Title : A case of probable Progressive Supranuclear Palsy Frontal type (PSP-F) presenting as psychosis
Abstract:
Background: Progressive supranuclear palsy (PSP) is the second most common parkinsonian disorder after idiopathic Parkinson’s disease; yet, it remains frequently misdiagnosed, with only 4,000 confirmed cases reported in the UK by the PSP Association .While neuropsychiatric symptoms in PSP are well-documented, psychosis as a presenting complaint is exceedingly rare.This case describes a 48-year-old patient who presented with psychosis resistant to antipsychotic treatment, alongside executive dysfunction. emphasising the need for clinicians to consider neurodegenerative conditions in atypical presentations.
Case Presentation: The patient presented with severe depression and psychotic symptoms resistant to multiple antidepressants and antipsychotics. Her condition deteriorated, leading to subsequent hospitalisation. Despite extensive psychiatric interventions, including electroconvulsive therapy, her symptoms persisted, prompting neurological evaluation.
Outcome: A provisional diagnosis of PSP was established after ruling out autoimmune encephalitis and utilising the Movement Disorder Society’s diagnostic criteria. A DaT scan showed subtle reduction in tracer uptake in the left putamen, indicating decreased presynaptic dopaminergic transporter activity. Hallmark features of PSP were identified clinically, alongside no pathognomonic neuropathological signs on imaging. indicating a ‘probable’ diagnosis of PSP. Paired with prominent frontal lobe dysfunction, PSP-F subtype is currently the most likely diagnosis.
Follow Up Discussion: This case illustrates the diagnostic challenges posed by neuropsychiatric symptoms in PSP. It highlights the need for clinicians to consider PSP in patients with persistent psychiatric symptoms, especially when accompanied by parkinsonism. Future management may include trials of clozapine to address psychotic symptoms without exacerbating parkinsonian features and neurorehabilitation tailored to the patients PSP subtype, especially important if PSP is recognised early, extending functional ability and maximising quality of life.
