Huntington Hastalığı’nın Nöropsikiyatrik Yönü

Huntington Hastalığı; kore ve distoni, koordinasyon bozukluğu, bilişsel performansta bozulmalar ve davranışsal sorunlar gibi farklıfenotipler ile ortaya çıkabilen, genetik olarak otozomal dominant geçiş özelliğine sahip, ilerleyici tipte bir nörodejeneratif hastalıktır. Bilişselve motor belirtilerin yanı sıra nöropsikiyatrik belirtiler de hastalığın çekirdek belirtileri arasında yer almaktadır. Huntington Hastalığı’ndanöropsikiyatrik belirtiler oldukça sık görülmekte ve hastalığın farklı dönemlerinde psikiyatrik bozuklukların görülme prevelansı %33-76 olaraktahmin edilmektedir. Nöropsikiyatrik belirtilerin görülme sıklığı hastalığın evrelerine göre farklılık gösterse de başlangıcının motor belirtilerbaşlamadan yıllar önce olabileceği de bilinmektedir. Huntington Hastalığı’nda sık görülen nöropsikiyatrik belirti ve bozukluklar depresyon,anksiyete, intihar, irritabilite, apati, obsesif-kompulsif belirtiler, perseverasyonlar, psikoz, uyku bozuklukları ve cinsel işlev bozuklukları olaraksayılabilir. Nöropsikiyatrik belirtiler aileler üzerindeki yükün en önemli nedenlerinden birini oluşturmakta, günlük işlevsellikteki azalma ilebakım kurumlarına yerleştirilme ve hastaneye yatışların en önemli öngörücüsü olarak değerlendirilmektedir. Hem sıklığı hem de sonuçlarıgöz önüne alındığında Huntington Hastalığı’ndaki nöropsikiyatrik belirtilerin tanınması ve bu belirtilere müdahale edilmesi hastalar, hastayakınları ve bakımverenleri için oldukça önemlidir. Hastalıkta görülen nöropsikiyatrik belirtilerin tedavisi ile ilgili yüksek kanıt düzeyinesahip araştırmalar olmasa da daha düşük kanıt düzeyine sahip çalışmalar, vaka bildirimleri ve uzman görüşlerine dayalı tedavi kılavuzlarıson yıllarda yazında kendine yer bulmuştur. Bu alanda dikkat edilmesi gereken başka bir konu da risk altındaki bireylerin değerlendirilmesi,genetik danışmanlık ve bu değerlendirmeler sırasında güvenli bir protokolün oluşturulmasıdır. Bu yazıda Huntington Hastalığı’nda sık görülennöropsikiyatrik bozukluklar, bu bozuklukların tedavisi ve risk altındaki bireyleri değerlendirmede dikkat edilmesi gereken durumlar güncelyazın ışığında derlenmiştir.

Neuropsychiatric Aspects of Huntington’s Disease

Huntington’s Disease is a progressive neurodegenerative disorder inherited in an autosomal dominant fashion with distinct phenotypesas chorea and dystonia, incoordination, cognitive disorders, and behavioural problems. In addition to cognitive and motor symptoms,neuropsychiatric symptoms are among the core symptoms of the disease. Neuropsychiatric symptoms are quite common in Huntington’sDisease and the prevalence of neuropsychiatric disorders in different stages of the disease is estimated to be 33-76%. Although the prevelanceof neuropsychiatric symptoms varies among the stages of the disease, it is also known that the onset of these symptoms may be years beforethe onset of motor symptoms. Common neuropsychiatric symptoms and disorders in Huntington’s Disease include depression, anxiety, suicide,irritability, apathy, obsessive-compulsive symptoms, perseverations, psychosis, sleep disorders, and sexual dysfunctions. Neuropsychiatricsymptoms constitute one of the most important factors for the burden on families, and are considered to be the most important predictors ofdecrease in daily functionality and institutionalizations in care centers and hospitalizations. Considering both its frequency and outcomes, it isvery important for patients, their relatives and caregivers to recognize and intervene in neuropsychiatric symptoms of Huntington’s Disease.Although there are no studies with a high level of evidence on the treatment of neuropsychiatric symptoms of the disease, studies with lowerlevels of evidence, case reports and treatment guidelines based on expert opinions are found in the literature in recent years. Another issue tobe considered in this area is the evaluation of individuals at genetic risk, genetic counseling and setting a safe protocol during these evaluations.In this article, neuropsychiatric disorders common in Huntington’s Disease, the management of these disorders and the conditions to beconsidered in the evaluation of individuals at genetic risk are reviewed in the light of current literature.

