Psychiatric Mimics Medical diagnoses that Manifest as Psychiatric Symptoms

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Psychiatric MimicsMedical diagnoses that
Manifest as Psychiatric Symptoms

• Derek S. Mongold MD
• Resident in Psychiatry and Family medicine
• 01-20-09

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Objectives

• Show importance of searching for and ruling out
  medical causes of psychiatric illness
• Familiarize audience with general principals that
  point toward a medical causes of psychiatric
  illness
• Review specific diseases often mentioned in
  psychiatric literature

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Overview

• Importance of ruling out Medical Mimics
• General Principles
• Mnemonics
• ROS and physical exam examples
• Specific diseases
• Conclusion

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Importance of Ruling Out Medical Mimics

• 5-42 of patients referred for psychiatric
  treatment have an underlying medical illness
  responsible for their symptoms.1
• Conservative estimates suggest 10 of persons in
  outpatient settings have an organic disease
  causing the symptoms. 2
• Higher in the elderly and much higher in
  inpatient settings.

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Importance of Ruling Out Medical Mimics

• Johnson (1968) performed detailed physical exams
  on 250 patients on an inpatient psychiatric unit2
  
• 12 had problems that seemed to be caused by
  physical illness
• 80 of these had been missed by a physician
  before admission
• 6.6 were initially missed even after the
  admission workup

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Importance of Ruling Out Medical Mimics

• Sox et. al. (1989) did a thorough medical
  evaluation on 509 patients in community mental
  health programs in California2
• 14 had medical illness that was causing or
  exacerbating their mental illness
• Koran performed thorough medical assessments on
  529 patients drawn from eight community mental
  health centers in California2
• 17 were found to have an organic condition that
  either caused or exacerbated the their mental
  illness

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Importance of Ruling Out Medical Mimics

• Bartsch et. al. performed a comprehensive
  evaluation on 175 clients from two Colorado
  CMHCs2
• 16 had conditions that could cause or exacerbate
  their mental disorder

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General Principles

• Lecture will focus on two common settings where
  it is important to rule out general medical
  conditions
• Emergency room evaluations for diagnosis and
  medical clearance
• Outpatient clinic visits

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Case Study

• ED consults you for a 49 yo female with new onset
  anxiety and panic
• She told the ED resident she would rather be dead
  than to continue feeling the way she does
• When you interview her, she continues to make
  vague suicidal threats and refuses to go home

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Case Study

• Since you have 4 other consults pending, you
  decide it would be easiest to admit her, and you
  quickly finish an HP
• In your haste, you failed to realize she smoked
  and was on OCPs. She was also tachypnic and had
  a resting tachycardia
• After admission, nursing staff paged to tell you
  she was getting agitated from lack of treatment
  and wondered if you could give her something

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Case Study

• You order Ativan, which causes her to rest
  comfortably the rest of the night
• In the morning you realize she will be resting
  comfortably for quite a long time.

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General Principles

• Symptoms that suggest psychiatric illness
• Past psychiatric history
• Flat or blunted affect
• Alert and oriented
• Gradual onset
• Progressive course without fluctuations
• Abnormal thought process (esp. thought blocking.
  Circumstantial and tangential thinking are less
  reliable)

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General Principles

• Symptoms that suggest psychiatric illness
• Medication noncompliance
• Family history
• Few or no medical conditions
• Past history of trauma or abuse
• Good response to typical treatments
• Typical symptoms
• Auditory hallucinations

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General Principles

• Symptoms that suggest psychiatric illness
• Onset is age appropriate
• Anxiety disorders (extremely variable age of
  onset, however)
• GAD Usual onset is adolescence or early
  adulthood3
• Social Phobia Peak onset in teens with common
  onset 5-353
• Panic disorder Mean age of presentation is 25
  years3
• OCD Mean age of onset is 203
• Depression
• 50 of patients experience first episode before
  age 403

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General Principles

• Symptoms that suggest psychiatric illness
• Onset is age appropriate
• Bipolar disorder
• Most often starts with depression. Mean age of
  switch to bipolar disorder is 323
• Psychosis
• Schizophrenia
• Peak onset is 10-25 in men and 25-35 in women3
• 3-10 of women present after age 40 in a bimodal
  distribution that does not include men3
• Onset before age 10 or after age 60 is extremely
  rare3

