detail discussion of psychiatric and medical issues causing diagnostic confusion for experts of both of these fields

1. BY

2. Ongoing discussion will emphasize on Mental symptoms, which occur due to direct physiological effect of a general medical condition. How to evaluate an individual with mental symptoms of any sort? Differential diagnosis of mental disorders/symptoms with General medical conditions. INTRODUCTION

3. In evaluating individuals with mental symptoms of any sort Approach for ‘Mental Disorders’ Due to a General Medical Condition

4. Step 1 To review the history & physical examination Step 2 Laboratory tests/imaging studies To see if there is evidence for presence of a general medical condition that could plausibly cause the mental symptoms in question. Step 3 Involves determining whether these symptoms could be better accounted for by a primary mental disorder. Step 4 If proves to be a medical condition as a possible cause, whether emergent symptomatic Rx needed? Approach for ‘Mental Disorders’ Due to a General Medical Condition

5. Approach for ‘Mental Disorders’ Due to a General Medical Condition (ALGORITHM)

6. Approach for ‘Mental Disorders’ Due to a General Medical Condition

7. Common Psychiatric Disorders Due to General Medical Conditions A Brief Overview

8. Psychotic Disorder

10. Psychotic Disorder Due to a General Medical Condition

13. CASE VIGNETTE 1 Ziegler (1930) reported a case of “myxedema madness” in a 48-year-old woman who, at the age of 45 years, had undergone radiation treatment for Grave’s disease. She was treated with thyroid hormone, but eventually became noncompliant. Soon thereafter “she began to feel that her husband was paying attention to another woman and that he was trying to do away with her by means of gas or the electric chair. During a game at a party in her own home during the holidays in 1928, she refused to sit in a chair designated for her, thinking it might be a plot to kill her. She also felt that her husband was trying to poison her and refused to take desiccated thyroid hormoneat home on account of such a belief. On several occasions subsequently, when desiccated thyroid hormone was administered in suffi cient quantity, at the repeated and urgent request of her physician, the delusions entirely disappeared and she felt so much better that she concluded that it would be foolish to be taking medicine and discontinued taking it. On such occasions, the psychosis would slowly return in the same form as before.”

14. Mood Disorder

15. Mood disorders due to general medical conditions may occur either with depressive features or manic features. With Depressive Features Definition A mood disorder secondary to a general medical condition with depressive features is characterized by a prominent and persistent depressed mood or loss of interest, and by the presence of evidence, from the history, physical examination, or laboratory tests, of a general medical condition capable of causing such a disturbance. With Manic Features Definition Mood disorder due to a general medical condition with manic features is characterized by a prominent and persistently elevated, expansive, or irritable mood, which, on the basis of the history, physical or laboratory examinations, can be attributed to an underlying general medical condition. Mood disorder

17. Depression Due to a General Medical Condition Secondary to Precipitants Medications Propranolol, Interferon, ACTH, Prednisone, Reserpine, Alpha-methyldopa, Nifedipine, Ranitidine, Bismuth subsalicylate, Anticholinergic withdrawal (“cholinergic rebound”) Secondary to Diseases with Distinctive Features Hypothyroidism (hair loss, dry skin, voice change) Hyperthyroidism (weight loss with increased appetite, Tachycardia) Cushing’s syndrome (moon facies, hirsutism, acne, “buffalohump”) Addison,s disease (nausea, vomiting, postural dizziness) Multiple sclerosis (various focal findings) Epilepsy Occurring as Part of Certain Neurodegenerative or Dementing Disorders Alzheimer’s disease, Multi-infarct dementia, Diffuse Lewy body disease, Parkinson’s disease Miscellaneous Cerebral tumors Hydrocephalus Pancreatic cancer Hyperparathyroidism Systemic lupus erythematosus Poststroke depression

