Medical Causes of Psychiatric Disease
Jennifer Kwack, New York Medical College; Martin L. Kutscher, MD, Departments of Pediatrics and Neurology, New York Medical College.
CC: KT is a 16 y.o. boy presenting with a two day history of not eating, talking, or moving.
HPI: One year prior to admission, KT began diminished concentration, poor school performance, and neglect of daily living skills. He was increasingly withdrawn from family and friends. Additionally, KT experienced decreased appetite with a ten-pound weight loss, episodes of occasional urinary incontinence; and slowness in gait, movements, and speech. These symptoms progressed in severity until one month prior to admission, when the patient went into a totally "statue-like" state where he completely stopped talking and moving, and only stared into space. There was a questionable history of a tick bite. He was brought to the emergency room where initial labs showed only mild dehydration. KT was admitted to the psychiatric unit where further work-up revealed a positive serum ELISA for Lyme disease, but a normal spinal tap that was negative for Lyme by PCR analysis. The child was treated with two weeks of IV ceftriaxone with variable clinical improvement, and was discharged three weeks after admission. However, two days after discharge, the patient again went into a "statue-like" state and was brought back to the ER for further evaluation. There had been no change in the quality of his voice, heat or cold intolerance, nausea, vomiting, changes in bowel habits, fever, or flu-like symptoms.
EXAMINATION: General physical examination was unremarkable. Neurological examination showed the above mental state, with waxy posturing of the extremities, but no focality.
The list of differential diagnoses is quite extensive. The psychiatric presentations range the entire gamut of Axis I and II disorders of the DSM-IV, including psychosis, delusion; and disorders of mood, anxiety, sleep, sex, and personality.
Initially, KTs symptoms point to a psychiatric cause-- most likely depression or atypical schizophrenia. The onset of both of these diseases is common in adolescence and can present with "catatonic" like symptoms. However, this case brings to light the different neurological and medical categories of disease that can present with psychiatric symptoms.
Tumor, trauma, and other intracranial lesions always have to be considered when discussing symptoms involving the central nervous system. If the symptoms in this case are indeed organically based, they are most consistent with frontal lobe lesions.
Dysfunction of the frontal lobe causes three types of syndromes:
Alteration in motor activities: Involvement of both frontal lobes can cause akinetic mutism, a condition that leaves the patient motionless but not paralyzed, and speechless with wandering eye movements (Hecaean & Albert, 1975). Other movement disorders include decreased psychomotor activity, motor perseveration, and compulsive manipulation.
Personality changes: Pathology involving the inferior orbital frontal region typically causes euphoria, hyperactivity, and irritability. However, involvement of the frontal convexity presents as apathy, indifference, slowness, and a depression-like picture (Blumer & Benson, 1975).
Cognitive changes: These include primarily problems of attention and memory, especially in integrating new experience. Furthermore, dementia of the frontal lobe type is accompanied by extremes of behavior such as gluttony or total neglect of food, speech disorders like echolalia or mutism, and the expression of numerous somatic complaints (Neary, 1990).
Seizures presenting as status epilepticus can cause altered behavior and mental state. Partial complex and absence seizures would be most likely to present in this fashion. Eye fluttering, lip smacking, fumbling, twitching movements, or a past history of seizures may be clues.
Hereditary Degenerative Neurological Disease
Numerous degenerative neurological conditions can present with psychiatric symptoms. Wilsons disease is an autosomal recessive inherited deficiency of ceruloplasmin that results in progressive accumulation of copper in the liver, brain, cornea, and kidney. Although most patients present with hepatomegaly, cirrhosis or hepatitis sometime after the age of five, forty percent of patients can present in the second or third decade with neurological symptoms. Ten to twenty-five percent of patients present with psychiatric disturbances such as dementia, psychoneurosis, manic-depressive or schizophrenic psychosis, or frontal lobe type behavior abnormalities (Schienberg & Sternleib, 1984). Juvenile onset Huntingtons disease may also present with intellectual deterioration, poor performance in school, personality changes or depression.
There is also a group of childhood degenerative disease that present as dementia or psychosis including adrenoleukodystrophy, gangliosidosis, Niemann-Pick, mucopolysacharidosis, Fabrys and Krabbes disease. Adolescent adrenoleukodystrophy (ALD) is often confused with psychiatric disorders and dementia. Often, poor school performance, difficulty concentrating, and hyperactivity are among the initial presenting complaints.