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General Principles

• Symptoms that suggest medical conditions
• No past psychiatric history
• Rapid onset (Hours to days)
• Disorientation or memory impairment
• Fluctuating course
• Decreased level of consciousness
• Abnormal vitals or physical exam
• Patient unable to provide adequate history

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General Principles

• Symptoms that suggest medical conditions
• Recent change in medication
• Lack of a family history
• Multiple medical conditions
• No past history of trauma or abuse
• Poor response to standard therapy
• Onset is age inappropriate
• Atypical symptoms
• Olfactory, tactile, even visual hallucinations

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Before We Go Further

• Delirium
• Very common and important to rule out
• 10-30 of medically ill patients who are
  hospitalized exhibit delirium3
• 30 of ICU patients exhibit delirium3
• 40-50 of hip surgery patients exhibit delirium3
• Up to 90 of postcardiotomy patients exhibit
  delirium in some studies3
• 80 of terminally ill patients develop delirium3

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Before We Go Further

• Delirium
• Can be confused with almost any psychiatric
  disorder
• Caused by
• Generalized medical condition
• Substance induced
• Multiple causes
• NOS

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Mimics That Can present as Various Diseases and
Will Not Be Covered In Detail

• Substance related disorders and their withdrawal
  syndromes
• Medication Side Effects/Intoxication/Withdrawal

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Important Psychiatric Diseases That Will Not Be
Covered

• Personality changes
• Dementia
• Delirium

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Mnemonics
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ABC Mnemonic for Psychiatric MimicsMost Helpful
in ED setting

• A and B Airway and breathing
• C CNS and CVS
• D Drugs and medications
• E Electrolytes and endocrinology
• F Fever
• G to Z Other conditions

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THINC MED Mnemonic

• T Tumors
• H Hormones
• I Infections and Immune Diseases
• N Nutrition
• C CNS
• M Miscellaneous
• E Electrolytes and Environmental Toxins
• D Drugs

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GENeral MEDical CONDITions Mnemonic

• Germs (infectious)
• Epilepsy
• Nutritional
• Metabolic encephalopathy
• Endocrine disorder
• Demyelinating disease

• CVA
• Offensive toxins
• Neoplasm
• Degeneration
• Immune disease
• Trauma

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The REVIEW OF SYSTEMS is my favorite way to
remember medical Mimics
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HP

• General
• ROS Fever, chills, generalized myalgas
• PE Fever, Nucal rigidity
• HEENT
• ROS Vision changes, Olfactory or tactile
  hallucinations, recent sore throat
• PE Kayser-Fleischer rings (Wilsons), Goiter,
  proptosis (Thyroid), Argyll Robertson pupils of
  tertiary Syphilis (small irregular pupils that
  constrict to accommodation, but not light)

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HP

• Cardiovascular
• ROS Chest pain, Palpitations
• PE Irregular rate or rhythm (dysrhythmias),
  Murmur (MVP)
• Respiratory
• ROS SOB
• PE Tachypnia, resting tachycardia (PE)
  Unilateral Breath sounds (Pneumothorax), Wheezes
  (asthma), crackles (pneumonia)

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HP

• GI
• ROS Abdominal pain, diarrhea, blood or mucous in
  their stool
• PE Abdominal pain, guarding, distention
  (colitis, PUD), hepatomegaly (Wilsons, hepatic
  encephalopathy)
• GU
• ROS Dysuria, ulcers
• PE Suprapubic tenderness, flank pain, Chancre

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HP

• MS
• ROS Weakness, fatigue, need to move
• PE Tremor, abnormal gait
• Skin
• ROS Rash or changing spots on the skin
• PE Kaposis sarcoma (AIDS), Yellowish skin
  (Addisons, Jaundice, Wilsons), thin skin,
  purple striae (Cushing's), malar rash (SLE), pale
  (anemia),

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HP

• Endocrine
• ROS Heat or cold intolerance, Menstrual
  irregularities, weight change, Palpitations,
  polyuria, polydipsia
• PE goiter (thyroid), abnormal pigmentation,
  orthostatic hypotension (Addison's), obesity,
  moon face, thin skin, purple striae (Cushing's),
  tetany (parathyroid), HTN (pheochromocytoma)

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HP

• Neurologic
• This is the largest system to review and examine
  with the most relevance. I will assume you are
  already performing a detailed ROS and PE and not
  review it.

