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A Research Guided Approach to the Prevention and Management ... A Research Guided Approach to the Prevention and Management ... Document Transcript

  • Faculty Disclosure Neuropsychiatric Masquerades: Medical and Neurological Disorders That • Jose R. Maldonado, MD, is a member of the Present With Psychiatric Symptoms Speakers Bureau for Forest Pharmaceuticals, Inc., Eli Lilly and Company, and Pfizer Inc. He currently receives grant and/or research José R. Maldonado, MD support from Hospira and Abbott _________________________________________ _________________________________________ _________________________________________ _________________________________________ Clues Suggestive of Learning Objectives “Organic” Mental Disorders • By participating in this session, you will be • New onset psychiatric symptoms presenting able to: after age 40 Recognize the most common infectious disorders presenting with • Symptoms occurring … psychiatric symptoms During the course of a major medical illness Explain the incidence, epidemiology and impairing organ function (e.g., neurological, clinical features of the most common endocrine, renal, hepatic, cardiac, pulmonary) or neuropsychiatric disorders masquerading While taking medications having as psychiatric illness psychoactive effects Recommend the research-based, effective treatment options for these conditions _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 1
  • Clues Suggestive of Clues Suggestive of “Organic” Mental Disorders “Organic” Mental Disorders • History of taking multiple medication (both • Presence of altered states of mind, LOC, mental prescribed and OTC) status changes, cognitive impairment; episodic, recurrent, cyclic course • History of substance abuse • Cortical dysfunction (e.g., dysphagia, apraxia, • Family history of degenerative or inheritable agnosia, visuospatial) neurological disorders (e.g., Alzheimer’s disease, • Diffuse subcortical dysfunction (e.g., slowed speech/ Huntington’s disease) mentation/ movement, ataxia, incoordination, tremor, chorea, asterexis, dysarthria • Family history of inheritable metabolic disorders • Presence of visual, tactile or olfactory (e.g., DM, Pernicious Anemia, Porphyria) hallucinations _________________________________________ _________________________________________ _________________________________________ _________________________________________ Clues Suggestive of Lab Tests For Detecting “Organic” Mental Disorders Physical Illness In Ψ Patients • Physical findings: • CBC • Toxicology screening Abnormal vital signs • Chemistry panel • Urine for uroporphyrias Evidence of organ dysfunction, focal neurological and porphobilinogen deficits • TFT’s Gait abnormalities • Screening test for • Serum ceruloplasmin Changes in strength: weakness, paralysis syphilis (VDRL or RPR) • Chest X-ray Gait abnormalities: ataxia • HIV serology for high • ECG Speech: slurring, aphasia, word finding difficulties, risk patients perseveration • EEG Eye exam: • B12 and folate • CT/MRI • Pupilary changes—asymmetries • Urinalysis (with protein • Nystagmus (often a sign of drug intoxication) and glucose levels) _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 2
  • Per History Consider Medical Disorders That can Additional Tests Induce Psychiatric Symptoms • Lumbar puncture Metabolic Connective • Skulls films Endocrine Endocrine Infectious Tissue CNS • Blood alcohol level or • serum and urine Thyroid disorder Hepatic disorder HIV SLE Dementia breathalyzer copper • Hyper- • Wilson’s Neurocystercercosis Fibromyalgia Delirium • Hypo- • Encephalopathy PANDAS Multiple Sclerosis • Heavy metal screen • Monospot Adrenal disorder • Hyper Porphyria Vitamin def Neuroborrilosis Neurosyphilis Seizure DO (e.g., TLE) • Skin test for TB or • Hypo- • B-12 Herpes NPH • Medication levels brucellosis • Pheo • B-1 Subdural Parathyroid DO Electrolyte Pneumonia hematoma • Antinuclear antibodies • Pregnancy test Pancreatic DO imbalances UTI Tumor • Hyperglycemia Sepsis Meningitis • Hypoglycemia Malaria Encephalitis • Stool test for Legionnaire disease occult blood Typhoid Diphtheria • ABG’s Rheumatic fever _________________________________________ _________________________________________ _________________________________________ _________________________________________ Medical Disorders That can Medical Disorders That can Induce Psychiatric Symptoms Induce Psychiatric Symptoms Rx and Examples Toxins Prescription Chemotherapeutic Rx’s Rx and Toxin Examples drugs • Immunosuppressants (e.g., cyclosporin) Substances of Alcohol • Antiviral Rx’s (e.g., interferon) Abuse • Cocaine • Antiparkinsonian Rx’s • Marijuana • Cardiovascular Rx’s • PCP • Thyroid Rx’s • Anticholinergic Rx’s • LSD • Corticosteroids • Heroin • Psychostimulants • Amphetamines • Sympathomimetics • Jimson weed • Sedative & CNS-depressants • GHB (e.g., barbiturates, benzodiazepines) • Opioids _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 3
  • Endocrine Disorders Presenting With Psychiatric Symptoms • Hypothyroidism (myxedema madness) Hypothyroidism associated with rapid onset may clinically present with delirium and psychosis In the elderly may present like dementia-like Endocrine Disorders symptoms Subclincal hypothyroidism can be virtually indistinguishable from depression Characterized by depression, anxiety, cognitive impairment Other symptoms include fatigue, weight gain, memory loss The above make hypothyroid look like a mood disorder _________________________________________ _________________________________________ _________________________________________ _________________________________________ Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Hyperthyroidism (Graves disease) • Hypoadrenalism Can present with either depression or anxiety 1ry = Addison’s disease May be misdiagnosed as either mood disorder or anxiety disorder • Causes: TB of adrenal gland; adrenoleukodystrophy; amyloidosis; drugs May even look like CNS-intoxication (e.g., ketoconazole, metyrapone); Associated symptoms: hemochromatosis; HIV; sarcoidosis; • Weight loss despite increased PO consumption metastases; bilateral adrenalectomy) • Heat intolerance • Diaphoresis • Warm skin • Proptosis 2 ry = ACTH Deficiency Hypoadrenalism In elderly can present as apathetic hyperthyroidism—a form (usually caused by disease of the pituitary gland, that presents with psychomotor retardation and cognitive which leads to adrenal failure as 2ry effect) deficits, often misdiagnosed as “apathetic depression” • Causes: exogenous synthetic steroid use; Hyperthyroidism can also lead to mania in bipolar patients diseases of pituitary gland _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 4
  • Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Hypoadrenalism (Addison’s Disease) • Hypoadrenalism (Addison’s Disease) Can be easily confused for depression Diagnosis: Presenting symptoms: • Hyperpigmentation • Fatigue • Hypotension (SBP usually <110mg) • Weight loss • Postural hypotension • Anorexia (may be confused with anorexia nervosa) • Lab tests: ▪ cortisol (usually <200nmol) ▪ ACTH (usually > 80ng/l) • Hyperpigmentation of skin (especially oral mucosa) ▪ NA+ ▪ K+ be a tip-off ▪ CBC: eosinophilia • Hypotension Treatment: • Vomiting • Oral hydrocortisone (blood level goal: 1000nmol/l in • Nausea AM; 100 – 300 nmo;/l in PM) _________________________________________ _________________________________________ _________________________________________ _________________________________________ Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Hyperadrenalism (Cushing’s Disease) • Hyperadrenalism (Cushing’s Disease) Presents with Sx’s characteristic of depression in Causes: about ½ of patients • Characterized by fatigue, weight gain, mood lability, • Pituitary adenomas decreased concentration, depressed mood, • Ectopic ACTH Syndrome (e.g., lung CA) decreased libido, and sleep disturbances • Adrenal tumors Presenting physical symptoms: • Truncal obesity Diagnosis: • HTN • 24-hr Urinary Free Cortisol Level (>100 mcg/24) • Acne • Dexamethasone Suppression Test • Hirsutism • CRH Stimulation Test • Hyperglycemia Both test above help differentiate excess ACTH • Abdominal striae production due to pituitary adenomas vs ectopic • Proximal muscle weakness ACTH-producing tumor _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 5
  • Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Pheochromocytoma • Pheochromocytoma Catecholamine releasing tumors of the adrenal Diagnosis: medulla • Plasma catecholamines & metanephrines Presents with Sx’s characteristic of anxiety • 24-hr urinary catecholamines disorders: & metanephrines • Often paroxysmal attacks of anxiety that resemble • CT or T-2 weighted MRI of “panic attacks” head, neck & chest Presenting physical symptoms: • Clonidine-suppression test • ↑HR • Adrenal gland pressure—will cause a burst of catecholamines which will quickly reproduce the symptoms • Diaphoresis Treatment: • When a good history is taken the anxiety attacks • Surgical resection of tumor caused by pheochromocytomas will not meet the diagnostic criteria for panic attacks Pre-tx with phenoxybenzamine (an irreversible B-blocker) or labetolol (combined alpha/beta blocker) to prevent Absence of phobic avoidance intraoperative HTN _________________________________________ _________________________________________ _________________________________________ _________________________________________ Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Hyperparathyroidism • Hyperparathyroidism “Bones, stones, groans and psychic moans” Diagnosis: Usually caused by a parathyroid adenoma Characterized by: • Parathyroid hormone blood level • Hypercalcemia that can lead to confusion, psychosis • Calcium blood level and delirium at very high levels • Bone density measurement test • At lower levels more usual symptoms are depressed mood, decreased memory, loss of appetite, decreased • Abdominal imaging may reveal the presence of concentration, fatigue kidney stones • Tell-tale symptoms: GI symptoms (anorexia) Treatment: Muscle weakness (and restless leg syndrome) • Surgical removal Renal stones Bone/joint changes or pain _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 6
  • Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Hypoparathyroidism • Hypoparathyroidism Psychiatric presentations may include: Diagnosis: • Depression • Low serum calcium level • Anxiety • High serum phosphorus level • Irritability with severe cognitive impairment Onset of psychiatric symptoms may precede physical • Low serum parathyroid hormone level manifestations • Low serum magnesium level (possible) Physical symptoms may include: • Abnormal heart rhythms on ECG (possible) • Tetany and seizures from hypocalcemia Treatment: • Neuropsychiatric symptoms (weakness, fatigue and • Oral calcium carbonate slowed cognition) caused by hypomagnesemia mediated inhibition of PTH release • Vitamin D supplement _________________________________________ _________________________________________ _________________________________________ _________________________________________ Endocrine Disorders Presenting With Endocrine Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Diabetes Mellitus/Hypoglycemia (cont.) • Diabetes Mellitus/Hypoglycemia Differential diagnosis of hypoglycemia include: • Alcohol use Early in its course initial symptoms • Fasting (e.g., fatigue & weight gain) may be confused with psychiatric disorders • Insulinoma • Factitious hypoglycemia Hypoglycemia can cause profound decease in Psychiatric symptoms (e.g., psychosis or mood cognitive functioning—especially associative changes) occur in up to 80% of patients with learning, attention, mental flexibility insulinomas. Suspect if symptoms are episodic and Acute hypoglycemia can cause anxiety relieved by food intake Factitious hypoglycemia can be uncovered by measurement of C-peptide if suspected _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 7
  • Endocrine Disorders Presenting With Psychiatric Symptoms • Hypoglycemia (low blood sugar) Symptoms can be variable and include delirium or coma Can include palpitations, sweating, anxiety, Metabolic Disorders 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 _________________________________________ _________________________________________ _________________________________________ _________________________________________ Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Wilson’s Disease Also called hepatolenticular degeneration • Wilson’s disease Prevalence is 1 per 30,000 live births Usual presentation: movement disorder, An autosomal recessive disorder of copper psychosis, and personality changes around metabolism, with associated decrease transport of the second to third decades copper from the liver into bile, leading to accumulation • 35% of patients present with neurological of copper in the organism, primarily liver symptoms: Parkinsonian-like tremor, • In acute liver injury copper may be released in the blood rigidity, clumsiness of gait, slurring of and cause hemolytic anemia speech, inappropriate and uncontrollable • In chronic cases, the copper accumulates in the brain and grinning, and drooling cause neuropsychiatric symptoms _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 8
  • Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Wilson’s disease (cont.) Wilson’s Disease Three subgroups of brain disease: (Oder 1993) • Clues to diagnosis: • Bradykinesia, rigidity, cognitive impairment, and 1) Kayser-Fleischer organic mood syndrome were associated with rings* adjacent to the cornea during dilatation of 3rd ventricle slit-lamp examination • Ataxia and tremor were associated with focal 2) 24 hour collection— thalamic lesions increased urine copper, • Dyskinesia, dysarthria, and organic personality decreased serum copper syndrome were associated with lesions in putamen and low serum ceruloplasm (<20mg/dl) and palladium 3) Increased amounts of liver and urinary cooper 10% present with psychiatric problems ranging 4) Elevated concentrations of copper in the CSF: ↑ 3-4 fold from subtle personality changes to overt 5) Imaging study: MRI*: Showing hyperintensities in the bilateral basal ganglia and thalami shown by T2-weighted depression, paranoia and catatonia MRI of the brain _________________________________________ _________________________________________ _________________________________________ _________________________________________ Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms Wilson’s Disease Porphyria • Treatment • An autosomal dominant disorder resulting from a partial Once diagnosis is confirmed, treatment should start as soon deficiency of porphobilmogen deaminase (PBGD), an as possible, either in symptomatic or asymptomatic patients enzyme required in heme biosynthesis pathway Penicillamine 500mg2 PO is the drug of choice • Acute intermittent porphyria (AIP) can be associated with • Response is quite slow and takes one year to maximum effect psychiatric symptoms (e.g., psychosis) even when • Neurologic symptoms may worse in the first months of treatment physical manifestations (abdominal pain, neuropathy, • Penicillamine treatment should be lifelong autonomic dysfunction) are not present • Prednisone, 20 mg orally, is usually required to treat adverse drug reactions • 90% of individuals remain biochemically and clinically • Acute liver injury may not respond to therapy and require liver normal throughout life. However, clinical expression of the transplantation disease is usually linked to factors that stimulate or Trientine or zinc are alternatives to penicillamine depresses the activity of nonspecific delta-aminolevulinic • They work by blocking the absorption of copper and increases copper acid synthase in the liver. This can be environmental such excretion in the stool1 1Brewer 1998 as nutritional status, drugs, steroids and other chemicals _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 9
  • Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms Porphyria (Cont.) Acute Porphyria • Attacks: Clinical features • Often presents after puberty and more commonly Early sx’s: minor behavioral changes: Anxiety, in women restlessness & insomnia • Most common presenting complains are Autonomic neuropathy abdominal pain and other GI distress. Urinary • Gastrointestinal incontinence is also common Abdominal pain: Opiate treatment Vomiting: Chlorpromazine treatment • Other symptoms include: tachycardia, HTN, fever, sweating, restlessness and tremor Constipation: Lactulose treatment • Pain: Back; Extremities • Cardiovascular Hypertension; Tachycardia—Treat with β-blockers _________________________________________ _________________________________________ _________________________________________ _________________________________________ Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms Acute Porphyria • Acute porphyria • Attacks: Clinical features (cont.) Attacks: Clinical features Motor-Sensory neuropathy • Psychiatric symptoms: • Weakness: May be diffuse; Respiratory Hysteria involvement in some cases Anxiety • Sensory loss: Distal Apathy or depression • Tendon reflexes: Reduced Phobias Psychosis CNS: Rule out hyponatremia Agitation • Seizures Mania-like states • Confusion Delirium _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 10
  • Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Porphyria • Porphyria Treatment: Diagnosis: 1. During acute attack: 1. Predominantly Neurological Symptoms: i. Stop alcohol and tobacco ii. Treat infections and electrolyte imbalances a. Urinary delta-aminolevulinic acid iii. IV heme b. Urinary porphobilinogen iv. Treat with IV glucose/CHO c. Total urinary porphyrin v. If carbohydrates do not work or there is evidence of bulbar paralysis, then use IV heme preparations with hemin (3-4 These are high during psychosis and less so during mg/kg IV over 10-15 minutes per day x >4 days) or heme asymptomatic periods arginate. Blood and urine levels of delta-aminolevulinic 2. Predominantly Cutaneous Symptoms: acid and porphobilinogen are promptly lowered and symptoms improve, usually within several days a. Total plasma porphyrins • Heme arginate or Hematin • Dose: 3 mg/kg per day for 3–4 consecutive days • Side effects: Thrombophlebitis, Coagulopathy & Anaphylactic reactions _________________________________________ _________________________________________ _________________________________________ _________________________________________ Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms Vitamin B12 (Cobalamin) Deficiency Vitamin B12 (Cobalamin) Deficiency (cont.) • Usually caused by pernicious anemia • Diagnosis: • B12 is obtained in the diet from animal sources, leaving vegans susceptible to depletion; Normally it Test for B12 deficiency with red cell folate, serum B12, takes months to years to deplete stores methylmalonic acid levels or homocysteine levels • B12 deficiency is a common cause of macrocytic Use of the Schilling test for detection of pernicious anemia anemia has been supplanted for the most part by serologic testing for parietal cell and intrinsic factor • Neurological symptoms: antibodies Memory loss Irritability • Treatment: Dementia Supplementation with oral vitamin B12 is a safe and Are caused by demyelination, leading to degeneration of effective treatment for the B12 deficiency state lateral and posterior columns _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 11
  • Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Thiamine deficiency (B1) • Thiamine deficiency (B1) Wernicke’s Encephalopathy Thiamine (B1) is an essential co-enzyme in neural • Represents a true medical emergency function and carbohydrate metabolism • Presentation is usually acute Commonly associated with chronic alcohol intake • Worsened/precipitated by the addition of carbohydrates Nevertheless, a significant percentage of cases (23%) • Caused by atrophy of mamillary bodies, visible on head MRI are caused by disorders other than alcoholism: • Diagnostic triad: Ophthalmoplegia (nystagmus, abducens nerve paresis, hyperemesis, starvation, dialysis, malignancy, AIDS conjugate gaze paresis) Diagnosis: Ataxia (stance, gait) • Can detect thiamine deficiency with erythrocyte Confusion/Encephalopathy (global, listlessness, inattentiveness, thiamine transketolase ↓ concentration, disorientation, indifference, and inattention) Wernicke’s-Korsakoff’s Syndrome = 2 states: • Treatment: Best treatment is prevention: Adequate diet/nutrition • Acute Wernicke’s encephalopathy Thiamine supplementation: • Chronic Korsakoff’s disorder (KD) or Alcohol 100 mg IV prior to carbohydrate loading Amnesic Disorder 100 mg PO q D _________________________________________ _________________________________________ _________________________________________ _________________________________________ Metabolic Disorders Presenting With Metabolic Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Thiamine deficiency (B1) • Thiamine deficiency (B1) Korsakoff’s Disorder = Alcohol Amnesic disorder Korsakoff’s Disorder = Alcohol Amnesic disorder • Disease course: • Characterized by selective anterograde and Begins with a global confusional state (patient retrograde amnesia, leading to confabulation appears apathetic, slow, oblivious to their • Onset: usually after years of heavy etoh use; most surroundings, prominent memory impairment) pts >40 y/o Followed by a period of alertness, jovial attitude, but • Prognosis: poor, once established it usually persistent retrograde and anterograde amnesia persists indefinitely, < 20% recovery Eventually, the amnesia impairs memory-based cognitive functions, especially learning _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 12
