Psychiatric Mimics Medical diagnoses that Manifest as Psychiatric

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Psychiatric Mimics Medical diagnoses that Manifest as Psychiatric Symptoms Derek S. Mongold MD Resident

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

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

Overview Importance of ruling out Medical Mimics n General Principles n Mnemonics n ROS

Overview Importance of ruling out Medical Mimics n General Principles n Mnemonics n ROS and physical examples n Specific diseases n Conclusion n www. derekmongold. com

Importance of Ruling Out Medical Mimics 5 -42% of patients referred for psychiatric treatment

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

Importance of Ruling Out Medical Mimics n Johnson (1968) performed detailed physical exams on

Importance of Ruling Out Medical Mimics n Johnson (1968) performed detailed physical exams on 250 patients on an inpatient psychiatric unit 2 12% had problems that seemed to be caused by physical illness n 80% of these had been missed by a physician before admission n 6. 6% were initially missed even after the admission workup n www. derekmongold. com

Importance of Ruling Out Medical Mimics n Sox et. al. (1989) did a thorough

Importance of Ruling Out Medical Mimics n Sox et. al. (1989) did a thorough medical evaluation on 509 patients in community mental health programs in California 2 n n 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 California 2 n 17% were found to have an organic condition that either caused or exacerbated their www. derekmongold. com mental illness

Importance of Ruling Out Medical Mimics n Bartsch et. al. performed a comprehensive evaluation

Importance of Ruling Out Medical Mimics n Bartsch et. al. performed a comprehensive evaluation on 175 clients from two Colorado CMHCs 2 n 16% had conditions that could cause or exacerbate their mental disorder www. derekmongold. com

General Principles n Lecture will focus on two common settings where it is important

General Principles n 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” n Outpatient clinic visits n www. derekmongold. com

Case Study ED consults you for a 49 yo female with new onset anxiety

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

Case Study n n n Since you have 4 other consults pending, you decide

Case Study n n n 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

Case Study You order Ativan, which causes her to “rest comfortably” the rest of

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

General Principles n Symptoms that suggest psychiatric illness Past psychiatric history n Flat or

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

General Principles n Symptoms that suggest psychiatric illness Medication noncompliance n Family history n

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

General Principles n Symptoms that suggest psychiatric illness - Onset is age appropriate -

General Principles n Symptoms that suggest psychiatric illness - Onset is age appropriate - Anxiety disorders (extremely variable age of onset, however) - - GAD: Usual onset is adolescence or early adulthood 3 Social Phobia: Peak onset in teens with common onset 5 -353 Panic disorder: Mean age of presentation is 25 years 3 OCD: Mean age of onset is 203 Depression - 50% of patients experience first episode before age 403 www. derekmongold. com

General Principles n Symptoms that suggest psychiatric illness - Onset is age appropriate -

General Principles n 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 women 3 3 -10% of women present after age 40 in a bimodal distribution that does not include men 3 Onset before age 10 or after age 60 is extremely rare 3 www. derekmongold. com

General Principles n Symptoms that suggest medical conditions n n n n No past

General Principles n Symptoms that suggest medical conditions n n n n 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

General Principles n Symptoms that suggest medical conditions n n n n Recent change

General Principles n Symptoms that suggest medical conditions n n n n 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 n Olfactory, tactile, even visual hallucinations www. derekmongold. com

Before We Go Further n Delirium n Very common and important to rule out

Before We Go Further n Delirium n Very common and important to rule out n 10 -30% of medically ill patients who are hospitalized exhibit delirium 3 n 30% of ICU patients exhibit delirium 3 n 40 -50% of hip surgery patients exhibit delirium 3 n Up to 90% of postcardiotomy patients exhibit delirium in some studies 3 n 80% of terminally ill patients develop delirium 3 www. derekmongold. com

Before We Go Further n Delirium Can be confused with almost any psychiatric disorder

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

Mimics That Can present as Various Diseases and Will Not Be Covered In Detail

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

Important Psychiatric Diseases That Will Not Be Covered Personality changes n Dementia n Delirium

Important Psychiatric Diseases That Will Not Be Covered Personality changes n Dementia n Delirium n www. derekmongold. com

Mnemonics www. derekmongold. com

Mnemonics www. derekmongold. com

ABC Mnemonic for Psychiatric Mimics Most Helpful in ED setting A and B :

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

THINC MED Mnemonic T = Tumors n H = Hormones n I = Infections

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

GENeral MEDical CONDITions Mnemonic Germs (infectious) n Epilepsy n Nutritional n n Metabolic encephalopathy

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

The REVIEW OF SYSTEMS is my favorite way to remember medical Mimics www. derekmongold.