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Differential Diagnosis
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Anxiety

• Medial Illnesses causing chronic anxiety
  symptoms1
• 25 are neurologic
• 25 are endocrinologic
• 12 are due to circulatory problems
• 12 due to rheumatoid-collagen vascular disorders
• 12 are due to chronic infection
• 14 are due to other diseases

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Anxiety

• Metabolic
• Acidosis
• Electrolyte abnormalities
• Wilsons
• Pernicious anemia
• Porphyria
• Neurologic
• Brain tumors
• CVA
• Encephalopathies
• Epilepsy (esp. temporal lobe)
• Myasthenia gravis
• Pain
• Closed head injury
• Degenerative diseases
• Dementias
• Huntingtons
• Autoimmune disorders
• MS

• Drugs
• Endocrine
• Adrenal disorders
• Glucose dysregulation
• Parathyroid dysfunction
• Thyroid dysfunction
• Gonadal hormone dysfunction
• Respiratory
• Asthma
• Pneumothorax
• PE
• Cardiovascular
• MI
• Dysrhythmias
• CHF
• Anemia and hypovolemia
• Mitral valve prolapse
• GI
• Colitis

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Depression

• Autoimmune disorders
• MS
• SLE
• Infectious
• Limbic Encephalitis
• CJD
• Neurosyphilis
• Lyme disease
• Neoplastic
• Brain tumor
• Pancreatic cancer
• Other cancer
• Collagen-Vascular diseases
• Sleep Disorders
• Obstructive sleep apnea
• Insomnia

• Drugs
• Endocrine
• Adrenal disorders
• Thyroid disorders
• Parathyroid disorders
• Gonadal Hormone dysfunction
• Metabolic
• Nutritional deficiencies
• Neurological
• CVA
• Epilepsy
• NPH
• Traumatic Brain injury
• Degenerative Diseases
• Dementias
• Parkinsons
• Huntingtons

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Bipolar Disorder (Mania)

• Drugs
• Endocrine
• Cushings Syndrome
• Thyrotoxicosis
• Metabolic
• Hemodialysis
• Hepatic encephalopathy
• Uremia
• B12 deficiency
• CNS disorders
• CVA
• Closed head injuries
• Epilepsy
• CNS tumors

• Degenerative diseases
• Huntingtons
• MS
• Dementias
• Infections
• Sydenhams chorea
• Neurosyphilis
• CJD
• Auto immune
• SLE
• Other
• Chorea gravidarum

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Psychosis

• Degenerative Disorders
• Dementia
• Huntingtons
• Parkinsons
• Friedreichs ataxia
• Autoimmune disorders
• MS
• SLE
• Paraneoplastic syndrome
• Infections
• Viral encephalitis
• Neurosyphilis
• Lyme disease
• HIV
• CNS Parasites
• Tuberculosis
• Sarcoidosis
• Prion diseases
• Space occupying lesions

• Drugs and toxins
• Endocrinopathies
• Adrenal disorders
• Thyroid dysfunction
• Parathyroid dysfunction
• Pituitary dysfunction
• Metabolic disorders
• Porphyria
• Wilsons
• Amino acid metabolism disorders
• Etc.
• Nutritional and vitamin deficiencies
• Vitamin A, D, B12
• Magnesium, Zinc, Niacin
• CNS disorders
• CVA
• Epilepsy
• Closed head injuries
• Hydrocephalus

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Specific Diseases
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Specific Diseases

• Most commonly talked about diseases in
  Psychiatric literature
• However, uncommon presentations of common
  diseases are more common than common
  presentations of uncommon diseases

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Head Trauma

• Incidence 200100,0006
• Most common at 15-25 years of age3
• Male Female ratio 313
• Neuropsychiatric sequelae resulting from head
  trauma3
• 10 of patients with mild head trauma
• 50 of patients with moderate head trauma

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Head Trauma

• Two major clusters of symptoms are seen3
• Cognitive impairment
• Decreased speed of processing, decreased
  attention, trouble with memory, learning and
  problem solving.
• Behavioral sequelae
• Depression, impulsivity, aggression, personality
  change
• Behavioral Sequelae often exacerbated by alcohol
  use

