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Psychiatric Mimics Medical diagnoses that Manifest as Psychiatric Symptoms

Psychiatric Mimics Medical diagnoses that Manifest as Psychiatric Symptoms. Derek S. Mongold MD Resident in Psychiatry and Family medicine 01-20-09. Objectives. Show importance of searching for and ruling out medical causes of psychiatric illness

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Psychiatric Mimics Medical diagnoses that Manifest as Psychiatric Symptoms

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  1. Psychiatric MimicsMedical diagnoses that Manifest as Psychiatric Symptoms Derek S. Mongold MD Resident in Psychiatry and Family medicine 01-20-09

  2. Objectives Show importance of searching for and ruling out medical causes of psychiatric illness Familiarize audience with general principals that point toward a medical causes of psychiatric illness Review specific diseases often mentioned in psychiatric literature www.DerekMongold.com

  3. Overview • Importance of ruling out Medical Mimics • General Principles • Mnemonics • ROS and physical exam examples • Specific diseases • Conclusion www.DerekMongold.com

  4. Importance of Ruling Out Medical Mimics 5-42% of patients referred for psychiatric treatment have an underlying medical illness responsible for their symptoms.1 Conservative estimates suggest 10% of persons in outpatient settings have an organic disease causing the symptoms. 2 Higher in the elderly and much higher in inpatient settings. www.DerekMongold.com

  5. Importance of Ruling Out Medical Mimics Johnson (1968) performed detailed physical exams on 250 patients on an inpatient psychiatric unit2 12% had problems that seemed to be caused by physical illness 80% of these had been missed by a physician before admission 6.6% were initially missed even after the admission workup www.DerekMongold.com

  6. Importance of Ruling Out Medical Mimics Sox et. al. (1989) did a thorough medical evaluation on 509 patients in community mental health programs in California2 14% had medical illness that was causing or exacerbating their mental illness Koran performed thorough medical assessments on 529 patients drawn from eight community mental health centers in California2 17% were found to have an organic condition that either caused or exacerbated the their mental illness www.DerekMongold.com

  7. Importance of Ruling Out Medical Mimics Bartsch et. al. performed a comprehensive evaluation on 175 clients from two Colorado CMHCs2 16% had conditions that could cause or exacerbate their mental disorder www.DerekMongold.com

  8. General Principles Lecture will focus on two common settings where it is important to rule out general medical conditions Emergency room evaluations for diagnosis and “medical clearance” Outpatient clinic visits www.DerekMongold.com

  9. Case Study ED consults you for a 49 yo female with new onset anxiety and panic She told the ED resident she would rather be dead than to continue feeling the way she does When you interview her, she continues to make vague suicidal threats and refuses to go home www.DerekMongold.com

  10. Case Study Since you have 4 other consults pending, you decide it would be easiest to admit her, and you quickly finish an H&P In your haste, you failed to realize she smoked and was on OCP’s. She was also tachypnic and had a resting tachycardia After admission, nursing staff paged to tell you she was getting “agitated” from lack of treatment and wondered if you could give her something www.DerekMongold.com

  11. Case Study You order Ativan, which causes her to “rest comfortably” the rest of the night In the morning you realize she will be “resting comfortably” for quite a long time. www.DerekMongold.com

  12. General Principles • Symptoms that suggest psychiatric illness • Past psychiatric history • Flat or blunted affect • Alert and oriented • Gradual onset • Progressive course without fluctuations • Abnormal thought process (esp. thought blocking. Circumstantial and tangential thinking are less reliable) www.DerekMongold.com

  13. General Principles Symptoms that suggest psychiatric illness Medication noncompliance Family history Few or no medical conditions Past history of trauma or abuse Good response to typical treatments Typical symptoms Auditory hallucinations www.DerekMongold.com

  14. General Principles Symptoms that suggest psychiatric illness Onset is age appropriate Anxiety disorders (extremely variable age of onset, however) GAD: Usual onset is adolescence or early adulthood3 Social Phobia: Peak onset in teens with common onset 5-353 Panic disorder: Mean age of presentation is 25 years3 OCD: Mean age of onset is 203 Depression 50% of patients experience first episode before age 403 www.DerekMongold.com

  15. General Principles Symptoms that suggest psychiatric illness Onset is age appropriate Bipolar disorder Most often starts with depression. Mean age of switch to bipolar disorder is 323 Psychosis Schizophrenia Peak onset is 10-25 in men and 25-35 in women3 3-10% of women present after age 40 in a bimodal distribution that does not include men3 Onset before age 10 or after age 60 is extremely rare3 www.DerekMongold.com

  16. General Principles • Symptoms that suggest medical conditions • No past psychiatric history • Rapid onset (Hours to days) • Disorientation or memory impairment • Fluctuating course • Decreased level of consciousness • Abnormal vitals or physical exam • Patient unable to provide adequate history www.DerekMongold.com

