Psychiatric Presentations of Medical Illness

[Guest guest]

http://www.alternativementalhealth.com/articles/diamond.htm

 

Editor's note: The following is the finest article we have found on

the subject of medical causes of severe mental symptoms. We are

grateful to Dr. Diamond for his permission to reprint.

 

The reader should note that this article only covers standard medical

causes of mental symptoms and does not include many other physical

causes, such as nutritional imbalances and metabolic abnormalities,

listed in other articles on AlternativeMentalHealth.com. It should

also be noted that some studies have shown that, when extensive

testing is done, medical causes may account for substantially more

than 10% of patients with mental symptoms (particularly Hall

[reporting a 46% causal connection], American Journal of Psychiatry,

1980 and Koranyi, Archives of General Psychiatry, 1979). Lastly, many

clinicians believe that patients may suffer from medical conditions,

such as hypothyroidism, that can be missed by standard medical lab

tests and, therefore, be overlooked on studies applying standard

medical screening.

 

 

Psychiatric Presentations of Medical Illness

 

An Introduction for Non-Medical Mental Health Professionals

 

Ronald J Diamond M.D.

University of Wisconsin Department of Psychiatry

6001 Research Park Blvd

Madison, Wisconsin 53719

 

Revised 1/7/2002

 

 

Introduction

 

Every time a patient comes into your office, your emergency room or

your hospital, there is a very real possibility that what seems to be

a psychological problem is caused by some physical illness. The

depressed patient may have an under active thyroid gland. The patient

with panic attacks may have a pheochromocytoma, a tumor that secretes

epinephrine. And the patient, whose personality change and increased

irritability is thought to be caused by his marital problems, may

actually have a brain tumor causing the personality changes and

exacerbating longstanding marital issues.

 

How common is this problem? Very...and not very. Most of your clients

will not have a medical disease masquerading as an emotional problem.

In fact, one of the problems is that most really serious medical

illnesses are rare enough that we all get sloppy and stop looking for

them. Most of the time our medical workups are unnecessary-but most of

the time is not the same as all of the time. It is not necessary to

live in abject terror about missing all of the patients with

unsuspected medical illnesses that come to you with symptoms of

depression or anxiety. On the other hand, medical causes of

psychiatric symptoms should always be considered. As a mental health

professional, you need to know enough about these medical illnesses to

make some basic assessment about whether a further medical assessment

is necessary and how to focus that assessment so as to make it as

productive as possible.

 

Ex.-Johnson (1968) performed detailed physical exams on 250 patients

admitted to an inpatient psychiatric unit. 12% of these patients were

admitted to the psychiatric unit for problems that seemed to be caused

by physical illness

 

80% of these had been missed by physician before admission

6.6% were initially missed even after the admission workup

60% had abnormal physical findings

 

Ex.-Hall (1978) performed a detailed assessment on 658 consecutive

psychiatric outpatients - 9.1% had a significant medical illness-

 

Ex.-Slater (1965) studied 85 patients (32 men and 53 women) diagnosed

as having " hysteria " - follow up 7-11 years. More than a third proved

to have organic disease

 

Ex.-Sox et. al. (1989) did a thorough medical evaluation on 509

patients in community mental health programs in California.- 200 (or

39%) had at least one active, important, physical disease, Staff at

the mental health program was aware of only 47% of these. Research

program discovered previously undiagnosed, important diseases in 63 of

these patients. 14% had medical illness that was causing or

exacerbating their mental illness

 

Ex.-Koran performed thorough medical assessments on 529 patients drawn

from eight community mental health centers in California. 17% were

found to have an organic condition that either caused or exacerbated

the emotional symptoms for which the person was being treated.

 

Ex.-Bartsch et. al. performed a comprehensive evaluation on 175

clients from two Colorado CMHCs. A previously undiagnosed physical

health problem was found in 20% of the clients. 16% had conditions

that could cause or exacerbate their mental disorder. 19 clients had

a metabolic abnormality (elevated calcium, etc.).

7 clients had a neurological disorder (memory loss, post concussion

syndrome, etc.) 7 clients had an adverse medication effect. 4

clients had some other disorder, including cancer

 

Conservative estimates suggest that 10% of persons initially seen in

outpatient settings for psychological symptoms have an organic disease

causing the symptoms. This figure is higher in the elderly, in persons

with certain diagnosis such as hysteria, and much higher in inpatient

settings.

 

What can one do about it?

 

Even internists and neurologists, working in academic centers and

aware of the possibility of organic illness, miss medical illnesses

with disturbing frequency. There is no set of tests that can

definitively rule everything out. Some illnesses are hard to diagnose,

especially at the beginning. Others are so rare that they are not

thought of so that the specific tests that would allow the diagnosis

are not considered. Still other times the illnesses present

atypically. The patient's symptoms seem different than those described

in the medical textbooks, so that a medical illness is missed.