Kaynakça

A’Campo LEI, Spliethoff-Kamminga NGA, Roos RAC (2012) The Patient Education Program for Huntington’s Disease (PEP-HD). J Huntingtons Dis, 1:47-56.

Adrissi J, Nadkarni NA, Gausche E, Bega D (2019) Electroconvulsive therapy (ECT) for refractory psychiatric symptoms in Huntington’s disease: a case series and review of the literature. J Huntingtons Dis, 8:291-300.

Anderson KE (2005) Huntington’s disease, and related disorders. Psychiatr Clin North Am, 28:275-290.

Anderson KE, van Duijn E, Craufurd D, Drazinic C, Edmondson M, Goodman N et al. (2018). Clinical management of neuropsychiatric symptoms of huntington disease: expert-based consensus guidelines on agitation, anxiety, apathy, psychosis and sleep disorders. J Huntingtons Dis, 7:355-366.

Anderson KE, Eberly S, Groves M, Kayson E, Marder K, Young AB et al. (2016) Risk factors for suicidal ideation in people at risk for Huntington’s disease. J Huntingtons Dis, 5:389-394.

Arran N, Craufurd D, Simpson J (2014) Illness perceptions, coping styles and psychological distress in adults with Huntington’s disease. Psychol Health Med, 19:169-179.

Ataöv G, Akbaş I, Gül O, Balaban OD, Tanrıverdi Seda (2020) Psikiyatri servisinde Huntington Hastalığı vakası. 5. Psikiyatri Zirvesi ve 12. Anksiyete Kongresi, 29-31 Ekim Antalya, Türkiye. Kongre Özet Kitabı pp: 272.

Bachoud-Lévi AC, Ferreira J, Massart R, Youssov K, Rosser A, Busse M et al. (2019). International guidelines for the treatment of Huntington's disease. Front Neurol, 10:710.

Baker CR, Domínguez D JF, Stout JC, Gabery S, Churchyard A, Chua P et al. (2016) Subjective sleep problems in Huntington’s disease: a pilot investigation of the relationship to brain structure, neurocognitive, and neuropsychiatric function. J Neurol Sci, 364:148-153.

Bayram E, Mercan FN, Akbostancı MC (2015) Uneventful recovery from a suicide attempt with tetrabenazine: a case report. Turk J Neurol, 21:175-176.

Beglinger LJ, Paulsen JS, Watson DB, Wang MC, Duff K, Langbehn DR et al. & PREDICT-HD Investigators of the Huntington Study Group (2008) Obsessive and compulsive symptoms in prediagnosed Huntington's disease. J Clin Psychiatry, 69:1758-1765.

Bhattacharyya KB (2016). The story of George Huntington and his disease. Ann Indian Acad Neurol, 19:25-28.

Blackwell AD, Paterson NS, Barker RA, Robbins TW, Sahakian BJ (2008) The effects of modafinil on mood and cognition in Huntington’s disease. Psychopharmacology, 199:29-36.

Boyle A, Malloy PF, Salloway S, Cahn-Weiner DA, Cohen R, Cummings JL (2003) Executive dysfunction and apathy predict functional impairment in Alzheimer disease. Am J Geriatr Psychiatry, 11:214-221.

Camacho M, Barker RA, Mason SL (2018) Apathy in Huntington’s Disease: A review of the current conceptualization. J Alzheimers Dis Parkinsonism, 8:431.

Chatterjee A, Anderson KE, Moskowitz CB, Hauser WA, Marder KS (2005). A comparison of self-report and caregiver assessment of depression, apathy, and irritability in Huntington’s disease. J Neuropsychiatry Clin Neurosci, 17:378-383.

Chu EMY, O’Neill M, Purkayastha DD, Knight C (2019) Huntington’s disease: a forensic risk factor in women. J Clin Mov Disord, 6:3.

Connors MH, Teixeira-Pinto A, Loy CT (2020) Psychosis and longitudinal outcomes in Huntington disease: the COHORT Study. Neural Neurosourg Psychiatry, 91:15-20.

Craig KJ, Hietanen H, Markova IS, Berrios GE (2008) The Irritability Questionnaire: A new scale for the measurement of irritability. Psychiatry Res, 159:367-375.

Craufurd D, Thompson JC, Snowden JS (2001) Behavioral changes in Huntington disease. Neuropsychiatry Neuropsychol Behav Neurol, 14:219-226.

