Pineal Tumours And Psychiatric Manifestations

Introduction

This article discusses the pineal gland, commonly referred to as the "third eye" of the brain. Its nickname originates from its location, which is deep in the brain, and it is important for hormone secretion and regulation of an important process called the circadian rhythm. However, when a tumour is present, this small gland can create significant issues and many symptoms. In this discussion, we aim to understand pineal tumours and the impact they can have on a person’s mental health.

Pineal tumours

The pineal gland

The pineal gland is a small, pea-sized gland located deep in the brain.¹ It is called the "third eye" because of its role in regulating sleep and wake cycles and is very sensitive to light.¹ This gland also produces melatonin - the sleep hormone - which is crucial to the circadian rhythm, sleep, and wake cycles.¹

Types of pineal tumours

Pineal tumours are abnormal growths in or around the pineal gland. Like other tumours, they can be malignant (and possibly spread to other parts of the body) or benign (remain in one part of the body), There are different types of pineal tumours, including:

• Germ cell tumours: These tumours develop from the cells that form eggs or sperm and are the most common type
• Pineal parenchymal tumours: These tumours grow directly from the pineal gland and there are five subtypes
• Gliomas: These tumours arise from the brain’s supportive tissue known as glial cells

How common are they?

Pineal tumours are rare, accounting for only about 1% of all brain tumours. They can occur at any age but are most commonly diagnosed in teenagers and young adults.

How are pineal tumours diagnosed?

Diagnosing pineal tumours can be challenging because of their deep location in the brain. Doctors may use a combination of imaging tests, such as MRI or CT scans, and biopsy samples to confirm the diagnosis of a pineal tumour. They can cause a wide range of symptoms, which can sometimes be mistaken for other conditions, and also vary depending on the tumour’s location.² Pineal tumours may cause increased pressure inside the skull because of increased production of cerebrospinal fluid (CSF) or blockage of its normal flow.² CSF is the fluid that surrounds and cushions the brain and spinal cord. This problem is known as hydrocephalus. Signs and symptoms may include:

• Headaches
• Nausea
• Vomiting
• Eye movement issues
• Balance problems

Because of the lack of symptom specificity, it may take some time and multiple tests to accurately diagnose a pineal tumour. Recognising the symptoms and diagnosing pineal tumours early is important so that treatment can start promptly. By understanding pineal tumours better, doctors can provide more targeted and effective treatments.

Psychiatric symptoms of pineal tumours

• Changes in Mood: Patients with pineal tumours may have mood swings (examples include periods of depression, anxiety, or irritability)³
• Cognitive Impairment: Cognitive difficulties like memory and concentration issues, and confusion can impact daily functioning³
• Psychotic Symptoms: Some patients may show psychotic symptoms, such as hallucinations (seeing or hearing things that are not there) or delusions (false, fixed beliefs)³
• Sleep Disturbances: Odd sleep patterns, including insomnia or excessive daytime sleepiness, can occur because of the gland's role in regulating circadian rhythms by producing the special hormone melatonin⁴
• Personality Changes: Pineal tumours can lead to personality changes, like more impulsivity, apathy, or social withdrawal

Case studies and examples

Case summary: ‘David’'s journey with pineal tumour-related psychosis⁵

‘David’, a 17-year-old teenager facing subthreshold psychotic symptoms, was referred to the University of California Los Angeles’ (UCLA) Center for Assessment and Prevention of Prodromal States (CAPPS) program due to concerning changes in his behaviour. The UCLA CAPPS program focuses on identifying and intervening in the early (or prodromal) stages of mental health disorders to prevent the onset of full-blown psychosis or other serious mental illnesses. Despite initial minor struggles during his parents' divorce, David's academic performance plummeted during puberty. He also had unusual behaviours including excessive water drinking and cognitive decline.⁵

Multiple treatments, including therapy and medication, failed to alleviate his symptoms. Tests showed he was suffering from a germinoma. He needed chemotherapy and a stem cell transplant. Post-treatment, David's symptoms improved significantly and his tumour regressed.

David's journey shows just how important early detection and holistic treatment are for individuals facing psychiatric symptoms caused by pineal tumours.⁵ This ensures the best possible outcome for the individual and their family.

Case summary: memory problems⁶

A 32-year-old man had severe memory loss without normal brain tumour symptoms. Instead of headaches or vision issues, he struggled to remember recent events and had difficulty staying motivated.

Tests revealed a tumour in his pineal region which was affecting his memory. Despite the tumour's presence, there was no buildup of fluid in the brain (hydrocephalus) which is a common symptom with these tumour types. 

Surgery, which removed part of the tumour, confirmed it as a germinoma - originating from the cells that create eggs or sperm. This case shows that brain tumours can cause unexpected symptoms.⁶ It also shows the need for careful diagnosis and treatment to ensure the best possible outcome for the individual.

What does this mean for diagnosis and treatment?

Underlying mechanisms

Currently, there is no clear reason why these symptoms occur.³ It could be that the tumour's location and its impact on surrounding brain structures may cause them. There could be a hormone imbalance or problem with the gland itself. A tumour can press on nearby areas such as the thalamus or hypothalamus and as a result, affect mood and sleep leading to mood swings and sleep disturbances like insomnia or excessive sleep.³ If the tumour interferes with the production of melatonin it can cause sleep problems.⁴ It can also worsen mood problems.⁷ There are numerous different ways that these tumours can affect a person, making diagnosis a challenge.

Diagnostic challenges

Psychiatric symptoms associated with pineal tumours can be very nonspecific and overlap with many mental disorders.³ This can lead to trouble in diagnosing the tumour and finding the reason why the symptoms are present. Psychosis could be indicative of schizophrenia or other mental disorders. This is especially true in the absence of other symptoms of hydrocephalus like headaches or trouble walking. Doctors should perform a thorough investigation to make a diagnosis. This includes imaging like CTs and MRIs and psychiatric assessments. This is done to differentiate tumour-related symptoms (which don't have an underlying cause and are ‘secondary’) from primary psychiatric conditions.³

Treatment implications

The potential symptoms of pineal tumours need to be recognised. It is very important and helps with treatment decisions. In addition to addressing the underlying tumour through surgery, radiation therapy, or chemotherapy, the management of psychiatric symptoms may require medications, therapy, or supportive care. This ensures care is as holistic as can be and that the physical and mental symptoms are addressed properly.

Long-term mental health outcomes

The presence of psychiatric symptoms can greatly affect a patient. Symptoms such as depression, anxiety, and cognitive impairment, may occur even after cancer treatment and require ongoing management and support. These symptoms occur not only because of the tumour but also because of the physical, emotional, and mental struggles.^8,9

Psychosocial implications

Families and patients can be impacted both socially and psychologically because of stigma, social isolation, and impaired relationships. The long-term effects on the individual and their families are difficult to estimate.^8,9

Long-term follow-up

To conquer the mental aspect, management of psychiatric symptoms and their impact on daily functioning for the individual should be part of their routine follow-up.⁹ To help with coping, psychological education and support services such as the Brain Tumour Charity can be used. Even the NHS has a search engine to help find local cancer services. These resources are available so people can manage the psychological challenges associated with pineal tumours and any other individual or family needs as they navigate this difficult time and journey.

Summary

Pineal tumours can greatly impact individual mental health and long-term well-being. This finding can lead to an arduous diagnostic journey for the patient and their family. Psychiatric symptoms can vary from psychosis to cognitive impairment and a comprehensive approach to diagnosis, treatment, and long-term management is important.