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Psychiatric Disorder Due To General Medical Conditions Psychiatric Disorders Due To General Medical Conditions
David A. Beck, M.D., F.A.C.P.
¾ The differential diagnosis for a mental syndrome in a patient should always include consideration of any general medical disease or disorder a patient may have. ¾ Additionally, any prescription, non-prescription or illegal substances a patient is taking ™ Delirium – Clinical Description and Course ¾ Impaired memory function ¾ Hypoactive or hyperactive ¾ Key Features ƒ Rapid onset of mental confusion hours to days ƒ Rapid fluctuations in the severity of symptoms ™ Delirium – Clinical Description and Course ¾ The morbidity and mortality associated from unrecognized or untreated delirium are ¾ 22-76% chance of dying that hospitalization ¾ Prolongs hospitalization and worsens outcome ¾ Thorough examination of the patient’s mental status ¾ Folstein’s Mini-Mental Status Examination (MMSE) – most widely used and best known ƒ Wemicke’s encephalopathy/Withdrawal ƒ Hypertensive encephalopathy ƒ Hypoglycemia ƒ Hypoperfusion ƒ Hypoxemia ƒ Intracranial bleed/infection ƒ Meningitis/encephalitis ƒ Poisons/medications ¾ Infection ¾ Withdrawal ¾ Acute metaboloic ¾ Trauma ¾ CNS pathology ¾ Hypoxia ¾ Deficiencies ¾ Endocrinopathies ¾ Acute vascular ¾ Toxins/drugs ¾ Heavy metals ¾ The primary management goal is to discover and attend to reversible causes for delirium. ¾ Ideal medication – should not suppress respiratory drive, cause excessive sedation, cause hypotension, or be deliriogenic (e.g., anticholinergic) ƒ Haldol – drug of first choice ¾ Environmental interventions sometimes help ƒ Nurses and family members can reorient the patients. ƒ Clock, calendar, and familiar objects ƒ Adequate light, eyeglasses or hearing aid ƒ Do no place two delirious patients in the same room ¾ Characteristics of a depression secondary to a medical illness compared to a primary major depression ƒ 1. Older age at onset ƒ 2. More likely to respond to electroconvulsive therapy ƒ 3. More likely to be improved at discharge ¾ Characteristics of a depression secondary to a medical illness compared to a primary major depression. ƒ 4. More likely to show “organic” features in the mental status examination ƒ 5. More likely to have much lower incidence of family history of alcoholism and ƒ 6. Less likely to have suicidal thoughts and commit suicide ™ Mood Disorders Due To A General Medical Condition ¾ 1. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: ƒ 1. depressed mood or markedly diminished interest or pleasure in all, or almost all, ™ Mood Disorders Due To A General Medical Condition ¾ 2. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. ¾ 3. The disturbance is not better accounted for by another mental disorder. ™ Mood Disorders Due To A General Medical Condition ¾ 4. The disturbance does not occur exclusively during the course of a delirium. ¾ 5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. ¾ Characteristics of secondary anxiety disorder as opposed to a primary anxiety disorder include: ƒ 1. Onset before age 18 or after age 35 in patients with no personal or familial ƒ 2. Characteristic fluctuations in severity and duration. ƒ 3. Duration of less than 2 years. ¾ Characteristic of secondary anxiety disorder as opposed to a primary anxiety disorder include: ƒ 4. Absence of other psychiatric symptoms such as phobias or conversion disorder. ƒ 5. Absence of a recent major psychosocial stressor. ™ Anxiety Disorder Due To General Medical Condition ¾ 1. Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the ¾ 2. There is evidence from the history, physical examination, or lab findings that the disturbance is the direct physiological consequence of a general medical condition. ¾ 3. The disturbance is not better accounted for by another mental disorder. ™ Anxiety Disorder Due To General Medical Condition ¾ 4. The disturbance does not occur exclusively during the course of delirium. ¾ 5. The disturbance causes clinically significant distress or impairment in social, occupations, or other important areas of functioning. ™ Psychotic Disorder Due To General Medical Condition ¾ 1. Prominent hallucinations or delusions. ¾ 2. Evidence from the history, physical exam, or lab findings that the disturbance is the direct physiological consequence of a general medical condition. ¾ 3. Not better accounted for by another mental disorder. ¾ 4. Does not occur exclusively during the course of a delirium. ™ Personality Change Due To A General Medical Condition ¾ 3 separate frontal lobe syndromes that in practice tend to overlap. ƒ 1. Orbitofrontal syndrome: Disinhibition, impulsive, “pseudopsychopathic” ƒ 2. Frontal convexity syndrome: apathy ƒ 3. Medial-frontal syndrome: akinesia ¾ Dramatic behavioral change, totally uncharacteristic behavior, loss of social tact, rude, tasteless, inappropriate language, antisocial behavior. ¾ Labile emotions, inappropriate sexual behavior, easily distracted, lack ability to monitor ¾ Insight and judgment markedly impaired. ™ Personality Syndrome Associated with Seizure Disorder ƒ Emotional “viscosity” (pedantic and over inclusive thinking) ƒ Hyperreligiosity ƒ Hypergraphia ƒ Intense emotional reactions ƒ Humorlessness ƒ Hypermoralism ƒ Changes in