Mental Disorders Due to a Medical Condition

I. Introduction

General medical conditions may cause and be associated with a variety of mental disorders. The psychiatrist should always be aware of (1) any general medical condition that a patient may have and (2) any prescription, nonprescription, or illegal substances that a patient may be taking.

II. Mood Disorder Due to a General Medical Condition

A. Epidemiology

Appears to affect men and women equally.
As many as 50% of all poststroke patients experience depressive illness. A similar prevalence pertains to individuals with pancreatic cancer.
Forty percent of patients with Parkinson’s disease are depressed.
Major and minor depressive episodes are common after certain illnesses such as Huntington’s disease, human immunodeficiency virus (HIV) infection, and multiple sclerosis (MS).

B. Diagnosis and clinical features

Patients with depression may experience psychological symptoms (e.g., sad mood, lack of pleasure or interest in usual activities, tearfulness, concentration disturbance, and suicidal ideation) or somatic symptoms (e.g., fatigue, sleep disturbance, and appetite disturbance), or both psychological and somatic symptoms.
Diagnosis in the medically ill can be confounded by the presence of somatic symptoms related purely to medical illness, not to depression. In an effort to overcome the underdiagnosis of depression in the medically ill, most practitioners favor including somatic symptoms in identifying mood syndromes (Table 9-1).

C. Differential diagnosis

Substance-induced mood disorder. Mood disorder due to a general medical condition can be distinguished from substance-induced mood disorder by examination of time course of symptoms, response to correction of suspect medical conditions or discontinuation of substances, and, occasionally, urine or blood toxicology results.

Table 9-1 DSM-IV-TR Criteria for Mood Disorder Due to a General Medical Condition

A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
1. Depressed mood or markedly diminished pleasure in all, or almost all, activities
2. Elevated, expansive, or irritable mood.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood in response to the stress of having a general medical condition).
The disturbance does not occur exclusively during the course of a delirium.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify:

With depressive features: if the predominant mood is depressed, but the full criteria are not met for a major depressive disorder

With major depressive-like episode: if all criteria for major depressive episode are met, except, clearly, for the criterion that the symptoms are not due to the physiological effects of a substance or a general medical condition

With manic features: if the predominant mood is elevated, euphoric, or irritable

With mixed features: if the symptoms of mania and depression are present, but neither predominates

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.

Delirium. Mood changes occurring during the course of delirium are acute and fluctuating and should be attributed to that disorder.
Pain syndromes. Pain syndromes can depress mood through psychological, not physiological means, and may appropriately lead to a diagnosis of primary mood disorder.
Sleep disorders, anorexia, and fatigue. In the medically ill, somatic complaints, such as sleep disturbance, anorexia, and fatigue, may be counted toward a diagnosis of major depressive episode or mood disorder due to a general medical condition, unless those complaints are purely attributable to the medical illness.

D. Course and prognosis.

Prognosis for mood symptoms is best when etiological medical illnesses or medications are most susceptible to correction (e.g., treatment of hypothyroidism and cessation of alcohol use).

E. Treatment

Pharmacotherapy. The underlying medical cause should be treated as effectively as possible. Standard treatment approaches for the corresponding primary mood disorder should be used, although the risk of toxic effects from psychotropic drugs may require more gradual dose increases. Standard antidepressant medications, including tricyclic drugs, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and psychostimulants, are effective in many patients.
Psychotherapy. At a minimum, psychotherapy should focus on psychoeducational issues. The concept of a behavioral disturbance secondary to medical illness may be new or difficult for many patients and
families to understand. Specific intrapsychic, interpersonal, and family issues are addressed as indicated in psychotherapy.

III. Psychotic Disorder Due to a General Medical Condition

To establish the diagnosis of psychotic disorder due to a general medical condition, the clinician first must exclude syndromes in which psychotic symptoms may be present in association with cognitive impairment (e.g., delirium and dementia of the Alzheimer’s type). Disorders in this category are not associated usually with changes in the sensorium.

A. Epidemiology

The incidence and prevalence in the general population are unknown.
As many as 40% of individuals with temporal lobe epilepsy experience psychosis.
The prevalence of psychotic symptoms is increased in selected clinical populations, such as nursing home residents, but it is unclear how to extrapolate these findings to other patient groups.

