Dec '25 • General discussion
Robin Williams had Lewy body dementia. He was treated for depression for years.
Robin Williams saw psychiatrists for depression and anxiety.
They missed his Parkinson's disease.
By autopsy, he had severe Lewy body dementia throughout his brain.
This is the pattern I see constantly.
Psychiatric symptoms first. Motor symptoms later. Diagnosis years too late.
Here's what most miss:
Lewy body dementia and Parkinson's are the same disease.
Same abnormal protein. Same brain pathology.
Just different timing of which symptoms appear first.
The psychiatric presentation:
- Depression that doesn't respond to antidepressants.
- Visual hallucinations - seeing people or animals that aren't there.
- Paranoid delusions - convinced spouse is having an affair.
- REM sleep behavior disorder - acting out dreams violently.
These aren't psychiatric illness. They're neurodegenerative disease.
What happened with Robin Williams:
May 2014 (and years before): anxiety and depression worsening. Psychiatrists tried medications. Nothing worked.
July 2014: subtle tremor noticed.
August 2014: died by suicide.
Autopsy: diffuse Lewy bodies throughout brain.
The psychiatric symptoms were neurological all along.
The pattern I look for:
- New-onset depression after age 60.
- Antidepressants don't help.
- Spouse reports violent nightmares.
I examine carefully:
- Mild cogwheel rigidity in wrists. Barely detectable.
- Reduced arm swing on one side when walking.
- Slight facial masking.
- Handwriting getting smaller.
These motor signs are subtle. Easy to miss if you're not looking.
But they're there. Usually.
Why this gets missed:
- Psychiatrists normally don't do any physical exam.
- Providers don't connect psychiatric symptoms to Lewy Body Pathology.
- Families don't realize vivid dreams are a red flag.
By the time motor symptoms are obvious, disease is advanced.
The clinical clues:
- REM sleep behavior disorder precedes diagnosis by 10-15 years.
- Visual hallucinations suggest Lewy bodies - detailed people, animals, children.
- Fluctuating cognition. Sharp one hour, confused the next.
- Severe sensitivity to antipsychotics - can cause rigidity, immobility, death.
Why this matters:
- Treatment is completely different.
- Antipsychotics can kill Lewy body patients.
- Cholinesterase inhibitors often work better in Lewy body than Alzheimer's.
Families need to know what's coming.
I diagnose 2-3 Lewy body cases monthly.
Almost all were initially treated for psychiatric illness or a number of other things.
That's OK, the message isn't we have have to be perfect up front, it's knowing when more exploration is needed.
Any older adult with new psychiatric symptoms needs a motor exam.
Every single time.
Because the treatment difference can be life or death.
💬 Have you seen psychiatric symptoms that turned out to be neurological?
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Robin Williams had Lewy body dementia. He was treated for depression for years.
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