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

H&P n General ROS: Fever, chills, generalized myalgas n PE: Fever, Nucal rigidity n

H&P n General ROS: Fever, chills, generalized myalgas n PE: Fever, Nucal rigidity n n HEENT ROS: Vision changes, Olfactory or tactile hallucinations, recent sore throat n 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) n www. derekmongold. com

H&P n Cardiovascular ROS: Chest pain, Palpitations n PE: Irregular rate or rhythm (dysrhythmias),

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

H&P n GI ROS: Abdominal pain, diarrhea, blood or mucous in their stool n

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

H&P n MS ROS: Weakness, fatigue, need to move n PE: Tremor, abnormal gait

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

H&P n Endocrine ROS: Heat or cold intolerance, Menstrual irregularities, weight change, Palpitations, polyuria,

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

H&P n Neurologic n This is the largest system to review and examine with

H&P n Neurologic n 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

Differential Diagnosis www. derekmongold. com

Differential Diagnosis www. derekmongold. com

Anxiety n Medial Illnesses causing chronic anxiety symptoms 1 25% are neurologic n 25%

Anxiety n Medial Illnesses causing chronic anxiety symptoms 1 25% are neurologic n 25% are endocrinologic n 12% are due to circulatory problems n 12% due to rheumatoid-collagen vascular disorders n 12% are due to chronic infection n 14% are due to other diseases n www. derekmongold. com

Anxiety n n n Drugs Endocrine n Adrenal disorders n Glucose dysregulation n Parathyroid

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

Depression n n Drugs Endocrine n n n CVA Epilepsy NPH Traumatic Brain injury

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

Bipolar Disorder (Mania) n n Drugs Endocrine n n n n Hemodialysis Hepatic encephalopathy

Bipolar Disorder (Mania) n n Drugs Endocrine n n n n Hemodialysis Hepatic encephalopathy Uremia B 12 deficiency n n n n n CVA Closed head injuries Epilepsy CNS tumors Sydenham’s chorea Neurosyphilis CJD Auto immune n n Huntington’s MS Dementias Infections n CNS disorders n Degenerative diseases n Cushing’s Syndrome Thyrotoxicosis Metabolic n n SLE Other n Chorea gravidarum www. derekmongold. com

Psychosis n n Drugs and toxins Endocrinopathies n n n Metabolic disorders n n

Psychosis n n Drugs and toxins Endocrinopathies n n n Metabolic disorders n n n Porphyria Wilson’s Amino acid metabolism disorders Etc. n Vitamin A, D, & B 12 Magnesium, Zinc, Niacin n n CVA Epilepsy Closed head injuries Hydrocephalus n n n n n Viral encephalitis Neurosyphilis Lyme disease HIV CNS Parasites Tuberculosis Sarcoidosis Prion diseases Space occupying lesions n n MS SLE Paraneoplastic syndrome Infections n n Dementia Huntington’s Parkinson’s Friedreich’s ataxia Autoimmune disorders n CNS disorders n Degenerative Disorders n Nutritional and vitamin deficiencies n n Adrenal disorders Thyroid dysfunction Parathyroid dysfunction Pituitary dysfunction n CVM Tuberous sclerosis Neoplastic Chromosomal abnormalities n n n Klienfelter’s Fragile. X XXX syndrome www. derekmongold. com

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Specific Diseases www. derekmongold. com

Specific Diseases www. derekmongold. com

Specific Diseases Most commonly talked about diseases in Psychiatric literature n However, uncommon presentations

