Series (Part 3): Organic Causes of Psychiatric Illness

Section II
Psychosis-
Patients that Appear Out of Touch with RealityA. Consider Organic Disease
If you do not look for it you will not find it. Be suspicious of “medical clearance”.

1. Other symptoms that suggest organic disease include:
o a patient over 40 with no previous psychiatric history
o hallucinations that are visual and vivid in color, that change rapidly
o olfactory (smell) hallucinations
o illusions: misinterpretations of stimuli
o large recent weight changes

2. A brief, minimal neurological exam can be easily and rapidly done, even on very agitated patients (even by someone who is not a physician).
o Observe gait and body movement to rule out weakness, paralysis, ataxia and other gait disturbances and choreoathetoid movements
o Check eyes:
– Make sure pupils are equal and reactive to light.
– Check to see if eyes move fully in all directions.
– Check for vertical and horizontal nystagmus: refers to rapid movements of jerking of the eyes, and can be either up and down (vertical) or back and forth (horizontal). It is most easily seen if the client is asked to look up or over to the side as far as possible. Nystagmus is frequently present with drug intoxications, and vertical nystagmus is never a normal finding in functional psychosis.
o Observe face for asymmetries.
o Observe speech for slurring, aphasias, word finding difficulties, and perseveration.

The above observations are possible on a completely uncooperative patient. Summers et. al. have outlined a very rapid physical exam for screening purposes (see bibliography).

3. Consider medical emergencies that can present as psychiatric illness
a. Hypoglycemia (low blood sugar): symptoms can be variable and include delirium or coma. Can include palpitations, sweating, anxiety, 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.
b. Diabetic Ketosis or non-ketotic hyperosmolarity (blood sugar so high that it upsets body chemistry): delirium with history of diabetes, increased breathing, sweet smell of acetone on breath (can be mistaken for smell of alcohol), dehydration, decreased blood pressure.
c. Wernickes-Korsakoff’s syndrome: acute thiamine (vitamin B6) deficiency so severe that it can cause rapid brain damage. Usually found in alcoholics. Symptoms include nystagmus (rapid small jerking movements of eyes), cerebellar ataxia (person moves as if drunk), evidence of peripheral neuropathy, ocular palsies (inability to move both eyes together in all directions) If in any doubt, give thiamine l00 mg. IM. This is not diagnostic but will prevent any further brain damage.
d. DT’s (delirium tremens): drug withdrawal from alcohol or other sedative hypnotics. Frequently missed and can be medically very serious. Symptoms include elevated autonomic signs, agitation, visual and tactile hallucinations and history of alcohol abuse. Onset is usually three to four days after reduction or discontinuation of alcohol.
e. Hypoxia (low blood oxygen): from pneumonia, heart attack, COPD (chronic obstructive pulmonary disease), arrhythmias (abnormal heart rhythm), etc.
f. Meningitis (infection of the covering of the brain): be alert for stiff neck and fever.
g. Subarachnoid hemorrhage (rapid arterial bleeding into the brain): stiff neck, fluctuating consciousness and headache. If there is a fluctuating consciousness along with stiff neck and headache, a spinal tap for diagnosis needs to be done immediately.
h. Subdural hematoma (bleeding from veins under the outside covering of the brain, which compresses the brain over hours to weeks or even longer): symptoms are variable but frequently (not invariably) there is a history of head trauma.
i. Anticholinergic (atropine) poisoning: from overdose of tricyclics or over-the-counter drugs, or from organophosphate insecticides. Classic symptoms include:
o Flushing “red as a beet”
o Mouth dry “dry as a bone”
o Dilated pupils “blind as a bat”
o Delirious “mad as a hatter”
These patients will also have increased pulse and sometimes elevated blood pressure. Most fatalities are from cardiac arrhythmias, although seizures are not uncommon.
B. Differentiate psychosis from delirium
Psychosis refers to an impairment in reality testing because of hallucinations, delusions or grossly disorganized thinking. Psychosis can be caused by organic diseases where we know the cause or by a variety of mental illnesses ranging from a brief reactive psychosis to schizophrenia.

