Neuropsychiatric Features of Medical Disorders PDF
Preview Neuropsychiatric Features of Medical Disorders
Neuropsychiatric Features of Medical Disorders CRITICAL ISSUES IN PSYCHIATRY An Educational Series for Residents and Clinicians Series Editor: Sherwyn M. Woods, M.D., Ph.D. University of Southern California School of Medicine Los Angeles, California A RESIDENT'S GUIDE TO PSYCHIATRIC EDUCATION Edited by Michael G. G. Thompson, M.D. STATES OF MIND: Analysis of Change in Psychotherapy Mardi J. Horowitz, M.D. DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment Marc A. Schuckit, M.D. THE INTERFACE BETWEEN THE PSYCHODYNAMIC AND BEHAVIORAL THERAPIES Edited by Judd Marmor, M.D., and Sherwyn M. Woods, M.D., Ph.D. LAW IN THE PRACTICE OF PSYCHIATRY Seymour L. Halleck, M.D. NEUROPSYCHIATRIC FEATURES OF MEDICAL DISORDERS James W. Jefferson, M.D., and John R. Marshall, M.D. ADULT DEVELOPMENT: A New Dimension in Psychodynamic Theory and Practice Calvin A. Colarusso, M.D., and Robert A. Nemiroff, M.D. SCHIZOPHRENIA John S. Strauss, M.D., and William T. Carpenter, Jr .. M.D. A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher. Neuropsychiatric Features of Medical Disorders James W.Jefferson, M.D. and John R. Marshall., M.D. University of Wisconsin Medical School Madison. Wisconsin PLENUM MEDICAL BOOK COMPANY NEW YORK AND LONDON Library of Congress Cataloging in Publication Data Jefferson, James W. Neuropsychiatric features of medical disorders. (Critical issues in psychiatry) Bibliography: p. Includes index. 1. Neuropsychiatry. 2. Neurologic manifestations of general diseases. 3. Psychological manifestations of general diseases. I. Marshall, John R., 1939- II. Title. III. Series. [DNLM: 1. Mental disorder-Etiology. 2. Diagnosis. 3. In ternal medicine. 4. Drug therapy-Adverse effects. WB 115 J453n) RC343.J36 616.047 81-2550 ISBN· 13: 978'1'4684'3922-9 e·ISBN·13: 978'1'4684-3920'5 AACR2 DOl: 10.1007/978'1-4684-3920-5 1981 Plenum Publishing Corporation II) Softcover reprint of the hardcover 1st edition 1981 233 Spring Street, New York, N.Y. 10013 Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher To parents, wives, and children-especially ours Foreword When Critical Issues in Psychiatry was conceived, there were several sub jects I considered to be of crucial importance in a series devoted to residents and clinicians in psychiatry, as well as to other mental health professionals. Of prominence was the pressing need for an in-depth and scholarly exam ination of the interface between medicine and psychiatry. I had been amazed to find that not a single book, to my mind, adequately addressed the psy chological symptoms and manifestations of both common and rare medical illness. It seemed to me that there was a need for a work which would achieve the following goals: First, it would assist in the differential diagnosis of functional psychiatric symptoms versus symptoms secondary to recog nized or unrecognized medical illness; second, it would elucidate the psy chological symptoms resulting from pharmacologic and other therapeutic interventions in medical illness; and third, it would examine the use of psychopharmacological agents in the presence of medical illness and the drugs used to treat that illness. Dr. Jefferson is Board Certified in both internal medicine and psychiatry, and both Drs. Jefferson and Marshall have extensive clinical experience from their many years of consultation/liaison work in psychiatry. Their experience and expertise have resulted in what I believe to be a monumental contri bution to the literature. With both comprehensiveness and conciseness, each chapter addresses an organ system of the body and reviews those medical illnesses and disorders which can present with or be accompanied by psy chiatric symptoms. In each instance, the condition's clinical features and laboratory findings are described, the psychiatric manifestations are delin eated and discussed, the psychophysiological basis of the symptomatology is elucidated when the mechanisms are known, and the psychological symp toms or complications which can accompany treatment are comprehensively reviewed. Whether discussing endocrine dysfunction, ketoacidosis, or the mitral-valve-prolapse syndrome, the authors describe patients and condi tions which might present in any mental health professional's office, or, for that matter, in the office of an internist or primary care physician. It is the nightmare of every psychiatrist and nonmedical psychotherapist that despite best intentions and efforts, one will regard as functional a patient vii viii FOREWORD whose primary problem is an underlying medical illness. It is an unfortunate reality that there have undoubtedly been patients who have suffered (and died) because of shortsighted, unidimensional, psychological misinterpre tation. Knowledge is our best insurance against such tragedies. Since it is difficult for most psychiatrists and other mental health professionals to maintain their medical expertise, the authors have done an important service to the profession by providing this first truly comprehensive resource and reference. In doing so, they have exhaustively reviewed and evaluated the existing literature, while at the same time retaining clinical relevance and readability. As a psychiatrist and psychoanalyst, I regard this volume as essential for ready availability in my daily clinical work. It is likely that nonmedical psychotherapists and mental health professionals of all disciplines will find the book of great value. This will undoubtedly be true of internists, neu rologists, family practitioners, and other primary care specialists who must address themselves daily to the differential diagnosis and management of psychological symptoms which may be related to medical illness. Sherwyn M. Woods, M.D., Ph.D. Series Editor Preface Many books have been published in recent years dealing with psychosomatic illness, liaison-consultation psychiatry, the psychological care of the med ically ill, and general hospital psychiatry. Our book makes no attempt to duplicate these efforts, but rather focuses on other aspects of the medical-psychiatric interface. These include: 1. The neuropsychiatric features of medical disorders 2. The neuropsychiatric effects of medical drugs 3. Psychotropic drugs and medical disorders It is written for clinicians in order to assist them in the difficult area of differential diagnosis, illustrating the perils of misdiagnosis and emphasiz ing the dictum that only accurate diagnosis can lead to specific, effective treatment. We insist that psychiatric symptoms not be automatically con sidered indicative of "functional" illness but that they also be recognized as integral parts (and sometimes the leading edge) of many medical disorders. This is not to deny the importance of recognizing and understanding psy chological stressors, psychological responses to illness, and the psycholog