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Epilepsy

• A seizure is a transient disturbance of cerebral
  function caused by a spontaneous, excessive
  discharge of neurons3
• Incidence 50100,00010
• Prevalence 500-1,000100,00010

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Epilepsy

• 30-50 of epileptics have psychiatric
  difficulties sometime in their life3
• 60 of epileptics have nonconvulsive seizures,
  most commonly partial seizures4
• Of those with partial seizures 40 do not show
  classic focal findings on EEG4

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Epilepsy

• Anxiety
• More closely associated with partial seizures4
• May be difficult to differentiate from panic
  attacks4
• Mood Disorder Symptoms
• Depression occurs in gt50 of epileptics, but only
  in 30 of matched controls4
• Suicide rate in people with epilepsy is 5X that
  of the general population. 4
• Up to 25X higher with temporal lobe epilepsy. 4

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Epilepsy

• Psychosis
• 10 of patients with complex partial epilepsy
  have psychotic symptoms3
• Up to 6-12X more common than in the general
  public4

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Brain Tumors

• Incidence 16.5100,0005
• Prevalence 131100,00011
• Mental symptoms are experienced by 50 of
  patients with brain tumors3
• Of patients with mental symptoms, 80 have
  lesions in frontal or limbic regions3
• Almost any psychiatric symptom can be seen

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Immune disorders

• Systemic Lupus Erythematosus
• Autoimmune inflammatory disorder that involves
  multiple organ systems
• The great Mimicker
• Prevalence 40-150100,0006
• Female Male ratio 1016
• African American women have 2.5-3X incidence of
  Caucasian women6

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Immune disorders

• Systemic Lupus Erythematosus
• Approximately 50 of patients show
  neuropsychiatric manifestations3
• Depression, insomnia, emotional lability,
  nervousness, confusion
• Treatment with corticosteroids causes further
  risk of neuropsychiatric manifestations
• Must have a high index of suspicion

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Immune disorders

• Systemic Lupus Erythematosus
• Signs
• Malar (butterfly) rash
• Discoid rash
• Photosensitivity
• Oral ulcers
• Renal disease
• Positive ANA

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SLE

• Malar rash

• Discoid Rash

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Immune Disorders

• Multiple Sclerosis
• Episodic, inflammatory, multifocal, demyelinating
  disease of unknown etiology associated with white
  matter lesions3,4
• Prevalence 50100,0003
• Physical symptoms are varied but of a neurologic
  origin and often focal.

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Immune Disorders

• Multiple Sclerosis
• 95 of MS patients experience depressed mood,
  agitation, anxiety, irritability, apathy,
  euphoria, disinhibition, hallucinations, or
  delusions4
• Depressive symptoms occur in over 75 of
  patients4
• Associated with an increased rate of suicide
• 25 of patients exhibit euphoric mood that is
  not, but may be confused with hypomania3
• 10 of patients will have sustained euphoria.
• gt50 of patients will have mild cognitive defects
  and 20-30 have severe defects3

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Immune Disorders

• Multiple sclerosis
• Signs
• Clonus
• Clumsiness
• Dysarthria
• Paralysis/paresis
• Anesthesia/hyperesthesia

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Endocrine Disorders

• Hyperthyroidism
• Several causes, end result is excess T3 and T4
• Incidence6
• 100100,000 female
• 33100,000 male
• Physical complaints include easy fatigability,
  generalized weakness, insomnia, weight loss,
  tremulousness, palpitations, sweating

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Endocrine Disorders

• Hyperthyroidism
• Several causes, end result is excess T3 and T4
• Incidence6
• 100100,000 female
• 33100,000 male
• Physical complaints include easy fatigability,
  generalized weakness, insomnia, weight loss,
  tremulousness, palpitations, sweating

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Endocrine Disorders

• Hyperthyroidism
• Psychiatric complaints
• Classically presents as anxiety
• Serious psychiatric symptoms include manic
  excitement, delusions, hallucinations3
• Elderly patients may present with apathy,
  psychomotor retardation and depression4

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Endocrine Disorders

• Hyperthyroidism
• Signs
• Goiter
• Expothalmos
• Moist skin/excessive sweating

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Hyperthyroidism

• Goiter

• Goiter and exophthalmos

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Endocrine Disorders

• Hypothyroidism
• Lack of thyroid hormone
• Prevalence 500-1000100,000
• Female gt male 51-101
• gt65 years old 6-10 of women and 2-3 of men
• Physical complaints include Weakness, fatigue,
  cold intolerance, constipation, weight gain,
  hearing impairment, dry skin