  17. General Principles Symptoms that suggest medical conditions Recent change in medication Lack of a family history Multiple medical conditions No past history of trauma or abuse Poor response to standard therapy Onset is age inappropriate Atypical symptoms Olfactory, tactile, even visual hallucinations www.DerekMongold.com

  18. Before We Go Further Delirium Very common and important to rule out 10-30% of medically ill patients who are hospitalized exhibit delirium3 30% of ICU patients exhibit delirium3 40-50% of hip surgery patients exhibit delirium3 Up to 90% of postcardiotomy patients exhibit delirium in some studies3 80% of terminally ill patients develop delirium3 www.DerekMongold.com

  19. Before We Go Further Delirium Can be confused with almost any psychiatric disorder Caused by Generalized medical condition Substance induced Multiple causes NOS www.DerekMongold.com

  20. Mimics That Can present as Various Diseases and Will Not Be Covered In Detail Substance related disorders and their withdrawal syndromes Medication Side Effects/Intoxication/Withdrawal www.DerekMongold.com

  21. Important Psychiatric Diseases That Will Not Be Covered Personality changes Dementia Delirium www.DerekMongold.com

  22. Mnemonics www.DerekMongold.com

  23. ABC Mnemonic for Psychiatric MimicsMost Helpful in ED setting A and B : Airway and breathing C : CNS and CVS D : Drugs and medications E : Electrolytes and endocrinology F : Fever G to Z : Other conditions www.DerekMongold.com

  24. THINC MED Mnemonic T = Tumors H = Hormones I = Infections and Immune Diseases N = Nutrition C = CNS M = Miscellaneous E = Electrolytes and Environmental Toxins D = Drugs www.DerekMongold.com

  25. GENeral MEDical CONDITions Mnemonic Germs (infectious) Epilepsy Nutritional Metabolic encephalopathy Endocrine disorder Demyelinating disease CVA Offensive toxins Neoplasm Degeneration Immune disease Trauma www.DerekMongold.com

  26. The REVIEW OF SYSTEMS is my favorite way to remember medical Mimics www.DerekMongold.com

  27. H&P General ROS: Fever, chills, generalized myalgas PE: Fever, Nucal rigidity HEENT ROS: Vision changes, Olfactory or tactile hallucinations, recent sore throat PE: Kayser-Fleischer rings (Wilson’s), Goiter, proptosis (Thyroid), Argyll Robertson pupils of tertiary Syphilis (small irregular pupils that constrict to accommodation, but not light) www.DerekMongold.com

  28. H&P Cardiovascular ROS: Chest pain, Palpitations PE: Irregular rate or rhythm (dysrhythmias), Murmur (MVP) Respiratory ROS: SOB PE: Tachypnia, resting tachycardia (PE) Unilateral Breath sounds (Pneumothorax), Wheezes (asthma), crackles (pneumonia) www.DerekMongold.com

  29. H&P GI ROS: Abdominal pain, diarrhea, blood or mucous in their stool PE: Abdominal pain, guarding, distention (colitis, PUD), hepatomegaly (Wilson’s, hepatic encephalopathy) GU ROS: Dysuria, ulcers PE: Suprapubic tenderness, flank pain, Chancre www.DerekMongold.com

  30. H&P MS ROS: Weakness, fatigue, need to move PE: Tremor, abnormal gait Skin ROS: Rash or changing spots on the skin PE: Kaposi’s sarcoma (AIDS), Yellowish skin (Addison’s, Jaundice, Wilson’s), thin skin, purple striae (Cushing's), malar rash (SLE), pale (anemia), www.DerekMongold.com

  31. H&P • Endocrine • ROS: Heat or cold intolerance, Menstrual irregularities, weight change, Palpitations, polyuria, polydipsia • PE: goiter (thyroid), abnormal pigmentation, orthostatic hypotension (Addison's), obesity, moon face, thin skin, purple striae (Cushing's), tetany (parathyroid), HTN (pheochromocytoma) www.DerekMongold.com

  32. H&P Neurologic This is the largest system to review and examine with the most relevance. I will assume you are already performing a detailed ROS and PE and not review it. www.DerekMongold.com

  33. Differential Diagnosis www.DerekMongold.com

  34. Anxiety Medial Illnesses causing chronic anxiety symptoms1 25% are neurologic 25% are endocrinologic 12% are due to circulatory problems 12% due to rheumatoid-collagen vascular disorders 12% are due to chronic infection 14% are due to other diseases www.DerekMongold.com

