medical illnesses with psychiatric symptoms

medical or mental

• the mind and body are intertwined

• a client is a holistic entity

• a new medical diagnosis or illness is stressful and life changing

• patients being treated for medical or surgical problems may display behaviors of aggression, depression, anxiety, anger, suspicion, or psychosis

• identification of a medical condition can be challenging, especially in an individual with an existing psychiatric condition

medical mimics

disorders that present with psychiatric symptoms directly resulting from an underlying medical condition

• cause of psychiatric symptoms is medical illness

diagnostic overshadowing

attributing symptoms of a physical illness to a mental illness

misdiagnosing

can result in unnecessary or harmful treatment, delay in treatment, increased hospital stay and costs

DSM 5 diagnosis

• if mental disturbance is caused by physiological effects of another medical condition

  • unspecified mental disorder due to another medical condition

  • other specified mental disorder due to another medical condition

• if mental disturbance is caused by the physiological effects of a drug or medication

  • substance/medication-induced disorders

medical mimics associated with mood disorders

• cushings disease

• fibromyalgia/chronic fatigue syndrome

• hyper/hypothyroidism

• sleep apnea

• mononucleosis

• CVA

• vitamin B12 deficiency

• TBI

• hyper/hypoparathyroidism

• kidney or liver failure

• multiple sclerosis

• systemic lupus erythematosus

• parkinsons disease

• huntingtons

• dementia

medical illnesses with psychotic symptoms

• cushings disease

• estrogen withdrawal

• hyper or hypothyroidism

• hypoglycemia

• cerebrovascular diseases

• CNS infection, neoplasm, or trauma

• vitamin B deficiencies

• hypoparathyroidism

• liver failure

• multiple sclerosis

• pancreatitis

• renal failure

• brain tumors

• epilepsy

symptoms of psychotic disorder d/t another medical condition

• hallucinations

• delusions

• disorganized speech and thought patterns

• symptoms of a medical condition not associated with mental disorders that may cause psychosis (ex: schizophrenia spectrum disorder)

• symptoms may be temporary and brief or long term, persisting long after the associated medical condition has been resolved

mimics associated with anxiety disorders

• cardiac arrhythmias

• CVD

• cushings disease

• hyper/hypothyroidism

• pulmonary embolism

• rheumatoid arthritis

• hyperventilation or hypoxia

• hypoglycemia

• pneumonia

• B12 deficiency

• COPD

• CHF

psychiatric side effects (PCEs) from pharmacological treatment

• PSEs often resemble spontaneous psychiatric syndromes

• occurs with usual doses, intoxication, or withdrawal of treatment

• range from short-lasting anxiety to severe confusion

• suicide

risk factors for PSEs

• polypharmacy

• high doses

• route of administration

• faster administration (by any route)

• narrow therapeutic index

• metabolic conditions (hepatic insufficiency, slow metabolizer)

• augmented permeability of blood-brain barrier

• very young or elderly patients

• postpartum or other situations of stress (ICU)

medications with common psychiatric side effects

• antiepileptic agents

• beta blockers

• corticosteroids and anabolic steroids

• interferon

• benzodiazepine (withdrawal)

• fluroquinolones

• isoniazid, sulfonamide antibiotics, anticholinergics

• acyclovir/ganciclovir

• psychostimulants, dopaminergic agents (anti-parkinson)

• OTC cough and cold preparations

• opioids

• stimulants (cocaine, amphetamine)

antiepileptic agents PSEs

• delirium

• psychosis

• irritability

beta blocker PSEs

• delirium

• psychosis

• depression

corticosteroids and anabolic steroids PSEs

• mood changes

• psychosis

interferon PSEs

depression

benzodiazepine (withdrawal) PSEs

• anxiety

• agitation

fluroquinolones PSEs

• restlessness

• irritability

isoniazid, sulfonamide antibiotics, anticholinergics PSEs

delirium

acyclovir/ganciclovir PSEs

hallucinations

psychostimulants, dopaminergic agents PSEs

• psychosis

• agitation

• irritability

OTC cough and cold preparations PSEs

• delirium

• confusion

• hallucinations

opioid PSEs

• anxiety

• irritability

stimulant PSEs

• paranoia

• psychosis

• depression

• hallucinations

medications with induction of a psychoactive state

• antihypertensives

• oral contraceptives

• steroids

• cancer chemotherapy agents

• benzodiazepines

• barbituates

• histamine 2 blockers

commonly abused substances

• alcohol

• opioids

• amphetamines (ecstacy, meth)

• cocaine

• benzodiazepines

• barbituates

• steroids

• LSD

hallmark risk factors of a medical mimic

• normal functioning prior to sudden onset of mental symptoms

• late onset of initial presentation

• known underlying medical condition

• atypical presentation of a specific psychiatric diagnosis

• disturbance of gait, balance, or both

• visual, olfactory, or tactile hallucinations

• ilicit or recent substance use

other high risk features for a medical mimic

• absence of personal and family history of psychiatric illnesses

• family concern

• medication use

• abnormal vital signs or significant abnormalities on exam

• waxing and waning mental status or abnormal mental status exam findings

• disorientation with clouded consciousness

• recent memory loss

• history of head injury

• treatment resistance or unusual response to treatment (worse after antipsychotic or anxiolytic)

high risk individuals for a medical mimic

• elderly

• patients with history of substance abuse

• patients without history of psychiatric illness

• patients with preexisting medical illness

• patients with preexisting medical illness

• patients from lower socioeconomic status

lab and metabolic assessments

• pulse ox

• CMP, CBC

• assessment of therapeutic drug levels

• blood alcohol level

• UA and UDS

• thyroid function testing

• erythrocyte sedimentation rate and/or C-reactive protein

• screening for syphilis, lyme disease, lupus, and demyelination disorder

• AIDS/HIV screening

nursing implications

• a client is a holistic entity

• be aware of medical mimics and understand that common psychiatric symptoms often arise from medical illnesses

• emotional dimensions may be overlooked in med-surg or primary care

• provide reassurance and support to families and clients

• be sensitive to the emotional experiences of clients with medical illnesses

nursing interventions

• perform accurate, thorough health history and physical exam of all clients

• ask everyone about substance use

• review current prescriptions, OTC meds and alternative meds and recent changes

• monitor lab and report abnormal labs immediately