This is Part 2 of the post Why do psychiatrists need to study other aspects of medicine – anatomy, the digestive system, the urinary system, etc? As I mentioned before, I won’t give an in depth medical school explanation of what the various disease and conditions are. What I’m listing is by no means complete. They are just some of the reasons why psychiatrists need to have a medical background.
A psychiatrist is a physician who specializes in the diagnosis, treatment, and prevention of mental illnesses and substance use disorders. He or she must graduate from college and then medical school, and go on to complete four years of residency training in the field of psychiatry. (Many psychiatrists undergo additional training so that they can further specialize in such areas as child and adolescent psychiatry, geriatric psychiatry, forensic psychiatry, psychopharmacology, and/or psychoanalysis.) This extensive medical training enables the psychiatrist to understand the body’s functions and the complex relationship between emotional illness and other medical illnesses. The psychiatrist is thus the mental health professional and physician best qualified to distinguish between physical and psychological causes of both mental and physical distress.” Psychiatrists’ medical background, training and experience allow them – under state licensing laws – to prescribe medication, and order and interpret medical tests. These procedures are essential for the appropriate diagnosis and treatment of mental disorders, just as they are for all other medical illnesses. Psychiatrists are also uniquely qualified to approach care and treatment from a therapeutic, as well as a medical, foundation.
Today, Part 2, I will discuss in more detail several psychiatric symptoms of physical disorders such as brain disorders, schizophrenic symptoms, anxiety, depression, sexual dysfunction and mania. I’ll also give a list of some common prescription and over the counter medications which can cause or exaggerate psychiatric symptoms.
Brain disorders with psychiatric symptoms
1. Acute confusional state Delirium
2. Chronic brain syndromes
3. Dementias, focal disorders tumors, vascular events acute confusional state (delirium) Common in pathological and surgical units (5 – 15%) and in Intensive treatment units (20-30%.) The person is disorientated, cannot remember some things and is uneasy and shows hyperactivity, irritability, fear or aggression, even delusions or hallucinations and ideas of persecution.
Other physical disorders cause psychiatric symptoms similar to schizophrenia, mania and depression.
1. Schizophrenic symptoms
Delirium, dementias, brain tumors, cerebrovascular episodes, brain lesions, epilepsy, Cushing syndrome, hyperthyroidism, hypothyroidism, hypoparathyroidism, medication and toxic substances, syphilis, AIDS, multiple sclerosis, hepatic insufficiency, hypoglycemia, electrolyte disorders, uremia, acute intermittent porphyria, lupus erythematosus
2. Depressive symptoms
Brain tumors, epilepsy, vitamin B12 deficiency, Cushing’s syndrome, hypothyroidism, Addison’s disease, hyper parathyroidism, hypopituitarism, medication and toxic substances, syphilis, AIDS, Malta fever, monocytic angina, hepatitis, multiple sclerosis, electrolyte disorders, uremia, acute intermittent porphyria, Alcoholism, Sydenham’s Chorea, Carcinoid syndrome (small intestine cancer), Malignancies, especially of the pancreas, Parkinsonism, Sedative/hypnotic abuse, Amphetamine and other sympathomimetics, Folic acid deficiency, Insecticide and gaseous poisonings, Hartman’s Disease, Viral illnesses (mono, etc.), Steroids and other medications
3. Manic symptoms
Brain tumors, vitamin B1 deficiency, Cushing syndrome, medication and other substances, syphilis, AIDS, multiple sclerosis, acute intermittent porphyria
4. Anxiety symptoms
Cushing syndrome, hyperthyroidism, pheochromocytoma, AIDS, Amphetamines and other sympathomimetics, Alcohol (intoxication or withdrawal), Hyperadrenalism, Hyperparathyroidism, Hyperthyroidism, Kleinfelter’s Syndrome
5. Psychosis with hallucinations and delusions
Hepatitis, amphetamines and other sympathomimetics, porphyria, alcohol withdrawal (paranoia also), Von Gierke’s Disease, anticholinergic intoxication, cerebral allergies, hallucinogens (PCP, LSD, etc.), hypertension (seizures), Temporal lobe epilepsy, Mixed sensory lobe seizures, Pick’s Disease, medication toxicity (Antabuse, cimetidine, levadopa, anticonvulsants, etc.), Addison’s disease, limbic seizures, cerebral vasculitis (SLE), Schilder’s disease, hypothyroidism, uremia (chronic), multiple sclerosis, azotemia (chronic), neurosyphilis, hypocalcemia, encephalitis, Fanconi’s Syndrome, metal poisonings, Huntington’s disease, vitamin A toxicity, brain tumors, Simmond’s Disease, pernicious anemia, electrolyte imbalances, hypoparathyroidism, Wilson’s disease, hyperthyroidism, vitamin B-12 deficiency, sensory deprivation, hyperinsulinism, steroids or Cushing’s disease
6. Behaviors and conditions associated with occult seizures
- Multiple personalities, especially when there is dissociation.
- Depression with withdrawal, psychomotor retardation, loss of interest, slowed thinking and/or fatigue.
- Automatic behavior, often with bizarre movements and agitation.
Visual auras, with or without feelings of confusion, strange sensations in the head or other parts of the body.
- Hallucinations, especially auditory.
- Abdominal sensations, with an awareness of having illusions, and rigidity or adversive (away from the body) movements.
- Thoughts described as “cloudy,” claims to have “difficulty thinking,” and use of expressions like “things are mixed up,” complaints of vague perceptual distortions.