  35. Anxiety Drugs Endocrine Adrenal disorders Glucose dysregulation Parathyroid dysfunction Thyroid dysfunction Gonadal hormone dysfunction Respiratory Asthma Pneumothorax PE Cardiovascular MI Dysrhythmias CHF Anemia and hypovolemia Mitral valve prolapse GI Colitis PUD Esophageal dysmotility Metabolic Acidosis Electrolyte abnormalities Wilson’s Pernicious anemia Porphyria Neurologic Brain tumors CVA Encephalopathies Epilepsy (esp. temporal lobe) Myasthenia gravis Pain Closed head injury Degenerative diseases Dementias Huntington’s Autoimmune disorders MS Infections AIDS Pneumonia TB Mono www.DerekMongold.com

  36. Depression Drugs Endocrine Adrenal disorders Thyroid disorders Parathyroid disorders Gonadal Hormone dysfunction Metabolic Nutritional deficiencies Neurological CVA Epilepsy NPH Traumatic Brain injury Degenerative Diseases Dementias Parkinson’s Huntington’s Autoimmune disorders MS SLE Infectious Limbic Encephalitis CJD Neurosyphilis Lyme disease Neoplastic Brain tumor Pancreatic cancer Other cancer Collagen-Vascular diseases Sleep Disorders Obstructive sleep apnea Insomnia www.DerekMongold.com

  37. Bipolar Disorder (Mania) Drugs Endocrine Cushing’s Syndrome Thyrotoxicosis Metabolic Hemodialysis Hepatic encephalopathy Uremia B12 deficiency CNS disorders CVA Closed head injuries Epilepsy CNS tumors Degenerative diseases Huntington’s MS Dementias Infections Sydenham’s chorea Neurosyphilis CJD Auto immune SLE Other Chorea gravidarum www.DerekMongold.com

  38. Psychosis Drugs and toxins Endocrinopathies Adrenal disorders Thyroid dysfunction Parathyroid dysfunction Pituitary dysfunction Metabolic disorders Porphyria Wilson’s Amino acid metabolism disorders Etc. Nutritional and vitamin deficiencies Vitamin A, D, & B12 Magnesium, Zinc, Niacin CNS disorders CVA Epilepsy Closed head injuries Hydrocephalus Degenerative Disorders Dementia Huntington’s Parkinson’s Friedreich’s ataxia Autoimmune disorders MS SLE Paraneoplastic syndrome Infections Viral encephalitis Neurosyphilis Lyme disease HIV CNS Parasites Tuberculosis Sarcoidosis Prion diseases Space occupying lesions CVM Tuberous sclerosis Neoplastic Chromosomal abnormalities Klienfelter’s FragileX XXX syndrome www.DerekMongold.com

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  41. Specific Diseases www.DerekMongold.com

  42. Specific Diseases Most commonly talked about diseases in Psychiatric literature However, uncommon presentations of common diseases are more common than common presentations of uncommon diseases www.DerekMongold.com

  43. Head Trauma Incidence 200:100,0006 Most common at 15-25 years of age3 Male : Female ratio 3:13 Neuropsychiatric sequelae resulting from head trauma3 10% of patients with mild head trauma 50% of patients with moderate head trauma www.DerekMongold.com

  44. Head Trauma Two major clusters of symptoms are seen3 Cognitive impairment Decreased speed of processing, decreased attention, trouble with memory, learning and problem solving. Behavioral sequelae Depression, impulsivity, aggression, personality change Behavioral Sequelae often exacerbated by alcohol use www.DerekMongold.com

  45. Epilepsy A seizure is a transient disturbance of cerebral function caused by a spontaneous, excessive discharge of neurons3 Incidence 50:100,00010 Prevalence 500-1,000:100,00010 www.DerekMongold.com

  46. Epilepsy 30-50% of epileptics have psychiatric difficulties sometime in their life3 60% of epileptics have nonconvulsive seizures, most commonly partial seizures4 Of those with partial seizures 40% do not show classic focal findings on EEG4 www.DerekMongold.com

  47. Epilepsy Anxiety More closely associated with partial seizures4 May be difficult to differentiate from panic attacks4 Mood Disorder Symptoms Depression occurs in >50% of epileptics, but only in 30% of matched controls4 Suicide rate in people with epilepsy is 5X that of the general population. 4 Up to 25X higher with temporal lobe epilepsy. 4 www.DerekMongold.com

  48. Epilepsy Psychosis 10% of patients with complex partial epilepsy have psychotic symptoms3 Up to 6-12X more common than in the general public4 www.DerekMongold.com

  49. Brain Tumors Incidence: 16.5:100,0005 Prevalence 131:100,00011 Mental symptoms are experienced by 50% of patients with brain tumors3 Of patients with mental symptoms, 80% have lesions in frontal or limbic regions3 Almost any psychiatric symptom can be seen www.DerekMongold.com

  50. Immune disorders • Systemic Lupus Erythematosus • Autoimmune inflammatory disorder that involves multiple organ systems • “The great Mimicker” • Prevalence: 40-150:100,0006 • Female : Male ratio 10:16 • African American women have 2.5-3X incidence of Caucasian women6 www.DerekMongold.com

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