Psychiatry In Medicine
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Psychiatry In Medicine



detail discussion of psychiatric and medical issues causing diagnostic confusion for experts of both of these fields

detail discussion of psychiatric and medical issues causing diagnostic confusion for experts of both of these fields



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Psychiatry In Medicine Presentation Transcript

  • 1. BY
  • 2. Ongoing discussion will emphasize on
    Mental symptoms, which occur due to direct physiological effect of a general medical condition.
    How to evaluate an individual with mental symptoms of any sort?
    Differential diagnosis of mental disorders/symptoms with General medical conditions.
  • 3. In evaluating individuals with mental symptoms of any sort
    Approach for ‘Mental Disorders’ Due to a General Medical Condition
  • 4. 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?
    Approach for ‘Mental Disorders’ Due to a General Medical Condition
  • 5. Approach for ‘Mental Disorders’
    Due to a General Medical Condition
  • 6. Approach for ‘Mental Disorders’ Due to a General Medical Condition
  • 7. Common Psychiatric Disorders Due to General Medical Conditions
    A Brief Overview
  • 8. Psychotic Disorder
  • 9.
    A psychotic disorder due to a general medical conditionis characterized clinically by hallucinations or delusions occurring in a clear sensorium, without any associated decrement in intellectual abilities.
    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
  • 10. Psychotic Disorder Due to a General Medical Condition
  • 11. Common etiologies :
    • Secondary to Precipitants
    e.g., Medications (Neuroleptics, dopaminergic drugs, sympathomimmetics, disulfiram e.t.c.)
    Post encephalitic psychosis
    Posttraumatic brain injury
    • Secondary to Diseases with Distinctive Features
    Epilepsy(ictal, interictal, post ictal) Huntington’s disease
    Sydenham’s chorea Chorea gravidarum
    Hashimoto’s encephalopathy Wilson’s disease
    Hyperthyroidism Hypothyroidism
    Cushing’s syndrome
    • Secondary to Miscellaneous Causes
    Cerebral tumors Cerebral infarction
    Multiple sclerosis Neurosyphilis
    Vitamin B12 deficiency
    Psychotic Disorder Due to a General Medical Condition
  • 12.
    Ziegler (1930) reported a case of “myxedema madness”
    in a 48-year-old woman who, at the age of 45 years, had
    undergone radiation treatment for Grave’s disease. She
    was treated with thyroid hormone, but eventually became
    noncompliant. Soon thereafter “she began to feel that her
    husband was paying attention to another woman and that
    he was trying to do away with her by means of gas or the
    electric chair. During a game at a party in her own home
    during the holidays in 1928, she refused to sit in a chair
    designated for her, thinking it might be a plot to kill her.
    She also felt that her husband was trying to poison her and
    refused to take desiccated thyroid hormoneat home on account
    of such a belief. On several occasions subsequently,
    when desiccated thyroid hormone was administered in suffi
    cient quantity, at the repeated and urgent request of her
    physician, the delusions entirely disappeared and she felt
    so much better that she concluded that it would be foolish
    to be taking medicine and discontinued taking it. On such
    occasions, the psychosis would slowly return in the same
    form as before.”
  • 14. Mood Disorder
  • 15. Mood disorders due to general medical conditions may occur either with depressive features or manic features.
    With Depressive Features
    A 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
    Mood 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
  • 16.
  • 17. Depression Due to a General Medical Condition
    Secondary to Precipitants
    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)
    Occurring as Part of Certain Neurodegenerative or Dementing Disorders
    Alzheimer’s disease, Multi-infarct dementia, Diffuse Lewy body disease, Parkinson’s disease
    Cerebral tumors Hydrocephalus
    Pancreatic cancer Hyperparathyroidism
    Systemic lupus erythematosus Poststroke depression
    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.
  • 19. Mania Due to a General Medical Condition
    Secondary to Precipitants
    Corticosteroids or adrenocorticoptrophic hormone, Levodopa, Zidovudine, Oral contraceptives
    Isoniazid, Buspirone
    • Closed head injury
    • 20. Hemodialysis
    • 21. 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)
    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 Metachromaticleukodystrophy
    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.”
  • 23. Anxiety Disorder
  • 24. Anxiety Disorder Due to a General MedicalCondition with Panic Attacks or withGeneralized Anxiety
    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.
  • 25.
  • 26.
    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.
  • 28.
  • 29.
    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.”
  • 31. Catatonic Disorder
  • 32. 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
  • 33.
  • 34. Causes of Catatonia Due to a GeneralMedical Condition
    Stuporous Catatonia
    Associated with epilepsy
    Ictal catatonia
    Postictal catatonia
    Benzodiazepine withdrawal
    Viral encephalitis
    Herpes simplex encephalitis
    Encephalitis lethargica
    Focal lesions, especially of the frontal lobes
    Miscellaneous conditions
    Hepatic encephalopathy Systemic lupus erythematosus
    Lyme disease, in stage III Subacutesclerosingpanencephalitis, in stage I
    Excited Catatonia
    Viral encephalitis
  • 35. 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.
  • 36. Personality Change
    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
  • 38.
  • 39. Causes of Personality Change of theNonspecific or Frontal Lobe Type
    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
    Miscellaneous Causes
    Granulomatousangiitis Vitamin B12 deficiency
    Limbic encephalitis Mercury intoxication
    *Particularly likely to cause a frontal lobe syndrome.
  • 40. 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.
  • 41. Mental Disorder Not Otherwise Specified Due
    to a General Medical Condition
  • 42. 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.
  • 43. Pseudobulbar Palsy & Klüver–Bucy Syndrome
    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.
  • 44.
    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.”
  • 46.
    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 parahippocampalgyrus, hippocampus and amygdala.”