 

The most common problem, however, is that we do not think about the

possibility of medical illness and, therefore, we do not specifically

look for medical illness. IF YOU DO NOT LOOK FOR IT, YOU WILL NOT FIND

IT. The purpose of this paper is not to get you to the point of being

able to diagnose every possible disease. Rather, it is to give you a

starting point-to know when to be particularly suspicious (or

worried), to know something about the most common illnesses, and to

learn enough to communicate with the consulting physician so that you

can make sure that your patient gets the best possible evaluation.

 

There are at least three problems with trying to present this kind of

brief review for non-medical mental health professionals.

 

The first is that there are a huge number of different possible

illnesses to worry about. I am not about to try to list all possible

illnesses or to give complete descriptions but, rather, to get you to

think about some of the common illnesses that you are most likely to

see in your practice.

 

The second problem is that it is almost impossible to talk about

medical illnesses without lapsing into medical jargon. This is half a

paper about medical illnesses, and half a paper on learning a new

language that will hopefully help you when you need to communicate to

other physicians.

 

The third problem is both more subtle and more serious. Non-medical

mental health professionals organize the world according to

psychological symptoms. The question is, what medical illnesses can

cause depression, anxiety, etc.? The problem is that the depression

caused by a brain tumor may be identical to the depression caused by

marital discord or by an endogenous depression. What is likely to be

different is the patient's history and the associated signs and

symptoms apart from the depression. Unfortunately, listing illnesses

according to which ones can cause depression or which ones can cause

anxiety does not produce a coherent organization. Many illnesses can

cause many different psychological symptoms. More importantly, such a

listing would not help to understand what other questions to ask to

help separate physical from psychological illnesses.

 

Physicians organize the world much differently. The easiest way to

remember all of the separate facts and to see patterns is to organize

illnesses according to physiological systems. Throughout this paper I

will keep talking about endocrine systems, neurological systems and

cardiopulmonary systems. For someone who has been through medical

school, this becomes the obvious way to organize things, but it is not

always so obvious for the rest of the world. The problem with

categorizing according to psychiatric symptoms will become obvious as

you go through this paper. A huge number of illnesses can present as

depression, and the vast majority of these illnesses can also present

as anxiety or delirium. It does not do much good to think about the

list of illnesses that can present as depression unless you begin to

think about some of the other associated symptoms that those illnesses

also have-and the best way to organize these associated symptoms is to

understand what organ systems the illness effects.

 

Having said all of that, I will try to organize illnesses by their

psychological effects, and, at the same time, try to introduce the way

that physicians would organize their thinking about those illnesses.

 

 

Section I

General Approach

 

A. Always consider the possibility of organic disease- If you do not

look for it you will not find it.

 

1. Be suspicious of " medical clearance " .

 

Unfortunately, physicians tend to dismiss psychiatric patients for

several reasons. There is a tendency to assume that all psych patients

are just " nuts " without " real illness " . Physicians are often

uncomfortable around patients who are obviously depressed or who are

acting bizarrely, or who they are afraid might act bizarrely. At times

these patients behave in ways that make evaluation more difficult,

either by being unwilling to give a full history, unable to give an

accurate description of symptoms, or too frightened to allow a full

physical examination.

 

2. People with schizophrenia get sick too.

 

The fact that someone is actively psychotic does not mean that they do

not also have a serious medical illness. One should always be

concerned that a medical illness might, in fact, be the cause of the

psychosis. But even in patients who clearly have schizophrenia or some

other diagnosable mental illness and who have had an excellent medical

workup in the past, it is important to consider whether their current

complaints or recent change in behavior could be related to a medical

illness. In fact, psychotic patients are more difficult to evaluate,

and if they do happen to have a serious medical illness, it is more

likely to get missed.

 

Studies have demonstrated that disliked patients are more likely to

have an undiagnosed organic brain syndrome than more likable patients,

and it is just those disliked patients that will often get the most

cursory and incomplete physical evaluation. My guess is that patients

who are most different from their physicians are also more likely to

have a medical illness missed, and this is especially true of

psychiatric patients.

 

3. Be alert for presentations, which make medical illness more

likely-but do not stop considering medical illness just because these

are not present.

o a patient over 40 with no previous psychiatric history

o no history of similar symptoms

o coexistence of chronic disease

o a history of head injury

o a change in headache pattern

o a patient who gets worse when given antipsychotic or anxiolytic

medications

 

4. Look for symptoms, which make medical illness more likely.

 

o a change in headache pattern

o visual disturbances, either double vision or partial visual loss

o speech deficits, either dysarthrias (problems with the mechanical

production of speech sounds) or aphasias (difficulty with word

comprehension or word usage).

o abnormal autonomic signs (blood pressure, pulse, temperature)

o disorientation and/or memory impairment

o fluctuating or impaired level of consciousness

o abnormal body movements

o frequent urination, increased thirst (possible symptoms of diabetes)

o significant weight change, gain or loss

 

5. Do not assume that a certain symptom " must " be of psychological

origin.

For example, it used to be thought that male impotence was almost

always a psychological problem. A recent study of 105 impotent men

reported that 75% had impotency based either on a medical illness such

as diabetes mellitus, or were using drugs that were likely to cause

impotence. Of 34 men with hormonal problems who accepted medical

treatment, 33 had return of sexual function. Fourteen of these men had

previously undergone psychotherapy for this same problem.