  • Metabolic Disorders Presenting With Psychiatric Symptoms Wernicke-Korsakoff Syndrome • Thiamine deficiency (B1) (cont.) Korsakoff’s Disorder = Alcohol Amnesic disorder • Diagnosis: CT, MRI: normal or some degree of cerebral atrophy EEG: normal Pathology: petechial hemorrhages in mamillary bodies, structures surrounding 3rd ventricle & aqueduct of Sylvius (i.e., limbic system) • ≠ Alcoholic Dementia: most likely the result of multiple factors: WKS, contusions, hematomas, TBI, hepatic encephalopathy, hydrocephalus _________________________________________ _________________________________________ _________________________________________ _________________________________________ Infectious Disorders Presenting With Psychiatric Symptoms • Mild Neurocognitive Disorder (MND) 20-30% of asymptomatic or early symptomatic seropositive persons will have mild- neurocognitive disorder (MND) Infectious Diseases • MND may predispose toward frank dementia 50% of persons with AIDS have neuropsychiatric deficits Prevalence of dementia in AIDS patients is variable (15-66%) Annual Incidence of dementia in AIDS is 14% 75% of AIDS patients die within 6 months of the diagnosis of dementia _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 13
  • Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • HIV Associated Dementia (HAD) HAD affects 14% of patients with HIV • HIV Associated Dementia (HAD) Incidence has decreased with the introduction HIV-associated dementia classification system: of HAART • Stage 0: Normal Characterized by the following symptoms: • Stage 0.5: Subclinical or Equivocal • Motor Symptoms: • Cognitive symptoms: Frontal release signs Impaired short term Minimal or equivocal symptoms Exaggerated DTR’s memory Mild (soft) neurological signs Disturbed smooth Reduced No impairment of work or activities of daily living (ADL) eye movements concentration Lower extremity • Stage 1: Mild Decreased coordination weakness Unequivocal intellectual or motor impairment. Motor weakness Behavioral changes Decreased capacity to perform (e.g., apathy and Able to do all but the most demanding work or ADL rapid-alternating movements social withdrawal) Late: unresponsiveness, urinary/ fecal incontinence, mutism _________________________________________ _________________________________________ _________________________________________ _________________________________________ Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • HIV Associated Dementia (HAD) • HIV Associated Dementia (HAD) HIV-associated dementia classification system: (cont.) Diagnostic Laboratory Tests: • Stage 2: Moderate • MMSE scores usually in mid-20’s Cannot work or perform demanding ADL • CT scan: white matter lucencies Capable of self-care • T2-weighted MRI: areas of high signal output Ambulatory, but may need a single prop • Stage 3: Severe • Abnormal EEG Major intellectual disability • Ophthalmology exam reveals cotton wool spots Cannot walk unassisted on retina • Stage 4: End-Stage • Decreased CD4, high serum and CSF Beta-2 Nearly vegetative microglobulin, increased CSF neopterin and quinolinic acid _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 14
  • Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neurocystercercosis • PANDAS Caused by the larval form of Tenia Solium (pork tapeworm) • Characterized by childhood obsessive compulsive Humans are the definitive host for this worm acquired disorder occurring earlier than usual and usually has by ingestion of the egg form by auto-infection or an abrupt onset with relapsing-remitting course consumption of contaminated food Pathogenesis is thought to involve anti-strep antibodies Neurocystercercosis presents with seizures, psychosis that cross-react with epitomes in the basal ganglia or depression Disorder is related to the classic Sydenham’s chorea, but Patients tend to be younger, present with acute onset of PANDAS has more behavioral components; while symptoms, and usually have no prior psychiatric history Sydenham’s chorea has more movement disorder Diagnostic clues: symptoms than PANDAS • Travel history, country of origin and proximity to livestock Treatment consists of immunotherapy may aid in diagnosis PANDAS = Pediatric autoimmune neuropsychiatric disorder associated with streptococcus infection _________________________________________ _________________________________________ _________________________________________ _________________________________________ Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neuroborrilosis: CNS-Lyme Disease Caused by infection by the tick borne spirochete • Neuroborrilosis: CNS-Lyme Disease Borrelia Burgdorfori Disease presentation: 3% risk of acquiring Lyme disease with each tick bite • Acute Symptoms: Erythema migrans: characteristic rash 1st month after infection patients may complain of Diagnosis: headache, fatigue, and myalgias • Exposure history • Chronic physical symptoms: • Erythema migrans rash Arthritis, carditis with conduction defects, and CNS • Serological evidence and 1 out of 3: symptoms like Bell’s Palsy (in up to 10% of 1) Arthritis patents) 2) Neurological symptoms (cranial or peripheral neuropathy, meningitis, encephalomyelitis, encephalitis) 3) Cardiac conduction defects _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 15
  • Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neuroborrilosis: CNS-Lyme Disease • Neuroborrilosis: CNS-Lyme Disease Disease presentation: (cont.) Disease presentation: (cont.) • Neurological symptoms/meningoencephalitis: • Psychiatric symptoms: Cognitive dysfunction: difficulty with concentration More commonly depression confusion, memory difficulties. Day time Less common: panic attacks, transient paranoia, hypersomnolence, myoclonus, apraxia, ataxia, illusions or hallucinations, anorexia, paresthesias, seizures and/or irritability. These depersonalization, violent outburst, OCD, patients are initially misdiagnosed as suffering agitated mania, sensitivity to light or sound, from MS personality change _________________________________________ _________________________________________ _________________________________________ _________________________________________ Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neuroborrilosis: CNS-Lyme Disease Differential diagnosis: • Neuroborrilosis: CNS-Lyme disease • (For neurological symptoms) MS, fibromyalgia, chronic Rx: fatigue syndrome, other infections • Somatization disorder (due to multiple vague somatic • w/o CNS involvement: complaints) 3-4 weeks of Vibramycin (100 mg BID), amoxicillin Clue to diagnosis: (500 mg BID), or Ceftin 500 mg BID 1. Serologic studies with ELISA and Western Blot or PCR • w/ CNS involvement: 4-6 wks of IV veftriaxone for borrelial DNA 2. These serologic studies may be equivocal (2 g QD) or Cefotaxime (2 g Q8) 3. Late stage CSF may be normal • Vaccine was introduced in 1999 with 50-75% 4. MRJ may show demyelinating disorder of effectiveness 5. EEG is usually normal 6. PET is helpful because it shows global or heterogeneous hypoperrasion _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 16
  • Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neurosyphilis Caused by Treponema Pallidium • Syphilis In the late stages of syphilis spirochetes invade Primary syphilis: the meninges • Lesion at site of infection within 2-3 weeks • Patients with syphilis are more likely to develop neurosyphilis if T. Pallidium is found in the CSF Secondary syphilis: 5 years after primary infection • Recurrent rash with onset 6 weeks to 6 months Presentation: after initial exposure. There is a latent stage for • Progressive changes in personality that may involve delusions of grandeur, emotional lability or paranoia 2-10 years • Neuropsychiatric symptoms: memory loss, Tertiary syphilis: carelessness, dementia, depression or seizures • It is important to check for HIV status in patients • Involves the skin, bone, aorta and CNS with syphilis because there is significant comorbidity between these 2 infections _________________________________________ _________________________________________ _________________________________________ _________________________________________ Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neurosyphilis is divided in four stages: • Neurosyphilis: Clues to diagnosis: 1. Asymptomatic with abnormal CSF 1. Abnormal CSF with elevated lymphocytes and or protein 2. Meningovascular syphilis characterized by headache, 2. CSF VDRL is positive in only 27-92% nuchal rigidity, irritability and delirium *Treponemal tests are not standardized for diagnostic 3. Tabes dorsalis with posterior column degeneration such use on CSF and should not be used as confirmation as ataxia, areflexia, paraesthesias, incontinence, of neurosyphilis1 impotence and Argyll Robertson pupil 3. Serum tests: 4. General Paresis or paralysis of the insane, dementia Rapid Plasma Reagin test (RPR) or venereal disease research laboratories (VDRL) paralytica If positive, then follow up with fluorescent treponemal • A general change in personality is usually seen with antibody absorption tests (FTA-ABS) apathy, lability, paranoia and coarsening of behavior 4. Signs of tertiary syphilis • Dementia involves prominent impairment of memory, 5. MRI or CT may show evidence of organic brain disease language, and loss of initiative and psychomotor slowing 1Davis, 1989 _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 17
  • Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Neurosyphilis—Clues to diagnosis: 5. MRI or CT may show evidence of organic brain disease • Neurosyphilis: Rx: 1. Benzathine Penicillin results in no measurable CSF levels 2. IV penicillin G (3-4 million units IV q4 for 10-14 days. This requires hospitalization Figure 1. Computed tomography of Figure 2. Magnetic resonance imaging of 3. If allergic to PCN, use ceftriazone Ig IV QD for brain shows (left) prominence of brain shows (left) slightly enlarged lateral 10 days temporal horns and (right) ventricles and (right) increased signal in enlargement of lateral and third medial portion of temporal lobes ventricles involving hippocampal gyri South Med J, 2002 Southern Medical Association _________________________________________ _________________________________________ _________________________________________ _________________________________________ Infectious Disorders Presenting With Infectious Disorders Presenting With Psychiatric Symptoms Psychiatric Symptoms • Herpes Encephalitis • Herpes Encephalitis Characterized by abrupt onset of fever, personality Clue to diagnosis: change, headaches, followed by cognitive changes 1. CSF shows leukocytosis, moderate protein elevation and a normal or depressed glucose. PCR analysis and focal neurological signs such as aphasia, visual will detect HSV DNA field deficits, hemiparesis or partial seizures 2. 80% of pts with biopsy-proven herpes simplex Neuropsychiatric symptoms: encephalitis will have focal EEG abnormalities showing: slowing or repetitive epileptiform • Initially presents with hallucinations, memory loss, or discharges in the frontotemporal area behavioral disturbances 3. Brain MRI • The disease is rapidly progressive resulting in Rx: refractory seizures, coma and death within 2 weeks • Acyclovir and Vidarbine (Vira-A) • Survivors may exhibit postencephalitic symptoms • Even with treatment, fewer than 40% will survive with of amnesias, aphasia and Kluver-Bucy syndrome minimal or no sequelae or dementia • If untreated: 40-70% mortality _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 18
  • Clinical Case Clinical Case (Cont.) • 28 y/o man presents to the ED with high fever; • Examination: progressive, severe, generalized throbbing Well-built man ill-appearing headache; blurred vision; and increasing Pulse rate is 110 bpm; temp 38.3’C (101’F); rr 22bpm; confusion. These symptoms started 3 days ago BP 116/72mmHg • History: He is well hydrated. No scleral icterus or oral candidal infection. Pupils are equal and reactive. No The patient had previously been healthy and active; palpable adenopathy or rashes he works in the oil fields The patient is confused; disoriented to person, time He is married and does not smoke, drink alcohol or and place; and agitated. Cranial nerves are intact. use illicit drugs Fundi are normal. He can move all his limbs. DTR’s He has had no blood transfusions and takes are normal; plantar reflexes are equivocal. Neck is no medications supple. Remainder of the examination is normal _________________________________________ _________________________________________ _________________________________________ _________________________________________ Clinical Case (Cont.) • Laboratory studies: WBC 18,000uL, with 70% polymorphonuclear neutrophils and 30% lymphocytes. Hgb 13.1g/dl; platelets count 20,000/uL; ESR 90mm/h. Serum sodium 138mEq/L; potassium 4mEq/L; chloride 102mEq/L; Calcium 9.2mg/dL; blood glucose 101mg/dL; blood urea nitrogen 29mg/dL; serum creatinine 1mg/dL; total Connective Tissue Disorders bilirubin 1mg/dL; aspartate aminotransferase 22U/L; alkaline phosphatase 112U/L. results of coccidial serologic testing and drug screening are negative. Urinalysis results are normal CSF pressure is increased. CSF protein level is 180mg/dL; glucose 92; WBC 116/uL; RBC 80/uL. Gram staining of CSF shown WBC’s but no organism • You order an MRI of the brain _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 19