- Episodes with fixed, staring gaze and unresponsiveness, even while continuing to perform tasks. Usually can’t remember what occurred during that period of time.
- Episodic bouts of violence.
Inappropriate actions or gestures, unresponsive or irrelevant replies, aimless wandering around or dazed, vacant facial expression, often with amnesia.
- Hysterical dissociation, a confused state while still performing tasks, with amnesia often lasting hours, days or weeks.
- Regular episodes of schizophrenic behavior of short duration but sometimes severe enough to require hospitalization; between episodes, normal behavior resumes, although may appear more withdrawn than before episodes began.
- A history of schizophrenia and no response in medications. Ambivalence along with a decrease in speech cohesiveness and organization.
- Episodes of schizophrenic behavior that always seem to start in the same way.
It has been recognized for many years that drugs not only cure medical disease but may also cause it. Medication reactions account for 3-5% of admissions to acute-care facilities, 0.3% of admissions to hospitals, and 7% of admission to intensive care units.(1) One seventh of hospital days are devoted to drug toxicity at an estimated cost of 3 billion dollars.(2 ) As advances in medical science and technology increase, the risk of iatrogenic illnesses rises proportionately (iatrogenic illnesses are those caused by medical interventions themselves including procedures, medications, and even hospitalization). Unfortunately, medication induced side effects are frequently misdiagnosed as mental illness by health care providers and mental health practitioners.
The entire issue of the July 1993 Medical Letter on Drugs and Therapeutics 3 was devoted to a review of one hundred and sixty nine different medications that may cause psychiatric symptoms that could be mistaken for mental illness. These include such commonly prescribed drugs as Dilantin, Tagamet, Cardizem, Motrin, Mevacor, Reglan, Flagyl, Procardia, Darvon, Inderal, most steroid preparations and Benadryl. The adverse effects range from hallucinations (seeing, hearing, smelling, or feeling things that are not real) and delusions (beliefs that have no basis in reality) to confusion, disorientation, agitation, apprehension, mania, panic attacks, depression and irritability.
These adverse effects may, in some cases, be dose related in that they occur only at higher doses and disappear if the dose is reduced. In other cases, some people experience what are called idiosyncratic side effects. In this case a person has an inherent sensitivity to a medication, regardless of dose, and the side effect may be one that would not ordinarily be expected in most situations. This may sometimes even cause the opposite effect from what was intended. These invariably disappear when the medication is discontinued. Finally, another set of psychiatric-like symptoms may occur when certain medications are precipitously discontinued or withdrawn too rapidly. This is most commonly seen with steroids, atropine-like drugs, narcotics and most minor tranquilizers. Patients, frequently the elderly, precipitously stop medications of this sort without physician consultation because they are too expensive, because they feel they may be having side effects, or because they fear becoming too dependent on the medication. The withdrawal effects can be eliminated with a medically supervised, gradual reduction of the dose.
Unfortunately, medication induced side effects are frequently misdiagnosed as mental illness by health care providers and mental health practitioners. To complicate things even further, many of the illnesses for which these 169 medications are prescribed may themselves cause psychiatric symptoms. Obvious examples include thyroid disease, autoimmune illnesses, seizure disorders, and adrenal gland dysfunction among others. To tease apart which psychiatric symptom is due to the illness itself and which is due to the medication prescribed for the illness is frequently a quite formidable challenge. In other situations, prescribed medication can precipitate attacks of underlying medical conditions such as porphyria. This is a metabolic condition which can be triggered by medications including barbiturates (or their derivatives), and which causes abdominal pain that may be accompanied by psychiatric symptoms.
An earlier edition of The Medical Letter 4 reviewed medically prescribed drugs that can also cause sexual dysfunction, a complaint for which consumers frequently seek the help of mental health professionals. One hundred and ten different medications fall into this category including such frequently prescribed drugs as Tenormin, Pepcid, Lopid, Indocin, Prilosec, Minipress, Haldol, Navane, Thorazine, Stelazine, Mellaril, Trilafon, Zantac, Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro and the thiazide diuretics among others. Of the antidepressants, Wellbutrin tends to cause the least amount of sexual dysfunction. Sexual dysfunction is frequently cause for a patient stopping medication without telling their physician which then only complicates the medical condition for which the drug was prescribed in the first place. On the other hand, they may remain on the medication, not recognizing the drug is causing the sexual problem, and seek mental health treatment or sexual counseling.
Psychotherapy, counseling, behavior modification or the introduction of psychiatric medication will clearly not resolve problems that are precipitated by medications being used to treat medical conditions. This will only prolong, and many times significantly complicate, what appears to be a psychiatric condition. This, of course, only intensifies the person’s suffering and very much increases the cost of treatment.
Discontinuing the medication, or switching to another that does not have the same side effects, costs literally nothing and can be accomplished in anywhere from a day to two or three weeks.
In this era of soaring health costs it is critical that consumers of health care be educated as to the potential adverse psychiatric effects of prescribed medications and that they are afforded a careful medical review of any drugs they may be taking for physical conditions they are diagnosed as having a mental illness or sexual dysfunction and before counseling, psychotherapy, behavior modification or before psychotropic medication is introduced.
Some prescription drugs with known psychiatric reactions include:
- Sulfonamides and other antibacterials
- Hormonal drugs
- Acne drugs
- ADHD drugs
- Beta-blockers and other cardiovascular drugs
- Statin drugs