 

B. Be Holistic

 

A psychiatric assessment should include the whole person, including

the medical history and physiology of that person. This is needed to

rule out a medical illness, but also so that you can understand the

person's current feelings and functioning within the context of what

has happened to the person in the past and what is happening now.

 

Much of the information that you need to suspect a medical illness is

readily available as part of a psychiatric assessment. It is important

to know how to organize this information so that it is useful, and to

fill in gaps in your information so that important areas are not

missed. (Note that a comprehensive psychiatric evaluation would

include additional areas such as personal developmental history and

current social support system, in addition to the assessment areas

discussed below.)

 

1. Symptoms

o Start with a clear description of all of the patient's symptoms.

o How did they begin? How long has he had them? What has the

progression of symptoms been like?

o Include a careful review of other " extraneous " symptoms the patient

may have-starting at the top with questions about headache and

dizziness and ending at the bottom with questions about leg sores and

trouble walking. This " review of systems " is an extremely important

part of a medical assessment.

 

2. History

o Include history of similar problems in the past

o History of past medical problems including all medical

hospitalizations and surgeries

o Family history, both medical and psychiatric

 

3. Current medical status

o Ask about all current medical illnesses

o Ask about all current medications (Include specific questions about

vitamins, birth control, over the counter meds, etc.)

o Ask about past medical problems, past surgeries, past medical

hospitalizations

o Ask about any head injury, coma, periods of unconsciousness, seizures.

o Obtain name of person's physician--date of last contact--for what

purpose

 

4. Current habits

o Ask about drug use, starting with questions about tobacco, caffeine

and alcohol and proceeding on to questions about other drugs

o Ask about exercise and activity patterns, sleep patterns

 

5. Observation.

The assessment starts when you first meet the patient, not when you

first sit down to begin talking in your office.

o General appearance: How does the person look? How are they dressed?

Do they appear ill? Then go to more specific observations.

o Skin: Is it very dry or abnormally colored? Extremely pale skin or

lips may suggest anemia. A yellow skin may indicate jaundice and liver

disease. Dry skin and hair may be a sign of hypothyroidism.

o Eyes: Are they focused? Are the pupils equal? Are they aligned with

each other? Differences in pupil size may indicate brain masses such

as tumors. Wildly dilated pupils may indicate a variety of drugs

including hallucinogens, stimulants, and anticholinergics. Constricted

pupils may indicate opiates. Bulging eyes can be a sign of

hyperthyroidism.

o Observe body movement to rule out weakness, clumsiness, ataxia,

facial asymmetry, asymmetry of movements, choreiform movements

( " worm-like " or other involuntary movements, usually occurring less

than 2 times/second), tremors. Observe for other neurological

abnormalities such as motor stereotypy (repetitive stereotyped movements).

o Gait disturbance is a very common finding in a wide range of medical

conditions.

Dubin (1983) studied 1140 patients cleared medically on a psychiatric

service.

o 38 subsequently found to have a medical illness

o 14 of the 38 had either gait disturbance, weight loss, hypertension,

abnormal vital signs or significant medical history

 

6. Mental status examination

o appearance

o degree of cooperation

o presence of perceptual distortions (hallucinations and illusions)

o mood (both appropriateness and quality)

o speech (both quality and content)

o motor activity

o general cognitive abilities

- attention

- memory

- judgment

- fund of knowledge

o Also consider evidence of specific neurological deficits:

- aphasias (difficulties with speech) can be broken down into

v word finding difficulties (nominal aphasias)

v difficulty understanding speech (receptive aphasias) or

v difficulty producing speech (expressive aphasia)

- agnosias (recognition of complex shapes)

- apraxias (execution of proper manipulation of objects)

- perseveration (inability to switch tasks or mental sets)

Each of these can occur with varying degrees of severity.

 

7. Physical exam.

A full physical examination is obviously not possible if you are not a

physician, and even psychiatrists rarely perform a physical

examination themselves. Some parts of a physical examination are easy,

even for non-physicians.

o Blood pressure, preferably lying and standing (or you can ask a

patient about any recent blood pressure checks, or ask them to get

their blood pressure taken at one of the blood pressure machines that

seem to be in every bank and drugstore)

o Pulse for evaluation of rate and arrhythmias (irregularities of

heart rhythm)

o Check eyes to see if they move equally and fully in all directions,

equal and reactive pupils, and nystagmus (small " jerky " movements of

eyes when client looks up or to the side)

o Assessment of the condition of the patient's skin, looking for such

things as dryness, dehydration, nutritional status, rashes, edema,

petechiae

 

A useful screen for picking up physical disease in psychiatric

patients includes:

o Laboratory tests: TSH (thyroid test), CBC (complete blood count),

SGOT (liver function test), Fasting glucose [or random glucose if

fasting not possible] (screen for diabetes), serum albumin, serum

calcium, vitamin B12, and urinalysis

o History of epilepsy, emphysema, asthma, diabetes, thyroid disease,

history of blood or pus in the urine, or history of high blood pressure

o HIV positive or history of high risk behavior for HIV

o Symptoms of chest pain while at rest, headaches associated with

vomiting or loss of control of urine or stool

o Physical findings of high blood pressure

(adapted from Sox et al 1989)

 

C. Develop a " differential diagnosis " that systematically considers

possible medical illnesses. Consider all of the medical illness that

could fit the set of symptoms. What further information would help

distinguish between these various possibilities?

o As a way of organizing your information about the patient

o focusing your attention

o and targeting what further information is needed.