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

Head Trauma Incidence 200: 100, 0006 n Most common at 15 -25 years of

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

Head Trauma n Two major clusters of symptoms are seen 3 n Cognitive impairment

Head Trauma n Two major clusters of symptoms are seen 3 n Cognitive impairment n Decreased speed of processing, decreased attention, trouble with memory, learning and problem solving. n Behavioral sequelae n Depression, impulsivity, aggression, personality change n Behavioral Sequelae often exacerbated by alcohol use www. derekmongold. com

Epilepsy A seizure is a transient disturbance of cerebral function caused by a spontaneous,

Epilepsy A seizure is a transient disturbance of cerebral function caused by a spontaneous, excessive discharge of neurons 3 n Incidence 50: 100, 00010 n Prevalence 500 -1, 000: 100, 00010 n www. derekmongold. com

Epilepsy 30 -50% of epileptics have psychiatric difficulties sometime in their life 3 n

Epilepsy 30 -50% of epileptics have psychiatric difficulties sometime in their life 3 n 60% of epileptics have nonconvulsive seizures, most commonly partial seizures 4 n Of those with partial seizures 40% do not show classic focal findings on EEG 4 n www. derekmongold. com

Epilepsy n Anxiety n More closely associated with partial seizures 4 n May n

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

Epilepsy n Psychosis 10% of patients with complex partial epilepsy have psychotic symptoms 3

Epilepsy n Psychosis 10% of patients with complex partial epilepsy have psychotic symptoms 3 n Up to 6 -12 X more common than in the general public 4 n www. derekmongold. com

Brain Tumors Incidence: 16. 5: 100, 0005 n Prevalence 131: 100, 00011 n Mental

Brain Tumors Incidence: 16. 5: 100, 0005 n Prevalence 131: 100, 00011 n Mental symptoms are experienced by 50% of patients with brain tumors 3 n Of patients with mental symptoms, 80% have lesions in frontal or limbic regions 3 n Almost any psychiatric symptom can be seen n www. derekmongold. com

Immune disorders n Systemic Lupus Erythematosus Autoimmune inflammatory disorder that involves multiple organ systems

Immune disorders n Systemic Lupus Erythematosus Autoimmune inflammatory disorder that involves multiple organ systems n “The great Mimicker” n Prevalence: 40 -150: 100, 0006 n Female : Male ratio 10: 16 n African American women have 2. 5 -3 X incidence of Caucasian women 6 n www. derekmongold. com

Immune disorders n Systemic Lupus Erythematosus n Approximately 50% of patients show neuropsychiatric manifestations

Immune disorders n Systemic Lupus Erythematosus n Approximately 50% of patients show neuropsychiatric manifestations 3 n Depression, insomnia, emotional lability, nervousness, confusion Treatment with corticosteroids causes further risk of neuropsychiatric manifestations n Must have a high index of suspicion n www. derekmongold. com

Immune disorders n Systemic Lupus Erythematosus n Signs n Malar (butterfly) rash n Discoid

Immune disorders n Systemic Lupus Erythematosus n Signs n Malar (butterfly) rash n Discoid rash n Photosensitivity n Oral ulcers n Renal disease n Positive ANA www. derekmongold. com

SLE Discoid Rash Malar rash www. derekmongold. com

SLE Discoid Rash Malar rash www. derekmongold. com

Immune Disorders n Multiple Sclerosis Episodic, inflammatory, multifocal, demyelinating disease of unknown etiology associated

Immune Disorders n Multiple Sclerosis Episodic, inflammatory, multifocal, demyelinating disease of unknown etiology associated with white matter lesions 3, 4 n Prevalence 50: 100, 0003 n Physical symptoms are varied but of a neurologic origin and often focal. n www. derekmongold. com

Immune Disorders n Multiple Sclerosis n n 95% of MS patients experience depressed mood,

Immune Disorders n Multiple Sclerosis n n 95% of MS patients experience depressed mood, agitation, anxiety, irritability, apathy, euphoria, disinhibition, hallucinations, or delusions 4 Depressive symptoms occur in over 75% of patients 4 n n 25% of patients exhibit euphoric mood that is not, but may be confused with hypomania 3 n n Associated with an increased rate of suicide 10% of patients will have sustained euphoria. >50% of patients will have mild cognitive defects and 20 -30% have severe defects 3 www. derekmongold. com