  • Connective Tissue Disorders Presenting Connective Tissue Disorders Presenting With Psychiatric Symptoms With Psychiatric Symptoms • Systemic Lupus Erythematosus • Systemic Lupus Erythematosus Psychosis 2ry to Lupus Cerebritis: SLE is a connective tissue disease of unclear • 5% of SLE pts usually within the first 2 years etiology that is characterized by recurrent • Characterized by bizarre thinking with delusions or episodes of destructive inflammation of several hallucinations, poor attention span, easy distraction, misinterpretation of surroundings agitation, organs including the skin, joints, kidneys, blood combative behavior, and “clouding of consciousness” vessels and CNS Auditory hallucinations are usually caused by steroid therapy Visual and tactile hallucinations are frequently due to SLE Presentation: • Rx: • Primary psychiatric disturbances: Response to steroids—prednisone 1-2 mg/kg/day. If no improvement is seen then switch to cytotoxic therapy – Psychosis cyclophosphamide1 Cognitive defects While waiting for effects of therapy, treat with antipsychotics—haloperidol Dementia 1Neuwelt 1995 _________________________________________ _________________________________________ _________________________________________ _________________________________________ Connective Tissue Disorders Presenting Connective Tissue Disorders Presenting With Psychiatric Symptoms With Psychiatric Symptoms • Systemic Lupus Erythematosus • Systemic Lupus Erythematosus Cognitive Dysfunction: Secondary psychiatric disturbance: • 21-80% of SLE patients presents with difficulty in short or long • Depression, anxiety, and manic behavior are more term memory, impaired judgment and abstract thinking, typically functional1 aphasia, apraxia, agnosia and personality changes1 Depression: usually begins acutely and reflects the pt’s • Cognitive dysfunction appears to be evanescent and is not reaction to chronic illness and lifestyle limitations including directly correlated with active disease or corticosteroid therapy difficulty with pregnancy, fatigue, decreased sun exposure, and chronic medication use • Impaired remote memory appears to be associated with a history of past CNS involvement vs. impaired immediate Anxiety: pts may be anxious about consequences of their illness including disfigurement, disability, dependency, loss memory and concentration implies increased disease activity of a job, social isolation and death. May be manifested in Dementia: panic attacks • Characterized by severe cognitive dysfunction occurs in pts Mania: usually associated with corticosteroids with lupus that have had multiple small ischemic strokes • Steroids cause hypomanic symptoms in 30% of patients caused by antiphospholipid antibodies and is usually worsened who take them while depressive symptoms are seen in 10% by high dose corticosteroids of patients 1Hay 1994 1Jennekens 2002 _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 20
  • Connective Tissue Disorders Presenting Connective Tissue Disorders Presenting With Psychiatric Symptoms With Psychiatric Symptoms • Fibromyalgia • Fibromyalgia Fibromyalgia is a non specific disorder characterized Differential Diagnosis: dysthymic disorder, GAD, by many diffuse complaints including pain, stiffness, somatization, and chronic pain syndrome tender muscles and joints, overwhelming fatigue, distress and sleep disturbances Psychological abnormalities such as depression, anxiety, and chronic pain with functional disability Criteria for classification of fibromyalgia: may develop on patients with fibromyalgia A. Widespread pain—present for 3 months • 25% of patients diagnosed with fibromyalgia have B. Presence of 11 of 18 tender points—bilateral sites of occiput, lower cervical, trapezius, supraspmatus, second rib, lateral major depression epicondyle, gluteal, greater trochanter, and knees • 50% of patients with fibromyalgia have a lifetime • Additional features include: sleep disturbance, fatigue, history of major depressive episodes complaints of weakness, headaches, cold sensitivity, • Many of the symptoms of fibromyalgia overlap with paresthesia or dysesthesia, swellings, Raynaud's phenomena, restless legs, exercise intolerance, and irritable major depression including fatigue, lack of energy, bowel and bladder and sleep disturbances _________________________________________ _________________________________________ _________________________________________ _________________________________________ Connective Tissue Disorders Presenting Connective Tissue Disorders Presenting With Psychiatric Symptoms With Psychiatric Symptoms • Fibromyalgia • Multiple Sclerosis No laboratory data including serological studies, EMG, MS is a demyelinating disease that affects around 250,000 muscle or nerve biopsies exist to confirm diagnosis people in the U.S. Goldenberg et al. found that the Minnesota Multiphase First described by Jean-Marie Charcot Personality Inventory-2 show elevations in • Charcot's Triad: (Nystagmus, Intention Tremor & Scanning hypochondriacal and hysteria subscales similar to those Speech). of other chronic pain patients Epidemiology: Rx: • 2:1 women to men ratio • No single medical or psychiatric intervention has been • Most prevalent among whites of northern European descent effective • Prevalence increases with distance from the equator • Current approach is supportive counseling, behavioral modification, education, physical conditioning and limited Disease Course: pharmacological intervention • Usually has relapsing-remitting course • There have been no conclusive medication trial • Two types: benign and chronic progressive types _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 21