ical approaches and treatments that are a necessary aspect of dealing with these conditions. Indeed, a clinician lacking these attributes would be unidimensional and of limited affectiveness. They are simply not our sub iect matter. With the exception of the introductory chapter, the book is disorder rather than symptom-oriented and follows a general medical textbook for mat. While we emphasize the neuropsychiatric features of medical disorders and medical drugs, we present them in a framework that provides an over view of the disorders with regard to etiology, clinical features, diagnosis, and treatment. In this way, we stress the interrelationship between symp toms and disorder, recognizing and deploring the all too common tendency to treat them as separate, unrelated entities. The book does not cover all medical disorders, since many do not have well defined, unique neuropsychiatric features and were, thus, excluded. We apologize for omissions that would have been appropriate inclusions and would appreciate having those brought to our attention. Neurologic disorders were intentionally excluded, in part due to the availability of texts such as Behavioral Neurology (Pincus and Tucker; Oxford University Press, ix x PREFACE 1978), Psychiatric Aspects of Neurologic Disease (Benson and Blumer; Grune and Stratton, 1975) and Organic Psychiatry (Lishman; Blackwell Scientific, 1978). Although we are well aware of major controversies surrounding the use of terms such as psychological, physical, functional, organic, medical, and psychiatric, we saw little option but to use them (often within quotation marks) in the conventional sense. While recognizing that distinctions may blur and that terminology may be clumsy and subject to misinterpretation, we have attempted to use a language that, while imprecise, will be familiar to most of our readers. We recognize and value psychiatry as a medical speciality; hence the term "medical disorder" refers to a non psychiatric medical disorder while the term "psychiatric disorder" refers to a psychiatric medical disorder. Readers will find it apparent that we consider unsound the common practice of assuming the presence of a psychiatric illness merely because a physical disorder seems absent. Misdiagnosis is likely if a clinician has not considered a comprehensive differential diagnosis or has not obtained the appropriate laboratory tests. It is also possible that current diagnostic techniques are not sufficiently refined to detect illnesses that will eventually fall within the nonpsychiatric medical domain. Historically, neurosyphillis was considered a psychiatric illness until the spirochete was discovered and effective treatments developed. Psychiatric diagnosis is clearly not diagnosis by elimination, and if positive support for a psychiatric diagnosis is not available, it is far better to label the disorder "of unknown etiology." This avoids stigmatizing the patient with unwarranted assumptions and allows for ongoing diagnostic considerations in both medical and psychiatric arenas. We wish to thank the Department of Psychiatry at the University of Wisconsin and the Wisconsin Psychiatric Institute for providing an atmo sphere within which writing this book was both facilitated and encouraged. We are especially grateful to our trainees who provided both tolerance and critical comment when these topics were presented in seminars. Without the secretarial assistance of Jean Thomas. Pam Miller, and especially Lynn DeWeese, we would have been stymied at the start. Sherwyn Woods, as Editor-in-Chief of the Critical Issues in Psychiatry series, provided continual encouragement, valuable suggestions, and a much appreciated tolerance for delay. Finally, Hilary Evans, Senior Medical Editor of the Plenum Publishing Company, has done all that is humanly possible to alleviate the pains of publishing. James W. Jefferson and John R. Marshall Madison Contents Chapter 1 Physical Illness and Psychiatric Symptoms ........................ .... ..... 1 Overview ................................................................................................. 1 Representative Psychiatric Symptoms .................................................. 3 Anxiety ................................................................................................ 3 Depression ........................................................................................... 6 Fatigue ................................................................................................. 7 Hallucinations ..................................................................................... 9 References ............................................................................................... 11 Chapter 2 Cardiovascular Disorders ................................................................. 13 Heart Failure ........................................................................................... 13 General Considerations ...................................................................... 13 Clinical Features ................................................................................. 13 Arrhythmias ................................................. ........................................... 15 Palpitations ......................................................................................... 16 Arrhythmias and the Cerebral Circulation ........................................ 17 Diagnosis of Arrhythmias ................................................................... 18 Blood Pressure ....................... .......... ........................ ...... .............. ........... 18 Hypotension ........................................................................................ 18 Hypertension ....................................................................................... 19 Atherosclerotic Heart Disease ................................................................ 22 Angina Pectoris ................................................................................... 22 Myocardial Infarction ......................................................................... 24 Syncope .................................................................................................. 25 Cardiac Tumors ...................................................................................... 26 Infective (Bacterial) Endocarditis ........................ ............ ...................... 27 Functional Cardiac Disorders .. ..................... .......... ............................... 28 Mitral Valve Prolapse Syndrome (MVPS) ............................................. 30 Impotence ............................................................................................... 32 Thoracic Outlet Syndrome ................................................ .......... ...... .... 32 xi
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