 

The goal is not to come up with a specific diagnosis. The goal is to

organize the data that you collect about the patient so that you can

decide what to do next, how worried you need to be, and when and how

and what to say to your consulting physician if you decide further

medical assessment is necessary.

 

The basic mental health assessment must, of course, be supplemented

with appropriate outside consultation, which will include a physical

examination and appropriate laboratory tests, but this should be

focused by the differential diagnosis. BOTH YOU AND THE DOCTOR ARE

MORE LIKELY TO FIND IT IF YOU ARE LOOKING FOR SOMETHING SPECIFIC THAN

IF YOU ARE GROPING RANDOMLY. For Example:

o with " hysterical " symptoms, consider MS

o with mental status changes occurring over days to weeks, together

with alcoholism or chronic headache, consider subdural hematoma (slow

bleed inside the skull under the dura membrane that covers the brain)

o with depression along with weight gain, ask about cold intolerance

and dry skin and consider hypothyroidism

 

Laboratory and other diagnostic tests should be used to pursue

specific parts of the differential diagnosis list. Diagnostic tests

are much more likely to give useful results when you and the doctor

are clear what question you have in mind and what specific test is

needed to answer that specific question. For Example:

o EEG detects abnormal brain function

o CAT scan detects abnormal anatomy

 

If you are asking for a " drug screen " to find out if the client has

recently used an illicit drug, find out if your laboratory can measure

the drug or drugs that you expect this person might be using, and

whether blood or urine tests are better depending on the particular

drug and time since ingestion. Most labs can test for the presence of

cocaine, but LSD is used in much smaller amounts and may not be

detectable even if recently used. This kind of question can be

answered by a call to the chemistry lab of the local hospital, but

such a call requires that you step out of your typical " non-medical "

role and interact with a strange and often forbidding medical system.

 

 

D. Work with and actively involve the consulting physician.

At different times with different doctors and different clinical

situations this will mean different things. It always means making the

consultation request as clear as possible. What kind of answer do you

want back from the doctor? What are you most worried about? What

information do you already have about the client? You might think that

your job is just to get the client to see the doctor, and the rest of

the job is up to the doctor. This is true-and not true. The doctor

will typically spend less than 15 minutes with the patient to collect

a history, do the physical, order the tests and write a note in the

chart.

 

If the client is less than articulate, important information is likely

to get lost. This is a particular problem with older clients, those

who are hard of hearing or who have other communication problems, or

those who are less organized or less clear in their thinking. It is

also a problem when the symptoms you want evaluated are vague, or your

concerns leading to the referral do not relate to a particular

" medical " symptom. Your job must include organizing the information

that you have collected and transmitting it to the doctor in such a

way as to do your client the most good.

 

Telling the client to see his local doctor, or phoning the local

internist with a request to " Please do a physical exam on this

client. " is much less likely to lead to a reasonable consultation

result than a request, " This client has a depression that seems very

atypical. Could you please see if there could be a medical illness

involved? " Or even better yet, " This patient is complaining of

depression with decreased energy level, but he is also complaining of

increased weight, cold intolerance, decreased libido and extremely dry

skin. He was treated for hyperthyroidism 15 years ago. Could you see

if any thyroid problems or any other medical problems might be

increasing his depression? "

 

Most of the time you will not be able to frame a consult request with

as much detail as this last example-but in all cases the more the

better. Often, the referral to the physician is based on a pattern

suggesting a higher probability of medical illness, rather than any

particular symptom suggesting a particular illness. For example, any

client who initially develops psychiatric symptoms over the age of 40

should have a medical workup. If this is the reason you are referring

the client, then the physician needs to have that information.

 

Finally, there are differences of communication styles between mental

health professionals and physicians. The social worker or psychologist

is likely to want to give the physician a complete description of the

patient and the problem in a phone discussion that may go on for many

minutes. The physician is likely to be in the middle of office hours,

with a clinic full of patients waiting to be seen. A brief, succinct

and very focused description and problem statement with a focused

consultation request is likely to be better received by a physician

than the more complete communication often expected between

psychotherapists.

 

Common assumptions that lead to missed diagnosis:

o mistaking symptoms for their causes

o listening without fully considering all possibilities

o equating psychosis with schizophrenia

o relying on a single information source

 

 

Section II

Psychosis-

Patients that Appear Out of Touch with Reality

 

A. Consider Organic Disease

If you do not look for it you will not find it. Be suspicious of

" medical clearance " .