  • Connective Tissue Disorders Presenting Connective Tissue Disorders Presenting With Psychiatric Symptoms With Psychiatric Symptoms • Multiple Sclerosis Visual Evoked Potentials • Multiple Sclerosis Diagnosis: Oligoclonal Bands in CSF Psychiatric Presentations: • Neurologic examination • Charcot noted psychiatric symptoms of depression, pathological laughter, and "stupid indifference" • Head & Spine MRI = “MS plaques” in T2-weighted 1. Depression: & FLAIR sequences Depression rates range from 45-62% ? cerebral involvement vs. psychological reaction to living with a • Sensory Evoked Potential debilitating and chronic illness1, 2 Testing (visual, brainstem Higher rates of depression when compared to patients auditory and with other chronic illness supports the cerebral somatosensory) demyelination theory Cerebral involvement is more closely related to • Cerebrospinal Fluid (CSF) depression in MS than is spinal cord involvement Analysis: CSF IgG concentration is increased relative to Depression in MS is unrelated to neurological status other CSF proteins (e.g., albumin), and CSF gel and degree of cognitive impairment electrophoresis reveals oligoclonal bands in 90% of cases 1Diaz-Olavarrieta 1999; 2Nyenhuis 1995—psychological rxn _________________________________________ _________________________________________ _________________________________________ _________________________________________ Connective Tissue Disorders Presenting Connective Tissue Disorders Presenting With Psychiatric Symptoms With Psychiatric Symptoms • Multiple Sclerosis • Multiple Sclerosis Psychiatric Presentations: Cognitive Deficits1 2. Pathological laughter: • The pattern of cognitive decline was not uniform: Associated with pseudobulbar palsy, or bilateral MS patients were more frequently impaired on damage to the fiber tracts connecting the cortex to measures of recent memory, sustained attention, verbal subcortical forebrain structures fluency, conceptual reasoning, and visuospatial 3. “Stupid indifference” is now described as perception and less frequently impaired on measures of anosodiaphoria, or a condition in which patients language and immediate and remote memory with cerebral injuries are unconcerned about their • Cognitive impairment was not significantly associated neurological deficits. MRI studies show these with illness duration, depression, disease course, or patients to have lesions in the frontal lobes medication usage, but was significantly (albeit weakly) 4. Bipolar Disorder correlated with physical disability 2x as likely in MS pts 1Rao 1991 _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 22
  • Types of Dementia • Cortical Dementias • Subcortical Dementias Symptoms: Symptoms: • Amnesia (difficulty • Cognitive slowing forming new memory) • Impaired memory retrieval • Aphasia • Decreased attention • Apraxia • Apathy Dementia-Like Syndromes • Agnosia • Visuospatial impairment • Depression & mood/ability • Disinhibition Pathology: • Extrapyramidal or UMN signs • Caused by disease in Pathology: temporal & parietal association areas and • Usually in subcortical white matter, limbic memory circuit prefrontal cortex, basal ganglia or thalamus Example: Alzheimer’s Example: Parkinson’s disease, disease vascular dementias, progressive supranuclear palsy _________________________________________ _________________________________________ _________________________________________ _________________________________________ Major Classes of Disorders That can Types of Dementia Cause Dementia • Irreversible • Treatable Class Examples TBI/Head injury Degenerative Alzheimer’s, Lewy Body disease, Pick’s disease Alzheimer disease (50%) Disorders Infections Vascular dementia (40%) Subcortical Disorders Parkinson’s disease, Huntington’s disease, Normal pressure Wilson’s disease Parkinson disease hydrocephalus Vascular Disorders Lacunar infarcts, large vv. Occlusion Lewy body dementia Brain tumors Demyelinating MS, metachromatic leukodystrophy Huntington disease Toxic exposure Disorders Metabolic disorders (of the Creutzfeldt-Jakob liver, pancreas or kidneys) Traumatic Disorders TBI & DAI: Posttraumatic encephalopathy, disease subdural hematoma Hormone disorders Neoplastic Disorders Metastatic disease, meningiomas, gliomas Pick disease Poor oxygenation (hypoxia) (frontotemporal Hydrocephalus Normal pressure hydrocephalus Drug reactions, overuse, dementia) or abuse Toxic Disorders Occupational exposures: solvents, heavy metal. Nutritional deficiencies Hypoxic Disorders Anoxic brain injury, hypoxemia Chronic alcoholism Metabolic Disorders CHF, encephalopathies (particularly hepatic) _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 23
  • Delirium in the General Hospital Delirium Pathogenesis Definition • From use or overdose with various medications with anticholinergic potential (tricyclics or over-the-counter drugs, An sub/acute organic mental syndrome featuring: or organophosphate insecticides) • Global cognitive impairment • Classic symptoms include Confusion “red as a beet” (flushing) Disorientation “dry as a bone” (lack of perspiration) Disturbance of consciousness Attentional deficits “blind as a bat” (mydriasis) Memory disturbance “mad as a hatter” (delirium) Confabulation Medication side-effect // polypharmacy Paranoia • Some of the proposed theories include: • Development of perceptual disturbance Reduced/deficient cerebral metabolism (↓ EEG) Deficiency/imbalance of neurotransmitters: • Decreased or increased psychomotor activity • ↓ Achol synthesis & release (Central anticholinergic state: ↓Achol) • Disordered sleep-wake cycle • Enhanced central dopaminergic activity (↑ DA) • Increased glutamate release ( ↑ GLU) • Fluctuating presentation: waxing & waning • Enhanced central noradrenergic activity ( ↑ NE) _________________________________________ _________________________________________ _________________________________________ _________________________________________ Delirium: DSM-IV-TR Criteria Differential Diagnosis of Delirium: Critical Items I. Disturbance of consciousness (i.e., reduced clarity of Disorder System Clinical Examples awareness of the environment) with reduced ability to Infectious Encephalitis, meningitis, syphilis, septicemia focus, sustain or shift attention Withdrawal Syndromes CNS-depressants: alcohol, barbiturates, sedative-hypnotic Rx. II. Change in cognition (such as memory deficit, Acute Metabolic Acute Metabolic encephalopathies: acidosis/alkalosis, electrolyte disorientation, language disturbance) or… disturbances, hepatic/renalfailure, hypersensitivity reactions Trauma Trauma: head, heat stroke, post-operative status (especially post- The development of a perceptual disturbance that is cardiotomy states), severe burn not better accounted for by a preexisting, established or CNS Pathology Seizures, neoplasms, abscesses, hemorrhages, stroke, vasculitis, evolving dementia normal pressure hydrocephalus (NPH) Hypoxia Pulmonary/cardiac failure, hypoperfusion, anemia, hypotension, intra- III. The disturbance develops over a short period of time operative complications, carbon monoxide poisoning (usually hours to days) and tends to fluctuate during the Deficiencies Nutritional deficiencies: : B12, folate, hypovitaminosis, niacin (B3, course of the day pellagra), thiamine (B1, Beriberi and Wernicke's). Encephalopathies Hyper/hypo adrenalcorticism, hyper/hypo glycemia, hyper/ IV. There is evidence from the history, physical examination hypothyroidism or laboratory findings that the disturbance is caused by Acute Vascular Hypertensive encephalopathy, shock the direct physiological consequences of a general medical condition Toxins/Medications/ Substances Medications (especially anticholinergic Rx), poisons, pesticides, solvents. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Heavy Metals Lead, manganese, mercury Washington, D.C.: American Psychiatric Association, 1994:129-33. _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 24
