- Psychosis is not the same as schizophrenia!
- If you do not look for organic causes you will not find them
- Be suspicious of "medical clearances"
1. Symptoms that suggest organic disease include:
- A patient with no previous psychiatric history
- Hallucinations that are visual, vivid in color, or that change rapidly; Olfactory (smell) hallucinations
- Illusions: misinterpretations of stimuli
- Recent weight changes; chronic or acute malnutrition; sleep deprivation
- Ingestion of toxic substances as food; other poisoning by toxic ingestion, inhalation or injection (including vaccinations)
- Significant psychological trauma, especially chronic and severe
- Head injury (traumatic brain injury = TBI)
2. Medical emergencies that can present as psychiatric illness:
Syndromes related to chronic alcohol usage or withdrawal, including Delerium Tremens and other forms of alcoholic encephalopathy; hypoxia (low blood oxygen); meningitis/encephalitis; subarachnoid hemorrhage; adverse drug effects; cardio-pulmonary diseases.
Psychosis vs. Delirium
Psychosis refers to an impairment in reality testing because of hallucinations, delusions or grossly disorganized thinking. Psychosis can be caused by organic diseases where the cause is knowable or by a variety of mental illnesses ranging from a brief reactive psychosis to schizophrenia.
Delirium refers to an acute organic brain syndrome causing a global cognitive impairment, with disorientation, memory impairment, and disturbances of consciousness. Illnesses causing deliriums are often life threatening, and a delirium should be considered to be a medical emergency.
Symptoms of delirium include:
- Disorientation or memory impairment
- Fluctuating or impaired level of consciousness, decreased awareness of environment
- Labile affect
- Impaired judgment or impaired insight
- Abnormal autonomic signs (changes in blood pressure, pulse, temperature, abnormal sweating, flushing, etc)
Medical Illnesses that can Present as Psychoses
1. Progressive neurological diseases: Multiple sclerosis, Huntington's chorea and Alzheimer's disease can present as dementia
2. Central nervous system infections: Encephalitis, Meningitis, HIV
3. Space occupying lesions within the skull: Brain tumors, hemorrhage, abscesses
4. Metabolic disorders
5. Endocrine disorders: Hypothyroidism, Cushing's syndrome and Hypoglycemia, either from insulin secreting tumor or administration of insulin
- Accumulation of toxins from severe liver or kidney disease
- Disturbances in electrolytes
- Acute intermittent porphyria
- Wilson's disease: abnormality of copper metabolism that causes damage to brain and liver.
- Systemic lupus erythematosis (and other autoimmune diseases)
6. Deficiency states/Malnutrition:
7. Temporal lobe epilepsy (or partial complex seizure disorder) or seizures caused by withdrawal from anti-epileptic drugs, tranquilizers or “mood stabilizers”
- Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome
- Pellegra (nicotinic acid deficiency) and other B complex deficiencies, esp. vitamin B6
- Zinc deficiency
- Legal prescription drugs: psychostimulants such as, Ritalin, Effexor, Wellbutrin, Adderall, Strattera, and other amphetamines; SSRIs, antipsychotics, tranquilizers, L-DOPA
- Illicit drugs: cocaine, crack, methamphetamine, Ecstasy, Dexedrine, LSD, hallucinogens
Anxiety/Nervousness/Mania (So-Called Bipolar “Disorder”)
1. Psychological manifestations: Inner feelings of terror, tension, apprehension and dread, derealization, depersonalizations, fear of impending insanity
2. Intellectual disturbances: Decreased concentration, disorganized thinking, loss of IQ
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
Medical Illnesses that can Present with
Strongly suspect medical causes for anxiety in patients who suddenly develop nervousness which disrupts their normal activity
1. A multitude of organic brain syndromes, including these neurological illnesses (representing 25% of medical causes of anxiety syndromes)
2. Endocrine disorders (25% of medical causes of anxiety symptoms)
- Cerebral vascular insufficiency/transient ischemic attacks (TIAs).