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Endocrine Disorders

• Hypothyroidism
• Psychiatric manifestations include
• Depression is most commonly seen
• Untreated severe hypothyroidism leads to
  Myxedema madness which can lead to paranoid,
  depression, hypomania, and hallucinations
• 10 of patents have residual neuropsychiatric
  symptoms after hormone replacement3

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Endocrine Disorders

• Hypothyroidism
• Signs
• Dry, coarse skin
• Facial puffiness
• Thin, dry hair
• Delayed relaxation of DTRs
• Myxedema
• Goiter

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Endocrine Disorders

• Hyperparathyroidism
• Excess parathyroid hormone causes hypercalcemia
• Prevalence 250100,0006
• Incidence 42100,0006
• Male gt 60 100100,000
• Female gt 60 300-400100,000
• Physical complaints include painful bones,
  renal stones, abdominal groans, and psychic
  moans

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Endocrine Disorders

• Hyperparathyroidism
• Psychiatric manifestations include
• 50-60 of patients have delirium, personality
  changes or apathy
• 25 of patients have cognitive impairments

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Endocrine Disorders

• Hyperparathyroidism
• Signs
• Nephrolithiasis
• GI distress
• Osteoporosis
• HTN
• Short QT interval
• Pancreatitis
• Pancreatic calcifications

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Endocrine Disorders

• Adrenocortical excess
• Caused by endogenous production (Cushings) or
  exogenous administration
• Cushings is rare, corticosteroid administration
  is common
• Psychiatric symptoms include
• Agitated depression and often suicide in
  Cushing's
• Mania and Psychosis often seen with exogenous
  steroids
• Steroid withdrawal often leads to severe
  depression

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Endocrine Disorders

• Adrenocortical insufficiency
• Incidence 0.6100,000
• Prevalence 4100,000
• Only occasionally causes psychiatric symptoms
  including irritability, depression, and rarely
  psychosis
• Hypoparathyroidism
• Deficiency of parathyroid hormone leads to
  hypocalcaemia
• Rare
• Can cause delirium and personality changes

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Nutritional Disorders

• Thiamine deficiency
• Leads to Beriberi and Wernicke-Korsakoff syndrome
  which is classically seen in alcoholics
• Prevalence 800-2,800100,000
• 0.8 to 2.8 percent of the general population have
  Wernicke lesions at autopsy
• Lesions seen in 12.5 of alcohol abusers and
  29-59 of those with alcohol related deaths
• Psychiatric symptoms include apathy, depression,
  irritability, nervousness, and poor
  concentration. Severe memory disorders can
  develop with prolonged deficiencies

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Nutritional Disorders

• Cobalamin (B12) deficiency
• Caused by lack of dietary intake, malabsorption
  (worsened by antacids) or pernicious anemia
• Incidence 15,000100,000
• Up to 15 of adults gt659
• Psychiatric symptoms include Apathy depression,
  irritability, moodiness
• Can lead to an encephalopathy called
  megaloblastic madness which is characterized by
  delirium, delusions, hallucinations, dementia,
  and paranoia3

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Nutritional Disorders

• Cobalamin (B12) deficiency
• Signs
• Neuropathy
• Megaloblastic anemia
• Glositis
• Hepato-splenomegaly
• Niacin Deficiency
• Rare
• Causes apathy, irritability, insomnia,
  depression, and delirium as well as dermatitis,
  peripheral neuropathies and diarrhea

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Metabolic disorders

• Common metabolic disorders do not typically
  present initially with neuropsychiatric
  complaints, but can later lead to problems.
  These include
• Hepatic encephalopathy
• Uremic encephalopathy
• Hypoglycemic encephalopathy
• Diabetic Ketoacidosis and Hyperosmolar
  hyperglycemic state
• Rare metabolic disorders can initially present
  with only neuropsychiatric complaints. Most
  commonly tested is Acute intermittent porphyria
  (AIP)

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Metabolic disorders

• Acute intermittent porphyria (AIP)
• Disorder of heme biosynthesis. Leads to excess
  porphyrins
• Incidence 110,000-100,000
• However, some studies show that 0.2-0.5 of
  chronic psychiatric patients may have undiagnosed
  porphyrias3
• Autosomal dominant.
• Affects Women gt men
• Classic triad of symptoms