Immune Disorders n Multiple sclerosis n Signs n Clonus n Clumsiness n Dysarthria n

Immune Disorders n Multiple sclerosis n Signs n Clonus n Clumsiness n Dysarthria n Paralysis/paresis n Anesthesia/hyperesthesia www. derekmongold. com

Endocrine Disorders n Hyperthyroidism Several causes, end result is excess T 3 and T

Endocrine Disorders n Hyperthyroidism Several causes, end result is excess T 3 and T 4 n Incidence 6 n n 100: 100, 000 female n 33: 100, 000 male n Physical complaints include easy fatigability, generalized weakness, insomnia, weight loss, tremulousness, palpitations, sweating www. derekmongold. com

Endocrine Disorders n Hyperthyroidism Several causes, end result is excess T 3 and T

Endocrine Disorders n Hyperthyroidism Several causes, end result is excess T 3 and T 4 n Incidence 6 n n 100: 100, 000 female n 33: 100, 000 male n Physical complaints include easy fatigability, generalized weakness, insomnia, weight loss, tremulousness, palpitations, sweating www. derekmongold. com

Endocrine Disorders n Hyperthyroidism n Psychiatric complaints n Classically presents as anxiety n Serious

Endocrine Disorders n Hyperthyroidism n Psychiatric complaints n Classically presents as anxiety n Serious psychiatric symptoms include manic excitement, delusions, hallucinations 3 n Elderly patients may present with apathy, psychomotor retardation and depression 4 www. derekmongold. com

Endocrine Disorders n Hyperthyroidism n Signs n Goiter n Expothalmos n Moist skin/excessive sweating

Endocrine Disorders n Hyperthyroidism n Signs n Goiter n Expothalmos n Moist skin/excessive sweating www. derekmongold. com

Hyperthyroidism Goiter and exophthalmos www. derekmongold. com

Hyperthyroidism Goiter and exophthalmos www. derekmongold. com

Endocrine Disorders n Hypothyroidism Lack of thyroid hormone n Prevalence 500 -1000: 100, 000

Endocrine Disorders n Hypothyroidism Lack of thyroid hormone n Prevalence 500 -1000: 100, 000 n n Female > male 5: 1 -10: 1 n >65 years old 6 -10% of women and 2 -3% of men n Physical complaints include: Weakness, fatigue, cold intolerance, constipation, weight gain, hearing impairment, dry skin www. derekmongold. com

Endocrine Disorders n Hypothyroidism n Psychiatric manifestations include: n Depression is most commonly seen

Endocrine Disorders n Hypothyroidism n Psychiatric manifestations include: n Depression is most commonly seen n Untreated severe hypothyroidism leads to “Myxedema madness” which can lead to paranoid, depression, hypomania, and hallucinations n 10% of patents have residual neuropsychiatric symptoms after hormone replacement 3 www. derekmongold. com

Endocrine Disorders n Hypothyroidism n Signs n Dry, coarse skin n Facial puffiness n

Endocrine Disorders n Hypothyroidism n Signs n Dry, coarse skin n Facial puffiness n Thin, dry hair n Delayed relaxation of DTR’s n Myxedema n Goiter www. derekmongold. com

Endocrine Disorders n Hyperparathyroidism Excess parathyroid hormone causes hypercalcemia n Prevalence 250: 100, 0006

Endocrine Disorders n Hyperparathyroidism Excess parathyroid hormone causes hypercalcemia n Prevalence 250: 100, 0006 n Incidence 42: 100, 0006 n n Male > 60 = 100: 100, 000 n Female > 60 = 300 -400: 100, 000 n Physical complaints include: “painful bones, renal stones, abdominal groans, and psychic moans” www. derekmongold. com

Endocrine Disorders n Hyperparathyroidism n Psychiatric manifestations include n 50 -60% of patients have

Endocrine Disorders n Hyperparathyroidism n Psychiatric manifestations include n 50 -60% of patients have delirium, personality changes or apathy n 25% of patients have cognitive impairments www. derekmongold. com