  • Delirium: Diagnostic Criteria Delirium Subtypes (Based on Sub-Types*) 46% Hyperactive (3 or more) Hypoactive (4 or more) Hypervigilance Unawareness Restlessness Lethargy Fast/loud speech Decreased alertness Anger/irritability Staring Combativeness Sparse/slow speech 24% Impatience Apathy Uncooperative Decreased motor activity Laughing Swearing/singing Euphoria Wandering 30% Easy startling Distractibility Hypoactive Hyperactive Mixed Nightmares Persistent thoughts *Adapted from Liptzin and Levkoff; Br j Psych 1992 _________________________________________ _________________________________________ _________________________________________ _________________________________________ Differential Diagnosis: Hypoactive Delirium Medical Causes of “Anxiety” _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 25
  • Medical Causes of “Anxiety” Class Examples Cardiopulmonary Arrhythmias, mitral valve prolapse, pulmonary embolism, chronic obstructive pulmonary disease, asthma, and congestive heart failure Neurological Seizure disorder, head injury, and vestibular disease Metabolic and Hyper- or hypothyroidism, hyperparathyroidism, hypoglycemia, adrenal endocrine dysfunction, pheochromocytoma, and vitamin B12 deficiency Inflammatory and Systemic lupus erythematosus and HIV infectious Medications Stimulant and sympathomimetic (e.g., theophylline, pseudoephedrine [Sudafed], and albuterol) Medical Causes of antiparkinsonian cardiovascular “Mood Disorders” antidepressant (especially SSRIs) anxiolytic (primarily when taken in as-needed fashion) corticosteroid insulin thyroid preparations caffeine preparations Substance of Abuse Stimulants (e.g., amphetamines, cocaine, caffeine), cannabis, PCP, (intoxication) inhalants, and hallucinogens Substance of Abuse Alcohol, barbiturates, benzodiazepines, opioids, and nicotine (withdrawal) Toxins Carbon monoxide, paint, and gasoline fumes _________________________________________ _________________________________________ _________________________________________ _________________________________________ Medical Causes of “Mood Disorders” Medical Causes of “Mood Disorders” Neurological Parkinson's disease, Huntington's disease, Wilson's disease, MS, Endocrine Hypo- and hyperthyroidism, hypercalcemia, hypo- and cerebrovascular disease, brain tumor, traumatic brain injury, temporal lobe epilepsy and dementia hyperadrenocorticism, hypo- and hyperparathyroidism, DM and vitamin B12 deficiency Metabolic and Hypo- and hyperthyroidism, hypercalcemia, hypo- and hyperadrenocorticism, Endocrine hypo- and hyperparathyroidism and vitamin B12 deficiency Metabolic Electrolyte disturb, renal failure, vitamin defic or excess, porphyria, Wilson’s Disease, environmental toxins, Prescribed Substances Stimulant and sympathomimetic (e.g., methylphenidate and theophylline heavy metals Corticosteroid Antiparkinsonian (e.g., L-dopa [Larodopa] and bromocriptine [Parlodel]) GI IBS, chronic pancreatitis, Crohn’s, cirrhosis, hepatic Antidepressant (inducing manic symptoms); immunosuppressant (e.g., encephalopathy cyclosporine [Neoral] and tacrolimus [Prograf]) Antihypertensive (e.g., β-blockers and methyldopa) Infectious/Inflammatory Systemic lupus erythematosus, neurosyphilis, and HIV Cancer chemotherapy (e.g., vincristine, vinblastine, interferon and procarbazine) Oral contraceptives CV MI, angina, CABG, cardiomyopathies CNS depressant (e.g., benzodiazepines and barbiturates) Heavy metals and toxins (e.g., paint and carbon monoxide) Pulmonary COPD, sleep apnea, reactive airway disease Substances of abuse Stimulants (e.g., cocaine), opioids, hallucinogens, phencyclidine (PCP) and Malignancies and Pancreatic carcinoma, brain tumors, paraneoplastic (intoxication) CNS depressants (e.g., alcohol). Hematological syndromes, anemias Substances of abuse Stimulants (e.g., cocaine) and CNS depressants (e.g., alcohol) (withdrawal) Autoimmune SLE, fibromyalgia, rheumatoid arthritis _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 26
  • Medical Causes of “Psychosis” Psychosis” Class Examples Neurologic Parkinson's disease, Huntington's disease, MS, visual and auditory defects, epilepsy (TLE), cerebrovascular accident and head trauma Metabolic and endocrine Hypo- and hyperthyroidism, hypo- and hyperadrenocorticism, hypo- and hyperglycemia, hypoxia, hypercarbia, renal failure, hepatic failure and Wilson’s disease Infectious and inflammatory Systemic lupus erythematosus and HIV Nutritional deficiencies Vitamin B12 and thiamine Medical Causes of Prescribed medications Opioid & anticholinergic (e.g., benztropine and diphenhydramine) Cardiovascular (e.g., digoxin, procainamide, methyldopa) Cancer chemotherapy (e.g., procarbazine) “Psychosis” Corticosteroid (e.g., prednisone and dexamethasone) Immunosuppressant (e.g., cyclosporine and tacrolimus); antiparkinsonian (e.g., L-dopa and bromocriptine) Antitubercular (e.g., isoniazid, sympathomimetic (e.g., theophylline and phenylephrine) Sedative-hypnotic, Anxiolytic Disulfiram (Antabuse) Substances of abuse Stimulants (e.g., amphetamine and cocaine), hallucinogens, PCP, inhalants, cannabis, (intoxication) opioids and alcohol Substances of abuse Etoh (withdrawal) Toxins Heavy metals, nerve gases, organophosphate insecticides, carbon monoxide and volatile substances such as gasoline and paint _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Session 21-3: Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms 27
  • Neuropsychiatric Masquerades: Medical and Neurological Disorders That Present With Psychiatric Symptoms José R. Maldonado, MD 1. Primary psychiatric manifestations of systemic lupus erythematosus (SLE) include: A. Psychosis B. Cognitive deficits C. Dementia D. All of the above E. None of the above 2. The psychiatric condition not considered a differential diagnosis for fibromyalgia is: A. Dysthymia B. Generalized anxiety disorder C. Schizophrenia D. Somatization disorder E. Chronic pain syndrome 3. The subgroups of brain syndromes associated with Wilson’s disease include all, except: A. Pseudoparkinsonism associated with dilatation of the 3rd ventricle B. Ataxia and tremor associated with focal thalamic lesions C. Dyskinesia, dysarthria and personality changes associated with lesions in putamen and palladium D. Manic episodes associated to frontal disinhibition 4. Which would be the most appropriate psychiatric syndrome associated with neurosyphilis? A. Early onset OCD B. Panic attacks C. Myxedema madness D. Dementia Answer: 1. D 2. C 3. D 4. A Session 21-3: Self-Assessment Questions and Answers 28