 

1. Other symptoms that suggest organic disease include:

o a patient over 40 with no previous psychiatric history

o hallucinations that are visual and vivid in color, that change rapidly

o olfactory (smell) hallucinations

o illusions: misinterpretations of stimuli

o large recent weight changes

 

2. A brief, minimal neurological exam can be easily and rapidly done,

even on very agitated patients (even by someone who is not a physician).

o Observe gait and body movement to rule out weakness, paralysis,

ataxia and other gait disturbances and choreoathetoid movements

o Check eyes:

- Make sure pupils are equal and reactive to light.

- Check to see if eyes move fully in all directions.

- Check for vertical and horizontal nystagmus: refers to rapid

movements of jerking of the eyes, and can be either up and down

(vertical) or back and forth (horizontal). It is most easily seen if

the client is asked to look up or over to the side as far as possible.

Nystagmus is frequently present with drug intoxications, and vertical

nystagmus is never a normal finding in functional psychosis.

o Observe face for asymmetries.

o Observe speech for slurring, aphasias, word finding difficulties,

and perseveration.

 

The above observations are possible on a completely uncooperative

patient. Summers et. al. have outlined a very rapid physical exam for

screening purposes (see bibliography).

 

3. Consider medical emergencies that can present as psychiatric illness

a. Hypoglycemia (low blood sugar): symptoms can be variable and

include delirium or coma. Can include palpitations, sweating, anxiety,

tremor, vomiting. If in doubt, give candy or orange juice sweetened

with sugar. In an emergency room, give 50 cc. of 50% dextrose for both

treatment and diagnosis.

b. Diabetic Ketosis or non-ketotic hyperosmolarity (blood sugar so

high that it upsets body chemistry): delirium with history of

diabetes, increased breathing, sweet smell of acetone on breath (can

be mistaken for smell of alcohol), dehydration, decreased blood pressure.

c. Wernickes-Korsakoff's syndrome: acute thiamine (vitamin B6)

deficiency so severe that it can cause rapid brain damage. Usually

found in alcoholics. Symptoms include nystagmus (rapid small jerking

movements of eyes), cerebellar ataxia (person moves as if drunk),

evidence of peripheral neuropathy, ocular palsies (inability to move

both eyes together in all directions) If in any doubt, give thiamine

l00 mg. IM. This is not diagnostic but will prevent any further brain

damage.

d. DT's (delirium tremens): drug withdrawal from alcohol or other

sedative hypnotics. Frequently missed and can be medically very

serious. Symptoms include elevated autonomic signs, agitation, visual

and tactile hallucinations and history of alcohol abuse. Onset is

usually three to four days after reduction or discontinuation of alcohol.

e. Hypoxia (low blood oxygen): from pneumonia, heart attack, COPD

(chronic obstructive pulmonary disease), arrhythmias (abnormal heart

rhythm), etc.

f. Meningitis (infection of the covering of the brain): be alert for

stiff neck and fever.

g. Subarachnoid hemorrhage (rapid arterial bleeding into the brain):

stiff neck, fluctuating consciousness and headache. If there is a

fluctuating consciousness along with stiff neck and headache, a spinal

tap for diagnosis needs to be done immediately.

h. Subdural hematoma (bleeding from veins under the outside covering

of the brain, which compresses the brain over hours to weeks or even

longer): symptoms are variable but frequently (not invariably) there

is a history of head trauma.

i. Anticholinergic (atropine) poisoning: from overdose of tricyclics

or over-the-counter drugs, or from organophosphate insecticides.

Classic symptoms include:

o Flushing " red as a beet "

o Mouth dry " dry as a bone "

o Dilated pupils " blind as a bat "

o Delirious " mad as a hatter "

These patients will also have increased pulse and sometimes elevated

blood pressure. Most fatalities are from cardiac arrhythmias, although

seizures are not uncommon.

 

 

B. Differentiate psychosis from delirium

Psychosis refers to an impairment in reality testing because of

hallucinations, delusions or grossly disorganized thinking. Psychosis

can be caused by organic diseases where we know the cause or by a

variety of mental illnesses ranging from a brief reactive psychosis to

schizophrenia.

 

Delirium refers to an acute organic brain syndrome causing a global

cognitive impairment, with disorientation, memory impairment, and

disturbance of consciousness. Illnesses causing deliriums are often

life threatening, and a delirium should be considered to be a medical

emergency.

Symptoms of delirium include:

o disorientation or memory impairment

o fluctuating or impaired level of consciousness, decreased awareness

of environment

o labile affect

o impaired judgment or impaired insight

o abnormal autonomic signs (changes in blood pressure, pulse,

temperature, abnormal sweating, flushing, etc)

 

DSM IV Diagnostic criteria for Delirium

A. Disturbance of consciousness (i.e., reduced clarity of awareness of

the environment) with reduced ability to focus, sustain, or shift

attention.

B. A change in cognition (such as memory deficit, disorientation,

language disturbance) or the development of a perceptual disturbance

that is not better accounted for by a preexisting, established, or

evolving dementia.

C. The disturbance develops over a short period of time (usually hours

to days) and tends to fluctuate during the course of the day.