Delirium refers to an acute organic brain syndrome causing a global cognitive impairment, with disorientation, memory impairment, and disturbance of consciousness. Illnesses causing deliriums are often life threatening, and a delirium should be considered to be a medical emergency.
Symptoms of delirium include:
o disorientation or memory impairment
o fluctuating or impaired level of consciousness, decreased awareness of environment
o labile affect
o impaired judgment or impaired insight
o abnormal autonomic signs (changes in blood pressure, pulse, temperature, abnormal sweating, flushing, etc)

DSM IV Diagnostic criteria for Delirium
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition. (From DSM-IV, 4th edition 1994, APA Press)
C. Medical Illnesses that Can Present as Psychosis

1. Progressive neurological diseases
a. Multiple sclerosis: no typical signs or symptoms. It may begin very suddenly and affect any part of the neurological system. Early in its course, diagnosis may be extremely difficult.
b. Huntington’s chorea: hereditary illness that includes movement disorder but can present with psychosis initially.
c. Alzheimer’s disease and Pick’s disease: progressive diseases that cause dementia, but can initially present in a wide variety of ways. Alzheimer causes diffuse dementia, while Pick’s primarily affects the frontal lobes of the brain.

2. Central nervous system infections
a. Encephalitis (viral infection of the brain-usually Herpes Simplex): usually presents with fever and seizures, but various mental symptoms including catatonia or psychosis may present before any clear cut neurological symptoms. Usually has a fluctuating mental status.
b. Neurosyphilis (syphilis of the central nervous system).
c. HIV infections: HIV encepalopathy commonly includes apathy, decreased spontaneity and depression and may present before any other signs of AIDs are present. AIDS can also first present as delirium with paranoia and other prominent psychotic features.

3. Space occupying lesions within the skull
a. Brain tumors
b. Bleeding within the skull
c. Brain abscess

4. Metabolic disorders
a. Accumulation of toxins from severe liver or kidney disease.
b. Disturbances in electrolytes, either too low a serum level of sodium or too high a serum level of calcium.
c. Acute intermittent porphyria (disease of porphyrin metabolism): very rare, but may present as classical psychosis. Often has abdominal pain or other gastrointestinal symptoms such as vomiting.
d. Wilson’s disease: abnormality of copper metabolism that causes damage to brain and liver if untreated.
e. Systemic lupus erythematosis (autoimmune disease): usually a slowly progressive illness with joint and muscle pain, but it can present very suddenly. The nervous system is commonly involved and can present with depression, dyscontrol syndromes (unexpected impulsive or aggressive behavior), or psychosis.

5. Endocrine disorders
a. Myxedema (underactive thyroid gland-hypothyroidism)
b. Cushing’s syndrome (too much cortisol caused by overactive adrenal gland or overactive pituitary gland)
c. Hypoglycemia, either from insulin secreting tumor or administration of insulin

6. Deficiency states
a. Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome
b. Pellegra (nicotinic acid deficiency) and other B complex deficiencies
c. Zinc deficiency

7. Temporal lobe epilepsy (or partial complex seizure disorder)

8. Drugs-
a. prescription
· oL-DOPA
· oAmphetamine
b. illicit drugs
· cocaine, crack, methamphetamine, stimulants
· hallucinogens
D. Consider other mental illness in addition to schizophrenia
Not all psychosis is schizophrenia. Do not over diagnose. Without a history, it is impossible to distinguish an acute psychotic episode that will rapidly resolve from an exacerbation of schizophrenic illness that will continue to be an ongoing problem.

 

Be sure to read tomorrow’s post Part 4: Anxiety

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Comments
One Response to “Series (Part 3): Organic Causes of Psychiatric Illness”
  1. Ken says:

    I have reactive hypoglycemia. Before it was diagnosed I was told I had stress (“all in my head”). I wish the ER people had read this article and given me dextrose instead of Valium! Thanks for posting this. Steph (my blog http://www.reactivehypoglycemia.info)

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