- Anxiety states and personality changes following traumatic brain injuries (TBI)
- Infections of the central nervous system
- Degenerative disorders
- Toxic Disorders
- Lead Intoxication
- Mercury intoxication: from mercury-contaminated fish, dental fillings, vaccinations
- Manganese intoxication: from industrial exposure
- Organophosphate insecticides (similar to nerve gas)
- Partial complex seizures
3. Cardiopulmonary disorders: Often with shortness of breath, rapid breathing, chest pain.
- Adrenal hyperfunction (Cushing's syndrome)
- Hypoglycemia (decreased blood glucose)
- Menopausal and premenstrual syndromes
4. Pheochromocytoma (epinephrine secreting tumors)
- Pulmonary embolus
- Arrhythmias (irregularities of heart beat)
- Chronic obstructive pulmonary disease (COPD)
- Mitral valve prolapse
Medications as a Cause of Anxiety/Nervousness
1. Non-psychotropic drugs
2. Psychotropic drugs
- Sympathomimetics found in non-prescription cold and allergy medications: epinephrine, norepinephrine, isoproteronol, levodopa, dopamine hydrochloride, dobutamine, terbutaline sulfate, ephedrine, pseudo-ephedrine
- Xanthene derivatives (coffee, colas, over-the-counter pain remedies):
- aminophylline, theophylline, caffeine
- Anti-inflammatory agents
- Thyroid preparations
- Insulin (hypoglycemic reaction)
- Others: nicotine, caffeine, monosodium glutamate (MSG)
- Withdrawal from caffeine and/or nicotine
3. Licit and illicit drugs can cause anxiety and severe insomnia while taking them or while withdrawing from them
- Antidepressants; SSRIs, tricyclics, Ritalin and other psychostimulant drugs (for treatment of “ADHD”)
- Tranquilizing drugs: antipsychotics (akathisia may present as anxiety); “mood-stabilizers”
- Anti-cholinergic medications; sedating antihistamines (found in over-the-counter sleep preparations); anti-parkinson agents.
- Caffeine/Nicotine/Alcohol-intoxication or withdrawal
- Stimulants-cocaine, amphetamines, etc
Many varieties of expression: “Major” depression: (deep and/or long-lasting depression (either single episode or recurrent); “Dysthymia” (mild and/or brief episodes of depression).; adjustment reaction with depressed mood; and bereavement
Medical Illnesses that can Present as Depression/Sadness
1. Depressive syndromes caused by viral illnesses: influenza, infectious mononucleosis, viral hepatitis, viral pneumonia, and viral encephalitis
2. Cancer of all types
3. Cardiopulmonary disease, especially with hypoxia
4. Sleep apnea: should be suspected in a patient with sleep disturbance and daytime somnolence
5. Endocrine Diseases
6. Collagen-Vascular Diseases: Systemic lupus erythematosus (SLE); Scleroderma; Dermatomyositis
- Hyperthyroidism or thyrotoxicosis
- Adrenal hypofunction (Addison's Disease) or hyperfunction (Cushing’s Disease)
- Post-partum status, post-menopausal, and premenstrual syndromes
7. Central Nervous System Diseases
- Multiple Sclerosis
- Brain tumors, hemorrhages and other intracranial masses.
- Complex partial seizures
- Strokes, especially affecting left side of brain (right side of body)
Many Rx Drugs, even Antidepressants, can Cause Depression/Sadness
In one study of family practice patients, 43% of patients diagnosed as depressed were taking medications that can cause depression!
Remember: Withdrawal from legal and illicit drugs, whether abused, over-used, abruptly discontinued, slowly tapered or not, commonly causes potentially serious syndromes that are NOT mental illnesses, including anxiety/nervousness, depression, suicidality, aggression, akathisia, insomnia, irrational thinking, fatigue and tiredness. ALL drugs of abuse can actually cause depression.
- All antihypertensive medications can cause depression!
- Digitalis as well as many other cardiac drugs
- All drugs for hyperacidity
- NSAIDs (non-steroidal anti-inflammatory drugs)
- Antidepressants and antipsychotic medications: can cause permanent Parkinsonian, dyskinesia or akinesia (inhibition of spontaneity) that can both feel and look like true depression
- All anxiolytics/tranquilizers, “mood stabilizers” and sedative hypnotics can cause depression
- Steroids (prednisone and cortisone)
Bipolar Disorder is very commonly simply agitation, anxiety, insomnia an/or hyperstimulation caused by agitation-inducing SSRI antidepressants that are prescribed for a pre-existing “unipolar depression”. Thus the so-called bipolar disorder that has “emerged” is actually a misnomer and should instead be called unipolar sadness with drug-induced mania rather than Bipolar Disorder of unknown cause!
This article was partially excerpted, with many additions and subtractions, from a long article published on 1-7-2002, entitled: Psychiatric Presentations of Medical Illness: An Introduction for Non-Medical Mental Health Professionals, By Ronald J Diamond M.D. on the Safe Harbor website, an Alternative Mental Health website, no longer in existence.