Can a brain tumor cause anxiety, paresthesias, and cognitive impairment in a patient with a history of Selective Serotonin Reuptake Inhibitor (SSRI) discontinuation syndrome and prediabetes?

Can a Brain Tumor Cause These Symptoms?

Yes, a brain tumor can absolutely cause anxiety, paresthesias, and cognitive impairment, and should be considered in the differential diagnosis, particularly given the atypical presentation with multiple neuropsychiatric symptoms. 1

Clinical Rationale for Considering Brain Tumor

Cognitive Impairment as a Hallmark Feature

• Cognitive impairment is present in 90% of patients with primary brain tumors and 91% of patients with brain metastases before any treatment begins, making it one of the most common presenting features 2
• The most frequently impaired cognitive domains include memory, attention, and executive functioning—symptoms that can easily be misattributed to psychiatric conditions or medication effects 2
• Brain tumors cause cognitive dysfunction through both local damage and disruption of cognitive networks, meaning even small tumors can produce diffuse symptoms 2

Psychiatric Symptoms Without Focal Neurological Signs

• Brain tumors frequently present with psychiatric symptoms in the absence of obvious neurological findings, which is a critical diagnostic pitfall 3, 4
• The National Comprehensive Cancer Network specifically recommends considering brain tumors in patients with new-onset psychiatric symptoms, atypical presentations, or personality changes, even without focal neurological signs 1
• Case reports document patients presenting with depression, anxiety, personality changes, and cognitive symptoms who had minimal or no neurological signs on examination, yet harbored significant brain tumors 3, 4

Paresthesias and Sensory Symptoms

• While paresthesias are less commonly emphasized in the brain tumor literature, tumors affecting the parietal lobe can produce sensory symptoms and paresthesias 3, 4
• The combination of sensory symptoms with cognitive and psychiatric manifestations should heighten suspicion for structural brain pathology 4

Critical Diagnostic Considerations

Why This Patient Warrants Imaging

• SSRI discontinuation syndrome typically resolves within days to weeks, not months, and should not cause progressive or persistent cognitive impairment 1
• The presence of multiple neuropsychiatric domains affected simultaneously (anxiety, sensory symptoms, cognition) suggests a structural rather than purely functional etiology 2, 1
• Prediabetes alone does not typically cause this constellation of symptoms in the absence of severe metabolic derangement 1

Recommended Diagnostic Approach

• Obtain brain MRI with and without contrast as the gold standard imaging modality for detecting brain tumors 1
• Perform validated cognitive screening using tools such as the Hopkins Verbal Learning Test, Trail Making Test, or Stroop Test to objectively document cognitive deficits 2
• Assess for depression and anxiety using standardized scales, as these occur in 21.7% of brain tumor patients and significantly impact quality of life 1

Common Diagnostic Pitfalls to Avoid

Attribution Bias

• Do not assume all symptoms are explained by SSRI discontinuation or psychiatric illness without ruling out structural pathology, especially when symptoms persist beyond expected timeframes 1, 3
• Clinicians often miss brain tumors because cognitive impairment and psychiatric symptoms are attributed to depression, anxiety, or medication effects 3, 4

The "Neurologically Silent" Brain Tumor

• Absence of classic neurological signs (papilledema, focal weakness, seizures) does not exclude brain tumor 3, 4
• Tumors in certain locations (frontal, temporal, parietal lobes) can produce predominantly psychiatric and cognitive symptoms with minimal motor or sensory findings on examination 4

Timing and Progression

• New-onset or worsening cognitive symptoms warrant imaging regardless of other explanations 1
• Progressive symptoms or failure to improve with treatment of presumed psychiatric conditions should prompt reconsideration of structural causes 3

Clinical Bottom Line

Brain imaging with MRI should be obtained in this patient given the combination of anxiety, paresthesias, and cognitive impairment, particularly if symptoms are progressive, persistent beyond expected SSRI discontinuation timeframes, or atypical in presentation 1. The high prevalence of cognitive impairment as a presenting feature of brain tumors (90%), combined with the well-documented phenomenon of "neurologically silent" tumors presenting with psychiatric symptoms alone, makes this a diagnosis that cannot be missed 2, 3.