D. There is evidence from the history, physical examination, or

laboratory findings that the disturbance is caused by the direct

physiological consequences of a general medical condition. (From

DSM-IV, 4th edition 1994, APA Press)

 

 

C. Medical Illnesses that Can Present as Psychosis

 

1. Progressive neurological diseases

a. Multiple sclerosis: no typical signs or symptoms. It may begin very

suddenly and affect any part of the neurological system. Early in its

course, diagnosis may be extremely difficult.

b. Huntington's chorea: hereditary illness that includes movement

disorder but can present with psychosis initially.

c. Alzheimer's disease and Pick's disease: progressive diseases that

cause dementia, but can initially present in a wide variety of ways.

Alzheimer causes diffuse dementia, while Pick's primarily affects the

frontal lobes of the brain.

 

2. Central nervous system infections

a. Encephalitis (viral infection of the brain-usually Herpes Simplex):

usually presents with fever and seizures, but various mental symptoms

including catatonia or psychosis may present before any clear cut

neurological symptoms. Usually has a fluctuating mental status.

b. Neurosyphilis (syphilis of the central nervous system).

c. HIV infections: HIV encepalopathy commonly includes apathy,

decreased spontaneity and depression and may present before any other

signs of AIDs are present. AIDS can also first present as delirium

with paranoia and other prominent psychotic features.

 

3. Space occupying lesions within the skull

a. Brain tumors

b. Bleeding within the skull

c. Brain abscess

 

4. Metabolic disorders

a. Accumulation of toxins from severe liver or kidney disease.

b. Disturbances in electrolytes, either too low a serum level of

sodium or too high a serum level of calcium.

c. Acute intermittent porphyria (disease of porphyrin metabolism):

very rare, but may present as classical psychosis. Often has abdominal

pain or other gastrointestinal symptoms such as vomiting.

d. Wilson's disease: abnormality of copper metabolism that causes

damage to brain and liver if untreated.

e. Systemic lupus erythematosis (autoimmune disease): usually a slowly

progressive illness with joint and muscle pain, but it can present

very suddenly. The nervous system is commonly involved and can present

with depression, dyscontrol syndromes (unexpected impulsive or

aggressive behavior), or psychosis.

 

5. Endocrine disorders

a. Myxedema (underactive thyroid gland-hypothyroidism)

b. Cushing's syndrome (too much cortisol caused by overactive adrenal

gland or overactive pituitary gland)

c. Hypoglycemia, either from insulin secreting tumor or administration

of insulin

 

6. Deficiency states

a. Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome

b. Pellegra (nicotinic acid deficiency) and other B complex deficiencies

c. Zinc deficiency

 

7. Temporal lobe epilepsy (or partial complex seizure disorder)

 

8. Drugs-

a. prescription

· oL-DOPA

· oAmphetamine

b. illicit drugs

· cocaine, crack, methamphetamine, stimulants

· hallucinogens

 

 

D. Consider other mental illness in addition to schizophrenia

Not all psychosis is schizophrenia. Do not over diagnose. Without a

history, it is impossible to distinguish an acute psychotic episode

that will rapidly resolve from an exacerbation of schizophrenic

illness that will continue to be an ongoing problem.

 

 

Section III

Anxiety

 

A. Think About the Phenomenology of Anxiety

1. Psychological manifestations: Inner feelings of terror, tension,

apprehension and dread, derealization, depersonalizations, fear of

impending insanity

 

2. Intellectual disturbances: Decreased concentration, disorganized

thinking, sensory flooding

 

3. Somatic manifestations: Autonomic or visceral symptoms, including

palpitations, chest pain, tachycardia, fatigue, weakness,

perspiration, flushing, numbness, tingling of extremities, vertigo,

shortness of breath, headache, blurred vision, tinnitus, diarrhea,

tremor, fainting

 

 

B. Differential Diagnosis of Anxiety

1. Primary anxiety disorders

o Panic disorder with or without agoraphobia

o Social phobia and other simple phobias

o Obsessive-compulsive disorder

o Post-traumatic stress disorder

o Generalized anxiety disorder

o Adjustment disorder with anxious mood

o Depression may be a secondary feature

 

2. Other mental illness that can present as anxiety

o Psychosis

o Agitated Depression

o Manic-depressive disorder (depressed phase)

 

3. Hyperventilation syndrome

 

 

C. Medical illness presenting with anxiety

Strongly suspect medical cause for anxiety in patients younger than 18

or older than 35 who suddenly develop anxiety which disrupts their

normal activity and who have an otherwise negative psychiatric history

(Hall 1980).

