Mental Disorders Secondary to General Medical

Conditions

Evaluation of patients who present to hospitals or

physicians with altered behavior and/or mentation can
be time-consuming and difficult and may lead to
symptoms being quickly and prematurely dismissed as
psychiatric in nature.
According to the Diagnostic and Statistical
Manual of Mental Disorders (DSM-V), the
psychiatric presentation of a medical illness is
classified as "the presence of mental
symptoms that are judged to be the direct
physiological consequences of a general
medical condition."
The following features suggest a medical
origin to psychiatric symptoms:

• Late onset of initial presentation

• Known underlying medical condition
• Atypical presentation of a specific psychiatric diagnosis
• Absence of personal and family history of psychiatric
illnesses
• Illicit substance use
• Medication use
• Treatment resistance or unusual response to treatment
• Sudden onset of mental symptoms
• Abnormal vital signs
• Waxing and waning mental status
 Table. Medical Disorders that can Induce Psychiatric Symptoms**(
Adapted from Williams E, Shepherd S. Medical clearance of psychiatric patients. Emerg Med Clin North Am. May 2000; 18:2;
193.)1
edical and Toxic CNS Infectious Metabolic/Endocri Cardiopulmona Other
fects ne ry
[Alcohol  Subdural  Pneumonia  Thyroid  Myocardial  Systemic
hematoma disorder infarction lupus
Cocaine  Urinary tract
erythemat
 Tumor infection  Adrenal  Congestive
Marijuana sus
disorder heart failure
 Aneurysm  Sepsis
Phencyclidine  Anemia
 Renal disorder  Hypoxia
(PCP)  Severe  Malaria
 Vasculitis
hypertension  Hepatic  Hypercarbia
Lysergic acid  Legionnaire
disorder
diethylamide  Meningitis disease
(LSD)  Wilson disease
 Encephalitis  Syphilis
Heroin  Hyperglycemia
 Normal pressure  Typhoid
Amphetamines hydrocephalus  Hypoglycemia
 Diphtheria
Jimson weed  Seizure disorder  Vitamin
 HIV
deficiency
Gamma-  Multiple sclerosis
 Rheumatic
hydroxybutyrate  Electrolyte
fever
(GHB) imbalances
 Herpes
Benzodiazepines  Porphyria

