Past NEURopsychiatric (neuron) CME 2026

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Title:   ‘From Movement Disorder to Mind Disorder: A Complex Journey in GBA-Associated Parkinson’s Disease’

Presenter: Dr Nur Syamimi Binti Che Md Azim

Supervisor: Dr Muhammad Nabhan Khalil Bin Azizan 

Attendees: Neuropsychiatrists, neuropsychiatry fellows, Psychiatrist  an area of interest in neuropsychiatry (AOI), and general psychiatry trainees, medical officers

Synopsis:

A 42-year-old Malay man with no prior psychiatric history was diagnosed with young-onset Parkinson’s disease (YOPD) in 2022, following a one-year history of progressive right-sided rigidity, bradykinesia, and painful muscle spasms. He initially demonstrated a good response to levodopa therapy; however, his disease course was complicated by early motor fluctuations, including wearing-off phenomena and levodopa-induced dyskinesia. Over time, he developed features of dopamine dysregulation syndrome, characterized by compulsive self-escalation of dopaminergic medications to supratherapeutic doses. Subsequently, he presented with recurrent neuropsychiatric symptoms, including visual and auditory hallucinations, paranoid delusions, and somatic passivity phenomena, temporally associated with dopaminergic overuse and amantadine initiation. These episodes were accompanied by behavioral disturbances, including aggression and risk-related behaviors. He also reported symptoms of depression and anxiety, including low mood, guilt, hopelessness, and passive death wishes, in the context of significant psychosocial stressors such as divorce, bereavement, unemployment, and financial instability. These symptoms led to psychiatric admission, during which his initial presentation of reduced engagement raised the possibility of catatonia. Antipsychotic treatment was initiated, with subsequent transition to clozapine, resulting in significant improvement in both psychotic symptoms and dyskinesia. Diagnostic complexity arose due to caudate nucleus atrophy observed on neuroimaging, raising suspicion for Huntington’s disease; however, this was excluded through genetic testing. Notably, genetic analysis identified a glucocerebrosidase (GBA) gene mutation, supporting a diagnosis of GBA-associated YOPD, and cognitive assessment revealed mild impairment. This case illustrates the complex interplay between neurodegenerative disease progression, treatment-related complications, and psychosocial stressors in YOPD, particularly in the presence of a GBA mutation. It highlights the challenges in managing dopamine dysregulation syndrome and medication-induced psychosis, as well as the potential role of clozapine in addressing both psychosis and dyskinesia in such patients.

Title:  At the crossroads of-Medication, Mind, or Movement Disorder? 

Presenter: Dr Ong Chuan Ying

Supervisor: Dr Chin Han Lim

Attendees: Neuropsychiatrists (Dr Chee KY and those from other hospitals), neuroradiologist (Dr. Hairuddin and his team Dr. Wahida), neurologists (Dr. Chin Mann Leon [HRPB], Dr Shahir [HKL]), and other psychiatric colleagues from Ipoh General Hospital. 

Synopsis:

At the Crossroads of Medication, Mind, or Movement Disorder? presents a diagnostically complex case of a 57-year-old man with long-standing schizophrenia who developed progressive parkinsonism and global cognitive decline in the context of chronic exposure to oral and long-acting injectable antipsychotics. Following treatment interruption, he manifested a striking combination of asymmetric parkinsonism, dystonia, dyskinesia, cerebellar signs, abnormal ocular movements (round-the-house eye signs), gait impairment, and rapid loss of functional independence. Cognitive impairment was profound, precluding formal objective testing (NUCOG), with behavioural assessment (BATCH) demonstrating severe impairment across all domains. Neuroimaging revealed small-vessel disease with multiple chronic lacunar infarcts, microhaemorrhages, and cerebral atrophy, further blurring the distinction between drug-induced parkinsonism, tardive syndromes, Parkinson-plus disorders (PSP/MSA), and vascular parkinsonism or dementia. In this context, functional imaging—particularly FDG-PET and TRODAT (DAT) scans—is crucial in differentiating neurodegenerative from medication-related pathology and guiding management decisions, underscoring the need for a pragmatic, multidisciplinary neuropsychiatric approach that prioritises potentially reversible contributors while closely monitoring disease progression.