B. Etiology.

Virtually any cerebral or systemic disease that affects brain function can produce psychotic symptoms. Degenerative disorders, such as Alzheimer’s disease or Huntington’s disease, can present initially with new-onset psychosis, with minimal evidence of cognitive impairment at the earliest stages.

C. Diagnosis and clinical features.

Two subtypes exist for psychotic disorder due to a general medical condition: with delusions, to be used if the predominant psychotic symptoms are delusional, and with hallucinations, to be used if hallucinations of any form comprise the primary psychotic symptoms (Table 9-2). To establish the diagnosis of a secondary psychotic syndrome, determine that the patient is not delirious, as evidenced by a stable level of consciousness. Conduct a careful mental status assessment to exclude significant cognitive impairments, such as those encountered in dementia or amnestic disorder.

D. Differential diagnosis

Psychotic disorders and mood disorders. Features may present with symptoms identical or similar to psychotic disorder due to a general medical condition; however, in primary disorders, no medical or substance cause is identifiable, despite laboratory workup.

Table 9-2 DSM-IV-TR Criteria for Psychotic Disorder Due to a General Medical Condition

Prominent hallucinations or delusions.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
The disturbance is not better accounted for by another mental disorder.
The disturbance does not occur exclusively during the course of a delirium.

Specify:

With delusions: if delusions are the predominant symptom

With hallucinations: if hallucinations are the predominant symptom

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.

Delirium. May be present with psychotic symptoms; however, delirium-related psychosis is acute and fluctuating, commonly associated with disturbance in consciousness and cognitive defects.
Dementia. Psychosis resulting from dementia may be diagnosed as psychotic disorder due to a general medical condition, except in the case of vascular dementia, which should be diagnosed as vascular dementia with delusions.
Substance-induced psychosis. Most cases of nonauditory hallucinosis are due to medical conditions, substances, or both. Auditory hallucinations can occur in primary and induced psychoses. Stimulant (e.g., amphetamine and cocaine) intoxication psychosis may involve a perception of bugs crawling under the skin (formication). Diagnosis may be assisted by chronology of symptoms, response to removal of suspect substances or alleviation of medical illnesses, and toxicology results.

E. Course and prognosis.

Psychosis caused by certain medications (e.g., immunosuppressants) may gradually subside even when use of those medications is continued. Minimizing doses of such medications consistent with therapeutic efficacy often facilitates resolution of psychosis. Certain degenerative brain disorders (e.g., Parkinson’s disease) can be characterized by episodic lapses into psychosis, even as the underlying medical condition advances. If abuse of substances persists over a lengthy period, psychosis (e.g., hallucinations from alcohol) may fail to remit even during extended intervals of abstinence.

F. Treatment.

The principles of treatment for a secondary psychotic disorder are similar to those for any secondary neuropsychiatric disorder, namely, rapid identification of the etiological agent and treatment of the underlying cause. Antipsychotic medication can provide symptomatic relief.

IV. Anxiety Disorder Due to a General Medical Condition

The individual experiences anxiety that represents a direct physiological, not emotional, consequence of a general medical condition. In substance-induced anxiety disorder, the anxiety symptoms are the product of a prescribed medication or stem from intoxication or withdrawal from a nonprescribed substance, typically a drug of abuse.

A. Epidemiology

Medically ill individuals in general have higher rates of anxiety disorder than do the general population.
Rates of panic and generalized anxiety are especially high in neurological, endocrine, and cardiology patients.
Approximately one third of patients with hypothyroidism and two thirds of patients with hyperthyroidism may experience anxiety symptoms.
As many as 40% of patients with Parkinson’s disease have anxiety disorders. Prevalence of most anxiety disorders is higher in women than in men.

B. Etiology.

Causes most commonly described in anxiety syndromes include substance-related states (intoxication with caffeine, cocaine,
amphetamines, and other sympathomimetic agents; withdrawal from nicotine, sedative–hypnotics, and alcohol), endocrinopathies (especially pheochromocytoma, hyperthyroidism, hypercortisolemic states, and hyperparathyroidism), metabolic derangements (e.g., hypoxemia, hypercalcemia, and hypoglycemia), and neurological disorders (including vascular, trauma, and degenerative types). Many of these conditions are either inherently transient or easily remediable.

