psychiatry in medicine

PSYCHIATRIC SYMPTOMS WITH MEDICAL DISORDERS

A Brief overview

BY

Dr. AdilPG/MO, MW-1

Ongoing discussion will emphasize on a) Mental symptoms, which occur due to direct

physiological effect of a general medical condition.

b) How to evaluate an individual with mental symptoms of any sort?

c) Differential diagnosis of mental disorders/symptoms with General medical conditions.

INTRODUCTION

In evaluating individuals with mental symptoms of any sort

Approach for ‘Mental Disorders’ Due to a General Medical Condition

First questions

to ask?

Symptoms caused by a

general medical

condition

Symptoms occurring as

a part of primary mental disorder

Step 1 To review the history & physical examination

Step 2 Laboratory tests/imaging studies To see if there is evidence for presence of a general medical condition that could plausibly

cause the mental symptoms in question.

Step 3 Involves determining whether these symptoms could be better accounted for by a primary mental disorder.

Step 4 If proves to be a medical condition as a possible cause, whether emergent symptomatic Rx needed?



(ALGORITHM)

Common Psychiatric Disorders Due to

General Medical Conditions

A Brief Overview

P

sychotic Disorder

DEFINITION A psychotic disorder due to a general medical condition is

characterized clinically by hallucinations or delusions occurring in a clear sensorium, without any associated decrement in intellectual abilities.

MAJOR DIFFERENTIAL DIAGNOSIS

a) Deliriumb) Dementia

Both these conditions are clearly distinguished from psychotic disorder due to a general medical condition by the presence of confusion or significant intellectual deficits.

Psychotic Disorder Due to a General Medical Condition

Common etiologies : Secondary to Precipitantsa. e.g., Medications (Neuroleptics, dopaminergic drugs, sympathomimmetics,

disulfiram e.t.c.) b. Post encephalitic psychosisc. Posttraumatic brain injury Secondary to Diseases with Distinctive Features Epilepsy(ictal, inter ictal, post ictal) Huntington’s disease Sydenham’s chorea Chorea gravidarum Hashimoto’s encephalopathy Wilson’s disease AIDS SLE Hyperthyroidism Hypothyroidism Cushing’s syndrome Secondary to Miscellaneous Causes Cerebral tumors Cerebral infarction Multiple sclerosis Neurosyphilis Vitamin B12 deficiency


Ziegler (1930) reported a case of “myxedema madness”in a 48-year-old woman who, at the age of 45 years, hadundergone radiation treatment for Grave’s disease. Shewas treated with thyroid hormone, but eventually becamenoncompliant. Soon thereafter “she began to feel that herhusband was paying attention to another woman and thathe was trying to do away with her by means of gas or theelectric chair. During a game at a party in her own homeduring the holidays in 1928, she refused to sit in a chairdesignated for her, thinking it might be a plot to kill her.She also felt that her husband was trying to poison her andrefused to take desiccated thyroid hormone at home on accountof such a belief. On several occasions subsequently,when desiccated thyroid hormone was administered in sufficient quantity, at the repeated and urgent request of herphysician, the delusions entirely disappeared and she feltso much better that she concluded that it would be foolishto be taking medicine and discontinued taking it. On suchoccasions, the psychosis would slowly return in the sameform as before.”

CASE VIGNETTE 1

Mood Disorder

Mood disorders due to general medical conditions may occur either with depressive features or manic features.

With Depressive Features DefinitionA mood disorder secondary to a general medical condition with depressive features is

characterized by a prominent and persistent depressed mood or loss of interest, and by the presence of evidence, from the history, physical examination, or laboratory tests, of a general medical condition capable of causing such a disturbance.

With Manic Features DefinitionMood disorder due to a general medical condition with manic features is characterized

by a prominent and persistently elevated, expansive, or irritable mood, which, on the basis of the history, physical or laboratory examinations, can be attributed to an underlying general medical condition.

