Series (Part 2): Organic Causes of Psychiatric Illness

Section I
General ApproachA. Always consider the possibility of organic disease- If you do not look for it you will not find it.

1. Be suspicious of “medical clearance”.

Unfortunately, physicians tend to dismiss psychiatric patients for several reasons. There is a tendency to assume that all psych patients are just “nuts” without “real illness”. Physicians are often uncomfortable around patients who are obviously depressed or who are acting bizarrely, or who they are afraid might act bizarrely. At times these patients behave in ways that make evaluation more difficult, either by being unwilling to give a full history, unable to give an accurate description of symptoms, or too frightened to allow a full physical examination.

2. People with schizophrenia get sick too.

The fact that someone is actively psychotic does not mean that they do not also have a serious medical illness. One should always be concerned that a medical illness might, in fact, be the cause of the psychosis. But even in patients who clearly have schizophrenia or some other diagnosable mental illness and who have had an excellent medical workup in the past, it is important to consider whether their current complaints or recent change in behavior could be related to a medical illness. In fact, psychotic patients are more difficult to evaluate, and if they do happen to have a serious medical illness, it is more likely to get missed.

Studies have demonstrated that disliked patients are more likely to have an undiagnosed organic brain syndrome than more likable patients, and it is just those disliked patients that will often get the most cursory and incomplete physical evaluation. My guess is that patients who are most different from their physicians are also more likely to have a medical illness missed, and this is especially true of psychiatric patients.

3. Be alert for presentations, which make medical illness more likely-but do not stop considering medical illness just because these are not present.
o a patient over 40 with no previous psychiatric history
o no history of similar symptoms
o coexistence of chronic disease
o a history of head injury
o a change in headache pattern
o a patient who gets worse when given antipsychotic or anxiolytic medications

4. Look for symptoms, which make medical illness more likely.

o a change in headache pattern
o visual disturbances, either double vision or partial visual loss
o speech deficits, either dysarthrias (problems with the mechanical production of speech sounds) or aphasias (difficulty with word comprehension or word usage).
o abnormal autonomic signs (blood pressure, pulse, temperature)
o disorientation and/or memory impairment
o fluctuating or impaired level of consciousness
o abnormal body movements
o frequent urination, increased thirst (possible symptoms of diabetes)
o significant weight change, gain or loss

5. Do not assume that a certain symptom “must” be of psychological origin.
For example, it used to be thought that male impotence was almost always a psychological problem. A recent study of 105 impotent men reported that 75% had impotency based either on a medical illness such as diabetes mellitus, or were using drugs that were likely to cause impotence. Of 34 men with hormonal problems who accepted medical treatment, 33 had return of sexual function. Fourteen of these men had previously undergone psychotherapy for this same problem.

B. Be Holistic

A psychiatric assessment should include the whole person, including the medical history and physiology of that person. This is needed to rule out a medical illness, but also so that you can understand the person’s current feelings and functioning within the context of what has happened to the person in the past and what is happening now.

Much of the information that you need to suspect a medical illness is readily available as part of a psychiatric assessment. It is important to know how to organize this information so that it is useful, and to fill in gaps in your information so that important areas are not missed. (Note that a comprehensive psychiatric evaluation would include additional areas such as personal developmental history and current social support system, in addition to the assessment areas discussed below.)

1. Symptoms
o Start with a clear description of all of the patient’s symptoms.
o How did they begin? How long has he had them? What has the progression of symptoms been like?
o Include a careful review of other “extraneous” symptoms the patient may have-starting at the top with questions about headache and dizziness and ending at the bottom with questions about leg sores and trouble walking. This “review of systems” is an extremely important part of a medical assessment.