Endocrine Disorders n Hyperparathyroidism n Signs n Nephrolithiasis n GI distress n Osteoporosis n

Endocrine Disorders n Hyperparathyroidism n Signs n Nephrolithiasis n GI distress n Osteoporosis n HTN n Short QT interval n Pancreatitis n Pancreatic calcifications www. derekmongold. com

Endocrine Disorders n Adrenocortical excess Caused by endogenous production (Cushing’s) or exogenous administration n

Endocrine Disorders n Adrenocortical excess Caused by endogenous production (Cushing’s) or exogenous administration n Cushing’s is rare, corticosteroid administration is common n Psychiatric symptoms include n n Agitated depression and often suicide in Cushing's n Mania and Psychosis often seen with exogenous steroids n Steroid withdrawal often leads to severe depression www. derekmongold. com

Endocrine Disorders n Adrenocortical insufficiency n n Incidence 0. 6: 100, 000 Prevalence 4:

Endocrine Disorders n Adrenocortical insufficiency n n Incidence 0. 6: 100, 000 Prevalence 4: 100, 000 Only occasionally causes psychiatric symptoms including irritability, depression, and rarely psychosis Hypoparathyroidism n n n Deficiency of parathyroid hormone leads to hypocalcaemia Rare Can cause delirium and personality changes www. derekmongold. com

Nutritional Disorders n Thiamine deficiency n n n Leads to Beriberi and Wernicke-Korsakoff syndrome

Nutritional Disorders n Thiamine deficiency n n n Leads to Beriberi and Wernicke-Korsakoff syndrome which is classically seen in alcoholics Prevalence 800 -2, 800: 100, 000 n 0. 8 to 2. 8 percent of the general population have Wernicke lesions at autopsy n Lesions seen in 12. 5% of alcohol abusers and 2959% of those with alcohol related deaths Psychiatric symptoms include apathy, depression, irritability, nervousness, and poor concentration. Severe memory disorders can develop with prolonged deficiencies www. derekmongold. com

Nutritional Disorders n Cobalamin (B 12) deficiency Caused by lack of dietary intake, malabsorption

Nutritional Disorders n Cobalamin (B 12) deficiency Caused by lack of dietary intake, malabsorption (worsened by antacids) or pernicious anemia n Incidence 15, 000: 100, 000 n n Up n to 15% of adults >659 Psychiatric symptoms include Apathy depression, irritability, moodiness n Can lead to an encephalopathy called “megaloblastic madness” which is characterized by delirium, delusions, hallucinations, dementia, and www. derekmongold. com paranoia 3

Nutritional Disorders n Cobalamin (B 12) deficiency n Signs n n n Neuropathy Megaloblastic

Nutritional Disorders n Cobalamin (B 12) deficiency n Signs n n n Neuropathy Megaloblastic anemia Glositis Hepato-splenomegaly Niacin Deficiency n n Rare Causes apathy, irritability, insomnia, depression, and delirium as well as dermatitis, peripheral neuropathies and diarrhea www. derekmongold. com

Metabolic disorders n Common metabolic disorders do not typically present initially with neuropsychiatric complaints,

Metabolic disorders n Common metabolic disorders do not typically present initially with neuropsychiatric complaints, but can later lead to problems. These include n Hepatic encephalopathy n Uremic encephalopathy n Hypoglycemic encephalopathy n Diabetic Ketoacidosis and Hyperosmolar hyperglycemic state • Rare metabolic disorders can initially present with only neuropsychiatric complaints. Most commonly tested is Acute intermittent porphyria (AIP) www. derekmongold. com

Metabolic disorders n Acute intermittent porphyria (AIP) Disorder of heme biosynthesis. Leads to excess

Metabolic disorders n Acute intermittent porphyria (AIP) Disorder of heme biosynthesis. Leads to excess porphyrins n Incidence 1: 10, 000 -100, 000 n n However, some studies show that 0. 2 -0. 5% of chronic psychiatric patients may have undiagnosed porphyrias 3 n Autosomal dominant. n Affects Women > men n Classic triad of symptoms www. derekmongold. com