 

1. Anxiety secondary to organic brain syndromes

o Apt to have a labile mood

o Confusion which may be confused with psychosis

o Mental status exam should demonstrate cognitive deficits, especially

memory deficits

-delirium

-dementia

 

2. Other neurological illnesses (25% of medical causes of anxiety

symptoms)

a. Cerebral vascular insufficiency: transient ischemi attacks lasting

from 10-15 seconds up to an hour (brief blocks in the arteries to the

brain causing temporary loss of brain blood supply)

b. Anxiety states and personality change following head injury

c. Infections of the central nervous system

o Meningitis: fever, stiff neck, and delirium

o Neurosyphilis: may present as almost anything

d. Degenerative disorders

o Alzheimer's dementia

o Multiple sclerosis: may be marked early on by vague and changing

medical complaints

o Huntington's chorea: may present early as anxiety or other

functional disorder before the movement disorder is evident-always has

a positive family history

e. Toxic Disorders

o Lead Intoxication: loss of appetite, constipation and colicky

abdominal pain followed by irritability and restlessness

o Mercury intoxication: from contaminated fish

o Manganese intoxication: from industrial exposure

o Organophosphate insecticides (similar to nerve gas): from chemical

or insecticide exposure

f. Partial complex seizures

 

3. Endocrine disorders (25% of medical causes of anxiety symptoms)

a. Hyperthyroidism (increased thyroid hormone) commonly presents as

anxiety, but may present as depression and is one of the most common

endocrine abnormalities. Most common in 20- to 40-year-old women. The

anxiety of hyperthyroidism may present with manic-like euphoria or

agitation, along with weight loss, heat intolerance, rapid pulse, fine

intention tremor and often exophthalmoses (bulging of the eyes caused

by abnormal deposition of fat behind the eyeball).

b. Adrenal hyperfunction or Cushing's syndrome: has a variety of

causes, including tumors of the pituitary or adrenal glands or from

steroids given to treat other illnesses. There is often a change in

fat distribution with dorsal (back) hump, round face and thin arms and

legs, hirsute (abnormal hairiness), acne, decreased menstruation in

women and impotency in men.

c. Hypoglycemia (decreased blood glucose): usually associated with a

history of diabetes and insulin or other hypoglycemic medications.

Rarely from an insulin secreting tumor. Hypoglycemia as a response to

dietary carbohydrate challenge is probably over diagnosed, and

associated symptoms may not always be due to changes in blood glucose.

d. Hypoparathyroidism (decreased parathyroid hormone): almost always

associated with a history of thyroid surgery. It often presents with

overwhelming anxiety, either with or without personality change.

e. Menopausal and premenstrual syndromes.

 

4. Cardiopulmonary disorders: Often presents with shortness of breath,

rapid breathing, complaints of chest pain, chest pain that are worse

with exertion.

a. Angina

b. Pulmonary embolus

c. Arrhythmias (irregularities of heart beat)

d. Chronic obstructive pulmonary disease (COPD)

e. Mitral valve prolapse (generally harmless)

 

5. Pheochromocytoma (epinephrine secreting tumors)

 

 

D. Medications as a cause of anxiety

TAKE A CAREFUL AND DETAILED HISTORY.

o ask about all drugs that a patient is taking, licit and illicit,

prescribed and over the counter

o ask about all illnesses that a patient has had

o asthmatics take combinations of sympathomimetics and xanthines

(aminophylline, theophylline)

o patients with allergies may take ephedrine

o patients with diabetes may be hypoglycemic from their insulin

o thyroid preparations may be prescribed for thyroid illness,

following thyroid surgery (from years ago), or even for weight loss

 

1. Non-psychotropic medications

a. Sympathomimetics (often found in non-prescription cold and allergy

medications): epinephrine, norephinephrine, isoproteronol, levodopa,

dopamine hydrochloride, dobutamine, terbutaline sulfate, ephedrine,

pseudo-ephedrine

b. Xanthene derivatives (asthma medications, coffee, colas,

over-the-counter pain remedies): aminophylline, theophylline, caffeine

c. Anti-inflammatory agents: indomethacin

d. Thyroid preparations

e. Insulin (via hypoglycemic reaction)

f. Corticosteroids

g. Others: nicotine, ginseng root, monosodium glutamate

h. Drug withdrawal: caffeine, nicotine

 

2. Psychotropic medications

a. Antidepressants (including MAO-inhibitors), drugs for treatment of

attention deficit disorders (on rare occasions cause anxiety-type

syndromes)

b. Tranquilizing drugs: benzodiazepines (paradoxical response most

common in children and in elderly), antipsychotics (akathisia may

present as anxiety)

c. Anticholinergic medications can cause a delirium which, in early

stages, may easily be confused with anxiety: scopolamine and sedating

antihistamines (found in over-the-counter sleep preparations)

antiparkinsonian agents, tricyclic antidepressants, antipsychotics

 

3. Drugs--licit and illicit

a. Caffeine-intoxication or withdrawal

b. Nicotine-withdrawal even more than acute intoxication

c. Stimulants-cocaine, amphetamines, etc.

d. Alcohol or alcohol withdrawal

 

E. Drug withdrawal is a common cause of anxiety type syndromes

A large number of drugs can cause withdrawal states with symptoms of

anxiety or even agitation. All sedative hypnotics, tricyclic

anti-depressants and anti-cholinergics can cause withdrawal.

