Series (Part 5): Organic Causes of Psychiatric Illness

 Thanks to Suzanne Swanson for alerting me to errors with the posting of this series.  Here is a re-post of Part 5 of Organic Causes of Psychiatric Disorders

Section IV
Depression

A. Differential Diagnosis: Psychiatric Illness

1. Primary Affective Disorders
a. Major depression, either single episode or recurrent bipolar disorder
b. Dysthymia
c. Adjustment disorder with depressed mood
d. Bereavement

2. Depression Secondary to other Functional Disorders
B. Medical Illnesses that can present as Depression
1. Post viral depressive syndromes: especially influenza, infectious mononucleosis, viral hepatitis, viral pneumonia, and viral encephalitis

2. Cancer
a. Cancer of the pancreas commonly presents as depression
b. Lung Cancer, especially oat cell carcinoma
c. Brain tumors, either primary tumors or metastastic, may present with depression

3. Cardiopulmonary disease with hypoxia (decreased oxygen in the blood): acute hypoxia often leads to symptoms resembling anxiety or panic. Chronic hypoxia may present with lassitude, apathy, psychomotor retardation and other symptoms confused with depression.

4. Sleep apnea: should be suspected in a patient with sleep disturbance and daytime somnolence

5. Endocrine Disease
a. Hypothyroidism (under active thyroid): causes a general slowing of all body functions. Patient complains of fatigue, weight gain, constipation, and, when asked, will describe cold intolerance, dry skin and hair, and hoarseness or deepening of the voice. Often very insidious but easily diagnosed and treated ONCE SUSPECTED.
b. Hyperthyroidism or thyrotoxicosis (overactive thyroid): usually associated with anxiety but may present as depression, especially in the elderly who may have few classical signs of thyroid disease.
c. Adrenal hypofunction (Addison’s Disease): often presents with weakness and fatigue, along with low blood pressure and hyponatremia (low serum sodium) and hyperkalemia(increased serum potassium).
d. Adrenal hyperfunction (Cushing’s Disease): either from steroid medication, pituitary, adrenal or other ACTH secreting tumors. Various affective disturbances, either depression or mania, are common. Syndrome is marked by truncal obesity, hypertension, puffy face, and hirsutism.
e. Hyperparathyroidism: usually from small tumors of the parathyroid glands. Early symptoms develop insidiously and can include lassitude, anorexia, weakness, constipation and depressed mood. The classic symptoms of bone pain and renal colic often develop only years later.
f. Post-partum, post menopausal, and premenstrual syndromes.

6. Collagen-Vascular Diseases
This is a strange set of different diseases where the person essentially becomes allergic to parts of their own body. It can affect all parts of the body and can, at times, cause death.

Systemic lupus erythematosus (SLE) is most often seen in women 13-40 years old. It often presents initially with nonspecific symptoms such as fatigue, malaise, anorexia and weight loss, all of which can lead to the diagnosis of functional depression.

7. Central Nervous System Disease
a. Multiple Sclerosis
b. Brain tumors and other intracranial masses (masses inside of the skull) such as subdural hematomas (bleeding under the dural sack that surrounds the brain): masses, especially in the frontal and temporal areas, can grow for years and cause psychiatric symptoms before any focal neurological abnormality is apparent.
c. Complex partial seizures: ictal-repetitive behaviors during the seizure, interictal-personality changes between seizures, increased lability of emotions, quick to anger, increased preoccupation with religion, hypergraphia (increased writing).
d. Strokes, especially effecting left side of brain (right side of body)
C. Medications that can cause Depression
Ex.-Katerndahl found that 43% of patients diagnosed as depressed in a family practice clinic were taking medications that can cause depression.

1. Interferon (for treatment of hepatitis C infections)
2. Antihypertensive medications (drugs used to control high blood pressure): reserpine and alpha-methyldopa are probably the worst, but propranolol has been implicated and all antihypertensives are suspect
3. Digitalis preparations, along with a variety of other cardiac medications
4. Cimetidine: used for gastric ulcer disease
5. Indomethacin and other non-steroidal anti-inflammatory medications
6. Disulfuram (Antabuse): usually described by patients as more a sense of fatigue than true depression
7. Antipsychotic medications: can cause an akinesia or inhibition of spontaneity that can both feel and look like a true depression. This is much less common with the newer “atypical” antipsychotic medications
8. Anxiolytics: all sedative hypnotics from the barbiturates to the benzodiazepines have been implicated both in causing depression and making it worse in susceptible individuals
9. Steroids, including prednisone and cortisone
D. Drugs of abuse that can cause depression
1. Alcohol: very commonly a cause of depression, as well as a reaction to depression
2. Stimulant withdrawal

Bibliography
Books:
Cummings, JL. Clinical Neuropsychiatry, Grune & Stratton, 1990.
Hall, R.C.W. (ed). Psychiatric Presentations of Medical Illness, SP Medical and Scientific Books, NY, 1980.
Jefferson, J.W. and Marshall, J.R. Neuropsychiatric Features of Medical Disorders, Plenum Medical Book Company, NY, 1981.
Soreff, S.M. and McNeil Handbook of Psychiatric Differential Diagnosis, PSG Publishing Company, Littleton, MA, 1987.
Taylor, R.L. Mind or Body: Distinguishing Psychological from Organic Disorder: Screening for Psychological Masquerade. Springer Publishing, 1990. (This book is specifically written for the non-medical mental health professional.)

Articles:
“Drugs that Cause Psychiatric Symptoms”, The Medical Letter, July 23, 1993.

Dietch, J.T. “Diagnosis of Organic Anxiety Disorders”, Psychosomatics 22:8, August, 1981.

Johnson, R., and Ananth, J. “Physically Ill and Mentally Ill”, Can J Psychiatry, vol. 3l, April, 1986.

Sox, CH et. al. “A Medical Algorithm for Detecting Physical Disease in Psychiatric Patients”, Hosp and Comm Psych 40 (12), Dec 1989, 1270-1276.

Summers et al. “The Psychiatric Physical Examination”, J Clin Psychiatry 42:3, March, 1981.

Weinberger, Daniel R. “Brain Disease and Psychiatric Illness: When Should a Psychiatrist Order a CAT Scan?” Am J Psychiatry 141:12, Dec. 1984.

Weissberg, M.P. “Emergency Room Medical Clearance: An Educational Problem”, Am J Psychiatry 136:6, June, 1979.
Wise, MG and Taylor, SE. “Anxiety and Mood Disorders in Medically Ill Patients”, J of Clin Psychiatry, vol 51, supplement Jan 1990.

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