Craufurd D, Snowden J (2002) Neuropsychological and neuropsychiatric aspects of Huntington’s disease. In: Huntington’s disease (Eds G Bates, P Harper, L Jones):62-94. New York, NY, Oxford University Press.

Dale M, van Duijn E (2015) Anxiety in Huntington’s disease. J Neuropsychiatry Clin Neurosci, 27:262-271.

Danivas V, Moily NS, Thimmaiah R, Muralidharan K, Purushotham M, Muthane U et al. (2013) Off label use of lithium in the treatment of Huntington's disease: A case series. Indian J Psychiatry, 55:81-83.

Duff K, Paulsen JS, Beglinger LJ, Langbehn DR, Stout JC (2007) Predict-HD Investigators of the Huntington Study Group: Psychiatric symptoms in Huntington’s disease before diagnosis: the predict-HD study. Biol Psychiatry, 62:1341-1346.

Eddy CM, Parkinson EG, Rickards HE (2016) Changes in mental state and behaviour in Huntington’s disease. Lancet Psychiatry, 3:1079-1086.

Fedoroff JP, Peyser, C, Franz ML, Folstein SE (1994) Sexual disorders in Huntington’s disease. J Neuropsychiatry Clin Neurosci, 6:147-153.

Fiedorowicz JG, Mills JA, Ruggle A, Langbehn D, Paulsen JS (2011) PREDICT-HD Investigators of the Huntington Study Group Suicidal behavior in prodromal Huntington disease. Neurodegener Dis, 8:483-490.

Gibson JS, Rhoten BA, Ridner SH, Claassen DO (2022) Perceived effects of neuropsychiatric symptoms on functional status in early-stage Huntington disease. West J Nurs Res, 44:141-150.

Goh AM, Wibawa P, Loi SM, Walterfang M, Velakoulis D, Looi JC (2018). Huntington’s disease: neuropsychiatric manifestations of Huntington’s disease. Australas Psychiatry, 26:366-375.

Goodman AOG, Barker RA (2010) How vital is sleep in Huntington’s disease? J Neurol, 257:882-987.

Goodman AOG, Rogers L, Pilsworth S, McAllister CJ, Shneerson JM, Morton AJ et al. (2011) Asymptomatic sleep abnormalities are a common early feature in patients with Huntington’s disease. Curr Neurol Neurosci Rep, 11:211-217.

Groves M, van Duijn E, Anderson K, Craufurd D, Edmondson MC, Goodman N et al. (2011) An international survey-based algorithm for the pharmacologic treatment of irritability in Huntington’s disease. PLoS Curr, 3:RRN1259.

Groves M (2017) The highly anxious individual presenting for Huntington disease-predictive genetic testing: the psychiatrist's role in assessment and counseling. In Handbook of Clinical Neurology (Eds AS Feign, KE Anderson): 99-105. Cambridge, MA, Elsevier.

Gubert C, Renoir T, Hannan AJ (2020) Why Woody got the blues: The neurobiology of depression in Huntington's disease. Neurobiol Dis, 142:104958.

Harris KL, Kuan WL, Mason SL, Barker RA (2020) Antidopaminergic treatment is associated with reduced chorea and irritability but impaired cognition in Huntington’s disease (Enroll-HD). J Neurol Neurosurg Psychiatry, 91:622-630.

Herzog-Krzywoszanska R, Krzywoszanski L (2019) Sleep disorders in Huntington’s disease. Front Psychiatr, 10:221.

Honrath P, Dogan I, Wudarczyk O, Görlich KS, Votinov M, Werner CJ et al. (2018) Risk factors of suicidal ideation in Huntington's disease: literatüre review and data from Enroll-HD. J Neurol 265:2548-2561.

Hubers AA, van Duijn E, Roos R, Craufurd D, Rickards H, Landwehrmeyer GB et al. (2013) Suicidal ideation in a European Huntington’s Disease Population. J Affect Disord, 151:248-258.

Huntington G (1872) On chorea. The Medical and Surgical Reporter, 26(15):317-321.

Ishihara L, Oliveri D, Wild EJ (2021) Neuropsychiatric comorbidities in Huntington’s and Parkinson’s Disease: A United States claims database analysis. Ann Clin Transl Neurol, 8:126-137.

Jaini A, Yomtoob J, Yeh C, Bega D (2020) Understanding HD psychosis: an analysis from the ENROLL-HD Database. Tremor Other Hyperkinet Mov, 10:16.