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Metabolic disorders

• Acute intermittent porphyria (AIP)
• Classic triad of symptoms
• Acute, colicky abdominal pain
• Motor polyneuropathy
• Psychosis
• Other psychiatric symptoms include anxiety,
  insomnia, mood lability, and depression3
• Barbiturates precipitate attacks and are
  absolutely contraindicated even in patients with
  a family history of disease3

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Metabolic Disorders

• Wilsons Disease
• Autosomal recessive defect in copper excretion
• Prevalence of 3100,0004
• Patients complain of tremor, RUQ pain,
  spasticity, dysphagia, chorea

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Metabolic Disorders

• Wilsons Disease
• 10-15 of patient present with psychiatric
  symptoms. Patients who present differently may
  still have psychiatric symptoms. These include
• Most commonly patients have bizarre, possibly
  frontal behavior. But also may have depressive,
  schizophreniform, and bipolar symptoms.

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Metabolic Disorders

• Wilsons Disease
• Signs
• Half of patients present with liver
  manifestations including hepatitis, cirrhosis, or
  fulminant hepatitis.
• Kayser-Fleischer rings
• Tremor
• Spasticity
• Rigidity
• Chorea
• dysarthria

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Infectious diseases

• Lyme disease
• Infection caused by the spirochete Borrelia
  burgdorferi. Transmitted by Ixodid ticks
• Incidence is extremely variable depending on
  location
• Overall incidence is 8.2100,0006
• Physical complaints include bulls eye rash of
  erythema migrans (60-80), fever, headache,
  myalgas, joint pain, neuropathies

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Infectious diseases

• Lyme disease
• Psychiatric symptoms of Lyme disease include
  memory lapses, difficulty concentrating,
  irritability and depression3
• A chronic encephalopathy may develop
  (Neuroborreliosis) causing a wide range of
  neuropsychiatric symptoms and even mimic MS and
  cause seizures4
• Signs
• Erythema migrans at sight of tick bite

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Erythema Migrans
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Infectious diseases

• Herpes simplex encephalitis
• Incidence 0.2100,0007
• Most common focal encephalitis3
• Affects frontal and temporal lobes
• Common Symptoms include anosmia, olfactory and
  gustatory hallucinations, personality changes and
  bizarre or psychotic behaviors3

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Infectious Disease

• Other, less common infections
• Chronic Meningitis
• Rabies
• Neurosyphilis
• Subacute Sclerosing Panencephalitis (SSPE)

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Infectious Disease

• Other, less common infections
• Prion Disease
• CJD and vCJD
• Prevalence 0.1100,00012
• KURU
• Gerstmann-straussler-scheinker disease
• Fatal familial insomnia

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Conclusion
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Conclusion

• Medical mimics are common in psychiatric
  patients.
• They are often missed by physicians
• A high index of suspicion is needed to discover
  mimics
• A few basic principles and Mnemonics as well as
  medical knowledge of a some specific diseases
  will help uncover these mimics

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General Principles

• Symptoms that suggest medical conditions
• No past psychiatric history
• Rapid onset (Hours to days)
• Disorientation or memory impairment
• Fluctuating course
• Decreased level of consciousness
• Abnormal vitals or physical exam
• Patient unable to provide adequate history

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General Principles

• Symptoms that suggest medical conditions
• Recent change in medication
• Atypical symptoms
• Lack of a family history
• Multiple medical conditions
• No past history of trauma or abuse
• Poor response to standard therapy
• Onset is age inappropriate
• Atypical symptoms
• Olfactory, tactile, even visual hallucinations