Mood disorder

Secondary to Precipitants

Medications Propranolol, Interferon, ACTH, Prednisone, Reserpine, Alpha-methyldopa, Nifedipine,

Ranitidine, Bismuth subsalicylate, Anticholinergic withdrawal (“cholinergic rebound”)

Secondary to Diseases with Distinctive Features Hypothyroidism (hair loss, dry skin, voice change) Hyperthyroidism (weight loss with increased appetite, Tachycardia) Cushing’s syndrome (moon facies, hirsutism, acne, “buffalohump”) Addison,s disease (nausea, vomiting, postural dizziness) Multiple sclerosis (various focal findings) Epilepsy

Occurring as Part of Certain Neurodegenerative or Dementing Disorders

Alzheimer’s disease, Multi-infarct dementia, Diffuse Lewy body disease, Parkinson’s disease

Miscellaneous Cerebral tumors Hydrocephalus Pancreatic cancer Hyperparathyroidism Systemic lupus erythematosus Poststroke depression

Depression Due to a General Medical Condition

Kraepelin (1913) reported the case of a 40-year-old man who “had been irritable for 2 years, … and he slept badly …. At home, he expressed ideas of sin—that he had made false entries in his books and would be locked up, and was bringing ruin on his friends as well as himself.” The patient was admitted, and, during a hospital interview,

Kraepelin described him as follows: You will see at once that the man, aged 40 years, whom I am bringing before you today is suffering from depression. This haggard-looking patient, very pale and ill-nourished, sits in a languid attitude, staring straight before him with a gloomy, listless air, and pays us no particular attention. He hardly even turns his head when spoken to, but he answers in a low voice and very laconically…. He says … there is nothing left of himself but “this miserable skeleton.”

Kraepelin felt the diagnosis would have been difficult “if the physical examination of the patient had not brought complete enlightenment. We see that not only is the right pupil more dilated than the left, but both are completely inactive to light, although the reaction to distance is maintained.” Kraepelin’s diagnosis was neurosyphilis, a diagnosis made on the basis of finding Argyll Robertson pupils on the routine physical examination. Further history confirmed the diagnosis, revealing, as it did, the occurrence of secondary syphilitic rash some 12 years prior to admission.

CASE VIGNETTE 2

Secondary to Precipitants Medications Corticosteroids or adrenocorticoptrophic hormone, Levodopa, Zidovudine, Oral contraceptives Isoniazid, Buspirone Closed head injury Hemodialysis Encephalitis

Secondary to Diseases with Distinctive Features Hyperthyroidism (proptosis, tremor, tachycardia) Cushing’s syndrome (moon facies, hirsutism, acne, “buffalo hump”, ) Multiple sclerosis (various focal findings) Cerebral infarction (sudden onset with associated localizing signs) Sydenham’s chorea Chorea gravidarum Hepatic encephalopathy (asterixis, delirium) Uremia (asterixis, delirium) Epilepsy

Occurring as part of Certain Neurodegenerative or Dementing Diseases Alzheimer’s disease , Neurosyphilis, Huntington’s disease

Miscellaneous or Rare Causes Cerebral tumors Systemic lupus erythematosus Vitamin B12 deficiency Metachromatic leukodystrophy

Mania Due to a General Medical Condition

Liebson (2000) reported the case of a 53-year-old man with a right thalamic

hemorrhage, who presented with headache and left-sided hemiparesis and

hemianesthesia. Four days later he displayed significant change in his mood. One

week after the stroke his “mood was remarkably cheerful and optimistic … he

was noted to praise extravagantly the hospital food, and the nurses found him

“talkative.” When he arrived on our ward 11 days after the stroke he was

flirtatious with female staff and boasted of having fathered 64 children. His

girlfriend was surprised when he kissed her in front of the staff because he had

never publicly displayed affection before. He reported excellent energy and

expansively invited all the staff to his home for Thanksgiving . . . The mania

resolved gradually over a 10-week period after (the) stroke.”

CASE VIGNETTE 3

Anxiety Disorder

Pathologic anxiety secondary to a general medical condition may occur in the form of well-circumscribed and transient panic

attacks or in a generalized, more chronic form. Panic attacks have an acute or paroxysmal onset, and are characterized by

typically intense anxiety or fear, which is accompanied by various “autonomic” signs and symptoms, such as tremor, diaphoresis, and palpitations.

Generalized anxiety tends to be of subacute or gradual onset, patients, rather than

complaining of feeling anxious per se, may complain of being worried, tense, or ill at ease. Autonomic symptoms tend not to be as severe or prominent as those seen in panic attacks: shakiness, palpitations (or tachycardia), and diaphoresis are perhaps most common.