18. CASE VIGNETTE 2 Kraepelin (1913) reported the case of a 40-year-old man who “had been irritable for 2 years, … and he slept badly …. At home, he expressed ideas of sin—that he had made false entries in his books and would be locked up, and was bringing ruin on his friends as well as himself.” The patient was admitted, and, during a hospital interview, Kraepelin described him as follows: You will see at once that the man, aged 40 years, whom I am bringing before you today is suffering from depression. This haggard-looking patient, very pale and ill-nourished, sits in a languid attitude, staring straight before him with a gloomy, listless air, and pays us no particular attention. He hardly even turns his head when spoken to, but he answers in a low voice and very laconically…. He says … there is nothing left of himself but “this miserable skeleton.” Kraepelin felt the diagnosis would have been difficult “if the physical examination of the patient had not brought complete enlightenment. We see that not only is the right pupil more dilated than the left, but both are completely inactive to light, although the reaction to distance is maintained.” Kraepelin’s diagnosis was neurosyphilis, a diagnosis made on the basis of finding Argyll Robertson pupils on the routine physical examination. Further history confirmed the diagnosis, revealing, as it did, the occurrence of secondary syphilitic rash some 12 years prior to admission.

20. Hemodialysis

21. EncephalitisSecondary to Diseases with Distinctive Features Hyperthyroidism (proptosis, tremor, tachycardia) Cushing’s syndrome (moon facies, hirsutism, acne, “buffalo hump”, ) Multiple sclerosis (various focal findings) Cerebral infarction (sudden onset with associated localizing signs) Sydenham’s chorea Chorea gravidarum Hepatic encephalopathy (asterixis, delirium) Uremia (asterixis, delirium) Epilepsy Occurring as part of Certain Neurodegenerative or Dementing Diseases Alzheimer’s disease , Neurosyphilis, Huntington’s disease Miscellaneous or Rare Causes Cerebral tumors Systemic lupus erythematosus Vitamin B12 deficiency Metachromaticleukodystrophy

22. CASE VIGNETTE 3 Liebson (2000) reported the case of a 53-year-old man with a right thalamic hemorrhage, who presented with headache and left-sided hemiparesis and hemianesthesia. Four days later he displayed significant change in his mood. One week after the stroke his “mood was remarkably cheerful and optimistic … he was noted to praise extravagantly the hospital food, and the nurses found him “talkative.” When he arrived on our ward 11 days after the stroke he was flirtatious with female staff and boasted of having fathered 64 children. His girlfriend was surprised when he kissed her in front of the staff because he had never publicly displayed affection before. He reported excellent energy and expansively invited all the staff to his home for Thanksgiving . . . The mania resolved gradually over a 10-week period after (the) stroke.”

23. Anxiety Disorder

24. Anxiety Disorder Due to a General MedicalCondition with Panic Attacks or withGeneralized Anxiety Pathologic anxiety secondary to a general medical condition may occur in the form of well-circumscribed and transient panic attacks or in a generalized, more chronic form. Panic attacks have an acute or paroxysmal onset, and are characterized by typically intense anxiety or fear, which is accompanied by various “autonomic” signs and symptoms, such as tremor, diaphoresis, and palpitations. Generalized anxiety tends to be of subacute or gradual onset, patients, rather than complaining of feeling anxious per se, may complain of being worried, tense, or ill at ease. Autonomic symptoms tend not to be as severe or prominent as those seen in panic attacks: shakiness, palpitations (or tachycardia), and diaphoresis are perhaps most common.

27. CASE VIGNETTE 4 Rush et al. (1977) describe a patient with simple partial seizures that manifested as panic attacks. The patient, at the age of 44 years, began to have “attacks of palpitation accompanied by dizziness, faintness and anxiety . . . occurred during wakefulness and sleep, and, if asleep, the patient was awakened by them.”At the age of 49 years, he was evaluated and an electroencephalogram, obtained in between attacks, “revealed mild slowing with intermittent, low-voltage, sharp waves over the right temporal region. Because of the paroxysmal nature of the attacks and the electroencephalographic abnormality, the patient was reevaluated utilizing telemetry.”During telemetry, the patient had an attack: “he was pale and mildly diaphoretic and was tightly gripping his chair . . . no abnormal movements were detected . . . (he) remained fully alert and was not incontinent.” Concurrent with the attack, ictal electroencephalographic activity was observed on the right. At craniotomy a glioma was removed from the right frontal lobe and the attacks subsequently did not recur.