Prescription drugs
Case study

Mr. A was a 52-year-old gentleman with hypertension and

alcohol dependence in complete remission who comes for
an evaluation for first-time depressive symptoms and
worsening memory. He reports that his symptoms began
about 1 month ago prior to a fall in his home with a minor
head injury that did not involve medical intervention.
Symptoms experienced include decreased appetite,
concentration, and insomnia. He also reports depressed
mood and noticeable problems remembering simple things
like phone numbers or location of keys. Physically he has
no complaints except a subtle headache that doesn't seem
to go away. How does one evaluate such a patient and what
are the considerations?
 Neurologic Disorders
Seizure disorder
Epilepsy
• one of the most common chronic neurologic diseases
•30-50% of patients with a seizure disorder will have
psychiatric symptoms sometime during the course of their
illness.
•Psychiatric symptoms can be viewed in the context of their
time relationship with the seizures as pre ictal, ictal, post ictal,
and inter ictal.
•Two major categories of seizures i.e partial and generalized.
Generalized seizures simultaneously
involve both cerebral hemispheres, with
classic symptoms of loss of consciousness,
tonic-clonic movements or limbs, tongue
biting, and incontinence.
 Partial seizures
•focal signs and symptoms.
Simple partial seizures
•No impairment of consciousness
•usually stem from primary motor, sensory, or visual
cortical regions.
Complex partial seizures
•associated with impairment of consciousness
•usually originate from a focus in the temporal lobe.
•psychiatric signs abound, with memory
dysfunction, affective auras, perceptual changes
(eg, hallucinations), and depersonalization.
 Temporal lobe epilepsy,
•Most common psychiatric abnormality is
personality change.
•Hyper-religiosity,
•Hyper-graphia,
•Hypo-sexuality.
•Psychosis ~10%
•Mood disorder symptoms.
•30% of patients suicide attempts
•Fear and anxiety are the most common
ictal affective states.
 Parkinson disease(PD)
•Disorder characterized by movement abnormalities caused by
degeneration of the neurons in the substantia nigra.2
•PD affects approximately 1% of the population older than 50
years
•Up to 2.5% of the population older than 70 years.3
• PD affects all races about equally
•Men are more often affected than women.
Hallmark clinical signs of the motor triad include
(1) tremor, usually a rest tremor involving the hands, (pill
rolling)
(2) rigidity
(3) bradykinesia/akinesia.
•Classic motor signs not obvious early in the
disease
•Patients may initially present with depression.4
•Similarities in the symptoms common to major
depression and PD include impaired
memory/concentration, slowed psychomotor
activity, restricted affect, and fatigue or decreased
energy.
•The prevalence of major depression in patients
with PD is estimated to be 40%, with prevalence
rates of 4-70%.5
•Depression can precede development of motor
symptoms,
•Depression itself may be a neurologic sign of PD.
•PD commonly presents with anxiety symptoms
-general anxiety disorder, social phobia, and panic
disorder, with a prevalence rate of 25%.6
•The anxiety syndromes in PD are apparently
related to an underlying brain disease, with
evidence implicating noradrenergic dysfunction. In
several studies, anxiety syndromes developed
before or after the onset of motor symptoms.7
•Hallucinations and delusions can also occur in as
many as 40% of patients with PD.8
•PD must be considered in the differential
diagnosis of an elderly person presenting with
first-time depression/anxiety symptoms,
especially when the patient appears depressed
but denies experiencing a depressed mood.
•up to 30% of patients with Parkinson disease
harbor suicidal ideations.10
 Brain tumors
•Brain tumors and cerebro vascular disease are important
causes of psychiatric symptoms.
•Patients with these diseases can present with virtually any
symptom.
•A complete clinical history and neurologic examination are
essential in diagnosing either condition.
•Up to 50% of patients with brain tumors have
manifestations of a psychiatric nature.11
•Generally, meningiomas are likely to cause focal symptoms
because they compress a limited region in the cortex,
whereas gliomas can cause more diffuse symptoms.
•Delirium is most often secondary to a large, fast-growing,
or metastatic tumor.
•Frontal lobe tumors, account for 88% of
patients with psychiatric symptoms.
•Common symptoms :-cognitive
impairment, personality, motor and
language dysfunction.12
•Patients also bowel or bladder
incontinence.
•Dominant temporal lesions :-memory and
speech abnormalities and hallucinations
•Non dominant tumors :-auditory agnosia.
•Bilateral lesions :-Korsakoff amnesia.
•Occipital :-visual hallucinations, agnosia, and
Anton syndrome (denial of blindness).
•The visual pathways all cross in the temporal,
parietal, and occipital lobes; therefore, visual
hallucinations can occur with lesions in any of
these locations.
•Limbic and hypothalamic tumors cause
affective symptoms such as rage, mania,
emotional lability, delusions and altered sexual
behavior.13
.
Multiple sclerosis (MS)
•Demyelinating disorder characterized by multiple
episodes of symptoms of a neuropsychiatric
nature related to multifocal lesions in the white
matter of the CNS.
•Prevalence is estimated to be approximately 50
cases per 100,000 people.
•MS is more frequent in colder and temperate
climates than in tropical locales, which may
suggest a viral etiology.
•MS is more common in women than in men and
usually manifests in persons aged 20-40 years.
•This disorder is a highly variable illness, with
differences among patients and changes within a patient
over time.
Symptoms can be categorized as cognitive and
psychiatric.
Recent reviews of neuropsychological performance in
patients with MS indicate that 30-50% have cognitive
deficits.14 Of the cognitive deficits, memory loss is the
most common and affects approximately 40-60% of
patients.15
Abstract reasoning, planning, and
organizational skills are some of the functions
also affected by MS. Dementia may eventually
ensue.
Behavioral symptoms in MS include
personality changes and feelings of euphoria
and/or depression
Suicide attempts are common in patients with MS
who are depressed. Personality changes and
emotional dyscontrol can also occur. Patients
sometimes laugh without cause or weep suddenly.
Such emotional lability can be disturbing for
patients and their families and can make
assessment of psychiatric symptoms more difficult
in patients with MS.
Infectious Diseases
Neurosyphilis
•Neurosyphilis, as a result of the invention of
penicillin has been rare.
•AIDS has reintroduced the infection in
certain urban settings.
•The infection is caused by the organism
Treponema pallidum, which invades the
parenchyma of the brain.
•Neurosyphilis is usually clinically apparent
as a part of tertiary syphilis
•Neurosyphilis occurs only after a latent period of
10-20 years after the primary infection.
•Infection with HIV negates this general rule.
•Neurosyphilis primarily affects the frontal lobes,
which can result in personality changes,
irritability, decreased self-care, mania, and
progressive dementia.
•Delusions of grandeur occur in 10-20% of
patients.
•Early evidence of neurosyphilis includes
tremors, dysarthria, and Argyll Robertson pupils.
•A progressive dementia incongruent with
advanced age.
•Meningitis
•Acute bacterial, fungal, and viral meningitis can be
associated with a psychiatric presentation with or
without abnormal vital signs.
Patients usually present with acute confusion,
headaches, memory impairments, and fever with
possible neck stiffness.
Herpes simplex encephalitis
Herpes simplex virus (HSV) is one of the most
common and devastating causes of sporadic and
severe focal encephalitis. Infection with HSV can
occur in any person—age, sex, and demographic
region are irrelevant.
•HSV infection is characteristically localized to the
temporal and frontal lobes.
•Patients with HSV encephalitis commonly present
with bizarre, inconsistent behavior and a waxing and
waning mental status.
•Symptoms often include seizures, anosmia,
olfactory and gustatory hallucinations, personality
changes, and psychosis.
•Consider if a prodrome of 1-7 days of upper
respiratory tract infection with headache, fever, and
subsequent bizarre psychiatric symptoms.
•Lumbar puncture, serology studies, neuroimaging,
and EEG are helpful in confirming the diagnosis.
HIV encephalopathy
•The number of infected people continues to
increase, especially among poor and socially
disadvantaged persons although the rate of
increase has declined over the years.
•Patients with AIDS have psychiatric and
neurologic symptoms from lesions (eg, primary
CNS lymphoma) or opportunistic infections.
•HIV itself can cause a subacute encephalitis and
dementing complex.
•Clinically, HIV encephalopathy manifests as a
progressive subcortical dementia with nonspecific
CSF abnormalities and cerebral atrophy with
ventricular dilation.