Anxiety Disorder Due to a General MedicalCondition with Panic Attacks or with

Generalized Anxiety

Rush et al. (1977) describe a patient with simple partial seizures that

manifested as panic attacks. The patient, at the age of 44 years, began to

have “attacks of palpitation accompanied by dizziness, faintness and

anxiety . . . occurred during wakefulness and sleep, and, if asleep, the

patient was awakened by them.”At the age of 49 years, he was evaluated

and an electroencephalogram, obtained in between attacks, “revealed mild

slowing with intermittent, low-voltage, sharp waves over the right

temporal region. Because of the paroxysmal nature of the attacks and the

electroencephalographic abnormality, the patient was reevaluated utilizing

telemetry.”During telemetry, the patient had an attack: “he was pale and

mildly diaphoretic and was tightly gripping his chair . . . no abnormal

movements were detected . . . (he) remained fully alert and was not

incontinent.” Concurrent with the attack, ictal electroencephalographic

activity was observed on the right. At craniotomy a glioma was removed

from the right frontal lobe and the attacks subsequently did not recur.

CASE VIGNETTE 4

Laplane et al. (1984) described the case of a “41-yearold healthy man (who) was stung on the left arm by a wasp. He immediately sustained a convulsive coma for 24 hours, then adopted intensive choreic movements … and impairment of gait. These extrapyramidal symptoms diminished over several months . . . .“Two years after the encephalopathy, he began to show stereotyped activities. The most frequent consisted in mental counting, for example, up to twelve or a multiple of twelve, but sometimes it was a more complex calculation.

Such mental activities sometimes were accompanied by gestures, such as a finger pacing of the counts. To switch on and off a light for 1 hour or more was another of his most common compulsions. When asked about this behavior he answered that he had to count . . . that he could not stop it . . . that it was stronger than him . . . .“Neurological examination showed abnormal movements. . . .He had a permanent facial rictus with some facial or mandibular movements somewhat resembling tics. With his finger movements it was difficult to distinguish between involuntary or ‘voluntary’ activity associated with mental counting. Walking was a mixture of parkinsonism and choreic disturbances. “Standard and sleep EEG were normal. CT scans were performed in the orbito-meatal plane . . ..

The main lesions consisted of low density areas bilaterally in the internal part of the lenticular nucleus.”

CASE VIGNETTE 5

C

atatonic Disorder

Catatonia exists in two subtypes, namely, stuporous catatonia (also known as the akinetic or “retarded” subtype) and excited catatonia.

Stuporous catatonia characterized by varying combinations of mutism,

immobility, and waxy flexibility; associated features include posturing, negativism, automatic obedience, and “echo” phenomena.

Excited catatonia manifests with varying degrees of bizarre, frenzied,

and purposeless behavior.

Catatonic Disorder Due to a General Medical Condition

Stuporous CatatoniaAssociated with epilepsy Ictal catatonia Postictal catatoniaMedication Neuroleptics Benzodiazepine withdrawalViral encephalitis Herpes simplex encephalitis Encephalitis lethargicaFocal lesions, especially of the frontal lobesMiscellaneous conditions Hepatic encephalopathy Systemic lupus erythematosus Lyme disease, in stage III Subacute sclerosing panencephalitis, in stage I

Excited Catatonia Viral encephalitis

Causes of Catatonia Due to a GeneralMedical Condition

Lim et al. (1986) described a case of ictal catatonia occurring in the midst of a complex partial seizure. The patient was a 67-year-old man who was brought to the hospital after being confused for two weeks.

When examined, he “sat quietly in a chair, with no spontaneous speech or movement. He responded to questions with few words and manifested frequent echolalia and persistance ….

On the third hospital day the patient suddenly became catatonic. His mouth and eyes were opened widely with dilated reactive pupils. He held his arms and legs rigidly in the air and would maintain his extremities in any bizarre posture indefinitely.” An EEG demonstrated spiking in the left fronto-central area; the patient was given intravenous phenytoin and recovered completely.

CASE VIGNETTE 6

P

ersonality Change

INTRODUCTION The personality of an adult represents a coalescence of various

personality traits present in childhood and adolescence, and is generally quite enduring and resistant to change.

Appearance of a significant change in an adult’s personality is an ominous clinical sign and indicates the presence of intracranial pathology.

Individuals themselves may not be aware of the change. However, those who have known the individual over time, often note that the individual is “not himself” anymore.

In most cases, the change is nonspecific in nature.

