Series (Part 4): Organic Causes of Psychiatric Illness

Thanks to Suzanne Swanson for pointing out errors with this series.  Today and Wednesday I will re-post parts 4 and 5.

Organic Causes of Psychiatric Disorders (part 4)

Section III
Anxiety

A. Think About the Phenomenology of Anxiety
1. Psychological manifestations: Inner feelings of terror, tension, apprehension and dread, derealization, depersonalizations, fear of impending insanity

2. Intellectual disturbances: Decreased concentration, disorganized thinking, sensory flooding

3. Somatic manifestations: Autonomic or visceral symptoms, including palpitations, chest pain, tachycardia, fatigue, weakness, perspiration, flushing, numbness, tingling of extremities, vertigo, shortness of breath, headache, blurred vision, tinnitus, diarrhea, tremor, fainting
B. Differential Diagnosis of Anxiety
1. Primary anxiety disorders
o Panic disorder with or without agoraphobia
o Social phobia and other simple phobias
o Obsessive-compulsive disorder
o Post-traumatic stress disorder
o Generalized anxiety disorder
o Adjustment disorder with anxious mood
o Depression may be a secondary feature

2. Other mental illness that can present as anxiety
o Psychosis
o Agitated Depression
o Manic-depressive disorder (depressed phase)

3. Hyperventilation syndrome
C. Medical illness presenting with anxiety
Strongly suspect medical cause for anxiety in patients younger than 18 or older than 35 who suddenly develop anxiety which disrupts their normal activity and who have an otherwise negative psychiatric history (Hall 1980).

1. Anxiety secondary to organic brain syndromes
o Apt to have a labile mood
o Confusion which may be confused with psychosis
o Mental status exam should demonstrate cognitive deficits, especially memory deficits
-delirium
-dementia

2. Other neurological illnesses (25% of medical causes of anxiety symptoms)
a. Cerebral vascular insufficiency: transient ischemi attacks lasting from 10-15 seconds up to an hour (brief blocks in the arteries to the brain causing temporary loss of brain blood supply)
b. Anxiety states and personality change following head injury
c. Infections of the central nervous system
o Meningitis: fever, stiff neck, and delirium
o Neurosyphilis: may present as almost anything
d. Degenerative disorders
o Alzheimer’s dementia
o Multiple sclerosis: may be marked early on by vague and changing medical complaints
o Huntington’s chorea: may present early as anxiety or other functional disorder before the movement disorder is evident-always has a positive family history
e. Toxic Disorders
o Lead Intoxication: loss of appetite, constipation and colicky abdominal pain followed by irritability and restlessness
o Mercury intoxication: from contaminated fish
o Manganese intoxication: from industrial exposure
o Organophosphate insecticides (similar to nerve gas): from chemical or insecticide exposure
f. Partial complex seizures

3. Endocrine disorders (25% of medical causes of anxiety symptoms)
a. Hyperthyroidism (increased thyroid hormone) commonly presents as anxiety, but may present as depression and is one of the most common endocrine abnormalities. Most common in 20- to 40-year-old women. The anxiety of hyperthyroidism may present with manic-like euphoria or agitation, along with weight loss, heat intolerance, rapid pulse, fine intention tremor and often exophthalmoses (bulging of the eyes caused by abnormal deposition of fat behind the eyeball).
b. Adrenal hyperfunction or Cushing’s syndrome: has a variety of causes, including tumors of the pituitary or adrenal glands or from steroids given to treat other illnesses. There is often a change in fat distribution with dorsal (back) hump, round face and thin arms and legs, hirsute (abnormal hairiness), acne, decreased menstruation in women and impotency in men.
c. Hypoglycemia (decreased blood glucose): usually associated with a history of diabetes and insulin or other hypoglycemic medications. Rarely from an insulin secreting tumor. Hypoglycemia as a response to dietary carbohydrate challenge is probably over diagnosed, and associated symptoms may not always be due to changes in blood glucose.
d. Hypoparathyroidism (decreased parathyroid hormone): almost always associated with a history of thyroid surgery. It often presents with overwhelming anxiety, either with or without personality change.
e. Menopausal and premenstrual syndromes.

4. Cardiopulmonary disorders: Often presents with shortness of breath, rapid breathing, complaints of chest pain, chest pain that are worse with exertion.
a. Angina
b. Pulmonary embolus
c. Arrhythmias (irregularities of heart beat)
d. Chronic obstructive pulmonary disease (COPD)
e. Mitral valve prolapse (generally harmless)

5. Pheochromocytoma (epinephrine secreting tumors)
D. Medications as a cause of anxiety
TAKE A CAREFUL AND DETAILED HISTORY.
o ask about all drugs that a patient is taking, licit and illicit, prescribed and over the counter
o ask about all illnesses that a patient has had
o asthmatics take combinations of sympathomimetics and xanthines (aminophylline, theophylline)
o patients with allergies may take ephedrine
o patients with diabetes may be hypoglycemic from their insulin
o thyroid preparations may be prescribed for thyroid illness, following thyroid surgery (from years ago), or even for weight loss

1. Non-psychotropic medications
a. Sympathomimetics (often found in non-prescription cold and allergy medications): epinephrine, norephinephrine, isoproteronol, levodopa, dopamine hydrochloride, dobutamine, terbutaline sulfate, ephedrine, pseudo-ephedrine
b. Xanthene derivatives (asthma medications, coffee, colas, over-the-counter pain remedies): aminophylline, theophylline, caffeine
c. Anti-inflammatory agents: indomethacin
d. Thyroid preparations
e. Insulin (via hypoglycemic reaction)
f. Corticosteroids
g. Others: nicotine, ginseng root, monosodium glutamate
h. Drug withdrawal: caffeine, nicotine

2. Psychotropic medications
a. Antidepressants (including MAO-inhibitors), drugs for treatment of attention deficit disorders (on rare occasions cause anxiety-type syndromes)
b. Tranquilizing drugs: benzodiazepines (paradoxical response most common in children and in elderly), antipsychotics (akathisia may present as anxiety)
c. Anticholinergic medications can cause a delirium which, in early stages, may easily be confused with anxiety: scopolamine and sedating antihistamines (found in over-the-counter sleep preparations) antiparkinsonian agents, tricyclic antidepressants, antipsychotics

3. Drugs–licit and illicit
a. Caffeine-intoxication or withdrawal
b. Nicotine-withdrawal even more than acute intoxication
c. Stimulants-cocaine, amphetamines, etc.
d. Alcohol or alcohol withdrawal

E. Drug withdrawal is a common cause of anxiety type syndromes
A large number of drugs can cause withdrawal states with symptoms of anxiety or even agitation. All sedative hypnotics, tricyclic anti-depressants and anti-cholinergics can cause withdrawal.

Be sure to read tomorrow’s post Part 5: Depression

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