2. History
o Include history of similar problems in the past
o History of past medical problems including all medical hospitalizations and surgeries
o Family history, both medical and psychiatric

3. Current medical status
o Ask about all current medical illnesses
o Ask about all current medications (Include specific questions about vitamins, birth control, over the counter meds, etc.)
o Ask about past medical problems, past surgeries, past medical hospitalizations
o Ask about any head injury, coma, periods of unconsciousness, seizures.
o Obtain name of person’s physician–date of last contact–for what purpose

4. Current habits
o Ask about drug use, starting with questions about tobacco, caffeine and alcohol and proceeding on to questions about other drugs
o Ask about exercise and activity patterns, sleep patterns

5. Observation.
The assessment starts when you first meet the patient, not when you first sit down to begin talking in your office.
o General appearance: How does the person look? How are they dressed? Do they appear ill? Then go to more specific observations.
o Skin: Is it very dry or abnormally colored? Extremely pale skin or lips may suggest anemia. A yellow skin may indicate jaundice and liver disease. Dry skin and hair may be a sign of hypothyroidism.
o Eyes: Are they focused? Are the pupils equal? Are they aligned with each other? Differences in pupil size may indicate brain masses such as tumors. Wildly dilated pupils may indicate a variety of drugs including hallucinogens, stimulants, and anticholinergics. Constricted pupils may indicate opiates. Bulging eyes can be a sign of hyperthyroidism.
o Observe body movement to rule out weakness, clumsiness, ataxia, facial asymmetry, asymmetry of movements, choreiform movements (“worm-like” or other involuntary movements, usually occurring less than 2 times/second), tremors. Observe for other neurological abnormalities such as motor stereotypy (repetitive stereotyped movements).
o Gait disturbance is a very common finding in a wide range of medical conditions.
Dubin (1983) studied 1140 patients cleared medically on a psychiatric service.
o 38 subsequently found to have a medical illness
o 14 of the 38 had either gait disturbance, weight loss, hypertension, abnormal vital signs or significant medical history

6. Mental status examination
o appearance
o degree of cooperation
o presence of perceptual distortions (hallucinations and illusions)
o mood (both appropriateness and quality)
o speech (both quality and content)
o motor activity
o general cognitive abilities
– attention
– memory
– judgment
– fund of knowledge
o Also consider evidence of specific neurological deficits:
– aphasias (difficulties with speech) can be broken down into
v word finding difficulties (nominal aphasias)
v difficulty understanding speech (receptive aphasias) or
v difficulty producing speech (expressive aphasia)
– agnosias (recognition of complex shapes)
– apraxias (execution of proper manipulation of objects)
– perseveration (inability to switch tasks or mental sets)
Each of these can occur with varying degrees of severity.

7. Physical exam.
A full physical examination is obviously not possible if you are not a physician, and even psychiatrists rarely perform a physical examination themselves. Some parts of a physical examination are easy, even for non-physicians.
o Blood pressure, preferably lying and standing (or you can ask a patient about any recent blood pressure checks, or ask them to get their blood pressure taken at one of the blood pressure machines that seem to be in every bank and drugstore)
o Pulse for evaluation of rate and arrhythmias (irregularities of heart rhythm)
o Check eyes to see if they move equally and fully in all directions, equal and reactive pupils, and nystagmus (small “jerky” movements of eyes when client looks up or to the side)
o Assessment of the condition of the patient’s skin, looking for such things as dryness, dehydration, nutritional status, rashes, edema, petechiae

A useful screen for picking up physical disease in psychiatric patients includes:
o Laboratory tests: TSH (thyroid test), CBC (complete blood count), SGOT (liver function test), Fasting glucose [or random glucose if fasting not possible] (screen for diabetes), serum albumin, serum calcium, vitamin B12, and urinalysis
o History of epilepsy, emphysema, asthma, diabetes, thyroid disease, history of blood or pus in the urine, or history of high blood pressure
o HIV positive or history of high risk behavior for HIV
o Symptoms of chest pain while at rest, headaches associated with vomiting or loss of control of urine or stool
o Physical findings of high blood pressure
(adapted from Sox et al 1989)

C. Develop a “differential diagnosis” that systematically considers possible medical illnesses. Consider all of the medical illness that could fit the set of symptoms. What further information would help distinguish between these various possibilities?
o As a way of organizing your information about the patient
o focusing your attention
o and targeting what further information is needed.

The goal is not to come up with a specific diagnosis. The goal is to organize the data that you collect about the patient so that you can decide what to do next, how worried you need to be, and when and how and what to say to your consulting physician if you decide further medical assessment is necessary.