Table 9-3 DSM-IV-TR Criteria for Anxiety Disorder Due to a General Medical Condition

Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with anxiety in which the stressor is a serious general medical condition).
The disturbance does not occur exclusively during the course of a delirium.
The disturbance causes clinical significant distress or impairment in social, occupational, or other important areas of functioning.

Specify:

With generalized anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation

With panic attacks: if panic attacks predominate in the clinical presentation

With obsessive-compulsive symptoms: if obsessions or compulsions predominate in the clinical presentation

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.

C. Diagnosis and clinical features.

Anxiety stemming from a general medical condition or substance may present with physical complaints (e.g., chest pain, palpitation, abdominal distress, diaphoresis, dizziness, tremulousness, and urinary frequency), generalized symptoms of fear and excessive worry, outright panic attacks associated with fear of dying or losing control, recurrent obsessive thoughts or ritualistic compulsive behaviors, or phobia with associated avoidant behavior (Table 9-3).

D. Differential diagnosis

Primary anxiety disorders. Anxiety disorder due to a general medical condition symptomatically can resemble corresponding primary anxiety disorders. Acute onset, lack of family history, and occurrence within the context of acute medical illness or introduction of new medications or substances suggest a nonprimary cause.
Delirium. Individuals with delirium commonly experience anxiety and panic symptoms, but these fluctuate and are accompanied by other delirium symptoms such as cognitive loss and inattentiveness; furthermore, anxiety symptoms diminish as delirium subsides.
Dementia. Dementia often is associated with agitation or anxiety, especially at night (called sundowning), but an independent anxiety diagnosis is warranted only if it becomes a source of prominent clinical attention.
Psychosis. Patients with psychosis of any origin can experience anxiety commonly related to delusions or hallucinations.
Mood disorders. Depressive disorders often present with anxiety symptoms, mandating that the clinician inquire broadly about depressive symptoms in any patient whose primary complaint is anxiety.
Adjustment disorders. Adjustment disorders with anxiety arising within the context of a psychological reaction to medical or other life stressors should not be diagnosed as anxiety disorder due to a general medical condition.

E. Course and prognosis

Medical conditions responsive to treatment or cure (e.g., correction of hypothyroidism and reduction in caffeine consumption) often provide concomitant relief of anxiety symptoms, although such relief may lag behind the rate or extent of improvement in the underlying medical condition.
Chronic, incurable medical conditions associated with persistent physiological insult (e.g., chronic obstructive pulmonary disease) or recurrent relapse to substance use can contribute to seeming refractoriness of associated anxiety symptoms.
In medication-induced anxiety, if complete cessation of the offending factor (e.g., immunosuppressant therapy) is not possible, dose reduction, when clinically feasible, often brings substantial relief.

F. Treatment.

Aside from treating the underlying causes, benzodiazepines are helpful in decreasing anxiety symptoms; supportive psychotherapy (including psychoeducational issues focusing on the diagnosis and prognosis) may also be useful. More specific therapies in secondary syndromes (e.g., antidepressant medications for panic attacks, SSRIs for obsessive–compulsive symptoms, behavior therapy for simple phobias) may be of use.

V. Sleep Disorder Due to a General Medical Condition

A. Diagnosis.

Sleep disorders can manifest in four ways: by an excess of sleep (hypersomnia), by a deficiency of sleep (insomnia), by abnormal behavior or activity during sleep (parasomnia), and by a disturbance in the timing of sleep (circadian rhythm sleep disorders). Primary sleep disorders occur unrelated to any other medical or psychiatric illness (Table 9-4).

B. Treatment.

The diagnosis of a secondary sleep disorder hinges on the identification of an active disease process known to exert the observed effect on sleep. Treatment first addresses the underlying neurological or medical disease. Symptomatic treatments focus on behavior modification, such as improvement of sleep hygiene. Pharmacological options can also be used, such as benzodiazepines for restless legs syndrome or nocturnal myoclonus, stimulants for hypersomnia, and tricyclic antidepressant medications for manipulation of rapid eye movement (REM) sleep.

VI. Sexual Dysfunction Due to a General Medical Condition

Sexual dysfunction often has psychological and physical underpinnings. Sexual dysfunction due to a general medical condition subsumes multiple forms
of medically-induced sexual disturbance, including erectile dysfunction, pain during sexual intercourse, low sexual desire, and orgasmic disorders (Table 9-5).

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