30. CASE VIGNETTE 5 Laplane et al. (1984) described the case of a “41-yearold healthy man (who) was stung on the left arm by a wasp. He immediately sustained a convulsive coma for 24 hours, then adopted intensive choreic movements … and impairment of gait. These extrapyramidal symptoms diminished over several months . . . .“Two years after the encephalopathy, he began to show stereotyped activities. The most frequent consisted in mental counting, for example, up to twelve or a multiple of twelve, but sometimes it was a more complex calculation. Such mental activities sometimes were accompanied by gestures, such as a finger pacing of the counts. To switch on and off a light for 1 hour or more was another of his most common compulsions. When asked about this behavior he answered that he had to count . . . that he could not stop it . . . that it was stronger than him . . . .“Neurological examination showed abnormal movements. . . .He had a permanent facial rictus with some facial or mandibular movements somewhat resembling tics. With his finger movements it was difficult to distinguish between involuntary or ‘voluntary’ activity associated with mental counting. Walking was a mixture of parkinsonism and choreic disturbances. “Standard and sleep EEG were normal. CT scans were performed in the orbito-meatal plane . . .. The main lesions consisted of low density areas bilaterally in the internal part of the lenticular nucleus.”

31. Catatonic Disorder

32. Catatonia exists in two subtypes, namely, stuporous catatonia (also known as the akinetic or “retarded” subtype) and excited catatonia. Stuporous catatonia characterized by varying combinations of mutism, immobility, and waxy flexibility; associated features include posturing, negativism, automatic obedience, and “echo” phenomena. Excited catatonia manifests with varying degrees of bizarre, frenzied, and purposeless behavior. Catatonic Disorder Due to a General Medical Condition

34. Causes of Catatonia Due to a GeneralMedical Condition Stuporous Catatonia Associated with epilepsy Ictal catatonia Postictal catatonia Medication Neuroleptics Benzodiazepine withdrawal Viral encephalitis Herpes simplex encephalitis Encephalitis lethargica Focal lesions, especially of the frontal lobes Miscellaneous conditions Hepatic encephalopathy Systemic lupus erythematosus Lyme disease, in stage III Subacutesclerosingpanencephalitis, in stage I Excited Catatonia Viral encephalitis

35. Lim et al. (1986) described a case of ictal catatonia occurring in the midst of a complex partial seizure. The patient was a 67-year-old man who was brought to the hospital after being confused for two weeks. When examined, he “sat quietly in a chair, with no spontaneous speech or movement. He responded to questions with few words and manifested frequent echolalia and persistance…. On the third hospital day the patient suddenly became catatonic. His mouth and eyes were opened widely with dilated reactive pupils. He held his arms and legs rigidly in the air and would maintain his extremities in any bizarre posture indefinitely.” An EEG demonstrated spiking in the left fronto-central area; the patient was given intravenous phenytoin and recovered completely. CASE VIGNETTE 6

36. Personality Change

37. INTRODUCTION The personality of an adult represents a coalescence of various personality traits present in childhood and adolescence, and is generally quite enduring and resistant to change. Appearance of a significant change in an adult’s personality is an ominous clinical sign and indicates the presence of intracranial pathology. Individuals themselves may not be aware of the change. However, those who have known the individual over time, often note that the individual is “not himself” anymore. In most cases, the change is nonspecific in nature. Personality Change Due to a GeneralMedical Condition

39. Causes of Personality Change of theNonspecific or Frontal Lobe Type Secondary to Precipitants Closed head injury Head trauma with subdural hematoma Postviral encephalitis Gunshot wounds Cerebral infarction Secondary to Cerebral Tumors Frontal lobe* Corpus callosum* (in its anterior part) Temporal lobe Occurring as Part of Certain Neurodegenerative or Dementing Disorders Pick’s disease* Fronto-temporal dementia* Alzheimer’s disease* Amyotrophic lateral sclerosis* Progressive supranuclear palsy* Huntington’s disease Wilson’s disease Lacunar syndrome* Normal pressure hydrocephalus AIDS Neurosyphilis Miscellaneous Causes Granulomatousangiitis Vitamin B12 deficiency Limbic encephalitis Mercury intoxication *Particularly likely to cause a frontal lobe syndrome.