Given the positive ELISA for Lyme in this case, one would have to consider encephalitis high on the differential list as well as other infectious causes. Other causes of encephalitis besides Lyme are arbovisuses, HIV, and herpes virus. Subacute sclerosing panencephalitis (SSPE) is also a diagnosis to be considered. It is a slow, progressive inflammatory disease of childhood or early adolescence that affects males three times more frequently than females. SSPE usually follows a measles infection or vaccination. Early on, the behavioral changes include disobedience, easy distractibility, social withdrawal, sleeplessness, and hallucinations. Myoclonus, seizures, and mental deterioration ensue, with coma and death in one to three years. Neuro-syphilis also presents with manifestations of frontal lobe disease including subtle personality changes, poor judgment, irritability, and lack of interest in personal appearance. With time, patients become more apathetic and disoriented. In immuno-compromised patients, one should also consider other causes of chronic meningitis such as M. tuberculosis, Cryptococcus, and Coccidioides.
Rheumatic fever and immune streptococcal reactions (PANDAS) may include psychiatric, attentional, and movement disorders. Vasculitis (such as lupus) can also frequently cause psychiatric symptoms.
Several metabolic and endocrine disorders can present with psychiatric symptoms. Hyperthroidism can present with confusional behavior, anxiety, and agitated depression; while hypothyroidism can present as dementia, paranoia, depression, hypomania, schizophreniform psychosis, and hypomania. Pituitary adenomas can cause Cushings syndrome in which 70% of cases manifest easy fatigability, irritability, depression, mental dullness and memory impairment (Skuster et al, 1992). Hypopituitarism can present with a slowly progressive dementia with signs of mental slowness, depression, and emotional changes. Steroid treatment can cause major psychiatric changes.
Another metabolic condition, acute intermittent porphyria, can present with psychosis. It is diagnosed by colicky abdominal pain, motor polyneuropathy, dark urine, and psychosis. The psychiatric symptoms range from anxiety and insomnia to depression and frank psychosis, and often go misdiagnosed as atypical schizophrenia or schizoaffective disorder.
One must always consider substance abuse, especially with teenagers. Medicinal drugs frequently cause iatrogenic psychiatric side effects. Mercury poisoning and other heavy metals such as lead can cause changes in mentation. Inorganic mercury poisoning can cause severe depression, irritability, and florid psychosis. Organic mercury poisoning can cause a mild dementia like picture in addition to depression and irritability.
Vitamin deficiencies can also cause psychiatric type symptoms. Vitamin B12 deficiency has been characterized by irritability and emotional instability that gradually progresses to depressive psychosis and intellectual deterioration. It should be a particular concern in patients with a history of gastric surgery, malabsorption, or a strict vegetarian diet. Thiamine deficiency is also associated with Wernicke-Korsakoff syndrome, and can present with memory loss or impairment.
As is evident, there are many medical and neurological conditions that present with psychiatric symptoms. One must approach these symptoms without bias and an open mind to properly assess and diagnose the patient. Although the investigation to make the correct diagnosis in such cases can be quite extensive and time consuming, the rewards can be great. To date, no medical diagnosis has been found for KT.
Blumer, D. & Benson, DF. Personality changes with frontal and temoral lobe lesions. In Benson, DF, Blumer, D. (eds). Psychiatric aspects of neurologic disease. New York, Grune & Stratton, 1975, pp.151-170.
Brooks, DS., Murphy, MB., Janota, I., et al. Early onset Huntingtons chorea, diagnostic clues. British Journal of Psychiatry, 151:850-852, 1987.
Hecaean, H. , Albert, ML. Disorders of mental functioning related to frontal lobe pathology. In Benson, DF., Blumer, D. (eds). Psychiatric aspects of neurologic disease. New York, Grune & Stratton, 1975, pp.137-149.
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Schienberg, H., Sternleib, I. Wilsons Disease: Major problems in internal medicine, vol.23, Philadelphia, WB Saunders, 1984.
Skuster, DZ., Digre, KB., & Corbett, JJ. Neurologic conditions presenting as psychiatric disorders. Psychiatric Clinics of America, 15(2), pp.311-323.