 

 

 

Section IV

Depression

 

A. Differential Diagnosis: Psychiatric Illness

 

1. Primary Affective Disorders

a. Major depression, either single episode or recurrent bipolar disorder

b. Dysthymia

c. Adjustment disorder with depressed mood

d. Bereavement

 

2. Depression Secondary to other Functional Disorders

 

 

B. Medical Illnesses that can present as Depression

 

 

1. Post viral depressive syndromes: especially influenza, infectious

mononucleosis, viral hepatitis, viral pneumonia, and viral encephalitis

 

2. Cancer

a. Cancer of the pancreas commonly presents as depression

b. Lung Cancer, especially oat cell carcinoma

c. Brain tumors, either primary tumors or metastastic, may present

with depression

 

3. Cardiopulmonary disease with hypoxia (decreased oxygen in the

blood): acute hypoxia often leads to symptoms resembling anxiety or

panic. Chronic hypoxia may present with lassitude, apathy, psychomotor

retardation and other symptoms confused with depression.

 

4. Sleep apnea: should be suspected in a patient with sleep

disturbance and daytime somnolence

 

5. Endocrine Disease

a. Hypothyroidism (under active thyroid): causes a general slowing of

all body functions. Patient complains of fatigue, weight gain,

constipation, and, when asked, will describe cold intolerance, dry

skin and hair, and hoarseness or deepening of the voice. Often very

insidious but easily diagnosed and treated ONCE SUSPECTED.

b. Hyperthyroidism or thyrotoxicosis (overactive thyroid): usually

associated with anxiety but may present as depression, especially in

the elderly who may have few classical signs of thyroid disease.

c. Adrenal hypofunction (Addison's Disease): often presents with

weakness and fatigue, along with low blood pressure and hyponatremia

(low serum sodium) and hyperkalemia(increased serum potassium).

d. Adrenal hyperfunction (Cushing's Disease): either from steroid

medication, pituitary, adrenal or other ACTH secreting tumors. Various

affective disturbances, either depression or mania, are common.

Syndrome is marked by truncal obesity, hypertension, puffy face, and

hirsutism.

e. Hyperparathyroidism: usually from small tumors of the parathyroid

glands. Early symptoms develop insidiously and can include lassitude,

anorexia, weakness, constipation and depressed mood. The classic

symptoms of bone pain and renal colic often develop only years later.

f. Post-partum, post menopausal, and premenstrual syndromes.

 

6. Collagen-Vascular Diseases

This is a strange set of different diseases where the person

essentially becomes allergic to parts of their own body. It can affect

all parts of the body and can, at times, cause death.

 

Systemic lupus erythematosus (SLE) is most often seen in women 13-40

years old. It often presents initially with nonspecific symptoms such

as fatigue, malaise, anorexia and weight loss, all of which can lead

to the diagnosis of functional depression.

 

7. Central Nervous System Disease

a. Multiple Sclerosis

b. Brain tumors and other intracranial masses (masses inside of the

skull) such as subdural hematomas (bleeding under the dural sack that

surrounds the brain): masses, especially in the frontal and temporal

areas, can grow for years and cause psychiatric symptoms before any

focal neurological abnormality is apparent.

c. Complex partial seizures: ictal-repetitive behaviors during the

seizure, interictal-personality changes between seizures, increased

lability of emotions, quick to anger, increased preoccupation with

religion, hypergraphia (increased writing).

d. Strokes, especially effecting left side of brain (right side of body)

 

 

C. Medications that can cause Depression

Ex.-Katerndahl found that 43% of patients diagnosed as depressed in a

family practice clinic were taking medications that can cause depression.

 

1. Interferon (for treatment of hepatitis C infections)

2. Antihypertensive medications (drugs used to control high blood

pressure): reserpine and alpha-methyldopa are probably the worst, but

propranolol has been implicated and all antihypertensives are suspect

3. Digitalis preparations, along with a variety of other cardiac

medications

4. Cimetidine: used for gastric ulcer disease

5. Indomethacin and other non-steroidal anti-inflammatory medications

6. Disulfuram (Antabuse): usually described by patients as more a

sense of fatigue than true depression

7. Antipsychotic medications: can cause an akinesia or inhibition of

spontaneity that can both feel and look like a true depression. This

is much less common with the newer " atypical " antipsychotic medications

8. Anxiolytics: all sedative hypnotics from the barbiturates to the

benzodiazepines have been implicated both in causing depression and

making it worse in susceptible individuals

9. Steroids, including prednisone and cortisone

 

 

D. Drugs of abuse that can cause depression

1. Alcohol: very commonly a cause of depression, as well as a reaction

to depression

2. Stimulant withdrawal

 

 

Bibliography

Books:

Cummings, JL. Clinical Neuropsychiatry, Grune & Stratton, 1990.

Hall, R.C.W. (ed). Psychiatric Presentations of Medical Illness, SP

Medical and Scientific Books, NY, 1980.

Jefferson, J.W. and Marshall, J.R. Neuropsychiatric Features of

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Soreff, S.M. and McNeil Handbook of Psychiatric Differential

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Taylor, R.L. Mind or Body: Distinguishing Psychological from Organic

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Summers et al. " The Psychiatric Physical Examination " , J Clin

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