40. Moersch (1925) described a 54-year-old man in whom, three months earlier, “a gradual mental change had been observed. The patient lost his ambition and interest in work . . . he became careless . . . and seemed little concerned about his shortcomings. For two weeks before his examination he had been content to sit aimlessly at home, or to play with his children. He voided at any time and even defecated in his clothes . . . . During general examination, the patient was indifferent and aimless, would sit and look at a newspaper, which might be upside down. He was oriented in all spheres, and his attention might be held for a few moments when aroused. He would follow his son about in a fairly good-natured manner, but always object to being examined, saying that he was not sick. He showed considerable perseveration, repeating movements at times for long periods. For example, one evening he sat before a wash bowl for over a half-hour, turning the faucets on and off.” This patient’s frontal lobe syndrome, manifest with apathy, disinhibition, and perseveration, constituted the presentation of a tumor of the anterior portion of the corpus callosum, to which the patient eventually succumbed. CASE VIGNETTE 7

41. Mental Disorder Not Otherwise Specified Due to a General Medical Condition

42. This is a residual category in DSM-IV-TR for those clinical situations in which the mental disorder occurring secondary to a general medical condition does not fall into one of the specific categories described earlier. Of these various disorders, two are worthy of description, namely, pseudobulbar palsy and the Klüver–Bucy syndrome. Both disorders are commonly seen in dementia clinics, and their occurrence often prompts a request for psychiatric consultation. INTRODUCTION

43. Pseudobulbar Palsy & Klüver–Bucy Syndrome Pseudobulbar Palsy When fully developed, this syndrome is characterized by emotional incontinence (also known as “pathological laughing and crying”), dysarthria, dysphagia, a brisk jaw-jerk and gag reflex, and difficulty in protruding the tongue. Klüver–Bucy Syndrome The full syndrome is characterized by hypermetamorphosis, agnosia (albeit of a peculiar kind), hyperorality, emotional placidity, and hypersexuality.

45. CASE VIGNETTE 8 SA Kinnier Wilson (1924) provided a classic example of emotional incontinence following bilateral cerebral infarctions: “A woman of age 57 years had suffered from left hemiplegia for one year, when a second stroke occurred involving the right side. Ever since the latter, the daughter remarked that her mother had become, as she put it, ‘hysterical,” laughing and crying at nothing. “On examination the patient was seen to have a distinctly vacant, apathetic facial expression at rest. She was able to move the facial muscles voluntarily on both sides, though there was slight weakness of the left corner of the mouth. On the slightest stimulus, even when the observer simply came to her bedside, she at once assumed a excessively mournful expression , her mouth opened widely, and a long, almost noiseless bout of weeping ensued, lasting for many seconds, even minutes, at a time . . . . During the spasmodic crying, both sides of the face moved equally, and the eyes suffused with tears. Laughing attacks were extremely rare in comparison.”

47. CASE VIGNETTE 9 Mendez and Foti (1997) describe a 40-year-old with epilepsy secondary to old infarction of the left temporoparietal area. Grand mal status epilepticus occurred, lasting several hours, during which the patient sustained anoxic damage to both temporal lobes. Upon recovery from the status, the patient “had a voracious appetite and indiscriminate eating habits, which included paper towels, plants, styrofoam cups, and even feces. At one point, he drank urine from a catheter bag. He tended to wander about the ward touching objects or people and made inappropriate comments of a sexual nature . . . On the day of his death . . . he had wandered about the ward picking up whatever he could find and putting it into his mouth . . . (and) had a respiratory arrest after stuffing his mouth with surgical gauze . . . . Neuropathological examination disclosed an old infarction in the left posterior cerebral artery territory, virtual absence of the left anterior temporal lobe, and atrophy of the right parahippocampalgyrus, hippocampus and amygdala.”

48. THANX 4 CALM LITENING