Jhanjee A, Anand KS, Bajaj BK (2011). Hypersexual features in Huntington’s. Singapore Med J, 52:131-133.

Kachian ZR, Cohen-Zimerman S, Bega D, Gordon B, Grafman J (2019) Suicidal ideation and behavior in Huntington’s disease: systematic review and recommendations. J Affect Disord, 250:319-329.

Kar SK, Shahi MK, Tripathi A, Sharma PK (2017). Predicting prognosis of psychosis in Huntington's disease: Case report and review of literature. J Neurosci Rural Pract, 8:469-471.

Karabulut HG, Akbostancı C, Atbaşoğlu C, Bökesoy I, Mutluer N (2000) Predictive testing in Huntington’s Disease: neurologic, genetic and psychiatric evaluation. Parkinson Hastalığı ve Hareket Bozuklukları Dergisi, 3:7-12.

Karagas NE, Rocha NP, Stimming EF (2020). Irritability in Huntington’s disease. J Huntingtons Dis, 9:107-113.

Kirkwood SC, Siemers E, Viken R, Hodes ME, Conneally PM, Christian JC et al. (2002) Longitudinal personality changes among presymptomatic Huntington disease gene carriers. Cogn Behav Neurol, 15:192-197.

Kolenc M, Kobal J, Podnar S (2017) Female sexual dysfunction in presymptomatic mutation carriers and patients with Huntington’s Disease. J Huntingtons Dis, 6:105-113.

Laccone F, Engel U, Holinski-Feder E, Weigell-Weber M, Marczinek K, Nolte D et al. (1999) DNA analysis of Huntington's disease: five years of experience in Germany, Austria, and Switzerland. Neurology, 53:801-806.

Levy ML, Cummings JL, Fairbanks LA, Masterman D, Miller BL, Craig AH et al. (1998) Apathy is not depression. J Neuropsychiatry Clin Neurosci, 10:314-319.

Loi SM, Walterfang M, Velakoulis D, Looi JC (2018) Huntington’s disease: Managing neuropsychiatric symptoms in Huntington’s disease. Australas Psychiatry, 26:376-380.

Mandich P, Lamp M, Gotta F, Gulli R, Iacometti A, Marchese R et al. (2017). 1993–2014: two decades of predictive testing for Huntington's disease at the Medical Genetics Unit of the University of Genoa. Mol Genet Genomic Med, 5:473-480.

Marshall J, White K, Weaver M, Wetherill LF, Hui S, Stout JC et al. (2007). Specific psychiatric manifestations among preclinical Huntington disease mutation carriers. Arch Neurol, 64:116-121.

Martinez-Horta S, Perez-Perez J, van Duijn E, Fernandez-Bobadilla R, Carceller M, Pagonabarraga J et al. (2016). Neuropsychiatric symptoms are very common in premanifest and early stage Huntington's disease. Parkinsonism Relat Disord, 25:58-64.

Morris M (1991) Psychiatric aspects of Huntington’s disease. In Huntington’s Disease,( Ed. PS Harper):81–126. London, UK, WB Saunders.

Nakano T, Ono S, Yamaguchi J, Sugimoto R, Yamaguchi N, Morimoto Y et al. (2013) Modified electroconvulsive therapy for the treatment of refractory schizophrenia-like psychosis associated with Huntington’s disease. J Neurol, 260:312-314.

Nance M, Paulsen JS, Rosenblatt A, Wheelock V (2011) A Physician’s Guide to the Management of Huntington’s Disease. United States, Huntington’s Disease Society of America.

Neutel D, Tchikviladzé M, Charles P, Leu-Semenescu S, Roze E, Durr A et al. (2015) Nocturnal agitation in Huntington disease is caused by arousal-related abnormal movements rather than by rapid eye movement sleep behavior disorder. Sleep Med, 16:754-759.

Nimmagadda SR, Agrawal N, Worrall-Davies A, Markova I, Rickards H (2011) Determinants of irritability in Huntington’s disease. Acta Neuropsychiatr, 23:309-314.

Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A et al. (2008) Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry, 192:98-105.

Oosterloo M, Craufurd D, Nijsten H, van Duijn E (2019) Obsessive-compulsive and perseverative behaviors in Huntington’s disease. J Huntingtons Dis, 8:1-7.

Paoli RA, Botturi A, Ciammola A, Silani V, Prunas C, Lucchiari C et al. (2017) Neuropsychiatric burden in Huntington’s disease. Brain Sci,7:67.

Paulsen JS (2009) Functional imaging in Huntington’s disease. Exp Neurol, 216:272-277.

