Series (Part 1): Organic Causes of Psychiatric Illnesses

Many times we can overlook the possibility of an organic condition causing psychiatric symptoms.  As a PSI coordinator I had the ability to observe several cases where a new mother had a severe condition that ‘mocked’ a postpartum depressive disorder.

The most striking was a mother whose baby was hospitalized with pneumonia at 14 days old.  The following week the mother was diagnosed with postpartum depression.  When she came home from her OB appointment, she found her bedroom ceiling on her bed, covered in black mold (stachybotrus).  This insidious condition was causing all types of depressive symptoms and it could have gone undetected if her ceiling had not given way.

Following is an excellent article reminding us that psychiatric disorders sometimes have underlying medical causes.  It will be published over five days and it includes special sections on anxiety, psychosis, and depression.  (I don’t know why the little smiley faces appear in the text, bear with it please). 

Be sure to click “SUBSCRIBE To” in the right-hand column to read each part of this series.

 

Editor’s note: The following is the finest article we have found on the subject of medical causes of severe mental symptoms. We are grateful to Dr. Diamond for his permission to reprint.The reader should note that this article only covers standard medical causes of mental symptoms and does not include many other physical causes, such as nutritional imbalances and metabolic abnormalities, listed in other articles on AlternativeMentalHealth.com.

It should also be noted that some studies have shown that, when extensive testing is done, medical causes may account for substantially more than 10% of patients with mental symptoms (particularly Hall [reporting a 46% causal connection], American Journal of Psychiatry, 1980 and Koranyi, Archives of General Psychiatry, 1979). Lastly, many clinicians believe that patients may suffer from medical conditions, such as hypothyroidism, that can be missed by standard medical lab tests and, therefore, be overlooked on studies applying standard medical screening.

 

Psychiatric Presentations of Medical Illness

An Introduction for Non-Medical Mental Health Professionals

Ronald J Diamond M.D.
University of Wisconsin Department of Psychiatry
6001 Research Park Blvd
Madison, Wisconsin 53719

Revised 1/7/2002

 

Introduction
Every time a patient comes into your office, your emergency room or your hospital, there is a very real possibility that what seems to be a psychological problem is caused by some physical illness. The depressed patient may have an under active thyroid gland. The patient with panic attacks may have a pheochromocytoma, a tumor that secretes epinephrine. And the patient, whose personality change and increased irritability is thought to be caused by his marital problems, may actually have a brain tumor causing the personality changes and exacerbating longstanding marital issues.

How common is this problem? Very…and not very. Most of your clients will not have a medical disease masquerading as an emotional problem. In fact, one of the problems is that most really serious medical illnesses are rare enough that we all get sloppy and stop looking for them. Most of the time our medical workups are unnecessary-but most of the time is not the same as all of the time. It is not necessary to live in abject terror about missing all of the patients with unsuspected medical illnesses that come to you with symptoms of depression or anxiety. On the other hand, medical causes of psychiatric symptoms should always be considered. As a mental health professional, you need to know enough about these medical illnesses to make some basic assessment about whether a further medical assessment is necessary and how to focus that assessment so as to make it as productive as possible.

Ex.-Johnson (1968) performed detailed physical exams on 250 patients admitted to an inpatient psychiatric unit. 12% of these patients were admitted to the psychiatric unit for problems that seemed to be caused by physical illness.

80% of these had been missed by physician before admission
6.6% were initially missed even after the admission workup
60% had abnormal physical findings

Ex.-Hall (1978) performed a detailed assessment on 658 consecutive psychiatric outpatients – 9.1% had a significant medical illness-

Ex.-Slater (1965) studied 85 patients (32 men and 53 women) diagnosed as having “hysteria” – follow up 7-11 years. More than a third proved to have organic disease

Ex.-Sox et. al. (1989) did a thorough medical evaluation on 509 patients in community mental health programs in California.- 200 (or 39%) had at least one active, important, physical disease, Staff at the mental health program was aware of only 47% of these. Research program discovered previously undiagnosed, important diseases in 63 of these patients. 14% had medical illness that was causing or exacerbating their mental illness

Ex.-Koran performed thorough medical assessments on 529 patients drawn from eight community mental health centers in California. 17% were found to have an organic condition that either caused or exacerbated the emotional symptoms for which the person was being treated.