sexual behavior (usually hypersexuality) ƒ Subcortical type of dementia in up to 50% ƒ Peripheral neuropathies may suggest increased CNS involvement ¾ HIV encephalopathy: Subacute encephalitis infects primarily the astrocytes. ƒ Results in progressive subcortical dementia without focal neurological signs. ¾ Presentation: ¾ Any age from puberty on ¾ Attacks take many forms ¾ Typically: acute abdominal pain, pain in limbs or back, nausea, vomiting, headache, ¾ Diagnosis: detection of excess porphobilinogen in urine ¾ Urine tends to be red with standing, acidification or heating. ¾ South African variety – examination of stools – extracts have “brilliant pink” uThe differential diagnosis for a mental syndrome in a patient should always include consideration of any general medical disease or disorder a patient may have prescription or illegal substances a patient is taking should be considered Delirium - Clinical
Description and Course
uImpaired memory functionuHypoactive or hyperactiveuKey features uRapid onset of mental confusion hours to days uRapid fluctuations in the severity of symptoms Delirium - Clinical
Description and Course
u The morbidity and mortality associated from unrecognized or untreated delirium are substantial u Prolongs hospitalization and worsens outcome Screening/Assessment
uThorough examination of the patient’s uFolstein’s Mini-Mental Status Examination (MMSE) - most widely used and best known screening mental status examination Screening/Assessment
u Wernicke’s encephalopathy/Withdrawalu Hypertensive encephalopathyu Hypoglycemiau Hypoperfusionu Hypoxemiau Intracranial bleed/infectionu Meningitis/encephalitisu Poisons/medications Management
discover and attend to reversible causes for delirium.
u Ideal medication - should not suppress respiratory drive, cause excessive sedation, cause hypotension, or be deliriogenic (e.g., anticholinergic) Management
uNurses and family members can reorient the uClock, calendar, and familiar objectsuAdequate light, eyeglasses or hearing aid uDo not place two delirious patients in the same uCharacteristics of a depression secondary to a medical illness compared to a primary major depression. u1. Older age at onset u2. More likely to respond to electroconvulsive u 3. More likely to be improved at discharge uCharacteristics of a depression secondary to a medical illness compared to a primary major depression. u4. More likely to show “organic” features in u5. More likely to have much lower incidence of family history of alcoholism and depression u6. Less likely to have suicidal thoughts and Mood Disorder due to a General Medical Condition u1. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: u(1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities.
u(2) elevated, expansive, or irritable mood Mood Disorder due to a General Medical Condition physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
u3. The disturbance is not better accounted Mood Disorder due to a General Medical Condition exclusively during the course of a delirium.
significant distress or impairment in social, ccupational, or other important areas of functioning.
disorder as opposed to a primary anxiety disorder include: u1. Onset before age 18 or after age 35 in patients with no personal or familial psychiatric histories.
u2. Characteristic fluctuations in severity and disorder as opposed to a primary anxiety disorder include: u4. Absence of other psychiatric symptoms such u5. Absence of a recent major psychosocial Anxiety Disorder due to General Medical Condition u1. Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate in the clinical picture.
physical examination, or lab findings that the disturbance is the direct physiological consequence of a general medical condition.
u3. The disturbance is not better accounted Anxiety Disorder due to General Medical Condition exclusively during the course of a delirium.
significant distress or impairment in social, occupational or other important areas of functioning.
Psychotic Disorder due to a General Medical Condition u1. Prominent hallucinations or delusions.
u2. Evidence from the history, physical exam, or lab finding that the disturbance is the direct physiological consequence of a general medical condition.
u4. Does not occur exclusively during the Personality Change Due to a General Medical Condition u3 separate frontal lobe syndromes that in u1. Orbitofrontal syndrome: Disinhibition, u2. Frontal convexity syndrome: apathy u3. Medial-frontal syndrome: akinesia uncharacteristic behavior, loss of social tact, rude, tasteless, inappropriate language, antisocial behavior. behavior, easily distracted, lack ability to monitor and evaluate own behavior. uInsight and judgment markedly impaired. Personality Syndrome Associated with Seizure Disorder uSubcortical type of dementia in up to 50%uPeripheral neuropathies may suggest increased uHIV encephalopathy: Subacute encephalitis, uResults in progressive subcortical dementia uPresentation: uAny age from puberty onuAttacks take many forms. uTypically: acute abdominal pain, pain in limbs or back, nausea, vomiting, headache, severe constipation. uUrine turns red with standing, acidification, stools - extracts have “brilliant pink”fluorescence under ultraviolet light.

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