Metabolic disorders n Acute intermittent porphyria (AIP) n Classic triad of symptoms n Acute,

Metabolic disorders n Acute intermittent porphyria (AIP) n Classic triad of symptoms n Acute, colicky abdominal pain n Motor polyneuropathy n Psychosis Other psychiatric symptoms include anxiety, insomnia, mood lability, and depression 3 n Barbiturates precipitate attacks and are absolutely contraindicated even in patients with a family history of disease 3 n www. derekmongold. com

Metabolic Disorders n Wilson’s Disease Autosomal recessive defect in copper excretion n Prevalence of

Metabolic Disorders n Wilson’s Disease Autosomal recessive defect in copper excretion n Prevalence of 3: 100, 0004 n Patients complain of tremor, RUQ pain, spasticity, dysphagia, chorea n www. derekmongold. com

Metabolic Disorders n Wilson’s Disease n 10 -15% of patient present with psychiatric symptoms.

Metabolic Disorders n Wilson’s Disease n 10 -15% of patient present with psychiatric symptoms. Patients who present differently may still have psychiatric symptoms. These include n Most commonly patients have bizarre, possibly frontal behavior. But also may have depressive, schizophreniform, and bipolar symptoms. www. derekmongold. com

Metabolic Disorders n Wilson’s Disease n Signs n Half of patients present with liver

Metabolic Disorders n Wilson’s Disease n Signs n Half of patients present with liver manifestations including hepatitis, cirrhosis, or fulminant hepatitis. n Kayser-Fleischer rings n Tremor n Spasticity n Rigidity n Chorea n dysarthria www. derekmongold. com

Infectious diseases n Lyme disease Infection caused by the spirochete Borrelia burgdorferi. Transmitted by

Infectious diseases n Lyme disease Infection caused by the spirochete Borrelia burgdorferi. Transmitted by Ixodid ticks n Incidence is extremely variable depending on location n n Overall n incidence is 8. 2: 100, 0006 Physical complaints include “bulls eye” rash of erythema migrans (60 -80%), fever, headache, myalgas, joint pain, neuropathies www. derekmongold. com

Infectious diseases n Lyme disease n Psychiatric symptoms of Lyme disease include memory lapses,

Infectious diseases n Lyme disease n Psychiatric symptoms of Lyme disease include memory lapses, difficulty concentrating, irritability and depression 3 n. A chronic encephalopathy may develop (Neuroborreliosis) causing a wide range of neuropsychiatric symptoms and even mimic MS and cause seizures 4 n Signs n Erythema migrans at sight of tick bite www. derekmongold. com

Erythema Migrans www. derekmongold. com

Erythema Migrans www. derekmongold. com

Infectious diseases n Herpes simplex encephalitis Incidence 0. 2: 100, 0007 n Most common

Infectious diseases n Herpes simplex encephalitis Incidence 0. 2: 100, 0007 n Most common focal encephalitis 3 n n Affects n frontal and temporal lobes Common Symptoms include anosmia, olfactory and gustatory hallucinations, personality changes and bizarre or psychotic behaviors 3 www. derekmongold. com

Infectious Disease n Other, less common infections Chronic Meningitis n Rabies n Neurosyphilis n

Infectious Disease n Other, less common infections Chronic Meningitis n Rabies n Neurosyphilis n Subacute Sclerosing Panencephalitis (SSPE) n www. derekmongold. com

Infectious Disease n Other, less common infections n Prion Disease n CJD n and

Infectious Disease n Other, less common infections n Prion Disease n CJD n and v. CJD Prevalence: 0. 1: 100, 00012 n KURU n Gerstmann-straussler-scheinker n Fatal disease familial insomnia www. derekmongold. com

Conclusion www. derekmongold. com

Conclusion www. derekmongold. com

Conclusion “Medical mimics” are common in psychiatric patients. n They are often missed by

Conclusion “Medical mimics” are common in psychiatric patients. n They are often missed by physicians n A high index of suspicion is needed to discover mimics n A few basic principles and Mnemonics as well as medical knowledge of a some specific diseases will help uncover these mimics n www. derekmongold. com