Ex.-Bartsch et. al. performed a comprehensive evaluation on 175 clients from two Colorado CMHCs. A previously undiagnosed physical health problem was found in 20% of the clients. 16% had conditions that could cause or exacerbate their mental disorder. 19 clients had a metabolic abnormality (elevated calcium, etc.).
7 clients had a neurological disorder (memory loss, post concussion syndrome, etc.) 7 clients had an adverse medication effect. 4 clients had some other disorder, including cancer

Conservative estimates suggest that 10% of persons initially seen in outpatient settings for psychological symptoms have an organic disease causing the symptoms. This figure is higher in the elderly, in persons with certain diagnosis such as hysteria, and much higher in inpatient settings.

What can one do about it?

Even internists and neurologists, working in academic centers and aware of the possibility of organic illness, miss medical illnesses with disturbing frequency. There is no set of tests that can definitively rule everything out. Some illnesses are hard to diagnose, especially at the beginning. Others are so rare that they are not thought of so that the specific tests that would allow the diagnosis are not considered. Still other times the illnesses present atypically. The patient’s symptoms seem different than those described in the medical textbooks, so that a medical illness is missed.

The most common problem, however, is that we do not think about the possibility of medical illness and, therefore, we do not specifically look for medical illness. IF YOU DO NOT LOOK FOR IT, YOU WILL NOT FIND IT. The purpose of this paper is not to get you to the point of being able to diagnose every possible disease. Rather, it is to give you a starting point-to know when to be particularly suspicious (or worried), to know something about the most common illnesses, and to learn enough to communicate with the consulting physician so that you can make sure that your patient gets the best possible evaluation.

There are at least three problems with trying to present this kind of brief review for non-medical mental health professionals.

The first is that there are a huge number of different possible illnesses to worry about. I am not about to try to list all possible illnesses or to give complete descriptions but, rather, to get you to think about some of the common illnesses that you are most likely to see in your practice.

The second problem is that it is almost impossible to talk about medical illnesses without lapsing into medical jargon. This is half a paper about medical illnesses, and half a paper on learning a new language that will hopefully help you when you need to communicate to other physicians.

The third problem is both more subtle and more serious. Non-medical mental health professionals organize the world according to psychological symptoms. The question is, what medical illnesses can cause depression, anxiety, etc.? The problem is that the depression caused by a brain tumor may be identical to the depression caused by marital discord or by an endogenous depression. What is likely to be different is the patient’s history and the associated signs and symptoms apart from the depression. Unfortunately, listing illnesses according to which ones can cause depression or which ones can cause anxiety does not produce a coherent organization. Many illnesses can cause many different psychological symptoms. More importantly, such a listing would not help to understand what other questions to ask to help separate physical from psychological illnesses.

Physicians organize the world much differently. The easiest way to remember all of the separate facts and to see patterns is to organize illnesses according to physiological systems. Throughout this paper I will keep talking about endocrine systems, neurological systems and cardiopulmonary systems. For someone who has been through medical school, this becomes the obvious way to organize things, but it is not always so obvious for the rest of the world. The problem with categorizing according to psychiatric symptoms will become obvious as you go through this paper. A huge number of illnesses can present as depression, and the vast majority of these illnesses can also present as anxiety or delirium. It does not do much good to think about the list of illnesses that can present as depression unless you begin to think about some of the other associated symptoms that those illnesses also have-and the best way to organize these associated symptoms is to understand what organ systems the illness effects.

Having said all of that, I will try to organize illnesses by their psychological effects, and, at the same time, try to introduce the way that physicians would organize their thinking about those illnesses.

 

Be sure to read tomorrow for Part 2.

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