Personality Change Due to a GeneralMedical Condition

Secondary to Precipitants Closed head injury Head trauma with subdural hematoma Postviral encephalitis Gunshot wounds Cerebral infarction

Secondary to Cerebral Tumors Frontal lobe* Corpus callosum* (in its anterior part) Temporal lobe

Occurring as Part of Certain Neurodegenerative or Dementing Disorders Pick’s disease* Fronto-temporal dementia* Alzheimer’s disease* Amyotrophic lateral sclerosis* Progressive supranuclear palsy* Huntington’s disease Wilson’s disease Lacunar syndrome* Normal pressure hydrocephalus AIDS Neurosyphilis

Miscellaneous Causes Granulomatous angiitis Vitamin B12 deficiency Limbic encephalitis Mercury intoxication

*Particularly likely to cause a frontal lobe syndrome.

Causes of Personality Change of theNonspecific or Frontal Lobe Type

Moersch (1925) described a 54-year-old man in whom, three months earlier, “a gradual mental change had been observed. The patient lost his ambition and interest in work . . . he became careless . . . and seemed little concerned about his shortcomings. For two weeks before his examination he had been content to sit aimlessly at home, or to play with his children. He voided at any time and even defecated in his clothes . . . .

During general examination, the patient was indifferent and aimless, would sit and look at a newspaper, which might be upside down. He was oriented in all spheres, and his attention might be held for a few moments when aroused. He would follow his son about in a fairly good-natured manner, but always object to being examined, saying that he was not sick. He showed considerable perseveration, repeating movements at times for long periods. For example, one evening he sat before a wash bowl for over a half-hour, turning the faucets on and off.”

This patient’s frontal lobe syndrome, manifest with apathy, disinhibition, and perseveration, constituted the presentation of a tumor of the anterior portion of the corpus callosum, to which the patient eventually succumbed.

CASE VIGNETTE 7

Mental Disorder Not

Otherwise Specified Due

to a General Medical

Condition

This is a residual category in DSM-IV-TR for those clinical situations in which the mental disorder occurring secondary to a general medical condition does not fall into one of the specific categories described earlier.

Of these various disorders, two are worthy of description, namely, pseudobulbar palsy and the Klüver–Bucy syndrome.

Both disorders are commonly seen in dementia clinics, and their occurrence often prompts a request for psychiatric consultation.

INTRODUCTION

Pseudobulbar Palsy When fully developed, this syndrome is

characterized by emotional incontinence (also known as “pathological laughing and crying”), dysarthria, dysphagia, a brisk jaw-jerk and gag reflex, and difficulty in protruding the tongue.

Klüver–Bucy Syndrome The full syndrome is characterized by

hypermetamorphosis, agnosia (albeit of a peculiar kind), hyperorality, emotional placidity, and hypersexuality.

Pseudobulbar Palsy & Klüver–Bucy Syndrome

SA Kinnier Wilson (1924) provided a classic example of emotional

incontinence following bilateral cerebral infarctions: “A woman of age 57

years had suffered from left hemiplegia for one year, when a second stroke

occurred involving the right side. Ever since the latter, the daughter

remarked that her mother had become, as she put it, ‘hysterical,” laughing

and crying at nothing.

“On examination the patient was seen to have a distinctly vacant, apathetic

facial expression at rest. She was able to move the facial muscles voluntarily

on both sides, though there was slight weakness of the left corner of the

mouth.

On the slightest stimulus, even when the observer simply came to her

bedside, she at once assumed a excessively mournful expression , her mouth

opened widely, and a long, almost noiseless bout of weeping ensued, lasting

for many seconds, even minutes, at a time . . . . During the spasmodic

crying, both sides of the face moved equally, and the eyes suffused with

tears. Laughing attacks were extremely rare in comparison.”

CASE VIGNETTE 8

Mendez and Foti (1997) describe a 40-year-old with epilepsy secondary to

old infarction of the left temporoparietal area. Grand mal status epilepticus

occurred, lasting several hours, during which the patient sustained anoxic

damage to both temporal lobes. Upon recovery from the status, the patient

“had a voracious appetite and indiscriminate eating habits, which included

paper towels, plants, styrofoam cups, and even feces. At one point, he drank

urine from a catheter bag. He tended to wander about the ward touching

objects or people and made inappropriate comments of a sexual nature . . .

On the day of his death . . . he had wandered about the ward picking up

whatever he could find and putting it into his mouth . . . (and) had a

respiratory arrest after stuffing his mouth with surgical gauze . . . .

Neuropathological examination disclosed an old infarction in the left

posterior cerebral artery territory, virtual absence of the left anterior

temporal lobe, and atrophy of the right parahippocampal gyrus,

hippocampus and amygdala.”

CASE VIGNETTE 9

THANX 4 CALM

LITENING

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