General Principles n Symptoms that suggest medical conditions n n n n No past

General Principles n Symptoms that suggest medical conditions n n n n 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

General Principles n Symptoms that suggest medical conditions n n n n Recent change

General Principles n Symptoms that suggest medical conditions n n n n Recent change in medication Atypical symptoms 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 n Olfactory, tactile, even visual hallucinations www. derekmongold. com

References n n n 1. Massachusetts General Hospital Handbook of General Hospital Psychiatry 5

References n n n 1. Massachusetts General Hospital Handbook of General Hospital Psychiatry 5 th edition by Stern et. Al. 2004. Elsevier 2. Psychiatric Presentations of Medical Illness, An Introduction for Non-Medical Mental Health Professionals. By Ronald J Diamond M. D. University of Wisconsin Department of Psychiatry 6001 Research Park Blvd Madison, Wisconsin 53719. Found at: http: //www. alternativementalhealth. com/articles/diamond. htm 3. Synopsis of Psychiatry 10 th edition by Kaplan & Sadock. 2007. Lippincott williams & Wilkins 4. Massachusetts General Hospital Psychiatry Update and Board Preparation second edition by Stern & Herman. 2004. Mc. Graw-Hill 5. American Brain Tumor Association. Found at http: //www. abta. org/site. Files/Site. Pages/4 CE 78576 D 87 BD 194 A 363 ACE 796099 B 03. pdf 6. Epocrates Dx version 1. 50, based on 5 -minute clinical consult by Frank J. Domino, MD 7. emedicine article found at http: //emedicine. medscape. com/article/1165183 -overview 8. Uptodate online 9. American Family Physician March 1, 2003. online at http: //www. aafp. org/afp/20030301/979. html 10. Article found online at http: //www. epilepsynse. org. uk/File. Storage/Professionalsarticles/main_content/Chapter 1 Sander. pdf 11. Prevalence estimates for primary brain tumors in the United States by behavior and major histology groups by Davis et. Al. Neuro Oncol 2001 3(3): 152 -158; DOI: 10. 1215/15228517 -3 -3 -152 found online at http: //neurooncology. dukejournals. org/cgi/content/abstract/3/3/152 12 online article at http: //www. neurologychannel. com/cjd/index. shtml www. derekmongold. com

Anxiety n n n Drugs Endocrine n Adrenal disorders n Glucose dysregulation n Parathyroid

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

Depression n n Drugs Endocrine n n n CVA Epilepsy NPH Traumatic Brain injury

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

Bipolar Disorder (Mania) n n Drugs Endocrine n n n n Hemodialysis Hepatic encephalopathy

Bipolar Disorder (Mania) n n Drugs Endocrine n n n n Hemodialysis Hepatic encephalopathy Uremia B 12 deficiency n n n n n CVA Closed head injuries Epilepsy CNS tumors Sydenham’s chorea Neurosyphilis CJD Auto immune n n Huntington’s MS Dementias Infections n CNS disorders n Degenerative diseases n Cushing’s Syndrome Thyrotoxicosis Metabolic n n SLE Other n Chorea gravidarum www. derekmongold. com

Psychosis n n Drugs and toxins Endocrinopathies n n n Metabolic disorders n n

Psychosis n n Drugs and toxins Endocrinopathies n n n Metabolic disorders n n n Porphyria Wilson’s Amino acid metabolism disorders Etc. n Vitamin A, D, & B 12 Magnesium, Zinc, Niacin n n CVA Epilepsy Closed head injuries Hydrocephalus n n n n n Viral encephalitis Neurosyphilis Lyme disease HIV CNS Parasites Tuberculosis Sarcoidosis Prion diseases Space occupying lesions n n MS SLE Paraneoplastic syndrome Infections n n Dementia Huntington’s Parkinson’s Friedreich’s ataxia Autoimmune disorders n CNS disorders n Degenerative Disorders n Nutritional and vitamin deficiencies n n Adrenal disorders Thyroid dysfunction Parathyroid dysfunction Pituitary dysfunction n CVM Tuberous sclerosis Neoplastic Chromosomal abnormalities n n n Klienfelter’s Fragile. X XXX syndrome www. derekmongold. com