Paulsen JS, Ready RE, Hamilton JM, Mega MS, Cummings JL (2001) Neuropsychiatric aspects of Huntington’s disease. J Neurol Neurosurg Psychiatry, 71:310-314.

Paulsen JS, Miller AC, Hayes T, Shaw E (2017) Cognitive and behavioral changes in Huntington disease before diagnosis. In: Handbook of Clinical Neurology. Elsevier, pp. 69-91.

Paulsen JS, Hoth KF, Nehl C, Stierman L, The Huntington Study Group (2005) Critical periods of suicide risk in Huntington's disease. Am J Psychiatry 162:725-731.

Ratna N, Kamble NL, Venkatesh SD, Purushottam M, Pal PK, Jain S (2020) Psychiatric morbidity and poor follow-up underlie suboptimal functional and survival outcomes in Huntington’s disease. BMC Neurol, 20:87.

Rawlins M (2010) Huntington’s disease out of the closet? Lancet, 376:1372-1373.

Ready RE, Matthews M, Leserman A, Paulsen JS (2008) Patient and caregiver quality of life in Huntington’s disease. Mov Disord, 23:721-726.

Reedeker W, van der Mast RC, Giltay EJ, Kooistra TA, Roos RA, van Duijn E (2012a) Psychiatric disorders in Huntington’s disease: A 2-year follow-up study. Psychosomatics, 53:220-229.

Reedeker N, Bouwens JA, Giltay EJ, Le Mair SE, Roos RA, van der Mast RC et al. (2012b). Irritability in Huntington’s disease. Psychiatry Res, 200:813-818.

Rodrigues FB, Abreu D, Damásio J, Goncalves N, Correia-Guedes L, Coelho M et al. (2017) Survival, mortality, causes and places of death in a European Huntington's disease prospective cohort. Mov Disord Clin Pract, 4:737-742.

Ross CA, Tabrizi SJ (2011) Huntington's disease: from molecular pathogenesis to clinical treatment. Lancet Neurol, 10:83-98.

Ross CA, Aylward EH, Wild EJ (2014) Huntington disease: natural history, biomarkers and prospects for therapeutics. Nat Rev Neurol, 10:204-216.

Rossi G, Oh JC (2020) Management of agitation in huntington's disease: a review of the literature. Cureus,12:e9748.

Salman S, Balaban OD, Erten E, Karamustafalioglu N (2018) İlk başvurusu psikiyatrik belirtilerle olan bir Huntington Hastalığı olgusu. 3. Psikiyatri Zirvesi ve 10. Anksiyete Kongresi, 15-18 Mart 2018 Antalya, Türkiye. Kongre Özet Kitabı sayfa: 249-250.

Savva E, Schnorf H, Burkhard PR (2009) Restless legs syndrome: an early manifestation of Huntington’s disease? Acta Neurol Scand, 119:274-276.

Scheuing L, Chiu CT, Liao HM, Linares GR, Chuang DM (2014) Preclinical and clinical investigations of mood stabilizers for Huntington's disease: what have we learned? Int J Biol Sci, 10:1024-1038.

Serpell L, Waller G, Fearon P, Meyer C (2009) The roles of persistence and perseveration in psychopathology. Behav Ther, 40:260-271.

Sexton A, West K, Gill G, Wiseman A, Taylor J, Purvis R et al. (2021) Suicide in frontotemporal dementia and Huntington disease: analysis of family-reported pedigree data and implications for genetic healthcare for asymptomatic relatives. Psychol Health, 36:1397-1402.

Silver A (2003) Cognitive-behavioural therapy with a Huntington’s gene positive patient. Patient Educ Couns, 49:133-138.

Sinanović O (2020) Psychiatric disorders in neurological diseases. In Mind and Brain: Bridging Neurology and Psychiatry, (Ed V Demarin): 65-79.Cham, Switzerland, Springer.

Slaughter JR, Martens M.P, Slaughter KA (2001) Depression and Huntington’s disease: Prevalence, clinical manifestations, aetiology, and treatment. CNS Spectr, 6:306-326.

Solberg OK, Filkuková P, Frich JC, Feragen KJB (2018) Age at death and causes of death in patients with Huntington Disease in Norway in 1986–2015. J Huntingtons Dis, 7:77-86.

Squitieri F, Cannella M, Porcellini A, Brusa L, Simonelli M, Ruggieri S (2001) Short-term effects of olanzapine in Huntington disease. Neuropsychiatry Neuropsychol Behav Neurol, 14:69-72.