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References

• 1. Massachusetts General Hospital Handbook of
  General Hospital Psychiatry 5th edition by Stern
  et. Al. 2004. Elsevier
• 2. Psychiatric Presentations of Medical
  Illness,An Introduction for Non-Medical Mental
  Health Professionals. By Ronald J Diamond M.D.
  University of Wisconsin Department of Psychiatry
  6001 Research Park Blvd Madison, Wisconsin 53719.
  Found at http//www.alternativementalhealth.com/
  articles/diamond.htm
• 3. Synopsis of Psychiatry 10th edition by Kaplan
  Sadock. 2007. Lippincott williams Wilkins
• 4. Massachusetts General Hospital Psychiatry
  Update and Board Preparation second edition by
  Stern Herman. 2004. McGraw-Hill
• 5. American Brain Tumor Association. Found at
  http//www.abta.org/siteFiles/SitePages/4CE78576D8
  7BD194A363ACE796099B03.pdf
• 6. Epocrates Dx version 1.50, based on 5-minute
  clinical consult by Frank J. Domino, MD
• 7. emedicine article found at http//emedicine.med
  scape.com/article/1165183-overview
• 8. Uptodate online
• 9. American Family Physician March 1, 2003.
  online at http//www.aafp.org/afp/20030301/979.htm
  l
• 10. Article found online at http//www.epilepsynse
  .org.uk/FileStorage/Professionalsarticles/main_con
  tent/Chapter1Sander.pdf
• 11. Prevalence estimates for primary brain tumors
  in the United States by behavior and major
  histology groups by Davis et. Al. Neuro Oncol
  2001 3(3)152-158 DOI10.1215/15228517-3-3-152
  found online at http//neuro-oncology.dukejournals
  .org/cgi/content/abstract/3/3/152
• 12 online article at http//www.neurologychannel.c
  om/cjd/index.shtml

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Anxiety

• Metabolic
• Acidosis
• Electrolyte abnormalities
• Wilsons
• Pernicious anemia
• Porphyria
• Neurologic
• Brain tumors
• CVA
• Encephalopathies
• Epilepsy (esp. temporal lobe)
• Myasthenia gravis
• Pain
• Closed head injury
• Degenerative diseases
• Dementias
• Huntingtons
• Autoimmune disorders
• MS

• Drugs
• Endocrine
• Adrenal disorders
• Glucose dysregulation
• Parathyroid dysfunction
• Thyroid dysfunction
• Gonadal hormone dysfunction
• Respiratory
• Asthma
• Pneumothorax
• PE
• Cardiovascular
• MI
• Dysrhythmias
• CHF
• Anemia and hypovolemia
• Mitral valve prolapse
• GI
• Colitis

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Depression

• Autoimmune disorders
• MS
• SLE
• Infectious
• Limbic Encephalitis
• CJD
• Neurosyphilis
• Lyme disease
• Neoplastic
• Brain tumor
• Pancreatic cancer
• Other cancer
• Collagen-Vascular diseases
• Sleep Disorders
• Obstructive sleep apnea
• Insomnia

• Drugs
• Endocrine
• Adrenal disorders
• Thyroid disorders
• Parathyroid disorders
• Gonadal Hormone dysfunction
• Metabolic
• Nutritional deficiencies
• Neurological
• CVA
• Epilepsy
• NPH
• Traumatic Brain injury
• Degenerative Diseases
• Dementias
• Parkinsons
• Huntingtons

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Bipolar Disorder (Mania)

• Drugs
• Endocrine
• Cushings Syndrome
• Thyrotoxicosis
• Metabolic
• Hemodialysis
• Hepatic encephalopathy
• Uremia
• B12 deficiency
• CNS disorders
• CVA
• Closed head injuries
• Epilepsy
• CNS tumors

• Degenerative diseases
• Huntingtons
• MS
• Dementias
• Infections
• Sydenhams chorea
• Neurosyphilis
• CJD
• Auto immune
• SLE
• Other
• Chorea gravidarum

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Psychosis

• Degenerative Disorders
• Dementia
• Huntingtons
• Parkinsons
• Friedreichs ataxia
• Autoimmune disorders
• MS
• SLE
• Paraneoplastic syndrome
• Infections
• Viral encephalitis
• Neurosyphilis
• Lyme disease
• HIV
• CNS Parasites
• Tuberculosis
• Sarcoidosis
• Prion diseases
• Space occupying lesions

• Drugs and toxins
• Endocrinopathies
• Adrenal disorders
• Thyroid dysfunction
• Parathyroid dysfunction
• Pituitary dysfunction
• Metabolic disorders
• Porphyria
• Wilsons
• Amino acid metabolism disorders
• Etc.
• Nutritional and vitamin deficiencies
• Vitamin A, D, B12
• Magnesium, Zinc, Niacin
• CNS disorders
• CVA
• Epilepsy
• Closed head injuries
• Hydrocephalus

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