pituitary adenomas. This technique allows for focused, high-dose
treatment of pituitary adenomas and results in greater rate of control of tumor
growth and better rates of normalization of increased hormone secretion

15. Case Report
Treatment Complexities of a
YoungWoman Suffering
Psychosis and Pituitary
Adenoma

16. • A 28-year-old woman who, over a decade, had 9 hospitalizations for psychosis
in psychiatry, the final four in a one-year period. This rapid deterioration led us
to uncover potential interactions between her medication for a prolactin-
secreting pituitary tumor and those she was receiving for psychosis. The clinical
effects of increased prolactin levels are poorly understood; however, there is
some evidence that increases in serum prolactin may be associated with
several psychiatric disorders , and conventional neuroleptic medications may
cause an increase in serum prolactin levels.
• Dopamine antagonists are used to treat psychotic symptoms, while dopamine
agonists are used to treat prolactinomas. As a result of the potential
counteractive nature of the treatments, effective management of individuals
who present with both problems is extremely difficult. A lack of guidelines
regarding the monitoring for hyperppatients receiving antipsychotics only
serves to exacerbate the problemrolactinoma in.

17. • Ms. L was first hospitalized at the age of 18. She was in a catatonic state, her
chin was hairy, and she was circling her fingers repetitively. The following day
she was able to speak but was bizarre and inappropriate, believing she had been
admitted because she was cruel to animals as a child. Ms. L reconstituted
quickly, and after two weeks on the antipsychotic drug olanzapine 10 mgs at
bedtime, she gave the following history.
• She had been feeling ill only during the past year when her mother, who suffers
from schizophrenia, had a long hospitalization following a divorce from Ms. L’s
father. Ms. L was not a substance abuser. She had lived with her father who, she
explained, had previously physically, sexually, and emotionally abused her. Ms. L
had had severe hirsutism for two years. Her prolactin level was 125.1 units
(normal range: 20–25 ng/mL). Her diagnosis at this point was psychotic episode,
post traumatic episode had to be ruled out. Magnetic resonance imaging (MRI)
of the brain was ordered and revealed a pituitary tumor. An endocrinologist
prescribed 5 mg bromocriptine to shrink the microneuroadenoma.

18. • Ms. L’s second admission was 6 months later when she expressed feelings of
suicidality to the occupational therapist at her group home. An interview with a
consultant revealed no Axis 1 diagnosis. She was discharged with a diagnosis of
troubled grief reaction and prescribed olanzapine 20 mg qhs, paroxetine 20 mg
daily (qd), procyclidineHCl 5 mg twice a day (bid), and, in addition,
bromocriptine 5 mg qhs to treat the pituitary tumor. She was to go to a
rehabilitation program and see a therapist in the youth service. Some time later,
she left for the Middle East, where she had one admission to hospital for a
psychotic state.
• On her return to North America, she was diagnosed by our outpatient
department with schizophrenia and treated with risperidone. She continued to
have hbromocriptine.
• irsutism and to be treated by her endocrinologist with

19. • On Ms. L’s fourth hospital admission, she was preoccupied with religious ideas
and had minimal insight and judgment. She was prescribed 16 mg risperidone
and quetiapine 200 mg in the morning for her psychosis. The following year Ms.
L was again admitted psychotic and anxious, hyperventilating, showing poor
eye contact, and moving her fingers in a circular motion. She had told her
parents she had felt paranoid and suicidal. Again her insight and judgment were
poor. She had not complied with the psychiatric follow-up treatment as her
mother, in her own psychotic state, had cancelled it. In hospital, Ms. L remained
psychotic on 100 mg of loxapine and 500 mg quetiapine. She was given
electroconvulsive therapy, and this seemed to help her. She agreed to
placement in a group home and to take her medications on discharge. Ms. L was
prescribed flupenthixoldecanoate 75 mg 2 weeks I.M., divalproex sodium
500 mg and loxapineHCl 25 mg. A year later, in 2005, her endocrinologist
prescribed cabergoline to treat the pituitary adenoma to replace the
bromocriptine she had been receiving for five years.

20. • Ms. L’s next hospitalization five years later was the first of four in one year. She
was sad and tearful, felt her psychiatric medications were not working, and had
stopped them. Her last dose of flupenthixoldecanoate had been several months
prior. She was experiencing impaired concentration, memory, and energy. She
had cut her hair bizarrely, felt she had psychic abilities, and reported that her
vision was impaired. Ms. L was highly regressed, initially refusing treatment, but
once restarted on her oral medications, she re-compensated quickly. She
remained with behaviors such as rocking and circular hand movements and
returned to the group home never having remembered or understood why she
had suddenly left it. She was discharged on divalproex sodium 500 mg thrice
daily , procyclidine HCl 5 mg and loxapineHCl 25 mg for her psychosis and
continued cabergoline 0.5 mg twice weekly for the pituitary adenoma.

21. • Three weeks after discharge, Ms. L was picked up by the police in an apartment
lobby where she had spent the night. Ms. L was confused and catatonic, again
suffering impaired insight, judgment, and memory. She spoke of being
possessed, hearing voices, and having visual hallucinations. She was discharged
with ziprasidone 40 mg added to her prescription and a follow up with her
endocrinologist. An MRI showed that her microadenoma had shrunk. Four
weeks later, without apparent provocation, Ms. L quietly walked out of her
group home during dinner. She was found by police roaming barefoot. She
again had serious memory problems and disorganized thinking. Her ziprasidone
was increased to 60 mg, the loxapine decreased to 12.5 mg, and
electroencephalography (EEG) was suggested to rule out seizures in an effort to
explain her memory loss which was normal.

22. • Her doctor had concerns about the possible psychotic side effects of the
dopamine agonist cabergoline used to treat the pituitary tumor and
hyperprolactinemia. The general physician to the psychiatric ward had been
encouraged to consult the involved endocrinologist on this issue, and this
resulted in the cabergoline being discontinued. Ms. L was reorganized enough
to begin to eat and participate in milieu treatment. She had trials of both
ziprasidone and aripiprazole but remained psychotic in her thinking, for
example, getting orders from the devil. Clozapine was started, and the
psychosis began to remit. The endocrinologist felt Ms. L could be kept off the
cabergoline if it impaired her mental status. Ms. L continued to improve and
has not been hospitalized since. Was it getting off the cabergoline or starting
the Clozaril that ultimately led to her improved state, or, as we believe, a
combination of both?

23. Thank you