Stahl CM, Feigin A (2020) Medical, surgical, and genetic treatment of Huntington Disease. Neurol Clin, 38:367-378.

Stober T, Wussow W, Schimrigk K (1984) Bicaudate diameter: the most specifi c and simple CT parameter in the diagnosis of Huntington’s disease. Neuroradiology, 26:25-28.

Strassburger K, Andrich J, Saft C (2008) Bupropion: first experience in Huntington’s Disease. J Neurol Neurosurg Psychiatry, 79:29-30.

Szymuś K, Bystrzyński A, Kwaśniak-Butowska M, Konkel A, Leśnicka A, Nowacka M et al. (2020). Sexual dysfunction in Huntington’s Disease-a systematic review. Neurol Neurochir Pol, 54:305-311.

Thompson JC, Harris J, Sollom AC, Stopford CL, Howard E, Snowden JS et al. (2012) Longitudinal evaluation of neuropsychiatric symptoms in Huntington’s disease J Neuropsychiatry Clin Neurosci, 24:53-60.

Tibben A (2002) Genetic counseling and presymptomatic testing. In Huntington’s Disease (Eds G Bates, P Harper, L Jones):198-250. New York, Oxford University Press.

Tsuang D, Almqvist EW, Lipe H, Strgar F, DiGiacomo L, Hoff D et al. (2000) Familial aggregation of psychotic symptoms in Huntington’s disease. Am J Psychiatry, 157:1955-1959.

Vamos M, Hambridge J, Edwards M, Conaghan J (2007) The impact of Huntington'sdisease on family life. Psychosomatics, 48:400-404.

van der Meer L, van Duijn E, Wolterbeek R, Tibben A (2014) Offspring of a parent with genetic disease: childhood experiences and adult psychological characteristics. Health Psychol, 33:1445-1453.

van Duijn E, Kingma EM, van der Mast RC (2007) Psychopathology in verified Huntington's disease gene carriers. J Neuropsychiatry Clin Neurosci, 19:441-448.

van Duijn E, Kingma EM, Timman R, Zitman FG, Tibben A, Roos RAC et al. (2008) Cross-sectional study on prevalences of psychiatric disorders in mutation carriers of Huntington’s disease compared with mutation-negative firstdegree relatives. J Clin Psychiatry, 69:1804-1810.

van Duijn E, Reedeker N, Giltay EJ, Roos RAC, van der Mast RC (2010) Correlates of apathy in huntington’s disease.J Neuropsychiatry Clin Neurosci, 22:287-94.

van Duijn E, Craufurd D, Hubers AA, Giltay EJ, Bonelli R, Rickards H et al. for the European Huntington’s Disease Network Behavioural Phenotype Working Group (2014) Neuropsychiatric symptoms in a European Huntington’s disease cohort (REGISTRY). J Neurol Neurosurg Psychiatry, 85:1411-1418.

van Duijn E, Vrijmoeth EM, Giltay EJ, Bernhard F, Landwehrmeyer G, REGISTRY investigators of the European Huntington's Disease Network (2018) Suicidal ideation and suicidal behavior according to the C-SSRS in a European cohort of Huntington's disease gene expansion carriers. J Affect Disord, 228:194-204.

Wahlin TBR (2007). To know or not to know: a review of behaviour and suicidal ideation in preclinical Huntington's disease. Patient Educ Couns, 65:279-287.

Walker FO (2007) Huntington’s disease. Lancet, 369:218-228.

Wesson M, Boileau NR, Perlmutter JS, Paulsen JS, Barton SK, McCormack MK et al. (2018) Suicidal ideation assessment in individuals with premanifest and manifest Huntington Disease. J Huntingtons Dis, 7:239-249.

Wetzel HH, Gehl CR, Dellefave-Castillo L, Schiffman JF, Shannon KM, Paulsen JS (2011) Huntington Study Group: Suicidal ideation in Huntington disease: the role of comorbidity. Psychiatry Res, 188:372-376.

Wolf RC, Vasic N, Schönfeldt-Lecuona C, Ecker D, Landwehrmeyer GB (2008). Functional imaging of cognitive processes in Huntington's disease and its presymptomatic mutation carriers. Der Nervenarzt, 79:408-420.

Kaynak Göster

AMA Balaban Ö. D. , Atbaşoğlu E. C. Huntington Hastalığı’nın Nöropsikiyatrik Yönü. Psikiyatride Güncel Yaklaşımlar. 2022; 14(1): 98-112.