The basic mental health assessment must, of course, be supplemented with appropriate outside consultation, which will include a physical examination and appropriate laboratory tests, but this should be focused by the differential diagnosis. BOTH YOU AND THE DOCTOR ARE MORE LIKELY TO FIND IT IF YOU ARE LOOKING FOR SOMETHING SPECIFIC THAN IF YOU ARE GROPING RANDOMLY. For Example:
o with “hysterical” symptoms, consider MS
o with mental status changes occurring over days to weeks, together with alcoholism or chronic headache, consider subdural hematoma (slow bleed inside the skull under the dura membrane that covers the brain)
o with depression along with weight gain, ask about cold intolerance and dry skin and consider hypothyroidism

Laboratory and other diagnostic tests should be used to pursue specific parts of the differential diagnosis list. Diagnostic tests are much more likely to give useful results when you and the doctor are clear what question you have in mind and what specific test is needed to answer that specific question. For Example:
o EEG detects abnormal brain function
o CAT scan detects abnormal anatomy

If you are asking for a “drug screen” to find out if the client has recently used an illicit drug, find out if your laboratory can measure the drug or drugs that you expect this person might be using, and whether blood or urine tests are better depending on the particular drug and time since ingestion. Most labs can test for the presence of cocaine, but LSD is used in much smaller amounts and may not be detectable even if recently used. This kind of question can be answered by a call to the chemistry lab of the local hospital, but such a call requires that you step out of your typical “non-medical” role and interact with a strange and often forbidding medical system.
D. Work with and actively involve the consulting physician.
At different times with different doctors and different clinical situations this will mean different things. It always means making the consultation request as clear as possible. What kind of answer do you want back from the doctor? What are you most worried about? What information do you already have about the client? You might think that your job is just to get the client to see the doctor, and the rest of the job is up to the doctor. This is true-and not true. The doctor will typically spend less than 15 minutes with the patient to collect a history, do the physical, order the tests and write a note in the chart.

If the client is less than articulate, important information is likely to get lost. This is a particular problem with older clients, those who are hard of hearing or who have other communication problems, or those who are less organized or less clear in their thinking. It is also a problem when the symptoms you want evaluated are vague, or your concerns leading to the referral do not relate to a particular “medical” symptom. Your job must include organizing the information that you have collected and transmitting it to the doctor in such a way as to do your client the most good.

Telling the client to see his local doctor, or phoning the local internist with a request to “Please do a physical exam on this client.” is much less likely to lead to a reasonable consultation result than a request, “This client has a depression that seems very atypical. Could you please see if there could be a medical illness involved?” Or even better yet, “This patient is complaining of depression with decreased energy level, but he is also complaining of increased weight, cold intolerance, decreased libido and extremely dry skin. He was treated for hyperthyroidism 15 years ago. Could you see if any thyroid problems or any other medical problems might be increasing his depression?”

Most of the time you will not be able to frame a consult request with as much detail as this last example-but in all cases the more the better. Often, the referral to the physician is based on a pattern suggesting a higher probability of medical illness, rather than any particular symptom suggesting a particular illness. For example, any client who initially develops psychiatric symptoms over the age of 40 should have a medical workup. If this is the reason you are referring the client, then the physician needs to have that information.

Finally, there are differences of communication styles between mental health professionals and physicians. The social worker or psychologist is likely to want to give the physician a complete description of the patient and the problem in a phone discussion that may go on for many minutes. The physician is likely to be in the middle of office hours, with a clinic full of patients waiting to be seen. A brief, succinct and very focused description and problem statement with a focused consultation request is likely to be better received by a physician than the more complete communication often expected between psychotherapists.

Common assumptions that lead to missed diagnosis:
o mistaking symptoms for their causes
o listening without fully considering all possibilities
o equating psychosis with schizophrenia
o relying on a single information source

Be sure to read tomorrow’s post, Part 3- Psychosis.

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Comments
One Response to “Series (Part 2): Organic Causes of Psychiatric Illness”
  1. Heath says:

    I’m not one to bother with a reply to a post but that was excellent!

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