MENTAL AND BEHAVIORAL DISORDERS DUE TO GENERAL MEDICAL

CONDITIONS

Learning Objectives Identify Psychiatric symptoms in

the following: Thyroid diseases (thyrotoxicosis, myxodema) Hyperadrenalism (cushing’s syndrome), Hypoadrenalism (Addison’s disease) Hyperglycemia and hypoglycemia

Learning Objectives

Renal failure and electrolyte disturbance

Hepatic encephalopathy Vitamin B deficiency Cerebral hypoxia

Acute(organic) brain syndrome/Delirium

This condition is the consequence of both medical and surgical disorders

Etiology consists of intracranial as well as extracranial causes

Clinical feature are diverse and according to underlying physical ailment

Management is that of cause and symptoms

Hyperthyroidism/Thyrotoxicosis

The symptoms are: Symptoms of anxiety Restlessness Over activity Lability of mood Other symptoms of increased thyroid activity Mental symptoms may precede or may be

the only indication of hyperthyroidism

Hyperthyroidism/Thyrotoxicosis

Hyperthyroidism should be differentiated from primary anxiety state, depressive illness and schizophreniform psychosis.

Hypothyroidism/Myxoedema

It usually manifests at middle aged or elderly ladies but no age or sex is exempt.

The psychiatric symptoms may be:1. Mental lethargy2. Loss of spontaneity3. Dulling of comprehension4. Mild memory impairment5. Frequently a depressed mood6. May present as delirium

Hypothyroidism/Myxoedema

Typically the voice is husky and skin is coarse. Deafness is common. Deep tendon

Reflexes are slow and there is delayed relaxation of muscles.

A combination of myxoedema coma and hyperthyroidism may leads to death

Sheehan’s Syndrome

It results from post partum necrosis of anterior pituitary.

The picture is usually of intensely pale middle aged women with a fine and prematurely wrinkled skin sitting drowsily by the fire on a warm summer day

Sheehan’s Syndrome

The clinical picture is:1. Lack of initiative2. Increased susceptibility to cold3. Increased desire for rest and sleep4. Depression of mood.5. Emaciation6. Impotence in males and

amenorrhoea in females

Addison’s Disease

May be caused bilateral primary atrophy of the glands or infection of the adrenal glands or necrosis due to hemorrhagic shock. The symptoms are:

1. Apathy2. Hypotension3. Pigmentation of exposed part of skin4. Depression5. Episodes of delirium may occur

Cushing’s Syndrome

It can be caused by tumors of pituitary gland or may be the result of primary hyperplasia of adrenals and thus prolonged excessive secretion of steroid hormones. The physical features are:

1. Red moon shaped face2. Hirsutism3. Obesity4. Buffalo-hump

Cushing’s Syndrome The mental symptoms are:

1. Depression of mood is the commonest but rarely elation may be seen

2. Episodes of disturbed behaviour like excitement or anxiety can be present

3. Auditory hallucinations and paranoid delusions may be observed

Diabetes Mellitus

Two main psychiatric syndromes:1. Delirium2. Diabetic cerebral arteriopath.

“INSULINOMA”: Major features are intermittent

bizarre behaviour occurring after exercise in the late morning or before break fast in the early morning.

There is pallor, sweating, anxiety, unsteadiness and depersonalization.

Very frequently physical symptoms are the sole features.

METABOLIC DISORDERS

Renal Failure and Electrolyte Disturbance

In this condition mental state of a patient changes as the uremia increases

Early changes include undue fatigue, drossiness and impaired concentration. Slowing of thought process and memory disturbances then follow

Renal Failure and Electrolyte Disturbance

Subsequently tremors, muscle twitching, neuropathy and epileptic fits start occurring.

This picture can also be seen in patient with chronic renal failure who are being treated be dialysis. Anxiety and depression are other common psychiatric symptoms in patient on dialysis.

Hepatic Encephalopathy

This state can be seen in viral hepatitis or in association with an established case of cirrhosis

Prodromal symptoms include anergia, headache, disturbed sleep leading to confuional state and coma.

Hepatic Encephalopathy

Chronic encepthalopathy occurs in all types of cirrhosis

There are reversible episodes of altered consciousness leading to stupor

This state is also associated with increased sleep. Other features are hepatic foetor, flapping tremers and splenomegaly

Vitamin B Deficiency

1. Thiamine. (B-1) Deficiency Deficiency of thiamine is the cause

of Wernicke’s encephalopathy which may terminate in a transient or permanent memory impairment and Korsakoff’s psychosis.

Vitamin B Deficiency

2. Nicotinic Acid Deficiency The features are dermatitis,

dysphagia, dierrhoea, delirium and dementia.

Other symptoms are weakness of muscles, paraesthesias, depression and confusional state

Vitamin B Deficiency3. Vitamin B12 Deficiency. Major causes are gastrectomy and

defective diet. The symptoms are pernicious

anaemia, sub acute combined degeneration of the cord and psychiatric squellae like depression, anxiety, irritability and poor memory.

In some cases mental symptoms may precede the neurological and haematological abnormalities.

Cerebral Hypoxia

The causes are CO poisoning exposure to high altitude, respiratory diseases and congestive cardiac failure.

The mental sequellae are more marked in the elderly with co-existing disease of the cerebral vessels.

The symptoms are that of fluctuating delirium with associated behavioural symptoms.